key: cord-277558-w2srv5em authors: babuna, pius; yang, xiaohua; gyilbag, amatus; awudi, doris abra; ngmenbelle, david; bian, dehui title: the impact of covid-19 on the insurance industry date: 2020-08-10 journal: int j environ res public health doi: 10.3390/ijerph17165766 sha: doc_id: 277558 cord_uid: w2srv5em this study investigated the impact of covid-19 on the insurance industry by studying the case of ghana from march to june 2020. with a parallel comparison to previous pandemics such as sars-cov, h1n1 and mers, we developed outlines for simulating the impact of the pandemic on the insurance industry. the study used qualitative and quantitative interviews to estimate the impact of the pandemic. presently, the trend is an economic recession with decreasing profits but increasing claims. due to the cancellation of travels, events and other economic losses, the ghanaian insurance industry witnessed a loss currently estimated at gh ȼ112 million. our comparison and forecast predicts a normalization of economic indicators from january 2021. in the meantime, while the pandemic persists, insurers should adapt to working from remote locations, train and equip staff to work under social distancing regulations, enhance cybersecurity protocols and simplify claims/premium processing using e-payment channels. it will require the collaboration of the ghana ministry of health, banking sector, police department, customs excise and preventive service, other relevant ministries and the international community to bring the pandemic to a stop. abstract: this study investigated the impact of covid-19 on the insurance industry by studying the case of ghana from march to june 2020. with a parallel comparison to previous pandemics such as sars-cov, h1n1 and mers, we developed outlines for simulating the impact of the pandemic on the insurance industry. the study used qualitative and quantitative interviews to estimate the impact of the pandemic. presently, the trend is an economic recession with decreasing profits but increasing claims. due to the cancellation of travels, events and other economic losses, the ghanaian insurance industry witnessed a loss currently estimated at gh coronavirus disease, scientifically reclassified as covid-19, has assumed global pandemic proportions [1] . it attained a pandemic status declared by the world health organization (who) on 11 march 2019 [1] . the current spread of the virus at a fast rate compared to previous pandemics has resulted in a total lockdown of nations, ban on travels, public gatherings and closure of offices. there has been global closure of businesses as well as the loss of jobs and lives. the general economic situation is a global recession. in most instances, the insurance industry and governments all over the world have become the beacons of hope to which people look for rescue from total annihilation. however, due to the fast increase in infection cases greater than the recovery of infected people, the pandemic has overwhelmed many governments and financially weakened some insurance companies. the impact ȩ coronavirus disease (covid-19) dashboard cost efficiency of insurance firms in ghana efficiency, productivity and returns to scale economies in the non-life insurance market in south africa evaluating the cost efficiency of insurance companies in ghana backyard poultry flocks and salmonellosis: a recurring, yet preventable public health challenge the impact of the antonine plague the black death and its effect on fourteenth-and fifteenth-century art the black death: the great mortality of 1348-1350. a brief history with documents updating the accounts: global mortality of the 1918-1920 "spanish" influenza pandemic novel origin of the 1918 pandemic influenza virus nucleoprotein gene segment world war i may have allowed the emergence of the geography and mortality of the 1918 influenza pandemic sequence of the 1918 pandemic influenza virus nonstructural gene (ns) segment and characterization of recombinant viruses bearing the 1918 ns genes origin of hiv type 1 in colonial french equatorial africa? gender and monitoring the response to hiv/aids pandemic challenges in the development of an hiv-1 vaccine human immunodeficiency virus type 1, human protein interaction database at ncbi the emergence of hiv/aids in the americas and beyond a history of aids: looking back to see ahead novel swine-origin influenza virus a (h1n1): the first pandemic of the 21st century the emergence of novel swine influenza viruses in north america cases of swine influenza in humans: a review of the literature swine influenza a (h1n1) triple reassortant virus infection pathogenesis of swine influenza virus (thai isolates) in weanling pigs: an experimental trial the first pandemic of the 21st century sars-cov virus-host interactions and comparative etiologies of acute respiratory distress syndrome as determined by transcriptional and cytokine profiling of formalin-fixed paraffin-embedded tissues sars coronavirus vaccine development ebola outbreak in west africa: a neglected tropical disease estimating the future number of cases in the ebola epidemic-liberia and sierra leone the ebola epidemic: a global health emergency ebola outbreak: ethical use of unregistered interventions a comparative study of strains of ebola virus isolated from southern sudan and northern zaire in 1976 ebola hemorrhagic fever: tandala, zaire, 1977-1978 identification of the ebola virus in gabon in 1994 containing a hemorrhagic fever epidemic: the ebola experience in uganda laboratory diagnosis of ebola hemorrhagic fever during an outbreak in yambio, sudan newly discovered ebola virus associated with hemorrhagic fever outbreak in uganda human ebola outbreak resulting from direct exposure to fruit bats in luebo, democratic republic of congo ebola hemorrhagic fever ebola virus outbreaks in africa: past and present ebola haemorrhagic fever associated with novel virus strain covid-19) epidemics, the newest and biggest global health threats: what lessons have we learned? the economics of epidemic diseases pandemics of the poor and banking stability pandemic risk: how large are the expected losses? profitability shocks and recovery in time of crisis evidence from european banks tourism and covid-19: impacts and implications for advancing and resetting industry and research the coronavirus and the great influenza pandemic: lessons from the 'spanish flu' for the coronavirus's potential effects on motality and economic activity growth dynamics: the myth of economic recovery aggregate and firm level stock returns during pnademics in real time financing hiv/aids programs in sub-saharan africa. health aff epidemics and economics: new and resurgent infectious diseases can have far-reaching economic repercussions assessing the impact of a pandemic on the life insurance industry in south africa acknowledgments: thanks to all authors for their efforts in conducting this research. the authors declare no conflict of interest. key: cord-034351-5br4faov authors: xu, shuang-fei; lu, yi-han; zhang, tao; xiong, hai-yan; wang, wei-bing title: cross-sectional seroepidemiologic study of coronavirus disease 2019 (covid-19) among close contacts, children, and migrant workers in shanghai date: 2020-10-02 journal: int j environ res public health doi: 10.3390/ijerph17197223 sha: doc_id: 34351 cord_uid: 5br4faov (1) background: along with an increasing risk caused by migrant workers returning to the urban areas for the resumption of work and production and growing epidemiological evidence of possible transmission during the incubation period, a study of coronavirus disease 2019 (covid-19) is warranted among key populations to determine the serum antibody against the sars-cov-2 and the carrying status of sars-cov-2 to identify potential asymptomatic infection and to explore the risk factors. (2) method: this is a cross-sectional seroepidemiologic study. three categories of targeted populations (close contacts, migrant workers who return to urban areas for work, and school children) will be included in this study as they are important for case identification in communities. a multi-stage sampling method will be employed to acquire an adequate sample size. assessments that include questionnaires and blood, nasopharyngeal specimens, and feces collection will be performed via home-visit survey. (3) ethics and dissemination: the study was approved by the institute review board of school of public health, fudan university (irb#2020-04-0818). before data collection, written informed consent will be obtained from all participants. the manuscripts from this work will be submitted for publication in quality peer-reviewed journals and presented at national or international conferences. since the first known case of pneumonia infected with the novel coronavirus was reported in the city of wuhan in late december of 2019, coronavirus disease 2019 (covid-19), caused by sars-cov-2 and announced by the world health organization on 11 february 2020, unexpectedly and quickly spread in china and many other countries with rapid geographical expansion and a sudden increase in the number of cases [1, 2] . on january 20, covid-19 was added into china's "law on prevention and control of infectious diseases" as a class b notifiable disease and necessitated prevention and control measures as a class a because of its emergences [3] . on 23 january, the chinese government began to limit population movement in and out of wuhan. in the following week, provinces in mainland china successively launched response level i of the major public health emergency to respond to the covid-19 epidemic, including the lockdown of whole cities, cancelation of celebration activities of spring festival (chinese new year), and deferral of attendance at school and work. to our knowledge, the common clinical features of covid-19 are non-specific, such as fever, dry cough, and bilateral and peripheral ground-glass and consolidative pulmonary opacities on chest computed tomography (ct) scans, in addition to other symptoms including dyspnea, headache, muscle soreness, and fatigue [4, 5] . according to the released data from the chinese center for disease control and prevention, the overall case-fatality rate (cfr) was 2.3%, though the cfr was much higher among the critical (49%) and the elderly cases (20-30%). of the total cumulative confirmed cases on february 11, 2020, the majority (81%) were classified as non-pneumonia and mild pneumonia, and no death has been documented among those with mild or severe symptoms [6] . at the end of february 2020, a total of 79,824 confirmed covid-19 cases were recorded in mainland china, of whom 41,625 had been discharged and 2870 had died [7] . thus far, the majority of published studies focused on hospitals and confirmed/suspected cases rather than on the population at risk in communities. along with the resumption of work and production activities and the adjustment of the emergency response level, an increasing number of migrant workers across the whole country are gradually returning to urban areas, which adds an extra burden on disease prevention and management. meanwhile, several studies provided epidemiological evidence of possible transmission of sars-cov-2 from pre-symptomatic and asymptomatic cases (asymptomatic people with sars-cov-2 detected in respiratory specimens or immunoglobulin m (igm) detected in serum) [8, 9] . thus, a cross-sectional seroepidemiologic study of covid-19 among key populations is warranted to determine the potential risk of sars-cov-2 infection in different scenarios. the study introduces no significant risk to participants, with no medication or intervention involved. the study was approved by the institute review board of school of public health, fudan university (irb#2020-04-0818). before data collection, the purpose and procedures of the study will be explained to all the eligible participants. written informed consent will be obtained from all participants and from the parents of minors. participants can withdraw from the study at any point without any adverse consequences. all data are anonymous and will be managed confidentially. to determine the serum antibody level against the sars-cov-2 and the carrying status of sars-cov-2 among key susceptible populations to identify potential asymptomatic infection and to explore the risk factors. three categories of study participants will be recruited in the study as they are important for case finding in communities. participants must meet the following inclusion criteria: close contacts: the definition of "close contacts" is based on prevention and control of novel coronavirus pneumonia (6th edition), which refers to people who had unprotected close contact (within 1 meter) with a confirmed or suspect case within two days before illness onset, or with an asymptomatic infected person within two days before sampling [10] . in china, the tracing and management of close contacts is implemented by the local center for disease control and prevention (cdc), and all identified close contacts are recorded in health administration departments. • volunteer to participate in the survey and provide written informed consent. domestic migrant workers returning to urban areas for work: • aged 18 years and above; • unconfirmed covid-19 cases; • volunteer to participate in the survey and provide signed informed consent. school children: • aged above 6 years; • attending primary school, middle school, or high school (non-vocational high school); • unconfirmed covid-19 cases; • volunteer to participate in the survey and provide signed informed consent themselves and/or through their parent(s). • history of any neurologic disorders; • language disorders. this is a cross-sectional study design. the sample size is calculated according to the following formula: where nsrs is the sample size under simple random sample assumption; zα/2 is the statistic corresponding to level of confidence, assumed to be 1.96 (when α = 0.05); d is precision, assumed to be 20%*p [11] ; k is the missing rate, assumed to be 10% [11] ; n is the minimum required sample size; p is the expected seroprevalence of antibodies against sars-cov-2 among the target populations. however, these parameters for the above three categories of study participants remain unclear. although the spread of sars-cov-2 is much faster than that of the sars-cov in 2003, these two coronaviruses share a similar transmission mode, such as airborne transmission and close person-to-person contact, via respiratory droplets from sneezing or coughing, and fomites. thus, we consider referring to the transmission data of sars epidemic. in 2003, after the sars epidemic, the seroprevalence of antibodies against sars-cov tested by enzyme-linked immunosorbent assay (elisa) among close contacts, general population and school children were 0.19-4.87%, 0.0083-2.26% and 0-1.70%, respectively [12] [13] [14] [15] [16] . similarly, we assume the expected seroprevalence of sars-cov-2 among close contacts, migrant workers, and school children to be 5%, 3%, and 2%, respectively. if the research designers in different regions obtain more specific local data, they can adjust the calculations. finally, in our design, the expected sample sizes for close contacts, migrant workers, and school children are 2028, 3450, and 5228, respectively. multi-stage sampling methods will be employed to acquire adequate sample size. primary sampling units (psus) are sampled with a probability proportional to size (pps), that is, the number of subunits within each psu. given the different population sizes of the three categories of study participants and the different sampling strategies, the selected psus for each target population may not be identical. for close contacts, the specific sample size will be determined by the cumulative number of contacts in the city. it is best to include all contacts of the confirmed covid-19 cases, to maximize the statistical power of the study. otherwise, one-stage design with cluster sampling is chosen. here, "size" in pps refers to the number of close contacts in each district, which is now replaced by the size of confirmed covid-19 cases because there are no open data about close contacts in shanghai. the four districts, from the total 16, selected as psus with pps sampling were pudong district, xuhui district, yangpu district, and songjiang district ( table 1) . all eligible close contacts in the selected districts will be enrolled. for migrant workers returning to the city for work, a two-stage design with pps and successive sampling is chosen. at the first stage, pps ("size" here refers to the floating population count in each district) sampling is employed to select four psus. considering the distribution of floating population in each district released by the shanghai statistics bureau in 2018, pudong district, putuo district, baoshan district, and qingpu district were selected (table 2) . at the second stage, a fixed number of individuals will be enrolled using successive sampling. for migrant workers, to our knowledge, migrants returning to shanghai are required to actively register with the village/neighborhood committees since january, 2020. thus, all eligible migrant workers in each psu will be recruited one-by-one from the registers until the expected sample size is reached. for school children, a three-stage design with pps, simple random sampling (srs), and cluster sampling is chosen. at the first stage, pps ("size" here refers to the number of schools in each district at the second stage) sampling is employed to select 4 psus. taking shanghai for example again, based on the data from shanghai education bureau [17], pudong district, jing'an district, minhang district, and songjiang district were selected (table 3) . at the second stage, schools in each district will be stratified as primary school, middle school, and high school, and srs will be used to select 1~2 schools from each stratum. at the third stage, 1 or 2 classes in each grade will be chosen at random, and all eligible students should be enrolled (the specific number of classes can be adjusted by the admission size). the sample size for school children is "deff" (the design effect in cluster sampling, assumed to be 1.5), which multiplies the expected value (n = 5228). sociodemographic characteristics: name, telephone (mobile) number, date of birth, sex, e-mail address, current address, ethnicity, job, educational level, parent employment status, educational level (only for children) and preferred mode of contact (telephone, email, or express delivery); 2. underlying conditions: pregnancy, obesity, cancer, diabetes, hypertension, heart disease, asthma requiring medication, chronic lung disease (non-asthma), chronic liver disease, chronic hematological disorder, chronic kidney disease, chronic neurological impairment/disease, and other underlying conditions. in addition, respiratory-pathogen-related vaccinations will be reviewed. clinical symptoms within the last 14 days: body temperature, fever, chill, dry cough, sore throat, runny nose, shortness of breath, nausea, vomiting, diarrhea, and other symptoms. general exposure information: possible contact with confirmed/suspected cases, visits to medical facilities, and travel history (including destination, transfer, and duration) within the last 14 days. appropriate personal protective equipment should be worn when specimens are being collected. specimens of close contacts will be collected by the designated local cdcs and medical facilities. specimens of migrant workers and school children will be collected by qualified technicians. all specimen containers should be labeled with the full name of the person being sampled, time and date of collection, and one other unique identifier such as the national medical insurance number. blood specimen: a 5 ml whole-blood sample will be collected with a vacutainer with no anticoagulant. once the blood is drawn, the vacutainer should be inverted 5 or 6 times and placed at room temperature. when the blood specimen is sent to the laboratory, the vacutainer will be centrifuged for 10 min at 1500-2000 rpm at room temperature. serum will be extracted by pipette and stored in a sterile spiral plastic tube. in addition, another 5 ml whole-blood sample will be collected with a vacutainer containing edta anticoagulant. once the blood is drawn, the vacutainer should be inverted at least 10 times and placed at room temperature for 30 min. then the vacutainer will be centrifuged for 10 min at 1500-2000 rpm at room temperature. plasma and blood cells will be separately collected into sterile spiral plastic tubes. • nasopharyngeal (np) swab: two np swabs will be collected for each eligible participant. the swab will be directly put in the nose parallel to the base of the np passage. the swab should move without resistance until reaching the nasopharynx, located about one-half to two-thirds the distance from the nostril to an ear lobe. if resistance occurs, the swab will be removed, and an attempt will be made to take the sample entering through the same or the other nostril. once the swab reaches nasopharynx, the swab will be rotated 180 • , or left in place for 5 s to saturate the swab tip; and then the swab will be removed slowly. then the swab head will be inserted into the tube containing 3.5 ml of virus preservation buffer (virus transport medium (containing hank's balanced salt solution, polymyxin b, vancomycin, bovine serum albumin, cryoprotectant, biobuffer, etc.), shanghai comagal microbial technology co. ltd.) and swab shaft will be evenly broken at the scored line to fit in tube and replace cap tightly. feces or anal swab: 3-5 ml of stool that has not been mixed with urine will be collected in a clean, dry, leak-proof container. if it is not convenient to collect fecal samples, an anal swab can be collected. the disinfectant cotton swab will be gently inserted into the anus to a depth of 3-5 cm, then it will be gently rotated pulled out, and immediately put into a 15 ml screw-capped sampling tube containing 3-5 ml virus preservation buffer. then, the swab shaft will be evenly broken at the scored line to fit in tube and the cap will be replaced tightly. blood specimens, np swabs, and anal swabs should be taken at the home visit. feces could be collected the next day. all specimens will be shipped to the laboratory in a sealed biohazard bag within 24 h after collection at 4 • c on ice packs. if transportation will be delayed more than 24 h, specimens should be reserved at −70 • c and shipped on dry ice. it is important to avoid repeated freezing and thawing of specimens. laboratory examinations • serological testing: the serum specimen will be available for qualitative detection of sars-cov-2-specific total antibodies (including igm, igg, iga, and other antibody types) with novel coronavirus (2019-ncov) antibody test kit (chemiluminescence immunoassay method) (registered number: 20203400198), developed by xiamen innodx biotech co., ltd. (xiamen, china) and which is the world's first approved total antibody detection reagent with the double-antigen sandwich method for sars-cov-2. it can rapidly and simply detect specific antibodies within 29 min. • etiological testing: a real-time fluorescence-based reverse transcriptase-polymerase chain reaction (rt-pcr) assay will be applied to the np specimen and feces to detect sars-cov-2. the primers and probes (targeting open reading frame 1ab (orf 1ab) and nucleocapsid protein (n) in the novel coronavirus genome) used for sars-cov-2 detection by rt-pcr is from the novel coronavirus pneumonia: laboratory testing guideline, released by national health commission of the prc. in addition, np specimens will be further examined for a total of 41 respiratory pathogens (table 4 ) via gene chips (micro-fluid chip for respiratory pathogens, product number: 4398986). in this cross-sectional survey, participants with serological evidence (sars-cov-2-specific igm and igg detectable in serum) or etiological evidence (real-time fluorescent rt-pcr indicating positive for sars-cov-2 nucleic acid) will be diagnosed as confirmed cases. the study design is presented in figure 1 . investigators will communicate with the selected participants or guardians in advance to assure their intention of participating this program. the refusers will be replaced by resampling without replacement in each psu. investigators will visit the eligible participants at the appointed time; obtain written informed consent; complete the questionnaire survey; and collect blood specimens, np swabs, and annal swabs. feces specimens are limited to diarrheal participants and will be self-collected with sterile containers. investigators will take them in the next day. during the investigation, investigators will inform the participants of laboratory results via their preferred mode of contact, such as telephone, email, or express delivery. the identified asymptomatic cases in the survey will immediately report to local cdcs and transfer to medical facilities. the primary benefit of the investigation is to prevent the further spread of the virus. on completion of the investigation, data will be imported into the data analysis software (spss version 23.0 and sas version 9.4) for data cleaning and statistical analysis. the prevalences of sars-cov-2-specific antibodies in serum and those of sars-cov-2, and other respiratory pathogens in np specimens will be presented with their 95% confidence intervals (cis). participants' characteristics will be described as means ± sds for normally distributed variables, as medians, and interquartile ranges (iqrs) for non-normally distributed variables, and as frequencies and proportions for categorical variables. bivariate and multivariable analyses will be performed to identify potential factors associated with infection of sars-cov-2 and other respiratory pathogens among study participants. differences between groups will be compared with independent-samples t tests or mann-whitney u tests (for continuous variables), χ 2 tests or fisher's exact tests (for categorical variables), and analysis of variance or kruskal-wallis where applicable. appropriate statistical models (logistic regression models and generalized linear mixed models) will be performed to estimate the odds ratios (ors) of factors associated with sars-cov-2 infection. adjusted odds ratios (aors) will be obtained using a multivariable model, including the following covariates: age, gender, occupation, education. further analysis will be determined upon more discussion. a p-value <0.05 will be considered statistically significant. on completion of the investigation, data will be imported into the data analysis software (spss version 23.0 and sas version 9.4) for data cleaning and statistical analysis. the prevalences of sars-cov-2-specific antibodies in serum and those of sars-cov-2, and other respiratory pathogens in np specimens will be presented with their 95% confidence intervals (cis). participants' characteristics will be described as means ± sds for normally distributed variables, as medians, and interquartile ranges (iqrs) for non-normally distributed variables, and as frequencies and proportions for categorical variables. bivariate and multivariable analyses will be performed to identify potential factors associated with infection of sars-cov-2 and other respiratory pathogens among study participants. differences between groups will be compared with independent-samples t tests or mann-whitney u tests (for continuous variables), χ 2 tests or fisher's exact tests (for categorical variables), and analysis of variance or kruskal-wallis where applicable. appropriate statistical models (logistic regression models and generalized linear mixed models) will be performed to estimate the odds ratios (ors) of factors associated with sars-cov-2 infection. adjusted odds ratios novel coronavirus (2019-ncov): situation report, 22. 2020; world health organization early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia national health commission of the people 's republic of china. announcement by the national health commission relationship to duration of infection updated understanding of the outbreak of 2019 novel coronavirus (2019-ncov) in wuhan the novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19)-china, 2020. china cdc wkly national health commission of the people's republic of china. the latest status of 2019-novel-coronavirus (2019-ncov) pneumonia at 24 o' clock clinical characteristics of 24 asymptomatic infections with covid-19 screened among close contacts in nanjing a familial cluster of infection associated with the 2019 novel coronavirus indicating possible person-to-person transmission during the incubation period national health commission of the people' s republic of china. protocol on prevention and control of novel coronavirus pneumonia sars-cov antibody prevalence in all hong kong patient contacts seroprevalence of igg antibodies to sars-coronavirus in asymptomatic or subclinical population groups severe acute respiratory syndrome among children epidemiological research on sars coronavirus antibody in serum among healthy population of qingyuan city seroepidemiological study on severe respiratory syndrome among different population in taiyuan the authors declare no conflict of interest. key: cord-278870-pct184oa authors: finell, eerika; vainio, annukka title: the combined effect of perceived covid-19 infection risk at work and identification with work community on psychosocial wellbeing among finnish social sector and health care workers date: 2020-10-19 journal: int j environ res public health doi: 10.3390/ijerph17207623 sha: doc_id: 278870 cord_uid: pct184oa it has been well documented that both risk perception and group identification are related to psychosocial well-being. however, their combined effect has rarely been analyzed. we examined the combined effect of perceived risk associated with covid-19 infection at work and work community identification on psychosocial well-being (i.e., frequency of stress symptoms) among health care and social sector workers in finland (n = 1279). data were collected via an online questionnaire in june 2020 and analyses of covariance were conducted. perceived covid-19 infection risk at work was classified into high, medium and low risk. in total, 41% of participants reported a high risk. after all background variables were included, participants who reported high perceived infection risk and low work community identification reported stress symptoms more often than those who reported high perceived risk and high identification (p = 0.010). similarly, the former differed significantly from all other comparison groups (medium and low risk, p < 0.001), being the most stressed. we found that perceived infection risk and work community identification were not related to each other. our conclusion is that high work community identification can buffer employee stress when faced with a high perceived health risk. in the context of the covid-19 pandemic, work organizations with a high infection risk should advance the possibility of employees’ identification with their work community. a new coronavirus disease, caused by the sars-cov-2 virus and identified as covid-19, was first acknowledged in china in 2019 and rapidly became a global threat to the health of many employees working in the social and health care sectors. there is evidence that covid-19 has a disproportional impact on health care workers both physically and psychologically, causing a high incidence of disease, death, and a number of psychological problems, including stress, depression and anxiety [1] [2] [3] [4] . although psychological symptoms have been found to be particularly high among those working on the frontline during the pandemic [5] [6] [7] [8] , non-frontline heath care workers have also reported such symptoms [9] . moreover, these symptoms have been more severe among females and younger workers [4, 10, 11] , as well as for those with prior mental health problems [12, 13] . in addition to these cases, social sector workers, who have seldom been acknowledged in the recent covid-19 literature, have also faced risk of infection in their work [14] . for example, in england and wales, social care workers had a significantly raised rate of death between march and may 2020 [2] . it is clear that covid-19 is causing psychological stress to social sector and health care workers due to the increased risk of personnel infection, fear of spreading the disease, concern for one's own family if one becomes sick [3] , lack of knowledge on the disease as well as deaths among other professionals [15] . on the one hand, perceived health risk is important in order to motivate individuals to engage in health-protective behaviors [16] . on the other hand, the perceived risk is associated with increased stress symptoms, in particular when the management of the risk is at least partly beyond one's own behavioral control [17, 18] . among health care and social sector workers, the perceived infection risk is dependent on the protective measures taken by organizational infrastructures and governments. accordingly, confidence in protective measures has been found to be associated with reduced psychological symptoms [13, 19, 20] . various protective strategies against covid-19-related occupational stress and its negative effects have been considered, ranging from resilience enhancement to providing adequate organizational support systems [12] [13] [14] . curiously, in the context of social sector and health care workers, the role of organizational group processes has rarely been discussed. according to the "social cure" perspective to social identity, group membership has a positive impact on well-being and health [21] -an association shown to be prevalent among medical service workers [22] . groups can provide powerful psychological resources to their members, such as social support, which can reduce stress symptoms [23] [24] [25] . for example, people who identify with a group perceive other group members' social support more positively than people who do not. in addition, those reporting high levels of work community identification are more confident of receiving support from other group members when needed than those less inclined to identify [23, 25] . thus, when occupational organizations consider protective strategies against stress that is related to covid-19 infection risk at work among social sector and health care workers, promoting identification with their work community might be one key protective factor that can buffer this stress. this article analyses the combined effect of the perceived risk associated with covid-19 infection at work with work community identification on psychosocial well-being (i.e., frequency of stress symptoms) among health care and social sector workers in finland. we analyze both groups because in finland, social sector and health care workers often work in the same organizations and institutions as part of multi-professional teams. to our knowledge, the buffering effect of group identification on the relationship between perceived health risk and stress symptoms has yet to be empirically tested. drawing on the "social cure" perspective [25] , we test our main hypothesis that those social sector and health care workers who report both a high perceived covid-19 infection risk at work and low work community identification suffer significantly more often from stress symptoms than those who report high perceived covid-19 infection risk and high work community identification. the data were collected through the union of health and social care professionals in finland, which distributed the invitation and the link to an online questionnaire to its members. in total, 1555 members filled in and submitted the online questionnaire, with a response rate of 5%. in the first page, participants were informed about the aim of the research and had the opportunity to scroll through the form before answering questions; participants were not obliged to respond to any of the items, ensuring full voluntarism could be guaranteed, and informed consent was positively required. only participants who provided informed consent, were in paid or salaried employment, and were 18-64 years old were included. the final sample included 1279 participants. the data were collected between 28 may and 16 june 2020 using the limesurvey program. the ethics committee of the tampere region approved this study (41/2020). the outcome measure was self-reported stress symptoms (i.e., stress symptoms) measured by four items: "during last two months, how frequently you have suffered from": (a) fatigue, apathy or lack of energy; (b) difficulties in falling asleep or recurrent awakenings at night; (c) tenseness, nervousness or irritability; (d) feeling that it is "all just too much"? these items were drawn from the finnish quality of work life survey [26] and have often been used as indicators of stress and mental exhaustion [27, 28] . in these analyses, the items were measured on a five-point scale, with the number selected corresponding to the frequency of symptoms experienced: 0 = never, 1 = less often, 2 = once or twice a month, 3 = a few times a week, and 4 = almost daily. the items were summed and then divided by the total number of items the participants responded to. the rate was calculated if at least two items were answered. the reliability was good (cronbach's alpha = 0.84). the perceived risk associated with covid-19 at work (i.e., perceived risk at work) was measured by one item: how likely do you consider the following things will happen in relation to your work in six months: i will have covid-19 infection in my workplace. a similar item has been used elsewhere [29] . see also [30] . the response scale varied from "very likely" (1) to "very unlikely" (5) . responses reporting that the risk had already materialized (n = 6), as well as those who reported that the question did not apply to them (n = 82), were coded as missing values. the item was recategorized with 0 corresponding to the risk is unlikely (values 4 and 5 in the original scale), 1 corresponding to the risk is intermediate (value 3 in the original scale) and 2 corresponding to the risk is likely (values 1 and 2 in the original scale). the work community identification was measured by two items adapted by doosje et al. ("i feel strong ties with other members of my work community", "my work community is an important part of me") [31, 32] . the five response options varied between 'totally disagree' (1) and 'totally agree' (7) . the items were summed and divided by the number of items (mean = 5.11, standard deviation (sd) = 1.43). the rate was calculated if at least one item was answered. responses reporting that the question did not apply to them (n = 18) were coded as missing values. the reliability was good (cronbach alpha = 0.88). then, the summed variable was recategorized into two categories, using the mean as a cut-off value (0 = low identification; 1 = high identification). finally, we formed one new combined variable. we combined perceived risk at work and work community identification as follows: 1 = low risk and high identification, 2 = low risk and low identification, 3 = medium risk and high identification, 4 = medium risk and low identification, 5 = high risk and high identification, and 6 = high risk and low identification. the background variables were gender, age, number of people living in the household, highest level of education, occupational group, working time pattern (e.g., two-shift work, three-shift work) and whether the participant belonged to a covid-19 infection risk group. the working time pattern was controlled because shift work is associated with insomnia [33] . the occupational group was determined through the following response options: 0 = social sector work and 1 = health care work. if requested, participants had the possibility to report another occupational group. in total, 11 participants reported that they worked both in social sector and health care work. due to the small frequency of this latter category, it was not included in the analysis and was coded as a missing value [34] . a further 9 participants reported that they worked in the education sector. these participants were categorized alongside those who worked in the social sector (0 = social sector work, 1 = health care work). in addition, we controlled the perceived risk associated with covid-19 in one's spare time (i.e., perceived risk in spare time): how likely do you consider the following thing will happen in your spare time in next six months: i will have covid-19 infection in my spare time. the response scale varied from very likely (1) to very unlikely (5) . the item was recategorized as the perceived risk at work, as explained above. responses reporting that the risk had already materialized (n = 6) were coded as missing values. finally, we assessed trust in the finnish authorities by a single item: i trust the finnish authorities in their treatment of the coronavirus pandemic. the response scale varied from totally agree (1) to totally disagree (5). the effects of all the variables on perceived risk at work and work community identification were examined using cross-tabulations and analyses of variance. the effects of all the variables on stress symptoms were examined using analyses of variance and pearson correlation coefficients. the main and combined effects of perceived risk at work and work community identification on stress symptoms were subjected to an analysis of covariance (ancova). this analysis was carried out using ibm spss statistics for windows, version 25.0. (ibm corp., armonk, ny, usa) the missing data were handled by using listwise deletion. the percentage of missing data varied from 0% (age) to 10% (perceived risk in spare time). the mean of the missing values was 2% per variable. the majority of the participants were women, aged between 35 and 44 years, and had tertiary education. table 1 presents the frequencies and means of all the variables, as well as their associations with the predictors and the outcome variable. in total, 41% of participants reported a high risk of covid-19 infection at work. perceived risk at work was significantly associated with all background variables with the exception of gender, highest education, occupational group, and belonging to a covid-19 risk group (see table 1 ). the risk perception decreased with age, so that whilst 67% of the youngest age group reported a high risk, only 32% of those in the age group 55-64 reported the same. those who reported medium risk lived in significantly bigger households (mean = 3.20, sd = 1.36) than those who reported low (mean = 2.92, sd = 1.30) or high risk (mean = 3.01, sd = 1.36). a higher percentage of those who had two-shift work (48%), three-shift work (46%) or who worked atypical hours (49%) reported a higher covid-19 infection at work than those who had regular day (36%) or evening/night work (23%). in addition, 18% of participants who reported high perceived risk at work also reported high perceived risk in their spare time, whereas the percentage among medium-and low-risk groups was 8% and 7%, respectively. finally, those who reported high risk had significantly less trust in the finnish authorities to effectively manage the coronavirus pandemic (mean = 2.44, sd = 1.05) than those who reported low (mean = 2.18, sd = 1.07) or medium risk (mean = 2.28, sd = 0.90). there was no significant association found between perceived risk and work identification. from the background variables, the work community identification was only significantly associated with working time patterns and having trust in the finnish authorities (see table 1 ). those who had three-shift work, or worked atypical hours, reported higher work identification (56% and 68%, respectively) than those in two-shift work (50%), regular day work (48%), or regular evening or night work (21%). finally, those with low work identification had less trust in the finnish authorities to manage the pandemic (mean = 2.45, sd = 1.04) than those with high identification (mean = 2.22, sd = 0.96). stress symptoms were significantly associated with all the background variables except the number of people living in the household, occupational group, working time pattern and perceived risk in spare time (see table 1 ). women reported stress symptoms (mean = 2.29, sd = 0.93) more often than men (mean = 2.01, sd = 0.96), participants from the age group 25-34 reported symptoms the most often (mean = 2.52, sd = 0.87) and their stress level differed significantly from all the others except those in the 18-24 age group. similarly, those who had secondary education reported these symptoms more often (mean = 2.42, sd = 0.93) than those with tertiary education (mean = 2.24, sd = 0.94). in addition, participants who belonged to a covid-19 risk group reported stress symptoms more often (mean = 2.42, sd = 0.97) than those who did not (mean = 2.22, sd = 0.93). finally, the lower the level of trust participants reported in the finnish authorities to manage the coronavirus pandemic, the greater the propensity to report stress symptoms. both predictors were significantly associated with stress symptoms (see table 1 ). participants who perceived a high risk of covid-19 infection in their workplace reported stress symptoms more often than those who perceived only a medium or low risk. this association was still significant after all the background variables were included in the model (f(2, 1001) = 30.84, p < 0.001, ηp 2 = 0.06). estimated marginal means and standard errors of unadjusted and adjusted models are reported in table 2 below. similarly, participants with low work identification reported stress symptoms more often than those with high work identification. once again, this association was still significant after all the background variables were included in the model (f(1, 1018) = 13.87, p < 0.001, ηp 2 = 0.01). estimated marginal means and standard errors of unadjusted and adjusted models are reported in table 3 . in light of these results, we examined the combined effect of perceived risk at work and work community identification on stress symptoms. the estimated marginal means, standard errors and pairwise comparisons of unadjusted and adjusted models are reported in table 4 . in the unadjusted model, the combined effect was significantly associated with stress symptoms (f(5, 1178) = 22.01, p < 0.001, ηp 2 = 0.09). participants who reported high perceived risk and low work identification reported stress symptoms with significantly greater frequency than those who reported high perceived risk and high identification. all the mean differences between this category and other combined categories were significant. after inserting all the background variables into the model, the combined effect was still significantly associated with stress symptoms (f(5, 997) = 15.25, p < 0.001, ηp 2 = 0.07). similarly, the means of participants who reported both high risk and low work identification still differed significantly from all the other categories. there were no statistically significant interactions between perceived risk and work identification in the unadjusted (f(2, 1178) = 0.43, p = 0.650) or fully adjusted models (f(2, 986) = 0.49, p = 0.611). 1.75 0.07 1 < 2 ** ,a , 1 < 3 ***, 1 < 4 ***, 1 < 5 ***, 1 < 6 *** 2. low risk + low identification 121 2.07 0.08 2 > 1 ** ,a , 2 < 4 * ,b , 2 < 5 ***, 2 < 6 *** 3. medium risk + high identification 206 2.13 0.06 3 > 1 ***, 3 < 4 * ,c , 3 < 5 ***, 3 < 6 *** 4. medium risk + low identification 211 2.33 0.06 4 > 1 ***, 4 > 2 * ,b , 4 > 3 * ,c , 4 < 6 *** 5. high risk + high identification 249 2.43 0.06 5 > 1 ***, 5 > 2 ***, 5 > 3 ***, 5 < 6 * ,d 6. high risk + low identification 241 2.63 0.06 6 > 1 ***, 6 > 2 ***, 6 > 3 ***, 6 < 4 ***, 6 < 5 * ,d 1. low risk + high identification 150 1.80 0.07 1 < 2 ** ,e , 1 < 3 ***, 1 < 4 ***, 1 < 5 ***, 1 < 6 *** 2. low risk + low identification 117 2.08 0.08 2 > 1 ** ,e , 2 < 4 * ,f , 2 < 5 ** ,g , 2 < 6 *** 3. medium risk + high identification 199 2.14 0.06 3 > 1 ***, 3 < 4 * ,h , 3 < 5 ** ,i , 3 < 6 *** 4. medium risk + low identification 204 2.32 0.06 4 > 1 ***, 4 > 2 * ,f , 4 > 3 * ,h , 4 < 6 ** ,g 5. high risk + high identification 236 2.41 0.06 5 > 1 ***, 5 > 2 ** ,g , 5 > 3 ** ,i , 5 < 6 * ,j 6. high risk + low identification 235 2.62 0.06 6 > 1 ***, 6 > 2 ***, 6 > 3 ***, 6 < 4 ** ,g , 6 < 5 * ,j 1. low risk + high identification 148 1.79 0.09 1 < 2 ** ,k , 1 < 3 ***, 1 < 4 ***, 1 < 5 ***, 1 < 6 *** 2. low risk + low identification 116 2.09 0.10 2 > 1 ** ,k , 2 < 4 * ,l , 2 < 5 ** ,g , 2 < 6 *** 3. medium risk + high identification 198 2.15 0.08 3 > 1 ***, 3 < 5 ** ,i , 3 < 6 *** 4. medium risk + low identification 199 2.32 0.08 4 > 1 ***, 4 > 2 * ,l , 4 < 6 *** 5. high risk + high identification 236 2.41 0.08 5 > 1 ***, 5 > 2 ** ,g , 5 > 3 ** ,i , 5 < 6 * ,b 6. high risk + low identification 230 2.63 0.08 6 > 1 ***, 6 > 2 ***, 6 > 3 ***, 6 < 4 ***, 6 < 5 * ,b 1. low risk + high identification 133 1.82 0.10 1 < 2 * ,m , 1 < 3 ** ,i , 1 < 4 ***, 1 < 5 ***, 1 < 6 *** 2. low risk + low identification 106 2.09 0.11 2 > 1 * ,m , 2 < 5 ** ,n , 2 < 6 *** 3. medium risk + high identification 172 2.14 0.09 3 > 1 ** ,i , 3 < 5 ** ,a , 3 < 6 *** 4. medium risk + low identification 178 2.27 0.09 4 > 1 ***, 4 < 6 *** 5. high risk + high identification 219 2.40 0.09 5 > 1 ***, 5 > 2 ** ,n , 5 > 3 ** a , 5 < 6 * ,b 6. high risk + low identification 207 2.63 0.09 6 > 1 ***, 6 > 2 ***, 6 > 3 ***, 6 < 4 ***, 6 < 5 * our results support the hypothesis that those with low work community identification and high perceived covid-19 infection risk at work show greater frequencies of stress symptoms than those with high identification and high perceived infection risk. the former group differed significantly from all other comparison groups in reporting the most stress symptoms. in addition, participants who reported high work community identification and low perceived covid-19 infection risk at work reported significantly fewer stress symptoms than any other group. finally, participants who reported a medium infection risk and low identification only showed significant differences from those who reported either high risk and low identification or no stressors at all (e.g., no risk and high identification). these findings show that higher levels of work community identification may act as a buffer against stress factors in the field of social sector and health care work, especially when employees perceive a high health risk in their workplace. as the social cure model argues, group identification is an important source of security, support and belonging and its effect on well-being has been demonstrated in many studies [25] . to our knowledge, however, this is the first study which has demonstrated this relationship in the context of the covid-19 pandemic and risk perception. our results contribute to the extant literature in a number of other ways. first, the findings lend support to previous analyses reporting a link between risk perceptions and stress [17, 18] by showing a strong relationship between higher perceptions of covid-19 infection risk in the workplace and the increased frequency of stress symptoms. secondly, work community identification and stress symptoms were also related. participants reporting low levels of work community identification also reported stress symptoms more often than those reporting high levels of work community identification. this also supports findings that have been found before, albeit in a different context [35] . in contrast, work community identification and covid-19 infection risk at work were not significantly associated with each other. this contradicts previous research suggesting that the greater the identification with a group, the lower the perceived risk is likely to be [36, 37] . this claim was predicated on the basis that group identification increases trust. although it is likely that this occurs in particular contexts (e.g., family celebrations) [38] , this is unlikely to be the case in all circumstances. one important factor that might explain this inconsistency is the degree to which people are able to control their risk. in our cases, social sector and health care workers rarely have sufficient control over the risk factors, or necessary resources, that are able to make meaningful reductions to their perceived risk (e.g., proximity to infection; having enough personal protective equipment). thus, people can report high levels of work community identification, and exhibit high levels of trust, but if the loci of risk controls are out of reach of the community, then group identification is unlikely to relate positively to perceptions of risk. this opens an important avenue for future research, namely, to explore in greater detail, and in more diverse contexts, how levels of control over risk-management resources affect the relationships between group identification and risk perception. finally, empirical research that has analyzed the well-being of social sector workers during covid-19 pandemic is rare [14] . our social sector and health care workers did not significantly differ in risk perception, work community identification or frequencies of stress symptoms. these occupational groups often work in the same organizations and institutions as part of multi-professional teams and thus share the same covid-19 risk. more research analyzing the well-being of social sector workers is needed in the context of covid-19. our results have strong practical implications. the findings can make a valuable contribution to the development of strategies for social sector and health care professionals to maintain their well-being under stressful working conditions during the covid-19 pandemic. given that risk perception and stress are mutually related [17, 18] , their interplay may produce a vicious circle which can end up in exhaustion and burn out. the social cure approach suggests that developing greater group identity is a powerful psychological resource in a such context [25] . our results highlight the role of work community identification in contributing to social sector and health care workers' ability to cope with stressors that cannot be avoided at work. for example, employers can strengthen the sense of community in their organizations by providing opportunities to share experiences within the group in a safe way and develop mutual trust as well as by recognizing and acknowledging the powerful role of collective strategies that the work community has successfully used in the past and adapting them to current environment [22] . naturally, our findings have their limitations. the data are cross-sectional; thus, our reasoning is strongly based on previous research and theories. in addition, although our sample was representative of members of the union of health and social care professionals in finland, the response rate was lower than we would have preferred, and it is possible that those with higher levels of concern about their work condition had a greater motivation to answer than those who perceived that their work conditions were risk free or of low risk. these factors limit the generalizability of the results. in addition, the effect size was quite small. although work community identification may act as a buffer, practical factors such as having enough personal protective equipment are of course essential for controlling the stress caused by covid-19 infection risk. cross-cultural, longitudinal and experimental data are needed to confirm the findings. our findings have shown that participants who report low work community identification and high perceived covid-19 infection risk at work were significantly more stressed than other participants. this finding indicates that the combined effect of work community identification and risk perception needs to be considered in efforts to reduce the psychological stress social sector and health care workers face during the covid-19 pandemic. our findings provide further support to the notion that group processes are essential to people's psychosocial well-being and that this is especially salient in times of health crises. covid-19 and mental health: a review of the existing literature office for national statistics. coronavirus (covid-19) related deaths by occupation, england and wales: deaths registered between 9 the covid-19 pandemic and the health care providers; what does it 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volunteers: a cross-sectional investigation taking the strain: social identity, social support, and the experience of stress the effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (covid-19) in january and february 2020 in china the new psychology of health: unlocking the social cure three decades of working conditions. findings of finnish quality of work life surveys psychiatric illness in general practice: a detailed study using a new method of case identification validity of a single-item measure of stress symptoms covid-19: risk perception and coping strategies risk perceptions of covid-19 around the world perceived intragroup variability as a function of group status and identification guilty by association: when one's group has a negative history individual vulnerability to insomnia, excessive sleepiness and shift work disorder amongst healthcare shift workers. a systematic review the chi-square test of independence analytic review of social identification and health in organizational contexts when trust goes wrong: a social identity model of risk taking the psychology of health and well-being in mass gatherings: a review and a research agenda a social identity perspective on covid-19: health risk is affected by shared group membership we want to thank the union of health and social care professionals for the data collection. the authors declare no conflict of interest. key: cord-264560-hxvadp24 authors: liu, jui-yao; chen, tzeng-ji; hwang, shinn-jang title: analysis of imported cases of covid-19 in taiwan: a nationwide study date: 2020-05-09 journal: int j environ res public health doi: 10.3390/ijerph17093311 sha: doc_id: 264560 cord_uid: hxvadp24 in the early stages of the 2019 novel coronavirus disease (covid-19) pandemic, containment of disease importation from epidemic areas was essential for outbreak control. this study is based on publicly accessible data on confirmed covid-19 cases in taiwan extracted from the taiwan centers for disease control website. we analysed the characteristics, infection source, symptom presentation, and route of identification of the 321 imported cases that were identified from 21 january to 6 april 2020. they were mostly returned taiwanese citizens who had travelled to one or more of 37 countries for tourism, business, work, or study. half of these cases developed symptoms before arrival, most of the remainder developed symptoms 1–13 days (mean 4.0 days) after arrival, and 3.4% never developed symptoms. three-quarters of the cases had respiratory symptoms, 44.9% had fever, 13.1% lost smell or taste, and 7.2% had diarrhoea. body temperature and symptom screening at airports identified 32.7% of the cases. of the remainder, 27.7% were identified during home quarantining, 16.2% were identified via contact tracing, and 23.4% were reported by hospitals. under the strict enforcement of these measures, the incidence of locally acquired covid-19 cases in taiwan remains sporadic. in conclusion, proactive border control measures are effective for preventing community transmission of this disease. the 2019 novel coronavirus disease (covid-19) caused by severe acute respiratory syndrome (sars) coronavirus 2 (sars-cov-2) that emerged in wuhan, china in december 2019 was declared a global pandemic on 11 march 2020 by the world health organization [1] . as of 29 april 2020, the disease has spread to 185 countries, with 3,114,659 confirmed cases and 216,989 deaths [2] . the case fatality rate is about 6.9% globally, but mortality in elderly patients with comorbidities is higher [3] [4] [5] . under the current circumstances, in which there is no vaccine available for prevention and no effective antiviral drug for treatment, almost all people in the world are susceptible to this novel person-to-person transmitted disease [5] . the complexity and high volume of international air travel has allowed the disease to spread rapidly [6] [7] [8] . in the early stages of this pandemic, containment of disease importation from epidemic areas was essential for preventing indigenous outbreaks [9] . without adequate control measures, persistent and imperceptible virus importation via air travellers may cause large-scale community transmission. this could lead to an outbreak that may exceed the capacity of the healthcare system with disastrous results [10] . the taiwanese authorities have made efforts to contain the importation of the disease by issuing travel advisories and implementing flight bans, entry restrictions, airport screening, home quarantining of travellers from high-risk areas, isolation of confirmed cases, and thorough contact tracing [11] [12] [13] . the taiwan centers for disease control (cdc) established fever screening sites with infrared thermal imaging cameras in international airports in 2003 following the sars outbreak of that year. during the covid-19 outbreak, they have been performing airport screening at these fever screening sites. travellers entering taiwan with fever or respiratory symptoms must have oropharyngeal specimens collected for covid-19 testing and are subject to home quarantining for 14 days, as are travellers from areas where the disease is epidemic. people in home quarantine must stay at home (or at another designated location) and not go out, and they must maintain a distance of at least one metre from their family, record body temperature and health status every day, and cooperate with tracking measures implemented by their local borough chief. individuals who develop symptoms such as fever, coughing, or runny nose while in home quarantine are sent to designated medical facilities for covid-19 testing. when covid-19 cases are confirmed, they are immediately hospitalized in negative pressure isolation rooms, and taiwan cdc personnel conduct investigations within 24 h to identify their contacts. any contacts who have covid-19-related symptoms are hospitalized for testing. contacts who do not show symptoms or who test negative for covid-19 are placed in home isolation for 14 days for further follow-up and testing. people in home isolation must stay at home (or other designated location) and not go out, similarly to those in home quarantines. the local health authority checks their health status twice daily, and symptomatic individuals are sent to hospital for medical attention and covid-19 testing. the approach of the taiwanese authorities appears to have been successful in the outbreak control, it is nevertheless important to understand the characteristics of the imported cases of the disease to know how it works. the aim of this study is to analyse the imported cases of covid-19 in taiwan to assess their basic demographic characteristics, disease source, symptom presentation, and routes of identification. open-access data and press releases concerning covid-19 in taiwan that were available on the website of the taiwan cdc were collected [14] . the press releases, which included attached files, provided detailed information about the confirmed covid-19 cases in taiwan, including their category (imported or locally acquired), citizenship, sex, age group, travel history, date of arrival, reason for travel, date of disease onset, date of specimen collection for covid-19 testing, date of disease confirmation, and route of identification. the taiwan cdc listed covid-19 as a notifiable disease on 15 january 2020. this meant that hospitals and clinics had to notify the health authorities if patients were diagnosed with covid-19 and provide their travel details, contact histories and clinical presentation, as well as send specimens (throat swab and sputum) to the taiwan cdc for confirmation via reverse transcription polymerase chain reaction (rt-pcr). the date of disease onset was defined as the date of symptom onset. the countries or areas the imported cases had visited within 14 days prior to disease onset were defined as the source of their infection. all imported covid-19 cases confirmed in taiwan from 21 january to 6 april 2020 were included in this study. descriptive statistics and plots of age group, sex, infection source, days from arrival to symptom onset, days from arrival to disease confirmation, and routes of identification were performed using pasw statistics 18 (spss, chicago, il, usa). one-way analysis of variance (anova) was used to compare effective reproduction number (r) and mean number of days from arrival to disease confirmation between routes of identification, using bonferroni post hoc tests and 95% confidence intervals (ci). the case fatality rate of the imported cases was compared with that of the locally acquired cases using a chi-squared test. a two-tailed p-value of < 0.05 was considered statistically significant. there was a cumulative total of 373 confirmed cases of covid-19 in taiwan from 21 january to 6 april 2020, 321 (86.1%) of which were imported. of the imported cases, 96.6% were taiwanese and 53.0% were female. their age range was 4-88 years; young people occupied a large proportion. of them, 37.4% were in age group of 20-29 years, 23.7% were in age group of 30-39 years ( figure 1 acquired cases using a chi-squared test. a two-tailed p-value of < 0.05 was considered statisticall significant. there was a cumulative total of 373 confirmed cases of covid-19 in taiwan from 21 january t 6 april 2020, 321 (86.1%) of which were imported. of the imported cases, 96.6% were taiwanese an 53.0% were female. their age range was 4-88 years; young people occupied a large proportion. o them, 37.4% were in age group of 20-29 years, 23.7% were in age group of 30-39 years ( figure 1 ). th main reasons for travel were tourism (104, 32.4%), business or work (88, 27.4%), study (85, 26.5% family visit (17, 5.3%), or residency (11, 3.4%) ( table 1 ). the first 11 confirmed imported cases were all from wuhan, china. the other imported cases were from east and south asia (8.4%), the middle east and africa (11.0%), europe (51.0%), north america (26.8%), south america (1.9%), and oceania (1.3%) ( figure 2 ). of the cases aged 10-19 and 20-29 years, 76.5% and 53.3%, respectively, were studying abroad. they returned home because their educational institutions were closed in response to the outbreak. there were some instances of several cases who were studying at the same college in the united kingdom or spain, where clusters of infections occurred on campus. there were also several clusters of cases from tour groups that were travelling in egypt, turkey, or europe. an aeroplane that flew from new york to taipei on 30 march 2020 carried 12 passengers who were subsequently confirmed to be infected with covid-19. only 44.9% of the cases had fever. a large majority (73%) of the cases had respiratory symptoms, comprising cough (45.5%), sore throat (31.2%), rhinorrhoea or nasal stuffiness (29.9%), chest tightness or pain (5.6%), and dyspnea (3.4%). some cases had flu-like symptoms, such as malaise (16.2%), myalgia or arthralgia (12.5%), or headache (10.6%). a proportion of the cases (13%) had the neurological symptoms of loss of smell or taste. few of the cases (8%) had gastrointestinal symptoms, specifically diarrhoea (7.2%), nausea or vomiting (0.9%), and abdominal pain (0.9%), and even fewer (2%) had ophthalmic symptoms such as itching, congestion, or pain in the eyes. eleven cases (3.4%) did not have any symptoms (table 2) . about half (50.5%) of the imported cases had developed symptoms before arrival (mean 5.4 days, range 0-30 days before arrival) ( figure 3 ). of the cases who did not display symptoms on arrival, most (93.1%) developed symptoms 1-13 days after arrival (mean 4.0 days, median three days) ( figure 3 ). eleven of the imported cases did not develop any symptoms; these were identified via contact testing. only 44.9% of the cases had fever. a large majority (73%) of the cases had respiratory symptoms, comprising cough (45.5%), sore throat (31.2%), rhinorrhoea or nasal stuffiness (29.9%), chest tightness or pain (5.6%), and dyspnea (3.4%). some cases had flu-like symptoms, such as malaise (16.2%), myalgia or arthralgia (12.5%), or headache (10.6%). a proportion of the cases (13%) had the neurological symptoms of loss of smell or taste. few of the cases (8%) had gastrointestinal symptoms, specifically diarrhoea (7.2%), nausea or vomiting (0.9%), and abdominal pain (0.9%), and even fewer (2%) had ophthalmic symptoms such as itching, congestion, or pain in the eyes. eleven cases (3.4%) did not have any symptoms (table 2) . about half (50.5%) of the imported cases had developed symptoms before arrival (mean 5.4 days, range 0-30 days before arrival) (figure 3 ). of the cases who did not display symptoms on arrival, most (93.1%) developed symptoms 1-13 days after arrival (mean 4.0 days, median three days) ( figure 3) . eleven of the imported cases did not develop any symptoms; these were identified via contact testing. of the imported cases, 32.7% were identified in airport screening, 27.7% during home quarantine, 16.2% through contact tracing, and 23.4% sought medical attention themselves and were reported by the hospitals (table 3) . almost two-thirds (64.8%) of the cases who had developed symptoms before arrival were identified in airport screening. of the cases who were asymptomatic on arrival, 39.6% were identified during home quarantine, 28.3% were identified through contact tracing, and 32.1% were reported by hospitals (figure 4) . table 3 . reproduction number (r) and time from arrival to disease confirmation of the 321 imported covid-19 cases in taiwan from 21 january to 6 april 2020, stratified by route of identification. of the imported cases, 32.7% were identified in airport screening, 27.7% during home quarantine, 16.2% through contact tracing, and 23.4% sought medical attention themselves and were reported by the hospitals (table 3 ). almost two-thirds (64.8%) of the cases who had developed symptoms before arrival were identified in airport screening. of the cases who were asymptomatic on arrival, 39.6% were identified during home quarantine, 28.3% were identified through contact tracing, and 32.1% were reported by hospitals (figure 4 ). the number of imported cases increased dramatically after 11 march 2020, when covid-19 was declared a global pandemic ( figure 5 ). the mandatory 14-day home quarantine was extended to all travellers from all countries on 19 march 2020. this measure kept all travellers from high-risk areas confined to their homes under close monitoring, and prevented them from moving around in their communities. after implementation of this measure, most of the imported cases were contained in the number of imported cases increased dramatically after 11 march 2020, when covid-19 was declared a global pandemic ( figure 5 ). the mandatory 14-day home quarantine was extended to all travellers from all countries on 19 march 2020. this measure kept all travellers from high-risk areas confined to their homes under close monitoring, and prevented them from moving around in their communities. after implementation of this measure, most of the imported cases were contained in home quarantine or home isolation before they were identified ( figure 5 ). the time from arrival to disease confirmation of the imported cases was 1-28 days (mean 6.3 days) ( figure 6 ). few of the cases identified during home quarantining had longer than 14 days of time from arrival to disease confirmation because they delayed reporting their symptoms or had borderline covid-19 test results, which necessitated repeat sampling and testing for confirmation. the cases identified through airport screening had the shortest time from arrival to disease confirmation (mean 2.6 days, 95% ci: 2.4-2.7 days, p < 0.01) as compared to cases identified via the other routes (table 3 ). the time from symptom onset to disease confirmation was 1-32 days (mean 7.0 days). the time from arrival to disease confirmation of the imported cases was 1-28 days (mean 6.3 days) ( figure 6 ). few of the cases identified during home quarantining had longer than 14 days of time from arrival to disease confirmation because they delayed reporting their symptoms or had borderline covid-19 test results, which necessitated repeat sampling and testing for confirmation. the cases identified through airport screening had the shortest time from arrival to disease confirmation (mean 2.6 days, 95% ci: 2.4-2.7 days, p < 0.01) as compared to cases identified via the other routes ( table 3) . the time from symptom onset to disease confirmation was 1-32 days (mean 7.0 days). the time from arrival to disease confirmation of the imported cases was 1-28 days (mean 6.3 days) ( figure 6 ). few of the cases identified during home quarantining had longer than 14 days of time from arrival to disease confirmation because they delayed reporting their symptoms or had borderline covid-19 test results, which necessitated repeat sampling and testing for confirmation. the cases identified through airport screening had the shortest time from arrival to disease confirmation (mean 2.6 days, 95% ci: 2.4-2.7 days, p < 0.01) as compared to cases identified via the other routes (table 3 ). the time from symptom onset to disease confirmation was 1-32 days (mean 7.0 days). figure 6 . time from arrival to disease confirmation for imported covid-19 cases in taiwan from 21 january to 6 april 2020. the incidence of locally acquired covid-19 cases remains sporadic although there are hundreds of imported covid-19 cases in taiwan (figure 7) . nineteen of the 52 (36.5%) locally acquired cases were infected by 16 of the 321 imported cases, yielding an r of 0.06 for all imported cases and 1.2 for the 16 imported cases. these were family, friends, colleagues, and classmates of the imported cases. no locally acquired cases were infected by the cases who were identified via airport screening. the r was significantly related to the route of identification (p < 0.05; table 3 ). that of the cases identified via contact tracing was significantly higher than that of the cases identified through airport screening (0.15 versus 0, p < 0.05; table 3 ). three of the 321 imported cases and three of the 52 locally acquired cases had died. the case fatality rate of the imported cases was significantly lower than that of the locally acquired cases (0.9% versus 5.8%, p = 0.01). the incidence of locally acquired covid-19 cases remains sporadic although there are hundreds of imported covid-19 cases in taiwan (figure 7) . nineteen of the 52 (36.5%) locally acquired cases were infected by 16 of the 321 imported cases, yielding an r of 0.06 for all imported cases and 1.2 for the 16 imported cases. these were family, friends, colleagues, and classmates of the imported cases. no locally acquired cases were infected by the cases who were identified via airport screening. the r was significantly related to the route of identification (p < 0.05; table 3 ). that of the cases identified via contact tracing was significantly higher than that of the cases identified through airport screening (0.15 versus 0, p < 0.05; table 3 ). three of the 321 imported cases and three of the 52 locally acquired cases had died. the case fatality rate of the imported cases was significantly lower than that of the locally acquired cases (0.9% versus 5.8%, p = 0.01). there were two waves of covid-19 importation in taiwan. the first wave was from china, and was well contained by early preventive measures. the taiwan cdc performed onboard inspection for all direct flights arriving from wuhan since 31 december 2019. over the next few weeks, they gradually expanded the range of restrictions on travel to china and implemented the 14-day home quarantine for travellers from china after wuhan went into lockdown. the second wave of covid-19 importation came from 36 other countries around the world, mainly the united states, the united kingdom, and several other european countries. inspection of the arrival dates of the second wave of imported cases reveals that these arrivals in taiwan were ahead of the timing of covid-19 outbreak in the other countries. the first cases imported from italy arrived on 1 february, when there were only two confirmed cases in italy [2]. these were four members of a taiwanese family that travelled to italy, with a transfer at the airport in hong kong, from 22 january to 1 february. three of the family members developed symptoms of cough or fever during the journey. there may have been many as-yet undiscovered cases of covid-19 in italy at that time. the mandatory 14-day home quarantine was extended to travellers from italy on 27 february, from other european countries on 14 march, from the middle east and africa on 16 march, from east and south asia on 17 march, and finally to travellers from all countries on 19 march. the imported cases identified in home quarantine seemed to have a lower r than those identified via hospital notification or contact tracing (table 3) . however, some individuals in home quarantine did not adhere to the instructions to stay at home, which would have exposed otherwise-unaffected people to the risk of infection [15, 16] . there were two waves of covid-19 importation in taiwan. the first wave was from china, and was well contained by early preventive measures. the taiwan cdc performed onboard inspection for all direct flights arriving from wuhan since 31 december 2019. over the next few weeks, they gradually expanded the range of restrictions on travel to china and implemented the 14-day home quarantine for travellers from china after wuhan went into lockdown. the second wave of covid-19 importation came from 36 other countries around the world, mainly the united states, the united kingdom, and several other european countries. inspection of the arrival dates of the second wave of imported cases reveals that these arrivals in taiwan were ahead of the timing of covid-19 outbreak in the other countries. the first cases imported from italy arrived on 1 february, when there were only two confirmed cases in italy [2]. these were four members of a taiwanese family that travelled to italy, with a transfer at the airport in hong kong, from 22 january to 1 february. three of the family members developed symptoms of cough or fever during the journey. there may have been many as-yet undiscovered cases of covid-19 in italy at that time. the mandatory 14-day home quarantine was extended to travellers from italy on 27 february, from other european countries on 14 march, from the middle east and africa on 16 march, from east and south asia on 17 march, and finally to travellers from all countries on 19 march. the imported cases identified in home quarantine seemed to have a lower r than those identified via hospital notification or contact tracing (table 3) . however, some individuals in home quarantine did not adhere to the instructions to stay at home, which would have exposed otherwise-unaffected people to the risk of infection [15, 16] . airport screening of body temperature and respiratory symptoms was able to detect 32.7% of the imported covid-19 cases and 64.8% of those who had developed symptoms before arrival. the remaining cases who had developed symptoms before arrival evaded detection because they had taken antipyretic drugs, did not honestly declare their symptoms, or their symptoms were mild or not involving the respiratory tract. in fact, travellers with any suspicious symptoms are able to notify the airport health-screening personnel and be tested for covid-19. nevertheless, airport screening is an effective measure to identify symptomatic imported cases soon after their arrival. there was clustering of the imported covid-19 cases among household members, members of the same tour group, passengers on the same aeroplane, and even students from the same overseas campus. the cases identified via contact tracing had a higher r and a longer interval between arrival and disease confirmation than those identified via other routes ( table 3 ). the cases who never developed symptoms were difficult to identify without testing the contacts of confirmed cases. thus, thorough contact tracing and testing is important for interrupting all possible transmission chains [17] . taiwan has several advantages in terms of outbreak control. first, more than 99.9% of the population is enrolled in the national health insurance (nhi) program. individuals with a history of travel and suspicious symptoms have therefore been willing to seek medical attention because the costs of covid-19 testing and treatment are covered by the government. second, the nhi smart card stores information of border entry and exit records and the home quarantine or isolation status of the insured individual, which alerts medical personnel to high-risk patients. third, nhi claim data can provide a list of symptomatic patients who sought medical attention after returning from high-risk countries, which can be used to implement quarantine measures and retrospective contact tracing. most of the covid-19 cases who have moderate to severe disease present with fever [18] , but half of our imported covid-19 cases did not have a fever. body temperature screening at the airport did not detect all cases, and in particular missed those without obvious symptoms. most of our imported cases had mild disease and would have been difficult to identify if their travel and contact history had not been available [19] . in addition to respiratory symptoms, some cases had neurological symptoms, such as loss of smell or taste [20] , or gastrointestinal symptoms like diarrhoea. the clinical presentations of covid-19 involve multi-organ systems not limited to the respiratory tract. some imported cases had long duration of symptoms display before arrival, the longest in this study was 30 days, and still could be tested positive for sars-cov-2 nucleic acid by rt-pcr. prolonged viral shedding [3] , a long transmissibility period, and the fact that asymptomatic or paucisymptomatic patients can transmit this disease make the disease control challenging [21] [22] [23] . proactive border control measures to contain the importation of covid-19 via airport screening, quarantining of travellers from epidemic areas, and thorough contact tracing are effective for preventing community transmission of this disease. under the strict enforcement of these measures, the incidence of locally acquired covid-19 cases in taiwan remains sporadic. world health organization. coronavirus disease (covid-19) pandemic global cases clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for disease control and prevention report of the who-china joint mission on coronavirus disease 2019 (covid-19) pandemic. available online potential for global spread of a novel coronavirus from travellers give wings to novel coronavirus (2019-ncov) impact of international travel and border control measures on the global spread of the novel 2019 coronavirus outbreak the effect of travel restrictions on the spread of the 2019 novel coronavirus (covid-19) outbreak wuhan novel coronavirus (covid-19): why global control is challenging? public health initial rapid and proactive response for the covid-19 outbreak-taiwan's experience response to covid-19 in taiwan: big data analytics, new technology, and proactive testing isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-ncov) outbreak cecc urges people subject to home quarantine/isolation to follow related regulations to protect everyone's health covid-19-the law and limits of quarantine covid-19 epidemic in switzerland: on the importance of testing, contact tracing and isolation epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study coronavirus disease (covid-19) in a paucisymptomatic patient: epidemiological and clinical challenge in settings with limited community transmission a new symptom of covid-19: loss of taste and smell. obes. (silver spring) 2020 clinical characteristics of 24 asymptomatic infections with covid-19 screened among close contacts in nanjing transmission of 2019-ncov infection from an asymptomatic contact in germany a novel coronavirus emerging in china-key questions for impact assessment we would like to thank the taiwan centers for disease control for providing open-access data pertaining to the confirmed covid-19 cases on website. we thank anthony abram for editing and proofreading this manuscript. the authors declare no conflicts of interest. int. j. environ. res. public health 2020, 17, 3311 key: cord-013317-s6ss95h6 authors: gallè, francesca; calella, patrizia; napoli, christian; liguori, fabrizio; parisi, eduardo alfonso; orsi, giovanni battista; liguori, giorgio; valerio, giuliana title: are health literacy and lifestyle of undergraduates related to the educational field? an italian survey date: 2020-09-12 journal: int j environ res public health doi: 10.3390/ijerph17186654 sha: doc_id: 13317 cord_uid: s6ss95h6 background: health literacy (hl) is a fundamental ability to successfully deal with health and illness issues. this study aimed to assess hl among undergraduates from healthcare and non-healthcare degree courses of two italian universities and the association between their hl, lifestyles, and bmi assumed as health outcome. methods: the health literacy assessment tool (hlat-8) and the newest vital sign (nvs) were used to assess health literacy dimensions. demographic and anthropometric data, adherence to mediterranean diet (md), physical activity levels, and smoking habits were assessed in the enrolled sample to highlight possible associations. results: a total sample of 806 undergraduates (46% males, mean age 21.01 ± 1.78 years) was recruited. higher hl scores were found among healthcare rather than non-healthcare students (28.7 ± 4.5 vs. 26.7 ± 4.2 for hlat-8 and 4.9 ± 1.5 vs. 3.9 ± 1.8 for nvs, p < 0.01). however, healthcare undergraduates were more likely to report unhealthy behaviors. body mass index (bmi) was associated with literacy and numeracy skills only in non-healthcare undergraduates. significant associations were found between hl scores and adherence to md in both groups. in the regression analysis, educational field and md were shown to be predictors of hl scores. conclusions: attending a healthcare related degree course was associated with higher hl scores but not with healthy behaviors. this issue should be addressed considering the role that healthcare professionals may have in educating patients towards a healthy lifestyle. adherence to md seems to be related to higher hl scores. health literacy (hl) is defined as the individual's ability to successfully deal with health and illness issues [1, 2] . it is determined by a set of aspects related to knowledge, motivation, and competences fundamental to make judgments and decisions concerning health care, disease prevention, and health promotion [3, 4] . according to nutbeam (2008) , hl includes three levels: a functional literacy, which refers to basic reading and writing skills and to the ability of applying these skills to health-related materials; interactive literacy, which implies more advanced cognitive and social skills in order to obtain and elaborate information from different sources; and, finally, critical literacy, which is needed to critically analyze information and use quality information to make informed decisions about health [5] . in line with these definitions, it is assumed that sufficient hl increases the individuals' ability to access, appraise, and use health-related information adequately, and to make good choices for their own health, while low levels of hl induce the inappropriate access and use of health resources [6, 7] . the hl concept is context-specific: in clinical settings, hl might refer to the personal resources patients need to successfully navigate health services, while, in public health, it might be defined as the set of knowledge and skills needed to prevent disease and to promote health in everyday life [5, 8] . poor hl has been associated with several health outcomes and factors that may impair the functioning of health care systems, such as inadequate access to care, reduced adherence to medication, poorer self-rated health status, higher hospitalization and mortality rates, lack of understanding and use of preventive services, greater use of emergency care, inequity, and increase of health-care costs [9] [10] [11] [12] [13] [14] . based on these considerations, the assessment of hl seems to be fundamental in order to implement effective public health policies and educational interventions in a population [15] [16] [17] [18] [19] [20] [21] [22] . on the basis of the aims pursued, several dimensions of hl can be evaluated: health numeracy represents the skill to use and interpret mathematical calculations for health purposes, such as taking medication as prescribed; health prose literacy is the ability needed to follow written medical instructions; other dimensions concern skills necessary to seek communication and information regarding health [15] . according to the health literacy skills conceptual framework, all these dimensions can influence individuals' health-related behaviors, such as diet and physical activity (pa), which can subsequently influence health outcomes, such as body mass index (bmi), morbidity and mortality [15, 23, 24] . nevertheless, lifestyle and health status may also contribute to learn, unlearn, reinforce or degrade hl skills in a dynamic process [15] . since lifestyle is established in the earlier years of a person's lifespan, developing an adequate hl at an early age is fundamental to adopt those behaviors which characterize a healthy lifestyle-mainly adequate diet, sufficient pa, and no smoking, which can positively affect health in adulthood [25] . indeed, a strong association between hl, high-risk or unhealthy behaviors, and physical health outcomes (e.g., weight status) was found in adolescents, while studies on young adults are still limited [26] [27] [28] . some investigations were performed to evaluate hl among university students attending healthcare related courses in order to improve their core hl curriculum in the perspective of their future role in health education [29] [30] [31] . however, the characterization of hl among undergraduates attending non healthcare-related courses may be also important in order to prevent unhealthy behaviors such as unbalanced diet, inactivity, smoking and alcohol consumption [32] [33] [34] [35] . the hl of graduates must be adequate so that they can guide others in maintaining and improving their health and well-being, and improve the economy of their country; therefore, educational curricula should consider this item [36] . this study aims to: (i) evaluate the levels of hl, in all its dimensions, among undergraduates attending healthcare and non-healthcare related degree courses in two italian universities; (ii) identify possible group differences; (iii) investigate the relationship between undergraduates' hl, health-related behaviors and bmi assumed as health outcome. a cross-sectional study was carried out in 2019 among students from "parthenope" university of naples and "sapienza" university of rome. the investigation was performed anonymously in accordance with the italian regulation on personal data protection and with the world medical association declaration of helsinki. participants provided voluntarily informed written consent to participation. the study was approved by the ethical committee of the university of campania "luigi vanvitelli" (approval number 478/2019). participants were recruited by convenience from healthcare (nursing) and non-healthcare (economics and movement sciences) degree courses. during lessons, a researcher invited the students to participate in the investigation, explaining the aim of the study and guaranteeing the anonymity of data collection and treatment. the questionnaires included a general section regarding demographic characteristics such as gender, age, and degree course. in order to calculate the bmi, participants were also asked to self-report their weight and height values. two previously validated questionnaires were used to investigate diet and pa habits. the first one, proposed by sofi et al. [37] , was employed to explore the adherence to the mediterranean diet (md) model. participants were asked to provide information regarding their usual daily/weekly consumption of eight food groups (fruit, vegetables, legumes, cereals, fish, meat and meat products, dairy products, alcohol, and olive oil). the second one, the international physical activity questionnaire [38] , investigated students' pa levels as vigorous pa (days per week and minutes per day), moderate pa (days per week and minutes per day), walking (days per week and minutes per day), and sedentary lifestyle (average daily time spent sitting). finally, a question concerning tobacco smoking (non-smoker or quitter/smoker) was posed. in order to highlight different issues related to specific hl skills requiring targeted educational interventions [26] , two validated questionnaires were used to assess all the domains of participants' hl: the eight-item health literacy assessment tool (hlat-8) developed by abel et al. [39] and the newest vital sign (nvs), introduced by weiss et al. [40] . the hlat-8 explores hl for public health purposes and includes items specifically aimed at measuring the ability of accessing, understanding, evaluating and communicating health-related information. it assesses hl through eight likert-scale items; a score is attributed to each answer, and the sum of the eight scores indicates the hl level of each respondent. the total score range is 0-37, with higher scores indicating higher levels of hl. the nvs is a quick screening instrument widely used to assess hl by using an ice cream nutrition label that the respondent may hold and review; subsequently, six questions regarding that nutrition label are posed. four or more correct answers indicate adequate hl, while a score ≤3 indicates limited hl. the nvs is a valid tool to measure literacy and numeracy skills; it is short, accurate, and can be employed in settings where time of administration is limited [41] . a descriptive analysis was carried out on demographic characteristics, declared behaviors, and hl levels. continuous outcomes were reported as mean values ± standard deviation (sd); data regarding gender and smoking habit were reported as number and percentages. the number of participants with a hlat-8 score ≥ the 75th percentile value, assumed as an indicator of better literacy, and that of the students reporting an nvs score ≥ to 4, corresponding to an adequate literacy, were also calculated for each group. the comparison between students from healthcare and non-healthcare degrees was performed through the student's t-test for continuous outcomes and chi-squared test for non-continuous outcomes. the cohen's d value was calculated to assess the effect size for these comparisons (small 0.10-0.40, medium 0.50-0.70, large ≥0.80). pearson's and spearman correlations were performed either to analyze the association between the two questionnaires employed to assess hl or the association between hl levels and the lifestyle behaviors. multiple logistic regression analyses were performed to identify the significant predictors of each hl score. the dependent variables were built by considering if reported hl scores were ≥75th percentile for hlat-8 or ≥4 for nvs. age, gender, md score, and total weekly pa (categorized as lower or equal/higher than median value), educational field, and bmi (classified as normal weight or overweight/obese) were considered as independent variables. a value of p < 0.05 was assumed as the significance level. data were analyzed with ibm spss version 26 for windows (spss, chicago, il, usa). overall, 806 out of 3692 (21.8%) total students attending the enrolled degree courses completed the questionnaires: 262 out of 921 (28.4%) nursing students and 544 out of 2771 (19.6%) economics/movement sciences students. the demographic characteristics, the lifestyle outcomes, and the mean hl scores for both the whole sample and the two subgroups are summarized in table 1 . as for the variables related to lifestyle, the group of students from the healthcare related degree course showed a significantly lower mean bmi than the other participants, whereas the other variables indicated that a low adherence to md, inactivity, and smoking habits were more common in this group. in particular, nursing undergraduates reported significantly lower levels of moderate-vigorous pa and higher sitting time. as for the hl levels, the mean hlat-8 and nvs scores as well as the percentages of individuals with better hl scores were significantly higher in nursing students than in other undergraduates. medium effect size values were obtained only for age and nvs score differences between groups. considering the significantly different gender composition of the two groups, the hl levels of healthcare and non-healthcare undergraduates were also compared by gender. significant differences in hl scores from the two educational fields were confirmed in male as well as in female participants (supplementary table s1 ). the results of the correlation analyses are reported in table 2 . the scores from the two hl questionnaires showed several correlations with individual characteristics or lifestyle components in both the whole sample and the two subgroups. bmi appeared to be positively correlated to nvs score in undergraduates from non-healthcare related degrees. md adherence was associated with both hl tools in the total sample and in the two subgroups independently of the questionnaire used, with the only exception of hlat-8 in nursing students. pa resulted in being positively associated with hl only in nursing undergraduates: total pa correlated with hlat-8 questionnaire scores, while moderate-vigorous pa correlated with nvs results. no correlations were found for age, smoking habit and sitting time. the results of the logistic regressions performed considering hl scores as outcomes are shown in table 3 . reporting a higher hl score by either the hlat-8 questionnaire or the nvs was significantly associated to the attendance of a healthcare related degree course and to a higher md adherence. no significant associations were found with age, gender, bmi, or pa. this study evaluated the levels of hl among italian undergraduates, comparing results between healthcare and non-healthcare students. we also examined the relationship between hl, lifestyle, and bmi. our findings show that attending a healthcare related degree course was associated with higher hl levels. the adherence to the mediterranean diet model seems to be also related to better hl skills. as indicated by nvs score, 68.8% of the whole sample showed adequate literacy and numeracy, while the communication and information skills evaluated through the hlat-8 questionnaire were above average, with significantly higher levels found in nursing students. since its definition, several studies were carried out worldwide to estimate the hl levels of different populations and in different settings [16] [17] [18] [19] [20] [21] [22] . in the united states, the 2003 national assessment of adult literacy reported a 36% rate for low hl in a sample of 14,592 respondent adults [18] , while more than 43% of american adults have been reported to have insufficient hl skills [16] . in europe, a research project entitled "european health literacy survey" (hls-eu) launched in 2011 to investigate hl in eight european countries through a 86-item survey, showed limited hl skills in about 47% of respondents, with consistent differences (29-62%) across countries [19, 22] . as for italy, recent investigations have reported inadequate hl as a predominant phenomenon; palumbo et al. investigated hl in a representative sample of 1000 italian individuals with the same tool used for the hls-eu [21] . the survey showed an insufficient level of hl in the 54.6% of the sample. a recent study by lorini et al. carried out on a population-based sample of 223 adults by using three measurement tools reported values of inadequate hl ranging from 40.4% to 75.4% on the basis of the different questionnaire used [20] . in particular, 59.6% of individuals showed an adequate literacy as resulting by the nvs. therefore, our results suggest that undergraduates, especially those attending healthcare related degree courses, may have a better level of hl respect to the general population. this should be confirmed in future investigations. in 2019, rüegg and abel showed that hl may be associated with many material, psychosocial, and health-related factors, and with socioeconomic status. among the covariates they considered, interest in health topics was included among the best predictors for a good hl level [42] . this finding is in accordance with the results we found among nursing undergraduates. furthermore, we analyzed the association between hl, lifestyle, and bmi. a positive association was found between md and all the hl dimensions, and the logistic regression suggests that md may influence hl. the protective role of md on multiple health outcomes has been widely demonstrated [43] . moreover, the adoption of this pattern is associated with other healthy habits such as having an active lifestyle and not smoking [44] . in our study, the adherence to a md pattern was not associated with other lifestyle behaviors (data not shown), but it was related to hl. according to the study by geboers et al. [23] , we did not find association between hl and smoking. contrary to the findings of other studies, the hl of our total sample was not clearly related to pa, nor to bmi as physical health outcome [23, 26] . in the group analysis, pa was found to be related with hl domains in healthcare students, and bmi was associated with literacy and numeracy skills only in non-healthcare undergraduates. these results highlight the differences existing between the two groups examined and deserve further investigations. interestingly, hl and healthcare educational field were found to be associated even if healthcare students showed a lower adherence to healthy lifestyle than their counterparts. although a direct relation between individuals' hl skills and health behaviors and outcomes has been demonstrated, literature shows that many factors including health status, attitudes, motivation, and self-efficacy may mediate this relation. moreover, these mediators may also be influenced by socio-cultural features, support, and available resources [15] . our results suggest the need to further explore these items in future studies. the two questionnaires used in this study were used successfully in previous investigations to assess hl among young adults [36, 39] . in our experience, they were well accepted and understood by participants, and their results showed a good level of concordance. this study has some limitations. first of all, the limited size and the composition of the sample do not allow to generalize our findings. the degree courses were chosen by convenience and students participated voluntarily. therefore, a selection bias should not be excluded. randomized studies involving more representative samples would confirm our findings. furthermore, our sample showed a significant difference in gender composition between groups, with females mainly represented among healthcare undergraduates. although this is an aspect frequently reported in studies carried on the same target population [33, 45] , differences in hl levels between the two educational fields were maintained when males and females were examined separately, and gender was not significantly associated with hl outcomes in multiple regression analyses. second, all the data collected were self-reported. it is possible that, besides inaccurate information regarding weight and height, participants reported incorrect estimates of their own hl abilities. furthermore, we did not analyze the working condition of participants. considering that being a working student may have effects on pa levels, it should have been investigated as a possible lifestyle predictor [33] . however, the use of two investigation tools and the involvement of undergraduates from two different areas of study represent new items that may contribute to characterize the domains and the determinants of hl. furthermore, the analysis of the relationships between students' behaviors and hl opens new perspectives for future research. the findings of this study show an adequate hl level in undergraduates, mainly among those attending healthcare-related degree courses. however, the majority of these students did not report healthy behaviors. this issue should be addressed considering the role that healthcare professionals may have in educating patients towards a healthy lifestyle. furthermore, in this study, hl was associated with the adherence to the md pattern. this suggests that having better knowledge and skills regarding health may lead to better food habits. further investigations regarding these aspects are needed. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/18/6654/s1, table s1 : differences in hl scores of female and male participants grouped by educational field with related p and d values. health education as social policy health literacy revisited: what do we mean and why does it matter? health literacy and public health: a systematic review and integration 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ehealth literacy the development of building wellness™, a youth health literacy program associations between health literacy and health behaviors among urban high school students quality of health literacy instruments used in children and adolescents: a systematic review health literacy in childhood and youth: a systematic review of definitions and models systematic review and conceptual framework for health literacy training in health professions education exploring health literacy in medical university students of chongqing, china: a cross-sectional study health literacy among danish university students enrolled in health-related study programmes relationships between food consumption and living arrangements among university students in four european countries-a cross-sectional study a cross-sectional study investigating lifestyle and weight perception of undergraduate students in southern italy healthy lifestyles of the university population assessment of weight status, dietary habits and beliefs, physical activity, and nutritional knowledge among university students health literacy: a cross-disciplinary study in american undergraduate college students mediterranean diet and health status: an updated meta-analysis and a proposal for a literature-based adherence score international physical activity questionnaire: 12-country reliability and validity health literacy among young adults: a short survey tool for public health and health promotion research quick assessment of literacy in primary care: the newest vital sign cognitive function, and health: results of the litcog study the relationship between health literacy and health outcomes among male young adults: exploring confounding effects using decomposition analysis mediterranean diet and health outcomes: a systematic meta-review associations between lifestyle factors and an unhealthy diet understanding knowledge and behaviors related to covid-19 epidemic in italian undergraduate students: the epico study the authors thank elena maria ferro and fulvia perrelli for their contribution in participant recruitment. the authors declare no conflict of interest. key: cord-283514-7rjo9k4d authors: šagát, peter; bartík, peter; prieto gonzález, pablo; tohănean, dragoș ioan; knjaz, damir title: impact of covid-19quarantine on low back pain intensity, prevalence, and associated risk factors among adult citizens residing in riyadh (saudi arabia): a cross-sectional study date: 2020-10-06 journal: int j environ res public health doi: 10.3390/ijerph17197302 sha: doc_id: 283514 cord_uid: 7rjo9k4d this study aimed to estimate the effect of the coronavirus disease 2019 (covid-19) quarantine on low back pain (lbp) intensity, prevalence, and associated risk factors among adults in riyadh (saudi arabia). a total of 463 adults (259 males and 204 females) aged between 18 and 64 years and residing in riyadh (saudi arabia) participated in this cross-sectional study. a self-administered structured questionnaire composed of 20 questions regarding demographic characteristics, workand academic-related aspects, physical activity (pa), daily habits and tasks, and pain-related aspects was used. the lbp point prevalence before the quarantine was 38.8%, and 43.8% after the quarantine. the lbp intensity significantly increased during the quarantine. the low back was also the most common musculoskeletal pain area. furthermore, during the quarantine, a significantly higher lbp intensity was reported by those individuals who (a) were aged between 35 and 49 years old, (b) had a body mass index equal to or exceeding 30, (c) underwent higher levels of stress, (d) did not comply with the ergonomic recommendations, (e) were sitting for long periods, (f) did not practice enough physical activity (pa), and (g) underwent teleworking or distance learning. no significant differences were found between genders. the covid-19 quarantine resulted in a significant increase in lbp intensity, point prevalence, and most associated risk factors. at present, the problems associated with low back pain (lbp) represent a major concern for public health authorities, as well as for the general population in developed countries [1] . worldwide, it has been estimated that the lbp prevalence ranges from 1.4 to 20.0% [2] . lbp is, in fact, the most common cause of work-related musculoskeletal disorders in certain regions [3] , and it also causes significant problems in both the personal and professional lives of individuals. this includes sleeping disorders, disability, invalidity, work absenteeism, lack of productivity, and difficulties in carrying out the profession chosen by each worker [4] . the economic impact of lbp also represents a big concern worldwide. in western countries, it has been estimated that the costs of back pain range between 1 and 2% of the gross national product [5] . in the united states, experts have calculated that this condition's total cost exceeds $100 billion per year [6] . the onset of lbp is often associated with the adoption of poor postures at work; heavy lifting; performing repetitive movements; trunk flexion, rotation, and hyperextension; pushing; pulling; carrying; whole-body vibrations [7] . in addition, certain factors can aggravate the lbp intensity, including age, gender, hypertension, smoking, ergonomics, lack of job satisfaction, being overweight or obese, lack of physical activity (pa), and depression [8, 9] . knowing these factors is essential because it is possible to design a prevention strategy once they are identified. as for saudi arabia, the prevalence of lbp has been analyzed in recent studies. most of them were done with specific groups, and it was found that the prevalence among nurses was 80% [10] , 70% in dentists [3] , 73.9% in health personnel [11] , 68% among female secondary school teachers [12] , and 57.3% among male high school teachers [13] . in contrast, only a few epidemiological studies have been conducted that aimed to analyze the prevalence of the general population in saudi arabia. in this sense, awaji [14] found out in a recent review study that the lbp prevalence in this country ranges between 53.2% and 79.17%. however, the aforementioned prevalence levels may vary when the individual habits and lifestyle are modified. in this respect, the onset of the coronavirus disease 2019 (covid19) has forced many governments worldwide to make a series of decisions to prevent the pandemic´s rapid spread [15] . the precautionary measures implemented include social distancing, capacity limitations in public spaces and private homes, isolation, quarantine, and curfew enforcement [16] . therefore, it is conceivable that all these events are likely to have affected people's lives physically, emotionally, and psychologically. in fact, mattioli et al. [17] state that quarantine measures have a negative impact on human beings in many aspects, which include (a) increased anxiety, anger, and stress; (b) decreased outdoor exercise and the overall amount of pa; (c) both stress and depression, which can lead individuals to adopt unhealthy dietary habits. since many of these aspects are factors that worsen lbp, as explained before, it is conceivable that during the covid-19 quarantine, the prevalence of this condition has increased. in this context, the present study´s purpose was to estimate the effect of the mentioned quarantine on lbp intensity, prevalence, and risk factors among adult citizens residing in riyadh (saudi arabia). we hypothesized that (a) the prevalence of lbp, as well as its intensity among those citizens who already had this condition, has increased; (b) the factors aggravating lbp have undergone significant variations. an analytical cross-sectional study was undertaken. adults (330 saudi citizens and 133 foreigners; 259 males and 204 females; age: 35.63 ± 9.84 years) voluntarily participated in the current research. the inclusion criteria were (a) being aged between 18 and 64 years; (b) did not suffer from chronic psychological, physiological, or psychosomatic conditions; (c) were not hospitalized during the pandemic; (d) were a resident in saudi arabia; (e) stayed in riyadh before and during the quarantine decreed by the saudi authorities. all subjects received detailed information about the objectives, benefits, and risks associated with participation in this study. they also signed an informed consent form indicating their willingness to participate in the current research. the sample selection process was performed following the steps described in figure 1 [18, 19] . to assess the factors determining the presence of back pain, a self-administered structured questionnaire composed of 20 questions was used (questionnaire s1, supplementary material). it was established that the following dimensions should be included: (a) demographic characteristics (age, gender, height, weight), (b) work-or academic-related aspects (the type of work or academic activity performed before and after the quarantine and type of activities performed while working or studying), (c) pa (type, frequency, duration), (d) daily habits and tasks (sitting, moving), (e) painrelated aspects (location and intensity before and after the quarantine), and (f) psychological aspects (stress level before and during quarantine). equal importance was assigned to each item. to facilitate understanding the questionnaire, all items were written in simple, short, and plain language [20] . the questionnaire responses were structured on a scale of whole numbers from 1 to 5. by way of example, pain was rated from "no pain" to "extreme pain," and stress was rated from "no stress" to "maximal stress." before drafting the questionnaire, it was subjected to a validation process, as described in figure 2 [18] . to ascertain the factors determining the presence of back pain, a self-administered structured define the target population: riyadh adult residents. sample frame selection: adults residing in riyadh who stayed in this city before and during the covid-19 quarantine and neither suffered from chronic conditions nor were hospitalized. determine sample size: it was calculated using the following formula n = z 2 p x qn / e 2 (n -1) + z 2 p x q; (n = sample size, n = population size, z = confidence level, p = probability of success, q = probability of failure, e = sampling error) [19] . the interval of confidence was set at 95%, the margin of error at 5%, and the probability of success at 0.5. once the calculation was performed, it was determined that the minimum number of subjects that should participate in the study to have a representative sample to of the studied population was 385. data collection: data was collected by using a self-administered structured questionnaire distributed via google forms. sampling technique selection: a stratified random sampling was used based on the city districts. to assess the factors determining the presence of back pain, a self-administered structured questionnaire composed of 20 questions was used (questionnaire s1, supplementary materials). it was established that the following dimensions should be included: (a) demographic characteristics (age, gender, height, weight), (b) work-or academic-related aspects (the type of work or academic activity performed before and after the quarantine and type of activities performed while working or studying), (c) pa (type, frequency, duration), (d) daily habits and tasks (sitting, moving), (e) pain-related aspects (location and intensity before and after the quarantine), and (f) psychological aspects (stress level before and during quarantine). equal importance was assigned to each item. to facilitate understanding the questionnaire, all items were written in simple, short, and plain language [20] . the questionnaire responses were structured on a scale of whole numbers from 1 to 5. by way of example, pain was rated from "no pain" to "extreme pain," and stress was rated from "no stress" to "maximal stress." subsequently, the reliability was also verified. for this purpose, a pre-trial was performed. thirty subjects were asked to fill out the questionnaire. then, the cronbach alpha value was calculated by considering each item´s variances and the total variance [21] ; the value obtained was α = 0.82, which reflected an adequate internal consistency. before drafting the questionnaire, it was subjected to a validation process, as described in figure 2 [18] . subsequently, the reliability was also verified. for this purpose, a pre-trial was performed. thirty subjects were asked to fill out the questionnaire. then, the cronbach alpha value was calculated by considering each item´s variances and the total variance [21] ; the value obtained was α = 0.82, which reflected an adequate internal consistency. contact with potential study participants was established through the riyadh municipality forum groups that were available on social media. next, 1000 individuals were selected through a simple randomization process using spss software version 22.0 (spss, inc., chicago, il, usa). subsequently, the questionnaire was distributed among the selected citizens on 10 may 2020 at 8 a.m. and it was filled out anonymously. the collection of questionnaire responses finished on 17 may 2020 at 11.59 p.m. at that specific time, 811 responses had been received (81.1% response rate). among these 811 respondents, 348 were ruled out because they did not meet the inclusion criteria. therefore, the final sample was composed of 463 subjects. additionally, it is very important to highlight the chronology of the curfew implementation in riyadh´s city regarding the questionnaire dissemination timing. from the evening of 23 march 2020, a nationwide curfew planned for 21 days was implemented between 7 p.m. and 6 a.m. [22] . on 6 april 2020, a 24-hour curfew was announced. movement was restricted to only essential travel between 6 a.m. and 3 p.m. the curfew´s sequential lifting started on 28 may 2020, until the total removal on 21 june 2020 [23] . the study was conducted in accordance with the principles outlined in the helsinki declaration. it was also approved by the institutional review board of the bioethics committee at prince sultan university in riyadh, saudi arabia (approval no. 18/2020). preparing the content validation form: the form contained one scale to rate the items from 1 to 5. selecting a review panel of experts: a panel of 10 experts was created. all of them had at least five years of research experience plus an extensive knowledge of the research contents. content validation: content validation was performed online. all experts received clear instructions about the content validation process. item rating: experts were required to rate each item and provide a final score. calculating content validation item: the item-level content validity index (i-cvi) was calculated using the following formula: i-cvi = (agreed item)/(number of experts). only those items with an i-cvi higher than 0.75 were included. contact with potential study participants was established through the riyadh municipality forum groups that were available on social media. next, 1000 individuals were selected through a simple randomization process using spss software version 22.0 (spss, inc., chicago, il, usa). subsequently, the questionnaire was distributed among the selected citizens on 10 may 2020 at 8 a.m. and it was filled out anonymously. the collection of questionnaire responses finished on 17 may 2020 at 11.59 p.m. at that specific time, 811 responses had been received (81.1% response rate). among these 811 respondents, 348 were ruled out because they did not meet the inclusion criteria. therefore, the final sample was composed of 463 subjects. additionally, it is very important to highlight the chronology of the curfew implementation in riyadh´s city regarding the questionnaire dissemination timing. from the evening of 23 march 2020, a nationwide curfew planned for 21 days was implemented between 7 p.m. and 6 a.m. [22] . on 6 april 2020, a 24-hour curfew was announced. movement was restricted to only essential travel between 6 a.m. and 3 p.m. the curfew´s sequential lifting started on 28 may 2020, until the total removal on 21 june 2020 [23] . the study was conducted in accordance with the principles outlined in the helsinki declaration. it was also approved by the institutional review board of the bioethics committee at prince sultan university in riyadh, saudi arabia (approval no. 18/2020). all results are presented as mean (interquartile ranges). kolmogorov-smirnov and levene's tests were used to verify the normality and homoscedasticity, respectively. since the data did not follow a normal distribution and the cohort sizes created to establish comparisons between specific conditions (i.e., gender, body mass index (bmi), age) was unequal, nonparametric tests were used. therefore, comparisons of two sets of data were made using the mann-whitney u test, whereas the kruskal-wallis h test was conducted to make comparisons between more than two sets of data using dunn-bonferroni corrections. to make comparations between paired nominal data, mcnemar's test was conducted. comparations of dichotomous dependent variables between three or more groups were made by using cochran's q test with bonferroni corrections. the spearman test was used to calculate the correlation between variables, with the results being interpreted as follows: r = 0 null correlation, 0.01≤ r ≤ 0.09 very weak, 0.10 ≤ r ≤ 0.29 weak, 0.30 ≤ r ≤ 0.49 moderate, 0.50 ≤ r ≤ 0.69 strong, and r ≥ 0.70 very strong. to estimate the effect-size (es), after applying the mann-whitney u test, the following formula was used: n. an es of 0.2 was considered small, 0.5 moderate, and 0.8 large [24] . the percentage of change was calculated using the following formula: % change = ([final value − initial value]/initial value) × 100. the level of significance was set at p < 0.05. the statistical analysis was performed using spss software version 22.0 (spss, inc., chicago, il, usa). the curfew decreed by the saudi authorities implied the adoption of certain legal and institutional measures and mobility restrictions, which has impacted population habits and lifestyles. as shown in table 1 , the most prevalent musculoskeletal pain area was the low back, followed by the neck, shoulders, thoracic area, and legs during the quarantine. furthermore, during confinement, the percentage of subjects who reported thorax and lower body pain significantly increased. additionally, the individuals who indicated they did not suffer pain in any body area decreased but not significantly. the incidence of neck pain was clearly higher in women, whereas low back pain was fairly higher in men. the confinement resulted in a significant increase in the percentage of the population carrying out teleworking and distance learning. regarding the time spent sitting and moving, the number of respondents who were sitting all or most of the time during the quarantine significantly increased, whereas the percentage of interviewees who were moving always or most of the time significantly decreased. the cohorts of individuals who spent the same time sitting as moving experienced a slight decrease, which was not significant. as for pa, the percentage of subjects who did not practice pa and practiced only once a week significantly increased. additionally, the number of individuals who practiced pa two, three, six, or seven times a week significantly decreased. finally, during confinement, the percentage of subjects who reported more stress significantly increased. furthermore, several comparisons were made between different sample cohorts and conditions ( table 2 ). in this way, it was observed that the lbp intensity reported by the subjects was significantly higher than before the quarantine (p < 0.001, es = 0.18). however, no significant differences in lbp intensity were observed either before or during the quarantine between genders. regarding the age, the 35-to-49-year-old cohort reported the higher lbp intensity, followed by the 50-to-64-year old cohort and the 18-to-34-year-old cohort before and during the quarantine. significant differences were found between the 18-to-34-year-old cohort and the 35-to-49-year-old cohort before the quarantine (p < 0.001, es = 0.29) and during the quarantine (p < 0.001, es = 0.63), and between the 35-to-49-year-old and the 50-to-64-year-old cohort before the quarantine (p < 0.001, es = 0.11) and during the quarantine (p < 0.001, es 0.15). however, no significant lbp intensity differences were found between the 18-to-34-year-old and the 50-to-64-year-old cohort, either before or during the quarantine. as for the bmi categories, the normal weight group reported a significantly lower lbp intensity than the overweight group before the quarantine (p < 0.001, es = 0.54) and during the quarantine (p < 0.001, es = 0.61), and than the obese group before the quarantine (p < 0.001, es = 2.37) and during the quarantine (p < 0.001, es = 2.38). likewise, the overweight group reported lower pain than the obese group before the quarantine (p < 0.001, es = 1.65) and during the quarantine (p < 0.001, es = 2.38). individuals who suffered moderate or severe stress levels presented a significantly higher lbp intensity during the quarantine (p < 0.001, es = 0.26) but not before. furthermore, a significantly higher lbp intensity was observed among the subjects who did not comply with the ergonomic recommendations before (p < 0.001, es = 2.39) and during the quarantine (p < 0.001, es = 2.32). significant differences in the lbp intensity were observed between the individuals who underwent teleworking or online learning and the subjects who did not during the quarantine (p = 0.001, es = 0.15) but not before the quarantine. furthermore, those survey respondents who were moving always or most of the time reported a significantly lower lbp intensity, both before (p = 0.046, es = 0.194) and during the quarantine (p < 0.001, es = 0.188) than the individuals who were sitting all the time or most of the time. regarding the number of times per week the interviewees practiced pa, before the quarantine, the subjects who did not practice pa reported significantly higher lbp intensity than those who practiced pa four or five times a week (p < 0.001, es = 0.75) and six or seven times a week (p = 0.007, es = 0.89). similarly, the individuals who practiced pa once a week reported significantly higher lbp intensity than those who practiced four or five times a week (p < 0.001, es = 0.68) and six or seven times a week (p < 0.001, es = 1.16). the cohort who practiced pa two or three times a week also reported a higher lbp intensity than the subjects who practiced four or five times a week (p < 0.001, es = 0.49) and six or seven times a week (p < 0.001, es = 0.99). no significant differences were found in lbp intensity between the cohort who practiced pa four or five times a week and the cohort who practiced pa six times a week or every day. 22 march 2020; pain was rated by the interviewees from 1 to 5, with 1 being no pain and 5 being extreme pain. from 10 may to 17 may 2020; pain was rated by the interviewees from 1 to 5, with 1 being no pain and 5 being extreme pain. § significant difference between both periods (before and during the quarantine), # significant difference from the age cohort who were moving always or most of the time, + significant difference from the 35-49-year-old age cohort, † significant difference from the normal weight cohort, † † significant difference from the overweight group, ¥ significant difference from the cohort that perceived mild or no stress, significant difference from the cohort that complied with the ergonomic recommendations, significant difference from the cohort that did not carry out teleworking or distance learning, # significant difference from the cohort that was moving always or most of the time, & significant difference from the cohort that did not practice pa, && significant difference from the cohort that practiced pa once a week, &&& significant difference from the cohort that practiced pa two or three times a week, &&&& significant difference from the cohort that practiced pa four or five times a week. for during the quarantine, it was found that those individuals who did not practice pa presented a higher lbp intensity than those who practiced once a week (p < 0.001, es = 0.52), two or three times a week (p = 0.019, r = 0.16), four or five times a week (p = 0.043, es = 0.14), and six or seven times a week (p < 0.001, es = 0.87). similarly, the subjects who practiced pa once a week, presented a higher lbp intensity than the interviewees who practiced pa two or three times a week (p = 0.005, es = 0.16), four or five times a week (p < 0.001, es = 0.26), and six or seven times a week (p < 0.001, es = 0.38).the lbp intensity reported by the cohort of respondents who practiced pa two or three times a week was also significantly higher than those who practiced pa six or seven times a week (p < 0.001, es = 1.07). finally, the cohort who practiced pa four or five times a week reported a significantly higher lbp intensity than the individuals who practiced pa six times a week or every day (p < 0.001, es = 1.06). the associations between the lbp risk factors were also estimated ( table 3 ). it was found that there was a significant positive correlation between the lbp intensity and time spent sitting during the quarantine, perceived stress before and during the quarantine, and bmi before and after the quarantine. a significant negative correlation was found between the weekly practice of pa during the quarantine and the lbp intensity. on the contrary, no significant correlation was observed between the lbp intensity and time spent sitting before the quarantine, weekly frequency of pa before the quarantine, compliance with ergonomic recommendations before and during the quarantine, and age before and during the quarantine. table 3 . correlations between back pain intensity and personal and environmental factors. one of the present study´s main findings werethat the lbp´s point prevalence significantly increased after the lockdown, going from38.8% before the quarantine to 43.8% during the quarantine. both figures are notably higher than the 23.8% lbp point prevalence observed by alanzi et. al. [25] in a cross-sectional community-based study in the city of arar (northern saudi arabia). the target population of both studies was composed of adults. the substantial differences between the city of riyadh and arar in terms of size and population (4,205,961 vs. 148,540 inhabitants) [26] could be the reason for this discrepancy. another factor that might partially explain the lack of concordance between both studies is the increasing incidence of back pain over time in saudi arabia, as was observed in other countries [27] . in fact, al-arfaj et al. [28] reported a low back pain prevalence of 18.8% in 2003 in the region of al-qassim (saudi arabia), which would confirm the increasing tendency over time within the kingdom. however, our study´s lbp point prevalence was considerably lower than the 53.2% to 79.17% found by awaji [14] in a review made using seven cross-sectional studies conducted in saudi arabia. in other recent studies also undertaken in saudi arabia among specific professional groups, the point prevalence of lbp found was 80% in nurses [10] , 57.3% in male high school teachers [13] , 55% among faculty members [29] , 40.5% in medical students [30] , 51.6% in taxi drivers, 31.4% in office workers [31] , and 21.2% among health sciences students [32] . hence, in most of these cases, the point prevalence was higher than in our study, which could be related to the burden of work, type of professional or academic activity carried out by each group, and poor posture at work [33] . worldwide, the lbp´s point prevalence found in countries such as canada, the united states, sweden, belgium, finland, israel, and the netherlands ranges between 1.4 and 20.0% [3] . therefore, the present study, and most of the studies conducted in saudi arabia, revealed a higher lbp point prevalence in saudi arabia than in foreign countries. according to this study's results, it was also possible to verify that the most common musculoskeletal pain area was the low back, followed by the neck. this result coincides with most of the existing studies conducted in saudi arabia that were related to musculoskeletal disorders [3, 30, 31, 34] . however, this result was slightly different from the results found by sirajudeen et al. [29] since they observed that the neck was the most common pain area, followed by the low back. furthermore, it is also noteworthy that during the quarantine, the percentage of respondents who reported pain in all of the neck, shoulders, trunk, low back, and legs increased in all cases. in contrast, the percentage of subjects who did not present pain in any of the mentioned body areas decreased. the respondents´average lbp intensity was significantly higher than before the quarantine, which reflected the negative effect of the restrictions undergone by individuals. as for gender, a higher prevalence of lbp was found in males both before and after the lockdown in our study. however, no significant differences were observed in back pain intensity between both genders. although this result is consistent with the study conducted by ferguson et al. [35] among manual material handling workers in the united states, recent studies have reported a higher lbp prevalence in women [3, 9, 34] . therefore, it would be very useful to clarify the real impact of the gender factor on lbp in future research. moreover, the covid-19 quarantine decreed by the saudi authorities has caused significant changes in citizens´lifestyles. while the number of times per week devoted to practicing pa decreased, the time spent sitting increased. similarly, the percentage of individuals who reported more stress during the quarantine was much higher than those who suffered more stress before the lockdown. consequently, it can be assumed that the alteration of these three factors increased the incidence of lbp. thus, the subjects who were moving all the time or most of the time, the cohort who presented mild or no stress, and those who practiced pa with higher frequencies reported significantly lower lbp intensities (see table 2 ). similarly, the association between pa and lbp has been examined by alzahrani et al. [36] through a meta-analysis, where they found a lower lbp prevalence among those individuals who regularly practiced pa. taulaniemi et al. [37] found that exercise could reduce low back pain by improving lumbar movement control, abdominal strength, and physical functioning. the negative effect of prolonged sitting on lbp intensity verified in this study also coincides with the results obtained byşimşek et al. [4] . furthermore, mörl&bradl [38] suggest that extended periods of sitting implies the absence of lumbar muscle activation. this results in low conditioning of the low back muscles, which in turn overloads passive structures of this body area, such as intervertebral discs and ligaments. similarly, our study´s results verified the negative effect of stress on lbp intensity, which is consistent with previous studies [10] . at this point, it is important to note that the perceived level of stress, both before and during quarantine, positively correlated with the lbp intensity, which reflected the relevant effect that this factor exerts in aggravating the pain. as shown in table 1 , the percentage of individuals who carried out teleworking or distance learning during the quarantine increased drastically. in this sense, significant differences in lbp intensity were reported by the subjects who conducted teleworking or distance learning during the quarantine but not before. a feasible explanation of this matter could be related to the burden of work or the study load that was undertaken. as demonstrated in previous research, bmi has proven to be an lbp risk factor [39] . in the present study, the normal weight cohort reported a significantly lower lbp intensity than the overweight and obese groups. likewise, the overweight group reported lower pain than the obese group. this occurred because the excessive weight represented an additional overload for the spine structures. excessive body weight can compress the spine and intervertebral discs, which may increase the risk of suffering nerve compression, disc and ligament degeneration, and impairment of the lumbosacral structures [40] . interestingly, the 18-to-34-year-old age and the 50-to-64-year-old age cohorts reported a significantly lower lbp intensity than the 35-to-49-year-old age cohort. although these results contradict some recent research [4, 9] , they are consistent with a study carried out by shammari et al. [34] , in which it was observed that the 30-to-39-year-old age group presented higher disabling musculoskeletal symptoms. furthermore, this could be attributed to the higher workload and stress level that middle-aged adults undertook [41] . as for the correlations found between potential lbp risk factors and lbp intensity, stress and bmi had a significant positive correlation with lbp intensity before and during the quarantine, which reflected the evident effect of these two factors in aggravating lbp. additionally, only during but not before the quarantine, there was a significant negative correlation between lbp intensity and pa, and a significant positive correlation between lbp intensity and time sitting. therefore, these two factors exerted a clear influence during but not before the quarantine. in this way, it is possible to interpret that the lbp intensity increased mainly due to the variation in certain risk factors rather than their presence. in other words, it is conceivable that when people's habits and routines undergo important alterations, their lbp intensity increases. however, this possibility has not been confirmed yet. therefore, it might be clarified in future research. furthermore, no significant correlations were found between age and compliance with ergonomic recommendations with lbp intensity either before or after the quarantine. regarding age, the lack of correlation can be explained because, in the current research, the adults aged between 35 and 49 years old reported a higher lbp intensity, as indicated previously. however, something slightly different seems to have happened with the adherence to ergonomic recommendations because, despite the significant differences observed between cohorts set by the degree of compliance with the mentioned recommendations, no significant correlation was found between this factor and the lbp intensity. hence, in this specific case, it cannot be ruled out that those subjects who presented a higher lbp intensity had developed greater ergonomic awareness such that this circumstance may have increased the dispersion of variables observed when the correlation was calculated. the lack of correlation between the lbp intensity and certain lbp risk factors could also be attributed to the sample heterogeneity. furthermore, it might reflect that, on the one hand, it is easy to identify lbp risk factors in small samples of specific groups (i.e., students, teachers, nurses), but on the other hand, it is difficult to identify those factors when evaluating larger samples or the general population. hence, this aspect must be taken into account in epidemiological studies. due to the complexity of the current research, to verify the association between lbp intensity and potential risk factors, a univariate analysis was used. therefore, a possible joint variation of some of the mentioned risk factors cannot be excluded since a multivariate analytical approach was not adopted. in the present study, we assumed that increased sitting time and stress and decreased weekly practice of pa led to an increased lbp intensity since all the mentioned aspects are risk factors associated with lbp. however, it cannot be entirely ruled out that the sequence of events was the opposite. that is to say, the increase in lbp intensity might have been the cause but not the consequence of the decreased weekly practice of pa or increased stress. however, what has been verified was that the quarantine increased specific lbp risk factors and the prevalence of this musculoskeletal disorder. therefore, it is necessary to take measurements to reverse this situation without delay. as such, a greater negative impact on adult citizens´quality of life can be avoided. finally, it is necessary to mention the limitations of the study. due to the social distancing requirements, reduced mobility, and meeting restrictions, it was not possible to include certain measurements, such as inflammatory biomarkers and vitamin d levels, which could have provided relevant information regarding lbp risk factors, as observed in previous studies [42] [43] [44] [45] . furthermore, the lbp intensity was ascertained four weeks after the order of confinement. in this respect, it is necessary to recognize that some authors consider that pain recall is not entirely reliable [46] , whereas other authors hold the opposite view [47] . additionally, individuals suffering from chronic conditions and subjects that were hospitalized were not included in the current research. thus, it was not possible to verify the confinement effect in this segment of the population. the confinement decreed due to the covid-19 pandemic led to a significant increase in lbp intensity among adults residing in riyadh. similarly, the lbp point prevalence increased from 38.8 to 43.8%. the low back was also the most common musculoskeletal pain area. being aged between 35 and 49 years old, having a bmi equal to or exceeding 30, undergoing stress, non-adherence to ergonomic recommendations, prolonged sitting, the insufficient practice of pa, and undergoing teleworking or distance learning were associated with a higher lbp intensity. author contributions: conceptualization, p.š. and p.b.; methodology, p.p.g.; writing-original draft preparation, p.š. and d.k.; writing-review and editing, d.i.t., p.b., and p.p.g. all authors have read and agreed to the published version of the manuscript. global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the global burden of disease study real-world incidence and prevalence of low back pain using routinely collected data prevalence of work-related musculoskeletal disorders and ergonomic practice among dentists in jeddah, saudi arabia prevalence and risk factors of low back pain among health-care workers in denizli personal and societal impact of low back pain: 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intensity recall at 3 months in senior patients accuracy of recall of usual pain intensity in back pain patients funding: this research received no external funding. the authors declare no conflict of interest. key: cord-279116-auo80gaq authors: vallejo-martín, macarena; canto, jesús m.; san martín garcía, jesús e.; perles novas, fabiola title: prejudice and feeling of threat towards syrian refugees: the moderating effects of precarious employment and perceived low outgroup morality date: 2020-09-03 journal: int j environ res public health doi: 10.3390/ijerph17176411 sha: doc_id: 279116 cord_uid: auo80gaq refugees frequently experience traumatic situations that result in the deterioration of their psychological well-being. in addition, perceived prejudice and discrimination against them by the host society can worsen their mental health. in this research study, using a spanish sample, prejudice towards syrian refugees is analyzed taking into account feeling of threat (realistic or symbolic), precarious employment, and perceived outgroup morality. using a total of 365 participants, our results reveal that individuals feel more prejudice towards refugees when the former scored higher in realistic threat and symbolic threat, were in a highly precarious situation of employment and perceived refugees as being more immoral. furthermore, it was found that persons who scored high in realistic threat and at the same time were in a situation of precarious employment, were those who displayed greater prejudice. the results likewise pointed to individuals who scored high in symbolic threat and in outgroup morality as being those who felt greater rejection towards the refugees. accordingly, our results confirm the importance of feeling of threat in relation to prejudice, and highlight two important moderating factors: precarious employment and perceived outgroup morality. according to the united nations high commissioner for refugees (unhcr) [1] , in recent years we have been immersed in a humanitarian crisis which has led to the displacement of millions of people due to wars or violence in their countries of origin. specifically, it is estimated that there are 70.8 million forcibly displaced people in all of the world, with 25.9 million of them being refugees. this phenomenon called "the refugee crisis", is characterized by the growing number of forced displacements toward europe and other western countries [2] . the main countries of origin are syria, afghanistan, south sudan and myanmar [1] . in fact, the case of syria represents the largest exodus that has taken place since world war ii [3] . the circumstances causing the refugees to flee their countries make this displacement different from other types of voluntary migration, as it is frequently characterized by forced departure, fear and traumatic experiences. this feature often leads to refugees experiencing, once they are settled, mental health problems and a significant deterioration in their mental health [4, 5] and wellbeing [6] . in particular, refugees have a high prevalence of mental disorders, specifically post-traumatic stress disorder and depression [7, 8] . research carried out by chung et al. [9] on syrian refugees shows that 43% of them have post-traumatic stress disorder and that they have higher levels of psychological stress when they have witnessed situations of horror, death, etc. in addition, the study highlights differences in the mental health of refugees depending on the host country. on the other hand, the degree of acceptance and integration of the host country is also a key element for the mental health of this sector of the population, since there is a negative relationship between perceived prejudice and the psychological wellbeing of potentially stigmatized minority groups [10] . in this sense, the meta-analysis undertaken by pascoe and smart richman [11] , which takes into account the results of 134 studies carried out in diverse countries, revealed that stress levels increase when there is perceived discrimination. until now there have been few studies that analyze which factors contribute to prejudice and discrimination of the host country towards refugees. at the same time, the impact of perceived threat of ethnic prejudice is well documented [12] . nevertheless, until now there have been no studies that have taken an analysis of outgroup threat in relation to prejudice towards refugees into account in the spanish context, with this being an essential variable for the understanding of intergroup relations, formation of negative stereotypes towards outgroups [13] [14] [15] and as such, for mental health and psychological wellbeing. cottrell and neuberg [16] hold that the specific emotions that we feel toward other groups arise from the perception that such groups threaten certain aspects that are important to us, such as, for example, economic resources or values. accordingly, when individuals perceive that members of other groups put into question or threaten elements they value, they experience outgroup hostility. in recent years, the intergroup threat theory (itt) [17] has become an important theoretical framework for understanding the key role of threatening elements in the genesis of ethnic prejudice, taking into account one of the most relevant approaches in this field [18] . the itt distinguishes between two basic sources for threat: realistic threat and symbolic threat. realistic threat implies the perception of competition between ingroup and outgroup for scarce resources, such as employment, social services, education and healthcare [19] . at the same time, symbolic threat refers to the perception of differences in values and beliefs that members of outgroups are thought to have. in this sense, symbolic threat is focused on worldview and moral values, along with fear of losing ingroup customs, language and traditions as a consequence of interaction with members of the outgroup [20] . the itt, and its previous versions [21, 22] , have demonstrated that perceived threat, both symbolic and realistic, plays a central role in intergroup attitudes, and it is a predictive variable for prejudice in various social contexts [17] . this relation between intergroup threat and greater resentment and hostility towards immigrants has been reflected in different studies, for recently arrived immigrants [23, 24] as well as for those who are settled residents [25] . however, different research studies have brought to light that the degree to which each type of threat is related to prejudice depends to a large extent on the nature of the relation between the groups being considered [26] . stated in another way, different minority groups can provoke different perceptions of threat [17, 27, 28] . due to the fact that the type and importance of the threat induced depend on the specific characteristics of the intergroup context, different outgroups can evoke differential attitudinal reactions among members of the majority group [29] . along these lines, one of the most recent studies is that of jedinger and eisentraut [18] . these authors hypothesize an effect of different types of threat on ethnic prejudices based on perceived characteristics in minority groups. the results of this study, undertaken within the german context, show that negative attitudes towards muslims and third-generation turks arise mainly from a perception of economic threat and cultural threat, while the refugees and the romani are also linked to threat involving public safety and criminality. in the spanish context, the relation between hostility towards immigrants and perceived realistic and symbolic threat have been dealt with in different studies [30] [31] [32] [33] ; nevertheless, until now, this relationship has not been studied in the refugee population. although in colloquial terms concepts such as prejudice, discrimination, racism, and stereotypes are used interchangeably, we should bear in mind that they are not synonymous concepts. traditionally, prejudice has been conceived as a negative attitude towards a certain social group [34] , but nowadays the role of emotions has become especially relevant. from the theory of the inter-group emotions [35] , prejudice is considered as an emotion that depends on the social, political, and cultural context in which intergroup relations take place [36] . on the other hand, social stereotypes are beliefs about characteristics that a group of people have stemming from simply belonging to a social group [37] . the question as to why we associate different attributes to certain social groups has been a recurrent one in the study of stereotypes. in general, it has been confirmed that the formation of stereotypes is a complex phenomenon that can be explained by cognitive, affective, socio-motivational, and cultural processes [38] . according to the stereotype content model [39, 40] , judgement about others derives from structural relationships that the groups maintain with one another. these relationships are determined by whether these groups compete for resources or if they are high or low status. for the model's first approaches [39, 40] , the social perception towards the outgroup is developed on the basis of two dimensions: warmth and competence. later, leach, ellemers and barreto [41] established that the dimension of warmth in fact encompasses two different dimensions: sociability and morality. sociability is associated with the desire to interact with others (for example, being friendly or nice). at the same time, morality refers to the degree to which the behavior of the person or group evaluated is considered proper (for example, a trustworthy or sincere person). the existence of these two differential dimensions and their impact on prejudice has been confirmed in diverse studies [42] [43] [44] [45] . furthermore, it seems that the dimension of morality is the one with most weight when it comes to determining our evaluation of certain groups [46, 47] . one of the most recent studies on refugees in the spanish context corresponds to that by ordóñez-carrasco, blanc, navas and rojas-tejada [48] . in this research, the dimension of outgroup morality is linked [42] to the acculturated preferences towards syrian refugees. according to these authors, when the host population perceives a high degree of outgroup morality, and as such, the outgroup is no longer a threat, the former are seen as more flexible and permissive with regard to the outgroup maintaining its culture of origin in the private sphere. our study, thus, points out the importance of perceived morality in prejudice and in the strategies of acculturation, not only with respect to immigrants, but also individuals who are refugees. in this study, we seek to determine the role of outgroup threat in its two dimensions, realistic and symbolic, in the ethnic prejudice of the spanish population towards syrian refugees. in europe, two types of opposing discourse converge with respect to refugees [49] . on one hand, there is the discourse where human rights take precedence and there is a call for countries to offer protection to people coming from other ones that are in conflict; on the other hand, there is other discourse that highlights the risk and threat represented by mass acceptance of people who have been forced to emigrate [48] . in recent years, in spain, the number of people requesting asylum has grown exponentially, going from 5947 in 2014 to 118,264 in 2019 [50] . specifically, according to spanish commission for refugees (cear) [50] , the number of syrian refugees in spain is estimated to be between 12,000 and 15,000 people. the latest data on syrian asylum seekers in spain, corresponding to 2019, indicated a number of 2775. this increase within such a short time is important in the host population's perception of refugees, because among the main variables involved in the activation of threat and negative attitudes towards outgroups are the size of the foreign population and competition for resources brought about by the country's economic context [22, 31, 51] . in line with the itt [17] , in our study we expected the participants to show greater prejudice when they felt a higher degree of realistic threat (h1a) and symbolic threat (h1b) toward syrian refugees. at the same time, the refugee crisis is framed within the context of the economic and financial crisis in europe, which, together with the austerity measures, have brought about a lesser degree of openness from the european population towards persons coming from other countries [52] . during periods of crises, the perception that minority groups pose a threat for scarce resources and for the national cultural homogeneity becomes exacerbated [51] . specifically in spain, the economic crisis of 2008 was severe and intense and intergroup relations were sharply impacted by this social reality. this socioeconomic context diminished the quality and level of life of spain's citizens (spaniards and immigrants), who have had to compete for jobs and social resources in a society in crisis for a decade [30] . in this sense, we expect to obtain that those persons that were in a situation of precarious employment, defined in this study as individuals who are unemployed or employed in a job that they viewed as having very negative conditions, would show greater levels of prejudice towards refugees (h2). in addition, as realistic threat implies perceived competition for resources, among which is employment [22] , we expected that the situation of precarious employment would be a moderating factor for the same. accordingly, we hypothesized that individuals would feel greater hostility towards syrian individuals when they scored high in realistic threat and were in situation of precarious employment (h3). finally, the dimension outgroup morality was taken into account in the study, which, as stated earlier, is considered the most important for the stereotype content and one of the most relevant factors in outgroup hostility [42, 53] . in line with results from other studies on ethnic prejudice towards minority groups in the spanish context [43, 48, 54] , it was expected that when individuals perceived low morality in the syrian refugees, they would show greater prejudice towards them (h4). furthermore, we hypothesized that perceived morality would be a moderating effect for symbolic threat. thus, it was expected that when individuals perceived that their main traditions and values were endangered [20] by the arrival of syrian refugees, that is-they felt threatened by them in the symbolic dimension, and at the same time, felt that they were immoral [42] , harmful and dishonest persons (h5)-they would show greater outgroup hostility. a total of 472 individuals participated in this study, from which those who were not in a position to be employed (such as students, retirees, people with disabilities, etc.) were discarded, resulting in a final total of 365. among the participants, 51.5% were women and 48.5% men. the average age was 40.35 (sd = 11.61), in ages ranging between 19 and 67. as for education level, the distribution was the following: 21.9% basic education, 28.1% secondary education 28.8% university studies, and 21.3% vocational/professional training. regarding employment status, 17.6% were unemployed and 28.5% were employed and viewed their job in a negative light, while 53.9% had a job which they evaluated positively and as being in line with their expectations. sociodemographic questionnaire. the participants were asked about sociodemographic characteristics such as their sex, age, educational level, employment status, and political viewpoint. outgroup threat perception scale. to measure outgroup threat, the escala de percepcion de amenaza exogrupal-epae (outgroup threat perception scale) [32] was used. it is composed of a total of 13 items which range from response 1 ("not at all") to 5 ("very much so") that assess two factors: realistic threat (9 items) and symbolic threat (4 items). the items to measure symbolic threat refer to the degree to which the individuals feel that refuges endanger educational and family values, religious beliefs and cultural traditions. at the same time, the items that assess realistic threat indicate the extent to which individuals feel that the refugees put at risk access to jobs, healthcare, education, welfare benefits, the economic stability of the country, health, public order, and personal and national security. the cronbach's alpha obtained was 0.87 for symbolic threat and 0.89 for realistic threat. stereotyped dimension of outgroup morality. a scale was designed based on the research of leach, ellemers and barreto [41] in the spanish version [43] . participants were asked to what degree they considered the refugees honest, trustworthy, sincere, respectful, fair and well-intentioned for a range of responses that went from 1 ("not at all") a 5 ("very much so"). the reliability coefficient was 89. prejudice. a scale of emotions was used [55] , composed of 10 items with responses ranging from 1 ("not at all") to 5 ("very much so"), which measured the affective component of the prejudicial attitude towards refugees through negative emotions (fear, unease, anger, disgust, hate, deception, disdain, frustration, resentment, and agitation). the cronbach's alpha obtained was 0.92. the data were collected in malaga (spain). the questionnaire was administered by doctoral students from the faculty of psychology and speech therapy at the university of malaga, who had been previously trained in social and community research. the sample was random using the snow-ball sampling method [56] , asking for voluntary collaboration from participants. the questionnaire was anonymous and data confidentiality was assured as was the fact that results would only be used for academic purposes. in addition, participants read a debriefing explaining the goals of the study and they also were able to request an additional oral debriefing. the ethical guidelines of this research were approved by the research ethics committee of the university of málaga (85-2019-m). the data were gathered between november 2019 and february 2020. once the data screening was performed, the spss v23.0 statistical software (spss inc., chicago, il, usa) was used to calculate the reliability, descriptive statistics, and correlations of the measured variables. first, the reliability was calculated for each of the scales used for the variables realistic threat, symbolic threat, outgroup morality and prejudice. with respect to employment status, participants were classified into two groups: (1) highly precarious employment: this includes unemployed individuals or individuals who perceive their job as having very negative work conditions and (2) low degree of precariousness: composed of individuals who have a job that they view as being in accordance with their expectations and with good working conditions. later, the descriptive statistics were measured (mean and standard deviation) and the correlation among variables. lastly, a hierarchical regression analysis was carried out through the process macro for spss [57] . first, the descriptive statistics and the correlations between variables were calculated. the results show that the participants obtained a medium-low score in realistic threat (m = 2.22; sd = 1.10) and symbolic threat (m = 2.11; sd = 1.07), medium-high in outgroup morality (m = 3.17; sd = 0.89) and low in prejudice towards the refugees (m = 1.49; sd = 0.91). as for the relationship between the variables, it was observed that for higher levels of realistic threat, there were higher levels of symbolic threat (r = 0.597; p < 0.01), higher levels of prejudice towards refugees (r = 0.381; p < 0.01), and lower levels of perceived morality (r = −0.450; p < 0.01). at the same time, at higher levels of symbolic threat there were greater level of prejudice towards refugees (r = 0.401; p < 0.01) and lower levels of perceived morality (r = −0.499; p < 0.01). it was also found that with higher levels of outgroup morality there was lower prejudice (r = −0.422; p < 0.01). then, a hierarchical regression analysis was carried out (table 1 ), in which the criterion variable prejudice towards refugees (r 2 c = 0.399; f (4, 365) = 21.938, p = 0.001). in the first step, age and gender included as control variables, not being statistically significant (gender: β = 0.017, t = 0.068, p = 0.946; age: β = 0.190, t = 0.792, p = 0.440). in the second step, four predictor variables were included: realistic threat, symbolic threat, outgroup morality and precarious employment. finally, in the third step, the interactions between realistic threat and precarious employment and symbolic threat and outgroup morality were included. all of these variables had a significant effect on greater prejudice towards refugees. individuals showed more prejudice when they felt threatened by the refugees in the realistic dimension (β = 0.447, t = 2.07, p = 0.020) and the symbolic one (β = 0.759, t = 3.53, p = 0.001), perceived low morality in the refugees (β = −0.276, t = −3.70, p = 0.000) and were in highly precarious employment (β = 0.146, t = 2.33, p = 0.021). it was likewise found that the interaction between realistic threat and precarious employment was significant (β = 0.561, t = 2.65, p = 0.009). to understand the interaction between variables we follow the process suggested by aiken and west [58] . the test of simple slopes revealed that the realistic threat of participants predicted prejudice when they were in highly precarious employment ((+1 sd) (β = 0.439, t = 5.55, p = 0.000) but not when precarious employment was low (−1 sd) (β = 0.137, t = 2.09, p = 0.057). that is, individuals showed more prejudice when they perceived a higher threat regarding resources with respect to refugees and were in a situation of precarious employment. (figure 1 ). at the same time, interaction between symbolic threat and outgroup morality was significant (β = −0.300, t = −4.40, p = 0.000). the test of simple slopes revealed that symbolic threat in the participants predicted prejudice when they showed low levels of outgroup morality (−1 sd) (β = 0.260, t = 3.91, p = 0.000), but not with high levels (+1 sd) (β = 0.012, t = 1.40, p = 0.888). that is, when individuals perceived a risk to their values and customs from the syrian refugees and thought that the latter were not honest or trustworthy, more prejudice was felt ( figure 2 individuals showed more prejudice when they felt threatened by the refugees in the realistic dimension (β = 0.447, t = 2.07, p = 0.020) and the symbolic one (β = 0.759, t = 3.53, p = 0.001), perceived low morality in the refugees (β = −0.276, t = −3.70, p = 0.000) and were in highly precarious employment (β = 0.146, t = 2.33, p = 0.021). it was likewise found that the interaction between realistic threat and precarious employment was significant (β = −0.561, t = −2.65, p = 0.009). to understand the interaction between variables we follow the process suggested by aiken and west [58] . the test of simple slopes revealed that the realistic threat of participants predicted prejudice when they were in highly precarious employment ((+1 sd) (β = 0.439, t = 5.55, p = 0.000) but not when precarious employment was low (−1 sd) (β = 0.137, t = 2.09, p = 0.057). that is, individuals showed more prejudice when they perceived a higher threat regarding resources with respect to refugees and were in a situation of precarious employment. (figure 1 ). at the same time, interaction between symbolic threat and outgroup morality was significant (β = −0.300, t = −4.40, p = 0.000). the test of simple slopes revealed that symbolic threat in the participants predicted prejudice when they showed low levels of outgroup morality (−1 sd) (β = 260, t = 3.91, p = 0.000), but not with high levels (+1 sd) (β = 0.012, t = 1.40, p = 0.888). that is, when individuals perceived a risk to their values and customs from the syrian refugees and thought that the latter were not honest or trustworthy, more prejudice was felt ( figure 2 ). in this study we have sought to study the relationship of the feeling of threat, level of employment precariousness, and perception of outgroup morality with prejudice towards syrian refugees in the spanish context. the majority of refugees experience diverse emotional problems and a deterioration in their psychological wellbeing as a consequence of the traumatic experiences they live through [59] . the response of the host society during their arrival and the perception of being accepted can be key to their integration and recovery [60] and, in contrast, perceived discrimination can generate disorders such as depression and anxiety [61, 62] . in keeping with the itt [17] , outgroup threat plays an important role in understanding outgroup hostility towards the collective studied. in this sense, our results are in line with what was posited in h1: the host population shows more prejudice when it feels threatened by the syrian individuals, due to competition for resources (h1a) and because the refugees could put their values, traditions and worldview at risk. (h1b). different studies along these lines have corroborated the relationship between hostility towards minority groups and realistic threat [12, 13, 17, 63] as well as symbolic threat [25, 64] . on the other hand, our h2 postulated that individuals who were in a situation of highly precarious employment would experience more negative emotions towards syrian refugees. indeed, our results are in line with what we expected, with individuals in highly insecure employment being those who showed greater outgroup hostility. from the classic theory of realistic threat for analyzing prejudice [65] , it was established that when groups compete for resources, more intense intergroup rejection behavior and emotions arise, leading to increased prejudice and discrimination. in addition, according to our data, the situation of precarious employment is a moderating factor in the feeling of realistic threat, as was formulated in h3. when individuals scored high in this dimension of threat and are in a situation of precarious employment more prejudice towards syrian refugees was displayed. this relationship is worthy of note, given the current healthcare crisis, which is also provoking a social and economic crisis, considerably increasing levels of unemployment. specifically, in spain following the outbreak of the covid-19 pandemic, the current unemployment rate (may 2020) is at 14.4%. in situations of crisis, the perception of threat increases [51] and minority groups (for example, immigrants and refugees) can become scapegoats for taking out frustration [66] and consequently prejudice is increased. therefore, fostering policies of employability and improving in this study we have sought to study the relationship of the feeling of threat, level of employment precariousness, and perception of outgroup morality with prejudice towards syrian refugees in the spanish context. the majority of refugees experience diverse emotional problems and a deterioration in their psychological wellbeing as a consequence of the traumatic experiences they live through [59] . the response of the host society during their arrival and the perception of being accepted can be key to their integration and recovery [60] and, in contrast, perceived discrimination can generate disorders such as depression and anxiety [61, 62] . in keeping with the itt [17] , outgroup threat plays an important role in understanding outgroup hostility towards the collective studied. in this sense, our results are in line with what was posited in h1: the host population shows more prejudice when it feels threatened by the syrian individuals, due to competition for resources (h1a) and because the refugees could put their values, traditions and worldview at risk. (h1b). different studies along these lines have corroborated the relationship between hostility towards minority groups and realistic threat [12, 13, 17, 63] as well as symbolic threat [25, 64] . on the other hand, our h2 postulated that individuals who were in a situation of highly precarious employment would experience more negative emotions towards syrian refugees. indeed, our results are in line with what we expected, with individuals in highly insecure employment being those who showed greater outgroup hostility. from the classic theory of realistic threat for analyzing prejudice [65] , it was established that when groups compete for resources, more intense intergroup rejection behavior and emotions arise, leading to increased prejudice and discrimination. in addition, according to our data, the situation of precarious employment is a moderating factor in the feeling of realistic threat, as was formulated in h3. when individuals scored high in this dimension of threat and are in a situation of precarious employment more prejudice towards syrian refugees was displayed. this relationship is worthy of note, given the current healthcare crisis, which is also provoking a social and economic crisis, considerably increasing levels of unemployment. specifically, in spain following the outbreak of the covid-19 pandemic, the current unemployment rate (may 2020) is at 14.4%. in situations of crisis, the perception of threat increases [51] and minority groups (for example, immigrants and refugees) can become scapegoats for taking out frustration [66] and consequently prejudice is increased. therefore, fostering policies of employability and improving work conditions not only foment a more socially cohesive society, but also one where potential intergroup conflicts can be prevented. lastly, in this study we have taken into account the stereotyped dimension of morality, so that when individuals perceive the syrian refugees as not being honest or trustworthy, they showed more prejudice, in accordance with h4. different studies [46, 47] have determined that the dimension of morality is the one carrying most weight when determining valuations of certain groups and is a determining factor in regards to prejudice [42, 53] . furthermore, in our study we have been able to verify that morality is a moderating factor for symbolic threat, as was posited in h5. when individuals feel that syrian refugees constitute a threat to their worldview, traditions and ways of understanding life and presuppose that these have unethical or socially harmful values, they display a higher degree of outgroup hostility. as a main limitation of our study, we point out that in our research the consideration of individuals with a highly precarious employment has been made up of two elements: an objective one, being unemployed, and subjective, one's own assessment of their work conditions as being negative, understanding that the feeling of threat from outgroups can be activated in the lowest socio-economic groups and among those with fewer resources. in future studies, it would be worthwhile verifying if there are differences with respect to the level of prejudice and the perception of threat by individuals who are unemployed contrasted with those who, although are working, consider their employment to be of low quality. at the same time, it should be analyzed, if after the covid-19 pandemic, with the resulting higher unemployment rate (which is currently about 20%), the negative conception and rejection of refugees has increased. it would also be important to know if there are differences in the level of prejudice according to the level of education and the perceived social class. along these lines, it would be of importance to check for possible differences in the stereotypes towards different groups of refugees, for example, towards venezuelans, who represent the largest group of refugees in spain [50] . we also consider it relevant to study the possible differences that may exist in psychological well-being between the local population and refugees. likewise, it would be convenient to analyze the perception of rejection felt by the refugee population since the threat of stereotyping in minority groups can increase anxiety and deteriorate mental health [67] . lastly, we should add that, in future research, it would be of value to consider ideological viewpoints in relation to prejudice. in this vein, the study carried out in different european countries by wike, stokes and simmons [68] points out that individuals with a right-wing political ideology are more concerned about the arrival of refugees and show more negative attitudes towards minorities (especially muslims). at the same time, the ideological variables of right-wing authoritarianism [69] and social dominance [70] have been widely related to prejudice [71] [72] [73] and outgroup threat [74] . according to the geneva convention [75] , states must share responsibility for taking in those individuals who have to flee their countries of origin because they are in danger. however, european countries, until now, have not developed a true policy of integration for this collective. this inevitably leads to the host population feeling threatened and to the existence of different elements that can increase prejudice. in the shared beliefs held regarding outgroups, cultural factors, socialization processes and political, social and economic circumstances all play a central role [76] . the degree of understanding and framework in which intergroup relations are established have an effect at the collective level, according to the group they are immersed in, as well at the individual level. in the case of the individuals making up the minority groups, the perception of societal rejection and discrimination could lead to a loss of psychological wellbeing, and as such, deterioration in mental health [61] . the fact that at this moment, syria is one of the countries with the highest number of displaced persons as a consequence of the war [1] , and that a significant volume of refugees have arrived in spain within a short span of time [50] , makes it necessary to attend to this social reality for the sake of constructing a more cohesive society, fomenting equality among fellow citizens and improving the mental health of the refugee collective. in this study, we have been able to confirm that the feeling of threat towards refugees is moderated by the perception of employment precariousness and outgroup morality-elements that must be taken into consideration for improving the inclusion and integration of this collective and for developing positive intergroup relations. the results of this research show that for future intervention programs aimed at reducing racism and xenophobia, it is important to deconstruct the perception of refugees as a threat, to seek empathy with this group and to highlight their possible contribution to the host society. the 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jordy; ragazzoni, luca; barone-adesi, francesco title: excess deaths and hospital admissions for covid-19 due to a late implementation of the lockdown in italy date: 2020-08-05 journal: int j environ res public health doi: 10.3390/ijerph17165644 sha: doc_id: 267034 cord_uid: s3hf4bo5 in italy, the covid-19 epidemic curve started to flatten when the health system had already exceeded its capacity, raising concerns that the lockdown was indeed delayed. the aim of this study was to evaluate the health effects of late implementation of the lockdown in italy. using national data on the daily number of covid-19 cases, we first estimated the effect of the lockdown, employing an interrupted time series analysis. second, we evaluated the effect of an early lockdown on the trend of new cases, creating a counterfactual scenario where the intervention was implemented one week in advance. we then predicted the corresponding number of intensive care unit (icu) admissions, non-icu admissions, and deaths. finally, we compared results under the actual and counterfactual scenarios. an early implementation of the lockdown would have avoided about 126,000 covid-19 cases, 54,700 non-icu admissions, 15,600 icu admissions, and 12,800 deaths, corresponding to 60% (95%ci: 55% to 64%), 52% (95%ci: 46% to 57%), 48% (95%ci: 42% to 53%), and 44% (95%ci: 38% to 50%) reduction, respectively. we found that the late implementation of the lockdown in italy was responsible for a substantial proportion of hospital admissions and deaths associated with the covid-19 pandemic. in early january a novel strain of coronavirus, sars-cov-2, a virus which follows a human-tohuman transmission, was identified in the hubei province of china as the causative agent for a new disease later defined as coronavirus disease 2019 (covid-19), a respiratory disease which is often characterized by influenza-like symptoms but which can also evolve (3-5% of the cases) into acute respiratory distress syndrome, or even sepsis, and multi-organ failure which might lead to death [1] . starting from an outbreak in china, the scale of the emergency has rapidly grown globally, leading the world health organization (who) to declare the pandemic status on march 11th, 2020 when many countries had already introduced unprecedented physical distancing and containment measures to various extents [2] . as of may 28th, 2020 almost six million of covid-19 cases and 361,836 deaths have been recorded worldwide [3] . the effect of containment measures in curbing the covid-19 epidemic varied among countries [4] [5] [6] [7] [8] [9] . while a combination of stringent policies together with wide early-phase testing coverage and effective contact tracing strategies was effective in halting the covid-19 epidemic in countries such as mainland china, hong kong, and south korea, in others the epidemic slowed only recently [3, 5, 6, 8] . factors explaining differences in time patterns might be found in the readiness of government responses and in the degree of compliance of the population to the implemented policies [5] [6] [7] [8] [9] . italy, which has passed 232,000 confirmed cases and 33,000 deaths [10] , is one of the most affected countries in the world so far and the first in europe where the public health emergency rapidly escalated at the national level. on march 9th, 2020 the government ordered a national lockdown, a measure including: (a) strict home confinement of the entire population; (b) closure of all non-essential commercial activities; (c) mobility restrictions related to the involved municipalities [11] . the lockdown remained in place until may 3rd, when a slowdown of the epidemic in the different italian regions allowed its release [12] . compared with china, italy introduced containment measures later in the course of the national epidemic, about one month after the first covid-19 case was reported in the country. italy's lockdown was enforced 13 days after the one in hubei, when normalizing for the time when the outbreak hit 50 cases in both countries [8] . this prompted a debate, in italy and abroad, on the causes of such a delay and on how many covid-19 cases could have been avoided, had the lockdown been implemented earlier [13] . a formal investigation into possible government mismanagement of the covid-19 crisis is currently ongoing [14] . the aim of this study was to evaluate the health effects of late implementation of the lockdown in italy. for this reason, we estimated the number of deaths and hospital admissions for covid-19 that would have occurred if the lockdown had been implemented one week earlier than it was actually enforced. in the present analysis we used data on the daily number of covid-19 cases, hospitalized patients, and deaths recorded in italy from february 24th, the first day national data were made available, to may 3rd, the last day of implementation of the national lockdown. figures were provided by the official website of the italian department of civil protection [10] . first, we evaluated the effect of the italian lockdown using interrupted time series (its) analysis. we modeled the time-series of daily new cases, y t , using the following quasi-poisson regression model, accounting for the possible overdispersion of data: where t is the time elapsed since the start of the study; t 2 is the time elapsed since the implementation of lockdown (set to 0 before the lockdown); x is a dummy variable indicating the pre-lockdown period (coded 0) or the post-lockdown period (coded 1); y is the logarithm of the number of new cases at time t; α is the intercept of the model; β 1 represents the trend of new cases before the lockdown; β 2 is the step change following the lockdown; β 3 is the slope change following the lockdown; and e t is the error term of the model. preliminary analysis of the data suggested that no adjustment was required for autocorrelation of the error terms e t . we also assumed a two-week lag between the implementation of the lockdown (march 9th) and the start of its effects (march 23rd), to take into account the covid-19 incubation period and the diagnostic delay after symptoms onset [15] . second, we evaluated the effect of an early lockdown on the trend of new cases, creating a counterfactual scenario where the lockdown was implemented one week in advance (i.e., on march 2nd instead of march 9th). third, based on the expected number of new cases, we predicted the corresponding number of intensive care unit (icu) admissions, non-icu admissions, and deaths, using a previously published mathematical model [16] . briefly, the model simulates the progress of infected individuals between different compartments during the course of an epidemic: isolated at home, admitted in a non-icu ward, admitted in icu, recovered, dead. finally, we compared the number of hospital admissions and deaths under the actual and counterfactual scenarios. all the analyses were performed using the r software (r core team (2013). r: a language and environment for statistical computing. r foundation for statistical computing, vienna, austria. url http://www.r-project.org/). from february 24th to may 3rd, 210,717 cases of covid-19 were observed in italy. there was an exponential increase in the number of new covid-19 cases until march 22nd, followed by a sharp reduction (table 1; figure 1 ). table 1 reports estimated coefficients, while related predictions are plotted in figure 1 together with the expected number of new cases under the counterfactual scenario. on may 3rd, the number of new cases under the counterfactual scenario was less than half than that estimated under the observed scenario. and deaths under the actual and counterfactual scenarios. all the analyses were performed using the r software (r core team (2013). r: a language and environment for statistical computing. r foundation for statistical computing, vienna, austria. url http://www.r-project.org/). from february 24th to may 3rd, 210,717 cases of covid-19 were observed in italy. there was an exponential increase in the number of new covid-19 cases until march 22nd, followed by a sharp reduction (table 1; figure 1 ). table 1 reports estimated coefficients, while related predictions are plotted in figure 1 together with the expected number of new cases under the counterfactual scenario. on may 3rd, the number of new cases under the counterfactual scenario was less than half than that estimated under the observed scenario. figure 2 shows differences in the total number of cases, non-icu admissions, icu admissions, and deaths under the two scenarios. the plots show that an early implementation of the lockdown would have averted about 126,000 covid-19 cases, 54,700 non-icu admissions, 15,600 icu admissions, and 12,800 deaths. on the relative scale, this corresponds to a reduction of 60% (95%ci: 55% to 64%), 52% (95%ci: 46% to 57%), 48% (95%ci: 42% to 53%) and 44% (95%ci: 38% to 50%), respectively (table 2 ). figure 2 shows differences in the total number of cases, non-icu admissions, icu admissions, and deaths under the two scenarios. the plots show that an early implementation of the lockdown would have averted about 126,000 covid-19 cases, 54,700 non-icu admissions, 15,600 icu admissions, and 12,800 deaths. on the relative scale, this corresponds to a reduction of 60% (95%ci: 55% to 64%), 52% (95%ci: 46% to 57%), 48% (95%ci: 42% to 53%) and 44% (95%ci: 38% to 50%), respectively (table 2 ). moreover, the maximum hospital demand would have been much lower under the counterfactual scenario. the peak number of non-icu admissions would have been 14,336 rather than 29,010 (−51%; 95% ci: −45% to −56%). a similar reduction would be expected for icu admissions as well (2300 vs 4068 beds; −44%, 95%ci: −38% to −49%). moreover, the maximum hospital demand would have been much lower under the counterfactual scenario. the peak number of non-icu admissions would have been 14,336 rather than 29,010 (−51%; 95% ci: −45% to −56%). a similar reduction would be expected for icu admissions as well (2300 vs. 4068 beds; −44%, 95%ci: −38% to −49%). in italy, the covid-19 pandemic led to the implementation of containment measures at the highest level, with a national lockdown enforced on march 9th, 2020. despite this, by the time the epidemic curve started to flatten, the health system had already exceeded its capacity in different areas of the country, raising concerns that the public health response was indeed delayed. we found that if restrictive measures had been enforced one week earlier, this would have had a significant impact on the evolution of the epidemic in terms of hospital admissions and deaths. by may 3rd, we estimated that there would have been a 60% reduction of covid-19 cases and 44% of confirmed deaths would have been averted. the covid-19 pandemic is threatening public health preparedness and medical response capacity globally. our findings add to a growing body of evidence supporting the need for rapid responses to contain the current covid-19 pandemic and similar threats that could occur in the future [5, 6, 12] . besides italy, other european countries profoundly impacted by the pandemic such as spain, france, and the uk, as well as the us, also hesitated to enforce containment measures in a timely manner [8] , with a consequent health, economic, and societal impact that still needs to be fully assessed. lack of collaboration between national health systems, as well as delayed communication by international organizations might be some of the factors explaining the late response to the emergency. public health intelligence at both the international and national level should identify all barriers and challenges associated with the current pandemic to improve response in the future. this is particularly necessary in this phase of the pandemic, as a possible second wave of infections is expected in the next months. as most european countries are gradually lifting restrictions, there is a need to enhance the existing surveillance systems and develop strategies for timely reactions to a new increase in the number of infections. to our knowledge, this is the first study assessing the impact of the delay in the implementation of containment measures on the spread of covid-19 epidemic, and the associated burden on the health system. however, several caveats merit discussion. first, analyses were conducted using publicly available data on confirmed cases, which did not account for the proportion of undetected cases, estimated to be high in italy, especially in the regions more affected by the epidemic [17] . this means that, on the absolute scale, our estimates should be regarded as conservative. on the other hand, assuming that the timing of the lockdown is not associated with the detection rate, which seems plausible, the relative estimates provided are expected to be unbiased. second, we did not take into account how the different hospital demand under the two scenarios affected the treatment of critical patients. in the actual scenario, hospitals in the worst-hit areas often exceeded their capacity and experienced ventilator shortages [8, 16] . this affected their capacity to deliver effective care to all critical patients. on the other hand, under the counterfactual scenario the maximum hospital demand would have been about 50% lower. for this reason, we probably underestimated the positive effects of an early lockdown in terms of reduced icu admissions and deaths. the covid-19 pandemic has been requiring unanticipated and extraordinary containment measures, which has raised concerns about public health preparedness of health systems globally. the late implementation of the lockdown in italy was responsible for a substantial proportion of hospital admissions and deaths associated with the covid-19 pandemic. understanding factors contributing to such a delayed response is fundamental to strengthen public health preparedness and timing in response capacity. clinical characteristics of coronavirus disease 2019 in china modelling the covid-19 epidemic and implementation of population-wide interventions in italy impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in hong kong: an observational study interventions to mitigate early spread of sars-cov-2 in singapore: a modelling study the effect of human mobility and control measures on the covid-19 epidemic in china sars-cov-2 and europe: timing of containment measures for outbreak control association of public health interventions with the epidemiology of the covid-19 outbreak in wuhan, china department of civil protection emergenza coronavirus: la risposta nazionale the guardian italians struggle with 'surreal' lockdown as coronavirus cases rise covid-19 epidemic in italy: evolution, projections and impact of government measures the new york times italy's virus shutdown came too late. what happens now? available online npr prosecutors question italy's top leaders over coronavirus response report of the who-china joint mission on coronavirus disease 2019 (covid-19) predicted effects of stopping covid-19 lockdown on italian hospital demand report 13-estimating the number of infections and the impact of non-pharmaceutical interventions on covid-19 in 11 european countries key: cord-287426-tzqke3ci authors: herrero, rocío; vara, mª dolores; miragall, marta; botella, cristina; garcía-palacios, azucena; riper, heleen; kleiboer, annet; baños, rosa mª title: working alliance inventory for online interventions-short form (wai-tech-sf): the role of the therapeutic alliance between patient and online program in therapeutic outcomes date: 2020-08-25 journal: int j environ res public health doi: 10.3390/ijerph17176169 sha: doc_id: 287426 cord_uid: tzqke3ci background: therapeutic alliance (ta) between the patient and therapist has been related to positive therapeutic outcomes. because internet-based interventions are increasingly being implemented, a tool is needed to measure the ta with internet-based self-guided programs. the working alliance inventory for online interventions (wai-tech-sf) was adapted based on the wai short form (hatcher & gillaspy, 2006). the objectives of this study were: (1) to analyse the psychometric properties of the wai-tech-sf; (2) to explore the differences in the wai-tech-sf scores according to different categories of the sample; and (3) to analyse whether the wai-tech-sf can predict therapeutic outcomes and satisfaction with the treatment. methods: 193 patients diagnosed with depression were included and received blended cognitive-behavioural therapy. measures of preferences, satisfaction, and credibility about the treatment, ta with the online program, depressive symptoms, and satisfaction with the treatment were administered. results: an exploratory factor analysis revealed a one-dimensional structure with adequate internal consistency. linear regression analyses showed that the wai-tech-sf predicted changes in depressive symptoms and satisfaction with the treatment. conclusions: wai-tech-sf is a reliable questionnaire to assess the ta between the patient and the online program, which is associated with positive therapeutic outcomes and satisfaction with the treatment. evidence shows that the therapeutic alliance (ta) (also called the working alliance) has a relevant influence on therapeutic outcomes [1] . several meta-analyses have found that ta is moderately patients and the online program, and it showed similar psychometric properties to the original scale (i.e., the wai). in this adaptation, items were slightly adapted by replacing "therapist" with "online program", and items corresponding to the bond subscale were reworded to preserve comprehension. results showed lower scores on the bond subscale, and the total scores on wai-tech were not associated with the change in therapeutic outcomes. however, findings are limited due to the small sample size and the absence of factor analysis to analyse the psychometric properties in this study. thus, the ta developed by the patients in ibis and, specifically, in blended cognitive-behavioural therapy (cbt) (i.e., combining individual face-to-face sessions with online intervention modules) has not been completely understood. the present study was conducted in the context of a european project called "e-compared", in which previous findings found that only therapist-rated ta (but not patient-rated ta) was predictive of changes in depression scores during a blended treatment in a sample of 73 patients [30] . thus, it seems that technology is a third factor in the relationship between patient and therapist, which adds more complexity to this relationship. hence, the need to measure not only the relationship between the patient and the therapist, but also between the patient and the technology, is undeniably relevant due to the growing emergence of ibis. previous studies have found that individuals have the ability to form a bond and be open with an online application [28] . however, it is still important to develop a reliable questionnaire and explore whether the three-dimensional structure proposed originally for face-to-face therapy is also maintained in the ta with the online program in self-guided ibis where there is hardly any interaction with a therapist or person supporting the intervention. to do so, an adaptation of the wai-sf to measure the ta with the online program was carried out. an exploratory factor analysis was conducted in order to avoid determining the psychometric structure a priori, given the controversial structure of ta when technologies are involved (e.g., the structure was uni-dimensional in miragall et al. [25] ; or bi-dimensional in gómez-penedo et al. [24] ). in addition, other potential variables influencing the ta with the online program were explored, as well as the capacity of the ta with the online program to predict therapeutic outcomes and satisfaction with the treatment. the study was conducted in a sample of depressive patients who were receiving a self-guided ibi in the context of the national health systems of different european countries. hence, the aims of this study were: (1) to analyse the psychometric structure of the wai-tech-sf, a questionnaire designed to assess the ta between the patient and the online program in a self-guided ibi; (2) to explore whether there are differences in wai-tech-sf scores based on sex, age-range, level of education, initial severity of depression, preference for any of the treatments offered, and expectations about and credibility of the treatment; and (3) to explore whether higher wai-tech-sf scores predict the therapeutic outcomes (i.e., change in depressive symptom scores) and satisfaction with the treatment. one-hundred and ninety-three patients took part in this study (ages ranging from 19 to 69 years old: m = 40.44 years old; sd = 12.79; 64.2% women). patients were recruited as part of the clinical trial conducted in the e-compared project (eu-health.2013 n.603098). the sample was composed of european citizens diagnosed with depression in either primary or specialized care. regarding their nationalities, 38.2% of the sample were from germany, 16.2% from sweden, 12.0% from spain, 9.8% from france, 8.4% from the netherlands, 6.3% from the uk, and 2.1% from switzerland. patients were excluded if they were under 18 years old, had serious psychiatric comorbidity, or did not have access to a computer or the internet. all the patients were diagnosed with depression using the mini. in terms of their symptoms, 10.9% of the sample showed mild symptoms of depression, 33.2% showed moderate symptoms, 36.8% showed moderate-severe symptoms, and 19.2% showed severe depressive symptomatology. in addition, 50.8% of the sample had some suicidal risk, and 61.1% of the sample had a comorbid diagnosis, such as panic disorder, agoraphobia, or social phobia. regarding their educational level, 56.0% of the sample had a high educational level, 31.6% had a medium educational level, and 12.4% had a low educational level. all participants were informed about the study and gave their informed consent before the beginning of the trial, in accordance with the declaration of helsinki. the study was approved by the corresponding ethical committee in each country: (a) france: comité de protection des personnes, ile de france v (15033-n all the e-compared project interventions combined individual cbt delivered through face-to-face sessions and online sessions [31] . the interventions received by patients had some variations across the countries, but followed common guidelines [31] . in this regard, the ratio between the number of face-to-face sessions and the number of online modules varied across countries, but at least 1/3 of the sessions were face-to-face (i.e., between 3 and 10 sessions), and at least 1/3 were online (i.e., between 6 and 10 sessions). as a minimum, the bcbt included modules of psychoeducation, cognitive restructuring, behavioural activation, and relapse prevention. in addition, each country site was able to include additional components, such as mindfulness, coping skills training, or problem solving, but these additional components could not make up more than a quarter of the total intervention. face-to-face sessions were provided by: (1) licensed cbt therapists in mental health care; (2) cbt therapists in training under the supervision of an experienced licensed cbt therapist in mental health care; (3) a licensed psychologist with a cbt orientation in primary care; or (4) psychologists in training under the supervision of a licensed psychologist with a cbt orientation in primary care. all of them were trained in how to deliver the blended treatment. each face-to-face session lasted around 20-60 min (i.e., 45-60 min in specialized care and 20-45 min in primary care), while the online session lasted for as long as the patients took to read each session. a summary of the intervention components and the online vs. face-to face ratio are shown in table 1 . working alliance inventory applied to internet (wai-tech-sf) is an adaptation of the wai-sf [16] elaborated by the authors. it is a 12-item self-report questionnaire designed to assess the ta with the online program in a self-guided ibi, with responses rated on a seven-point likert scale, ranging from 1 (never) to 7 (always). the questionnaire was designed to cover the same structure as the original scale, with three dimensions: (1) therapeutic goals (items 1, 2, 8, 10), (2) tasks (items 4, 6, 10, 11), and (3) bonds (items 3, 5, 7, 9) . the total score ranges from 12 to 84. the mean and standard deviation for this sample were m = 57.84 and sd = 16.39. details about its adaptation appear in the "procedure" section. the questionnaire was administered at post-assessment. patient health questionnaire-9 (phq-9; [32] ) is a nine-item mood module that can be used to screen and diagnose patients with depressive disorders. it is based directly on the criteria for major depressive disorder in the diagnostic and statistical manual of mental disorders (4th ed.) [33] and its accuracy for screening to detect major depression has been demonstrated [34] . the nine items are each scored on a 0-3 scale, with the total score ranging from 0-27 and higher scores indicating more severe depression. the means and standard deviations for this sample were m = 15.50 and sd = 4.63 (pre-assessment), and m = 9.05 and sd = 5.35 (post-assessment). the phq-9 has been shown to have good psychometric properties [35] . the questionnaire was administered at pre-and post-assessment. in this study, cronbach's alphas ranged from 0.73 to 0.87. international neuropsychiatric interview (mini 5.0; [36] ) is a structured diagnostic interview based on the diagnostic and statistical manual of mental disorders (dsm-iv) and on international classification of diseases (icd-10) criteria. the mini has been translated into 65 languages and is used for both clinical and research practices. the full mini. 5.0, with the exception of anorexia nervosa, bulimia nervosa, and antisocial personality disorder, was used to provide a diagnosis at pre-assessment. preference for treatment questionnaire (ad-hoc instrument) was used to assess participants' treatment preference from the options of bcbt, tau, or no preference. specifically, the following question was asked: "if you had the chance to choose your depression treatment, which one would you prefer to receive?" credibility and expectancy questionnaire (ceq; [37] ) was used to assess the prior predisposition of patients to the proposed intervention. the scale consists of six items divided into two factors: expectancy (with three questions rated on a 10-point scale, ranging from 1 to 9) and credibility (with one question rated on a 10-point scale and two questions rated on a 1-100% scale). the means and standard deviations for this sample were m = 17.59 and sd = 4.92 (in a scale ranging from 3 to 27) and m = 19.32 and sd = 5.15 (on a scale ranging from 3 to 27) for expectancy and credibility, respectively. in this study, cronbach's alphas were 0.86 for expectancy and 0.72 for credibility. client satisfaction questionnaire (csq-8; [38] ) was used to assess patients' satisfaction with the treatment. this questionnaire has been translated into multiple languages, and it is used to measure global patient satisfaction. the questionnaire consists of eight items rated on a four-point scale, with total scores ranging from 8 to 32. the mean and standard deviation for this sample were m = 25.39 and sd = 5.00. the questionnaire was administered at post-assessment. in this study, cronbach's alpha was 0.92. an adaptation of the patient version of the wai-sf [16] was carried out following the recommendations of hambleton and patsula [39] . thus, the purpose of the wai-tech-sf is to measure agreement about goals, tasks, sense of trust, comfort, and bonding between the patient and the "online program". to this end, the sentences on the current scale were kept as similar as possible to the originals, but "my therapist" or therapy was replaced with "online program". items are displayed in table 2 . once the wai-tech-sf had been adapted, it was applied in the context of the e-compared european project to the participants receiving the bcbt. all the patients in the project were recruited in the national health systems of the countries involved, in either primary or specialised care. their status was assessed with the mini interview, performed by a clinical psychologist. if patients met the inclusion criteria, they were allocated to one of two conditions: bcbt or treatment as usual (tau) (for more details about the trial, see kleiboer et al. [31] ). all participants filled out the phq-9 questionnaire to assess the severity of their depressive symptoms and their preference for the intervention ("blended", "tau", or "no preference"), and the ceq scale was used to assess the patients' expectations and credibility with regard to the intervention offered. for the purposes of the current study, only participants allocated to the bcbt condition were taken into account, given that those in the tau condition did not receive any therapeutic support online. once patients had finished the intervention, they were assessed again on their depressive symptoms, their satisfaction with the treatment through the csq scale, and their ta with the self-guided ibis using the wai-tech-sf. all statistical analyses were performed using the spss v.26 (ibm corp, armonk, ny, usa). the percentage of missing values in the wai-tech-sf, phq-9, and ceq scores ranged from 0% to 1.6%. after testing that the values were missing at random using little's mcar test (p > 0.05), they were imputed using the expectation-maximization algorithm method [40] . then, several analyses were carried out. first, to analyse the psychometric properties of the wai-tech-sf, skewness and kurtosis were analysed to check the normality of the data [41] . kaiser-meyer-olkin (kmo), and barlett's test of sphericity was used to ensure the suitability of the data for performing an exploratory factor analysis (efa). parallel analysis [42] was applied using a macro for spss [43] to determine the number of factors retained in the efa. then, to explore the factor structure of the wai-tech-sf, an efa was conducted using a maximum likelihood estimation extraction method because the data were normally distributed [41] . internal consistency of the total score was assessed using cronbach's alpha coefficient [44] . second, preliminary analyses were conducted to ensure that relevant assumptions of t-tests, anovas, and simple/multiple regression (i.e., normality, linearity, homoscedasticity, and absence of multicollinearity) were met. third, independent-samples t-tests and one-way anovas were performed to find out whether there were significant differences in the wai-tech-sf scores based on sex, age range (18-34 vs. 35-49 vs. > 50), level of education (low vs. medium vs. high), initial severity on phq scores (mild vs. moderate vs. moderate-severe vs. severe), preference for any of the treatments offered (no preference vs. blended vs. tau), and expectations and credibility towards the treatment. expectations and credibility scores were categorized as low (mean-1 standard deviation), medium (mean), and high (mean + 1 standard deviation). t-values are reported as absolute values. fourth, two simple linear regression analyses (using the enter method) were carried out to study whether the wai-tech-sf scores predicted the changes in phq scores and satisfaction with the treatment. phq scores were calculated using the differences between post-and pre-assessment scores (post-pre). thus, positive values indicated an increase in depression symptoms, whereas negative values indicated a decrease in depression symptoms. finally, a power analysis was conducted to determine whether the present study was adequately powered with our sample size (n = 193) (the sample size of this study was initially calculated for testing the hypothesis that bcbt was not inferior to the tau condition on the primary clinical outcome (i.e., symptoms of depression at 3 months after baseline) (see kleiboer et al. [31] ), but not for the secondary outcomes and analyses). using g*power v. 3.1.9.743 (heinrich-heine-universität, düsseldorf, germany), we calculated power for: (1) an omnibus f-test "fixed effects, one-way"; (2) a t-test "differences between two independent means"; and (3) an omnibus f-test "lineal multiple regression: fixed model, r 2 deviation from zero". an effect size of f = 0.20 or f 2 = 0.12 was used because there is still limited data in this field and d = 0.40 is a standard in psychology, according to brysbaert [45] . results indicated that the current study had 69.38% and 62.68% power for one-way anovas with three and four groups, respectively, 75.49% for the t-test, and 99.77% for the regression analyses with one predictor to detect a medium effect size at p < 0.05. a random percentage of missing values was found, with little's mcar test, χ 2 (33) = 14.27, p = 0.998, ranging from 0 to 1.6% per item. consequently, items' missing values were imputed using the expectation-maximization algorithm method [38] . the sample's normality was assumed because skewness values were <|2|, and kurtosis values were <|7| [46, 47] (see table 2 ). the kmo value was (0.96), and the barlett's test of sphericity value, χ 2 (66) = 2587.26, p < 0.001, showed that it was appropriate to perform a factor analysis. regarding the number of factors to extract, parallel analysis [40] showed that one factor had to be retained because only one factor had an eigenvalue (raw data eigenvalue = 9.08) greater than the eigenvalue at the 95th percentile for randomly generated data (95th percentile eigenvalue = 1.53) [48] . factorial rotation with one dimension was performed using the maximum likelihood extraction method, which showed that one dimension explained 73.49% of the total variance. the factorial solution showed that all the items had minimum factor loadings and communalities above ≥0.30 (see table 2 ). cronbach's alpha coefficient for the wai-tech-sf was high for the overall scale (α = 0.97). we analysed the item-total correlation, and the exclusion of any item increased the alpha value for the overall scale. table 3 shows the means and standard deviations of the wai-tech-sf scores according to sex, age-range, level of education, initial severity on phq scores, preference for any of the treatments offered, and expectations and credibility towards the treatment. independent-sample t-tests and one-way anovas showed that there were no significant differences in the wai-tech-sf scores based on sex, age-range, initial severity of depression, preferences for any of the treatments offered, expectations about the treatment, and credibility of the treatment. however, there were significant differences in the wai-tech-sf scores based on the level of education. patients with high (vs. low) education levels achieved higher scores on the wai-tech-sf, p = 0.042. given the number of potential predictor variables of the wai-tech-sf, we also carried out a stepwise linear regression in order to analyse the explained variance by each variable. to do so, age, expectations, and credibility towards the treatment were maintained as continuous variables. categorical predictor variables (i.e., level of education, initial severity of depression, and preference for any of the treatments offered) were transformed into dummy-coded variables. the reference category was "low" (vs. "medium and high") for level of education, "mild" (vs. moderate, moderate-severe and severe) for initial severity of depression, and "no preference" (vs. blended and treatment as usual) for preference for any of the treatments offered. results of this regression analysis showed that two models were significant. the first model the model where changes in phq pre-post intervention scores were predicted by wai-tech-sf scores was statistically significant, f(1,188) = 14.42, p < 0.001, explaining 6.7% of the variance. higher scores on the wai-tech-sf predicted a greater decrease in depression symptoms. similarly, the model in which satisfaction with the treatment was predicted by the wai-tech-sf scores was statistically significant, f(1,187) = 185.53, p < 0.001, explaining 49.7% of the variance. higher scores on the wai-tech-sf predicted higher scores on satisfaction with the treatment (see table 4 ). the objectives of this study were: (1) to explore the psychometric structure of a questionnaire (i.e., the wai-tech-sf) designed to assess the ta with an online program in a self-guided ibi and cbt program in a sample of depressive patients in the context of the national health systems of different european countries; (2) to analyse whether there were differences in the wai-tech-sf scores based on several socio-demographic variables, initial symptoms of depression, preference for any of the treatments offered, and expectations and credibility towards the treatment; and (3) to study the capacity of the wai-tech-sf scores to predict the therapeutic outcomes (i.e., changes in depressive symptoms) and satisfaction with the treatment. with regard to the psychometric properties of the wai-tech-sf, a unidimensional structure emerged in the efa that accounted for 73.49% of the explained variance. all the factors had high factor loadings, and the overall scale had excellent internal consistency. this unidimensionality is in line with the structure found in the validation of the wai applied to virtual and augmented reality (wai-var, [25] ). however, this structure is inconsistent with the three-dimensional structure of bordin's [4] theory and the original validation of the wai-sf carried out by hatcher and gallispy [16] to measure ta in the face-to-face context, distinguishing three separate factors: tasks, goals, and bonds. nevertheless, the structure of this questionnaire is controversial because a bi-factorial structure has also been found in other validations of the wai, such as in gómez-penedo et al. [24] , who found that in the ta with the therapist in ibis, "goals and tasks" loaded in the same factor, whereas "bond" loaded in a separate factor. according to our findings, a three-dimensional structure cannot be assumed a priori in the context of ibis. more specifically, in the case of the ta with an online program during a self-guided ibi, the theoretical distinction between task, goals, and bond with the online program was not psychometrically significant, and a single factor could explain the majority of the explained variance of the ta between the patient and the online program. however, these results should be interpreted with caution because ibis are continuously evolving, and a more personalized treatment that uses algorithms to provide personalized feedback or set individualized goals or tasks depending on the emotional state or unique needs of each patient throughout the treatment could generate a more differentiated factorial structure of the wai-tech-sf. another possible explanation for the structure of the wai-tech-sf is related to the fact that the ta with the online programs is highly complex, and merely replacing the words is not sufficient to capture the subtle differences in these different kinds of ta. in other words, perhaps the dimensions of the questionnaire should be completely reframed [28] . in this regard, henson, peck, and torous [49] developed the digital-wai (d-wai), a six-item self-report questionnaire based on bordin's three dimensions, but aligned with the purpose of smartphone-based interventions (e.g., "bond" is aimed at measuring the capacity of the app to offer support and guide them through challenges). more recently, miloff et al. [50] adopted this approach of developing novel items and validated the virtual therapist alliance scale (vtas), which assesses the three components of the ta with virtual therapists in an automated exposure treatment format for patients with fear of spiders. two factors emerged in the exploratory factor analysis ("task, goal, and copresence" and "bond and empathy") that had small and non-significant correlations with therapeutic outcomes at post-treatment, but moderate and significant correlations at follow-up. regarding the differences in the wai-tech-sf scores according to different characteristics of the sample, overall, no differences were found. that is, the ta with the self-guided ibi was achieved by the patients independently of their sex, their age, the severity of their depression before starting the intervention, their preferences for doing the intervention in the assigned condition, or the expectations and credibility towards the treatment. the average score on the wai-tech-sf was around 58 (on a scale ranging from 12 to 84). nevertheless, patients with a higher level of education scored higher on ta with the online program than patients with a low level of education. this finding was also corroborated by the exploratory multiple regression analysis, in which all the different characteristics of the sample were introduced as potential predictors of the wai-tech-sf scores. results showed that level of education, but also the age, were positive significant predictors of the ta with the self-guided ibi, explaining 4.9% of the variance. regarding level of education, this higher ta could be related to the fact that more positive therapeutic outcomes in ibis are also predicted by having a higher level of education [51] . moreover, these findings may be associated with the lower preferences for ibis expressed by people with a lower level of education [52] , or the related barriers to the use of a less-known technology (e.g., low trust and lack of confidence in the capacity of ibis to actually help). the lower preference for technology adoption has also been related to age (e.g., because of their lower proficiency). moret-tatay et al. [53] found that older adults showed lower scores in mobile device and computer proficiency than younger adults. consequently, adapted computer systems for older people have been designed to reduce the barriers that this population encounter. mitzer et al. [54] found that the use of an adapted computer system for older people at the mid-and long-term was predicted by the earlier use of the system, the higher cognitive abilities (i.e., executive functioning), and computer efficacy. hence, future studies should assess technology proficiency and cognitive abilities before starting a self-guided ibi in order to avoid the problems associated with the level of education and age, such as the adherence to the therapy. nevertheless, older patients achieved higher ta in our study. one possible explanation for this finding is that the lower technology proficiency typically found in the population could have been compensated by the greater involvement in the therapy. regarding the capacity of the ta with the self-guided ibi to predict therapeutic outcomes, the findings highlight the importance of considering the wai-tech-sf scores to predict the change in depressive symptoms and satisfaction with the intervention. the ta with the online program explained 6.7% of the change in depressive symptoms, and 49.7% of the satisfaction with the treatment. consequently, the relationship between "patient-online program ta" and therapeutic outcomes is also in line with the positive relationship found between the "patient-therapist ta" and the therapeutic outcomes in face-to-face therapy [1, 2] and ibis [3, 21] . however, to our knowledge, this is the first study to confirm the relationship between "patient and online program ta" and therapeutic outcomes. by contrast, kiluk et al. [29] did not find that the total scores on the long form of the wai-tech were associated with the change in therapeutic outcomes. hence, so far, only the present study and miragall et al. [25] found a significant relationship between the ta with the technology (i.e., the ta between the patient and virtual and augmented reality) and therapeutic outcomes. therefore, this finding supports the need to work directly on the ta when it is poor because it has important consequences for therapeutic outcomes. future studies should include algorithms to detect low ta scores after each session, in order to adjust the goals, tasks, and bond between the patient and the online program during an ibi. this study has some limitations. first, the wai-tech-sf was only administered at the end of the treatment, which did not allow us to explore whether the "patient and online program ta" preceded the symptoms and satisfaction throughout the therapeutic sessions. thus, having these measures during the treatment would allow us to establish the causal effect of ta on the therapeutic outcomes. future studies should administer the wai-tech-sf in earlier therapeutic sessions (e.g., third session) in order to examine the ta through the therapy. second, the study sample was only composed of depressive patients. therefore, future studies should replicate this study in a sample of patients with several diagnoses (e.g., anxiety, post-traumatic stress disorder) in order to confirm whether the same psychometric structure is found, and to detect its capacity to predict therapeutic changes in other mental disorders. third, the adherence or number of sessions performed by the patients was not registered. thus, future studies should analyse whether the ta affects adherence and, in turn, the therapeutic outcomes. fourth, the statistical analyses of ta were only conducted with the patients that accepted to fill in the questionnaire after the self-guided ibi was finished. however, the normal distribution (e.g., skewness = −0.56; kurtosis = −0.83) and the wide range of variability of the wai-tech-sf scores (i.e., from 12 to 84) allowed us to draw reliable conclusions. the importance shown by the ta with the technology points out the question regarding the impact of ta at early stages of the treatment, and the role that it can play in predicting efficacy and preventing dropouts. finally, the importance of having self-guided ibi that promotes an adequate ta between the patient and the online program should be noted, especially when resources are scarce. several situations, such as the covid-19 pandemic, could prevent individuals from accessing the traditional face-to-face therapy. consequently, cbt delivered through telehealth services are undeniably crucial in order to provide timely psychological support, especially in vulnerable populations [55] . in conclusion, this study reveals that patients with major depression can develop ta with an online program during a self-guided ibi in the context of primary care. thus, patients can feel that the program is "taking care" of them, in terms of allowing them to achieve therapeutic goals, proposing appropriate tasks to achieve these goals, and making them feel "embraced" and "cared for" by the program. according to our exploratory factor analysis, the wai-tech-sf is a reliable questionnaire to measure this construct, but it would be advisable to calculate an overall score for the total scale, rather than using the traditional theoretical three-dimensional "task-goals-bonds" structure of ta. moreover, it would be beneficial to explore the ibi preferences of the patients with lower education levels before starting the intervention, in order to ensure that their level of education does not interfere with their capacity to develop ta with the online program. finally, this study highlights the importance of considering the "patient and online program ta" because the wai-tech-sf score was a significant predictor variable of both the change in depressive symptoms and satisfaction at the end of the treatment. further research is needed to more deeply understand the ta achieved in the "patient-technology-therapist" 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underlying dimensions: the use (and abuse) of factor analysis in personality and social psychology bulletin exploratory factor analysis considering the therapeutic alliance in digital mental health interventions measuring alliance toward embodied virtual therapists in the era of automated treatments with the virtual therapist alliance scale (vtas): development and psychometric evaluation predicting outcome of internet-based treatment for depressive symptoms preferences for internet-based mental health interventions in an adult online sample: findings from an online community survey a spanish adaptation of the computer and mobile device proficiency questionnaires (cpq and mdpq) for older adults technology adoption by older adults: findings from the prism trial staying connected during the covid-19 pandemic this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we would like to thank ciberobn, an initiative of isciii (isc iii cb06 03/0052). the authors declare no conflict of interest. key: cord-269969-xl1ooxoj authors: duong, tuyen van; pham, khue m.; do, binh n.; kim, giang b.; dam, hoa t. b.; le, vinh-tuyen t.; nguyen, thao t. p.; nguyen, hiep t.; nguyen, trung t.; le, thuy t.; do, hien t. t.; yang, shwu-huey title: digital healthy diet literacy and self-perceived eating behavior change during covid-19 pandemic among undergraduate nursing and medical students: a rapid online survey date: 2020-09-30 journal: int j environ res public health doi: 10.3390/ijerph17197185 sha: doc_id: 269969 cord_uid: xl1ooxoj assessing healthy diet literacy and eating behaviors is critical for identifying appropriate public health responses to the covid-19 pandemic. we examined the psychometric properties of digital healthy diet literacy (ddl) and its association with eating behavior changes during the covid-19 pandemic among nursing and medical students. we conducted a cross-sectional study from 7 april to 31 may 2020 at 10 public universities in vietnam, in which 7616 undergraduate students aged 19–27 completed an online survey to assess socio-demographics, clinical parameters, health literacy (hl), ddl, and health-related behaviors. four items of the ddl scale loaded on one component explained 71.32%, 67.12%, and 72.47% of the scale variances for the overall sample, nursing, and medical students, respectively. the ddl scale was found to have satisfactory item-scale convergent validity and criterion validity, high internal consistency reliability, and no floor or ceiling effect. of all, 42.8% of students reported healthier eating behavior during the pandemic. a 10-index score increment of ddl was associated with 18%, 23%, and 17% increased likelihood of healthier eating behavior during the pandemic for the overall sample (or, 1.18; 95%ci, 1.13, 1.24; p < 0.001), nursing students (or, 1.23; 95%ci, 1.10, 1.35; p < 0.001), and medical students (or, 1.17; 95%ci, 1.11, 1.24; p < 0.001), respectively. the ddl scale is a valid and reliable tool for the quick assessment of digital healthy diet literacy. students with higher ddl scores had a higher likelihood of healthier eating behavior during the pandemic. the unprecedented coronavirus disease (covid-19) pandemic has created vast socioeconomic burdens [1] , morbidity, and mortality [2, 3] . the pandemic has also changed eating behaviors for the worse [4] [5] [6] [7] . to deal with this challenge, the usa national institute of health nutrition research task force developed a 2020-2030 strategic plan to improve health and prevent or combat diseases and conditions that have been affected by food and nutrition [8] . healthy dietary intake has shown protective effects on the immune systems and health outcomes during the covid-19 crisis [9, 10] . there are no data available, and rigorous clinical trials conducted to elaborate and confirm the benefits of a healthy diet in the current covid-19 pandemic. diversified and balanced diets improve the immune response to viral infection (e.g., sars-cov-2) [11] , helping to reduce the severity [12] and any complications of covid-19 [13] . yet, unhealthy eating behaviors rapidly increased worldwide [14, 15] , including in vietnam [16] . in asean countries, the proportions of disordered eating attitudes among university students were 10%-20.6% [17] . the covid-19 pandemic has also caused an "infodemic" of diverse information and sources [18, 19] . health literacy [20] and ehealth literacy [21] are highly recommended as strategic approaches to contain the pandemic. nursing and medical students were mobilized to respond to the global health crisis [22] [23] [24] [25] , and because these future health workers can help combat misinformation and disinformation [26, 27] , their digital literacy should be promoted [28, 29] . it is critical to promote healthy dietary behaviors to improve health outcomes [30] and contain the covid-19 disease and its consequences [31] [32] [33] . the assessments of eating behaviors and nutritional status are critical to identifying comprehensive approaches for managing covid-19 [34] and suggesting sustainable food intake [35] . to identify behavior changes and develop strategies to improve students' eating behaviors, their ability to access, understand, appraise, and apply the healthy diet information on the internet during the pandemic requires a short, valid, and reliable survey tool. we examined the psychometric properties of an expanded digital healthy diet literacy (ddl) domain of health literacy to investigate associations between ddl and eating behavior changes during the covid-19 pandemic among nursing and medical students at 10 public universities in vietnam. we conducted a cross-sectional online survey from 7 april to 31 may 2020. participants from 10 universities across vietnam were recruited, including those from six universities in the nation's north, two in the south, and two in the country's central region. the study settings were all public universities that train and provide the nation's healthcare workforce. undergraduate medical and nursing students were invited as they are the medical university's major focus and the country's future healthcare providers. the data collection procedure was similar to a previous study [36] . in brief, researchers as university lecturers invited students to voluntarily participate, and there were no direct benefits or compensations for participating in the survey. lecturers sent the survey link to student leaders via email, messenger, and zalo. the student leaders sent the link to other students. the online consent forms were signed before taking the survey. students filled in the form with their name and phone number to avoid duplications, while data were coded and analyzed confidentially. a total sample of 7616 students (out of 32,632 possible participants) aged 21 to 27 years completed the survey. the studied and possible students at each university are listed in table 1 . students reported sociodemographic information, including age, gender, academic year (1 to 6 for the medical field, 1 to 4 for nursing field), academic field (medical vs. nursing), and ability to pay for medication (very or fairly difficult vs. very or fairly easy). clinical parameters were assessed including self-reported body height (cm) and weight (kg). body mass index (bmi, kg/m 2 ) was also calculated. students also reported health problems that resembled symptoms of covid-19, which were recorded as suspected covid-19 symptoms (s-covid-19-s) [37] . these included common symptoms of fever, cough, and dyspnea along with less common symptoms of myalgia, fatigue, sputum production, confusion, headache, sore throat, rhinorrhea, chest pain, hemoptysis, diarrhea, and nausea/vomiting. if students had any of those symptoms, they were classified as having s-covid-19-s or symptoms like covid-19. chronic health problems were assessed using charlson comorbidity index items [38, 39] . health literacy (hl) was evaluated using a 12-item short-form health literacy questionnaire (hls-sf12) that has been widely used in asian countries [40] , including in vietnam [41] [42] [43] . the hls-sf12 questionnaire was used to measure comprehensive health literacy, including four stages of information processing (e.g., accessing, understanding, appraising, and applying), and three domains of health (e.g., health care, disease prevention, and health promotion) [44, 45] . during the covid-19 pandemic, digital healthy diet literacy (ddl) guides people towards healthier eating behaviors that can improve immune resistance [9, 10] . therefore, as an expanded concept of health literacy, ddl refers to the ability to access, understand, judge, and apply digital healthy-diet-related information to improve healthy eating behavior and health outcomes that are critical to contain the pandemic. we adapted the hl conceptual framework and expanded a ddl domain by adding four more items to assess the information processing ability, including the ability to (1) . . . find reliable and accurate healthy diet information on the internet, (2) . . . understand healthy diet information and dietary guidelines on the internet, (3) . . . judge whether healthy diet information on the internet is applied for individuals, and (4) . . . apply healthy diet information from the internet into individuals' daily lives to eat healthily. participants reported difficulty in performing each task item based on 4-point likert scales from 1 = very difficult to 2 = fairly difficult, 3 = fairly easy, and 4 = very easy. the hl and ddl indices were standardized to a unified metric from 0 to 50 with higher scores representing better hl or ddl [46] using formula (1): where index is the specific index calculated, mean is the mean of all participating items for each individual, 1 is the minimal possible value of the mean (leading to a minimum value of the index of 0), 3 is the range of the mean, and 50 is the chosen maximum value. both hls-sf12 and ddl are subjective measures. students reported their current health-related behaviors compared with before the pandemic [36] . we did not assess the actual dietary intake or eating habits in this study. students simply self-reported the perception of eating behaviors. students rated their eating behavior as less healthy, unchanged, and healthier. they also ranked their smoking, drinking, and physical activity on a scale ranging from never to stopped, less, unchanged, and more. during the pandemic, healthier eating, continued or additional physical activity, and decreases in or the cessation of both smoking and drinking are crucial, along with the risk management strategies of hand-washing, mask-wearing, and social distancing [31] . on the one hand, we did not investigate whether the "unchanged" eating behavior during the pandemic was considered "unhealthy" or "healthy" behavior. on the other hand, in health promotion, people are suggested to comply with healthy behaviors on every basis. these healthy behaviors are even more important during the pandemic; people should have healthier eating behaviors that can improve immune function and prevent viral infection. therefore, we aimed to compare the "healthier diet" and other behavioral categories, including "unchanged" and "less healthy". similarly, because physical activity and cessation/reduction of smoking/drinking are suggested, "never, stopped, or less" were grouped into one category, and "unchanged or more" was another category. "healthier diet" and "unchanged or more physical activity" were positive behaviors; "unchanged or more" smoking or drinking were negative behaviors. the study was reviewed and approved by the institutional ethical review committee of hanoi university of public health, vietnam (irb no. 133/2020/ytcc-hd3). students voluntarily took the survey. principal component analysis (pca) with the oblique rotation (promax) method was utilized to assess the construct of the ddl scale. correlations between the ddl scale and its four items were estimated using spearman's correlation test which provided evidence of item-scale convergent validity. in addition, the correlation between ddl and hls-sf12 was estimated using the pearson correlation test that provides evidence of criterion validity [47] . cronbach's alpha test was used to check the internal consistency of the ddl scale. the floor and ceiling effects of the ddl scale were assessed by calculating percentages of the possibly lowest and highest ddl index scores. the frequency of eating behaviors (less healthy/unchanged vs. healthier) in different categories of socio-demographics, clinical parameters, and other health-related behaviors were explored using a chi-square test. in addition, a one-way anova test was used to check the distribution of hl and ddl scales by two categories of eating behavior. multivariable logistic regression models were used to assess the associations of hl and ddl along with eating behavior change. adjusted variables in the multivariable model were those demonstrating the associations with eating behavior change at p < 0.20 in the univariable analysis [48] . in order to exclude colliders which may cause multicollinearity, spearman's correlation test was used to check correlations between them. if the case of a moderate or high correlation, a representative variable was selected in the multivariable analysis. data analysis was conducted using ibm spss version 20.0 for windows (ibm corp., armonk, ny, usa). p < 0.05 was set for statistical significance. the mean age was 21.4 ± 1.8 years. out of all ages, 37.5% were men, 60.1% were 3rd-6th-year students, 75.7% were medical students, and 51.8% reported the ability to pay for medications at a very easy or fairly easy level. of the study sample, 20.8% were underweight, 6.5% were overweight or obese, 19.2% reported s-covid-19-s, and 4.4% reported one or more chronic health problems. in all, 2.9%, 6.3%, and 69.7% of students reported "unchanged or more" smoking, drinking, and physical activity during the pandemic as compared to that before the pandemic, respectively. during the pandemic, 42.8% of students reported healthier eating behavior compared to before the pandemic. means of hl and ddl scores were 34.4 ± 6.9 and 33.9 ± 8.5, respectively (table 2 ). hl index, mean ± sd 34.4 ± 6.9 34.0 ± 6.9 34.9 ± 6.9 <0.001 34.4 ± 6.9 34.0 ± 6.9 34.9 ± 6.9 <0.001 34.4 ± 6.9 34.0 ± 6.9 34.9 ± 6.9 < 0.001 ddl index, mean ± sd 33.9 ± 8.5 33 * result of one-way anova test or chi-square test appropriately. ** suspected covid-19 symptoms included common symptoms (fever, cough, dyspnea) and less common symptoms (myalgia, fatigue, sputum production, confusion, headache, sore throat, rhinorrhea, chest pain, hemoptysis, diarrhea, and nausea/vomiting). the kaiser-meyer-olkin values (kmo) for the whole scale of the overall sample, nursing, and medical students were 0.78, 0.77, and 0.79, respectively. in addition, ranges of kmo values for individual items of the overall sample, nursing, and medical students were 0.75-0.83, 0.74-0.81, and 0.75-0.83, respectively. these values were higher than 0.6, which was set for measuring the sampling adequacy [49] . furthermore, bartlett's test of sphericity values of the overall sample, nursing, and medical students were less than 0.05 which indicated data suitability for the pca [49] . four items were strongly loaded on a single component and explained 71.32%, 67.12%, and 72.47% of the scale variance in the overall sample, nursing, and medical students, respectively ( table 3) . ranges of correlations between the ddl scale and its four items were 0.80-0.83, 0.76-0.80, and 0.81-0.84 for the overall sample, nursing, and medical students, respectively. this provides adequate evidence of the item-scale convergent validity [50] . the ddl correlated with hl at a rho value of 0.68 for all, which provided satisfactory evidence of the criterion's validity [47] . table 3 . construct, convergent, criterion validity, internal consistency, floor, and ceiling effects of digital healthy diet literacy scale (n = 7616). cronbach's alpha values of the ddl scale for the overall sample, nursing, and medical students were 0.86, 0.83, and 0.87, respectively, which were larger than 0.70, indicating the satisfactory reliability [51] . percentages of the lowest and highest score in the overall sample (0.20% and 12.00%), nursing students (0.30% and 7.90%), and medical students (0.20% and 13.30%) were smaller than 15% which were reflected no floor and ceiling effects [52] . age highly correlated with the academic year (rho = 0.95), gender moderately correlated with the academic field (rho = 0.36), and smoking moderately correlated with drinking (rho = 0.50; table s1 ). therefore, age, gender, and drinking were selected with medical payment ability, bmi, chronic health conditions, and physical activity for the overall sample; with bmi, and physical activity for the sample of nursing students; and with medical payment ability, chronic health conditions, and physical activities for the sample of medical students in the multivariable analysis. after adjusting for these mentioned confounders, a 10-score increment of hl and ddl indices were associated with the increased likelihood of healthier eating behavior of 23% and 18% for the overall sample, 24% and 23% for the sample of nursing students, and 23% and 17% for the sample of medical students (table 4 ). the current study shows the digital healthy diet literacy (ddl) scale is a brief, valid, and reliable tool with satisfactory construct, criterion, and convergent validity, with a high level of internal consistency reliability, and with no floor or ceiling effect. the psychometric properties of the expanded ddl domain of hl were similar to the hls-sf12 scale [40, 41, 53] and e-healthy diet literacy (e-hdl) scale [54] . moreover, the performance of the ddl scale was similar in medical and nursing students. in a previous study, the e-hdl scale was developed with inconsistent response options for eleven survey questions. the number of questions was not equally distributed in different subscales [54] . therefore, a shorter ddl questionnaire with the same concept and response options of the original health literacy that is needed for research and practice [44, 45] . in this study, our findings illustrate that higher scores of health literacy and digital healthy diet literacy were positively associated with healthier eating behavior during the pandemic for both nursing and medical students. college students with higher ehealth literacy engaged better in positive health-promoting behaviors [29, 55] . a previous study also showed that higher e-hdl scores were associated with better health status and health-related behaviors in the general population in taiwan [54] . in addition, food literacy was found to be associated with healthier food consumption in the public in the netherlands [56] and canada [57] . in university settings, it is strategic to create opportunities (e.g., academic courses, media, and the internet) and motivators (e.g., social responsibility, and personal development) for students to develop food literacy and apply them in improving healthy eating behaviors and health outcomes [58] . digital healthy diet literacy should be emphasized and taken into account for better decision making and health outcomes [59] . medical school students play important roles in responding to the pandemic [22, 23, 60] and can promote healthy behaviors (e.g., healthy eating, preventive behaviors) to their peers, communities, and patients using social media or other available modalities [61, 62] . improving digital literacy focusing on a healthy diet for nursing and medical students is a strategic approach [28, 29] that can influence public behavior in positive ways. we conducted an online cross-sectional study in which the findings cannot be interpreted as causal relationships. the category of "unchanged" eating behavior during the pandemic does not distinguish "unhealthy" from "healthy" behaviors that may potentially bias the analysis. in addition, we did not use questions about actual nutritional habits or behaviors and diet. the actual dietary intake was not assessed in the current study. future studies are suggested to recruit questionnaires investigating dietary intake, such as a food frequency questionnaire or a 24 h food record form. another limitation was that respondents were not informed about the meaning of "healthy eating behaviors" that may cause reporting bias and potentially affect the association between ddl and eating behaviors. furthermore, the test-retest reliability of the ddl scale was not evaluated. however, the findings from the large sample analysis can possibly be generated to nursing and medical students. despite the limitations, the online survey is suggested in conducting the study with fewer resources required and providing timely evidence for research and practice, further contributing to covid-19 containment. future studies are suggested to compare ddl, eating behaviors, and their association in students with those in general populations and healthcare workers. a longitudinal design is recommended to assess the long-term effect and causality. the digital healthy diet literacy scale with four items (ddl-4) was an extended domain of a comprehensive health literacy framework. this scale was found to be a valid and reliable tool for the quick assessment of students' ability to access, understand, appraise, and apply healthy diet information found on the internet. nursing and medical students with higher hl or ddl scores had a higher likelihood of healthier eating behavior. the findings of our study provide a brief, valid, and reliable tool for research and practice during and after the covid-19 pandemic. funding: this work was supported by the taipei medical university (108-6202-008-112; 108-3805-022-400). we would like to thank all experts, research assistants, and students who participated in the study. the authors declare no conflict of interest. the socio-economic implications of the coronavirus pandemic (covid-19): a review global, regional, and national estimates of the population at increased risk of severe covid-19 due to underlying health conditions in 2020: a modelling study estimating excess 1-year mortality associated with the covid-19 pandemic according to underlying conditions and age: a population-based 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by the american college health association towards the measurement of food literacy with respect to healthy eating: the development and validation of the self perceived food literacy scale among an adult sample in the netherlands food literacy and healthy diets of canadian parents: associations and evaluation of the eat well campaign challenges, opportunities, and motivators for developing and applying food literacy in a university setting: a qualitative study which literacy for health promotion: health, food, nutrition or media? we signed up for this!"-student and trainee responses to the covid-19 pandemic medical student education in the time of covid-19 school nurses on the front lines of healthcare: the approach to maintaining student health and wellness during covid-19 school closures this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-264811-xbeipob9 authors: choi, yongin; kim, james slghee; choi, heejin; lee, hyojung; lee, chang hyeong title: assessment of social distancing for controlling covid-19 in korea: an age-structured modeling approach date: 2020-10-14 journal: int j environ res public health doi: 10.3390/ijerph17207474 sha: doc_id: 264811 cord_uid: xbeipob9 the outbreak of the novel coronavirus disease 2019 (covid-19) occurred all over the world between 2019 and 2020. the first case of covid-19 was reported in december 2019 in wuhan, china. since then, there have been more than 21 million incidences and 761 thousand casualties worldwide as of 16 august 2020. one of the epidemiological characteristics of covid-19 is that its symptoms and fatality rates vary with the ages of the infected individuals. this study aims at assessing the impact of social distancing on the reduction of covid-19 infected cases by constructing a mathematical model and using epidemiological data of incidences in korea. we developed an age-structured mathematical model for describing the age-dependent dynamics of the spread of covid-19 in korea. we estimated the model parameters and computed the reproduction number using the actual epidemiological data reported from 1 february to 15 june 2020. we then divided the data into seven distinct periods depending on the intensity of social distancing implemented by the korean government. by using a contact matrix to describe the contact patterns between ages, we investigated the potential effect of social distancing under various scenarios. we discovered that when the intensity of social distancing is reduced, the number of covid-19 cases increases; the number of incidences among the age groups of people 60 and above increases significantly more than that of the age groups below the age of 60. this significant increase among the elderly groups poses a severe threat to public health because the incidence of severe cases and fatality rates of the elderly group are much higher than those of the younger groups. therefore, it is necessary to maintain strict social distancing rules to reduce infected cases. coronavirus disease 2019 (covid-19) is a novel viral disease that is currently threatening public health worldwide. the virus responsible for the disease was initially called novel coronavirus (2019-ncov) due to its novelty. analysis of the phylogeny and taxonomy of 2019-ncov have shown that the virus belongs to the subgenus sarbecovirus, which sars-cov belongs to [1], but is more closely related to bat sars-cov [2, 3] . thus, 2019-ncov was named "severe acute respiratory syndrome coronavirus 2" or "sars-cov-2" [4] . cases of sars-cov-2 display symptoms such as fever, dry cough, dyspnea, and diarrhea, which are similar to symptoms noted in mers-cov and sars-cov. however, the distribution of each symptom differs [5] . in this study, we use the outbreak data of covid-19 in the seoul and gyeonggi provinces between 1 february and 15 june 2020 [18, 19] . figure 1 shows the epidemic curve of confirmed cases of covid-19 over the date of illness onset. a total of 1577 covid-19 cases were reported. covid-19 incidences were divided into different age groups to capture the age-dependent transmission dynamics. figure 1a shows that the number of imported cases comprised about 39.6% infected cases before may but drastically diminished to about 4.0% afterward. figure 1b shows that about 55.2% of infected cases were among ages 20-49 throughout the whole outbreak, and from may 1 through 14, about 76.8% of infected cases were among ages 20-39. table 1 shows the incidence data by age group and the sources of infection in the target area during the period. the sample dataset used in this study is shown in table s1 in supplementary section a. int the transmission dynamics of covid-19 are greatly affected by governmental control policies such as social distancing, school closures, and lockdowns. the korean government has attempted to implement appropriate control policies in response to changes in the number of infected people. in korea, on 23 february, the increasing level of covid-19 cases raised the alert to its highest level of "red", thus strengthening the overall response system to possible epidemics [20] . as a result of this increase in the number of infected people, different levels of social distancing were implemented by the korean government [21] . a brief description of the four levels of social distancing in korea is shown in table 2 , and further details about the social distancing policies are given in table s3 in supplementary section b. the transmission dynamics of covid-19 are greatly affected by governmental control policies such as social distancing, school closures, and lockdowns. the korean government has attempted to implement appropriate control policies in response to changes in the number of infected people. in korea, on 23 february, the increasing level of covid-19 cases raised the alert to its highest level of "red", thus strengthening the overall response system to possible epidemics [20] . as a result of this increase in the number of infected people, different levels of social distancing were implemented by the korean government [21] . a brief description of the four levels of social distancing in korea is shown in table 2 , and further details about the social distancing policies are given in table s3 in supplementary section b. as seoul and gyeonggi provinces are densely populated with diverse people, to enhance the realism of our model, it is beneficial to consider the heterogeneity in contact networks. two of the most important heterogeneous aspects of a contact network are location and age since different locations are often visited by certain age groups, which leads to consistent contact with specific age groups. for instance, people tend to have contact with people of a similar age outside their households (i.e., schools and workplaces). since our age-structured model allows us to adjust the transmission rates among different age groups and since the location is closely linked to an individual's contact pattern with certain age groups, we applied these location-based contact patterns to the transmission rates. we divided the contact locations into four categories: school, workplace, household, and other locations. for each location category, we used the specific contact matrix of korea from [21] to build our model. each contact was defined by either physical or nonphysical contact; physical contact includes skin-to-skin contact like kissing, handshaking, etc., whereas nonphysical contact includes, as seoul and gyeonggi provinces are densely populated with diverse people, to enhance the realism of our model, it is beneficial to consider the heterogeneity in contact networks. two of the most important heterogeneous aspects of a contact network are location and age since different locations are often visited by certain age groups, which leads to consistent contact with specific age groups. for instance, people tend to have contact with people of a similar age outside their households (i.e., schools and workplaces). since our age-structured model allows us to adjust the transmission rates among different age groups and since the location is closely linked to an individual's contact pattern with certain age groups, we applied these location-based contact patterns to the transmission rates. we divided the contact locations into four categories: school, workplace, household, and other locations. for each location category, we used the specific contact matrix of korea from [21] to build our model. each contact was defined by either physical or nonphysical contact; physical contact includes skin-to-skin contact like kissing, handshaking, etc., whereas nonphysical contact includes, e.g., a two-way conversation with three or more words in the physical presence of another person but no skin-to-skin contact [24] . each location-specific contact matrix is a 16 × 16 square matrix, which represents the mean number of instances of contact between individuals of five-year age groups, such as 0-4, 5-9, 10-14, 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49 , 50-54, 55-59, 60-64, 65-69, 70-74, and 75 and above. each element is the contact rate of an individual in one of the 16 age groups with people in the other 16 age groups at the specific locations. more precisely, the location-specific contact matrix m is written as [25] where each element m ij denotes the mean number of contacts an individual in age group i makes with individuals in age group j per day. note that contact matrix m is not necessarily symmetrical, which is a general feature that is also found in [26] [27] [28] . since the focus areas are seoul and gyeonggi province, and the location-specific matrices of the whole region of korea are only available in [25] , we estimated the location-specific matrices of the focus area by using the proportion of the population of the area compared to that of korea. we assumed the total population to be constant since the period of interest covers less than a year. we used the census data of korea from january 2020 throughout the simulations. a summary of the data can be found in figure s2 and table s2 in supplementary section b, which describe how to calculate the contact matrix of the focus area. the calculated location-specific matrices for seoul and gyeonggi province are shown in figure s4 in supplementary section b. a full contact matrix m is composed of a linear combination of the location-specific contact matrices [25] : where m w is the workplace contact matrix, m s is the school contact matrix, m h is the household contact matrix, and m o is the contact matrix for all other locations, except for the workplace, school, and household; c w , c s , and c o are constants, and c h is a 16 × 16 diagonal matrix, which are each multiplied by their respective matrices. based on the real policies of school closure and social distancing levels in korea, we composed five different contact matrices by adjusting c w , c s , c h , and c o as m o , m c , m c w , m c m , and m c s , which denote the contact matrices of the cases of school openings with no social distancing, school closures with no social distancing, school closures with weak social distancing, school closures with medium social distancing, and school closures with strong social distancing, respectively. when the school is closed, c s = 0 since there are no contacts made in the school. on the other hand, when the school is closed, c h = diag(1.5, 1.5, 1.5, 1.5, 1.1, 1.1, . . . , 1.1) 16 , where diag( ) n denotes the diagonal matrix with n diagonal entries, such that for age groups below the age of 20, contact rates increased by 50.0% and for age groups 20 and above, contact rates increased by 10.0% [29] . for social distancing, when there is no social distancing, weak social distancing, medium social distancing, or strong social distancing, we assumed c o = 1, 0.7, 0.5, 0.3, respectively, such that c o decreases under stronger social distancing. note that different types of c o levels were tested while decreasing the orders of c o for stronger social distancing, as shown in figures s12 and s13 in supplementary section d, but we present only one case due to the lack of a significant difference in the fitting and simulation results. an example of a scenario/policy-specific contact matrix of seoul and gyeonggi province-school closure with no social distancing, m c -is shown in figure 3 ; a comparison with the equivalent version for korea is provided in figure s3 in supplementary section b. table 3 shows a summary of the contact matrices for different policies. the contact matrices for each scenario/policy are shown in figure s5 . medium social distancing 1 * 0 * (1.5, 1.5, 1.5, 1.5, 1.1, 1.1, … , 1.1) 0.5 * school closing strong social distancing 1 * 0 * (1.5, 1.5, 1.5, 1.5, 1.1, 1.1, … , 1.1) 0.3 * * values with an asterisk (*) are assumed. ** i16 and diag(·)16 denote the 16 × 16 identity matrix and the diagonal matrix with diagonal entries, respectively. we developed a mathematical model to describe the transmission dynamics of covid-19 by employing an s-e-i-h-r compartment model with 16 age groups. in this model, , , , , and denote the susceptible, exposed, infectious, hospitalized, and recovered/removed population of age group , respectively. the diagram for the model is shown in figure 4 . we developed a mathematical model to describe the transmission dynamics of covid-19 by employing an s-e-i-h-r compartment model with 16 age groups. in this model, s i , e i , i i , h i , and r i denote the susceptible, exposed, infectious, hospitalized, and recovered/removed population of age group i, respectively. the diagram for the model is shown in figure 4 . we developed a mathematical model to describe the transmission dynamics of covid-19 by employing an s-e-i-h-r compartment model with 16 age groups. in this model, , , , , and denote the susceptible, exposed, infectious, hospitalized, and recovered/removed population of age group , respectively. the diagram for the model is shown in figure 4 . (3) are described in table 4 . b i infection probability of a person in age group i per contact in this model, the asymptomatic infectious population is excluded. although recent studies around the world suggest the presence and significance of an asymptomatic infectious population [31, 32] , we found that it is appropriate to apply the settings from our area of interest and the time period we are observing. hence, we refer to a recent antibody test for covid-19 for randomly selected subjects in korea [33] , which includes 1833 subjects from seoul and 278 subjects from gyeonggi province, where only 1 subject was found positive (a total of 3555 subjects were tested through a screening inspection and plague reduction neutralization test; 1555 serum samples were collected from 21 april through 19 june from 192 regions in korea, and 1500 hospitalized patients from seoul were tested from 25 may through 28 may). thus, the ratio of asymptomatic infected people to infected people was estimated to be very small in korea. for this reason, together with the difficulty in determining the proportion of asymptomatic infections accurately, we did not consider a compartment for asymptomatic infections in the mathematical model. the parameter 1/q is the median value computed from the data for each period, and its values are given in table 5 . we estimate the transmission rate β ij by utilizing the least squares method, lsqcurvefit, which is an embedded function in matlab. to measure the potential of the disease transmission in each period, we use the effective reproduction number r t , which is the average number of secondary cases infected by an index case in a population of both susceptible and nonsusceptible hosts. r t is computed as r t = ρ(g), where ρ is the spectral radius of the next generation matrix g [34] . the derivation of the value of r t is described in supplementary section c. this study used the data available in [18, 19] . the datasets were already fully anonymized and did not include any identity information. thus, ethical approval was not required for this analysis. the covid-19 data for gyeonggi province are accessible in [18] , and the data for seoul city are available upon request [19] . we estimated the transmission rate using the epidemiological data described in section 2. depending on each period, we estimated the transmission rates corresponding to the age group by applying the least squares method to the age-specific incidence data. we observed that the number of incidence data for each 5-year age group was not sufficient to estimate the transmission rate between age groups due to the absence of reported cases in some periods. thus, to clarify the different properties of transmission rates between age groups, we estimated the transmission rate for 10-year age groups, such as 0-9, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, and 70 and above, by combining two 5-year age groups into one 10-year age group. figure 5 compares the observed and estimated covid-19 cases for (a) incidence and (b) cumulative incidence among all ages. the results of the data-fitting for each age group are shown in figures s6 and s7 in supplementary section d. in a population of both susceptible and nonsusceptible hosts. is computed as = ( ), where is the spectral radius of the next generation matrix g [34] . the derivation of the value of is described in supplementary section c. this study used the data available in [18, 19] . the datasets were already fully anonymized and did not include any identity information. thus, ethical approval was not required for this analysis. the covid-19 data for gyeonggi province are accessible in [18] , and the data for seoul city are available upon request [19] . we estimated the transmission rate using the epidemiological data described in section 2. depending on each period, we estimated the transmission rates corresponding to the age group by applying the least squares method to the age-specific incidence data. we observed that the number of incidence data for each 5-year age group was not sufficient to estimate the transmission rate between age groups due to the absence of reported cases in some periods. thus, to clarify the different properties of transmission rates between age groups, we estimated the transmission rate for 10-year age groups, such as 0-9, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, and 70 and above, by combining two 5-year age groups into one 10-year age group. figure 5 compares the observed and estimated covid-19 cases for (a) incidence and (b) cumulative incidence among all ages. the results of the data-fitting for each age group are shown in figures s6 and s7 in supplementary section d. table 5 shows the values of the estimated infection probability and the effective reproduction number depending on the age group and period. here, is a vector consisting of the infection probability for eight age groups instead of sixteen age groups (i.e., = for ∈ {0-9, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70+}), and each subsequent pair of equals (i.e., = = , = = , ⋯ , = = ). the value of was bigger than 2 in period 1, but after governmental control policies began in period 2, it decreased below 2. in particular, in periods 3 and 4, when medium and strong levels of social distancing were implemented, respectively, the value of became much less than 1. however, significant local infections have occurred since 24 april, when infected cases linked to club attendance among the table 5 shows the values of the estimated infection probabilityb and the effective reproduction number r t depending on the age group and period. here,b is a vector consisting of the infection probability for eight age groups instead of sixteen age groups (i.e.,b = b k for k ∈ {0-9, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70+}), and each subsequent pair of b i equalsb k (i.e.,b 0−9 = b 0−4 = b 5−9 , b 10−19 = b 10−14 = b 15−19 , · · · ,b 70+ = b 70−74 = b 75+ ). the value of r t was bigger than 2 in period 1, but after governmental control policies began in period 2, it decreased below 2. in particular, in periods 3 and 4, when medium and strong levels of social distancing were implemented, respectively, the value of r t became much less than 1. however, significant local infections have occurred since 24 april, when infected cases linked to club attendance among the young age groups were reported [23] . in the period between 24 april and 6 may, the r t value was estimated to be 2.4846, and the governmental control policies against local infections were implemented in period 7, which decreased the value of r t to 0.8047. in periods 1 and 2, the time taken to be diagnosed from symptom onset, 1/q, was estimated at 8 and 5 days, respectively, but decreased to 3-4 days since 29 february when social distancing began. in the transition from period 2 to period 3, medium social distancing was implemented, and the infection probabilityb for age groups 0-9, 10-19, 20-29, 30-39, and 40-49 decreased by 37.8%, 86.1%, 21.3%, 40.6%, and 17.8%, respectively, while that of the age groups 50-59, 60-69, and 70+ increased by more than 400.0%, which resulted in a decrease of r t of 0.6776. once the strong social distancing started in period 4,b either decreased or remained at similar level for almost all age groups, resulting in the r t decreasing by 0.1145. in period 5-2, theb for age groups 20-29 and 30-39 increased rapidly, resulting in an increase of r t of 2.4846. we investigated the potential effect of social distancing under various scenarios. in table 6 , between 24 april and 31 august, we created seven scenarios along the baseline considering the social distancing strengths described in section 2.2. these scenarios were designed to test the effects from the strongest case (scenario 1) to the weakest case (scenario 7). weak weak weak figure 6 shows (a) a comparison of the time-dependent cumulative incidences for the scenarios and (b) the age-specific cumulative incidences up to 31 august 2020. figure 6a illustrates the effects of different social distancing combinations under each scenario, and in figure 6b , we can observe how each scenario affects different age groups accordingly. the incidence plot corresponding to figure 6a is shown in figure s8a . the simulation results of the incidence and cumulative incidence for each age group are shown in figures s9 and s10 in supplementary section d, respectively. table 7 shows the cumulative incidence of each age group up to 31 august 2020. young age groups were reported [23] . in the period between 24 april and 6 may, the value was estimated to be 2.4846, and the governmental control policies against local infections were implemented in period 7, which decreased the value of to 0.8047. in periods 1 and 2, the time taken to be diagnosed from symptom onset, 1/q, was estimated at 8 and 5 days, respectively, but decreased to 3-4 days since 29 february when social distancing began. in the transition from period 2 to period 3, medium social distancing was implemented, and the infection probability for age groups 0-9, 10-19, 20-29, 30-39, and 40-49 decreased by 37.8%, 86.1%, 21.3%, 40.6%, and 17.8%, respectively, while that of the age groups 50-59, 60-69, and 70+ increased by more than 400.0%, which resulted in a decrease of of 0.6776. once the strong social distancing started in period 4, either decreased or remained at similar level for almost all age groups, resulting in the decreasing by 0.1145. in period 5-2, the for age groups 20-29 and 30-39 increased rapidly, resulting in an increase of of 2.4846. we investigated the potential effect of social distancing under various scenarios. in table 6 , between 24 april and 31 august, we created seven scenarios along the baseline considering the social distancing strengths described in section 2.2. these scenarios were designed to test the effects from the strongest case (scenario 1) to the weakest case (scenario 7). weak weak weak figure 6 shows (a) a comparison of the time-dependent cumulative incidences for the scenarios and (b) the age-specific cumulative incidences up to 31 august 2020. figure 6a illustrates the effects of different social distancing combinations under each scenario, and in figure 6b , we can observe how each scenario affects different age groups accordingly. the incidence plot corresponding to figure 6a is shown in figure s8a . the simulation results of the incidence and cumulative incidence for each age group are shown in figures s9 and s10 in supplementary section d, respectively. table 7 shows the cumulative incidence of each age group up to 31 august 2020. (a) (b) figure 6 . cumulative incidence for scenarios of social distancing: (a) the time-dependent cumulative incidence for the total age group and (b) the age-specific cumulative incidence from 1 february to 31 august 2020. strong, medium, and weak social distancing is denoted by s, m, and w, respectively, and w+ denotes weak social distancing+ defined in table 2 . table 7 show that if a strong level of social distancing had been maintained for all three periods, the number of infected people would have decreased by about 44.6%. on the other hand, if a weak level of social distancing was implemented for the three periods, the number of incidences would have increased by about 29.2%. however, when the intensity of social distancing is reduced in all the scenarios, the number of incidences increases in proportion with the degree of the intensity reduction. in particular, people who are between the ages of 0 and 19 present a minimum number of infected cases in all the scenarios of social distancing. in other words, the number of infected cases among those between the ages of 0 and 19 was the least affected by the strength of social distancing. for those between 50 and above, the number of infected cases increased drastically (28.4, 42.4 , and 42.0 percent increase for age groups 50-59, 60-69, and 70+, respectively) in scenario 7 compared to the baseline, showing that without sufficiently strong social distancing, the age groups of 50 and above became noticeably vulnerable compared to the younger age groups. scenarios 6 and 7 used the same weak social distancing strength from 24 april through 29 may. the only difference is in the social distancing strength during the longest period of 29 may-31 august, where scenario 6 uses strong social distancing, and scenario 7 uses weak social distancing. despite the strength differences for the period of approximately three months, the effects on ages 0-19 appear to be minimal compared to those for people aged 20 and above. moreover, the number of infected cases among those age 40 and above was effectively reduced even though social distancing was weak starting from 29 may. corresponding to figure 6b , the comparison of age for each scenario is shown in figure s11a in supplementary section d. figure 7 shows (a) the monthly incidence of cases for the total age group under all scenarios and (b) a comparison of the monthly incidence among the two age groups of 20-49 and 50 and above for the baseline (scenarios 1 and 7) . the monthly incidence of the other scenarios for these two age groups is shown in figure s11b ,c in supplementary section d. table 8 shows the monthly incidence of the total age group, the age groups of 20-49, and those of 50 years and above for all scenarios. in the four months of may through august, compared to the baseline, the total incidence increased by 43.9% under scenario 7 but decreased by 66.6% for scenario 1. table 8 . monthly incidence of the total age group, the age groups of 20-49, and those 50 years and older (50+) for all scenarios. the percentage below incidence represents the percentage increase or decrease from the baseline. may (a) (b) figure 7 . cumulative incidence based on scenarios: (a) the monthly incidence for the total age group and (b) the monthly incidence of the two age groups of 20-49 and 50 and older (50+) for the baseline (scenarios 1 and 7). in this study, we analyzed the epidemiological data of covid-19 cases in seoul and gyeonggi province between 1 february and 15 june 2020. the symptoms, transmission rates, and fatality rates of this disease differ by age, and the risks of severe symptoms and fatality rates are greater with an increase in age [13] . to take these aspects into account, we developed an age-structured model that describes the age-dependent dynamics of covid-19. in the age-structured model developed in this study, we estimated the transmission rate by applying the contact matrix obtained from [25] to the actual incidence and population data for seoul and gyeonggi province. since the control policies implemented by the governmental authorities affect the dynamics of infectious diseases [13, 35] , we divided the whole period between 1 february and 15 june into seven distinct periods following important changes in governmental control policies. we observed that the simulated incidence curve with the fitted transmission rate matches well with the actual incidence data of each age group over the whole period. using the developed age-structured model, we investigated the effect of social distancing under various scenarios in the focus area. for each of the seven distinct periods, we estimated the infection probabilityb for each age group and the effective reproduction number r t , which led to three interesting results. first, as the social distancing strength increased, r t decreased from 2.1971 to 0.0001 until 24 april. until the serious infections linked to clubs began to emerge, social distancing was effective in preventing local transmission. in period 5-2, the behavioral changes among those aged 20-39 [23] were suspected to be the primary cause of the escalating outbreaks after 24 april, among which the r t increased to 2.4846. secondly,b differed greatly depending on the age group. despite an increase in social distancing strength, the age groups 50 and above experienced an increase inb during period 3, while the transmission rates for the age groups younger than 50 decreased. this suggests that social distancing affects different age groups with different magnitudes, with younger age groups being more effective while under control. thirdly, in period 6 during the weak social distancing, age groups 50 and above showed a greater change inb than age groups 20-49. this resulted in critical situations featuring an elevated number of deaths since the fatality rate is generally greater for people age 50 and above [17] . the baseline scenario reflected the actual social distancing policies implemented by the korean governmental authorities between 1 february and 15 june 2020. in other scenarios, it was assumed that various levels of social distancing, different from the baseline scenario, were implemented in periods 5, 6, and 7. the simulation results in table 7 showed that if a strong level of social distancing has been implemented for all three periods, the number of infected people would have decreased by about 44.6%. on the other hand, if a weak level of social distancing was maintained for the three periods, the number of infected people would have increased by about 29.2%. for all the scenarios, the results showed that a reduction in the intensity of social distancing produced an increase in the number of infected persons. notably, the number of incidences in the age groups 60 years and above increased significantly compared to that of other age groups, which represents a very dangerous situation, as the fatality rate of the elderly groups is much higher than that of the younger groups [17] . therefore, it is necessary to properly maintain a high-level intensity of social distancing to lower the fatality rate and reduce medical expenses. however, the social and economic costs that may emerge from strengthening social distancing should also be considered. to investigate the effects of social distancing, we assumed that all schools were closed during the whole period of this study. we also reviewed some previous studies on the effects of school closures during different disease outbreaks [27, 36] . indeed, during the covid-19 pandemic, many of our sampled schools have been opened since mid-may, except when there were recorded incidences of infected people in a school or its nearby area. schools under such conditions were closed for a certain period, and quarantine policies were implemented differently for each school. however, it was difficult to provide an accurate reflection on the effects of schools opening/closing in this study since there are no reports on group infections in all schools over the whole period. therefore, we propose that our model is more suitable for analyzing the impact of fixed and clear-cut control policies like social distancing, rather than the impact of schools opening/closing on the transmission of covid-19. despite the limitations in our study, we successfully developed an age-structured model using the epidemiological data in seoul and gyeonggi province by implementing an age and location-based contact matrix, which is not a well-known model for covid-19. through this study, we analyzed the effects of different social distancing policies and further extended those effects to simulate different scenarios. as the social distancing strength was weakened, people age 50 and above were directly affected, showing a more significant increase in transmission rate than that among people age 20-49. strong social distancing can be very effective in reducing the number of infected cases, as shown in scenario 1, where the cumulative incidence was reduced by 44.6% compared to the baseline. in this paper, we developed an age-structured mathematical model for assessing the age-dependent transmission of covid-19 in korea. the target area was seoul and gyeonggi province, the most populated area in korea. we divided the total human population in the target area into different age groups. we estimated the transmission rate for each age group in seven distinct periods using the covid-19 data and contact matrix for each age group and investigated the effect of social distancing on the control of the disease in the age-structured model under various scenarios. in the most optimal scenario (scenario 1), the reduced cumulative incidence of 44.6% from the baseline established that social distancing strength can have a critical impact on the mitigation of transmission dynamics. our modeling approach for covid-19 has novelty in that we estimated the transmission rates of different age groups in seven distinct periods following government control policies. the modeling approach presented in this work can be applied to other target areas worldwide if sufficient epidemiological data and contact matrices for the various age groups are available. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/20/7474/s1, section a: data analysis (table s1 : dataset sample; figure s1 : cumulative incidence of seoul/gyeonggi province by (a) age group, (b) source of infection, and (c) region); section b: contact matrix and control policy ( figure s2 . population of south korea and seoul/gyeonggi province in january 2020 by age groups; table s2 estimation of transmission rate: incidence of each age groups. incidences by local transmission (local and imported transmission) are blue-colored estimation of transmission rate: cumulative incidence of each age groups. incidences by local transmission (local and imported transmission) are blue-colored scenario simulation: (a) incidence and (b) cumulative incidence of all ages. s, m, w denote strong, medium, weak social distancing, respectively, and w+ denotes weak social distancing+. black circles are actual incidence data scenario simulation: incidence of each age groups scenario simulation: cumulative incidence of each age groups; figure s11. other figures. (a) is scenario specific analysis on monthly incidence of two age groups of 20-49 and 50 or older (50+) for the baseline, scenario 1 and 7 on different types c o levels for strong, medium and weak social distancing: (a) c o monthly incidence of two age groups of 20-49 and 50 or older (50+) on different three types c o levels for strong, medium and weak social distancing: (a),(b) c o bat origin of a new human coronavirus: there and back again a pneumonia outbreak associated with a new coronavirus of probable bat origin a new coronavirus associated with human respiratory disease in china the species severe acute respiratory syndrome-related coronavirus: classifying 2019-ncov and naming it sars-cov-2 a novel coronavirus outbreak of global health concern world health organization. who director-general's opening remarks at the media briefing on covid-19-11 coronavirus disease 2019 (covid-19) situation report-51 coronavirus disease 2019 (covid-19) situation report-209 vaccines: status report. immunity draft landscape of covid-19 candidate vaccines coronavirus disease 2019 (covid-19) advice for the public cmmid covid-19 working group age-dependent effects in the transmission and control of covid-19 epidemics the effect of control strategies to reduce social mixing on outcomes of the covid-19 epidemic in wuhan, china: a modelling study age-structured modeling of covid-19 epidemic in the usa, uae and algeria korea centers for disease control & prevention. cases in korea by city/province gyeonggi infectious disease control center korea centers for disease control & prevention. the updates of covid-19 (23 februrary) in korea social contacts and mixing patterns relevant to the spread of infectious diseases projecting social contact matrices in 152 countries using contact surveys and demographic data projecting social contact matrices to different demographic structures measured dynamic social contact patterns explain the spread of h1n1v influenza inferring the structure of social contacts from demographic data in the analysis of infectious diseases spread impact of non-pharmaceutical interventions (npis) to reduce covid19 mortality and healthcare demand report 2: estimating the potential total number of novel coronavirus cases in wuhan city asymptomatic transmission, the achilles' heel of current strategies to control covid-19 presumed asymptomatic carrier transmission of covid-19 korea centers for disease control & prevention. updates on covid-19 in korea (as of 9 july). available online modelling the effective reproduction number of vector-borne diseases: the yellow fever outbreak in luanda stochastic methods for epidemic models: an application to the 2009 h1n1 influenza outbreak in korea a modeling study of school closure to reduce influenza transmission: a case study of an influenza a (h1n1) outbreak in a private thai school the data for seoul city used in this research were provided by a government-wide r&d funding project for infectious disease research (gfid) in the korea (grant no. hg18c0088). the authors declare no conflict of interest. the funders had no role in the study design, data collection and analysis, the decision to publish the results, or the preparation of the manuscript. key: cord-259971-e3h8pr1v authors: nwachukwu, izu; nkire, nnamdi; shalaby, reham; hrabok, marianne; vuong, wesley; gusnowski, april; surood, shireen; urichuk, liana; greenshaw, andrew j.; agyapong, vincent i.o. title: covid-19 pandemic: age-related differences in measures of stress, anxiety and depression in canada date: 2020-09-01 journal: int j environ res public health doi: 10.3390/ijerph17176366 sha: doc_id: 259971 cord_uid: e3h8pr1v background: the spread of covid-19 along with strict public health measures have resulted in unintended adverse effects, including greater levels of distress, anxiety, and depression. this study examined relative presentations of these psychopathologies in different age groups in a canadian cohort during the covid-19 pandemic. methodology: participants were subscribers to the text4hope program, developed to support albertans during the covid-19 pandemic. a survey link was used to gather demographic information and responses on several self-report scales, such as perceived stress scale (pss), generalized anxiety disorder 7-item (gad-7) scale, and patient health questionnaire-9 (phq-9). results: there were 8267 individuals who completed the survey, giving a response rate of 19.4%. overall, 909 (11.0%) respondents identified as ≤25 years, 2939 (35.6%) identified as (26–40) years, 3431 (41.5%) identified as (41–60) years, 762 (9.2%) identified as over 60 years, and 226 (2.7%) did not identify their age. mean scores on the pss, gad-7, and phq-9 scales were highest among those aged ≤25 and lowest amongst those aged >60 years old. conclusions: the finding that the prevalence rates and the mean scores for stress, anxiety, and depression on standardized scales to decrease from younger to older subscribers is an interesting observation with potential implications for planning to meet mental health service needs during covid-19. with its discovery in wuhan, china, and its subsequent rapid spread around the world, the coronavirus disease (covid19) pandemic has caused palpable fear [1] [2] [3] to manage the illness in the absence of a proven cure or an effective vaccine, governments have adopted extreme public health measures including shutting down all but essential services and industries, promoting hand hygiene measures, restricting travel and closing borders, implementing social distancing, self-isolation, and quarantine measures [4] . typically, social distancing has been achieved through limiting the distance between individuals in public spaces, limiting the number of individuals who are allowed to gather together, self-isolation/quarantine for 14 days after travel or if individuals present with covid-19 like symptoms or have been in contact with potentially infected individuals. these measures have caused a widespread disruption of both the social fabric of society and economic activities [5] . these abrupt changes to the pattern of human activities have had indirect negative effects on the physical and mental health of individuals across the world. self-isolation measures and quarantine, despite their considerable clinical utility, often have unintended adverse effects [6] including greater levels of distress, anxiety, depression, and post-traumatic stress disorder (ptsd). for the current covid-19 pandemic, published studies examining rates of anxiety and depression are consistently reporting prevalence estimates of around 20% [7] [8] [9] . a recent meta-analysis reported rates of depression and anxiety that exceed 20% with differences in certain demographic variables such as gender and occupation [10] . in the severe acute respiratory syndrome (sars) outbreak in taiwan during late april to mid-may 2003, a relationship between age and the development of psychological symptoms was reported, with younger age groups at higher risk [11] . for the covid-19 pandemic, several studies have also reported a possible negative relationship between depression, anxiety, ptsd, and age [7, 12] . in an online survey of chinese subjects, prevalence of generalized anxiety disorder and depressive symptoms was significantly higher in participants younger than 35 years than in participants aged 35 years or older [13] with age and amount of time spent focusing on covid-19 identified as potential risk factors for psychological illness. individuals ≤35 years of age appear to be more likely to develop anxiety and depressive symptoms during the covid-19 pandemic [14] . in a nationwide survey examining psychological distress among chinese people in the covid-19 pandemic using a covid-19 peritraumatic distress index (cpdi) [15] ; the authors examined frequency of anxiety, depression, specific phobias, cognitive change, avoidance and compulsive behavior, physical symptoms, and loss of social functioning in the past week, with scores on the cpdi ranging from 0 to 100. a cpdi score between 28 and 51 indicates mild to moderate distress while a score ≥52 indicates severe distress. in that study, participants under 18 years had the lowest cpdi scores. individuals from 18-30 years or >60 years of age presented the highest cpdi scores, thus presenting a more nuanced view of the effect of the pandemic on psychological symptoms across the age spectrum. possible explanations for their finding include the idea that teenagers and children have shown relatively low morbidity and mortality in the pandemic and therefore may feel less stressed by it and, because of school closures and quarantine measures they may recognize that they have had limited exposure to the coronavirus. younger adults on the other hand may be exposed to more information about the virus via social media, a factor that has been shown to increase vulnerability [16] . in addition, their loss of social connections with friends may have further increased their vulnerability to mental distress. the highest mortality rates for the virus are reported among the elderly, thus potentially exposing this age group to be more adversely affected psychologically [15] . the majority of initial studies examining the impact of age on stress, anxiety, and depression levels in the current covid-19 pandemic arise from asia. this present study sets out to examine the evidence for the impact of age on stress, anxiety, and depression levels in the covid-19 pandemic from the perspective of a canadian cohort with the goal of informing policy planning in relation to age-appropriate mental health supports and resource allocations during this covid-19 pandemic period. this was a cross-sectional survey exploring the mean differences of perceived stress, anxiety, and depression symptom scores among subscribers of various age categories who enrolled in the text4hope program. the study recruitment procedures and statistical methods have been described in related papers [17] . in summary, the text4hope program is a daily supportive text message service, launched by alberta health services (alberta, edmonton), the provincial health authority on 23 march 2020 to support the mental health of albertans during the covid-19 pandemic. subscribers were sent an online survey link with an accompanying message: "to help us evaluate the text4hope program's effectiveness, please complete a short survey . . . ." the survey questions included demographic information such as gender, age, ethnicity, education, relationship status, employment status, and housing status. respondents also completed clinical self-assessments for stress, anxiety, and depression using the perceived stress scale (pss), the generalized anxiety disorder 7-item (gad-7) scale and the patient health questionnaire-9 (phq-9), respectively. participant consent was implied by submission of subscribers' survey responses. the survey link has no expiry date as enrollment to the text4hope program is ongoing. ethical approval for the research was obtained through the university of alberta health research ethics board (pro00086163). data analysis was undertaken using spss version 26 (ibm inc, endicott, ny, usa) [18] . demographic characteristics of respondents were summarized in absolute numbers and percentages, by age category. one-way analysis of variance (one-way anova) with two tailed significance (p-value < 0.05) was performed to assess the differences between the ethnic groupings and the corresponding mean scores for pss, gad-7, and phq-9, respectively. as all variables violated the homogeneity of variance assumption based on the levene statistic test of homogeneity, we determined statistically significant differences for the mean scores for the various clinical measures across age groups using the welch f test and a games-howell post hoc test. of the 44,992 subscribers who joined text4hope in the first 6 weeks, 8267 responded to the online survey invitation, yielding a 19.4% response rate. our sample size of 8267 indicates that any prevalence rate estimates for the entire sample of 44,992 subscribers would have a 99% confidence interval and a margin of error of only 1.28%. of the 8267 respondents, 909 (11.0%) identified as ≤25 years, 2939 (35.6%) identified as aged 26-40 years, 3431(41.5%) identified as aged 41-60 years, 762 (9.2%) identified as >60 years, and 226 (2.7%) did not identify their age. the mean age for our sample was 42.09 years (standard deviation = 13.44 years). additional demographic characteristics of the respondents are shown in table 1 , which indicates a majority of respondents self-identified as female, (n = 6991, 87.1%), caucasian (n = 6579, 82.3%), with post-secondary education (n = 6835, 85.2%), as employed (n = 5883 73.3%), as married, cohabiting, or partnered (n = 5706, 71.1%), and as home-owners (n = 5194, 65.9%). the data displayed in table 2 illustrate the prevalence rates for clinically meaningful stress, anxiety, and depression. these data suggest the prevalence of high/moderate stress, likely gad and likely mdd were highest in those aged 25 or under and lowest in those aged over 60 years. mean scores for all the respondents were 20.79 (sd = 6.83, n = 7589) on the pss, 9.68 (sd = 5.87, n = 6944) on the gad-7 scale, and 9.43 (sd = 6.29, n = 7082) on the phq-9 scale. the data displayed in table 3 indicate that the mean scores on the pss, gad-7, and phq-9 scales were highest among those aged 25 years and under and lowest amongst those who were over 60 years old. there is an observed trend for the mean scores for all three scales to decrease with a shift from a younger age bracket to an older age bracket. results from the levene test for homogeneity of variances suggested there was a violation of the assumption of equality of means for the pss, gad-7, and phq-9 scales (p > 0.05). because of this, it was appropriate to apply the welch f test and a games-howell post hoc test to determine mean score differences on the three scales between the different age groups. welsh f tests confirmed that the differences between the groups in terms of their mean pss, gad-7, and phq-9 scores were statistically significant. there were statistically significant differences between and within age groups for scores on the pss (f = 319.89, p < 0.001), gad-7 scale (f = 225.23, p < 0.001), and phq-9 (f = 195.82, p < 0.001). the results of the games-howell post hoc test are as presented in table 4 . the results displayed in table 4 confirm statistically significant differences in mean scores on the pss, gad-7, and phq-9 scales between each of the age categories and any other age category (p < 0.001 for each comparison). the mean scores for the pss, gad-7, and phq-9 scales declined significantly with a shift from a younger age to an older age group suggesting that older respondents had less stress, anxiety, and depression symptoms compared to younger respondents. for each of the three scales, the greatest mean differences were observed between respondents who were ≤25 years compared to those >60 years. for the pss and the gad-7, the respective mean differences in scores was 8.75, with a 95% ci of 7.89-9.61 and p < 0.001, and 6.41, with a 95% ci of 5.57-7.24 and p < 0.001. for the phq-9, the mean difference in the score between these age groups was 5.88, with a 95% ci of 5.14-6.63 and p < 0.001. overall, the results suggest a decrease in severity of stress, anxiety, and depression symptoms with increasing age during covid-19 in a canadian sample. our results indicate that about two-thirds of our respondents were aged between 26 and 60 years, and the remaining respondents were aged either 25 years and under or over 60 years. this contrasts with a study by gonzalez-sanguino et al. [7] where the majority of respondents were aged between 18-39 years (56.63%). the respondents in our sample were spread over a wider middle age range. furthermore, the average age of the sample population in the study by gonzalez-sanguino et al. [7] was lower than the average age for our study participants (37.92 vs. 42.09, respectively). our study results are, however, similar to those of other studies which have a lower representation of the elderly population [7, 8] ; and this underrepresentation of this important segment of the population may limit us in relation to inferences made for those over 60 years of age in this study. our results indicate that the prevalence rates for moderate/high stress, likely gad, and likely mdd as well as the mean scores on the pss, gad-7, and phq-9 scales were highest amongst those aged under 25 years, and lowest amongst those over 60 years. this finding is consistent with some previous studies that reported higher scores in stress, anxiety, and depressive symptoms in younger people compared to older ages [7, 11, 12] . the finding that people aged 60 years and above reported lower scores on our rating scales is both interesting and curious, given that covid-19 infections have been shown to cause significantly higher morbidity and mortality in this age group compared to the younger age group [19, 20] . since there was stronger emphasis of the need for people over 60 years to take more stringent measures with social distancing and they are also likely to have higher prevalence of underlying medical conditions, it may have been expected that they would be more distressed during the pandemic. on the other hand, older people tend to be less socially mobile than younger ones, thus possibly explaining their reported lower scores on rating scales for stress, anxiety, and depression during a pandemic lockdown. people above 60 years are also more likely to have experienced various major life events in the past, possibly including having lived through past epidemics or pandemics, hence their increased resilience as found in our study. additionally, younger people, especially those under 25 years, may have perceived their academic, social, occupational, and economic prospects to be more threatened by covid-19 compared to those over 60 years and this will likely, at least in part, explain their increased stress levels according to our study [13, 14] . as outlined in the introduction, several studies have reported lower rates of anxiety and depression in older age groups compared to younger ones [7, 11, 12] . another hypothesis that could be propounded to explain this finding include that younger people, especially those under 25 years of age, are known to spend more time on social media and other news outlets. for example, in a 2019 us study, 90% of people aged 18 to 29 were active on social media, compared to 45% of those aged over 65 years [21] . high consumption rates of news about the covid-19 pandemic have been associated with increased levels of distress [16] . having said this, one might also have expected that increased opportunities for social connection through social media outlets that are readily available to younger people would limit the impact of physical distancing on them, perhaps compared to older adults. one group particularly vulnerable to the effects of the covid-19 pandemic continues to be older adults in senior care homes [19] . at the time this survey was designed in the context of text4hope, that fact was not known. it is likely that the majority of seniors responding to the text4hope survey are not in care, and this limitation must be taken into account in interpreting these and similar results on decreased severity of mental health indices in the older population. more research directed specifically at understanding the impact of social connectedness with stress, anxiety, and depression is needed to shed more light in this area. according to the uk office for national statistics, a population-based survey found that people over seventy years of age reported feeling happier than those aged 16 to 69 years during the period before a national lockdown was imposed in the wake of covid-19 in the united kingdom (uk) [22] . interestingly, this gap in reported feelings of happiness between the groups decreased by the third week of the lockdown. again, the uk government recommended stricter social distancing measures for those over 70 years of age, possibly explaining why they would have become increasingly more anxious and distressed as the pandemic continued. in comparison, our study data were collected at a single point at the beginning of the lockdown when social distancing was imposed across the province of alberta, canada. the clinical and practical utility of our study derives mainly from the its potential to serve as a guide to healthcare planners in directing treatment and support services in a more targeted and age-appropriate way during this covid-19 pandemic and related crisis situations in the future. with the knowledge that younger people, including students [4], tend to suffer disproportionately higher levels of stress, anxiety, and depression, equitable attention must be paid to ensure that their needs are met in all relevant areas. for example, online platforms may be used to deliver psychotherapeutic interventions and support networks to young people in their homes so as to minimize the spread of the virus while mitigating their increased vulnerability to mental distress during the pandemic. educational institutions and authorities may also need to develop online platforms and portals to aid the delivery of lectures and other learning materials with a view to maintaining as much of their daily structure and routine as possible. our study was limited in being a snapshot of self-reported experiences of mental health signs and symptoms at the beginning of the alberta lockdown, as opposed to a more longitudinal evaluation, especially if administered by a trained clinician. it is possible therefore that data collected a few weeks further down the line from our original data set would reflect similar findings as did the aforementioned uk study [3] . furthermore, our study is not representative of the population in alberta either by age or gender [23] and so our findings may not be generalized to the entire population. in addition, although the anova analysis allowed for comparison of the stress, anxiety, and depression levels between all the age groups as a strength, it did not take into account potential confounding factors such as sex, ethnicity, relationship status, employment and education status, which is a limitation. age is likely to be one of the several factors upon which vulnerability to mental health effects of covid-19 would be based. in addition, other social determinants of health, along with co-morbid physical health conditions, are known to play significant parts in increasing vulnerability in times of crisis [10] . any interventions aimed at mitigating mental health effects of covid-19 must therefore take of all these various factors into account. finally, our survey did not ask participants about pre-existing stress, anxiety, and depression. it is possible that some respondents had these baseline stress, anxiety, and depression and so the reported scores on the standardized scales may not all be attributable to the covid-19 pandemic. our results also indicate that both the prevalence rates as well as the mean scores for stress, anxiety, and depression on standardized scales were highest amongst those under 25 years, and lowest amongst those over 60 years. the trend for mean scores across the stress, depression, and anxiety scales to decrease in severity from younger to older age has potential implications for planning to meet mental health service needs during covid-19. innovative and cost-effective interventions such as supportive text messaging which are independent of geographic location, are free to the end user, do not require expensive data plans, and can reach thousands of people simultaneously [24] [25] [26] [27] [28] [29] [30] [31] could be useful particularly to a younger age population who seem to be most impacted psychologically during the covid-19 pandemic. author contributions: i.n. participated in writing-original draft preparation, and writing-review and editing. n.n. participated in writing-original draft preparation, and writing-review and editing. r.s. participated in data curation, and writing-review and editing. a.g. participated in data curation, and writing-review and editing. w.v. participated in data curation, and writing-review and editing. s.s. participated in data curation, and writing-review and editing. m.h. participated in conceptualization, methodology, writing-review and editing. l.u. participated in writing-review and editing. a.j.g. participated in methodology, writing-review and editing. v.i.o.a. participated in conceptualization, methodology, validation, formal analysis, supervision, funding acquisition, writing-original draft preparation, data curation, and writing-review and editing. all authors have read and agreed to the published version of the manuscript. funding: this study was supported by grants from the mental health foundation, the calgary health trust, the university hospital foundation, the alberta children's hospital foundation, the royal alexandra hospital foundation, and the alberta cancer foundation. the sponsors had no role in the design, execution, interpretation, or writing of the study. early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia progression of mental health services during the covid-19 outbreak in china a novel coronavirus from patients with pneumonia in china the socio-economic implications of the coronavirus pandemic (covid-19): a review the psychological impact of quarantine and how to reduce it: rapid review of the evidence mental health consequences during the initial stage of the 2020 coronavirus pandemic (covid-19) in spain immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china impact on mental health and perceptions of psychological care among medical and nursing staff in wuhan during the 2019 novel coronavirus disease outbreak: a cross-sectional study prevalence of depression, anxiety, and insomnia among healthcare workers during the covid-19 pandemic: a systematic review and meta-analysis prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured sars caring unit during outbreak: a prospective and periodic assessment study in taiwan idoiaga-mondragon, n. stress, anxiety, and depression levels in the initial stage of the covid-19 outbreak in a population sample in the northern spain generalized anxiety disorder, depressive symptoms and sleep quality during covid-19 outbreak in china: a web-based cross-sectional survey study on the public psychological states and its related factors during the outbreak of coronavirus disease 2019 (covid-19) in some regions of china a nationwide survey of psychological distress among chinese people in the covid-19 epidemic: implications and policy recommendations mental health problems and social media exposure during covid-19 outbreak covid-19: closing the psychological treatment gap during the pandemic, a protocol for implementation and evaluation of text4hope (a supportive text message program) case-fatality rate and characteristics of patients dying in relation to covid-19 in italy epidemiology working group for ncip epidemic response. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) in china population who currently use any social media from office for national statistics: personal and economic well-being in great britain population of alberta, by age and sex six-months outcomes of a randomised trial of supportive text messaging for depression and comorbid alcohol use disorder perception of patients with alcohol use disorder and comorbid depression about the usefulness of supportive text messages coronavirus disease 2019 pandemic: health system and community response to a text message (text4hope) program supporting mental health in alberta alcohol use disorder and comorbid depression: a randomized controlled trial investigating the effectiveness of supportive text messages in aiding recovery randomized controlled pilot trial of supportive text messaging for alcohol use disorder patients randomized controlled pilot trial of supportive text messages for patients with depression supportive text messages to reduce mood symptoms and problem drinking in patients with primary depression or alcohol use disorder: protocol for an implementation research study cross-sectional survey evaluating text4mood: mobile health program to reduce psychological treatment gap in mental healthcare in alberta through daily supportive text messages acknowledgments: support for the project was received from alberta health services and the university of alberta. the authors declare no conflict of interest. key: cord-013420-0nmil3yt authors: tombat, kabir; van dijk, jitse p. title: roma health: an overview of communicable diseases in eastern and central europe date: 2020-10-20 journal: int j environ res public health doi: 10.3390/ijerph17207632 sha: doc_id: 13420 cord_uid: 0nmil3yt the roma are europe’s largest minority. they are also one of its most disadvantaged, with low levels of education and health and high levels of poverty. research on roma health often reveals higher burdens of disease in the communities studied. this paper aims to review the literature on communicable diseases among roma across eastern and central europe. a pubmed search was carried out for communicable diseases among roma in these parts of europe, specifically in romania, bulgaria, hungary, serbia, slovakia, the czech republic and north macedonia. the papers were then screened for relevance and utility. nineteen papers were selected for review; most of them from slovakia. roma continue to have a higher prevalence of communicable diseases and are at higher risk of infection than the majority populations of the countries they live in. roma children in particular have a particularly high prevalence of parasitic disease. however, these differences in disease prevalence are not present across all diseases and all populations. for example, when roma are compared to non-roma living in close proximity to them, these differences are often no longer significant. the romani, or roma are the largest transnational minority in europe. through linguistic, anthropological and more recently genetic mapping, their roots can be traced to original nomadic communities in north-west india [1] . they began their migration westwards between the 6th to 10th century, with groups settling along the way, finally entering europe in the 12th century. roma communities across europe and central asia gradually formed diverse endogamous sub-groupings, still retaining large parts of their language and culture [1, 2] . in europe alone they now number around 11 million, the vast majority living in eastern and central europe (table s1 ). the history of roma people in europe is marked by discrimination and persecution. in romania, they were enslaved [3] ; in britain they were declared criminals and had to choose between exile or death [4] . during nazi rule, they became the victims of genocide, which the roma call "porajmos" [5] . in eastern europe, roma children were taken from their parents in an attempt at assimilation. more recently, in the czech republic, roma women were unwittingly sterilised even after the turn of the millennium [6] . even now, in 2020, in the midst of the coronavirus pandemic, a few roma settlements in slovakia and bulgaria are being subjected to disproportionately high levels of surveillance and policing [7] . these are just a few examples of discrimination and persecution which the roma have endured and continue to face. though commonly thought of as itinerant, most roma are actually settled, partly on account of forced assimilation policies. by all accounts, the roma are extremely disadvantaged. most people identifying as roma live in informal settlements, often with facilities which are far below the national standards of the countries they are settled in [8] . roma are also routinely found to have worse social, economic and health indicators than their non-roma counterparts. ninety percent of roma live below national poverty lines. less than one third are in paid employment. only 15 per cent of roma have completed high school, and 45 per cent of roma households lack proper sanitation [8, 9] . roma children are only 34 to 45 per cent as likely to be vaccinated as non-roma, and they routinely face barriers in accessing healthcare [10] [11] [12] . in 2005, nine central and southern eu countries-bulgaria, croatia, the czech republic, hungary, north macedonia, romania, serbia, montenegro and slovakia-along with several international organisations, launched the decade of roma inclusion 2005-2015, committing to allocate resources with the aim of integration and ending discrimination and poverty of roma communities. this was followed by the roma integration 2020 project, with similar goals [13] . there are numerous papers examining the prevalence of specific diseases in certain roma communities. this paper aims to examine the occurrence of communicable diseases among roma across eastern and central europe. publications were selected based on a pubmed search, starting in 2005 and ending july 2020. the literature selected describes the occurrence of communicable disease among the roma in eastern european countries. these were limited to eu member states or states in the accession process with sizeable roma populations. eu member states and those in the accession process were chosen for ease of comparability based on the similarity of their legal systems, policies and institutions. the roma population had to be sizeable, i.e., being defined as at least 5 per cent of the total population and/or amounting to at least 200,000 persons. the size of the roma population was also taken into account for compatibility purposes. for example, russia and ukraine are currently not in the process of eu accession and were therefore excluded, despite having sizeable roma populations. the countries of study selected were romania, bulgaria, hungary, serbia, slovakia, the czech republic and north macedonia (table s1 ). including countries outside of these parameters was beyond the scope of this short study, but they nevertheless warrant further research. turkey, which has an estimated roma population of 2.75 million, was excluded since eu accession negotiations have reached a virtual standstill. spain, france and the uk, which are eu member states with sizeable roma populations outside central and eastern europe, were also intentionally excluded. the following search strategy was employed. the search string detailed the target population, i.e., the roma; the geographical focus, i.e., the seven specified countries; and lastly communicable diseases (supplementary material s1). text word terms were used for "roma" and its more commonly-used exonyms and endonyms, such as romani, gypsy, romany, sinti. certain terms carrying a geographical marker not relevant to the intended geographical area of study, such as gitano, which is one of the terms used for roma people in spain, were intentionally excluded. gypsy, sinti and their various iterations were included, despite being geographically inappropriate, owing to their generic usage for the roma in english publications. text word terms were employed for the countries selected to make the search as broad as possible. using the same search string without specifying countries yielded almost 1177 results, many of which focused on orthopaedic papers dealing with range of motion (rom), rod outer-segment membrane protein, or non-included countries such as greece and spain. for communicable diseases, a combination of mesh and text word terms were used for the various communicable diseases specifically, including but not limited to listing all the diseases mentioned on the who regional office for europe's pages on communicable diseases [14] , as well as umbrella terms such as sexually transmitted diseases. this was done to make the search as broad as possible. the decade of roma inclusion was launched in 2005, when several european governments committed to improve the conditions of their roma minorities. this search yielded 96 results. other filters such as language and "human" or "other animal" were not used, since the paper classification was often incomplete. out of the 96 papers, all of which pertained to humans, only 85 were marked as "human". the titles and abstracts were then preliminarily screened for relevance, as shown in figure 1 . papers were included if they pertained to prevalence of any communicable diseases among the roma community within any of the specified seven countries. papers exclusively describing outbreaks were therefore excluded. the papers had to have been published in english and had to have full text availability. opinion pieces, editorials and commentaries were excluded. if titles and abstracts were ambiguous in terms of the above criteria, the full text was scanned as well. this resulted in 35 papers which were selected for closer examination. papers were further excluded, if on scanning the full texts they were found not to fulfil the inclusion criteria stated in the initial screening, such as describing prevalence data. this resulted in papers being excluded for not reporting data on the basis of ethnicity and not reporting specific disease occurrence. further exclusions were made for multiple papers based on the same databases, for which the population and prevalence data were identical. this was the case of five papers from the hepameta team in slovakia. in this case, only the first published paper was included. as umbrella terms such as sexually transmitted diseases. this was done to make the search as broad as possible. the decade of roma inclusion was launched in 2005, when several european governments committed to improve the conditions of their roma minorities. this search yielded 96 results. other filters such as language and "human" or "other animal" were not used, since the paper classification was often incomplete. out of the 96 papers, all of which pertained to humans, only 85 were marked as "human". the titles and abstracts were then preliminarily screened for relevance, as shown in figure 1 . papers were included if they pertained to prevalence of any communicable diseases among the roma community within any of the specified seven countries. papers exclusively describing outbreaks were therefore excluded. the papers had to have been published in english and had to have full text availability. opinion pieces, editorials and commentaries were excluded. if titles and abstracts were ambiguous in terms of the above criteria, the full text was scanned as well. this resulted in 35 papers which were selected for closer examination. papers were further excluded, if on scanning the full texts they were found not to fulfil the inclusion criteria stated in the initial screening, such as describing prevalence data. this resulted in papers being excluded for not reporting data on the basis of ethnicity and not reporting specific disease occurrence. further exclusions were made for multiple papers based on the same databases, for which the population and prevalence data were identical. this was the case of five papers from the hepameta team in slovakia. in this case, only the first published paper was included. a quality assessment was then carried out. this relied on the joanna briggs critical appraisal checklist for prevalence studies [15] . this was further quantified by assigning a numerical value of 1 to every yes. ultimately, 19 papers were selected for review, as illustrated in figure 1 and table 1 . the included papers studied mostly high-risk sub-populations of roma. all the papers involved roma in settlements with substandard living conditions. twelve of the 19 papers are from slovakia. the czech republic and north macedonia are not represented in the final selection of papers to be studied. many papers are authored by the same research teams, for example, six papers from slovakia a quality assessment was then carried out. this relied on the joanna briggs critical appraisal checklist for prevalence studies [15] . this was further quantified by assigning a numerical value of 1 to every yes. ultimately, 19 papers were selected for review, as illustrated in figure 1 and table 1 . the included papers studied mostly high-risk sub-populations of roma. all the papers involved roma in settlements with substandard living conditions. twelve of the 19 papers are from slovakia. the czech republic and north macedonia are not represented in the final selection of papers to be studied. many papers are authored by the same research teams, for example, six papers from slovakia are by the hepameta team and rely on the same database, which examines a cross-section of roma and non-roma in košice in eastern slovakia. table s2 . + roma and non-roma from settlement regions in addition to non-roma from other regions. ro-romania; bg-bulgaria; hu-hungary; sk-slovakia; srb-serbia. the prevalence of human immunodeficiency virus (hiv) among pregnant roma women (n = 862) was 0.6 per cent vs. 0.1 per cent among "white" women (n = 10,192) in a pilot prevention of mother-to-child hiv transmission programme in south-east romania. the study was carried out in constanta county, which was known for an hiv outbreak [16] . young roma men in bulgaria (n = 405) had an hiv prevalence of 0.5 per cent [20] . in budapest, hungary, however, neither of the two populations of roma surveyed had hiv, despite one group being made up of injecting drug users (idus) [18, 19] . hepatitis infection prevalence in table 2 [22] . a subpopulation of the same sample was tested for hepatitis e virus (hev), and 21.5 per cent of roma tested positive vs. 7.2 per cent of non-roma [31] . a romanian cervical cancer screening study found human papillomavirus (hpv) prevalence among roma (n = 124) to be 6.5 per cent vs. 15.5 per cent of women identifying as romanian (n = 1615). in fact, the only minority with a lower prevalence at 4.2 per cent consisted of women identifying as ukrainian (n = 24) [32] . parasitic disease in children was the focus of six of the ten studies covering parasitic diseases. except for one paper describing an 8.7 per cent prevalence of trichomonas among young roma men in sofia, bulgaria [17] , all the other papers cover roma in slovakia ( table 3) . the prevalence of microsporidia in the stool samples of clinically-healthy roma children (n = 72) from settlements in eastern slovakia was 30.6 per cent. of these, the prevalence of enterocytozoon bieneusi was 4.2 per cent and encephalitozoon cuniculi 26.4 per cent. the highest prevalence was found in boys aged 6-9 years (n = 11) at 45.5 per cent, and the risk of infection was 1.8 times higher in the group of boys [21] . among children aged 1-2 years hospitalised at the institute for child and youth health care of vojvodina in novi sad, serbia, 10.0 per cent of roma children (n = 59) had parasitic skin disease (pediculus humanus capitis and scabies) vs. 0.0 per cent of the non-roma children (n = 59) [24] . the prevalence of cryptosporidium in the stool samples of clinically-healthy roma children (n = 53) in eastern slovakia was 11.3 per cent, whereas 0.0 per cent of the non-roma children sampled (n = 50) tested positive. roma babies less than one year old had the highest prevalence, at 22.7 per cent [25] . in the košice region of eastern slovakia, seropositivity to toxocara was 22.1 per cent among roma (n = 429) compared to 1.0 per cent among non-roma (n = 394). increasing age (odds ratio (or) 2.512, 95% confidence interval (ci) 1.477-4.271) and the lack of household hygiene facilities (or 2.512, 95% ci 1.477-4.271) were both strong risk factors for seropositivity [26] . in another slovakian study, prevalence among roma children (n = 67) was 40.3 per cent vs. 2.3 per cent among non-roma children (n = 44) [34] . the prevalence of helminthic infections in hospitalised and non-hospitalised children in the prešov and košice regions of eastern slovakia was 25.8 per cent among roma children (n = 275) vs. 0.7 per cent among non-roma children (n = 150). a single species, ascaris lumbricoides, accounted for 87.5 per cent of all helminthic infections. the age groups 3-5 years (n = 64) and 6-10 years (n = 57) among roma had the highest prevalence of these infections at 31.3 per cent and 30.2 per cent, respectively [27] . in medzev, 36 km west of košice, 85 per cent of roma children (n = 60) had helminthic infections vs. 23.8 per cent of non-roma children (n = 21). seroprevalence for strongyloides stercoralis specifically was 33.3 per cent in roma children vs. 23.8 per cent in non-roma [28] . in the hepameta population, seropositivity for trichinella or echinococcus was 0.5 per cent and 0.2 per cent among roma tested (n = 429). however, no significant difference was found with regard to non-roma (n = 394) [29] . prevalence of toxoplasma gondii in the hepameta population in eastern slovakia, determined by seroprevalence of t. gondii antibodies, was 45.0 per cent among roma (n = 420) compared to 24.1 per cent among non-roma (n = 386). prevalence among non-roma living in the vicinity of the roma settlements (n = 158) was 30.4 per cent compared to 19.7 per cent among non-roma outside this area (n = 228) [30] . in a group of roma children from across slovakia (n = 67), seroprevalence was 20.9 per cent vs. 7.1 per cent among non-roma children (n = 42) [33] . papers on bacterial disease among the roma all examine sexually transmitted diseases (table 4) . a study of young roma men in sofia, bulgaria (n = 296) found that 21.7 per cent had at least one std (trichomonas, chlamydia, gonorrhoea or syphilis) and that the rates of gonorrhoea and syphilis were 1807 and 312 times the national levels, respectively [17] . a later study by the same group of researchers examining a larger group of young roma men found much lower rates of infection [20] . the prevalence of syphilis in a sample of volunteers tested at a health camp in a predominantly roma neighbourhood of budapest, hungary was 1.8 per cent among roma (n = 50) vs. 0.0 per cent among non-roma (n = 14) [18] . a study by the same authors on idus in budapest showed that 16.7 per cent of roma idus (n = 42) were positive for either chlamydia or syphilis vs. 8.3 per cent of non-roma idus (n = 144), while none of the idu's sampled tested positive for gonorrhoea [19] . the prevalence of chlamydia trachomatis in the hepameta population in eastern slovakia was 7.2 per cent among the roma (n = 208) compared to 5.3 per cent among non-roma (n = 132). however, this difference was not significant. roma women (n = 142) had a prevalence of 8.5 per cent compared to 4.5 per cent among roma men (n = 66). there was no difference in prevalence among non-roma men (n = 75) and women (n = 57) [23] . the aim of this paper was to review the literature on communicable diseases among roma across eastern and central europe. we found that roma communities have disproportionately high prevalence of communicable diseases, and are identified as being at high risk of infection throughout these parts of europe. studies on communicable diseases among roma appear to originate primarily from slovakia. romania, which has the highest population of roma in the eu, has surprisingly little research published on them. in this review only two papers on romanian roma met the selection criteria. the reasons for this disparity need to be examined. this review was only concerned with papers written in english, so it is possible that more information is available in the national languages. the papers reviewed all involved segregated roma, i.e., those living in settlements. though this might seem to be a limitation, it is known that most roma in europe identifying as roma live predominantly in informal settlements [8] . furthermore, data collection along ethnic lines remains a contentious issue [35] . additionally, most integrated roma no longer identify as roma, or might not even know of their roma heritage [36] . as a result, there is a lack of usable data on roma living outside the settlements. this review indicates that roma sometimes do not have a higher prevalence of communicable diseases. no significant difference between roma and non-roma was found in chlamydia cases in the hepameta population in eastern slovakia. in fact, roma men had fewer cases of chlamydia than either non-roma men or women. nevertheless, the authors of this review tentatively state that roma are at a higher risk of contracting chlamydia, and are more likely to suffer from adverse effects of infection because of the barriers to healthcare which they face [23] . drawing from the same hepameta population, seropositivity for trichinella or echinococcus showed no statistical differences between roma and non-roma [29] . among a group of idus in budapest, neither the roma nor the non-roma idus had hiv [19] . non-roma living in close proximity to roma do not have very different prevalence of communicable diseases than the roma. in fact, roma may even have lower rates of disease. this is evidenced by some surprising findings. non-roma residents of a predominantly roma neighbourhood of budapest had higher hbv rates than their roma neighbours, while neither of the groups had any cases of hiv [18] . a hepameta subpopulation in slovakia showed higher rates of t. gondii among non-roma living in close proximity to roma settlements [30] . roma have a relatively high prevalence of communicable diseases overall. notwithstanding the instances mentioned above, roma have a higher occurrence of communicable diseases than non-roma. the most common reasons hypothesised by authors for the higher rates of disease are lack of water, poor sanitation and hygiene, crowded living spaces, high-risk sexual behaviours, and exposure to animals and waste [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] . several studies found that roma, especially roma children, have a particularly high prevalence of parasites. this is especially troubling, given that roma children have been found to suffer from significantly higher levels of morbidity than their non-roma peers [24] , and because parasites such as microsporidia and toxocara can be life-threatening. many of these are diseases of poverty, so they can potentially be treated and prevented, but they may result in significant morbidity if not managed. some studies found that roma have high rates of sexually transmitted diseases. in sofia, for example, the prevalence of gonorrhoea and syphilis was many hundred times the national levels [17] . on the other hand, despite repeated studies describing high-risk sexual behaviour, the prevalence of stds is sometimes not very high [20, 23] . amirkhanian et al. hypothesize that this is probably due to the social insularity of the groups [20] . this might also explain the lower rates of hpv among roma in romania [32] . this review is the first to attempt an examination of the prevalence of communicable diseases among roma across eastern and central europe. however, some limitations should be mentioned. papers were not screened very stringently for quality, given the dearth of research in this area. while this enabled the review to include a much broader range of papers, it also meant however that not all the papers included lent themselves to rigorous statistical analysis. papers written in languages other than english were not searched for or included, as a result of which useful data might be missing. transnational, national and regional databases of health were not examined either. finally, analyses of impacts, such as socio-cultural aspects of the community, could only be included in as far as they were analysed in the reviewed papers. firstly, the higher prevalence of disease within roma settlements, along with many of the risk factors for infections, should be a cause for concern and action. the roma minority represents an untapped repository of knowledge and skill, and a lot more resources should be devoted to removing barriers to their full participation in all areas of society. secondly, and perhaps more concerning to many, there is the fact that as long as segregated roma continue to exhibit a higher prevalence of disease, they remain a reservoir for neglected and immunisable diseases which could easily spill over into the general population. this has happened several times already in the case of measles [37, 38] . lastly, roma communities that do not have a high disease burden also need attention. once diseases enter these insular communities, they are likely to spread rapidly given the high infection potential associated with lack of infrastructure, poor hygiene and frequent high-risk behaviours [23] . roma in eastern and central europe continue to have a higher prevalence of communicable diseases than the majority populations of the countries they live in. roma children in particular have a particularly high prevalence of parasitic disease. however, these differences in disease prevalence are not always present across diseases and roma populations. in the case of hpv in romania for example, roma women have less than half the rate of the disease than non-roma romanian women. additionally, when roma are compared to non-roma living in close proximity to them, these differences are often no longer significant. this does not change the reality that roma communities continue to score lower on socio-economic indicators, have a disproportionately high incidence of communicable diseases, and have been found to be at high risk of infection. the following are available online at http://www.mdpi.com/1660-4601/17/20/7632/s1, table s1 : roma over europe, s1: search terms, table s2 : quality assessment. the authors declare no conflict of interest. reconstructing the population history of european romani from genome-wide data european roma groups show complex west eurasian admixture footprints and a common south asian genetic origin the cost of roma slavery trouble with gypsies in early modern england roma holocaust remembrance has lessons for europe today roma women reveal that forced sterilisation remains policing of european covid-19 lockdowns shows racial bias-report. the guardian the situation of roma in 11 eu member states; publications office of the european union undp in europe and central asia. 2020. available online the roma vaccination gap: evidence from twelve countries in central and south-east europe are barriers in accessing health services in the roma population associated with worse health status among roma? access to health care for roma children in central and eastern europe: findings from a qualitative study in bulgaria roma integration 2020|roma decade. rcc.int. 2020. available online communicable diseases. euro.who.int. 2020. available online mother-to-child transmission of hiv infection in romania: results from an education and prevention programme hiv risk behavior patterns, predictors, and sexually transmitted disease prevalence in the social networks of young roma (gypsy) men in sofia hiv and selected blood-borne and sexually transmitted infections in a predominantly roma (gypsy) neighbourhood in budapest, hungary: a rapid assessment vulnerability to drug-related infections and co-infections among injecting drug users in high-risk sexual behavior, hiv/std prevalence, and risk predictors in the social networks of young roma (gypsy) men in bulgaria occurrence of microsporidia as emerging pathogens in slovak roma children and their impact on public health high hepatitis b and low hepatitis c prevalence in roma population in eastern slovakia the prevalence of chlamydia trachomatis in the population living in roma settlements: a comparison with the majority population the health status of roma children-a medical or social issue significantly higher occurrence of cryptosporidium infection in roma children compared with non-roma children in slovakia seroprevalence of human toxocara infections in the roma and non-roma populations of eastern slovakia: a cross-sectional study schusterová, i. occurrence of the most common helminth infections among children in the eastern slovak republic the roundworm strongyloides stercoralis in children, dogs, and soil inside and outside a segregated settlement in eastern slovakia: frequent but hardly detectable parasite a community-based study to estimate the seroprevalence of trichinellosis and echinococcosis in the roma and non-roma population of slovakia exposure to toxoplasma gondii in the roma and non-roma inhabitants of slovakia: a cross-sectional seroprevalence study seroprevalence of hepatitis e virus in roma settlements: a comparison with the general population in slovakia hpv testing for cervical cancer in romania: high-risk hpv prevalence among ethnic subpopulations and regions the cross-sectional study of toxoplasma gondii seroprevalence in selected groups of population in slovakia seroepidemiology of human toxocariasis in selected population groups in slovakia: a cross-sectional study collecting ethnic statistics in europe: a review the socio-economic determinants of the health status of roma in comparison with non-roma in bulgaria, hungary and romania measles outbreak in a french roma ongoing measles outbreak in greece related to the recent european-wide epidemic key: cord-275711-ejw3ausf authors: mon-lópez, daniel; de la rubia riaza, alfonso; hontoria galán, mónica; refoyo roman, ignacio title: the impact of covid-19 and the effect of psychological factors on training conditions of handball players date: 2020-09-05 journal: int j environ res public health doi: 10.3390/ijerph17186471 sha: doc_id: 275711 cord_uid: ejw3ausf the spread of covid-19 has altered sport in spain, forcing athletes to train at home. the objectives of the study were: (i) to compare training and recovery conditions before and during the isolation period in handball players according to gender and competitive level, and (ii) to analyse the impact of psychological factors during the isolation period. a total of 187 participants (66 women and 121 men) answered a google forms questionnaire about demographics, training, moods, emotional intelligence, and resilience sent using the snowball sampling technique. t-test and analysis of variance (anova) were used to compare sport level and gender differences. linear regressions were used to analyse the psychological influence on training. handball players reduced training intensity (in the whole sample; p = 0.44), training volume (especially in professional female handball players; p < 0.001), and sleep quality (especially in professional male handball players; p = 0.21) and increased sleep hours (especially in non-professional female players; p = 0.006) during the isolation period. furthermore, psychological factors affected all evaluated training and recovery conditions during the quarantine, except for sleep quantity. mood, emotional intelligence, and resilience have an influence on physical activity levels and recovery conditions. in addition, training components were modified under isolation conditions at p < 0.001. we conclude that the covid-19 isolation period caused reductions in training volume and intensity and decreased sleep quality. furthermore, psychological components have a significant impact on training and recovery conditions. currently, a virus called coronavirus 2 (sars-cov-2 or covid-19) has quickly spread to many countries around the world, causing an unexpected pandemic [1] . consequently, quarantine and isolation periods have been imposed on citizens. in spain, the lockdown started on 14 march, 2020 [2] . on the sporting fields, official competitions and trainings were postponed or suspended [3] . specifically, in handball, the last matches in spain were played on 7-8 march, 2020, and all handball players had to remain in their respective houses at least until 4 may, 2020 (almost eight weeks). during detraining periods (off-season), monitoring the external load of players (volume and intensity) is necessary to ensure the maintenance of fitness [4] . accordingly, technological devices such as heart rate monitors or global positioning systems (gps) can be used to quantify the training load jointly with individual questionnaires associated with the rating-of-perceived-exertion (rpe) scale [5] . drastic reductions in physical activity levels or cessation of training entail a decrease in the athlete's physiological and neuromuscular adaptations, and even increases the injury risk [1] . after a period of more than 3-4 weeks, this can result in negative effects on body composition, aerobic capacity (vo 2 max), repeated sprinting ability, and strength and power in the lower limbs of the body [6] . specifically, the physical activity reduction caused by covid-19 (eight weeks) could decrease strength by 8-12% and fast fibre areas by 15% as well as lower muscle electrical activity [7] . furthermore, other factors relevant to sport performance such as sleep quantity and quality, food/nutrition, hydration or mood could be affected by detraining periods [8, 9] . however, the effects caused by stopping training during the quarantine were different depending on the sport and the athlete's profile [10] . specifically in handball, the most important differences caused by a period of non-competition (off-season) were identified in jumping performance levels, shooting velocity, maximum concentric strength of the upper limbs, and the power of upper and lower limbs [11, 12] . moreover, isolation periods associated with a lack of training sessions and official competitions in a team sport might also have led to decreased communication between players and coaching staff, and to inadequate individual training conditions [13] . hence, isolation periods might have led players to a partial or total reversal of the adaptations produced by the training process or 'detraining' [7] . together, isolation and sporting inactivity periods tend to produce psychological disorders [14] . factors like quarantine duration, fears of infection, frustration, boredom, inadequate supplies, and inadequate information could be the most important 'stressors' leading to adverse mental effects [15] . however, the consequences derived from an isolation period do not have the same prevalence throughout the population. thus, young female students were the social group that suffered the most stress, anxiety, and depression during the covid-19 quarantine [16] . interestingly, physical exercise positively influenced mood [17] and the athletes' well-being [18] , even in those who were in a non-specific training, recovering from injury, or off-season period [4] . thus, the exercise load modified the subjective perception of well-being [19] and reductions in physical activity levels entailed an increase in the prevalence of the higher severity of depressive disorders [14] . in addition, variations in the strength levels registered after an off-season period in which a training programme had been implemented were related to psychological factors and self-perception [20] . another relevant psychological area for the athlete's performance is emotional intelligence (ie), which can be defined as the dynamic capacity to solve problems derived from the emotions of oneself and others [21] . thus, motivation towards training and physical activity are associated with higher ie values [22] . however, this factor could be negatively affected by sport inactivity periods due to low levels of interaction between the different participants in competition (coaches, players, coaching staff, opponents, etc.) [23] . accordingly, during isolation periods, the promotion and development of intrinsic motivation levels would become essential to decreasing anxiety and stress levels [21] . the covid-19 quarantine has had effects at different levels (physical, physiological, psychological, emotional) due to a change in the athletes' daily lives and training habits. the importance of this research lies in the need to know how the general state (physical, psychological, and emotional) of a handball player evolves over long periods of detraining in order to apply adequate strategies to return to physical activity. therefore, the objectives of this study were (i) to compare training components (intensity, volume, and recovery conditions) before and during the isolation period in handball players by gender and competitive level, and (ii) to analyse the impact of psychological factors (mood, emotional intelligence, and resilience) on training components during the isolation period. the research design corresponding to this study was non-experimental, cross-sectional, retrospective, and descriptive, based on conducting a survey through the google forms web platform (google llc, mountain view, ca, usa). the inclusion criteria were that all participants must be nationally federated handball players (royal spanish handball federation) during the 2019-2020 season. a total of 215 handball player questionnaires were collected. surveys of injured athletes (n = 12), athletes not resident in spain (n = 13), under 16 years old (n = 12), and players infected with covid-19 during the survey (n = 1) were excluded from the study. there were 187 handball players in the final sample (n = 121; 64.7% men and n = 66; 35.30% women). accordingly, the gender proportion in our study was almost identical to the spanish handball player population (64% men vs. 36% women) [24] . the men were 23.61 ± 6.19 years old and the women were 22.65 ± 4.62 years old and had been confined for 34.66 ± 3.33 days and 34.97 ± 3.12 days, respectively. in the last two years, 26 male and 18 female players had been called up by their national or autonomic teams. six men (5%) and one woman (1.5%) had recovered from covid-19 when they filled out the questionnaire. handball players were divided into two categories: professionals ('división de honor-asobal' and 'división de honor plata' for men and 'division de honor-guerreras iberdrola league' for women) and non-professionals (other national leagues). descriptive variables of playing position, sport level, mood states, emotional intelligence, and resilience variables are shown in table 1 . the first demographic and training questionnaire was adapted to handball from football [25] jointly by five studies and sport university teachers with wide academic (more than five years) and investigative experience in the sport field. later, the demographic questions were evaluated by two expert international handball coaches with more than 20 years' experience and their feedback was used by the researchers to develop the definitive version of the demographic questions. two external psychology experts assisted with adding the appropriate psychological tests for the study. the spanish validated versions of the profile of mood states (poms) [26] , the wong law emotional intelligence scale short form (wleis-s) [27] , and the brief resilience scale (brs-ii) [28] were used to measure mood state, emotional intelligence, and resilience, respectively. the study variables were distributed into three categories: demographic, training, and psychological variables. the demographic variables were (q1-q8): gender (male or female); age (years); place of residence (spain or another country); number of days confined (days); sport level (competition category); professional or non-professional classification according to two criteria ([1] 'level of dedication/remuneration': for professionals, there is a high percentage of sport contracts while non-professionals receive no remuneration for sport practice; [2] 'competition structure': professionals participate in competitions structured in one group at the national level, while non-professionals compete in categories divided by groups according to geographical and economic criteria and, therefore, do not exclusively take competitive performance factors into account); selected by the national team in the last two years (yes or no); playing position (goalkeeper, wing, lateral-back, centre-back or pivot); and personal experience with covid-19 (no experience, covid-19 infected, or covid-19 recovered). the [26] , emotional intelligence [27] , and resilience [28] showed excellent to acceptable reliabilities. notes: t-a = tension-anxiety; sea = self-emotion appraisal; oea = other's emotion appraisal; uoe = use of emotion; roe = regulation of emotion; brs = brief resilience scale; prof = professional players; n-prof = non-professional players. the final version of the survey was formatted into a google forms questionnaire (see supplementary materials file s1) and was sent via whatsapp to personal contacts and published on twitter using the snowball sampling technique [29] . snowball sampling is a method of gathering information to access specific groups of people. the researcher asks the first few samples, who are usually selected via convenience sampling. the existing study subjects recruit future subjects among their acquaintances. sampling continues until data saturation. this method is the most effective when the members of the population are not easily accessible [30] . one follow-up was sent to the whatsapp contacts to improve the response rate after five days. although we do not know the response rate, the final number of participants can be considered as a very representative dataset [31] . the questionnaire was available online for ten days starting on 16 april, 2020, just one month after the state of alarm was declared in spain [2] . these dates were selected due to the special situation of spain, which at that time had the second highest total number of cases of covid-19 infections [32] . the questionnaire was open and anonymous to verify the sincerity of the answers. an unlimited time to complete the survey was provided to all athletes. once the deadline for admitting surveys was closed, they were reviewed to remove contradictory responses (checking the congruence between the data provided by the players) or repeated (checking two or more submissions with the same responses in a short period of time), deleting one response from the database. all participants signed an informed consent form before completing the survey. this study was approved by the ethics committee of the polytechnic university of madrid. the data were described by arithmetic mean (m) and standard deviation (sd). the normal distribution of the variables was checked using the kolmogorov-smirnov and shapiro-wilk tests. paired sample t-tests were used to compare the pre-isolation and isolation periods and independent sample t-tests were performed to check gender differences [25] . when statistically significant differences were found, the effect size was estimated using cohen's d index (d) [33] , establishing two cut-off points: medium effect (0.30) and large effect (0.60). the confidence interval for the effect size was set at 95% and the percentage of change was calculated by (% = (m1 − m2/m1) × 100). the anova of two factors was used to analyse the differences between professionals and non-professionals, male and female, and the interaction of both [34] . to set the differences between groups, a post-hoc analysis was carried out using the bonferroni test. finally, two-step hierarchical regression was performed to analyse the relationships between the psychological and training variables. ibm spss statistics software (spss 25.0. ibm corp., armonk, ny, usa) was used for the mathematical calculations. the level of significance was set at p < 0.05. the analysis by gender showed differences in the psychological variables of depression (t (185) = −2.54; p = 0.012) and fatigue (t (185) = −2.02; p = 0.045) with lower values for women and higher values for men in vigour (t (185) = 2.18; p = 0.03), sea (t (185) = 2.23; p = 0.027) and roe (t (185) = 2.14; p = 0.034). moreover, a higher percentage of women in the sample played in higher categories than men p = 0.036. for the whole group, rpe, tdays, thours, and squality were reduced while shours increased (all p < 0.001). similar results were obtained when the analysis was carried out by gender. only the squality (p = 0.005) in men and tdays (p = 0.001) and squality (p = 0.001) in women presented different significant values (see table 2 ). result are summarised in table 3 . with regard to training conditions (volume and intensity), professional players had higher rpe values than non-professionals during confinement (f (1,183) = 4.09; p = 0.044) and trained more days than non-professionals before (f (1,183) = 51.58; p < 0.001) and during the isolation period (f (1,183) = 20.13; p < 0.001). additionally, women trained more days than men both before (f (1,183) = 5.17; p = 0.024) and during the isolation period (f (1,183) = 7.23; p = 0.008). similar results were obtained with regard to the training hours, where professional players trained more hours than non-professionals before (f (1,183) = 69.59; p < 0.001) and during the isolation periods (f (1,183) = 25.27; p < 0.001) and women trained more hours than men both before (f (1,183) = 11.69; p = 0.001) and during the isolation periods (f (1,183) = 4.09; p = 0.017). furthermore, the interaction for gender and professional level variables was significant before (f (1,183) = 7.49; p = 0.007) and during the isolation period (f (1,183) = 12.95; p < 0.001). in relation to recovery (shours and squality), professional players slept more hours than non-professionals (f (1,183) = 20.47; p < 0.001) and had better sleep quality (f (1,183) = 7.66; p = 0.006) before the isolation period. moreover, the interaction for gender and professional level variables was only significant for the sleep hours before the isolation period (f (1,183) = 5.18; p = 0.017). for the rest of the comparisons, no significant effects were detected (p > 0.05). five two-step hierarchical regression analyses were performed using rpe, tdays, thours, shours, and squality as the criterion in each case. mood status (tension-anxiety, depression, anger, vigour, fatigue, and friendship) was entered at the first step while emotional intelligence (sea, oea, uoe, and roe) and resilience were entered at the second step (see table 4 ). according to the rpe criterion, the model was non-significant at step 1 (p > 0.05). at step 2, uoe and resilience were significant predictors (f (11,175) = 2.22, p = 0.02, r 2 = 0.12, β = 0.23 and β = −0.17, respectively). the ∆r 2 was significant from step 1 to step 2 (p = 0.015). based on the tdays criterion, depression, vigour, and fatigue were significant predictors (f (6,180) = 3.56, p < 0.001, r 2 = 0.11, β = 0.25; β = 0.24 and β = −0.28, respectively) at step 1. at step 2, depression and fatigue retained significance and uoe was a significant positive predictor (f (11,175) = 3.32, p < 0.001, r 2 = 0.17, β = 0.24). the ∆r 2 was significant from step 1 to step 2 (p = 0.018). in relation to the thours criterion, depression, vigour, and fatigue were significant predictors (f (6,180) = 3.56, p = 0.01, r 2 = 0.09, β = 0.25; β = 0.22 and β = −0.26, respectively) at step 1. at step 2, depression and fatigue retained significance and uoe was a significant positive predictor (f (11, 175) = 2.66, p < 0.001, r 2 = 0.14, β = 0.19). the ∆r 2 was not significant from step 1 to step 2 (p > 0.05). regarding the shours criterion, the model was not significant in step 1 or step 2 (p > 0.05). for the squality criterion, the model was non-significant at step 1 (p > 0.05), but at step 2, tension-anxiety was a significant predictor (f (11,175) = 2.11, p = 0.02, r 2 = 0.12, β = −0.25). the ∆r 2 was not significant from step 1 to step 2 (p > 0.05). this study is one of the first to analyse the impact of the isolation period caused by covid-19 on the training (intensity and volume) and recovery conditions (quantity and quality of sleep) of professional and non-professional handball players according to the influence of transitory psychological factors (moods) and personality trait (emotional intelligence and resilience). based on the results yielded: (i) training and recovery conditions of the handball players were modified during the isolation period, reducing the intensity-rpe (in the whole sample), volume-tdays and thours (especially in professional female handball players) and sleep quality-squality (especially in professional male handball players) and increasing sleep hours-shours (especially in non-professional female players); and (ii) the psychological factors analysed (mood, emotional intelligence, and resilience) had an impact on training and recovery conditions, except for sleep quantity, during the covid-19 lockdown. training levels during the isolation period decreased in both intensity (rpe, p < 0.001, d = −0.93 (−54.44%)) and volume (tdays, p < 0.001, d = −0.53 (−14.42%); thours, p < 0.001; d = −1.28 (−89.56%)) in the whole sample. this change could activate the reversibility principle in the players, producing anatomical, functional, and physiological maladjustments [3] . accordingly, the isolation period could cause negative effects like the reduction of cardiorespiratory capacity, deceleration of the metabolic process, a decrease in muscle activity and the process of energy generation, and a decrease in hormonal production [7] . in addition, other detrimental effects on performance such as collective tactical disorganisation or the lack of interaction between teammates could appear in team sports [13] . one possible factor for the decrease in training levels during quarantine could have been the lack of equipment or insufficient space to exercise. this fact implies that the intensity and specificity of the training could have been replaced by global exercises at a constant speed [20] . thus, the neuromuscular adaptations of the training process achieved before the isolation period have gradually disappeared, losing the technique and speed-power in the basic skills of a team sport [12] . furthermore, movement restrictions have caused a deterioration of the players' fitness due to the impossibility of applying for strength training programs, producing what is known as 'long-term atrophic decrease' [35] . however, the training load does not seem to have decreased in the same way among all the players, especially when considering the volume (days and hours of training). regarding the competition level, there was a greater training time reduction in professional handball players (tdays, p = 0.004; thours, p < 0.001) than in non-professionals (tdays, p > 0.05; thours, p > 0.05). similar results were found by skoufas et al. [36] , who demonstrated that athletes with a higher competitive level reduced their training volume more than others during the off-season or non-competitive periods due to the higher initial levels of physical activity. in addition, the lack of qualified staff (coaches, physical trainers, etc.) to guide the physical-sport activity and the absence of contact and interaction with teammates could also be explanatory causes [37] . this activity reduction could lead to an increase in the body fat percentage, a decrease in the lean mass percentage, a reduction in sprint ability, a decrease in the rate of production of muscular energy, and/or a reduction in aerobic capacity [13] . regarding gender, a greater reduction in training volume was observed in men (tdays, p < 0.001, d = −0.54 (−17.64%); thours, p < 0.001, d = −1.13 (−90.88%)) than in women (tdays, p = 0.003, d = −0.56 (−9.39%); thours, p < 0.001, d = −1.73 (−87.31%)). similar results by gender were detected in the study of giustino et al. [38] in which men reduced the amount of exercise and energy expenditure during the isolation period. furthermore, men preferred to do physical activity outdoors more frequently than women [39] . however, when gender and competitive level were considered together, the decrease in training volume was greater in professional female players (tdays, p < 0.001; thours, p < 0.001) than in professional male players (tdays, p = 0.021; thours, p > 0.05). this result could be biased by the presence of a greater number of women who participated in the professional handball category (46.97%) compared to the number of professional male handball players (38.02%). the physical activity levels in professional female handball players before the isolation period were higher and the reduction was greater. along this line, professional female athletes reduced their training volume more during quarantine (76%) than professional males (74%). less communication with coaches and teammates, poorer adaptation to physical activity planning, a deterioration of rest and recovery conditions, and the thought of restarting competition in the long-term could be some of the factors that explain the difference in training volume by gender [10] . from a psychological perspective, several factors seem to have mitigated the decrease in training intensity and volume during the isolation period. the psychological component that had the greatest impact on training conditions was the use of emotions-uoe (rpe, r 2 = 0.12, p = 0.01; tdays, r 2 = 0.17, p = 0.01; thours, r 2 = 0.14, p = 0.03). team sport players tend to manage and use their emotions more easily and frequently for different purposes, better adapting to the environment's conditions [21] . therefore, a greater skill in the uoe would have enabled handball players to maintain higher external load parameters during the isolation period. greater contact with other teammates and friends, the clear and simple design, and planning of workout routines for training and encouraging an exercise-prone mood seem to have facilitated the control and management of negative feelings interrupting, to a lesser extent, training conditions [10, 17] . interestingly, the present study yielded two surprising a priori results associated with moods and personality traits. the first connects, as opposed to other studies in different fields [22, 40] , a lower resilience (brs) with a higher training intensity (r 2 = 0.12, p = 0.046). difficulty and confusion in measuring perceived training intensity (rpe) in isolated situations could have caused a relatively lower effort record, associated with a higher degree of control and experience [19] . the second finding links higher levels of depression to a higher training volume (tdays, r 2 = 0.17, p = 0.01; thours, r 2 = 0.14, p = 0.01;). players seek relief from depression and anxiety symptoms in physical-sport activity, thanks to a high commitment to sport excellence and high levels of athletic identity [41] . in relation to the recovery of physical activity pre-and post-isolation, the whole sample presented an increase in quantity of sleep (shours, p < 0.001, d = 0.69 (10.20%)) and a decrease in quality of sleep (squality, p < 0.001, d = −0.34 (−15.20%)). considering the correlation between physical activity levels and mental well-being [18] , the limitation or cessation of exercise could cause a deterioration in sleep quality, which is closely associated with well-being. the factor with the greatest negative impact on sleep quality during the isolation period was tension-anxiety (r 2 = 0.12, p = 0.01). isolation conditions could lead to worries about the athlete's fitness and restarting competition. these could be the main precursor factors of psychological disorders during quarantine such as stress, depression, or irritability [1, 15] . however, other behaviours could have affected sleep quality during the isolation period such as nutritional changes and a sedentary lifestyle [10] . on one hand, a decrease in the consumption of foods rich in vitamin d and carbohydrates could have caused a worsening in the athlete's recovery capacity [3] . on the other hand, negative changes in lifestyle (lower levels of physical activity, higher use of technologies, higher consumption of alcohol and other addictions, etc.) could have caused an alteration in sleep quality and fatigue perception [37] . however, tension-anxiety levels were higher in professional male handball players. together, the need to keep an adequate physical condition (self-perception of the physical profile) [20] to compete at top levels ('liga asobal' and 'liga de division de honor plata') and the impossibility of training under appropriate conditions could have caused adverse mental health states [42] that did not allow for optimal rest conditions. accordingly, increases in fatigue and injury risk could lead to a decrease in the player's recovery capacity [43] . regarding sleep quantity, an increase in sleep hours during the isolation period was detected in handball players, especially in non-professional female players. this change could be associated with changes in lifestyle caused by mobility restrictions. the time spent lying in bed increased and waking time was delayed, thus increasing sleep hours [44] . the greater daily flexibility of schedules in the young population, similar to handball players, could have been an opportunity to develop sleep habits that are more closely linked to their endogenous body rhythms, favouring a greater number of sleep hours [8] . similar results were found in other sports. on a psychological and emotional level, clemente-suárez, et al. [45] detected, in olympic and paralympic athletes, a higher impact of the isolation period (psychological inflexibility) on professional players and on women due to greater experimentation with stressful situations. considering the training conditions in team sports, mon-lópez et al. [25] found how the frequency, duration, and intensity of training were reduced during the quarantine in football players in spain. in relation to rest conditions, pillay et al. [10] demonstrated the alteration of sleep patterns (reduction in sleep quality), which led to an increase in the level of fatigue and the rate of injuries in a study with 692 athletes from 15 different sports. therefore, it seems that the effects of isolation period have generally been perceived as negative by the athletes. due to the deterioration of the fitness in handball players caused by the quarantine, coaches, physical trainers, technical staff, sports institutions, and national and international sports federations should plan strategies and training programmes aimed at reducing the detraining effects according to the athlete's gender and competitive level to avoid potential adverse effects such as injuries. however, even with continuous and accurate player monitoring, there could be a certain degree of non-control of the variables analysed due to the implications of government laws connected to public health. thus, the impact of these variables on the player's fitness could undergo modifications external to sport training. based on the scientific evidence, specific exercises should be proposed to personalise the training and recovery process of athletes, especially in handball players. setting clear training objectives through simple training tools and resources; personalised definition of the training external load variables according to a holistic vision of the context and the sport experience of the player during the previous competitive period (injuries, minutes played, competitive experience, etc.) [13] ; organise a 'player support network' by the experts (coach, doctor, psychologist, nutritionist, etc.) through the use of technology (phone calls, video calls, email, etc.) to guarantee suitable physical and psychological levels for the return to competition; design an individualised home fitness training programme according to available space and equipment resources tailored to the athlete's characteristics and current needs [3] ; provide adequate recovery and rest methods (sleep and relaxation techniques, stretching, supplementation, etc.) [9] ; and daily monitoring of the athlete's well-being, physical state, recovery capacity and psychological state [19] . although this is one of the first studies on the effects of covid-19 on handball players, some limitations should be mentioned. the unprecedent social and sport context in which the research was carried out and the isolation situation were novel regarding the sport training process and additional data would be necessary. moreover, the final sample of the study was 187 players, which limited the statistical power and possibly resulted in a self-selection bias associated with the athlete's gender and level of competition. accordingly, the results should be considered with caution, especially due to the sample imbalance with a greater presence of professional female handball players. another important aspect was that to ensure the sincerity of the answers, the questionnaires were anonymous, which implied the impossibility of confirming the athletes' identities. future study designs could consider including more variables in relation to demographic characteristics (level of studies, place of residence, etc.), training and recovery conditions (available space, training machines, etc.), and mood (motivations, etc.) of the players. on the other hand, an improvement in the monitoring systems for the training quantity and quality would be desirable in order to draw more precise conclusions. furthermore, conducting a longitudinal study covering the pre-, during and post-isolation periods through various measurements could provide information on how such a long detraining period influences the habits of handball players. the covid-19 isolation period had significant adverse effects on the training and recovery conditions of handball players, leading to physical deconditioning and worsening sleep conditions. relevant training reductions in volume and intensity were detected, especially in women and professionals, while a decrease in sleep quality was identified in professional handball players, especially in men. the psychological components had a significant impact on training and recovery conditions during the isolation period. psychological traits associated with personality such as resilience or emotional intelligence (use of emotions-uoe) were modifying factors of the training intensity and volume, and moods, based on components such as fatigue, depression, and tension-anxiety had a greater impact on the rest and recovery conditions of the players as well as on the external load of training. the set model of mood and personality traits (emotional intelligence and resilience) was explanatory of the training and recovery conditions of handball players during the isolation period, especially on the physical activity levels associated with a reduction in the days and hours that players use for exercise. medical recommendations for home-confined 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intelligence, motivational climate and levels of anxiety in athletes from different categories of sports: analysis through structural equations development of emotional intelligence through physical activity and sport practice. a systematic review positive personality-trait-like individual differences in athletes from individual-and team sports and in non-athletes how has covid-19 modified training and mood in professional and non-professional football players? versión breve en español del cuestionario poms para deportistas adultos y población general validation of the spanish version of the wong law emotional intelligence scale (wleis-s) reliability and validity of the brief resilience scale (brs) spanish version snowball sampling: using social networks to research non-heterosexual women snowball sampling: a purposeful method of sampling in qualitative research. strides dev dual-career through the elite university student-athletes' lenses: the international fisu-eas survey covid-19) situation report 83; world health organization statistical power analysis for the behavioral sciences detraining produces minimal changes in physical performance and hormonal variables in recreationally strength-trained men the effect of arm and forearm loading on the throwing velocity of novice handball players: influences during training and detraining traininginhome-home-based training during covid-19 (sars-cov2) pandemic: physical exercise and behavior-based approach physical activity levels and related energy expenditure during covid-19 quarantine among the sicilian active population: a cross-sectional online survey study gender and age differences in levels, types and locations of physical activity among older adults living in car-dependent neighborhoods physical activity is associated with grit and resilience in college students: is intensity the key to success? the experience of depression during the careers of elite male athletes depression is under-recognised in the sport setting: time for primary care sports medicine to be proactive and screen widely for depression symptoms recovery strategies in elite sport: focus on both quantity and quality of sleep impact of covid-19 lockdown on sleep quality in university students and administration staff modulators of the personal and professional threat perception of olympic athletes in the actual covid-19 crisis we wish to thank all handball players who completed the questionnaire. the authors declare no conflict of interest. key: cord-271898-cct702cv authors: duplaga, mariusz title: the acceptance of key public health interventions by the polish population is related to health literacy, but not ehealth literacy date: 2020-07-29 journal: int j environ res public health doi: 10.3390/ijerph17155459 sha: doc_id: 271898 cord_uid: cct702cv background: public health and health promotion rely on many different interventions, which range from health education and communication, through community mobilisation and changes to environmental conditions, to legal and fiscal actions. the introduction of the increased tax on sugar-sweetened beverages (ssb), popularly called sugar tax (st), and a mandatory programme of vaccinations are the strategies inciting the most vivid discussions in polish society. the study was intended to assess the determinants of the attitudes of polish society regarding the st and to vaccinations. methods: for the analysis, the data originating from the survey of a representative adult sample of polish society (n = 1000) was used. the survey was based on computer-assisted telephone interviewing (cati). the assessment of the relationships between the selected variables and the opinions about the introduction of the st and the safety and effectiveness of vaccinations were carried out using the chi(2) test and univariate logistic regression models. results: the acceptance of the st and vaccination showed a significant relationship to the level of health literacy (hl) but not to ehealth literacy (ehl). respondents having a higher rather than lower hl; older rather than younger; married rather than singles; retired, or on a disability pension, rather than vocationally active and nonusers of the internet rather than users were more likely to show an acceptance for both interventions. those more frequently using health care services and those with chronic diseases showed a greater belief in the safety and effectiveness of vaccinations. conclusions: the relationship between the opinions of the two public health interventions analysed and the sociodemographic variables demonstrated similar patterns. interestingly, the opinions were associated only with hl and not with ehl and users of the internet were more sceptical about the interventions. the concept of health literacy (hl) is of crucial importance for health promotion. the definition of health literacy proposed by the world health organisation (who) belongs to the most popular [1] . it is clear that a focus on the ability to access and use health-related information is essential, but these are not the only aspects of health literacy. the definition proposed by the who puts the emphasis, not only on the cognitive, but also on social skills. the context of hl is usually associated with the readiness of people to safeguard their health and to manage their contacts with the health care system. there is growing evidence that insufficient hl may be associated with many unfavourable effects. these include displaying unhealthy behaviours [2, 3] , lower attention to preventive actions [4] , lower knowledge about the disease, not following the physician's recommendations and limited understanding of the treatment regimen [5] [6] [7] , worse control of the disease [8] , and even, a higher risk of hospitalisation and mortality [9] . some authors also indicated that the lower hl of people is associated with higher expenditure on health care [10] . the concept of digital hl or ehealth literacy (ehl) is used in parallel. it is related to the accessing, understanding, appraisal and application of health-related information available from digital resources [11] . considering that the internet is currently one of the primary sources of health information, the role of ehl seems to be obvious; however, the relationship between hl and ehl is not entirely clear. according to norman and skinner, hl is one of the types of literacy needed for developing ehl [11] . the correlation between both types of literacy, as substantiated in some studies, is at a level of 0.4 [12, 13] . however, the association between ehl and health behaviours or clinical outcomes is not so well documented as it is for hl. some authors emphasise a broader meaning of hl going beyond the individual context. according to baur, a health literate society should be able to create better public health [14] . such a perception of health literacy which is a precondition of public health actions, resulted in the call to establish the concept of "public health literacy". according to freedman et al. (2009) , individuals who demonstrate such health literacy, are able to consider and act on health concerns in a community context [15] . the association between hl and the attitudes to community-or nation-wide public health policies has not been frequently examined. from the onset, health promotion has been proposed as a doctrine combining a whole array of strategies including, not only the development of individual skills, but also the formation of supportive environments, the mobilisation of the community, reorientation of health care services and the shaping of public health policies [16] . it is evident that health promotion relies on many forms of interventions, even if the role of health education and health communication has been frequently overemphasised. however, it appears that in certain circumstances, educational efforts may provide an inadequate response to public health challenges and governments must, therefore, apply legal and fiscal interventions. in many countries, vaccination programmes are mandatory [17] . the taxes or duties imposed on alcohol and tobacco products remain one of the most obvious examples of fiscal measures intended to moderate their consumption [18] . in the last decade, the tax applied to products with a high sugar content became a favoured tool to reduce the harmful effect of sugar-sweetened beverages (ssb) on obesity [19] . the immunisation schedule requires mandatory vaccinations against tuberculosis, hepatitis b, diphtheria, tetanus, pertussis, poliomyelitis, haemophilus influenzae type b, pneumococci, measles, mumps and rubella in poland [20] . the national institute of public health's 2018 annual report indicated that depending on the voivodeship, 87.3% to 96.4% of children aged three had been vaccinated against measles, mumps and rubella. however, between 2012 and 2018, the number of polish parents who refused to accept the vaccination programmes available to their children has increased significantly, from 5340 to 48,609 [21] . this is commonly associated with the influence of antivaccination movements that incite doubts about the safety and effectiveness of vaccines [22] . in 2019, after a discussion lasting several years, the government prepared legislation for a special tax to be imposed on ssb in response to the growing rates of obesity in polish society. to date, no research has been undertaken to find if hl may be linked to the acceptance of such public health interventions which have triggered significant public debate. the main aim of this study was to assess the association between hl and ehl with the opinions about vaccinations and the introduction of the st held by a representative sample of the adult polish population. the role of other variables, including the utilisation of health care resources, the use of information technologies and the sociodemographic characteristics were also analysed. the analysis was based on the data obtained from a survey carried out on a representative sample of the adult polish population (n = 1000). the participants of the survey were recruited by the biostat company (biostat sp. z o.o., rybnik, poland) which has extensive experience in conducting opinion polls [23] . the survey was undertaken using the computer-assisted telephone interviewing (cati) technique and was completed in one week in mid-december 2016. the sample group was selected by the stratified proportional sampling of the database of mobile and stationary phone numbers developed by the biostat company. the survey was carried out with a 58-item questionnaire, including a 16-item short version of the health literacy survey questionnaire (hls-eu-q16) [24] ; an 8-item polish version of the ehealth literacy scale (pl-eheals) [25, 26] and a set of the items asking about the utilisation of health care resources; health status; the use of the internet; opinions on public health interventions and sociodemographic characteristics. more details on the sampling procedure and the structure of the questionnaire is available elsewhere [3] . statistical analysis was performed with ibm spss v.24 software (ibm corp. armonk, ny, usa). descriptive statistics were calculated for the variables used in the analysis; absolute and relative frequencies for categorical variables and mean and standard deviation for continuous variables. chi2 test and univariate logistic regression models were used to assess the association between variables reflecting the opinions about vaccinations and the introduction of the st as well as potential determinants. in the case of continuous variables, the differences between categories were assessed with either the student's t-test or the u mann-whitney test, depending on the distribution of the variable. for independent variables used in the univariate logistic regression models, odds ratio (or) and 95% confidence intervals (95%) were calculated. the dependent variables used in the logistic regression were developed after dichotomisation of the two items asking respondents for their opinions about (1) the safety and effectiveness of vaccination, and (2) the introduction of the sugar tax. the initial responses to these items were ranked on a 5-point likert scale from "i decidedly agree" to "i decidedly do not agree" with a neutral option in the middle. the responses "i decidedly agree" and "i agree" were coded as "1", other answers as "0". independent variables used in the logistic regression models included the sociodemographic variables (sex, age, level of education, place of residence, net household income, marital status and vocational activity), the utilisation of health care services (visits to health care facilities, hospitalisations), health status (self-assessed health status, the prevalence of chronic diseases), the use of information technologies (it; internet and smartphone use), health literacy (hl) and e-health literacy (ehl). the hl score was calculated according to the guidelines given in the european health literacy survey project [24] . the total score was calculated only if there were at least 14 meaningful responses to the individual questions. the response options "very difficult" and "difficult "were assigned with value "0" and "easy" and "very easy" with value "1". the total score ranged from 0-16 [3, 24] . the ehl score was calculated as the sum of individual scores after assigning values from 1 to 5 to the response options (from "decidedly not" to "decidedly yes"). the minimum total eheals that could be achieved was 0 and the maximum was 40. respondents filled the questionnaire anonymously after obtaining the information about the study and confirming they agree to participate. the study was conducted in accordance with the declaration of helsinki, and the protocol was approved by the bioethical committee at jagiellonian university (no. 122.6120.313.2016 from november 24, 2016). the characteristic of the study group is shown in table 1 . its sociodemographic structure corresponds with that of the general population at the same time. the mean age was 45.87 (16.16 ). an hl score could be calculated for the 842 respondents; the mean value (standard deviation, sd) was 12.99 (3.11) . the ehl score was calculated only for internet users (n = 849) as 28.91 (5.36) . furthermore, 37.3% of the respondents were convinced that the introduction of the st was an appropriate measure to reduce obesity in society, 22.6% were undecided and 40.2% did not agree. in turn, 64.4% of respondents believed that vaccines are safe and effective for preventing infectious diseases, 23.1% were unsure, and only 12.5% expressed a negative opinion. the respondents convinced of the safety and effectiveness of vaccinations achieved higher hl scores than those expressing the opposite opinion (mean (sd), 13.15 (3.03) vs. 12.70 (3.24) , u mann-whitney test, p = 0.046). in the univariate logistic model, an increase of hl score of one point was associated with a 5% increase in the probability of a positive opinion (or, 95% ci: 1.05, 1.001-1.10). the opinion was not related to the ehl score (or, 95% ci: 0.99, 0.97-1.01). the results of chi 2 tests and univariate logistic regression modelling for the opinion about vaccination as a dependent variable are presented in table 2 . among sociodemographic variables, there was a significant association between the opinion and age, marital status and vocational status. older respondents were more convinced about the safety and effectiveness of vaccinations (mean age (sd): 48.20 (15.68) vs. 41.67 (16.18) , student's t-test, p < 0.001). with every year of age, there was a 3% increase in positive opinions about vaccinations (or, 95% ci: 1.03, 1.02-1.04). married persons were more than two times more likely to appreciate vaccinations than singles (or, 95% ci: 2.23, 1.67-2.27) and widowed persons, divorced or separated nearly 2.5 times (or, 95% ci: 2.45, 1.57-3.82). as for the vocational status, the employees of public or private entities were less likely to have a positive opinion than those on retirement or those receiving a disability pension (or, 95% ci: 1.76, 1.27-2.44) but more likely than university students or pupils (or, 95% ci: 0.54, 0.34-0.86). the analysis based on the chi2 test has not shown any association between the opinions about vaccinations and the place of residence. nevertheless, the univariate regression model confirmed that respondents living in urban areas with a population of 100,000-200,000, were less convinced about the safety and effectiveness of vaccinations than those living in rural areas (or, 95% ci: 0.60, 0.39-0.92). the opinion expressed about vaccinations was also associated with the number of visits to health care institutions in the preceding year. those that had to make visits most frequently in the preceding year (at least six or more times) were nearly twice as likely to express a positive opinion about vaccinations (or, 95% ci: 1.86, 1.22-2.83). a positive opinion was also associated with a higher prevalence of chronic diseases and with an unsatisfactory self-assessment of health status. the respondents who suffered from one or more chronic diseases were more inclined to appreciate vaccinations (or, 95% ci: 1.44, 1.07-1.96 and 1.63, 1.12-2.36, respectively). the persons who assessed their health status as very good or perfect were nearly 50% less likely to express a positive opinion than persons unsatisfied with their health (or, 95% ci: 0.55, 0.33-0.91). the users of both the internet and smartphones were less positive about vaccinations (or, 95% ci: 0.56, 0.38-0.83 and 0.48, 0.27-0.84). there was a statistically significant association between the hl score and the attitude towards the introduction of the sugar tax. with an increase of the hl score by one point, the probability of a positive opinion increased by 8% (or, 95% ci: 1.08, 1.03-1.13; table 3 ). in turn, there was no significant association between the ehl score and this opinion (or, 95% ci: 1.01, 0.99-1.03). the opinion about the st showed a similar pattern of the associations with sociodemographic factors as with the opinions about vaccinations. older persons were more likely to be positive about the st (or, 95% ci: 1.02, 1.01-1.03). singles were less inclined to express a positive opinion than married persons (or, 95% ci: 1.89, 1.39-2.56) widowed, divorced or separated persons (or, 95% ci: 1.84, 1.19-2.84). retired persons, or on a disability pension, were more in favour of the sugar tax than employees (or, 95% ci: 1.41, 1.04-1.91) but students and pupils were less in favour (or, 95% ci: 0.41, 0.23-0.73). there was no association between the variables reflecting the utilisation of health care services and the opinion about the introduction of the st. interestingly, the highest acceptance was shown by the persons assessing their health as satisfactory (45.0%) and the lowest by those assessing it as very good or perfect (29.2%) or as unsatisfactory (31.6%). the univariate regression model showed that there was a significant difference only for the comparison of persons assessing their health as satisfactory and unsatisfactory (or, 95% ci: 1.77, 1.08-2.90). finally, the chi 2 test indicated a significant association both between the opinion about the st and the use of the internet (p = 0.007) or a smartphone (p = 0.034). the association was maintained for internet use only in the univariate regression model. internet users less frequently agreed that vaccines are safe and effective (or, 95% ci: 0.62, 0.44-0.88). in poland, the majority of the population (64.4%) would appear to believe that vaccination is a safe and effective method of preventing infectious diseases. only 12.5% of the respondents were sceptical about vaccines. however, only 37% of respondents believed that the introduction of the st was an appropriate measure to limit the prevalence of obesity, but 40%were of the opposite opinion. the analysis showed that the attitude towards crucial public health interventions depends on a person's level of hl but not on their ehl. furthermore, older persons, married people and the retired or receivers of disability pensions more frequently showed acceptance both for the introduction of the st and vaccinations than, respectively, younger persons, single people and employees. the users of the internet and smartphones were less inclined to accept such interventions as were those who self-assessed their health as very good or perfect. persons with chronic disease or those who declared more frequent visits to health care institutions were more likely to appreciate vaccinations, but not the st. according to the who working group on vaccine hesitancy, there is a very extensive list of determinants of vaccine hesitancy. these may be divided into three domains: firstly influences arising from historical, sociocultural, environmental, health system/institutional economic and political factors; secondly, influences stemming from the personal perception of a vaccine or the social environment, and finally, issues related directly to vaccines and vaccination [27] . this reported survey was mainly focused on the sociodemographic characteristics, the utilisation of health care services and the use of it. it seems that the general attitude towards vaccination has been rarely researched. eilers et al. have confirmed that the acceptance for several types of vaccines is higher among persons of 65 years and older than among those aged 50-65 [28] . a study carried out in italy showed that vaccine hesitancy was associated with perceived economic hardship and actual refusal with a lower level of parental education [29] . greater age, receiving information on vaccinations from a physician and the higher quality of such information as well as better knowledge about vaccines were associated with a more positive attitude towards vaccination in a mixed group of polish pupils, students, patients, parents and healthcare professionals [30] . most studies reporting on the variables related to the opinions of the general public, or specific populations, about vaccinations are focused on particular types of vaccines. novak et al. analysed the data from the 2016 national survey of u.s. adults [31] and assessed the acceptance of influenza vaccination based on actual vaccination rates. they found that the highest rates of acceptance were by non-hispanic whites and blacks and those aged 65 years and older. the systematic review on influenza vaccination in high-income countries carried out by lucyk et al. showed that higher socioeconomic status assessed based on education, income, social class, occupation and the level of deprivation was associated with higher levels of influenza vaccination [32] . mat et al. published a systematic review of acceptance factors of pneumococcal vaccination among the adult population [33] . according to these authors, there were three groups of factors influencing acceptance: the provider's domain, patients' perception and sociodemographic factors. in some studies, the group of sociodemographic factors, gender and age were reported to show a significant association with the acceptance of vaccination. higher acceptance was found among women than men and by those aged at least 65 years old. another study performed in the usa, limited to the population of adults aged 65 or above, revealed that the uptake of the pneumococcal vaccine was lower among: those of black and hispanic ethnicity, than among non-hispanic whites; by the poor rather than those with the highest income; among those with a low level of education than among those with at least college education and finally among those living in rural communities or urban inner-city areas, rather than those living in suburban areas [34] . according to the systematic review published by lopez et al., higher acceptance of human papillomavirus (hpv) vaccine was associated most consistently with female gender and younger age of respondent parent, female gender of the adolescent, higher household income and previous childhood vaccinations [35] . a recent study by polla et al. revealed that among parents, those who were unmarried were more likely to be hesitant about the importance of hpv vaccination [36] . the analysis reported in this paper showed that a higher level of hl was reflected in a higher acceptance of vaccinations. consistently, according to the systematic review published by berkman et al. in 2011, low hl was related to a lower probability of accepting influenza immunisations [4] . however, the results of the systematic review focused on the relationship between hl and attitudes towards various types of vaccinations, published by lorini et al. in 2018 [37] , revealed a more complex picture. the authors included only nine studies in their analysis of respondents representing diverse groups; four studies were undertaken on parents of children who received vaccinations, two among adult citizens, one among adults aged 65 years or more, one among females attending college and one among hispanic females. the studies yielded unequivocal findings, especially in relation to parents' attitudes. in the study performed in israel, higher communicative and critical hl of parents was associated with a greater likelihood of not vaccinating their children [38] . in the study among dutch parents, all respondents were willing to vaccinate their children against rotavirus when the vaccine was supplied within the national immunization programme, but only by those with lower levels of education and lower hl when the vaccine was to be provided by the free market [39] . another study, performed in the usa, did not find a significant association between maternal hl and the immunisation status of children [40] . in the study carried out in india, higher maternal hl was associated with the likelihood of a child receiving the diphtheria-tetanus-pertussis vaccine [41] . in other groups of respondents, the relation between hl and vaccination uptake varied. higher hl in the usa increased the likelihood of influenza vaccination among older adults [42, 43] , and hpv vaccination by undergraduate women [44] . higher hl was also associated with a higher awareness of hpv and the hpv vaccine by adults in the usa. additionally, in the usa there was no association between the likelihood of influenza vaccination among adult hispanic women [45] and adults younger than 40 years [43] . the authors of the systematic review concluded that the role of hl in predicting vaccine hesitancy or acceptance is influenced by various factors including the country, people's age and the type of vaccine [37] . further studies tend to confirm that the relationship between health literacy and the acceptance of vaccinations is not straightforward and depends on the characteristics of the studied group. in 2018, castro-sanchez et al. found a significant association between hl measured with the short assessment of health literacy for spanish adults and the newest vital sign in pregnant women and the vaccination rates against influenza and pertussis [46] . women rejecting the influenza vaccine had higher hl. recently, zhang et al. assessed the relation between hl measured with the standard 47-item version of hls-eu questionnaire and the attitudes towards vaccination in a group of older adults 65 years and greater [47] . they found that lower competencies related to accessing and appraising health information were associated with more significant problems in reaching decisions about vaccination. the reported study found no significant association between ehl and the acceptance of vaccination, but the use of the internet and smartphones was related to a lower acceptance. the overview of systematic reviews published in 2018 by dumit et al. revealed that ehealth interventions and technology might be useful tools for increasing the uptake of immunisations [48] . however, there are few studies which report on a relationship between ehl and the attitudes towards vaccinations. the research performed by britt et al. on college students, based on the theory of planned behaviour, showed that ehl was positively associated with the intent for hpv vaccination but not with the actual vaccination behaviour [49] . in a later study in a similar group of respondents from 2017, britt et al. found that ehl was positively associated with beneficial health behaviours identified by the american college health association including seeking for the information on vaccinations and also to a smaller degree, undergoing vaccinations, among college students [50] . additionally, in 2017 aharony and goldman reported that parents refusing to vaccinate their children had a higher perceived ehl than hesitant parents or those accepting vaccinations. additionally, they found that nonrefuser parents had the highest knowledge about vaccinations and the parents refusing vaccinations had the least knowledge [51] . in 2020, mutur published the results of a survey on ehl and motivators for hpv prevention among young adults in kenya [52] . she found a positive correlation between ehl and hpv knowledge, perceived risk, self-efficacy and response efficacy. the authors of a systematic review on the association between hl, ehl and health outcomes among patients with long-term conditions found only a few studies in which ehl was assessed [53] . none were related to vaccination attitudes or practices. currently, ehl as gained new momentum due to the covid-19 pandemic, but it seems that any high expectations related to its impact on fighting misinformation are yet to be confirmed [54] . the acceptance of the st has been extensively studied in many countries. in the last decade, surveys carried out in australia showed that about 40% to 70% of the population were in favour of the tax imposed on ssb. in 2012, morley et al. reported that 69% of the surveyed participants were in favour of a tax on ssb [55] . parents were more likely than nonparents and respondents with a higher socioeconomic status, rather than those with a lower status supported a tax on soft drinks and unhealthy food. in 2017 the results of a survey about taxation and nutrition labelling as interventions addressing the incidence of childhood obesity were published [56] . interestingly, only one-third of respondents strongly supported the introduction of the sugar tax, and 40% were equivocal about it. the level of acceptance of an ssb tax among parents was related to the household's weekly consumption of soft drinks. in 2018, sainsbury et al. published the results of an online survey on a nationally representative sample of australian adults which found that 54.5% of the participants supported ssb taxation. the binary logistic regression models showed that women more than men, younger rather than older respondents and those with a university degree rather than those who did not complete high school, supported the introduction of the tax [57] . the acceptance of ssb taxation was also reported by farrell et al. in 2019. according to this team, 42% of the australian population were in favour of the tax imposed on ssb and that the greatest opposition to the tax was expressed by the most disadvantaged group [58] . the analysis performed by miller et al. on the data coming from two surveys: a face-to-face survey conducted in 2014 and cati survey in 2017, also showed that persons who attained higher levels of education expressed greater support for ssb tax than those with lower levels of education [59] . the acceptance of a sugar tax was frequently much greater if the tax revenue was to be allocated to obesity prevention, subsidies on healthy food or programmes promoting physical activity [59, 60] . in june 2017, belanger-gravel et al. examined separately support for and the perceived effectiveness of public health interventions aimed at the reduction of obesity among 1000 18-64 years old respondents resident in quebec, canada [61] . the introduction of the tax on ssb was strongly supported by 32.8% and somewhat less enthusiastically by a further 27.0% of respondents. 56.3% of respondents assessed this intervention as effective. the survey performed on usa citizens in 2012 by rivard et al. , demonstrated that ssb tax was supported by 36% of respondents [62] . greater support was expressed by younger respondents, who had attained higher levels of education and those with body mass index (bmi) <30 kg/m 2 . however, the study published in 2014 by gollust et al. showed that the tax as a strategy to reduce the consumption of ssb was supported by only 22% of adult americans who responded to an online survey [63] . in 2015, donaldson et al. reported that support for the ssb tax was expressed by 52% of respondents participating in a telephone-based survey [64] . the support was related to gender, race, political orientation, ssb consumption but not to age, level of education or annual income. in the study performed by curry et al. on adults in kansas in 2018, support for a tax on ssb was confirmed by 40% of respondents, and as in the study of donaldson et al. it was higher for women and supporters of the democratic party [65] . in this study, younger respondents were significantly more supportive than older people. petrescu et al. in two parallel online surveys compared the acceptability of nudging initiatives aimed at tackling obesity in the uk and usa on samples of 1093 and 1082 respondents, respectively [66] . taxation intervention was acceptable to 45.5% of respondents from the uk and 40.7% from the usa. in the uk sample, the perceived effectiveness of the intervention was the only significant predictor of the acceptance of taxation. among respondents from the usa, the acceptance was associated with the perceived effectiveness and the belief that the environment is responsible for obesity. a french survey published by julia et al. in 2015 showed that an st was perceived as an important measure in improving the health of the population by nearly 58% of respondents. the support was even higher if the revenues from the tax were to be used for improving the health care system [67] . contrary to the findings from australia and the usa, greater support was expressed by the older rather than the younger respondents. those who reached higher levels of education were also more supportive. in 2019, kwon et al. reported the results of a multi-country survey (australia, canada, mexico, uk, usa) to assess public support for food policies promoting healthy diets [68] . they found that taxes on sugary drinks were supported by 30.0% in the usa to 53.8% in mexico. if the revenue raised from the tax were to be spent on subsidising health food, the support would increase considerably to 37.2% in the usa to 66.3% in mexico. an analysis of the determinants in the pooled data from five countries revealed higher support by females than males, older age groups than the youngest groups, and minorities in comparison to the majorities. according to the latest study on public acceptability of an ssb tax in the netherlands, lower acceptability was associated with a lower educational level, being overweight, moderate or high ssb consumptions and living in a household with adolescents [69] . finally, the systematic review with a meta-analysis based on 20 papers reporting the results of 22 studies, published in 2019 by eykelenboom et al., showed that 42% of the public supported the ssb tax; 39% accepted it as a measure to reduce obesity, and 66% supported it if the revenue is used for some type of health-improving initiative [70] . in poland, contrary to the findings from other countries the sex of respondents was not associated with the acceptance of the sugar tax as a measure to decrease the prevalence of obesity. in many countries, a significant association between age and support for the st was reported. in australia and the usa usually, younger respondents revealed higher acceptance than older people. in surveys performed in other countries, as in poland, older rather than younger respondents were more supportive of the st. finally, in many surveys, again contrary to findings from poland, the level of education was associated with the support for the st. the results of the survey reported in this paper have not shown a relationship between these variables. in surveys carried out in other countries, hl, ehl and internet use were not analysed in respect of the attitude towards sugar taxation. as the penetration of the internet is growing, and in many societies, the number of nonusers is relatively low, many surveys are performed online. therefore, the use of the internet is less frequently considered as a determinant of specific health-related behaviours or attitudes. nonetheless, it may be puzzling why neither hl nor ehl was assessed as a determinant of the acceptance of fiscal interventions to combat the consumption of unhealthy products. it may be related to the fact that hl is still treated more like a construct reflecting an ability to tackle individual health issues than its relevance to the broader public health context. interestingly, among the positive impacts of the introduction of a public health product tax in hungary, an improvement of hl was reported [71] . there are some limitations of this study which need to be considered. initially, although the sample size is sufficient to reflect general trends in the polish population, it may be too small to clarify the relationships between specific variables. decidedly, further surveys on large samples would be needed to explain the importance of potential determinants of the attitudes towards specific public health measures. furthermore, the survey was undertaken using the technique of cati which may result in less profound consideration of the issues presented in the questionnaire. finally, the survey was performed at the moment when it was not clear that the government was considering the introduction of the st. therefore, for some respondents, the prospect of such a public health intervention could seem very distant, and others would not fully understand its consequences. as for the question about vaccinations, a more targeted approach to the study group probably would be needed as the opinions of parents to the vaccination of their children may be different from the opinions of nonparents or older persons. the survey performed on the polish population showed that there are potentially many variables affecting the opinions regarding the introduction of the st and the safety and effectiveness of vaccinations. apart from the sociodemographic factors like age, marital status or vocational status, the utilisation of health care services, the self-perception of health or the prevalence of chronic diseases as well as the use of it should be considered. interestingly, it transpired that hl, but not ehl, is related to the acceptance of the st and vaccination. it may also be surprising that internet users are more sceptical about such public health interventions. the studies focusing on the relationship between hl and the acceptance of immunisations undertaken on various populations, and concerning specific types of vaccines, yielded unequivocal results. it seems that higher hl does not necessarily lead to a higher acceptance of vaccinations. it may strongly depend on the characteristics of the surveyed population. surprisingly, the literature on an association between hl or ehl and the acceptance of public health policies is very limited. there is a scarcity of studies which analyse the relationship between hl, ehl and the attitudes to the sugar tax. one could expect that higher hl and ehl should result in higher support for health-promoting fiscal interventions. kickbusch, i. health promotion glossary health literacy and public health: a systematic review and integration of definitions and 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messages in a mid-atlantic u.s. state. public health nutr public attitudes and support for a sugar-sweetened beverage tax in america's heartland public acceptability in the uk and usa of nudging to reduce obesity: the example of reducing sugar-sweetened beverages consumption public perception and characteristics related to acceptance of the sugar-sweetened beverage taxation launched in france in 2012 a multi-country survey of public support for food policies to promote healthy diets: findings from the international food policy study public acceptability of a sugar-sweetened beverage tax and its associated factors in the netherlands political and public acceptability of a sugar-sweetened beverages tax: a mixed-method systematic review and meta-analysis assessment of the impact of a public health product tax; national institute for food and nutrition science directorate general the author thanks john r. blizzard, a retired uk university senior lecturer, chartered engineer and churchill fellow, for proofreading of the manuscript. the author declares no conflict of interest. key: cord-255602-3pzh5ur9 authors: moscadelli, andrea; albora, giuseppe; biamonte, massimiliano alberto; giorgetti, duccio; innocenzio, michele; paoli, sonia; lorini, chiara; bonanni, paolo; bonaccorsi, guglielmo title: fake news and covid-19 in italy: results of a quantitative observational study date: 2020-08-12 journal: int j environ res public health doi: 10.3390/ijerph17165850 sha: doc_id: 255602 cord_uid: 3pzh5ur9 during the covid-19 pandemic, risk communication has often been ineffective, and from this perspective “fake news” has found fertile ground, both as a cause and a consequence of it. the aim of this study is to measure how much “fake news” and corresponding verified news have circulated in italy in the period between 31 december 2019 and 30 april 2020, and to estimate the quality of informal and formal communication. we used the buzzsumo application to gather the most shared links on the internet related to the pandemic in italy, using keywords chosen according to the most frequent “fake news” during that period. for each research we noted the numbers of “fake news” articles and science-based news articles, as well as the number of engagements. we reviewed 2102 articles. links that contained fake news were shared 2,352,585 times, accounting for 23.1% of the total shares of all the articles reviewed. our study throws light on the “fake news” phenomenon in the sars-cov-2 pandemic. a quantitative assessment is fundamental in order to understand the impact of false information and to define political and technical interventions in health communication. starting from this evaluation, health literacy should be improved by means of specific interventions in order to improve informal and formal communication. on 11 march 2020, only ten years after the h1n1 swine influenza pandemic [1] , a new respiratory virus surged globally to gain recognition as a pandemic disease [2] . initially, the disease was mistakenly considered not substantially more disruptive than influenza [3] . this is a respiratory rna virus from the family of coronaviruses. the "coronavirus study group" from the international committee on taxonomy of viruses called it sars-cov-2 (severe acute respiratory syndrome coronavirus 2), due to the similarities with the sars virus (sars-cov) [4] . the first cases in italy were reported on 30 january 2020, when a couple of tourists tested positive in rome [5] . since the beginning of march, data regarding the covid-19 (coronavirus disease-2019) pandemic began to dominate newscasting and news outlets in italy. simultaneously, the scientific community (biologists, epidemiologists, and clinicians) was buzzing fervently and generating a tremendous amount of articles as they began to learn more about the virus. by mid-july 2020, the pandemic accounted for 13,486,823 cases, with 581,965 deaths and 7,876,115 recovered patients worldwide [6] . the socioeconomic consequences of the pandemic have been devastating and countless, and for the most part they are to be evaluated yet. such an overwhelmingly devastating infectious disease was not foreseen in the popular imagination. sars-cov-2 managed digital and health illiteracy can account for most of the inaccurate news stories depicting the cause of the pandemic, whether suggesting it is a virus engineered purposely in a wuhan laboratory [21] , a biological military weapon [22] , or a result of 5g (5 th generation) technology being implemented in many countries [23] . some people were singled out as culprits guilty of causing the pandemic, such as bill gates [24] . we can even find news stories claiming that as-yet undiscovered vaccines for sars-cov-2 are harmful and useless [25, 26] . such fake stories are intentionally built to rapidly and tumultuously spread over the internet and social media. their popularity is rapidly increasing, such that retractions are always published too late. as many philosophers used to say, "a lie can run around the world before the truth can get its boots on" [27] . the seriousness of the situation was duly described in a recent issue of the lancet, which published a statement in support of scientists, public health, and medical professionals, condemning all theories validating a non-natural origin of the sars-cov-2 virus and citing a list of articles proving the enormous amount of studying that was going into the sequencing of the genome of this novel pathogen [28] [29] [30] [31] [32] . the lancet again published an article in 2015 denouncing the still underestimated inadequateness of health literacy in europe [16] , and more recently it published an article by paakkar that underlines how health literacy is a serious concern in light of the recent events surrounding the covid-19 pandemic [33] . this phenomenon is a challenge not only for older adults, but also for young people and university students. a recent study demonstrates that less than 50% of students have high levels of health literacy, and that they learnt about the covid-19 pandemic via social media and the internet [34] . in order to understand the reason for the success of fake news in such situations, it is necessary to analyze the impact of the quarantine on the italian population and the psychological strain that it caused. an online survey conducted in italy during the lockdown established the prevalence of psychiatric symptoms linked to the pandemic in the general population [35] , such as anxiety and depression. this is closely related to the spread of fake news, because such articles can be more successful when the population is experiencing a stressful psychological situation. moreover, during the lockdown the population spent more time on the internet and social media, so the impact of false information was higher than normal. in human history, such an abundance of health information from more or less trustworthy sources has never been seen before, and without an appropriate cultural background and literacy, it is difficult for the public to understand that the best scientific knowledge on covid-19 needs time to grow and that there is a need to critically assess available information [36] . "fake news" has inevitably and indubitably influenced health communication in the covid-19 emergency and it is clear that it might continue to do so for the foreseeable future, contributing to social unrest and uneasiness. the aim of this study is to measure-using nine specific key words-how much false and true information have circulated in italy in the period between 31 december 2019 and 30 april 2020, as part of the phenomenon called infodemia [37] . more generally, we hope to shed some more light on the fake news phenomenon and the reasons for its popularity. we used the buzzsumo pplication [38] in order to gather the most shared links or posts on the internet and social media related to sars-cov-2 and the covid-19 pandemic. the buzzsumo application is one of the most popular social media trend analysis tools, which is often used in marketing research in order to highlight content that has a very strong engagement score (i.e., number of shares, links, comments, and backlinks), either on the internet or social media. buzzsumo gathers data across the social media platforms facebook, pinterest, reddit, and twitter to generate a list of article links with the highest online engagement. engagement is defined as the total number of interactions that users have with a particular article link, including actions such as "liking", "commenting", and "sharing" on social media [39, 40] . since buzzsumo is free of charge when using the 7-day trial feature, we decided to use this tool to make the study more transparent and reproducible. we restricted our search to three specific date ranges: (1) 31 december 2019-19 february 2020; (2) 20 february 2020-10 march 2020; (3) 11 march 2020-30 april 2020. the data ranges were selected according to self-evident pivotal moments in the events timeline of the covid-19 pandemic in italy (details in the buzzsumo application allows web content research through the use of keywords. we selected 9 different search bars, each of which was composed of two keywords. the search bars we applied always contained the word "coronavirus" and one other specific associated term, which was different for each search bar. the terms we inserted after "coronavirus" were: "vaccine" (in italian "vaccino"), "origin" ("origine"), "laboratory" ("laboratorio"), "plot" ("complotto"), "hiv" ("hiv"), "vitamin c" ("vitamina c"), "vitamin d" ("vitamina d"), "garlic" ("aglio"), "5g" ("5g"). the keywords were chosen according to the most frequent topics of the "fake news" that spread during the covid-19 pandemic. such a specific set of keywords was purposefully chosen because it reflected our intent to only look for health-related news stories about covid-19. the 9 keywords were chosen in a consensus meeting of the research group, since they were the most likely to uncover health-related false information using the buzzsumo search engine, and specifically fake news that would not meet our exclusion criteria. searches were filtered by time and language (italian), and for each one of the 9 terms a search was conducted on the three specific date ranges we exposed previously. therefore, we conducted 27 separated searches. we noted the total findings that the buzzsumo application was able to provide. we manually revised each one of the top shared results (links, posts, videos, articles), looking for false information (disinformation, misinformation, and mal-information) and incomplete or false coverage of covid-19-related content, as well as science-based news and articles about those topics. we applied strict exclusion criteria when conducting our review. we excluded content that was merely a report of events, focusing on medical and scientific subjects. an article was immediately excluded when the content did not deal specifically with health or science, i.e., the focus may have been on the socioeconomic consequences of the pandemic, which was a topic we excluded from our fake news review. moreover, we decided to include articles that were reporting fake news about sars-cov-2 to give a sense of reasonable doubt, i.e., claiming that there were certain allegations about a certain topic but pointing out that such allegations had no evidence whatsoever supporting them. articles were classified as fake news if the content was not supported by scientific literature or when the data reported were used to make inappropriate conclusions about sars-cov-2. the contents of the most frequent fakes found for each topic are reported in table 2 . we concluded each search when all of the findings were examined or once we had reviewed 100 articles by adding the number of false articles to the number of science-based articles. each link was independently reviewed by two of the authors. in case of disagreement between the authors, a third author was involved in the review. for each search, we noted the number of excluded articles, the number of fakes, and the number of science-based articles examined. moreover, we noted the amount of engagement with the fake and science-based articles that we considered for our study. we also noted the source of every "fake" article reviewed. data were collected and additionally analyzed with microsoft excel. overall, we reviewed 2102 articles that were generated by our keywords search on buzzsumo. the analyzed topics attracted public attention with unequal distribution:-laboratory, vaccine, and 5g articles accumulated more shares than other topics. altogether throughout the three periods, links that contained untrue information were shared 2,352,585 times, accounting for about 23.1% of the total shares of all the articles reviewed. the topics most contaminated with fakes were vitamin d (89.4%), hiv (77.8%), and garlic (71.2%). a synoptic comprehensive analysis of the data we gathered from the keyword search is shown in d. comprehensive and synoptic data analysis of all content analyzed are reported in figure 1 . moreover, we summarized the distributions of the numbers of shares and new articles in table 3 . the increasing percentage of "fake news" for numerous topics of research seems directly linked to specific events, for example when popular or well-established sources start supporting theories about sars-cov-2 without presenting evidence for their claims. as a significant example, we can analyze the fluctuations of this false information when searching "coronavirus hiv". in the first period, there was 1 fake article with 767 total shares, in the second period there was 1 fake article with 3 total shares, and finally in the third period there were 15 fake articles with 72,715 total shares. such a rapid increase can be traced back to some statements about the origin of the virus by the 2008 nobel prize for medicine winner dr. montagnier, which were not supported by any evidence. something similar seemed to happen when searching for "coronavirus laboratory" ("coronavirus laboratorio"). in the first period, this term accounted for 55 fake articles and 1,039,224 total shares, while in the second period only 23 fake articles and 12,972 total shares were counted. the first period coincided with claims by a news reporter from a popular newscast about the alleged laboratory origin of the virus in wuhan. the increasing percentage of "fake news" for numerous topics of research seems directly linked to specific events, for example when popular or well-established sources start supporting theories about sars-cov-2 without presenting evidence for their claims. the trend even more evident when searching "coronavirus garlic" ("coronavirus aglio"), where in the first and second periods 0 fake articles and 0 shares emerged, while in the third period 7 fake articles received 5284 total shares, whereby garlic was described as a miraculous treatment for covid-19 without presenting any evidence whatsoever [44] . when searching for "coronavirus vaccine" ("coronavirus vaccine"), the total numbers of shares between the first and third period increased from 14,106 to 206,900, an 18.5-fold increase, following the more extensive media coverage about vaccine research for sars-cov-2. similar patterns of fluctuations of false information were found for the other keywords for topics dealing with prevention or treatment of covid-19. in conclusion, it was concluded with no exception for any given keyword that fake news in the covid-19 pandemic succeeded multiple times in overshadowing formal verified news. this phenomenon was in many cases not only limited to the gross number of new articles produced, but also the number of shares on social media. fake news indubitably and perceivably affected health communication during the covid-19 pandemic. what this study tried to achieve was to quantitively gauge the amount of fake news and to decipher the common patterns and mechanisms that underlie the tumultuous spread of fake news on social media. the data gathered was also able to show how apparently few fake news story (i.e., a low number of new articles out of the total percentage) can account for a vast majority of shared news stories on social media (i.e., high number of shares as a percentage). this is very self-evident when looking at the data for the keyword "garlic" ("aglio"), where 18% of the news stories that were classified as fake accounted for almost 70% of the shares on social media. the spread of false information, or so-called "fake news", in non-official communication can ultimately be considered a very disruptive and dangerous phenomenon that can profoundly undermine health and risk communication, particularly in an emergency, such as the one we are living through. the number of news stories regarding the covid-19 pandemic continued to increase through the three periods we considered, which is easily understandable, as the virus started to spread dramatically throughout the globe and newscasts increasingly focused on that subject. as the number of news stories increased, so did the number and percentage of untrue information about the covid-19 pandemic. our observations regarding the percentage distribution between shares and news were particularly interesting (table 3 ). in 6 out of 9 search topics ("vitamina c", "vitamina d", "aglio", "5g", "laboratorio", "hiv"), the percentage of shares for fake articles was greater than that of verified new articles. for example, regarding the keyword "hiv", the percentage of fake regarding was 11.1% (therefore, the percentage of real news was 88.9%). this ratio is not mirrored when observing the percentages of shares for both fake and real news. shares of "fake news" accounted for 77.8%, while shares of real news accounted for 22.2%. this means that on average, "fake news"-standardized for the same number of total news results-seems to have a higher number of shares when compared to real news; that is, a much higher likelihood of being shared and known. the tendency to produce false content is born and spread for a variety of reasons. one of the main reasons is when such news stories are conveyed by authoritative figures, as in the case of the lab incident in wuhan while testing an hiv vaccine [21] . when this scenario finds the support of well-known figures, it becomes popular and quasi-real, even without being supported by data or evidence, feeding off the idea that there is some sort of plot to silence people that are perceived as menacing or challenging the status quo in the scientific community. other reasons can be attributed to the fact that covid-19 is not only a health issue, but also a large-scale socioeconomic disaster, which is so deeply impactful that it has monopolized international newscasts. the pandemic contributed further complicated the political relations between the us and china, the two biggest economies in the world, to the point that some are calling it a new cold war [45] . in this context, fake news has become a political tool used to discredit either country, inflaming already difficult diplomatic relations [46, 47] . the last and perhaps more important reason can be found in the scapegoating phenomenon. one dramatic aspect of the response to the pandemic was the desire to assign responsibility by identifying the culprit, which is a recurrent situation in history. for instance, during the black death in 1347, this role was attributed to the jewish people-they were accused of poisoning the water wells with the intent of killing all christians. the same happened in the 1630 plague-in "the betrothed", manzoni described how the blame was casted upon disease spreaders, astral influences, or poisonous exhalations, the so-called miasmas [48] . the scapegoating phenomenon exploits existing social divisions of religion, race, ethnicity, class, or gender identity, fueling social conflict and friction between governments and the general population [49] . to understand the reasons for the popularity of "fake news", it will be necessary to deeply analyze and better understand the psychological mechanisms underlying its success. the universe of "fake news" is heterogeneous, but recurring elements are identifiable in terms of the context, methods of diffusion, and the target population that the fake news is addressed to. as for the context, social networks have proven to be the most fertile ground for the spread of false facts. they offer a great space for profiles and pages that are created with the precise intent of generating and spreading fake news [50, 51] . false facts are usually presented with some distinguishing features-the content is mostly represented in the title, while the page that shows the entire text (once the title is clicked) often shows only a bare repetition of the key concept [52] . titles are usually short with "clickbait" features, written in larger fonts, with a sly use of colors and photos. the aim is to appeal and attract an audience that is used to ratiocinating intuitively, through "heuristics" (mental shortcuts that simplify the analysis of the text) that lead to "biases" (cognitive distortions that lead to misinterpretation of the text) [53] . the intrinsic features of the target population also play a role in the spread of "fake news". recent studies show that subjects prone to depression, disappointment, suspicion, and religious fundamentalism are more susceptible to this type of content [54] . age is also positively correlated with the probability of believing in and sharing false facts. although the key psychological mechanisms still require thorough research, many experiments point to a correlation with the scores obtained in tests that assess analytical skills, such as the cognitive reflection test (crt) [55] . crt is a simple test that attributes a low score to a subject that shows "intuitive" reasoning (that is more impulsive and emotional) and a high score to a subject that shows predominantly "analytical" reasoning (that gives more thoughtful responses), according to the dual-process theory [56] . subjects who are more inclined to believe in "fake news" have lower scores, showing a predominantly "intuitive" style and being guided by the sensations aroused by the news itself, by biases and heuristics, and by interrupting fact-checking processes [57] . intuitive reasoning can especially be found (but not always) in older people or in those with lower educational attainment, while the "analytical" style tends to be applied more frequently in people with higher educational level and younger age [58] . social media also allows for massive repetition of "fake news" content, creating some sort of "echo chamber" phenomenon. the constant repetition of the same false information can trigger a feeling of familiarity in the reader, determining a further drop in attention and fact-checking. this all finally results in a greater acceptance of the content propagated by the "fake news" story-the more false content is shared, the more a user is led to believe it [58] [59] [60] [61] [62] . in this scenario, several research studies are aimed at finding strategies to reduce the impact of "fake news" and inaccurate information. this goal could be achieved by limiting the repetition and massive sharing of inaccurate content. however, it is a difficult approach, since repetition and echo-chamber effects are intrinsic characteristics of social media. another possible solution would be to immediately deny and discredit "fake news". this strategy could work provided that the retraction is rapid and effective. it has been proven that even after pointing out incorrect information, the initial influence of false information cannot be undone. according to a study that investigated the persistence of feelings, some individuals, especially those with lower cognitive abilities, may continue to foster negative feelings or express discomfort towards a certain topic even after disconfirmation of the false information [63] . a strategy that has been more successful in the fight against "fake news" promotes the use of nudging; it would be enough, in fact, to remind the subjects to pay attention in assessing the veracity of some statements before reading them in order to improve their ability to understand which news is false and which is not [64] . furthermore, a greater comprehension, acknowledgement, and application of health literacy can support policy action on multiple levels to address major public health challenges. health literacy should be built deliberately as a population-level resource and community asset, and the relevance of mass and social media suggests including them in planning communication interventions related to environmental health and in verifying their results [65, 66] . the latter studies suggests that the route to defeat "fake news" may hopefully be less complicated than we think. our study illustrates the "fake news" phenomenon in the covid-19 pandemic. the spread of false content related to health communication was a very prominent feature throughout the three periods we considered, which had a deep and meaningful impact upon the general population. it was an element that undoubtedly undermined informal communication during the health emergency. health-related fake articles have been thoroughly studied and analyzed, especially in the last few years, when they became a disruptive element in the conversation about vaccines. it was not a surprise to encounter false facts during the covid-19 pandemic. such mendacious and false new articles are easily traced back to their source and probably do not require more top-down, specific qualitative studies about their origin and nature. however, we believe that a quantitative and qualitative evaluation is fundamental in order to assess the real impact of fake news and to start defining political and technical interventions in health communication. in conclusion, we believe that there are two paths to minimize the impact of "fake news". on the one hand, we must improve health and digital literacy-it has been demonstrated that a low level of health literacy brings people who have suspected symptoms related to covid-19 to feel more stressed and depressed than people who have higher levels of health literacy [67] , which also happens to medical students in terms of their fear for covid-19 [68] . having better literacy is helpful in fighting the fear and stress related to the pandemic. on the other hand, we must start favoring better informal communication and more organized formal communication. along these lines, it is hoped that social media companies-arguably some of the most important communication platforms today-will be able to further improve, strengthen, and reinforce their policies against "fake news". an insight into the swine-influenza a (h1n1) virus infection in humans the economic times the species and its viruses-a statement of the coronavirus study group readability of online patient education material for the novel coronavirus disease (covid-19): a cross-sectional health literacy study fake news" defining "fake news" a typology of scholarly definitions fake news as a critical incident in journalism perceived social presence reduces fact-checking health literacy in europe: comparative results of the european health literacy survey (hls-eu) abstract p532: the italian pilot of the health literacy survey 2019 in the cuore project for the who action network on measuring population and organizational health literacy (m-pohl). circulation 2020 statement in support of the scientists, public health professionals, and medical professionals of china combatting covid-19 a pneumonia outbreak associated with a new coronavirus of probable bat origin genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding full-genome evolutionary analysis of the novel corona virus (2019-ncov) rejects the hypothesis of emergence as a result of a recent recombination event covid-19: health literacy is an underestimated problem assessment of covid-19 knowledge among university students: implications for future risk communication strategies a nationwide survey of psychological distress among italian people during the covid-19 pandemic: immediate psychological responses and associated factors critical health literacy and the covid-19 crisis how to fight an infodemic available online: www.buzzsumo the spread of medical fake news in social media-the pilot quantitative study ?_com_liferay_asset_publisher_web_portlet_assetpublisherportlet_ instance_2r1idyn3mpb6_redirect=https%3a%2f%2fwww.iss.it%2fcovid-19-bufale%3fp_p_id% 3dcom_liferay_asset_publ history in a crisis-lessons for covid-19 the spread of low-credibility content by social bots judgment under uncertainty: heuristics and biases. in utility, probability, and human decision making belief in fake news is associated with delusionality, dogmatism, religious fundamentalism, and reduced analytic thinking the cognitive reflection test as a predictor of performance on heuristics-and-biases tasks an analysis of clinical reasoning through a recent and comprehensive approach: the dual-process theory susceptibility to partisan fake news is explained more by a lack of deliberation than by willful ignorance who falls for fake news? the roles of bullshit receptivity, overclaiming, familiarity, and analytic thinking why people fail to recognize their own incompetence the impact of repetition-induced familiarity on agreement with weak and strong arguments misinformation and morality: encountering fake-news headlines makes them seem less unethical to publish and share fake news': incorrect, but hard to correct. the role of cognitive ability on the impact of false information on social impressions fighting covid-19 misinformation on social media: experimental evidence for a scalable accuracy nudge intervention interdisciplinary perspectives on health literacy research around the world: more important than ever in a time of covid-19 environment and health: risk perception and its determinants among italian university students people with suspected covid-19 symptoms were more likely depressed and had lower health-related quality of life: the potential benefit of health literacy fear of covid-19 scale-associations of its scores with health literacy and health-related behaviors among medical students funding: this research received no external funding. the authors declare no conflict of interest. key: cord-283537-49ic7p3u authors: chong, ka chun; goggins, william; zee, benny chung ying; wang, maggie haitian title: identifying meteorological drivers for the seasonal variations of influenza infections in a subtropical city — hong kong date: 2015-01-28 journal: int j environ res public health doi: 10.3390/ijerph120201560 sha: doc_id: 283537 cord_uid: 49ic7p3u compared with temperate areas, the understanding of seasonal variations of influenza infections is lacking in subtropical and tropical regions. insufficient information about viral activity increases the difficulty of forecasting the disease burden and thus hampers official preparation efforts. here we identified potential meteorological factors that drove the seasonal variations in influenza infections in a subtropical city, hong kong. we fitted the meteorological data and influenza mortality data from 2002 to 2009 in a susceptible-infected-recovered model. from the results, air temperature was a common significant driver of seasonal patterns and cold temperature was associated with an increase in transmission intensity for most of the influenza epidemics. except 2004, the fitted models with significant meteorological factors could account for more than 10% of the variance in additional to the null model. rainfall was also found to be a significant driver of seasonal influenza, although results were less robust. the identified meteorological indicators could alert officials to take appropriate control measures for influenza epidemics, such as enhancing vaccination activities before cold seasons. further studies are required to fully justify the associations. hong kong, a city located in the south china sea, has a humid subtropical climate with winter (december-february) temperatures that usually range from 10 to 20 °c, warm springs and autumns, and hot summers (june-september) with daytime temperatures in the low to mid 30 s and nighttime temperatures in the high 20 s. in temperate regions, influenza has a clear seasonal pattern with an exponential increase in infections in the winter, which is followed by a fade-out period of a few months. in subtropical regions, there is no sufficient understanding of the seasonal pattern of influenza and its relationship with meteorological factors. the number of epidemic peaks can differ across various subtropical regions, with the peaks usually occurring at different periods within a year [1] [2] [3] . according to the world health organization (who), influenza epidemics result in 250 to 500 thousand deaths worldwide annually [4] . in hong kong, the influenza hospitalization rate and the pneumonia and influenza (p&i) associated mortality were estimated to be 29 and 4.1 per 100,000 person-years respectively [5, 6] . hong kong was also regarded as an epicenter of pandemic influenza in southeast asia. insufficient information about viral activity creates difficulties in forecasting the disease burden and thus hampers official preparation efforts. despite numerous researches that have discovered meteorological factors associated with various activities of influenza, little is known about the drivers of transmission or its seasonal variations for different climates. a small variation in influenza transmission could result in amplification and damping of infection oscillations over time and thus sustain a seasonal pattern [7] . possible drivers of influenza transmission include meteorological variations [8] , susceptible numbers [9, 10] , and social mixing [3] . recently, shaman et al. employed a mathematical model to demonstrate that the seasonal pattern of influenza in the united states could be drawn based on the process of simulations driven by the absolute humidity [8] . this finding motivated a further investigation of potential meteorological drivers for subtropical climates. in this study, meteorological determinants that could drive the seasonal variations of influenza in hong kong were investigated by a mathematical model. we hypothesized that the transmission rates in a population-level model, as well as the infection oscillations of seasonal influenzas, are affected by meteorological factors. identification of the drivers will help to improve the understanding of influenza transmission and to alert officials to implement preemptive control measures for seasonal influenza. data on deaths from p&i from 2002 to 2009 in hong kong were obtained from the hong kong census and statistics department (figure 1 ). the mid-year population (nyear) from 2002 to 2008 was collected from the hong kong census and statistics department [11] . we separated each wave of p&i deaths by year from week 35 to week 34 of the following year. as the wave of 2007 was stopped earlier, it would start from week 35 until week 23 of 2008. the 2008 wave is from week 24 to week 16 of 2009, in order to prevent the overlap of cases after the outbreak of the 2009 h1n1 pandemic. the weekly average of meteorological parameters: air temperature, relative humidity, total rainfall, total solar radiation, wind direction, and wind speed from 2002 to 2009 were collected from the hong kong observatory. the time series of the data is shown in figure 2 . actual vapor pressure (e) was calculated as a metric for absolute humidity by the teten's formula [12, 13] : where es(ta) is the saturation vapor pressure (hpa), rh is the relative humidity (%), and ta is the air temperature (°c). the es was calculated as follows: ta ta ta e s 7 . 237 27 . 17 exp 105 . 6 ) ( the saturation vapor pressure in the teten's formula can also be obtained by the integration of clausius-clapeyron equation and is acceptable for most meteorological purposes [12, 14] . as the wind data was in the polar coordinate scale, we develop wind velocity variables in the cartesian scale that encompasses wind direction and wind speed, thus preventing the problem of northerly bearings being split at true north. two parameters of wind velocity (east-to-west and north-to-south) were used as metrics for wind data in the analysis. we extended the susceptible-infected-recovered (sir) model from chowell et al. [15] to describe the dynamic system of seasonal influenza. in this model, a population is comprised of four compartments: susceptible (s(t)); infectious (i(t)); recovered (r(t)); and dead (d(t)), at each time point t. the sir model consists of four differential equations that describes the rates of subject movements for each of the time steps. we assumed homogeneous mixing, meaning that each individual has the same chance of contacting another individual within the population. in the compartmental model, once susceptible individuals in compartment s(t) get infected, they will move to compartment i(t) and stay there for the infectious period. when the infectious period is over, the individuals in compartment i(t) will recover and move to compartment r(t) or will die and move to compartment d(t). in this model, the time-varying transmission rate per individual is βt and the force of infection for time t is βti. we denote s(t), i(t), r(t), and d(t) as s, i, r, and d as the subpopulations in each compartment for time t. the deterministic system of equations are as follows: we assumed that the length of the generation interval (gi) follows an exponential distribution with mean = 1/(γ + δ). suppose cfp is the average case fatality proportion, the mortality rate is δ = (cfp/(1 − cfp)) and δi is the influenza deaths generated by the differential equations. to make the model coefficients more comparable to each other, meteorological variables are transformed by subtracting the mean and divided by the standard deviation (sd) over their sampling period. let xt i be a particular i-th independent variable (e.g., air temperature at time t), the transformed form would be: where i x is the sample mean and σ i x is the sd for the sampling period. the meteorological effects are related to βt using the following linear component: where n is the number of independent variables. the model will determine the significant drivers to the influenza transmission rate. in the differential equations, we assumed a 5-day length of gi [16] and a 0.2% cfp [17] . to account for the variation of partial immunity to the seasonal influenza, we followed previously published procedures [15, 18] . the initial number of susceptibles in equation (3) was calculated by where d(0) was set to be the number of p&i deaths in the first epidemic week. thus, the initial number of recovered individuals can be calculated as rather than fixing a value, mid-year population (nyear) was used for each wave, so as to reduce the impact from natural mortality and birth. the weekly p&i death data was fitted to model generated deaths (i.e., δi) and the meteorological time series data consisted of the variables (xt i ) for each epidemic wave. parameters i(0), b0, b1,…,bn could be estimated by least-squares fitting to the data. as weekly data was used, t was measured in weeks. statistically significant meteorological parameters (p-value of bi < 0.05) were declared as potential drivers to seasonal variations of influenza. a stepwise variable selection approach was adopted and the best fitted model was chosen as the one with all statistically significant variables and the lowest akaike information criterion (aic) [19] : where m is the number of data points, p is the total number of parameters, and sse is the sum of square errors. instead of sampling, all possible parameter combinations were assessed by a grid search. as the absolute humidity was derived from the temperature and relative humidity, they could not be included in the same variable pool during the stepwise variable selection, due to the co-linearity problem. the variable set with temperature, relative humidity, plus other variables and the set with absolute humidity plus other variables were separately adopted in the variable selection in order to draw two final models. the best fitted model was then chosen based on aic value (lower being better). adjusted r-square (adj-r 2 ) is the measure of proportion of variance explained by the model after the parsimony adjustment. the difference of adj-r 2 between the null model and fitted model (δadj-r 2 ) was interpreted as the proportion of variance explained by the meteorological factors. we conducted a sensitivity analysis addressing two aspects: (1) model parameters: sensitivity analysis was performed by varying the length of the gi for 3 days and 7 days [16] and the cfp for 0.1% and 0.4% [17] . (2) model structure: in addition to the linear form of equation (5), a multiplicative exponential form was also adopted in model fitting to test whether this would produce different results: table 1 summarizes the results of the best fitted models with lowest aic and all statistical significant meteorological parameters. compared with the null models (βt = constant), models with meteorological parameters had better goodness of fit in terms of their aic (figure 3 ). no null model was found to be the best fitting model after the stepwise variable selection. with the exceptions of the 2003 and 2005 p&i waves, adj-r 2 was always greater than 40%, indicating that models with selected meteorological parameters explained more than 40% of the variance in p&i mortality after the adjustment of number of parameters. except for 2004, the models with significant meteorological factors could account for more than 10% of variance in addition to the null model (i.e., δadj-r 2 > 10%). for the 2008 epidemic, the meteorological parameters accounted for more than 50% of the variability in the p&i data. nevertheless, the p&i data of the 2004 epidemic could not be well explained by the best fitted models. as shown in table 1 , air temperature and rainfall were the most common significant variables driving the seasonal variations of the p&i waves from 2002 to 2008. the air temperature was negatively associated with the time-varying transmission rate βt in six of the seven epidemics; for one sd decrease in temperature, the transmission rate would increases by 4.1, 9.8, 2.6, 2.9, 5.2, 3.7 (×10 −9 ) for the years 2002, 2003, 2004, 2006, 2007 and 2008 respectively. moreover, rainfall was positively associated with the transmission intensity in five of the seven epidemic waves. when there was a sd increase in rainfall, the transmission rate would increases by 10.7, 4.5, 2.3, 9.8, 5.5 (×10 −9 ) for the years 2003-2006, and 2008 respectively. a negative association was found for 2007. surprisingly, relative humidity and absolute humidity did not show much contribution to the variance of βt among all the p&i epidemics. a sensitivity analysis was conducted to test the impact of our results from different parameter settings. in brief, varying the cfp (0.1% and 0.4%) and gi (3 and 7 days) only produced a slight effect on the goodness of fits. as shown in figures 4 and 5 , the best fitting curves were highly similar. in terms of aic and adj-r 2 , no significant differences were produced as a result of using different cfp and gi settings (tables 2 and 3 ). the fitness of the models with either cfp = 0.1% or gi = 3 days were worse than the other models in several epidemic waves. the effect of temperature was only slightly sensitive to the variation in cfp and gi. in most situations, air temperature continued to be identified as a common driver of seasonal variations. when gi = 3 days, air temperature significantly drove the variations in all epidemics. whereas the effect of rainfall was moderately sensitive to variations in cfp and gi. rainfall was identified as the significant driver of four of the studied influenza epidemics. the decrease of rainfall's significance may be due to the model variance shared with relative humidity. the meteorological variable selection was not sufficiently sensitive, even if the model structure was changed to the exponential form (table s1 ). recent studies have demonstrated that environment factors account for a proportion of the seasonality, as well as infection oscillations, of influenzas in temperate regions [8, 9] . here we used a mathematical model to explore the potential meteorological drivers for seasonal oscillations of influenza in a subtropical city, hong kong. through modulating the transmission rates by the meteorological factors in an infectious disease model, the seasonal variations of influenza infections could be well-depicted. according to our results, although no meteorological parameters dominated the seasonal variations for all epidemics, air temperature significantly modulated the fluctuations of transmission rates for most of the epidemics between 2002 and 2009. rainfall was also found to be a significant driver for most of the epidemics, although its direction of association was not unidirectional and it was moderately sensitive to changes in the model parameters. in many laboratory and epidemiological studies, air temperature is often found to be associated with influenza transmissions [1, [20] [21] [22] [23] [24] . an epidemiological study from chan et al. [1] found that temperature and relatively humidity were associated with the activity of seasonal influenza in hong kong; a cold and humid climate was related to higher activities of both influenza a and b. lowen et al. [21] conducted an experimental study using a guinea pig model to demonstrate that cold temperature favored to the spread of the influenza virus. our study extended these findings by showing that cold temperature was associated with the mechanism driving seasonal oscillations at a population level. this is perhaps due to prolonged survival of viral particles under colder conditions. nevertheless, the effect of temperature could be confounded by other factors [25] . for example, a decrease in temperature could enhance crowding at indoor activities, and would thus increase the contact, aerosol and droplet transmission intensity. in our study, we could not identify any strong evidences that absolute humidity drove the seasonal variability in hong kong, even though experimental and modeling studies have shown that absolute humidity was related to viral survivorship and was capable of driving the seasonality of influenza in temperate regions [9, 10, 25] . one possible explanation for this is that the absolute humidity in hong kong was high all year around, compared to temperate areas. like other tropical and subtropical regions, use of air conditioning is common in hong kong when the temperature is high. one could argue that, using air conditioning would lower the indoor absolute humidity and thus modulate the survivorship of the influenza virus. the effect from air exchange would indeed offset the impact of disease transmission. in addition to cold temperature, experimental studies have indicated that a low relative humidity could enhance the influenza transmission [21] . according to our results, relative humidity was not identified as a significant driver for the seasonal variation of influenza infection. this might be accounted for by the relative unpopularity of indoor heating in hong kong compared to temperate regions. moreover, the predominant mode of influenza virus spread was proposed to be different between temperate and tropical regions [26] . relative humidity would be more insensitive for transmissions by the contact route than by the aerosol route. previous studies shown that rainfall could be used as a predictor to forecast influenza infection rates for sub-tropical regions, but not in all temperate regions [27] . these authors also indicated that rainfall was correlated with seasonal influenza transmission in hong kong [20] , and this finding was in line with other tropical areas [28] . nevertheless, there remains no clear and definitive explanation for the mechanism of rainfall driving the influenza seasonality. although low temperature and dry air have been proven to be favorable for survival of viral particles [22] , no study has investigated the relationships between rainy conditions and bulk aerosol transport. one plausible mechanism is that rainfall could affect human social behaviors, such as indoor activities, and therefore influence the number of contacts and the risk of exposure to contaminated environments or infected individuals. in our study, we found that rainfall significantly drove some epidemics but that its direction of association was not unidirectional, likely due to the problem of multicollinearity, which has been investigated in our association analysis (table s2) . solar radiation could cause seasonal variations in vitamin d photosynthesis that may affect immune responses as well as playing a role in the influenza seasonality [29, 30] . the preventive efficacy of vitamin d supplementation against influenza infections has also been demonstrated in trial studies [31] . our study did not identify solar radiation as a driver for the seasonality of influenza infection. this result was not surprising because the effect of solar radiation on the population of the subtropics is not as well documented as in temperate regions. in addition, influenza a would be more likely affected by vitamin d status than influenza b [31] . this factor might confound our findings when p&i data was adopted in the study. nevertheless, the role of solar radiation in seasonality remains controversial because it has been difficult to explain the influenza dynamic in outdoor environments; most transmissions occur in indoor environments through airborne transmission or contact [32] . rather than pooling all of our data, the purpose of conducting the analysis by seasons was to investigate the meteorological effects independent of the between-season variations. the between-season effect was made up by "nuisance variables", which could result from variations of reporting rate and other potential factors that affected the susceptibility numbers [10] , such as the vaccination effectiveness. although the partial immunity of the seasonal influenza was adjusted in our analysis, some factors are difficult to measure and interpret. analysis by seasons could confound the relationship between meteorological factors and transmission rate, and thus generate inconsistency for the estimated coefficients (e.g., a negative association of rainfall in 2007). an additional analysis was conducted using the pooled data and the results were summarized in supplementary table s3 . by this approach the main finding was unchanged (i.e., a low temperature drove the influenza transmission). it should be noted that between-season effect accounted for 20% of the total variance in addition to the meteorological determinants. in our study, there is undoubtedly some degree of correlation between meteorological variables. hence, we additionally conducted a correlation analysis in which the pearson correlation coefficients and variance inflation factors (vif) were drawn from the pooled data, with the results summarized in supplementary table s2 . although positive correlations were found between temperature and solar radiation, and between rainfall and humidity, no serious effect of multicollinearity was found for any of the predictors based on a simple rule-of-thumb (i.e., all vifs were less than 3). one limitation of our study is that we only investigated the environmental drivers for disease transmission and could therefore not completely rule out confounding factors. according to some studies [8] [9] [10] 22] , some seasonal changes of host behavior (e.g., international travel [33, 34] and school holidays [35] ) might also affect the transmission dynamics. it has been shown that the closure of kindergartens and primary schools was able to reduce the disease transmission rate by around 25% for the 2009 influenza a/h1n1 pandemic. nevertheless, its effect upon the seasonal variation of influenza is controversial. some studies [10, 36] pointed out that no substantial effect on the transmission reduction could be detected when schools were closed. in addition, our results were undoubtedly affected by the demographics of the population (e.g., age and gender). subjects with different clinical status, such as chronic obstructive pulmonary disease, may also have confounded the likelihood of p&i deaths. the sufficiency of details to address these issues requires a huge effort in data collection, which remains difficult to achieve at this stage. further research is warranted to investigate the effects of seasonal social/behavior patterns. a limitation to our study is that the use of p&i mortality to represent the influenza activity may not be completely adequate and could potentially bias the findings. although some studies have preferred using p&i mortality [15] , we also analyzed the p&i excess mortality to test the robustness of the study finding. we adopted the traditional serfling approach to estimate the excess mortality [37, 38] . the serfling method is a linear regression model using harmonic terms to calculate the expected mortality in the absence of influenza virus activity. the number of excess deaths attributable to influenza was estimated as the difference between the observed and the upper 95% limit of the prediction interval of baseline deaths. the details were noted in supplementary table s4 . from the results, the principal finding was unchanged (i.e., air temperature remained a significant driver of the seasonal patterns). it should be noted that no climatic variables can be fitted into the year 2003 due to few p&i excess mortality. this might be due to the mitigation measures for the severe acute respiratory syndrome (sars) epidemic that potentially also reduced the number of influenza cases [39] . undoubtedly, it has been widely recognized that the disease severity of influenza, in terms of excess p&i deaths and hospitalization, tended to be higher in the influenza a dominant seasons than in those with influenza b as the dominant virus strains [5] . moreover, some influenza b epidemics resulted in increased hospitalizations but not increased mortality [40] . as a result, our findings might be less precise for mild influenza seasons and may not reflect the general influenza experience in hong kong. this is a common limitation in studies that employed mortality surveillance. in addition to death data, influenza-like illness (ili) surveillance has been commonly adopted as a proxy for influenza activity. nevertheless, the definition of ili failed to document significant influenza-associated morbidity and mortality [5] . as such, ili is a poor indicator of influenza activity when adopted in areas with a less defined pattern of seasonality [41] . laboratory surveillance data would be a better indicator for influenza activity but large efforts would be required to gather and collate such data. the data used in this study was only applied the retrospective fitting. further studies would have to be conducted to validate these results. for example, more data is required to extend the model application to projecting the sir curve for model validations [8] . plausible causality and potential interactions should also be justified, such as direct and indirect effects of air temperatures [22] . nevertheless, our study represents an initial step towards identifying potential meteorological determinants for driving the seasonal variations of influenza in a subtropical region. this study identified the potential meteorological drivers for the seasonal variations of influenza in a subtropical city, hong kong. results show that the cold air temperature was a significant driver for increasing the transmission intensity of seasonal influenza from 2002 to 2009. rainfall was also found to be a significant driver for some seasons, although this result was less robust. an accurate would enable officials to take appropriate control measures for influenza epidemics, such as maintaining sufficient indoor temperature and enhancing vaccination activities prior to the cold seasons. further laboratory and epidemiological studies are required to validate and justify the associations proposed here. seasonal influenza activity in hong kong and its association with meteorological variations influenza in tropical regions 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avian influenza seasonal influenza in the united states, france, and australia: transmission and prospects for control model selection and multimodel inference: a practical information-theoretic approach modeling and predicting seasonal influenza transmission in warm regions using climatological parameters influenza virus transmission is dependent on relative humidity and temperature influenza seasonality: underlying causes and modeling theories hospital admissions as a function of temperature, other weather phenomena and pollution levels in an urban setting in china associations between mortality and meteorological and pollutant variables during the cool season in two asian cities with sub-tropical climates: hong kong and taipei absolute humidity modulates influenza survival, transmission, and seasonality high temperature (30 ºc) blocks aerosol but not contact transmission of influenza virus meteorological parameters as predictors for seasonal influenza the role of temperature and humidity on seasonal influenza in tropical areas the seasonality of pandemic and non-pandemic influenzas: the roles of solar radiation and vitamin d influenza, solar radiation and vitamin d. dermatoendocrinology randomized trial of vitamin d supplementation to prevent seasonal influenza a in schoolchildren a note on the inactivation of influenza a viruses by solar radiation, relative humidity and temperature modeling the impact of air, sea, and land travel restrictions supplemented by other interventions on the emergence of a new influenza pandemic virus assessing the impact of airline travel on the geographic spread of pandemic influenza school closure and mitigation of pandemic (h1n1) effects of school closures, 2008 winter influenza season methods for current statistical-analysis of excess pneumonia-influenza deaths the impact of influenza epidemics on mortality: introducing a severity index respiratory infections during sars outbreak the impact of influenza epidemics on hospitalizations clinical signs and symptoms predicting influenza infection this study was supported by the project (2012zx09303012-002) from the shenzhen research institute, the chinese university of hong kong, shenzhen, china. the authors thank the hong kong observatory, the hospital authority and the environmental protection department for providing the datasets for this study. the authors also thank external reviewers for their expertise advice on constructing the manuscript. william goggins and maggie haitian wang collected the data and conducted the data analysis. ka chun chong conducted the data analysis, summarized the results, and wrote the manuscript. benny chung ying zee initiated the research and revised the manuscript. all the authors read and approved the final version of the manuscript. the authors declare no conflict of interest. key: cord-285386-kvo544hh authors: wen, ya; chen, huaruo; pang, liman; gu, xueying title: the relationship between emotional intelligence and entrepreneurial self-efficacy of chinese vocational college students date: 2020-06-23 journal: int j environ res public health doi: 10.3390/ijerph17124511 sha: doc_id: 285386 cord_uid: kvo544hh the purpose of this study is to explore the relationship between emotional intelligence and entrepreneurial self-efficacy. the sample consisted of 529 students. the tools used to measure the relationship between emotional intelligence and entrepreneurial self-efficacy were the emotional intelligence scale developed by wong and law and the entrepreneurial self-efficacy scale developed by zhan. the results showed that there was a significant difference between male and female college students in entrepreneurial self-efficacy, but no significant difference between male and female college students in emotional intelligence. in entrepreneurial self-efficacy as well as emotional intelligence, there were significant differences between the third grade and the first and second grade, respectively. in addition, the results showed a significant positive correlation between entrepreneurial self-efficacy and emotional intelligence. with the improvement of the emotional intelligence level of vocational college students, the entrepreneurial self-efficacy will increase. the lower the emotional intelligence, the faster the improvement in entrepreneurial self-efficacy. the higher the emotional intelligence, the more stable the entrepreneurial self-efficacy. the university stage is considered an ideal entrepreneurial period, especially for vocational colleges’ students, who pay more attention to entrepreneurship and innovation education. encouraging the cultivation of the emotional intelligence of vocational college students in life will help to improve personal entrepreneurial self-efficacy. this research emphasizes that improving the emotional intelligence of vocational college students can enhance their sense of self-efficacy in entrepreneurship and help students with entrepreneurship and career development. entrepreneurship is of great significance to a country's economic growth and decline in unemployment [1, 2] . under the policy background of "mass entrepreneurship and innovation" in china, the research on college students' innovation and entrepreneurship has grown exponentially. how to enhance the self-efficacy of college students' entrepreneurship and promote their entrepreneurship and employment to the maximum extent is an important issue for colleges to accelerate economic and social development, improve the talents cultivation pattern, and promote the success of college students [3] . vocational colleges are an important part of china's higher education system, vocational students are the guarantee of technical talents for china's development [4] . generally, they need to study in since 2000, the literature on emotional intelligence has been endless, especially the research on positive psychological qualities such as emotional intelligence and well-being has attracted the attention of many scholars. the relationship between emotional intelligence and subjective well-being was analyzed, supporting emotional intelligence as a key skill for personal growth and social development [22] . there is a positive correlation between trait emotional intelligence and subjective well-being; a negative correlation between emotional intelligence and stress and social anxiety has also been confirmed [23] . regarding the relationship between adolescent emotional intelligence and mental health, many researchers have conducted research and found that adolescents with lower parental violence have higher emotional intelligence, and emotional intelligence is related to positive adolescent development [24] [25] [26] . in addition, studies have found that adolescents with low emotional intelligence report a higher risk of suicide than those with high emotional intelligence [27] . a study of 524 italian college students found that traits of emotional intelligence are a source of happiness and hope [28] . in the field of organizational behavior, emotional intelligence is also concerned by scholars. a study shows that employee emotional intelligence has a positive predictive effect on psychological capital and job performance, and some studies have concluded that the interaction between role ambiguity and emotional intelligence has significant significance in explaining the dimension of engagement [29] [30] [31] . career adaptability is a popular concept in organizational behavior in recent years [32, 33] . a study based on cross-lagged panel analysis found that emotional intelligence can predict career adaptability [34] . in addition, a study of senior managers showed that the relationship between emotional intelligence and occupational personality scales showed that emotional intelligence was positively correlated with many occupational scales [35] . can emotional intelligence be cultivated? how effective is the cultivation? many researchers have discussed this. a meta-analysis of emotional intelligence training shows that, regardless of the form, training interventions for emotional intelligence are considered effective [36, 37] . in the field of organizational behavior, studies have found that interventions on emotional intelligence may effectively improve job satisfaction [38] . an interview-based study found that training nurses' emotional intelligence is beneficial to their mental health [39] . when it comes to entrepreneurial self-efficacy, self-efficacy needs to be discussed. the concept of self-efficacy is derived from bandura's social learning theory. according to the basic perspective of social learning theory, generally speaking, when people are in or facing a predicament that is bad for themselves, many people often show psychological fear and try to avoid or get rid of various unfavorable situations and problems that they think are difficult to cope with [40, 41] . the self-efficacy refers to the ability of individuals to show very decisive judgments and behaviors when they are in or facing such unfavorable situations or problems, to effectively complete tasks, and to overcome difficulties and problems [42, 43] . hackett and betz (1981) proposed to extend the theory of self-efficacy to the career field. at the same time, some researchers applied self-efficacy to the field of entrepreneurship to generate entrepreneurial self-efficacy [44, 45] . some scholars describe entrepreneurial self-efficacy as entrepreneurial self-confidence in specific tasks [46] ; others define entrepreneurial self-efficacy as confidence in individuals' ability to complete the entrepreneurial process [47] . some scholars defined the concept of entrepreneurial self-efficacy from three dimensions: the first dimension is to apply self-efficacy to specific aspects of entrepreneurial spirit; the second dimension is to emphasize the content level of self-efficacy, the third dimension is the validity of self-efficacy belief [48] . entrepreneurial self-efficacy is an important influencing factor of entrepreneurial intention, and entrepreneurial intention is a key indicator of entrepreneurial behavior prediction and interpretation [49] . the relationship between entrepreneurial self-efficacy and entrepreneurial intention has attracted the attention of many scholars, especially in the field of higher education. some researchers have found that there is a positive correlation between the quality of entrepreneurship education and entrepreneurial self-efficacy [50] . in practice-oriented entrepreneurship courses, higher entrepreneurial self-efficacy is associated with higher entrepreneurial intention [51] , and entrepreneurial self-efficacy has a strong predictive effect on entrepreneurial intention [52] . in addition, some researches based on the social career cognition theory (scct) also show that entrepreneurial self-efficacy is positively related to entrepreneurial intention [53] . some scholars have pointed out that entrepreneurial self-efficacy has a strong impact on entrepreneurial self-efficacy for college students [54] . a study of engineering college students found that, in addition to the positive moderation effect of social norms on the relationship between entrepreneurial self-efficacy and entrepreneurial intention, entrepreneurial education is also positively related to the intention of entrepreneurial activities [55] . other researchers have found that the relationship between employment perception, entrepreneurial intention, career adaptability, and self-efficacy of college students and job seekers is positively correlated with career adaptability and general self-efficacy [56] . in summary, entrepreneurial self-efficacy is an important factor affecting entrepreneurial intention, and it is of great significance for individuals to form entrepreneurial intention or to complete entrepreneurial behaviors. entrepreneurial self-efficacy is closely related to the performance of enterprises. a study on the self-efficacy of entrepreneurs in central asia concluded that self-efficacy has a direct and intermediary effect on performance [57] . in addition, the evidence on south african enterprises supports that entrepreneurial self-efficacy is significantly related to the competitiveness of enterprises during the entrepreneurial stage of searching, planning, and integrating resources and personnel [58] . besides, a study on the performance of small french companies has concluded that self-efficacy and work efficiency are positively related to corporate performance [59] . based on multilevel regression analyses, it was found that entrepreneurial self-efficacy can be used as a personal resource to help entrepreneurs turn increasing uncertainty into exploration and opportunity identification [60] . studies by some scholars have shown that entrepreneurial self-efficacy is an important variable in predicting entrepreneurial behavior and entrepreneurial success in the field of entrepreneurship. entrepreneurial self-efficacy is affected by individual internal and external factors, including social, cultural, and economic background, personality, and ability. entrepreneurial motivation, entrepreneurial attention, and participation are extremely significantly correlated with entrepreneurial self-efficacy [61] . in recent years, a large number of studies have shown that entrepreneurial self-efficacy, as an important part of entrepreneurial cognition, is significantly related to entrepreneurial motivation and ability, and has a good predictive effect on entrepreneurial decision-making, behavior, and performance [62] . in addition, the relationship between entrepreneurial self-efficacy and some demographic variables, such as gender, has also attracted the attention of researchers. as early as 2011, some researchers have explored the role models and self-efficacy on the formation of career intentions, and found that role models have a strong effect on females' self-efficacy [63, 64] . some scholars have explored the relationship between the sample's gender role and the entrepreneur's self-efficacy under the cross-cultural background, and the research shows that the entrepreneur's self-efficacy is more affected by the gender role positioning [65] . in addition, a study on entrepreneurial self-efficacy of college students showed that female college students' self-efficacy and the number of entrepreneurial role models were related to increased entrepreneurial intention [66] . at present, there are relatively few studies on the relationship between emotional intelligence and entrepreneurial self-efficacy. some studies have found that entrepreneurial passion has a mediating role in the relationship between self-efficacy and sustainability, indicating that emotion has an important value in entrepreneurship [67] ; based on the fuzzy-set qualitative comparative analysis (fsqca), some researchers conducted causal and effective decision tests on the structural effects of entrepreneurial passion, entrepreneurial self-efficacy, and risk perception [68] . some studies have explored the relationship between emotional intelligence and entrepreneurial self-efficacy. a survey based on britons (16-84 years) showed that the differences in individual entrepreneurship were partly caused by differences in trait emotional intelligence [14] . in addition, some scholars have researched the relationship between entrepreneurial self-efficacy of spanish entrepreneurs and college students and their big five personality and emotional intelligence, and found that entrepreneurs and students with high emotional intelligence have common entrepreneurial psychological characteristics, such as extraversion, openness, high emotional intelligence score, and low neuroticism score [69] . a study showed that there is a significant difference in the entrepreneurial ability of college students with different emotional intelligence levels, and emotional intelligence has a strong predictive power for entrepreneurial ability [70] . emotional intelligence has a good predictive effect on college students' entrepreneurial self-efficacy [71] . vocational colleges are one of the important types of higher education in china, and they are an important part of vocational education. at this stage, college students and undergraduates of vocational colleges belong to the same age group and are comparable and can be used for reference at the same level. from the theoretical perspective, the study of the relationship between entrepreneurial self-efficacy and emotional intelligence of chinese vocational college students is helpful to explore and improve entrepreneurial theory, test the cross-cultural consistency of entrepreneurial theory, and at the same time, expand the research object of emotional intelligence and entrepreneurial self-efficacy. from the perspective of practice, in recent years, china has increasingly emphasized the role of vocational education in the development of social economy. it is of positive value to study the emotional intelligence and entrepreneurial self-efficacy of vocational college students for the development of entrepreneurial education. however, there are few studies on the emotional intelligence and entrepreneurial self-efficacy of students in chinese vocational colleges. in this study, questionnaires were distributed in some provinces of china. among the students of grade 1-3 in liberal arts, science and engineering, and management in more than 10 vocational colleges, a total of 550 students were randomly selected as the objects of investigation. a total of 529 valid questionnaires were collected, with an effective rate of 96%. among them, 290 are male, accounting for 55%; 239 are female, accounting for 45%. there are 196 students in the first grade, 157 in the second grade, and 176 in the third grade. using the entrepreneurial self-efficacy scale (eses) compiled by zhan. the scale has a total of 19 items, which are composed of four factors of opportunity recognition efficacy, relationship efficacy, management efficacy, and risk tolerance efficacy [72] . the basic information of eses is shown in table 1 , and details of topics can be seen in appendix a table a1 . using likert's seven-point scoring method, the higher the score, the higher the level of entrepreneurial self-efficacy in the project. the cronbach's alpha for this study was 0.946. emotional intelligence was measured using wong and law's "emotional intelligence scale" (wleis), the scale has a total of 16 items, including four dimensions of appraisal of self-emotions, appraisal of others' emotions, regulation of emotion, and use of emotion on cognition [73] . the basic information of wleis is shown in table 2 , and details of topics can be seen in appendix a table a2 . using likert's seven-point scoring method, the higher the score, the higher the emotional intelligence in the project. the cronbach's alpha for this study was 0.936. data collection was in the form of paper quality forms distributed in class. first, the education center was contacted, the purpose of the study explained, and authorization requested to complete the scale. the answer of the scale is anonymous, the data filled in by students is confidential, and the research purpose is exclusive. in this study, the distribution, filling, and recovery of the scale were conducted during the class time; the students who participated in filling in the scale were in a suitable environment without external interference for about 30 min. all data were analyzed by spss 25 (ibm, new york, ny, usa) and amos 7.0 (ibm, new york, ny, usa), including descriptive statistics, variance analysis, correlation analysis, and regression analysis. the basic information of the research sample is shown in table 3 . among the vocational college students participating in this study, 37% were first grade, 30% were second grade, and 33% were third grade. of the students, 86% had "work experience" and 14% "no work experience". of the students, 40% had never had entrepreneurship training, 50% of students had attended one or two entrepreneurial courses or lectures, and 10% of students had received more systematic entrepreneurship education. table 4 shows that in terms of entrepreneurial self-efficacy, the overall performance of vocational college students shows a positive trend. the highest score is 133, the lowest is 19, and the median is 99. if the score exceeds the median, the entrepreneurial self-efficacy tends to be positive. in the total scale and scores, the opportunity recognition, relationship, and management mean values of vocational college students' entrepreneurial self-efficacy exceed the corresponding median value, but the overall mean value and risk tolerance are slightly lower than the median value, which shows that the current college students' entrepreneurial self-efficacy tends to be positive, but the overall level is only in the middle level. among them, the average score of opportunity recognition is the highest, followed by relationship, management, and risk tolerance. table 4 shows that in terms of emotional intelligence, the overall trend of vocational college students also shows a positive trend. the highest score of total emotional intelligence scale is 126, the lowest score is 37, and the median score is 85. if the score exceeds the median, it can be considered that the emotional intelligence tends to be positive. in the total scale and scores, the average value of emotional intelligence of vocational college students is higher than the corresponding median value, but only slightly higher than the median value, which shows that the current college students' emotional intelligence tends to be positive, but the overall level is only above the middle level. among them, the average score of use of emotion is the highest, followed by regulation of emotion, appraisal of others' emotions, and appraisal of self-emotions. in order to analyze the correlation between emotional intelligence and entrepreneurial self-efficacy. according to pearson product-moment correlation, there is a correlation between emotional intelligence and entrepreneurial self-efficacy. the correlation coefficient between the two variables is 0.413, which belongs to a moderate degree of correlation. cronbach's alpha reliability values for the scales used are given in table 5 on the diagonals in bold. cfa was used to test whether the measurement model is consistent with the data, and several fitting indexes were calculated to determine whether the structural model is consistent with the sample data. all values obtained from the model fitting index indicate that the model agrees well with the data. table 6 shows the average variance extraction (ave), composite reliability (cr), maximum shared variance (msv), and average square root value. the cr value greater than the specified threshold of 0.7 indicates high reliability. in all of our study structures, the value of ave is greater than 0.5, which indicates a high level of convergent validity. for all variables used in the study, the square root of ave is greater than the inter-structure correlation, which indicates a high level of discriminant validity. when the msv value is less than the ave value, discriminant validity is further established. the results show that all msv values are less than ave, which provides further support for discriminant validity. the scores of entrepreneurial self-efficacy and emotional intelligence of college students of different genders were tested by independent sample t-test (see table 7 ). the results showed that under the condition of homogeneity of variance, there was significant difference between male and female college students in entrepreneurial self-efficacy (t = 3.933, p < 0.001). in the four subscales, opportunity recognition, relationship, and risk tolerance of male college students were significantly higher than that of female college students, and management was not significant. there was no significant difference in emotional intelligence between male and female college students (t = 2.553, p > 0.05). among the four subscales, only appraisal of others' emotions and regulation of emotion are significant. note: * p < 0.05, ** p < 0.01, *** p < 0.001. the scores of entrepreneurial self-efficacy and emotional intelligence of college students in different grades were tested by independent sample t-test (see tables 8 and 9 ). the results showed that under the condition of homogeneity of variance, there was no significant difference in entrepreneurial self-efficacy of college students in grade one, two, and three. in order to explore the specific sources of differences, lsd multiple comparative analysis was carried out. the results showed that there were significant differences between the third grade and the first and second grade, respectively. there was no difference in the opportunity dimension of entrepreneurial self-efficacy among different grades. there was no significant difference in the other dimensions of entrepreneurial self-efficacy between grade one and grade two. there was significant difference in the other dimensions of entrepreneurial self-efficacy between grade one and grade three and grade two and grade three. the results show that, in terms of emotional intelligence, there was no significant difference in entrepreneurial self-efficacy between grade one, grade two, and grade three students. in order to explore the specific sources of differences, lsd multiple comparative analysis was carried out. the results showed that there were significant differences between the emotional intelligence of grade three and grade one and grade two, respectively; there was no significant difference between the emotional intelligence of grade one and grade two college students. a detailed analysis of the regression of entrepreneurial self-efficacy according to different emotional intelligence dimensions shows that there is a linear relationship between entrepreneurial self-efficacy and emotional intelligence of vocational college students, as shown in figure 1 . at the same time, based on the data, according to the research of guerra bustamante et al., this paper divides emotional intelligence into three levels of low, middle, and high according to the standard of percentile, and makes linear regression analysis [74] . on the basis of the regression equation of emotional intelligence and entrepreneurial self-efficacy, especially the state of the slope, we found that when emotional intelligence increases, individuals will think that their entrepreneurial self-efficacy is higher, and when emotional intelligence decreases, individuals have less entrepreneurial self-efficacy. in addition, we also found that when emotional intelligence is low, entrepreneurial self-efficacy improves faster than when emotional intelligence is higher. self-efficacy. in addition, we also found that when emotional intelligence is low, entrepreneurial selfefficacy improves faster than when emotional intelligence is higher. by exploring the emotional intelligence and entrepreneurial self-efficacy of chinese vocational college students, this study expanded the previous literature research concerning emotional intelligence and entrepreneurial self-efficacy of vocational college students. this study explores the entrepreneurial self-efficacy and emotional intelligence of a sample of chinese vocational college students. on the one hand, it broadens the field of emotional intelligence; on the other hand, it explores the factors that affect entrepreneurial self-efficacy. first, our research showed that there is a positive correlation between entrepreneurial self-efficacy and emotional intelligence reported by vocational college students. we also found that entrepreneurial self-efficacy increased most quickly when emotional intelligence was low, and entrepreneurial self-efficacy was more stable when emotional intelligence was higher. we found that the total score of male entrepreneurial self-efficacy of vocational college students was significantly higher than that of female students, which shows that from the overall point of view, male students are more confident in entrepreneurship than female students. similar results have been obtained in other studies. zhou and yang, taking undergraduates and postgraduates as samples, found that male scores in entrepreneurial self-efficacy were significantly higher than female scores [75] . jin's research on college students also found that male students scored significantly higher than female students in all dimensions of entrepreneurial self-efficacy [76] . specifically, opportunities recognition, relationship, and risk tolerance of male college students were significantly higher than that of female college students, and management was not significant, which may be related to the impact of traditional chinese culture on women. for vocational college students, the difference in the management was not significant, which is also a noteworthy discovery. this study found that there was no significant difference in emotional intelligence between male and female students in vocational colleges. previous studies have shown that the difference between men and women in emotional intelligence has been inconclusive. specifically, there were significant differences between male and female college students in appraisal of others' emotions and regulation by exploring the emotional intelligence and entrepreneurial self-efficacy of chinese vocational college students, this study expanded the previous literature research concerning emotional intelligence and entrepreneurial self-efficacy of vocational college students. this study explores the entrepreneurial self-efficacy and emotional intelligence of a sample of chinese vocational college students. on the one hand, it broadens the field of emotional intelligence; on the other hand, it explores the factors that affect entrepreneurial self-efficacy. first, our research showed that there is a positive correlation between entrepreneurial self-efficacy and emotional intelligence reported by vocational college students. we also found that entrepreneurial self-efficacy increased most quickly when emotional intelligence was low, and entrepreneurial self-efficacy was more stable when emotional intelligence was higher. we found that the total score of male entrepreneurial self-efficacy of vocational college students was significantly higher than that of female students, which shows that from the overall point of view, male students are more confident in entrepreneurship than female students. similar results have been obtained in other studies. zhou and yang, taking undergraduates and postgraduates as samples, found that male scores in entrepreneurial self-efficacy were significantly higher than female scores [75] . jin's research on college students also found that male students scored significantly higher than female students in all dimensions of entrepreneurial self-efficacy [76] . specifically, opportunities recognition, relationship, and risk tolerance of male college students were significantly higher than that of female college students, and management was not significant, which may be related to the impact of traditional chinese culture on women. for vocational college students, the difference in the management was not significant, which is also a noteworthy discovery. this study found that there was no significant difference in emotional intelligence between male and female students in vocational colleges. previous studies have shown that the difference between men and women in emotional intelligence has been inconclusive. specifically, there were significant differences between male and female college students in appraisal of others' emotions and regulation of emotion. satsangi and agarwal et al. found that there was significant gender difference in emotional intelligence of postgraduates, and female postgraduates reported higher emotional intelligence scores [77] . zhao et al. showed that there was no significant gender difference in emotional intelligence of chinese college students [78] . marzuki et al. did not find gender differences in emotional intelligence among university students [79] . on the one hand, the gender difference of emotional intelligence of vocational college students may be related to the scale selected for measurement; on the other hand, although the same scale may have an impact on the measurement results, such as the number of subjects sampled, region, nationality, and so on, it may be possible to find the reasons from the fields of biology, psychology, sociology, education, and so forth. in this study, the comparison of entrepreneurial self-efficacy among the three grades found that the entrepreneurial self-efficacy of the third grade students was significantly higher than that of the first and second grade students, and there was no significant difference between the first and second grade students. this is different from some studies. for example, chen and yin's research showed that there is no significant difference in entrepreneurial self-efficacy among college students of different grades [80] .the result of this study may be that the college students in vocational colleges need to find jobs in the third grade, and it may be more difficult for the college students in vocational colleges to find jobs than the general four-year undergraduate students in china. in this context, entrepreneurship, as an important employment path, may be actively concerned by the graduates in the third grade. therefore, the third grade students have a higher sense of entrepreneurship self-efficacy. on the comparison of emotional intelligence of three grades of students in vocational colleges, it was found that the emotional intelligence of the third grade students was significantly higher than that of the first and second grade students, and there was no significant difference between the first and second grade students, which is different from the previous research. lu et al. investigated the emotional intelligence of vocational college students and found that the emotional intelligence of junior students was lower than that of freshmen and sophomores; zhang and xu also found that there was a period of low emotional intelligence in the junior students [81, 82] . the emotional intelligence of the junior school students in this study was higher than that of the students in other grades, probably because with the growth of individual age comes the enrichment of life experience, the increase of college students' maturity, the improvement of their perception of self and other emotions, and the more effective management and regulation of their own emotions [83, 84] . as in previous studies, we found that there was a significant positive correlation between entrepreneurial self-efficacy and emotional intelligence, indicating that emotional intelligence is one of the influencing factors of entrepreneurial self-efficacy. people with high emotional intelligence also have strong entrepreneurial self-efficacy, which may be due to the importance of self-perception and self-regulation in the development of entrepreneurial self-efficacy, while emotional intelligence involves emotional evaluation and regulation, which may promote the improvement of entrepreneurial self-efficacy [85] . in addition, the results showed that emotional intelligence had a significant negative correlation with gender, a significant positive correlation with grade, and a significant negative correlation with major. there was a significant negative correlation between entrepreneurial self-efficacy and gender, a significant positive correlation between entrepreneurial self-efficacy and grade, and a significant negative correlation between entrepreneurial self-efficacy and major. in conclusion, the correlation between entrepreneurial self-efficacy and emotional intelligence was high, and gender, age and other variables had little relationship with entrepreneurial self-efficacy and emotional intelligence. the correlation coefficient between entrepreneurial self-efficacy and emotional intelligence was large, indicating that college students with high emotional intelligence also have a stronger entrepreneurial self-efficacy. the entrepreneurial process means the establishment and maintenance of multiple interpersonal relationships, which means more competition and pressure. managing and regulating one's emotions is an essential quality for successful entrepreneurs [12, 86, 87] . only when entrepreneurs have the ability to control and adjust their own emotions, and know how to think in a different way, can they form a higher sense of self-efficacy, and have the confidence to recognize entrepreneurial opportunities in the environment, conduct interpersonal relationship management, entrepreneurial management, and tolerate entrepreneurial risks [88] [89] [90] . at the same time, we found that when emotional intelligence is at a lower level, the improvement of entrepreneurial self-efficacy is more obvious; while when emotional intelligence is at a higher level, the improvement of entrepreneurial self-efficacy is relatively slow. this seems to indicate that when the emotional intelligence of vocational college students is low, improving the individual's emotional intelligence is more likely to improve students' entrepreneurial self-efficacy. however, when the level of emotional intelligence of college students is high, the improvement of entrepreneurial self-efficacy becomes relatively slow. does this mean that at this stage, in addition to emotional intelligence having a certain predictive effect on entrepreneurial self-efficacy, other factors may also have some impact on entrepreneurial self-efficacy, such as some personality characteristics, psychological qualities of the individual, or some other external factors [91] [92] [93] . there are some limitations when explaining current research. first, the cross-sectional design was used in this study, and the relationship between the variables cannot be explained causally. from this perspective, longitudinal research is more likely to clarify the relationship between entrepreneurial self-efficacy and emotional intelligence of vocational college students [94] . moreover, the sample size selected in this study was limited. perhaps a larger sample size will make the effect of this study more obvious [95] . the findings of this study require more college students from vocational colleges to participate in repeated tests before they are more likely to increase the universality of our results. although this study has some limitations, this study also has its unique value. previous studies have studied the factors that affect entrepreneurial self-efficacy, but there is less research on the relationship between emotional intelligence and entrepreneurial self-efficacy. besides, an interesting finding of this study is that individuals with different emotional intelligence levels have significant differences in entrepreneurial self-efficacy, which is also a complement to previous research. this research is not only of special significance to the entrepreneurship education of chinese vocational college students, but also may play a positive role in the entrepreneurship education of other technical students with similar background of higher education in the world. in the 21st century of the knowledge economy, the successful entrepreneurship of an individual is inseparable from a high sense of entrepreneurial self-efficacy. it is particularly important to carry out entrepreneurship education at the university stage to improve the individual's entrepreneurial self-efficacy [96] [97] [98] . for example, in the design of undergraduate entrepreneurship education, emotional intelligence is included, and social and emotional learning courses are referenced to comprehensively improve the emotional intelligence of college students in vocational colleges in china, helping to improve college students' entrepreneurial self-efficacy [99] [100] [101] [102] . in addition, future research also needs to consider other factors, such as entrepreneurial personality and entrepreneurial passion, which affect vocational college students' entrepreneurial self-efficacy, in addition to emotional intelligence. finally, on the basis of on a comprehensive exploration of the factors that affect entrepreneurial self-efficacy, emotional intelligence and other factors are incorporated into the system of entrepreneurship education for vocational college students. through the combination of multiple factors, the improvement of entrepreneurial self-efficacy can be promoted among college students, thus increasing the probability of successful entrepreneurial behavior, creating the entrepreneurial environment for chinese vocational college students and other similar higher-education-system students in the world, improving the employment quality of college students, and promoting the social and economic development. in summary, it is important to study the relationship between entrepreneurial self-efficacy and emotional intelligence of college students in chinese vocational colleges. in order to further enhance the entrepreneurial self-efficacy of college students in vocational colleges, the future research can try the following three aspects: first, improve the educational training path for college students' emotional intelligence; second, explore related factors that affect entrepreneurial self-efficacy in addition to emotional intelligence and explore the common mechanism of emotional intelligence and other factors on the entrepreneurial self-efficacy of vocational college students; 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support in data analysis and writing revision. the authors declare no conflict of interest. key: cord-011537-e20zaosw authors: vicent, maría; sanmartín, ricardo; vásconez-rubio, oswaldo; garcía-fernández, josé manuel title: perfectionism profiles and motivation to exercise based on self-determination theory date: 2020-05-05 journal: int j environ res public health doi: 10.3390/ijerph17093206 sha: doc_id: 11537 cord_uid: e20zaosw this study complements extant variable-centered research that focus on the relationship between perfectionism and the autonomous and controlled motivation to exercise. a person-centered approach is used for identifying perfectionism profiles as well as analyzing inter-profile differences in terms of the six regulatory styles located on the autonomy-control continuum. a sample of 597 (m(age) = 22.08, sd = 3.33) ecuadorian undergraduates enrolled in a sport science degree program was employed. latent profile analysis based on two higher-order perfectionism dimensions, perfectionistic strivings (ps) and perfectionistic concerns (pc), supported a four-class solution: non-perfectionists (low ps and pc), adaptive perfectionists (high ps and low pc), maladaptive perfectionists (high ps and pc), and moderate perfectionists (moderate ps and pc). adaptive perfectionists obtained the highest means on intrinsic, integrated, and identified regulations. however, these differences where only significant when compared with moderate perfectionists, and only in the case of integrated regulation, in comparison with non-perfectionists. in contrast, maladaptive perfectionists obtained significantly higher scores on introjected and external regulations as well as on amotivation than the other three classes. results are discussed in light of self-determination theory. there is a certain consensus in the fact that perfectionism can be considered as a multidimensional trait of personality defined by two higher-order dimensions, perfectionistic strivings (ps) and perfectionistic concerns (pc), which capture the underlying structure of instruments design to assess this construct. ps reflects the desire to reach perfection and to pursue unrealistically high standards; representing the adaptive, or at least not maladaptive, dimension of perfectionism. in contrast, pc is considered a maladaptive dimension that involves aspects associated with self-criticism, concerns over making mistakes, fears about social negative evaluation, and lack of satisfaction with achievements [1] . research on perfectionism in sport and exercise has significantly increased during the last 10 years [2] . this growing interest could be partly due to the "perfectionism paradox" [3, 4] . this is the term that flett and hewitt [3, 4] used to explain the fact that sport and exercise seem to encourage perfectionism, whereas perfectionism, in turn, might act as a vulnerability factor for athletes and exercisers. indeed, perfectionism has been associated with a wide range of problems in the sport and exercise domain, such as burnout [5] , training distress [6] , favorable attitudes toward doping [7] , negative affect and intentions to drop out [8] , depression, worry, anxiety [9] , etc. however, the consequences of perfectionism vary depending on the dimension analyzed. hill et al. [10] performed a meta-analytical review about multidimensional perfectionism in sport and exercise, concluding that pc was clearly maladaptive, characterized by a negative pattern of motivation regulation and emotion/well-being, as well as no effects in terms of athletic performance. by contrast, ps showed an ambiguous pattern of relationships, since it was characterized by a mix of maladaptive and adaptive motivation and emotion/wellbeing, and adequate performance. therefore, some perfectionist dimensions contain greater potential for vulnerability than others, and even those that appear to be more adaptive (such as ps) hold some perils for exercisers and athletes [2, 11, 12] . self-determination theory (sdt) [13] is a broad empirically based meta-theory widely employed to understand motivated behavior in the sport and exercise domains [14] [15] [16] . sdt considers different types of motivation located on an autonomy-control continuum between intrinsic motivation and amotivation [17] . in the specific context of exercise, intrinsically motivated behaviors are those performed because of the inherent pleasure that accompanies practicing exercise, and it represents the most autonomous regulation. on the contrary, amotivation represents the lack of intentionality and motivation. extrinsically motivated behaviors are placed between these two extremes and they can be expressed in four regulations depending on the degree of self-determination: external, introjected, identified, and integrated. external regulation represents the less autonomous (or more controlled) type of extrinsic motivation, whereas integrated regulation is the most self-determined extrinsic motivation. an individual externally regulates exercises due to reward contingencies, coercion, or external pressures, whereas in introjected regulation, behavior is motivated by an internal obligation and a sense of guilt. on the contrary, in identified regulation the individual consciously recognizes the worth and value of doing exercise. finally, integrated regulation means a full endorsement of the exercise and sport with other individual's values and identifications (for example, being consistent with a healthy lifestyle, among others) [18] . in accordance with ryan and deci [17] , each of these regulatory behaviors has its own specific determinants, qualities and phenomenology, as well as different consequences in terms of well-being and performance. specifically, the more autonomous the motivation is (i.e., identified, integrated, and intrinsic), the greater wellbeing, healthy development, and effective performance will be. in contrast, those regulations considered more controlled (i.e., introjected and external) have revealed positive associations with impoverished adjustment (see [15] for a review). autonomous motivation has also been associated with positive body image and healthy eating habits/behaviors, whereas controlled motivation has been inversely related to these outcomes [19] . in addition, concerning moral attitudes and antisocial behavior, research has identified pervasive positive influences of autonomous motivation on keeping winning in perspective and a prosocial moral attitude. in contrast, positive effects of controlled motivation on acceptance of gamesmanship and cheating have been found [20] . a considerable number of studies have paid attention to the relationship between perfectionism and self-determination types of motivation, most of them conducted in the sport domain. stoeber et al. [21] performed a review of the literature examining the relationship between autonomous and controlled motivation, and the six regulatory styles (intrinsic, integrated, identified, introjected, external, and amotivation). in this review, authors concluded that pc is mainly associated with regulatory styles characterized by lower degrees of self-determination, such as introjected regulation, external regulation, and amotivation. by contrast, ps is more closely linked to regulatory styles characterized by higher degrees of self-determination (i.e., intrinsic, integrated, and identified regulation). unfortunately, as stoeber et al. [21] noticed, most of the studies included in their literature review missed the inclusion of some of the six regulatory styles and/or they only differentiate between autonomous versus controlled motivation. from our knowledge, stoeber et al. [22] carried out the only study that has analyzed the relationship between perfectionism and the full sdt's motivational continuum. specifically, this study was conducted in the work domain, with a sample of 131 british employees. correlational analyses showed positive and significant associations between ps and intrinsic, integrated, identified, and introjected regulation, as well as negative and significant associations between ps and amotivation, whereas non-significant correlations were observed between ps and external regulation. in contrast, positive and significant correlations were obtained between pc and introjected and external regulations and amotivation, whereas non-significant correlations were observed between pc and the highest degrees of self-determination (i.e., intrinsic, integrated, and identified). however, the question about how the combination of ps and pc, resulting in different profiles, can lead to different outcomes in terms of the six regulatory styles is still pending analysis. although research about perfectionism has been traditionally based on a variable-centered approach, studies from a person-centered approach have increased during the last years. this is because a person-centered approach brings us closer to the "real person" identifying profiles of different levels on perfectionist dimensions, which are, in turn, associated with different outcomes [23] . of the different person-centered approach techniques, latent profile analysis (lpa) is now considered the most appropriate method as it offers many advantages over traditional ones [24] . based on this technique, gilman et al. [25] identified three profiles of perfectionism in a sample of 718 high school students from usa, labeled as adaptive perfectionists (high ps and low pc), maladaptive perfectionists (high ps and pc), and non-perfectionists (comparatively low ps). these three profiles classified, respectively, the 25%, 17%, and 58% of participants. similar results were found by moate et al. [26] , in a sample of 78 counselor educators from the usa, who identified the following classes: adaptive perfectionists (61.8%), with high ps and low pc; maladaptive perfectionists (15.7%), with high ps and pc; and non-perfectionists (22.25%) with low ps and medium pc. on the other hand, in a sample of 183 undergraduates from russia, wang et al. [27] identified adaptive perfectionists (high ps and relatively low pc), maladaptive perfectionists (high ps and pc), and non-perfectionists (low ps and pc), the prevalence of these profiles being 39%, 34%, and 27%, respectively. lastly, moate et al. [28] , using a sample of 528 doctoral students from the usa, obtained a three class solution: adaptive perfectionists (high ps and low pc), maladaptive perfectionists (high ps and low pc), and non-perfectionists (low ps and moderate pc), representing 58.1%, 28.8%, and 13.1% of the population, respectively. in all the studies cited above, the revised almost perfect scale (aps-r) [29] was employed to assess perfectionism. using the sport-multidimensional perfectionism scale-2 (sport-mps-2) [30] , pacewicz et al. [31] also identified three profiles of sport perfectionism in north american high-performance athletes. pure personal standards perfectionists (52.6%) obtained high ps and low pc and mixed perfectionists (27.17%) reported high ps and pc, whereas non-perfectionists (16.19%) manifested low ps and medium pc. by contrast, herman et al. [32] , in a sample of african-american sixth grade students, obtained four classes, i.e., non-critical or adaptive, with high ps and low pc; critical or maladaptive, with high ps and pc; non-perfectionist with low ps and pc; and non-striving with severely low scores on ps and low pc. perfectionism was assessed by using a three-dimensional version of the child and adolescent perfectionism scale (caps-14) [33] . prevalence for the four classes was 27%, 41%, 23%, and 9%, respectively. this study explored, from a person-centered approach, whether different profiles of perfectionism were differentially associated with the full sdt's motivational continuum in the specific context of exercise. specifically, the perfectionism dimensions pc and ps were used as measures to perform a latent profile analysis (lpa) of the data. lpa has received increasing attention as a method of stablishing perfectionism profiles, as has been explained before. although the class-solution differed from one study to another probably because of the different samples, domains, and measures of perfectionism employed, most of previous research has supported a three-class solution: adaptive perfectionists (i.e., high ps and low pc), maladaptive perfectionists (i.e., high ps and pc), and non-perfectionists (i.e., low ps and pc) [25] [26] [27] [28] 31] . in accordance with previous literature [21] , if this three-class model fits the data, we hypothesize that: (a) adaptive perfectionists would experience the highest levels of autonomous motivation (i.e., intrinsic, integrated, and identified); (b) maladaptive perfectionists would show more controlled motivation (i.e. introjected, external, and amotivation), and (c) non-perfectionists would report the lowest levels of both autonomous and controlled motivation. a total sample of 597 ecuadorian undergraduates enrolled in a sport science degree program took part in this study (m age = 22.08, sd = 3.33). among them, 131 were female (21.94%) and 466 (78.06%) were male. following the ethical standards established in the 1964 declaration of helsinki and its later amendments, written inform consent was requested. the assessment instruments were completed by the participants voluntarily and anonymously in approximately 30 min. a duly trained research team member was always present to explain the procedure to the participants, as well as to solve any questions that may arise. to measure the two forms of perfectionism (i.e., ps and pc), a multi-measure approach was followed. the frost's multidimensional perfectionism scale (fmps) [34] and the hewitt's multidimensional perfectionism scale (hmps) [35] were employed. both fmps and hmps were adapted into ecuadorian spanish using a direct and back-translation method. the fmps is a 36-item self-report measure that assesses five perfectionism dimensions in a likert-type format with a five-point response: concern over mistakes (cm), personal standards (ps), parental expectations (pe), parental criticism (pc), doubts about actions (da), and organization (o). the hmps is a 45-item measure of self-oriented perfectionism (sop), socially prescribed perfectionism (spp), and other-oriented perfectionism (oop) by using a seven-point rating scale response. in accordance with previous research [36] , the cm, pe, pc, da, and spp are usually employed as indicators of pc, whereas ps, o, sop, and oop are commonly used as indicators of ps. an exploratory factor analysis (efa) with the data at hand supported the structure proposed by bieling et al. [36] , as all dimensions obtained factor loadings above 0.50 in one of the two higher order perfectionism dimensions, with the exception of oop, whose factor loadings were -0.29 for ps and 0.05 for pc. therefore, oop was excluded from the following analysis. the reliability coefficients, cronbach's alpha, for the present study were acceptable: the behavioral regulation in exercise questionnaire (breq-3) validated in a spanish sample of exercisers [37] was employed. this 23-item instrument assesses the six regulatory styles of the sdt's motivational continuum in the context of sport and exercise: intrinsic, integrated, identified, introjected, external, and amotivation. responses are scored using a five-point likert scale. two ecuadorian experts verified the adequacy of the items wording to ecuadorian spanish. no changes were recommended. the reliability coefficients, cronbach's alpha, for the present study were acceptable: intrinsic (α = 0.78), integrated (α = 0.78), identified (α = 0.70), introjected (α = 0.76), external (α = 0.87), and amotivation (α = 0.73). statistics, including means (m), standard deviations (sd), and pearson's correlation coefficients, were calculated for the relationship between ps, pc, and the six factors of the breq-3. effect sizes of these correlations were considered small when values oscillated between 0.10 and 0.30; moderate between 0.30 and 0.50, and large for values ≥0.50 [38] . lpa was conducted to determine whether a latent class structure could be identified on the basis of the two perfectionism dimensions, ps and pc. statistical analyses begin with a class, which suggests a classification adjustment for all individuals. next, individuals were successively assigned to an ascending number of classes. the following criteria were considered to define which number of classes best fitted to the data [39] : (a) the lowest values of the akaike information criterion (aic) and the bayesian information criteria (bic); (b) p-values below 0.05 associated to the vuong-lo-mendell-rubin likelihood-ratio test (lrt) and the bootstrap likeli-hood ratio test (blrt); (c) entropy values close to one. in addition to these indices and statistics, in order to have a meaningful class classification, no solution including small classes was considered (with less than 25 classified cases). subsequently, a multivariate analysis of variance (manova) was performed in order to determine whether there were differences in the mean levels of the six types of motivation regulatory styles (i.e., intrinsic, integrated, identified, introjected, external, and amotivation) across the different latent classes, using eta square to determine the magnitude of effect. post hoc tests using the bonferroni method were conducted to identify between which profiles there were significant differences. in order to calculate the magnitude of these differences, the cohen's d index was used. this index was interpreted considering cohen's criteria [38] : descriptive statistics and bivariate correlations among study scales are reported in table 1 . positive and significant correlations of a moderate magnitude were found between ps and pc. ps also positively and significantly correlated, with small effect sizes, with all sdt's continuum regulatory styles, with the exception of amotivation, whose correlations did not reach statistical significance. similarly, pc significantly and negatively correlated with moderate effect sizes, with introjected, external, and amotivation, whereas negative and significant correlations of a small magnitude were found between pc and intrinsic. the model fit of the six estimated latent profile solutions are displayed in table 2 . the aic and bic had lower values for each class solution that increased one class. a five-class solution obtained the lowest bic whereas the six-class solution obtained the lowest aic. however, these two class solutions also presented one class that showed less than 25 participants and were therefore rejected by the established criterion. regarding lrt, all class solutions, with the exception of the six-class model, presented a p-value below 0.05. combining all the criteria, the four-class solution was the most optimal. this model also obtained the highest entropy value, indicating a good precision in the classification of 80% of cases as estimated by posterior probabilities. in terms of interpretability, this four-class solution distinguished the following perfectionism profiles: class 1 (n = 33) reported low levels on both ps and pc dimensions, thus, it was labeled as non-perfectionists. class 2 (n = 29) was labeled as adaptive perfectionists, as they reported high ps scores and low pc scores. class 3 (n = 129) was labeled maladaptive perfectionism, as it classified participants who showed both high ps and pc. finally, because individuals (n = 406) were characterized by medium levels of ps and pc, class 4 was labeled as moderate perfectionists. figure 1 illustrates the standardized means of the two-specific indicators (ps and pc) for each of the four latent classes. a manova determined whether these four classes differed in their levels of the six regulatory motivational styles. statistically significant differences were found for all the variables assessed (lambda de wilks = 0.83, f (18,591) = 6.32, p < 0.001, η 2 = 0.06). non-perfectionists obtained the lowest mean scores on integrated, identified, introjected, external and amotivation, whereas moderate perfectionists scored the lowest on intrinsic and integrated. in contrast, adaptive perfectionists reported the highest mean scores on intrinsic, integrated, and identified, whereas maladaptive perfectionists scored the highest on introjected, external, and amotivation (see table 3 ). table 3 . means, standard deviations, and inter-class statistic signification on the six regulatory styles. when examining post hoc comparisons (see table 4 ), maladaptive perfectionists reported significantly higher levels of introjected, external, and amotivation than the other three profiles of perfectionism. moderate perfectionists also reported higher scores than non-perfectionists on introjected. the magnitudes of these differences were moderate and large for all cases (d = 0.55-1.37), with the exception of the maladaptive and moderate perfectionists contrasts in amotivation, whose effect sizes where of a small magnitude (d = 40). on the other hand, adaptive perfectionists had significantly higher scores on intrinsic, integrated, and identified when compared with moderate perfectionists, as well as on integrated when compared with non-perfectionists. moderate and small effect sizes were found for these differences (d = 0.47-0.69). there were no statistically significant inter-classes differences for the rest of the contrasts analyzed. the purpose of this study was (a) to examine whether discernible profiles could be identified among undergraduate students enrolled in a sport science degree on levels of ps and pc, and (b) whether these profiles differed in terms of the six types of motivation located on the autonomy-control continuum described by ryan and deci [13, 18, 19] in the specific domain of exercise. following previous research [25] [26] [27] [28] 31] , it was hypothesized that a three-class model of perfectionism would be found. however, a four-class model (adaptive, maladaptive, non-perfectionists, and moderate) obtained a better fit and entropy values than a three-class model. of the four classes identified in the current study, three matched those described by previous research for a three-class model: adaptive perfectionists (high ps and low pc), maladaptive perfectionists (high ps and pc), and non-perfectionists (low ps and pc). additionally, a fourth profile, moderate perfectionists, representing those participants with medium levels of both ps and pc, was identified. in terms of prevalence, this fourth profile reported the highest prevalence (68%) followed by maladaptive perfectionists (21%), whereas adaptive (6%) and non-perfectionists (5%) represented a lower amount of participants. the considerable proportion of individuals classified in moderate perfectionists in comparison with the other three profiles could be due to the fact that this class represents more normal levels of perfectionism, whereas the other three classify more extreme cases. it is not possible to compare the prevalence obtained by moderate perfectionists with previous research because this class was not previously identified by any lpa [25] [26] [27] [28] 31, 32] . regarding the other three classes, as can be deduced from the literature review, there is no consistent results about the prevalence of each class. thus, although adaptive perfectionists and non-perfectionists were, respectively, the most and least prevalent classes in most of the studies [27, 28, 31] , maladaptive perfectionists classified the lowest number of participants in other works [25, 26] , whereas non-perfectionists obtained the highest prevalence in the analysis performed by gilman et al. [25] . our results are in line with the majority of studies, which found that non-perfectionists classified the lowest proportion of participants [27, 28, 31] . overall, differences found between our findings and results from previous research that have examined perfectionism profiles by using lpa [25] [26] [27] [28] 31, 32] could be due to the different instruments employed to assess perfectionism as well as the sample characteristics. in respect of inter-profile differences in the six regulatory styles of motivation, as hypothesized, adaptive perfectionists experienced the highest levels of autonomous motivation (i.e., intrinsic, integrated, and identified). however, these differences were only statistically significant in the case of adaptive and moderate perfectionists contrasts for the three most autonomous regulatory styles, and in the case of adaptive and non-perfectionists contrasts, for the integrated style. on the contrary, non-significant differences were found between adaptive and maladaptive perfectionists profiles in terms of intrinsic, integrated, and identified motivation. individuals with high levels of ps are characterized by being very organized, persistent, and focused on achieving high standards of performance. considering that both adaptive and maladaptive perfectionists profiles are characterized by showing high levels of ps, this fact supports the idea that this perfectionist facet might predispose to more autonomous motivated regulations for practicing physical activity, in accordance with previous research [21] . however, adaptive perfectionists (high ps and low pc), when compared with maladaptive perfectionists (high ps and pc), would be more likely to be motivated for exercise with a sense of personal control over behavior, including enjoyment and personal affinity to sport and exercise [40] . that is, adaptive perfectionists could benefit more from their ps's motivational outcomes than maladaptive perfectionists because of the negative motivational consequences of having high pc. in fact, as expected, maladaptive perfectionists experienced the highest levels of amotivation, external, and introjected motivation when compared with the other three profiles. it is important to mention that the majority of these differences involved moderate and even large effect sizes, indicating that they are not only significant, but they also represent theoretical relevance and practical consequences for daily life [41] . these results could be due to the fact that maladaptive perfectionists was the only perfectionist class characterized by high pc, and they would be in line with previous studies that positively associate pc with regulatory styles characterized by lower degrees of self-determination [21] . these results evidence the fact that maladaptive perfectionists present maladjusted motivational trends. on the one hand, maladaptive perfectionists are more likely to experience motivations for doing exercise only partially internalized into the self (i.e., introjected and external). this might be explained because pc is characterized by harsh self-criticism, fear to failure, and the belief that the environment is highly demanding and critical. hence, because in introjected and external regulations the individual is motivated, respectively, by internal and external rewards or punishments [17] , we speculate that maladaptive perfectionists would be more introjected and externally regulated by a sense of coercion, internal contingencies, and external pressures [40] when they expected success. on the other hand, after repeated failures or when a certain failure is expected, maladaptive perfectionists could experience amotivation, that is, a lack of intention and commitment [17] to exercise, in order to avoid a certain punishment or because they feel they are not able to effectively attain the expected outcomes. additionally, it was expected that non-perfectionists would report the lowest levels of both autonomous and controlled motivation. nevertheless, this hypothesis was partially supported by the results of this study. thus, non-perfectionists reported the lowest levels of integrated, introjected, external, and amotivation. however, when inter-profile contrasts were analyzed, statistically differences only emerged for non-perfectionists and adaptive perfectionists comparisons on integrated motivation, non-perfectionists and maladaptive perfectionists comparisons on introjected, external, and amotivation, and between non-perfectionists and moderate perfectionists on introjected regulation. hence, non-perfectionists individuals would be characterized by having what vansteenkiste et al. [42] called a "low quantity motivation" profile. although, apparently, these non-perfectionists outcomes could be interpreted as the most negative on the basis of quantitative theories of motivation, research has evidenced that the quality of motivation matters [42] . in fact, it seems that "the presence of controlled motivation, next to either a high amount of autonomous motivation or a low amount of autonomous motivation, yields no benefits at all" [42] (p. 684). controlled motivation (i.e., introjected and external regulations) has been, indeed, associated with poorer wellbeing, healthy eating habits and behaviors, moral attitudes, experience, and performance outcomes in the context of sport and exercise (e.g., [15, 19, 20] ). consequently, maladaptive perfectionists would be more likely to experience a more damaging motivational orientation than non-perfectionists. several limitations of this study should be mentioned. first of all, having used a cross-sectional design does not allow us establishing causality relationships. longitudinal and experimental perspectives would help to clarify the relationship (and its direction) between perfectionism and the sdt continuum. additionally, it is important to underline that our participants were recruited from a sample of undergraduate students enrolled in a sport science degree from ecuador. thus, these results should be generalized with caution to other samples such as professional athletes or different ethnic and age groups. additionally, it would be interesting to analyze whether these same findings can be extrapolated to other life domains, such as academic. furthermore, women were underrepresented in our study, because only 21.94% of the total sample were female. future studies might examine gender differences performing separate lca for males and females as well as testing whether these profiles show similar or different motivational outcomes across sex. in a similar way, future studies might also explore whether these results vary across age and socio-economic status. in spite of the limitations, this is, from our knowledge, the first study that has addressed the relationship between perfectionism and motivation using a person-centered approach. moreover, the fact that both constructs have been examined considering the six regulatory styles of the autonomy-control continuum in the specific domain of exercise is also a novelty. in this research, four types of perfectionism profiles consistently emerged: adaptive perfectionists, maladaptive perfectionists, moderate perfectionists, and non-perfectionists. in terms of prevalence, a considerable amount of participants classified in these three first profiles in comparison with non-perfectionists evidence that perfectionism is a widely extended trait of personality. especially striking is the fact that two out of 10 individuals are at a potential risk of mental health problems because of their high levels of dysfunctional perfectionism. these results are in line with flett and hewitt [43] , who recently have referred to this widespread and growing prevalence of perfectionism as the "perfectionism pandemic." therefore, specific interventions should be addressed to maladaptive perfectionists for reducing their high levels of perfectionism, especially those more dysfunctional forms, such as pc. overall, in light of sdt theory [13, 17] , the results obtained indicate that adaptive perfectionists would report the most beneficial outcomes in terms of motivation since they tend to exercise as emanating from, and an expression of, one's self. in contrast, maladaptive perfectionists would display the poorer motivational functioning, as they tend to perceived external or internal pressures and duties or even a lack of intentionality and motivation to exercise. in accordance with the sdt theory [13, 17] , contexts can only produce autonomous regulation if they support autonomy, and therefore, allow a person to feel competent, related, and autonomous. in the same way, contexts can produce external regulation if there are relevant threats or rewards and the person feels competent enough to fulfill the demands. hence, it is recommended that trainers and exercise instructors take special attention to maladaptive perfectionist exercisers, implementing motivational techniques that emphasize intrinsic goals in an autonomy-supportive way [44] . positive conceptions of perfectionism: approaches, evidence, challenges perfectionism in sport, dance, and 16 exercise the perils of perfectionism in sports and exercise the perils of perfectionism in sport" revisited: toward a broader understanding of the pressure to be perfect and its impact on athletes and dancers profiles of perfectionism, parental climate, and burnout among competitive junior athletes. scand perfectionism and training distress in junior athletes: a longitudinal investigation perfectionism and attitudes towards doping in athletes: a continuously 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multidimensional perfectionism scale 2 perfectionism, coping, and burnout among intercollegiate varsity athletes: a person-oriented investigation of group differences and mediation developmental origins of perfectionism among african american youth the structure and correlates of perfectionism in african american children the dimensions of perfectionism perfectionism in the self and social contexts: conceptualization, assessment, and association with psychopathology is perfectionism good, bad, or both? examining models of the perfectionism construct hacia una mayor comprensión de la motivación en el ejercicio físico: medición de la regulación integrada en el contexto español statistical power analysis for the behavioral sciences structural equation modeling: applications using mplus perfectionism and junior athlete burnout: the mediating role of autonomous and controlled motivation calculating and reporting effect sizes to facilitate cumulative science: a practical primer for t-tests and anovas motivational profiles from a self-determination perspective: the quality of motivation matters the perfectionism pandemic meets covid-19: understanding the stress, distress and problems in living for perfectionists during the global health crisis recommending goals and supporting needs: an intervention to help physical education teachers communicate their expectations while supporting students' psychological needs this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord-265786-nstd8xak authors: kimhi, shaul; eshel, yohanan; marciano, hadas; adini, bruria title: a renewed outbreak of the covid−19 pandemic: a longitudinal study of distress, resilience, and subjective well-being date: 2020-10-23 journal: int j environ res public health doi: 10.3390/ijerph17217743 sha: doc_id: 265786 cord_uid: nstd8xak considering the potential impact of covid-19 on the civil society, a longitudinal study was conducted to identify levels of distress, resilience, and the subjective well-being of the population. the study is based on two repeated measurements conducted at the end of the pandemic’s “first wave” and the beginning of the “second wave” on a sample (n = 906) of jewish israeli respondents, who completed an online questionnaire distributed by an internet panel company. three groups of indicators were assessed: signs of distress (sense of danger, distress symptoms, and perceived threats), resilience (individual, community, and national), and subjective well-being (well-being, hope, and morale). results indicated the following: (a) a significant increase in distress indicators, with effect sizes of sense of danger, distress symptoms, and perceived threats (cohen’s d 0.614, 0.120, and 0.248, respectively); (b) a significant decrease in resilience indicators, with effect sizes of individual, community, and national resilience (cohen’s d 0.153, 0.428, and 0.793, respectively); and (c) a significant decrease in subjective well-being indicators with effect sizes of well-being, hope, and morale (cohen’s d 0.116, 0.336, and 0.199, respectively). to conclude, covid-19 had a severe, large-scale impact on the civil society, leading to multidimensional damage and a marked decrease in the individual, community, and national resilience of the population. the covid-19 pandemic, which erupted in china in 2019, is an infectious disease caused by a newly discovered strain of coronavirus. this epidemic has spread rapidly worldwide. as of july 2020, an increasing prevalence of morbidity and mortality has been observed in several countries, while other countries present a consistent decline in the number of patients and deaths [1, 2] . this pandemic has severely disrupted the proper functioning of the global community, leading to the closure of schools and academic institutions, partial or complete lockdowns, reduced public transportation and aviation, unemployment and economic hardships, decline of global stock markets, and panic shopping due to widespread concerns about supply shortages [3] . the restrictive measures that have been implemented by many governments to protect public health have substantially impacted the levels of distress, resilience, and subjective well-being of civil societies. these three concepts, which substantially influence on the capacity of any society to cope with adversities such as pandemics, will be explained. israeli public to examine three groups of indicators: distress, resilience, subjective well-being. to the best of our knowledge, no study has yet examined the effects of the coronavirus on the level of these three groups of indicators in a sample of a country's population. the first measurement was made at a time of reduced restrictions on the population, such as the lifting of the lockdown, and the overall perception was that the crisis was over, while the second measurement was conducted during the renewed outbreak of the crisis and severe aggravation of the economic situation. therefore, we hypothesize the following: resilience indicators will significantly correlate with swb indicators, and both will significantly and negatively correlate with distress indicators, across the two measurements. these correlations will show medium effect size compared to pre covid-19 levels. resilience and swb indicators will significantly decrease between t1 and t2. these decreases will show medium effect size compared to pre covid-19 levels. 3 . distress indicators will significantly increase between t1 and t2. these increases will show medium effect size compared to pre covid-19 levels. to investigate the impact of the covid-19 pandemic on the levels of distress, resilience, and subjective well-being of the israeli population, a longitudinal study was designed based on two repeated measurements. the study was performed on a large sample of respondents who answered the same questionnaire at two repeated measurements (paired sample). the first measurement (t1) was carried out in early may 2020 (4-7 may), when the first wave of the pandemic seemed to recede, and the full lockdown and other limitations on the population were lifted. the second measurement (t2) was conducted in mid-july 2020 (12) (13) (14) (15) with the re-emergence of the pandemic in israel (the "second wave"), which led to the re-imposition of restrictions on the population. three groups of indicators were measured in both measurements: distress (sense of danger, distress symptoms, and perceived threats), resilience (individual, community, and national resilience), and subjective well-being (well-being, hope, and morale), assuming that a pandemic of this magnitude would affect all these three groups of indicators. to better understand the trends of the population's resilience, distress, and subjective well-being over time, the current two repeated measurements were compared with previous research results, which were based on a representative sample of the israeli population. these findings show the resilience and distress levels of the israeli population as found in 2018, during a relatively quiet period in terms of security risks, thus representing a baseline measurement [24] . the data were collected by an internet panel company that consists of over 65,000 panelists, representing all demographic sectors and geographic locations (https://sekernet.co.il/). a stratified sampling method was used, which is aligned with the data published by the israeli central bureau of statistics, to appropriately include the varied groups of the israeli population concerning gender, age, and geographic dispersal. the utilization of internet panels has been increasing rapidly, and its validity has been widely discussed [25] . the participants in both measurements were a paired sample of jewish israeli respondents who answered an online questionnaire distributed by an internet panel company. the first measurement (answered by n = 1100) was conducted during 4-7 may, with the release from the full lockdown imposed on israeli residents. during that week, all the individuals tested for the virus were found to be negative for covid-19 (surveillance of covid-10 in israel, 2020) [26] . the second measurement (answered by 82% of the original sample; n = 906) was conducted between 12 and 15 july 2020. in this period, the rising numbers of confirmed covid-19 patients (2.2% of the individuals tested for the virus were found to be positive for covid -19) , increasing the probability of the re-issuing of restrictive measures to combat the pandemic, including lockdowns. the demographic and psychological characteristics of the sample population are detailed in table 1 . all the questionnaires employed in the present study have been used by us in previous studies with one difference: wherever the original item in the questionnaire referred to a security threat and/or a security situation, the wording of the item was modified to suit the coronavirus crisis. the following scales are included in this study. sense of danger. this scale pertains to the level of the individual, social, and national sense of danger [27] . four additional items that focus on the covid-19 have been added to the original 7 items: e.g., "to what extent are you afraid that you will have difficulty finding work after the corona crisis?" or "to what extent are you afraid that you will not have anyone to help you financially?" these 11 items were rated by a scale ranging from 1 = not at all to 5 = very much. the scale's cronbach's alpha reliability in the current study was good: α = 0.86 (t1) and α = 0.88 (t2). distress symptoms. two subscales of the brief symptom inventory (bsi) scale were employed in the present study: anxiety (3 items) and depression (5 items) [28] . the item about suicidal thoughts was removed from this scale for ethical reasons. respondents were asked to report the extent to which they are currently suffering from any of the problems presented. the responses range from 1 = not at all to 5 = to a very large extent. the internal reliabilities of these scales in the present study were high: α = 0.91 (t1) and α = 0.92 (t2). perceived threats. a threat is a potential danger of harm to an individual as perceived by the individual [29] . a threat can be defined as potential damage. the threat can be related to different areas, e.g., physical, social, psychological, economic, and more. in the present study, we asked the respondents to rate four different threats: economic, health, security, and a threat arising from the political situation in israel. the political threat is important because israel has faced three rounds of election with no clear-cut balance between parties during the year that preceded the coronavirus pandemic eruption. the third election was carried out on 2 march 2020, approximately one week before the world health organization (who) declared that covid-19 could be characterized as a pandemic (11 march 2020, see https://www.who.int/news-room/detail/27--04-2020-who-timeline---covid-19). thus, the period of the coronavirus pandemic in israel was also characterized by political instability. the answers to this question constitute a 5-point scale, ranging from 1 = not threatening at all to 5 = threatening to a very large extent. we have used the sum of all 4 threats as an index for threat perception. individual resilience. the short version of this questionnaire [30, 31] includes 10 items about a sense of personal resilience in the face of difficulties. examples of questions are as follows: "i am able to adapt when changes occur"; "i am not easily discouraged by failures". responses to the questionnaire items are ranked using a 5-point scale ranging from 0 = not true at all to 4= true nearly all the time. in the present study, the internal scale reliability of the scale was high in both measurements: α = 0.89 (t1) and α = 0.90 (t2). community resilience. this resilience scale includes 10 items that relate to the subjects' identification with their community and their confidence in their ability to cope with the difficulties they will face [32] . responses to the questionnaire items represent a 5-point scale, ranging from 1 = do not agree at all to 5 = agree to a very large extent. examples of items are as follows: "the municipal authority in my locality is functioning properly in the corona crisis", "i can trust people in my locality to come to my aid in case of a crisis, including the corona crisis". the current study internal scale reliabilities were high in both measurements (α = 0.93). national resilience (nr). the original national scale [16] includes 13 items, whereas the scale in the present study includes 16 items. the three additional items pertain specifically to the covid-19 crisis. examples of the original scale items are as follows: "in a national crisis, the israeli society will stand behind the decisions of the government and its leader," and "israel is my home and i do not intend to leave it". an example of a new item is, "i have full confidence in the ability of the israeli healthcare system to take care of the population during the coronavirus crisis." the response scale for the national resilience items ranges from 1 = do not agree at all to 6 = strongly agree. the internal reliability of the scale was high in both measurements (α = 0.91). well-being. this scale consists of nine items concerning individuals' perception of their lives in the present regarding various contexts, such as work, family life, health, free time, and others [33] . this scale is based on the recovery scale we have used in previous studies. responses to these items range from 1 = very bad to 6 = very good. this measurement scale has been validated in previous studies, and its reliability in the present study was found to be good in both measurements (α = 0.87). level of hope. this tool, which has been constructed specifically for the present study, is based on an earlier study [34, 35] that was designed to measure the level of hope for peace between israel, the arab nations, and the palestinians. its two dimensions are personal and collective hope. the current scale of hope, in the context of coronavirus, includes five items. two of them refer to the personal level (e.g., "i hope that i will emerge strengthened from the coronavirus crisis") and three items refer to the collective level (e.g., "i hope that israeli society will emerge strengthened from the coronavirus crisis"). the internal reliability of the scale in the present study was found to be high in both measurements (α = 0.92). morale. the level of personal morale was examined by a single item: "how would you define your morale these days?" the response scale ranges from 1 = not good at all to 5 = very good. demographic characteristics. respondents reported eight demographic variables: age (18-30, 31-40, 41-60. 60 +), gender (1 = male, 2 = female), level of religiosity (1= non-religious to 4 = very religious), family income relative to the average income in israel (1 = much lower than the national average to 5 = much higher than the national average), political attitudes (1 = extreme left to 5 = extreme right), level of education (1 = elementary to 5 = graduate degree and higher), familial status (single, married, divorced, couple), number of children (no children to 4 children or more). table 1 presents the distribution of these attributes among the present sample. we used 4 statistical calculations to examine our hypotheses: (a) we calculated pearson correlations between the study variables in each of the two repeated measurements. (b) we analyzed the differences in the psychological variables between the two measurements, using the general linear model for two repeated measures, further calculating the effect sizes. (c) to examine the structure of the national resilience and the differences between the two measurements, we performed a factor analysis on the national resilience items and examined the difference in each factor in the two measurements using a general linear model. (d) finally, to measure the difference in the four perceived threats between the two measurements, we used the general linear model analysis. to examine our first hypothesis, we calculated the correlation matrix among the nine investigated psychological variables (table 2) . table 2 to examine our second and third hypotheses regarding the difference between the investigated variables in t1 and t2, general linear model analyses for two repeated measures have been calculated (table 3) . results indicate the following: (a) there is a significant difference between t1 and t2 mean scores of all the nine examined variables. (b) the three resilience indicators decreased significantly between t1 and t2 (p < 0.001). (c) the three distress indicators increased significantly between t1 and t2 (p < 0.05). (d) the three swb indicators decreased significantly between t1 and t2 (p < 0.001). (e) the largest decrease among the resilience indicators occurred in the level of national resilience (as can be seen by the largest effect size: cohen's d= 0.793). the largest increase among the distress indicators was found in the sense of danger (cohen's d= 0.614). the largest decrease among the quality of life indicators was related to hope assessments (cohen's d = 0.336). table 3 also presents the differences between five variables that were originally collected among a different national sample at the end of 2018 (a relatively calm period security-wise, referred to as a "baseline" pre covid-19 measurement), with their current corresponding variables at t2. results indicate that compared with this baseline measurement (2018 national sample), the level of distress symptoms in t2 is higher, whereas the levels of resilience and well-being are lower. these results fully support our hypotheses. to better understand the decrease in the levels of national resilience, we launched a factor analysis (principal component and varimax rotation) on the nr scale of t2 and compared the mean of each item and factor with its corresponding mean item score in t1 (table 4 ). four factors emerged and were labeled as "trust in the state and its leader"; "trust in the israeli society"; "patriotism"; and "trust in the public institutions of israel". the overall variance explained by these four factors is 69.39% of the total variance of the national resilience variable. all four factors decreased significantly from t1 to t2 (p < 0.001). the highest decrease was presented in factor 1: "trust in the state and its leader". an examination of the differences in the levels of perceived threats between t1 and t2 (table 5 ) indicates a significant increase in each of the following threats: political, economic, health, and security (p < 0.001). furthermore, the results indicate that the political threat was perceived as the highest risk, followed by economic, health, and security risks, in both periods. nonetheless, a bigger effect size was noted in the difference between the two measurements concerning the health threat (cohen's d = 0.272). the present study examined indicators of distress, resilience, and subjective well-being, using two repeated measurements among a paired sample of respondents. we hypothesized that resilience and swb would be positively associated with each other and negatively associated with distress indicators. we also hypothesized that the resilience and swb would decrease, while distress indicators would increase, between the two measurements, due to the growing impact of the prolonged covid-19 pandemic crisis. overall, our results supported our three hypotheses and revealed that among the civil society, positive indicators such as resilience, morale, hope, and well-being weakened in t2 in relation to both t1 and to the pre covid-19 pandemic. the negative indicators, such as sense of danger, distress symptoms, and perceived threats, rose in t2 in relation to both t1 and to the pre covid-19 pandemic. the first measurement was conducted in early may 2020 at the end of a long lockdown imposed on israeli residents, when the country seemed to have emerged from the crisis after the reduction in new cases following the "first wave" of the coronavirus outbreak. the second measurement was carried out two months later, in mid-july, at a time when the coronavirus pandemic emerged once more and was perceived as a threat to all israelis. according to the findings of the current study, all indices that may contribute toward an effective coping with the crisis, without exception, significantly weakened during t2 compared with t1, and also compared to a relatively calm period in 2018 (pre covid-19 pandemic). the substantial decrease in the national resilience level between the two measurements, compared to the less drastic decrease presented for individual and community resiliencies, seems to represent a loss of trust in governmental bodies and the country's leader. this finding is understandable, considering previous findings that highlighted that the adaptation of governmental institutions to the changing needs of the population is essential to national resilience [36, 37] . the perception that the expected adaptation of governmental entities did not materialize sufficiently is strengthened by the large-scale demonstrations against the government that spread throughout israel. furthermore, a previous study indicated that the baseline level of patriotism was extremely high among israelis [16] . however, an unexpected finding of the present study was a general decrease in patriotism between t1 and t2. the respondents appear to lose some of their faith in the country that does not appear to come to their aid in the current complex economic conditions, and as a result, they are less optimistic about the future of the country in general and their status specifically. in addition to the marked decrease in national resilience, the results also indicate a significant decrease in individual and community resilience, albeit to a lesser extent. the decreased community resilience is somewhat surprising, as previous studies have presented a rise in the levels of community resilience during periods of elevated risks [38] . furthermore, an earlier study that was conducted in 2018, following a military clash between the israeli defense forces and the palestinian islamic jihad terror organization in gaza strip, indicated that the average community resilience of the southern participants (residing closest to the high-risk area) was significantly higher compared to the national sample [38] . another study that examined the israeli population's resilience during the peak of the covid-19 pandemic, which included an overall lockdown versus the initial phase of lifting the lockdown, indicated no change regarding both individual and community resilience [39] . based on these studies, it seems appropriate to claim that the decline of individual and community resilience in the current study is exceptional and reflects the above-mentioned lack of belief in governmental institutions, as well as in other authorities that are responsible for managing the economic, social, and educational ramifications of the covid-19 pandemic. the distress indicators that were examined in the current study (sense of danger, distress symptoms, and perceived threats) showed, as expected, a significant increase between the two measurements. in a previous study, which dealt with the impact of the coronavirus crisis compared to a pre-crisis baseline measurement [39] , we found that a sense of danger is a more "sensitive" measure of the distress. similarly, in the present study, we found that the gap between the two measurements was larger concerning feelings of danger compared to the distress symptoms and perceived threats. further research is required to assess whether, when the coronavirus pandemic is contained, the decline of these three indicators will take place at similar or different rates. it is important to note that the sense of danger should be regarded as an expected response to threatening situations, as it serves as a warning mechanism targeted to alert people of possible harm that may be caused to individuals or their environment. such a sense of danger may be accompanied by a parallel attempt to minimize stress responses and reinforce a sense of "control" to maintain proper functioning [40] . in the present study, the level of hope was found to be significantly and positively correlated with resilience, and negatively correlated with distress, and it was found to be significantly lower in t2 compared to t1. in our opinion, the level of hope emphasizes the importance of the psychological dimension in managing the covid-19 crisis. hope refers to the anticipation of a better future [41, 42] . in an ongoing crisis that is characterized by great uncertainty, it may be difficult for people to anticipate an improved future. the positive correlation that was found between hope and the level of morale indicates further that people experience psychological difficulties that affect hope and despair. all four levels of examined threats-economic, health, security, and political risks-increased from t1 to t2. the highest threat perceived by respondents was the political threat, followed by economic, health, and security threats. these results reflect the current fragile political situation that characterizes the israeli society, which may lead to a fourth election within two years. the increase in the economic threat expressed the fact that many self-employed people in israel were severely impacted as a result of the coronavirus pandemic and have not as yet received the expected economic assistance from the state. a substantial number of people became unemployed or are on "unpaid vacation", and although they received some financial compensation from the state, they still feel insecure or uncertain about their financial situation. similar to findings from other countries [43] , the economic threat remains the second highest of the four threats examined, even among individuals who were not directly hit by this pandemic. the fear of what the future may hold economically and otherwise is significant. regarding the security threat, there has also been an increase in its perception, even though apparently, and perhaps due to the coronavirus, the security situation in israel is at present relatively improved. these results may perhaps be derived from the reports that have been broadcast in the past weeks in the media concerning mysterious attacks and explosions in iran and syria, which may be attributed by some to the actions of the state of israel. these reports may raise concerns among people about future security developments to come. as in any other research, this study is not exempt from limitations. the most notable limitation is the reliance on the internet panel sample on which this study is based. despite the large sample and the widespread distribution of all demographic variables, it is not possible to guarantee that this sample represents the adult population in israel. nonetheless, as previously noted, internet panels have been frequently used in studying the varied phenomenon among the population, and their validity has been widely studied and confirmed. even though the current study was conducted in israel, we believe that the findings may also apply to other countries dealing with the covid-19 pandemic crisis, most especially as the civil societies in many countries were substantially impacted, including the healthcare, economic, and societal systems. this assumption is strengthened by our findings that the varied groups among the israeli society, such as sectors with different economic levels, political attitudes, or religious beliefs, show similar trends. furthermore, preliminary findings from a recent study that was conducted (based on the same tools) in brazil and the philippines present similar results regarding the relationships between resilience, swb, and distress indices [44] . additional studies are needed to support this assumption. four notable limitations of this study should be mentioned. the first limitation is that the sample is based on a web sample and not on a random sample. the second limitation is the fact that this is a correlative study that does not allow inference to be derived. the third limitation of this study is the fact that the study was conducted in israel; as no parallel longitudinal study was conducted thus far in other countries, it is difficult to generalize the findings, most especially considering varied biases and cultural diversities. the fourth limitation is that the health status of the respondents before covid-19 was not studied and thus was not controlled for a possible mediating effect. the main conclusion of the current study is that the coronavirus crisis has had a severe and large-scale impact on the civil society. it has caused multidimensional damage to the population (with health, economic, political, and social ramifications), which in turn has caused a marked decrease, with substantial effect sizes, in the national, community, and individual resilience of the population. the negative impact of the covid-19 pandemic on levels of distress and resilience is more severe compared to crises that result from security risks. based on the results of this study, it seems that israeli society's ability to deal with a prolonged crisis has weakened. it is recommended that such longitudinal studies be continued, both in israel and in other societies, to identify trends in the capacities to deal with continued crises and better understand the factors that may empower or weaken the societal resilience of civil populations. how will country-based mitigation measures influence the course of the covid-19 epidemic? response to covid-19 in taiwan: big data analytics, new technology, and proactive testing assessing the impact of reduced travel on exportation dynamics of novel coronavirus infection (covid-19) children exposed to warfare: a longitudinal study gulf war-related trauma and psychological distress of kuwaiti children and their mothers weighing the costs of disaster: consequences, risks, and resilience in individuals, families, and communities the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk traumatic stress in the age of covid-19: a call to close critical gaps and adapt to new realities resilience theory and research on children and families: past, present, and promise the road to resilience. retrieved resiliency: enhancing coping with crisis and terrorism; the nato science for peace and security programme the temporal elements of psychological resilience: an integrative framework for the study of individuals, families, and communities resilience definitions, theory, and challenges: interdisciplinary perspectives social resilience the role of public opinion in israel's national security measuring national resilience: a new short version of the scale (nr-13) risk and resilience in family well-being during the covid-19 pandemic psychological resilience and dysfunction among hospitalized survivors of the sars epidemic in hong kong: a latent class approach the relational activation of resilience model: how leadership activates resilience in an organizational crisis evaluation of wellness determinants and interventions by citizen scientists clarifying the concept of well-being: psychological need satisfaction as the common core connecting eudaimonic and subjective well-being a nationwide survey of psychological distress among chinese people in the covid-19 epidemic: implications and policy recommendations effects of the covid-19 pandemic and nationwide lockdown on trust, attitudes toward government, and well-being predictors of individual, community and national resiliencies of israeli jews and arabs use of internet panels to conduct surveys ministry of health elderly israeli holocaust survivors during the persian gulf war: a study of psychological distress the scl-90-r and brief symptom inventory (bsi) in primary care. in handbook of psychological assessment in primary care settings determinants of students' perceptions of conventional and unconventional war threats development of a new resilience scale: the connor-davidson resilience scale (cd-risc) psychometric analysis and refinement of the connor-davidson resilience scale (cd-risc): validation of a 10-item measure of resilience aharonson-daniel, l. conjoint community resiliency assessment measure-28/10 items (ccram28 and ccram10): a self-report tool for assessing community resilience individual and public resilience and coping with long-term outcomes of war the dominance of fear over hope in the life of individuals and collectives emotions in conflict: correlates of fear and hope in the israeli-jewish society the future public service: seize the opportunity covid-19 risk assessment tool: dual application of risk communication and risk governance community and national resilience and their predictors in face of terror recovery from the covid-19 pandemic: distress and resilience cognitive and behavioral components of resilience to stress future time perspective, hope and life satisfaction: a study on emerging adulthood students' voice: the hopes and fears of student-teacher candidates appealing to economic (vs. health) risk may be more effective to fight covid-19: a multilevel analysis in 24 countries distress and resilience in days of covid-19: international study of samples from israel, brazil, and the philippines the authors declare no conflict of interest. the funders had no role nor any intervention or influence on any part of the study, including in the design, execution, interpretation or writing of the study. key: cord-258965-g47n531n authors: ekpenyong, bernadine; obinwanne, chukwuemeka j.; ovenseri-ogbomo, godwin; ahaiwe, kelechukwu; lewis, okonokhua o.; echendu, damian c.; osuagwu, uchechukwu l. title: assessment of knowledge, practice and guidelines towards the novel covid-19 among eye care practitioners in nigeria–a survey-based study date: 2020-07-16 journal: int j environ res public health doi: 10.3390/ijerph17145141 sha: doc_id: 258965 cord_uid: g47n531n the aim of this study was to explore knowledge, practice of risk and guidelines of the novel corona virus disease (covid-19) infection among the eye care practitioners and the potential associated factors. a cross-sectional self-administered online survey was distributed via emails and social media networks between 2nd and 18th may 2020 corresponding to the week of the lockdown in nigeria to eye care practitioners (ecps). data for 823 respondents were analyzed. knowledge and risk practice were categorized as binary outcome and univariate and multivariate linear regression were used to examine the associated factors. the mean score for covid-19-related knowledge of public health guidelines was high and varied across the ecps. ophthalmic nurses, ophthalmologists and optometrists showed higher covid-19-related knowledge than other ecps (p < 0.001), particularly those working in the private sector. more than 50% of ecps stated they provided essential services during the covid-19 lockdown via physical consultation, particularly the ophthalmologists. most respondents reported that the guidelines provided by their association were useful but expressed their lack of confidence in attending to patients during and after the covid-19 lockdown. compared to other ecps in nigeria, more ophthalmic nurses received training in the use of personal protective equipment (ppe). this survey is the first to assess knowledge, attitudes and practice in response to the covid-19 pandemic in nigeria. ecps in nigeria displayed good knowledge about covid-19 and provided eye care services during the covid-19 lockdown in nigeria, despite the majority not receiving any training on the use of ppes with concerns over attending to patients. there is need for the government to strengthen health systems by improving and extending training on standard infection prevention and control measures to ecps for effective control of the pandemic and in the future as essential health workers. the emergence of the novel coronavirus disease in 2019 in december 2019 in the city of wuhan, the chinese province of hubei city, halted the ever-busy human society and threatened every nation [1] . a completely different type of acute pneumonia [2] which had close resemblance to the previous middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars) viruses but appeared to be much more lethal than the two was reported [3] . the infection soon became a cause of concern with the world health organization, declaring the rapid spread of cases of covid-19 a pandemic on 11th march, 2020 and recommended that a globally coordinated effort was needed to fight the pandemic [4] . while there is currently no vaccine for covid-19 [5] , the symptoms can include fever, flu-like symptoms such as a cough, sore throat and fatigue and/or shortness of breath, diarrhea, nausea and vomiting [6] . the risk of death in covid-19-infected individuals increases with older age, presence of hypertension, diabetes and coronary heart diseases [7] . there are also reports of conjunctivitis and transmission of the virus by aerosol contact with conjunctiva [8] with some uncertainty as to whether the virus is evident in human tears [1] . on the 28th of january 2020, sub-saharan africa's first confirmed case of covid-19 was announced in nigeria. this led to the activation of the country's national coronavirus emergency operation centre by the government. during to the ebola outbreak of 2014, of the 15,000 confirmed cases, there were over 9000 suspected cases in west africa, but this was controlled in just 92 days [9] . currently, the control of covid-19 is becoming challenging for the nigerian government despite the mobilization of resources and manpower by the nigeria centre for disease control ncdc [9, 10] . there are about 16,658 confirmed cases of covid-19 and 424 lost lives of humans from the infection (16 june 2020). the majority of the cases are in the former capital city of lagos (7319 cases, 82 deaths), federal capital city of abuja (1264 cases, 26 deaths) and kano (1158 cases, 50 deaths) [10] . as the country continues to experience steady increase in the number of confirmed cases [10] , the different levels of government have taken proactive steps to curtail the spread of coronavirus throughout the country. movements were restricted within and between states, and the society observed a partial lockdown in response to the pandemic. current evidence suggests that the implementation of outbreak response strategies for covid-19 can limit the disease. however, these situational responses affect businesses including their interactions with relevant regulators/professional bodies causing the government to respond through the nigerian national assembly's emergency stimulus bill, the central bank of nigeria's policy measure which dedicated its credit facility to develop the healthcare sector [11] . unlike some businesses and occupations considered as essential services, eye care professions (ecp) discontinued operations during the lockdown denying many patients-particularly those in need of emergency care or receiving routine injections for management of blinding eye diseases such as diabetes macular edema-access to eye care. ecps may be susceptible to infection due to close patient proximity during examination such as slit lamp examination, applanation tonometry and the potential contamination of instruments [12] ; however, medical visits related to systemic and ocular disease or injury where there is significant risk of permanent vision loss because of any postponement of care, as determined by the treating ecp, are considered essential visits [13] . other conditions considered by ecps as essential services have been summarized in table 1 . additionally, the same groups burdened by covid-19 complications could also suffer more vision problems including individuals with hypertension, respiratory conditions, and heart disease and the elderly [14] . patients who have lost or broken their glasses or contact lenses with consideration given to prescription needs and level of disability without correction are considered as essential services [13] . there are also concerns existing around the pandemic with various reports from news outlets and social media reporting how best to limit the chance of infection, with significant amounts of misinformation and speculation [5] which many patients may request clarification from their ecps to keep them safe through this period. the aim of this study was to assess knowledge and practice of covid-19 exposure risk among ecps as well as understand their confidence in current federal ministry of health (fmoh) guidelines for identifying possible covid-19 cases, knowledge of personal protective equipment (ppe) recommendations and training in its usage when managing such cases. the impact of covid-19 lockdown among practitioners was also assessed. this survey is among the first to assess knowledge level, practice of risk and awareness of the guidelines for consulting patients at risk or confirmed cases of covid-19 in nigeria incorporating responses from all tiers of ecps in nigeria. the findings will also provide first evidence on ecps' knowledge of covid-19 in nigeria. this will help to reduce their risk, and that of their family, of contracting the virus, reduce morbidity and mortality associated with being infected. evidence from the study can also be used to implement emergency policies to counter the spread and impact of a similar outbreak in future. the study will provide clarity on the essential nature of ecps services to help policy making in future outbreaks. this study on the knowledge, practice, impact and guideline on covid-19 was conducted among eye care practitioners in nigeria. according to the world bank group (2019), nigeria has an estimated population of 195,874,740 people. majority of eye care service practitioners are located in the cities [15] . nigeria is home to 7000 registered optometrists [16] , about 300 ophthalmologists [17] , 2000 ophthalmic nurses [18] and 941 dispensing opticians [16] . all eye care practitioners practicing in nigeria have overlapping roles without distinct borders. ophthalmologists undergo a minimum of four (4) years postgraduate training after a medical degree and provide surgical as well as medical eye care [19] . optometry is a licensed professional program completed in a minimum of six (6) years leading to the award of doctor in optometry (od) which empowers optometrists to provide general eye care including treating eye diseases, refractive errors, low vision and contact lenses [16] . an ophthalmic nurse has a one-year post-basic nursing training in eye care and work with other ecps to engage in blindness prevention activities and care for patients for ocular surgeries. dispensing opticians obtain a three-year national diploma and work in optical laboratories to interpret and dispense optical prescriptions [20] . a self-administered questionnaire developed and used previously for ecps [21] was modified and pre-tested to ensure that it was suitable for use in nigeria. the initial survey was piloted among 10 optometrists who were not part of the study team and did not participate in the final survey to ensure clarity and understanding as well as to determine the duration for completing the questionnaire prior to disseminating them. the study adhered to the principles of the 1967 helsinki declaration (wma, 2013) and the protocol was approved by the human research ethics committee of the cross river state ministry of health, nigeria (ref #: crsmoh/rp/rec/2020/116). participation was anonymous and voluntary. informed consent was obtained from all participants prior to commencement of the study and after the study protocol has been explained. participants consented to voluntarily participate in this study by answering either a 'yes' or 'no' to the question inquiring whether they voluntarily agree to participate in the survey. a 'no' response meant that the participants could not progress to answering the survey questions and were excluded from the study. the required sample size for this study was determined using a single population proportion formula given as: in the absence of similar studies in nigeria, the study assumed a proportion of 50% of the population and used a desired precision of 4% and 95% confidence level for a two-sided test. to make up for non-response rate of 25%, the sample size was determined to be 800 persons, which was adequate to detect statistical differences in the analysis of online cross-sectional study on covid-19 among ecps in nigeria. respondents were proportionately determined across the 4 categories of ecps. a self-administered anonymous online survey was administered using convenience sampling technique, on a first-come bases until the required number was obtained within the one-month duration of the survey. a total of 823 questionnaires were fully completed and retrieved in the estimated proportions for the different categories of ecps except for ophthalmic nurses where we got less than the required sample (ophthalmologists [n = 66], optometrists [n = 598], ophthalmic nurses [n = 48] and dispensing opticians [n = 111] ). the survey was created in survey monkey and disseminated to registered ecps in nigeria including optometrists, ophthalmologists, opticians, ophthalmic nurses, and ophthalmic technicians between 2nd and 18th may 2020. distribution was through the administrative heads of the various professional bodies including the ophthalmological society of nigeria (osn), nigerian optometric association (noa), nigeria ophthalmic nurses association (nona) and association of nigerian dispensing opticians (ando) and individually. a link to the online survey was disseminated via the emails and social media platforms (facebook and whatsapp) of the different professional organizations. survey link remained active from 2 may to 18 may 2020, within which time participants completed the survey. the practitioners did not receive incentives for participating in the study and were not under any obligation to complete the survey. participants included ecps who were currently registered to provide clinical services at different levels of eye care within nigeria at the time of the study. responses from non-ecps, non-nigerians, ecps practicing outside nigeria, and non-practicing practitioners were excluded from the analysis. the survey tool was shown in table s1 and consisted of 36 items divided into five sections (demographic characteristics, knowledge, practice of risk of contracting the infection, impact and guidance) utilizing closed-ended questions and a four point 'likert-type scale' to score participants' responses. the responses ranged from 'yes' (score '1 ) to 'no' (score '-1 ). a 'not sure' response was scored as 'zero'. for responses utilizing likert scale, the scores ranged from '3 for 'extremely confident' to '1 for confident and '-1 was scored for 'not-confident' the impact of covid-19 pandemic on practitioners, their family members and practices, including questions on their confidence in the current fmoh guidelines for identifying possible covid-19 cases, their knowledge of personal protective equipment (ppe) recommendations, and training in its usage during consultation were assessed. the explanatory (independent) variable included basic characteristics and explanatory factors including gender, age in categories, region of practice, level of education, marital, employment and religion status, type of ecp, practice setting and practice years. the dependent variables in the regression analysis was knowledge relating to covid-19. the total score ranged from 1 to 9. the scores were derived from questions inquiring on 'whether the participants knew the occupation classified as 'essential work' by the ministry of health during the covid-19 lockdown', if ecps could correctly identify from a list of nine items, the recommended ppes by the ncdc in preventing covid-19 transmission, during consultation of confirmed/suspected cases for health care workers? descriptive statistics and multivariable analysis were performed to demonstrate the outline of the findings of this study and sample characteristics. the responses were presented descriptively in tables. first, the entire cohort-men and women-was analyzed -to determine the knowledge towards covid-19. then, chi-square tests were used to examine the variability in responses by gender, for the different ecps, concerning the knowledge, practice and understanding of the guidelines of the fmoh. the variability in responses between ecps from the different specialties concerning their understanding of guidelines was also assessed. univariate linear regression analysis was calculated in order to assess the unadjusted coefficient. all confounding variables with a p value < 0.20 were retained and used to build a multivariable linear regression model. a manual stepwise backwards model was used to estimate the adjusted estimate for independent variables and to determine factors associated with kap scores towards covid-19. a p-value ≤ 0.05 was considered statistically significant and we checked homogeneity of variance and multicollinearity using variance inflation factors (vif). all statistical analyses were carried out using the statistical program for social sciences, version 25.0 (spss inc, chicago, illinois, usa). a total of 823 respondents (males, n = 374, 45.4%, females n = 449, 54.6%) aged 21-72 years (mean age ± sd, 38 ± 10 years) completed the online questionnaire. about 84.3% were aged less than 50 years and male respondents were significantly older than the females (39 ± 10 years, 95% ci 38-39.7 versus 37 ± 10 years, 95% ci 36.3-38.2; p = 0.033). table 2 presents the demographic characteristics of the respondents including their employment status and years of practice. the total knowledge score relating to covid-19 ranged from 1 to 9 with a mean score of 6.98 ± 2.00. figure 1 shows the mean knowledge score for each eye care profession in the survey. there was a significant difference in the mean knowledge score between the professions (one way analysis of variance, p < 0.0001) with post hoc analysis revealing that the differences was only when ophthalmic nurses (7.71 ± 1.81), optometrists, ophthalmologists (7.10 ± 1.85 and 7.39 ± 2.08, respectively) were compared with the opticians (5.77 ± 2.34, p < 0.0001) who had the least knowledge of covid-19 transmission. no other multiple comparison showed significant difference. in the multivariable analysis, we found that, after adjusting for all cofounders in the final model, eye care profession (job title) was the only factor associated with knowledge of risk towards covid-19 (adjusted coefficient, −0.182, 95% confidence interval −0.601, −0.22; p < 0.0001) ( table 3 ). in the multivariable analysis, we found that, after adjusting for all cofounders in the final model, eye care profession (job title) was the only factor associated with knowledge of risk towards covid-19 (adjusted coefficient, -0.182, 95% confidence interval -0.601, -0.22; p < 0.0001) ( table 3) . table 4 shows the opinion of ecps with respect to covid-19 during the lockdown. over 70% of the subjects reported lack of confidence in the guideline of the federal ministry of health did not consider eye care workers as "essential workers" during the lockdown. notwithstanding, 43.2% were either not so confident or not at all confident attending to any patient during the lockdown while 54.6% also reported they were not so confident or not all confident attending to covid-19 patient or those at risk of covid-19. when questioned about their level of confident attending to patients after the lockdown, 26.3% of eye care professionals reported lack of confident attending to patients even after the lockdown is over and for majority of the practitioners (90%), covid-19 will change the way the deliver eye care service in their practice. the results also revealed that a high proportion of eye care professionals provided eye care services to patients during the lockdown (figure 2 ) with more ophthalmologists and an equal proportion of optometrists and ophthalmic nurses providing services. of the various means of consultation during the lockdown (figure 2) , it can be seen that many ophthalmologists (73%), optometrist and ophthalmic nurses (65% and 62%, respectively) did so via physical consultations in the clinic. more optometrist than ophthalmologist (10.4% vs. 6.1%) utilized videoconferencing to provide this much-needed service during the lockdown while consultation over the phone, social media were also utilized by ecps during the lockdown (figure 2 ). compared to other practitioners, a significant higher percentage of optometrists reported that their professional association provided information on guidelines during covid-19 ( figure 3) . for over 80% of the respondents from each eye care profession, the guidelines were useful and regarding the use of personal protective equipment (ppe), less than 40% of each eye care professionals received training on the use of ppe in the control of covid-19. slightly more ophthalmic nurses (28.9%) received training on ppe compared to the ophthalmologists (14.0%) but this was at borderline significance (p = 0.056) (figure 3 ). 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% compared to other practitioners, a significant higher percentage of optometrists reported that their professional association provided information on guidelines during covid-19 ( figure 3 ). for over 80% of the respondents from each eye care profession, the guidelines were useful and regarding the use of personal protective equipment (ppe), less than 40% of each eye care professionals received training on the use of ppe in the control of covid-19. slightly more ophthalmic nurses (28.9%) received training on ppe compared to the ophthalmologists (14.0%) but this was at borderline significance (p = 0.056) (figure 3 ). compared to other practitioners, a significant higher percentage of optometrists reported that their professional association provided information on guidelines during covid-19 ( figure 3 ). for over 80% of the respondents from each eye care profession, the guidelines were useful and regarding the use of personal protective equipment (ppe), less than 40% of each eye care professionals received training on the use of ppe in the control of covid-19. slightly more ophthalmic nurses (28.9%) received training on ppe compared to the ophthalmologists (14.0%) but this was at borderline significance (p = 0.056) (figure 3) . this is the first study to assess the knowledge, attitude and guidelines of all tiers of ecps regarding the public health initiatives for the novel coronavirus in nigeria. the study found that knowledge about covid-19 preventive guidelines was high among ecps and ophthalmic nurses, ophthalmologists and optometrists were significantly more knowledgeable compared to opticians. the majority of the ecps did not receive training on the proper use of ppes despite a significant proportion stating that they attended to patients during the lockdown period. although the majority of the ecps felt that their professional association provided some useful information on guidelines during the pandemic, this was considered grossly inadequate for many of the ophthalmologists and ophthalmic nurses. more than half of the ecps expressed lack of confidence in caring for patients at risk of covid-19 and, for more than a quarter of them, this will continue even after the lockdown is over. similarly high covid-19-related knowledge was reported in the general nigerian population [22] , and that of the chinese population [23] as well as those of the health care practitioners [14] but an earlier survey found a lack of understanding of the public health guidelines related to covid-19 among ecps in the uk. the study included 100 ecps (ophthalmologists, optometrists, ophthalmic nurses and healthcare assistants) [21] . compared to the uk study, the present study found high knowledge scores among respondents and this difference may be related to timing of both studies as the time lag may have allowed for the respondents in the present study to learn more about covid-19 and, as such, demonstrated higher knowledge scores. at the time of the uk study, the coronavirus outbreak had just been designated a pandemic by the who [4] , although the first confirmed case was reported in the uk on 29 january 2020. the significant association found between covid-19-related knowledge and the category of ecp may be attributed to the ophthalmic nurses having more training on ppes than other ecps, which may have translated to the higher knowledge scores. although the nigerian federal ministry of health do not consider ecps as essential workers, a large proportion of the respondents disagreed with this and more than half confirmed that they provided emergency eye care services via physical examination of patients during the lockdown. this finding suggests the need to consider the inclusion of ecps as part of the essential healthcare team since ocular emergencies can occur at any time and viral conjunctivitis may be a symptom of covid-19 [16, 24] . several guidelines to limit the risk of infection and help ecps safely provide eye care services have been published by the ophthalmic associations, societies and researchers during the pandemic [10, 12, 16, [25] [26] [27] [28] [29] [30] . this is vital as several procedures involve the practitioner to be in close proximity to patients and as such proper use of ppe is essential. a survey of optometrists and opticians conducted in austria, germany and switzerland reported that over 50% of the ecps planned to wear masks during refraction, contact lens fitting and practiced hand washing and disinfection before performing procedures [31] . however, training in the use of ppe is important to avoid the ecp being infected. the finding that majority of ecps did not receive any training on proper use of ppes, was concerning and potentially dangerous, as it puts the practitioner at high risk of contracting covid-19 [32, 33] . an interesting finding of this study was the increased use of telemedicine for delivering eye care services during the covid-19 pandemic, although only a few utilized this service. there is need for education on the methods of delivering this service and the associated benefits for ecps in nigeria. in addition, the fact that majority of the participants in this study were optometrist may be a reflection of the higher number of registered optometrists compared to ophthalmologists and the fact that most of them are practicing in urban centers [34] . this study has some limitations. firstly, the majority of the respondents were practicing in urban areas and their responses may not represent that of ecps practicing in rural areas. secondly, the low number of responses from ophthalmic nurses was lower than estimated from their registry, and this may affect the responses obtained from the group. future studies should consider other ways of reaching this subgroup as their knowledge and practice as front-line workers is important. in addition, further studies are needed to investigate the knowledge and preparedness of ecps in rural settings to provide service during the covid-19 pandemic in nigeria. despite these limitations, this study is strengthened by the larger sample size compared to a previous study [21] . another strength of this study was the representation of the opinions of all tiers of ecps who are involved in the delivery of eye care services during the lockdown in nigeria. in addition, the study was the first to provide evidence on knowledge, practice and guidelines of african ecps during a pandemic. it identified major gaps in the ability of the ecps to continue providing care during and after the pandemic which, if not addressed, might put the ecps and their patients at risk of contracting the virus infection during consultation. addressing these gaps is important to build confidence among ecps and their patients during a pandemic and, more so, as most african countries prepare for a possible second wave of the virus. this study demonstrated that ecps in nigeria were knowledgeable about covid-19 and readily explored several avenues to serve the nigerian population during the covid-19 lockdown. however, the ecps reported lack of confidence on the non-inclusion of eye care workers as essential in the government guidelines for the control of this pandemic, which places them at increased risk. therefore, to ensure that ecps continue to provide the needed services during the pandemic or similar events, there is need for training on the proper use of ppe and recognition as essential worker; this will, in turn, boost their confidence when attending to patients even after the lockdown. the nigerian government need to strengthen health systems by improving and extending training on standard infection prevention and control measures for effective control of the pandemic. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/14/5141/s1, table s1 : survey tool used in this study. funding: this research did not receive any funding. deadliest enemy: our war against killer germs world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) clinical and ct features in pediatric patients with covid-19 infection: different points from adults who declares covid-19 a pandemic the covid-19 pandemic: important considerations for contact lens practitioners coronavirus disease 2019: coronaviruses and blood safety clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study sars-cov-2 may be related to conjunctivitis but not necessarily spread through the conjunctiva sars-cov-2 and conjunctiva nigeria responds to covid-19; first case detected in sub-saharan africa covid-19 nigeria. nigeria centre for disease control briefings: nigerian emergency economic stimulus bill: all you need to know; brooks and knights legal consultants novel coronavirus disease 2019 (covid-19): the importance of recognising possible early ocular manifestation and using protective eyewear policy institute's response to covid-19: doctors of optometry essential care guidelines for covid-19 pandemic knowledge, attitude, and practice regarding covid-19 among healthcare workers in henan strengths, challenges and opportunities of implementing primary eye care in nigeria odorbn. legislation lagos: optometrists and dispensing opticians registration board of nigeria (odorbn). 2020. available online international council of ophthalmology nigerian nurses decry lack of suitable eyecare facilities ophthalmology training in nigeria: the trainee ophthalmologists' perspective. niger dispensing opticianry calabar: college of health technology survey of ophthalmology practitioners in a&e on current covid-19 guidance at three major uk eye hospitals survey data of covid-19-related knowledge, risk perceptions and precautionary behavior among nigerians. data brief 2020, 30, 105685 knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey assessing viral shedding and infectivity of tears in coronavirus disease 2019 (covid-19) patients protecting yourself and your patients from covid-19 in eye care protective equipment (ppe) for coronavirus disease (covid-19): interim guidance precautionary measures needed for ophthalmologists during pandemic of the coronavirus disease 2019 (covid-19) guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with coronavirus disease (covid-19) preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore. can ophthalmology practice during the covid-19 pandemic pandemic: survey of future use of personal protective equipment in optometric practice acceptability and necessity of training for optimal personal protective equipment use perception of job-related risk, training, and use of personal protective equipment (ppe) among latino immigrant hog cafo workers in missouri: a pilot study estimated number of ophthalmologists worldwide (international council of ophthalmology update): will we meet the needs acknowledgments: the authors are grateful to the nigerian optometric association for their financial contribution for data collection. the authors declare no conflict of interest. key: cord-262647-kkvekors authors: niwa, makoto; hara, yasushi; sengoku, shintaro; kodama, kota title: effectiveness of social measures against covid-19 outbreaks in selected japanese regions analyzed by system dynamic modeling date: 2020-08-27 journal: int j environ res public health doi: 10.3390/ijerph17176238 sha: doc_id: 262647 cord_uid: kkvekors in japan’s response to the coronavirus disease 2019 (covid-19), virus testing was limited to symptomatic patients due to limited capacity, resulting in uncertainty regarding the spread of infection and the appropriateness of countermeasures. system dynamic modelling, comprised of stock flow and infection modelling, was used to describe regional population dynamics and estimate assumed region-specific transmission rates. the estimated regional transmission rates were then mapped against actual patient data throughout the course of the interventions. this modelling, together with simulation studies, demonstrated the effectiveness of inbound traveler quarantine and resident self-isolation policies and practices. a causal loop approach was taken to link societal factors to infection control measures. this causal loop modelling suggested that the only effective measure against covid-19 transmission in the japanese context was intervention in the early stages of the outbreak by national and regional governments, and no social self-strengthening dynamics were demonstrated. these findings may contribute to an understanding of how social resilience to future infectious disease threats can be developed. coronavirus disease 2019 (covid-19), a respiratory disease caused by a novel coronavirus that initially emerged in the city of wuhan at the end of 2019 [1] , has quickly spread all over the world. because of its novelty, which means the lack of specific medicine for it, the dominant countermeasures are isolation and supportive medication. this indicates that a large number of hospital beds will be needed. thus, control strategies such as early diagnosis, isolation, and hospitalization are essential. a lack of strategy can lead to the collapse of the healthcare system if it is overwhelmed by patients. in handling the complex covid-19 transmission processes in the population and the effects of societal factors, the idea to use system dynamics, describing complex social systems as a collective set of mathematical equations, was drawn based on some considerations. first, a stock-flow model in this study examines four research questions. (1) is a modeling approach effective in overcoming the lack of information (actual number of infected patients)? (2) what are the most important measures to prevent the spread of infection? (3) what are the factors that influence infection among societal factors (in demography and behavior)? (4) what is important in the future response to new infectious diseases? there are several studies dealing with measures against covid-19. yan et al. summarized various countermeasures by different authorities [1] . summarized recommendations are mainly on behavior (washing hands, keeping rooms ventilated and sanitized, wearing masks, avoiding social activities, staying away from crowded areas, and observing social distancing). dickens et al. used an agent-based model to test the effectiveness of home-based and institutional isolation. the analysis clarified the usefulness of institutional containment and risks of home-based isolation [7] . gerli et al. investigated the lockdown effort of european countries, and pointed out the importance of timeliness of lockdown [8] . still, no studies encountered the ambiguity of the covid-19 situation in japan. making the best use of the flexibility and simplicity of system dynamics, this study aims to grasp the whole picture of the covid-19 outbreak in japan using abundant information on demography and behavior. to detect potential regional differences, three regions that have enough confirmed cases and have urban cities were analyzed. they were tokyo (the capital), the osaka prefecture, and the hokkaido prefecture. to avoid complexity, prefectures that have satellite cities were not analyzed. as analytical approaches, the following five analyses were performed. first, the effects of medical countermeasures were illustrated using causal loop analysis. second, a stock flow model describing the mass of infected population was developed to analyze the dynamics of infection. third, the effectiveness of actions preventing the saturation of medical capacity was tested by simulation. fourth, the relationships between transmission reduction efficiency and regional differences in social factors were explored. finally, the effects of social factors on disease preventive behavior were analyzed using causal loop analysis to provide suggestions for a sustainable society beyond new infectious diseases. the number of confirmed positives by polymerase chain reaction (pcr) virus testing by day was obtained from local governments [9] [10] [11] and summarized. population, airport arrivals from foreign countries, and the number of employees working in the region were obtained from japanese government statistics [12] . reduction in outings was derived from a published analysis by the national institute of informatics, which utilized the location information of mobile phones [13] . the number of companies by industries and the average number of employees by industries located in the region of interest were provided by teikoku databank (tdb), available through the tdb center for advanced empirical research on enterprise and economy (tdb-caree), hitotsubashi university, tokyo, japan. tdb is a major corporate credit research company in japan that collects various corporate data through door-to-door surveys. around 1700 field researchers visit and interview firms to obtain corporate information in every industrial category and location. causal loop and stock-flow models were built using vensim ple (ventana systems inc., harvard, ma, usa). data summary was performed using microsoft excel (office 365; microsoft corporation, redmond, wa, usa). to visualize the interrelations between variables, causal loop diagrams were constructed. components recognized by preceding studies or prior knowledge were included as variables, and they were logically interrelated. as medical components, infection, contact, inapparent infection, preventive behavior, recovery, susceptible proportion [14] , coming from another region, limitation of diagnosis, the challenge of mass screening, lack of hospital capacity, inadequate medication, and deaths were included. as social components, intervention by national or local government [3] , awareness raising regarding physical distancing and hygiene measures [15] , countermeasures by private or public enterprises [16] , new business practices, working from home, and contact reduction in commuting were included. stock flow models regarding population as a stock were built to describe the epidemic dynamics in three eminent epidemic regions: the tokyo metropolitan area, osaka prefecture, and hokkaido prefecture. the timeframe was set after 11 march 2020, in order to capture the covid-19 outbreak in late march and april 2020. as a stock (population), susceptible, newly infected, inapparently infected (mild symptoms), having moderate symptoms or developing diseases, having serious symptoms, having non-serious symptoms, isolated, hospitalized, recovered, and dead population were prepared. inbound virus carriers (in incubation period) were assumed to have arrived before 3 april 2020, when virus testing for all airport arrivals was started. the number of inbound carriers was estimated as 746,525 in march 2020 [12] and the assumed positive rate 0.003. the estimated carriers were then divided in proportion to the population of the region. the flow between stocks was parameterized according to the scenario depicted in figure 1 . flow rate was mathematically expressed as the quotient of the sub-population divided by duration of flow. parameters given exogenously are shown in table 1 . only patients with serious symptoms were assigned to virus testing, as was done in japan, int. j. environ. res. public health 2020, 17, 6238 4 of 12 and the theoretical ratio of all infected patients to virus tested patients was set to 5 based on the given parameters. the effective reproduction number was left as an endogenous variable and estimated from manual curve fitting against the number of diagnosed patients over the time (representative data is shown in table s1 ). the model was qualified by observing the consistency of dimension in the process of model building and visual inspection of agreement between predicted and real positive patient numbers. int. j. environ. res. public health 2020, 17, 4 of 12 parameters. the effective reproduction number was left as an endogenous variable and estimated from manual curve fitting against the number of diagnosed patients over the time (representative data is shown in table s1 ). the model was qualified by observing the consistency of dimension in the process of model building and visual inspection of agreement between predicted and real positive patient numbers. the causal loop diagram is shown in figure 2 . there were two clinically important endpoints: infection and deaths. most causal loops for infection were self-intensifying loops; thus, reducing the intensity was important. connection points were contacts; thus, reducing such contacts was important. the only antagonistic effect loop was the reduction of susceptible rate via increase in recovered population. a strategy to intensify this antagonistic loop (i.e., obtaining of social immunity) was partially possible, but an increase in recovery was supported by an increase in infection rate. an increase in infection rate intensified disease transmission through increased contact and at the same time caused inadequate isolation of non-diagnosed patients and inadequate medication, meaning the possibility of overflow of medical systems. regarding death, the causal loops were simple. less infection, improved hospital capacity, better medication, and improved virus testing efficiency were important for reducing deaths. the initial (baseline) isolation effect was parameterized by manual curve fitting to the actual diagnosed patient number in the early phase. in tokyo, the isolation effect was negligible at baseline. this indicates that transmission efficiency was almost the same as expected from the basic reproduction number. in osaka and hokkaido, a two-phase spread was assumed from the increased patient number. the isolation effect was reduced 10% in osaka and 68% in hokkaido. after parameterization, transmission without intervention was simulated. in tokyo, infection spread out rapidly and overwhelmed most of the population in 150 days ( figure 3 ). virus testing and hospitalization was completely saturated. comparison of the actual patient number and the simulation is shown in figure 4 . clear divergence was observed, and the effect of intervention is suggested. based on the scale in the x-axis of the graph, the state of emergency was declared on day 27, and was expanded to cover the whole nation on day 36. to simplify the analysis, the effects of interventions were combined with isolation effect and the parameter; transmission efficiency was computed as an endogenous parameter. curve fitting was done in a sequential manner, from earlier timeframe to later timeframe, assuming that intervention was done sequentially. after the curve fitting in the intervention phase, transmission efficiency under intervention was reduced by 75% (25% remaining efficiency) in tokyo, which started in early april (when the state of emergency was declared) ( figure 5 , left). in osaka, in addition to the first reduction in early april, the second phase started at the end of april when the japanese holiday season began. transmission efficiency was reduced by 60% and 85% (40% and 15% remaining efficiency) in the first and second phase, respectively ( figure 5 , center). in hokkaido, where a regional state of emergency had been declared in february 2020 and was lifted in the middle of march, transmission efficiency decreased to 68% (32% remaining efficiency) at the end of march. subsequently, it increased to 90% at the end of april (10% remaining efficiency), two weeks after the inclusion of the region in the state of emergency (in the middle of april) and at the beginning of the holiday season ( figure 5 , right). net remaining transmission efficiency relative to baseline under the best intervention was 25%, 17%, and 31% in tokyo, osaka, and hokkaido, respectively. the causal loop diagram is shown in figure 2 . there were two clinically important endpoints: infection and deaths. most causal loops for infection were self-intensifying loops; thus, reducing the intensity was important. connection points were contacts; thus, reducing such contacts was important. the only antagonistic effect loop was the reduction of susceptible rate via increase in recovered population. a strategy to intensify this antagonistic loop (i.e., obtaining of social immunity) was partially possible, but an increase in recovery was supported by an increase in infection rate. an increase in infection rate intensified disease transmission through increased contact and at the same time caused inadequate isolation of non-diagnosed patients and inadequate medication, meaning the possibility of overflow of medical systems. regarding death, the causal loops were simple. less infection, improved hospital capacity, better medication, and improved virus testing efficiency were important for reducing deaths. the initial (baseline) isolation effect was parameterized by manual curve fitting to the actual diagnosed patient number in the early phase. in tokyo, the isolation effect was negligible at baseline. this indicates that transmission efficiency was almost the same as expected from the basic reproduction number. in osaka and hokkaido, a two-phase spread was assumed from the increased patient number. the isolation effect was reduced 10% in osaka and 68% in hokkaido. after parameterization, transmission without intervention was simulated. in tokyo, infection spread out rapidly and overwhelmed most of the population in 150 days (figure 3 ). virus testing and hospitalization was completely saturated. comparison of the actual patient number and the simulation is shown in figure 4 . clear divergence was observed, and the effect of intervention is suggested. based on the scale in the x-axis of the graph, the state of emergency was declared on day 27, and was expanded to cover the whole nation on day 36. reproduction number. in osaka and hokkaido, a two-phase spread was assumed from the increased patient number. the isolation effect was reduced 10% in osaka and 68% in hokkaido. after parameterization, transmission without intervention was simulated. in tokyo, infection spread out rapidly and overwhelmed most of the population in 150 days (figure 3 ). virus testing and hospitalization was completely saturated. comparison of the actual patient number and the simulation is shown in figure 4 . clear divergence was observed, and the effect of intervention is suggested. based on the scale in the x-axis of the graph, the state of emergency was declared on day 27, and was expanded to cover the whole nation on day 36. to simplify the analysis, the effects of interventions were combined with isolation effect and the parameter; transmission efficiency was computed as an endogenous parameter. curve fitting was done in a sequential manner, from earlier timeframe to later timeframe, assuming that intervention starting from 3 april 2020, all airport arrivals were tested for the virus and isolated if they were virus positive. this ideally meant that no more inbound virus carriers were joining the community. the effect of this quarantine was investigated by simulation. to simplify the analysis, no false negatives were assumed. simulation was run on an assumption that airport arrivals in march 2020 continued and that the positive rate stayed flat at 0.003. as a result, a 1%, 2%, or 8% increase in the number of infected patients at the end of april was expected. in tokyo and osaka, where countermeasures for transmission were effective, no serious impact of inbound virus carriers was expected by simulation. in hokkaido, where controls in april were not effective, inbound carriers moderately affected the community. a previous study indicated that a delay in locking down cities results in the rapid spread of the disease [8] . thus, the effect of delayed intervention was simulated. a comparison was made on all infected patients simulated, as confirmed positives do not reflect the real infected population in the current situation. simulations were run on tokyo and osaka, which were the targets of the first phase of the state of emergency. delaying the intervention for one week resulted in 140% and 75% more total infections in tokyo and osaka, respectively (the osaka case was simulated with a holiday effect). this result shows a similar but slightly lesser impact of intervention delay reported in a previous study; generally, reporting an 11-day delay results in 10 times the mortality. under this scenario, an overflow in virus testing and hospital capacity was observed. to examine the potential effects of societal factors on covid-19 transmission, the relationship between several societal factors and transmission was explored. factors potentially related to disease transmission are shown in table 2 . under this real condition, no overflow in virus testing or hospital capacity was observed. starting from 3 april 2020, all airport arrivals were tested for the virus and isolated if they were virus positive. this ideally meant that no more inbound virus carriers were joining the community. the effect of this quarantine was investigated by simulation. to simplify the analysis, no false negatives were assumed. simulation was run on an assumption that airport arrivals in march 2020 continued and that the positive rate stayed flat at 0.003. as a result, a 1%, 2%, or 8% increase in the number of infected patients at the end of april was expected. in tokyo and osaka, where countermeasures for transmission were effective, no serious impact of inbound virus carriers was expected by simulation. in hokkaido, where controls in april were not effective, inbound carriers moderately affected the community. a previous study indicated that a delay in locking down cities results in the rapid spread of the disease [8] . thus, the effect of delayed intervention was simulated. a comparison was made on all infected patients simulated, as confirmed positives do not reflect the real infected population in the current situation. simulations were run on tokyo and osaka, which were the targets of the first phase of the state of emergency. delaying the intervention for one week resulted in 140% and 75% more total infections in tokyo and osaka, respectively (the osaka case was simulated with a holiday effect). this result shows a similar but slightly lesser impact of intervention delay reported in a previous study; generally, reporting an 11-day delay results in 10 times the mortality. under this scenario, an overflow in virus testing and hospital capacity was observed. to examine the potential effects of societal factors on covid-19 transmission, the relationship between several societal factors and transmission was explored. factors potentially related to disease transmission are shown in table 2 . as a semi-quantitative observation, baseline transmission efficiency seemed to be related to population density, as supported by the theory described in [21] . the maximum intervention effect was similar across the regions. the intervention effect before the holiday season seemed related to a reduction in outings. although tokyo has the most workers and most companies' headquarters, outings were efficiently reduced before the holiday season. this good response in tokyo can be partly attributed to companies in the capital placing emphasis on business continuity [22] , thus facilitating working from home. in contrast, the reaction in hokkaido after the expansion of the state of emergency was relatively slow, and the transmission efficiency declined two weeks after the expansion. the interrelationship of societal factors and disease preventing behavior is shown in figure 6 . the potential relationship suggested in the previous section was considered. some factors are hypothetical. in this case, a noticeable effect of preventing behavior was observed, and intervention by government was apparent. this implies that intervention by government was essential and no self-strengthening dynamics were noticeable in the society in the early phase of the outbreak. as a semi-quantitative observation, baseline transmission efficiency seemed to be related to population density, as supported by the theory described in [21] . the maximum intervention effect was similar across the regions. the intervention effect before the holiday season seemed related to a reduction in outings. although tokyo has the most workers and most companies' headquarters, outings were efficiently reduced before the holiday season. this good response in tokyo can be partly attributed to companies in the capital placing emphasis on business continuity [22] , thus facilitating working from home. in contrast, the reaction in hokkaido after the expansion of the state of emergency was relatively slow, and the transmission efficiency declined two weeks after the expansion. the interrelationship of societal factors and disease preventing behavior is shown in figure 6 . the potential relationship suggested in the previous section was considered. some factors are hypothetical. in this case, a noticeable effect of preventing behavior was observed, and intervention by government was apparent. this implies that intervention by government was essential and no self-strengthening dynamics were noticeable in the society in the early phase of the outbreak. the rapid spread of covid-19 is threatening health systems with capacity challenges. the united states, with the largest number of patients as of march 2020, seems to be challenged by a healthcare capacity problem [23] . the inpatient bed occupancy rate varies by region, with the highest being 79% (in maryland, may 2020) [24] . the highest intensive care unit (icu) bed occupancy rate is 84% (in the district of columbia, may 2020). japan, with only 7.3 beds per 100,000 inhabitants [25] , is one of the countries that suffer from hospital bed shortage [26] . as of april 2020, there were 12,500 beds for novel infectious diseases nationwide, while there were 10,000 patients in japan [27] . although 31,383 hospital beds were ensured by 21 may 2020 [28], health systems are still at risk. some local governments even have plans to provide care to low-risk patients in hotels. under this condition, a control strategy to reduce the peak number of patients remains important. to reduce the transmission as an effort to delay and lower the epidemic peak, governments imposed restrictions on movement in local communities. many countries, such as china, italy, the us, and the uk, locked down their cities to prevent the spread of the disease. in japan, a state of emergency was declared on 7 april 2020, giving authorities the power to enforce stay-at-home orders and to close businesses. although japanese authorities did not describe the countermeasures as a lockdown, prefectural authorities asked people to refrain from traveling across prefectures, unnecessarily going out, and to stay away from public gatherings [29] . in addition, all schools were closed. initially, this affected the capital, tokyo, and six other prefectures (saitama, chiba, kanagawa, osaka, hyogo, and fukuoka). subsequently, it was expanded nationwide on 16 april 2020. information on the effectiveness of these interventions is warranted, but the whole context of what is happening is not well understood because of the limited testing capacity. no one knows the actual number of patients infected. to overcome this, the use of a structured model with an apparent/inapparent infection ratio and efficiency of virus testing was considered. this study primarily analyzed covid-19 transmission dynamics and the effects of initial measures by governments. a special feature of the current model is that it includes symptom rate, virus testing capacity, and hospital capacity, which were major concerns in the early phase of the covid-19 outbreak. the current model heavily depended on demographic data and has fewer accompanying variables in comparison to prior system dynamics studies [4] . consideration of more detailed variables, especially health-protective behaviors such as the practice of hygiene or physical distancing measures, may help identify important factors in basic societal systems regarding disease prevention. in addition, the association of human activity and temperature or humidity is possible [30] . specific research on each component to provide detailed information is warranted. in the causal loop diagram, the importance of reducing contacts was highlighted. a strategy to obtain social immunity by allowing infection is theoretically possible; however, realistically, allowing infection leads to an increase in deaths through an increase in disease transmission and inadequate medication. stock and flow analysis confirmed that an increase in infections overwhelms healthcare systems. the stock-flow model adequately described the dynamics of the covid-19 outbreak in three japanese regions. baseline isolation effect in the early phase was negligible in tokyo, little in osaka, and considerable in hokkaido. primarily, this could be related to population density as supported by transmission theory [21] and observations in the united states [30] . the hypothetical mechanism for the associations between population density and transmission proposed by rubin et al. is increased droplet transmission and potentially airborne transmission in close proximity [30] . after the state of emergency declaration in april, transmission efficiency of the disease markedly decreased to 17-31% of the baseline. in this case, the disease was primarily controlled by national and local government interventions. the most important measure was the reduction of contacts in the early phase of the outbreak by national and local governments. attempts to build a causal loop diagram for interrelationship analysis revealed that no self-strengthening dynamics were noticeable in the society. this indicates that interventions by the government were essential in the meantime. as a potential reinforcing loop, a loop with new business practice and awareness raising regarding physical distancing and hygiene measures was hypothesized. any other well-recognized component did not construct any reinforcing loops. further investigation to confirm the self-strengthening dynamics, beginning with new business practice, and efforts to strengthen such dynamics are warranted for a sustainable society. the strength of this study is the use of sd techniques. stock-flow modeling is relatively simple, but it was effective in showing the overall dynamics of virus transmission when virus testing was inadequate. stock-flow modeling also enabled estimation of the impact of interventions. further simulation is possible for virus testing efficiency, hospital capacity, and a new medicine. the limitations of this study are as follows. the stock-flow model utilized simple arithmetic operations and described the average dynamics of a population. this does not adequately describe the probability process that should be demonstrated by more complex models or multi-agent models. the model was constructed based on the fundamental monitor and control strategy in japan but detailed approaches may have slightly changed over time based on local government's policy. in addition, model validity was not fully investigated although basic validity, such as dimension consistency and consistency of predicted and real positives, was checked. the approach of leaving one parameter as endogenous made extensive validation somewhat challenging. this could be overcome by comparing multiple regions as external validation; however, no other region in japan has enough patients to be used in building models with comparative accuracy. nevertheless, the model sufficiently described the outbreak of covid-19 in three japanese regions and was useful in describing the early phase of the outbreak. a more precise investigation should be conducted in the future for the development of science. the basic structure of the current stock-flow model reflects japanese national response strategy for covid-19 to limit virus testing to patients with obvious symptoms for better use of diagnostic resources. this makes comparing the effectiveness of measures across countries difficult, which is an important theme with this new disease. nevertheless, this approach enabled determination of the possible effects caused by saturation of virus testing, which was important in analyzing the effectiveness of measures undertaken by japanese authorities. further analysis using newly collected epidemic data and more detailed social activity data is warranted in the future. this study primarily highlighted the importance of reducing contacts via causal loop and stock-flow model analysis. moreover, the importance of interventions by government in the early phase of new infectious diseases was emphasized, as no reinforcing loop to act against infection was found in the society. exploration of self-strengthening dynamics, beginning with new business practice and efforts, is warranted for a sustainable society. the first 75 days of novel coronavirus (sars-cov-2) outbreak: recent advances, prevention, and treatment system dynamics approaches and collective action for community health: and integrative review a social ecological model of syndemic risk affecting women with and at-risk for hiv in impoverished urban communities using participatory system dynamics modeling to examine the local hiv test and treatment care continuum in order to reduce community viral load obesity trend in the united states and economic intervention options to change it: a simulation study linking ecological epidemiology and system dynamics modeling towards modeling and simulation of integrated social and health care services for elderly. stud. health technol. inform institutional, not home-based, isolation could contain the covid-19 outbreak covid-19 mortality rates in the european union, switzerland, and the uk: effect of timeline, lockdown rigidity, and population density updates on covid-19 in tokyo latest updates on covid-19 in osaka hokkaido covid-19 information site controlling epidemic spread by social distancing: do it well or not at all. bmc public health public health interventions and epidemic intensity during the 1918 influenza pandemic an urgent survey of japanese companies' organizational responses to covid-19 covid-19 pathophysiology: a review covid-19: guide on home-based care, screening & isolation ward set up insight into 2019 novel coronavirus-an updated interim review and lessons from sars-cov and mers-cov high population densities catalyse the spread of covid-19 iir working paper wp#20-11 projecting hospital utilization during the covid-19 outbreaks in the united states current hospital capacity estimates-snapshot united-states-resource-availability-for-covid-19/ united-states-resource-availability-for-covid-19.pdf running out of beds and gear, tokyo medical staff say japan's 'state of emergency' already here japan broadcasting corporation basic policies for novel coronavirus disease control association of social distancing, population density, and temperature with the instantaneous reproduction number of sars-cov-2 in counties across the united states this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we also appreciate all open source and database developers used in this research. key: cord-255228-nopt5ql5 authors: romero-blanco, cristina; rodríguez-almagro, julián; onieva-zafra, maría dolores; parra-fernández, maría laura; prado-laguna, maría del carmen; hernández-martínez, antonio title: sleep pattern changes in nursing students during the covid-19 lockdown date: 2020-07-20 journal: int j environ res public health doi: 10.3390/ijerph17145222 sha: doc_id: 255228 cord_uid: nopt5ql5 the prevalence of poor sleep quality among students is very high and, in nursing students, has been associated with reduced performance, behavioral changes, dietary changes, and even aggressive behavior due to changes in sleep patterns. the lockdown in response to covid-19 may have resulted in lifestyle changes that affected sleep quality. for this reason, the objective of this study is to determine the difference in nursing students’ sleep quality before and during the lockdown, put in place in response to the coronavirus (covid-19) pandemic. to meet this objective, we conducted a longitudinal observational study on 207 nursing students, with two cut-off points (february and april). the main dependent variable was sleep quality, measured using the pittsburgh sleep quality index (psqi) and its seven components. parametric and nonparametric tests were used for paired and unpaired data, as well as group-stratified analysis. the mean time students spent in bed was 7.6 h (standard deviation (sd) = 1.1 h) before lockdown and 8.5 h (sd = 1.2 h) during lockdown. the psqi score got 0.91 points worse during lockdown (95% ci, −0.51, −1.31). of the five components, five were statistically significantly affected (p ≤ 0.05), and of these, the most changed were sleep latency, sleep duration, and sleep efficiency. when stratified by group, we observed differences in women, first-year students, second-year students, alcohol consumers, those of normal weight, and those that live with family. the main conclusion is that although students spent more time in bed, overall sleep quality was worse during lockdown, as well as being worse in five of the seven components. coronavirus disease (covid-19) has been declared an international emergency by the world health organization (who). the rapid spread of the disease has meant that unprecedented restrictions have been implemented to control its spread and mitigate its impact [1] . in response to the outbreak, the spanish government issued a royal decree (463/2020) declaring a 15-day national emergency, closing the country's borders on 15 march [2] . these measures were accompanied by a series of social distancing measures, including closing schools, universities, retirement homes, and sports venues, and restricting all movement in the most affected areas [2] . during previous outbreaks, the psychological impact on the noninfected population revealed significant psychological morbidities, negative emotions, and sleep problems [3] . an existing study in patients with sars (severe acute respiratory syndrome) reported that people in quarantine were more likely to have symptoms of insomnia [4] . the current covid-19 pandemic is causing psychosocial problems such as stress, worry, fear, anxiety, depressive symptoms, and sleep disorders in the general public [5] [6] [7] [8] . it is also resulting in low levels of sleep quality caused by stress and anxiety [9] . university students may be one of the populations affected. in recent months, university students have modified their routines due to the covid-19 pandemic. we also need to consider that the transition from secondary education to university already involves significant changes for students, with sleep being one of the most common problems they face [10] . on top of the usual changes that altered sleep patterns cause, the lockdown has forced teaching systems to adapt, allowing students to adapt their study hours since they no longer have to attend their usual morning classes. all of these changes to teaching and schedules are an additional factor in sleep problems, as well as affecting academic performance [11, 12] . although few studies have reported on stress levels caused by the lockdown in spain, one recent study [13] showed that stress levels increased in the spanish population after the lockdown was imposed and that those most affected by stress, anxiety, and depression were those aged 18-25. the prevalence of sleep disorders is quite high among the general population and is associated with significant morbidity and mortality [14] . it is estimated that among university students, the prevalence of poor sleep quality is around 60% [15] or even higher. previous studies talk about impaired performance, behavioral changes, dietary changes, and even aggression in nursing students caused by altered sleep patterns [16] [17] [18] . the effects of lockdown on sleep disorders are not yet very well understood, but we know that the population spent more time in bed, spent more time on digital devices close to bedtime, went to bed and got up later, and their sleep quality worsened [19] . our aim was to identify whether university students would experience changes in sleep quality during lockdown compared to normal times. the purpose of this study was, therefore, to analyze sleep quality and its various associated factors during face-to-face teaching (before the pandemic) and compare it with that observed during remote teaching (during the pandemic). the hypothesis of this study was that students' sleep quality worsened due to the pandemic and the resulting lockdown. a longitudinal study was carried out on nursing students, with two sample points. the first sample point was between 15 to 30 january, 2020, prior to the state of alarm being put in place, and the second sample point was between 1 and 15 april, 2020. this study has received the approval of the ethics and clinical research committee of ciudad real, spain, with a protocol number (c-291, 11/2019). this study was carried out within the context of another study that we conducted on healthy habits and lifestyles, with an estimated follow-up period of 9 months. due to the state of alarm and lockdown, recruitment of subjects was suspended, so we decided to study the impact of lockdown on the population already participating. there were no exclusion criteria, other than failure to fully complete the questionnaire. to estimate the sample considering a bilateral hypothesis, the following criteria were used: variance in the pre-lockdown control group of 8.35, obtained using the pittsburgh sleep quality index, a beta risk of 20% (power = 80%), a confidence level of 95%, and a clinically important difference of 0.8 points on the pittsburgh scale in overall sleep pattern alteration with respect to the control group. it was therefore estimated that 205 study subjects would be needed. we used an ad hoc self-administered questionnaire and collected sociodemographic information such as sex, age, weight, height, place of residence during the academic year, smoking habits, and alcohol consumption. tobacco and alcohol consumption were dichotomized as yes/no. for perceived health status, the eq-5d questionnaire (euro quality of life -5 dimensions) was used [20] . to assess adherence to the mediterranean diet, we used the prevencion con dieta mediterranea (predimed) questionnaire [21] , which uses 14 questions to assess the frequency of food consumption and eating habits. each question had a possible score of 0 or 1. the results allow classification into low adherence or high adherence. we also asked participants how many minutes of moderate and intense physical activity they did a week, to assess whether they met the physical activity recommendations of the world health organization (who) [22] . the main dependent variable was sleep quality, measured using the pittsburgh sleep quality index (psqi) [23] . the psqi contains 19 items and seven clinically important components in relation to sleep difficulties: subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, use of sleep medication, and daytime dysfunction. responses were given based on a likert-type scale from 0 to 4. to evaluate them, a sleep profile was obtained for each of the components, ranging between 0 and 3, as well a global score of between 0 and 21. global sleep scores of 5 or less were deemed good quality; scores above 5 were deemed low quality. the survey was conducted during the second university semester. the first data collection point was two weeks after exams, while the second data collection point was 4 weeks after the start of the lockdown. students in their first three years of study attended between 5 and 8 h of theory classes a day (morning and evening schedule), starting at 9 in the morning, while final-year students attended clinical practice from monday to friday for 7 h a day (morning shift), starting at 8 in the morning. at the second data collection point, the students had not left their homes in one month; theory classes were being held virtually. the schedule for the virtual classes was the same as before lockdown. in spain, it was forbidden to leave home except for essential purposes such as buying food or going to the hospital. those who violated the rules were fined 600 euros or even imprisoned. first, we performed descriptive statistics using absolute and relative frequencies for categorical variables and mean with standard deviation (sd) for the quantitative variables. next, we performed bivariate analysis on the whole sample for paired data between the global psqi scores and its components for the two sample points (pre-lockdown and lockdown). for the analysis, we used the parametric student-fisher t-test and the nonparametric wilcoxon signed-rank test. finally, we performed the same analyses again, but this time stratified for different subgroups. we obtained mean differences (md) with a confidence interval of 95% (ci). next, we analyzed the relationship between different sociodemographic and lifestyle factors and sleep quality (psqi). to do this, we used repeated measures analyses of covariance (ancova) to estimate the mean difference in psqi scores and the eta squared (η 2 ) effect size. for the comparisons, we used the bonferroni method. all calculations were done using the program spss v24.0 (ibm corp, new york, ny, usa). a total of 207 nursing students participated in this study, after excluding ten students with incomplete responses. the mean age was 20.6 years (sd = 4.62; age range 17-53). 81.6% of the participants (169) were women, 75.8% (157) were of normal weight, and 9.7% (20) were smokers. the rest of the demographic characteristics and health parameters are shown in table 1 . next, we studied the sleep changes that occurred between the two sample points, observing statistically significant differences overall (global psqi score), in sleep efficiency, and in five of the seven components that make up the psqi, both in the parametric and nonparametric tests. the three most changed components were, in descending order: sleep latency, sleep duration, and sleep efficiency. the psqi score got 0.91 points worse during lockdown (95% ci, −0.51, −1.31). further information is shown in table 2 . the prevalence of poor sleep quality in the sample analyzed was 60.4% at the first sample point and 67.1% at the second. the times at which the students went to bed and got up were assessed at both points in time, and we observed statistically significant differences (p < 0.001) for both of these parameters. the students' usual bedtime was delayed by slightly more than one hour (1.08 ± 1.2), and the time the students got up was two hours later than it was during face-to-face teaching (2.0 ± 1.4). the mean time the students spent in bed was 7.6 h (sd = 1.1 h) before lockdown and 8.5 h (sd = 1.2 h) during lockdown. next, we stratified the sample by group and analyzed the variation between the psqi scores obtained at both time periods (table 3) . we observed statistically significant differences, with lower psqi scores during lockdown with respect to the before lockdown in the following categories: women, normal weight, first-year students, second-year students, alcohol drinkers, and living with parents. we also observed statistically significant differences between the two periods, but these differences were present in all categories that made up the strata smoking habit, anxiety/depression, adherence to a mediterranean diet, and physical activity recommendations. finally, when we did the repeated measures ancova, we observed that only smoking and anxiety/depression were related to factors that could influence sleep quality. specifically, smokers' experienced a reduction in sleep quality of 2.29 points (95% ci, 0.73-3.85) with respect to nonsmokers, and students that reported anxiety/depression experienced a reduction in sleep quality of 1.74 points (95% ci, 0.85-2.63) with respect to those that did not. the effects of covid-19 go beyond physical health. it also has psychological consequences including emotional distress, anxiety, fear, depression, suicidal tendencies, public stigma, discrimination, racism, xenophobia, post-traumatic symptoms, and sleep disorders [24] . we found differences in the students' sleep quality between both periods analyzed, with worse sleep quality during the lockdown. in the stratified analysis, we observed that this worsening of sleep quality was maintained in the subgroups women, first-year students, and second-year students. we also observed that these differences remain statistically significant in the quality of sleep before and during lockdown for those with a normal bmi, those who consumed alcohol, and those who lived with family during the academic year. although worse quality of sleep was seen in other subgroups, these differences were not statistically significant due to their low statistical power, as these subgroups had a much smaller sample size. in relation to the data obtained in this study, recent research suggests that lockdown has worsened sleep quality despite increasing its quantity, observing that there has been an increase in mental health problems such as anxiety, depression, and even suicidal thoughts [18, 25] . it seems that the pandemic and the fear of infection have increased suicidal ideation, with insomnia having a significant impact: the more severe the insomnia, the greater the effect on these types of thoughts [26] . therefore, this study's stratification of sleep quality before and after lockdown could be very useful for future interventions. the pittsburgh index (psqi) has been used to assess sleep quality in adults for many years [27] . in our results, the students obtained scores above five in the pre-lockdown stage and scores above six in the post-lockdown stage, in line with recent studies that reported psqi scores higher than 5 in 85% of subjects, which is considered pathological [28] . looking at the results obtained at each of the time points analyzed, we observed that at the first data collection point, the psqi score was around 5 (the borderline sleep quality score) in all students except smokers and those with anxiety or depression, who had higher scores. conversely, nondrinkers and those with a low bmi obtained the lowest scores. at the second data collection point, smokers obtained average scores of 8.9, followed by those with anxiety or depression. the lowest scores at the second data collection point were again nondrinkers and students with a lower bmi. although the relationship between bmi and sleep quality is not very clear, it seems that an inverse relationship between these two parameters had already been observed in a previous study [29] . in the general population, there is a close relationship between obesity and sleep problems, with unhealthy eating habits and inadequate physical activity also having an influence [30, 31] . in this study, the psqi score obtained at each of the two time points analyzed was higher at higher bmis. however, we only observed changes in sleep quality among students with a normal weight, perhaps because of the low sample sizes in the other categories. regarding tobacco and alcohol consumption, poor sleep quality is related to alcohol consumption [32] and smoking [33] in university students, as observed in previous studies. both drinkers and smokers showed significant increases in their psqi scores during lockdown, but, as we have already mentioned, smokers achieved the worst sleep quality scores out of all the groups analyzed. poor sleep quality is associated with smokers, although this data is not always easy to observe in self-reported questionnaires and more specific data are needed [34] . in this case, when assessing the effect on smokers and on nonsmokers, we found significantly worse sleep quality in both groups during lockdown. however, while nonsmokers scored around six on the psqi, smokers scored higher than eight, on average. the criteria for poor sleep quality differ depending on gender [35] , with gender differences in variables such as latency and waking during the night, and women experiencing more problems than men [36] . in this study, both genders obtained similar total scores; however, lockdown caused significant changes in women but not in men. in all the sleep parameters analyzed, higher scores were obtained during lockdown, indicating worse sleep quality, except in component 3 (duration of sleep). students slept more hours, as we can see from the score in this component and the differences in the times the participants went to bed and the times they got up. on the surface, this might suggest better quality sleep, but in fact, the opposite is true. at both the sample points, sleep duration (component 3) received a healthy score, as both values exceeded seven hours. despite an increase in the number of hours spent in bed, component 4 shows that sleep efficiency (the ratio between time in bed and actual sleep time) declined during the lockdown. in other words, even though students spent more hours in bed, they took longer to fall asleep. although the psqi global scores increased, indicating worsening of sleep quality, sleep timing delayed (indicative of potentially lower social jetlag due to a discrepancy between endogenous circadian rhythm and actual sleep times imposed by social obligations). this might be favorable or beneficial to students since they no longer need to wake up early for class [37] , but the effects of lockdown were more detrimental to students' sleep, and the sleep timing delay did not strongly affect. of the 7 components analyzed, we observed the biggest differences in the second, sleep latency. sleep latency refers to the time it took students to fall asleep, with subjects asked how often they had trouble getting to sleep within 30 min. in university students, this parameter is related to internet addiction [38] . these data, together with recent studies showing that the population increased their use of technology before going to bed during lockdown [18] , explain our findings. as well as analyzing each of the components, we looked at the sleep efficiency score. this parameter is evaluated in component 4. although there is a certain amount of controversy about which values should be considered normal and even how efficiency should be measured [39] , the optimum psqi score of 0 is for those with a habitual sleep efficiency above 85%. in this study, mean values remained around this figure at both time points analyzed, but we did observe significant differences, with mean values of 86.19% during lockdown compared to 89.57% before lockdown. we found no significant differences in the component "use of sleep medication". some authors think that component 6 may not be advisable in measuring the overall sleep quality score in young adults [23] , although this parameter is undoubtedly very interesting when it comes to establishing the prognosis and treatment for sleep problems. similarly, we observed no differences in component 7, daytime dysfunction, which refers to sleepiness while performing everyday activities. previous studies looking at daytime dysfunction in university students [40] observed that it worsened as the academic year went on, although not significantly. based on the results we obtained, it seems that this component and component 6 are those least affected by lockdown. in the spanish population, poor sleep quality has been linked to poor health, poor diet, and low physical activity [41] . in this study, the psqi scores were similar in both sets of data; lockdown significantly worsened the participants' sleep quality regardless of whether they adhered to the mediterranean diet. in terms of physical activity, this study assessed whether compliance with the 150 min of physical activity per week had any bearing on the global psqi score. the results showed significant changes, although the scores were similar for both groups. we did not collect any data on the type of physical activity (aerobic/anaerobic) carried out by participants, nor did we examine sleep efficiency or other parameters in relation to physical activity. previous studies have observed that physical activity had a beneficial effect on sleep quality, although it did not affect all components equally, and there were also differences depending on the type of exercise the subjects did [42] . in their review, dinis et al. observed a correlation between sleep quality and depression [43] . other factors, like stress, also affect university students' sleep patterns [15] . in this study, lockdown worsens sleep quality both for those who reported problems with anxiety or depression and those who did not. however, those that reported anxiety or depression had initial sleep quality scores one point higher than those who did not and, as the repeated measures ancova shows, anxiety/depression and smoking were presented as factors that could influence the change in sleep quality. regarding the students' year of study, the initial sleep quality scores were similar, although they were lower according to the earlier the year of study. first-and second-year students experienced significant changes during lockdown. the initial years in nursing studies are mainly theoretical, becoming much more practical as time goes on, with a greater number of clinical credits. previous studies on medical students in their final years of study and with clinical contact found high levels of stress and poor sleep quality [44] . this could also be the case for nursing students. also, the fact that students in earlier years of study experienced significantly worse sleep quality during lockdown suggests that the same reasoning applies; students in their final years of study had their placements canceled, while students in their first years of study had to adapt to a new way of teaching and virtual assessments in order to pass the year, which could have increased stress and worsened sleep quality. another interesting aspect was the place of residence during the academic year. before lockdown, scores are similar for each variable, however, lockdown only caused significant changes to those living with family. living with other students during the academic year, such as at university residences or shared flats, had an influence on sleep quality [45] . all students living in university residences or rented flats had to return to their family homes and this could have improved sleep quality, preventing any significant differences in the scores during lockdown. our study has various limitations that should be considered. firstly, it is an observational study, all study subjects volunteered to participate in the questionnaire and there were no exclusion criteria, so there may be a selection bias. secondly, we did not measure whether there was any risk of exposure to covid-19 infection, a factor that could have influenced sleep quality in the study subjects. another limitation is the reliance on self-reported sleep measures as opposed to objective measures (for example, actigraphy). finally, the lack of significance in some of the strata analyzed may be due to the lack of statistical power. as for the strengths, this is the first study that compares sleep disturbance just before and during the lockdown in spain. although students spent more time in bed during lockdown, we observed a reduction in sleep quality, in terms of both global psqi score and in five of its components, during the covid-19 lockdown. the sleep parameters related to the use of medication and daytime dysfunction saw no changes. we did not observe any relationship between sleep quality during lockdown and physical activity, eating habits, tobacco consumption, or anxiety/depression. conversely, gender, body mass index, year of study, alcohol consumption, and place of residence during the academic year seem to be related to sleep quality and the effects of lockdown. more complete studies should be carried out that include accelerometry data and evaluate the long-term impact of these changes. it would also be interesting to analyze the effect of late chronotype and its relationship to poor sleep quality among students. who. coronavirus 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sleep problem prevalence, sex differences, and mental health correlates sleep in university students prior to and during covid-19 stay-at-home orders the relationship between sleep quality and internet addiction among female college students measuring sleep efficiency: what should the denominator be? a longitudinal analysis of the relationships among daytime dysfunction, fatigue, and depression in college students impact of sleep health on self-perceived health status the effects of physical activity on sleep: a meta-analytic review quality of sleep and depression in college students: a systematic review sleep quantity, quality, and insomnia symptoms of medical students during clinical years: relationship with stress and academic performance college residential sleep environment funding: this research received no external funding. the authors declare no conflict of interest. key: cord-263518-6puccigu authors: maarefvand, masoomeh; hosseinzadeh, samaneh; farmani, ozra; safarabadi farahani, atefeh; khubchandani, jagdish title: coronavirus outbreak and stress in iranians date: 2020-06-20 journal: int j environ res public health doi: 10.3390/ijerph17124441 sha: doc_id: 263518 cord_uid: 6puccigu iran has faced one of the worst covid-19 outbreaks in the world, and no studies to date have examined covid-19-related stress in the general iranian population. in this first population-based study, a web-based survey was conducted during the peak of the outbreak to assess stress and its correlates in the iranian population. a 54-item, valid, and reliable questionnaire, including items on demographic characteristics and past medical history, stress levels, awareness about signs and symptoms of covid-19, knowledge about at-risk groups and prevention methods, knowledge about transmission methods, trust in sources of information, and availability of facemasks and sanitizers, was deployed via social and mass media networks. a total of 3787 iranians participated in the study where the majority of the participants were females (67.4%), employed (56.1%), from developed provinces (81.6%), without chronic diseases (66.6%), and with ≥13 years of formal education (87.9%). the mean age of study participants was 34.9 years (range = 12–73), and the average stress score was 3.33 (sd = ±1.02). stress score was significantly higher for females, those who were 30–39 years old, housewives, those with chronic diseases, individuals who were aware that there is no vaccine to prevent covid-19, those who could not get facemasks or sanitizers, and individuals with higher knowledge about at-risk groups (p < 0.05). there was a significant correlation of stress scores with knowledge about prevention methods for covid-19 (r = 0.21, p = 0.01) and trust in sources of information about covid-19 (r = −0.18, p = 0.01). all of the predictors, except knowledge of two important at-risk groups and education, had a significant effect on stress scores based on a multivariate regression model. the covid-19 outbreak could increase stress among all population groups, with certain groups at higher risk. in the high-risk groups and based on experience with previous pandemics, interventions are needed to prevent long-term psychological effects. professional support and family-centered programs should be a part of pandemic mitigation-related policymaking and public health practices. since the emergence of the covid-19 outbreak in china in december 2019, the disease has rapidly spread across the world [1] [2] [3] [4] [5] [6] [7] . by june 2020, covid-19 had affected more than 8 million people who tested positive, and almost half a million people died worldwide [8] . iran reported its first confirmed case of covid-19 infection in february 2020 in qom [9] . soon after, other provinces in iran reported covid-19 cases, and as a result, schools and universities were closed in the affected provinces, and several cultural, sports, and religious gatherings were canceled as well. in early april 2020, there were 8522 covid-19-associated deaths worldwide, with a large proportion of deaths being reported from iran [10] . travel and other types of warnings and advisories have been issued by the iranian government regularly since the first case was found [11] . despite growing attempts to increase public awareness on prevention, people around the world were suffering from widespread fear, stress, and anxiety. this could be more prominent in areas of peak transmission and spread, with people feeling stressed and anxious about the transmission of the disease. for example, a major psychological burden on the public was identified during the peak of the covid-19 outbreak in china [12] [13] [14] . young people, people who spent too much time searching for information or working on the frontlines, healthcare workers with exposure to confirmed or suspected cases, and survivors of covid-19 had the highest levels of anxiety, depression, and mental distress [13] [14] [15] . the outbreak itself and the control measures may lead to widespread fear and panic, especially stigmatization and social exclusion of confirmed patients, survivors, and family members, which may escalate into further negative psychological reactions, including adjustment disorder and depression [16] . during the covid-19 pandemic, chinese individuals, especially those who were quarantined and had limited access to face-to-face communication, experienced serious psychological problems (e.g., anxiety, psychosis, depression). [16] . in the published literature, post-traumatic stress disorder (ptsd) and depressive disorders have been reported as prevalent long-term psychological consequences of epidemics [13] . patients with confirmed or suspected covid-19 may experience fear of the consequences of infection with a potentially fatal new virus, and those in quarantine might experience boredom, loneliness, and anger. for example, in the early phase of the sars outbreak, a range of psychiatric morbidities, including persistent depression, anxiety, panic attacks, psychomotor excitement, psychotic symptoms, delirium, and even suicidality, was reported [15] . however, much of the evidence on covid-19 relating to the stress of the pandemic has emerged from china, and few studies have examined the burden of covid-19-related stress in the general population from other countries. one of the worst covid-19 outbreaks was reported from iran, and no studies have examined the stress in the general iranian population or in the middle east. thus, the purpose of this study is to measure iranians' stress levels and the associated factors during the covid-19 outbreak. a web-based cross-sectional study was conducted in the general iranian population, targeting internet-using volunteers. a multi-item online questionnaire was deployed via the main page of the iranian scientific association of social work to the general public. this valid and reliable questionnaire was developed based on a comprehensive literature review and expert panel guidance to measure perceptions and distress during an influenza pandemic [13, 14, 17, 18] . study participants were recruited using social networks such as telegram, whatsapp, and instagram. this questionnaire was online for 5 days (from 26 february to 1 march 2020), and 3787 iranians took the survey. the questionnaire could be taken online using a secure html interface, where all security conditions for data and personal information were provided to potential study participants. each questionnaire could be completed only once per device. respondents were required to answer every question. they were able to review or change their answers before submitting final responses to the questionnaire. participants were informed about the purpose of the study and emphasized that their participation was voluntary and anonymous. this study was approved by the iranian scientific association of social work (98/p/419) for ethical procedures and scientific protocols. a 54-item questionnaire was used to collect data and information in this study . the questionnaire included items about demographic characteristics and past medical history, stress levels, awareness about signs and symptoms of covid-19, awareness about at-risk groups, knowledge about covid-19 transmission methods, knowledge about effective covid-19 prevention methods, awareness of the lack of a vaccine to prevent covid-19, trust in information sources about covid-19, and availability of facemasks and sanitizers. the questionnaire included six questions about demographic characteristics and past medical history to assess gender, age, province of residence, years of formal education, employment status (full-time, part-time, unemployed, housewife, student, or retired), and chronic diseases (including respiratory problems such as asthma and lung disease, cancer, stroke, diabetes, heart diseases such as heart failure and high blood pressure, kidney diseases such as kidney failure, liver diseases such as hepatitis and cirrhosis, psychiatric illnesses such as depression and anxiety, and alcoholism or drug addiction). stress-related data was collected by asking five questions about the level of feeling calm, tense, upset, relaxed, and worried. studies show that participants who receive short questionnaires are more likely to respond [19] . hence, the expert panel chose a brief set of stress-related questions that have been used in an epidemic situation [17] . for each question, participants could select responses from a set of options (very high, high, moderate, low, and very low, with a score range of 5-1 for each question). the mean of the responses on the five questions measures the stress level of individuals, and a higher score indicates higher stress. internal consistency reliability of the stress scale was assessed by computing cronbach's alpha from the total sample of participants and was found to be high (α = 0.81). additionally, there were five questions about awareness of signs and symptoms of covid-19 (true or false, with a score range of 1-0 for each question), two questions about the awareness of at-risk groups (true or false, with a score range of 1-0 for each question), four questions about the knowledge about covid-19 transmission methods (true/false/not sure with a score range of 2-0 for each question), and one statement about the awareness of lack of covid-19 prevention vaccine: "there is no vaccine for covid-19" (true/false/not sure with a score range of 2-0). a group of questions (n = 19) was included about the knowledge of effective covid-19 prevention methods (true/false/not sure, with a score range of 2-0 for each question). the internal consistency reliability for this scale (n = 19 questions) was assessed by computing cronbach alpha and was found to be reasonable (α = 0.73). ten questions were about the participants' trust in various sources of information about covid-19. sources of information included people they interact with (such as family, friends, and colleagues), health professionals, official websites (such as the ministry of health website), health centers (such as hospitals and public health centers), social networks (such as whatsapp, telegram, and instagram), television, radio, newspapers, online news agencies, and international websites such as who website. participants could indicate their level of trust in each of these sources using a 6-point likert scale (very much, much, moderate, low, very low, and not trustable, with a score range of 5-0 for each question). the mean of the score on the 10 trust-related questions was the average of individual scores of trust in sources of information about covid-19. to assess the internal consistency reliability of this scale on trust in sources of information, we computed a cronbach alpha from the final sample of respondents, and the reliability was found to be high (α = 0.83). the questionnaire also included questions about the availability of facemasks and disinfectant gel and sanitizers to assess the individuals' access to these protective strategies (yes/no, with a score range of 1-0 for each question). data were in excel file and were checked for duplicates and any errors before importing and analyzing using ibm spss 22 (chicago, il, usa). in the primary approach, a descriptive analysis of demographic and background characteristics of study participants was conducted. next, we compared the average stress scores using t-tests or anova based on demographic characteristics, awareness about signs and symptoms of covid-19, awareness about at-risk groups, knowledge about covid-19 transmission methods, knowledge about covid-19 prevention methods, awareness about the unavailability of covid-19 prevention vaccine, trust in sources of information, and the availability of facemasks and sanitizers. the effect of the predictor variables on stress was assessed by univariate and multivariate generalized linear models. first, each predictor variable was entered into the univariate model separately, then the variables that had p-values < 0.2 were entered into the multivariate model simultaneously. statistical significance was assumed at p < 0.05. a total of 3787 iranians with a mean age of 34.9 years (range = 12-73 years) participated in the study. table 1 illustrates the demographic characteristics of the study population and average stress scores differences among groups. the majority of the study population were females (67.4%), employed (56.1%), from developed provinces (81.6%), without chronic diseases, and had more than 13 or more years of formal education (87.9%). the majority of participants reported that during the last week, they could not get facemasks (74%) or sanitizers and disinfectant gel (50.2%). less than half (44.5%) of the participants were aware of at least three important symptoms of covid-19, and most of them (78.5%) knew that elderly people and individuals with background diseases have a higher risk of infection. the majority of participants had very good knowledge about covid-19 transmission (97%) and prevention (97.3%) methods and knew that there is no approved vaccine for covid-19 (83.5%). most of the participants reported that they had high trust in various sources of information about covid-19 (65.9%). the average scores of participants' knowledge about the transmission and prevention methods for covid-19 were 1.72 (±0.28) and 1.72 (±0.27), respectively. the average score on trust in the sources of information about covid-19 was 2.89 (sd = ±0.85). the average stress score for the study population was 3.33 (sd = ±1.02). the relationship between demographic characteristics and stress was measured by t-test and anova. the mean of stress scores was significantly higher for females, people in the age group of 30-39 years, housewives, those with chronic diseases, individuals who were aware that there is no vaccine to prevent covid-19, those who could not get facemasks or sanitizers, and individuals who knew about at-risk groups (p < 0.05) ( table 1) . anova was performed to study the relationship between stress and awareness about symptoms and at-risk groups. the mean of stress scores was statistically significantly different by levels of knowing two important at-risk groups (p < 0.05), but there was no significant difference by knowledge on five important symptoms (p > 0.05). pearson's correlation coefficients showed that participants' knowledge about transmission methods of covid-19 did not correlate with stress scores (r = 0.11, p = 0.08), whereas there was a statistically significant correlation of stress scores with knowledge about prevention methods for covid-19 (r = 0.21, p = 0.01) and trust in sources of information about covid-19 (r = −0.18, p = 0.01). univariate and multivariate generalized linear models were fitted on the stress scores. demographic variables (including gender, age, employment, education, province, awareness of no approved vaccine for covid-19, background disease), knowledge about transmission and prevention methods, awareness about signs and symptoms and at-risk groups, and trust in sources of information about covid-19 were individually entered in the univariate models. subsequently, variables that had p-values <0.2 were simultaneously entered in the multivariate model ( table 2 ). all of the variables, except knowledge on the two important at-risk groups and education, were significantly associated with stress scores in the multivariate model. in this first large national study from iran, high-levels of stress were reported by the general public during the covid-19 outbreak. unfortunately, the long-term effect of such high levels of stress, resulting in serious mental health issues, would be an additional burden on the iranian public and healthcare system as an aftermath of the pandemic. our findings provide further evidence of the mental health crises created by emerging infectious disease pandemics. following the outbreaks of hiv, ebola, and sars in other countries, the prevalence of psychological symptoms was reported, and many individuals had experienced long-lasting psychiatric problems [18, [20] [21] [22] . there is an interaction between external conditions (threat) and internal ones (vulnerability) that influences the level of risk for debilitating stress that could lead to mental health problems [20] [21] [22] [23] . in this study, we identified unique groups with high stress. first, across various studies, women have reported high stress. in this study and given the pandemic, it is highly likely that women face multiple and additional stressors, including work, taking care of others in the household, arranging for materials and supplies for the household, and arranging school work and education for children. their routines have been dramatically changed and profoundly disrupted, causing more stress. second, individuals with chronic diseases have higher stress in general, and this could be accentuated by the lack of sanitizers, protective masks, and the awareness of lack of a vaccine to prevent covid-19 infection. the lack of protective supplies and heightened awareness could have severely impacted even those without chronic diseases or lifestyle problems. third, those in the middle age groups and working-class could have more stress due to multiple social, economic, and personal stressors. it could be possible that they are worried about losing their jobs or their income. those who had part-time jobs were more stressed than those who had full-time jobs. the instability of part-time jobs, low incomes, and lack of savings could affect some groups more than others. additionally, healthcare access, coverage, and the ability to pay are influenced by employment, and this could be a major stressor for middle-aged working-class individuals. fourth, there is an interesting relationship between education and stress levels. individuals with lower stress had the lowest and highest education levels compared to those who had 13-16 years of formal education. one possible reason could be that during the covid-19 outbreak in iran, there was a lot of misinformation circulating on social media networks. those with lesser education were not generally able to read the information in other languages (such as english) and had lesser access to mass media and technology to use social media. however, with increasing education, this stress seemed to have been alleviated, possibly due to the ability to screen for and use authentic information [24] [25] [26] [27] [28] [29] . similar to many epidemics in the past and the response of various governments, it appears that mental health care is not a priority for governments during such national crises, epidemics, and disasters. in addition, factors such as the rural-urban divide, lack of access to technology and authentic information, income inequality, availability of healthcare or other resources, lack of awareness, and literacy could pose additional burdens and cause psychological distress [13] [14] [15] [16] 18, [20] [21] [22] . [18, [20] [21] [22] [23] . during these epidemics, the consequences on the psycho-social well-being of at-risk communities were largely overlooked. for example, in the ebola-affected regions, few measures were taken to address the mental health needs of confirmed patients, their families, medical staff, or the general population, and this resembles the responses to all recent epidemics. the absence of mental health and psycho-social support systems and the lack of well-trained psychiatrists and/or psychologists in these regions increased the risks of psychological distress and progression to psychopathology [21] [22] [23] [24] [25] . continuous surveillance and monitoring of the psychological consequences for outbreaks should become a part of disaster and pandemic preparedness efforts worldwide. moreover, interventions should be geared towards the most affected and vulnerable individuals as a part of a population mental health promotion strategy [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] . currently, according to the notification of basic principles for emergency psychological crisis interventions by the national health commission of china, mental health care should be provided for patients with covid-19, close contacts, suspected cases who are isolated at home, patients in fever clinics, families and friends of affected people, health professionals caring for infected patients, and the public [13] [14] [15] [16] . however, xiang and colleagues claim that the mental health needs of patients with confirmed covid-19, patients with suspected infection, quarantined family members, and medical personnel have been poorly handled and believed that the organization and management models for psychological interventions in china must be improved [15] . similar challenges are now being seen across the severely affected countries and will continue to emerge in regions that will be severely affected with covid-19 or any future pandemics and epidemics [23] [24] [25] . social media, fear and misinformation, myths, and rumors have added to the global burden of information overload and psychological distress [26] [27] [28] . pandemic response policies should include mental health promotion practices as a key initiative in dealing with the psycho-social burden of pandemics. additional research is needed in the form of long-term prospective studies to assess the causal mechanisms and impact of stress caused by the covid-19 pandemic. the results of this study are subject to several potential limitations. first, the study results are restricted by all traditional limitations of cross-sectional study designs (e.g., reliance on self-reported behaviors, recall bias in participants, socially desirable responses, and the inability to establish cause-and-effect relationships). second, this study measured the prevalence of variables rather than incident cases, and we were unable to assess the levels of variables before covid-19 outbreak in iran as a control. third, stress patterns in individuals often have a variety of simultaneous influences that need to be accounted for. fourth, a major threat to external validity is that the sample is limited in nature and extent (e.g., dominated by female participants, those who were employed and <49 years old, and from developed provinces). this would mean that the results of the study cannot be generalized to several groups of individuals across the region and other countries. despite these limitations, our study is the first and largest study across the middle east, with robust measures, of covid-19-associated stress and the factors associated with stress during the pandemic. based on our field experiences and a comprehensive review of literature, we recommend the following strategies for mental health promotion and disease mitigation in communities during the covid-19 pandemic or any future epidemics or disasters [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] . people may speculate and/or spread rumors, myths, and misinformation about covid-19 or infectious disease agents. this has been a major problem with the current pandemic, given the widespread use of mass and social media methods, increasing stress and spreading panic. it is essential to encourage the public not to spread misinformation and inform them of verified and credible sources of information. governments should engage in effective and efficient risk communication and share information regarding disease prevention methods and strategies. governments and scientific organizations should provide clear information about covid-19 or any infectious disease-related symptoms, signs, transmission methods, and prevention strategies through scientific websites, daily briefings, and public awareness campaigns. this will help citizens deal with pandemics more effectively and also mitigate the chain of transmission and spread of disease. denying epidemics and the associated population health risks will cause a loss of confidence in the government and credibility of scientific organizations, which poses an additional burden on disease management and population health services. lack of effective flow of information and disease-related data and statistics has been a major problem worldwide with the covid-19 pandemic. people may be worried, anxious, and depressed due to the constantly changing alerts, media cycle, and social or mass media coverage regarding the spread of covid-19. therefore, providing psychological support services by volunteer social workers, psychologists, psychiatrists, and counselors could help alleviate stress and persistent excessive arousal. in this regard, long-distance psycho-social support (including telecounseling and online services) can be deployed. because people's routines may change dramatically during pandemics and quarantine periods, they should receive compassionate services and guidance on becoming familiar with alternative programs and lifestyles. opening online platforms with audio-and video-based information and demonstrations and providing counseling services and telephone helplines for those with new-onset symptoms or existing mental illnesses can be used until routine mental healthcare services are available. grief counseling for people who have lost their family members due to covid-19, or those who lose family members due to other epidemics and disasters, is critical. strategies such as stress reduction, conflict resolution, crisis call centers, child protection, and custody conflict mitigation are some areas of emphasis for psycho-social service providers. it is also so important to pay attention to the possibility of deprived families who have infected members due to the stigma caused by the disease, and provide special support for them to ensure their access to essential facilities and services. while our study did not specifically look at frontline workers, and essential service and healthcare professionals, existing evidence indicates the heavy toll that pandemics such as covid-19 can take on the physical and mental health of certain at-risk groups. disrupted sleep-wake cycle, patient and client overflow, long working hours, changing practice protocols, fractured communication, and shortage of materials, equipment, and supplies can cause high stress among these populations in disasters and pandemics. individual-level, intrapersonal, and organizational level interventions to reduce stress and burnout should be implemented (e.g., shift rotations, work hours limitation, employee assistance programs, enforcing protocols, coordinated workflow and information processes, just to name a few). a major stressor among individuals and families during epidemics is financial or economic. governments should support employers and strengthen social protection, especially for vulnerable families (including elder people, disabled or sick people, and female-headed households). family-friendly policies and programs are necessary to support affected people during the covid-19 pandemic (including employment and income protection, flexible working arrangements, paid leave to care for family members and access to health care and medical services, direct benefit transfers, food distribution for needy families, among others). governments across the world have rolled out stimulus plans and advisories for tax and debt moratoriums that should provide temporary assistance to needy families. voluntary activities during this period can significantly contribute to social solidarity and social cohesion. it is recommended that these activities be encouraged. skilled volunteer professionals could be involved in a wide range of activities to reduce the economic, social, and health impacts of the epidemic. nonprofit organizations can play a key role in mobilizing skilled volunteer professionals. the no-harm principle is essential to providing volunteer services during an epidemic. the covid-19 outbreak has severely increased psychological distress among people in iran. it has changed people's routines in several aspects and made it difficult to cope with the new situation. affected people, especially vulnerable groups, need professional support and community-based mental health promotion services to deal with the multiple stressors and burden imposed by the current pandemic. family-centered social and economic policies and programs are necessary to support people during the covid-19 epidemic. employment and income protection, flexible working arrangements, paid leave to care for family members and access to medical services, cash transfers, and food distribution for low-income or no-income families, and providing long-distance psycho-social interventions are some examples of family-friendly policies to support people during this pandemic or any future epidemics of a regional or global nature. outbreak of pneumonia of unknown etiology in wuhan china: the mystery and the miracle early transmission 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a web-based cross-sectional survey immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china timely mental health care for the 2019 novel coronavirus outbreak is urgently needed recommended psychological crisis intervention response to the 2019 novel coronavirus pneumonia outbreak in china: a model of west china hospital. precis the design of a survey questionnaire to measure perceptions and behaviour during an influenza pandemic: the flu telephone survey template (flutest) impact of ebola experiences and risk perceptions on mental health in sierra leone effect of questionnaire length, personalisation and reminder type on response rate to a complex postal survey: randomised controlled trial mental health of nurses working at a government-designated hospital during a mers-cov outbreak: a cross-sectional study ebola outbreak and mental health: current status and recommended response associations between mental health and ebola-related health behaviors: a regionally representative cross-sectional survey in post-conflict sierra leone psychiatric aspects of coronavirus (2019-ncov) infection psychiatry of pandemics: a mental health response to infection outbreak multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science mohamadi bolbanabad, a. perceived stress due to covid-19 in iran: emphasizing the role of social networks infodemic" and emerging issues through a data lens: the case of china global health crises are also information crises: a call to action new guidelines to help employers support families during covid-19 psychological interventions for people affected by the covid-19 epidemic risk management of covid-19 by universities in china social protection and job responses to covid-19: a real time review of country measures assessment of iranian nurses' knowledge and anxiety toward covid-19 during the current outbreak in iran mental health and psychosocial aspects of coronavirus outbreak in pakistan: psychological intervention for public mental health crisis this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we acknowledge all participants involved in this study. ronaghi voluntarily assisted us in developing the online questionnaire and supported the research team in preparing a page on the isasw website. authors would also like to thank lili derakhshan, maryam latifian, anis rookhosh, roghayyeh yazdani, leila fatehi, fatemeh nourshargh, zahra khanlary, mahboubeh tavakoli, samaneh mohebbi, and ayoub mohammadi for their support and efforts for the survey announcement. the authors declare no conflicts of interest regarding this study. key: cord-273565-0en2sl3q authors: scarano, antonio; inchingolo, francesco; lorusso, felice title: facial skin temperature and discomfort when wearing protective face masks: thermal infrared imaging evaluation and hands moving the mask date: 2020-06-27 journal: int j environ res public health doi: 10.3390/ijerph17134624 sha: doc_id: 273565 cord_uid: 0en2sl3q individual respiratory protective devices and face masks represent critical tools in protecting health care workers in hospitals and clinics, and play a central role in decreasing the spread of the high-risk pandemic infection of 2019, coronavirus disease (covid-19). the aim of the present study was to compare the facial skin temperature and the heat flow when wearing medical surgical masks to the same factors when wearing n95 respirators. a total of 20 subjects were recruited and during the evaluation, each subject was invited to wear a surgical mask or respirator for 1 h. the next day in the morning at the same hour, the same subject wore a n95 mask for 1 h with the same protocol. infrared thermal evaluation was performed to measure the facial temperature of the perioral region and the perception ratings related to the humidity, heat, breathing difficulty, and discomfort were recorded. a significant difference in heat flow and perioral region temperature was recorded between the surgical mask and the n95 respirator (p < 0.05). a statistically significant difference in humidity, heat, breathing difficulty, and discomfort was present between the groups. the study results suggest that n95 respirators are able to induce an increased facial skin temperature, greater discomfort and lower wearing adherence when compared to the medical surgical masks. coronavirus disease is an infectious mild to moderate respiratory illness caused by a newly discovered coronavirus [1, 2] . this infection is a serious disease in patients with other pathologies, especially in older people with underlying medical problems such as chronic respiratory disease, cancer, cardiovascular disease, and diabetes. these patients develop serious acute pneumonia with a high mortality rate [3] . a primary way in which the virus spreads is through droplets of saliva, produced during coughs or sneezes or through discharge from the nose from an infected person. airborne bacteria or viruses can spread infectious diseases, which can become major public health concerns. in particular, tuberculosis (tb) and influenza are major problems in clinical practice [4] . these diseases can be a hazard which can infect care workers. for this reason, it is important to implement airborne infection control by using a good prevention strategy in health-care sites. in fact, the exhaled air of infected humans is one of the prime sources of ambient contamination by bacteria or contagious viruses. droplets are also particularly dangerous for possible transmission when there is a virus, such as influenza, in high concentrations of airborne particles in closed or small environments [5] . in case of a pandemic involving an airborne-transmissible agent, doctors must use a mask for protection. it is important to evaluate the flow of air through the respirator to understand if there are any points of concern for the health of the doctors. however, the use of protective face masks (pfms) will not be effective if masks are not used appropriately. due to resistance to airflow and discomfort related to buildup of facial heat, especially in hot and humid weather, many people use a pfm with lack of compliance to safety regulations [6, 7] . the direct surgical mask has a low/moderate filter performance with lower levels of airflow resistance, while the high heat and humidity under a pfm can cause moisture to condense on the outer surface of the pfm, which consequently impairs respiratory heat loss and imposes an increased heat burden [8] . the factors that reduce the discomfort of heat on the face are nasal breathing, use of exhalation valves, reduction of pfm dead space parameters, and cup-shaped or duckbill designs. it has been suggested that facial temperature augmentation can trigger a panic disorder caused by elevated co 2 levels under the pfm, with hot flashes and sweating. in fact, wearing a surgical mask or respirator produces a significant increase in skin temperature, especially under the mask. for some subjects in a workplace, this could be sufficient to cause thermal discomfort. a pfm induces a significant augmentation of facial skin effects on thermoregulation. for this reason, many people use an pfm incorrectly, without covering the nose, or, after a few minutes, this can lead to partial uncovering of the nasal area. impatience with the thermal effects of pfm leads to discomfort and can induce a decreased use and concomitant decreased protection for the user. the purpose of the present study was to evaluate facial skin temperature, discomfort and hands moving the mask when wearing surgical masks or n95 respirators, with thermal infrared imaging. during the study period, february 2020, 20 voluntary male workers met the inclusion criteria with a mean age of 50 (45-55) in the department of oral surgery of the university of chieti-pescara, italy. the study was conducted in observance of the helsinki declaration (revised version of tokyo in 2004) and good clinical practice guidelines. all patients gave informed consent to the adopted noninvasive procedure. the inclusion criteria were experience in using respirators and absence of respiratory diseases. the volunteers were all in phototypes ii or iii of the fitzpatrick scale [9] for the facial areas being evaluated. the exclusion criteria were allergic rhinitis and nasal septum deviations, showing facial aging, lax skin, facial treatment antiaging, severe illness, facial skin disease, head and neck radiation therapy, chemotherapy, facial skin resurfacing, and uncontrolled diabetes. all volunteers had all previously experienced using respirators. in the previous hours, they had not undergone athletic training. after a thorough preliminary examination, the volunteers underwent facial temperature evaluation, having been extensively informed about the study procedures. the volunteers were requested to enter a room with a constant temperature for 1 h before the study to allow them to acclimatize. this study was undertaken to investigate the effects of wearing a pfm on facial skin temperature when the subject was not actively working. the perception ratings related to the humidity, heat, breathing difficulty, and overall discomfort of the enrolled subjects were recorded. discomfort was scored by means of a 100-mm scale from 0 (no discomfort) to 100 (worst discomfort imaginable). the infrared thermography evaluation was performed in a climate-controlled environment (temperature: 22-24 • c, relative humidity percentage: 50 ± 5%, without any direct ventilation into the mouths of the subjects). the environmental humidity was measured by a built-in integrated sensor (atmo-tube, san francisco, ca, usa). the sensor provided a measurement of relative humidity (rh) at regular intervals with a resolution of 0.5% and a humidity range from 0% to 100%. the facial temperature of the perioral region was recorded by a 14-bit digital infrared camera (flir sc660 qwip, flir systems, danderyd, sweden). the general acquisition parameters were set with the following specifications: 320 × 240 pixels focal plane array; 8-9 µm spectral range; 0.02 k noise equivalent temperature differences (netds); 50-hz sampling rate; optics: germanium lens; f 20; and f/1.5. the camera was positioned at 0.50 m away from the facial region to obtain the maximum spatial resolution. the thermographic images were recorded at a rate of 10 images per second, and consequently re-aligned by the use of an edge-detection based method implemented with an in-house software package. a thermal video was recorded, and the photos were developed via dedicated software. temperature changes in the perioral and facial areas were elaborated on the realigned thermal images. the complete act of breathing was recorded by a thermal video, and the temperature changes were calculated by the dedicated software using frame-by-frame records. the average temperature for inhalation and expiration acts were considered for the statistical evaluation. for the thermal evaluations, we considered the emissivity of 0.98 for skin, 0.93 for surgical mask and n95 (any color). the emissivity value is the same for both surgical and n95 because both surfaces are roughened and have the same thermal characteristics. thermographic data measurements were performed by the software package flir quickreport v.1.2 (flir systems inc., north billerica, ma, usa), which is able to obtain the maximum, minimum, and average temperature of a perioral region. during the evaluation, the subject was invited to wear a surgical mask or respirator for 1 h and read the newspaper, mainly in silence, speaking aloud for only 10 min. in the first experiment, the volunteer wore a filter type respirator for 1 h. the next day in the morning at the same time of day, the subject wore a n95 mask for 1 h with the same protocol. as a result, there were two variables, no respirator versus respirator, and before and after wearing two different pfm. skin temperature was recorded before wearing the surgical mask or respirator, during 1 h of wearing, and immediately after having removed the pfm, a video record was taken for another 10 min. therefore, during protective mask wearing, was a thermal video recorded for 1 h resulted in 10 by 60 by 60 = 36,000 images per investigated subject. a power analysis was performed using clinical software to determine the number of samples needed to achieve statistical significance for quantitative analysis of facial temperature. a calculation model was adopted for dichotomous variables (yes/no effect) using the incidence effect designed to discern the reasons (85% for the test group and 10% for the control group), with alpha = 0.05 and power = 95%. the optimal number of samples for analysis was 20 patients per group. numerical results are presented as the ±sd means of all the experiments. the data outcome was collected and statistically evaluated by the software package graphpad 6 (prism, san diego, ca, usa). the normal distribution of the study data was evaluated by the shapiro-wilks test to evaluate the normal distribution. the t-student test was performed to compare the study variables means in each group. the level of significance was set at p < 0.05. the videos were converted to infrared images of the facial temperature distribution when wearing the different facemask types. during expiration, the temperature change induced by the airflow appeared in the central area of the mask, while no temperature changes were detected laterally, at the top, or at the bottom of the mask. the superficial area of the surgical mask showed a homogeneous distribution of the heat flow detected by ir during breathing. the n95 respirator group detected a non-homogeneous flow on the mask. the ir images of facial skin temperature distributions were taken during wearing of the mask, immediately after removal of the mask, and 10 min after removal of the mask. the ir thermography images demonstrated significant temperature changes at the perioral region and superior lip immediately after removal of the mask, compared with baseline conditions in both types of pfm. no statistical differences were detected in other regions of the face. differences were detected in the mask-skin contact sites after removal of the mask, compared with baseline conditions (figures 1 and 2) . the temperature of the upper lip recovered almost to baseline readings approximately 10 min after mask removal. no temperature augmentations were observed in the forehead, cheeks, and nose/mouth regions. the surgical mask surface showed large temperature changes during inhalation and exhalation (t inhalation: 28.9 ± 3.1 °c; t exhalation: 31.4 ± 3.6 °c). the n95 respirator surface showed significantly fewer temperature fluctuations during the breathing acts (t inhalation: 26.0 ± 3.6 °c; t exhalation: 29.3 ± 3.8 °c). after the protection device removal, a significant difference in perioral facial temperature was detected (p < 0.05), between the the temperature of the upper lip recovered almost to baseline readings approximately 10 min after mask removal. no temperature augmentations were observed in the forehead, cheeks, and nose/mouth regions. the surgical mask surface showed large temperature changes during inhalation and exhalation (t inhalation: 28.9 ± 3.1 °c; t exhalation: 31.4 ± 3.6 °c). the n95 respirator surface showed significantly fewer temperature fluctuations during the breathing acts (t inhalation: 26.0 ± 3.6 °c; t exhalation: 29.3 ± 3.8 °c). after the protection device removal, a significant difference in perioral facial temperature was detected (p < 0.05), between the the temperature of the upper lip recovered almost to baseline readings approximately 10 min after mask removal. no temperature augmentations were observed in the forehead, cheeks, and nose/mouth regions. the surgical mask surface showed large temperature changes during inhalation and exhalation (t inhalation: 28.9 ± 3.1 • c; t exhalation: 31.4 ± 3.6 • c). the n95 respirator surface showed significantly fewer temperature fluctuations during the breathing acts (t inhalation: 26.0 ± 3.6 • c; t exhalation: 29.3 ± 3.8 • c). after the protection device removal, a significant difference in perioral facial temperature was detected (p < 0.05), between the surgical mask (mean t removal: 35.9 ± 3.4 • c; ∆t: 0.7 ± 0.5 • c) and the n95 (mean t removal: 36.9 ± 4.2 • c; ∆t: 1.2 ± 0.5 • c) (tables 1 and 2). a statistical difference in discomfort was observed (p < 0.01). additionally, statistical differences were observed regarding the number of touches to the facial mask or face during the 1 h (p < 0.05). subjects wearing the n95 touched it 25 times to move it, while those wearing the surgical mask performed this gesture 8 times. this underscores the discomfort that a facial mask with a major airflow resistance causes (table 3) . table 3 . infrared thermal measurements of the perioral region surface. temperature differences between baseline and inhalation, between inhalation and exhalation and between baseline and mask removal. (mean, sd. student's t-test). ∆t b-rem : temperature difference between baseline and inhalation; ∆t in-ex : temperature difference between inhalation and exhalation; ∆t in-ex : temperature difference between baseline and mask removal. the outcomes of the present study indicate that fitting a surgical mask or respirator during 1 h of continuous wearing led to an increase in facial skin temperature under the face mask, while removing the face mask tended to rapidly decrease it after 1 min, returning to the baseline after 5 min. a face mask prevents transpiration and protects against airborne transmitted bacteria or viruses and it is very important to wear one in a health care situation, especially during a pandemic [10, 11] . this may increase skin temperature irrespective of workload. the increases we observed under the mask were between 0.7 ± 3.3 • c and 1.9 ± 3.5 • c in the respirator. these were lower when the volunteers wore surgical masks. for both types (surgical masks and n95 respirators), increased skin temperature was observed at >34.5 • c, a level which may induce slight sensations of thermal discomfort. on this basis, the larger rise in lip temperature seen in these subjects could possibly be a result of increased airflow resistance to both pfms. the study size of 20 subjects is sufficient for basic technical hypotheses but is insufficient for the evaluation of other multifactorial effects. for example, we only enrolled healthy subjects. pulmonary, cardiac, and metabolic pathologies could greatly influence the results of this study. in the present study, we used thermal infrared imaging because this technique is extensively used for evaluating the superficial temperature of bone [12] , facial skin [13] , and oral mucosae [14] . the increased perioral temperature observed in our study could be explained by the fact that wearing a face mask for a certain period of time causes reduction in heat loss from the body by evaporation, conduction, convection, and radiation [15] . a pfm avoids normal transpiration and cooling of the skin, and the space beneath it (dead space) is filled with warm, moist expired air during most of the breathing cycle. additionally, surgical masks may increase airway resistance, and a statistically significant decrease in the blood o2 saturation level of surgeons has been found; however, these data were not confirmed by this new study [16] . in this study, we evaluated the effect of facial masks used for 1 h; however, in many situations, masks are worn for longer periods of time. therefore, a greater effect on the general discomfort of the wearer is conceivable. another interesting study has demonstrated an increase in oral temperature when someone is wearing a face mask for a sufficient time, and this condition can influence a wrong diagnosis of fever [16] . in this study, the authors discovered that the subjects wearing and not wearing masks had intraoral temperature above 37.5 and 37.3 • c, respectively, and when the n95 mask was worn the intraoral temperature was statistically significantly different than when wearing the surgical mask. the face is extremely important for thermoregulation of the body; it is two to five times more effective at suppressing sweating and thermal discomfort than the cooling effect of a similar dermal area elsewhere on the body. in fact, the face accounts for 20% of the total drive from the skin and has a high concentration of thermoreceptors [17] [18] [19] . the facial region and head form an area that is a critical structure for cooling, because is the most sensitive to temperature sensation, whereas temperature sensing is poor on the extremities, with the exception of the fingers, and intermediate in other regions [20, 21] . in moderate environmental conditions, such as other areas of bare skin, the surface temperature is about 2-4 • c lower than the internal temperature [22] , while temperature gradients from the core to the skin in defined regions, such as fingers or toes, are of 7.0 or even 9 • c, which is not uncommon in healthy people. perioral and nasolabial region skin temperature in an adult can be around 35.3 ± 1.4 or 35.2 ± 1.3 • c [23] . body temperature is maintained constant through a combination of physiological mechanisms. in the perioral and nasal region, the pfm that covers the mouth and nose impedes the greater cooling impact of facial skin temperature [24] . moreover, the straps and head harness of a tight-fitting mask can reduce the venous flow from the head. many studies have reported that pfms increase the skin temperature of the lips by 1.9 • c after 15 min without any effect on other regions of the face and little effect on core temperature, and this may have a significant impact on the perception of thermal discomfort [25] . the increase in facial skin temperature induced by pfms has been documented in different studies, and this significantly influences thermal sensations of the whole body, because cutaneous thermal receptor impulses from the face to the central nervous system are more important than from other regions. the face is the most sensitive region, while the lower extremities (i.e., thigh, calf, sole, and toe) are the least, and it has higher sensitivity to warm temperature and could influence maintaining thermal homeostasis. in fact, when the face of a healthy individual was exposed to heating, local sweating on the leg was augmented three times more than when heating was applied on the leg [17, 26] . in this study, we found that the surgical mask produces a slight facial skin temperature augmentation, with more comfort during, and thus increased adherence to, correct use. for this reason, it is better to wear a surgical mask correctly than an n95 which, due to the discomfort, causes displacements with the hands and temporary withdrawals of the mask from the face. a high number of removals of respirators from the face was recorded in the present study, and thermal discomfort may contribute to this. this result should be added to the results obtained by investigators who have shown that wearing a n95 surgical mask does not reduce the risk of infection. in fact, n95 respirators vs. surgical masks as worn by outpatient health care personnel showed no significant difference in the incidence of laboratory-confirmed influenza [11] . the effectiveness of medical masks is not inferior to that of n95 respirators and surgical masks provide similar protection to that of n95 respirators, because respiratory viruses are primarily transmitted by large droplets. n95 respirators are structured to filter against inhaling small airborne particles and fit tightly to the face, while surgical masks are structured against big airborne particles with a loose fit to the face with minor resistance to airflow. n95 respirators appeared to have a larger protective effect than surgical masks, but a recent meta-analysis demonstrated that there were insufficient data to established definitively whether n95 respirators are superior to surgical masks in protecting workers against transmissible acute respiratory infections in clinical settings [27] . in fact, the scientific evidence that n95 respirators are superior to surgical masks is sparse, and findings are insufficient within and across studies [28] . in light of the results reported by our research, a surgical mask presents better adherence and it is better to wear one correctly than an n95, as many studies suggest that the major obstacle against respiratory infections is not the type of pfm worn but the rate of adherence, with a range varying from 10% to 84% [6, 7, 29] . another important consideration is the high frequency of touching the n95 observed, which increases self-infection of microorganisms. in fact, contaminated hands are a route to disseminating respiratory infections [30] . the wearing of n95 while not working over the course of 1 h has a significant impact on facial skin temperature, discomfort, and hands moving the mask, which compromises safety and suggests that in working conditions, there is an increase in these parameters. a limitation of the present study was that all subjects were non-working males and that males present a higher skin temperature than females [31] , and we did not investigate the difference between the two sexes; however, none of the volunteers were affected by nasal or respiratory diseases. this study was conducted during the italian lockdown, and in our department, there were only male patients. another limitation of this study is that all subjects were wearing the filter on day 1 and the n95 mask on day 2, and we did not randomize order across the subjects to reduce systematic errors. we hypothesize that nasal and respiratory diseases or working increase discomfort during wearing and use of the pfm. in conclusion, the n95 mask produces a major increase in skin facial temperature with major discomfort, and volunteers have shown greater 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effect of local cooling on sweating rate and cold sensation. pflügers arch regional sensitivity and spatial summation in the warmth sense estimation of mean body temperature from mean skin and core temperature biophysical parameters of skin: map of human face, regional, and age-related differences development of a draft british standard: the assessment of heat strain for workers wearing personal protective equipment the effect on heart rate and facial skin temperature of wearing respiratory protection at work the distribution of cutaneous sudomotor and alliesthesial thermosensitivity in mildly heat-stressed humans: an open-loop approach effectiveness of n95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis effectiveness of masks and respirators against respiratory infections in healthcare workers: a systematic review and meta-analysis time dependent infrared thermographic evaluation of facemasks preventive behaviors and mental distress in response to h1n1 among university students in guangzhou, china thermographic imaging of facial skin-gender differences and temperature changes over time in healthy subjects this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no acknowledgment for the present investigation. the authors declare no conflict of interest. key: cord-267874-k6tmu5gi authors: ramírez, ivan j.; lee, jieun title: covid-19 emergence and social and health determinants in colorado: a rapid spatial analysis date: 2020-05-29 journal: int j environ res public health doi: 10.3390/ijerph17113856 sha: doc_id: 267874 cord_uid: k6tmu5gi the aim of this rapid analysis was to investigate the spatial patterns of covid-19 emergence across counties in colorado. in the u.s. west, colorado has the second highest number of cases and deaths, second only to california. colorado is also reporting, like other states, that communities of color and low-income persons are disproportionately affected by covid-19. using gis and correlation analysis, this study explored covid-19 incidence and deaths from march 14 to april 8, 2020, with social determinants and chronic conditions. preliminary results demonstrate that covid-19 incidence intensified in mountain communities west of denver and along the urban front range, and evolved into new centers of risk in eastern colorado. overall, the greatest increase in covid-19 incidence was in northern colorado, i.e., weld county, which reported the highest rates in the urban front range. social and health determinants associated with higher covid-19-related deaths were population density and asthma, indicative of urban areas, and poverty and unemployment, suggestive of rural areas. furthermore, a spatial overlap of high rates of chronic diseases with high rates of covid-19 may suggest a broader syndemic health burden, where comorbidities intersect with inequality of social determinants of health. on march 11, 2020, the world health organization announced officially the coronavirus pandemic which was first detected in wuhan, china in december of 2019 [1] . by march 16, 2020 , the new coronavirus labeled covid-19 had spread globally across 151 territories affecting 167,511 persons and killing more than 6500 [2] . ten days later, the u.s. emerged as the epicenter of covid-19, surpassing china's case count [3, 4] . as of april 13, 2020, the u.s. reported 582,468 cases of covid-19 and 23,622 deaths [5] , representing approximately 30% and 20% of the world's covid-19 morbidity and mortality. in the u.s., the state of colorado, which is the focus of this study, reported the third highest number of covid-19 cases (n = 7691) in the west, following the states of california and washington, respectively [6, 7] . approximately 329 deaths were documented, since the first case of covid-19 was reported on february 20 in colorado [6, 8] . recent reports indicate, like in many other states [9] , that covid-19 incidence and deaths are disproportionately affecting communities of color in colorado [10, 11] . as of april 13, 2020, approximately 36.7% of cases and 26.7% of deaths were persons of hispanic, non-hispanic black, and non-hispanic native hawaiian or pacific islander origins, of which hispanics shared the greatest burden of covid-19 incidence and deaths [11] . although the colorado department of public health and environment (cdphe) has yet to release socioeconomic information about covid-19 cases, it is likely that these racial and ethnic disparities also correspond to inequalities in the social determinants of health, "the conditions in places where people live, learn, work, and play" [12] . as governmental and nongovernmental organizations report, communities of color and lower income persons face greater vulnerability to covid-19 due to social, health and environmental disparities, such as lack of access to healthy foods, quality housing, health insurance and healthcare, and greater exposure to ambient air pollution [9, 13] . relatedly, such communities are also disproportionately affected by preexisting chronic conditions such as diabetes, cancer, and asthma [14] , which may increase risk for severe covid-19 health outcomes [15] [16] [17] . in massachusetts, for example, researchers estimated that areas with higher levels of poverty, overcrowding, and populations of color were significantly associated with excess deaths during the first 15 weeks of 2020 [18] . similarly, in new york, hospitalizations and deaths are distributed unevenly across racial and socioeconomic lines [19] . in colorado, the executive director of cdphe states, ' we know that social and health care inequities affect outcomes, and that becomes even more apparent in times of disaster' (as quoted in [10] ). within this context, the aim of this rapid study was to examine the initial spatial patterns of covid-19 in colorado and explore preliminary associations with social determinants of health and chronic conditions. using geographic information systems (gis) and bivariate correlation analyses, this study investigated covid-19 incidence and deaths from march 14, 2020 to april 8, 2020 at the county-level and the wider social, economic, and health context of emergence. understanding the geographic patterns of covid-19 in colorado and the social determinants context may assist public health investigators with socially relevant insights, particularly as new information emerges about covid-19 disparities among colorado's population. publicly available covid-19 data were downloaded daily from the colorado covid-19 online summaries, including geospatial information from cdphe [6, 20] and their open data portal [21] . covid incidence data include laboratory-confirmed and probable cases, and persons who tested positive for covid-19 while visiting were assigned to the county where they were identified [22] . social determinants of health data were retrieved from the social vulnerability index (svi) dataset (2014-2018) from centers for disease control and prevention (cdc) (see [23] for variables' details). these svi data intended for the assessment of population vulnerability to disasters [24] , include proxy variables for socioeconomic status, household composition, and minority status. to date, svi data have been employed to examine wildfires [25] , physical inactivity [26] , and mental health and housing affordability [27] . among svi variables, a few indicators may be more relevant to vulnerability and exposure such as poverty and overcrowding, both of which have been correlated with influenza [28, 29] , and recently, covid-19 [18] , although at the census-tract and zipcode levels. chronic conditions, such as asthma and diabetes hospitalizations (age-adjusted, per 100,000), heart disease mortality (age-adjusted, per 100,000), cancer mortality (age-adjusted, per 100,000), and obesity prevalence (adults, %), as well as influenza hospitalizations (age-adjusted, per 100,000) and mental health-related outcomes (suicide deaths and drug-related deaths, both per 100,000) were obtained from cdphe [21] , cdc [30] , and county health rankings [31] . health data represent the time period, 2013-2017, except for cancer (2012-2016) and obesity (2017). all datasets represent county-level estimates. the state of colorado has a population of 5,695,430 distributed across 64 counties, including those in the denver metropolitan region (see figure 1 ). dot density and choropleth maps of covid-19 cases for march 14, 2020 and april 8, 2020 were generated in arcgis pro (esri inc., redlands, ca, usa) [32] . an inverse distance weighted (idw) algorithm was also used to interpolate and create a 3d continuous surface for mapping the sequential progression of covid-19 rates across counties at five time points (march 14, march 18, march 25, april 1, and april 8). the fundamental assumption of idw is that the interpolated surface is the result of locational dependency at the sampling points, whose influence decreases as the distance increases from its sampled location [33] . the idw maps represent crude hotspots of covid-19 incidence displayed from high (red) to low (blue) rates. to estimate the change in disease incidence, rate ratios comparing county-level covid-19 incidence rate differences between march 14 and april 8 were calculated by dividing the current rate by the older rate. the ratio represents how many times higher the current rate is compared to the older rate. covid-19-related mortality was assessed by calculating two estimates: percent of deaths in a county relative to the total number of deaths in colorado and case fatality rate. the latter measurement was estimated by dividing county-level cases by county-level deaths and multiplying by 100. whose influence decreases as the distance increases from its sampled location [33] . the idw maps represent crude hotspots of covid-19 incidence displayed from high (red) to low (blue) rates. to estimate the change in disease incidence, rate ratios comparing county-level covid-19 incidence rate differences between march 14 and april 8 were calculated by dividing the current rate by the older rate. the ratio represents how many times higher the current rate is compared to the older rate. covid-19-related mortality was assessed by calculating two estimates: percent of deaths in a county relative to the total number of deaths in colorado and case fatality rate. the latter measurement was estimated by dividing county-level cases by county-level deaths and multiplying by 100. covid-19 outbreak data [34] , which cdphe began releasing on april 15, 2020 consisting of cases and deaths, associated with facilities by county, mainly for senior living, but also including meat-packing plants and jails, were also evaluated from march 11 to april 8. to contextualize covid-19 emergence, county-level profiles were generated to compare descriptively the wider social and health (i.e., chronic conditions, mainly) determinants context in colorado. rate ratios were calculated for each of the health outcome variables and social determinants of health indicators by dividing the county-level value by the state average. similar profiles and rate ratios were utilized to contextualize mental health and housing disparities at the census tract-level in colorado [27] . potential associations between covid-19 incidence and death rates with social and health determinants were estimated using pearson's correlation in ibm-spss (ibm corp., armonk, ny, usa) [35] . lastly, using rate ratios described earlier, the spatial overlap of counties with several chronic conditions above the state average were compared with counties with higher rates of covid-19 incidence. covid-19 outbreak data [34] , which cdphe began releasing on april 15, 2020 consisting of cases and deaths, associated with facilities by county, mainly for senior living, but also including meat-packing plants and jails, were also evaluated from march 11 to april 8. to contextualize covid-19 emergence, county-level profiles were generated to compare descriptively the wider social and health (i.e., chronic conditions, mainly) determinants context in colorado. rate ratios were calculated for each of the health outcome variables and social determinants of health indicators by dividing the county-level value by the state average. similar profiles and rate ratios were utilized to contextualize mental health and housing disparities at the census tract-level in colorado [27] . potential associations between covid-19 incidence and death rates with social and health determinants were estimated using pearson's correlation in ibm-spss (ibm corp., armonk, ny, usa) [35] . lastly, using rate ratios described earlier, the spatial overlap of counties with several chronic conditions above the state average were compared with counties with higher rates of covid-19 incidence. figure 2 shows the spatial distribution of covid-19 cases (dot density) and incidence rates for march 14, 2020 and april 8, 2020. on march 14, there were 101 cases of covid-19 and 3 deaths distributed across 15 counties. the first cases reported in colorado were mainly located in mountain communities in the rocky mountain west (e.g., eagle, gunnison, and summit counties), the denver metropolitan region (e.g., arapahoe, denver, douglas, and jefferson counties), the northern area of the urban front range (weld and larimer), and el paso county (see figure 2 top panel). by april 8, colorado reported a total of 6202 cases of covid-19, 226 deaths, and 1221 hospitalizations. on april 8, the highest number of cases (n = 549) and deaths (n = 34) were documented. the state incidence rate was 108.9 (per 100,000 persons), the case fatality rate was 3.6%, and 19.7% of cases were hospitalized. as figure 2 (bottom panel) illustrates, the number of counties that reported covid-19 cases increased, from 15 to 56 out of 64 counties. the highest and lowest incidence rates (excluding counties without cases) were reported in eagle county (718.2 per 100,000) and prowers county (8.3 per 100,000). figure 2 shows the spatial distribution of covid-19 cases (dot density) and incidence rates for march 14, 2020 and april 8, 2020. on march 14, there were 101 cases of covid-19 and 3 deaths distributed across 15 counties. the first cases reported in colorado were mainly located in mountain communities in the rocky mountain west (e.g., eagle, gunnison, and summit counties), the denver metropolitan region (e.g., arapahoe, denver, douglas, and jefferson counties), the northern area of the urban front range (weld and larimer), and el paso county (see figure 2 top panel). by april 8, colorado reported a total of 6202 cases of covid-19, 226 deaths, and 1221 hospitalizations. on april 8, the highest number of cases (n = 549) and deaths (n = 34) were documented. the state incidence rate was 108.9 (per 100,000 persons), the case fatality rate was 3.6%, and 19.7% of cases were hospitalized. as figure 2 (bottom panel) illustrates, the number of counties that reported covid-19 cases increased, from 15 to 56 out of 64 counties. the highest and lowest incidence rates (excluding counties without cases) were reported in eagle county (718.2 per 100,000) and prowers county (8.3 per 100,000). figure 3 displays the spatial progression of covid-19 incidence across five time points: march 14, march 18, march 25, april 1, and april 8. incidence rates are displayed from high (red) to low (blue) intensity. initially, the centers of covid-19 incidence were the mountain communities and ski towns, popular tourist destinations, west of denver. by march 25, the spread of covid-19 incidence expanded along the urban front range, where centers of risk were quickly evolving from denver and its metropolitan counties to el paso (south of denver) and weld (north of denver) counties. the geography of low risk (blue) diminished greatly across the state. on march 25, 36 counties were reporting cases of covid-19, which then increased to 51 counties by april 1. between april 1 and april 8, the intensity of covid-19 risk around denver and northern colorado, e.g., weld county, had vastly increased. there were also new possible centers of risk in southeastern colorado (e.g., baca), and counties north and south (e.g., pitkin) of gunnison, eagle and summit. figure 3 displays the spatial progression of covid-19 incidence across five time points: march 14, march 18, march 25, april 1, and april 8. incidence rates are displayed from high (red) to low (blue) intensity. initially, the centers of covid-19 incidence were the mountain communities and ski towns, popular tourist destinations, west of denver. by march 25, the spread of covid-19 incidence expanded along the urban front range, where centers of risk were quickly evolving from denver and its metropolitan counties to el paso (south of denver) and weld (north of denver) counties. the geography of low risk (blue) diminished greatly across the state. on march 25, 36 counties were reporting cases of covid-19, which then increased to 51 counties by april 1. between april 1 and april 8, the intensity of covid-19 risk around denver and northern colorado, e.g., weld county, had vastly increased. there were also new possible centers of risk in southeastern colorado (e.g., baca), and counties north and south (e.g., pitkin) of gunnison, eagle and summit. table 1 shows the change in covid-19 incidence rates between march 14 and april 8 expressed as ratios. the counties by rank order according to the greatest increase in disease incidence are displayed. the greatest positive change in covid-19 incidence was observed in weld county, where the rate increased by 204.7 times, followed by el paso and larimer counties, both where rates increased by approximately 174-178 times since march 14. table 2 shows the counties with greatest percentage of deaths and their case fatality rates by april 8. five counties (denver, weld, el paso, jefferson, and arapahoe) accounted for 76.7% of all deaths in colorado. among these counties, weld and el paso had the highest case fatality rates. in general, the highest percentages of deaths were located along the urban front range, whereas the highest case fatality rates were generally located in rural counties outside of the urban front range (see table a1 in appendix a), with the exception of el paso. figure 4 displays the number of covid-19 outbreaks associated with facilities, mainly for senior living, but also including meat packing plants and jails. a total of 63 outbreaks were reported from march 11 to april 8, 2020. outbreak-related cases and deaths accounted for 12.9% and 55.3% of the total covid-19-related morbidity and mortality in colorado. the counties of arapahoe and denver reported the highest number of outbreaks (n = 30 in total). the highest number of covid-19 cases and deaths associated with outbreaks were documented in weld, arapahoe, and denver counties. together these three counties represented an estimated 61.6% (n = 492) and 64.8% (n = 81) of all outbreak-related cases and deaths. among these counties, weld was the most affected with a reported 204 cases and 27 deaths. table 3 lists the number of covid-19 outbreaks with cases and deaths sequentially from march 11 to april 8. as table 3 indicates, beginning on march 23, covid-19 outbreaks were reported every day, with the exception of march 26, until april 8. on april 3 the highest number of outbreaks, cases and deaths were documented. approximately 40.0% (n = 102) of covid-19 case counts on april 3 were linked to an outbreak at a meatpacking plant in weld county [21] . table 3 lists the number of covid-19 outbreaks with cases and deaths sequentially from march 11 to april 8. as table 3 indicates, beginning on march 23, covid-19 outbreaks were reported every day, with the exception of march 26, until april 8. on april 3 the highest number of outbreaks, cases and deaths were documented. approximately 40.0% (n = 102) of covid-19 case counts on april 3 were linked to an outbreak at a meatpacking plant in weld county [21] . preliminary associations with social and health determinants and covid incidence were assessed descriptively that highlight ratios comparing values of indicators generally with state averages. table 4 shows profiles of the seven counties with the highest covid-19 incidence rates in colorado. in bold are ratios above 1 which generally represent the number of times higher a variable is compared to the state average for variables that suggest higher social vulnerability (the exception is the per capita income variable where a higher ratio indicates a higher socioeconomic status and therefore, suggests less social vulnerability). some indicators that appear significant (e.g., by frequency) include limited english, single parent household, no health insurance, multiple unit structures, overcrowding, housing cost burden, and population density. other indicators, although not as frequent suggest that covid-19 incidence overlapped with higher rates of chronic conditions like asthma and diabetes, and also influenza, particularly in denver, morgan, and weld counties. using pearson's correlation, the analysis showed that covid-19 incidence rates were positively associated with per capita income (r = 0.32, p-value = 0.009) and multiple unit structures (r = 0.40, p-value = 0.001), and negatively associated with mobile homes (r = −0.31, p-value = 0.014). the aforesaid correlations, although not causative, suggest urban settings, relative to rural settings were at greater risk for covid-19 incidence. another correlation analysis focused on percentage of covid-19 deaths and social and health determinants further supported an urban connection to incidence (see table 5 ). in addition to per capita income and multiple unit structures, population density and asthma hospitalizations were significantly and positively associated with percentage of covid-19 deaths, as well as minority, all variables that are characteristic of urban areas. among these variables population density had the strongest association (r = 0.60; p-value = 0.000). cdc reports higher cumulative incidence of covid-19 in urban areas with greater concentrations of people and interactions, which may facilitate a greater exposure to airborne transmission of the virus, e.g., in mass gatherings, events [36] , and public transit [37] . table 6 displays associations between social and health determinants and the case fatality rates of covid-19. unlike percentage of deaths and incidence, the case fatality rates of covid-19 suggest that rural areas are at greater risk to death. social determinants such as poverty and unemployment, variables which have higher prevalence in rural areas in colorado, were significantly and positively associated with covid-19 case fatality rates. although many of the counties with the highest case fatality rates in colorado are places with smaller populations, which can be misleading, these areas are least equipped to manage covid-19 risk. for example, many rural counties depend on medicaid (~38.7%) and several are without hospitals (~23.4%), according to the colorado health institute [38] . in addition, internet disparities may affect rural populations' access to covid-19-related information for prevention and to seek care. broadband access is not widely available in rural areas in colorado and approximately 23.0% of the rural population does not have access to high-speed internet [39] . table 7 compares rate ratios of covid-19 incidence with an array of multiple chronic conditions in counties with higher incidence rates of covid-19. cancer and heart disease represent age adjusted mortality rates. as the table indicates, 31.6% (n = 6) of these counties had at least three out of five chronic conditions with rates above the state average. half of the counties with multiple chronic conditions were located along the urban front range, while the other half of counties were located in rural eastern colorado. initial reports of covid-19 risk show that individuals with pre-existing chronic conditions such as hypertension, asthma, diabetes, and cancer may increase the chances for severe illness and death [15] [16] [17] . in our county-level study, the preliminary findings suggest a potential association between asthma hospitalization and covid-19 deaths (%) and potential spatial overlap with covid-19 incidence at the population-level. among counties with covid-19 incidence rates above the state average, 42.1% (n = 8) of counties also had higher rates of asthma hospitalizations. according to national jewish health [40] , it is possible that covid-19 may have a greater impact on asthma sufferers, which may experience more severe symptoms. in new york city, 5.0% of covid-19 patients were also comorbid with asthma [41] , although this percentage, thus far, is lower than what researchers expected [42] . by far, diabetes has been the most frequent pre-existing chronic condition associated with disease severity of covid-19 [15] . although a significant association between diabetes and covid-19 incidence or death was not found in our analysis, this present study did find that 36.8% of counties (n = 7) with higher incidence of covid-19 also had higher rates of diabetes hospitalizations. another chronic condition that frequently overlapped with higher incidence rates of covid-19 in colorado was cancer incidence (31.6%, n = 6 counties). initial research shows that cancer patients that contracted covid-19 appear to be more likely to experience multiple severe outcomes [17] . in summary, this rapid analysis examined the geographic patterns of covid-19 emergence during an initial period of spatial progression across counties in colorado. from march 14 to april 8, 2020, covid-19 incidence intensified around the first areas of detection, i.e., mountain communities and ski towns west of denver (e.g., eagle and gunnison) and north and south of denver's metropolitan area (e.g., weld and el paso), and evolved into new hot spots of risk north and south of eagle county, and in eastern colorado. overall the greatest increase in covid-19 incidence rates was observed in weld county, which reported the highest incidence rate along the urban front range, even higher than counties within denver's metropolitan area. weld county also had the second highest percentage of deaths in colorado, and the greatest number of cases and deaths associated with outbreaks at many senior living facilities and a meat packing plant, in particular, where 245 persons were infected of which 6 died [43] . a preliminary analysis of covid-19 incidence and deaths reveals that percentage of deaths are higher along the urban front range, while the rate of death (i.e., case fatality) is potentially higher in some rural counties with smaller populations. some social and health determinant factors associated (not causal) with patterns of higher covid-19-related death rates were population density and asthma hospitalization, suggestive of urban areas, and poverty and unemployment, suggestive of rural areas. although in general chronic conditions were not correlated with covid-19 incidence, except asthma, an assessment of spatial overlap of multiple chronic conditions with covid-19 suggests that areas of higher rates of several chronic conditions (e.g., diabetes and cancer) may potentially coincide (i.e., at the county-level) with areas of higher rates of covid-19. in colorado, the number of people diagnosed with multiple chronic conditions has been rising. in 2015, the prevalence of multiple chronic conditions (mccs) among colorado's adult population, particularly older individuals-a growing demographic-was 35.2% [44] , an estimate significantly higher than the u.s. average (25.7%). as chronic conditions accrue, they decrease the quality of life and increase risk for mortality [45] . for public health, this may suggest a higher number of individuals vulnerable to covid-19 in certain counties, and draws attention to a larger syndemic health problem where synergies between covid-19 intersect with mccs, as well as inequality of social determinants of health. as lockdown restrictions began to ease in colorado in early may [46] , as well as across the u.s., the state reported 16,635 confirmed and probable cases of covid-19, 842 deaths, and 163 outbreaks at facilities, many senior living-related, across 56 counties [6] . colorado at this time ranked second among states in the u.s. west in the number of cases and deaths [7] . as the number of covid-19 cases continue to rise, racial and ethnic disparities in covid-19 incidence increase as well. approximately, 45.3% of cases are hispanics and blacks (as of may 3), even though these communities only make up 25.6% of colorado's population [6] . although testing in colorado has increased (as of may 3, 81,352 persons have been tested), the capacity to adequately address the pandemic in the state remains limited by supply (according to the governor) [47] . colorado's covid-19 response is also challenged by the ability of communities to decrease exposure to covid-19 by social distancing, an important preventive measure for respiratory diseases. according to the colorado health institute [48] , which developed an index in colorado based on overcrowding, population density, and workplace data (e.g., essential workers), the practice of social distancing is challenging for lower income persons and communities of color, including immigrants, because of crowded housing and work that requires they be present and work in close proximity to others. the colorado health institute index suggests that social distancing is not only a problem for urban areas in the denver metro, such as the suburbs of adams county. it is also a challenge for rural communities within counties such as weld, where there is a higher proportion of persons working in low-wage essential jobs [48] with greater exposures to covid-19, and the least capacities to cope with health effects (e.g., with health insurance) and the economic fallout. this study has several limitations given the nature of a rapid study (i.e., short time frame) and the rapidly evolving context of the pandemic, which includes changes to the counts of new cases and deaths as new information updates previous daily summaries posted online. the most recent assessment of case counts in colorado shows a difference of 26 cases between the estimate used in this study for april 8 and may 3, for example [6] . that is approximately a 1% difference in cases. additionally, testing is limited in colorado, and information by county is not yet available publicly to gain a better understanding of how widespread covid-19 was geographically. furthermore, the study did not have access to geographic-level race/ethnicity or socioeconomic information about covid-19 incidence. therefore, evaluating the impact of social determinants on communities of color through correlations at the population-level is only a preliminary view. lastly, the urban/rural differences (e.g., higher death rates and unemployment in rural areas) found in this study warrant further examination since we only analyzed county-level estimates. conducting a finer analysis with more locally spatial information including socioeconomic and race/ethnicity data, for example, may reveal that within counties death rates are much higher in urban areas with high unemployment, poverty and other social disparities, as a recent study has shown in massachusetts [18] . nevertheless, our study provides potential insights for future investigators to consider when additional covid-19 data becomes available, including census tract-level estimates and demographic information to better understand geographic patterns and social and health risk factors. 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determinants of influenza hospitalization in the united states. influenza respir neighborhood socioeconomic status and influenza hospitalizations among children united states cancer statistics: data visualizations; cancer burden: co, usa environmental systems research institute (esri) esri. how inverse distance weighted (idw) works. available online ibm-spss statistics for windows, version 25.0; ibm corp geographic differences in covid-19 cases, deaths, and incidence-united states revealed: nearly 100 us transit workers have died of covid-19 amid lack of basic protections blazing a trail for colorado: a rural health strategy for medicaid and medicare. colorado health institute as important as electricity. the coloroado trust covid-19 and asthma covid-19 fatalities asthma is absent among top covid-19 risk factors, early data shows. the new york times leads nation for most covid-19 deaths connected to meat processing plants chronic disease state plan multiple chronic conditions: a public health challenge why did polis ease coronavirus restrictions? because, he says, many 'simply can't pay their rent' if they stay home colorado is rapidly increasing its coronavirus testing capacity and supplies are on the way colorado covid-19 social distancing index: maps identify neighborhoods and towns least able to socially distance this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-256041-k4y6t0i5 authors: gómez-salgado, juan; andrés-villas, montserrat; domínguez-salas, sara; díaz-milanés, diego; ruiz-frutos, carlos title: related health factors of psychological distress during the covid-19 pandemic in spain date: 2020-06-02 journal: int j environ res public health doi: 10.3390/ijerph17113947 sha: doc_id: 256041 cord_uid: k4y6t0i5 measures to prevent and contain the covid-19 health crisis include population confinement, with the consequent isolation and interruption of their usual activities. the aim of the study is to analyse psychological distress during the covid-19 pandemic. for this, a cross-sectional observational study with a sample of 4180 people over the age of 18 during quarantine was developed. variables considered were sociodemographic variables, physical symptoms, health conditions, covid-19 contact history and psychological adjustment. the data were collected through a self-developed questionnaire and the general health questionnaire (ghq-12). bivariate analyses were performed, including chi-squared test and student’s t-test. predictive ability was calculated through logistic regression. results obtained showed a high level of psychological distress (72.0%), with a higher percentage in women and people of lower middle age. statistically significant differences were found in the variable working situation (χ² = 63.139, p ≤ 0.001, v = 0.123) and living with children under the age of 16 (χ² = 7.393, p = 0.007, v = 0.042). the predictive variables with the highest weight were sex (or = 1.952, 95% ic = (1.667, 2.286)), presence of symptoms (or = 1.130, 95% ci = (1.074, 1.190)), and having had close contact with an individual with confirmed covid-19 (or = 1.241, 95% ci = (1.026, 1.500)). these results could enrich prevention interventions in public health and, in particular, in mental health in similar pandemic situations. coronavirus disease 19 has created a rapidly widening health crisis with dramatic consequences. on 31 december 2019, the wuhan municipal health commission in china notified the world health organization (who) of 27 cases of pneumonia of unknown origin [1] . on 30 january 2020, who declared an international public health emergency following the covid-19 outbreak that began in wuhan, china. by that date, 83 cases had been identified across 18 different countries outside china [2, 3] . following the increase in the spread to more than 118,000 cases in 114 countries and 4291 deaths, on 11 march 2020, who reported its pandemic consideration [4] . as a result of the rapid evolution of in spain, being female, younger, having negative self-perceptions about aging, being more time exposed to news about covid-19, having more contact with relatives different to those with whom they co-reside, fewer positive emotions, less perceived self-efficacy, lower quality of sleep, the higher expression of emotion and higher loneliness have been associated with psychological distress during isolation measures as a result of the covid crisis [38] . this variability in the risk and protective factors of psychological distress against covid-19 suggests the need for further epidemiological studies to consolidate the results. although there is agreement on the increase of psychological distress in the population during the pandemic, the characteristics of this situation are disparate, and the phenomenon is not yet clearly described [39] . the objective of the study is to analyse the psychological distress in a spanish population sample during the covid-19 pandemic, identifying the predictive character and role that sociodemographic variables, the presence of physical symptoms, and other health-related variables may have. as a hypothesis, it is stated that the health crisis caused by covid-19 does not generate psychological distress in the population. this research employed a cross-sectional observational study design. the initial sample consisted of 4615 people, recruited between march 26 (13 days after the start of confinement) and april 26. as inclusion criteria for the participants, the following were established: (i) being 18 years of age or older, (ii) living in spain during the covid-19 pandemic, and (iii) accepting the informed consent. 435 questionnaires were eliminated for having a percentage of questions answered of less than 99%, which resulted in a final sample of 4180 participants distributed in 50 provinces and the two small spanish autonomous cities located in north africa. based on the sociodemographic characteristics of the sample, 74.0% were women and 26.0% men. the distribution by sex of the spanish general population is 49.0% women and 51.0% men [40] . the average age of the participants stood at 40.26 years (sd = 13.18). the most common marital status was married or living as a couple (57.8%) followed by being single (33.9%). most of the participants had university studies or higher educational level (76.9%) and the 20.0% had upper secondary education. demographic data of the general spanish population indicate that 17% of the population has university studies [40] . in relation to the employment situation, the 44.7% of the subjects were working away from home, 20.7% worked exceptionally from home (teleworking), and 34.5% were not working at the time of their participation in the studio. most participants (70.1%) were spending covid-19 confinement in a flat or apartment and the 28.8% was confined in a house. the 48.4% of the participants stated that they lived with children or youngsters under the age of 16 at the time of their participation in the study. lastly, 9.1% indicated that they cohabited with people with disabilities. this study aims to collect information on varied dimensions to assess the mental health and associated behaviours of the general population so as to assess the impact of this health crisis. therefore, the dependent variable was psychological adjustment and as independent variables sociodemographic data, the presence of physical symptoms of covid-19, participants' health status, and history of possible contacts or exposure to covid-19 were considered. the sociodemographic variables included were sex, age, marital status, education level, employment status, number of people living with, living with a child or adolescent, and living with a disabled person. the participants were asked about the prevalence of the most common symptoms of covid-19 indicated by who over the past 14 days [41] : fever equal to or greater than 38 • c, cough, headache, myalgia, dizziness, diarrhoea, sore throat, coryza, chills, and difficulty in breathing. a self-developed questionnaire was designed including the symptoms as items and dichotomous responses ("yes/no"). in relation to the state of health, the level of the participants' current physical and mental health was assessed through dichotomous response questions ("yes/no") to the following items: suffering a chronic illness, having a disability, taking some medication, having been hospitalised in the last 14 days, and having been attended by some health service in the last 14 days. to this end, the process was based on wang et al. approach [16] . an item with five response options was used to measure perceived health: very bad, bad, not so good, good, and very good. this indicator was initially proposed by ilder and benyamini [42] and used with small variants, in subsequent pandemic research [13, 16, 23, 43] . it was assessed whether the person was quarantined due to having had a risk contact or covid-19 infection, as well as whether they had had a covid test. the contact history was evaluated by three questions with three answer categories (yes, no, i don't know), which evaluate direct/indirect contact with infected people or with people or materials suspected of being infected. a fourth taxonomic item ("yes/no") assessed cohabitating with people at risk of being infected. psychological adjustment was measured through the general health questionnaire (ghq-12), a psychometric instrument widely used as a screening of non-psychotic psychiatric disorders [44] . it consists of 12 items with four answer options. each item can get a score of 0 (if options 1 or 2 are chosen) or 1 (if options 3 and 4 are selected), getting from its sum a total score ranging from 0 to 12. this questionnaire developed by goldberg has been translated and validated in many countries, presenting cronbach's alpha values from 0.82 to 0.86 [44] and demonstrating, in addition, a good reliability in its version for spanish speakers with 0.86 and 0.76 in the spanish population [45, 46] ; it has also been previously used in other sars-like epidemics [23] . for this study, the overall score was used as a single factor whose reliability, estimated by cronbach's alpha, was of 0.851. the cut-off point set for the general population was 3, considering those subjects with scores greater than or equal to 3 more prone to potential psychiatric morbidity cases [47, 48] . the independent variables were assessed through a self-elaborated questionnaire. for the design of the questionnaire, a bibliographic review was carried out on the psychological effect that other epidemics, and their prevention measures, had had on the population in the past. with the accumulated evidence, a first version of the instrument was built and evaluated by a panel of experts made up of 10 health professionals: three doctors, four nurses, and three psychologists, two of which were specialists in clinical psychology. after the appropriate modifications were made, piloting was carried out with 57 participants, obtained through a sampling for convenience, all over 18 years of age and with a similar proportion of men and women in the sample (50.9% and 49.1%, respectively) and an average age of 41.87 (sd = 11.86). most participants reported being married (56.1%) and having completed postgraduate studies, whether a master's or doctoral degree (57.9%). they were all asked to complete the survey from different electronic devices. none of the participants expressed comprehension problems or doubts about what they were asked, nor were there any errors regarding the platform or design on the different devices (personal computer, tablet or smartphone) used by the participants. data were collected through the online data collection and survey platform qualtrics ® xm. as a telematics application, the confinement measures decreed by the health alarm state did not affect data collection. the sampling method was through the "snowball" effect, initiated by sending the information through email lists to universities and professional colleges who were asked to facilitate their dissemination. the helsinki declaration [49] has been taken into consideration. participation in the study was entirely voluntary, and the explicit permission of the participants was obtained through informed consent for the confidential use and processing of data, according to the current laws in force on the protection of personal data. data were stored anonymously, with the assignment of a registration number so that it was not possible to identify the participants' responses. the project was approved by the research ethics committee of huelva, belonging to the andalusian ministry of health (pi 036/20). the analyses were performed using the spss 26.0 version statistical software (ibm, armonk, ny, usa)-an initial descriptive analysis was performed by calculating the means and frequency of the variables. the presence or non-presence of psychological distress was studied in each of the independent variables. subsequently, bivariate analyses were performed, including chi-squared test and student's t-test for independent samples, depending on the type of variable. the size indexes of the crammer's v and cohen's d effect were also calculated with the following cut-off points: 0 to 0.19, negligible; 0.20 to 0.49, small; 0.50 to 0.79, medium; from 0.80 on, high [50] . then, with the aim of studying the predictive ability for psychological distress of the different sets of variables, logistic regression analyses (controlled by sex and age) were carried out including variables with p value < 0.05. thus, model 1 included sociodemographic variables, and model 2 was related to physical symptoms, model 3 showed health-related variables, and model 4 dealt with contact history. finally, those variables that showed a predictive character in each of the models were included in a global model (model 5). odds ratios (ors) were calculated with a 95% confidence interval. table 1 details the mean scores and standard deviations of the answers provided by the subjects in each of the questions that make up the ghq-12. the results show that items 5 "have you been constantly felt overwhelmed and tense?" (m = 2.88; sd = 0.88) and 7 "have you been able to enjoy your normal activities every day?" (m = 2.81; sd = 0.87) were the ones with the highest score. on the contrary, the items that presented a lower score were the item 11 "have you thought that you are a person who is worthless?" (m = 1.40; sd = 0.77) and item 10 "have you lost self-confidence?" (m = 1.78; sd = 0.90). the average score obtained in the total of the 12 points scale was 4.99 (sd = 3.44). establishing a cut-off point of 3 or more points, the results showed that a 72.0% of the 4180 study participants presented psychological distress. in the light of the sociodemographic variables (table 2) , the results showed statistically significant differences between both groups as for sex (χ 2 = 174.332, p ≤ 0.001, v = 0.204) and age (t = 9131, p ≤ 0.001, cohen's d = 0.337), though effect sizes were small. a greater presence of psychological distress was observed in women (79.6%) and in persons of lower middle age (m = 39.03, sd = 12.42) with respect to the group that did not present this psychic morbidity (m = 43.43, sd =14.51). statistically significant differences were also found regarding the variable working situation (χ 2 = 63.139, p ≤ 0.001, v = 0.123) and in terms of living with children or youngsters under the age of 16 (χ 2 = 7.393, p = 0.007, v = 0.042). the highest percentage of psychological distress was observed among people who were working outside home (48.5%), and a low percentage of psychological distress was observed among people living with children or youngsters under the age of 16 (49.7%). in relation to the presence of symptoms in the 14 days prior to the participation in the study (table 3) , more than half of the sample claimed to have had headache (53.3%); cough (30.6%), myalgia (29.3%), sore throat (27.2%), and coryza (20.1%). to a lesser extent, subjects reported having suffered from diarrhoea (17.1%), dizziness (13.0%), chills (12.2%), breathing difficulty (7.6%), and fever higher than 38 • c for at last one day (3.1%). on the other hand, according to the number of symptoms, the highest percentage (35.6%) stated that they had developed three or more symptoms in the 14 days prior to their participation in the study, followed by 23.4% of participants who had not developed any of these symptoms. similar percentages were among those who reported having had a symptom (20.7%) and two symptoms (20.4%). statistically significant differences were observed between the presence of physical symptoms and psychological distress (p < 0.001 in all cases). statistically significant differences were also found regarding the mean number of symptoms (t = −16.347, p ≤ 0.001, cohen's d = 0.510), with an average effect size. the group of subjects with psychological distress had a higher number of symptoms (m = 2.40, sd = 1.99), as compared to the group that did not present this psychic morbidity (m = 1.44, sd = 1.57). based on health-related variables (table 4) , 29 .8% of respondents reported suffering from some form of chronic disease. among these subjects, the most commonly reported diseases were high blood pressure (29.0%) and chronic respiratory disease (25.3%), and to a lesser extent diabetes (8.3%), immunosuppression disease or situation (7.0%), metabolic syndrome (5.9%), chronic cardiovascular disease (5.0%), and active cancer (2.6%). referring to the need for medical care, 0.6% of subjects reported having been hospitalised in the last 14 days, and 9.2% reported receiving healthcare at a health centre, clinic, or hospital. 4.9% of participants reported being quarantined for covid-19 symptoms and 9.9% reported the diagnostic test (69.2% negative, 22.2% positive, and 8.7% do not know the result). the variables related to the presence of psychological distress were the need for healthcare in a health centre, clinic, or hospital (χ 2 = 20.902, p < 0.001, v = 0.071), having been quarantined (χ 2 = 14.989, p < 0.001, v = 0.060), and having been done the diagnostic test (χ 2 = 27.174, p < 0.001, v = 0.081). for all of them, the size of the effect was negligible. lastly, and taking into account the subjects' assessment of their perceived health in the last 14 days, the results also showed statistically significant differences between the two groups (t = 15.425, p ≤ 0.001, cohen´s d = 0.540), with an average effect size. the group of subjects with psychological distress expressed a worse assessment of their health (m = 3.89, sd = 0.77), as compared to the group without psychological distress (m = 4.29, sd = 0.66). in relation to contact history in the last 14 days (table 5 ), 42.7% of participants reported having maintained or not knowing if they had maintained close contact with an individual with confirmed infection with covid-19. 49.0% of respondents claimed to have had casual contact, and 59.7% said they had maintained or did not know if they had maintained contact with any person or material suspected of being infected with covid-19. in relation to the presence of infected people in the participants' immediate circle, 80.4% indicated not having a relative infected with the virus and 96.7% said they did not live with any confirmed infected family members. all contact history variables in the last 14 days showed a statistically significant relationship with the presence of psychological distress (p <.05 in all cases). however, the effect sizes were negligible. logistic regression analyses have shown an adequate adjustment in general and an explained variance of 17.9% in the overall model, with correct classification percentages of each model around 73%, which has allowed to identify the predictive variables of psychological distress. logistic regression models, controlled by sex and age, are displayed in table 6 . model 1 (sociodemographic variables) showed a predictive ability of 9.8% (χ 2 = 292.808, p < 0.001). the result of the hosmer-lemeshow test indicated that this model did not present a good fit (χ 2 = 22.806, p = 0.004). sex, specifically female (or = 2.316, 95% ci = (1.991, 2.694)), age (or = 0.977, 95% ci = (0.72, 0.982)), and employment situation were predictive, correctly classifying 72.8% of subjects with sensitivity and specificity parameters of 96.4% and 11.9%, respectively. with model 2, regarding physical symptoms, the variance value explained amounted to 12.6% (χ 2 = 380.970, p < 0.001). those participants who had a higher number of symptoms in the 14 days prior to their participation in the study (or = 1.301, 95% ci = (1.245, 1.360)) were more likely to present psychological distress. this model correctly classified 73.0% of participants (sensitivity 95.0% and specificity 16.5%). model 3, which includes health-related variables, had a predictive capacity of 14.8% (χ 2 = 448.018, p < 0.001), slightly higher than the previous model. this model provided sensitivity and specificity values of 95.1% and 19.4%, correctly classified to 74.0% of the sample. however, it did not present a good fit (hosmer-lemeshow chi-squared value =26.294, p < 0.01). participants with a higher score in self-rated health (or = 0.474, 95% ci = (0.424, 0.530)) were less likely to present psychological distress. however, those subjects who had recently been diagnosed with covid-19 were 1.365 times more likely to have psychological distress (95% ci = 1.014, 1.838) . the contact history variables are included in model 4, which provided an explained variance rate of 11.1% (χ 2 = 333.388, p < 0.001). having had a close contact with an individual with confirmed infection with covid-19 (or = 1.391, 95% ci = (1.137, 1.701) ), as well as having had any contact with any person or material suspected of being infected (or = 1.415, 95% ci = (1.176, 1.702)) had predictive ability, correctly classifying 72.9% of the participants (95.3% sensitivity and 15.3% specificity). finally, model 5 (global model), which included the variables that had a predictive character in the previous models, presented a predictive ability of 17.9%, correctly classifying 74.5% of the participants (93.5% sensitivity and 25.7% specificity). the variables that showed the greater weight, with ors greater than 1, were sex (or = 1.952, 95% ci = (1.667, 2.286)), number of symptoms presented in the last 14 days (or = 1.130, 95% ci = (1.074, 1.190)), having had close contact with an individual with confirmed infection with covid-19 (or = 1.241, 95% ci = (1.026, 1.500)), and having had contact with any person or material suspected of being infected (or = 1.258, 95% ci = (1.052, 1.503)). other predictive variables with ors less than 1 were age, employment status, and self-rated health. in this study, various sociodemographic variables, variables related to the presence of physical symptoms, and other health-related ones have been identified as predictors of the presence of psychological distress symptoms among the spanish population during a period of health alert due to the covid-19 epidemic. in spain, during the initial moments of confinement, 72.0% of the study participants showed risk of psychiatric morbidity (or distress). this figure is much higher than the ones found in previous studies carried out on the spanish population, that placed psychiatric morbidity at 18.0% [51] or 19.1% [52] , not having subsequent data [42] . specific studies on the psychological impact during epidemics place the prevalence of psychological distress between 22.9% and 56.7% [20] [21] [22] [23] [24] 53] . in our study, the highest percentage level of psychological vulnerability during an epidemic can be found. these high results may be due to the fact that the covid-19 pandemic in our country has affected the spanish population in a more serious way than previous pandemics and the feeling of alarm is greater. as for the role that sex may play in relation to psychological vulnerability in epidemic situations, some studies have found that being male was associated with greater distress during the recovery period of sars [20] but, in most studies, females were associated with greater vulnerability. women are found to suffer greater distress during the h 1 n 1 influenza outbreak [28] or during equine influenza [21] , and a longitudinal study on the impact of the sars outbreak in hong kong [54] found that women were more likely to suffer anxiety. one of the first studies conducted during the covid-19 epidemic identified an increased risk of anxiety, depression, and stress among women [16] . as for the general indicators of mental health in spain, being a woman is associated with greater vulnerability [51]. our results are in line with those found in most studies, showing that women present significantly higher levels of distress (with low size effect), and this can therefore be understood as an individual risk factor in the face of the impact of the covid-19 epidemic. the results show that, although weakly, younger people are at higher risk of suffering higher levels of distress. these data are consistent with those from previous studies in epidemic states, and in which being younger was associated with an increased risk of distress [21] or increased psychiatric morbidity [53] . however, a study similar to the present one conducted at the beginning of the covid-19 quarantine identified an increased risk of psychological distress among people over 60 years of age [33] . mental health indicators in spain show that psychiatric morbidity increases with age [49] . our data indicate that the youngest part of the study population is the one with the highest psychiatric morbidity. this result can be understood in line with sim [53] and taylor [21] , due to the relationship they establish regarding differences in coping styles. thus, youngest adults are less resilient in the face of adversity and also less able to understand that it is an extreme situation that implies radical and sudden changes in the lives of people, and which are not the result of an individual decision. as for the relationships found between the degree of distress and living with children during confinement, the data showed that people with children have a greater psychological vulnerability. however, the effect size was negligible. this result coincides with those by taylor's study [19] which suggests that people with a child are more likely to have psychological distress, explaining that those who have a child are usually younger adults and hence the association with the greatest risk. on the other hand, as brooks [10] and naushad [29] state, there is no link between having children and any psychological impact in their reviews. however, mazza et al., in their recent study, conducted during the covid-19 crisis in italy, identified an association between having no children and a higher level of depression [36] . in relation to the employment situation, most previous studies have analysed the role of economic income and its changes as a result of labour measures taken during an epidemic. thus, reduced or low level of economic income was consistently related to an increased risk of psychological impact [10, 13, 21] . general indicators of mental health in spain show that low levels or lack of economic income, as well as lack of employment, are associated with lower mental health [51] . our data, however, indicated, weakly, that in the pandemic situation by covid-19, those who have to work away from home had a higher level of distress. this outcome can be related with a higher risk of contagion and concern for all its consequences, as they can spread the disease to the family and due to the high degree of uncertainty about the disease. in this line, mihashi's study [20] shows how the perception of risk is associated with psychiatric morbidity during and after recovery of sars. on the other hand, the results obtained by jahanshahi et al. on the effects of covid-19 quarantine in iran suggest that participants who had to stop working because of the pandemic had more psychological distress than those who worked from home or at their workplace [34] . quarantine for at least 14 days is associated with increased anxiety and anger [14] , as well as with increased symptoms of post-traumatic stress disorder [13, 19, 30] . our data showed that quarantine was associated with increased psychiatric morbidity (negligible size effect). in the line posed by hawryluck et al. [13] , being quarantined can be interpreted by these people like trauma or personal assault. our study coincides with previous ones associating perceived low health with a higher level of stress and psychological impact in general [16, 53] . we have also observed, with an average size effect, that a worse perception of health was linked to increased psychiatric vulnerability. the presence of covid-19 symptoms was also related to the level of distress, so the presence of some symptoms can be considered a factor associated with increased psychological morbidity. the study on the psychological impact of covid-19 conducted by wang [16] identified that myalgia, dizziness, chills, sore throat, and having a cold were associated with a greater psychological impact of the outbreak. additionally, the presence of covid-19 symptoms was associated with higher levels of stress, anxiety, and depression [31] . similarly, during an outbreak of sars, the presence of symptoms such as fever was linked to the risk of higher distress, which can be understood on the basis that the onset of symptoms can reinforce the sense of vulnerability and threat of infection [53] . the presence of mers symptoms was related to an increase in anger scores [14] . also, testing and history of contact with infected people or objects were related, with negligible size effect, to increased psychiatric morbidity. no data from previous studies reveal the role that testing or diagnostic tests may play on the effects of psychological morbidity, but there are studies that indicate that the presence of risk contact may be a predictor of acute stress disorder [10] or post-traumatic stress disorder [19] , having found a relationship between anxiety and having had contact with materials suspected of being infected [16] . our result can answer to what wu [19] raised by showing that protective measures are often relaxed with close people such as family and friends. however, knowing that contact has been made with a person who has subsequently become ill increases the feeling of danger, similar to the risk of contracting the illness, also increasing psychological vulnerability. among the limitations of the study, as it is cross-sectional observational design which only informs of the perception at the time it was performed, it does not allow to establish cause-and-effect relationships but, on the contrary, it does provide with very valuable and difficult to obtain information about how the problem generated by the pandemic is lived just at the time of further escalation of the contagion curve, this being the largest contribution of the article. the sample collection was not randomised and the ratio by sex was asymmetrical and does not correspond to the distribution of the spanish population. these factors were compensated with a large sample and representation from all provinces and autonomous cities, having taken into account the variable sex in the analysis. comparing these data with those from other epidemics is difficult because the measures established in confinement or isolation are highly variable, even in different geographical areas within the same pandemic, variables that, as seen in this study, have a great influence in the development of psychological distress. it may be interesting to make other cuts of the study at a more advanced stage of the pandemic and at the end of the pandemic in order to assess its evolution. the study, conducted during the health alert decree with confinement measures at home except for essential activities, and initiated at the beginning of growth of the contagion curve, shows that a high percentage (72%) of participants had psychological distress, being this percentage higher among women (79.6%). people who work outside home in essential activities are more likely to suffer psychological distress, and those who lived with children or under-16 youngsters were less likely to show this distress. the most common symptoms in the last 14 days were headache, cough, myalgia, sore throat, and rhinitis; three or more symptoms are more commonly found. although one out of three participants had a chronic disease, only 9.2% had required health care and less than one percent (0.6%) required hospital care. a high percentage (42.7%) claimed to have had contact or not knowing whether they had had contact with any infected person or material. however, a vast majority claimed not having had any infected family member (80.4%) and not living with any infected family member (96.7%). an association was found between psychological distress and a poor assessment of health. among the variables that predict psychological distress are, therefore: being female, age, employment situation, number of symptoms, perception of poor health, having been in close contact with an infected person, as well as having been in contact with people or material suspected of being infected. these results should be explored in depth and considered for awareness-raising and information programmes during pandemics or other crisis situations, as they could enrich prevention interventions in public health and, in particular, in mental health. the information provided by the present study can help to design interventions for the psychological and emotional recovery of the population after the pandemic. it can also help in the design of mental health prevention programs aimed to protect the population from psychological distress in case of future pandemics. the authors declare no conflict of interest. world health organization. novel coronavirus (2019-ncov) situation report emergency committee regarding the outbreak of novel coronavirus (2019-ncov) china coronavirus: who declares international emergency as death toll exceeds 200 world health organization. who director-general's opening remarks at the media briefing on covid-19-11 boletín oficial del estado real decreto-ley 10/2020. boletín oficial del estado multidisciplinary research 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with different predictors first study on mental distress in brazil during the covid-19 crisis a nationwide survey of psychological distress among italian people during the covid-19 pandemic: immediate psychological responses and associated factors affective temperament, attachment style, and the psychological impact of the covid-19 outbreak: an early report on the italian general population association of self-perceptions of aging, personal and family resources the differential psychological distress of populations affected by the covid-19 pandemic report of the who-china joint mission on coronavirus disease 2019 (covid-19). available online self-rated health and mortality: a review of twenty-seven community studies relations of sars-related stressors and coping to chinese college students' psychological adjustment during the 2003 beijing sars epidemic the validity of two versions of the ghq in the who study of mental illness in general health care the 12-item general health questionnaire (ghq-12): reliability, external validity and factor structure in the spanish population propiedades psicométricas y valores normativos del general health questionnaire (ghq-12) en población general española the general health questionnaire montero-piñar, i. morbilidad psíquica, existencia de diagnóstico y consumo de psicofármacos: diferencias por comunidades autónomas según la encuesta nacional de salud de statistical power analysis for the behavioral science salud mental en españa y diferencias por sexo y por comunidades autónomas psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease longitudinal assessment of community psychobehavioral responses during and after the 2003 outbreak of severe acute respiratory syndrome in hong kong key: cord-011540-9jvoa8vr authors: suárez-barraza, manuel f.; miguel-davila, josé a. title: kaizen–kata, a problem-solving approach to public service health care in mexico. a multiple-case study date: 2020-05-09 journal: int j environ res public health doi: 10.3390/ijerph17093297 sha: doc_id: 11540 cord_uid: 9jvoa8vr purpose: mexico’s public hospitals are experiencing major operational problems which seriously affect the care of mexican citizens. some hospitals have initiated efforts to apply the kaizen philosophy to improve this situation. therefore, the purpose of this article is to analyze the methodological impact of kaizen–kata implementation in mexican public hospitals that have tried to solve operational problems using this improvement approach. design/methodology/approach: the service organization implemented kaizen–kata methodology in order to improve one operational problem-process in health care. a case-study approach was used in this research in order to understand the effects of the kaizen–kata methodology in solving problems in their operational procedures. findings: six specific drivers were identified when applying the kaizen–kata methodology. furthermore, the impact on the levels of implementation of the kaizen–kata methodology in each of the improvement teams studied was also identified. research limitations: the main limitation of the research is that only three case-studies are presented thus it is not possible to generalize its results. practical implications (where possible): other public hospitals can use this specific example as a working guide to solve the operational problems of health systems. originality/value: a methodology of continuous improvement in manufacturing was imported from the industry sector for application in an operational health care process. the kaizen–kata methodology contributed significantly to improving issues involving delays, customer complaints, process reworks and extra-cost, among other effects of operational problems. following the change of government in 2018, mexico's health system began to bring to light several operational and service problems that had been dragging on before, and that have increased in these years of the new government of mexico [1] . the structure of the health system dates back to the beginning of the 20th century, known as the social protection system in health (spss); it was created in 1905, at the time of president porfirio díaz, with the inauguration of the general hospital of mexico and in 1917 with the first public institution known at the time as the department of public health. currently, spss is made up of two sectors [2] : (i) the public sector, which includes a variety of social security institutions such as the mexican social security institute (imss), the institute of security and social services for state workers (issste), petróleos mexicanos (pemex), the ministry of defense (sedena), the ministry of the navy (semar) and other institutions and programs that • rq2: what is the level of application of the different steps of kaizen-kata methodology in its implementation when solving operational problems? the answers to these research questions can be found in the results obtained after the implementation of kaizen-kata methodology in three public hospitals. thus, this paper is structured in four main parts. the first part sets out a conceptual framework based on two components: (i) the first one explains the term "kata" and background methodologies based on the kaizen philosophy, in addition to studies on the application of kaizen in the health sector, (ii) the second part explains the methodological section that describes the data collection of the case study. the third part presents the results of the application of kaizen-kata in the service organization. the fourth part ends the research article with concluding remarks. kaizen is the name of an ancient working philosophy coined by maasaki imai [16] in 1986 in his well-known book "kaizen: the key to japanese competitive success" [16, 17] ). over the years, different authors have taken interest in its theoretical construction [18, 19] , while other authors have advanced towards new approaches for its application and implementation. such is the case of mike rother [20] , who wrote the bestselling book "toyota kata", in which the author shows elements or routines behind the resolution of operational problems through setting improvement goals, applying rapid improvement actions and learning from them. authors such as lilja et al. [21] clearly consider it an innovation process using the formula of "define-test-feedback-revise" iterations or loops. other authors such as suárez-barraza [18] have visualized it as a group of macro and micro metaphors from toyota motor corporation, in which standardization, routines and organizational non-routines (the kata) allow the organization to generate improvements and innovate to solve its operational problems. suárez-barraza [22] developed eight steps to a problem-solving routine (the improvement kata), capable of tackling the failures that arise in any type of organization. these eight steps are: (1) profiling and/or identifying the problem; (2) determining the effects of the problem; (3) evaluating the current situation of the problem; (4) identifying the root causes of the problem; (5) proposing an improvement action plan; (6) reviewing the results of the application; (7) correcting or, where appropriate, standardizing the improvement actions proposed; and finally, (8) drawing final conclusions. finally, ferenhoff et al. [23] indicate in their findings that toyota kata improves employees' problem-solving skills by linking their efforts to continuously working-process improvement projects; this increases their technical knowledge and management skills. already in the work of womack and jones [24] reference was made to the application of lean thinking and kaizen philosophy in the health care system. in fact, achieving reasonable response time and acceptable service quality, as well as putting the patient at the center of operations, remains a challenge for today's health administrations. authors such as young et al. [25] and spear [26] argue that making kaizen efforts in health systems can help avoid errors, delays, inadequate processes, duplication and all kinds of muda (japanese word that is translated as waste. defined as: any activity that consumes resources and does not add value to the process) in health care process activities. kohlberg et al. [10] , with their pioneering article, emphasize that continuous improvement models help to significantly improve the performance of processes and services in health care systems (specifically those of sweden in this case). later, in another seminal article, dahlgaard et al. [27] provide a definition in lean in health care: "creating a culture of continuous improvement and employee involvement to reduce unnecessary activities and satisfy patients and stakeholders". two decades have passed, and the literature on the application of kaizen in health systems has focused on explaining the efforts of lean thinking. some authors such as bortolotti et al. [28] have found 14 specific factors that increase employees' problem-solving capacity when using kaizen in health care. the clarity of goals, the degree of difficulty of objectives, the autonomy of work teams and the support of management are critical to the success in the application of kaizen. on the other hand, harald aij and teunissen [29] evaluate the leadership model of dombrowski and mielke [30] , where techniques such as hoshin kanri, gemba kaizen and self-development are techniques that confirm sustainable applications of kaizen in health care. another group of brazilian authors, such as coehlo et al. [31] , presents a case study in which the performance improvement in space requirements was 75% and the reduction in waiting time for care was from 2 h to 30 min. coelho et al. [31] also point out that lean kaizen efforts can eliminate at least three hours of overtime per day. more recently, abdallah and alkhaldi [32] identified four lean bundles related to the application of these techniques in the health care sector. these four bundles are: total quality management and kaizen; human resource management training and employee empowerment; just-in-time (jit), focused on inventories and supply chain; and finally, total productive maintenance (tpm), focused on the maintenance of biomedical equipment. in order to strengthen the robustness of the research, as well as to answer the two research questions posed, it was decided to follow a qualitative methodology focused on multiple case studies [33] . this type of research has the following characteristics: (i) an individual point of view is obtained which provides reality close to the object and where the researcher is the instrument; (ii) it studies a limited number of people or particular cases; and (iii) it is based on rich descriptions that facilitate a profound and detailed analysis, rather than generalizations [34] . according to yin [33] , studying a given phenomenon from a qualitative and case study perspective allows us to explore possible causal reasons for the phenomenon in depth by understanding how and why it occurs; for this reason, this methodological approach was used in this research. therefore, in order to study the application of kaizen-kata in the service processes of public hospitals, the role of non-intrusive participative observer was assumed with each hospital selected. for this, the "theoretical sampling" criterion [4, 35] was chosen, which-unlike the statistical sample concept-refers to a type of purposeful sampling in which the researcher selects an individual based on his broad potential for contributing to the development and testing of theoretical constructs. this process continues with other cases until data saturation occurs or a point is reached at which no more results will be found. the data collection process was carried out between may and december 2019 in three public hospitals in mexico (see table 1 ). in this way, three public hospitals in mexico were selected by theoretical sampling. the reason for their selection was based on three main arguments: (i) the three hospitals had had at least three years' experience in quality certifications and application of total quality-management techniques; (ii) the public hospital directors were very open to making changes in their daily operations; (iii) the three hospitals are linked to the strategic projects of the health goals of the federal government of mexico. thus, the three hospitals stand out in effort and performance with respect to other hospitals in the area in terms of service quality and response times. the data collection process for the case studies adhered to the following methods: direct observation. observing the health environment directly is a priority that even public officials in the current government respect; understanding service processes in the workplace (gemba) is key to understanding failures and muda of public hospitals [36] . this research was no exception and the workplaces where the processes took place were studied with corresponding attention. as direct observation protocol, emphasis was placed on studying the processes of accident and emergency (a&e) management and care of citizens (potential patients) when they go to a general practitioner. in all three case studies, this encompassed offices, health care centers, a&e wards, surgery and storage rooms, among others. in addition, inspections consisted of two weekly visits of 2 h each during the months of may to december 2019. the researchers participated in a non-intervention observer role in order to take notes on the work of each worksite where the operational problem of each team occurred. non-intrusive participative observation. a role of "non-intervention" was exercised in the daily management of hospitals [34] . in cases a and c the researchers had the opportunity to participate in some work meetings of the kaizen-kata teams at the time of applying the methodology (only as observers). this was helpful to the researchers, as campbell and gregor [37] point out, in order to understand the set of problems to be investigated if they themselves become familiar with the object of study and the experiences that lie behind them. using this method of data collection, 28 field events were carried out during these months, which included work meetings of the kaizen-kata teams, presentation of some improvement projects, as well as specific meetings of the leaders of the continuous-improvement teams with some of the employees who applied the tools of the methodology. the role of the researcher during these observations was one of total exclusion from the events observed. on no occasion did he participate by giving a point of view or making a comment. furthermore, attention was paid at all times to avoid transmitting any verbal communication in the form of gestures of approval or disapproval when any of those observed presented an idea or an argument during meetings. documentary analysis. this consisted of reviewing the selected material in the form of documents that each hospital provided for study, having access to work manuals, the government's website with respect to the department of health, administrative manuals, operation manuals and, in the case of hospital a, its iso 9000-quality manual, as well as documented improvement projects. during the collection of this material, special attention was given to obtaining evidence from different documentary sources referring to a similar set of facts [34] . this process provided essential support in reducing the retrospective bias that generally appears in in-depth interviews, given that managers and/or directors of hospitals go back at least five years to reconstruct events of some management practices, increasing the probability of mistakes being made or their memories failing [38] . in-depth semi-structured interviews. these were held with the staff of each of the three case studies. a total of 14 semi-structured interviews between 1 and 1 1 2 h in length were conducted (see table 2 ). each of the interviews followed a specific semi-structured script, revolving around questions that allowed the interviewee to tell his or her experience, emotions and stories focused on the application of the kaizen-kata methodology in each hospital. each interview was recorded and transcribed no more than two days after it took place. moreover, all 14 interviews took place in the hospitals of the individuals studied. in practical terms, each interview attempted to understand "how" applications or implementations of kaizen-kata were carried out in their hospital and of course, the impact it had in terms of improving patient treatment, response time and medical solutions for each patient and each service. it should be remembered that the stories of these people are linked with their own personal experience of their day-to-day hospital management work and therefore, in line with the research questions, the aim was to understand their daily reality as far as possible [37] . table 2 shows a summary of all the participants interviewed for the research. finally, around 156 pages of a researcher's diary were written up, including all the notes made on each occasion when the process was monitored; this diary was of supreme importance since it represented a source of information for guiding and adjusting the research when this was necessary. once all the data were collected, they were downloaded into a database in which each of the methods and data collected were located [33] . the idea was to maintain a "constant comparison" of the data [35] and to be able to identify common codes from the data obtained [39] . in order to generate a measurement of the impact obtained in the case studies, a radar chart was designed based on an adaptation of the steps of the kaizen-kata methodology used by suárez barraza [22] . for this particular research, the kaizen-kata methodology is defined as a theoretical framework as follows: "a methodology of the kaizen philosophy represents a constant effort of improvement in daily work, in which an improvement team seeks to identify, analyze and solve the root causes of a problem in an operative process of the organization with the goal of changing its status quo" [22] . in that sense, it reorganized them into seven steps for practical purposes: (1) identification of the problem; (2) effects or consequences of the problem; (3) data collection through the check list; (4) prioritization of the main effects through the pareto diagram; (5) determination of the root causes (ishikawa diagram); (6) elaboration of the improvement action plan and its implementation; and finally, (7) standardization of the process. each of these steps was analyzed by the eight kaizen teams (kts) of the three hospitals, so that each one could evaluate the impact of each step of the methodology in the resolution of the selected operational problems. the assessment was made by rating the steps from 1 (no application) to 5 (high application/effective). the data collection procedure was carried out by distributing and collecting a small questionnaire with the indicated scale; once the task of filling in the questionnaire for all members of each kt was completed, the first author met with them to analyze and discuss the application of the kaizen-kata methodology and its impact on the selected operational problems. in addition, some members of these teams were interviewed (the same participants as in the interview mentioned above) to get more information about the impact of the kaizen-kata methodology. table 3 shows the characteristics of each kt that participated in the study. the main reasons for selecting the number of teams were: (i) the size of the hospital, (ii) staff trained in quality systems and kaizen, (iii) staff experience and availability. as indicated in the methodology section, the research was carried out in three public hospitals in mexico. at the time of the study, each hospital was in a different phase of applying the kaizen-kata methodology, while aiming to solve operational problems in the service processes of their hospitals. case a had made the most progress and gained the most experience in the implementation; case b was at a similar stage, but with less time of application. and finally, case c was a smaller hospital which had started a pilot test of the methodology with several processes in its hospital. to explain this section, each step of the methodology applied is described briefly for each hospital, with examples of each of the steps. as can be seen in the development and implementation phases of kaizen-kata methodology, its application took place from november 2018 to january 2020, during different periods for each hospital. the continuous-improvement project was implemented in four phases, supported at all times by a specialist in kaizen-kata methodology (first author): (i) phase of preparation and identification of the problems; (ii) phase of measuring the current situation of the problems; (iii) phase of prioritization of the effects and search for root causes; and, (iv) improvement action plan and its implementation. during the preparation phase, three main actions were carried out: (i) elementary diagnosis of the current situation of each hospital in terms the development of kaizen-kata application; (ii) training seminars in each hospital about the kaizen philosophy; and, finally, (iii) training of kts who held their first sessions to identify the operational problem to be improved. the initial diagnosis in each case showed failures and errors in public services: for example, long waiting times for patients to be treated or mismanagement of resources and inventories. therefore, based on different cases of application in hospitals in other countries, the implementation of kaizen-kata methodology was recommended to improve the performance of the three public hospitals studied [10, 40] . the second action was the realization of 20 h of training and coaching in an experimental seminar of kaizen-kata. the purpose of the seminar was to lay the foundations of the necessary knowledge of the kaizen philosophy and the steps of application of kaizen-kata methodology, as well as to create kts in a formal way during the seminar. the seminar participants were managers, area leaders and operational staff representing key players in the hospital's processes. following the kaizen-kata seminar training, each participant was provided with the necessary knowledge of the japanese philosophy, as well as the skills needed to apply kaizen-kata methodology, including quality tools, such as check list, a pareto diagram and an ishikawa diagram. finally, with the kaizen teams structure in place in each hospital, each team proceeded to identify its operational problems and the effects or consequences of each problem. for the purposes of an objective, unbiased analysis, only the implementation of kaizen-kata methodology in three teams (of a total of 8) that successfully concluded the application of the methodology is described; in other words, this research shows in an exemplary way the results of three of the four teams that concluded the application of the kaizen-kata methodology in an "optimal way". thus, for case a, the kt called "a&e-a" identified the problem of: "failures at the time of admission of emergency patients". the kt of case b called "patient care" identified the problem of "delays in patient care when they consult a general practitioner". and finally, the kt from case c called "cystic fibrosis quick-innovation" identified the problem of: "shortage of specific drugs for cystic fibrosis". after this phase, each kt specifically developed its list of eight possible effects or consequences of each of the identified problems. table 4 shows these effects of the problem. each of the three kts selected for the study recorded the frequencies of the different effects detected. the measurement period was three months for each case, with each effect measured daily. the frequency of incidence sought at all times to reflect how many times the effect occurred, and a member of each team recorded it on a checklist. data collection was open in each hospital and at no time was it a hidden investigation or one in which other employees felt harassed at the time of data collection. both the kaizen-kata staff team and the kt leaders explained in detail how data collection was to be done. instead, each kt was urged to be as involved as possible with each employee with the aim of improving or solving the problem, as a result of which every worker who was not on the kt collaborated actively. table 4 shows the total results obtained from the three months of measurement. the penultimate step in the methodology applied by each of the three kts was the construction of pareto diagrams to prioritize the effects of the problems. each pareto diagram allowed each kt to determine the 80%-20% rule of the pareto principle. the result was the determination of 20% of the priority effects where the true root causes of each problem lies. a total of 8 pareto diagrams was constructed, one for each team; an example of the three kts that concluded the application of the kaizen-kata methodology with excellence is shown in figure 1 . as can be seen, 80% of the pareto principle, i.e., 80% of the errors, are due to four or five effects. for example, for case a it is four effects, for case b five effects and for case c between four and five effects. within each of the effects are the root causes of the problems studied by each kt. duplication of tasks by trying to solve "the problem quickly" 8 as a next step, each kt developed the ishikawa cause-effect diagram in this "relentless" search for root causes. the root causes of the problems are the clues to completely eliminating the problem and its consequences or effects. for this reason, the construction of four or five ishikawa diagrams allowed the teams to identify the most common and recurrent causes that could be the roots of each problem. figure 2 shows an example of each of the diagrams constructed for each team demonstrating successful application of kaizen-kata methodology. the penultimate step in the methodology applied by each of the three kts was the construction of pareto diagrams to prioritize the effects of the problems. each pareto diagram allowed each kt to determine the 80%-20% rule of the pareto principle. the result was the determination of 20% of the priority effects where the true root causes of each problem lies. a total of 8 pareto diagrams was constructed, one for each team; an example of the three kts that concluded the application of the kaizen-kata methodology with excellence is shown in figure 1 . as can be seen, 80% of the pareto principle, i.e., 80% of the errors, are due to four or five effects. for example, for case a it is four effects, for case b five effects and for case c between four and five effects. within each of the effects are the root causes of the problems studied by each kt. as a next step, each kt developed the ishikawa cause-effect diagram in this "relentless" search for root causes. the root causes of the problems are the clues to completely eliminating the problem and its consequences or effects. for this reason, the construction of four or five ishikawa diagrams allowed the teams to identify the most common and recurrent causes that could be the roots of each problem. figure 2 shows an example of each of the diagrams constructed for each team demonstrating successful application of kaizen-kata methodology. globally and from deeper levels of the ishikawa diagram, at least four types of root causes could be identified: (i) lack of operating standards; (ii) lack of process documentation; (iii) inventory system failures; (iv) failure to train workers in process protocols and customer service so that "quick" service results. each of these causes was taken into account by the kaizen-kata teams to address the last step of the kaizen-kata methodology. the last step taken by the kaizen-kata team was to draw up an improvement action plan with the aim of establishing improvement actions and dates to implement them, as well as specifying persons in charge. the main improvement actions revolved around the documentation of processes, the definition of operating standards once the processes were identified, the training of personnel for new processes and formulating protocols for customer service and attention. for the kaizen-kata teams, the construction of a detailed plan which helps them to eliminate operational problems of their hospitals is a key piece of management for improving working conditions; in fact, for the leaders of the kaizen-kata teams it was found to be very "strange" to work with this new perspective. however, the implementation took approximately three to five months depending on the equipment and the hospital. the result was successful in virtually all teams, with 95%-100% implementation (table 5 ). globally and from deeper levels of the ishikawa diagram, at least four types of root causes could be identified: (i) lack of operating standards; (ii) lack of process documentation; (iii) inventory system failures; (iv) failure to train workers in process protocols and customer service so that "quick" service results. each of these causes was taken into account by the kaizen-kata teams to address the last step of the kaizen-kata methodology. the last step taken by the kaizen-kata team was to draw up an improvement action plan with the aim of establishing improvement actions and dates to implement them, as well as specifying persons in charge. the main improvement actions revolved around the documentation of processes, the definition of operating standards once the processes were identified, the training of personnel for new processes and formulating protocols for customer service and attention. for the kaizen-kata teams, the construction of a detailed plan which helps them to eliminate operational problems of their hospitals is a key piece of management for improving working conditions; in fact, for the leaders of the kaizen-kata teams it was found to be very "strange" to work with this new perspective. however, the implementation took approximately three to five months depending on the equipment and the hospital. the result was successful in virtually all teams, with 95%-100% implementation (table 5 ). based on the results of the implementation of kaizen-kata methodology in these three public hospitals, it can be stated that there was a successful application in health service processes in each of the cases studied. practically all the kaizen-kata teams in public hospitals solved their operational problems; 50% lowered the level of incidents of operational effects, while the other 50% completely eliminated operational problems successfully (see table 3 ). in accordance with the results from table 3 , the four teams that managed to conclude the methodology (the first three of which with excellent results) were: (1) the a&e team from case a; (2) the cystic fibrosis team, "high-calibre specialists" from case a; (3) the patient care team from case b; and finally, (4) the cystic fibrosis team, "quick innovation" from case c. taking into account that kaizen-kata methodology was applied by 8 teams in 3 public hospitals, 50% concluded with successful results. on the other hand, the fact that 50% of kaizen teams that did not conclude the methodology, does not mean that they were not successful; on the contrary, they continue working on the steps that remained of the kaizen-kata methodology (see table 3 ). in fact, of the four teams that were unfinished, the average compliance with the methodology was 95.25%. in addition, each kaizen team that had not completed by the time the results were documented reached advanced steps in implementing the improvement action plan, either in reviewing the implementation results or in searching for root causes. the answer to the first research question posed about how kaizen-kata methodology is applied in the resolution of operational problems in public hospitals in mexico is based on the procedure carried out and the empirical data obtained in the case study of the three hospitals. of the eight kaizen-kata teams studied, at least three of them achieved successful results, while another two finished their improvement projects by reducing the incidences or frequencies of operational problem effects. at the time of documenting the research, four of the eight teams had finished and the other four had remained at the step of searching for root causes, developing an action plan for improvement or verifying the results to standardize the process (steps 5, 6 and 7). it is verifiable that all kaizen-kata teams in public hospitals experienced a form of systematic and continuous improvement which gave them a guiding light in the "sea" of operational problems that these hospitals in mexico experience. the successful application in solving operational problems in public hospitals of techniques and tools focused on kaizen philosophy is also corroborated in the literature in different countries such as the usa, sweden, the uk, germany and egypt, among others [28, 29, 32, 41, 42] . for this reason, at least six critical drivers were identified during the application of kaizen-kata methodology: effective and committed leadership from the general directors of the hospitals and the middle management of each public hospital (section heads, area heads, internists). exhaustive on-the-job or in-house training of the techniques and tools specific to the steps of kaizen-kata methodology. this is not an easy aspect to implement, as there is no culture of these techniques, and employees are not engineers. this driver allowed a profound knowledge of each technique and tool studied. creation of a network of improvement teams called kaizen-kata, which allowed a space for dialog on improvement, and a comprehensive and participatory training forum to eliminate problems that arose on a daily basis. maintaining the specific follow-up of each kaizen-kata improvement project through the assistance of a specialized consulting, two-person staff team appointed in each hospital. disciplined implementation of kaizen-kata methodology, applied strictly step-by-step for the resolution of public hospital problems in the "action trench" (in the gemba [workplace]), confirming the work of bortolotti [28] and ishijima et al. [42] . this involved complete redesign of each public hospital's strategy, moving from a reactive and "complaining" vision to a much more proactive vision of improvement and change. 6. the application of the kaizen-kata methodology allowed the change from a work routine of "simple" execution of operational process activities to a work routine with learning where continuous improvement and problem-solving are part of the day to day procedures. this new way of working was perceived by the employees of public hospitals as "strange". however, it gradually became their new working paradigm (execution and continuous improvement). the literature confirms the presence of several of these critical drivers indicated; however, as a vital contribution of our research it was contrasted that in a work culture such as that of the mexican public health sector, the improvement teams integrated in kaizen-kata methodology worked more as mechanisms to promote change and improvement, compared to other workers (protesters and gossipers who were prone to blame hospital directors), without realizing that they themselves were generating the change. in addition, having a simple, clear and easy to apply improvement methodology (i.e., specific steps) clarified the path of change of old management practices. on the other hand, to answer the second research question regarding the level of application of the different steps of kaizen-kata methodology in its implementation when solving operational problems, we rely on the specific questionnaire pertaining thereto. each of the teams studied presents differences in the implementation of the methodology according to the working environment of each hospital and the level of understanding of the methodology by each team in each hospital. figures 3-5 show the results of the radar graphs of the 8 kaizen-kata teams studied. as can be seen in the hospital of case a, of medium-large size, it had the capacity to implement more kaizen-kata equipment; in total, there were five teams in different areas of the hospital, able to apply the kaizen-kata methodology in varied ways. there were kaizen-kata teams such as the "a&e a" and "cystic fibrosis" teams which achieved 4 or 5 points (high effective application) in most steps of the methodology. in this type of successful team, the most difficult step to achieve once implemented was the standardization of improvement activities; this is probably due to the resistance to change of bureaucratic structures in public hospitals. data collection in the gemba allows for a deeper application of the ishikawa diagram; for this reason, some teams were delayed in the progress of the application of the methodology. these teams had some areas of opportunity at the conclusion of some of the steps of the methodology which delayed the implementation process; for example, the cardiology team skipped the prioritization step (construction of the pareto diagram) due to an oversight, which caused delays in implementation. case b, being smaller in size, only had two kaizen-kata teams. the "patient care" team performed well and many of its members were staff, motivated to improve the service provided to patients, for example, by trying to improve waiting times in the pre-consultation room. therefore, the application of the methodology was successful (mostly five points). the other team ("central a&e"), with a greater workload due to being in the emergency department, had more areas of opportunity when applying kaizen-kata methodology. the step where the process got stuck was the improvement action plan, because several of its actions required some technical investment from the hospital, such as new stretchers, ambulances and medical-support equipment in a&e. the improvement project was left at a point of "work in progress", with the kaizen-kata team trained and motivated. case b, being smaller in size, only had two kaizen-kata teams. the "patient care" team performed well and many of its members were staff, motivated to improve the service provided to patients, for example, by trying to improve waiting times in the pre-consultation room. therefore, the application of the methodology was successful (mostly five points). the other team ("central a&e"), with a greater workload due to being in the emergency department, had more areas of opportunity when applying kaizen-kata methodology. the step where the process got stuck was the improvement action plan, because several of its actions required some technical investment from the hospital, such as new stretchers, ambulances and medical-support equipment in a&e. the improvement project was left at a point of "work in progress", with the kaizen-kata team trained and motivated. the other three kaizen-kata teams shown in the graph had problems from the early stages or when developing the tools in the ishikawa diagram that look for root causes of the problem. this tool requires a lot of quantitative data (carried over from the previous steps of the methodology) to be able to establish the qualitative cause-effect relationships at the time of construction. a quantitative data collection in the gemba allows for a deeper application of the ishikawa diagram; for this reason, some teams were delayed in the progress of the application of the methodology. these teams had some areas of opportunity at the conclusion of some of the steps of the methodology which delayed the implementation process; for example, the cardiology team skipped the prioritization step (construction of the pareto diagram) due to an oversight, which caused delays in implementation. case c, the smallest of the public hospitals, implemented a single kaizen-kata unit. the team of cystic-fibrosis doctors and nurses worked in a disciplined way to eliminate the problem of "drug shortages" for treating cystic fibrosis, including improving and optimizing their warehouse inventory model-a small, but highly motivated team, as can be seen from their scores of 4-5 on the entire methodology. finally, it is important to point out that the literature on the application of kaizen-kata is practically non-existent when it comes to describing the operational discipline in application of each step of the methodology by the kts, that is, how each team applies each step or the "improvement routine". a poorly applied or "not applied" (skipped) step will result in "failures" or unobserved areas of opportunity in the resolution of operational problems posed [21, 43, 44] . a noteworthy fact was the observation in some of the steps of the implementation of different inhibitors (elements that block efforts towards improvement) which limited the efficiency of the methodology, such as "resistance to change in other areas of the hospital", "excessive bureaucracy and regulations", "disbelief in other areas", "laziness on the part of some workers" and even "organizational myopia" (indicating that there are no problems in the hospitals, that "everything is fine"). this research examines the application of the kaizen-kata methodology to solve operational problems in public hospitals in mexico. our findings detected six critical drivers in the application: (1) leadership of senior management; (2) operational discipline in the application of the methodology; (3) network of kaizen-kata teams; (4) the team of support staff; (5) on-the-job training in the gemba; and (6) a shift towards proactive vision and continuous improvement routines for all the employees. we also observed that, of the eight teams studied, at least three produced a "successful application" of four or five points, while others ran up against barriers or inhibitors that hindered the implementation of kaizen. thus, according to the results found using the qualitative methodology of the case study, there was no attempt to conclude that kaizen-kata methodology is the "total solution" to "all" operational problems of public hospitals. however, the progress in the application of the kaizen-kata methodology up to the final levels exhibited by practically all the teams demonstrates that work routines of these public employees, who are used to work related bureaucracy, have changed radically; this is due to having the opportunity of and space for dialog (the kaizen team) to improve their own operational problems in their daily work. in fact, as an additional observation, without being able to be empirically contrasted at the time of closing this article, public hospitals that applied kaizen-kata methodology seem to be responding case b, being smaller in size, only had two kaizen-kata teams. the "patient care" team performed well and many of its members were staff, motivated to improve the service provided to patients, for example, by trying to improve waiting times in the pre-consultation room. therefore, the application of the methodology was successful (mostly five points). the other team ("central a&e"), with a greater workload due to being in the emergency department, had more areas of opportunity when applying kaizen-kata methodology. the step where the process got stuck was the improvement action plan, because several of its actions required some technical investment from the hospital, such as new stretchers, ambulances and medical-support equipment in a&e. the improvement project was left at a point of "work in progress", with the kaizen-kata team trained and motivated. case c, the smallest of the public hospitals, implemented a single kaizen-kata unit. the team of cystic-fibrosis doctors and nurses worked in a disciplined way to eliminate the problem of "drug shortages" for treating cystic fibrosis, including improving and optimizing their warehouse inventory model-a small, but highly motivated team, as can be seen from their scores of 4-5 on the entire methodology. finally, it is important to point out that the literature on the application of kaizen-kata is practically non-existent when it comes to describing the operational discipline in application of each step of the methodology by the kts, that is, how each team applies each step or the "improvement routine". a poorly applied or "not applied" (skipped) step will result in "failures" or unobserved areas of opportunity in the resolution of operational problems posed [21, 43, 44] . a noteworthy fact was the observation in some of the steps of the implementation of different inhibitors (elements that block efforts towards improvement) which limited the efficiency of the methodology, such as "resistance to change in other areas of the hospital", "excessive bureaucracy and regulations", "disbelief in other areas", "laziness on the part of some workers" and even "organizational myopia" (indicating that there are no problems in the hospitals, that "everything is fine"). this research examines the application of the kaizen-kata methodology to solve operational problems in public hospitals in mexico. our findings detected six critical drivers in the application: (1) leadership of senior management; (2) operational discipline in the application of the methodology; (3) network of kaizen-kata teams; (4) the team of support staff; (5) on-the-job training in the gemba; and (6) a shift towards proactive vision and continuous improvement routines for all the employees. we also observed that, of the eight teams studied, at least three produced a "successful application" of four or five points, while others ran up against barriers or inhibitors that hindered the implementation of kaizen. thus, according to the results found using the qualitative methodology of the case study, there was no attempt to conclude that kaizen-kata methodology is the "total solution" to "all" operational problems of public hospitals. however, the progress in the application of the kaizen-kata methodology up to the final levels exhibited by practically all the teams demonstrates that work routines of these public employees, who are used to work related bureaucracy, have changed radically; this is due to having the opportunity of and space for dialog (the kaizen team) to improve their own operational problems in their daily work. in fact, as an additional observation, without being able to be empirically contrasted at the time of closing this article, public hospitals that applied kaizen-kata methodology seem to be responding better to the coronavirus crisis by having teams prepared with previous learning of a particular methodology. as a proposal to extend the work, a study of this in the future would be interesting. the kaizen-kata methodology also explores the possibility of innovating and redesigning processes using other approaches and information technologies such as the implementation of erp [45] . this topic could also lead to interesting future research in public hospitals. finally, a limitation of the work is that results and conclusions of the study cannot be generalized because only three public hospitals were studied; however, this work may represent an implementation guide for other public hospitals in mexico and other countries that have similar problems in becoming more efficient. supervisa sfp hospitales de neurología y pediatría; periódico reforma: ciudad de méxico sistemas de salud en méxico. salud pública méxico la salud es un ideal alcanzable cuando se tiene la osadía de hacer historia reforma integral para mejorar el desempeño del sistema de salud en méxico. salud pública méxico health insurance in mexico: achieving universal coverage through structural reform. healh aff niveles de evaluación de calidad, in la calidad de la atención de salud en méxico a través de sus instituciones protocol: value stream maping in healthcare. a systematic literature review. wpom-working pap a decade of lean in healthcare: current state and future directions. glob lean in healthcare from employees' perspectives measuring lean initiatives in health care services: issues and findings lean and learning: action learning for service improvement an overview of six sigma applications in healthcare industry a kaizen approach for public healthcare: a qualitative study in mexico continuous improvement project within kaizen: critical success factors in hospitals knowledge forum and q&a and health care with masaaki imai the key to japan's competitive success la filosofía de mejora continua e innovación incremental detrás de la administración por calidad total thoughs on kaizen and its evolution: three different perspectives and guiding principles introduction to the special issue on kaizen: an ancient operation innovation strategy for organizations of the xxi century managing people for improvement, adaptiveness, and superior results is innovation the future of quality management? searching for signs of quality and innovation management merging toyota kata as a km solution to the inhibithors of implementing lean service in services companies using industrial processes to improve patient care fixing health care from inside, today quality and lean health care: a system for assessing and improving the health of healthcare organisations the social benefits of kaizen initiatives in healthcare: an empirical study lean leadership attributes: a systematic review of the literature lean leadership-fundamental principles and their application process improvement in a cancer chemotherapy unit lean bundles in health care: a scoping review qualitatative research practices: a guide for social science student and researchers the discovery of grounded theory: strategies for qualitative research developing framework for continuous improvement of patient care in united states hospitals: a process approach mapping social relations. in a primer in doing institutional ethnography unbundling the structure of inertia: resource versus routine rigidity qualitative data analysis, a method source book applicability of the 5s management method for quality improvement in health-care facilities: a review developing lean and agile supply chain in health care. supply chain manag tqm" approach into public hospitals in egypt standardization without standardization? a case study of toyota motor corporation transferring japanese kaizen activities to overseas plants in china enterprise resource planning systems: digitization of healthcare service quality this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflicts of interest. the fund sponsor had no role in any of the research areas. key: cord-267996-5l9shks8 authors: tysiąc-miśta, monika; dziedzic, arkadiusz title: the attitudes and professional approaches of dental practitioners during the covid-19 outbreak in poland: a cross-sectional survey date: 2020-06-30 journal: int j environ res public health doi: 10.3390/ijerph17134703 sha: doc_id: 267996 cord_uid: 5l9shks8 the coronavirus infectious disease 2019 (covid-19) pandemic has put enormous pressure on health care systems around the world. dentistry has had to adjust to the new epidemic situation to not only bring relief to suffering patients but also to avoid becoming a source of sars-cov-2 transmission. methods: a comprehensive, cross-sectional survey was conducted between april 6 and 16, 2020 among 875 polish dental practitioners. the aim of the research was to assess dentists’ attitudes and professional approaches resulting from the covid-19 pandemic. results: 71.2% of dentists who responded to the questionnaire decided to suspend their clinical practice during that particular time. the main factors for this fact were the shortage of personal protective equipment (ppe), the respondents’ subjective perceptions of the risk of covid-19 contraction and a general feeling of anxiety and uncertainty regarding the covid-19 situation. the authors observed a significant decrease in the number of patients admitted weekly in april 2020 (12.06; sd, 11.55) in comparison to that in the time before the state of pandemic was declared on march 11, 2020 (49.21; sd, 24.97). conclusions: due to the unpreparedness of the dental sector, both in national health and private settings, most of the polish dentists decided to voluntarily suspend their clinical practice in order to mitigate the spread of the disease. the covid-19 outbreak has revealed numerous shortcomings in the dental care system, especially regarding the insufficient coordination of health services related to the pandemic and lack of advanced ppe. this has led to an overwhelming feeling of fear, confusion and anxiety among dental professionals in poland and a sudden decrease in the number of performed dental procedures. hopefully enriched with the recent experience and due to the implementation of proper strategic and long-term measures, dental practitioners will be better prepared and adapted to global health care disruptions in the future. from december 8, 2019, a series of pneumonia cases in wuhan, hubei province, china began to emerge [1] . according to data released by the world health organization (who) up to june 18, 2020, coronavirus disease 2019 has affected close to 200 countries, with a total of 8,223,454 confirmed cases and 444,813 deaths worldwide [2] . on the same day, the overall number of confirmed cases in poland reached 30, 195 [3] . on 3 june 2020, the polish ministry of health (pmh) announced that since the beginning of the pandemic, 1659 nurses, 660 doctors and 85 midwives had been infected with sars-cov-2 [4] . variables, such as a lack of access to adequate, enhanced ppe; individuals' covid-19 contraction risk assessments; self-reported feelings of anxiety regarding the disease; gender; the acknowledgement of national guidance on how to treat patients during the recent health care crisis; and other factors such as age, years of clinical experience, marital status, having children, place of residence, risk group for coronavirus infection due to comorbidities and, finally, dentists' acknowledgement of the professional recommendations launched by the pda and pmh. our secondary aim was to assess the decrease in the number of dental patients admitted in april 2020 in comparison with that in the time before the beginning of the pandemic in poland in march 2020. the cross-sectional survey was conducted between the 6th and 16th of april 2020 among polish dental practitioners. the tool utilized for data collection was a specifically designed online google forms questionnaire. a representative sample group of dentists was gathered through four major facebook groups dedicated to polish dentists: "dentyści", "dentyści ogłaszają", "dentyści przypadki, kursy i dyskusje" and "lekarze dentyści nfz". the polish dental association and twenty-four polish district chambers of physicians and dentists were contacted via e-mail and asked to share information about the study with their members, encouraging them to participate. a total of 875 polish dentists responded to the questionnaire. the data were collected anonymously to ensure the reliability of all of the information and compliance with eu personal data protection legislation. ethical approval from the bioethical committee of the medical university of silesia in katowice poland was obtained. the quantitative statistical analysis included the chi-square test for 2 × 2 tables. in justified cases, it was supported by the determination of the odds ratio, together with a 95% confidence interval and verification using the mantel-haenszel test. in addition, in several cases where groups had insignificant numbers, fisher's exact test for 2 × 2 tables was used. additionally, the non-parametric mann-whitney test was implemented, and finally, the non-parametric kruskal-wallis test, supplemented by post-hoc tests in the variant proposed by conover, was utilized. the test results were considered significant when p < 0.05. a group of 875 dentists submitted completed questionnaires. according to the supreme medical council of the chamber of physicians and dentists (smccpd) on may 4, 2020, there were 37,845 professionally active dentists in poland [21] . the age of the participants of the survey ranged from 24 to 75 years (mean of 39.1; sd, 11 years). the respondents' demographic characteristics are presented in table 1 [21] . dental practitioners were asked whether they were continuing their clinical work during the covid-19 pandemic, following the implementation of special epidemic measures in march 2020. a total of 71.2% of the respondents decided to entirely suspend their dental practice. only 28.8% of the participants declared that they had carried on with their clinical duties. the fractional distribution of the various reasons for both choices is presented in the table 2 . more than one answer could have been chosen. the quantitative statistical analysis included the factors that might have had influence on dentists' decisions as to whether to work during the pandemic. a total of 75.3% of respondents said that they did not have sufficient access to ppe, while 24.7% declared the opposite. among those who decided to work, only 46% had adequate ppe supplies; 54% stated the opposite. in the group of dentists who suspended their clinical work, 83.9% of the respondents said that they did not have sufficient access to ppe, while 16.1% were satisfied with it. the results indicated a high significance of the relationship between the decision to work during the covid-19 pandemic and access to ppe (p < 0.001, chi-square test) and (p < 0.001, mantel-haenszel test). the odds ratio (or = 4.46) indicated that dentists who continued clinical work were four and a half times more likely to have access to ppe than those who suspended their work. an average value of sensitivity (0.460) and remarkably high specificity (0.840) for the tests were obtained (figure 1 ). other. 59 (9.5%) the quantitative statistical analysis included the factors that might have had influence on dentists' decisions as to whether to work during the pandemic. a total of 75.3% of respondents said that they did not have sufficient access to ppe, while 24.7% declared the opposite. among those who decided to work, only 46% had adequate ppe supplies; 54% stated the opposite. in the group of dentists who suspended their clinical work, 83.9% of the respondents said that they did not have sufficient access to ppe, while 16.1% were satisfied with it. the results indicated a high significance of the relationship between the decision to work during the covid-19 pandemic and access to ppe (p < 0.001, chi-square test) and (p < 0.001, mantel-haenszel test). the odds ratio (or = 4.46) indicated that dentists who continued clinical work were four and a half times more likely to have access to ppe than those who suspended their work. an average value of sensitivity (0.460) and remarkably high specificity (0.840) for the tests were obtained (figure 1 ). dentists were also asked about the most important necessities regarding dental practice during the covid-19 pandemic. more than one answer could have been chosen. the answers were grouped into five major categories, listed below in table 3 . table 3 . main demands in dental practices during the peak of the covid-19 pandemic. dentists were also asked about the most important necessities regarding dental practice during the covid-19 pandemic. more than one answer could have been chosen. the answers were grouped into five major categories, listed below in table 3 . procedures (no update on disinfection and work safety protocols, lack of goodwill from management to adjust the dental office to the new procedures) dentists assessed covid-19's occupational contraction risk as 4.77 (sd, 0.59) on a 5-point scale. based on the mann-whitney test (p < 0.001), we found that those who did not work rated the risk significantly more highly than dentists who continued their clinical practice ( figure 2 ). a total of 74.8% of those who suspended their work estimated the threat as 5, whereas only 25.2% of those who continued their work rated it as high. overall, 82.9% of all the respondents assessed the risk as 5. adapted dental offices (separate rooms for doffing and donning of ppe, efficient ventilation systems) 63 (11.07%) procedures (no update on disinfection and work safety protocols, lack of goodwill from management to adjust the dental office to the new procedures) 53 (9.31%) dentists assessed covid-19's occupational contraction risk as 4.77 (sd, 0.59) on a 5-point scale. based on the mann-whitney test (p < 0.001), we found that those who did not work rated the risk significantly more highly than dentists who continued their clinical practice ( figure 2 ). a total of 74.8% of those who suspended their work estimated the threat as 5, whereas only 25.2% of those who continued their work rated it as high. overall, 82.9% of all the respondents assessed the risk as 5. the respondents rated their feelings of anxiety regarding the covid-19 pandemic as 3.61 (sd, 1.01) on a 5-point scale ( figure 3 ). dentists who suspended their clinical work rated their anxiety more highly than dentists who continued their practice (p < 0.001, mann-whitney test). the respondents rated their feelings of anxiety regarding the covid-19 pandemic as 3.61 (sd, 1.01) on a 5-point scale ( figure 3 ). dentists who suspended their clinical work rated their anxiety more highly than dentists who continued their practice (p < 0.001, mann-whitney test). the chi-square test showed that the groups differed in terms of gender (χ 2 = 13.129; p < 0.001). an additional analysis was conducted by calculating the value of the odds ratio (or) and subjecting it to verification using the mantel-haenszel test (χ 2 = 13.11; p < 0.001). the result of this test indicates that the or value is 1.9, which means that the chance there will be a man in the group of dentists who continued clinical work during the covid-19 pandemic was almost twice as high as that in the group of dentists who did not continue their work. an average value of sensitivity (0.250) and remarkably the chi-square test showed that the groups differed in terms of gender (χ 2 = 13.129; p < 0.001). an additional analysis was conducted by calculating the value of the odds ratio (or) and subjecting it to verification using the mantel-haenszel test (χ 2 = 13.11; p < 0.001). the result of this test indicates that the or value is 1.9, which means that the chance there will be a man in the group of dentists who continued clinical work during the covid-19 pandemic was almost twice as high as that in the group of dentists who did not continue their work. an average value of sensitivity (0.250) and remarkably high specificity (0.860) for the tests were obtained (figure 4 ). < 0.001, mann-whitney test). the chi-square test showed that the groups differed in terms of gender (χ 2 = 13.129; p < 0.001). an additional analysis was conducted by calculating the value of the odds ratio (or) and subjecting it to verification using the mantel-haenszel test (χ 2 = 13.11; p < 0.001). the result of this test indicates that the or value is 1.9, which means that the chance there will be a man in the group of dentists who continued clinical work during the covid-19 pandemic was almost twice as high as that in the group of dentists who did not continue their work. an average value of sensitivity (0.250) and remarkably high specificity (0.860) for the tests were obtained (figure 4) . female dentists showed a significantly higher level of self-reported anxiety ( figure 5 , p <0.001). the kruskal-wallis test confirmed (kw = 32.32; p < 0.001) significant differences among four groups of dentists: non-working females, working females, working males and non-working males ( figure 6 ). the kruskal-wallis test confirmed (kw = 32.32; p < 0.001) significant differences among four groups of dentists: non-working females, working females, working males and non-working males ( figure 6 ). the kruskal-wallis test confirmed (kw = 32.32; p < 0.001) significant differences among four groups of dentists: non-working females, working females, working males and non-working males ( figure 6 ). the conover post-hoc test showed that the biggest difference in the self-reported feeling of anxiety occurred between the group of non-working female dentists and the group of working male dentists (p < 0.01) ( table 4 ). the conover post-hoc test showed that the biggest difference in the self-reported feeling of anxiety occurred between the group of non-working female dentists and the group of working male dentists (p < 0.01) ( table 4 ). table 4 . self-reported feeling of anxiety level vs. gender: continuity of clinical work. conover post-hoc, significant results in bold. we analyzed the significance of the relationship between dentists' decision whether to continue clinical work and acknowledgement of the pda (figure 7 ) and the pmh (figure 8 ) guidelines. when assessing the pda recommendations, the chi-square test indicated statistical significance (χ 2 = 4.436; p = 0.035). the same situation occurred with that of the pmh guidelines (χ 2 = 4.443; p = 0.035). the or for the acknowledgement of the pda recommendations reached an average of 4.8 and for that of the pmh recommendations, 2.05. it means that dentists who continued to practice were almost five times more often acquainted with the pda guidelines and two times more often acquainted with the pmh guidelines compared to dentists who suspended their work. we noticed exceedingly high sensitivity (0.992) in detecting people who acknowledged the pda recommendations in the group of professionally active dentists (specificity, 0.037). the values of sensitivity and specificity calculated for the acknowledgement of the pmh recommendations in the subgroups of dentists who worked clinically and those who did not were 0.952 and 0.093, respectively. we analyzed the significance of the relationship between dentists' decision whether to continue clinical work and acknowledgement of the pda (figure 7 ) and the pmh (figure 8 ) guidelines. when assessing the pda recommendations, the chi-square test indicated statistical significance (χ 2 = 4.436; p = 0.035). the same situation occurred with that of the pmh guidelines (χ 2 =4.443; p = 0.035). the or for the acknowledgement of the pda recommendations reached an average of 4.8 and for that of the pmh recommendations, 2.05. it means that dentists who continued to practice were almost five times more often acquainted with the pda guidelines and two times more often acquainted with the pmh guidelines compared to dentists who suspended their work. we noticed exceedingly high sensitivity (0.992) in detecting people who acknowledged the pda recommendations in the group of professionally active dentists (specificity, 0.037). the values of sensitivity and specificity calculated for the acknowledgement of the pmh recommendations in the subgroups of dentists who worked clinically and those who did not were 0.952 and 0.093, respectively. we asked our respondents how they rated the assistance of the pda and pmh recommendations on a scale of 1 to 5. the pda guidelines were rated as 3.33 (sd, 1.00), and the pmh guidelines, as 3.0 (sd 1.00). dentists graded the work of the polish chamber of physicians and dentists as 2.29 (sd, 1.11) on a 5-point scale. we asked our respondents how they rated the assistance of the pda and pmh recommendations on a scale of 1 to 5. the pda guidelines were rated as 3.33 (sd, 1.00), and the pmh guidelines, as 3.0 (sd 1.00). dentists graded the work of the polish chamber of physicians and dentists as 2.29 (sd, 1.11) on a 5-point scale. a significant decrease in the number of patients admitted weekly by polish dentists before and during the covid-19 pandemic (figure 9 ) was observed (p < 0.0001, wilcoxon tests). we defined the period before the pandemic as the time before march 11, 2020, the day when the director-general of the who officially declared the present outbreak of coronavirus disease (covid-19) a pandemic. the period during the pandemic refers to the time frame of the conducted survey; that is, the time between april 6 and 16, 2020. the number of patients decreased from 49.21 (sd, 24.97) to 12.06 (sd, 11.55). these calculations only considered the number of patients treated by dentists who continued their clinical practice during the outbreak. in the entire group of examined dentists, the number of patients dropped from 47.13 (sd, 24.93) to 3.60 (sd, 8.31). a significant decrease in the number of patients admitted weekly by polish dentists before and during the covid-19 pandemic (figure 9 ) was observed (p < 0.0001, wilcoxon tests). we defined the period before the pandemic as the time before march 11, 2020, the day when the director-general of the who officially declared the present outbreak of coronavirus disease (covid-19) a pandemic. the period during the pandemic refers to the time frame of the conducted survey; that is, the time between april 6 and 16, 2020. the number of patients decreased from 49.21 (sd, 24.97) to 12.06 (sd, 11.55). these calculations only considered the number of patients treated by dentists who continued their clinical practice during the outbreak. in the entire group of examined dentists, the number of patients dropped from 47.13 (sd, 24.93) to 3.60 (sd, 8.31). we also investigated factors such as age, years of clinical practice (table 4) , marital status, having children, place of residence, belonging to the risk group for coronavirus infection due to comorbidities, and dentists' opinions on the lasting impact of covid-19 on dental procedures (table 5 ) in relation to the decision to continue dental practice or not. no statistical significance was observed. statistical characteristic mann-whitney test figure 9 . number of patients admitted by one dentist per week, and clinical performance before and during a peak of the covid-19 outbreak (p < 0.0001, wilcoxon test). we also investigated factors such as age, years of clinical practice (table 5) , marital status, having children, place of residence, belonging to the risk group for coronavirus infection due to comorbidities, and dentists' opinions on the lasting impact of covid-19 on dental procedures (table 6 ) in relation to the decision to continue dental practice or not. no statistical significance was observed. our research provided an insight into reasons and factors that influenced the attitudes of polish dentists during the covid-19 pandemic in poland. in our sample, women were predominant due to the fact that the number of female dentists in poland (77%) is higher than the number of male dentists (23%) [21] . the age and place of residence distributions are slightly less representative, evidencing a sort of selection bias, probably due to the social network dissemination of the questionnaire. on april 6, 2020, when we started to conduct the survey, there were 4201 people who had tested positive for covid-19 in poland; 99 of them were novel cases. up to that day, 98 polish citizens had died due to coronavirus infection, and 162 had recovered [22] . at the end of survey on april 16, 2020, there were 7771 confirmed cases; 189 of them were novel. two hundred and ninety-two poles had died and 774 had recovered up to that day. the number of cases had not reached its peak [23] . in this period, 71.2% of the respondents decided not to practice dentistry. in comparison to in other european countries, this situation was exceptional, because everywhere else, if any restrictions were imposed on the oral health care sector, they were implemented and executed by the authorities. our findings are similar to the results of a study conducted by ahmed and jouhar et al. in a group of 650 dentists from 30 countries (only one from poland), which found that 66% of respondents decided to suspend their dental practices until the number of covid-19 cases started to decline [24] . among the dentists who continued their clinical work during the pandemic, the main reason for their decision was the altruistic need to provide emergency and urgent dental procedures. this essential duty of medical/dental care is a fundamental principle of the dental profession. in a study conducted among 711 first year dental students from 14 countries, 36.3% declared that they decided to become a dentist to help poor and underprivileged people to improve their oral health [25] . on the contrary, the two main reasons for dentists to discontinue their clinical activities during the covid-19 pandemic were fear for their own wellbeing and, equally, the wellbeing of their close relatives/families. studies on earlier outbreaks of coronavirus infectious diseases such as sars [26] and mers [27] revealed many factors leading to psychological distress, including the fear of becoming infected while treating a patient or passing the infection on to family. in a previously mentioned study by ahmed and jouhar et al., 92% of dentists declared that they were afraid of carrying the covid-19 infection from their dental practice to their families [24] . additionally, in the study by duruck at el., facing covid-19 contraction threat, 90% of dentists were concerned about their families and about themselves [10] . according to the research conducted by maunder et al., many hospital staff members during the sars pandemic expressed conflict between their roles as health care providers and parents, feeling, on the one hand, a duty of care and, on the other hand, fear and guilt about potentially exposing their families to infection [28] . the second reason for dentists' decisions to suspend their clinical work was the fact that many of the respondents thought that the dental surgeries were not adequately equipped, and they believed that during a pandemic, there should be special emergency dental clinics assigned by the pmh. unfortunately, such clinics were not designated by the polish authorities. instead, the pda launched a campaign-"i do not panic. i treat responsibly"-to reassure dentists that with the implementation of enhanced infection control protocols, dental treatment could be resumed [29] . the pda also published a list of dental offices that volunteered to help patients with dental emergencies during the covid-19 pandemic [30] . the subject of ppe is discussed in almost every piece of survey-based research regarding dentists during the covid-19 pandemic. the necessity of having substantial knowledge and awareness regarding enhanced ppe utilization is emphasized. in the study conducted by ahmed and jouhar et al., 90% of respondents reported not wearing an n-95 mask while treating a patient. the research by duruk et al. [10] also showed that only 12% wore an n-95 mask. cagetti et al. reported that 55% of respondents used an fpp2 or fpp3 mask. based on this research, we do not know if it is a result of shortages in ppe supplies or a lack of willingness to implement adequate procedures [24] . in more recent studies from italy, it has been revealed that dentists' attitudes regarding ppe could be improved [31] . our research emphasizes the fact that during the time between april 6 and 16, 2020, access to ppe in poland was extremely limited. all the ppe resources were targeted to hospitals. the authorities did not take the oral health care sector, either public or private, into consideration. according to our research, access to ppe was a particularly important decisive factor for polish dentists as to whether to continue or suspend their clinical practice during the pandemic. in march 2020, the world health organization (who) released a press report highlighting the severe shortage of personal protective equipment (ppe) affecting health care workers worldwide during the covid-19 pandemic [32] . there was a myriad of reports about the lack of personal protective equipment (ppe) all over the world [33] [34] [35] , the royal college of surgeons of england conducted a survey on ppe between april 6 and 9, 2020, which revealed that more than half (57%) of doctors had described shortages of ppe in the past 30 days discussions around ppe were increasingly politicized and sensitive [36] , causing overwhelming anxiety both in health care professionals and patients [37] . due to the shortages, research on refreshing face masks for extended wear and reusing them after a cleaning process emerged [38] . the covid-19 outbreak had a large impact on health care providers all over the world. until may 12, 2020, the official number of infected health workers in italy amounted to 21,981. the number of deceased physicians reached 160, of whom 16 were dentists [39] . this reinforces the concept that close contact with positive patients, whether symptomatic or not, exposes health care workers to a higher risk of infection. sars-cov-2 has been demonstrated to remain aerosolized for 3 h after contamination and on plastics and stainless steel for up to 72 h. it has a half-life in aerosols that is relatively long and lasts approximately 1.1 to 1.2 hours [40] . in research by de stefani et al., italian dentists evaluated covid-19 danger as 8/10 and their worries about being at risk of contagion at work as 7.3/10 [41] . in another study from italy, 65% of responders evaluated the dentists' infection risk as very likely [39] . these results are coherent with our findings. most jordanian dentists participating in a survey on covid-19 perceived the risk as moderate, and almost one-third believed that it was not a serious public health issue; however, we have to be aware that there were no "local" cases in jordan at the time of this data collection [42] . anxiety, insomnia, depression, obsessive-compulsive symptoms and somatization are all well-known psychological hazards for health care workers during a pandemic [43] . duruk et al. [10] noticed that 95% of female and 88% of male dentists were concerned about being infected with covid-19 due to high occupational risk. according to our study, dentists who stayed at home during the outbreak also had a significantly higher level of self-reported anxiety. our findings are consistent with a study, which showed that front-line nurses had significantly lower vicarious traumatization scores than non-front-line nurses [44] . we believe that dentists who decided to work showed better coping mechanisms, which helped them to overcome their anxieties and to provide oral health care. we also found that men were two times more likely to work during the pandemic than their female counterparts. this may be due to the fact that some women declared in the questionnaire that they were pregnant or that they had to stay at home with their children, because kindergartens and schools in poland were closed because of the pandemic. however, we also noticed that women were more likely to suspend their clinical practice due to a self-reported feeling of anxiety. the highest level of anxiety was observed in the group of non-working women, and the lowest, in the group of working men. in the research by choy at el., female dentists had higher mean scores for patient-related, job-related, staff-related and technical-related stressors than male dentists in everyday dental practice [45] . on the contrary, in the research by shacham et al. [3] on factors related to the psychological distress caused by the covid-19 pandemic among israeli dentists and dental hygienists, gender did not have a significant impact. in order for dentistry to do its part in mitigating the spread of covid-19, new protocols for admitting dental patients were introduced. our research shows a great need for pda and pmh guidance and the notable impact of these authorities on the making of an informed decision on whether to provide dental treatment or not. the need for leadership and the feeling that one is not alone in a health care crisis of this magnitude was also emphasized by mauder [28] . in our study, we observed a vast decrease in the number of treated patients. this is consistent with an analysis conducted in china in the period february 1-10, 2020, when the number of dental patients declined by 38%. the conclusions of that finding were that the covid-19 situation significantly influenced people's dental care-seeking behavior and that they were not willing to go to dental institutions for non-urgent work. another important conclusion was that people's need for dental services might grow explosively when the threat of covid-19 is over [46] . this situation was the consequence of the pda and pmh recommendations, which suspended elective dental procedures and encouraged teleconsultations and e-prescriptions, in order to minimize the number of dental patients reporting to outpatient clinics to seek treatment. the second factor was the implementation of new, necessary infection control procedures. according to new guidelines, one patient per hour should be appointed. patient flux should be organized in such a way that only one patient in the waiting room is present [47] . dental practices established pre-check triages to measure and record the temperature of every staff member and patient with a contact-free forehead thermometer as a routine procedure. dental staff were required to ask patients questions about their health status regarding possible covid-19 symptoms, and patients' contacts needed to be provided with medical masks and hand disinfection agents once they entered the dental office [48] . if aerosol-generating procedures were impossible to avoid, dental dams, high-volume suction, and swabbing or disinfection of the teeth prior to the commencement of tooth preparation should have also been included [49] . after the procedure, all the disposable protections had to be removed, and high-level disinfection of the whole operating room with sodium hypochlorite 0.1% or 70% isopropyl alcohol performed. after each patient, an air change of at least five minutes was advised [50] . the first report on how to organize dental procedures under the premise of adequate protection measures during the covid-19 pandemic came from the school and hospital of stomatology of wuhan university, where the number of admitted patients was also reduced [6] . the covid-19 pandemic has introduced several new problems regarding oral health care in poland. due to shortages in the access to ppe, their prices have rapidly increased. in may 2020, the owners of public dental offices signed a petition to the nhf with a request to revise the evaluation of dental procedures [51] . on june 2, 2020, the nfh published a draft of a new decree regarding dentistry funding. though needs such as the increase in the funding of endodontic procedures have been recognized, the proposal was negatively assessed by the supreme medical council (smc) on june 8, 2020. according to the smc, the proposed changes will only slightly increase the valuation of the scheduled visits [52] . on the other hand, the inevitable increase in the prices of dental treatment in the private sector has encountered many unfavorable opinions from the news media and patients in poland [53] . it is predicted that the coronavirus pandemic will also have a negative financial impact on the dental sector as a whole, and many practitioners might not be able to restart their practice because of the new disease prevention protocols, which require investment. this will further reduce access to primary and specialist dental care [54] . on april 22, 2020, an association of polish dental employers was established, its main goals being to represent the social and economic interests of union members and initiate activities aimed at increasing the competitiveness of union members and the quality of dental services [55] . the authors suggest that a fund, which would provide financial support to its members in moments of crisis like this, should be established. shanafelt et al. identified that health care professionals tended to have five types of requests to their organization during the covid-19 pandemic: 'hear me, protect me, prepare me, support me and care for me'. it is critical that leaders understand the sources of distress, assure health care professionals that their concerns are recognized, and work to develop approaches that will help to minimize these concerns to the extent that they are able [56] . only by re-organizing health care systems in this manner, based on empathy and the understanding of employees' needs, would we be able to continue to have devoted and caring medical personnel. despite these difficulties, in june 2020, the majority of dentists in poland returned to work, implementing additional, strict infection control protocols. finally, as rosenberg argued, epidemics put pressure on the societies they strike, and as a result, they provide a sampling device for social analysis. they clearly demonstrate what really matters to a population and what they truly value. the history of epidemics offers considerable advice but only if people know the history and respond with wisdom [57] . hopefully, our research will add insight into how to reorganize dental care when future pandemics emerge. it is important to stress the limitations related to sampling error in this research, including the relatively moderate sample group. this could have been caused by the short period of data collection, leading to mainly dentists who were active on social media during the short period of data collection participating in the study. due to the lack of preparedness of the dentistry sector, both public and private, a substantial majority of polish dentists decided to voluntarily suspend their clinical practice. the covid-19 outbreak has revealed numerous shortcomings in the dental care system, especially regarding the insufficient coordination of services related to the pandemic globally and general deficit of advanced ppe. the direct result of the overwhelming fear, confusion and anxiety among dental staff, which was amplified by the high perception of covid-19 contraction risk, was a significant reduction in dental clinical practice in poland. a sudden decrease in the number of performed dental procedures and implementation of new infection control protocols has caused financial problems for many dental practices. it is expected that dentists, enriched with the experience acquired during the recent outbreak, will be able to efficiently redefine their scope of practice and adjust to the new circumstances. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study who coronavirus disease (covid-19) dashboard. available online coronavirus disease (covid-19) dashboard. available online ministerstwożongluje danymi o liczbie zakażonych pielęgniarek-portal pielęgniarek i położnych covid-19: present and future challenges for dental practice covid-19): emerging and future challenges for dental and oral medicine dental care and oral health under the clouds of covid-19 airborne transmission of sars-cov-2: the world should face the reality severe acute respiratory syndrome and dentistry|elsevier enhanced reader investigation of turkish dentists' clinical attitudes and behaviors towards the covid-19 pandemic: a survey study 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mapa pracujących gabinetów stomatologicznych. polskie towarzystwo stomatologiczne. 2020. available online epidemiological aspects and psychological reactions to covid-19 of dental practitioners in the northern italy districts of modena and reggio emilia shortage of personal protective equipment endangering health workers worldwide ethical rationing of personal protective equipment to minimize moral residue during the covid-19 pandemic in pursuit of ppe covid-19: third of surgeons do not have adequate ppe, royal college warns|the bmj ppe guidance for covid-19: be honest about resource shortages mitigating the psychological impact of covid-19 on healthcare workers: a digital learning package opinion to address a potential personal protective equipment shortage in the global community during the covid-19 outbreak covid-19 outbreak in north italy: an overview on dentistry. a questionnaire survey aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 covid-19 outbreak perception in italian dentists dentists' awareness, perception, and attitude regarding covid-19 and infection control: cross-sectional study among jordanian dentists general hospital staff worries, perceived sufficiency of information and associated psychological distress during the a/h1n1 influenza pandemic vicarious traumatization in the general public, members, and non-members of medical teams aiding occupational stress and burnout among hong kong dentists the impact of the covid-19 epidemic on the utilization of emergency dental services covid-19 and professional dental practice. the polish dental association working group recommendations for procedures in dental office during an increased epidemiological risk transmission routes of 2019-ncov and controls in dental practice novel coronavirus (covid-19) and dentistry-a comprehensive review of literature the severe acute respiratory syndrome coronavirus-2 (sars cov-2) in dentistry. management of biological risk in dental practice niemiłe zaskoczenie u dentystów the financial impact of covid-19 on our practice understanding and addressing sources of anxiety among health care professionals during the covid-19 pandemic the twitter pandemic: the critical role of twitter in the dissemination of medical information and misinformation during the covid-19 pandemic funding: this research received no external funding. the authors declare no conflict of interest. key: cord-264133-yj100ryt authors: anderson, gregory s.; di nota, paula m.; groll, dianne; carleton, r. nicholas title: peer support and crisis-focused psychological interventions designed to mitigate post-traumatic stress injuries among public safety and frontline healthcare personnel: a systematic review date: 2020-10-20 journal: int j environ res public health doi: 10.3390/ijerph17207645 sha: doc_id: 264133 cord_uid: yj100ryt public safety personnel (psp) and frontline healthcare professionals (fhp) are frequently exposed to potentially psychologically traumatic events (pptes), and report increased rates of post-traumatic stress injuries (ptsis). despite widespread implementation and repeated calls for research, effectiveness evidence for organizational post-exposure ptsi mitigation services remains lacking. the current systematic review synthesized and appraised recent (2008–december 2019) empirical research from 22 electronic databases following a population–intervention–comparison–outcome framework. eligible studies investigated the effectiveness of organizational peer support and crisis-focused psychological interventions designed to mitigate ptsis among psp, fhp, and other ppte-exposed workers. the review included 14 eligible studies (n = 18,849 participants) that were synthesized with qualitative narrative analyses. the absence of pre–post-evaluations and the use of inconsistent outcome measures precluded quantitative meta-analysis. thematic services included diverse programming for critical incident stress debriefing, critical incident stress management, peer support, psychological first aid, and trauma risk management. designs included randomized control trials, retrospective cohort studies, and cross-sectional studies. outcome measures included ppte impacts, absenteeism, substance use, suicide rates, psychiatric symptoms, risk assessments, stigma, and global assessments of functioning. quality assessment indicated limited strength of evidence and failures to control for pre-existing ptsis, which would significantly bias program effectiveness evaluations for reducing ptsis post-ppte. public safety personnel (psp; e.g., border services officers, public safety communications officials, correctional workers, firefighters, emergency managers, operational intelligence personnel, paramedics, and police) and frontline healthcare professionals (fhp; e.g., nurses, physicians, and staff in emergency, trauma, surgical, psychiatric, geriatric, and/or intensive care units, social workers and counsellors) are regularly exposed to potentially psychologically traumatic events (pptes), such as threats to their own life, witnessing violence, scenes of accidents, fatalities and suicide [1] [2] [3] [4] . pptes are distinct from other occupational stressors that can also impact the mental health of psp and fhp, such as shift work, among adult (aged 18 and older) psp and fhp. eligible psp occupations were border services officers, correctional workers, communications officials (e.g., dispatch operators, 911 operators), firefighters, paramedical professionals, and police. fhp occupations included nurses and personnel working in emergency rooms, trauma centers, and surgical teams, social workers and counsellors. other occupations recognized to experience a high risk of traumatic exposures were also considered, such as emergency management response teams and rail transit operators. eligible studies could be of any length of follow up, from any geographic location, but the search was restricted to studies published in 2008 onwards. exclusion criteria included study protocols, qualitative studies, case studies, investigations that tested the acceptability of a service among its participants, and investigations on the effectiveness of a service on job-related satisfaction without evaluating outcomes of interest (i.e., sickness absence, mental health symptoms, suicide rates). there were 22 electronic databases searched from 2008 to 9 december 2019, including psycinfo, pubmed, jstor, web of science and wiley, sage, taylor & francis, cambridge and oxford journal online. the electronic yield of records was supplemented with hand searches of the reference lists of included studies, with selected articles searched in google scholar. key terms used for database searches were derived from a population-intervention-comparison-outcome (pico) framework (see table 1 ). after the search was completed, all citations were imported into covidence-a web-based systematic review manager [24] . initial screening at the title/abstract stage was verified by having multiple reviewers screen the same 200 papers, with 99% agreement. there were two reviewers who then screened full papers to determine acceptability for inclusion in the systematic review. all discrepancies were resolved by consensus between the two reviewers. data were extracted from the published full-text reports of each included article independently by two reviewers. the data extraction was facilitated by customized tables developed in covidence directly. a pico framework was used to define variables for which data were sought. population variables included the sample size, age, sex, and years of employment in their profession. intervention variables included the type and duration of program (e.g., critical incident stress management or debriefing, peer support training, suicide prevention, and timing and frequency of individual or group sessions). comparison variables included the type and nature of the comparator group (e.g., waitlist controls or within-subject analysis of pre-and post-training measures). outcome variables included rates of absenteeism, scores on self-report instruments for stress, burnout, resilience, and symptom-based measures of mood disorders, anxiety disorders, ptsd, and other ptsis, such as the depression anxiety stress scale-21 (dass-21) [25] . physiological markers of stress were also included as outcome variables where available (e.g., heart rate, blood pressure, salivary and plasma cortisol), as were number of missed workdays. the 9-item newcastle-ottawa quality assessment scale for cohort studies was applied to assess study quality and the strength of research evidence in individual studies [26] . each study was evaluated on three domains (i.e., selection, comparability, outcome) and received a rating for a low or high risk of bias for each of nine items (i.e., a low risk of bias counts as one point) for a total possible score of nine. items where a low or high risk of bias could not be determined received an 'unclear' rating and were counted the same as a high risk of bias. while there is no established standard for interpreting total quality assessment scores, the current study will classify a total score of 9 as 'high quality', scores of 7 or 8 as 'moderate to high quality', scores of 5 or 6 as 'moderate to low quality', and scores below 5 as 'low quality'. data were qualitatively synthesized using descriptive tables to summarize the design, characteristics, and outcomes of each study (table 2) . individual studies were grouped using thematic analysis into broad categories to facilitate meaningful discussion points. the capacity for a quantitative meta-analysis was precluded by the diverse nature of studies considered and outcomes reported. there were 3277 records identified from a systematic literature review. there were 1150 duplicates removed, leaving 2127 studies for screening. there were 2067 records removed by title/abstract screening, leaving 69 studies for full-text review. there were 46 studies removed at the full-text stage (i.e., 40 had the wrong study design, 5 had the wrong population (military), and 1 was a dissertation). the systematic review process resulted in 14 eligible studies ( figure 1 ). the inconsistency in pre-post-evaluations and for measured and reported outcomes across studies made a quantitative meta-analysis on service effectiveness impossible. therefore, studies are thematically categorized and described below, followed by quality assessment of the strength of evidence across studies. post-traumatic growth inventory, problem-and emotion-focused coping and disengagement 94% of respondents indicated exposure to a critical incident during their career, 52% participated in cisd, and 64% of these participants reported stress reduction 2 weeks after attending. having a positive attitude toward cisd was positively associated with post-traumatic growth but not related to post-traumatic symptoms. participants indicated they receive support from co-workers and family, and reported minimal burnout. purely descriptive study, no comparison between groups or over time mean levels of post-traumatic stress (ies-r) and psychological distress (k-10) were generally low and did not differ between groups pre-or post-intervention. controlling for pre-intervention scores, cisd was associated with significantly less alcohol consumption one-month post-intervention relative to the screening only condition, but not the education group, and higher post-intervention quality of life compared to the education but not screening only group change in rate of work-related and standard sickness absence of reporting personnel 6 months before and after the program work-related sick leave decreased among employees for managers in the training group, and increased in the control group. standard sick leave rates increased among both groups, perhaps due to follow-up period being in the winter months there were 3277 records identified from a systematic literature review. there were 1150 duplicates removed, leaving 2127 studies for screening. there were 2067 records removed by title/abstract screening, leaving 69 studies for full-text review. there were 46 studies removed at the full-text stage (i.e., 40 had the wrong study design, 5 had the wrong population (military), and 1 was a dissertation). the systematic review process resulted in 14 eligible studies (figure 1 ). the inconsistency in pre-postevaluations and for measured and reported outcomes across studies made a quantitative meta-analysis on service effectiveness impossible. therefore, studies are thematically categorized and described below, followed by quality assessment of the strength of evidence across studies. . figure 1 . prisma flow diagram. the psp professions represented in the available studies were fire and rescue (including officers, volunteer firefighters, and duty managers) (n = 5) and police (including sworn and former officers, union representatives, and civilian employees) (n = 5); no eligible studies pertaining to other groups of psp were identified. fhp included nursing students completing a practical unit (n = 1), personnel in pediatric liver transplant centers (n = 1), and healthcare workers in large general hospitals (n = 1). the only other relevant occupation group represented in eligible studies included ppte-exposed public transport operators (n = 1). in total, 18,849 individuals were represented across studies. there were eight studies that explicitly evaluated ppte exposure or offered their respective service following an occupational ppte. the eligible study criteria for the current review (i.e., organizational services offered to buffer the negative psychological effects of experienced or future pptes) allowed for ppte exposure to be inferred for the remaining six studies based on participant occupations [1] [2] [3] [4] . thematic groups identified within the literature included cisd (n = 5: included 2 studies with undefined organizationally-offered or -facilitated debriefing) and critical incident stress management (cism, n = 1), as well as several peer support programs (n = 8) including types of psychological or mental health first aid and trauma risk management. study designs included randomized control trials (rcts) and cluster rcts (n = 4), retrospective cohort studies (n = 4), a prospective cohort study (n = 1), and cross-sectional studies (n = 5). control interventions included waitlist controls (n = 2), psychoeducation only and no peer support training (n = 1), or group versus video versus control versions of the intervention (n = 1). comparisons included regular training or service as usual, or the psp professions represented in the available studies were fire and rescue (including officers, volunteer firefighters, and duty managers) (n = 5) and police (including sworn and former officers, union representatives, and civilian employees) (n = 5); no eligible studies pertaining to other groups of psp were identified. fhp included nursing students completing a practical unit (n = 1), personnel in pediatric liver transplant centers (n = 1), and healthcare workers in large general hospitals (n = 1). the only other relevant occupation group represented in eligible studies included ppte-exposed public transport operators (n = 1). in total, 18,849 individuals were represented across studies. there were eight studies that explicitly evaluated ppte exposure or offered their respective service following an occupational ppte. the eligible study criteria for the current review (i.e., organizational services offered to buffer the negative psychological effects of experienced or future pptes) allowed for ppte exposure to be inferred for the remaining six studies based on participant occupations [1] [2] [3] [4] . thematic groups identified within the literature included cisd (n = 5: included 2 studies with undefined organizationally-offered or -facilitated debriefing) and critical incident stress management (cism, n = 1), as well as several peer support programs (n = 8) including types of psychological or mental health first aid and trauma risk management. study designs included randomized control trials (rcts) and cluster rcts (n = 4), retrospective cohort studies (n = 4), a prospective cohort study (n = 1), and cross-sectional studies (n = 5). control interventions included waitlist controls (n = 2), psychoeducation only and no peer support training (n = 1), or group versus video versus control versions of the intervention (n = 1). comparisons included regular training or service as usual, or alternative physical health or general wellness-focused interventions (n = 3). the duration of services or training sessions were commonly not reported (n = 7), but reported services were administered for 60 min beginning within an hour of the ppte concluding [40] or for approximately 90 min within three days of the ppte concluding [31] . the training program durations were 90 min [35] there were five studies that reported results of cisd or related debriefing (two studies with undefined organizationally-offered debriefing), of which three involved firefighters, one involved police, and one involved allied health professionals (see table 2 ). there were four cross-sectional or retrospective cohort designs with measurement at only one point in time. tuckey and scott [31] used an rct to compare results of the mitchell model group cisd with groups who received stress management education or screening only (control group). the results indicated no statistically significant differences in ptsi symptoms between groups at pre-or post-intervention, and a reduction in alcohol consumption one-month post-intervention for the active groups relative to the control group was not sustained at follow up. there were three studies that reported no statistically significant differences in mental health outcomes between those who did and did not have access to debriefing [28] [29] [30] . there was one study [27] that reported participants (n = 57) who received organizationally-offered or -facilitated 90 min debriefing (having to attend a group session, individual meeting with a psychologist, or both) reported higher perceived event-related stress and ptsd scores than non-debriefed participants at a 5 year follow up. there was one study [40] that reported on the introduction of 60 min of cism offered within 90 min of a ppte within a healthcare setting; however, the study found that there was little consistency with respect to the application of cism. the study by müeller-leonhardt and colleagues [40] had a low response rate (17.6%: n = 88), only 25% of potential post-ppte participants were offered post-incident cism, and no mental health measures were collected. therefore, the study offers no data to assess cism program effectiveness. there were eight studies that offered peer support programs for various outcomes (mental health and suicide prevention) and within various populations including police (n = 4), healthcare (n = 1), fire services (n = 2), and transportation (n = 1). there were three rcts [32, 35, 37] , each using different outcome measures (mental health, increased use of peer support services, sick leave), but all reporting favorable results. in a prospective cohort study, carleton et al. [33] reported short-lived, small, but statistically significant improvements in stigma following the road to mental readiness training program, but no statistically significant improvements in mental health. the two retrospective cohort studies [34, 36] examined sick days as an outcome measure, while one study [38] examined suicide rates. again, all studies reported favorable results, with varying quality of research and strength of evidence. finally, watson and andrews [39] used a cross-sectional study design and found evidence for improved mental health scores with fewer ptsi symptoms as measured by standardized tools and fewer barriers to care for police officers who worked within a force who received trauma risk management training. a summary of study quality ratings is illustrated in figure 2 . according to the interpretation standards established for the current review, none of the 14 studies were classified as high quality. all of the 14 studies received at least one high risk or unclear rating on the strength of evidence criteria. one study was rated moderate to high quality [35] , nine studies were of moderate to low quality [27, [31] [32] [33] [34] [36] [37] [38] [39] , and four studies were of low quality [28] [29] [30] 40 ]. there were 9 of 14 studies rated at a low risk of bias regarding the assessment of study outcomes based on the use of secure organizational records (e.g., rates of sickness absence and suicide) or empirically-validated mental disorder screening tools. there were five studies rated at a high risk of bias for using revised versions of previously validated measures [31, 32] or unvalidated self-report measures [29, 30, 40] , which could be prone to individual reporting biases (e.g., memory errors, desire to respond in a favorable way that minimized stigmatized attitudes or behaviors). except for four cross-sectional studies [28, 29, 39, 40] , all remaining studies provided sufficient time following participation in a ptsi mitigation service or program before collecting outcome measures, resulting in low risk of bias ratings based on time. there were 12 out of 14 studies that were rated as high risk (n = 3) or unclear (n = 9) regarding adequacy of follow up due to study design (e.g., cross-sectional or retrospective cohort studies), precluding measurements at more than a single point in time and precluding any valid assessment of service effectiveness. the remaining rcts [31, 37] or prospective cohort designs [33] that did conduct follow-up measures received high risk of bias ratings for failing to provide an analysis of baseline measures and/or demographic variables between participants lost at follow up and those who completed follow-up measures; however, carleton and colleagues [33] , and tuckey and scott [31] did apply appropriate statistical analyses (i.e., multilevel hierarchical modelling) to account for post-intervention attrition. int. j. environ. res. public health 2020, 17, x for peer review 13 of 20 criteria. one study was rated moderate to high quality [35] , nine studies were of moderate to low quality [27, [31] [32] [33] [34] [36] [37] [38] [39] , and four studies were of low quality [28] [29] [30] 40] . there were 9 of 14 studies rated at a low risk of bias regarding the assessment of study outcomes based on the use of secure organizational records (e.g., rates of sickness absence and suicide) or empirically-validated mental disorder screening tools. there were five studies rated at a high risk of bias for using revised versions of previously validated measures [31, 32] or unvalidated self-report measures [29, 30, 40] , which could be prone to individual reporting biases (e.g., memory errors, desire to respond in a favorable way that minimized stigmatized attitudes or behaviors). except for four cross-sectional studies [28, 29, 39, 40] , all remaining studies provided sufficient time following participation in a ptsi mitigation service or program before collecting outcome measures, resulting in low risk of bias ratings based on time. there were 12 out of 14 studies that were rated as high risk (n = 3) or unclear (n = 9) regarding adequacy of follow up due to study design (e.g., cross-sectional or retrospective cohort studies), precluding measurements at more than a single point in time and precluding any valid assessment of service effectiveness. the remaining rcts [31, 37] or prospective cohort designs [33] that did conduct follow-up measures received high risk of bias ratings for failing to provide an analysis of baseline measures and/or demographic variables between participants lost at follow up and those who completed follow-up measures; however, carleton and colleagues [33] , and tuckey and scott [31] did apply appropriate statistical analyses (i.e., multilevel hierarchical modelling) to account for post-intervention attrition. half of the studies included in the current review did not demonstrate that their sample was representative of the larger population of workers with respect to demographic variables such as sex, average age, or years of service, limiting generalizability of their results. all studies were rated at a low risk of bias regarding selection of the non-exposed cohort, which was either randomly selected from the same population in the case of rcts [31, 32, 35, 37] , or compared to a sample from the same larger population that did not offer the service in question [27, 34, 36, 38] , or not applicable for singlesample cross-sectional and prospective cohort study designs [28] [29] [30] 33, 39, 40] . there were four studies half of the studies included in the current review did not demonstrate that their sample was representative of the larger population of workers with respect to demographic variables such as sex, average age, or years of service, limiting generalizability of their results. all studies were rated at a low risk of bias regarding selection of the non-exposed cohort, which was either randomly selected from the same population in the case of rcts [31, 32, 35, 37] , or compared to a sample from the same larger population that did not offer the service in question [27, 34, 36, 38] , or not applicable for single-sample cross-sectional and prospective cohort study designs [28] [29] [30] 33, 39, 40] . there were four studies rated a high risk of bias due to participants self-reporting prior participation in, or exposure to, a given intervention [27, 28, 30] or due to a substantial proportion of the sample (41%) being unaware of the availability of the service prior to taking part in the study [40] . there was one study that received an unclear rating based on the study outcome, which measured participants' preference for, and not exposure to, various formal (e.g., cisd) and informal debriefing procedures [29] . most studies (12 of 14) were deemed at a high risk of bias for failing to control for, or account for, the most important factor in the study design or analysis-the presence of a ptsi or diagnosable mental disorder at the time of the study-which would substantially bias the study outcome (i.e., evaluating the effectiveness of a ptsi mitigation service). similarly, 8 out of 14 studies received a high-risk rating for failing to demonstrate that participants were apparently healthy at the start of the study and not already suffering from ptsis or ptsd. most studies (10 of 14) were at a low risk of bias for controlling for an additional factor in their study design or analysis, such as participant sex, age, and/or years of service, which have been statistically significantly associated with psp mental health outcomes. psp and fhp are regularly exposed to pptes, such as threats, violence, accidents, fatalities, and suicide, as well as occupational stressors (e.g., shift work, public scrutiny, harassment or bullying) [1] [2] [3] 5, 6] . ptsis resulting from pptes include symptoms of mood and anxiety disorders, as well as other mental disorders (e.g., ptsd), suicidal behaviors (i.e., ideation, planning, attempts), and maladaptive coping strategies (e.g., drug abuse, alcohol abuse, avoidance) [2, [6] [7] [8] . the impact of ptsis may include a reduction in the quality of occupational performance, increased absenteeism, sleep difficulties, a negative impact on relationships with others, burnout, other physical or psychological illnesses, disability, and early mortality [5, [41] [42] [43] . the economic burden of ptsis within psp and fhp in canada remains unknown, but productivity losses that result from mental disorders experienced in the canadian workforce are estimated to be anywhere between $16.6 billion [44] and $51 billion [45] [46] [47] annually. especially in light of the global novel coronavirus pandemic, identifying effective programs and services that can change the occupational health trajectories of psp and fhp following pptes, and mitigate ptsis, is imminently required. several discrete programs have been developed as part of efforts to mitigate the impact of pptes in both psp and fhp. most of the programs involve very diverse peer support and crisis-focused psychological interventions. as evidenced in the current review, the programs and any associated evaluations have varied greatly in study design, target audience, duration of training, timing of intervention, outcomes measured, and timing of follow up. comparing the effectiveness of programs with such diverse elements is extremely difficult, and quality assessments of the impact such programs may have on mental health and absenteeism of participants post-ppte are rarely available. nevertheless, the available programs can be broadly generalized into "peer support" and "crisis-focused" psychological interventions [9] . the most common, but diverse, interventions are described as "peer support programs", which rely on trained peers to create a supportive relationship with individuals who have experienced adverse events with emotional and social support, encouragement, and hope [10] . crisis-focused psychological intervention programs typically refer to a wide variety of cisd or cism derivations, offering problematically diverse direct support programming post-ppte exposure, often using the same name to describe very different programming. the assessed interventions may be conducted with a trained mental health professional or service provider and offer a time-limited (typically 24-72 h) intervention post-ppte [9] . the current review identified 14 studies measuring the effectiveness of peer support programs and crisis-focused psychological interventions among psp and fhp following exposure to a ppte with the hopes of mitigating ptsis, and ultimately ptsd. as the associated extent of literature is still early in development, the ability to draw conclusions about a particular service or intervention that is most effective for mitigating ppte sequela exceeds the available data; nevertheless, a few themes are apparent across the available studies. first, some administrations of the diverse programs often synonymously referred to as cisd may be beneficial, but the evidence remains insufficient; relatedly, some forms of organizationally-offered or -facilitated cisd may be problematic, but the evidence remains grossly insufficient. second, given the heterogeneity in results and effectiveness across psp and fhp, a "one-size-fits-all" approach may not be ideal. finally, while there was a diverse group of programs developing peer support, there is very preliminary evidence supporting peer support as associated with at least short-term favorable results. to facilitate iterative independent evaluation by researchers, established and transparent programs should be consistently applied, have defined structures (i.e., evidence-informed content and prescribed durations and evaluation intervals), and support fidelity and fidelity assessments. the results of such rigorous investigations into service effectiveness would in turn support evidence-based practices, profession-specific tailoring, and progressive improvements to ptsi mitigation strategies for at-risk occupational groups. there is substantial evidence for a variety of psychotherapies established for the treatment of conditions such as ptsd that may result from work-related pptes, including ppte-focused cognitive behavioral therapy, cognitive restructuring and cognitive processing therapy, and prolonged exposure, eye-movement and desensitization reprocessing [48] . comparatively, there is a dearth of literature examining the effectiveness of proactive strategies for mitigating ptsis following ppte exposure [49] . given that psp and fhp appear at greater risk for ppte exposures, the identification of effective post-exposure strategies for mitigating ppte-related disorders would be a substantial achievement. increasingly, studies have explored the unique mental health needs of psp using a ppte-informed lens. there is still a dearth of studies specifically focusing on psp from a treatment and programming perspective. beshai and carleton [9] characterized the timing of peer support and crisis-focused psychological intervention programs as before, during, or after a crisis, with some programs (e.g., peer support, cism) being offered at all three times. the format of the interventions varied between group and individual programs, with most interventions offering both. providers varied between mental health professionals, peer support personnel, community members, social workers, and psp team leaders. paralleling the current results, summarizing the results of programs and interventions reviewed, the authors concluded that there was "limited availability of research evidence and the important limitations in the available research make conclusive decisions regarding the use of such programs impossible" [9] (p. 8). the current results are similar to results from work performed with general population samples. forneris and colleagues [50] and forman-hoffman and colleagues [51] found limited evidence supporting whether timing, intensity, and dosage impacted the effectiveness of post-ppte programs designed to mitigate ptsis, and whether outcomes from early interventions were impacted by demographic characteristics, psychiatric comorbidities, and personal risk factors. their review evidenced that studies were limited by small study sizes, high attrition rates, and methodological shortcomings (e.g., absent randomization), problematic statistical methods, and a high risk of bias [50] [51] [52] . the current review also found inconsistent reporting of methodological approaches, outcome measures, and potential confounds to program effectiveness, including pre-existing ptsis or mental health conditions, symptom duration and/or severity, and concurrent treatment. the limited evidence available is favorable towards peer support programs, with small, but potentially important, short-term results. studies have inconsistently demonstrated increasing mental health knowledge as being associated with less stigmatic attitudes towards self and others [5, 30] , and more confidence for recognizing when a peer may need help with basic skills such as starting a conversation out of concern for others or supporting help-seeking behavior [5, 35] , with peer support research deserving further exploration [5] . there are studies indicating that mental health training is associated with increased participants' knowledge regarding mental health, decreases in their negative attitudes, and increases in supportive behaviors toward individuals with mental health problems [5, 53] ; however, due to a lack of consistent outcome measures, there is still no way to understand whether any services significantly change the mental health trajectory of psp and fhp following ppte exposure. the current review provides a recent update on past studies exploring the use of services designed to mitigate psychological sequelae among psp and fhp, focusing on the last 10 years of research. the broad search strategy and inclusive eligibility criteria facilitated the identification of studies encapsulating a broad range of service types and classes of psp and fhp. there are also several key limitations that can inform directions for future research. as a systematic review, many of the strengths and limitations of the present study are intimately tied to the nature of the available component studies. excluding studies published prior to 2008 reduced the yield and our capacity for quantitative meta-analysis. the broad inclusion criteria-while helpfully increasing the component studies available for the current review-substantially increased heterogeneity. consequently, for any particular group of psp, fhp, or other ppte-exposed workers, there were at most a few studies. additional studies are needed for understanding the potential impact of peer support and crisis-focused psychological intervention programs for psp, fhp, and other workers frequently exposed to pptes. future studies need to (1) use standardized outcome measures, (2) control for persons with a pre-existing ptsi among participants receiving interventions intended to mitigate ptsi development, and (3) use methods sensitive to changes over time. unfortunately, 12 of 14 studies reviewed were cross-sectional or retrospective cohort studies, precluding discussions of causation. future studies could also directly compare the effectiveness of different programs for different groups of workers using standardized outcome measures. additionally, large studies with longer follow-up periods are needed to determine the longevity of benefits over time. for example, carleton and colleagues [33] reported a small, but temporary, decrease in stigma following implementation of one version of the four-hour road to mental readiness (r2mr) course; however, the use of skills from the course declined at 6 and 12 month follow ups. the current recommendations align with previous recommendations, such as those of the 2008 australian government in "an organizational approach to preventing psychological injury", which emphasized the need to monitor and review the implementation and effectiveness of interventions using agreed upon performance indicators and targets to ensure continuous improvement [54] . future researchers should also pay close attention to the symptomology developed by each population of interest following occupational exposure to pptes, including the type, duration, and severity of ptsi symptoms, as well as any concurrent treatment. together with comparable outcome measures, more comprehensive reporting of ptsi symptoms and ppte exposures will further elucidate program effectiveness with greater scientific quality and rigor. there is inconsistent evidence for the effectiveness of several organizational services developed and deployed to mitigate the psychological impact of pptes among psp, fhp, and other workers frequently exposed to pptes. despite the lack of evidence, several organizations have implemented the crisis-focused psychological interventions and peer support services presently reviewed [5, 9, 46] . the broad variety of occupational populations sampled, intervention approaches implemented, and outcomes evaluated in the current review preclude denoting any service as superior to any other for mitigating ptsis. with numerous forms of every program, including cisd, each with different fidelity challenges with respect to application, and fundamental problems with study design and consistency of outcome measures, recent evidence of the effectiveness of post-ppte crisis-focused interventions for psp and fhp is sorely lacking and inconclusive. similarly, with the wide breadth of peer support programs observed and large variability in outcomes measures (many of which are unrelated to ptsi mitigation), there is low to moderate evidence to support their use with psp and fhp. despite the important contemporary efforts, there currently remains a substantial gap in research and peer-reviewed literature on the effectiveness of organizational programs, interventions, and services, as well as educational programs intended to reduce ptsis following ppte exposures among psp and fhp. as policy makers mobilize legislation for mental health services across sectors in response to the global coronavirus pandemic, formal evaluation of the effectiveness of the proffered services is needed through careful and rigorous independent research inquiry, especially for evaluating the suitability and effectiveness of services tailored to psp and fhp. exposures to potentially traumatic events among public safety personnel in canada rescuers at risk: a systematic review and meta-regression analysis of the worldwide current prevalence and correlates of ptsd in rescue workers current state of knowledge of post-traumatic stress, sleeping problems, obesity and cardiovascular disease in 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longitudinal assessment of the road to mental readiness training among municipal police sickness absence among peer-supported drivers after occupational trauma project reach out: a training program to increase behavioral health utilization among professional firefighters trim: an organizational response to traumatic events in cumbria constabulary workplace mental health training for managers and its effect on sick leave in employees: a cluster randomised controlled trial effects of a comprehensive police suicide prevention program the effect of a trauma risk management (trim) program on stigma and barriers to help-seeking in the police critical incident stress management (cism) in complex systems: cultural adaptation and safety impacts in healthcare physical evidence of police officer stress posttraumatic stress disorder and occupational performance: building resilience and fostering occupational adaptation police encounters with people in crisis: an independent review conducted by the honourable frank iacobucci for chief of police william blair mercer (canada) ltd. how much are you losing to absenteeism? health wealth career the association of treatment of depressive episodes and work productivity on the economics of post-traumatic stress disorder among first responders in canada looking at mental health in the workplace psychological interventions for post-traumatic stress symptoms in psychosis: a systematic review of outcomes the primary prevention of ptsd: a systematic review interventions to prevent post-traumatic stress disorder: a systematic review psychological and pharmacological treatments for adults with posttraumatic stress disorder: a systematic review update preventing ptsd after trauma. a brief review of psychological and technology-based approaches mental health first aid is an effective public health intervention for improving knowledge, attitudes, and behaviour: a meta-analysis working well: an organisational approach to preventing psychological injury. a guide for corporate, hr and ohs managers; commonwealth of australia the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-274778-wds40e6i authors: tejedor, santiago; cervi, laura; tusa, fernanda; portales, marta; zabotina, margarita title: information on the covid-19 pandemic in daily newspapers’ front pages: case study of spain and italy date: 2020-08-31 journal: int j environ res public health doi: 10.3390/ijerph17176330 sha: doc_id: 274778 cord_uid: wds40e6i spain and italy are amongst the european countries where the covid-19 pandemic has produced its major impact and where lockdown measures have been the harshest. this research aims at understanding how the corona crisis has been represented in spanish and italian media, focusing on reference newspapers. the study analyzes 72 front pages of el país and el mundo in spain and italy’s corriere della sera and la repubblica, collecting 710 news items and 3456 data evidences employing a mixed method (both qualitative and quantitative) based on content analysis and hemerographic analysis. results show a predominance of informative journalistic genres (especially brief and news), while the visual framing emerging from the photographic choice, tend to foster humanization through an emotional representation of the pandemic. politicians are the most represented actors, showing a high degree of politicization of the crisis. spain and italy, with 238,564 and 231,732 confirmed cases, respectively, are amongst the european countries where the covid-19 pandemic has produced its major impact and where lockdown measures have been the harshest. due to the reduced mobility and the imposed lockdown, the internet has proved to play a decisive role in terms of media consumption during the quarantine. social networks have occupied the first position among online platforms most frequently consulted by citizens. according to twitter, the information on the pandemic as well as the conversations related to the topic have caused a 23% boost in total active daily users, reaching the general level of 164 million users per trimester. news check-up has experienced a prominent growth at that stage. specifically, the peak of media consumption coincided with the first measures of social distancing and has increased in correspondence with governmental communications. these data should be interpreted within the current crisis of journalism and the crisis of media credibility. a recent survey of 27 countries by ipsos global advisor [1] shows how citizens are rather skeptical towards the information they receive from the media, especially when it comes to online press. in spain, 41% of the surveyed trust in television, whereas 39% expressed their preference for traditional media, such as printed press. making reference to the intentions, the research claims that half of the total number of the surveyed believe that printed papers have "good intentions" as opposed to 66% considering that online newspapers and web pages are the ones with "the worst intentions" [1] . based on the trust placed on the printed media-as the most credible and rigorous media-this research analyzes a total of 72 front pages of the main daily newspapers in spain and italy (36 each) . the research considers the daily newspaper's front page as a fundamental element that synthetizes and prioritizes the contents that the particular medium treats as the most important. at the same time, the front page maintains a direct relation to the digital version of the medium, somehow setting the agenda. in other words, the front page serves a privileged space for public identity construction [2] . the study, carried out between 24 february and 4 april 2020, collected 710 pandemic-related news pieces and 3456 data evidences, aimed at answering the following research questions: • how has the covid-19 pandemic been covered on the front pages of spain and italy's main daily newspapers? • what types of journalistic genres have been used? • what types of political or social figures and institutions appear the most? • what role has been assigned to an image/photograph in the coronavirus-related information items of the front page? the covid-19 crisis has posed new challenges to journalism. media play a fundamental role in framing a crisis, since providing the right information from a reliable source is the key issue in this type of pandemic. the world health organization (who) has used the term "infodemic" to define the overabundance of information introduced by coronavirus and to warn the citizens against the risks caused by this information excess, that contain a great amount of hoaxes and rumors. as sylvie briand, director of infectious hazards management at who's health emergencies program notices, this phenomenon is not new "but the difference now with social media is that this phenomenon is amplified, it goes faster and further, like the viruses that travel with people and go faster and further". the role of social media in spreading misleading health information is not new [3] , but the covid-19 crisis has shown the critical impact of this new information environment [4] . many studies have focused on and are still focusing on how the disintermediated role of social media may foster misinformation: scholars studying iran [5] and spain [6] , stress how social media spread rumors, others [7] try to analyze the structure of this infodemic, or concentrate on the effect of media exposure [8] . within this social media euphoria, very few studies have focused on legacy media, intended as the mass media that predominated prior to the information age-particularly print media, radio broadcasting, and television-even if reality is showing that legacy media still plays an important role [9] . a study [7] noticed how cnn has recently anticipated a rumor about the possible lockdown of lombardy (a region in northern italy) to prevent the pandemic, publishing the news hours before the official communication from the italian prime minister. as a result, people overcrowded trains and airports to escape from lombardy toward the southern regions before the lockdown was in place, disrupting the government initiative, aimed to contain the epidemic and potentially increasing contagion. other literature [10] stresses the importance of looking at mainstream media coverage pointing out the importance of a high quality scientific journalism [11] . the analysis of the printed daily newspapers' front pages has been object of recurrent studies for the last 50 years. starting with the classical works [12] [13] [14] [15] [16] [17] [18] [19] up to the contemporary researches [20] [21] [22] [23] , various studies have dealt with content analysis of that essential element of the printed press [24, 25] . other studies followed them, concentrating on the comparison between the front pages in printed and digital editions of a medium [26] . as previously highlighted, daily newspaper's front pages are considered to be the most important page, displaying informative priorities and editorial position in relation to current issues [27] . other studies [28] single out three core elements of a daily newspaper's front page: headlines, or visual linguistic set; texts, or visual paralinguistic set and images, or visual non-linguistic set. in this context, the importance of media and information literacy, seen as the citizens' ability to access, use, assess, and create responsible and ethical content [29] , has become crucial. media and information literacy refers to the vital role that information and media possess in the everyday life of a person, therefore this skill represents an indispensable component to exercise freedom of expression and information. in this vein, numerous studies [29] [30] [31] [32] stress the significance of a digital literacy development that would exceed studying merely technical or instrumental aspects to embrace the issues of the critical use of media. the research, based on previous studies [33] , analyzes a total of 710 news items extracted from 72 front pages of the four main daily newspapers of spain and italy (36 per country). el país and el mundo of spain alongside with corriere della sera and la repubblica of italy were chosen, based on their relevance and the availability of their front pages. the analysis has been carried out through the use of a template chart consisting of 15 parameters and 64 categories that were obtained mainly in inductive form. the study, possessing descriptive and explanatory character, employs a mixed method (both qualitative and quantitative) based on content analysis and complemented by direct observation and hemerographic analysis as the main techniques. the first technique focused on the analysis of various elements that constitute the front page designs by means of a template chart elaborated during the research process. subsequently, we implemented a hemerographic analysis of texts, headlines and images. the data were processed through descriptive statistics planning with spss software. the analytical chart has considered all the elements displayed in table 1 . coronavirus-related information occupies 71% of the front pages. precisely, 506 news items out of the total 710 focus on topics related to the covid-19 pandemic. as for the main journalistic genres, (see figure 1 ), we can observe brief as the most common. this journalistic genre, characterized by its conciseness and brevity, has been defined as brief, a summarized piece of news that solely reflects the most relevant data of the information, missing profound insight and context. the total of pandemic-related units possess the form of short pieces, that could oscillate between 1 or 5 lines. coronavirus-related information occupies 71% of the front pages. precisely, 506 news items out of the total 710 focus on topics related to the covid-19 pandemic. as for the main journalistic genres, (see figure 1 ), we can observe brief as the most common. this journalistic genre, characterized by its conciseness and brevity, has been defined as brief, a summarized piece of news that solely reflects the most relevant data of the information, missing profound insight and context. the total of pandemic-related units possess the form of short pieces, that could oscillate between 1 or 5 lines. news occupies the second position in the list of types of the texts about coronavirus at the analyzed front pages. the informative approach towards, in other words, dominates the representation of the crisis. the effort of the daily newspapers to inform their readers on the characteristics, impact and spread of the virus has been detected. nonetheless, it is worth mentioning that opinion articles (with a total number of 81 counted units) surpass other informative journalistic genres. moreover, the importance of the editorial photo with a total number of 38 units, solely accompanied by the footnote, demonstrates a comprehensive approach to the topic through the communicative value of the image. the location of news items at the daily newspapers' front pages can be considered another element of high value when it comes to the detection of importance of each topic. in this sense the studies grant more value to the upper part and the right part from the reader's standpoint. the right part is the most valuable of the odd-numbered page and the left part is the most important for the even-numbered pages. concretely, projecting an imaginary v onto the open double page, the higher the position on the v, the more value the piece has (both in terms of editorial and advertising rates). accordingly, results show that news about coronavirus appear mostly located in the upper part, but in the left zone (see figure 2 ). in this way, it is possible to point out that the newspapers place the news in an important area of their front pages. in addition, in second position, with a total of 81 news items, is the upper right-hand area. in this way, it is possible to point out that the news have been progressively occupying the areas of greatest visual impact of the front page. however, this set of news items is very close to the 147 news items on the pandemic that appear at the bottom of the front page, i.e., the one of least importance. a total of 76 appear at the bottom left and 71 at the bottom right. therefore, the distribution of the news on covid-19 between the two areas marked by the horizontal division of the first page (top/bottom) is very tight. news occupies the second position in the list of types of the texts about coronavirus at the analyzed front pages. the informative approach towards, in other words, dominates the representation of the crisis. the effort of the daily newspapers to inform their readers on the characteristics, impact and spread of the virus has been detected. nonetheless, it is worth mentioning that opinion articles (with a total number of 81 counted units) surpass other informative journalistic genres. moreover, the importance of the editorial photo with a total number of 38 units, solely accompanied by the footnote, demonstrates a comprehensive approach to the topic through the communicative value of the image. the location of news items at the daily newspapers' front pages can be considered another element of high value when it comes to the detection of importance of each topic. in this sense the studies grant more value to the upper part and the right part from the reader's standpoint. the right part is the most valuable of the odd-numbered page and the left part is the most important for the even-numbered pages. concretely, projecting an imaginary v onto the open double page, the higher the position on the v, the more value the piece has (both in terms of editorial and advertising rates). accordingly, results show that news about coronavirus appear mostly located in the upper part, but in the left zone (see figure 2 ). in this way, it is possible to point out that the newspapers place the news in an important area of their front pages. in addition, in second position, with a total of 81 news items, is the upper right-hand area. in this way, it is possible to point out that the news have been progressively occupying the areas of greatest visual impact of the front page. however, this set of news items is very close to the 147 news items on the pandemic that appear at the bottom of the front page, i.e., the one of least importance. a total of 76 appear at the bottom left and 71 at the bottom right. therefore, the distribution of the news on covid-19 between the two areas marked by the horizontal division of the first page (top/bottom) is very tight. figure 3 displays the main entities mentioned in the stories, that is to say institution or entities most recurrently mentioned or displayed. of the information, 46% mentions geographical scenarios (europe, madrid, milan, etc.). in this sense, there is a tendency to depersonalize the information and to extrapolate it to wider scenarios or territories. this aspect is important insofar as the subject is the element of the sentence that carries out the action contained in it. in 22% of the cases the front page news referred to national entities of non-political nature (the hospital, the emergency unit, the laboratory, the intensive care unit, the sports center, the cultural center, etc.). in particular, there is a notable reference to entities linked to hospitals and healthcare scenarios. national political entities (government, trade unions, spokespersons, minister of health, etc.) occupy the third position in the rank of entities linked to the news, with 19%. political entities from abroad (the who, the european union, the european parliament, etc.), with 9%, and non-political entities from abroad (especially universities, research groups or the media), with 4%, respectively, completed the list of entities. figure 3 displays the main entities mentioned in the stories, that is to say institution or entities most recurrently mentioned or displayed. of the information, 46% mentions geographical scenarios (europe, madrid, milan, etc.). in this sense, there is a tendency to depersonalize the information and to extrapolate it to wider scenarios or territories. this aspect is important insofar as the subject is the element of the sentence that carries out the action contained in it. in 22% of the cases the front page news referred to national entities of non-political nature (the hospital, the emergency unit, the laboratory, the intensive care unit, the sports center, the cultural center, etc.). figure 3 displays the main entities mentioned in the stories, that is to say institution or entities most recurrently mentioned or displayed. of the information, 46% mentions geographical scenarios (europe, madrid, milan, etc.). in this sense, there is a tendency to depersonalize the information and to extrapolate it to wider scenarios or territories. this aspect is important insofar as the subject is the element of the sentence that carries out the action contained in it. in 22% of the cases the front page news referred to national entities of non-political nature (the hospital, the emergency unit, the laboratory, the intensive care unit, the sports center, the cultural center, etc.). in particular, there is a notable reference to entities linked to hospitals and healthcare scenarios. national political entities (government, trade unions, spokespersons, minister of health, etc.) occupy the third position in the rank of entities linked to the news, with 19%. political entities from abroad (the who, the european union, the european parliament, etc.), with 9%, and non-political entities from abroad (especially universities, research groups or the media), with 4%, respectively, completed the list of entities. in particular, there is a notable reference to entities linked to hospitals and healthcare scenarios. national political entities (government, trade unions, spokespersons, minister of health, etc.) occupy the third position in the rank of entities linked to the news, with 19%. political entities from abroad (the who, the european union, the european parliament, etc.), with 9%, and non-political entities from abroad (especially universities, research groups or the media), with 4%, respectively, completed the list of entities. figure 4 details which kind of people are mostly mentioned within the main characters in the information on covid-19. interestingly, national political figures are the most numerous group with 28% of the total, stressing how the crisis is highly politicized. in second place, we find anonymous citizens who are protagonists in 27% of news items on the front page. if political figures normally make it to the front pages, within the covid-19 crisis, anonymous people have become co-protagonists of the front pages. public figures from different countries (with 14%) making statements about the pandemic outnumbered those affected by or suffering from the virus (with 11%) and international political figures (with 10%). finally, health personnel, who have generated important recognition and ovations, have only been the protagonists of 6% of the front page news about the virus, while researchers and scientists (with 4%) occupy the last place in percentage of presence in the front pages. headlines are also of great importance. their location on the page, and the type and size of the title contributes to underlining the importance of the information among the set of pieces selected to appear on that page. in relation to this (see figure 5 ), the study has identified a predominance (160) of appellative headlines, focused on drawing the reader's attention. for this reason, the headlines tend to be non-verbal and have very atomized structures that seek to convey to the reader news about a subject he or she already knows. as an example, figure 6 shows the headlines from italian la repubblica: "tutti a casa" (everybody is at home) and "chiude l'italia" (italy closes) to announce the lockdown measures. headlines are also of great importance. their location on the page, and the type and size of the title contributes to underlining the importance of the information among the set of pieces selected to appear on that page. in relation to this (see figure 5 ), the study has identified a predominance (160) of appellative headlines, focused on drawing the reader's attention. for this reason, the headlines tend to be non-verbal and have very atomized structures that seek to convey to the reader news about a subject he or she already knows. as an example, figure 6 shows the headlines from italian la repubblica: "tutti a casa" (everybody is at home) and "chiude l'italia" (italy closes) to announce the lockdown measures. headlines are also of great importance. their location on the page, and the type and size of the title contributes to underlining the importance of the information among the set of pieces selected to appear on that page. in relation to this (see figure 5 ), the study has identified a predominance (160) of appellative headlines, focused on drawing the reader's attention. for this reason, the headlines tend to be non-verbal and have very atomized structures that seek to convey to the reader news about a subject he or she already knows. as an example, figure 6 shows the headlines from italian la repubblica: "tutti a casa" (everybody is at home) and "chiude l'italia" (italy closes) to announce the lockdown measures. and generally opt for the structure of subject, verb and predicate, enunciating a topic related to the pandemic trying to answer the "what" and the "who" of such information. the expressive ones, which have an evocative function on an event known to the reader, are the scarcest (only 57 have been counted). this reduced number emphasizes the existence of a commitment among the media analyzed to avoid sensationalist headlines or those that seek only to externalize moods. another classification of headlines focuses on speech acts. in relation to these, as shown by figure 7 , the headlines with textual quotations-which reproduce, between quotation marks, the declaration of one of the protagonists of the information-predominate (67 in total). the majority presence of this type of headlines denotes an interest of the media in presenting the information from a personalized standpoint, thus, bringing the stories closer to the subjects that have generated them. indirectly quoted headlines (30) and partially direct headlines (24) accumulate a smaller number of cases. by analyzing the types of verbs used (see figure 8 ), a predominance of strong interpretative verbs, characterized by highlighting the intensity of an action, is detected (43 in total), followed by weak interpretive verbs (a total of 31) which, although with less intensity, denote a willingness of the journalist to give more intensity to an action. the narrative ones, which are more neutral, add up to the continuity of the news about covid-19 on the front pages of the media, both in italy and spain, justifies this tendency towards headlines of an appellative nature that allude to facts that are familiar to the citizens. the informative headlines, with a total of 112 units, are the most conventional and generally opt for the structure of subject, verb and predicate, enunciating a topic related to the pandemic trying to answer the "what" and the "who" of such information. the expressive ones, which have an evocative function on an event known to the reader, are the scarcest (only 57 have been counted). this reduced number emphasizes the existence of a commitment among the media analyzed to avoid sensationalist headlines or those that seek only to externalize moods. another classification of headlines focuses on speech acts. in relation to these, as shown by figure 7 , the headlines with textual quotations-which reproduce, between quotation marks, the declaration of one of the protagonists of the information-predominate (67 in total). the majority presence of this type of headlines denotes an interest of the media in presenting the information from a personalized standpoint, thus, bringing the stories closer to the subjects that have generated them. indirectly quoted headlines (30) and partially direct headlines (24) accumulate a smaller number of cases. and generally opt for the structure of subject, verb and predicate, enunciating a topic related to the pandemic trying to answer the "what" and the "who" of such information. the expressive ones, which have an evocative function on an event known to the reader, are the scarcest (only 57 have been counted). this reduced number emphasizes the existence of a commitment among the media analyzed to avoid sensationalist headlines or those that seek only to externalize moods. another classification of headlines focuses on speech acts. in relation to these, as shown by figure 7 , the headlines with textual quotations-which reproduce, between quotation marks, the declaration of one of the protagonists of the information-predominate (67 in total). the majority presence of this type of headlines denotes an interest of the media in presenting the information from a personalized standpoint, thus, bringing the stories closer to the subjects that have generated them. indirectly quoted headlines (30) and partially direct headlines (24) accumulate a smaller number of cases. by analyzing the types of verbs used (see figure 8 ), a predominance of strong interpretative verbs, characterized by highlighting the intensity of an action, is detected (43 in total), followed by weak interpretive verbs (a total of 31) which, although with less intensity, denote a willingness of the journalist to give more intensity to an action. the narrative ones, which are more neutral, add up to by analyzing the types of verbs used (see figure 8 ), a predominance of strong interpretative verbs, characterized by highlighting the intensity of an action, is detected (43 in total), followed by weak interpretive verbs (a total of 31) which, although with less intensity, denote a willingness of the journalist to give more intensity to an action. the narrative ones, which are more neutral, add up to a total of 19; while the perlocutionary ones, which incorporate an effect that is intended to be achieved by means of an action, are the least numerous, with 18 units counted. a total of 19; while the perlocutionary ones, which incorporate an effect that is intended to be achieved by means of an action, are the least numerous, with 18 units counted. out of all the pieces about the covid-19 crisis, 177, that is to say 35% of the total content on the pandemic, has some kind of photographic accompaniment. only 2 are in black and white, and in 8 have an artistic quality. the reduced number of photographs on the pandemic on the covers is striking, although it could be justified by the difficulty of obtaining images or doing so from a variety of themes that would allow for dynamism and renovation of the covers. regarding the characters that appear in the photographs, public figures such as pope francis, or celebrities, like sportsmen or writers have taken over the front pages (28.85%). the second leading role is played by anonymous citizens who appear in everyday scenes, with a total of 24%, and national politicians account for 19%. only 3% have images of people affected by or patients who have contracted coronavirus. international political figures account for 8% of the total. finally, health personnel only appear in 14% of the photographs and scientists and researchers in 3%. the visual framing also shows a certain level of both spectacularization (with the presence of celebrities) and politicization of the crisis, while health workers and scientists that actually are on the frontline of the fight against the virus are less visible. by comparing italian and spanish news outlets, we can observe how covid-19 occupies the majority of the information in both countries. nonetheless, while in spain it occupies 62% of the front page; in italy covid-19 related pieces cover a striking 80% of the information (see figure 9 ). italy was the first european country severely hit by the pandemic, so it makes sense to state that this unpleasant surprise somehow engulfed media attention. with regard to the information that presents a predominance of numeric data, the number of pieces is very low in both countries. spain, with 9%, and italy, with 2%, reinforce the scarcity of information focused only on figures or percentages. this might seem surprising, due to the overwhelming amount of data information (statistics, evolution of case numbers, etc.) we have received during the pandemic, nonetheless it confirms the interpretative role assumed by the printed press: while on line media can offer on line updating, the printed press offers a more interpretative vision of facts. figure 10 displays the main entities portrayed in the information. geographical names, that is to say cities or regions, are the most numerous in the information on covid-19 (51% in italy and 38% in spain), followed by national institutions not linked to politics, which, with 21% in italy and 24% in spain, show the prominence that this type of institution has acquired in the framework of this crisis. political institutions are those that occupy the third place with 16% of the total in italy and 25% out of all the pieces about the covid-19 crisis, 177, that is to say 35% of the total content on the pandemic, has some kind of photographic accompaniment. only 2 are in black and white, and in 8 have an artistic quality. the reduced number of photographs on the pandemic on the covers is striking, although it could be justified by the difficulty of obtaining images or doing so from a variety of themes that would allow for dynamism and renovation of the covers. regarding the characters that appear in the photographs, public figures such as pope francis, or celebrities, like sportsmen or writers have taken over the front pages (28.85%). the second leading role is played by anonymous citizens who appear in everyday scenes, with a total of 24%, and national politicians account for 19%. only 3% have images of people affected by or patients who have contracted coronavirus. international political figures account for 8% of the total. finally, health personnel only appear in 14% of the photographs and scientists and researchers in 3%. the visual framing also shows a certain level of both spectacularization (with the presence of celebrities) and politicization of the crisis, while health workers and scientists that actually are on the frontline of the fight against the virus are less visible. by comparing italian and spanish news outlets, we can observe how covid-19 occupies the majority of the information in both countries. nonetheless, while in spain it occupies 62% of the front page; in italy covid-19 related pieces cover a striking 80% of the information (see figure 9 ). italy was the first european country severely hit by the pandemic, so it makes sense to state that this unpleasant surprise somehow engulfed media attention. int. j. environ. res. public health 2020, 17, x for peer review 9 of 16 the characters that appear in the information correspond to very diverse profiles. national political figures are the most numerous, with 26% in italy and 37% in spain (see figure 11 ). this aspect contrasts with the reduced presence of institutions, as mentioned above. thus, it is possible to with regard to the information that presents a predominance of numeric data, the number of pieces is very low in both countries. spain, with 9%, and italy, with 2%, reinforce the scarcity of information focused only on figures or percentages. this might seem surprising, due to the overwhelming amount of data information (statistics, evolution of case numbers, etc.) we have received during the pandemic, nonetheless it confirms the interpretative role assumed by the printed press: while on line media can offer on line updating, the printed press offers a more interpretative vision of facts. figure 10 displays the main entities portrayed in the information. geographical names, that is to say cities or regions, are the most numerous in the information on covid-19 (51% in italy and 38% in spain), followed by national institutions not linked to politics, which, with 21% in italy and 24% in spain, show the prominence that this type of institution has acquired in the framework of this crisis. political institutions are those that occupy the third place with 16% of the total in italy and 25% in spain. the characters that appear in the information correspond to very diverse profiles. national political figures are the most numerous, with 26% in italy and 37% in spain (see figure 11 ). this aspect contrasts with the reduced presence of institutions, as mentioned above. thus, it is possible to point out that politics is personalized as party politics through the representation of figures of the different parties of the country that complies with the seminal findings of hallin and mancini [41] . the characters that appear in the information correspond to very diverse profiles. national political figures are the most numerous, with 26% in italy and 37% in spain (see figure 11 ). this aspect contrasts with the reduced presence of institutions, as mentioned above. thus, it is possible to [41] . in italy, citizens account for 30% of the total number of items; in spain, they account for only 17%. these differences are equally visible in the presence of researchers or scientists, which in italy is 9% and in spain reaches 26%. the main characters that appear in the photographs on the covers, displayed by figure 12 , show important differences between the two countries. celebrities or public figures are the ones that absorb the most attention, with 26% of the total in italy and 30% in spain. this aspect emphasizes the importance given to this type of profile in the information and awareness of the pandemic. citizens, with 16% in italy and 28% in spain, would be in second place. there is, therefore, a prominent role in italy, citizens account for 30% of the total number of items; in spain, they account for only 17%. these differences are equally visible in the presence of researchers or scientists, which in italy is 9% and in spain reaches 26%. the main characters that appear in the photographs on the covers, displayed by figure 12 , show important differences between the two countries. celebrities or public figures are the ones that absorb the most attention, with 26% of the total in italy and 30% in spain. this aspect emphasizes the importance given to this type of profile in the information and awareness of the pandemic. citizens, with 16% in italy and 28% in spain, would be in second place. there is, therefore, a prominent role for anonymous people. national politicians, with 24% and 17%, respectively, would be in third place. patients (with 4% and 3%) and researchers or scientists (with 2% and 3%) hardly appear in the cover images. even if health centers are not the most prominent settings in pictures, we observed how, when looking at the physical spaces represented in the news, summed up in figure 13 , we can observe similarities and differences. first, while italian newspapers offer an emotional representation of the crisis by granting an enormous importance to the representation of empty spaces (such as squares or symbolical touristic spots, like the trevi fountain in rome, that in a normal situation would be crowded), spanish news outlets completely avoid this option, that only account for 2% of the total pictures. in both cases, however, urban spaces are the most recurrent (with 27% in italy and 52% in spain). in addition, although their importance is not prominent, the spaces related to political life (congress, etc.) with 10% in italy and 22% in spain, have a significant presence in the cover photographs. health centers or health camps, with 19% and 12%, are other places that appear next to citizens' homes (with 19% and 10%, respectively). even if health centers are not the most prominent settings in pictures, we observed how, when portrayed, these spaces are emotionally charged to dramatize the tragedy. figure 14 shows two examples of spanish newspapers el mundo y el país showing coffins of victims in the middle of the crisis. even if health centers are not the most prominent settings in pictures, we observed how, when portrayed, these spaces are emotionally charged to dramatize the tragedy. figure the covid-19 crisis has been a shocking reality that took most countries by surprise. italy and spain have been amongst the first in europe to be hit by the pandemic. thus, observing media behavior is especially interesting. to answer our research questions, we can state that the covid-19 crisis has been covered mainly in an informative way: the analysis of the two main newspapers in spain and italy allows to observe a predominance of informative journalistic genres. in particular, the predominant genre is the brief, short news items, which lack contextual information, and do not offer in depth information to the readership. however, the choice of images, that is to say the visual framing of the stories, seems to suggest an emotional turn. in other words, even if the predominance of informative genres, together with the the covid-19 crisis has been a shocking reality that took most countries by surprise. italy and spain have been amongst the first in europe to be hit by the pandemic. thus, observing media behavior is especially interesting. to answer our research questions, we can state that the covid-19 crisis has been covered mainly in an informative way: the analysis of the two main newspapers in spain and italy allows to observe a predominance of informative journalistic genres. in particular, the predominant genre is the brief, short news items, which lack contextual information, and do not offer in depth information to the readership. however, the choice of images, that is to say the visual framing of the stories, seems to suggest an emotional turn. in other words, even if the predominance of informative genres, together with the avoidance of openly emotional headlines might suggest that the analyzed newspapers have avoided sensationalism, both the mentioned visual framing and the increased presence of anonymous citizens and celebrities among the subjects, can be interpreted as an attempt to humanize the information pieces, emotionally charging them. in particular, it is important to stress out the high level of politicization of the crisis: politicians have been the most recurrent actors both in the information and in the pictures. this, as seen, seems contradictory to the scarce presence of institutions. this result, however, should not be of surprise since, as already pointed out by hallin and mancini [41] , both spain and italy belong to the polarized pluralist model, in which party politics is predominant to institutional politics. moreover, both countries are characterized by high intensity political polarization, therefore the management of the crisis has been the source of harsh political conflicts between government and opposition, that has been reflected by the media. concretely, spanish media outlets are the ones that give a more political vision of the crisis. accordingly, we observed a trend to objectify the different news actions and events through the use of geographical entities. the use of physical enclaves (italy, spain, milan or madrid, for example) lead to a simplification or generalization of reality that can bias the reading and interpretation of what has happened. in the same vein, it is important to stress that both health personnel and researchers directly involved in the fight against the virus, have a negligible presence both in pictures and information. in conclusion, we can sum up that the protagonists of the pandemic are not those affected, or involved in the fight, but rather anonymous citizens, and especially celebrities and politicians. these results cannot be discussed without taking into consideration the general framework of the social responsibility theory. as pointed out by mcquail in his seminal work [42] , media should accept and fulfil certain obligations to the society and should meet high professional standards of accuracy, truth, objectivity and balance. therefore, journalists and professionals should be accountable to the society reflecting and respecting diversity, pluralism as well as diverse points of view and rights of reply. applying these criteria to the specific field of health communication, defined by sixsmith et al. [43] as the study and use of communication strategies to inform and influence individual and community decision that enhance health, encompassing health promotion, health protection, disease prevention and treatment, we see how media are pivotal to the overall achievement of the objectives and aims of public health. in this sense, media practitioners and their organizations should be in charge of delivering rigorous health information, aimed at creating awareness about people's health, to prevent diseases and encourage healthy living. one of the main requirements of good health journalism [44] , thus, is to present evidence-based news with proper perspective, and without giving rise to sensationalism or alarm. as pointed out by many studies [45, 46] journalism training, in order to cope with these new challenges, should lay special emphasis on these aspects, providing not only specific health journalism training, but developing specific media and information literacy training devoted to health issues. acknowledging the geographical limitations, our study allows a series of conclusions to be drawn, which, from a diagnostic perspective, may help both scholars and journalism practitioners and deepen on the behavior and reaction capacity of newspapers in front of important and tragic events such as planetary pandemic. from a scholarly perspective, our work is embedded in a stream of literature that considers media to play a crucial role in framing public debates and shaping public perceptions by selecting which issues are reported and how they are represented [20] [21] [22] [23] . even if, as said, our results are limited to spain and italy, we have shown that printed newspapers avoid the massive use of data or percentages, leaving live updates to on line media, concentrating on more informative and interpretative pieces. this, on the one hand suggest they still play a crucial role in molding public opinion by offering more interpretative content [9] , on the other they directly and indirectly interact with digital media, in charge of giving more live information. for this reason, our results suggest that legacy media should still be examined to see how they influence/are influenced in their interaction with online media. in addition, we have pointed how in both countries the pandemic has been highly politicized. this result, stressing out the salience of the political factor in representing the pandemic, underlines the need for more comparative research, analyzing media portrayal in different contexts and how different media, embedded in different political and cultural contexts, have reacted. in particular, the current corona crisis, having a global reach and effect, could be an ideal occasion to compare media behavior in different countries to observe the existence of similarities and differences, and to which extent different political cultures and political systems modify media reactions to a pandemic, following and proving hallin and mancini's model [41] . in addition, even if reference newspapers seem to opt for an informative approach, their visual framing and the choice of images (i.e., empty places) emotionally charges the information. in this sense, besides the need for more comparative research to prove that this is a global trend, from a practical standpoint, our results align with the findings of previous studies [45, 46] , stressing the need to promote media and information literacy, not only among citizens, but also among media professionals. as demonstrated, both the predominance of short news items, which lack contextual information, and the visual framing can make the process of processing the essence of information messages difficult, making the susceptibility of many people to misinformation as risky as susceptibility to the virus itself. thus, as previously pointed out, in order to achieve rigorous and responsible health information, journalism training should not only provide specific health journalism training, rather media and information literacy skills should be developed in this field. in the same vein, media and information literacy campaigns geared towards citizenship should focus specifically on health issues, since, as the current crisis has showed, health is one of the most sensitive topic when it comes to quality information to avoid the risk of misinformation. accordingly, the current corona crisis underlines the necessity of a reform of science communication. this pandemic has underlined that the media often does not offer rigorous scientific information, prioritizing a (possibly) misleading humanization of news. first, media professionals should be trained and help to implement fact-checking functions, particularly to debunk fake news, misinformation and disinformation on health subjects. moreover, a renewed cooperation and a greater communication between media, health experts, academia and policy makers is essential for improving quality of health news. for this, academic institutions, health bodies, and organizations engaged in scientific and medical research need to improve their communication with media, understanding the need to explain research findings, policies and trends to media professionals, who are in charge of "translating" and diffusing them to citizens. on the other side, media should rely on competent scholars from a wide range of disciplines, interacting, assessing and dialoguing with journalists in order to provide readers, and ultimately citizenship, with a better understanding of science-related issues such as a pandemic. la prensa sensacionalista y los sectores populares systematic literature review on the spread of health-related misinformation on social media effects of health information dissemination on user follows and likes during covid-19 outbreak in china: data and content analysis covid-19 related misinformation on social media: a qualitative study from iran social networks' engagement during the covid-19 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secciones de deportes en los diarios de información general españoles antes de 1936 análisis de contenido y superficie de las primeras páginas de los diarios autonómicos análisis de las temáticas y tendencias de periodistas españoles en twitter: contenidos sobre política, cultura, ciencia el diseño periodístico en la prensa diaria media literacy and new humanism fact-checking' vs. 'fakenews': periodismo de confirmación como recurso de la competencia mediática contra la desinformación the challenge of teaching mobile journalism through moocs: a case study análisis de los contenidos de elementos impresos de la portada de diario correo edición región puno cómo se fabrican las noticias. fuentes, selección y planificación la prensa on-line. los periódicos en la www digitizing the news. innovation in on-line newspapers el periodismo y los nuevos medios de comunicación internet para periodistas comparing media systems: three models of media and politics mass communication theory health communication and its role in the prevention and control of communicable diseases in europe: current evidence, practice and future developments health communication: the responsibility of the media in nigeria. spec tejedor calvo, s. analysis of journalism and communication studies in europe's top ranked universities: competencies, aims and courses análisis de los estudios de periodismo y comunicación en las principales universidades del mundo. competencias, objetivos y asignaturas this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-012462-q8u47hdp authors: olsavszky, victor; dosius, mihnea; vladescu, cristian; benecke, johannes title: time series analysis and forecasting with automated machine learning on a national icd-10 database date: 2020-07-10 journal: int j environ res public health doi: 10.3390/ijerph17144979 sha: doc_id: 12462 cord_uid: q8u47hdp the application of machine learning (ml) for use in generating insights and making predictions on new records continues to expand within the medical community. despite this progress to date, the application of time series analysis has remained underexplored due to complexity of the underlying techniques. in this study, we have deployed a novel ml, called automated time series (autots) machine learning, to automate data processing and the application of a multitude of models to assess which best forecasts future values. this rapid experimentation allows for and enables the selection of the most accurate model in order to perform time series predictions. by using the nation-wide icd-10 (international classification of diseases, tenth revision) dataset of hospitalized patients of romania, we have generated time series datasets over the period of 2008–2018 and performed highly accurate autots predictions for the ten deadliest diseases. forecast results for the years 2019 and 2020 were generated on a nuts 2 (nomenclature of territorial units for statistics) regional level. this is the first study to our knowledge to perform time series forecasting of multiple diseases at a regional level using automated time series machine learning on a national icd-10 dataset. the deployment of autots technology can help decision makers in implementing targeted national health policies more efficiently. accurate disease forecasts can help medical organizations in taking countermeasures and advance preparedness of hospitals and the general population. recently, machine learning (ml) techniques are being increasingly implemented in the analysis of healthcare data [1] . ml analysis can help combat diseases and improve medical systems by increasing their efficiency. particularly, deep learning, a subset of ml, has been extensively deployed over the past years due to increasing computer processing power and the availability of so-called big data sets [2, 3] . deep learning (dl) algorithms are able to perform highly complex computational analysis of massive labeled and unlabeled raw data [4] . while such dl applications have already been widely used as diagnostic tools either in disease predictions, [5] [6] [7] or in clinical [8, 9] or pathological image analysis [10, 11] , there is limited ml deployment described for time series forecasting in the current literature [12] . since epidemics or pandemics are known to cause not only individual, but also societal damages [13] [14] [15] , the majority of disease forecast models have been created for infectious diseases [12, [16] [17] [18] . analyses, in order to improve disease prevention, reduce medical costs, and allow officials to allocate resources effectively in response to public health issues. romania started using the us drg (diagnosis-related group) mechanism for hospital reporting in 2003 [43] . switching towards an australian system, the current version adopted by romania uses the same international classification of the diseases, which made the data compatible for analysis and comparison for the entire period of time [44] . data from the national drg database is reported monthly to the national school of public health, management and professional development (nsphmpdb) in bucharest. over a period of 11 years, starting from 2008 until 2018, all hospitalized patients in romania classified into a diagnosis-related group (drg) [45] were included in the database [46] . data was prepared from the primary national database using paxata in the datarobot platform [47] . datasets per analyzed affliction were extracted on a regional nuts 2 level according to the corresponding icd-10 codes provided by nsphmpdb (table s1 ). disease codes were searched and validated with the who icd-10 online application [48] and the "icd-10_am diagnosis and procedures list" provided by the national school of public health, management and professional development (nsphmpdb). only new hospitalized cases with targeted diseases recorded as the main diagnosis were selected and aggregated into new cases per month per nuts 2 region. the necessary features for creating a secondary time series database are shown in the flow chart of the study selection process ( figure s1 ). data is not normalized during data preparation. we further enriched the dataset with the number of working days in the month and the total number of days in the month, as well as a calendar of events of 26 public holidays (table s2 ). the secondary time series database is deposited online (https://www.synapse.org/#!synapse:syn22242698). after uploading each time series dataset onto the autots platform [49] and selecting the appropriate forecasting target, i.e., "new cases", a time frame needed to be set to define a rolling window to derive descriptive features relative to the forecast point, i.e., the time the prediction is being made. this so-called derivation window was empirically tested using 4, 6, 8, 10, and 12 months before the forecast point for each disease. the derivation window that produced models with the lowest gamma deviance was chosen (table 1) . a forecast window (fw) defines the range of future values chosen to be predicted relative to the forecast point, called forecast distances (fds). a fd of 24 months was used for each disease. after defining the modeling project settings and target, a model fitting procedure of preprocessing, algorithms, and postprocessing steps was performed by the autots tool ( figure s2 ). the autots platform simplifies model development by performing a parallel heuristic search for the best model or ensemble of models, based on both the characteristics of the data and the prediction target. during the modeling process, many independent challenger models are developed. the time series functionality works by encoding time-sensitive components (such as lags and moving averages) as features, transforming the original input dataset into a modeling dataset that can use conventional machine learning techniques. the autots tool automatically creates and selects time series features in the modeling data and automatically detects whether a project's target value is stationary. if the target is not stationary, or shows strong seasonality, it attempts to make it stationary by applying a differencing strategy prior to modeling, thus improving the accuracy and robustness of the underlying models. next, a series identifier is defined as the nuts 2 hospital region. more precisely, a column containing the nuts 2 region of the hospital must be identified, so that the different timepoints of a disease can be attributed to their corresponding nuts 2 region. this tells the autots tool that there are multiple subsets of data to model and evaluate in the dataset. importantly, having multiple series allows the algorithms to learn effects that are present across the nuts 2 regions. finally, information about the selected target variable and predictors is used to define a set of candidate blueprints for analysis; here, blueprint stands for the combination of data preprocessing steps, transformations, and machine learning algorithm. it then trains models for each blueprint and ranks them based on a validation and holdout accuracy score ( figure s2 ). in order to assess any model's performance, out-of-time validation (otv) is employed, which allows the selection of specific time periods to test the model stability, creating so-called data "backtests" [50] . backtesting ensures that each algorithm is learning its parameters, or "fitting" the data, on historical examples only, and model performance is only being evaluated on unseen, "out of sample", data in a proceeding period of time in the future. the length of training data used was 10 years for each dataset with three backtests used by the autots tool ( figure s3 ). the validation time period for each backtest was one year for all diseases, except diabetes, road injuries, stroke, and heart disease using eight months. across all projects, the final year of data was set aside as "holdout" data and was not evaluated until the final models were selected. the year 2018 was chosen as the holdout partition. the performances of these models are ultimately exposed, enabling the selection of the best model for the problem being addressed (table s3) . after the data had been examined by the platform, it began the modeling process. a wide variety of models are tried by the tool, including common techniques such as sarima and more modern approaches such as extreme gradient boosting. on average, 29 different models were tried per disease ( table 1 ). the models were evaluated according to a number of metrics, including gamma deviance, mean absolute error (mae), and mean absolute percentage error (mape). these scores were available for the first backtest, average of all backtests, and the holdout portion of the data. ultimately, the top performing models were chosen based on the score of the optimization metric chosen by the platform, either gamma deviance or root mean square error (rmse), on the holdout portion of the data. rmse is a frequently used goodness-of-fit statistic, which summarizes the discrepancy between observed values and the values expected under the model in question. it is a good measure of how accurately the model predicts the response, and it is the most important criterion for fit if the main purpose of the model is prediction. deviance is another goodness-of-fit statistic for models using the sum of squares of residuals (gamma) in ordinary least squares to cases where model-fitting is achieved by maximum likelihood. after the model was identified, it was further refined by examining permutation-based feature importance. features that contributed to the performance of the model were kept, while all other features were dropped. the model was run again using the new feature list, and if it performed better than the previous version of the model, it was selected as the final model (table s4) . to extract predictions out of the best performing model, first the model is retrained up to the last month available in the dataset, using the same hyperparameters. next, using the most recent observations as defined by the derivation window, predictions can be obtained from this updated model, which now consists of the estimated values of new cases per nuts hospital region for each of the 24 months in the forecast window. this study was reviewed and approved by the ethics committee of the national school of public health, management and professional development (nsphmpdb) from bucharest, romania (4854-04.11.2019) and by the medical ethics committee ii of the medical faculty mannheim, heidelberg university (2019-873r), germany. note. after choosing the length of training data for the backtests, derivation window (dw), and the length of forecasted data (fd), models were compared and validated for each disease by the aml (automated machine learning) platform. the year 2018 was chosen as holdout, and the predicted values were compared to the actual values. model selection was based on the gamma deviance or root mean square error (rmse). other calculated estimators were r-squared, the mean absolute error (mae) and the mean absolute percentage error (mape). the total number of compared models, as well as the final selected model, are listed. these final selected models were either the avg (average) blender, the extreme gradient boosting model or the elastic-net regressor. in order to perform time series forecasting, a series of data points in time order had to be prepared for each one of the top 10 deadliest diseases, as defined by the who [41] . for this purpose the corresponding icd-10 codes for ischemic heart diseases, stroke, chronic obstructive pulmonary disease, lower respiratory infections, alzheimer's disease, lung cancer, diabetes mellitus, road injuries, diarrheal diseases, and tuberculosis (table s1) were extracted from the whole icd-10 data set of hospitalized patients in romania from the period 2008-2018. since the aim of the study was to predict future new cases of each disease, only the icd-10 codes used as main diagnoses in the data set were employed. we have deliberately not included icd-10 codes categorized as secondary diagnoses, since physicians often tend to encode recoveries, anamnestic recalls, or unproven diagnoses in this category [51] . hence, new cases of each disease represent the absolute count of every main diagnosis that necessitated a hospitalization episode. these disease counts were further classified into eight nuts 2 regions to facilitate the detection of regional differences. the retrospective analysis of ischemic heart diseases revealed an obvious decline in new cases from 2009 to 2011 in all regions ( figure 1a) . a slight decrease in new cases was still observable after 2011 in most regions, apart from bucharest-ilfov and center, which were also the regions with the highest numbers of ischemic heart disease hospitalizations. stroke, on the other hand, showed a constant decline in almost all regions from 2008 to 2018, with the exception of north east, a region where the stroke counts started increasing after 2016 ( figure 1b) . overall, bucharest-ilfov had the highest stroke case counts. unexpectedly, bucharest-ilfov revealed the lowest case counts in chronic obstructive pulmonary disease, a disease with an obvious decline in new cases in all regions ( figure 1c ). lower respiratory infections showed an alternating course of case counts in almost all regions ( figure 1d ). in this case, a decline in new cases was observable from 2009 to 2012 followed by an overall, but sinusoidal, increase in new cases after 2012. next, alzheimer's disease counts showed a small trend upwards, with bucharest-ilfov being the region with the highest and concurrently stable case counts over the years ( figure 1e ). interestingly, the second highest counts of alzheimer's disease were observed in south muntenia with an obvious ascending slope. regarding lung cancer, there was a clear decline in case counts in bucharest-ilfov ( figure 1f ). in comparison, all other regions showed a rather small decline with at least half as many case counts compared to the bucharest-ilfov region. in case of diabetes mellitus, the counts of new cases were relatively stable over the years with bucharest-ilfov having the highest and south west oltenia the lowest numbers ( figure 2a) . differently, road injuries showed a clear decline from 2008 to 2018 throughout all regions with the numbers almost halving during this observation period ( figure 2b ). interestingly, bucharest-ilfov shared with north east the highest counts of road injuries, starting with 2015. while diarrheal diseases also showed a stable disease count with a noteworthy increase from 2009 to 2010 ( figure 2c ), tuberculosis displayed a striking decline of approximately 40% over the whole period of 10 years ( figure 2d ). most tuberculosis cases were noted north east, while the center region had the lowest counts. the year 2018 was chosen as the holdout partition ( figure 3 ). the holdout was not part of the training data set and only served for verifying the model. therefore, every trained model predicted the monthly case counts for 2018 and was compared to the actual values. the top performing model for each disease was selected based on the optimization metric chosen by the platform, either gamma deviance or rmse (table s3) . other estimators, such as r-squared (coefficient of multiple determination for multiple regression), mean absolute error (mae, average magnitude of the errors), and mean absolute percentage error (mape, average of the unsigned percentage error), were also taken into consideration. notably, ensembles of multiple models, in the form of an average (avg) blender model, yielded the lowest mae scores in most datasets (table 1) . this model takes the predictions from several input models and averages them together into a metamodel. predictions are made from each of the input models and ultimately combined. other selected models included extreme gradient boosting and elasticnet regressor. gradient boosting machines (gbms) are a generalization of freund and schapire's adaboost algorithm [52] to handle arbitrary loss functions. gbms differ from random forests in a single major aspect: rather than fitting individual decision trees in parallel, the gbm fits each successive tree to the residual errors from all the previous trees combined. extreme gradient boosting is a very efficient, parallel version of gbm that has been heavily optimized and tweaked for faster runtimes and higher predictive accuracy. elasticnet is a linear regression model trained with l1 (lasso regression) and l2 (ridge regression) prior as regularizer. this model is useful when there are multiple features which are correlated with one another. with the exception of tuberculosis, alzheimer's diseases, diarrheal disease, and road injuries, the mape was lower than 10% (table 1) . for the purpose of better visualization and comprehension, disease counts of the last two years in the analyzed dataset, namely, 2017 and 2018, were plotted on a monthly basis next to the predicted counts of 2019 and 2020 (figures 4 and 5) . the overall ischemic heart diseases development of new cases seems to remain stable with low fluctuations ( figure 4a) . a dip in case counts was noticed during december of each year. furthermore, there are parallel curve progressions of the predicted disease counts of every region, with bucharest-ilfov showing the highest case counts. while the prediction of stroke counts also shows a certain stability, south muntenia and north east predominantly reveal the highest numbers of stroke hospitalizations ( figure 4b ). moreover, bucharest-ilfov showed a decline in case counts starting with 2018. another reduction in case counts is observed with chronic obstructive pulmonary disease, especially in the north east region, when comparing the predicted years to the previous ones ( figure 4c ). furthermore, there is a peak in hospitalization episodes noticeable during wintertime in all regions for chronic obstructive pulmonary disease. next, lower respiratory infections will retain their strong fluctuation during the years ( figure 4d ). hospitalizations due to lower respiratory infections are usually high during the first three months of each year and have the lowest counts during the summer. noteworthy is a second relatively small peak occurring during october of each year. regarding alzheimer's disease, bucharest-ilfov and south muntenia have the most cases, while center, north west, west, and south east share highly similar numbers ( figure 4e ). here, south west oltenia remains the region with the fewest alzheimer's disease hospitalizations. another dip in counts is visible in this case during december. lung cancer has a similar disease course to alzheimer's disease ( figure 5a ). according to our prediction, there are no significant changes in lung cancer case counts when compared to 2017 and 2018. moreover, the predicted case counts of diabetes mellitus are very similar to the years before ( figure 5b ). another distinct seasonal trend with the peak during summer and the highest counts in north east and bucharest-ilfov is seen in road injuries ( figure 5c ). here, south west oltenia shows the lowest fluctuations of predicted counts. interestingly, we observed a partial dependence of 37% to calendar dates. spring holidays are associated with higher case counts of road injuries ( figure s4) . similarly, diarrheal diseases also show seasonality, with the highest counts in summer and lowest counts in winter, mainly in november and december ( figure 5d ). finally, there is yearly seasonality observed with tuberculosis, including the already known reduced hospitalization cases in december ( figure 5e ). there is a stable decline when looking at tuberculosis from the beginning of 2017 onwards, which is continued throughout 2019 and 2020. the regions north east and south west oltenia keep alternating in regard to the highest case counts. when compared to the current literature, this is the first study on a national icd-10 database to perform thorough time series forecasting on multiple diseases on a regional level using automl to select the most accurate of a multitude of models (table s5) . this is the first study to apply automated machine learning for time series forecasting on a nationwide icd-10 dataset. using data from all hospitalized patients from 2008-2018, we were able to analyze region-specific hospitalization counts for the ten deadliest diseases in romania and perform forecasts for the years 2019 and 2020. our findings corroborate previous studies in several important ways. cardiovascular diseases, such as ischemic heart diseases and stroke, are the leading cause of death in romania [53] . western countries, for example, have managed to lower the mortality caused by ischemic heart diseases due to improvement of primary prevention and advances in diagnostic approaches [54] . our retrospection of the last decade in romania echoes this statement to a certain extent as well, since the hospitalizations of ischemic heart diseases and stroke showed a continuous drop from 2008 until 2018. our predictions do not confirm this trend but show a rather stable count for these diseases for 2019 and 2020. since there have only been analyses on romanian macroregions [53] , our nuts 2 regional forecast could help decision makers identify specific regions with rising trends. given that romania has one of the highest estimated risks of developing stroke [55] , and the number of new stroke cases is expected to double by 2060 [56] , additional actions are mandatory in the public health sector to lower this incidence of these cardiovascular diseases. according to the who, chronic obstructive pulmonary disease cases will continue to grow in the future and become the third leading cause of death by 2030 [57] . romania has an intermediate prevalence, calculated at around 10% [58, 59] , and both our retrospective and forecasting analyses revealed decreasing numbers in chronic obstructive pulmonary disease hospitalizations. lower respiratory infections, on the other hand, consistently showed seasonality, with peaks in winter and lows in summertime. this is especially important for romania, since the influenza incidence is the highest among children aged 0-4 years [60] and the lower respiratory infections mortality rate per 100,000 people for all ages is the highest in this country when compared to the whole balkan peninsula [61] . alzheimer's disease presented a doubling in hospitalizations after 1994, with continuously growing numbers ever since [62] . while we also observed an upwards trend after 2008, our forecasting results revealed steady counts for 2019 and 2020. importantly, bucharest-ilfov and south muntenia are leading regions in alzheimer's hospitalizations in comparison to all other nuts 2 regions. similarly, high counts were seen for bucharest-ilfov and north west with lung cancer predictions. despite several indications that the incidence of lung cancer would continue to rise in romania [63, 64] , we observed a decline in hospitalization episodes. this might be due to nationally instituted antitobacco policies [63] . we have observed a fall in diabetes mellitus cases until 2012 and predicted constant counts. it should be noted that hospitalizations episodes do not necessarily reflect the overall incidence of a disease. this could be especially true for diabetes mellitus. while icd-10 hospitalization case counts are relatively constant, a rise in incidence has been predicted for romania [65] . road injuries, on the other hand, make up almost 10% of all injuries treated in emergencies clinics or hospitalizations [66] . while romania has managed to reduce road mortality, it still has the most road traffic fatalities in the european union [67, 68] . we even predicted the highest road-injury-related hospitalization cases in the north-east region during the summer peaks. in the case of diarrheal diseases, estimated to be the leading cause of death globally and having a declining incidence [69, 70] , we only noticed a slight reduction in new cases over the period 2008-2018 and predicted further stable counts. finally, tuberculosis, with romania known to have the highest incidence of extensively drug-resistant tuberculosis in the european union [71] , displayed promising declining hospitalization cases over the years. starting in 2002, romania has made significant progress in fighting the tuberculosis epidemic by implementing nationwide prevention and management programs [72] . this decreasing trend was supported with our forecast model. in line with other time-series analyses on tuberculosis that described a seasonality [18, 27, 28] , we see a strong dip in the hospitalization curve in december, followed by a steep rise in the early months of the year. this dip is visible in most diseases, namely, ischemic heart disease, chronic obstructive pulmonary diseases, alzheimer's, lung cancer, diabetes mellitus, and tuberculosis, not only in the predicted months of december 2019 and 2020, but also december 2017 and 2018. this is attributed to a fall in hospitalization cases due to the winter holidays of saint nicholas, christmas, and new year's eve. in summary, we performed an exhaustive, time-saving analysis with a nation-wide icd-10 medical dataset encompassing a period of eleven years. given the fact that hospitals use different applications to collect own patient data (diagnostics, blood tests etc.), which cannot be harmonized and aggregated, the icd-10 dataset represents the only major, internationally used big dataset that can be employed for medical studies. by utilizing a novel automated machine learning tool, we could perform highly accurate predictions of the ten leading causes of death on a regional level for the whole country of romania. while other machine learning studies usually use one model for one disease, the deployed autots platform compared a multitude of models and allowed the selection of the most accurate one. it is noteworthy that the used dataset did not contain any outpatient, but only hospitalization records. therefore, one important limitation of our study is the predicted case counts not representing the incidence of the ten analyzed causes of death, but rather the hospitalization episodes attributed to these diseases. another selection bias could arise from inconsistencies of the primary national database, since diseases are coded by healthcare workers. some hospitals may not have the necessary resources for training professional healthcare coders, given that some diseases have long lists of potentially relevant codes, which could lead to confusion. nevertheless, the predicted changes in case counts and their geographic dynamics can help officials performing countermeasures, allocating resources, or raising public awareness through more aimed operations. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/14/4979/s1, figure s1 : flow chart of study selection process, figure s2 : model development workflow process (model blueprint), figure s3 : schematic representation of model development procedure for lower respiratory infections, figure s4 : average of hospitalizations due to road injuries on selected public holidays in romania, table s1 : listing of icd-10 codes selected for data extraction and preparation from the whole icd-10 data set of hospitalized patients in romania during the period 2008-2018, table s2 : romanian public holidays, table s3 : exemplary listing of model performances calculated by the aml tool for lower respiratory infections, table s4 : exemplary summary statistics for lower respiratory infections, table s5 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burden of disease study european centre for disease prevention and control. tuberculosis surveillance and monitoring in europe tuberculosis remains a public health problem in romania we are grateful to victor s. olsavszky for scientific discussions. the authors declare no conflict of interest. key: cord-252894-c02v47jz authors: chae, sangwon; kwon, sungjun; lee, donghyun title: predicting infectious disease using deep learning and big data date: 2018-07-27 journal: int j environ res public health doi: 10.3390/ijerph15081596 sha: doc_id: 252894 cord_uid: c02v47jz infectious disease occurs when a person is infected by a pathogen from another person or an animal. it is a problem that causes harm at both individual and macro scales. the korea center for disease control (kcdc) operates a surveillance system to minimize infectious disease contagions. however, in this system, it is difficult to immediately act against infectious disease because of missing and delayed reports. moreover, infectious disease trends are not known, which means prediction is not easy. this study predicts infectious diseases by optimizing the parameters of deep learning algorithms while considering big data including social media data. the performance of the deep neural network (dnn) and long-short term memory (lstm) learning models were compared with the autoregressive integrated moving average (arima) when predicting three infectious diseases one week into the future. the results show that the dnn and lstm models perform better than arima. when predicting chickenpox, the top-10 dnn and lstm models improved average performance by 24% and 19%, respectively. the dnn model performed stably and the lstm model was more accurate when infectious disease was spreading. we believe that this study’s models can help eliminate reporting delays in existing surveillance systems and, therefore, minimize costs to society. infectious disease occurs when a person is infected by a pathogen from another person or an animal. it not only harms individuals, but also causes harm on a macro scale and, therefore, is regarded as a social problem [1] . at the korea center for disease control (kcdc), infectious disease surveillance is a comprehensive process in which information on infectious disease outbreaks and vectors are continuously and systematically collected, analyzed, and interpreted. moreover, the results are distributed quickly to people who need them to prevent and control infectious disease. the kcdc operates a mandatory surveillance system in which mandatory reports are made without delay to the relevant health center when an infectious disease occurs and it operates a sentinel surveillance system in which the medical organization that has been designated as the sentinel reports to the relevant health center within seven days. the targets of mandatory surveillance consist of a total of 59 infectious diseases from groups 1 to 4 by the kcdc. the targets of sentinel surveillance include influenza from group 3 along with 21 infectious diseases from group 5. overall, a total of 80 infectious diseases in six groups are monitored. in the current korean infectious disease reporting system, if there is a legally defined infectious disease patient at a medical organization, a report is made to the managing health center through the infectious disease web reporting system. the managing health center reports to the city and province health offices through another system and the city and province health offices report to the kcdc. in the conventional reporting system, some medical organizations' infectious disease reports are incomplete and delays can occur in the reporting system. for instance, in the traditional influenza surveillance system, around two weeks elapses between when a report is made and when it is disseminated [2] . the kcdc has been running an automated infectious disease reporting system as a pilot project since 2015. however, by 2017, only 2.3% of all medical organizations were participating in the pilot project. in medical organizations using the conventional infectious disease reporting system, a large number of missing and delayed reports can occur, which hinders a prompt response to infectious disease. as such, it is necessary to create a data-based infectious disease prediction model to handle situations in real time. furthermore, if this model can understand the extent of infectious disease trends, the costs to society from infectious disease can be minimized. an increasing number of researchers recognize these facts and are performing data-based infectious disease surveillance studies to supplement existing systems and design new models [3] [4] [5] [6] [7] [8] [9] . among these, studies are currently being performed on detecting infectious disease using big data such as internet search queries [10] [11] [12] [13] [14] [15] . the internet search data can be gathered and processed at a speed that is close to real time. according to towers et al., internet search data can create surveillance data faster than conventional surveillance systems [16] . for example, when huang et al. predicted hand, foot, and mouth disease using the generalized additive model (gam), the model that included search query data obtained the best results. as such, it has been reported that new big data surveillance tools have the advantage of being easy to access and can identify infectious disease trends before official organizations [17] . in addition to internet search data, social media big data is also being considered. tenkanen et al. report that social media big data is relatively easy to collect and can be used freely, which means accessibility is satisfactory and the data is created continuously in real time with rich content [18] . as such, studies have used twitter data to predict the occurrences of mental illness [19] and infectious disease [20] [21] [22] [23] in addition to predictions in a variety of other scientific fields [24] [25] [26] [27] . in particular, a study by shin et al. reported that infectious diseases and twitter data are highly correlated. there is the possibility of using digital surveillance systems to monitor infectious disease in the future [20] . when these points are considered, using search query data and social media big data should have a positive effect on infectious disease predictions. in addition to these studies, there are also studies that have used techniques from the field of deep learning to predict infectious disease [22, 23, 28, 29] . deep learning is an analysis method and, like big data, it is being actively used in a variety of fields [30] . deep learning yields satisfactory results when it is used to perform tasks that are difficult for conventional analysis methods [31] [32] [33] . in a study by xu et al., a model that used deep learning yielded better prediction performance than the generalized linear model (glm), the least absolute shrinkage and selection operator (lasso) model, and the autoregressive integrated moving average (arima) model [28] . as such, methods of predicting infectious disease that use deep learning are helpful for designing effective models. there are also examples of infectious disease prediction based on environmental factors such as weather [34] [35] [36] [37] . previous studies have confirmed that weather data comprises a factor that has a great influence on the occurrence of infectious diseases [38] [39] [40] . liang et al. showed that rainfall and humidity are risk factors for a hemorrhagic fever with a renal syndrome [41] . in addition, a study by huang et al. reported that trends in dengue fever show a strong correlation with temperature and humidity [42] . previous studies indicate that infectious disease can be predicted more effectively if weather variables, internet big data, and deep learning are used. most previous research has attempted to predict infectious disease using internet search query data alone. however, as discussed above, it is necessary to also consider various big data and environmental factors such as weather when predicting infectious disease. in addition, in the case of models that use deep learning, it is possible to improve prediction performance by optimizing the deep learning model by optimizing its parameters. therefore, the aim of this study is to design a model that uses the infectious disease occurrence data provided by the kcdc, search query data from search engines that are specialized for south korea, twitter social media big data, and weather data such as temperature and humidity. according to a study by kwon et al., a model that considers the time difference between clinical and non-clinical data can detect infectious disease outbreaks one to two weeks before current surveillance systems [43] . therefore, this study adds lag to the collected dataset to take temporal characteristics into account. in addition, in the design process, a thorough testing of all the input variable combinations is performed to examine the effects of each resulting dataset on infectious disease outbreaks and select the optimal model with the most explanatory power. the model's prediction performance is verified by comparing it with an infectious disease prediction model that uses a deep learning method and an infectious disease prediction model that uses time series analysis. ultimately, using the results obtained by this study, it should be possible to create a model that can predict trends about the occurrence of infectious disease in real time. such a model can not only eliminate the reporting time differences in conventional surveillance systems but also minimize the societal costs and economic losses caused by infectious disease. the remainder of this paper is organized as follows. section 2 describes the data sources and standards used in this study and introduces the analysis methodology used to design the prediction model. in section 3, the analysis results are described and their implications are discussed. section 4 discusses the results. section 5 concludes the paper. as mentioned above, this study uses four kinds of data to predict infectious disease, which includes search query data, social media big data, temperature, and humidity. the standards for the non-clinical data are as follows. data from 576 days between 1 january, 2016 and 29 july, 2017 was used. the infectious diseases selected for this study are subject to mandatory reporting. unlike those diseases subject to mandatory reporting, diseases subject to sentinel reporting aggregate data on a weekly basis. since prediction is also performed on a weekly basis, it is difficult to cope with infectious diseases in real time. therefore, diseases that are subject to sentinel reporting were excluded from the study. moreover, the study excluded infectious diseases with an annual occurrence rate of less than 100 as well as infectious diseases that have a statistically insignificant model with an adjusted r-squared value of less than 0.25 when regression analysis is performed using all variables. three infectious diseases satisfied all conditions, which include malaria, chickenpox, and scarlet fever. the search data was collected from the naver data lab (https://datalab.naver.com/keyword/trendsearch.naver). the usage share data provided by internettrend (http://internettrend.co.kr/trendforward.tsp) on search engines in the health/medicine field in the first half of 2017 shows that the naver search engine had the highest usage share (86.1%) in south korea. therefore, it was chosen as the search engine for extracting search data. note that the collected search data consists of only korean terms because the search engine is specific to south korea. the search queries used in this study consisted of the infectious disease's proper name and symptoms (e.g., "chickenpox" and "chickenpox symptoms" in korea). the frequency of inquiries using these search queries were used as the search data. the number of searches were normalized with respect to the largest number of searches within the study period. weather data (temperature and humidity) were collected from the korea meteorological administration's weather information open portal (https://data.kma.go.kr). hourly data collected from weather stations nationwide was converted into daily average data for each station. in gyeonggi-do province, where around half of south korea's population lives, there are many weather stations crowded together. there was a concern that simply finding the averages of the daily data for each station would cause errors to occur, so the following process was performed. first, the averages of the data from each station were collected for the eight provinces in south korea (gyeonggi-do, gangwon-do, chungcheongnam-do, chungcheongbuk-do, jeollanam-do, jeollabuk-do, gyeongsangbuk-do, and gyeongsangnam-do). next, the averages of the data for each of the eight provinces were found to obtain south korea's national average weather data. average temperature (degrees celsius) and average humidity (percentage) were recorded. social media big data was collected for each infectious disease from twitter through a web crawler that used the python selenium library. for the twitter data, the daily number of tweets mentioning infectious disease was recorded. lastly, infectious disease data was collected from the infectious disease web statistics system (https://is.cdc.go.kr/dstat/index.jsp). this data consists of the daily number of people who were infected throughout south korea. table 1 shows the sources and descriptions of the data. table 2 shows the statistics for each of the infectious disease variables used in this study. in the case of temperature and humidity, the same conditions were used, which means they were put in a shared category. the data in table 2 shows that an average of 166.76 people are infected with chickenpox daily with a standard deviation of 98.37 and the daily naver frequency average is 33.94 with a standard deviation of 15.50. we observed that all the statistics for chickenpox are higher than those for other infectious diseases. figure 1 shows the overall framework of the model used in this study including the data collection process and the comparison of models designed using the deep neural network (dnn) method, the long-short term memory (lstm) method, the autoregressive integrated moving average (arima) method, and the ordinary least squares (ols) method. this study constructed an infectious disease surveillance model that uses non-clinical search data, twitter data, and weather data. to design the optimal prediction model, the ols models that use all possible combinations of variables in the dataset were created. the adjusted r-squared values of each model were compared. in addition, lags of 1-14 days were added to each infectious disease and their adjusted r-squared values were compared in a preliminary analysis. a lag of seven days, which had high explanatory power for all infectious diseases, was selected as the optimal lag parameter. the optimal parameters were used to create the ols, arima, dnn, and lstm models. before analysis, this study applied a lag of seven days between the input variables (optimal variable combination) and their associated output variable (disease occurrence). the ols dataset was divided into a training data subset and a test data subset using a ratio of 8:2. this means all 569 rows of collected data were divided such that there were 455 rows for the training data subset and 114 rows for the test data subset. the training data subset was only used for model training. the test data subset was only used for prediction and performance evaluation in the model after training. the arima dataset was also divided into a training data subset and test data subset using a ratio of 8:2, but only the disease occurrences were required for arima. similarly to the data above, the 569 rows of disease occurrence data were divided into 455 rows for the training data subset and 114 rows for the test data subset. in the dnn and lstm models, the whole dataset was divided into training, validation, and test data subsets at a ratio of 6:2:2 and training was performed. this means all 569 rows of collected data were divided into 341 rows for the training data subset, 114 rows for the validation data subset, and 114 rows for the test data subset. the training data subset was used for model training. the validation data subset was only used for performance evaluation during training. the final model after training was the model that yielded the best performance when the validation data subset was used in training. the test data subset was only used for the prediction and performance evaluation. to compare the models, the root mean squared error (rmse) was used to evaluate the prediction rates. rmse is a common measurement for the difference between predicted and actual values. it is usually used in the other fields as well as in the prediction of infectious diseases [28, 44, 45] . rmse is calculated using the equation below. (1) this study constructed an infectious disease surveillance model that uses non-clinical search data, twitter data, and weather data. to design the optimal prediction model, the ols models that use all possible combinations of variables in the dataset were created. the adjusted r-squared values of each model were compared. in addition, lags of 1-14 days were added to each infectious disease and their adjusted r-squared values were compared in a preliminary analysis. a lag of seven days, which had high explanatory power for all infectious diseases, was selected as the optimal lag parameter. the optimal parameters were used to create the ols, arima, dnn, and lstm models. before analysis, this study applied a lag of seven days between the input variables (optimal variable combination) and their associated output variable (disease occurrence). the ols dataset was divided into a training data subset and a test data subset using a ratio of 8:2. this means all 569 rows of collected data were divided such that there were 455 rows for the training data subset and 114 rows for the test data subset. the training data subset was only used for model training. the test data subset was only used for prediction and performance evaluation in the model after training. the arima dataset was also divided into a training data subset and test data subset using a ratio of 8:2, but only the disease occurrences were required for arima. similarly to the data above, the 569 rows of disease occurrence data were divided into 455 rows for the training data subset and 114 rows for the test data subset. in the dnn and lstm models, the whole dataset was divided into training, validation, and test data subsets at a ratio of 6:2:2 and training was performed. this means all 569 rows of collected data were divided into 341 rows for the training data subset, 114 rows for the validation data subset, and 114 rows for the test data subset. the training data subset was used for model training. the validation data subset was only used for performance evaluation during training. the final model after training was the model that yielded the best performance when the validation data subset was used in training. the test data subset was only used for the prediction and performance evaluation. to compare the models, the root mean squared error (rmse) was used to evaluate the prediction rates. rmse is a common measurement for the difference between predicted and actual values. it is usually used in the other fields as well as in the prediction of infectious diseases [28, 44, 45] . rmse is calculated using the equation below. the optimal variable combinations for the model were selected by considering all possible models in the regression analysis. the models are combinations of the four types of data in the dataset (naver searches (n), twitter searches (tw), temperature (t), and humidity (h)). figure 2 shows the adjusted r-squared values of 15 regression models for each infectious disease. among the observed regression models, the models that are combinations of all variables had the best explanatory power. therefore, this combination was chosen as the optimal variable combination. the optimal variable combinations for the model were selected by considering all possible models in the regression analysis. the models are combinations of the four types of data in the dataset (naver searches (n), twitter searches (tw), temperature (t), and humidity (h)). figure 2 shows the adjusted r-squared values of 15 regression models for each infectious disease. among the observed regression models, the models that are combinations of all variables had the best explanatory power. therefore, this combination was chosen as the optimal variable combination. previous results [43] have shown that it is possible to predict infectious disease at an early stage if a model is designed to consider the time difference between clinical data and non-clinical data. based on this observation, our model was designed to consider the time difference in each data set. in this situation, "lag" refers to the time delay between the date the data is collected and the date at which the effects actually occur. this means analysis was performed by establishing the time difference between the four input variables used in this study and the output variable that is actually affected. for example, a lag of 1 means that the output variable of 2 january 2016 is calculated using the input variables of 1 january 2016. figure 3 shows the adjusted r-squared values of regression models when 1-14 days of lag were tested for each of the infectious diseases in order to select the optimal lag. in the case of chickenpox, it was found that lags of 1, 7, and 14 days yielded the highest explanatory power. for scarlet fever, it was found that lags of 4, 7, and 11 days yielded the highest explanatory power. in the case of malaria, it was found that lags of 1, 2, and 7 days yielded the highest explanatory power. for chickenpox and malaria, the lag with the highest explanatory power was one day. however, it was decided that this lag was not suitable for the ultimate goal of reducing the length of delay from reporting to dissemination. in the observed regression models, the explanatory power of a lag of seven days was high for all infectious diseases. therefore, it was decided that this lag was the most suitable and was used for later predictions. previous results [43] have shown that it is possible to predict infectious disease at an early stage if a model is designed to consider the time difference between clinical data and non-clinical data. based on this observation, our model was designed to consider the time difference in each data set. in this situation, "lag" refers to the time delay between the date the data is collected and the date at which the effects actually occur. this means analysis was performed by establishing the time difference between the four input variables used in this study and the output variable that is actually affected. for example, a lag of 1 means that the output variable of 2 january 2016 is calculated using the input variables of 1 january 2016. figure 3 shows the adjusted r-squared values of regression models when 1-14 days of lag were tested for each of the infectious diseases in order to select the optimal lag. in the case of chickenpox, it was found that lags of 1, 7, and 14 days yielded the highest explanatory power. for scarlet fever, it was found that lags of 4, 7, and 11 days yielded the highest explanatory power. in the case of malaria, it was found that lags of 1, 2, and 7 days yielded the highest explanatory power. for chickenpox and malaria, the lag with the highest explanatory power was one day. however, it was decided that this lag was not suitable for the ultimate goal of reducing the length of delay from reporting to dissemination. in the observed regression models, the explanatory power of a lag of seven days was high for all infectious diseases. therefore, it was decided that this lag was the most suitable and was used for later predictions. in this study, the ols model was used to select the optimal parameter values. it was also used as a comparison model to evaluate the prediction performance of the deep learning models. linear regression is a regression analysis technique that models the linear correlation between the output variable y and one or more input variables x in the collected data. the model has the following form. ols is the most simple and commonly used form of linear regression. it is a technique that minimizes the sum of squared errors and can solve the mathematical expression for ß, which is the parameter to be predicted, by using the equation below. ols analyses were performed by r version 3.3.3 (https://www.r-project.org/). because ols is the simplest form of linear regression analysis, it is not sufficient for comparison with deep learning models. therefore, we also compare the arima model, which is often used for the prediction of infectious diseases [44] [45] [46] . this will more clearly compare traditional analysis methods (ols and arima) with deep learning (dnn and lstm). the arima model is a method for analyzing non-stationary time series data. one characteristic of arima analysis is that it can be applied to any time series. in particular, it shows the detailed changes when the data fluctuates rapidly over time. in this study, we used seasonal arima because the collected data is seasonal. the seasonal arima model is denoted as arima(p, d, q)(p, d, q)s. where p is the order of the autoregressive part, d is the order of the differencing, q is the order of the moving-average process, and s is the length of the seasonal cycle. (p, d, q) is the seasonal part of the model. the seasonal arima model is written below. in this study, the ols model was used to select the optimal parameter values. it was also used as a comparison model to evaluate the prediction performance of the deep learning models. linear regression is a regression analysis technique that models the linear correlation between the output variable y and one or more input variables x in the collected data. the model has the following form. ols is the most simple and commonly used form of linear regression. it is a technique that minimizes the sum of squared errors and can solve the mathematical expression for ß, which is the parameter to be predicted, by using the equation below. ols analyses were performed by r version 3.3.3 (https://www.r-project.org/). because ols is the simplest form of linear regression analysis, it is not sufficient for comparison with deep learning models. therefore, we also compare the arima model, which is often used for the prediction of infectious diseases [44] [45] [46] . this will more clearly compare traditional analysis methods (ols and arima) with deep learning (dnn and lstm). the arima model is a method for analyzing non-stationary time series data. one characteristic of arima analysis is that it can be applied to any time series. in particular, it shows the detailed changes when the data fluctuates rapidly over time. in this study, we used seasonal arima because the collected data is seasonal. the seasonal arima model is denoted as arima(p, d, q)(p, d, q) s . where p is the order of the autoregressive part, d is the order of the differencing, q is the order of the moving-average process, and s is the length of the seasonal cycle. (p, d, q) is the seasonal part of the model. the seasonal arima model is written below. where y t refers to the value of the time series at time t, µ is the mean term, a t is the independent disturbance, b is the backshift operator, φ(b) is the autoregressive operator, and θ(b) is the moving average operator. φ s b s and θ s b s are the seasonal operators of the model. the arima analyses were carried out using the r version 3.3.3. the dnn model is a feedforward analysis method that is a basic model for deep learning. dnn is composed of a minimum of three node layers and, with the exception of the input node, each node uses a nonlinear activation function. dnn uses a supervised learning technique called backpropagation. in this study, an infectious disease prediction model that uses dnn was designed and the basic dnn model was compared with this more advanced deep learning model. the variables used in dnn are bias b, input x, output y, weight w, calculation function σ and activation function f (σ). each neuron in dnn uses the following equation. figure 4 shows the structure of a neuron in the dnn model. the dnn analyses were carried out using the "dense layer" option of the keras package in the python version 3.5.3 (https://keras.io/). there are 10 parameters available in the dense layer. we only modified the units, activation function, and dropout. the rest of the parameters used the default values (e.g., use_bias = true and kernel_regularizer = none). where refers to the value of the time series at time , is the mean term, is the independent disturbance, is the backshift operator, ( ) is the autoregressive operator, and ( ) is the moving average operator. ( ) and ( ) are the seasonal operators of the model. the arima analyses were carried out using the r version 3.3.3. the dnn model is a feedforward analysis method that is a basic model for deep learning. dnn is composed of a minimum of three node layers and, with the exception of the input node, each node uses a nonlinear activation function. dnn uses a supervised learning technique called backpropagation. in this study, an infectious disease prediction model that uses dnn was designed and the basic dnn model was compared with this more advanced deep learning model. the variables used in dnn are bias , input , output , weight , calculation function and activation function ( ). each neuron in dnn uses the following equation. figure 4 shows the structure of a neuron in the dnn model. the dnn analyses were carried out using the "dense layer" option of the keras package in the python version 3.5.3 (https://keras.io/). there are 10 parameters available in the dense layer. we only modified the units, activation function, and dropout. the rest of the parameters used the default values (e.g., use_bias = true and kernel_regularizer = none). the lstm model is suitable for predicting time series data when there is a time step with a random size [47] . it was thought that prediction performance could be improved by creating an infectious disease prediction model using lstm and the time series data collected in this study. an important advantage of recurrent neural networks (rnns) is that contextual information is available when mapping io sequences. however, there is a gradient problem in that the effect of a given input on the hidden layer can be increased or decreased significantly during the circular connection. as new inputs are overwritten, the sensitivity of the first input decreases over time. therefore, the network is "forgotten". the input gate, output gate, and forget gate are non-linear summation units that control the activation of the cell. the forget gate multiplies the previous state of the cell while the input and output gates multiply the io of the cell. the activation function f of the gate is a logistic sigmoid. the io activation functions g and h of the cell usually use hyperbolic tangents or logistic sigmoids. however, in some cases, h uses the identity function. as long as the forget gate is open and the input gate is closed, the memory cell continues to remember the first input. in this way, lstm is an algorithm that resolves a problem in traditional rnns [48]. the lstm model is suitable for predicting time series data when there is a time step with a random size [47] . it was thought that prediction performance could be improved by creating an infectious disease prediction model using lstm and the time series data collected in this study. an important advantage of recurrent neural networks (rnns) is that contextual information is available when mapping io sequences. however, there is a gradient problem in that the effect of a given input on the hidden layer can be increased or decreased significantly during the circular connection. as new inputs are overwritten, the sensitivity of the first input decreases over time. therefore, the network is "forgotten". the input gate, output gate, and forget gate are non-linear summation units that control the activation of the cell. the forget gate multiplies the previous state of the cell while the input and output gates multiply the io of the cell. the activation function f of the gate is a logistic sigmoid. the io activation functions g and h of the cell usually use hyperbolic tangents or logistic sigmoids. however, in some cases, h uses the identity function. as long as the forget gate is open and the input gate is closed, the memory cell continues to remember the first input. in this way, lstm is an algorithm that resolves a problem in traditional rnns [48] . the equations for forgetting, storing, renewing, and outputting information in the cell are shown below, respectively. when data (x t ) is input to the lstm cell in equation (7), function f t determines the information to be forgotten in the cell layer. in equations (8) and (9), information that will be newly saved in the cell layer is created in i t and c t in equation (10), the cell layer c t is renewed using f t , i t , and c t in equation (11), the cell layer's information is used and h t is the output. in equation (12), the cell state gets a value between −1 and 1 through the tanh function. the values of c t and h t are kept for the next iteration of lstm. lstm analyses were carried out using the "lstm layer" of the keras package in the python version 3.5.3. there are 23 parameters available in the lstm layer. we only set the units, activation function, return sequence, and dropout. the rest of the parameters used the default values (e.g., use_bias = true, recurrent regularizer = none, recurrent_constraint = none, and unit_forget_bias = none). figure 5 shows the parameter selection method for the deep learning approach used in this study. the adadelta, adagrad, adam, adamax, nadam, rmsprop, and stochastic gradient descent (sgd) optimizers were compared. all parameters of each optimizer used the default values of the keras package. for instance, in sgd, the learning late is 0.01, the momentum is 0, the decay is 0, and the nesterov momentum is false. in addition, the following activation functions were evaluated: exponential linear unit (elu), rectified linear unit (relu), scaled elu (selu), and softplus. lastly, various numbers of epochs (400, 600, 800, and 1000) were evaluated. the other parameters were fixed as follows: number of hidden layers = 4, number of units in each hidden layer = 32, batch size = 32, and drop out = 0. prediction models with variable and fixed parameters were trained on the data and the resulting models were compared to determine the optimal prediction model. to ensure the amount of dnn model data was the same as that of the lstm model, previous data from the same time period as the lstm was inserted. all deep learning models were implemented using the keras package in the python version 3.5.3. and drop out = 0. prediction models with variable and fixed parameters were trained on the data and the resulting models were compared to determine the optimal prediction model. to ensure the amount of dnn model data was the same as that of the lstm model, previous data from the same time period as the lstm was inserted. all deep learning models were implemented using the keras package in the python version 3.5.3. the regression model was formed based on 569 days of data in which a lag of seven days was applied to each infectious disease dataset. the dataset was divided up in an 8:2 ratio and each part was used for constructing the regression model and prediction. table 3 presents the ols results. each regression model had results that were below the level of significance (p < 0.05). the adjusted r-squared value was greater than 0.25 for all three infectious diseases, which means the models can be said to have significant explanatory power. of the infectious disease regression models, the chickenpox model yielded significant results for the naver search queries, temperature, and humidity. the scarlet fever model yielded significant results for the naver search queries and humidity. additionally, the malaria model yielded significant results for the naver search queries and temperature (p < 0.05). looking at these results together, the naver search query data was significant for all three infectious diseases and the twitter data was not significant for any of the three. it can be seen that the internet search query data can be used to design an infectious disease prediction model, which was reported by previous studies. however, the results for the twitter data differ from the results of previous studies. this is believed to be because naver accounted for the largest share (86.2%) of korean search engine use in the health/medicine field for the first half of 2017 while twitter accounted for the smallest share (0.5%) of social media use in the health/medicine field for the same time period (http://internettrend.co.kr/trendforward.tsp). however, the twitter data had an effect on the process of finding the model with the highest adjusted r-squared value. therefore, it is expected to have an effect on future analysis as well. the temperature had a significant relationship with all infectious diseases except for scarlet fever and humidity had a significant relationship with all infectious diseases except for malaria. the values of the coefficients show that the most significant variables for chickenpox and scarlet fever was the naver search query data (4.4589 and 2.1956, respectively) and, for malaria, it was the temperature values (0.0770). the effect of naver search query data in particular was significant for all three infectious diseases, which confirms that it can be suitable for predicting infectious disease. the seasonal arima model was evaluated using the same data used for ols. the autocorrelation function and the partial autocorrelation function were checked for the seasonality of infectious diseases and seasonality was observed. it was considered inappropriate to select the parameters (e.g., p, d, q) because cuts off and tails off are unclear. therefore, the optimal model for each infectious disease was selected based on the akaike information criterion (aic) and rmse. the aic and rmse were used to compare the arima models. table 4 shows the aic and rmse of the seasonal arima model for each infectious disease, which allows us to identify the top three arima model. in addition, the choice of parameter values did not substantially affect the aic and rmse of the model for a single infectious disease. to compare the performance of each model, figure 6 shows the 10 models with the lowest rmse of the test data subset. the numbers inside the parentheses in each model's name represent the optimizer, the activation function, and the number of epochs used in the models (e.g., dnn (1, 2, 3) indicates that the optimizer, the activation function, and the number of epoch are adadelta, relu, and 800, respectively). the metric used to compare the models is rmse, which shows the difference between the actual and predicted values. a smaller rmse value indicates a smaller difference between the actual and predicted values and indicates a higher prediction performance. table s1 shows the rmse and prediction graphs of the dnn and lstm models with the lowest rmse for chickenpox. it can be seen that the prediction graphs for each analysis method have similar shapes overall. the 10 dnn models for chickenpox had a mean rmse of 72.8215 and a standard deviation of 1.28, which shows stable model performance. when the prediction performances of each model were compared based on rmse, the top 10 dnn models showed a 24.45% performance improvement compared to the arima model. the mean rmse of the 10 lstm models was 78.2850, which is higher than the dnn models. the standard deviation was 3.64, which shows that the difference among lstm models was more marked than the difference among dnn models. despite this, the top 10 lstm models achieved an 18.78% performance improvement over the arima model on average. there was a difference between the dnn and lstm models' average figures and standard deviations. however, in the models with the lowest rmse for each analysis method, there was not a big difference, which indicates that there was not a large difference in performance when the optimal parameters for each analysis method were used. table s2 shows the rmse and the prediction graphs of the dnn and lstm models with the lowest rmse for scarlet fever. the shapes of the graphs for the dnn models are similar. for the lstm models, the shapes of the graphs are similar except for the model with the lowest rmse. unlike the graphs of the other lstm models, the graph lstm model with the lowest rmse showed a strong tendency to follow the actual trend. this result infers that a prediction model that is better than existing prediction models can be designed by changing the deep learning parameters to achieve optimization. as is the case with chickenpox, the mean rmse of the dnn model (34.4347) for scarlet fever was lower than that of the lstm model (36.8140) . the standard deviation of the dnn model (0.80) was also lower than that of the lstm model (1.37) . when comparing each model based on rmse, the top 10 dnn models showed a 23.28% performance improvement over the arima model and the lstm models showed a 17.97% performance improvement over the arima model. table s3 shows the rmse and the prediction graphs of the dnn and lstm models with the lowest rmse for malaria. like other infectious diseases, the dnn model prediction graphs have a similar shape. however, the shapes of the lstm model prediction graphs have a tendency to not follow the trend. the rmses of each prediction model, excluding the arima model, showed little difference. this is believed to be because the number of malaria occurrences is fewer than those of the other infectious diseases. therefore, adequate predictions could not be formed. diseases, the dnn model prediction graphs have a similar shape. however, the shapes of the lstm model prediction graphs have a tendency to not follow the trend. the rmses of each prediction model, excluding the arima model, showed little difference. this is believed to be because the number of malaria occurrences is fewer than those of the other infectious diseases. therefore, adequate predictions could not be formed. it is difficult to understand the special characteristics of each analysis method by simply comparing rmse figures alone. therefore, a detailed comparison was performed on the basic comparison models (ols and arima) and the analysis methods that use deep learning (dnn and lstm) . the deep learning models used for comparison were the models with the optimal performance and lowest rmse so that they could best represent each analysis method. with the best performance figure 7 shows the chickenpox predictions of the model with the lowest rmse out of the 10 models with the lowest rmse for each analysis method. the dnn model with the best performance it is difficult to understand the special characteristics of each analysis method by simply comparing rmse figures alone. therefore, a detailed comparison was performed on the basic comparison models (ols and arima) and the analysis methods that use deep learning (dnn and lstm). the deep learning models used for comparison were the models with the optimal performance and lowest rmse so that they could best represent each analysis method. with the best performance. figure 7 shows the chickenpox predictions of the model with the lowest rmse out of the 10 models with the lowest rmse for each analysis method. the dnn model with the best performance had the following specifications, which include optimizer = adadelta, activation function = relu, and number of epochs = 400 (dnn (1, 2, 1) ). the lstm model with the best performance had the following specifications, which include optimizer = nadam, activation function = softplus, epochs = 800 (lstm (5, 4, 3) ). the ols model's predictions had a smaller range of fluctuation than the deep learning models. from day 480, it seems to follow the trend, but it does not follow the small changes. after day 550, it cannot predict the downward shape even within a stable graph model. in short, the ols model is not suitable as a prediction model. the arima model's prediction graph has a very simple shape. this model is cyclic and there is a slight increasing trend in which the predicted value per cycle increases by a factor of about 2.5 each time. this model cannot predict the trend at all. it can only predict a stable cyclic behavior. in contrast, the dnn (1, 2, 1) predictions followed the actual occurrence trend well. moreover, it had a large range of fluctuation, which means it made accurate predictions overall. however, when the number of occurrences rose rapidly in days 510-520, it was unable to follow these values. the lstm (5, 4, 3) predictions had a smaller range of fluctuation than the dnn (1, 2, 1) model. its range of variance was small, which means it had a stable shape and it performed better than dnn (1, 2, 1) when the number of occurrences rose rapidly. predictions overall. however, when the number of occurrences rose rapidly in days 510-520, it was unable to follow these values. the lstm (5, 4, 3) predictions had a smaller range of fluctuation than the dnn (1, 2, 1) model. its range of variance was small, which means it had a stable shape and it performed better than dnn (1, 2, 1) when the number of occurrences rose rapidly. figure 8 shows the scarlet fever predictions of the models with the best performance for each analysis method. the dnn model with the best performance had the following specifications: optimizer = adadelta, activation function = elu, and number of epochs = 600 (dnn (1, 1, 2) ). the lstm model with the best performance had the following specifications: optimizer = adamax, activation function = elu, number of epochs = 400 (lstm (4, 1, 1) ). the ols model's predictions were completely unable to follow the trend, which was similar with the chickenpox case. the arima model's prediction has no particular merit because it also predicts a simple cycle. much like its figure 8 shows the scarlet fever predictions of the models with the best performance for each analysis method. the dnn model with the best performance had the following specifications: optimizer = adadelta, activation function = elu, and number of epochs = 600 (dnn (1, 1, 2) ). the lstm model with the best performance had the following specifications: optimizer = adamax, activation function = elu, number of epochs = 400 (lstm (4, 1, 1) ). the ols model's predictions were completely unable to follow the trend, which was similar with the chickenpox case. the arima model's prediction has no particular merit because it also predicts a simple cycle. much like its chickenpox prediction, it can only predict a stable cyclic behavior. the dnn (1, 1, 2) predictions were relatively close when the number of occurrences was low, but they were too low when the number of occurrences was high. lstm (4, 1, 1) had a larger range of variance than dnn (1, 1, 2) and its predictions were close when the number of occurrences was high. in the prediction graphs for all of the top performing scarlet fever models, none of the models were able to follow the trend on days 480-500 when there was a severe variance in the number of actual occurrences. looking at the mean of each model's predicted value for the number of occurrences, the lstm model (88.7568) was larger than the mean of the dnn model (77.096). these same results were also seen in the case of chickenpox (dnn model mean = 237.5318, lstm model mean = 241.5186). this showed that more suitable results can be obtained if the lstm model is used to predict the maximum value for the number of occurrences and the dnn model is used to predict the minimum value. figure 9 shows the malaria predictions of the models with the best performance for each analysis method. the dnn model with the best performance had the following specifications: optimizer = adamax, activation function = softplus, number of epochs = 800 (dnn (4, 4, 3) ). the lstm model with the best performance had the following specifications: optimizer = adadelta, activation function = softplus, number of epochs = 800 (lstm (1, 4, 3) ). the predictions of the analysis methods were not satisfactory, but the dnn (4, 4, 3) model's predictions seemed to follow the trend relatively well. the arima model predicts values close to 0. it is believed that the occurrences in the malaria data are less than those of other diseases and, therefore, not suited to time series analysis because occurrences are concentrated in the summer seasons. as seen in section 3.3, the lowest rmses of each prediction model excluding the arima model showed little difference. lstm (1, 4, 3) had a lower range of variance than ols and it seemed completely unable to make predictions. as mentioned before, the reason that predictions were inadequate for all of the models in addition to lstm (1, 4, 3) was that figure 9 shows the malaria predictions of the models with the best performance for each analysis method. the dnn model with the best performance had the following specifications: optimizer = adamax, activation function = softplus, number of epochs = 800 (dnn (4, 4, 3) ). the lstm model with the best performance had the following specifications: optimizer = adadelta, activation function = softplus, number of epochs = 800 (lstm (1, 4, 3) ). the predictions of the analysis methods were not satisfactory, but the dnn (4, 4, 3) model's predictions seemed to follow the trend relatively well. the arima model predicts values close to 0. it is believed that the occurrences in the malaria data are less than those of other diseases and, therefore, not suited to time series analysis because occurrences are concentrated in the summer seasons. as seen in section 3.3, the lowest rmses of each prediction model excluding the arima model showed little difference. lstm (1, 4, 3) had a lower range of variance than ols and it seemed completely unable to make predictions. as mentioned before, the reason that predictions were inadequate for all of the models in addition to lstm (1, 4, 3) was that the number of malaria occurrences was small and proper results could not be produced. the deep learning model showed outstanding performance compared to the traditional arima method. of all the dnn and lstm prediction models for chickenpox, the optimal models with the lowest rmse yielded 27.22% and 27.33% better performance than the arima model, respectively. the top 10 dnn models for chickenpox improved performance by an average of 24.45% and the lstm models improved performance by an average of 18.78%. the lowest rmses of the dnn and lstm prediction models for scarlet fever showed 26.25% and 23.79% improved performances compared to arima models. the top 10 dnn models for scarlet fever improved performance by an average of 23.28%. the lstm models improved performance by an average of 17.97%. as noted in the previous sections, it was difficult to predict infectious diseases when the number of infections was small and concentrated in one season. in effect, we observed that the incidence of malaria was high over days 160-250 and after day 530. this period corresponds to the summer season in korea. predicting infectious diseases with this particular data set was difficult and it was not suitable for the arima analysis. even using this particular data set, when dnn was used, the trend of infectious diseases was followed comparatively (figure 9 ). moreover, there is a possibility that the performance would be improved in the dnn model if more diverse parameters were adjusted. this means using deep learning has the advantage of scalability and this can be further investigated in future studies. the arima model that was used in this study was observed to be effective if the number of incidences of infectious diseases was regular and had no increasing or decreasing trends. however, when the predictions were compared according to each analysis method, the dnn and lstm deep learning models performed better than the ols and arima models by assuming that there was a sufficiently large number of occurrences. when comparing the dnn and lstm models, the best models had similar performance, but the dnn models were better in terms of average performance. however, when the number of occurrences was large, the lstm model made close predictions. it seems to be an analysis method that is suitable for circumstances when the number of occurrences is rapidly increasing and infectious disease is believed to be spreading. the deep learning model showed outstanding performance compared to the traditional arima method. of all the dnn and lstm prediction models for chickenpox, the optimal models with the lowest rmse yielded 27.22% and 27.33% better performance than the arima model, respectively. the top 10 dnn models for chickenpox improved performance by an average of 24.45% and the lstm models improved performance by an average of 18.78%. the lowest rmses of the dnn and lstm prediction models for scarlet fever showed 26.25% and 23.79% improved performances compared to arima models. the top 10 dnn models for scarlet fever improved performance by an average of 23.28%. the lstm models improved performance by an average of 17.97%. as noted in the previous sections, it was difficult to predict infectious diseases when the number of infections was small and concentrated in one season. in effect, we observed that the incidence of malaria was high over days 160-250 and after day 530. this period corresponds to the summer season in korea. predicting infectious diseases with this particular data set was difficult and it was not suitable for the arima analysis. even using this particular data set, when dnn was used, the trend of infectious diseases was followed comparatively (figure 9 ). moreover, there is a possibility that the performance would be improved in the dnn model if more diverse parameters were adjusted. this means using deep learning has the advantage of scalability and this can be further investigated in future studies. the arima model that was used in this study was observed to be effective if the number of incidences of infectious diseases was regular and had no increasing or decreasing trends. however, actual data can have trends and be irregular. therefore, deep learning can be an excellent analytical method when analyzing such data and predicting future situations. according to the results of the previous analyses, the deep learning model follows increasing and decreasing trends sufficiently well. moreover, the dnn and lstm models were observed to be sensitive to decreasing trends and increasing trends, respectively. infectious disease is a social problem in that it can cause not only personal damage but also widespread harm. for this reason, research is being conducted to minimize social losses by predicting the spread of infectious diseases. the aim of this study was to design an infectious disease prediction model that is more suitable than existing models by using various input variables and deep learning techniques. therefore, in this study, the optimal parameters were set using a variable selection method based on ols. the relationship between actual instances of disease occurrence and the internet search query data tends to have a time lag, which means a lag was added to each infectious disease's dataset to find the future trend. next, an analysis of arima, dnn, and lstm was performed with optimal parameters. the results of ols analysis using optimal parameters showed that the regression models for each infectious disease had significant results. of the four input variables, the naver search frequency had a significant relationship with all three infectious diseases. the performance of the ols and arima analysis was used to evaluate the deep learning models. looking at the results for dnn and lstm, both the deep learning models made much better predictions than the ols and arima models for all infectious diseases. moreover, the dnn models had the best performance on average, but the lstm models made more accurate predictions when infectious diseases were spreading. however, in the case of malaria, there were few occurrences of the disease compared to other infectious diseases, which means the predictions were not comparatively accurate. this study was also able to reveal special characteristics of the dnn and lstm models. the dnn model produced smaller values than the lstm model on average when predicting infectious diseases. suitable predictions can be made using the dnn model when predicting the minimum value for disease occurrence and using the lstm model when predicting the maximum value. in previous studies, deep learning algorithms were not used [10] [11] [12] [13] [14] [15] 17] or the amount of data considered was small [22, 23, 28, 29] . this study used social media big data and weather data, which have not been sufficiently considered in existing studies. it also used deep learning analysis, which yields high prediction performance to increase the performance of infectious disease predictions. the results showed that, when selecting the optimal parameters, adding all input variables had the highest explanatory power. this means that, by adding various data, it was possible to design a model with higher explanatory power. moreover, the lstm model results for scarlet fever indicate that it is possible to optimize a deep learning model by changing its parameters in various ways and, therefore, design a prediction model that is better than existing prediction models. this study has reviewed the factors involved with infectious disease occurrence using search query data and social media big data, which exist because of the development of the internet as well as temperature and humidity weather data. it also constructed traditional prediction models such as ols, arima, and deep learning prediction models such as dnn and lstm and compared their prediction performance to confirm that the models that use deep learning are the most suitable for infectious disease prediction. it is believed that infectious disease prediction models that employ deep learning can be used to supplement current infectious disease surveillance systems and, at the same time, predict trends in infectious disease. if this can reduce the time differences in reporting systems so that infectious disease trends can be known immediately, it is expected that immediate responses to infectious disease will become possible and costs to society can be minimized. according to a study by shin et al., an emerging infectious disease known as the middle east respiratory syndrome (mers) has a deep correlation with internet search data [20] and it will become possible to expand these methods to the real-time surveillance and prediction of emerging infectious diseases as well. however, this study has three limitations, which include a relatively short data collection period, regionally combined predictions, and a consideration of a narrow range of parameters in the deep learning model. the search query data collection time period used in this research was relatively short extending from 1 january 2016 to 29 july 2017. the particular spatial ranges of data were averaged across the whole of south korea. it is believed that, if the data is expanded and the spatial ranges are subdivided, the model's performance will improve. in addition, an effort was made to change the dnn and lstm model parameters and create a variety of prediction models, but the deep learning prediction models used in this study did not cover all the prediction models that could be implemented. parameters such as hidden layers and batch size were not considered. therefore, it is difficult to conclude that the most effective model was created. if more parameters are considered and more prediction models are made in future research, it is believed that prediction performance can be increased somewhat. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/15/8/1596/s1, table s1 : the root mean squared error (rmse) and prediction graphs of top 10 deep neural network (dnn) and long-short term memory (lstm) models for chickenpox. the seasonal autoregressive integrated moving average (arima) model is denoted as arima(p, d, q)(p, d, q) s . where p is the order of the autoregressive part, d is the order of the differencing, q is the order of the moving-average process, and s is the length of the seasonal cycle. (p, d, q) is the seasonal part of the model. the numbers in parentheses indicate each deep learning model's optimizer, activation, and number of epochs, respectively. (optimizer) 1: adadelta, 2: adagrad, 3: adam, 4: adamax, 5: nadam, 6: rmsprop, and 7: sgd, (activation function) 1: elu, 2: relu, 3: selu, and 4: softplus, (number of epochs) 1: 400, 2: 600, 3: 800, and 4: 1000, table s2 : the rmse and prediction graphs of the top 10 dnn and lstm models for scarlet fever, table s3 : the rmse and prediction graphs of top 10 dnn and lstm models for malaria. infectious disease, safety, state: history of infectious disease prevention and mers situation a profile of the online dissemination of national influenza surveillance data multiscale mobility networks and the spatial spreading of infectious diseases modeling the worldwide spread of pandemic influenza: baseline case and containment interventions seasonal transmission potential and activity peaks of the new influenza a(h1n1): a monte carlo likelihood analysis based on human mobility modelling disease outbreaks in realistic urban social networks strategies for mitigating an influenza pandemic 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data analytics deep learning for digital pathology image analysis: a comprehensive tutorial with selected use cases dermatologist-level classification of skin cancer with deep neural networks deep learning based tissue analysis predicts outcome in colorectal cancer time series analyses of hand, foot and mouth disease integrating weather variables short term effects of weather on hand, foot and mouth disease weather and virological factors drive norovirus epidemiology: time-series analysis of laboratory surveillance data in england and wales imported dengue cases, weather variation and autochthonous dengue incidence in cairns a large temperature fluctuation may trigger an epidemic erythromelalgia outbreak in china implications of temperature variation for malaria parasite development across the impact of variations in temperature on early plasmodium falciparum development in anopheles stephensi mapping the epidemic changes and risks of hemorrhagic fever with renal syndrome in shaanxi province a threshold analysis of dengue transmission in terms of weather variables and imported dengue cases in australia monitoring seasonal influenza epidemics in korea through query search forecast model analysis for the morbidity of tuberculosis in xinjiang, china time series analysis of dengue incidence in guadeloupe, french west indies: forecasting models using climate variables as predictors the authors declare no conflict of interest. key: cord-011906-ek7joi0m authors: throuvala, melina a.; griffiths, mark d.; rennoldson, mike; kuss, daria j. title: mind over matter: testing the efficacy of an online randomized controlled trial to reduce distraction from smartphone use date: 2020-07-05 journal: int j environ res public health doi: 10.3390/ijerph17134842 sha: doc_id: 11906 cord_uid: ek7joi0m evidence suggests a growing call for the prevention of excessive smartphone and social media use and the ensuing distraction that arises affecting academic achievement and productivity. a ten-day online randomized controlled trial with the use of smartphone apps, engaging participants in mindfulness exercises, self-monitoring and mood tracking, was implemented amongst uk university students (n = 143). participants were asked to complete online preand post-intervention assessments. results indicated high effect sizes in reduction of smartphone distraction and improvement scores on a number of self-reported secondary psychological outcomes. the intervention was not effective in reducing habitual behaviours, nomophobia, or time spent on social media. mediation analyses demonstrated that: (i) emotional self-awareness but not mindful attention mediated the relationship between intervention effects and smartphone distraction, and (ii) online vigilance mediated the relationship between smartphone distraction and problematic social media use. the present study provides preliminary evidence of the efficacy of an intervention for decreased smartphone distraction and highlights psychological processes involved in this emergent phenomenon in the smartphone literature. online interventions may serve as complementary strategies to reduce distraction levels and promote insight into online engagement. more research is required to elucidate the mechanisms of digital distraction and assess its implications in problematic use. attentional focus is one of the most fundamental resources and a key to successful and high-order work [1] . in the attention economy [2] , multiple online and offline activities compete for an alternative share of attention [3] . this trend is expected to grow in the face of increasing communication complexity and information overload [4] , which is becoming even more prevalent partially due to the vast online accessibility, immediacy and convenience of smartphones, acting as a major motivational pull for engagement [5] and prompting constant multitasking and frequent attentional loss [6] . there are currently more than 3.5 billion smartphone users [7] and smartphone use is an emergent area of research [8] [9] [10] . emerging evidence on cognitive function has shown that smartphone availability and daily interruptions compete with higher-level cognitive processes creating a cognitive interference effect [11] [12] [13] [14] [15] , associated with poorer cognitive functioning [16] [17] [18] [19] , performance impairments in daily life [20] and potential supplanting of analytical thinking skills by "offloading thinking to the device" [21] (p. 473). in spite of such initial evidence, there are cognitive correlates within the digital wellbeing apps or mhapps (apps that track an individual's behaviour, i.e., time spent online, or that aid cognitive, emotional and/or behavioural wellbeing) [96] have been suggested as supporting self-awareness and self-regulation [97] and utilized in mental healthcare given their functionality, accessibility, higher adherence rates, real-time assessment, low-cost and for their intervention potential [98, 99] . the literature suggests that evidence-based apps may be efficacious in raising self-awareness, mental health literacy and wellbeing, self-efficacy, and ability to cope [96, [100] [101] [102] . online psychological interventions are becoming more prominent in the digital age [103] , rendering numerous positive health outcomes [102, [104] [105] [106] [107] [108] , complementing service provision and recognized by governmental health institutions (e.g., national institute for health and care excellence (nice) in the uk) [109] . however, more research is required to determine the comparative effectiveness of these therapies and their components [110] in improving mental health and wellbeing and rigorous objective evaluation beyond their developers is required. to date, there have been a small number of internet-based interventions associated with device use in university settings. distraction is not considered a dysfunctional construct by itself, but has been implicated in emotion regulation, adhd, and other disorders [111] [112] [113] , and has been minimally examined in the context of the digital environment with no evidence to date as to strategies that could ameliorate its occurrence [114] . therefore, the aim of the present study was to test the preliminary efficacy of an online intervention based on cognitive behavioural principles (i.e., self-monitoring, mood tracking, and mindfulness) to reduce distraction and related psychological outcomes (i.e., stress) among university students. given: (i) young adults are keen users of smartphone apps, with increased vulnerability to self-regulation and technology use [74] , (ii) the high stakes for academic achievement, and (iii) the similarity in processes observed between gambling addiction and social media overuse [115] , the strategies of mindfulness, activity monitoring, and mood tracking utilized in gambling harm-reduction [86, 116, 117] are employed in the present study. these strategies were delivered and facilitated through the use of smartphone mhapps and were tested for their efficacy in reducing levels of distraction and related psychological outcomes and their role in inducing changes in wellbeing [118] [119] [120] . the following hypotheses were formulated: hypothesis 1 (h1). compared to the control condition at follow-up, students receiving the intervention would report: (i) lower rates of smartphone distraction, smartphone and social media use duration, impulsivity, stress, problematic social media use, fomo and nomo and (ii) higher levels of mindful attention, emotional self-awareness, and self-efficacy. hypothesis 2 (h2). at follow-up, high distractors (hds) compared to low distractors (lds) (based on a median-split analysis) would show a greater reduction in distraction and significant improvement in outcomes. hypothesis 3 (h3). the intervention will mediate the relationship between (i) mindful attention and smartphone distraction, and (ii) emotional awareness and smartphone distraction. additionally, online vigilance will mediate the relationship between smartphone distraction and problematic social media use. to the authors' knowledge and given the novelty of the construct of smartphone distraction, this is the first study to examine a preliminary online randomized controlled trial via mhapps for the reduction of smartphone distraction. the present study fills a gap in the smartphone literature by assessing the efficacy of engaging with behaviour change strategies (i.e., mindfulness, self-monitoring, and mood-tracking) used successfully in gambling harm prevention for the reduction of distraction. the present study tested the efficacy of a ten-day online app-delivered randomized controlled trial (rct) based on cognitive-behavioural principles to reduce distraction (primary outcome) and a number of secondary psychological outcomes: self-awareness, mindful attention, fomo, anxiety, and depression among university students. rcts are considered the gold standard in intervention effectiveness despite limitations addressed by scholars [121, 122] , primarily for the lack of external validity or methodological choices [123] . a pragmatic psychosocial intervention with an rct design was chosen [124] . the duration of the intervention was set given a pragmatic consideration of the free use period of one of the apps (headspace) and, secondly, due to the preliminary nature of this investigation. consolidated standards of reporting trials (consort) guidelines were followed in the protocol and the procedures and reporting of the intervention [125] . the intervention involved the active engagement for the period of ten consecutive days with three smartphone apps serving three different functions: to assess smartphone and social media use, conduct mindfulness sessions with an emphasis on eliminating distraction, and track mood and assess its impact on distraction, stress, self-regulation, and other measures. interaction with apps was encouraged to: (i) raise emotional awareness of common mood states, such as feeling down, worried, or stressed through mindfulness, (ii) guide basic smartphone monitoring, focusing skills, and awareness, and (iii) provide insight through mood tracking (table 1) . to further support active engagement with these intervention components, eligible participants were asked to keep a daily online activity log for the duration of the intervention (i.e., the number of screen-unlocks and the time of day and number of minutes for which the smartphone was used, usefulness of apps, etc.), to aid time perception of daily activities, raise awareness levels, and help increase the accuracy of self-reporting and adherence to the intervention [126, 127] . promoting self-awareness of media use and understanding of own behaviour was a key target of the intervention in order to curb distraction. the study was reviewed and approved (no. 2018/226) by the research team's university ethics committee. daily reminders and messages via blogging were sent as a reminder to maintain routine and reflect on levels of activity [126, 137] . participants were recruited using convenience and snowball sampling techniques. after gaining institutional ethical approval, the study was advertised to students through the research credit scheme, in university lectures and labs, and to the public through social media as an online intervention to assess the reduction of smartphone distraction. this experimental intervention demanded a significant time involvement and offering incentives increased the chances of participation and completion of the full ten-day intervention. in return for participation, students were offered either research credits or entry in a prize draw (£50 gift cards). participants were included in the study based on two screening criteria: regular smartphone and social media usage. only those affirming both and granting consent were able to continue with participation. following the completion of the survey, participants were allocated to one of the two conditions (intervention [ig] or control [cg] ) and further instructions for participation in the intervention were provided depending on the allocation condition. after initially providing age and gender demographics, participants responded to survey items regarding habitual smartphone and social media behaviour (estimates of duration of use), smartphone distraction severity, trait self-regulation, trait mindfulness and other psychological constructs (detailed in "materials"). the survey took approximately 25 min to complete. a total of 261 participants were recruited who participated in the baseline assessment. of these, 155 were undergraduate psychology students in the uk (59.3%). the sample comprised 47 males (18%) and 214 females (82%), with an age range of 18 to 32 years (m = 20.72, sd = 3.12). figure 1 depicts the flow of participants through the study procedures. after the baseline assessment, during the intervention period two individuals of the intervention group withdrew from the study and were not considered in the analysis. from the 259 remaining participants, seven were removed due to providing 90% incomplete data. the final sample considered at baseline was 252 participants (intention to treat (itt) group) and included 123 participants in the intervention group and 129 in the control group. participants who completed both assessments were considered in the per-protocol analysis (pp) (n = 143, 56% of the original sample), with 72 participants comprising the ig and 71 participants the cg. between the two groups, as standardising can easily distort judgements of the magnitude of an effect (due to changes to the sample sd but not the population sd, which may bias the estimate of the effect size measure, such as cohen's d) [178] . as cohen's d has been reported in other rct and pre-post intervention studies, cohen's d was estimated [179] . finally, because the sample sizes of the two groups were unequal, type iii sums of squares were used for the ancova. to test the third hypothesis and the hypothesized psychological mechanisms underlying the intervention results, three different mediation analyses were performed across the chosen psychological constructs using spss statistics (version 25) and process (model 4; [180] [181] [182] [183] ), using a non-parametric resampling method bootstrap with 5000 bootstrapped samples and bias-corrected 95% confidence intervals, to probe conditional indirect effects for the variables examined. these analyses were performed on the itt sample in post-intervention results. the survey consisted of sociodemographic and usage data (questions related specifically to smartphone and social media use [hours per day]). the demographic questions and user-related questions had open responses (i.e., "how many hours per day do you use social media?"). the following scales were used for the psychological measures of the study: the smartphone distraction scale [138] is a newly developed scale comprising of 16 likert-type items. the scale comprises four factors: attention impulsiveness, online vigilance, emotion regulation, and multitasking. scores range from 1 (almost never) to 5 (almost always) with higher scores representing a greater degree of distraction. individual items on the test were summed to give composite scores. sample items included in the scale are the following: "i get distracted by my phone notifications", and "i constantly check my phone to see who liked my recent post while doing important tasks". the scale has demonstrated good psychometric properties [138] and excellent reliability in the present study with a cronbach's alpha of 0.90 for time 1 (t1) and 0.88 for time 2 (t2). the mindful attention awareness scale (maas) [139] is a 15-item assessment tool that assesses the dispositional tendency of participants to be mindful in everyday life and has been validated among young people, university students and community samples [139, 140] . item statements reflect experience of mindfulness, mindlessness in general and specific daily situations and are distributed across a range of cognitive, emotional, physical, interpersonal, and general domains. response options are based on a six-point likert scale from 1 (almost always) to 6 (almost never). scores were averaged across the 15 items to obtain an overall mindfulness score with higher scores reflecting higher levels of dispositional mindfulness. sample items include "i could be experiencing some emotion and not be aware of it until sometime later" and "i find it difficult to stay focused on what's happening in the present" and exhibited a high degree of internal consistency in the present study with a cronbach's alpha of 0.92 for t1 and 0.93 for t2. the emotional self-awareness scale (esas) [92] was used to assess esa and comprises five variables: recognition, identification, communication, contextualization, and decision making. the scale consists of 32 items (e.g., "i usually know why i feel the way i do") rated from 0 (strongly disagree) to 4 (strongly agree). the total esa score ranged from 0 to 128, and sub-scale items are combined to produce a composite score with higher scores indicating higher esa. the esas has presented reasonable internal consistency (cronbach's alpha = 0.72, 0.69, and 0.76 for pre-test, post-test and six-week follow-up) [92] . the scale has demonstrated good validity in prior studies [92, 101] and adequate internal consistency in the present study (cronbach's alpha of 0.87 for t1 and 0.86 for t2). the perceived stress scale (pss) [141] is one of the most widely used scales to assess perceived stress and the degree of unpredictability, uncontrollability, and burden in various situations. the scale used was the 10-item version rated from 0 (never) to 4 (very often) with sample items such as "in the last month, how often have you felt that you were unable to control the important things in your life?", and "in the last month, how often have you felt that you were on top of things?" scores are obtained by summing the items, with the higher score indicating more perceived stress. the scale possesses good psychometric properties [142] and its internal consistency in the present study was 0.86 for t1 and 0.83 for t2. the seven-item generalized anxiety disorder scale (gad-7) [143] is a brief clinical measure that assesses for the presence and severity of generalized anxiety disorder (gad). the self-report scale asks how often during the last two weeks individuals experienced symptoms of gad. total scores range from 0-21 with cut-off scores of 5, 10, and 15 being indicative of mild, moderate, and severe anxiety, respectively. increasing scores on the gad-7 are strongly associated with greater functional impairment in real-world settings. sample items are rated from 0 (not at all) to 3 (nearly every day) and sample items include: "feeling nervous, anxious or on edge" and "trouble relaxing". the scale has been widely used and considered a valid and reliable screening tool in previous research, presenting good reliability, factorial and concurrent validity [144, 145] , and demonstrated excellent internal consistency in the present study (α = 0.93 t1 and α = 0.90 for t2). the self-report behavioural automaticity index (srbai) [146] was used to assess habitual strength. the four-item scale was used to assess the degree of automaticity and contained items such as: "using social media on my smartphone is something . . . i do automatically" and "i start doing before i realize i'm doing it". participants indicate their agreement with each item on a likert scale ranging from 1 (does not apply at all) to 7 (fully applies). scores were averaged across items to obtain an overall habit score, with higher scores indicating stronger habitual smartphone use behaviour. the scale has been reported as psychometrically sound in previous studies with good reliability, convergent and predictive validity [146, 147] and demonstrated good internal consistency in the present study with a cronbach's alpha of 0.87 (t1) and 0.89 (t2). the generalized self-efficacy scale (gse) [148] is a widely used psychometric instrument comprising ten items that assess perceived self-efficacy ("i can always manage to solve difficult problems if i try hard enough."). items are rated on a four-point scale ranging from 1 (not at all true) to 4 (exactly true). the gse has demonstrated satisfactory internal consistency and validity across studies [149, 150] . cronbach's alpha in the present study was 0.90 (t1) and 0.88 (t2). the online vigilance scale (ovs) [46] is a 12-item likert scale which assesses a relatively new construct in the internet-related literature, referring to individuals' cognitive orientation towards online content, expressed as cognitive salience, reactivity to online cues and active monitoring of online activity. sample items include "my thoughts often drift to online content" and "i constantly monitor what is happening online". scale items are rated on a four-point likert scale from 1 (does not apply at all) to 4 (fully applies). higher mean scores indicate a higher degree of online vigilance. the scale has evidenced sound construct and nomological validity and high internal consistency [46, 49, 78] . the cronbach's alpha in the present study was 0.89 (t1) and 0.87 (t2). the eight-item barratt impulsiveness scale-alternative version (bis-8) [151] is a psychometrically improved abbreviated version of the 11-item bis scale [151] presenting good construct and concurrent validity in young populations [152, 153] . the scale assesses impulsive behaviour and poor self-inhibition and uses a four-point likert scale from 1 (do not agree) to 4 (agree very much). sample items include: "i do things without thinking" and "i act on the spur of the moment". cronbach's alpha coefficient in the present study was 0.85 (t1) and 0.86 (t2). the deficient self-regulation measure [154] is a seven-item scale assessing deficient self-regulation in videogame playing adapted for unregulated internet use [155] . the scale is rated on a seven-point likert scale from 1 (almost never) to 7 (almost always) and has demonstrated sound psychometric properties [154] . the scale was adapted for smartphone use with sample items such as "i would go out of my way to satisfy my urges to use social media" and "i have to keep using social media more and more to get my thrill". the original scale and its adaptation has presented satisfactory psychometric properties [154, 155] . the cronbach's alpha coefficient in the present study was 0.89 (t1) and 0.87 (t2). the bergen social media addiction scale (bsmas) [115, [156] [157] [158] ] is a six-item self-report scale for assessing social media addiction severity based on the framework of the components model of addiction (salience, mood modification, tolerance, withdrawal, conflict, and relapse) [159] . each item examines the experience of using social media over the past year and is rated on a five-point likert scale from 1 (very rarely) to 5 (very often), producing a composite score ranging from 6 to 30. higher bsmas scores indicate greater risk of social media addiction severity. a sample question from the bsmas is "how often during the last year have you used social media so much that it has had a negative impact on your job/studies?" a cut-off score over 19 indicates problematic social media use [160] . the bsmas has presented sound psychometric properties [115, [156] [157] [158] with high internal consistency (α = 0.82) [161] . the cronbach's alpha in the present study was 0.91 (t1) and 0.87 (t2). the fear of missing out scale (fomos) [162] includes ten items and asks participants to evaluate the extent to which they experience symptoms of fomo. the scale is rated on a seven-point likert scale from 1 (not at all true) to 5 (extremely true of me). the statements include: "i fear others have more rewarding experiences than me... i get anxious when i don't know what my friends are up to...it bothers me when i miss an opportunity to meet up with friends...". a total score was calculated by averaging the scores, with higher mean scores indicating a greater level of fomo. this instrument has demonstrated good construct validity [162, 163] , and good internal consistency with cronbach's alphas of α = 0.93 [164] and 0.87 [64] with α = 0.87 in the present study. the nomophobia questionnaire (nmp-q) [165] comprises 20 items rated using a seven-point likert scale from 1 (strongly disagree) to 7 (strongly agree). total scores are calculated by summing up responses to each item, resulting in a nomophobia score ranging from 20 to 140, with higher scores corresponding to greater nomophobia severity. nmp-q scores are interpreted in the following way: 20 = absence of nomophobia; 21-59 = mild level of nomophobia; 60-99 = moderate level of nomophobia; and 100+ = severe nomophobia. the scale has demonstrated good psychometric properties [165, 166] with cronbach's alphas of 0.94 [165] and 0.95 [167] . in the present study, internal consistency was: 0.89 for (t1) and 0.88 for (t2) respectively. the intervention initially involved the search and identification of appropriate mobile apps (in both the apple itunes store and the android google play store) for daily self-monitoring of social media activity for mindfulness practices and mood tracking. the apps needed to be freely available in order to be accessible by the participants. due to time limitations, the development of an app that would encompass all three features (mindfulness of distraction, self-monitoring, and mood-tracking) was deemed adequate for the study given the ample availability of well-designed products offering these services. the following three freely available smartphone lifestyle apps were utilized: (i) antisocial (screen time): to self-monitor screen time/social media use and for voluntary self-exclusion (block app after time limit is reached), (ii) headspace (mindfulness): brief mindfulness sessions, (iii) pacifica (mood tracking): the app encouraged monitoring and tracking an individual's emotional state at various times during the day to enhance awareness. at the outset of the study, participants were directed to an information statement followed by the digital provision of informed consent before responding to the questions. at the end of the survey, they were automatically assigned through the automatic randomization procedure used by the online survey platform qualtrics to either an intervention or a control group. therefore, the intervention was double-blind (to participants and investigators). participants assigned to the ig were asked to download the apps onto their smartphones and to actively engage with all three apps daily for 10 days, which was the maximum free period offered by one of these apps. participants were encouraged to engage with mindfulness/focusing exercises to track their emotional state during the day and monitor patterns in their wellbeing as well as report daily on smartphone usage rates. thereafter, participants received daily notifications via email for the duration of the intervention to remind them to provide online reports about their own social media usage rates, apps accessed, checking frequency, potential self-restriction from use, and satisfaction with the intervention. this process was used to motivate engagement with the apps and accountability. efficacy was evaluated by having a cg condition where participants did not engage in any app use and only completed assessments on the first and tenth day. the target of the intervention was to induce a more mindful state, raise awareness of media and smartphone use, enhance self-regulation and therefore reduce distractions and time spent on smartphones and indirectly on social media by using these apps. the sample size for the rct was determined a priori using g*power v.3 software for the expected increased effectiveness of the intervention compared to control on the primary outcome distraction at post-assessment (t2). empirical reviews [168] have suggested a median standardised target effect size of 0.30 (interquartile range: 0.20-0.38), with the median standardised observed effect size 0.11 (iqr 0.05-0.29). the present study was a low-threshold intervention for a non-clinical population, so a mean effect of d = 0.30 was expected. with a power of 1-ß = 0.8, and a significance level of α = 0.05, the sample size was calculated to be n = 95 participants per group to find between-and within-group effects. to account for attrition rates in online interventions and control for both type i and ii error rates, n = 125 participants per group were targeted for recruitment [169] . all data were analysed through spss v.25 (chicago, il, usa). preliminary data analyses included examining the data for data entry errors, normality testing, outliers, and missing data. seven cases were treated with listwise deletion due to a very high percentage of incomplete data at baseline, resulting in a final sample size of 252. for the rest of the dataset, little's missing completely at random (mcar) test showed that data were missing completely at random (p = 0.449). multiple imputation was used to complete the dataset for the baseline analysis and for the non-completers from post-intervention assessment based on patterns of missingness. the data were also checked to ensure that all assumptions for the outlined statistical analyses were satisfied. the kolmogorov-smirnov test was used to evaluate the normal distribution of the variables, and skewness and kurtosis values were examined. for both assessments, all self-report data were normally distributed. assumptions of t-tests included normality, homogeneity of variance, and independence of observations. violations of the assumption of homogeneity of variance were tested using levene's test of equality of variances [170] . descriptive statistics were conducted to summarize the demographic characteristics of the sample as well as scores for the self-reported and performance-based measures of interest (i.e., stress). pearson's correlations examined bivariate relationships between smartphone distraction and psychological variables, and frequency of smartphone and social media use (presented in table 3 ). while allocation randomisation aimed to reduce any differences between the groups at baseline, a series of independent sample t-tests for the continuous variables and chi-square tests for the categorical variables (gender, ethnicity and education and relationship status) were conducted to analyse group mean differences and compare the baseline and post-intervention outcomes for the control and intervention groups. these were also applied at post-intervention outcomes for both the control and the intervention group. a decrease from the baseline to the post-intervention assessment was hypothesised for the primary outcomes of smartphone distraction, stress, anxiety, deficient self-regulation, fomo and nomo and an increase was hypothesized for mindful attention, self-awareness and self-efficacy. following the descriptive analysis, data from the baseline and post-intervention assessments were analysed to test each of the hypotheses provided to inform the assessment of the intervention efficacy. two approaches to analysis were adopted. first, to isolate any effect of the intervention, a per-protocol (pp) analysis was conducted to maintain the baseline equivalence of the intervention group produced by random allocation [171] . however, given the limitations to this first analysis approach and to minimise biases resulting from noncompliance, non-adherence, attrition or withdrawal [172, 173] , analysis was performed also on an intention-to-treat (itt) basis [172] . however, these results were not reported in the present study. the effects of the intervention were assessed with an analysis of covariance (ancova), with a minimum significance level at p < 0.05. ancova was chosen given that it is quite robust with regard to violations of normality, with minimal effects on significance or power [174, 175] with any differences between the groups at baseline, for the various assessments being used as covariates in the model and considered artefacts of the randomisation [176] . co-varying for baseline scores supported the analysis in two ways. first, while randomisation aimed to reduce any pre-intervention differences between the groups, residual random differences may have occurred. accounting for such differences isolated the effect of the intervention. partial eta-squared were used as measures of strength of association [177] . to better understand the effect size of the intervention, it has been recommended to use the differences in adjusted means (standardized mean difference effect sizes) between the two groups, as standardising can easily distort judgements of the magnitude of an effect (due to changes to the sample sd but not the population sd, which may bias the estimate of the effect size measure, such as cohen's d) [178] . as cohen's d has been reported in other rct and pre-post intervention studies, cohen's d was estimated [179] . finally, because the sample sizes of the two groups were unequal, type iii sums of squares were used for the ancova. to test the third hypothesis and the hypothesized psychological mechanisms underlying the intervention results, three different mediation analyses were performed across the chosen psychological constructs using spss statistics (version 25) and process (model 4; [180] [181] [182] [183] ), using a non-parametric resampling method bootstrap with 5000 bootstrapped samples and bias-corrected 95% confidence intervals, to probe conditional indirect effects for the variables examined. these analyses were performed on the itt sample in post-intervention results. the t-test results for the pre-test scores found no significant differences between the groups, indicating independence. the post-test scores were significantly lower in the intervention group. for the smartphone distraction scale, the mean pre-test score was 58.06 (sd = 7.69) for the intervention group and 59.72 (sd = 8.08) for the control group. the mean post-test score was 39.70 (sd = 17.67) for the intervention and 58.78 (sd = 17.47) for the control group, respectively. the pre-test score mean was not significantly different between groups (t = −0.70, ns), but the post-test score mean was significantly lower for the intervention group than for the comparison group (t = −6.69, p < 0.001). the pattern was similar in the results for the other variables except for nomo, habitual behaviour, and social media use per day. table 2 provides a summary of the baseline t-test and chi-square outcomes and internal consistency for each scale at each measurement period. all scales demonstrated good internal consistency for the sample considered. a series of bivariate pearson's r correlation analyses was conducted to examine the results obtained amongst sds and the secondary outcomes (table 3) . smartphone distraction correlated significantly with problematic social media use (r(252) = 0.63, p < 0.01), anxiety (r (252) = 0.46, p < 0.01), online vigilance (r (252) = 0.51, p < 0.01), automaticity (r (252) = 0.57, p < 0.01), impulsivity (r(252) = 0.45, p < 0.01), deficient self-regulation (r(252) = 0.33, p < 0.01), smartphone use/day (r(252) = 0.31, p < 0.01), p < 0.01), fomo (r(252) = 0.28, p < 0.01) and nomo (r(252) = 0.51, p < 0.01). however, smartphone distraction correlated negatively with two variables: mindful attention (r(252) = −0.52, p < 0.01) and self-awareness (r(252) = −0.34, p < 0.01). to test h1 and assess the effect of the intervention on smartphone distraction, two separate ancovas were conducted. first, to isolate any effect of the intervention, a per-protocol analysis was conducted. as depicted in table 4 online vigilance (r (252) = 0.51, p < 0.01), automaticity (r (252) = 0.57, p < 0.01), impulsivity (r(252) = 0.45, p < 0.01), deficient self-regulation (r(252) = 0.33, p < 0.01), smartphone use/day (r(252) = 0.31, p < 0.01), p < 0.01), fomo (r(252) = 0.28, p < 0.01) and nomo (r(252) = 0.51, p < 0.01). however, smartphone distraction correlated negatively with two variables: mindful attention (r(252) = −0.52, p < 0.01) and self-awareness (r(252) = −0.34, p < 0.01). to test h1 and assess the effect of the intervention on smartphone distraction, two separate ancovas were conducted. first, to isolate any effect of the intervention, a per-protocol analysis was conducted. as depicted in table 4 ancova analyses for the secondary outcomes were also tested across both pp and itt samples. specifically, for the pp sample, main effects of the experimental group on post-intervention outcomes after controlling for baseline scores were found for self-awareness (f(1, 140) in order to evaluate the effects of the intervention in the intervention group based on level of distraction and to assess whether the effects were consistent in the intervention group independent of degree of distraction, participants were classed into two categories of high distractors vs. low distractors depending on perceived distraction level. a median-split analysis with high vs. low distractor levels was determined by scores above vs. below the median and these were separately analysed inside the intervention group. therefore, a two-way mixed anova with time (pre-test and post-test) as within-factor and distraction severity (high and low distraction) as between-factor was performed to investigate the impact of the intervention (time) and degree of distraction (high vs. low) as assessed at baseline on distraction levels at post-intervention. this analysis was conducted only for the dependent variable for which the interactions were found to be significant. results more specifically for mediation 1, the intervention group was the proposed independent variable in these analyses, mindfulness was the proposed mediator, and smartphone distraction was the outcome variable. for mediation 2, stress was the proposed independent variable in these analyses, online vigilance was the proposed mediator, and smartphone distraction was the outcome variable. for mediation 3, smartphone distraction was the predictor, social media addiction was the outcome and online vigilance was the mediator. analysed variables included the t1 scores on the constructs examined as covariates to account for pre-intervention performance. for mediation 1, it was hypothesized that mindful attention would mediate the relationship between the intervention and smartphone distraction ( table 5) . no mediation effect was found for mindful attention on the variables. however, a main effect of the intervention on smartphone distraction (path a: b = −0.67, t = −8.23, p < 0.001) was found, but no main effect of mindful attention on smartphone distraction (path b; b = 1.16, t = 0.67, ns). table 5 . mediation effects of mindful attention and emotional self-awareness on intervention effects and smartphone distraction and of online vigilance on smartphone distraction and social media addiction (n = 252). for mediation 2, it was hypothesized that self-awareness would mediate the relationship between the intervention and smartphone distraction (table 5 ). an indirect effect was found on self-awareness on the variables (a × b: b = −2.02, bca ci = [−3.10, −1.59]), indicating mediation. the intervention significantly predicted self-awareness (path a; b = −6.78, t = −4.32, p < 0.001) and self-awareness significantly predicted lower levels of smartphone distraction (path b; b = 0.30, t = 4.02, p < 0.001). for mediation 3, it was hypothesized that online vigilance would mediate the relationship between distraction and social media addiction (table 5 ). an indirect effect was found on self-awareness on the variables (a × b: b = 0.02, bca ci = [0.01, 0.03]), indicating mediation. the intervention significantly predicted self-awareness (path a; b = −0.01, t = −3.32, p < 0.001) and self-awareness significantly predicted lower levels of smartphone distraction (path b; b = 1.66, t = 4.02, p < 0.001). the present study tested the efficacy of an online intervention employing an integrative set of strategies-consisting of mindfulness, self-monitoring and mood tracking-in assisting young adults to decrease levels of smartphone distraction and improve on a variety of secondary psychological outcomes, such as mindful attention, emotional awareness, stress and anxiety, and perceived self-efficacy, as well as to reduce stress, anxiety, deficient self-regulation, problematic social media use and smartphone-related psychological outcomes (i.e., online vigilance, fomo and nomo). results of the present study provided support for the online intervention effectiveness in impacting these outcomes. findings suggested that students receiving the intervention reported a significant reduction in the primary outcome of smartphone distraction, unlike students in the control group who reported a non-significant reduction in smartphone distraction. in terms of the secondary outcomes, participants in the intervention condition experienced a significant increase in self-awareness, mindful attention, and self-efficacy, and a significant decrease in smartphone use/day, impulsivity, stress, anxiety, deficient self-regulation, fomo, and problematic use. no significant results were found for social media use per day, habitual/automated use and nomo. according to the findings of the present intervention, it appears likely that practising mindfulness and monitoring mood and smartphone activity could lead to a desired behavioural change towards less distraction and less perceived stress with carry-over effects in self-awareness and self-efficacy, similar to interventions for other mental health problems [83, 85, 87, 91, 93, 184, 185] . these findings are consistent with the growing body of research indicating that mindfulness and self-monitoring are effective strategies to increase self-awareness and reduce stress [84] [85] [86] [87] [88] [89] [90] 186] . mindful attention could enhance awareness of individual media behaviour by: (i) raising understanding and awareness of disruptive media multitasking activities (i.e., predictors, patterns and effects), and (ii) raising awareness of different strategies for coping with digital distraction and of which strategies are most effective. second, self-monitoring could help in developing an understanding of media habits and time spent on smartphone and social media activities and could curb perceived excess smartphone interaction, consistent with other study findings [92, 101, 187, 188] . therefore, strategies employing increased mindfulness practice and self-monitoring could aid attentional capacity and self-awareness, which is considered a necessary condition in the behaviour change process of risky behaviours [189, 190] . third, mood tracking could enhance awareness of triggers of negative mood and ensuing negative emotional states acting as drivers for distraction. it appears that the same technologies which may impact negatively on young people may be used to leverage smartphone use [100] and deflect psychological distress if evidence-based behaviour change strategies are applied. intervention strategies such as mindfulness and self-monitoring may encourage increased self-awareness and thus help reduce distraction levels and increase mindful attention. the intervention was also successful in reducing secondary outcomes, such as stress levels and fomo, and it had a positive effect on emotion regulation and loss of control levels. distraction appears to be associated with higher access to social media content and is mediated by online vigilance. salience of smartphone-mediated social interactions (i.e., the salience dimension of online vigilance) has been found to be negatively related to affective wellbeing [49] . it has been reported that emotional dysregulation mediates the relationship between psychological distress and problematic smartphone use [191] . higher self-regulation online has been identified as a moderator between need to belong and problematic social media use in young people [192] and emotion dysregulation as a mediator between insecure attachment and addiction [193] . although distraction is an emotion regulation strategy with a protective function against emotionally distressing states [111] and dysphoric mood [194] , or is used for adaptive coping [195, 196] , deficits in attentional control, such as distraction, may also be implicated in stress, anxiety or other affective disorders [197] and in generalized anxiety disorder with core cognitive symptoms related to excessive thoughts and deficits associated with increased perseverative worry [198] . therefore, higher mindful attention and monitoring of mood may have influenced the reduction of distraction and the enhancement of emotional control. mediation analyses were also performed to understand the relationships between intervention effects on smartphone distraction via two mediators, mindful attention and self-awareness, and of online vigilance on the relationship between distraction and social media addiction. mediation effects were significant for the relationship among intervention effects and distraction via self-awareness, and for distraction and problematic social media use via online vigilance, indicating that self-awareness could be a potential behaviour strategy to mitigate distraction levels. however, the relationship among intervention effects and distraction was not significant via mindful attention as a mediator. therefore, in the present study it appeared that despite its statistically significant increase, mindful attention was not a mediating factor for distraction in the intervention. mindful attention could potentially be the vehicle to increasing emotional self-awareness [93, 184, 199] , prompting more controlled smartphone interactions. on the contrary, online vigilance was found to be a mechanism associated with smartphone distraction and problematic social media use, given the strong preoccupation with the content prompted even by the mere presence of smartphones, confirming previous findings [200] . therefore, despite its protective function, distraction may concurrently serve as a gateway to increased smartphone engagement and time spent on devices. time spent alone is not a defining factor and it has been argued instead that the interaction of content, context and time spent, as well as the meaning attached to these interactions, may determine the level of problematic media use [5, 201] . within smartphone use, distraction is a salient behaviour with evidence that distraction and mind-wandering are associated with online vigilance, which via reduced mindfulness may be associated with decreased wellbeing [78] . furthermore, inattention symptoms have been implicated in risk for smartphone addiction and problematic smartphone use [202] . therefore, handling distraction, which has neural correlates [203] , may be the means to resisting cue reactivity, implicated in smartphone addiction, in reduced cognitive performance [113] or in obsessive-compulsive symptoms [204] . further research is required to assess these cognitive and emotive dimensions of smartphone distraction and its effects on engagement in line with current trends [205] . however, it has been proposed that the construct of distraction extends beyond the debate on smartphone addiction by considering the role of the smartphone in coping with negative emotions and addressing preference for online vs. offline communications [206] . research is still conflicted in relation to the cognitive function of distraction. experimental smartphone research has provided initial evidence that social apps compared to non-social apps on smartphones do not capture attention despite their perceived high reward value [207, 208] , but other studies support a high interference effect [209] . therefore, more research is required to elucidate the mechanisms of digital distraction and delineate how digital technologies, individual choices, and contexts affect individuals' attention spans and attentional loss, as well as mental health conditions, such as adhd and anxiety and overall psychological wellbeing [210] . the present rct assessed the effectiveness of the impact of the use of mindfulness, self-monitoring, and mood tracking delivered through interaction with smartphone apps in reducing distraction arising from recreational smartphone use and social media use. the findings suggest that engaging with the aforementioned practices was effective in reducing distraction levels, stress, anxiety, deficient self-regulation, impulsivity and smartphone-related psychological outcomes, and improving mindful attention and emotional self-awareness and self-efficacy. some limitations need to be taken into consideration. first, a convenience sample of university students was used, which hinders the generalizability of the findings to other groups (i.e., older adults or children). however, this population was considered of primary interest for the study because university students are digital natives liable to experience negative academic consequences due to vulnerability to problematic smartphone use [211] . the effect sizes found in this rct were medium to large for the variables examined, exceeding the expected range for low-intensity, non-clinical interventions [212] . however, as a result of the main recruitment protocol, the intervention may have attracted participants who had an interest in the outcomes and a potential self-assessed vulnerability. therefore, the voluntary, self-selected nature of participation could have introduced a significant degree of participant response and confirmation bias [213] , resulting in the medium to high effect sizes. additionally, the high drop-out rates, consistent with other online rcts [214] , could have significantly affected the strength of the findings [215] , and the use of a passive control group might have led to an overestimation of the effects [216] . due to the use of market-available apps, actual adherence and engagement with the intervention was not accounted for, nor were reasons for dropout [217] . therefore, the findings should be treated with caution and replicated in future designs. future studies should systematically address response bias and include methods in the rct to improve the accuracy of self-reported data [218, 219] . combining self-report with behavioural data [220] , ecological momentary sampling [221] , psycho-informatics and digital phenotyping, the provision of a digital footprint for prognostic, diagnostic and intervention purposes [222] , could enhance the ecological validity of the study. equally, incorporating the measurement of brain activity using magnetic resonance imaging (mri) in interventions could greatly enhance accuracy of assessment of prevention efforts and understanding of the role of neurobiology in behaviour [223, 224] . the impact of the intervention on gender was not examined because this university student sample consisted mainly of female participants. considering the gender differences reported in smartphone use [48, 225] and in attention processes [226] , future studies should explore its effect, which could have significant implications for the intervention and prevention of attention failures and poor student outcomes [227] . additionally, the study design did not manage to provide a longer intervention period due to the lack of freely available apps for participants to use and did not include a second follow-up period to track maintenance of long-term effects, as is customary in rcts, or the use of qualitative process evaluation for a critical understanding of impact of the intervention components [228] . finally, social, economic and family conditions as well as other issues, which are critical to young people's psycho-emotional states and sense of identity, were not accounted for in the present study [229, 230] . despite these limitations, the study provides initial evidence for efficacy of strategies in curbing smartphone distraction and adds to the limited body of knowledge of cognitive-emotive processes in smartphone and social media use [205] . it also contributed to the still limited knowledge on interventions in smartphone distraction and constitutes a simple, first-step, low key intervention programme, which may be practised by individuals seeking support for attentional difficulties on a self-help basis or within a stepped-care clinical framework for prevention purposes [96] . experiencing distraction from smartphones and social media content, interferes with high-level cognitive processes and has productivity and emotional implications (i.e., stress) in various contexts and situations [51, [231] [232] [233] [234] , being further compromised by digital triggers and the structural design of smartphones prompting salience and reactivity [235] . these results have clinical implications as low-intensity interventions may prevent small scale emotional problems from developing into clinical disorders and can reduce incidences of mental health problems [236, 237] . practitioners may also find value in using mindfulness and monitoring practices as an adjunct to therapy for problematic use of smartphones. it may be of high value for academic institutions to build specific university-based programmes on maintaining balanced technology use, tackling unregulated and promoting positive smartphone use, or guiding students towards suitable methods to address attention problems more effectively [238, 239] . apps may also be utilized by schools for students that are faced with attentional/excessive use difficulties and in assisting young people to become aware of their emotions in preparation for learning more adaptive coping strategies. distraction is an emergent phenomenon in the digital era considering that the boundaries between work and recreation are increasingly blurred with both domains arguably dependent on the use of digital media [240] . more research on attentional processes within smartphone use could aid the understanding of these processes and impacts experienced across different age groups. psychological low-cost interventions may be effective in addressing precursors of problematic behaviours and enhancing wellbeing dimensions. the aim of the present study was to assess the efficacy of an rct combining evidence-based cognitive-behavioural strategies to reduce distraction from smartphone use, increase mindful attention, emotional self-awareness and self-efficacy and reduce stress, anxiety, deficient self-regulation and smartphone related psychological outcomes (i.e., online vigilance, fomo and nomo). second, it tested the mediating effect of mindful attention and self-awareness of the intervention on distraction, and of online vigilance on the relationship between distraction and social media addiction. findings suggested that students receiving the intervention reported a significant reduction in the primary outcome of smartphone distraction, whereas students in the control group reported a non-significant reduction in smartphone distraction. in terms of the secondary outcomes, participants in the intervention condition experienced a significant increase in self-awareness, mindful attention and self-efficacy and a significant decrease in smartphone use/day, impulsivity, stress and anxiety levels, fomo, deficient self-regulation and problematic social media use. no significant results were found for duration of social media use/day, habitual use and nomo. mediation effects of the intervention were also observed on distraction and problematic social media use via the mediators of emotional self-awareness and online vigilance in mitigating distraction levels. mindful attention was not found to be a mediating process for reducing distraction in the intervention. research on digital distraction is still scarce, yet there is increasing interest in cognitive impacts within digital environments. more evidence is required to assess the nature of attention failures and difficulties occurring both in normative and excessive online use. this evidence would allow an understanding of the prevalence and the nature of these difficulties, as well as their integration in intervention media literacy and risk prevention programmes, enhancing wellbeing, productivity and academic performance. the authors declare no conflict of interest. the forgotten frontier of attention cognition in the attention economy attention economies information and communication 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systematicreview with implications for ehealth education how to strengthen patient-centredness in caring for people with multimorbidity in europe? policy brief 22 icare4eu consortium understanding the determinants of digital distraction: an automatic thinking behavior perspective this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-268779-qbn3i2nq authors: alrasheed, hend; althnian, alhanoof; kurdi, heba; al-mgren, heila; alharbi, sulaiman title: covid-19 spread in saudi arabia: modeling, simulation and analysis date: 2020-10-23 journal: int j environ res public health doi: 10.3390/ijerph17217744 sha: doc_id: 268779 cord_uid: qbn3i2nq the novel coronavirus severe acute respiratory syndrome (sars)-coronavirus-2 (cov-2) has resulted in an ongoing pandemic and has affected over 200 countries around the world. mathematical epidemic models can be used to predict the course of an epidemic and develop methods for controlling it. as social contact is a key factor in disease spreading, modeling epidemics on contact networks has been increasingly used. in this work, we propose a simulation model for the spread of coronavirus disease 2019 (covid-19) in saudi arabia using a network-based epidemic model. we generated a contact network that captures realistic social behaviors and dynamics of individuals in saudi arabia. the proposed model was used to evaluate the effectiveness of the control measures employed by the saudi government, to predict the future dynamics of the disease in saudi arabia according to different scenarios, and to investigate multiple vaccination strategies. our results suggest that saudi arabia would have faced a nationwide peak of the outbreak on 21 april 2020 with a total of approximately 26 million infections had it not imposed strict control measures. the results also indicate that social distancing plays a crucial role in determining the future local dynamics of the epidemic. our results also show that the closure of schools and mosques had the maximum impact on delaying the epidemic peak and slowing down the infection rate. if a vaccine does not become available and no social distancing is practiced from 10 june 2020, our predictions suggest that the epidemic will end in saudi arabia at the beginning of november with over 13 million infected individuals, and it may take only 15 days to end the epidemic after 70% of the population receive a vaccine. coronavirus, a genus of the coronaviridae family, are enveloped viruses with a large plus-stranded rna genome. the genomic rna is 27-32 kb in size and is capped and polyadenylated. three serologically distinct groups of coronaviruses have been described, with viruses in each group characterized by their host range and genome sequence. coronaviruses belong to a large family of viruses known to cause illnesses ranging from the common cold to more severe diseases, such as middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars). a novel coronavirus, sars-coronavirus-2 (sars-cov-2) was identified in december 2019 in wuhan, china, as a coronavirus that had not been previously identified in humans; this novel coronavirus is also known as the coronavirus disease 2019 . since its identification, sars-cov-2 has spread rapidly, affecting over 200 countries and causing the 2019/2020 coronavirus pandemic. it was declared as a public health emergency of international concern on 30 january 2020 by the world health organization (who). to date, many countries and regions have implemented lockdown measures and strict social distancing to limit the propagation of the virus. from a strategic and healthcare management perspective, the propagation pattern of the disease and the prediction of its spread over time is of great importance, which can save lives and minimize the social and economic consequences. epidemiological modeling is a powerful tool that can help understand disease spread, control, and prevention. different mathematical epidemic models have been used in the literature, including statistical models [1] , mathematical models [2] [3] [4] [5] [6] [7] [8] [9] [10] , and network-based models [11] [12] [13] . mathematical epidemic models are used to predict the course of an epidemic and develop methods for controlling it by comparing different possible scenarios based on the observed data. one of the widely used models is the susceptible-infected-recovered (sir) model [14, 15] , where individuals are assigned into three compartments, i.e., susceptible (s), infected (i), and recovered (r). each individual belongs to one compartment and changes his/her state over time. an individual can transition from susceptible to infected with a specific infection rate. each individual can also transition from infected to recovered according to a specific recovery rate. this simple epidemic model works well for a homogeneous population that exhibits similar contact patterns, with contact probabilities between any two individuals considered to be equal. however, recent research has shown that the contact patterns in a real population are heterogeneous [16] . as bidirectional social contacts are key factors in disease spreading, modeling epidemics on contact networks has been increasingly used to understand disease transmission and evaluate the impact of potential disease control [17] [18] [19] . this is because contact relationships between individuals that allow infection propagation naturally define a network. hence, understanding the contact network structure can improve the predictions of the infection distribution among individuals and allow the simulation of the full epidemic dynamics. networks allow the modeling and simulation of disease control measures by manipulating the connections among different individuals. in this work, we propose a simulation model for the spread of covid-19 in saudi arabia using a network-based sir epidemic model. we first generated a contact network that captured the realistic social behaviors and dynamics of individuals in the population of saudi arabia. we aimed to match the model simulations with empirical data and then used the model to evaluate the effectiveness of the control measures employed by the saudi government, to predict the future dynamics of the disease in saudi arabia according to different scenarios, and to predict the percentage of individuals that must be vaccinated to stop the outbreak (when a vaccine becomes available). modeling the spread of covid-19 in saudi arabia has been discussed in the literature [20] [21] [22] [23] ; however, no studies used a network-based model that captured the social and dynamic properties that are intrinsic to saudi society. further, control measures, such as school closures, mosque closures, domestic flight shutdowns, and curfews, were not considered. the proposed model is used to explain how social measures, such as social distancing and regional lockdowns, influence the model parameters, which, in turn, change the number of infected cases over time. the proposed model considers the dynamic nature of individual contact behaviors and the variations in susceptibility and infectivity between individuals. the main contributions of the work can be summarized as follows: we built a model for contact networks that captures the social properties and dynamics intrinsic to saudi arabia's society. a set of attributes was defined for each node (representing each individual), including age, gender, nationality, and location. this is important as network structure and node attributes are crucial factors in the covid-19 epidemic spreading process. we built a network simulation model of the spread of covid-19 in saudi arabia using the widely adopted sir model. using our network simulations, we analyzed the processes by which covid-19 spreads. 3. we analyzed the effectiveness of the response of saudi authorities using our network simulations. 4. we predicted the future dynamics of the disease in saudi arabia under different scenarios. 5. we investigated the effectiveness of different vaccination strategies. in this work, we evaluated the effectiveness of saudi arabia's control measures on the epidemic dynamics. our results showed that strict local control measures, such as school closures, mosque closures, and flight shutdowns, play an important role in controlling the spread of the disease. in particular, mosque closures have the greatest impact on decreasing the transmission rate of the disease. our key results are in agreement with previous findings in china [11, 24, 25] and in the united states [11] . our model suggests that saudi arabia would have faced the peak of the outbreak on 21 april 2020 with a total of about 26 million infections if it had not imposed the control measures. this illustrates the importance of employing strict measures for flattening the epidemic curve of the infection and reducing the size of the epidemic. the strict social measures delay the peak of infection and minimize its period. altogether, these effects limit the burden on the healthcare system and prevent it from being overwhelmed. we also predicted the future dynamics of the outbreak in saudi arabia for the upcoming six months using multiple scenarios. according to the current data, the proposed model suggested that the peak would be roughly at the beginning of july, reaching a peak of 0.5% of the population if people did not practice strict social distancing. the peak represents the highest number of daily infections. using our simulations, we also computed the percentage of people that must be vaccinated to stop the epidemic. our results suggest that the outbreak can be contained by increasing the percentage of the vaccinated population (but without resorting to mass vaccination of the population). according to our results, the proposed simulation model provides insights that reflect the dynamic behavior of covid-19 under different scenarios. the results can guide the local healthcare system for making decisions during the critical periods of the epidemic. the rest of the paper is organized as follows. in section 2, we discuss related literature works, and, in section 3, we describe the method, including the contact network generation model, the data, and the network simulation model. in sections 4 and 5, we present and discuss the simulation results. finally, section 6 concludes the work. the epidemic progression of covid-19 has received increased attention from the research community since its outbreak in late 2019. the importance of understanding the virus transmission dynamics and further predicting the epidemic curve for public policy healthcare control measures has prompted multiple modeling efforts to control the outbreak [26, 27] . existing contributions in the epidemiological modeling of covid-19 include different types of models, such as statistical models [1] , mathematical models [2] [3] [4] [5] [6] [7] [8] [9] [10] , network-based models [11] [12] [13] , and phenomenological models [28] . due to their conceptual and mathematical simplicity, mathematical models, especially sir compartmental models, have long been popular in modeling epidemic dynamics [29, 30 ]. an sir model describes the spread of a disease in a population, where individuals are assigned into three compartments: susceptible (s), infected (i), and recovered (r) [14, 15] . however, previous studies [16] reported that compartmental models lack explicit modeling of contact structures among individuals, which play a crucial role in understanding and modeling the dynamics of the spread of directly transmissible diseases. compartmental models assume homogenous mixing, where all individuals are equally likely to encounter infection, which may not reflect reality [31] [32] [33] . manzo [16] argued that a major problem with these kinds of compartmental models is that they can only be used with population-wide interventions because they do not model the topology of realistic social interactions. for these reasons, network-based models have been considered as an alternative for the epidemiological modeling of directly transmissible diseases [17] [18] [19] . in such models, an infection may only spread over an arc between two nodes (or individuals) in the network that represents a contact. in the literature, several studies have addressed the deficiencies of previous compartmental models by extending sir-type models on a generated contact network [19] . for instance, salathe and jones [34] adopted this approach to study the effect of community structure on the epidemic dynamics of infectious disease and immunization intervention. volz [35] modeled sir dynamics on a static random network, which represents the population structure of susceptible and infected individuals and their contact patterns with an arbitrary degree distribution. the authors extended their work in [36] to cover a dynamic random network because contact patterns are inherently dynamic such that individuals tend to make and break relationships over time. miller et al. [30] proposed an edge-based compartmental model, which unlike compartmental models, assumes a heterogeneous contact rate and considers the partnership duration. read and keeling [37] investigated how local or global transmission routes in a contact network may affect the evolutionary selection of the transmission rate and infectious period, which determines the transmission dynamics of infectious diseases. ball et al. [38] proposed a stochastic sir network epidemic model with preventive dropping, where a susceptible individual can practice social distancing by removing its edge to an infectious individual. due to the importance of social mixing patterns on modeling epidemic dynamics and evaluating the employed control measures, many research efforts have been made to estimate the patterns in different countries [39] [40] [41] [42] . despite the success of network-based models, several published studies on covid-19 modeling, including those supporting policy decision making, have focused on compartmental models [2] [3] [4] [5] [6] [7] [8] [9] [10] [20] [21] [22] [23] 43] . manzo [16] urged researchers to direct their efforts toward network-based sir models and to start discussing a large-scale collection of empirical network data to foster such models. ferguson et al. [13] used a network-based model to study the impact of non-pharmaceutical interventions on reducing the spread of covid-19 to advise policymaking in the uk and other countries. the authors adopted an individual-based simulation model published in [44, 45] , where spatial details were included, such as the household, school, workplace, and the wider community. the authors used real data to define multiple attributes of the model, including age and household distribution size, average class sizes, staff-student ratios, and workplace size. peirlinck et al. [11] evaluated the effectiveness of intervention strategies and predicted the outbreak peak in china and the us. the authors modeled the covid-19 outbreak dynamics by combining a network model, where the nodes represent states and the edges represent connections between them, and an epidemic susceptible (s), infected (i), exposed (e), and recovered (seir) model. in their study, liu et al. [12] developed a contact network and a model without contact to simulate the unfortunate incident of the covid-19 outbreak in the diamond princess cruise ship in two stages. the first stage was unprotected contact and the second stage was divided into two scenarios: protected contact and airborne spread of the virus. the authors designed a small-world network-based chain-binomial model [46, 47] for the unprotected contact stage, a contact network epidemic model for protected contact for the crew stage, and a no-contact susceptible and infected model (ncsi) for the airborne spread for the passenger stage. they used bayesian inference and metropolis-hastings sampling to estimate the model parameters. several existing contributions modeled the covid-19 outbreak in saudi arabia using different models [20] [21] [22] [23] . for instance, alboaneen et al. [20] predicted that saudi arabia would have a maximum total cases of 79,000 using logistic growth and sir models. in [21] , alharbi et al. found that the sir model provided the best fit to the data compared to the generalized logistic, richards, and gompertz models. their results predicted that the total number of infected cases would reach 359,794 and that the pandemic would end by early september 2020. aletreby et al. [22] predicted that the pandemic would peak by the end of july 2020. further, the work in [23] used the sir model to predict future trends and compare the impact of control measures taken by saudi arabia and the united kingdom on the outcomes of covid-19 pandemic. their results indicated that early extreme measures imposed by the saudi authority played a major role in reducing the spread of the disease, compared to the uk. although there are some contributions that discussed covid-19 in saudi arabia [48] [49] [50] [51] [52] and others modeled the epidemic dynamics of the covid-19 outbreak in the country using different models, such as sir [20, 21, 23] , seir [22] , logistic growth [20] , and generalized logistic, richards, and gompertz models [21] , none have used a network-based model or considered the social properties and dynamics intrinsic to saudi arabia's society. control measures, such as school closures, mosque closures, domestic flight shutdowns, and curfews, were not considered. this work seeks to fill that gap by investigating the spread of covid-19 in saudi arabia using a network-based epidemic simulation model. the first positive covid-19 case in saudi arabia was confirmed on 2 march 2020 with more cases sporadically appearing in the following few weeks [53] [54] [55] . according to the saudi ministry of health [56] , the vast majority of infected people were home-comers from high-risk regions and their immediate contacts [53,57,58]. the proposed simulation is a stochastic discrete network-based model that explicitly represents individuals and their interactions. first, we created a synthetic contact network that matches the essential structural properties of saudi arabia's society. the synthetic population was constructed to statistically match the population demographics of saudi arabia. secondly, we modeled the spread of covid-19 in saudi arabia using a classic sir model. finally, we conducted the contact network generation, simulation, and all analyses using the python-based networkx library [59] . the generated network dataset, model parameters, and population demographics data are all available at https://github.com/halrashe/covid-19_sa_simulation. to simulate the spread of covid-19 in saudi arabia, we generated a contact network using the intrinsic properties and dynamics of saudi arabia's society. we preserved the saudi-related demographics and social features that are essential for the transmission of infection. therefore, our network generation model captures key individual and social aspects. first, the network captures the properties of individuals by assigning a set of attributes to each node, including age group, gender, citizenship, and location. secondly, the network conforms to several observed contact behaviors among individuals such as location and age assortativity [60] . we used data from the saudi general authority for statistics [61] to assign the distribution of individuals for each attribute [62, 63] (see figure a1 and table a1 in the appendix). this is computationally challenging [32, 64] ; therefore, a contact network with a population of n = 10,500 individuals was generated with given age group, gender, citizenship, and location distributions. the geographic locations used to construct the network corresponded to the 15 main administrative regions in saudi arabia. node connections represent contacts that may take place before and during the period of the epidemic. three connection types between node pairs were used in the network: familial, social, and random. see figure 1 for a schematic of the network. we define our undirected and unweighted contact network g = (v,e), where v represents the set of individuals in the population and e represents the contact relationships between them. in the contact network g, each individual belongs to a household and the household sizes correspond to the values for saudi arabia reported in [65] . each household is represented as a complete graph in which every node is connected to every other node by a familial edge. nodes from two different households can be linked in two ways, i.e., based on similarity (social edges) or at random (random edges). nodes are linked with social edges with a probability proportional to their similarity (i.e., a higher node similarity implies a higher chance of connection in the contact network). two nodes are considered similar when they exhibit similar attributes. the similarity of two nodes u and v, denoted as similarity (u,v) , is computed using the scaled euclidean distance between the two node vectors based on their attributes. let u and v be the vectors corresponding to nodes u and v. we first construct the vectors of the two nodes (the vector length is equal to the number of attributes describing each node, which is 4 in this case). the corresponding elements in both vectors have values of 0 and 1, respectively, if the two nodes have a different value for an attribute. otherwise, the corresponding elements of the two vectors have a value of 0. then, the similarity is computed as follows: where a and c are constants such that 3a + c = 1 and c >> a. the goal here is to assign the location attribute a larger weight because it plays the most important role in deciding the contact relationship among node pairs. if two nodes are not similar, then they may be connected randomly with a probability of p + loc if they both belong to the same location and with a probability of p + random if they belong to different locations (p + random << p + loc). each edge eu,v connecting node u and v has a type attribute describing its formation. here, we use three edge types. the first one is familial when the two nodes u and v belong to the same household. the second is social when eu,v is formed as a result of the similarity between u and v. the third one is random when eu,v is formed completely at random. social edges represent contact relationships as a result of sharing school, work, interests, and neighborhoods. random edges represent contact relationships that occur as a result of coming into contact with another individual in a public place, a taxi, an airport, etc., or due to social contact that is not based on similarity. to make the model more realistic, a set of random edges is removed from the network (for example, not all familial relationships resemble infection-leading forms of contact) based on the edge type. a familial edge is removed with a probability of p â�� familial, a social edge is removed with a probability of p â�� social, and a random edge is removed with a probability of p â�� random such that p â�� familial << p â�� social << p â�� random. algorithm 1 shows the contact network generation algorithm. figure 2 shows the main properties of the contact network used in the simulation. nodes are linked with social edges with a probability proportional to their similarity (i.e., a higher node similarity implies a higher chance of connection in the contact network). two nodes are considered similar when they exhibit similar attributes. the similarity of two nodes u and v, denoted as similarity(u,v), is computed using the scaled euclidean distance between the two node vectors based on their attributes. let u and v be the vectors corresponding to nodes u and v. we first construct the vectors of the two nodes (the vector length is equal to the number of attributes describing each node, which is 4 in this case). the corresponding elements in both vectors have values of 0 and 1, respectively, if the two nodes have a different value for an attribute. otherwise, the corresponding elements of the two vectors have a value of 0. then, the similarity is computed as follows: where a and c are constants such that 3a + c = 1 and c >> a. the goal here is to assign the location attribute a larger weight because it plays the most important role in deciding the contact relationship among node pairs. if two nodes are not similar, then they may be connected randomly with a probability of p + loc if they both belong to the same location and with a probability of p + random if they belong to different locations (p + random << p + loc ). each edge e u,v connecting node u and v has a type attribute describing its formation. here, we use three edge types. the first one is familial when the two nodes u and v belong to the same household. the second is social when e u,v is formed as a result of the similarity between u and v. the third one is random when e u,v is formed completely at random. social edges represent contact relationships as a result of sharing school, work, interests, and neighborhoods. random edges represent contact relationships that occur as a result of coming into contact with another individual in a public place, a taxi, an airport, etc., or due to social contact that is not based on similarity. to make the model more realistic, a set of random edges is removed from the network (for example, not all familial relationships resemble infection-leading forms of contact) based on the edge type. a familial edge is removed with a probability of p â�� familial , a social edge is removed with a probability of p â�� social , and a random edge is removed with a probability of p â�� random such that p â�� familial << p â�� social << p â�� random . algorithm 1 shows the contact network generation algorithm. figure 2 shows the main properties of the contact network used in the simulation. algorithm 1 contact network generation 1: create household clusters (complete graphs) with given average sizes 2: type(e uv ) â�� f amilial â�� e uv â�� e 3: for each pair of non-neighboring nodes u, v do 4: if similarity(u, v) > t then {t is the node pairs similarity threshold} 5: e â�� e â�ª e uv with probability p + social 6: type(e uv ) â�� social 7: else 8: if location(u) = location(v) then 9: e â�� e â�ª e uv with probability p + loc 10: type(e uv ) â�� random 11: else 12: e â�� e â�ª e uv with probability p + if type(e uv ) = social then 19: e â�� e â�� e uv with probability p â�� social 20: each of the square-shaped regions in the similarity matrix in figure 2b is formed because of the citizenship attribute. the bottom-left region corresponds to saudi individuals and the other two correspond to non-saudi individuals. non-saudi individuals are partitioned into two groups because two patterns of contact have been identified between non-saudi individuals. due to the model's stochasticity, similarity alone does not control edge formation (see the adjacency matrix in figure 2b . table 1 lists the structural properties of the underlying contact graph, which may have a significant impact on the dynamics of the disease [66] . the network density is zero for a network with no edges and 1 for a network with all possible edges. our contact network had a density of 0.036, revealing that it is a sparse network with every node connected to every other node (number of connected components is one). the node degree is the number of contacts an individual node has, which provides a quantitative measure of the node's role in the disease transmission process (figure 2c ). the maximum degree shows the most active node (or nodes) in the network, representing individuals contacting a large number of people, such as sales workers and delivery and taxi drivers in highly populated locations (e.g., riyadh). in addition, the network exhibits a small-world property with a high clustering coefficient and a short average path length and diameter. the network also shows a strong community structure. the modularity value [67] ranges between â��1 and 1 and is used to measure the quality of communities (higher modularity indicates stronger community structure). our contact network had 14 communities, each of which corresponded to a location (this is expected from the generation model used to create the network). generally, our contact network structure matches the properties of other contact networks [36, 68, 69] . however, unlike other contact network generation models, we did not assume any network properties in advance [64, [70] [71] [72] . each of the square-shaped regions in the similarity matrix in figure 2 (b) is formed because of the citizenship attribute. the bottom-left region corresponds to saudi individuals and the other two correspond to non-saudi individuals. non-saudi individuals are partitioned into two groups because two patterns of contact have been identified between non-saudi individuals. due to the model's stochasticity, similarity alone does not control edge formation (see the adjacency matrix in figure 2 (b). table 1 lists the structural properties of the underlying contact graph, which may have a significant impact on the dynamics of the disease [66] . the network density is zero for a network with no edges and 1 for a network with all possible edges. our contact network had a density of 0.036, revealing that it is a sparse network with every node connected to every other node (number of connected components is one). table 1 . contact network properties. definition value the transmission dynamics of covid-19 depend on the structure of the underlying contact network and individual susceptibilities. the susceptibility defines how likely an individual is to become infected if he or she comes into contact with an infected individual. since it is unknown what attributes of an individual determine his or her susceptibility, we used statistical tests on a real covid-19 patient dataset to identify them. to this end, we requested and received data about the patients in saudi arabia from the saudi ministry of health. the data consist of records of all individuals who were tested by taking nasopharyngeal swabs for covid-19 in saudi arabia between 2 march 2020 until 25 april 2020. several data cleaning steps were applied to the dataset before testing. the characteristics of the final dataset are shown in figure a2 and table a2 in the appendix. as can be seen in table a2 , the dataset is unbalanced because the majority of the cases are negative. therefore, we conducted oversampling for the positive class according to the synthetic minority over-sampling technique (smote) using python [73] . we then applied the pearson's chi-square statistical hypothesis test to both the original unbalanced dataset and the balanced dataset. chi-square was used to assess whether there was a significant statistical relationship between the attribute (i.e., age, gender, citizenship, and location; the independent variables) and the test result (the dependent variable). this is a well-known feature selection technique in machine learning [74] . our goal is to determine which attribute contribute to an individual's susceptibility. the resulting p-values for the attributes are presented in table 2 . it can be seen that all p-values were < 0.05, which implies a significant relationship. therefore, all attributes were included to estimate an individual's susceptibility. let g = (v,e) denote the contact network defined in section 3.1. to simulate the spread of covid-19 in saudi arabia, we ran a standard sir epidemic model on our contact network. according to this model, each node u has a state state(u) that is either susceptible, infected, or recovered (immune). transitions are only allowed from susceptible to infected or from infected to recovered. the sir model is a reasonable representation for covid-19, which assumes (up to this point) to lead to full immunity after recovery [75] . the epidemiology of covid-19 and its clinical characteristics are not fully known. therefore, we heavily relied on recently available data [54, 55] for disease transmission. based on the analysis in section 3.2, we identified four main attributes that play a role in the transmission of infection: age, gender, citizenship, and location. accordingly, each node u was assigned a susceptibility value susceptibility(u) describing its risk of infection. the transmission probability from an infected node v to a susceptible node u occurs with a probability proportional to the susceptibility of node u.; i.e., p u,v = susceptibility(u), where state(v) = infected. to find each susceptibility value, we extracted all possible events (attribute value combinations) from the available records and calculated the probability of each compound event. figure a3 and table a3 list the node susceptibility values. initially (at time 0), the population is fully susceptible with a single infected individual. the infected individual was chosen to have the same attributes (i.e., age group, gender, citizenship, and location) as the first recorded case in saudi arabia (a 40-year-old male from the eastern region). thereafter, the infection progresses via the contact network for several iterations (each iteration corresponds to one day). the incubation period was set to 14 days, which is the maximum incubation period recorded for covid-19 [76] . the recovery rate was set to 0.2 (see table 3 ). the major control measures employed by the saudi government were implemented in the model, which include school closures, mosque closures, domestic flight shutdowns, and in-home curfews. the model also implements social distancing, ground screening, partial business reopening, and business as usual. the major control measures, their dates, and assumed compliance rates used in the model are listed in table 4 . in some cases, control measures are not enough to prevent contact; for example, school friends can meet outside of school, and people can still travel by car to meet. in table 4 , a compliance rate of 35% for ground screening represents the percentage of people who were infected but only detected as a result of the ground screening. business as usual refers to the full reopening of businesses, where we assume that contact relationships are restored and social distancing is the only measure that affects the susceptibility of individuals. the compliance rates that produced simulation curves closest to the actual curve were selected. control measures were introduced by removing edges between relevant nodes and with a specific compliance rate. for example, school closures resulted in removing edges among node pairs who shared the same location and age group. edges were removed with a specific probability and among a specific percentage of relevant nodes. on the other hand, partial business reopening and business as usual result in adding removed edges between a given set of nodes and with a given probability. finally, we implemented social distancing as a reduction in the probability of infection (decreasing node susceptibility). to establish the simulation model parameters, we used the empirical data of confirmed cases of covid-19 in saudi arabia for the period from 2 march 2020 (first confirmed case) until 11 may 2020. the model parameters are listed in table 3 . we compare the actual and simulated results of the daily and cumulative new infected cases in figures 3 and 4 , respectively. note that all simulation results corresponded to averages of 10 simulations and were scaled to the actual number of infected cases. it can be seen from the figures that our model fit the reported data well. to further confirm the fit of our model, we predicted the daily cases for the period from 12 may 2020 to 18 june 2020 and compared it with the available actual data (see figure 5 ). all regulations imposed after 31 may are not implemented in the model, which may explain the overestimations of the simulated curve around 31 may. the values of the mean absolute percentage error (mape) and the symmetric mean absolute percentage error (smape) for the prediction were 17.7% and 14.6%, respectively. outlier values were removed due to the extreme sensitivity of the above error measures to outliers [77, 78] . the values of mape and smape before removing the outliers were 32.9% and 19.0%, respectively. we further simulated and analyzed the effect of the selected saudi control measures and their timings. then, we predicted the disease dynamics and measured the effect of vaccination. it can be seen from the figures that our model fit the reported data well. to further confirm the fit of our model, we predicted the daily cases for the period from 12 may 2020 to 18 june 2020 and compared it with the available actual data (see figure 5 ). all regulations imposed after 31 may are not implemented in the model, which may explain the overestimations of the simulated curve around 31 may. the values of the mean absolute percentage error (mape) and the symmetric mean absolute percentage error (smape) for the prediction were 17.7% and 14.6%, respectively. outlier values were removed due to the extreme sensitivity of the above error measures to outliers [77, 78] . the values of mape and smape before removing the outliers were 32.9% and 19.0%, respectively. it can be seen from the figures that our model fit the reported data well. to further confirm the fit of our model, we predicted the daily cases for the period from 12 may 2020 to 18 june 2020 and compared it with the available actual data (see figure 5 ). all regulations imposed after 31 may are not implemented in the model, which may explain the overestimations of the simulated curve around 31 may. the values of the mean absolute percentage error (mape) and the symmetric mean absolute percentage error (smape) for the prediction were 17.7% and 14.6%, respectively. outlier values were removed due to the extreme sensitivity of the above error measures to outliers [77, 78] . the values of mape and smape before removing the outliers were 32.9% and 19.0%, respectively. it can be seen from the figures that our model fit the reported data well. to further confirm the fit of our model, we predicted the daily cases for the period from 12 may 2020 to 18 june 2020 and compared it with the available actual data (see figure 5 ). all regulations imposed after 31 may are not implemented in the model, which may explain the overestimations of the simulated curve around 31 may. the values of the mean absolute percentage error (mape) and the symmetric mean absolute percentage error (smape) for the prediction were 17.7% and 14.6%, respectively. outlier values were removed due to the extreme sensitivity of the above error measures to outliers [77, 78] . the values of mape and smape before removing the outliers were 32.9% and 19.0%, respectively. we further simulated and analyzed the effect of the selected saudi control measures and their timings. then, we predicted the disease dynamics and measured the effect of vaccination. we further simulated and analyzed the effect of the selected saudi control measures and their timings. then, we predicted the disease dynamics and measured the effect of vaccination. to determine the efficacy of the imposed control measures in saudi arabia, we simulated the epidemic without each measure individually for the period from 2 march 2020 to 11 may 2020. then, we compared the resulting simulation curve with the original epidemic curve. the results of this analysis provided an estimate of the number of new cases that were prevented using the control measure. figure 6 illustrates the epidemic curves produced from not implementing the major control measures (i.e., school closures, mosque closures, domestic flight shutdowns, and curfews) imposed by the saudi government. to determine the efficacy of the imposed control measures in saudi arabia, we simulated the epidemic without each measure individually for the period from 2 march 2020 to 11 may 2020. then, we compared the resulting simulation curve with the original epidemic curve. the results of this analysis provided an estimate of the number of new cases that were prevented using the control measure. figure 6 illustrates the epidemic curves produced from not implementing the major control measures (i.e., school closures, mosque closures, domestic flight shutdowns, and curfews) imposed by the saudi government. the figure shows that removing any of the control measures caused the epidemic curve to reach the peak earlier compared to the actual curve. when the school closures measure is not implemented, the maximum percentage increase in the number of daily cases was 104% and the curve peak occurred earlier compared to the other curves. not implementing mosque closures and curfews also caused the curve to peak early compared to the actual curve. cancelling mosque closures caused 113% maximum percentage increase, while cancelling curfews caused only 23% increase. cancelling flight shutdowns resulted in 83% maximum percentage increase in the number of daily cases. to assess the impact of the selected date of each of the control measures, we simulated the epidemic with a late effective date for each measure. the results are shown in figure 7 the figure shows that removing any of the control measures caused the epidemic curve to reach the peak earlier compared to the actual curve. when the school closures measure is not implemented, the maximum percentage increase in the number of daily cases was 104% and the curve peak occurred earlier compared to the other curves. not implementing mosque closures and curfews also caused the curve to peak early compared to the actual curve. cancelling mosque closures caused 113% maximum percentage increase, while cancelling curfews caused only 23% increase. cancelling flight shutdowns resulted in 83% maximum percentage increase in the number of daily cases. to assess the impact of the selected date of each of the control measures, we simulated the epidemic with a late effective date for each measure. the results are shown in figure 7 , where figure 7a shows the impact of delaying school closures, figure 7b shows the impact of delaying mosque closures, figure 7c shows the impact of delaying domestic flight shutdowns, figure 7d shows the impact of delaying curfews, and figure 7e shows the actual curve (for ease of comparison). each figure also shows the percentage increase in the infection rate and the total number of infected cases when the corresponding control measure was delayed. the figure shows that delaying any of the control measures caused an increase in the infection rate and in the total number of infected cases. when the mosque closures measure was delayed, the total number of infected cases increased by 173% and the infection rate increased by 128%. delaying curfews caused 113% increase in the total number of infected cases and 45% increase in the infection rate. when school closures or flight shutdowns were delayed, the infection rate increased by 35% and 37%, respectively. delaying school closures and flight shutdowns increased the total number of infected cases by 17% and 49%, respectively. we used the proposed model to predict the future dynamics of the outbreak in saudi arabia for the upcoming period of six months (from 12 may to 31 december) with respect to three scenarios, representing multiple levels of adherence to the social distancing recommendations after 31 may 2020 (the announced business as usual date). figure 8 shows the number of infected individuals per day for all scenarios. in particular, figure 8(a)-(c) show the epidemic dynamics with poor (0% of population), moderate (50% of population), and strong (75% of population) compliance to social distancing, respectively. the level of adherence is defined by the percentage of people that practice social distancing. for comparison purposes, we also predicted the dynamics of the outbreak when no control measures or social distancing were imposed during the whole pandemic period starting from 2 march. the red curve in figure 8 shows that if no control measures were imposed, the peak of the infection was predicted to be about 1.6% on 21 april 2020 with a total outbreak size of 80% of the population (the peak refers to the highest number of daily infections) and the epidemic ended at the end of august 2020. the figure shows that delaying any of the control measures caused an increase in the infection rate and in the total number of infected cases. when the mosque closures measure was delayed, the total number of infected cases increased by 173% and the infection rate increased by 128%. delaying curfews caused 113% increase in the total number of infected cases and 45% increase in the infection rate. when school closures or flight shutdowns were delayed, the infection rate increased by 35% and 37%, respectively. delaying school closures and flight shutdowns increased the total number of infected cases by 17% and 49%, respectively. we used the proposed model to predict the future dynamics of the outbreak in saudi arabia for the upcoming period of six months (from 12 may to 31 december) with respect to three scenarios, representing multiple levels of adherence to the social distancing recommendations after 31 may 2020 (the announced business as usual date). figure 8 shows the number of infected individuals per day for all scenarios. in particular, figure 8a -c show the epidemic dynamics with poor (0% of population), moderate (50% of population), and strong (75% of population) compliance to social distancing, respectively. the level of adherence is defined by the percentage of people that practice social distancing. for comparison purposes, we also predicted the dynamics of the outbreak when no control measures or social distancing were imposed during the whole pandemic period starting from 2 march. the red curve in figure 8 shows that if no control measures were imposed, the peak of the infection was predicted to be about 1.6% on 21 april 2020 with a total outbreak size of 80% of the population (the peak refers to the highest number of daily infections) and the epidemic ended at the end of august 2020. population is practicing social distancing) after business return on 31 may 2020. the simulation results suggest that there would be two peaks at roughly the beginning of july and the middle of august. the peak of the infection will be 0.5% with a total outbreak size of about 47% of the population. according to this scenario, our model suggests that the epidemic will end at the beginning of november 2020 with over 13 million infected individuals, which is measured according to the number of active cases (i.e., when the number of active cases is close to zero). the epidemic curve in figure 8 (b) shows the disease dynamics when social distancing is practiced moderately (about 50% of the population practicing social distancing). the figure suggests that the first peak will remain below 0.4%, the second peak will be avoided, and the total number of infected individuals will be about 33% of the population. in figure 8 (c), the epidemic curve suggests that when most people practice social distancing (75% of the population), the total number of infected individuals will decrease to about 25%. we next explored the dynamics of the epidemic if part of the population is vaccinated. this is helpful to understand what percentage of the population must be vaccinated to stop the epidemic. we considered four scenarios where 0%, 30%, 50%, and 70% of the population was vaccinated. in the proposed model, vaccination is represented by removing the edges between a node u and part of its neighbor nodes. we show the epidemic curves and the results of multiple vaccination scenarios in figure 9 and table 5 , respectively. we assumed that a vaccine would become available on 10 june figure 8a shows the disease dynamics when social distancing adherence is poor (0% of the population is practicing social distancing) after business return on 31 may 2020. the simulation results suggest that there would be two peaks at roughly the beginning of july and the middle of august. the peak of the infection will be 0.5% with a total outbreak size of about 47% of the population. according to this scenario, our model suggests that the epidemic will end at the beginning of november 2020 with over 13 million infected individuals, which is measured according to the number of active cases (i.e., when the number of active cases is close to zero). the epidemic curve in figure 8b shows the disease dynamics when social distancing is practiced moderately (about 50% of the population practicing social distancing). the figure suggests that the first peak will remain below 0.4%, the second peak will be avoided, and the total number of infected individuals will be about 33% of the population. in figure 8c , the epidemic curve suggests that when most people practice social distancing (75% of the population), the total number of infected individuals will decrease to about 25%. we next explored the dynamics of the epidemic if part of the population is vaccinated. this is helpful to understand what percentage of the population must be vaccinated to stop the epidemic. we considered four scenarios where 0%, 30%, 50%, and 70% of the population was vaccinated. in the proposed model, vaccination is represented by removing the edges between a node u and part of its neighbor nodes. we show the epidemic curves and the results of multiple vaccination scenarios in figure 9 and table 5 , respectively. we assumed that a vaccine would become available on 10 june 2020 (the date was chosen to make the differences easily visible on the plot). before this date, all control measures are imposed with the compliance rates shown in table 4 . however, irrespective of the dates, the insights available in this simulation are useful for whenever a vaccine becomes available. table 4 . however, irrespective of the dates, the insights available in this simulation are useful for whenever a vaccine becomes available. figure 9 . epidemic curves of multiple vaccination scenarios. curves are smoothed using a savitzky-golay filter [79] (filter with a window length of 31 and a degree 3 polynomial). figure 9 and table 5 suggest that the outbreak and peak sizes are inversely proportional to the percentage of vaccinated population. further, we observe that the higher the percentage of population vaccinated is, the earlier the epidemic peaks and the epidemic ends. for example, when 30% of the population is vaccinated, the peak occurs on 1 july 2020 and ends on 4 november 2020. when 70% of the population is vaccinated, the peak occurs on 30 may 2020 and ends on 25 june 2020. the proposed network model allows the analysis and evaluation of various control measures that are used to slow or prevent the transmission of covid-19 in saudi arabia and to evaluate the timing of each measure. moreover, the model can be used to predict the future dynamics of the outbreak in saudi arabia with and without the availability of vaccination. the results presented in section 4.1 show the epidemic curves resulting from not implementing each of the four major control measures employed by the saudi government. the results reveal several important pieces of information. first, they suggest that all of the employed control measures played a significant role in delaying the peak of the epidemic, where the peak represents the highest number of daily infections. this can be seen by comparing the dashed vertical lines on the curves, which show the day at which the number of new cases reached the maximum peak (compared to the actual curve). secondly, it is apparent from the top curve in figure 6 , that implementing school closures had the maximum impact because canceling school closures caused the curve to reach the peak early compared to the other three curves. thirdly, the results suggest that the employed measures also played an important role in slowing down the infection rate. for example, the maximum percentage increase in the number of cases in the original curve was 49%, whereas it was 104%, 113%, and 83% without implementing school closures, mosque closures, and flight shutdowns, respectively. our results are in agreement with previous findings in china [11, 24, 25] and in the united states [11] . for example, the authors in [11] suggested that community mitigation actions such figure 9 and table 5 suggest that the outbreak and peak sizes are inversely proportional to the percentage of vaccinated population. further, we observe that the higher the percentage of population vaccinated is, the earlier the epidemic peaks and the epidemic ends. for example, when 30% of the population is vaccinated, the peak occurs on 1 july 2020 and ends on 4 november 2020. when 70% of the population is vaccinated, the peak occurs on 30 may 2020 and ends on 25 june 2020. the proposed network model allows the analysis and evaluation of various control measures that are used to slow or prevent the transmission of covid-19 in saudi arabia and to evaluate the timing of each measure. moreover, the model can be used to predict the future dynamics of the outbreak in saudi arabia with and without the availability of vaccination. the results presented in section 4.1 show the epidemic curves resulting from not implementing each of the four major control measures employed by the saudi government. the results reveal several important pieces of information. first, they suggest that all of the employed control measures played a significant role in delaying the peak of the epidemic, where the peak represents the highest number of daily infections. this can be seen by comparing the dashed vertical lines on the curves, which show the day at which the number of new cases reached the maximum peak (compared to the actual curve). secondly, it is apparent from the top curve in figure 6 , that implementing school closures had the maximum impact because canceling school closures caused the curve to reach the peak early compared to the other three curves. thirdly, the results suggest that the employed measures also played an important role in slowing down the infection rate. for example, the maximum percentage increase in the number of cases in the original curve was 49%, whereas it was 104%, 113%, and 83% without implementing school closures, mosque closures, and flight shutdowns, respectively. our results are in agreement with previous findings in china [11, 24, 25] and in the united states [11] . for example, the authors in [11] suggested that community mitigation actions such as isolation of infectious individuals, quarantine of close contacts, and travel restrictions impact the covid-19 disease infection rates. canceling curfews appeared to have a minimum impact on slowing down the infection rate compared to other measures as it only caused a 23% increase in the number of cases (red curve in figure 6 ). this is likely because the assumed compliance rate for this measure was only 50% (see table 4 ), which is the lowest compared to those of other measures. the time at which the control measures are implemented against the epidemic is critical. in section 4.2, we presented the epidemic curves after changing the effective date of each of the employed control measures. from the results, it can be observed that delaying one of the measures increased the total number of infected cases compared to when all measures were implemented (the actual curve). for instance, when the effective date of the school closure control measure was delayed by 14 days, the total number of infected cases increased by 17%. however, the highest increase in the number of infected cases was seen when mosque closures and curfews were delayed (173% and 113%, respectively). similar trends can be observed with respect to the infection rate as delaying mosque closures and curfew implementation caused maximum percentage increases (128% and 45%, respectively). this can be explained by the susceptibility of the nodes affected by each control measure. for example, mosque closures mainly affect contact relationships (edges) among adult males. generally, the node susceptibilities of adult male individuals are higher compared to those of other nodes (table a3 and section 3.2). delaying flight shutdowns had the least impact on the total number of infected cases (4% increase compared to the actual). this can be explained by the low number of edges that connect individuals from different locations (figure 2(d) ). the model was used to predict the future dynamics of covid-19 in saudi arabia for the upcoming period of six months with and without control measures. the results are shown in section 4.3. a number of observations can be made from the results. first, the size of the peak when no control measures were imposed would be disastrous as it would result in a total of over 26 million infected individuals, which would overwhelm the healthcare system. we next compare the three scenarios when control measures are imposed. first, if social distancing adherence is poor, the two peaks, occurring at roughly the beginning of july and the middle of august, would result in over 13 million infected individuals by the end of the epidemic (at the beginning of november 2020). this number is half of the number of infected individuals when no control measures were imposed. second, social distancing significantly decreased the infection peak and the total number of infections. our results contradict earlier findings [20, 21, 80, 81] . for example, [80] predicted that the 99% pandemic end in saudi arabia should have been on 30 may 2020. in [20] , the authors predicted that the final phase of the outbreak would occur by the end of june 2020 with a total of 79,000 infected individuals. further, the work in [21] predicted that pandemic would end by early september 2020 with a total of 359,794 infected individuals. in comparing the two scenarios (without control measures and with control measures), it is clear that employing different control measures is crucial for flattening the epidemic curve and reducing the final size of the epidemic. these measures also prolong the peak period and minimize the peak, which is crucial to avoid overwhelming the healthcare system. the model was used to predict the disease dynamics under multiple vaccination scenarios. the results (section 4.4) suggest that the epidemic will end in saudi arabia on 4 november 2020 if no one in the population is vaccinated (i.e., if no vaccination is available). at this point, a sufficient amount of the population developed immunity to the disease because they previously had the virus and had recovered. however, the results showed that, in this scenario, around 41% of the population may become infected, which is equivalent to over 13 million individuals, and the epidemic may reach its peak on 1 july 2020 with over a hundred thousand individuals infected. in the best-case scenario, when 70% of the population is vaccinated on 10 june the results suggested that it may take only 15 days to end the epidemic with an outbreak size of 13%. this period increases by almost two months when only 50% of the population is vaccinated. when 30% of the population is vaccinated, the results show that the epidemic may end in late september. note that specific recommendations for vaccination may consider multiple factors analyzed in this section, such as the outbreak size, peak size, and pandemic end date, but may also consider other factors, such as the vaccination cost and the number of critical cases. the proposed network generation and simulation models are part of an effort to create an accurate simulation of the spread of covid-19 in saudi arabia. however, the findings in this work are subject to several limitations. as with all models, the quality of our model depends on the quality of the underlying data. this includes the contact patterns, data of infected cases, and pathogen data. inadequate and missing data were replaced with assumptions and simplifications. for example, in the proposed contact network generation model, the contact patterns and edge formation among individuals were simplified to three contact types with corresponding assumed probabilities. therefore, a greater focus on realistic contact patterns in saudi arabia using a social contact survey could produce interesting findings that could enhance the accuracy of our model. moreover, the contact network used to simulate the disease was static. a dynamic network, in which nodes and edges are added and removed over time due to birth, death, and quarantine, would be more realistic to represent contact relationships among individuals; this is left for future work. our predictions also include inherent uncertainty as the model parameters were derived from limited clinical data. for example, the node susceptibilities were based on limited data (records from 2 march to 25 april). in addition, the population's actual compliance to the recommended control measures is unknown. therefore, the compliance rates used in the model were assumed. more information on population compliance rates would help improve the accuracy of the model. the goal of this work was to model and analyze the spread of covid-19 in saudi arabia using a network-based epidemic model. first, we generated a realistic contact network of individuals in saudi arabia. then, we used the sir model to simulate the spread of covid-19. the proposed model accounted for the dynamic nature of individual contact behaviors and the variations in susceptibility between individuals. the proposed simulation model was used to evaluate the effectiveness of the employed saudi control measures and their timings on the dynamics of the epidemic and to predict the future dynamics of the outbreak in saudi arabia. the model was also used to calculate the percentage of people that need to be vaccinated to stop the epidemic. funding: this research received no external funding. table b1 . distribution of nodes by age group, gender, citizenship, and location. the age distribution of individuals was based on citizenship and gender but is approximated 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china date: 2020-08-27 journal: int j environ res public health doi: 10.3390/ijerph17176256 sha: doc_id: 252870 cord_uid: 52fjx7s4 social distancing is one of the most recommended policies worldwide to reduce diffusion risk during the covid-19 pandemic. based on a risk management perspective, this study explores the mechanism of the risk perception effect on social distancing in order to improve individual physical distancing behavior. the data for this study were collected from 317 chinese residents in may 2020 using an internet-based survey. a structural equation model (sem) and hierarchical linear regression (hlr) analyses were conducted to examine all the considered research hypotheses. the results show that risk perception significantly affects perceived understanding and social distancing behaviors in a positive way. perceived understanding has a significant positive correlation with social distancing behaviors and plays a mediating role in the relationship between risk perception and social distancing behaviors. furthermore, safety climate positively predicts social distancing behaviors but lessens the positive correlation between risk perception and social distancing. hence, these findings suggest effective management guidelines for successful implementation of the social distancing policies during the covid-19 pandemic by emphasizing the critical role of risk perception, perceived understanding, and safety climate. as the number of global coronavirus cases explodes rapidly, threatening millions of lives, the covid-19 pandemic has become the fastest spreading, most extensive, and most challenging public health emergency worldwide since world war ii [1] . compared to seasonal influenza, this coronavirus appears to be more contagious and transmits much faster. for example, the basic reproduction rate r 0 for seasonal influenza is approximately 1.28, while for covid-19, this value comprises 3.3 on average [2] [3] [4] . with no efficacious treatments and vaccines available yet, social distancing measures are still one of the common approaches to reduce the rate of infection. moreover, for the foreseeable multiple waves of the pandemic, covid-19 prevention will continue to rely on physical distancing behaviors until safe vaccines or effective pharmacological interventions become accessible. accordingly, social distancing has been implemented by authorities across the globe to prevent diffusion of the disease. facing this global pandemic, even each government has issued advice about mobility restriction, the definition of social distancing, and distancing rules. however, the guidance documents differ social distancing has received increasing attention in numerous studies over recent decades, especially since the covid-19 outbreaks. in order to explore critical points and network patterns of these prior research studies, a co-word analysis was conducted. the literature keywords present the relationship between the study subjects and a concentration of the research content [18] . hence, the application of a co-word analysis on the existing literature can provide generic knowledge and network patterns in the studies on social distancing. an integrated search was conducted given the topic of social distancing, such as "physical distancing", "social isolation", "lockdown", etc. subsequently, 978 related papers published from 1 january 2000 through 28 june 2020 were retrieved using the web of science core database. then, using citespace software, which is designed as a tool for progressive knowledge domain visualization [19] , the co-occurrence matrix of keywords was calculated and visualized, as shown in figure 1 . the size of the keywords presents the frequency of co-occurrence and the connection shows the significance of co-occurrence [20] . based on the co-word analysis, the major research focus and inner bibliometric characteristics of social distancing were concluded from four perspectives, such as how social distancing affects the pandemic, the additional effects and challenges caused by social distancing, modeling and simulation of social distancing, and influencing factors. most of the previous studies [21] confirmed that social distancing has positive effects on the pandemic slowdown while several studies [22] seem not to confirm this. some studies believe that social distancing cuts off the transmission path of the virus, thereby reducing r 0 [23] . moreover, different mathematical models and simulations have displayed a good correlation with the data showed in biomedical studies, which offered a high level of evidence for the impact of social distancing measures to contain the pandemic [24, 25] . for example, based on simple stochastic simulations, cano et al. [26] evaluated the efficiency of social distancing measures to tackle the covid-19 pandemic. okuonghae and omame [27] found if at least 55% of the population would implement social distancing measures, the pandemic will eventually disappear according to the numerical simulations of the model. nevertheless, a systematic review and meta-analysis demonstrated that the social distancing regulation showed a non-significant protective effect, which can be caused by the persisting knowledge gaps in disparate population groups [22] . although various cohort studies and modeling simulations have found that the social distance regulations can effectively prevent the spread of the pandemic, the additional effects and challenges caused by social distancing cannot be ignored. for instance, anxiety associated with social distancing may have a long-term effect on mental health [28] and social inequality. furthermore, loneliness pandemics are arising from physical isolation as well [29] . as a form of reduced movement and face-to-face connections between people, social distancing has changed residents' conventional health behaviors, which may lead to increasing obesity, accidental pregnancies, and other health risks [30, 31] . a national survey carried out in italy demonstrated that individual needs shifted towards the three bottom levels of the maslow's pyramid (i.e., belongingness and love needs, safety needs, and physiological needs) due to the social isolation [32] . compared with the impact of social distancing, more previous studies focused on its influencing factors. first, at the national and cultural dimension levels, akim and ayivodji [33] concluded that certain economic and fiscal interventions were associated with higher compliance with social distancing. huynh [5] found that countries with higher "uncertainty avoidance index" indicate a lower proportion of public gatherings. likewise and moon [34] explored the role of cultural orientations and showed that vertical collectivism predicted stronger compliance with social distancing norms. then, at the level of public society, aldarhami et al. [35] conducted a survey indicating that the high level of public awareness affects social distancing implementation. besides, public health authorities and experts alike pointed out that mass media and information played an important role in developing public awareness and constructing social distancing behaviors among social populations [36] . lastly, from the perspective of individual behaviors and psychological factors, oconnell et al. [1] reported that more antisocial individuals may pose a health risk to the public and engage in fewer social distancing regulations. based on a cross-sectional online survey, yanti et al. [37] identified that the respondents who had sufficient knowledge and a good attitude would positively comply with safety behaviors, such as keeping a physical distance from others and wearing face masks in public places. although the evidence unambiguously supported that implementing the social distancing regulations has a crucial effect on restraining the pandemic [38] , recent studies found that mobility restrictions do not lead to an expected reduction of coronavirus cases [8, 39] . previous literature has conducted various analyses regarding the different factors motivating social distancing behaviors. however, facing the current enormous gap between the method and the existing practice, limited research has paid attention to the key factors from the perspective of risk management. because of the significant role that individuals and public awareness play in compliance with social distancing, this study focuses on the mechanism of the risk perception effect on social distancing. individual's perceived understanding and safety climate are also examined to identify their effectiveness in the relationship between risk perception and social distancing. based on a quantitative online survey with a sample size of 317 participants from china over the period of may 2020, we built the structural equation model (sem) and conducted hierarchical linear regression (hlr) analysis to examine how the selected moderators influence social distancing behavior. the remainder of the paper is organized as follows. section 2 will review the risk perception theories and develop several hypotheses with the conceptual framework. section 3 describes the research methodology, data collection, and measurement of latent variables. then, we analyze the data and examine hypotheses (section 4) and finally, discuss the implications and limitations of our findings (section 5) as well as draw the main conclusions (section 6). risk exists objectively, but distinct people will take different behavioral decisions when they perceive risk differently [40] . hence, even many medical experts stressed the importance of maintaining physical distancing amid the covid-19 pandemic and people's risk perception still colors beliefs about facts. the concept of risk perception differs among different disciplines [41] . in this study, risk perception in the context of the pandemic is defined as the psychological processes of subjective assessment of the probability of being infected by the coronavirus, an individual's perceived health risk, and available protective measures [42, 43] . compared to the concept of risk perception in other fields, the health risk perception and the severity caused by the consequences of subsequent behavioral decisions are the most prominent features. empirical evidence has indicated that health risk perception may significantly affect people's self-protective behaviors and increase negative consequences of health risks [44] . dionne et al. [45] found that risk perception associated with medical activities was a critical predictor of the epidemic prevention behaviors. accordingly, as reported, underestimation of the pandemic knowledge and health risks could lead to decreasing implementation of social distancing. most previous research focused on identifying influencing factors for people's health risk perception as risk perception largely determines whether individuals would take protective measures during the pandemic. also, there are various factors that reduce the substantial deviation between the actual objective risk and subjective feelings. perceived understanding is just one of the crucial factors that refers to situational awareness for the adoption of healthcare protections when facing the pandemic [46] . according to the theory of planned behavior, only when people realize that they are in a health risk or even death risk will they have the situational awareness to take further healthcare protections. effective and timely perceived understanding will greatly promote people to translate risk perception into actual actions [47] . perceived understanding plays a vital role in the adoption of healthcare behaviors. therefore, the following four hypotheses were developed, considering the findings from previous studies. perceived understanding about the covid-19 pandemic plays a mediating role between risk perception and social distancing behavior. facing huge economic pressure and public opinion, many companies and organizations gradually re-opened. at the same time, these institutions require their employees to implement the social distancing policies strictly. similarly, when people go out to eat, shop, and entertain, many public places remind people to maintain a physical distance. regardless of whether it is a social organization or a public place, this kind of a reminder message released through information media has virtually created a safe climate to require people to take necessary measures and reduce the spread of the virus. generally, the safety climate refers to individuals' perception of safety regulations, procedures, and behaviors in the workplace [48] . from the perspective of pandemic prevention and control, the safety climate relates to a consensus created by the work environment which will promote people consciously or unconsciously to take the appropriate safety measures. namely, safety climate reflects common awareness among employees on the importance of organizational safety issues [49] . numerous observations and studies attest to the relationship between safety climate and protective behavior. bosak et al. [50] found that a good safety climate was negatively related to people's risk behaviors. moreover, another study showed that safety climate completely mediated the effect of risk perception on safety management [49] . however, few studies focused on the influence of safety climate on people's self-protection behavior during the pandemic. taking protective measures, such as social distancing, wearing face masks, and other self-prevention behaviors, are instrumental to avoid the spread of the infection. an organization with a good safety climate can carry out relevant safety training and drills, so as to suppress the potential risk tendency and promote their employees' safety behaviors. therefore, if the working environment can strengthen the education and publicity of pandemic knowledge, people are more willing to take correct protective measures, such as maintaining a social distance. additionally, koetke et al. [51] also pointed out that safety climate (trust in science) played a moderating role in the relationship between conservative and social distancing intentions. to conclude, based on the above literature reviews, the conceptual framework of this study is illustrated in figure 2 . our last two hypotheses read as follows: according to the 44th china statistical report on internet development, which was announced by the china internet network information center (cnnic), in 2019, there were 854 million internet users in china. several studies exploring some physical or psychological influencing mechanisms, such as risk perception, showed no significant difference between internet users and non-users [52] . therefore, online questionnaires were randomly collected from internet users through wenjuan.com. a total of 317 completed responses were received with an effective rate of 94.63%, after excluding suspected unreal answers completed in less than 60 s. additionally, participants were first directed to review and provide their consent using an online informed consent form, which was pre-approved by a panel of experts and the institutional review board, before answering the survey questionnaire. the data collection was anonymously conducted throughout may 2020. the female participants constituted 48.3% of the sample, while 51.7% of the sample were male participants. among the respondents, most of them were young people, 31.9% belonged to the age group of 18-24 years, while 40.7% belonged to the age group of 25-39 years. a total of 84.5% of the participants had a college degree or above and only 6% had a lower level education than high school. out of the total sample, 48.6% reported to be living in rural areas and 51.4% lived in urban communities. it should be noticed that there were 15.14% of the participants living in hubei province, which used to be the epicenter of the covid-19 pandemic in china. the initial questionnaire contained 22 questions to measure these 4 latent variables, including risk perception-rp (7 items), perceived understanding-pu (4 items), social distancing-sd (5 items), and safety climate-sc (6 items). all the measurement items were prepared based on the review of related literature and methods (table 2) . for example, initial items for rp were generated following previous questionnaires conducted by dionne et al. [45] and kim et al. [53] . measurement items of pu were compiled based on the infectious disease-specific health literacy scale [54] and the study by qazi et al. [46] . the sc instrument statements were taken from the literature review and previously completed research [51, 55, 56] . based on the studies of swami et al. [57] and gudi et al. [58] , initial measurement questions of sd were developed. additionally, to ensure the validity of the draft questionnaire, the original survey instrument statements were revised based on the suggestions from a panel of experts, including 5 professionals of risk management, 5 public health specialists, and 5 community managers. then, necessary modifications were made by simplifying, rewording, and replacing several items after 15 experts reviewed the survey structure, wording, and item allocation. according to the expert panel's feedback, the item-level content validity index (i-cvi) of the 18 items were all greater than 0.78 and the scale-level cvi (s-cvi) is 0.97 (>0.90), indicating an excellent validity of this scale (see supplementary materials ). an initial survey with 22 items was first pilot tested among a randomly selected sample of 100 internet users. after conducting cognitive interviews with the pilot sample participants and analyzing the reliability and correlations, 4 measurement items (rp5, rp6, rp7, and sd5) with a item-to-total correlation below 0.5 were removed. finally, a formal questionnaire containing 18 items was developed. the response scale for all the survey items was a 5-point likert scale with categories ranging from 1 = "strongly disagree" to 5 = "strongly agree". all of the items were phrased positively, so that a higher score represented stronger agreement. table 2 displays an overview of the scale and questionnaire items. avoid contact with individuals who have influenza. avoid traveling within or between cities/local regions. avoid using public transport due to covid-19. avoid going to crowded places due to covid-19. * safety climate the government is concerned about the health of people. koetke et al. [51] ; neal et al. [55] ; wu et al. [56] sc2 i trust the covid-19 information provided by the government. there is a clearly stated set of goals or objectives for covid-19 prevention. people consciously follow the pandemic prevention regulations. being able to provide necessary personal protective equipment for workers during the pandemic. offering to workers as much safety instruction and training as needed during the pandemic. note: * items removed from the initial questionnaire. descriptive statistics and correlation analyses of the latent variables were first examined. then, the exploratory factor analysis (efa) and the confirmatory factor analysis (cfa) were conducted to verify the unidimensionality and reliability of the measurement items. the sem can be applied to control for measurement errors as well as to use parameters to identify interdependencies [2, 50] . hence, this approach is appropriate to test the hypotheses by conducting the path analyses. in addition, to examine the moderating effect, hlr was carried out to verify hypotheses h5 and h6. amos version 24.0 software was applied for cfa and sem (hypotheses h1-h4) . the remaining analyses, e.g., efa and hlr (hypotheses h5 and h6) , were done using spss 22.0. (ibm, armonk, ny, usa) the means, standard deviations (s.d.), and inter-correlations of all the measures are contained in table 3 . there are significant positive correlations between the four variables. rp has significant positive correlations with sd and pu, suggesting a partial support for hypotheses h1 and h2, respectively. moreover, both pu and sc showed a significant positive correlation with sd, indicating that hypotheses h3 and h5 were partially supported as well. reliability can be formally defined as the proportion of observed score variance, which is attributable to the true score variance. there exist several approaches to evaluate the reliability of a measuring item and internal consistency is the most widely used method in research with a cross-sectional design. the cronbach's alpha (î±) can be used to estimate the internal consistency [59] . a standard value for cronbach's alpha is 0.70 or above, which indicates strong internal consistency of adopted scales [60] . table 4 indicates that all four latent variables have good reliability (cronbach's î± > 0.7), suggesting that the measurement items are appropriate indicators of their respective constructs. the validity analysis is used to examine the accuracy of the measurement instrument, namely the validity of the scale. the validity analysis mainly includes the content validity and the construct validity, of which the content validity has been supported by the expert panel's recommendations and pre-tests, while the construct validity requires a combination of efa and cfa. first, the kaiser-meyer-olkin (kmo) test value was 0.888. in addition, the result of the bartlett test (ï� 2 = 3135.94, df = 153, p < 0.001) was large and significant. hence, the data shown in table 4 were suitable for cfa. then, the measurement items identified four factors that exactly correspond to four latent variables. these four factors explained 66.41% of the total variance. similarly, the cfa results confirmed the four-factor model. in this study, the goodness-of-fit statistics were found to be x 2/ df = 2. (1) and (2): where î» i and ï� 2 e i represent the regression weight (factor loading) and measure variance estimate of the measurement item i, respectively, and k is the number of measurement items. cr and ave are other effective measures to evaluate the construct validity. correspondingly, according to jobson [61] , the acceptable value of cr is 0.7 and above, while ave should be 0.5 and above. table 4 demonstrates that most of the values of cr and ave met the standards, suggesting an acceptable goodness-of-fit for the further sem analysis. based on the conceptual framework, the sem analysis was conducted to explore the relationship between rp, sd, and pu (as the mediator). the hypothesized model shown in figure 3 was first examined. table 5 summarizes the fit indices of the model, which indicates an excellent goodness-of-fit for the data based on the majority of indices. in this model, several path analyses were developed to test hypotheses h1, h2, and h3. as shown in table 6 , rp has significant positive relationships with pu (î² = 0.296, c.r. = 4.435, p < 0.001) and sd (î² = 0.238, c.r. = 4.421, p < 0.001). likewise, pu plays a significant positive role on sd (î² = 0.581, c.r. = 8.426, p < 0.001) as well. thus, it implies that hypotheses h1, h2, and h3 are supported. bias-corrected (bc) and percentile (pc) bootstrapping approaches were carried out to verify the mediating effect of pu. previous studies have found that bootstrapping was a proper method that can provide a robust test of mediating hypotheses [62] . accordingly, the significant effect of risk perception on social distancing could be assessed through perceived understanding by using the bootstrapping of 5000 sub-samples. as can be seen from table 7 , the values of the lower and upper limits (95% bc and pc bootstrap confidence intervals) for the indirect effect (î² = 0.100) were all greater than zero. moreover, the value of z (indirect effect/standard error) equals 2.5 (>1.96). subsequently, similar to an indirect effect, it was found that there were no zero values between the lower and upper limits (95% bc and pc bootstrap confidence intervals) for the direct effect (î² = 0.138, z = 3.45). therefore, perceived understanding partially mediates the positive effects of risk perception on social distancing. in other words, perceived understanding did not completely offset the effect of risk perception, which partially explains the social distancing. in summary, these results confirmed hypothesis h4. hypothesis h6 predicted that safety climate positively moderates the impact of risk perception on social distancing. to test the moderation effects, the hlr analysis was conducted. model 1 serves as a baseline with independent variables rp and sc. then, model 2 incorporated additional variables rpã�sc. table 8 presents the significant interaction effects of the two-way interaction effect between rp and sc on sd (model 2, rpã�sc, î² = â��0.242, p < 0.001). as shown in table 8 , while risk perception is positively associated with social distancing regardless of the value of safety climate, the safety climate further reduces the positive effect. thus, hypothesis h6 is partially supported. additionally, whether sc is in model 1 (î² = 0.566, p < 0.001) or model 2 (î² = 0.4689, p < 0.001), it presents a statistically significant positive relationship with sd, which further supports hypothesis h5. note: *** p < 0.001. vif represents variance inflation factor (vif = 1/tolerance), vif < 5 (acceptable). this study has continued to demonstrate that social distancing behaviors play a critical role in preventing the diffusion of the covid-19 pandemic. in identifying influencing factors that lead to social distancing, previous studies have highlighted risk perception as a leading indicator of protective behaviors [42, 44, 45] . people should be encouraged to promote risk perception in order to identify and rectify infection risks and health issues related to unprotected behaviors during the covid-19 pandemic. however, limited research has examined whether different risk perception of individuals affects their interpretation of the social distancing regulations in an equivalent manner. by investigating the measurement scales of risk perception, perceived understanding, safety climate, and social distancing across populations of internet users in china, this study addressed the mechanism of the risk perception effect on social distancing to improve individuals' physical distancing behaviors. this study provided evidence that risk perception and perceived understanding can significantly affect people's social distancing behaviors during the covid-19 pandemic. the results of the path analysis supported hypotheses h1, h2, and h3. it is evident from figure 3 , tables 5 and 6 that the path coefficients are significant and the overall hypothesized model has a good fit for the investigation. these findings are in line with aldarhami et al. [35] , zhong et al. [63] , and machida et al. [64] . a key principle of social distancing behavior is that risk perception is a critical condition for protective action. the results support the finding that higher risk perception motivates people to comply with social distancing. only by enhancing risk perception can people truly remain vigilant against the pandemic and take protective measures. therefore, when the government implements social distancing and other prevention measures, it must take into account the public risk perception and improve public environmental awareness through various means, such as social media, press conferences, standard therapy, and guidelines for the outbreak response. in particular, it is necessary to rectify pandemic rumors to prevent incorrect information that can potentially reduce public risk perception. besides, we confirmed a dual effect of perceived understanding on social distancing. first, perceived understanding was found to predict social distancing directly. these results are consistent with other studies [1, 46] which have shown that increased perceived understanding can encourage people to gain more knowledge about the pandemic and health risks, so that they would engage more in the social distancing regulations. then, we identified that perceived understanding as a factor showed an incomplete mediating effect on the relationship between risk perception and social distancing. previous literature regarding perceived understanding shows that it affects the social distancing behaviors related to the sources of information [46] . on the other hand, our results confirm an indirect positive effect of risk perception on social distancing through perceived understanding. hence, with the help of the authority of medical experts, we should promptly popularize scientific knowledge of the pandemic and prevention measures among communities to enhance public perceived understanding. in addition, the increase in risk perception can promote public desire to understand the pandemic and pay more attention to their own health risks. the authorities should improve pandemic information release channels. moreover, we identified that a positive perception of safety climate (î² = 0.566, p < 0.001) would promote adherence to social distancing and that this effect would be stronger than the risk perception (î² = 0.165, p < 0.001). this finding concurs with the study conducted by kouabenan et al. [49] . the achievement of a consensus on a safe climate requires the joint efforts of the organization and society. first, workplaces such as shops, cafeterias, office spaces, and public transit systems have to strengthen pandemic prevention and control drills. then, it is necessary to support community propaganda and scientific knowledge popularization and gather the individual consensus on self-protective behaviors. it is also strongly recommended to wear a face mask, keep a 2 m physical distance between workers, and use sanitary measures in public venues. finally, we demonstrated that safety climate, risk perception, and social distancing are the interacting factors, supporting our hypothesis that a moderating effect of safety climate on the relationship between risk perception and social distancing exists, as found in kouabenan et al. [49] , bosak et al. [50] , and koetke et al. [51] (see hypothesis h6). however, we did not find that safety climate increased the degree to which the risk perception positively affects social distancing. as shown in figure 4 , risk perception was positively related to social distancing under the conditions of a high safety climate as well as under the conditions of a low safety climate. more importantly, we found that safety climate is a factor that lessens the positive correlation between risk perception and social distancing. this moderating effect improves our understanding of the contexts in which risk perception affects social distancing. yet, as described by kouabenan et al. [49] , the safety climate was viewed as the key factor because it completely mediated the effect of perceived risk on safety behavior. one potential explanation for this difference of findings is the complex content of safety climate measurement items, because it actually includes three clauses. compared to the previous studies, we regarded the safety climate as the whole of social consciousness. the overall promotion of social protection awareness will replace the role of risk perception and may lead to compliance with social distancing through the public herd effect. therefore, while focusing on the importance of risk perception, we cannot ignore the positive incentives for social distancing brought by a good safety climate. in addition to enhancing employees' consensus on pandemic prevention, qualified organizations can physically isolate workspaces and public venues in time and space. for example, people should avoid going out for mass gatherings (lunches, shopping, traveling, education, leisure, etc.). then, for management commitment, they should physically divide the restaurant space, office space, and other public areas to ensure that people have sufficient isolation distance. flexible work scheduling, online office hours, and e-learning are encouraged for implementation. conclusively, application of innovating social distance management technologies (e.g., technologies that are based on an emerging range of ict technologies [65] like bluetooth, radio frequency identification, cloud mobile, and others) can assist with achieving an accurate measurement of the physical distance between individuals and momentarily reminding people to maintain a social distance as needed. in public venues, such as dining areas, using multimedia, posters, and ground stickers with social distancing reminders can create a good safety climate. although substantial efforts were put into this study to ensure the reliability and validity of the results, a few limitations still exist, which might be explored in further research. first, our sample does consist of chinese internet users but may not have all the attributes that perfectly match the characteristics of the current chinese population. without collecting data from other regions and having a representative sample, the generalizability of our findings is limited to a certain extent. a cross-regional, more representative study with a bigger sample size could be used in future studies in order to improve accuracy and generalizability of the results. second, we measured all the latent variables with a simple one-dimensional factor by using a cross-sectional design. the results could neither exclude the possibility of reverse causation nor prove the exact cause-and-effect relationships from a cross-sectional survey design. hence, further study could be extended by collecting longitudinal data through multiple rounds of experiments. furthermore, several previous studies measured risk perception from a multi-dimensional perspective. therefore, it would be meaningful to present risk perception as a multi-dimension construct, developing a multi-item scale to promote reliability and validity. moreover, this study takes into consideration risk perception that creates social distancing for the adoption of risk management. some other factors, like knowledge and beliefs of the covid-19 pandemic, mask-wearing, self-awareness in prevention of covid-19, number of confirmed covid-19 cases in a given region, death rate in a given region, and percentage of elderly population in a given region, can also be included in further research. finally, we considered the mediating and moderating effects of perceived understanding and safety climate. as contingent factors, these effects may interact with other factors, shifting the results conducted in the present study. besides, several control variables that are associated with population demographics, such as gender, age, and education level, did not show a significant impact on the relationships among these latent variables. this subject, however, is worth exploring in further research. this study investigated the impact of risk perception on social distancing during the covid-19 pandemic. based on the data collected from an online survey among 317 participants in china throughout may 2020, our analyses indicate that positive changes in social distancing behaviors are associated with increased risk perception, perceived understanding, and safety climate. the individual's perceived understanding partly plays a positive mediating role in the relationship between risk perception and social distancing behaviors. furthermore, the safety climate plays a negative role in the relationship between risk perception and social distancing because the safety climate seems to mitigate the effects of risk perception on social distance. hence, effective health promotion strategies directed at developing or increasing positive risk perception, perceived understanding, and safety climate should be conducted to encourage people to comply with the social distancing policies amid these unprecedented times. finally, these results are expected to contribute to management guidelines at the level of individual perception and public opinions as well as to assist with effective implementation of the social distancing policies in countries with a high risk of the covid-19 pandemic. pandemic is associated with antisocial behaviors in an online united states sample tracking changes in sars-cov-2 spike: evidence that d614g increases infectivity of the covid-19 virus early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia the reproductive number of covid-19 is higher compared to sars coronavirus does culture matter social distancing under the covid-19 pandemic? social distancing: how religion, culture and burial ceremony undermine the effort to curb covid-19 in south africa airborne or droplet precautions for 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korea study on the development of an infectious disease-specific health literacy scale in the chinese population the impact of organizational climate on safety climate and individual behavior core dimensions of the construction safety climate for a standardized safety-climate measurement analytic thinking, rejection of coronavirus (covid-19) conspiracy theories, and compliance with mandated social-distancing: direct and indirect relationships in a nationally representative sample of adults in the united kingdom knowledge and beliefs towards universal safety precautions during the coronavirus disease (covid-19) pandemic among the indian public: a web-based cross-sectional survey coefficient alpha and the internal structure of tests introduction to psychometric theory applied multivariate data analysis: volume ii categorical and multivariate methods testing mediation and suppression effects of latent variables: bootstrapping with structural equation models knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey adoption of personal protective measures by ordinary citizens during the covid-19 outbreak in japan social distancing 2.0 with privacy-preserving contact tracing to avoid a second wave of covid-19 the authors declare no conflict of interest. key: cord-279864-5ouuu49v authors: hou, jing; lv, dachao; sun, yuexia; wang, pan; zhang, qingnan; sundell, jan title: children’s respiratory infections in tianjin area, china: associations with home environments and lifestyles date: 2020-06-07 journal: int j environ res public health doi: 10.3390/ijerph17114069 sha: doc_id: 279864 cord_uid: 5ouuu49v children spend most of their indoors time at home, which may have substantial influence on their health. we conducted a cross-sectional study in the tianjin area, china to quantify the incidence of respiratory infections among children, and its association with home environments and lifestyles. the lifetime-ever incidences of croup, pneumonia and ear infection among children aged 0–8 in tianjin area was 9.2%, 28.7% and 11.6%, respectively. the incidence of common cold infections more than twice per year was 31.3%. home environments and lifestyles included strong risk factors for childhood respiratory infections. perceived dry air had the greatest association with childhood common colds (population attributable fraction (paf = 15.0%). modern floor covering had the greatest association with croup (paf = 14.7%) and ear infection (paf = 34.5%), while infrequent bedding sun-curing had the greatest association with pneumonia (paf = 18.7%). condensation (a proxy of poor ventilation) accounted for 12.2% of the incidence of croup (paf = 12.2%) and frequent common colds (paf = 8.4%). our findings indicate that factors related to “modern” home environments and lifestyles are risks for childhood respiratory infections. modifying such factors might reduce the incidence of respiratory infections among children. respiratory infection was the leading cause of global children mortality, accounting for 15-16% of under-five mortality, second only to prematurity [1] . in 2017 alone, an estimated 1.6 million children under age 5 died worldwide from respiratory infections, including 39,000 deaths in china [2] . there is no evidence for a robust relationship between respiratory infections and genetic or racial factors [3] . people spend most of their time indoors, especially children [4, 5] . infants and young children, compared to adults, are more vulnerable to environmental exposure because their immune systems are not fully developed [6] . household activities and environmental exposure at home are suspected risk factors for respiratory infections among children, especially in low income countries [7] . therefore, a global study on home environments and children's health was launched in eight countries/areas in 2000 [8, 9] , wherein children's health outcomes, home environments, lifestyles, socialeconomic status, and biological factors were investigated systematically [10] . home environmental exposures include chemical exposure (such as volatile organic compounds from building materials and decoration; no x from natural gas cooking), dampness and mold, and environmental tobacco smoke (ets) pre-and post-natally. many studies [11] [12] [13] [14] [15] have shown that dampness and mold in buildings are significantly associated with an increase in respiratory infections. people living in damp houses have been shown to be more likely to suffer from respiratory infections partly because of exposure to higher concentration of fungi and dust mites in damp environments [16, 17] . exposure to home indoor air pollutants such as ets [18] and chemical sources [19] have also been reported to be associated with respiratory infections among children. in addition to home environmental exposure, previous research has also shown that lifestyle factors and biological factors are important determinants of children's health [20] . sun-curing bedding and daily cleaning room are associated with fewer respiratory infections [21] . holberg et al. [22] and sun et al. [23] have demonstrated that daycare attendance was associated with more respiratory illness, asthma and allergy. occupancy level and type of daycare facility have been identified as important determinants of infection risk [24, 25] . the mode of infant delivery was found to affect early respiratory microbiota development, and may also play an important role in respiratory health later in life [26] . in addition, many studies in different countries have suggested that exclusive and prolonged breastfeeding was protective against respiratory infections [27] [28] [29] . with china's increasing wealth and urbanization in the past 40 years, chinese homes and lifestyles have changed dramatically. in urban areas, traditional chinese residential buildings, pingfang residences, have been replaced by high-rise apartments [10] . new furnishing materials have come into use [30] . homes have been tightened in order to save energy, resulting in poor ventilation [31] . along with this urbanization, a "modern" lifestyle has been adopted. it is less convenient for residents in urban areas to sun-cure bedding. fast food has become popular. childbirth tends to be cesarean delivery. breastfeeding time has been reduced, and daycare is being started earlier. in view of these changes in home environments and lifestyles in modern china, the main aim of this article is to study associations of respiratory infection outcomes in children with their home environments and lifestyles. this study is part of the china, children, homes and health (cchh) project [9, 32] . it was conducted from 2013 to 2015 in the tianjin metropolis, that is, the city of tianjin and its satellite city cangzhou. the tianjin metropolis is in northeast china, as shown in supplementary figure s1. metropolitan tianjin occupies an area of 11,920 km 2 and has a population of 15 million. cangzhou's area is 13,420 km 2 and its population is 7 million. in 2014, the gdps per capita for tianjin metropolis and cangzhou were usd 16,500 and usd 5800, respectively [33] . the average outdoor air temperature for spring, summer, autumn and winter are 13.4 • c, 25.7 • c, 13.6 • c and −1.7 • c, respectively, in tianjin and cangzhou [34] . cchh in tianjin metropolis consisted of two phases: phase i, a cross-sectional study and phase ii, a case-control study. in phase i, we analyzed data obtained from a questionnaire survey of children's health, demographic information, home environment and lifestyle. we selected daycares and primary schools from a list provided by the local municipal education commission, through a stratified random sampling method. finally, 24 institutes in urban, 6 in suburban and 9 in rural areas were involved in the survey. questionnaires were sent to daycare centers and primary schools, from where they were delivered to parents who responded to the questionnaires. the details of the questionnaire are provided in supplementary materials-questionnaire. the demographic information for investigated children included gender, age, family allergic history, home location and household income. questions related to home environment were about indoor dampness; building characteristics and indoor furnishings; exposure to environmental tobacco smoke; and pets at home. lifestyles referred to food habits; outdoor activity; home cleaning frequency; and children's daycare attendance. we also investigated biological factors for children such as their delivery mode, birth weight; and length of breastfeeding. questions on respiratory infections are as follows: • has your child ever had croup? (possible responses: yes; no) • has your child ever had doctor diagnosed pneumonia? (possible responses: yes; no) • has your child ever had ear infections? (possible responses: no; yes, 1-2 times; yes, 3-5 times; yes, >5 times) • in the last 12 months, how many times did your child have a common cold? (possible responses: none; 1-2 times; 3-5 times; 6-10 times; >10 times) all statistical analyses were performed with ibm spss statistics 22 (international business machines corporation (ibm), armonk, ny, usa). we accepted p-values < 0.05 as statistically significant. we first analyzed children's respiratory infections and their distribution by gender, age, family allergic history, home location and annual household income. the associations of childhood respiratory infections with home environments, lifestyles and biological factors were analyzed in univariate logistic regression models. odds ratios were calculated in logistic regression models with adjustment for gender, age, family allergic history, home location, household income and outdoor pollution (indicated by pm 10 concentrations, as shown in supplementary table s1 ). then, correlation coefficients among factors that reached significant levels (p < 0.05) were investigated by kendall correlation analyses. if the correlation coefficient was larger than 0.4, one factor in the pair was selected, and associations of the selected factors with respiratory infections were included in multivariate logistic regression models. finally, we put all the significant predictors in multivariate logistic regression models (using a forward conditional method) to identify the most important risk factors for respiratory infections among children. population attributable fraction (paf) is an estimate of the fraction of population with the health outcome that can be attributed to a particular risk factor or exposure. we calculated paf for a given exposure using the following formula [35] : where p 0 is the cumulative proportion of unexposed persons who develop the disease over the interval and p t is the cumulative proportion of the total population developing disease over the specified interval. the research office at tianjin university granted ethical approval for this study (no. 21207097). we received 7865 questionnaires, a response rate of 78%. ages were not reported for 204 children, while 295 children did not fit into the age range (0 to 8 years old). therefore, there are 7366 children in the final analysis. among these 7366 children, 52% were boys and 48% were girls. table 1 shows that children's respiratory infections had significant associations with family allergy history and home locations (p < 0.05). croup was reported more often for boys. more wealthy urban children had more infections compared to less wealthy rural children. dampness indicators and odors were defined as follows: (1) visible mold in child's room; (2) visible damp in child's room; (3) suspected moisture problem in child's home; (4) peeling or discolored floor covering in child's room; (5) flooding in child's room; (6) condensation on windowpane in winter in child's room; (7) perceived moldy odor; (8) perceived dry air. table 2 presents adjusted odd ratios (aor) of dampness problems for respiratory infections. we found that living in a damp room was associated with increased odds of respiratory infections. both pneumonia and the common cold were related to condensation on windowpanes. perceived dry air was a significant risk factor for all respiratory infections among children. the adjusted odds ratios of building characteristics for respiratory infections are presented in supplementary table s2 . infections (especially pneumonia) were associated with new apartments, modern floor covering, modern wall covering and use of air conditioners (ac). meanwhile, exposure to new furniture and redecoration in the child's early life due to home renovation was a risk factor for all respiratory infections. the adjusted odds ratio of environmental tobacco smoke (ets) and pet-keeping for respiratory infections are presented in supplementary table s3 . early life (i.e., during the first year of children's life or during pregnancy) exposure to ets, especially mother's smoking, increased the risks of children's respiratory infections. pet-keeping was a risk factor for infections. the adjusted odds ratios of daycare attendance for the studied respiratory infections among children are presented in supplementary table s4 . the type of childcare, starting age of daycare, exposure time and occupancy levels in daycare centers were analyzed. children in daycare centers were more susceptible to pneumonia and common colds than children who were mostly at home. children in daycare centers with more than 30 children have higher morbidity of pneumonia, ear infection and common colds. adjusted odds ratios for food habits, outdoor activity and cleaning habits for respiratory infections are presented in table 3 . spending ≥3 h per day watching tv was a strong risk for the common cold. children living in a frequently cleaned room with good ventilation and frequently sun-cured bedding had fewer respiratory infections. table 4 presents adjusted odds ratios of biological factors for respiratory infections among children. cesarean delivery is significantly associated with croup, pneumonia and ear infection. children who were not born on due week with less birth weight had a higher morbidity of pneumonia. factors that reached significant levels in univariate models were tested for correlation, as shown in supplementary table s5 . mold spots were correlated to damp spots. modern floor covering was correlated to building type. current pet keeping and environmental tobacco smoke were correlated to early life status. one factor in each of these paired variables was selected to be added to multivariate logistic regression models. finally, the variables mold spot, suspected moisture, floor moisture, condensation, moldy odor, perceived dry air, floor covering, cooling system, home renovation, early life smoking exposure, early life pets keeping, childcare type, size of daycare center, tv watching, room cleaning frequency, sun-curing bedsheets frequency, way of delivery, birth week and birth weight were used in the multivariate logistic regression model. multivariate analysis of associations of respiratory infections with these home environment, lifestyle and biological factors is shown in table 5 . dampness, condensation on windowpanes, moldy/perceived dry air, modern decoration materials and less frequency of sun-curing bed sheets were the greatest risk factors for croup, pneumonia, ear infections and common colds. in addition, attending day-care in a large class increased the risk of common colds and ear infections. the population attributable fractions (pafs) of home environment, lifestyle and biological factors for infections among children are shown in table 6 . the top contributor to childhood common colds is perceived dry air, while it is infrequent sun-curing bedding for pneumonia, and modern wall covering for croup and ear infection. condensation, a secondary attribution factor, contributes 12.2% and 9.2% to croup and frequent common colds, respectively. large class size is a risk factor for ear infection and common colds. in this study, a multivariate regression model was applied to identify the greatest home environmental, lifestyle and biological risks for children's infections. it was found that modern floor covering, perceived dry air (a proxy of indoor pollution), condensation on windowpanes (a proxy of poor ventilation), less sun-curing bedsheets and cesarean delivery are significantly associated with childhood infections. these factors might affect the development of the immune system and/or the transmission of infectious pathogens. with respect to biological factors, we found that cesarean delivery and not being born on the due day were significant risk factors with high population attributable fractions (paf) for childhood pneumonia. bosch et al. pointed out that cesarean delivery affects early respiratory microbiota development, thereby possibly increasing the frequency of respiratory infections later in life [26] . in our study, the cesarean delivery rate was 68% in tianjin metropolis, higher than the national level of 46% [36] and the recommended value by who of 15% [37] . our previous study showed that the tianjin modern urban area had a significantly higher cesarean delivery rate compared to the rural area close to tianjin [10] . in addition to cities having a higher cesarean delivery rate, city dwellings have increasingly modern materials being used for indoor furnishings and decoration [38] . china is currently the largest producer of wood-based panels, coating and furniture in the world. numerous new building furnishing materials have emerged in people's daily life. in the present study, we found that children who live in an urban apartment decorated with modern floor and wall coverings were more likely to have had respiratory infections. renovation during the first year of children's life was also a risk. considerable evidence has demonstrated that the chemical emissions of modern indoor materials (new wall coverings, new furniture, new synthetic carpets) are associated with increases in respiratory infections among children or infants [19] . home renovation and modern decoration materials are positively associated with high concentrations of formaldehyde, volatile organic compounds (vocs) and semi-vocs [39, 40] . these indoor pollutants may be associated with developmental delays in children, reduced activity of the immune system and direct toxicity [41, 42] . as a comparison, suburban or rural children who lived in pingfang dwellings with less "modern" redecoration and materials had fewer respiratory infections. it is interesting to find that perceived dry air had strong associations with pneumonia and common colds. the reported rate of "perceived dry air" is high in tianjin-53.1% in our study. "perceived dry air" has been shown to not necessarily be due to physically dry indoor air, but rather to polluted air [43, 44] . in spaces with poor ventilation, pollutants could not be efficiently removed [45] , which might irritate the respiratory tract and reflect in more complaints of dry air [44] . in this study, condensation on the child's room windowpanes in winter was a strong risk for respiratory infections among children. condensation on windowpanes in winter has been reported to be associated with insufficient ventilation in homes [31, 46] . chinese homes do not have a mechanical ventilation system. most of residential buildings in china still depend on the "natural ventilation" of open windows and infiltration to passively introduce outdoor air to indoors. in tianjin,~90% of homes closed the child's bedroom window at night in winter. thus, ventilation is mainly through infiltration, with a median value of 0.30 h -1 [31] . in such tight buildings, the poor ventilation rate could not efficiently dilute airborne-transmitted pathogens and subsequently results in their accumulation in our occupied spaces. a study conducted in army trainees found that rates of febrile acute respiratory diseases were significantly higher among trainees in modern (energy efficient design) barracks (an adjusted relative risk of 1.51) [47] . milton estimated that in offices with lower ventilation, relative risk for short-term sick leave was 1.53 (95% ci 1.22-1.92) [48] . a study conducted in chinese students' dormitories indicated a clear dose-response relationship between ventilation rate and common cold infections [49] . consistent with studies in america [50] and sweden [51] , our analysis demonstrated that daycare attendance was a significant risk factor for common colds among children in tianjin. daycare occupancy level and weekly exposure time are measures of contact with other children. we found that children spending more time in daycare or in higher occupancy daycare centers were susceptible to pneumonia, ear infections and common colds. attending daycares with higher occupancy level was a contributor for common cold infections ( table 6 , paf = 9.0%), next to poor ventilation in homes (indicated by condensation on windowpanes [52] ). more frequent contact with people may be a reasonable explanation for this observation. for respiratory infection viruses that are transmitted by small particle aerosols such as influenza, adenovirus, rhinovirus, and coronavirus, airborne transmission is considered the predominant transmission pathway [53, 54] ; however, contact (direct or indirect) can also spread these pathogens [55] . a study on the transmission of common colds in offices indicated that workers sharing offices have a significant risk of common colds compared to those working in single rooms (adjusted odds ratio-1.35) [56] . overcrowding in a large urban jail was reported to be a significant risk factor (p = 0.03) for an outbreak of pneumococcal disease among inmates [57] . currently in china, approximately 250 million families (accounting for 55% of the population in china) live in cities. rapid urbanization and modernization has led china to experience a dramatic change in both indoor environments and lifestyles in the past two decades [30] . modern high-rise apartments are constructed tightly and decorated with modern materials. the result is insufficient ventilation which causes increased concentrations of indoor-generated pollutants, including chemical compounds and airborne transmitted pathogens. it is almost impossible to sun-cure bedding frequently in modern urban buildings. it is common for children to attend daycare centers before three years old as both parents work in most cases. meanwhile, more health issues related to indoor environments are being observed. respiratory infections (as in this article), asthma and allergies [10] are more frequent in modern society, especially in homes with higher annual incomes (see table 1 ). in a previous study, we showed that indoor pollution increased significantly with increasing household income [40] . wealthier homes had more modern decoration materials (such as laminated wooden flooring) and household chemical products, all of which were associated with higher concentrations of modern chemical compounds (e.g., phthalates) [40] . as societies develop economically, ways to live a high-quality and healthy life need to be studied. parallel cchh studies performed in other cities have found similarly high rates of respiratory infections in children, especially in urban areas [21, 32] . the incidence of lifetime-ever pneumonia among children in modern cities (like tianjin-28.7%) are substantially higher than those in usa and european cities [58] . pneumonia is an infectious disease caused by bacteria or virus. the high infection rate of pneumonia in china may be partially due to insufficient vaccine coverage with the pneumococcal conjugate vaccine (pcv) and the hemophilus influenzae type b (hib) vaccine [58] . however, the incidence and severity or duration of pneumonia could be influenced by environmental factors [59] . our analysis in the present study is hierarchical so as to identify the important factors among a variety of possible risk factors. the most prominent risk factors from multivariate analysis were related to modern home environments and lifestyles. the higher rates of childhood respiratory infections are linked with a combination of biological, environmental and behavioral factors, which affect the development of immune system and the breeding and transmission of pathogens. in this study, surveys were performed using a stratified random sampling method. the response rate was 78%, which reduces the likelihood of selection bias. therefore, the strong association of infections with home environments and lifestyles is unlikely to be due to bias. modern floor covering, perceived dry air, condensation on the windowpanes in winter, and infrequent sun-curing of bedding are the strongest risks for childhood respiratory infections. "modern" home environments and lifestyles play an important role in the incidence of respiratory infections among children. increasing ventilation rate, frequent sun-curing of bedding and avoiding pollutants from furnishing and decoration materials might be effective measures to reduce the incidence of childhood respiratory infections. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/11/4069/s1, questionnaire: china-child-home-health, figure s1 : locations of tianjin metropolis and cangzhou city, china, table s1 : outdoor pm 10 concentrations in tianjin area (i.e., tianjin metropolis and cangzhou city) in 2013-2014, µg/m 3 table s2 : associations between building characteristics and respiratory infections among children, table s3 : associations between environmental tobacco smoke exposure, pet-keeping and respiratory infections among children, table s4 : associations between daycare and respiratory infections among children, monitoring health for the sdgs prevalence of respiratory and atopic disorders in chinese schoolchildren it's about time: a comparison of canadian and american time-activity patterns daily time spent indoors in german homes-baseline data for the assessment of indoor exposure of german occupants lung infection-a public health priority respiratory risks from household air pollution in low and middle income countries dampness in buildings and health (dbh): reports from an ongoing epidemiological investigation on the association between indoor environmental factors and health effects among children in sweden children, homes, health (cchh) modern life makes children allergic. a cross-sectional study: associations of home environment and lifestyles with asthma and allergy among children in tianjin region association between home dampness and presence of molds with asthma and allergic symptoms among young children in the tropics impact of a water-damaged indoor environment on kindergarten student 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risk for respiratory infections and asthma of children form of day care and respiratory infections among finnish children child care arrangements and repeated ear infections in young children development of upper respiratory tract microbiota in infancy is affected by mode of delivery the who collaborative study team on the role of breastfeeding on the prevention of infant mortality. effect of breastfeeding on infant and child mortality due to infectious diseases in less developed country: a pooled analysis breastfeeding and maternal and infant health outcomes in developed countries exclusive breastfeeding reduces acute respiratory infection and diarrhea deaths among infants in dhaka slums reducing health risks from indoor exposures in rapidly developing urban china air change rates at night in northeast chinese homes ten cities cross-sectional questionnaire survey of children asthma and other allergies in china meteorological data center of china meteorological administration. statistics of monthly average temperature use and misuse of population attributable fractions method of delivery and pregnancy outcomes in asia: the who global survey on maternal and perinatal health 2007-08 caesarean section: the paradox indoor svoc pollution in china: a review variations of formaldehyde and voc levels during 3 years in new and older homes phthalate exposure in chinese homes and its association with household consumer products early prenatal exposure to suspected endocrine disruptor mixtures is associated with lower iq at age seven prenatal phthalate exposure was associated with croup in swedish infants indoor air humidity and sensation of dryness as risk indicators of sbs human response to 78-h exposure to dry air indoor air quality, ventilation and their associations with sick building syndrome in chinese homes building characteristics, indoor air quality and recurrent wheezing in very young children (bamse) building-associated risk of febrile acute respiratory diseases in army trainees risk of sick leave associated with outdoor air supply rate, humidification, and occupant complaints in china, students in crowded dormitories with a low ventilation rate have more common colds: evidence for airborne transmission childhood upper respiratory tract infections: to what degree is incidence affected by day-care attendance? respiratory illness in preschool children with different forms of day care sbs symptoms in relation to dampness and ventilation in inspected single-family houses in sweden viral pneumonia in children rhinovirus transmission within families with children: incidence of symptomatic and asymptomatic infections the common cold shared office space and the risk of the common cold an epidemic of pneumococcal disease in an overcrowded, inadequately ventilated jail high pneumonia lifetime-ever incidence in beijing children compared with locations in other countries, and implications for national pcv and hib vaccination lifetime-ever pneumonia among pre-school children across china-associations with pre-natal and post-natal early life environmental factors we would like to express our special appreciation to louise b. weschler, who polished our language and clarified our expressions. the authors declare no conflict of interest. key: cord-271765-altqn10l authors: fernández-díaz, elena; iglesias-sánchez, patricia p.; jambrino-maldonado, carmen title: exploring who communication during the covid 19 pandemic through the who website based on w3c guidelines: accessible for all? date: 2020-08-05 journal: int j environ res public health doi: 10.3390/ijerph17165663 sha: doc_id: 271765 cord_uid: altqn10l health crisis situations generate greater attention and dependence on reliable and truthful information from citizens, especially from those organisations that represent authority on the subject, such as the world health organization (who). in times of global pandemics such as covid-19, the who message “health for all” takes on great communicative importance, especially from the point of view of the prevention of the disease and recommendations for action. therefore, any communication must be understandable and accessible by all types of people, regardless of their technology, language, culture or disability (physical or mental), according to the world wide web consortium (w3c), taking on special relevance for public health content. this study analysed whether the who is accessible in its digital version for all groups of citizens according to the widely accepted standards in the field of the internet. the conclusion reached was that not all the information is accessible in accordance with the web content accessibility guidelines 2.1, which implies that there are groups that are, to some extent, left out, especially affecting the elderly. this study can contribute to the development of proposals and suggest ways in which to improve the accessibility of health content to groups especially vulnerable in this pandemic. the use of the internet has increased in the last decade, as approximately 60% of the world's population now uses this medium. in 2020, there are more than 4.5 billion people using the internet [1]. therefore, not only has the capacity of access to the internet increased but more and more users have access to internet content, also as a source of information. in the face of a pandemic such as covid-19, access to reliable information by citizens is crucial as a means of preventing the disease and enabling citizens to take action in certain everyday situations, as demonstrated in a study by the european parliament's european science-media hub [2] . the world health organization (who) website is one of the main sources of information for the public, providing daily updates and interactive maps showing the evolution of the pandemic and offering credibility and security of information [2] . in addition to the who, other international sources of information stand out, such as the european centre for disease prevention and control and the european commission's coronavirus and coronavirus response page, as well as the european medicines agency, among others. as has happened in the world with the zika and ebola pandemics, the internet is not only a source of communication for prevention and action in the face of health crises but also becomes a channel for misinformation [3, 4] , making the need to share accurate and accessible information even more significant. the objective reasons for carrying out this study are mainly based on analysing the web accessibility of the world health organization (who) during the covid-19 pandemic. thus, the objective will be to determine whether the content offered to inform about the disease is prepared so that any person can access it, regardless of their technology (hardware, software, or network infrastructure), language, culture, or disability, whether physical or mental, as determined by the world wide web consortium (w3c). this institution is an international community that aims to ensure that anyone can access the content offered by a website, promoting the social value it provides for all citizens [5] . a lack of equity of access to health information can generate a digital divide [6, 7] and affect the ability to deal the disease [7] . consequently, it represents a social determinant of health. in addition, the elderly are an important group of citizens who benefit from web accessibility, since their skills are weaker as a result of age [8] . bearing in mind that older people are considered one of the main groups at risk in this pandemic, it is especially important that they are the ones who have the most access to the content offered by information sources such as the who [9] . from the point of view of web accessibility, it should be emphasised how few studies have been carried out on international and official organisations with important social responsibilities such as the who, as they are more oriented towards the education sector such as universities and local corporations such as town councils [10] [11] [12] [13] [14] . most of these studies do not focus on recent recommendations but only on some that have been detected in the area of education [15, 16] ; likewise, studies have shown that citizens' dependence on the media is more intense in crisis situations [17] . however, traditional media and the internet play different roles for people in these public health crises, and the internet's dependence on individuals is greater than that of traditional media [18] . therefore, one of the major contributions of this research is based on the originality of the analysis of universally accessible public health risk communication in times of global pandemic. likewise, the consideration that access to information is a health determinant is also relevant. this research is structured in the following blocks. after the introduction, the theoretical framework shows the who as the main health agency and information reference in the covid-19 pandemic. the methodology of the research is of an exploratory type, contemplating an analysis of the who' page using the wave tool and a manual review of each of the criteria of the content accessibility guidelines. the results obtained reflect the level of accessibility of the who according to international standards. the practical implications of this study highlight the need to raise awareness among health organisations such as the who about the importance of accessibility to their digital content in times of health crisis with the social objective of universal health information accessibility. the main contribution is the analysis of accessibility, taking particular account of elderly people, as one of the most vulnerable groups in this pandemic, and consequently, it provides practical proposals for addressing this challenge for health institutions. the who is an international organisation founded in 1948, and since then, the world has undergone great political and economic changes, not only from the point of view of health [19] . its headquarters are located in geneva, with 150 offices in different countries and six regional offices [20] . any country that is a member of the united nations can become a member of this organisation [21] . in order to become a member, countries must agree to its constitution, which currently includes 194 member states [21] . among the different activities addressed by this organisation, one of the main objectives is to provide universal health coverage by supporting integrated health services for citizens. they offer prevention, surveillance and a response to possible risks that may threaten citizen security, for example, in pandemics such as covid-19 [22] . this underlines the importance of this organisation as the importance of this organisation as the main source of information on this disease, which has become a pandemic caused by the coronavirus, the outbreak of which began in december 2019 in wuhan, china, and has affected the whole world [23] . the who acts as an agency that promotes accessibility in all its fields, including digital, and provides recommendations on its website [24] . for its part, the spanish association of scientific communication (aecc) [25] highlights the who as one of the main sources of consultation for the citizens of affected countries. in the united states, 53.1% of the population seeks health information on the internet [26] . in order to offer as much information as possible on covid-19, the who has created specific pages on prevention, symptoms and action protocols and even a solidarity page for donations to help research and detect the spread of the virus. these donations also go to unicef partners to support their work in communities that are the most vulnerable, such as children [27] . it is important to note that an outbreak such as covid-19 causes important social consequences, affecting social distance in the most affected countries and generating more anxiety [28] . all of the above have resulted in an increase in google searches for the keywords "world health organization" and "coronavirus world health organization" worldwide, which began to grow in early march, as can be seen in figure 1 . this search result confirms that the who has a social responsibility to provide quality content and information that is accessible to all types of people, since as the network evolves, different challenges are being addressed, resulting in a continuous need for relationships and trust [29] . moreover, it is a way of ensuring equity, eliminating disparities and improving the health of all groups [30] . it is important to highlight the responsibility that the management of pandemics entails for the who, since depending on the type, it involves a problem of uncertainty when the end of the pandemic is declared, as occurred in the case of influenza a (h1n1) in 2009 [31] . lamb-white [32] refers to the who's commitment to improving communicable diseases through the international health regulations (ihr) to improve public health, and this would therefore help countries to strengthen their capacity to achieve this. figure 2 shows the significant increase in visits, unique visitors and pages per visit in the last 6 months for the who website. moreover, it is surprising that the average duration of visits has also increased, so it can be said that the who website has been and is a reference for consultation on public health on a global level, especially in times of pandemics this search result confirms that the who has a social responsibility to provide quality content and information that is accessible to all types of people, since as the network evolves, different challenges are being addressed, resulting in a continuous need for relationships and trust [29] . moreover, it is a way of ensuring equity, eliminating disparities and improving the health of all groups [30] . it is important to highlight the responsibility that the management of pandemics entails for the who, since depending on the type, it involves a problem of uncertainty when the end of the pandemic is declared, as occurred in the case of influenza a (h1n1) in 2009 [31] . lamb-white [32] refers to the who's commitment to improving communicable diseases through the international health regulations (ihr) to improve public health, and this would therefore help countries to strengthen their capacity to achieve this. figure 2 shows the significant increase in visits, unique visitors and pages per visit in the last 6 months for the who website. moreover, it is surprising that the average duration of visits has also increased, so it can be said that the who website has been and is a reference for consultation on public health on a global level, especially in times of pandemics such as covid-19, as can be seen in the data. in addition, the semrush tool (semrush.com), comparing the who's traffic data with those of the website of the european centre for disease prevention and control (the second most popular website after the who's according to the european parliament's european science-media hub [2] ), shows that the who website visits increased from the end of february to april. prevention and control (the second most popular website after the who's according to the european parliament's european science-media hub [2] ), shows that the who website visits increased from the end of february to april. figure 2 shows that the who pages related to the covid-19 pandemic were the most visited in the last 6 months according to a study by the european science-media hub of the european parliament [2] . specifically, this tool has shown that in countries such as spain, the keyword "coronavirus" has increased organic traffic on the who website, accounting for more than 50% of organic web traffic, as can be seen in figure 3 , in addition to terms such as covid-19 being incorporated in the top positions, showing that citizens have real public health concerns through the search for these keywords that are incorporated into the ranking of new searches related to the who. apart from the organic traffic referenced above, it should be noted that the who is making great communication efforts to reach all citizens through the paid searches of search engines such as google, specifically through ads in different languages, depending on the search keyword. people with disabilities have many difficulties in becoming independent as a result of the lack of commitment of the different public policies in force. a report by the spanish committee of representatives of people with disabilities (cermi) states: "universal accessibility is the great failure of public policies in our country" [33] (p. 528). this causes people with disabilities to figure 2 shows that the who pages related to the covid-19 pandemic were the most visited in the last 6 months according to a study by the european science-media hub of the european parliament [2] . specifically, this tool has shown that in countries such as spain, the keyword "coronavirus" has increased organic traffic on the who website, accounting for more than 50% of organic web traffic, as can be seen in figure 3 , in addition to terms such as covid-19 being incorporated in the top positions, showing that citizens have real public health concerns through the search for these keywords that are incorporated into the ranking of new searches related to the who. [2] ), shows that the who website visits increased from the end of february to april. figure 2 shows that the who pages related to the covid-19 pandemic were the most visited in the last 6 months according to a study by the european science-media hub of the european parliament [2] . specifically, this tool has shown that in countries such as spain, the keyword "coronavirus" has increased organic traffic on the who website, accounting for more than 50% of organic web traffic, as can be seen in figure 3 , in addition to terms such as covid-19 being incorporated in the top positions, showing that citizens have real public health concerns through the search for these keywords that are incorporated into the ranking of new searches related to the who. apart from the organic traffic referenced above, it should be noted that the who is making great communication efforts to reach all citizens through the paid searches of search engines such as google, specifically through ads in different languages, depending on the search keyword. people with disabilities have many difficulties in becoming independent as a result of the lack of commitment of the different public policies in force. a report by the spanish committee of representatives of people with disabilities (cermi) states: "universal accessibility is the great failure of public policies in our country" [33] (p. 528). this causes people with disabilities to apart from the organic traffic referenced above, it should be noted that the who is making great communication efforts to reach all citizens through the paid searches of search engines such as google, specifically through ads in different languages, depending on the search keyword. people with disabilities have many difficulties in becoming independent as a result of the lack of commitment of the different public policies in force. a report by the spanish committee of representatives of people with disabilities (cermi) states: "universal accessibility is the great failure of public policies in our country" [33] (p. 528). this causes people with disabilities to encounter physical and technological barriers in their daily lives. consequently, it suggests that institutions with competences could address this matter and pay attention to accessibility to minimise the digital divide [6] , achieve health equity, and allow all groups to better face the disease [7] . according to webaim, the internet is an opportunity for people who have some kind of disability, since it allows them to access information through diverse content quickly and by means of different devices and software, for example, screen readers for people with vision problems. however, these opportunities that the world wide web (www) should offer through websites are not sufficiently optimised and adapted to the different needs of citizens according to their disability [34] . according to who data, the aging of the population and the increase in chronic diseases are one of the main reasons for the increase in disability rates, which is about 15% for the world's population [24] . in fact, age is a physical and social determinant directly correlated with health [30] . in times of crisis, communication through written messages is remembered more than those transmitted through other formats, so it must be not only accessible but also accurate so that it is understood by the majority of the population [35] . studies have confirmed that because of the speed with which these types of diseases such as covid-19 are transmitted, citizens and different countries need to increase their vigilance and prepare themselves through preventive responses [36] . communication is particularly important in this regard, as is access to equal opportunities for all. however, if information tends to be complex and ambiguous in terms of the interpretations that citizens may make, situations of panic and anxiety may arise [37] . exceptional crisis situations such as the covid-19 pandemic generate greater attention or dependence on information, especially reliable and accurate information. in addition to this maxim, which can be contrasted with previous literature, internet penetration makes it easy to access information and increases the level of information that each person has, which is why the following research questions are posed: rq1: does the who make itself accessible to all groups of citizens according to accepted standards in the field of the internet? rq2: what aspects of web content analysis can be improved, and which audiences are affected? this research analyses the web accessibility of the who website based on the web content accessibility guidelines 2.1 in an exploratory way. the analysis was carried out during the covid-19 pandemic in march-may 2020, coinciding with one of the world's most popular periods for citizens to search for information (figure 1) . the methodology was combined using a web accessibility evaluation tool and manual analysis carried out by an evaluator [38, 39] . the tool used for accessibility evaluation was the wave tool [40] , developed by the webaim organisation. the website accessibility conformity assessment methodology (wcag-em) was used, which is considered in the web content accessibility guidelines 1.0 but is applicable to wcag 2.1 [41] . as for the variables analysed, they belong to the web content accessibility guidelines (wcag), which explain how to make content more accessible to developers and other professional profiles related to web accessibility authoring and evaluation tools, including mobile accessibility [42] . it should be recalled in historical retrospect that wcag 1.0 was a recommendation in may 1999. it consists of a total of 14 guidelines and 65 priority 1, 2 and 3 checkpoints depending on the level of compliance [43] . wcag 2.0 was recommended in december 2008. unlike the previous ones, it is composed of 12 guidelines and four principles-perceptible, operable, understandable and robust-with 61 criteria for success [44] . however, the latest guidelines recommended in june 2018 are wcag 2.1, with a total of 13 guidelines and 78 compliance criteria; in this case, the w3c has included 17 new criteria, maintaining the four principles mentioned above [45] . the web content accessibility guidelines present different conformance levels-a, aa and aaa [43] [44] [45] [46] . in the case of wcag 1.0, the levels depend on satisfying the priority levels 1 to 3; for example, it is determined that level a is met when all the priority 1 checkpoints are satisfied [43] . however, in wcag 2.0 and 2.1, the levels do not refer to priorities 1 to 3; for example, it is determined that level a is met when all the level a compliance criteria are satisfied [45, 46] . in order to carry out a more in-depth analysis, six representative pages from the entire website were analysed (table 1 ). the sample was selected by taking representative pages that allow the checking of each of the analysed criteria; for example, a page with forms must be checked to determine the compliance of the labels in the fields, or a page with tables must be checked to ensure that the conent is in an accessible form; additionally, videos must be checked for their audiovisual accessibility. the methodology (wcag-em) suggested by w3c [41] recommends selecting representative urls for each criterion: standard page: a second-level reference page of the website that describes the structure of the website. page with tables: a page that shows content laid out using tables. page with forms: registration forms, application forms, information forms, etc. result of a search: the information necessary for the location of contents is extracted and checked by means of a keyword search; in this case of analysis, the word "covid-19" is used as an example. 6. page containing video: to analyse compliance with the guidelines in the case of videos. once the representative urls of the rest of the who website were selected, as shown in table 1 , the compliance with each of the variables to wcag 2.1 was analysed. these are shown in tables 2 and 3 , divided into levels of compliance a or double a respectively: after analysing each of the criteria, the results obtained were collected with the data analysis tool (table 4 ); the variables of the wcag 2.1 analysed are shown in the upper part of the table, facilitating manual data collection and the checking of compliance. the first step was to check if the success criterion could be applied to the analysed url and how many times it was applied to (a). the second step was to check whether the success criterion was approved (b) or not (m). the symbols have the following meanings (table 4) : p: pages analysed for each service a: pages to which the criterion applies b: pages that are correct according to the criterion m: pages that breach the criterion as can be seen in table 4 , the total number of pages analysed (tp) was calculated, the correct (tb) and incorrect (tm) pages were counted, and as a result, a percentage was obtained of the correct who pages, obtaining an average that represents the percentage of web accessibility compliance of each page analysed (%b). the formula is as follows: (%b) = (tb × 100/tp). source: author's elaboration based on the infoaccessibility observatory of discapnet [48] for the manual assessment phase, table 5 details the tools that enabled the level of compliance to be checked according to the wcag 2.1 guidelines on those points that required more in-depth review, apart from the wave tool, in the first phase. the analysis shows that the who website is 60% compliant regarding web accessibility based on the pages analysed; however, at the double-a level, the figure is slightly less than a 50% level of compliance. from the point of view of the four principles (appendix a, table a1 ) that underpin the wcag 2.1-perceptible, operable, understandable and robust-it can be seen that the principle that is most complied with on the who website is understandable at both levels, with 64% and 61.5% compliance, respectively. therefore, the who's digital health information is readable and understandable based on this principle [47] . however, robust is the worst performer at both the a and aa levels, at 50% and 0%, respectively. it is precisely this principle that focuses on adapting the content to user applications and providing technical aids [47] . the perceivable principle, directly related to the alternative text of the images, although it does not present outstanding values at level a with respect to the rest, is the second principle that best meets the double-a conformity criteria, with regard to the size and contrast of the text, benefiting those with vision problems derived from both age and sensory disabilities [47] . finally, it should be noted that the operable principle shows significant differences upon comparison at both levels, worsening at the double-a level, and therefore, navigation aspects have to be improved [47] . generally, the principles that are most closely adhered to are found in level a, so it is concluded that those in level aa are the ones that need to be improved for each compliance criterion analysed in the wcag 2.1. with respect to the total number of errors detected by the wave tool and later analysed manually, it is worth highlighting in figure 4 that the home page is the one with the most errors, followed by the form page and the page with tables. generally, the principles that are most closely adhered to are found in level a, so it is concluded that those in level aa are the ones that need to be improved for each compliance criterion analysed in the wcag 2.1. with respect to the total number of errors detected by the wave tool and later analysed manually, it is worth highlighting in figure 4 that the home page is the one with the most errors, followed by the form page and the page with tables. if one analyses it from the point of view of contrast errors, one will find that the page with the highest number of contrast errors is the table page, followed by the type page and the page with video ( figures 5 and 6 ). contrast errors are based on the fact that the visual presentation of the text and the images of the text must be sufficiently differentiated so that users with some type of visual disability can differentiate the text when reading, especially in the case of older age groups [47] . if one analyses it from the point of view of contrast errors, one will find that the page with the highest number of contrast errors is the table page, followed by the type page and the page with video ( figures 5 and 6 ). contrast errors are based on the fact that the visual presentation of the text and the images of the text must be sufficiently differentiated so that users with some type of visual disability can differentiate the text when reading, especially in the case of older age groups [47] . if one analyses it from the point of view of contrast errors, one will find that the page with the highest number of contrast errors is the table page, followed by the type page and the page with video ( figures 5 and 6 ). contrast errors are based on the fact that the visual presentation of the text and the images of the text must be sufficiently differentiated so that users with some type of visual disability can differentiate the text when reading, especially in the case of older age groups [47] . regarding the non-text content errors detected, it can be seen that they also happen on all pages, especially form pages (figure 7) , so people who need a screen reader will be especially affected because there is no alternative text for the images. regarding the non-text content errors detected, it can be seen that they also happen on all pages, especially form pages (figure 7) , so people who need a screen reader will be especially affected because there is no alternative text for the images. from the point of view of the type of errors detected, figures 8 and 9 show each of them in detail. it is worth noting from the comparison between the level a and double a errors that they coincide in both cases, and there are a total of seven success criteria with 100% error rates for the pages analysed. of the total errors detected, the most significant are those referring to non-text content within level a, as they are directly related to the alternative text of the image by means of the alt tag, preventing screen readers from accessing the content by means of images for visually impaired citizens and, in the case of level aa, the visible focus, since if the user cannot clearly see where the keyboard tab is when browsing the page, it is difficult for them to conduct proper and understandable navigation through the content. regarding the non-text content errors detected, it can be seen that they also happen on all pages, especially form pages (figure 7) , so people who need a screen reader will be especially affected because there is no alternative text for the images. from the point of view of the type of errors detected, figures 8 and 9 show each of them in detail. it is worth noting from the comparison between the level a and double a errors that they coincide in both cases, and there are a total of seven success criteria with 100% error rates for the pages analysed. of the total errors detected, the most significant are those referring to non-text content within level a, as they are directly related to the alternative text of the image by means of the alt tag, preventing screen readers from accessing the content by means of images for visually it is therefore determined that each of these errors detected requires a complete review that, in turn, contemplates alternative solutions based on guidelines established by the w3c to comply with the requirements set by the wcag 2.1. it is therefore determined that each of these errors detected requires a complete review that, in turn, contemplates alternative solutions based on guidelines established by the w3c to comply with the requirements set by the wcag 2.1. as a main point of discussion, it should be noted that the who [24] states on its website that one of its objectives as an international organisation is based on improving universal accessibility to health services, both in internet media and in physical media; however, its website does not show any kind of statement on accessibility with which they currently comply. it should be emphasised that the home page is one of the pages with the most errors; taking into account the fact that it is usually the first page that a user consults before proceeding to browse the rest of the web, it should be a principal target for improvement. in addition, the who recommends adopting digital media for health education [49] , so it could be considered a special committer to digital media. as is seen in previous research work, assuming this responsibility is necessary to ensure health equity and to reduce the digital divide, which can affect the ability to face the disease for some population groups [6, 7, 30] . considering the studies that have been carried out on citizens' dependence on the media in times of public health crisis, most are based on analysing the differences between dependence on traditional media and that on the internet [17, 18] , but they do not focus on analysing the information offered from the point of view of the accessibility of a particular agency and the social responsibility they have towards citizens facing a pandemic and seeking information. therefore, this study provides originality based on a specific case of accessibility in a health agency such as the who and provides points of improvement to make the content universal, at a crucial time of global pandemic, such as that presented by covid-19. furthermore, this article reinforces the conclusions reached by other studies in which it is highlighted that the population seeks information on public health mainly through the internet [18, 26] . from a technical point of view, more associated with web accessibility studies, it is worth mentioning that due to the recent approval of the wcag 2.1, most studies have focused on the previous guidelines, so there is a shortage of studies based on the new guidelines, among which [15, 16] , focusing on the education sector, stand out. based on the results obtained, it is considered that the who is not accessible to all groups of citizens according to the web content accessibility guidelines 2.1, being less than 50% accessible at one of the levels analysed. it is concluded that many aspects need to be improved in order to make it fully accessible. one of the main online messages transmitted by the who [27] is "health for all", and therefore, this research calls for "web accessibility for all" as the main aim and contribution to ensure that citizens have access to accurate, understandable and direct information; in short, there should be universal accessibility. it is also one of the overarching goals of the healthy people 2020 initiative that specifically pays attention to achieving health equity and improving the health of all groups [50] . hence, the concept of accessibility in times of crisis such as the covid-19 pandemic is especially relevant, regarding the social value of the web. among the most notable errors are those concentrated largely within the principles understandable and perceivable, which shows that they are essential variables of communication with citizens, since they are directly related to content that is easy to understand in the first case and offer text alternatives for non-text content in the second case, especially for people with vision problems who use screen readers and even groups of elderly citizens who have vision problems as a result of physical aging. it is therefore determined that one of the aspects that most needs to be improved in terms of accessibility parameters is directly related to these two principles. with regard to the limitations, it should be mentioned that the analysis could be completed with a heuristic study that would include manual checking as well as checking over time. on the other hand, comparison with other key information sources and the incorporation of who web users or those involved in this health crisis could offer a more complete vision of the phenomenon of web accessibility during a pandemic as well as the evaluation of the websites of other institutions. with regard to future lines of research, since wcag 2.1 must also be implemented in the mobile applications of public administrations, the analysis of the mobile applications of international organisations with social implications such as the who is proposed. it has also been considered as a future line of research to carry out user tests, a practice recommended by the w3c [51] . there are also different systems for groups with physical disabilities, where information can be collected from sources other than websites-for example, with bots-so it is proposed for these lines of research be considered in the future to make this research work more substantial. the practical implications of this study are mainly based on the fact that international organisations with competence in the matter should review the structure and texts as well as everything related to the content in order to approach this challenge in an equitable way and provide the interested public with the same options of access to information. this study allows us to consider the accesibility of the who web resources with a special focus on elderly groups. the diagnosis performed will help health organisations to make decisions and to pay attention to critical points. the absence of text in images (non-text content) and errors in the html code (parsing) should be stressed. this study acts as a first attempt to analyse accessibility for the most representative health institution, the who. this is the main social value that this research aims to convey, that the main sources of information-international organisations, whose responsibility for health is crucial in times of global pandemics such as the one we are experiencing-can be given solutions that provide greater visibility to the information. global digital overview european parliament's european science-media hub. esmh selection: sources of information about coronavirus twitter, and misinformation: a dangerous combination? zika virus misinformation on the internet objetivos del w3c. principios: web para todo el mundo el acceso a la información como determinante social de la salud. nutrición hospitalaria penman-aguilar, a. difference in health inequity between two population groups due to a social determinant of health introducción a la accesibilidad web. ¿qué es la accesibilidad web? available online european centre for disease prevention and control. risk assessment on covid-19. ecdc risk assessment la accesibilidad de los portales web de las universidades públicas andaluzas. rev. española doc web accessibility: study of maturity level of portuguese institutions of higher education universities of the kyrgyz republic on the web: accessibility and usability evaluating web accessibility metrics for jordanian universities the relationship between web content and web accessibility at universities accesibilidad de las revistas colombianas del área de humanidades bajo las pautas wcag 2.1. rev. espacios analisis de accesibilidad web en las universitated ecuatorianas para attender las necesidades de estudiantes con discapacidad canaries in the coal mine how young chinese depend on the media during public health crises? a comparative perspective what's the world health organization for? in final report from the centre on global health security working group on health governance world health organization (who) world health organization (who) world health organization (who) what is covid-19? available online disability and health: key facts lista de fuentes fiables sobre el nuevo coronavirus profiles of a health information-seeking population and the current digital divide: cross-sectional analysis of the california health interview survey world health organization (who) can information about pandemics increase negative attitudes toward foreign groups? a case of covid-19 outbreak networks as systems the concepts and principles of equity and health science and policy. h1n1 and the world health organisation world health organisation comité español de representantes de personas con discapacidad. derechos humanos y discapacidad an introduction to web accessibility, web standards, and web standards makers passing crisis and emergency risk communications: the effects of communication channel, information type, and repetition coronavirus disease 2019 (covid-19): a literature review public health communication in time of crisis: readability of on-line covid-19 information a comparative test of web accessibility evaluation methods applying heuristics to perform a rigorous accessibility inspection in a commercial context evaluating web accessibility of educational websites website accessibility conformance evaluation methodology. wcag-em web content accessibility guidelines (wcag) overview web content accessibility guidelines 1.0 web content accessibility guidelines (wcag) 2.0 accesibilidad web. wcag 2.1 de forma sencilla world wide web consortium (w3c) world wide web consortium (w3c) accesibilidad web en los portales de ayuntamientos de capitales de provincia who guidance for digital health: what it means for researchers involving users in evaluating web accessibility this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord-257575-qumwrgng authors: gómez, laura e.; monsalve, asunción; morán, mª lucía; alcedo, mª ángeles; lombardi, marco; schalock, robert l. title: measurable indicators of crpd for people with intellectual and developmental disabilities within the quality of life framework date: 2020-07-15 journal: int j environ res public health doi: 10.3390/ijerph17145123 sha: doc_id: 257575 cord_uid: qumwrgng this article proposes the quality of life (qol) construct as a framework from which to develop useful indicators to operationalize, measure, and implement the articles of the convention on the rights of persons with disabilities (crpd). a systematic review of the scientific literature on people with intellectual and developmental disabilities (idd) was carried out, with the aim of identifying personal outcomes that can be translated into specific and measurable items for each of the crpd articles aligned to the eight qol domains. following preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines, the systematic review was conducted across the web of science core collection, current contents connect (ccc), medline, kci-korean journal database, russian science citation index and scielo citation index, for articles published between 2008 and 2020. a total of 65 articles focusing on people with idd were selected. the results were grouped into four broad categories: conceptual frameworks used to monitor the crpd; instruments used to assess the rights set out in the crpd; recommendations on the use of inclusive research; and indicators or personal outcomes associated with specific rights contained in the crpd. changes in how people with intellectual disabilities and developmental disabilities (idd) are perceived, and prevailing attitudes toward them, are increasingly reflected not only in national laws and regulations, but also in specific international conventions currently being used worldwide to develop, implement, and monitor social policies and professional practices aimed at promoting the inclusion and independence of people with id in society [1] [2] [3] . more than a decade ago, in an effort to focus attention on the dignity of people with disabilities and their right to participate fully in community life in the same way as any other citizen, the united nations convention on the rights of persons with disabilities (crpd) was approved and ratified by 180 countries [4] . the crpd was an international milestone recognizing the change in attitudes toward people with disabilities, based on the premise that people with disabilities, including those with id, should have an active role in making decisions about their own lives, carry out productive activities, be included in society, and receive appropriate supports to allow them to live as full citizens, on an equal basis with others. thus, the crpd sets out rights that go far beyond what is strictly measured using conventional evaluation methods; (b) serve as a tool that professionals and relatives can use to detect any breach, abuse or denial of rights, thereby helping them enhance the supports they provide to people with id; and (c) provide guidance to organizations on the strengths and greatest needs of people with id in relation to rights that are encompassed in the crpd. in this way, the approach to the evaluation of rights set out in this article focuses more on the microsystem (i.e., improving the lives of people with id) and on the mesosystem (i.e., improving the provision of generic and professional supports offered by organizations) than on the macrosystem (i.e., lawmaking or production of official national statistics). several conceptual models of the qol construct exist in the field of id [18] [19] [20] , although all of them highlight four basic principles in their definition [16] : (a) qol is composed of several dimensions (i.e., multidimensional) that are the same for all people (i.e., universality); (b) it is influenced by personal and environmental factors; (c) it has both objective and subjective components; and (d) it is enhanced by individualized, person-centered supports. in this article, we focus on the qol model proposed by schalock and verdugo [20] . it is the most widely accepted and cross-culturally validated model of qol, and is used widely internationally by id support organizations and systems in support provision, organization transformation, and systems change. [21] [22] [23] [24] [25] [26] [27] . according to schalock and verdugo's conceptual framework, qol encompasses eight core domains that interact with each other. these domains include rights, self-determination, social inclusion, interpersonal relationships, personal development, emotional wellbeing, material wellbeing, and physical wellbeing. the eight domains can serve as a basis to evaluate the implementation of the 26 crpd articles on specific rights, through the measurement of core indicators and personal outcomes associated with qol. two pioneering studies have sought to operationalize the crpd through the qol conceptual framework. the first demonstrated the theoretical foundations of the close relationship between the 26 crpd articles and the eight qol domains, and put forward an initial proposal to organize the articles by qol domain [1] . the second article reported on the international consensus on the relationship between the core qol indicators and the crpd articles [2] . to this end, a delphi study was conducted with 153 experts (comprising people with id, family members, professionals, researchers, and law experts) from 10 countries (brazil, canada, the czech republic, germany, israel, italy, portugal, spain, taiwan, and the united states). consensus was reached on over 80 cross-culturally agreed and validated qol indicators, which were aligned to the eight qol domains. results from both of these studies are summarized in table 1 . they represent the framework for the systematic review presented in this article. the overall aim of this review is to take the next logical step in the operationalization of the crpd: to review the scientific literature on people with idd, in order to identify indicators and personal outcomes that can be translated into specific and measurable items for each of the crpd articles that are aligned to the eight qol domains. in particular, the present systematic review sought to answer the following questions: • what is discussed in the publications about the crpd and people with idd? • in the literature, what theoretical frameworks and assessment instruments are proposed to monitor the implementation of the crpd for people with idd? • what indicators or personal outcomes are mentioned in the scientific literature discussing the crpd articles that protect specific rights for people with idd? the following inclusion criteria were applied for this systematic review of the scientific literature. first, publications had to be peer-reviewed articles published since 2008, when the crpd came into force. thus, articles published between 2008 and january 15, 2020 were included. second, studies had to refer to the crpd and to people with idd. third, articles had to be published in english or in spanish. given that one of the aims of this research was to locate as many indicators and personal outcomes as possible, added to the fact that the specific nature of the search was unlikely to return a large volume of results, few exclusion criteria were predefined. following an examination of the complete references, results that had initially met the inclusion criteria set out above were subsequently excluded if they: (a) did not focus on the crpd; (b) did not include people with idd; (c) were letters, editorials, books, book chapters, indexes, and proceedings; or (d) were legal texts (i.e., documents limited to describing or analyzing regulations, laws, and conventions). articles that met this initial screening were retrieved and read in full, and were subsequently excluded if they: (a) were not related to the crpd; or (b) did not refer to indicators or personal outcomes associated with any of the 26 articles pertaining to specific rights (table 1) for people with idd. two separate searches were conducted in parallel: a search of the scientific literature in english and another of the scientific literature in spanish. the search terms were chosen based on the individual english-language and spanish-language contexts. in other words, no attempt was made to produce a literal translation of the search terms from english into spanish or vice versa, but the aim was rather to reproduce the meaning of the search terms and expressions taking into consideration possible cultural differences. for example, the term "learning disabilities" in spanish is not used as in other countries to refer to people with "intellectual disabilities", but instead refers to people with specific learning disorders, for example, in reading, writing, or solving mathematical problems. in order to identify studies on the crpd and people with id published in english, a systematic review was carried out on web of science (wos). the databases included in the search were web of science core collection, current contents connect (ccc), medline, kci-korean journal database, russian science citation index and scielo citation index, incorporating the publication timespan 2008-2020 as an inclusion criterion. the search terms used in the topic field were: "convention" or "crpd" or "uncrpd", combined with and "intellectual disability *" or "developmental disability *" or "intellectual developmental disorder *" or "learning disability *". table 2 summarizes the exact wos search, which returned a total of 200 publications. for the search in spanish, the two platforms of scopus and proquest were used, covering nine databases: bibliografía de la literatura española, econlit, literature online, philosopher's index, psycarticles, psycinfo, psyctests, ptsdpubs and publicly available content database. in both platforms, the search criteria were set to include papers published in spanish between the years 2008 and 2020. furthermore, the search in proquest was limited to "peer-reviewed" documents. in both databases, the spanish-language search terms were "convención" or "cdpd" or "cdpcd", combined with and "discapacidad intelectual" or "discapacidad * del desarrollo" or "trastorno * del desarrollo" in any field in proquest and in the "article title, abstract, keywords" fields in scopus. the spanish search yielded a total of 53 results (table 2) , giving a combined search total of 253 publications across the two languages. data from the 253 articles identified across the three search platforms were incorporated into one excel database. after four duplicates were removed-leaving a total of 249 articles -references (title, abstract, publication title, and pages) were screened by the first author of this paper for alignment with the inclusion and the exclusion criteria outlined above. this reference screening phase reduced the initial pool of documents to 136. articles were removed at this stage primarily because they were not related to the crpd (44.2%), they were not articles (18.6%), or they were limited to legal aspects (21.2%). a further 12.4% were not written in english or spanish, and 3.5% did not refer to or include people with idd. next, 30% (n = 75) of the results were randomly selected and reviewed by the third author in order to examine the reliability of the decisions about inclusion or exclusion. the level of agreement between the two researchers was 89.3% in the first round and was 100% with regard to the reason for excluding a document. the first four authors of this article discussed the eight papers for which there initially had been disagreement and reached a consensus for all of them. the next step was to retrieve the full-text versions of the 136 selected documents and to assess them for eligibility. after reviewing the full texts, 71 results were excluded because they were not related to the crpd (11.3%) or because they did not refer to explicit indicators or personal outcomes related to specific rights set out in the crpd (88.7%). replicating the process described above, 30% (n = 41) of the full-text documents were randomly selected and reviewed, this time by both the first and the third authors of this paper. in the first round, the decision to exclude an article or not on the basis of the two reasons outlined above obtained an inter-rater agreement of 80.5%. the first four authors then discussed the eight papers for which there had been disagreement, and a consensus was ultimately reached. as a result, 65 articles were considered to have met the inclusion criteria (marked with * in references) and form the pool of documents upon which the results of this review are based. the entire process is illustrated in figure 1 . first, the 65 articles selected for inclusion in this systematic review were grouped into four broad categories: (1) articles that refer to conceptual frameworks (e.g., qol models) for crpd monitoring (i.e., they relate to article 31 "statistics and data collection" or article 35 "reports by states parties"); (2) articles that propose or use instruments to assess the rights contained in the crpd (for a specific article or for several of the articles from 1 to 50); (3) articles that use or discuss inclusive research (given the solid foundation for ethical, inclusive research with people with disabilities provided for by the crpd, and particularly the explicit mention in article 33 "national implementation and monitoring" that "persons with disabilities and their representative organizations must be involved and participate fully in the monitoring process"); and (4) articles that include indicators or personal outcomes associated with one or more of the 26 articles pertaining to specific rights (i.e., articles 5 to 30 of the crpd). articles assigned to the third category-inclusive research-could simultaneously be classified into one of the other three categories. categories 1, 2 and 4, on the other hand, were considered mutually exclusive for article coding and categories 1 and 2 were prioritized over category 4. none of the articles could be classified in category 1 and 2 at the same time, but a few could be classified in categories 1 and 4, or categories 2 and 4. in these cases, they were assigned to categories 1 and 2, respectively, but they were also scrutinized in order to identify indicators or personal outcomes. (n = 41) of the full-text documents were randomly selected and reviewed, this time by both the first and the third authors of this paper. in the first round, the decision to exclude an article or not on the basis of the two reasons outlined above obtained an inter-rater agreement of 80.5%. the first four authors then discussed the eight papers for which there had been disagreement, and a consensus was ultimately reached. as a result, 65 articles were considered to have met the inclusion criteria (marked with * in references) and form the pool of documents upon which the results of this review are based. the entire process is illustrated in figure 1 . first, the 65 articles selected for inclusion in this systematic review were grouped into four broad categories: (1) articles that refer to conceptual frameworks (e.g., qol models) for crpd monitoring (i.e., they relate to article 31 "statistics and data collection" or article 35 "reports by states parties"); (2) articles that propose or use instruments to assess the rights contained in the crpd (for a specific article or for several of the articles from 1 to 50); (3) articles that use or discuss inclusive research (given the solid foundation for ethical, inclusive research with people with disabilities provided for by the crpd, and particularly the explicit mention in article 33 "national implementation and monitoring" that "persons with disabilities and their representative organizations must be involved and participate fully in the monitoring process"); and (4) articles that include indicators or personal outcomes associated with one or more of the 26 articles pertaining to specific rights (i.e., articles 5 to 30 of the crpd). articles assigned to the third category-inclusive research-could secondly, all the articles were coded and subgrouped according to the specific crpd article number they referred to. finally, all articles were classified depending on whether they were: (1) quantitative-descriptive papers; (2) qualitative-descriptive papers; (3) mixed methodology; (4) reviews; (5) position papers; or (6) descriptions or proposals for interventions, programs or practices. similar to the process used to test reliability at the article exclusion step, the inter-rater reliability was established for the coding criteria set out above. the first author coded 100% of the articles, and the third author coded 30% (n = 20). in the first round, the inter-rater agreement regarding the decision on category (i.e., framework, instrument, specific article, or inclusive research) was 95% (n = 1 disagreement); for the crpd article number it was 85% (n = 3 partial disagreements; there was total agreement on the main article being referred to but some disagreement when there were several secondary articles mentioned); and, finally, for the type of document (i.e., quantitative, qualitative, review, position, intervention), the inter-rater agreement was 85% (n = 3 disagreements). all disagreements were resolved by a discussion among the first four authors and a consensus was reached. a total of 65 articles published between 2008 and 2019 were included in this review. only four articles were identified for the publication years 2008-2010, with most published after 2017 (n = 31; me = 2016), and the highest publication output recorded in 2019 (n = 13). in all, 89.2% of the articles were indexed in wos, 9.2% in proquest, and 1.5% in scopus. most of the papers were written in english (86.15%), while only nine were written in spanish. these publications involved a total of 348 authors (or 411 including duplicates, where the same author has written more than one paper). with four publications each, the most prolific authors on this subject are j. with regard to the geographical regions covered by the studies, more than half were conducted in europe (53.8%), and one-quarter each in oceania (26.2%) and north america (23.1%). there is a lower volume of studies conducted in-or referring to-asia (10.8%), south america (9.2%), and africa (6.2%), while only one was carried out in the middle east (i.e., israel; 1.5%). out of a total of 34 countries, the highest number of studies was carried out in australia (n = 16), spain (n = 13), ireland (n = 11), canada (n = 8), england (n = 6), and the united states (n = 6). the vast majority of the publications (n = 48; 73.8%) focused on one or more of the 26 crpd articles pertaining to specific rights (i.e., articles 5 to 30). only eight papers (12.3%) addressed conceptual frameworks for crpd monitoring (i.e., they relate to article 31 "statistics and data collection" or article 35 "reports by states parties"), and five (7.7%) proposed or applied assessment instruments (for a specific article or for several of the articles from 1 to 50). a total of eight (12.3%) used or discussed inclusive research (article 33). most were descriptive studies (n = 34)-qualitative (29.2%), quantitative (18.5%), or mixed methodology (4.6%)-and theoretical articles or position papers (27.7%), while 11 were reviews (19.9%), and only four described interventions, programs or practices (6.2%). all referred to people with idd, although almost one-fifth (n = 12; 18.5%) discussed people with disabilities in general, while 6.2% referred specifically to people with down syndrome (n = 2), cerebral palsy (n = 1), or neurologic conditions (n = 1). in the literature, what theoretical frameworks and assessment instruments are proposed to monitor the implementation of the crpd for people with idd? of the eight papers that used or proposed conceptual frameworks to monitor or evaluate the crpd or its specific articles, all pointed to the qol framework and qol indicators that must be incorporated into comprehensive instruments to assess progress and identify needs and gaps in implementation. the qol model proposed by schalock and verdugo was the most commonly used [1, 2, 8, 9, 11] -although the cummins model [28] is also mentioned-and applications in specific contexts-namely "educational quality of life" [29] -are also discussed. as shown in table 3 , five of the studies named, applied or proposed specific measurement tools to assess qol (qol-q, integral scale, gencat scale, personal outcomes scale, personal wellbeing index), self-determination (air self-determination scale), or rights (rights of persons with disabilities ad hoc scale). only one study used qualitative instruments in the form of focus groups and in-depth interviews [30] . while all of these papers referred to a qol conceptual framework as a way of evaluating or monitoring the crpd (articles 31 and 35), some also focused on other crpd articles, the most common being (n = 2) article 7 (children with disabilities), article 19 (living independently and being included in the community), and article 24 (education). in the eight studies, the countries where this framework was most used or proposed were australia, the united states, and spain. in the five studies that used or proposed specific tools to monitor compliance with the crpd, a total of five instruments are cited ( table 4 ). none of them were originally designed with the specific objective of monitoring the crpd, although the structure of the itineris scale [31] -while inspired by the montreal declaration-was developed by five professionals who independently evaluated the relationship between the items in the scale and the preamble and first 30 articles of the crpd. the four other instruments proposed to monitor certain articles of the crpd are the rights subscales of qol scales, comprising the gencat scale or the integral scale [13] ; the national core indicators-adult consumer survey (nci-acs), aimed at assessing the quality of services [3, 32] ; and the european child environment questionnaire (eceq), which covers physical, social and attitudinal environmental features [33] . the number of items in these five instruments ranges from 8 to 51, and all are designed for adults with id, save for the eceq, which was developed for children with cerebral palsy. in addition, most of the instruments are self-reports administered directly to people with disabilities, while only two are other-reports answered by relatives or professionals. of the specific crpd articles assessed, the range covered by the instruments is limited to the first 30. articles 21 (freedom of expression and opinion, and access to information) and 22 (respect for privacy) are dealt with in most of the instruments (n = 4), followed by (n = 3) articles 3 (general principles), 9 (accessibility), 18 (liberty of movement and nationality), 23 (respect for home and the family), and 27 (work and employment). finally, the sociodemographic data gathered in these studies includes the following: (a) personal variables such as gender, age, ethnicity, language, religion, sexual orientation, level of id, cause of id, disability onset, civil status, educational level, need of assistive products, mental health diagnosis, problematic behavior, verbal expression, sensory impairment, support needs, residential type, mobility, socioeconomic status, guardianship, advocacy experience; (b) contextual variables such as region, degree of urbanicity, community size, level of involvement and frequency of contact with family or professionals, care and residential setting, type of school setting, employment. it is also important to mention the eight studies that focus on inclusive research, the majority of which were conducted in ireland (n = 5), the others in spain (n = 2) and australia (n = 1). the inclusive research model holds that people with disabilities with relevant experience related to the studied topic should be included in the research, not only as informants but participating and making decisions in all phases. this level of involvement is essential in order to comply with the part of article 33 where it states that "civil society, in particular persons with disabilities and their representative organizations, shall be involved and participate fully in the monitoring process". inclusive research incorporates a wide range of research approaches that have traditionally been referred to as "participative", "action", or "emancipatory". some authors have tried to differentiate between the techniques, arguing that the emancipatory approach is achieved when the initiative and research topic is proposed by people with disabilities, and it is they who control the research, while the participative approach places greater emphasis on the representation of people with disabilities at all stages of the research process [34, 35] . the most common ways for people with id to participate in these studies are by providing their views and opinions through focus groups, structured interviews, and workshops [35] [36] [37] [38] ; by acting not only as study participants, but also as advisory committee members and co-researchers [39, 40] , making it essential that they receive research training [41] . the most frequently cited limitations allude to the challenge of remaining inclusive throughout data collection and analysis, together with including people with complex support needs, such as those with profound and multiple disabilities or who use alternative or augmentative communication approaches. outcomes are mentioned in the scientific literature discussing the crpd articles that protect specific rights for people with idd? the indicators and personal outcomes identified in the 48 studies that deal with the specific rights in the crpd (arts 5-30) are aligned to the eight qol domains and presented below. article 24 (education): nine articles included in this review refer to specific indicators and personal outcomes related to inclusive education [8, [42] [43] [44] [45] [46] [47] [48] [49] in ordinary settings at all levels of education (preschool, primary, secondary, high school, vocational training, university). the specific indicators mentioned were the right to attend educational establishments near their community; individualized supports within the general education system; assessment of individual support needs in environments that maximize academic and social development; completion of stages and appropriate transitions between them; coordination among the different professionals involved; training about rights; training about sexuality, reproduction and family planning (understanding what sexual relationships are, risks, benefits and alternatives; questions about sexuality can be freely raised and resolved); training and preparation for independent living (in real-life contexts, from compulsory education); vocational guidance; adequate training and qualifications to get a job; individualized educational aids (e.g., teacher's aide, tutors, extended test time, modified course curriculum); appropriate materials; reasonable accommodations; quick access to necessary educational support products (e.g., specialized software, recording or note taking devices, audio/e-book devices); information, care, and guidance services for families (e.g., legislative measures and supports related to the education of their children); participation of the family in the education process; information, care, and guidance services for teachers about disability, supports and special educational needs; attitudes toward the inclusion of family members and teachers; meaningful learning experiences; participation in the activities of the school; the school and its staff enhance the person's self-esteem, satisfaction, autonomy, and self-confidence; friends at school (not only among staff or carers); educational institutions in a holistic perspective of health and care. • article 14 (liberty and security of person): 10 papers [8, 38, 40, 45, [48] [49] [50] [51] [52] [53] address this article, specifically freedom of choice (e.g., to choose where and with whom they live, the type of housing, moving house, what to cook, how to spend their free time and with whom); making their own decisions (including decisions about health); personal autonomy (e.g., control of their finances, handling their own money independently, not being overprotected by their family, not being underestimated by their parents or still being perceived as a child); control over life and life events (e.g., social outings, simple events in their daily lives); upbringing experiences focused on developing skills for independence and self-determined behaviors; coping strategies (e.g., impact of health problems on daily life); person-centered approach. • article 21 (freedom of expression and opinion, access to information): seven studies focus on access to-and understanding of-information, as well as opportunities to use information and express their opinion [8, 40, 48, 51, [54] [55] [56] . from these, the following personal outcomes were extracted: information in accessible formats (e.g., easy-read format); assistive products for communication and cognition (knowledge and awareness; customization); access to the internet, its content and digital services (e.g., adapted applications, internet sites and web browsers; modifying the mouse settings or enlarging the font); technological devices adapted to the person's specific needs (e.g., alternative mice, enlarged keyboards, touch screens, voice synthesis and recognition systems); technical support (e.g., configuring device security, securing the wireless network, installing an antivirus program, setting up the firewall, updating the operating system and software); participation in digital society (educational programs, individualized supports to understand new social interaction rules and conventions); self-advocacy (to have their voice heard, confidence to speak up, defend their health, sexual and emotional options). • article 23 (respect for home and the family): 10 articles included in the review [8, 39, 40, 49, [57] [58] [59] [60] [61] [62] refer to the right to have opportunities to meet people, establishing relationships, having friends, meeting the right person, and having a partner relationship (taking risks to be with the person they want, opposing control of the family and restrictive service regulations, receiving support without being treated as children or considered asexual or unable to raise children, choosing their sexual orientation, being listened to about their needs); to marry and found a family (retain their fertility on an equal basis with others, avoiding forced sterilization and covert contraception, making their own reproductive and sexual choices, deciding on the number of children to have); to keep their own children with them (i.e., receiving specific supports for the wellbeing of both children and parents with disabilities, obtaining legal custody of the children in case of divorce, avoiding the separation of children from their parents against their will on the basis of a disability, or denial of their rights as fathers/mothers); to receive sexual information, guidance, and support in caring for their children (e.g., basic care, nutrition, health, education; home-based learning and flexible support services over the long-term that are evidence-based, tailored to individual needs, and built on the strengths of each parent and family; monitoring of new needs); to be able to adopt and foster, and to access assisted reproduction; guidance and training for families and professionals who provide evidence-based methods and non-discriminatory support in sexuality (preventing negative attitudes of professionals and families toward sexuality, such as discouraging marriage and parenting, restricting sexual expression; disapproving relationships, allowing platonic but not intimate relationships); organization policy facilitating sexual experiences and comprehensive sex education programs (not only addressing biological facts but also allowing them to discuss the social and emotional aspects of relationships and sexuality, to learn about abuse and exploitation, to recognize the importance of desire and pleasure). • article 8 (awareness-raising): seven articles [8, 48, 59, [63] [64] [65] [66] provide indicators and personal outcomes related to advertising campaigns. the specific personal outcomes include giving them visibility; promoting normalization and generating awareness about disabilities; treating their image with respect; sensitizing and ensuring the realization of their rights; promoting equality; improving participation and inclusion; breaking stereotypes. in addition, there was an emphasis on the need for specific awareness campaigns focusing on the reality of women with id and their capability of parenting (associated with articles 6 and 23, respectively). • article 9 (accessibility): four studies [46, 48, 53, 67] mention specific elements that could be operationalized with respect to the accessibility of the environment. in particular, they refer to accessibility in health facilities, community centers, educational establishments, and workplaces; accessibility in public infrastructure; accessibility of leisure environments. • article 18 (liberty of movement and nationality): only one article [40] discusses the freedom to use public transport; freedom to move around and have control over their movements; being within walking distance of amenities and shops. • article 19 (living independently and being included in the community): 14 papers [8, [38] [39] [40] 42, 45, 47, 49, 50, 53, 63, 66, 68, 69] mention personal outcomes or indicators associated with the right to live independently and be included in the community (i.e., not to be institutionalized in segregated environments, not to be restricted in options for in-home residential and other community support services). to achieve this, the papers highlighted the right to receive the necessary individualized supports (person-centered planning, individualized support to live more independently) for everyday activities to do with autonomy in the home (e.g., getting to appointments, running errands, housework, personal finances, heavy household chores, preparing meals, personal care and medical care); support from professionals (sufficient personal resources) and service providers (to organize preferred housing, help find housemates, forge social connections); in housing, to facilitate flexibility in terms of rules and staff control, freedom to move around and to arrange daily home life, enjoy own space, individualized care, small groups, living with their partner; trust and support from family (role of the family as a source of support and as facilitators of autonomy, opportunities to practice skills, avoiding overprotection); special attention to access supports during and after moving (to organize move, types of support, relationships with supporters, quality of supporters); being within walking distance of amenities and shops; support for older people with disability; control over support arrangements (choose support workers and the kind of support they receive); housing affordability; access to information on independent living experiences. • article 20 (personal mobility): two articles [54, 63] include specific aspects related to this right. the indicators and personal outcomes mentioned are a way to be personally mobile (availability of assistive products for mobility; knowledge and awareness about them; customization); and a way to transport across environments (i.e., adapted transport; human support and vehicle available). • article 29 (participation in political and public life): seven studies [8, 49, 53, 66, [70] [71] [72] consider aspects related to the right of people with id to vote (e.g., information about the meaning and content of elections and democratic participation; understanding the information from the parties, the electoral procedures, and the voting paper; easy postal votes; accessible local polling stations; using pictures, symbols and logos on the voting paper; courses about voting and elections; easier-to-read election materials; support at polling stations and during the process of voting; treated respectfully by election officials; web accessible guides to voting); to be elected political members; priority on supportive legislation on disability issues in the government and crpd focus. • article 30 (participation in cultural life, recreation, leisure and sport): measurable indicators and outcomes are found in eight articles [40, [47] [48] [49] [50] 53, 66, 69] . they refer to being part of society, taking part in all aspects of their community life; having sufficient income to participate in the community; adequate information about community activities for families (e.g., organized social leisure activities); participating in activities with people without id (e.g., inclusive sports); promotion of active participation and play in their communities; enjoying leisure time (doing a variety of things alone or with others; relaxing and having fun; doing things they enjoy; going to pubs and night life; not being ignored at social events); awareness, positive attitudes and actions of other members of the community. • article 5 (equality and non-discrimination): five papers [49, 50, 54, 69, 73] identify the indicators and personal outcomes of not suffering stigma; not suffering discrimination (e.g., in insurance matters, in access to health care); not experiencing rejection and denial of their individuality, adulthood and capacity. • article 6 (women with disabilities): eight papers refer to the rights of women [8, 49, 52, [58] [59] [60] 65, 74] . most indicators and personal outcomes were already reflected in other crpd rights, but there was particular emphasis on the application of these rights-and respect for-women. the most frequently cited aspects in relation to women include prevention and intervention in gender-based violence (knowing their rights, knowing how to deal with acts of aggression perpetrated by men, easy-read guides on gender-based violence, providing information and raising awareness of id for people working with women who have been victims of gender-based violence, information services and specialist guidance on existing resources and intermediation in the public system, emotional support, legal advice); employment; avoiding overprotection (parents are usually more protective with daughters); taking into account the demands of women with id; right to participate in decisions about their lives. • article 7 (children with disabilities): six papers focus on the right of children with disabilities to express their views freely on all matters affecting them and to be provided with disabilityand age-appropriate assistance to realize that right [8, 46, 48, 67, 74, 75] . while most of the indicators and personal outcomes matched those already proposed and reflected in other crpd rights, it was stressed that these must also be fulfilled during childhood and adolescence. among these are the importance of children participating in civil life and decision-making (including health); the will and preferences of children with disabilities are respected on an equal basis with other children (e.g., children should be asked to express their views and preferences during legal procedures, using all possible ways of communication such as drawing and painting, body language, facial expressions; providing children with accessible information that allows them to express their opinion); promoting inclusion and preventing family vulnerability (e.g., avoiding separation from parents against their will on the basis of a disability and, where this is necessary, providing alternatives within the extended family or in the community in a family environment, child protection services); appropriate transition from child-specific to adult-specific services; the development of adaptive behavior skills; involving children in advocacy, decision-making or even human rights monitoring. • article 10 (right to life): only two papers give measurable aspects on the right to life [76, 77] . both specifically mention providing supports to make choices about end-of-life: to express their will and preference (using a range of intentional/unintentional and formal/informal behaviors); supporters to listen to the person's expression of preference by acknowledging, interpreting and acting on that preference); intimate or very close relationships between people with id and their supporters (knowledge of the person's life story; documentation of a person's history and life story through sharing of historical stories, images and video about the person being supported, by those who had known them for a long time, across multiple areas of their life; enjoyment of their company; willingness and ability to see the person "beyond their disability"); person-centered approach (encouraging the use of supports for end-of-life care in home settings, and recognizing variations in what "home" may be like with respect to end-of-life care). article 11 (situations of risk and humanitarian emergencies): states parties shall take all necessary measures to ensure the protection and safety of persons with disabilities in situations of risk, including situations of armed conflict, humanitarian emergencies and the occurrence of natural disasters. none of the papers included in this review refer to specific indicators or personal outcomes associated with this article. • article 12 (equal recognition before the law): a dozen articles [8, 49, 71, [74] [75] [76] [78] [79] [80] [81] focus on the promotion of supported decision-making strategies. they specifically report on the need to replace guardianship (disapproving of legal incapacity and substituted decision-making) with the supported decision-making model: empower them to exercise their own will and preferences (training about decision-making; providing information about supported decision-making to people with disabilities, their families, and professionals; taking into consideration individual concerns, experiences with legal systems and levels of literacy; identifying communication barriers; implementing measures to enable their voice to be heard); appropriate and ongoing support to exercise decision-making capacity in all areas of their lives (person-centered planning: all forms of support in the exercise of legal capacity must be based on their specific needs, will and preferences, not on what is perceived as being in their objective best interests; support is available at nominal or no cost and lack of financial resources is not a barrier to accessing support in the exercise of legal capacity; safeguards must be established for all processes relating to legal capacity and support in exercising legal capacity); dyad of decision-maker with id and a decision supporter (legal recognition of the support person(s) formally chosen by the person must be available and accessible, including mechanisms for third parties to verify the identity of a support person and challenge their actions if they believe that the support person is not acting in accordance with the will and preferences of the person concerned; the person has the right to refuse support and terminate or change the support relationship at any time; supporters' respect for rights, values, goals, experiences of individual; having good interpersonal skills and the ability to recognize conflicting interest; responding to the expression of will and preference by acknowledging, interpreting and responding to it; having a close and trusting relationship with the decision-maker or the capacity to build one; using formal decision-making agreements, committing time and providing support for as long as is needed for a decision to be reached; supporting decision makers to take risks, change their minds, make decisions others may not like, and extend their experiences; helping them to access information, discussing available information in understandable ways, and advocating for decisions made to be acted on; showing commitment, familiarity with disability, good communication and advocacy skills, common sense and ethical behavior); the person is encouraged to make their own decision by providing them with a range of options but not imposing choices; the person expresses will and preference, intentionally and unintentionally, using a range of modalities (e.g., behavior, vocalization, vocal pitch, muscle tone, facial expression, eye movement, self-harm, breath, unintentional physiological functions); the meetings are set up in a comfortable environment with the consent of the person. • article 13 (access to justice): only one paper specifically refers to access to justice (for women with id who have been victims of gender-based violence) [74] . it points to the need for ways to enable them to successfully engage with the legal system; support from workers and agencies in their interactions with the justice system; supports from police and judicial officers (e.g., adjusting their language, regarding complaints and statements as serious and with the same weight as they would for persons without disabilities, taking time to explain the law and its application, recognizing them as full persons before the law); training police and judicial officers about idd. • article 15 (freedom from torture or cruel, inhuman or degrading treatment or punishment): only four papers [50, 63, 73, 82] specify indicators or personal outcomes associated with this article: use of seclusion or solitary confinement (i.e., restrictive interventions, exclusionary practices); restraints (physical, mechanical, chemical); harmful treatments (e.g., inappropriate sedation, forced medication, failure to meet dietary requirements). article 22 (respect for privacy): the four papers [40, 49, 50, 69 ] that allude to this right identify the following indicators and personal outcomes: respect for privacy by flatmates, parents and caregivers (having their own room and space: private, peace and quiet; privacy of personal and intimate information; privacy related to sexuality). • article 16 (freedom from exploitation, violence and abuse): 12 articles specify indicators or personal outcomes on this aspect [8, 38, 40, 42, 49, 57, 59, 63, 65, 66, 74, 82] . those frequently cited include freedom from concealment, abandonment, abuse or neglect; segregation or exclusion (social and physical isolation); bullying (name calling; cyberbullying) in educational and social settings; experiencing vulnerability and not feeling safe (in relationships, in immediate environment); gender-based violence; sexual abuse (being able to detect abuse), physical violence (violent relationships); economic abuse. • article 17 (protecting the integrity of the person): six papers mention personal outcomes related to indicators of being treated with respect, dignity, and equity [40, 47, 49, 51, 52, 63] . for professionals, these include providing unconditional support, emotional support, a listening ear, empathy, patience, and trust; and that they know the people with idd well, understand their perspective, and value and respect them and their family. for the persons with disabilities, these include self-acceptance and self-awareness of disability, not showing low expectations of themselves because of disability; not experiencing exclusionary reactions, such as not being addressed in conversations or being ignored by professionals in different sectors; use of positive behavioral support. • article 25 (health): 10 articles [48, 50, 51, 56, 66, 67, 73, [83] [84] [85] discuss the right to health, highlighting indicators and personal outcomes associated with good physical health (e.g., healthy weight, absence of weight-related physical problems such as diabetes, gastrointestinal disorders, hypertension); prevention; access to appropriate information on health-related issues; promotion of healthy behaviors in accessible formats; good psychological health (absence of behavioral problems or psychiatric disorders); to have family and disability support worker advocacy (without conflicts of interests between their own needs/vision and those of their son or daughter); early screening and diagnosis (including comorbidities); community programs favoring cognitive, physical, and social development; shared decision-making among health care providers, children and families; supervised, justified and adjusted medication (especially, antipsychotic); rigorous data collection system and epidemiological data on prevalence of idd and mental illness; existence of idd mental health policy; tested for sexually transmitted diseases; no substance abuse or dependence (e.g., methamphetamine, alcohol, and marijuana). • article 26 (habilitation and rehabilitation): 12 papers [40, [48] [49] [50] [51] 54, 66, 67, 73, [83] [84] [85] focus on specific elements related to habilitation and rehabilitation, such as accessing quality efficient and specialized physical and mental health care and social care (speech therapists, psychologists, psychiatrists, physiotherapists, dentists, x-ray facilities, primary and tertiary health services); appropriate and affordable early and timely health services, interventions and care; coordination and communication between health, education and social services; health services close to home; appropriate transitions between health services (e.g., from pediatric to adult services); availability, knowledge and use of assistive devices and technologies related to habilitation and rehabilitation; health staff feeling competent to care for patients with idd (educational curricula for health professionals about disability; availability of specialized training; avoiding misperceptions; well-trained mental health professionals in dual diagnoses); health staff's positive attitudes (looking and directly talking to person with idd, willing to provide them with care; showing respect); individualized and capability-based services. • article 27 (work and employment): eight papers contain employment-related aspects [39, 40, 42, 46, 47, 49, 59, 66] : access to the labor market; having a (local) paid job (not being refused a job, promotion or interview because of disability); safe and suitable employment; satisfaction with the employment and salary (paid on an equal basis to others); adequate provision of accommodation and employment services (e.g., hours, duty, human support); employer and employee attitudes (e.g., aware of work strengths and limitations, not considering the person disadvantaged because of disability; negative attitudes when looking for employment; ongoing disability information and awareness activities for all employees; satisfactory treatment for employees); adequate job information, training and experience (advice on alternative employment; individualized training based on needs, studies, professional experience, interests and availability; skills training to find and keep a job; individual guidance to map out potential professional pathways; assessment and guidance on job options tailored to needs profile; presence of support persons to mediate with the company; tracking recruitment to make adjustments); employment as a way to meet people and friends; work-life balance measures (i.e., childcare while they work). • article 28 (adequate standard of living and social protection): 10 studies [8, 40, 43, 47, 53, 54, 59, 66, 67, 69] specify personal outcomes or indicators associated with this article: financial independence (adequate subsistence base); sufficient financial income to access housing (housing affordability); safe, accessible and suitable housing; aid to cover the additional expenses of supports and specialist care (economic support); having the necessary assistive products for environment and self-care (knowledge and awareness about them; customized); personal assistant when needed; leisure activities in people's home (e.g., listening to the radio, playing instruments, being at home with friends); saving and budgeting (including for holidays); satisfaction with income; assistance with managing money and budgeting; receiving disability benefits (not losing benefits for being employed); easing bureaucracy involved in getting personal assistance and personal budgets; flexibility of support funded; provision of social assistance when needed; existence of personal budgets/personal assistance schemes and awareness of these by people with disability; stability of funding over time; strong supportive legislation. this systematic review sought to answer three key questions. the first was to learn about the main themes covered in publications about the crpd and people with idd, a broad term that combines the fields of intellectual disability (diagnosis given to individuals who meet the criteria of significant limitations both in intellectual functioning and adaptive behavior as expressed in conceptual, social, and practical skills, and is manifest before age 18) and developmental disabilities (non-categorical label for a chronic disability manifest before age 22 but limited to persons with a specific diagnosis or for those whose disability manifest before age 22 results in substantial functional limitations in three or more major life activity areas and who require long-term services and supports) [86] . the vast majority of the publications focused on one or more of the 26 crpd articles pertaining to specific rights (i.e., articles 5 to 30), while only one-fifth either referred to conceptual frameworks for crpd monitoring or proposed or applied assessment instruments. while still an emerging approach, inclusive research [34] [35] [36] [37] [38] [39] [40] [41] , which encourages people with idd to participate as researchers at all stages of the research process, is increasingly being used or recommended in the scientific literature. the second research question focused on identifying the conceptual frameworks used to monitor the crpd or any of its specific articles. all of the reviewed papers that covered this aspect underscored the relevance of the qol framework to assess progress and identify needs and gaps in implementation. the most widely used framework was schalock and verdugo's eight-domain qol model (or a variation based on some of its specific domains, such as rights or self-determination). furthermore, a number of specific assessment instruments developed from this model have been used in studies to explore the implementation of the crpd (e.g., qol-q, integral scale, gencat scale, personal outcomes scale). other monitoring instruments used were the rights of persons with disabilities scale [11] , the itineris scale [31] , the national core indicators-adult consumer survey (nci-acs) [3, 32] , and the european child environment questionnaire (eceq). although some studies employed qualitative methods (e.g., focus groups), quantitative questionnaires remained the most widely used and recommended approach, particularly in the case of self-report instruments. the third research question focused on identifying indicators or personal outcome categories. the article that received the most coverage in the reviewed papers was living independently and being included in the community (article 19), followed by the right to freedom from exploitation, violence and abuse (article 16), and habilitation and rehabilitation (article 26). it is striking, however, that none of the publications referred to specific indicators associated with situations of risk and humanitarian emergencies (article 11). in light of the global covid-19 pandemic, this is unlikely to remain the case for much longer, and we would hope that future research will focus on the potential situations of discrimination or particular vulnerability faced by people with idd in the fight against this pandemic (e.g., if they received appropriate information on how to prevent and treat the infection, if they received the supports they needed during the pandemic, if they were discriminated against by the health services on the grounds of their disability). similarly, articles 13 (access to justice) and 18 (liberty of movement and nationality) require further attention. with regard to the latter, it would be important to see studies examining the violation of the rights of people with idd, where these people are also immigrants in a given country or refugees at a particular border. the review of the literature and the analysis of the selected studies also revealed some limitations in the conceptual framework used, specifically with regard to the alignment of the crpd articles to the qol domains. in particular, we found that article 15 (freedom from torture or cruel, inhuman or degrading treatment or punishment), included in the rights domain by verdugo et al. [1] , was closely linked in the literature to the indicators proposed for article 16 (freedom from exploitation, violence and abuse), assigned to the emotional wellbeing domain. given this close relationship, and following our review of the scientific literature, we propose that articles 15 and 16 both be included in the emotional wellbeing domain. in addition, overlaps in the indicators proposed by lombardi et al. [2] required the removal of some repetitions (e.g., indicators for article 30 were removed from the interpersonal relationships domain because they had also been included in the social inclusion domain; or the "safe and secure environment" indicators, which in the initial model featured as indicators of article 14, liberty and security of the person, but also of article 16, freedom from exploitation, violence and abuse, were finally assigned to the latter). we also reassigned indicators to a different article where it made more sense, as a result of what we found in our literature review. for example, "dating with persons of choice" was initially included as an indicator of article 5, equality and non-discrimination, in the rights domain. since all of the studies included this as an indicator of article 23, respect for home and the family, in the interpersonal relationships domain, we assigned it accordingly. in this way, as the authors themselves suggested [2] , a refinement of their proposal has been made based on an exhaustive review of the literature. articles 6 (women with disabilities) and 7 (children with disabilities) deserve particular mention. the literature review revealed that they do not contain additional rights to those already covered in other articles, but rather they are two cross-cutting articles that seek to draw attention to these two specific groups in view of their particular vulnerability. rather than including specific items in any assessment instruments that are developed, we would recommend that this information be collected as sociodemographic variables (i.e., gender, age) in order to verify whether these two conditions can have a significant impact on outcomes. finally, this review should be seen as a relevant, critical and necessary step in the development of future instruments to inform people with idd of their rights, and to inform supporting professionals and family members of these rights, while at the same time to monitor the implementation of the crpd. this review is just the first step in the process of operationalizating the crpd through tentative definitions composed of all indicators and outcomes found in the scientific literature. that said, additional steps in each country or culture will be necessary or advisable in order to further refine the pool of indicators and personal outcomes described here, with the aim of achieving a comprehensive list that is relevant to the target group. such an approach will help enhance the content validity of employing unique indicators to specific articles and qol domains. as part of this process, qualitative techniques such as focus groups and consultations with key experts and stakeholders including people with idd are recommended in order to provide evidences of their quality and validity. finally, their translation into specific measurable items and testing their psychometric properties will be necessary to determine their validity and utility. the key points that this review highlights are several. first, the relevance of the qol framework to assess progress and identify needs and gaps in the implementation of the crpd. second, the need of specific assessment instruments to explore the implementation of the crpd. and third, the lack of studies focused on situations of risk and humanitarian emergencies, access to justice, liberty of movement and nationality, women and children with disabilities. although it has been more than a decade since the crpd entered into force in a large number of countries, people with disabilities, especially people with idd, continue to see their fundamental rights undermined. to fully implement the crpd, there is an urgent need to operationalize its articles through the use of a validated conceptual model, such as the qol model discussed in this article, as a framework to develop and apply reliable and valid instruments that not only allow countries to monitor the fulfillment of the rights set out in the crpd in the macrosystem, but especially in the microsystem and the mesosystem. it is essential that people with idd and their support providers (natural and professional) know their rights and that these rights can be evaluated through instruments that demonstrate sufficient levels of validity and reliability. such a tool would facilitate relating the provision of individualized supports to specific crpd articles and implementing evidence-based practices for people with idd. such a process would enhance their qol as full citizens. based on an analysis of the scientific literature, this study constitutes an essential first step in the operationalization of the crpd and providing evidence of content validity for the future development of context-focused assessment instruments. the concept of quality of life and its role in enhancing human rights in the field of intellectual disability the concept of quality of life as framework for implementing the uncrpd examining the national core indicators' 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declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-013390-i5h7ob3n authors: salem, haya; daher-nashif, suhad title: psychosocial aspects of female breast cancer in the middle east and north africa date: 2020-09-18 journal: int j environ res public health doi: 10.3390/ijerph17186802 sha: doc_id: 13390 cord_uid: i5h7ob3n breast cancer, the most common cancer among women in the middle east and north africa (mena) region, is associated with social and psychological implications deriving from women’s socio-cultural contexts. examining 74 articles published between 2007 and 2019, this literature/narrative review explores the psychosocial aspects of female breast cancer in the mena region. it highlights socio-cultural barriers to seeking help and socio-political factors influencing women’s experience with the disease. in 17 of 22 arab countries, common findings emerge which derive from shared cultural values. findings indicate that women lack knowledge of breast cancer screening (bcs) and breast cancer self-examination (bse) benefits/techniques due to a lack of physicians’ recommendations, fear, embarrassment, cultural beliefs, and a lack of formal and informal support systems. women in rural areas or with low socioeconomic status further lack access to health services. women with breast cancer, report low self-esteem due to gender dynamics and a tendency towards fatalism. collaboration between mass media, health and education systems, and leading social-religious figures plays a major role in overcoming psychological and cultural barriers, including beliefs surrounding pain, fear, embarrassment, and modesty, particularly for women of lower socioeconomic status and women living in crises and conflict zones. breast cancer is the leading type of cancer for females across the arab (mena) region. adib et al. [1] noted that 30.1% of female cancer cases are breast cancer, while el-attar [2] found that breast cancer comprises between 16.2% and 38.4% of all types of cancer. in second place on the prevalence scale is non-hodgkin lymphoma (6.8%), followed by rectal (6.1%) and thyroid (5.7%) cancers. the least prevalent are buccal, gallbladder, and bladder cancers (0.7%). meanwhile, earlier studies found that colorectal cancer is the second most prevalent after breast cancer among women in some arab countries [3, 4] . while many studies in the mena region focused on prevalence, epidemiology, and etiology of female breast cancer, several studies highlighted the psychosocial experiences of the women who had been diagnosed. this study aims to review these studies and identify the main socio-cultural and demographic factors affecting arab women's psychosocial experiences through their journey with breast cancer. in their study of the epidemiology and management of breast cancer in arab countries, el saghir et al. [5] reported that people in the region are reluctant to speak openly about cancer and that it is highly stigmatized, to the extent that many refrain from mentioning it by name. hence there is a need to better understand the cultural and religious landscape in which breast cancer patients undergo their treatment, the specificities of which may influence their subjective experiences. recent studies have shown a positive impact of early examination, which leads to early diagnosis and breast-conserving surgery [5] . bener et al. [6] found that health workers rarely recommend examinations, resulting in women having inadequate knowledge about breast cancer screening [7, 8] . despite breast cancer being one of the most common cancers among women, the uptake of breast cancer screening (bcs) and breast cancer self-examination (bse) is still relatively low. donnelly et al.'s [9] multicenter cross-sectional quantitative survey conducted amongst arab women in qatar reported that in addition to the low levels of awareness and participation in bcs, only one-quarter of the participants reported that their doctors discussed and recommended bcs. women who did not undergo bcs cited as reasons the lack of physicians' recommendation, fear, and embarrassment [7, 9] . donnelly et al. [9] attribute late diagnosis of the disease to the low awareness of the importance of bcs. they link this low awareness to a variety of factors, mainly age, education, and the absence of a doctor's recommendation. a diagnosis of breast cancer can be disruptive to an individual's physical, psychological, interpersonal, and financial states [10] . breast cancer and its treatment are associated with a broad range of symptoms that impact physical, social [11] , mental (especially when self-esteem is influenced by changes in the body), and cognitive functioning. this upheaval can have a profound impact on women's well-being and quality of life. within clinical domains, quality of life has become an important health outcome measure, used to indicate which facets of an individual's life are most affected by a disease and its treatment [12] . wisloff et al. [13] demonstrate a link between compromised quality of life and clinical outcomes, including survival. sociodemographic factors emerge as an important theme in the quality of life literature [14] . past studies found that factors such as a patient's educational level, age, amount of spousal and familial support, employment and financial status, and stage of disease progression can predict the quality of life of patients with breast cancer [10, 15, 16] . in this paper, we present the main psychosocial aspects of being a woman with breast cancer in the mena region. this study is a narrative literature review, in which the researchers reviewed existing studies on the psychosocial aspects of female breast cancer in the mena region published between 2007 and 2019. we chose a literature review because we aimed to document the main findings by thematically analyzing and integrating the knowledge gained over a whole decade by several researchers in all arab countries. in this type of review, researchers can summarize shared themes across existing studies, bringing together their conclusions into a holistic interpretation contributed by the reviewers in doing so, we can also summarize similarities and differences, meaning that while we consider the socio-cultural similarities shared by the arab countries, we can also explore the uniqueness of a specific country that results from its local circumstances. literature review studies' results are narrative and qualitative rather than quantitative, and they enable the researcher to acknowledge, reflect, and assist the reviewed data. using a literature review allows us to analyze the psychological and socio-cultural barriers, needs, and challenges facing arab women with breast cancer. we began by searching academic databases including pubmed, scopus, ebsco, and jstor. we used the keywords "society", "culture", "breast cancer", "women", "screening", "quality of life", "attitudes", "stigma", "women", "arab", "muslim", "family", "coping", "mental health", and "religion". the study included only english language articles and covered both qualitative and quantitative studies. chapters in books, research reports, arabic articles, and studies and information published as abstract only were excluded. both authors, with the assistance of two students, reviewed the titles and abstracts gathered. we found 293 candidate articles, which were further reviewed and reduced to 74 articles ( figure 1 ; table s1 ). we included only research papers where the main topic was psychosocial experiences and psychosocial aspects of female breast cancer in the mena. in order to analyze and categorize the content of the articles included, we used conventional content analysis whereby identifying the main concepts and categories is derived directly from the text data [17] . in this type of analysis, researchers determine the presence of certain themes or concepts within the given qualitative data (i.e., text), that repeat themselves across the data. by using content analysis, researchers can identify the presence of certain themes and concepts, as well as identify meanings and relationships between the identified themes and concepts. for credibility assurance, the authors debriefed and discussed the methods and results with experts in the topic of this review from different health sciences fields. the team of experts included two public health researchers, a psychologist, a psychiatrist, a social sociologist, and a medical anthropologist. furthermore, the researchers evaluated the quality of their review by using the sanra scale. sanra scale is a validated tool developed to evaluate the quality of narrative and literature reviews [18] . the scale includes six items: justification of the article's importance, statement of concrete aims of the review, description of the literature research, referencing, scientific reasoning, and appropriate presentation of data. each item includes three levels, zero, one, and two, where two indicates that the review meets the criteria for quality. we evaluated the manuscript individually and then met to discuss gaps and ways to improve the manuscript in order to meet sanra's criteria. in reviewing the 74 papers on our final list, we identified five main themes that highlight the psychosocial aspects of female breast cancer in the mena region. these themes are 3.1. who cares? 3.2. sociodemographic and cultural determinants associated with breast cancer, 3.3. awareness and sources of knowledge, 3.4. quality of life of women with breast cancer, and 3.5. family support and relationships of women who have breast cancer. 3.1. who cares? states, themes, types, and subjects of the studies included bsc/bse was the most frequent topic, discussed in 27% of studies. this was followed by the topic of quality of life of women with breast cancer (23%). the least discussed topic was sexual functioning (6%). other prevalent themes included attitudes and beliefs regarding breast cancer, its examination and its treatment (19%); health care providers' roles (10%); and family support and mental health issues (8%) (figure 2 ). some countries conducted a higher number of studies than other countries. egypt, lebanon, palestine, qatar, and saudi arabia were amongst those who published the highest number of studies on the addressed issues. libya, syria, yemen, and sudan were amongst those who published the lowest numbers of studies. north africa's countries such as tunisia and morocco were in the middle. north african countries (tunisia, morocco, algeria, and mauritania) are considered francophone countries, and researchers in these countries publish in french more than in english. it is therefore likely that these countries have additional studies published in french, but these were not included in our review due to the exclusion criteria. among the middle eastern countries, syria, libya, and iraq had the lowest number of studies. this can be explained by the political crises and conflicts these countries have been experiencing since 2011, which have made conducting research more difficult. the most frequent research participants were diagnosed women, included in 45% of studies, healthy women (31%), health care workers (11%), the general population (10%), and family members (3%) (figure 3) . most of the studies were quantitative (70%), 20% were qualitative, and 10% were review studies. we argue that the number of the studies, the subjects, and the topics indicate who cares about which aspect of psychosocial experiences of female breast cancer. the studies reviewed in this paper indicate that an alarming number of women received their breast cancer diagnoses later in the course of their disease (stage iii and iv). socio-cultural and political factors, family values, and religious beliefs were consistently mentioned by the studies as the main factors contributing to women being late in seeking help and thus receiving a late diagnosis. economic status and political situation were reported as the most influential factors with regard to access to health care. the reviewed studies indicated that a lack of health insurance, low economic status/income, and distance from health care facilities (being unable to pay for transportation or accommodation near hospitals) seemed to be the most prominent causes of late diagnosis [1, [19] [20] [21] . conflicts and political crises were an additional reason for lack of access to healthcare systems. for example, palestinian women living in the west bank faced hardships passing military checkpoints. as a result, they considered the journey to a hospital for screening worthless and postponed seeking diagnosis until the late stages of the disease [22, 23] . religious beliefs were also found to have an impact on women's experiences. when women were questioned about their assumptions with respect to the causes of breast cancer, many linked it to religious causes, such as a test or punishment from god for previously committed sins [24] [25] [26] . in some contexts, women mentioned unique beliefs regarding the causes of breast cancer, including the increased use of hormonal birth control pills and not breastfeeding. women believed that islam promotes and encourages women to breastfeed and utilize natural birth controls for several reasons. one is to protect against breast cancer [25, 26] . furthermore, cultural norms and religious beliefs constituted barriers to early diagnosis and treatment [27, 28] religious practices, such as becoming more devout and praying much more often, as a means of coping with their illness were reported by women, as well as references to tawakkul (trust in god) [29] [30] [31] [32] . in addition, screening and early diagnosis were perceived to be worthless and futile since god is the only protector and healer, even though, opposingly, treatment was claimed to be necessary since "our bodies are lent to us by god" and must be taken care of [25, 26, 33] . a moroccan study that interviewed nurses and doctors showed that 60% of nurses believed that breast cancer can be cured by adhering to prayer without any kind of therapy [34] . moreover, screening was considered to be a breach of a woman's islamic modesty [35, 36] . some cultural values in the mena region necessitated having a female doctor for clinical breast examinations (cbe) and mammograms, which resulted in a delay in diagnosis of approximately 8 months among libyan, palestinian, and egyptian women [25, 37, 38] . furthermore, culturally, the term "cancer" has been shown to be associated with either death or baldness due to chemotherapy [29, 31] . this seemed to be a more common conception among arab women, leading them to avoid mentioning it to their families. for example, palestinian women living inside israel reported that they felt more comfortable communicating with jewish women during their chemotherapy sessions than with fellow palestinians who also suffered from breast cancer [39] . their comfort speaking about their diagnosis with strangers resulted from the social stigma and the way that cancer is perceived and framed by their close community. cancer was also linked to being attacked by someone's "evil eye", and was believed to be able to be resolved on its own or through the use of home remedies, such as rubbing the lump with olive oil [24, 29, 32, [40] [41] [42] [43] . knowledge about breast cancer risk factors and clinical features is a vital indicator of conducting regular bse, seeking cbe, and pursuing treatment. women, mostly working mothers, who had knowledge about bse practice lacked general information about the frequency and best time of their menstrual cycle to perform bse [44] [45] [46] [47] . knowledge of some indicators of breast cancer risk factors, such as the absence of non-lump breast signs, nipple retraction or changes in breast size and/or shape, other health symptoms like weight loss or fatigue, and denial of and fear of finding a lump, made women less likely to perform bse or undergo a cbe or mammogram [20, 27, 34, 37, 42, [48] [49] [50] . furthermore, women who successfully underwent a bse, cbe, or mammogram once did not repeat the screening tests regularly since they believed that the initial negative results accompanied by no breast changes made a second screening unnecessary [36, 51, 52] . for example, it was found that in the palestinian authority, more than 60% of women above the age of 50 had never undergone a mammography and did not know about the need for regular screening tests, while 72% had never had a cbe [22] . women who underwent cbe also performed bse regularly, which was also a common trend among qatari women [26] . it was also noted that women who performed screenings were motivated to do so because they knew someone (a family member or friend) who had suffered from breast cancer [22, 26, 32, 36, 45] . the gap between initial occurrence of symptoms and diagnosis among women of different arab nationalities living in the uae ranged from 3 months to 3 years, and this was largely explained by the inappropriate information that women had about the presentation of breast cancer [42] . a huge gap in the knowledge of the risk factors of breast cancer was also noticed among women in northern saudi arabia, which may have resulted in delayed diagnosis, as in the uae [53] . on the other hand, 15.5% of libyan women reported that they had been falsely reassured by their physicians that their breast lump was benign [37] . the impact of level of education on breast cancer awareness is very debatable. despite the expectation or hypothesis that women who attended university or who had higher levels of education would have had more knowledge about breast cancer diagnosis, screening, and risk factors, the actual correlation varied between countries. for example, female students attending the university of assuit and ain shams in egypt and taibah university in saudi arabia were found to have poor knowledge about breast cancer risk factors and clinical features [48, 54, 55] . even among those students who had a good level of knowledge about breast cancer and were aware of the existence of bse, the majority did not recognize the need to perform screenings regularly because of their young age or lack of knowledge on how to perform it. this lack related to a low interest in learning about the topic. similar results were found in a study of sudanese medical students who were trainees in the ob/gyn department at omdurman maternity hospital [56] . likewise, among omani women who had completed postgraduate studies, almost half had poor knowledge about breast cancer. similar results were also observed among jordanian female students of different majors and departments [57] . in addition to the deficiency in information, women reported that their primary source of information was not from health care providers but rather from the media, including the internet, social media, and television [9, 26, 32, 44, 45, 47, [58] [59] [60] [61] [62] . more than half of the subjects in the papers who underwent bse, cbe, and/or mammograms were advised by the doctors whom they trusted the most. in iraq, although both students and teaching staff at the technical institute of shatra showed a high percentage of awareness, 73% and 88%, respectively, only 25.4% and 24.4%, respectively, performed bse [63] . the participants of this study also reported that their principal sources of information (from the most to least popular) were the internet and television (47%), health care providers (27%), and family (26%) [63] . in palestine, only 15% of doctors recommended breast exams to their patients; 48% of them remarked that they did not know if radiotherapy was available to women in gaza. similarly, only 19% of female practitioners in saudi arabia ordered a mammogram for women over 40 years of age despite their high level of knowledge about breast cancer risk factors [64] . therefore, the lack of physicians' recommendations for screening was highlighted in most of the countries. researchers attributed this lack to the embarrassment and shame that derive from gender and body values within the discussed societies [26, 37] . researchers found that the patient's level of education influenced the level of knowledge of risk factors as well as the way women coped with the diagnosis. women who had a university degree or higher, especially those who were working, tended to experience less severe episodes of depression and anxiety and had better physical functioning [1, [65] [66] [67] [68] [69] . in other words, knowledge and education were found to be helpful in improving women's quality of life (qol). hence, we can conclude that increasing awareness and knowledge around breast cancer can be an alternative to physician recommendation. according to the who, quality of life (qol) is defined as an individual's perception of their position in life within the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns [70] . when arab women were asked about their definition of quality of life, they generally described their ability to fulfill their roles as mothers and wives [24, 28, 29, 33, 71] . lower income and higher financial stress were associated with a poor quality of life in addition to higher pain severity [71] . in yemen, younger women had worse scores on the quality of life scales [72] . this could be due to the socio-political crisis in which they live, which is described by many human rights organizations as the worst crisis of the century. adverse effects related to treatment interfered with general activity and social functioning and hindered women from performing their day-to-day chores as mothers and wives [24, 33, 71, 73, 74] . women described physical symptoms, including fever, nausea, fatigue, vomiting, dyspnea, poor appetite, and arm pain, which greatly impacted them psychologically, leading to depression, constant anxiety, sleep disturbances, and social difficulties. the reverse effect was also evident [67, [75] [76] [77] [78] . studies revealed that the extent of pain was influenced by the time of diagnosis as well as the mode of treatment. women who underwent radiation and/or immunotherapy scored best on a spiritual well-being scale [79, 80] . studies in egypt and jordan showed that physical and psychosocial symptoms were statistically significantly better in those who underwent breast-conserving surgery rather than modified radical mastectomy [66, 81] . in jordan, lumpectomy surgeries had better outcomes compared with mastectomies [66] . the studies indicated that the progression of women's psychiatric symptoms was significantly associated with advanced stages of the disease, such as metastasis, breast cancer relapse, and multiple tumors, and with continuous post-treatment pain [67, 71, 77, 80, 82] . hence, the stage of the disease was a direct factor in shaping their perception of quality of life. some of the issues commonly reported by women as consequences of therapy, that their physicians failed to mention, were loss of what represented their femininity, such as breast resection, hair loss, breast pain, lack of desire to engage in sexual activities, and vaginal dryness [24, 29, 66, 74, 83, 84] . in morocco, for example, 84% of women with breast cancer who continued sexual activity described it as being increasingly uncomfortable/unenjoyable, painful, and undesirable [77, 78, 83] . this was substantiated by research done in bahrain in which women were interviewed about their spouses' reactions to their illness. the women expressed that they felt rejected and weak [85] . another study in bahrain showed that husbands sometimes even interfered with the type of treatment their wives were to undergo by insisting on less aggressive forms of treatment or none at all [24] . this indicates that women's quality of life is partially shaped by gender hierarchies within their society. some women tried to tackle the decline in their quality of life caused by breast cancer by resorting to alternative medicine (such as special foods, herbs, supplements, spiritual activities) in parallel with, and sometimes instead of, their treatment plans due to a fear of the toxicity caused by chemotherapy. a high percentage of those women did so without consulting their doctors [43, 86] . the studies that were reviewed showed the importance of the role of the family in both diagnosis and treatment stages. for example, divorced and widowed saudi women scored lower on social well-being than their married counterparts [79] . patients were affected by the presence or absence of familial support as well as their families' reactions to the illness. an example of the importance of familial support was illustrated in a study performed by adib et al. [1] , which showed that iraqi migrants living in lebanon suffered from depression and anxiety more than lebanese women. this was mainly due to the lack of nuclear family, extended family, and community support, in addition to other factors such as economic status. furthermore, family structures often change when women are unable to perform their roles as wives and/or mothers [31, 40] . while the majority of women shared the news of their diagnosis with their closest family members, other women felt obliged to hide the news from their family members for various reasons. for example, some hid it from their husbands due to the fear of divorce or being forced to accept their husbands marrying a second wife [33, 84] . this behavior resulted from the impact of the breast cancer diagnosis and its implications for women's femininity, marriage, intimate relationships, and body image [33, 40] . women hid their diagnosis from their friends due to their fear of becoming a burden and of the social stigma associated with "that" disease. this made women hesitant about mentioning their hospital visits to avoid questions from people who knew them [33, 39] . hiding their diagnosis from family and friends led women not to receive the appropriate treatment in time because they were unable to hide the side effects of ongoing treatment [39] . some studies mentioned that women hide their diagnosis from their children to protect them from worry and grief. for example, mothers in saudi arabia who revealed their diagnosis to their children, despite experiencing a stronger mother-child bond, admitted that the news negatively affected their children's academic performance, which in turn increased the burden on the women [87] . hiding a diagnosis from children is a protective act resulting from mothers' fear of negatively impacting their children's emotional and academic performance. this is a mothering value, protecting the child despite being in need of support oneself. this review found that several socio-cultural and political factors affect arab women's quality of life when they are diagnosed with and treated for breast cancer. one of the interesting findings was that few studies addressed sexual functioning, family support, and mental health. these are essential needs that can be reflected directly in women's qol in the process of healing and facing cancer. we argue that researchers and health care workers should give these factors as much attention as they do the physical symptoms. we assume that the absence of studies on sexual functioning indicates that the sexuality, sexual health, and sexual functioning of women and their ability to express their attitudes and feelings toward it are still considered inappropriate or taboo [88] . similarly, the social stigma surrounding mental health constitutes a barrier to seeking help for the patient, and a barrier to researchers in asking patients about the issue [89] . in arab societies, family members tend to hide illness and disease from both their close community and strangers because the cultural value is to keep family issues in the home [89] . this can be explained by the fact that illness and disease are considered weaknesses that society must not see, because if they are seen, the family will be perceived as weak and vulnerable by society. the political events since 2011, beginning with the "arab spring", led to continuous crises in several countries, including syria, libya, yemen, and iraq. we assume that these events have affected women's life in general and have influenced the research agenda within these countries, which reflected by the scarcity of studies on women and breast cancer. in general, in times of conflict women become more vulnerable and women's issues are pushed to the bottom of national priorities [90] . sidel and levy [91] argue that armed conflicts may be associated with poor health and poor access to quality medical care, especially for women, children, and the elderly, that is, the vulnerable and those most affected by wars and conflicts. political conflicts have a direct impact on women's qol, healing processes, and the general ability to cope with breast cancer. hence, these women are essentially facing three battles: political, medical, and social. wars reproduce patriarchy within and between genders and thus require a focus on those institutions that are crucially responsible for the production of masculine identity [90] . almost half of the studies we reviewed focused their research on women who had been diagnosed with breast cancer, while one-third studied the experiences and attitudes of healthy women. this reflected the patient-centered approach in the studies, where women's voices were the main voices. despite this, most of the studies were quantitative. while quantitative methodologies tend to analyze phenomena in terms of prevalence and frequencies, qualitative methodologies aim to determine the meaning of a phenomenon and develop concepts that help in our understanding of the phenomenon through those who are involved in it, that is, the human participants. we attest that there is a need for more qualitative or mixed-methods studies in order to better understand women's experiences and needs. this will help to better implement the patient-centered approach in healthcare systems, which highlights patients' perspectives as a basic principle in health care [92] . socio-cultural factors, such as religion and cultural values, were found to play a major role in bse and bcs behaviors. the term "cancer" has a negative connotation because it is associated with death and end of life. in her work illness as metaphor (1978), susan sontag clarifies how fatalistic social perceptions and the framing of cancer, reflected in the language and metaphors used to refer to the disease, negatively influence women's perceptions, experiences, and healing processes [93] . the health belief model [94] considers cultural values and religion as significant variables affecting perceptions of illness and health, with a major impact on managing health and sickness in certain societies. in arab-muslim societies, that is all mena states, religion plays a role on three levels: the holy text (quran and hadith), the belief system that derives from the text, and the social-religious practices that derive from both [95] . in several contexts, there may be gaps between the holy text, the belief system, and the religious practice. in our review, the gap was between the perception of illness as a punishment or test that only god can heal, and the belief that our bodies are a gift from god and we have to take responsibility and care for them. this contradiction is reflected in women's screening behavior whereby they say that god gave us our bodies and it is our duty to care for them, yet they also engage in late screening behaviors resulting from fear, embarrassment, and rejection of the idea of being sick. another example of a gap between the quranic text and social beliefs is that envy is mentioned in the quran, the holy book for muslims, as something people should protect themselves from, but it is not referred to or based on the concept of the "evil eye." arab-muslim societies use the evil eye to refer to envy of others and every bad event they cannot explain. abu-rabia argues that the belief in the evil eye is embedded in the folklore of fallahin (peasant) societies throughout the middle east [96] . we argue that this belief in the evil eye influences perceptions of disease and illness, and affects the way women with breast cancer, and indeed other ill arab-muslim people, manage their diseases. religious and social leaders, as well as awareness campaigns in all platforms and forms, play a crucial role in re-structuring belief systems and encouraging women to seek early diagnosis and care for their health. the primary factor to consider in preparing these awareness campaigns is the access of women. access, in this context, refers to language and location. studies that considered the role of breast cancer awareness campaigns and investigated their impact on women reflect that these campaigns were ineffective in countries where they occurred abundantly. women in our review, such as women living in qatar and saudi arabia, recommended using the arabic language to distribute information. another common recommendation was to make the campaigns more culturally sensitive by locating informational booths in female-restricted areas instead of public malls, so that women would feel less exposed while visiting the booths [21, 38, 97] . in addition, in lebanon it was found that public information campaigns were occurring at a much lower rate in rural areas compared with in the cities [1] . women in rural areas were found to use more alternative and herbal medicine due to their distance from main health care centers. few studies mentioned alternative medicine, especially herbal remedies, as a tool women use during their trials to promote healing in parallel to the clinical treatment. azaizeh et al. [98] found that the eastern region of the mediterranean has been distinguished from other regions through a rich inventory of complementary alternative medicine, in particular herbal medicine. our review found that being a working and educated mother does not necessarily indicate better self-care or better awareness of bse; in fact, we found that knowing someone, such as a family member or friend, who was diagnosed with breast cancer had a stronger impact on self-health management, resulting from fear that prompted women to perform self-or clinical screening. similar results were found in non-arab countries, such as in serbia [99] . we assume that many eastern and western societies may express fear as an emotional reaction associated with the diagnosis of a close friend or family member. the difference between societies is in the way their culture shapes an individual's reaction to it. one of the cultural factors found to create delay in seeking diagnosis was a woman's preference in having a female doctor perform the clinical breast examination. the best way to counter this factor is to seek out female doctors. the healthcare system should also construct a culturally tailored system by providing more female doctors. in addition to a lack of female doctors available, our review found that the lack of a physician's recommendation for breast examination was significant. indeed, this is one of the major reasons women were unaware of the importance of bse and bce. some researchers attributed this lack of physician recommendation to the gender dynamics and cultural values of arab societies, which can result in embarrassment and avoidance by doctors who would be recommending bse or bce to their patients. lack of doctors' support and women's preference not to discuss health concerns with family members led them to rely on the media, social media, and the internet as their main resources of knowledge. although some cultural values created barriers to seeking early diagnosis, other cultural values promoted the healing processes. for example, the arab cultural structure is characterized by collectivism and patriarchy, which was found to play a positive role in the way women were able to deal with treatment. women reported relying on support from their extended families that lived nearby when they were in need. extended family members filled the woman's roles in mothering, housekeeping, and managing the daily lives of her nuclear family. studies from other regions in the world found the same results in terms of extended family support [100, 101] . furthermore, we found that migrant women fleeing war, such as iraqis, syrians, and yemenis who lived in other arab countries far from their extended families, lacked the necessary support and this was reflected in their poorer quality of life. socioeconomic and socio-cultural factors are important in shaping the quality of life of arab women with breast cancer. these factors are combined with clinical factors, such as the stage of disease and treatment modality. while all women with breast cancer generally share these experiences and impacts, the features of the society that arab women inhabit make the development of these experiences unique to them. gender hierarchies and patriarchy, family values and tribal mentality, cultural practices that contradict the holy religious texts, and cultural perceptions of cancer and women's bodies may make the experience of being diagnosed with and treated for breast cancer harder for women living in the mena. a limitation of this study is that it may not have included all relevant studies because the search was limited to four databases. indeed, literature reviews cannot include every study on the topic, and this is one limitation of this type of review. we also think that including the studies published in arabic and french, especially on north africa's countries, could enrich this review. further qualitative studies are recommended to explore 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patients in lebanon a cross-sectional study of anxiety and marital quality among women with breast cancer at a university clinic in western saudi arabia quality of life assessment: the world health organization perspective cancer-related post-treatment pain and its impact on health-related quality of life in breast cancer patients: a cross sectional study in palestine age related quality of life among selected breast cancer patients in the impact of breast cancer on quality of life among a sample of female iraqi patients factors affecting health related quality of life among women with breast cancer receiving chemotherapy health -related quality of life of kuwaiti women with breast cancer: a comparative study using the eortc quality of life questionnaire predictors of quality of life in a sample of lebanese patients with cancer health-related quality of life among breast cancer patients and influencing factors in morocco. asian pac a cross-sectional assessment of quality of life of 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maternal breast cancer on school-aged children in saudi arabia women's health and well-being in the united nations sustainable development goals: a narrative review of achievements and gaps in the gulf states daher-nashif, s. dementia caregiving in the middle east and north africa the paradoxes of masculinity: some thoughts on segregated societies the health impact of war bridging the gap: the separate worlds of evidence-based medicine and patient-centered medicine illness as metaphor and aids and its metaphors social learning theory and the health belief model islam and the gendered discourses of death the evil eye and cultural beliefs among the bedouin tribes of the negev knowledge, attitude, and behavior among saudis toward cancer preventive practice the state of the art of traditional arab herbal medicine in the eastern region of the mediterranean: a review. evidence based complement factors influencing participation in breast cancer opportunistic screening in belgrade, serbia exploration of the family's role and strengths after a young woman is diagnosed with breast cancer: views of women and their families the impact of culture and sociological and psychological issues on muslim patients with breast cancer in pakistan we thank amna al-sada and manwa al-shamari for their valuable help in collecting and reviewing part of the articles included in this study. the authors declare no conflict of interest. key: cord-010334-7ce0xhjo authors: li, chun; he, jianhua; duan, xingwu title: the relationship exploration between public migration attention and population migration from a perspective of search query date: 2020-04-01 journal: int j environ res public health doi: 10.3390/ijerph17072388 sha: doc_id: 10334 cord_uid: 7ce0xhjo rapid population migration has been viewed as a critical factor impacting urban network construction and regional sustainable development. the supervision and analysis of population migration are necessary for guiding the optimal allocation of urban resources and for attaining the high efficiency development of region. currently, the explorations of population migration are often restricted by the limitation of data. in the information era, search engines widely collect public attention, implying potential individual actions, and freely provide open, timelier, and large-scope search query data for helping explore regional phenomena and problems. in this paper, we endeavor to explore the possibility of adopting such data to depict population migration. based on the search query from baidu search engine, three migration attention indexes (mais) are constructed to capture public migration attention in cyber space. taking three major urban agglomerations in china as case study, we conduct the correlation analysis among the cyber mais and population migration in geographical space. results have shown that external-mai and local-mai can positively reflect the population migration inner regions and across regions from a holistic lens and that intercity-mai can be a helpful supplement for the delineation of specific population flow. along with the accumulation of cyber search query data, its potential in exploring population migration can be further reinforced. along with the rise of a city network, which is constructed under the push of different kinds of urban elements flows, the interactions among different cities have been emphasized in the planning of urban areas, including the interaction of population, material, information, technique, etc. hereinto, population interaction or population migration is one of the most important aspects. the floating of population is not only the flowing of individual human but also the transfer of demand, information, and technique carried by individuals [1, 2] . they discriminately impact economic, social, and political development of both resettled areas and out-migrating areas [3, 4] . timely measuring and analyzing of population migration are particularly crucial for suitably planning urban space and distributing urban resources. related explorations on population migration have been concerned as hotspots since the 1990s. a larger body of researches have been conducted, such as the labor market performance, social and physical status of migration [5] [6] [7] , the causes of migration flow [8] [9] [10] , the consequent impacts of migration [11] [12] [13] , the changing migration policies [14] [15] [16] , the classification research of population migration [17, 18] , the spatial pattern of population migration [19] , etc. these researches have been conducted mainly based on three kinds of data: national censuses data, regional field survey data, and cyber big data. in the traditional migration researches, population censuses and field survey are the principal sources to provide population data [20, 21] . for instance, zhu [22] explored the determined factors in urban area which influence migrants' settlement intention based on the data from a survey on the floating population in the coastal area of fujian province. he et al. [23] adopted national census data to examine the distinctive spatial patterns of floating and hukou population and evaluated their consequent impact on chinese urbanization and industrialization. with the development of cyber space and the popularization of personal mobile termination, numerous researches have implemented under the assistance of data from cyber space exploration of the change, characteristic, and pattern of population migration [24] [25] [26] [27] . for instance, blumenstock [28] analyzed migration pattern based on mobile phone records and revealed more subtle patterns that were not detected in the government population survey. zagheni et al. [29] used geolocated data for about 500,000 users of the social network website "twitter" to predict turning points in migration trends and to improve the understanding of migrant populations. those researches have contributed largely to promoting the understanding of the progress of population migration and their impact. however, the deficiencies in migration data still exist. studies based on national censuses data can explore the migrants in a large range but with a relatively large time interval of ten years, which hinders the short time-series analysis of population migration, and little can be inferred for specific years between censuses and for recent trends [29] . the researches based on field survey can provide detailed migration information, but it asks for a lot of time, manpower, and material resource to deploy, which are expensive for many researches. simultaneously, the field survey often has a certain spatial location and cannot cover a large spatial scope. the increasing cyber data has opened up a new opportunity to deepen our understanding of population migration. however, studies based on the network big data always need to deal with extensive data and complicated procedures in acquiring and processing the data. at the same time, some data sources are not available openly, such as cellphone signal data and gps data of resident activities, because those types of data include much individual private information that is protected by national law. a type of data with open, timelier, and easy-taking characteristics is necessary for effectively investigating the migration population. with the growing application of search engine in cyber space, search query data has been brought out to reflect the preference of public attention, which is generated from the personal behavior of internet search. this kind of data with opening and timelier characteristic has provided effective support for analyzing regional phenomena and problems [30] [31] [32] [33] . in such context, the concern is triggered about its applicability in population migration research. in current information era, most people tend to take migration after an inquiry of destinations. web search engine as the most widely used internet tools provides massive information to the migrants and obtains relevant public attention on the specific subject of migration. the relationship between internet search query data and population migration deserves more attention. however, the relationship between them is still unclear and there are a number of questions to be raised: can the search query data generated from migration-related information search offer some clues about population migration? if they can, how are they related? do cites with higher cyber search quantity have a larger migration population than the cities with lower search quantity? based on these questions, this paper endeavors to answer them and to propose a new angle to analyze population migration. a hypothesis can be made that the search queries generated from individual migration-related search can positively reflect population migration. based on the search query data from baidu search engine, we construct a series of migration attention indexes (mais) to explore public attention on migration. taking three main urban agglomeration areas of china as study area, the correlation analysis has been utilized to explore the relationship between mais and population migration to test the hypothesis. this paper is organized as follows. section 2 introduces the study area and data. section 3 elucidates the methodology of this paper, including the method and indicators that we applied in this paper. section 4 reports the result of correlation analysis between 3 of 18 mai and population migration. section 5 conducts further discussion based on the results in our study area. last, we conduct the conclusion of this paper. to verify the relationship between search query data in cyber space and population migration in geographical space, we select three urban agglomerations in china as case study: beijing-tianjin-hebei metropolitan region (bth), the yangtze river delta (yrd), and the pearl river delta (prd). there are 38 cities located in these regions, 10 cities from bth, 16 from yrd, and 9 from prd, as shown in figure 1 . these regions are chosen based on the following reasons: (1) extensive population migration can be detected in these areas. in 2015, the migration population in these areas has reached more than 8 million in total, accounting for 30.77% in china. exploration of migration in these regions can avoid the influence of random migration under the support of large quantities. (2) these regions with relatively higher internet penetration offer adequate search query data. by the end of 2015, internet penetrations of core cities in those three urban metropolitan areas are separately 76.5% for beijing, 73.1% for shanghai, 78.4% for guangzhou, and 83.2% for shenzhen. more widespread application of the internet can be identified in almost all the provinces cover bth, yrd, and prd [34] . (3) to verify the relationship between search query data in cyber space and population migration in geographical space, we select three urban agglomerations in china as case study: beijing-tianjin-hebei metropolitan region (bth), the yangtze river delta (yrd), and the pearl river delta (prd). there are 38 cities located in these regions, 10 cities from bth, 16 from yrd, and 9 from prd, as shown in figure 1 . these regions are chosen based on the following reasons: (1) extensive population the data used in this paper include the population migration data, search query data, and socioeconomic data. (1) there are three kinds of population migration data used in this study: the net inflow population, intercity population flow, and the floating population. the net inflow population delineates the total population migrated into the city during a specific period. intercity population flow is the population migrate from the original city to the terminal city. based on the prevalent use of series tencent's applications (e.g., wechat is the most used software for 79.6% of chinese netizens), more precise expression on the migration of population in china can be provided by tencent migration map under the support of enormous user base. considering the merit of tencent migration map and avoiding the self-certification of baidu, we obtained the net inflow population and intercity population flow from tencent migration map (https://heat.qq.com/qianxi.php) through web crawler technology. due to the specific hukou policy in china (which has been regarded as the central mechanism underlying the unsettled nature of the floating population), the floating population has been defined as the population living in the objective city more than six months without local registered hukou [35] . it was obtained through the deviance calculation of permanent residential population and household population in the local city, which were collected from regional statistical bureaus. (2) we obtain the search query data based on the support of baidu search engine, which is the most widely used search engine in china and freely provides the search trend of objective terms through baidu index (http://index.baidu.com/). the average daily queries of each migration keyword versus the name of the city (e.g., job + beijing) from 1 january 2015 to 31 december 2015 were collected based on baidu index. (3) relevant socioeconomic data were acquired from regional statistical bureau, including the tertiary industrial output-value, participant rate of urban basic medical care system, the number of schools, etc. the migration reasons were collected from the dynamic monitoring survey of china's migration population in 2015, which was conducted by the national health and family planning commission of china. we endeavor to verify the relationship between public attention on migration which was provided by search query in cyber space and the population migration in geographical space. migration attention indexes (mais) are proposed to express public attention on migration comprehensively. based on the different original location of migration search, we construct three mais as local-mai, external-mai, and intercity-mai to delineate the public attention generated from local city, attention from external areas, and attention flow among urban areas; then, the correlation analysis is conducted between mais in cyber space and urban migrants in geographical space to further verify the aforementioned hypothesis. the framework of this paper can be illustrated in figure 2 . specially, the net inflow population, intercity population flow, and the floating population have been collectively adopted to depict the movement of population in this paper. the definition of migration for them can be separately clarified as follows: the net inflow population of a city is defined as population that the city has received from the external areas, which is the result of movement of people with different origins and the same destination; the intercity population flow is also defined as the movement of people, which happens among different cities; and the floating population of a city is defined under the hukou policy of china (which has been regarded as the central mechanism underlying the unsettled nature of the floating population), of which the migration can be explained as the change in the place of personal residence. int. j. environ. res. public health 2020, 17, x 5 of 18 to verify the hypothesis that the migration-related search queries from individual users can positively reflect the population migration, three issues should be concerned: (1) what are the main driving factors cause population migration; (2) how to express those factors in cyber space through search query data; and (3) how to synthesize those search query data to comprehensively express public attention on migration in cyber space. for the first issue, based on the dynamic monitoring survey of china's migration population in 2015, we have conducted the statistic of population percentage on different migration reasons to confirm the main factors which cause population migration. for the second issue, a series of search keywords expressing different migration reasons has been selected. the baidu index of keywords versus the name of city has been collected to reflect the public attention on migration in cyber space. for the third issue, migration attention indexes (mais) have been constructed to integrate public attentions generated based on different migration reasons. to pointedly select search keywords that load public attention on migration. first, we confirm the main reason for population migration based on the dynamic monitoring survey of china's migration population in 2015. the percentage statistics of migrant population based on diverse migration reasons in the three different urban agglomerations are deployed. the results have been shown in table 1 ; we can see that work and trade, that study and training, that accompanying transferring of family members, and that relocation are the main migration factors in the study area. the percentages of population who migrate for the four reasons separately occupy 75.70%, 85.39%, and 89.77% in beijing-tianjin-hebei metropolitan region, the yangtze river delta, and the pearl river delta. to verify the hypothesis that the migration-related search queries from individual users can positively reflect the population migration, three issues should be concerned: (1) what are the main driving factors cause population migration; (2) how to express those factors in cyber space through search query data; and (3) how to synthesize those search query data to comprehensively express public attention on migration in cyber space. for the first issue, based on the dynamic monitoring survey of china's migration population in 2015, we have conducted the statistic of population percentage on different migration reasons to confirm the main factors which cause population migration. for the second issue, a series of search keywords expressing different migration reasons has been selected. the baidu index of keywords versus the name of city has been collected to reflect the public attention on migration in cyber space. for the third issue, migration attention indexes (mais) have been constructed to integrate public attentions generated based on different migration reasons. to pointedly select search keywords that load public attention on migration. first, we confirm the main reason for population migration based on the dynamic monitoring survey of china's migration population in 2015. the percentage statistics of migrant population based on diverse migration reasons in the three different urban agglomerations are deployed. the results have been shown in table 1 ; we can see that work and trade, that study and training, that accompanying transferring of family members, and that relocation are the main migration factors in the study area. the percentages of population who migrate for the four reasons separately occupy 75.70%, 85.39%, and 89.77% in beijing-tianjin-hebei metropolitan region, the yangtze river delta, and the pearl river delta. due to the transferring of family members always accompanying family relocation [36] , we have viewed them as one perspective and marked as relocation. therefore, three main reasons for population migration have been confirmed as work and trade, study and training, and relocation. to better exhibit and exploit search query data, relevant search exploit services based on search query data are produced, typically as google trend (www.google.com/trends/) and baidu index (http://index.baidu.com/). a series of researches have been conducted to analyze data from google trend and baidu index; the robustness and effectiveness of them have been assessed [37] [38] [39] . in china, compared to google, which is the largest search engine in the world, baidu shares more internet search engine market. in 2016, there are 731 million netizens in china and the number of search engine users has reached 602 million [34] . hereinto, baidu shares 77.07% of the internet search engine market, which is more than google china. especially, vaughan and chen [40] collected and compared the data from google and baidu and found that baidu index can offer more search volume data than google trend did in china. under such context, the baidu index is employed in this paper to obtain public search attention in the cyber space. focusing on the three main migration reasons, we endeavor to confirm the search keywords which reflect public attention on migration. the confirmation of search keywords is comprehensively confirmed under five steps. first, according to the least effort principle in network information retrieval behaviors, users incline to choice the search keywords in their common language with brief and straightforward features [21, 36, [41] [42] [43] [44] . we set the candidate keywords with brief structure and expressed them in chinese. second, the specific content of candidate keywords was derived from the three main migration reasons. relevant search terms for them were selected by brainstorming common words used in searching for migration and review of related literature [21, [45] [46] [47] . third, we have compared the daily average search query data of designated search keywords with similar words during the same period to confirm that the selected keywords are the most popular search keywords in the related aspects. for example, "ç§�æ�¿ (house renting)" has been compared to "å�ºç§� (rent)" and "ç§�èµ� (lease)"; collecting and organizing their average daily baidu index can find that "house renting"(11,795) gets much more attention than "rent"(477) and "lease"(636). fourth, we sift the candidate words to follow the principle of search query data for each keyword in each city to be delineated as a sequential time series with a yearly resolution. fifth, the correlation analysis between the last candidate keywords has been conducted and the one with a high correlation with others has been removed to reduce data redundancy. through the comprehensive consideration of keyword selection, the last keywords can be viewed as not only representing the meaning itself but also including some clues for other potential keywords. finally, six chinese keywords from baidu index have been confirmed to express public attention on migration in cyber space as list in table 2 . the migration attention indexes (mais) are designed to comprehensively express public attention on migration in cyber space comprehensively. first, we combine the candidate search keywords with the name of objective cities to obtain the cityward migration keywords, such as "school + beijing", "house price + shanghai", "recruitment + shenzhen", etc.; second, the average daily search volume of these cityward keywords are acquired based on baidu index from 1 january 2015 to 31 december 2015; third, the population percentages of different migration reasons are viewed as index weight to synthesize the corresponding baidu index into mais; fourth, according to the origin location of baidu index, the local-mai, external-mai, and intercity-mai are separately constructed to express public migration attention on objective cities from internal area of the objective cities, external areas, and other specific cities. the relationship among those indexes can be depicted as follows: where i is the objective city, j is the original city, mai i is the total migration attention city i has achieved from all regions, and local-mai i and external-mai i are separately the total migration attention city i has received from the urban internal area and external areas. intercity-mai ij is the public migration attention derived from city j to city i. the formula of those indexes can be shown as follows: where bi n is the average daily volume of baidu index about different search keywords under migration reason n; w in and w ijn are the weights of bi n , which are defined by the proportion of people who migrate into city i for this reason; and mai max is the max absolute value of mai indicators. to investigate the relationship between public migration attentions in cyber space and population migration in geographical space, we conduct the correlation analysis between mais and urban migrants. in the cyber space, local-mai, external-mai, and intercity-mai were selected to represent public migration attentions with different originations to objective cities; in geographical space, floating population, inflow population, and intercity population flow were collected. regarding the diverse kinds of migration and different definition of mais, the correlation analysis have been conducted from three aspects: (1) the correlation between local-mai and floating population, which reflects the relationship between migration attention generated from the local city and actual floating population inside the city; (2) the correlation analysis between external-mai and inflow population, which explores the relationship between migration attentions received from the external areas and actual inflow population of the objective city; and (3) the correlation analysis between intercity-mai and intercity population flow, which investigates the relationship between cyber migration attention flows and the actual population flows in the geographic space. pearson correlation coefficient is employed to test such correlations, the formula can be shown as follows: where r is the correlation coefficient of the two indexes and n is the number of cities. furthermore, we inquired about the relationship between urban external-mai in cyber space and urban comprehensive attractiveness for migrants (uam) in geographical space to further test the validity of the proposed indicators. based on the push-pull theory which has been widely used in analyzing migration action and willing [48] [49] [50] [51] , we confirmed the uam from urban pull perspective. the major migration reasons confirmed by the dynamic monitoring survey of china's migration population have been employed as reference in confirming the objective content of uam, including work and business, study and training, and relocation. the three aspects separately correspond with the three major migration reasons as job opportunity and income level, living condition, and educational opportunity of children. based on the data availability principle and integrated analysis of previous studies, eight indicators with respect to three aspects of urban pulling power have been selected as shown in table 3 . from job and income perspectives, tertiary industrial output-value (tiv) [52] and urban residents' per capita disposable income (ipc) [43] were employed to reflect urban job opportunities and income level; unemployment rate (ur), participant rate of urban basic medical care system (rbm) [53] , and per capita living area (lpc) [43] were utilized to expose the living condition of local residents; number of regular primary schools (psn), number of regular secondary schools (ssn), and number of university (un) were applied to reveal educational opportunity for migrants' children [44] . last, we adopted the principal component analysis (pca) to integrate the index system and to obtain the indicator which reflects urban comprehensive attractiveness for migrants. the components with eigenvalues greater than 1 and the cumulative ratio of total variance greater than 85% are extracted and rotated with the varimax method in spss 19.0 (international business machines corporation, new york, usa), so that each factor has the minimum number of high load variables, which can be expressed as follows: where uam k is urban comprehensive attractiveness for migrants of city k; m is the number of major components which make the cumulative ratio of the total variance greater than 85%; a i contributes the major components i to uam of the city; n is the number of indexes; c ij is the contribution of index j to the major components i; and x * kj is the standardized value of index j in city k. according to the definition of mai, the migration tendency of the person from the outside areas can be conveyed through external-mai. under the assistance of relevant migration data from the tencent map, we engaged in exploring the relationship between external-mai and urban migration population. pearson correlation coefficient was adopted to reveal the relationship between them; the results have been shown in table 4 and figure 3 . as we could observe, there are significant positive correlations between external-mai and population migration in the three urban agglomerations. the pearson coefficients are 0.948, 0.876, and 0.879 separately in bth, yrd, and prd, which has a holistic coefficient of 0.844. all of them have passed the significance test at 99% confidence level. focused on their spatial heterogeneity, the cities of bth has the highest correlation. corporation, new york, usa), so that each factor has the minimum number of high load variables, which can be expressed as follows: where uamk is urban comprehensive attractiveness for migrants of city k; m is the number of major components which make the cumulative ratio of the total variance greater than 85%; ai contributes the major components i to uam of the city; n is the number of indexes; cij is the contribution of index j to the major components i; and x * kj is the standardized value of index j in city k. according to the definition of mai, the migration tendency of the person from the outside areas can be conveyed through external-mai. under the assistance of relevant migration data from the tencent map, we engaged in exploring the relationship between external-mai and urban migration population. pearson correlation coefficient was adopted to reveal the relationship between them; the results have been shown in table 4 and figure 3 . as we could observe, there are significant positive correlations between external-mai and population migration in the three urban agglomerations. the pearson coefficients are 0.948, 0.876, and 0.879 separately in bth, yrd, and prd, which has a holistic coefficient of 0.844. all of them have passed the significance test at 99% confidence level. focused on their spatial heterogeneity, the cities of bth has the highest correlation. applying the principal component analysis, we obtained uam of target cities based on the statistical data; the correlation study was deployed between the comprehensive uam and external-mai. as shown in table 5 and figure 4 , we could observe a significant correlation between the uam and external-mai in the study areas. the coefficients of the whole area, bth, yrd, and prd are separately 0.829, 0.924, 0.984, and 0.789. the high correlation between them illustrated that urban received external-mai is highly correlated to the attractiveness of urban itself. the relationship between such a cyber-based index and a traditional statistic-based index can be implied. applying the principal component analysis, we obtained uam of target cities based on the statistical data; the correlation study was deployed between the comprehensive uam and external-mai. as shown in table 5 and figure 4 , we could observe a significant correlation between the uam and external-mai in the study areas. the coefficients of the whole area, bth, yrd, and prd are separately 0.829, 0.924, 0.984, and 0.789. the high correlation between them illustrated that urban received external-mai is highly correlated to the attractiveness of urban itself. the relationship between such a cyber-based index and a traditional statistic-based index can be implied. furthermore, the pearson correlation coefficients between the selected indexes and external-mai have been calculated, as shown in table 6 . we can see that all the two indexes for job opportunities and income levels have the highest correlation with external-mai in the study area. for the living condition perspective, a positive correlation can be observed between the participant rate of urban basic medical care system and external-mai in bth and yrp. however, significant correlations cannot be observed between the unemployment rate per capita living area with external-mai. paying attention to the education opportunities, significant correlations can be found in bth and yrd between the three educational indexes and population attention index. in prd, only the number of primary schools significantly correlates with external-mai. in the three urban agglomerations, the strongest correlations are depicted between the tertiary industrial output-value and external-mai, which reflect job opportunities in the areas being conventionally attractive for the potential migrants. insignificant low correlation between the unemployment rate per capita living area with external-mai can be detected. furthermore, the pearson correlation coefficients between the selected indexes and external-mai have been calculated, as shown in table 6 . we can see that all the two indexes for job opportunities and income levels have the highest correlation with external-mai in the study area. for the living condition perspective, a positive correlation can be observed between the participant rate of urban basic medical care system and external-mai in bth and yrp. however, significant correlations cannot be observed between the unemployment rate per capita living area with external-mai. paying attention to the education opportunities, significant correlations can be found in bth and yrd between the three educational indexes and population attention index. in prd, only the number of primary schools significantly correlates with external-mai. in the three urban agglomerations, the strongest correlations are depicted between the tertiary industrial output-value and external-mai, which reflect job opportunities in the areas being conventionally attractive for the potential migrants. insignificant low correlation between the unemployment rate per capita living area with external-mai can be detected. the results of correlation analysis between local-mai and local floating population have been shown in table 7 and figure 5 . we can see that, no matter in the whole study area or the individual urban agglomeration, high correlation coefficients were gained. especially in the yrd, the relevant coefficient has arrived at 0.950. prd has a relatively lower value but is still higher than 0.75. divided by the median value of local-mai and local floating population, the cities in the study area can be divided into four types. thereinto, 78.95% of them has high-high or low-low features. for the cities with higher-than-average floating population and higher-than-average local-mai, there are three located in the bth (beijing, tianjin, and baoding), two in yrd (shanghai and suzhou), and two in prd (shenzhen and guangzhou). to further excavate information from mai, the relationship between local-mai and external-mai has been explored; the results are shown in figure 6 . there is a highly positive correlation between the two indexes, of which the r is 0.7538 and p is 0.01. it is shown that the city with higher local-mai also has a higher external-mai to further excavate information from mai, the relationship between local-mai and external-mai has been explored; the results are shown in figure 6 . there is a highly positive correlation between the two indexes, of which the r is 0.7538 and p is 0.01. it is shown that the city with higher local-mai also has a higher external-mai to further excavate information from mai, the relationship between local-mai and external-mai has been explored; the results are shown in figure 6 . there is a highly positive correlation between the two indexes, of which the r is 0.7538 and p is 0.01. it is shown that the city with higher local-mai also has a higher external-mai to explore the relationship between intercity-mai and intercity population flow, the results have been shown in table 8 and figure 7 . as we could notice, the average value of intercity-mai is 1.00, guangzhou-shenzhen has the highest intercity-mai at 5.19; and shenzhen-chengde has the lowest index of 0.04. for the individual urban agglomeration, the intercity-mai among beijing, tianjin, and shijiazhuang has the highest top three values in bth. the same level of intercity-mai to explore the relationship between intercity-mai and intercity population flow, the results have been shown in table 8 and figure 7 . as we could notice, the average value of intercity-mai is 1.00, guangzhou-shenzhen has the highest intercity-mai at 5.19; and shenzhen-chengde has the lowest index of 0.04. for the individual urban agglomeration, the intercity-mai among beijing, tianjin, and shijiazhuang has the highest top three values in bth. the same level of intercity-mai can be found in yrd for shanghai, hangzhou, and suzhou. in prd, such level interactions are observed between guangzhou, shenzhen, and foshan. under the correlation analysis of these two indexes, a moderately positive correlation can be observed in the study area (see table 8 ). for the three urban agglomerations, prd has the highest correlation among them and the correlation in bth and yrd represents a relatively lower level. there are 59 pairs of cities that have a high-high correlation pattern (high intercity-mai and high intercity population flow), there into 15 pairs in bth, 24 pairs in yrd, and 20 pairs in prd; 147 pairs of cities exhibited the low-low correlation pattern, of which, in bth, yrd, and prd, are separately 46, 69, and 32. these two kinds of correlation patterns occupy 75% of the total. although relevant correlation coefficients of intercity-mai are relatively limited, it can capture the interaction trend of population flow at an acceptable level. population flow at an acceptable level. three uas bth yrd prd coefficient 0.5685 0.5283 0.5437 0.6369 sig (2-side) 0.0000 0.0000 0.0000 0.0000 the massive population migration is the specific phenomenon and the inevitable driving force promoting the urbanization of population in china and many developing countries. the collection of urban mais can obtain the public intention of migration based on individual search actions and can offer exploration of population migration. depending on the mais, we analyzed the correlation relationship between local-mai and external-mai; a high correlation has been discovered. it implied that the city with relatively higher local-mai has a higher external-mai. migration may be active in the high-high cities, such as shanghai, beijing, and shenzhen. according to the dynamic monitoring survey of china's migration population in 2015, the proportions of floating population inside these three cities separately reached 40.26%, 38.02%, and 67.51%, which are much higher than the average value of china at 18.00%. besides, they have separately occupied 12.22%, 11.99%, and 8.64% (ranked top 3) of the whole inflow population of the three urban agglomerations, which has the most dynamic the massive population migration is the specific phenomenon and the inevitable driving force promoting the urbanization of population in china and many developing countries. the collection of urban mais can obtain the public intention of migration based on individual search actions and can offer exploration of population migration. depending on the mais, we analyzed the correlation relationship between local-mai and external-mai; a high correlation has been discovered. it implied that the city with relatively higher local-mai has a higher external-mai. migration may be active in the high-high cities, such as shanghai, beijing, and shenzhen. according to the dynamic monitoring survey of china's migration population in 2015, the proportions of floating population inside these three cities separately reached 40.26%, 38.02%, and 67.51%, which are much higher than the average value of china at 18.00%. besides, they have separately occupied 12.22%, 11.99%, and 8.64% (ranked top 3) of the whole inflow population of the three urban agglomerations, which has the most dynamic migration in china. the predominant roles of them in attracting population outside the city are declared. active migration movement can be detected to support the hypothesis derived from the correlation relationship between local-mai and external-mai. analyzing the correlation of external-mai with uam, the reasonability of external-mai can be verified through the high correlation with conventional statistics analysis. based on the push-pull theory of migration, in the cities with higher urban pulling force, more influx of population can be observed. through the calculation of uam, which depicted urban pulling force, the city with higher external-mai can observe higher uam. the feature of external-mai coincides with the setting of push-pull theory. further, exploring the relationship between external-mai and the indexes which reflect urban migration attractiveness, there are significant correlations between tertiary industrial output-value and urban residents' per capita disposable income with the external-mai in the whole study area. most of the cities with higher job opportunities and income levels receive more migration attentions from the outside area. this finding coincides with the dynamics monitoring survey of migration population suggesting a migration reason in table 1 (work and trade as the predominant migration reason), which can represent the ability of mai indexes in capturing the impact of migration reasons. with respect to the indexes described urban living conditions, there are no significant correlations between the population migration attention and unemployment rate or per capita living area, this results may correspond to the great exception of potential migrants for their future urban condition, which can be explained by the todaro migration model from the perspective of development economics. todaro migration model argues that the migration of population is based on the "expected profit" of migrants. the hardships in urban life have not obtained enough attention from potential migrants, particularly for the rural-urban migrants who lack the necessary information as they enter a new different world [43] . further, the more schools a city has, the more public migration attention it receives. the positive correlation existing between the education indexes (the number of primary schools, secondary schools, and universities) and external public migration attention exposes that the educational opportunities also intensify the level of urban migration attention. in prd, the focus of educational concern only derives from the consideration of secondary schools; significant correlation has not been observed between the number of the other two levels of schools in the area, which may be attributed to the relatively lower education level of guangzhou province (the administrative province that prd belongs to) than the other two urban agglomerations. besides, we further adopted the neoclassical theory in population migration to explore the reasonability of mais. the per capita disposable income of urban residents, which has been viewed as the direct index depicting the possibility for migrants to improve economic benefit, has been adopted to conduct the correlation analysis with external-mai; the results have shown that the external-mai has significant positive correlation with the per capita disposable income of urban residents (with the correlation coefficients 0.650, 0.945, 0.752, and 0.780 separately in the whole study area, in bth, in yrd, and in prd). the reasonability of mais can be further identified. with the correlation analysis of external-mai and urban migration population, we could observe a significantly positive correlation. the resource endowment gap between different urban areas (e.g., economic development level, environmental quality, promotion of opportunities for individuals, etc.) triggers personal develop exception and forges migrant needs in flowing among diverse regions [22, 43] . collecting information about the targeted city by employing the search query engine is an efficient and low-cost approach to supplement requisite information before deploying actual migration to external areas. as noted as the correlation results of external-mai and urban inflow migrants in the study area, we can accept the hypothesis that the migration-related search queries from individual users were able to positively reflect urban inflow migrants. external-mai can be applied to reflect urban inflow migrants on the annual scale. the high correlation between local-mai and the floating population inside cities was a signal to prove their close relationship. nowadays, the floating population inner city has become an influential part in enacting urban planning and policy. generally speaking, the floating population lived with relatively weaker urban amenities than the local population [54, 55] . the desire of improving current conditions was more intensive for them, which was delineated by the high demand for new job opportunities, study chance, and the possibility of improving living quality, etc. driven by such basic needs, the corresponding search query can be brought into the cyber space and raises the high correlation between local-mai and floating population inside the city. intercity migration has already become one of the significant migration models in current china. we analyzed the correlation between intercity-mai and intercity population flow in 2015; a similar positive correlation can be observed as 0.57 (p-value 0.00) in the whole area. the results show that the representativeness of intercity-mai for population flow between different cities was effective, but the correlation relationship was relatively limited. it might be caused by two main reasons: (1) the selection of search keywords cannot cover every reason for migration flows. a unique keyword system may exhibit some deviation in reflecting the driving force of every population flow interaction; (2) migration movement has a lagging feature. it may happen a few months, years, or a much longer time after the search action. it also may be canceled or indefinitely delayed after information acquisition through searching, which makes the relatively lower correlation between intercity-mai and intercity population inflow. generally speaking, the correlation between intercity-mai and population flow is still on an acceptable level. it can be a supplement for the population flow research of insufficient data. in future work, the construction of a targeted search keywords system for objective population flow can be adopted to remedy such drawbacks. besides, for the three mai indexes, the different correlation coefficients in the three urban agglomerations revealed that regional disparity exists. we calculated the variance (var) and coefficient of variation (cv) of relevant correlation coefficients of three mai indexes, as shown in table 9 . it can be seen that all the vars are lower than 0.01 and that all the cvs are lower than 10%. the robustness of external-mai, local-mai, and intercity-mai in reflecting population can be partly ensured in the study area. furthermore, we have tested the significance of slope of the three trend lines, which were separately fitted based on external-mai and inflow population, local-mai and floating population, and intercity-mai and population flow to identify whether mai indexes could steadily reflect the migration situation in different urban agglomerations. all the significances of slopes have been rejected by significant testing at a significant level of 0.05 (sig = 0.43, 0.19, and 0.86 for external-mai, local-mai, and intercity-mai). the null hypothesis could be accepted as there is no significant deviance between the slopes. although the representations of mai are diverse in different regions, the deviances are nonsignificant. migration population has immense potential to push urbanization process in current china and other developing countries. exploration of population migration based on multisource data can bring more information about the noticeable driving force of urban development. in the information and network era, the mai indexes can reveal how the public put their attention on migration-related items. based on the cyber-based indexes, we explore the relationship between public migration attention in cyber space and urban migration population in geographical space inner region, across region, and between regions. the results can answer the questions mentioned in the introduction that search query data based mai indexes can positively reflect the situation of migration population inner region and across region and, for the population flow, that it is an alternative supplement and support when relevant data is deficient. population migration is a complex process driven by diverse forces; this paper conducted a series of analyses from the perspective of search query data in cyber space. however, some limitations exist: first, the selection of continuous search keywords is limited by the short period of data acquisition from the search query engine. following the incremental collection of search query data, more suitable search keywords should be selected to cover different aspects of public migration attention to thus better delineate the difference and characteristic of urban migrant population; second, this paper focus on the panel data analysis; future work will emphasize on the time-series analysis and excavate more information from a dynamic perspective. author contributions: c.l. participated in all phases; j.h. helped in conceiving and designing the research; x.d. helped in paper organization and language correction. all authors have read and approved the final manuscript. migration of skilled workers and innovation: a european perspective rural-urban migration and urbanization in china: evidence from time-series and cross-section analyses interprovincial migration, population redistribution, and regional development in china: 1990 and 2000 census 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in china a double-pull model of rural labor migration and its in situ urbanizationeffect: cases studies of three coastal areas in southeast china is the push-pull paradigm useful to explain rural-urban migration? a case study in uttarakhand push' versus 'pull' factors in migration outflows and returns: determinants of migration status and spell duration among china's rural population the analysis of economical pulling factors for migrants in beijing, shanghai and guangzhou after reform and opening life satisfaction in urban china: components and determinants labor migration and earnings differences: the case of rural china towards a labour market in china funding: this research was funded by china postdoctoral science foundation, grant number 2019m663592. the authors declare no conflict of interest. the founding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; and in the decision to publish the results. key: cord-283175-kh2rm2ir authors: roma, paolo; monaro, merylin; muzi, laura; colasanti, marco; ricci, eleonora; biondi, silvia; napoli, christian; ferracuti, stefano; mazza, cristina title: how to improve compliance with protective health measures during the covid-19 outbreak: testing a moderated mediation model and machine learning algorithms date: 2020-10-04 journal: int j environ res public health doi: 10.3390/ijerph17197252 sha: doc_id: 283175 cord_uid: kh2rm2ir in the wake of the sudden spread of covid-19, a large amount of the italian population practiced incongruous behaviors with the protective health measures. the present study aimed at examining psychological and psychosocial variables that could predict behavioral compliance. an online survey was administered from 18–22 march 2020 to 2766 participants. paired sample t-tests were run to compare efficacy perception with behavioral compliance. mediation and moderated mediation models were constructed to explore the association between perceived efficacy and compliance, mediated by self-efficacy and moderated by risk perception and civic attitudes. machine learning algorithms were trained to predict which individuals would be more likely to comply with protective measures. results indicated significantly lower scores in behavioral compliance than efficacy perception. risk perception and civic attitudes as moderators rendered the mediating effect of self-efficacy insignificant. perceived efficacy on the adoption of recommended behaviors varied in accordance with risk perception and civic engagement. the 14 collected variables, entered as predictors in machine learning models, produced an roc area in the range of 0.82–0.91 classifying individuals as high versus low compliance. overall, these findings could be helpful in guiding age-tailored information/advertising campaigns in countries affected by covid-19 and directing further research on behavioral compliance. public willingness to comply with the protective health measures proposed by authorities is critical for controlling the outcomes of an infectious disease outbreak [1], given that "behavioral changes can significantly affect the epidemic spread both qualitatively [ . . . ] and quantitatively" [2] . coronavirus disease 2019 (covid-19, also known as 2019-ncov), an acute respiratory illness with an unknown cause, emerged in china in december 2019 and, since then, has spread rapidly throughout most of the world. in january 2020, the world health organization declared it an international public health emergency and, shortly thereafter, a global pandemic [3] . on 30 january 2020, the first two cases of covid-19 in italy were confirmed by the italian government. in the following weeks and months, the health emergency generated devastating consequences for both local residents and national health workers. due to the lack of supported treatments and vaccines, italy (similar to other countries) implemented a policy of social and physical distancing, as well as a mandatory recommendation to "stay at home". however, the virus continued to escalate at an overwhelming rate, due in part to the failure of a portion of italian residents to observe the recommended health measures, despite the government's prevention information campaigns (issued from february onwards). to dissuade unsafe behaviors, the government was forced, on 19 march, to introduce penalties for those violating the guidance by leaving their domiciles for reasons other than stringent and absolute need. it is worth noting that, at this point in time, the contagion was already very advanced: on 18 march, the official cases reported by the government included 33, 190 infected, 4440 recovered, and 3400 deceased [4] [5] [6] [7] . the present research stemmed from the observation that, throughout this health crisis, italian residents (similar to those in other affected countries) have engaged in incongruous behaviors, thereby severely limiting the effective management of covid-19. to investigate this phenomenon more deeply, we selected and explored the effect of multiple psychological and psychosocial variables that were thought to relate to individual differences in compliance with the intervention measures and safety behaviors during the first phases of the covid-19 outbreak in italy. the belief that a recommended health behavior will have positive consequences and/or will reduce the public health threat (or its seriousness) is commonly defined as perceived efficacy or perceived benefits. in actuality, these terms indicate slightly different constructs, originating from different theoretical frameworks: the health belief model (hbm) [8] and protection motivation theory (pmt) [9, 10] , respectively. although perceived benefits also include non-health-related positive outcomes (e.g., having more money after quitting smoking), the term is often used synonymously with perceived efficacy. in this study, we use the term perceived efficacy very specifically to describe people's perception of the efficacy of the recommended preventive measures in reducing the risk of contagion. perceived efficacy has been studied in relation to a variety of general health measures, including engaging in physical activity, receiving vaccinations, and complying with medical treatment among psychiatric outpatients [11] [12] [13] ; the literature suggests that it is a key determinant for compliance with preventive health behaviors and that "only when a person feels that the recommended behavior is likely to lead to the desired outcome will adoption of the recommendations occur" ( [14] , p. 193). perceived efficacy has also been studied in the context of past epidemics/pandemics (e.g., h1n1) and the current covid-19 outbreak, demonstrating that it is one of the strongest predictors of compliance with preventive health behaviors [15] [16] [17] . self-efficacy is defined as "people's beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives" ( [18] , p. 71). of note, the concept also refers to an individual's belief about their ability to perform specific behaviors in particular situations [19] . a direct relationship between self-efficacy and behavioral change has been found in many health contexts (relating to e.g., cigarette smoking, weight control, contraceptive behavior, and alcohol abuse) [20, 21] and during past pandemics [22] , indicating a strong relationship between self-efficacy and health behavior change and maintenance. according to the health action process approach (hapa) [23] , three specific cognitions lead to an intention to act (i.e., motivation): (a) perceiving oneself as at risk (i.e., a risk perception), (b) believing that the recommended health behavior will reduce the threat (i.e., an efficacy perception), and (c) self-efficacy. although efficacy perception has been found to be a stronger predictor than self-efficacy in developing the intention to act [24] , "individuals need to know the contingencies between behaviors and outcomes [ . . . ], but they also need to be confident that they can really perform the behavior in question" (p. 493). accordingly, the present study aimed at revealing whether self-efficacy plays a mediating role in this relationship. we posited that feeling able to perform the recommended health behaviors would mediate the relationship between the perceived efficacy of those measures and compliance. research question 1 (rq1): self-efficacy would mediate the relationship between the perceived efficacy of the government health measures and compliance (simple mediational model). higher levels of perceived efficacy would increase compliance through higher self-efficacy. risk perception, defined as an individual's belief about the risk of potential harm, is a key construct of many theoretical frameworks for health behaviors (e.g., hbm, pmt, hapa). risk perception is influenced by the perceived severity of the specific health threat and the perceived likelihood of harm. as noted by brewer et al. [25] , previous studies have often used the terms "likelihood" and "vulnerability"/"susceptibility" interchangeably, even though the first represents "one's probability of being harmed by a hazard under certain behavior conditions" (p. 136), whereas the second can be defined as individual resistance or constitutional vulnerability. research on past epidemics/pandemics (e.g., h1n1) has not only shown risk perception to be a key driver of health behaviors, but it has also consistently found an association between risk perception and precautionary behaviors [26] [27] [28] , even though a meta-analysis highlighted that this association involves only small effect sizes [25] , especially with respect to perceived severity (r = 0.16). in the context of health psychology, significant interactions between risk perception and self-efficacy have been found; for example, research has identified an association between motivation to think about cardiovascular disease, use of health information, and knowledge acquisition [29] . however, some research has reported no significant direct effect of risk perception on preparedness measures. bourque et al. [30] for instance, found that the effect of risk perception was largely mediated by knowledge, perceived efficacy, and milling behavior in household preparedness for terrorism behavior in the united states. research question 2 (rq2): risk perception would moderate the relationship between the perceived efficacy of the government health measures and compliance (research question 2a), as well as the positive relationship between the perceived efficacy of the health measures and self-efficacy (research question 2b), and the positive relationship between self-efficacy and compliance (research question 2c) (moderated mediation models). higher perceived efficacy of the health measures would be associated with increased compliance with protective health measures, especially alongside higher risk perception. civic engagement can be defined as "the process of believing that one can and should make a difference in enhancing his or her community" [31] . it is typically thought to have two dimensions: attitudes and behaviors. however, since the present study was focused on cognitive variables, we primarily examined civic attitudes. due to the lack of a strong theoretical model for civic engagement in health contexts, no previous research has examined the link between civic engagement and health behaviors (or specifically, compliance with health measures). however, studies have focused on specific aspects of civic engagement, such as perceived moral responsibility. for example, a recent study [13] investigating the vaccination rate among nurses in hong kong considering hbm constructs and using perceived moral responsibility as a moderator found an insignificant effect. furthermore, previous studies have examined individuals' level of information regarding community health concerns during pandemics (including the current covid-19 pandemic), demonstrating a positive association between knowledge about a specific threat and preventive behaviors [16, 32, 33] . these results suggest that promoting knowledge about covid-19 might encourage the adoption of preventive behaviors. other facets of civic engagement-namely political efficacy and an interest in public affairs-have been found to be positively associated with self-efficacy [34] . furthermore, research on mobile donation as a new platform for technology-mediated civic engagement has demonstrated that perceived effectiveness (i.e., the degree to which consumers believe that the company will really donate as much as promised and that this donation will actually reach the needy recipients) has a positive effect on the intention to donate via mobile phone [35] . in this vein, the present study sought to explore the relationship between civic engagement (specifically, civic attitudes), perceived efficacy, self-efficacy, and compliance with protective health measures during the covid-19 pandemic. the covid-19 outbreak presents a unique opportunity to investigate the role of civic engagement-together with the aforementioned variables-since even asymptomatic individuals are able to spread the virus to vulnerable populations (e.g., older adults and the elderly) [36] . therefore, we included this variable as a moderator because it could potentially provide insight into how to improve compliance to the recommended preventive behaviors. indeed, in the research question 3 (rq3): civic attitudes would moderate the relationship between the perceived efficacy of the government health measures and compliance (research question 3a), as well as the positive relationship between the perceived efficacy of the health measures and self-efficacy (research question 3b), and the positive relationship between self-efficacy and compliance (research question 3c) (moderated mediation models). higher perceived efficacy of the health measures would be associated with increased compliance with the protective health measures, especially alongside higher levels of civic attitudes. figure 1 shows the proposed moderated mediation model. other facets of civic engagement-namely political efficacy and an interest in public affairshave been found to be positively associated with self-efficacy [35] . furthermore, research on mobile donation as a new platform for technology-mediated civic engagement has demonstrated that perceived effectiveness (i.e., the degree to which consumers believe that the company will really donate as much as promised and that this donation will actually reach the needy recipients) has a positive effect on the intention to donate via mobile phone [36] . in this vein, the present study sought to explore the relationship between civic engagement (specifically, civic attitudes), perceived efficacy, self-efficacy, and compliance with protective health measures during the covid-19 pandemic. the covid-19 outbreak presents a unique opportunity to investigate the role of civic engagement-together with the aforementioned variables-since even asymptomatic individuals are able to spread the virus to vulnerable populations (e.g., older adults and the elderly) [37] . therefore, we included this variable as a moderator because it could potentially provide insight into how to improve compliance to the recommended preventive behaviors. indeed, in the research question 3 (rq3): civic attitudes would moderate the relationship between the perceived efficacy of the government health measures and compliance (research question 3a), as well as the positive relationship between the perceived efficacy of the health measures and selfefficacy (research question 3b), and the positive relationship between self-efficacy and compliance (research question 3c) (moderated mediation models). higher perceived efficacy of the health measures would be associated with increased compliance with the protective health measures, especially alongside higher levels of civic attitudes. figure 1 shows the proposed moderated mediation model. the results of a previous review on demographic and attitudinal determinants of compliance with protective measures during a pandemic showed that being older, female, more educated, and non-white were associated with a higher likelihood of adopting the recommended health behaviors [38] . more recently, several studies have investigated which factors were associated with compliance with the preventive measures during the covid-19 pandemic. the results indicated that the the results of a previous review on demographic and attitudinal determinants of compliance with protective measures during a pandemic showed that being older, female, more educated, and non-white were associated with a higher likelihood of adopting the recommended health behaviors [37] . more recently, several studies have investigated which factors were associated with compliance with the preventive measures during the covid-19 pandemic. the results indicated that the demographic variables of male gender and younger age were associated with lower levels of compliance [38] [39] [40] , while-albeit not consistently-the demographic variables of a higher level of education and being married were associated with greater compliance [38] . together with age and education, we included level of personality dysfunction (as assessed by the dsm-5 approach [41] ) as a control variable, as several studies have shown that people react differently to threats according to certain personality traits [42, 43] . for instance, individuals with high levels of antagonism, which refers to aggressive tendencies accompanied by assertions of dominance and grandiosity, may argue with other people when their desires are not satisfied [44] . moreover, high levels of disinhibition are commonly related to greater impulsivity and sensation seeking, which could lead to a tendency to ignore real dangers or threats. finally, among personality traits, only agreeableness was associated with greater compliance, whereas aspects of the dark triad (i.e., narcissism, machiavellianism, and psychopathy) and antisocial traits were predictive of lower levels of compliance [45, 46] . despite the paucity of studies on personality variables and compliance with government recommendations during past pandemics, it is possible that higher levels of personality dysfunction could interfere with behavioral compliance. recently, researchers from a range of scientific fields (including the clinical and social sciences) have begun to emphasize the increased need to focus on prediction, rather than explanation, during data analysis [47] . machine learning (ml) is a branch of artificial intelligence that focuses on data prediction. ml algorithms automatically learn information from a set of data and make predictions on unseen data without being explicitly programmed to do so. ml techniques have been shown to be particularly useful in predicting human behavior, including high-risk behavior [48] [49] [50] [51] . indeed, one of the main advantages of ml is that it enables inferences to be made at the individual level, whereas traditional statistical methods focus primarily on the group level [52] . thus, ml predictive models support researchers in making predictions for individual subjects, which is particularly useful for the development of personalized and targeted prevention campaigns. in the present study, ml algorithms were applied to the 14 psychosocial variables to predict individuals' likelihood of complying with the covid-19 protective measures. research question 4 (rq4): which variables would predict, with maximal accuracy, high versus low compliance with the protective health measures prescribed by the italian government? the research team assembled an online survey inspired by the literature and collected data over five days (18) (19) (20) (21) (22) march 2020). the questionnaire was administered cross-sectionally on an online survey platform, which participants accessed via a designated link. the link was disseminated through the main means of communication and social networks, in order to reach a large number of subjects. the study was approved by the local ethics committee (board of the department of human neuroscience, faculty of medicine and dentistry, sapienza university of rome). ten questions were designed to investigate compliance with the covid-19 protective measures (e.g., "it is suggested that all persons avoid crowded places. are you complying with this?"). these questions were assessed on a five-point likert scale ranging from 1 (slightly) to 5 (extremely), with cronbach's alpha of 0.84. when covid-19 became pervasive, the italian government announced guidelines for preventing infection, including "disinfect hands often" and "stay at home". accordingly, 10 statements were provided to measure the perceived efficacy of 10 protective guidelines (e.g., "it is suggested that all persons avoid crowded places. do you find this useful?") using a five-point likert scale ranging from 1 (hardly) to 5 (extremely). cronbach's alpha was 0.93. participants' self-efficacy with respect to protecting themselves from covid-19 was measured using three questions (e.g., "i am confident in my ability to protect myself from covid-19") adapted from previously validated measures [22] , which were assessed on a five-point likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). cronbach's alpha was an acceptable 0.62. risk perception was assessed through two variables, perceived severity and perceived likelihood, using items adapted from cho and lee [22] and liao, cowling, lam, ng, and fielding [53] . perceived severity was assessed using four items (e.g., "if i got covid-19, it would be severe"), with a cronbach's alpha of 0.70. perceived likelihood was assessed using two items ("how likely is it that you will get covid-19 in this period?"), with cronbach's alpha of 0.80. six questions were assessed on a five-point likert scale ranging from 1 (not likely at all) to 5 (certain). the civic engagement scale (ces) [31] was employed. the ces is a 14-item scale based on an understanding of civic engagement as "the process of believing that one can and should make a difference in enhancing his or her community". it measures two specific aspects of civic engagement: attitudes and behaviors. the first subscale (attitudes), composed of eight items, assesses civic attitudes in terms of "the personal beliefs and feelings that individuals have about their own involvement in their community and their perceived ability to make a difference in that community". the second subscale (behaviors), composed of six items, assesses civic behaviors in terms of "the actions that people take to actively attempt to engage and make a difference in their community". both the attitudes and the behaviors subscale obtained high reliability in the validation study, with cronbach's alphas of 0.91 and 0.85, respectively. in the present sample, cronbach's alpha was 0.87 for both scales, and each item was assessed on a five-point likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). personality dysfunction was investigated using the personality inventory for dsm-5-brief form-adult (pid-5-bf) [54] . the pid-5-bf is a 25-item self-rated personality traits assessment. it measures five personality trait domains: negative affect, detachment, antagonism, disinhibition, and psychoticism. each domain is measured through five items, which are rated on a four-point likert scale ranging from 0 (very false or often false) to 3 (very true or often true). the overall measure generates scores in the range 0-75, with higher scores indicating greater overall personality dysfunction. each trait domain receives a score in the range 0-5, with higher scores indicating greater dysfunction in that specific personality trait domain. a total of 2812 respondents participated in the survey. all participants were aged 18 years or older and were living in italy. the online survey was closed on the sixth day following dissemination of the link. all participants voluntarily responded to the anonymous survey and indicated their informed consent within the survey. the procedures were clearly explained, and participants could interrupt or quit the survey at any point without explaining their reasons for doing so. two respondents were excluded from the sample because they were younger than 18 years, and 44 participants were excluded because they lived outside of italy during the outbreak. the final sample consisted of 2766 participants: 1982 (71.7%) females and 784 (28.3%) males. the mean age of the sample was 32.94 (13.2; range 18-90 years), and the majority was italian citizens (n = 2739, 99%) . most of the sample (n = 1194, 43 .2%) held a high school degree and were unmarried (n = 1866, 67.5%), unemployed (n = 1165, 42.1%), and childless (n = 2130, 77%) . furthermore, most participants reported to be staying at home (n = 2368, 85.6%) and going out up to once per day (n = 2559, 92.5%). a paired sample t-test was used to compare efficacy perception with behavioral compliance. cohen's d [55] effect size was inspected for each significant effect. the mediation and moderated mediation models were run using process version 3.5 [56] , as developed by preacher and hayes [57] for spss, version 25 (ibm, armonk, ny, usa). moderated mediation test simple mediation models (i.e., determining whether a given variable or mediator accounts for some or all of the relationship between two other variables) that may differ according to a further variable (e.g., if the mediation pathway is only present for individuals with higher or lower levels of certain variables). process estimates indirect effects (i.e., mediation) and conditional indirect effects (i.e., moderated mediation) using bootstrap confidence intervals. in the present study, the bias-corrected 95% confidence interval (ci) was calculated using 5000 bootstrapping resamples. effects were considered significant if the resulting ci did not contain 0. all measures, including compliance with protective health measures, were treated as continuous variables except for the ordinal covariate "education". considering process model templates [58] , we first tested a simple mediation model (model 4) to explore if the association between perceived efficacy of the recommended health measures and compliance was mediated by self-efficacy. next, we tested model 76 to verify the moderated effect of risk perception and civic attitudes on the direct and indirect effects of the perceived efficacy of the health measures on compliance. "high" and "low" levels of both moderators were determined at one standard deviation above and below the mean of each scale. taking into account previous findings [38] [39] [40] 42, 43] , all analyses controlled for age, education, and level of personality dysfunction. finally, ml models were trained and tested in weka 3.9 [59] . the procedure used to build the models is reported in the "results" section. descriptive statistics and scale correlations are reported in table 1 . a paired sample t-test was conducted to investigate differences between the perceived efficacy of the recommended safety behaviors and compliance. the result was statistically significant-t (2765) = 37.384; p < 0.001-with an effect size (= 0.711) approaching cohen's [55] standard for a large effect (= 0.80). the results further indicated a statistically significant reduction in scores for behavioral compliance (m = 41.7; sd = 6.20) relative to perceived efficacy (m = 44.8; sd = 6.17). subsequent paired sample t-tests were run for each safety measure prescribed by the italian government (e.g., "avoid hugs", "avoid handshakes," etc.). since the category of protective health measures was very heterogeneous, being composed of 10 behavioral types, we conducted t-tests for each measure. our aim was to thoroughly investigate whether a difference between perceived efficacy and compliance impacted some behaviors more than others. t-test results were significant for all protective measures except for "avoid handshakes": t (2765) = 1.253; p < 0.210; d = 0.024 (see table 2 ). research question 1 postulated that self-efficacy would mediate the relationship between the perceived efficacy of the recommended health measures and compliance. as shown in table 3 , the total effect of perceived efficacy on compliance was significant (b = 0.750 (se = 0.01); p < 0.001 (ci = 0.725, 0.775)). the mediation analyses showed that the indirect effect of perceived efficacy on compliance via self-efficacy was positive (0.034) and the bootstrapped 95% ci did not include 0 (0.026, 0.044). furthermore, the covariates age, education, and personality dysfunction were significant: the first showed a positive association with behavioral compliance, whereas the others showed a negative association with the outcome variable. the final mediation model explained 60% of the total variance in compliance with the health measures: 97% of the total effect on compliance was explained by the direct effect of perceived efficacy, whereas 3% was explained by the indirect effect of the mediator. the results of the moderated mediation model related to conditional indirect effects, as presented in table 4 . research question 2 was partially confirmed: risk perception emerged as a significant moderator in the relationship between the perceived efficacy of the recommended health measures and compliance (research question 2a), whereas no moderation effects of this variable emerged in either the relationship between perceived efficacy and self-efficacy or the relationship between self-efficacy and compliance (research questions 2b and 2c). similar results were found for the moderating role of civic attitudes. as shown in table 4 , this variable moderated the direct effect of perceived efficacy on compliance (research question 3a). however, no significant effects were found in the relationship between perceived efficacy and self-efficacy or the relationship between self-efficacy and compliance (research questions 3b and 3c). further, older age, lower educational levels, and lower personality dysfunction emerged as significant covariates that were positively associated with higher behavioral compliance. as shown in figure 2 , the simple slope analysis found that the positive relationship between perceived efficacy and behavioral compliance was significant (b = 0.78, p < 0.001) under both high (+1 sd) and low levels of perceived risk (−1 sd) to predict individuals' compliance with the covid-19 protective measures based on the collected psychosocial variables (rq1), participants were split into two classes: high compliance and low compliance. the cut-off for low versus high compliance was set to a total compliance score (i.e., the sum of the scores of all items concerning application of the safety measures) of 30, representing the midpoint of the total compliance score range (i.e., . thus, the low compliance class included participants with a total compliance score ≤ 30 (n = 171); the high compliance class included participants with a total compliance score > 30 (n = 2595). we followed the recommended procedure to ensure model generalization and to increase the replicability of the results, by splitting the data into two sets: a training set (used to train and validate the model) and a test set (used to test model accuracy on examples that had never been seen by the ml classifier) [54, 62] . in the present study, a percentage split of 80:20 training to test data was applied, with participants randomly assigned to one or the other set while maintaining the proportion between classes. therefore, the training set consisted of 2213 participants (2076 high compliance and 137 low compliance), and the test set consisted of 553 participants (519 high compliance and 34 low compliance). all the 14 collected variables were entered in the ml models as predictors: gender, age, education, work position, marital status, citizenship, child(ren), home/work, going out per day, selfefficacy, risk perception, civic attitudes, perceived efficacy, and personality disfunction. using these 14 predictors, ml algorithms were run and validated on the training sample (n = 2213) using a 10fold cross-validation procedure. specifically, k-fold cross-validation was used; this resampling compliance figure 2 . simple slope analysis of the effect of perceived risk and civic attitudes on the relationship between perceived efficacy and compliance. to predict individuals' compliance with the covid-19 protective measures based on the collected psychosocial variables (rq1), participants were split into two classes: high compliance and low compliance. the cut-off for low versus high compliance was set to a total compliance score (i.e., the sum of the scores of all items concerning application of the safety measures) of 30, representing the midpoint of the total compliance score range (i.e., . thus, the low compliance class included participants with a total compliance score ≤ 30 (n = 171); the high compliance class included participants with a total compliance score > 30 (n = 2595). we followed the recommended procedure to ensure model generalization and to increase the replicability of the results, by splitting the data into two sets: a training set (used to train and validate the model) and a test set (used to test model accuracy on examples that had never been seen by the ml classifier) [52, 60] . in the present study, a percentage split of 80:20 training to test data was applied, with participants randomly assigned to one or the other set while maintaining the proportion between classes. therefore, the training set consisted of 2213 participants (2076 high compliance and 137 low compliance), and the test set consisted of 553 participants (519 high compliance and 34 low compliance). all the 14 collected variables were entered in the ml models as predictors: gender, age, education, work position, marital status, citizenship, child(ren), home/work, going out per day, self-efficacy, risk perception, civic attitudes, perceived efficacy, and personality disfunction. using these 14 predictors, ml algorithms were run and validated on the training sample (n = 2213) using a 10-fold cross-validation procedure. specifically, k-fold cross-validation was used; this resampling procedure seeks to reduce variance in the model performance estimation by using a single training set and a single test set. it portions the sample into k = 10 subsets (folds), using 9 of them to train the model and the remaining subset to validate its accuracy. this procedure is repeated k = 10 times, with 1-fold left out each time as a validation set [61] . the final model metrics are obtained by averaging the metrics of the k = 10 validation subsets. finally, the models developed through the 10-fold cross-validation were tested on the test sample (n = 553). specific ml algorithms were selected to represent different classification strategies: logistic regression [62] , support vector machine [63] , naïve bayes [64] , and random forest [65] . this ensured that the results were stable across classifiers and did not depend on specific model assumptions. in running the classification algorithms, the class imbalance problem was addressed. ml methods work best with balanced datasets-a condition that is rarely met within scientific research with human subjects [66] . a different number of instances across classes may lead to an overall correct classification into the majority class and a complete misclassification of instances into the minority class. in the present research, the two classes were extremely unbalanced, with a ratio of 1:15 between the high compliance and low compliance groups. one strategy to overcome class imbalance consists of altering the relative costs associated with misclassifying the minority and majority classes, in order to compensate for the imbalance [67] . following this methodology, in the present study, the ml algorithms were designed in such a way that an error in classifying the minority class (low compliance) was weighted 15 times more than an error in classifying the majority class (high compliance). this cost-modifying strategy has been shown to provide better results in addressing class imbalance than other methods, such as random oversampling of the minority class or random undersampling of the majority class [67] . moreover, it should be noted that, for the goal of this task, it was more beneficial to obtain a lower number of false negatives than false positives; likewise, it was more beneficial to have a model with high sensitivity rather than high specificity. in other words, it was more important to not miss people with low compliance than to misclassify people as high compliance. the final classification results of the 10-fold cross-validation and test set are reported in tables 5 and 6 , respectively. the models' predictive performance was quantified using the following metrics: roc area, accuracy, precision, recall (or sensitivity), and f-measure (f1 score). of note, the classifiers showed an roc area in the range of 0.82-0.91 in the test set. however, random forest and naïve bayes classifiers highlighted a lower recall for low compliance compared to other classifiers, making them weaker models for the purposes of prediction. finally, to investigate the weight of the 14 predictors in the models, here we report the point-biserial correlation (r pb ) between the outcome and each predictor: perceived efficacy = 0.547; self-efficacy = 0.173; age = 0.104; going out per day = 0.101; perceived risk = 0.100; civic attitudes = 0.095; work/home = 0.080; child(ren) = 0.079; education = 0.077; marital status = 0.076; personality dysfunction = 0.072; gender = 0.060; work position = 0.057; citizenship = 0.029. public willingness to comply with the protective health measures proposed by authorities is critical for controlling the outcomes of an infectious disease outbreak. the situation in many countries during the current covid-19 pandemic indicates that, despite legal penalties and mass information campaigns, not all citizens have adopted the recommended behaviors to prevent the spread of the virus. thus, the present study sought to identify which psychological and psychosocial factors might improve compliance. the results confirmed our first research question, showing that self-efficacy significantly mediated the relationship between perceived efficacy and compliance. stated differently, our findings suggest that individuals who perceive themselves as able to carry out (i.e., those with self-efficacy) those behaviors judged as effective in reducing the threat (i.e., behaviors with perceived efficacy) are more likely to comply with the government measures. this finding highlights the key role of self-efficacy in the adoption and maintenance of recommended health actions [21] and suggests a relationship between self-efficacy and compliance with the preventive measures during the covid-19 pandemic, as previously reported for different populations (e.g., healthcare workers) [68, 69] . furthermore, some covariates were also significant: older age, lower education levels, and lower levels of personality dysfunction were all associated with increased compliance. these results parallel preliminary findings on the covid-19 outbreak, indicating that younger persons and those with higher education levels are less likely to comply with the recommended measures, especially those related to hygiene [70] . to the best of our knowledge, this study represents the first attempt to provide data on the association between personality functioning and compliance with health measures. the findings suggest that overall personality functioning may be significant in influencing individuals to adopt the protective measures recommended by authorities. for this reason, personality functioning should be assessed more frequently, and those already known to have a personality impairment (e.g., clinical patients) should be supported and controlled more promptly than others. our second and third research questions were only partially confirmed: on the one hand, risk perception and civic attitudes as moderators made the mediation of self-efficacy insignificant, thereby invalidating research questions 2b, 2c, 3b, and 3c. with respect to this unexpected result, we propose that the two relevant moderators made self-efficacy less important in influencing compliance with the health measures; however, further research investigating the associations between these variables is recommended. on the other hand, both risk perception and civic attitudes were found to significantly moderate the relationship between perceived efficacy and compliance. thus, the impact of perceived efficacy on compliance varied in accordance with risk perception and civic attitudes, thereby confirming research questions 2a and 3a. as the moderation coefficient for both constructs was positive, higher risk perception and civic attitudes were associated with a stronger effect of perceived efficacy on compliance. regarding risk perception, this result is in line with previous studies reporting a strong association between risk perception and changes in (or maintenance of) health behaviors in a variety of contexts, including epidemic/pandemics [26] [27] [28] 71] . with respect to civic attitudes, this is a novel finding of our study, as such attitudes have not previously been studied in the context of pandemic behavioral responses. the current finding of a link between civic attitudes and preventive health actions suggests the importance, for instance, of teaching civic education in the early school grades. finally, as regards the ml classification models outcome (rq1), it has been shown that the above-mentioned psychological and psychosocial variables are able to predict which individuals have high versus low compliance, with an roc area in the range of 0.82-0.91 and high sensitivity for the target class (low compliance). taken together, the results of the moderated mediation and ml models underline that the most important variable for compliance with the recommended health behaviors is perceived efficacy, as has been consistently indicated by previous studies on behavioral responses to epidemics [15, 16, 28] . this result suggests that, to foster compliance, communications regarding covid-19 containment measures should focus on perceived efficacy by highlighting the utility of the recommended behaviors. overall, our results indicated significantly lower scores in behavioral compliance compared to efficacy perception. the introduction of risk perception and civic attitudes as moderators rendered the mediating effect of self-efficacy insignificant. the impact of perceived efficacy on the adoption of recommended behaviors varied in accordance with risk perception and civic engagement. finally, the ml classification models' outcome showed that the psychological and psychosocial variables considered are able to predict which individuals have high versus low compliance. the present results should be interpreted with caution, due to some limitations. first, the cross-sectional study design, implemented during the first phases of the covid-19 outbreak in italy, prevented us from drawing causal inferences. we were unable to assess individuals' psychological functioning before the virus spread, and we were similarly unable to report behavioral compliance with the recommended health measures in more advanced phases of the outbreak. furthermore, the data collection via a web-based survey relied on voluntary sampling and self-reported data; thus, the data may be distorted by selection or social desirability biases. indeed, the survey clearly indicated the health authority recommendations (i.e., "it is suggested that . . . "). thus, by disagreeing with the written precautions, participants would have revealed their violation of the official recommendations. given that such violations would have been seen as socially undesirable, participants may have been reluctant to disclose this. despite these limitations, our findings have several significant implications due to the lack of relevant research on targeted interventions to enhance public compliance with government health recommendations during the covid-19 outbreak. government awareness communications and campaigns regarding covid-19 and related protective measures should be tailored to specific segments of the population, as defined by age and level of education. furthermore, countries affected by covid-19 should consider relevant psychological dimensions alongside their lockdown protocols [72] . in particular, government strategists may use the findings of the present study on the psychological characteristics of people who do and do not comply with the containment measures (i.e., perceived efficacy, risk perception, civic attitudes) to target their covid-19 communications more effectively. overall, we believe that our findings will be helpful in guiding age-tailored information/advertising campaigns in countries affected by covid-19 and directing further research on behavioral compliance. funding: this research received no external funding. the authors declare no conflict of interest. monitoring the level of government trust, risk perception and intention of the general public to adopt protective measures during the influenza a (h1n1) pandemic in the netherlands the effect of risk perception on the 2009 h1n1 pandemic influenza dynamics emergency committee regarding the outbreak of novel coronavirus (2019-ncov) a nationwide survey of psychological distress among italian people during the covid-19 pandemic: immediate psychological responses and associated factors the effect of the covid-19 lockdown on parents: a call to adopt 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in switzerland: insights from a longitudinal cohort study the dynamics of risk perceptions and precautionary behavior in response to 2009 (h1n1) pandemic influenza incremental conditions of isolation as a predictor of suicide in prisoners this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-264798-s31gncge authors: lu, tingting; lane, matthew; der horst, dan van; liang, xin; wu, jianing title: exploring the impacts of living in a “green” city on individual bmi: a study of lingang new town in shanghai, china date: 2020-09-28 journal: int j environ res public health doi: 10.3390/ijerph17197105 sha: doc_id: 264798 cord_uid: s31gncge urban planning and design in the 21st century is increasingly focusing on sustainability, illustrated by the proliferation of greener cities. while operational definitions and the actual planning of these cities can vary considerably (e.g., eco cities and low carbon cities), conceptually, at least, these terms overlap, particularly with regard to how they attempt to achieve both greener infrastructural design and healthier human lifestyles. this paper presents the findings of survey-based research carried out within lingang new town in shanghai in 2019. in the cities of the global north, the interplay between green infrastructural provision and public health has been of interest, especially in the context of social inequalities; however, there is little research from rapidly urbanizing countries where green urbanism is being increasingly promoted. using this newly constructed example, we identified a clear positive correlation between moving to a green city and the adoption of healthier lifestyles. the structural equation modelling results suggest that behaviors around the use of green space as well as perceptions of different green space have notable impacts on residents’ physical health, measured by body mass index (bmi). the findings further illustrate systemic inequalities among private housing, rental housing and public housing typologies with regard to the distribution of health benefits. urban planning in the 21st century is increasingly focused on sustainability and health [1, 2] . this is evidenced by use of terms such as green, eco and low carbon cities across different regions. in principle, these cities are defined by having greener economies, resource consumption, landscapes and communities than traditional cities. while operational definitions and actual configuration can vary considerably, conceptually, at least, these terms overlap with regard to how they attempt to achieve healthier human lifestyles [3] [4] [5] . the emergence of sustainable urban planning for health can be traced back to the 20th century when ebenezer howard planned "garden cities" in the uk and lewis mumford promoted "the city beautiful movement" in the us [6, 7] . these planning practices depended to an important extent on the provision of safe and accessible green space, as well as people's opportunities to seek local healthy recreation options. urban planning's emphasis on environmental factors has sustained in many regions, with exemplars such as freiburg in germany and hammarby in sweden, practicing sustainable design for better lives [8, 9] . lately there has been a rise in sustainable urban planning that seeks to invoke "green dreams" against a backdrop of "grey realities" in china [10, 11] . this is urgently needed for chinese cities as societal and economic development is fundamentally constrained by environmental capacities. the sustainable planning practices are particularly seen in the recent construction of holistically designed green cities across the country [12, 13] . existing studies record that over a hundred green cities have been proposed by local governments in china [14] [15] [16] . recently, a development scheme of one thousand sustainable communities has been launched by the national development and reform commission [12] . to date, however, few studies have inquired about the social implications of sustainable urban planning in china. one exception is a study of the famous case of sino-singapore tianjin eco-city, which argued these costly sustainable constructions fail to consider the fate of more marginalized and deprived communities [17] . beyond this, there is a lack of sufficient focus on the lived experience of residents in newly constructed green cities. the extent to which sustainable urban planning is leading to greener and healthier lifestyles by local inhabitants, remains under-researched. a plethora of previous studies found significant relationships between the quality of green space constructed and certain health outcomes, such as obesity, depression, diabetes and cancer [2, [18] [19] [20] [21] [22] [23] . meanwhile, a considerable plurality and complexity exists in attempting to define what constitutes "quality" green space in terms of the health benefits it can provide in both an environmental (through eco-system services) and a socio-cultural (through recreation and community-building) sense [24] [25] [26] [27] [28] [29] . the former often measures green space quality by its amounts, planting densities, and gradient vegetation structures, using the satellite image-based normalized difference vegetation index (ndvi) or deep learning-based image segmentation techniques [26, [30] [31] [32] . the latter (socio-cultural) theme analyzes residents' exposure to green space from both behavioral and attitudinal perspectives [27, 31, [33] [34] [35] . in this form, positive exposure to green space nurtures social networking, exercising, leisure, or even commercial and political functions activities. for example, the quality and quantity of amenities in community green space has a negative relationship with obesity prevalence [36] . secondly, green space users develop subjective perceptions based on the extent their needs are satisfied by the exposure to green space [37] . encompassing the multi-faceted relationship between green space exposure and urban health outcomes, scholars have argued that a "socio-ecological framework" has emerged as standard practice within the field. in such a framework, the lived experience of green space is identified as one of the most important factors for unlocking health benefits [24] . the existing literature has recognized the inequality of health benefit distribution among different social groups in terms of age, race, gender, and income [38] [39] [40] [41] [42] . few studies have explored this systemic inequality in the benefits derived from green space from the perspective of housing modes, however. previous research in this area has only examined the variation in housing conditions and its impact on health in isolation [36, 41, 43, 44] . in a newly constructed green city, housing mode or housing tenure choice may be associated with health through several potential pathways. first, green cities with sustainable planning methods provide accessible and quality green space as residential advantages to attract new inhabitants. this is similar to the creation of aesthetic suburban new towns that aim to decentralize a city's central population by the provision of suburban landscapes [45, 46] . the positive exposure to green space may encourage residents to purchase or rent housing in the green city. second, different housing modes are associated with various greening intervention in terms of green space proximity, green space types and green space quality. prior studies have shown that public housing units often have little or no vegetation while private housing in gated communities guarantees access to exclusive and amplified green space [36, 47, 48] . consequently, public housing tenants and private housing owners develop different exposure to and perception of green space. the variation in housing mode nurtures distinct lifestyles in terms of exercising and leisure, leading to different public health outcomes. for example, a public housing tenant may suffer from problems of obesity [36] . conversely, a homeowner of a gated community may enjoy high-end green provisions and thus develop a positive sense of wellbeing [49] . housing mode thus may serve as a mediation variable between one's green lifestyle and their level of health. this paper aims to examine residents' health benefits from moving to a brand-new green city-lingang new town (lnt)-in shanghai, thereby providing existing discussions on the relationship between sustainable urban planning and health with a new perspective rooted in housing modes. lnt is one of the most strategically important mega-urban projects in china [50] [51] [52] . it is located 30 km southeast of central shanghai, on land reclaimed from the sea, covering an area of 315 km 2 . historically, it was a peripheral farming area, and developed modern fish farming to feed shanghai during its rapid industrialization. as part of suburbanization, lnt framed its agenda as a new "garden city" in 2002, emphasizing an environmental message as part of this narrative [53] . five functional zones have been planned, with a central residential zone and a heavy-equipment manufacturing zone providing a modern environment while the rest of the zones remain as traditional townships. the original planning of lnt aimed to attract 0.8 million new residents by the end of 2020 [52] . in 2010, lnt was upgraded to a low carbon plot city by the shanghai municipal government [54] . many pivotal green infrastructural constructions began to unfold at this stage. among them, 8.6 km of greenways for walking and cycling, as well as the artificial dishui lake park of 5.6 km 2 , and an affiliated 20 km 2 of green space in the central residential zone, were presented as strategically important green infrastructure. quickly, high-quality green space extended into different functional zones, covering over 30% of the land use, turning lnt into a much greener area than much of metropolitan shanghai. recently, shanghai municipal government consulted a uk-based design company (arup) and local planning institutions to reinforce lnt as a landmark of global green development, with ambitions for green space and waterfront space to cover 65% of its land area [55] . meanwhile, the administrative committee of lnt has endeavored to advertise a green lifestyle and culture to the public, for which better health outcomes for residents act as a clear incentive [54] . the case study of lnt offers unique access to the physical health and green space perspectives of residents who have taken the decision to move to a new urban area explicitly targeting sustainable urban planning outcomes. our intellectual contribution is therefore twofold. firstly, we take a nuanced and attentive approach to the socio-cultural dimension of green cities, exploring the perception, behavior, and health of people who come to reside in these green spaces. secondly, from an urban planning perspective, we elevate the importance of indicators of health outcomes in assessing the value-added of urban green space planning and delivery in brand new green cities. using body mass index (bmi) as an indicator, we hypothesize that an individual's health level is affected by the experience of green space, and such a relationship is mediated by one's housing tenure choice. as shown in figure 1 , this paper examines both the direct effects of green space exposure and the indirect effects mediated by housing mode on bmi by using the structural equation modelling method. this paper aims to examine residents' health benefits from moving to a brand-new green city-lingang new town (lnt)-in shanghai, thereby providing existing discussions on the relationship between sustainable urban planning and health with a new perspective rooted in housing modes. lnt is one of the most strategically important mega-urban projects in china [50] [51] [52] . it is located 30 km southeast of central shanghai, on land reclaimed from the sea, covering an area of 315 km 2 . historically, it was a peripheral farming area, and developed modern fish farming to feed shanghai during its rapid industrialization. as part of suburbanization, lnt framed its agenda as a new "garden city" in 2002, emphasizing an environmental message as part of this narrative [53] . five functional zones have been planned, with a central residential zone and a heavy-equipment manufacturing zone providing a modern environment while the rest of the zones remain as traditional townships. the original planning of lnt aimed to attract 0.8 million new residents by the end of 2020 [52] . in 2010, lnt was upgraded to a low carbon plot city by the shanghai municipal government [54] . many pivotal green infrastructural constructions began to unfold at this stage. among them, 8.6 km of greenways for walking and cycling, as well as the artificial dishui lake park of 5.6 km 2 , and an affiliated 20 km 2 of green space in the central residential zone, were presented as strategically important green infrastructure. quickly, high-quality green space extended into different functional zones, covering over 30% of the land use, turning lnt into a much greener area than much of metropolitan shanghai. recently, shanghai municipal government consulted a ukbased design company (arup) and local planning institutions to reinforce lnt as a landmark of global green development, with ambitions for green space and waterfront space to cover 65% of its land area [55] . meanwhile, the administrative committee of lnt has endeavored to advertise a green lifestyle and culture to the public, for which better health outcomes for residents act as a clear incentive [54] . the case study of lnt offers unique access to the physical health and green space perspectives of residents who have taken the decision to move to a new urban area explicitly targeting sustainable urban planning outcomes. our intellectual contribution is therefore twofold. firstly, we take a nuanced and attentive approach to the socio-cultural dimension of green cities, exploring the perception, behavior, and health of people who come to reside in these green spaces. secondly, from an urban planning perspective, we elevate the importance of indicators of health outcomes in assessing the value-added of urban green space planning and delivery in brand new green cities. using body mass index (bmi) as an indicator, we hypothesize that an individual's health level is affected by the experience of green space, and such a relationship is mediated by one's housing tenure choice. as shown in figure 1 , this paper examines both the direct effects of green space exposure and the indirect effects mediated by housing mode on bmi by using the structural equation modelling method. the data for this paper were collected by a household questionnaire survey conducted in lnt from march to may 2019. a stratified sampling method was applied because lnt planned two residential areas, namely a new residential area and a traditional residential area (see figure 2 ). the former was near the dishui lake, mostly in the form of high-rise buildings that were affiliated with community gardens and accessible parks. in contrast, the latter residential area consisted of smaller and older neighborhoods in three towns, with less provision for green spaces of all kinds. the data for this paper were collected by a household questionnaire survey conducted in lnt from march to may 2019. a stratified sampling method was applied because lnt planned two residential areas, namely a new residential area and a traditional residential area (see figure 2 ). the former was near the dishui lake, mostly in the form of high-rise buildings that were affiliated with community gardens and accessible parks. in contrast, the latter residential area consisted of smaller and older neighborhoods in three towns, with less provision for green spaces of all kinds. the new residential area surveyed included eight neighborhoods with a total of 17,494 registered households. we selected three out of the eight neighborhoods with the highest occupation rate and distributed 100 questionnaires to each as an indoor household survey. questionnaires were submitted for completion by new inhabitants, either heads of households or their spouses. the traditional residential area surveyed had 42 neighborhoods with a total of 16,877 registered households. we distributed 150 questionnaires in four public spaces, aiming to seek new inhabitants of lnt in the wide range of neighborhoods in this residential area. all questionnaires were completed onsite. in total, we achieved 427 full responses of which 403 were deemed valid after missing value processing. the questionnaire included questions relating to residents' socio-demographic status, housing profiles, health and lifestyle. specifically, the following set of variables was measured: (1) outcome variable: individual bmi was used as the outcome variable. it is one of the most important proxy indicators used to represent one's physical health level in many relevant studies [23, 29, 56] . respondents were asked to report their height and weight for measuring bmi as a continuous variable. (2) variables of (green) lifestyle: both behaviors and perceptions related to the exposure of green space in lnt were measured in this research to reflect people's green lifestyles. the behavior aspect was measured by querying residents' frequency of using green space before moving to lnt and their current use of green space in lnt, with four-scale answers provided (1 = "less than once a week", 2 = "once or twice a week", 3 = "three to six times a week", 4 = "everyday"). we inspected residents' perceptions of green space in lnt in seven dimensions that were acknowledged as green space's key functions in the sustainable urban planning code: exercising, safety, accessibility, social interaction, commerce, public events, and environment quality. specifically, residents were asked four sets of questions, including to what extent the specific dimension of green space is important to them, and to what extent they are satisfied with every the new residential area surveyed included eight neighborhoods with a total of 17,494 registered households. we selected three out of the eight neighborhoods with the highest occupation rate and distributed 100 questionnaires to each as an indoor household survey. questionnaires were submitted for completion by new inhabitants, either heads of households or their spouses. the traditional residential area surveyed had 42 neighborhoods with a total of 16,877 registered households. we distributed 150 questionnaires in four public spaces, aiming to seek new inhabitants of lnt in the wide range of neighborhoods in this residential area. all questionnaires were completed onsite. in total, we achieved 427 full responses of which 403 were deemed valid after missing value processing. the questionnaire included questions relating to residents' socio-demographic status, housing profiles, health and lifestyle. specifically, the following set of variables was measured: (1) outcome variable: individual bmi was used as the outcome variable. it is one of the most important proxy indicators used to represent one's physical health level in many relevant studies [23, 29, 56] . respondents were asked to report their height and weight for measuring bmi as a continuous variable. (2) variables of (green) lifestyle: both behaviors and perceptions related to the exposure of green space in lnt were measured in this research to reflect people's green lifestyles. the behavior aspect was measured by querying residents' frequency of using green space before moving to lnt and their current use of green space in lnt, with four-scale answers provided (1 = "less than once a week", 2 = "once or twice a week", 3 = "three to six times a week", 4 = "everyday"). we inspected residents' perceptions of green space in lnt in seven dimensions that were acknowledged as green space's key functions in the sustainable urban planning code: exercising, safety, accessibility, social interaction, commerce, public events, and environment quality. specifically, residents were asked four sets of questions, including to what extent the specific dimension of green space is important to them, and to what extent they are satisfied with every dimensional function of green space of a specific kind. three kinds of green space were inspected, respectively, namely community gardens (in community), small parks (nearby community), and large parks, covering most of the green infrastructure types in lnt. answers on a likert scale were provided for these 28 questions, with the score ranging from 1 (indicating extremely unimportant/unsatisfied) to 7 (indicating extremely important/satisfied). (3) housing mode variable: residents' housing tenure choice in lnt was measured to constitute the housing mode variable. overall, there were three housing modes identified, namely private housing, rental housing and public housing. the private housing mode referred to residents who owned a local private property. the rental housing mode referred to tenants who rented from the housing market. public housing mode represented tenants who obtained subsidized housing provided by the local government. this housing mode was mostly provided to employees of state-owned enterprises in lnt as temporary accommodation. (4) covariates: respondents' individual profiles were considered as confounding variables. in terms of socio-demographic status, we surveyed the heads of household or their spouses for age, gender, marital status, hukou status, educational level and the household monthly income level. it is important to note that hukou status is one of the most crucial indicators of individual socio-economic capabilities. hukou is a household registration system in china that defines one's right to different socio-economic benefits. for example, the hukou origin determines the access to local socio-economic welfare support, such as education allowances and medical care. furthermore, only non-agricultural hukou holders can have urban welfare support, which is of a much higher standard than rural forms. in this research, we defined a respondent as a migrant if his/her hukou origin was outside shanghai. the type of hukou was categorized into agricultural and non-agricultural based on the type of hukou registration. a respondent with a college or above degree was regarded as having a high educational level. household monthly income in chinese currency "rmb" was classified into six levels (1 = "less than 1000", 2 = "1000-4999", 3 = "5000-10,000", 4 = "10,001-20,000", 5 = "20,001-30,000", 6 = "more than 30,000"). as for factors of work and life, we measured respondents' job type, commuting time, amount of spare time and length of time spent living in lnt. specifically, working for the public sector was considered as a stable job type in chinese cities. one's amount of spare time was likely to be affected by his/her employment status and commuting time. the residence length in lnt helped to verify respondents as new inhabitants of lnt. (5) control variable: a few variables relating to the lived experience in lnt were considered as control variables for analyzing bmi. first, respondents were asked to report their subjective perception of individual health, ranging from "completely unhealthy", "relatively unhealthy", "relatively healthy", to "completely healthy". the walking time from home to the nearest green space was surveyed, with four answers provided (1 = "less than 10 min", 2 = "11-20 min", 3 = "21-30 min", 4 = "more than 30 min"). structural equation modelling was used to estimate the effect of green lifestyles on one's bmi with housing mode acting as a mediation variable. individual socio-economic status was considered as covariates influencing housing mode and bmi, respectively. given that bmi can also be affected by the location of green space and subjective health level, both the walking time to nearest green space and the self-reported health level were added as control variables. table 1 shows residents' socio-economic profiles, exposure to green space and health level by housing mode. private, rental and public housing modes, respectively, occupy 56.8%, 29.3%, and 13.9% of the surveyed households. the private housing mode reports the highest proportions for variables of married (84.7%) and non-agricultural hukou (86.0%) as well as a relatively senior average age, compared to the rest. the rental housing mode provides accommodation for the largest proportions of the migrants (77.1%), the agricultural hukou holders (43.2%), and households of relatively lower income as compared to other housing modes. the public housing mode concentrates the highly educated (89.3%), and high-income earners, and the single and young as compared to the rest. in terms of work and life, the private housing mode has the highest proportion of full-time workers (88.2%) and the longest work-home travel duration. many residents of the private housing mode may have less spare time than their counterparts of other housing modes. with regard to the green lifestyle variables, residents of the public housing mode have the highest frequency of using green space both before moving to lnt and currently, despite having the longest travel time to the nearest green space. residents of the rental housing mode report a higher level than others for self-evaluated health and the experience of green space in lnt. with regard to local health, it is identified that the average bmi score of the sampled 403 respondents is 22.6, ranging from 15.6 to 32.9. according to the bmi standards announced by the chinese ministry of health, low weight, normal weight, overweight, and obesity are, respectively, considered as bmi < 18.5, 24 > bmi ≥ 18.5, 28 > bmi ≥ 24 and bmi ≥ 28 [57] . the results of our survey show that 66.0% of the respondents have a healthy weight, while 6.0% of the respondents are of a low weight, 24.5% are overweight and 3.5% are obese. according to the national health and family planning commission, the adult overweight rate was around 30.1% and the obesity rate was about 11.9% in 2012 in china [56] . it seems that respondents in lnt demonstrate a relatively positive level of health in terms of bmi, as the rates of overweight and obese individuals are 5.6% and 4.8% less than the national average. table 2 demonstrates that moving to lnt is improving residents' behavior regarding green space use. this is indicated by the relative change of frequency in using green space before and after moving to lnt. the majority (57.3%) of respondents barely used green space before (i.e., once every several weeks), but this group has now dropped to a minority of 39.0%. that means that about a third of these previously inactive residents (in terms of green space) have changed their behavior and are now weekly green space users. those who reported using green space multiple times a week almost doubled, with "1-2 times per week use" rising by 48.1% and "3-6 times per week use" rising by 46.3%. the small group of residents who reportedly used green space every day did not change much, increasing only by 14.5%. if we assume that increased green space use is a proxy indicator for a greener lifestyle, then we can posit that the move to lnt was particularly beneficial to those who were relatively inactive. furthermore, principle component analysis was employed to reduce the dimensionality of residents' perceptions of green space in lnt. table 3 demonstrates five components after applying a varimax rotation. they account for 67.5% of the cumulative variance of 28 attributes. the cronbach's alpha score, and the kaiser-meyer-olkin score, respectively, reach 0.933 and 0.894, showing a high internal consistency of attributes and an effective dimensional reduction effect by the analysis. specifically, component i has high positive loadings on attributes of exercising, safety and environmental quality of community gardens, indicating a group of residents who are satisfied by the exclusive green space provided within communities because of these functions. component ii has high positive loadings on safety and accessibility attributes of small parks located near to communities. in addition to safety and accessibility, component iii reports the attribute of quality environment of large parks as high loadings. the concentration of high loadings is found in the attributes of commerce and public events in green space for component iv, while clustering at other dimensions of value for component vi. two components show contradictory perceptions of green space, that is, while component vi reflects social values provided by green space, component v appreciates the physical values of green space in general. table 4 reflects the results of the structural equation modelling. model 1 shows the direct effect of green lifestyles on the private housing mode and bmi. given that green space perception may have indirect effect on bmi through housing modes, we added the private housing mode as a mediation variable in model 2. we replaced the housing mode with public housing in model 3 for a robustness test. model fit statistics of the three models reveal a good fit of structural equation modelling. the root mean square error of approximation, respectively, reached 0.060, 0.024, and 0.075, with all three comparative fixed indexes being larger than 0.95. variables relating to green space exposure associate differently to the private housing mode in model 2 and to the public housing mode in model 3. specifically, residents' relative change in frequency of using green space after moving to lnt shows a positive correlation with the private housing mode (β = 0.060, s.e. = 0.028, p = 0.035), but has a negative non-significant effect on the public housing mode after controlling for socioeconomic variables. as for the effects of green space exposure on bmi, perceptions of green space are significantly correlated with bmi in three models. for example in model 2, perception of large parks positively correlates to bmi (β = 0.169, s.e. = 0.087, p = 0.053), while the perception of small parks has a negative association with bmi (β = −0.174, s.e. = 0.100, p = 0.082). with regard to the socio-economic influences on bmi in model 1, females and the highly educated have a significantly lower level of bmi, with the coefficient of gender being −2.092 (p < 0.01) and the coefficient of educational attainment being −1.070 (p < 0.01), compared to the male groups and respondents without a college degree. a one-year increase in age increases individual bmi by 0.054 standard deviation (p < 0.01). socio-economic differentiation is clearly seen in the regressions of the housing mode. the private housing mode is attracting the married (β = 0.162, s.e. = 0.060, p = 0.007) and the non-agricultural hukou holders (β = 0.107, s.e. = 0.060, p = 0.073), while public housing is significantly associated with migrants (β = 0.090, s.e. = 0.039, p = 0.020) and the public sector (β = 0.080, s.e. = 0.038, p = 0.037). more importantly, choosing a private housing mode is found to have a direct and positive effect on respondents' bmi (β = 0.617, s.e. = 0.279, p = 0.027), even with the time to the nearest green space and the level of self-evaluated health held constant. model 3 reports the results with the public housing mode replacing the private housing mode. in contrast to private housing, the public housing mode negatively affects individual bmi (β = −0.947, s.e. = 0.367, p = 0.009). relations between the experience of green lifestyles and individual bmi are not altered when the housing mode is replaced, thus demonstrating the robustness of the model results. there are three main findings regarding the health outcomes of sustainable urban planning in this study. first, we find evidence that more green space nurtures healthier lifestyles. this is illustrated by the fact that a large proportion of previously inactive groups (e.g., used green space once a few weeks) have been encouraged to use green space at a higher frequency than previously. the adoption of green lifestyle choices from green space exposure is likely to be stimulated by effective sustainable urban planning for green infrastructure, as the prior literature suggests [58] . in the case of lnt, green space has been made accessible near residences for the majority of the new population, as this survey revealed that over 80% of residents were able to access green space within 20 min by walking. to a certain extent, lnt has been transformed from an industrial land at the urban periphery to a green new town with healthier lifestyles through the ample provision of green infrastructure. second, sustainable urban planning generates varied perceptions regarding green space exposure. the provision of safe, accessible, and high-quality green space appears to meet residents' demands. importantly, it is the effective exposure to small parks that mitigate against the risks of becoming (or staying) overweight and obese. in lnt, the planning and wide distribution of small parks in residential neighborhoods incentivizes many local users on a regular basis. in contrast, large parks may have opposite outcomes because they are of a limited amount and have unequal accessibility to all users. figure 3 displays the predicted negative relationship between small park perception and bmi, the positive relationship between large park perception and bmi, as well as the differences among three housing modes. there are three main findings regarding the health outcomes of sustainable urban planning in this study. first, we find evidence that more green space nurtures healthier lifestyles. this is illustrated by the fact that a large proportion of previously inactive groups (e.g., used green space once a few weeks) have been encouraged to use green space at a higher frequency than previously. the adoption of green lifestyle choices from green space exposure is likely to be stimulated by effective sustainable urban planning for green infrastructure, as the prior literature suggests [58] . in the case of lnt, green space has been made accessible near residences for the majority of the new population, as this survey revealed that over 80% of residents were able to access green space within 20 min by walking. to a certain extent, lnt has been transformed from an industrial land at the urban periphery to a green new town with healthier lifestyles through the ample provision of green infrastructure. second, sustainable urban planning generates varied perceptions regarding green space exposure. the provision of safe, accessible, and high-quality green space appears to meet residents' demands. importantly, it is the effective exposure to small parks that mitigate against the risks of becoming (or staying) overweight and obese. in lnt, the planning and wide distribution of small parks in residential neighborhoods incentivizes many local users on a regular basis. in contrast, large parks may have opposite outcomes because they are of a limited amount and have unequal accessibility to all users. figure 3 displays the predicted negative relationship between small park perception and bmi, the positive relationship between large park perception and bmi, as well as the differences among three housing modes. third, residents' bmi differs among public housing, private housing, and rental housing. this is likely influenced by different lifestyles that relate to a housing tenure choice. private homeowners have a relatively high bmi. they are most likely to be stable and occupied with work, leaving little spare time to experience green space. it is the private housing mode that has the highest proportion of senior and well-established families. this is consistent with national level statistics in china in that obesity and diabetes become more common as residents become older [56] . many rental housing tenants have a lower bmi than owners. this is possibly because tenants are mostly new to lnt, and have a relatively high frequency of using green space because of this (self-identified) excellence in green space provision. especially in public housing, tenants tend to have a low level of bmi. this differs from studies based in a western context in which tenants of public housing can suffer from being overweight [36, 47] . in urban china, green cities are state-led developments, which usually provide government-subsidized housing for accommodating public sector staff and attracting talented workers. in fact, in lnt, many residents in public housing are young and highly educated in the field of low-carbon technological development. however, it is important to note that the unhealthy status of low weight is mostly found in migrants-occupying 66.7%-who live in rental third, residents' bmi differs among public housing, private housing, and rental housing. this is likely influenced by different lifestyles that relate to a housing tenure choice. private homeowners have a relatively high bmi. they are most likely to be stable and occupied with work, leaving little spare time to experience green space. it is the private housing mode that has the highest proportion of senior and well-established families. this is consistent with national level statistics in china in that obesity and diabetes become more common as residents become older [56] . many rental housing tenants have a lower bmi than owners. this is possibly because tenants are mostly new to lnt, and have a relatively high frequency of using green space because of this (self-identified) excellence in green space provision. especially in public housing, tenants tend to have a low level of bmi. this differs from studies based in a western context in which tenants of public housing can suffer from being overweight [36, 47] . in urban china, green cities are state-led developments, which usually provide government-subsidized housing for accommodating public sector staff and attracting talented workers. in fact, in lnt, many residents in public housing are young and highly educated in the field of low-carbon technological development. however, it is important to note that the unhealthy status of low weight is mostly found in migrants-occupying 66.7%-who live in rental housing. being a migrant means having no access to welfare provided for local citizens, e.g., healthcare benefits. discrimination against migrants in health benefit distribution can still be seen in this form of sustainable urban planning. while green cities are expected to play dual roles as economic growth engines while implementing sustainable development in practice, there are increasing concerns about the social outcomes of this global trend within urban planning. particularly, questions around green infrastructure's role as a catalyst for healthy lifestyles through fair and equal access to quality green infrastructure need to be asked [24, 59] . in urban china, the emerging development of green cities has emphasized this infrastructural approach to positive, sustainable outcomes [11, 12, 16] . the pursuit of "green dreams" by motivated residents has been met with considerable investment in sustainable planning and design strategies. illustrating how the design-based provision of green space has encouraged more frequent use by residents after they move in, this study emphasizes the value of not only incorporating green space into the promotion of green lifestyles, but doing so in such a way as to stress how residents experience it in both physical and socio-cultural ways. our analysis yields two conclusions regarding how sustainable urban planning relates to residents' health. first, green city construction is contributing to an objective health level for new residents, represented by relatively high proportion of normal bmi. specifically, bmi is clearly linked to one's socio-economic profile and to green space-related mindsets and behaviors, especially those related to exercising, a sense of safety, and the environmental quality of small parks. second, there is a trend in socio-spatial inequality in terms of the distribution of health benefits. while private homeowners are more likely to have elevated bmi scores, disadvantaged social groups, such as low-skilled migrants, have below normal bmi scores. the unevenness of one's lifestyle and health can be exacerbated by local planning. to avoid marginalizing disadvantaged social groups [17, 52] , green city planning and design should focus on achieving a good distribution of green space access throughout green city neighborhoods, prioritizing this over the construction of larger spaces with prescribed uses for manifestation. a focus should be placed on presenting green space as a "blank canvas", allowing residents to invent a sense of place which harmonizes the physical and socio-cultural benefits of green space access. finally, it is important to couch our findings within the context of the current covid-19 pandemic (as an acute representation of a systemic challenge to urban public health) and the implications this has for both enforced and self-managed behavior changes in how green space is accessed and utilized. in addition to the relationships with green space access and use identified in this study, socio-economic status and bmi have also been shown to indicate various vulnerabilities to the covid-19 risk levels. the need for increased social distancing levels when utilizing green space in order to limit flu-like virus transmission will therefore unevenly impact certain cohorts of the urban population. with an increasing emphasis on the need to "build back better" following the pandemic, new urban developments (anywhere in the world, not just in china) need to pay extra attention to green space provision. how this green space is designed for and utilized by different segments of the urban population will remain an important area for furthering empirical analysis and conceptual understanding. 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and family planning commission of the people's republic of china. the management method of nutrition improvement work exploring health outcomes as a motivator for low-carbon city development: implications for infrastructure interventions in asian cities health implications of environmental and social resources for preadolescents in urban china this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we thank haishan yu for cooperating with the fieldwork. the authors declare no conflict of interest. key: cord-258762-vabyyx01 authors: garbey, marc; joerger, guillaume; furr, shannon title: a systems approach to assess transport and diffusion of hazardous airborne particles in a large surgical suite: potential impacts on viral airborne transmission date: 2020-07-27 journal: int j environ res public health doi: 10.3390/ijerph17155404 sha: doc_id: 258762 cord_uid: vabyyx01 airborne transmission of viruses, such as the coronavirus 2 (sars-cov-2), in hospital systems are under debate: it has been shown that transmission of sars-cov-2 virus goes beyond droplet dynamics that is limited to 1 to 2 m, but it is unclear if the airborne viral load is significant enough to ensure transmission of the disease. surgical smoke can act as a carrier for tissue particles, viruses, and bacteria. to quantify airborne transmission from a physical point of view, we consider surgical smoke produced by thermal destruction of tissue during the use of electrosurgical instruments as a marker of airborne particle diffusion-transportation. surgical smoke plumes are also known to be dangerous for human health, especially to surgical staff who receive long-term exposure over the years. there are limited quantified metrics reported on long-term effects of surgical smoke on staff’s health. the purpose of this paper is to provide a mathematical framework and experimental protocol to assess the transport and diffusion of hazardous airborne particles in every large operating room suite. measurements from a network of air quality sensors gathered during a clinical study provide validation for the main part of the model. overall, the model estimates staff exposure to airborne contamination from surgical smoke and biological material. to address the clinical implication over a long period of time, the systems approach is built upon previous work on multi-scale modeling of surgical flow in a large operating room suite and takes into account human behavior factors. there is a large debate on the possible airborne transmission of coronavirus 2 (sars-cov-2) in closed buildings [1, 2] . we are still understanding the sars-cov-2 spreading but scientists support the hypothesis of airborne diffusion of infected droplets from person to person at a distance that can be greater than two meters [3] . in the unfortunate case an elective surgery is practiced on an asymptomatic covid-19 patient and who was not tested positive, one may ask if the virus can escape an operating room (or) kept under positive pressure and expose staff in peripheral area to the disease. this question is particularly important to healthcare staff who spend multiple long hour shifts in a hospital system that manages covid-19 patients. to quantify airborne transmission from a physical point of view, we consider surgical smoke as a marker of airborne particle diffusion-transportation emitted from the surgical table area. surgical smoke is 95% water or steam and 5% particle material and therefore surgical smoke can act as a carrier for tissue particles, viruses, and bacteria [4] . today, the risk of surgical smoke has clearly been established [5] [6] [7] [8] [9] [10] [11] . one of the main difficulties is that surgical smoke carries ultra fine particles (ufp) as small as 0.01 microns, which are able to bypass pulmonary filtration, and small particles up to several microns [10] . it was recently shown in a study that air quality, especially concentration of fine particles, is associated with an increase in covid-19 mortality [12] . respiratory protection devices are used to protect staff in healthcare facilities with various degrees of success [13, 14] . we propose to construct a rigorous multi-scale computational framework to address these questions and use measurements of diffusion-transportation of surgical smoke particles with off-the-shelf portable sensors to calibrate the model. this methodology addresses only the physical side of the problem and therefore does not answer the effectiveness of airborne particles to induce covid-19. some of the difficulties encountered in such studies are that air sampling and infection may or may not be strongly correlated [15, 16] . however, it is an important step to quantify the level of exposure in order to estimate the corresponding viral load in part. transport and diffusion mechanisms are very effective for ufp to travel a long distance from the source in a short period of time. a 2020 report from china demonstrated that sars-cov-2 virus particles could be found in the ventilation systems in restaurants [17] and in hospital rooms of patients with covid-19 underlining how viable virus particles can travel long distances from patients [18] . clinical environments are too complex to model with the traditional modeling method of airflow and particle transportation because both the source intensity of surgical smoke [19] as well as the mechanism of propagation via door openings [20] are largely dominated by human factors. the geometric complexity of the infrastructure and of the heating, ventilation, and air conditioning (hvac) system limit the capability of computational fluid dynamics (cfd) [20, [20] [21] [22] [23] [24] [25] [26] to predict indoor air quality and health [27] . last but not least, droplet behavior depends not only on their size, but also on the degree of turbulence and speed of the gas cloud, coupled with the properties of the ambient environment (temperature, humidity, and airflow) [2] . we present in this paper a mathematical framework and experimental protocol to assess the transport and diffusion of hazardous airborne particles in any large or suite. human behavior factors are taken into account by using a systems and cyber-infrastructure approach [28] [29] [30] coupled to a multi-scale modeling of surgical flow in a large or suite [31] . overall, the model estimates staff's exposure to airborne contamination, such as surgical smoke or biological hazard. validation is provided by a network of wireless air quality sensors placed at critical locations in an or suite during the initial phase of the surgical-suite-specific study. a step-by-step construction of the model scaling up from the or scale to the surgical suite scale will be presented; the model integrates the transport mechanism occurring at the minute scale with the surgical workflow efficiency simulation over a one year period. to assess potential contamination from one or to another, the extent of the propagation of surgical smoke in the area adjacent to the or will be checked-this might be more significant than the level of concentration itself. to simulate the airflow and dispersion of surgical smoke, an or that is representative of the surgical suite shown in figure 1 was used. measurements for calibrations and verifications were conducted in a real or of this dimension when there were no surgeries taking place. figure 2 provides the schematic of all boundary conditions and geometric parameters. this cfd approach is used to justify and build a simplified large-scale model of the airflow in the surgical suite. a 3d cartesian coordinate system was used with length along the x-direction, width along the y-direction, and height along the z-direction. the or is 7.5 m long, 6 m wide, and has a height of 2.7 m (see figure 2 ). the model takes into account the architecture of the room, the operating table location, and the hvac system design in the or as well as in the hallway. the corridor was modeled as a rectangle of 12 m long, 2.5 m wide and a height of 2.7 m. the operating table is displayed as a rectangle in the middle of the or, and the anesthesia equipment is also simulated by a rectangle that is close to the table. the computation of the flow was done by using a pressure based solver and an ansys fluent solver in steady states first and then transient mode after. the model's geometry was meshed using an unstructured tetrahedral grid with about 10 6 elements. the exact size of the mesh depends on the angle of the door with its initial closed position since the mesh gets refined at the interfaces. the airflow is assumed to be turbulent [25] and was modeled using the k − turbulence model, taking into account gravity to introduce the boussinesq approximation in the navier-stokes equation. it is the most common model for indoor airflow simulation in which the turbulent kinetic energy k and turbulent dissipation rate are modeled. the temperature and pressure boundary conditions in the model were measured and are reported in the result section of this paper. typically, the or is kept cooler than the hallway, and the inlet vent inside the or blows air at a temperature as low as 13 • c. to match the ventilation infrastructure, the model has three different rows of inlet vents in the ceiling. the first row of 4 inlets is in the middle of the room. it blows on top of the surgical table a laminar flow directly on the surgical table to remove as fast as possible any contaminant close to the patient. in our model, one inlet vent is represented by 2 rectangles of 0.5 by 0.1 m each. then, there are two rows of three inlet vents on each side of the one on top of the or table: one on the left (1.7 m from the center of the or table) and one on right (1.5 m from the middle of the or table, see figure 2 . those are present to avoid any flow returning towards the operating table. the slightly different velocity flows for each inlet were implemented (see result section) in order to replicate the anemometry measurement (via peak meter ms6252b with an accuracy of ±2.0%) obtained near these inlets-it was noticed that the large surgical lights over the surgery field have the tendency to obstruct part of the inlet flow. the or also contains two outlet vents represented by two rectangles of 0.9 by 0.6 m placed on the wall at 0.1 m from the ground with the coordinates of the middle of the bottom part: (−3.35 m, 3.35 m, 0.1 m) and (3.35 m, −2.68 m, 0.1 m) taking the center of the or table at ground level as reference (0, 0, 0). these outlet of that suck out the air in the or with such a velocity that the outlets pump out less volume than the volume injected by the ceiling inlets, which creates a positive pressure of about 8 pa. pressurization is a key factor in controlling room airflow patterns in a healthcare facility. positive pressurization is used to maintain airflow from clean to less-clean spaces. the appropriate airflow offset to reach the desired pressure differential depends mostly on the quality of the construction of the room. it is difficult, if not impossible, to know what the room's leakage area is before finishing the construction and doing measurements of airflow. the facility management service (fms) of the hospital was able to supply the values of volume per minute that the inlets are blowing (1.15 m 3 /s) and of the volume going through the outlets (0.55 m 3 /s). as the surface of the outlets is known, the velocity of the outlet vents were 0.5 m/s for the left one and 0.4 m/s for the right one, reported on figure 2 . the volume of extra air in the or is the difference: 1.15 − 0.55 = 0.6 m 3 /s. due to the positive pressure of 8 pa present in the or, this additional volume leaks out of the or through either the door being left open or the narrow gap around the door when it is closed. in that case, the free boundary surface was estimated to be 0.17 m 2 . for the hallway, a uniform inflow boundary condition of 0.1 m/s was imposed in order to take into account the anemometry measurement mentioned above. this upstream boundary condition is completed by a free outlet boundary condition at the other end of the hallway. to be as realistic as possible, the two existing inlet vents' boundary conditions were respectively added for the inlet vent located on the ceiling and the other inlet located close to the entry door of the next or, both with a velocity of 1. to validate the model, measurements were done of velocity flow and of the concentration of particles at various locations that were close to specific regions of interest-the door-frame location in particular, measurements are reported in the result section. it is unrealistic, in practice, to build a cfd model of the whole surgical suite and run this model for an extensive period of time. next, an upscale model will be presented that will use the present cfd simulation to verify some of the key parameter values, especially relating to transmission parameters between ors and the hallway. as an example, consider a system of 10 identical ors aligned on one side of a hallway. each or has one door access to the hallway. this system is part of a standard or suite and represents one half of the facility in figure 1 that has an architectural design almost symmetric with its two circulation side-halls. computing the concentration of a so-called "marker," which can be a specific gas or set of airborne particles in the air of this or suite, is particularly of interest. this marker is generated from the location of the or's surgical table, where a surgeon is using an electrosurgical instrument that produces smoke from the thermal destruction of tissues. the marker can also be the particles resulting from evaporation of any alcohol-based chemical used either to prep the patient or to clean the or. the model has two parts: first, a compartment-like model that can monitor the indoor pollution [32]; second, a multi-scale agent-based model (abm) that simulates the surgical flow activity and the impact on the indoor air quality either from the source of surgical smoke or from door openings affecting the dispersion of pollutants [31] . staff movement throughout the or suite via door openings and closings will manifestly be a key mechanism for propagation of markers. the indoor air quality is a linear set of differential equations that will be slightly more complex than a standard compartment model since the coefficient will be stochastic, the sources and output/leaks of the particles term will have a time delay built in, and the hallway will require a transport equation. the rationale for building this specific model will come out of the set of experiments described hereafter. next, the description of the acquisition process to identify the production of airborne contaminants will be explained. for this experiment in a surgical training facility, electrosurgical energy was delivered on the surface of two pieces of pork meat, each 2 cm thick, placed on an or table. three types of energy delivery systems were compared: electrosurgery (conduction) via the covidien forcetriad monopolar device(medtronic, minneapolis, mn, usa), ultrasonic (mechanic) with the ethicon harmonic scalpel p06674 device (ethicon inc., somerville, nj, usa), and laser tissue ablation with erbe apc (argon plasma coagulation) 2 device (erbe elektromedizin gmbh, tübingen, germany). to keep the tissue burn superficial, a pattern of parallel lines was followed with each device and always used unburned areas of the meat. the energy was delivered for a period of 30s up to 60s in order to produce a large quantity of smoke and thus particles. the measurement was done by several laser particle counters from dylos corp (riverside, ca, usa) placed at various distances from the source (http: //www.dylosproducts.com/dc1700.html). they give an average particle count every minute in a unit system with units u d that correspond to 0.01 particles per cubic foot or 0.00028 particles per cubic meter (1 cubic foot = 0.0283168 cubic meter). a traditional problem with the validation of particle count in laboratory conditions is that particles are not all the same uniform size. according to smartair (http://smartairfilters.com/cn/en/), the dylos system output is highly correlated (r = 0.8) to a "ground true" measurement provided by a high-end system such as the sibata ld 6s (sibata scientific technology ltd., tokyo, japan) that is claimed to be accurate within 10% in controlled laboratory conditions. according to smartair, the dylos system seems particularly accurate at the lower concentration ends, which is of interest for this study's purpose. semple et al. [33] also compared the dylos system with a more expensive system: the sidepak am510 personal aerosol monitors (tsi incorporated, shoreview, mn, usa). they concluded that the dylos' output agrees closely with the one produced by the sidepak instrument with a mean difference of 0.09 µg/m 3 . the dylos sensors were set up to track particles of small size in the range from 0.5 to 2.5 microns, which are the sizes of biological material. the results were checked systematically by comparing the measures of several sensors at the same location to show consistency, as well as checked that the particle count lowers back down to nearly zero in a clean-air room with ac equipped with high efficiency particulate air (hepa) filters. each experiment was started from an initial clean-air condition of a small particle count, fewer than 50 units, which is much less than the number of particles counted during energy delivery. it took about 6 min to reach the initial clear-air count after each experiment. for each experiment, the concentration increased to a maximum after a short time delay s from the time the energy was delivered; this delay depends on the distance to the source. the concentration then exponentially relaxes to zero in time. consequently, the model of source dispersion is an exponential function as follows: the least squares fitting technique was used to interpolate the data with this function. the amplitude of the source a (see figure 3 ), the delay s on particle diffusion and transport to reach the sensor and the rate of "diffusion decay" ρ > 0 were identified. the accuracy on s, which measures the time interval between the source production and the peak of the signal, cannot be faster than one minute since the sensor only works at a one-minute timescale. a delay of s ≤ 1 was found to be a good approximation for all three energy devices. each experiment was done 4 to 5 times depending on the variability of the results. therefore, about 24 to 30 data points were available to identify the parameters a, s, and ρ for each energy device that was tested. now, the protocol experiment to assess the transport and diffusion of particles in different areas of a large or suite will be described. this set of experiments, as opposed to the previous one, was done in a large or suite late at night and on weekends when the ors were empty and had clean air with high-efficiency hvac. a hairspray product (lamaur vitae, unscented) was used as the marker and sprayed for a duration of 1 to 2 s to track its small particles while keeping the same positions of the dylos systems. the experiment first tested the propagation in a closed-door or with the source above the or surgical table. the spray nozzle was held facing the near-vertical direction, pointing to the ceiling. a distribution of sensors as displayed in figure 4 was used. the initial observation was that all four sensors distributed along the central line of the whole or space were getting a particle count of the same order of magnitude after an average of 15 s. the mixing of particles was quite extensive within a minute by reason of the hvac input/output design in the or, and that the concentrations on each sensor quickly relaxed to zero. this observation is also coherent with the results of the cfd model of the flow circulation described above. a method identical to the previous one was used to identify the key parameters a, s, and ρ characteristic of the dispersion of hairspray in the or. the model for or diffusion of particles is then where q denotes the global concentration of particles in each or, s(t = 0) denotes the source production that is non zero at time zero and ρ or denotes the diffusion decay inside the or. this simple ordinary differential equation (ode) model provides an average of particle concentration in the or at the minute timescale. a first-order implicit euler scheme with a time step dt of one minute is used: an entirely similar technique is used to describe the dynamic of particle diffusion and transport in the hallway, except that the hallway is discretized as a one-dimensional structure of consecutive hall blocks located at the same level as the or block. in this part of the experiment, the source is set in the hallway-see figure 1 . as noticed earlier, there is a slow but significant air flow speed v 0 in the hall, pointing in the direction of the main entrance of the surgical suite, situated on the right of the map in figure 1 . naturally, the high pressure of the or is designed to drive the airflow out and the front corridor seems to be a significant outlet. on the opposite end of the hall, situated on the left of the map, figure 1 , this velocity is close to zero. it is assumed that v 0 (x) is an affine function, with a linear growth from 0 to 0.1 m/s at mid-hall, and a constant value beyond. the model of hallway diffusion of particles is then d dt where d dt denotes the total derivative ∂ ∂t − v 0 ∂ x using the x coordinate system in the one space dimension hall model. to assess the transmission of particles from an or to the adjacent hallway with closed or doors, the same experiments were run with some of the sensors placed in the hallway either facing the closed door or sitting at a location in the hallway (see figure 4 ). as a matter of fact, the door of the or is not perfectly sealed due to the difference between the pressure inside the or and the lower pressure in the hallway, a significant airflow with velocity around the order of 1 m/s exists at the gap located between the door's edge and the door frame. [sentence removed]. a similar technique is used to represent the diffusion coefficient as well as the delay s that is now interpreted as the time it takes for the particles to flow from the or to the hallway right outside the door. this transmission condition will be entered into the model to couple equations (2) and (3). finally, an entirely similar approach is used to get the transmission in the compartment model when the door of a specific or is wide open. in such cases, the gradient of pressure between the or and the hallway nearly vanishes. at the doorstep, we are observing buoyancy-driven effects due to the difference in temperature between the or (cold air) and the hall (warm air). there is a convective flow exchange with cold air at the bottom going out of the or and hot air at the top going into the or [34] . during our experiment with particle sensors, we were able to validate the propagation of aerosol traveling into the or from outside when the door is left open. with the cfd model and taking into account the gravity, we simulated the contamination by adding a source of co 2 from the inlet at the beginning of the hallway and keeping the door open. it took 18 s for the gas to reach the door and start contaminating the or. this proved the importance of keeping the door closed to maintain the positive pressure in order to control the contamination rate and nosocomial propagation in the or suite. now, the simple compartment-like model to monitor, in time and in space, the diffusion and transport of particles with intermittent source production in each or will be assembled. such a source of pollutants corresponds to either the use of some chemicals or the use of electrosurgical instruments during surgery. the goal is to get the average rate at which the staff working in the or suite is getting exposed to particle concentration emanating from surgical smoke throughout the day. potential propagation of particles that may carry biological material from one or to another is also of interest. as discussed earlier, the concentration is tracked in time and in space with a coarse time step of one minute. this time step scale is coherent with the measurement system used for particle counting. one minute is also roughly the time that the particles emitted from a point source next to the or table need to transport and diffuse throughout the or block once released. the compartment model computes the global concentration of the particles in each or as well as in each section of the hall adjacent to the or. these concentrations are denoted respectively q j (t) for or number j at time t and p j (t) for the corresponding section of the hall-see figure 1 . the source of particles is denoted as s j (t). in principle, s j (t) should be non-zero for a limited period of time and follow a statistical model based on the different phases of the surgery and the knowledge of electrosurgical instrument used during a surgical procedure [19] . the coefficients of decay are defined inside different parts of the model (ρ or and ρ hall ) as well as the coefficients of transmission between these spaces (α or from the or to the hall and γ hall for the opposite). β or represents the flow from the or to the hall when the door is open. the frequency of door openings is following a statistical model based on where the surgery is at; δ door j is a function of time and is 1 if the door is open, 0 otherwise. the simulation of the surgery schedule uses data from the smartor project [30] , which will be detailed later on. only the door openings of the order of a minute will be counted and γ hall = β or will be assumed because the gradient of pressure between the or and hallway vanishes. the system model of marker transport-diffusion in the or suite is: an additional unknown to track back-flow of marker in the or coming from the hallway can be introduced with: using this equation, the number of particles going from one or to another can be separately counted. this number is expected to be very low-see "results" section. the model (4) and (5) is not a standard box model. first, the source term has a delay built-in to simulate the transmission conditions observed. second, equation (5) is a pde, more precisely a linear transport equation. third, most of the coefficients are stochastic, especially those related to door openings and sources that are linked to human behavior. because the system of equations is linear, the superposition principle has been implicitly used to retrieve each unknown coefficient from the experimental protocol. let us describe our surgical flow model more precisely in order to provide an accurate description on how we manage to compute the source term s j (t). for each of the standard or stages of the surgery, an attributed state value is given as follows: • phase 1: anesthesia preparation label as state = 1. the type of airborne marker expected to release depends on those state values. for example: in state 0, cleaning crew uses a lot of chemical products that quickly evaporate in the or. similarly, a different type of sterilization product is used to prep the patient in state 1. in state 2, cauterization is often used for a short period of time. in state 3, various phases of the surgery will require energy delivery instruments to cut tissue and access specific anatomy or tumors. a stochastic model of energy delivery is used that consists of delivering short time fractions of energy in several consecutive minutes. the parameters of that model are: the frequency of energy delivery denoted f , the duration of the impulse denoted ξ, and the number of repetition r. a uniform probabilistic distribution of events is used within these intervals of variation for each parameter. figure 5 provides a typical example of the number of door openings observed in the or at a 15-min interval. both the detection of door openings and a patient bed coming in and out were provided by the sensors of the cyber-physical infrastructure [28] . a stochastic model of door openings will be used based on a uniform frequency of door opening during surgery, even though this distribution is non-uniform in practice and tends to concentrate at the beginning and the end of a case. • and x on the horizontal axis corresponds respectively to the entering and exiting time of the bed of the patient. this example has two procedures. the model of air pollution in the surgical suite will first be tested with a simplified model of surgical flow as follows: to provide the timeline of events, the model assumes there are three surgical procedures in each or. the timeline of each surgery will be such that: phase 1 and phase 5 last 12.5 min ± 5 min, phase 2 and phase 4 last 15 min ± 5 min, phase 3 is the surgery itself that lasts 65 min ± 25 min. phase 6 corresponds to a turnover time between surgeries that lasts 30 min ± 10 min. this simplified model of surgery scheduling has the correct order of time-length for each phase. its simplicity allows a sensitivity analysis to run with respect to the key parameters of the indoor air quality model that can be easily interpreted. next, the model will be coupled on an abm of an existing large general-surgery suite in the hospital that has been calibrated by tracking about 1000 procedures over one-year [31] . this model is complex and specific to a 20 ors surgical suite of a 1700 bed hospital, which has been monitored for over two years. to asses, the impact of human behavior on the transport and diffusion of surgical smoke in the surgical suite over a period of one year, a realistic abm of the surgical flow and of people behavior is now used. a byproduct of this study is the assessment of the air quality and the risk factors associated with surgical smoke by coupling it to the present model of transport and diffusion of airborne particles generated by surgical smoke. the method to construct this model is briefly explained in this paragraph. the exact description of the model goes beyond the scope of this paper's focus on air quality and has been detailed in garbey et al. [31] . the mathematical model of surgical flow is built upon observations and robust clinical data covering 1000 procedures with a noninvasive array of sensors that automatically monitor the surgical flow. to this end, several ors were equipped with sensors that capture timestamps [28, 29, 35] corresponding to the different states described in the previous section. overall, the model can simulate the or status of a large surgical suite during any clinical day and can be run over a long period of time. the model is able to reproduce the statistic distribution pattern over a year of performance indicators: turnover time, induction of anesthesia time, the time between extubation, and patient exit. the model classifies the human factors impact and limitation of shared resources on flow efficiency. in the end, communication delays and sub-optimal or awareness in large surgical suites have significant impacts on performance and should be addressed. this paper concentrates on the duration of surgery state 3 that corresponds to how long surgical smoke is generated, and how behavior inducing or door openings are responsible in part for the spread of surgical smoke and other agents. the output of the abm model of surgical flow coupled to the air quality model is the number of hours per year that staff gets exposed to surgical smoke in the or and hallway. various scenarios have been run related to the rate of adoption of vacuum systems for surgical smoke and or door openings to discuss the influence of human behavior on those results. following are the results on the circulation of surgical smoke in a surgical suite starting from a local source of emission in the or and ending on global dispersion in the suite. a detailed cfd model of the airflow in the or along with its immediate adjacent structure will be used to build an upper-scale, simplified model. a series of air quality measurements based on the density of particles at specific locations will be used for calibration of the model and for validation purposes. the measured rate of particles generated by various energy sources, such as monopolar cautery, argon plasma coagulation (apc), and harmonic sources, are found by testing them in an or space allocated to training, i.e. without patients. the unit used for the source of the emission is 0.01 particles per cubic foot; it gives the measurements an order of magnitude from ten to thousands by which they can be compared. small particles are found in the range of 0.5 to 2.5 microns, which are the sizes of biological-material particles like viruses. as opposed to the results reported in weld et al. [36] , our off-the-shelf particle sensor does not give us access to the ufp count. a conservative estimate from weld et al. [36] results would be that the concentration number of ufp is 2 to 3 orders of magnitude larger than what is measured for the small particles. in table 1 , each source's mean, standard deviation, and diffusion coefficient are reported -more precisely α is the rate at which the pollutant concentration decreases, which is obtained from fitting a simple exponential decay model source exp −αt to the experimental data. there was no significant statistical difference between the rates of diffusion of the particles emitted by the monopolar versus the apc instruments. the coefficient of diffusion corresponding to the harmonic instrument is lower but has strong variation. we interpret this result with the fact that the range of size of particles produced by the harmonic instrument is wider and the distribution of size is random. in some trials the particles emitted were then too small, they can go down to 0.06 microns [36] , to be detected by our sensors while in other only detectable particle were produced. as mentioned earlier, covering the sensor with a surgical facemask dropped the number of large particles to some extent, but there are always leaks on the sides. as noticed in the literature standard, surgical facemasks do not protect from ufp. a 3-dimensional (3d) cfd model is used to simulate the dispersion of a single source of pollutant in an or. the dimensions used in the model are the ones in the surgical suite where the clinical study and validations were made. every or is different, but the order of magnitude of the physical quantities is the same for each or in our clinical study. figure 2 provides the geometric details of the simulation setup that takes into account the geometry of the room, location of air conditioning ducts, location of the doors, and air leaks due to positive pressure despite closed doors. table 2 lists the boundary conditions on velocities and temperatures of the or and its adjacent hallway obtained from measurements. the surgical smoke plume in the cfd model was simulated using an injection of co 2 at the location of the or table for a duration of 10 s. the co 2 phase was tracked in the multi-phase cfd simulation as a marker of pollution. the smaller the particle, the best the dispersion model would be based on gas transportation. figure 6 shows the dispersion of the plume inside and outside the or, while the door is closed. dispersion into the hallway was due to the air leaks between the door of the or and its frame. verification of the simulation was obtained by refining the mesh and time step until it reached a numerical convergence on the quantities of interest -in particular, the density of co 2 and velocity of flow at specific locations. table 3 provides a comparison between the different velocity values found by the model and by the direct measurement obtained at those locations. the time intervals were also computed: between the emission of the pollutant and the time when an air sensor detected the pollutant inside the or, close to the door, and in the hall outside the door. the results of table 3 provides the first level of validation of the cfd simulation. in table 3 , r 3 1 is the ratio of pollutant phase concentration between the sensor location 1 and 3 in the or in figure 4 , and is interpreted as a small particle density ratio as well. it is particularly interesting to notice that the flow at the door has a 3-dimensional component that is driven by the pressure gradient as well as the temperature difference between the or and the hallway. while the or is kept under positive pressure, it loses this pressure as soon as the door is opened. because the temperature of the or is generally cooler than the temperature of the hall, we observe from the cfd that the buoyancy effect causes back-flow between the adjacent hallway when the door is opened. this might be part of the mechanism of contamination between ors. this result is consistent with air quality measurements done in controlled experimental conditions presented hereafter. it was found that the mixing of contaminants from a burst source to the rest of the or is reached within a minute; applying a simplified compartment model to describe the or's contribution to pollutants using a time step of one minute became apparent. this upper-scale model described in the methodology section will be calibrated next. the identification of the model parameters from the experimental data-set corresponding to the setup in figure 4 is explained below. the experiment was designed first, to assess the delay of pollutant transmission between the or and the hallway depending on if the door was opened or closed, see figures 7 and 8 . second, to compute the rate at which pollutant concentration decreases. an exponential decay was observed in the or, which is consistent with the fact that diffusion is the main mechanism due to the small velocities present inside the model. however, the hallway behaves more like a duct with a combination of convection and diffusion running down the hallway. these measurements are consistent with the cfd simulation results shown previously. fitting the simplified model to the controlled experiment with a single source of smoke, the coefficients of diffusion in the or and in the hallway can be retrieved, as well as the convection velocity in the hallway-see table 4 . figure 7 . source in closed-door or and its impact on hallway air concentration: a 2 min delay in transmission from or to hallway and an exponential decay for each signal was observed. the diffusion coefficient in the or and the hallway are dependent on the hvac system that is, by design, more effective in the or than in the hallway. therefore, the rate of decay in the or is twice as large as the rate of the decay in the hallway. as reported before, the diffusion coefficient for the particle tracking setting is about the same for the spray source as it is for the monopolar or apc sources. the transmission condition with a closed or door is not negligible: it is about 4 times less than with an open door. from figure 9 , the traveling wave velocity is reconstructed and travels about one or width in a minute, v 0 is about 0.1 m/s at mid-hall location. this small velocity in the hallway could not be directly measured, but it is in agreement with the cfd simulation reported earlier. table 4 . parameters of the model obtained by fitting the outcome on single-source controlled experiments with injection source locations; 9 measures were used to obtain this table. the coefficients of decay are (ρ or and ρ hall ) as well as the coefficients of transmission between these spaces (α or ) from the or to the hall. β or represents the flow from the or to the hall when the door is open. 9 . effect of door opening and closing on propagation of marker from one or to the next or down the hall: • is the sensor close to the source in the or, is 10 times the concentration down the hall, and is 100 times the measured concentration in the next or down the hall-for convenience, we have plotted in solid line the exponential model fitting for the experimental datasets in the main or and in the hall. the most important result is summarized in figure 9 : surgical smoke emitted in a single or can rapidly reach the hallway within a minute due to the or door opening and is diluted by a factor of roughly 10. in the unfortunate event that the door of the next or is opened, then some trace of the surgical smoke emitted by the or upstream, can flow inside the next or down the hall; while the level of exposure to surgical smoke would be insignificant in this second or, it is clear that the standard positive pressure established in these ors cannot guarantee those airborne particles do not propagate from one or to another. over a period of several months, this rare event might be capable of propagating an airborne disease. in fact, the frequency of door openings of each or can be very high, as shown in figure 5 , that the probability of propagating airborne diseases and contaminating other ors seems inevitable. next, to systematically assess long-term exposure, the result obtained by coupling the air quality model with an agent-based model (abm) of the surgical flow will be reported on. figure 10 shows a measurement done during a clinical study with 3 consecutive laparoscopic procedures during the day. the red curve accounts for the number of particles detected by the sensor inside the or, while the blue curve provides the corresponding measurement from the hallway. patients' registration starts at 7 a.m., before any surgery occurs, and lasts all day until all surgeries are complete. large peaks of particle concentrations were observed during the times the or was being cleaned. these peaks were removed from the or acquisition curve that corresponds to the use of detergent. similarly, during the preparation and closing of the patient, the sensor sometimes captured the use of chemicals when preparing the sterile field or the leak of anesthetic gas. the red peak during the third procedure in figure 10 most likely corresponds to an excess of surgical smoke. as expected, the concentration of particles in the hall is not strictly correlated to the emission of surgical smoke in the or. the hallway collects pollutants from a number of ors under positive pressure at the same time. because of this, it is difficult to separate out surgical smoke from other sources in the hallway measurement, such as chemicals used in the preparation of patients located in ors upstream. the model is built to qualitatively reproduce the concentration of surgical smoke inside an or and its adjacent section of the hall. in our simulation (see figure 11 ), the emission of surgical smoke is restricted during the time the patient is intubated. this simulation was done on the whole surgical suite with a stochastic production of smoke in each or similar to the one reported in meeusen et al. [19] . one observation is the same pattern of pollutant concentration in the hallway as seen in the clinical dataset. in particular, there is no obvious correlation between the source of smoke in the or of that simulation and the concentration in the section of the adjacent hallway. in fact, while exposure to surgical smoke in the or is relatively intense in a short period of time and then vanishes, the pollutant is stagnant in the hallway for a much longer period of time and therefore contributes to long-term exposure. overall, the delay ∆t 2 in the transmission conditions in (4) and (5) has very little influence on the result and can be neglected. to expand the study, this simplified air quality model was then coupled to the abm of surgical flow that reproduces the daily activity of a large surgical suite over a long period of time [31] . the model was calibrated using custom-made sensor systems placed at key locations of the surgical suite to capture the daily activity over a period of a year [29] . this or suite, dedicated to general surgery, has about 20 ors distributed in a layout as seen in figure 1 and is rather typical of the activity in a large urban hospital. a simple stochastic model is assumed for the source of surgical smoke in each or, similar to the previous one. the probability p door ∈ (0, 1) of the number of or door openings per minute is a parameter of the model. on average, one door opening every two minutes during a surgery is rather standard. this is mainly due to the fact that the staff may have to support logistics in various ors at the same time, and that coordination of team activity is still done by a direct conversation in the surgical workflow. in fact, it is common knowledge that a door opening every 8 min on average would correspond to a very strict policy controlling traffic in the surgical suite, but it would only reduce the exposure in the hallway by half. from the simulation, it is concluded that long-term exposure to surgical smoke in the hallway is about the same order of magnitude as the one in the or. figures 12 and 13 demonstrate the effect of the frequency of door openings on the average concentration of pollutants that a staff member is exposed to during the day. there was a noticeable low concentration at the upstream end of the halls, which was confirmed by direct measurement with the particle counter. enforcing strict control on door openings may reduce the level of transport and diffusion of hazardous airborne particles in the hallway by half. the model can be ran to test a fictitious situation as in figure 14 where every other or has an ideal practice and generates no surgical smoke at all. the usage of ideal exhaust ventilation devices during surgery in half of the ors has a direct linear correlation with the rate of exposure in the hallway, and it seems to be the most efficient technique to reduce long-term exposure; it cuts down the staff's exposure to surgical smoke in the hallway by half. about half a million healthcare professionals are exposed, daily, to surgical smoke in their clinical activities. transport and diffusion of hazardous airborne particles such as virus, generated by surgical smoke in particular, and its long-term effects on staff have not been studied systematically yet. the debate on the impact of surgical smoke on patients' and staff's health is reminiscent of the incident involving airborne hazards from anesthetic gas [23, [38] [39] [40] [41] . the national study led by the american society of anesthesiologists established that "female members in the operational room-exposed group were subject to increased risks of spontaneous absorption, congenital anomalies in their children, cancer and hepatic and renal disease." while the link with waste anesthetic gas (wag) was not clearly established at that time, except in animal studies, the stream of work initiated in the 70's [23, 41] eventually ended up in a better management of wag "by always using scavenging systems, by periodically testing anesthetic machines for gas leaks, and by not emptying or filling vaporizers" [42] . unfortunately, the efficiency of surgical masks to prevent virus transmission or surgical smoke breath intake is usually tested using non-biological markers while their use in hospitals is mostly against airborne biological particles. standard surgical masks and filtration techniques are not effective on ufp, which include viruses and bacteria. for example the sars-cov-2 as a size comprised between 0.06 to 0.14 microns [43] . long et al., showed in a new meta-analysis that there was no significant difference in effectiveness between surgical masks and n95 masks against laboratory-confirmed respiratory viral infections [13] especially at higher inhalation flow rate [14] . seongman et al., also showed that for viruses, effectiveness of surgical mask (and cotton based masks in the paper) are dependent to virus concentration and flow rate of inhalation but also showed a higher concentration of viral load on the outside of the mask compared to the inside [44] . yang et al., built a multi-criteria decision-making method based on the novel concept of the spherical normal fuzzy to assist healthcare staff in the decision of which mask to wear [45] . an italian research team is underlining the possible correlation between concentration of particulate matter (pm) with propagation of the virus like, for example, in the north part of italy where industrial pollution is high [46] . high concentration of pm could be a vector of propagation and needs to be carefully observed inside building, especially hospitals. being able to know where these particles are and in what concentration seem then the best protection and awareness for staff to avoid staying too long in contact. deposition rate of these particles is not addressed in this paper and researchers are still debating about lifetime on surface of the sars-cov-2 virus [47] . a method to construct a surgical-suite-specific model of the transport-diffusion of airborne particles can quickly be calibrated with cost-effective wireless particle counters. coupling this indoor quality model to the previous multi-scale model of surgical flow [28] [29] [30] allows quantification of surgical smoke exposure across long periods of time and provides a rationale for recommendations. as a matter of fact, the abm of surgical workflow allows insight into the human behavior factor, which can be included in the analysis. this work may expose rare events, such as contamination from one or to another, which when accumulated over the months becomes a tangible risk. this study has potential because it can run for long periods of time and can address the complexity of hundreds of staff's spatiotemporal behaviors in a large or suite. the cfd model requires detailed geometric and boundary conditions to be reliable; the k − model is an approximation that has its own limit as well. running a cfd model is a tedious process both in setting up the mesh and simulation parameters, as well as in terms of central processing unit (cpu) time required. cfd was used here only to test the components of a hybrid stochastic compartment model that incorporates the mechanism of diffusion-transport of airborne particles at the surgical suite scale over a one-year period. a coarse statistical model was used for the source of surgical smoke: the actual generation of surgical smoke depends on the surgery team, type of procedure, and many more parameters. however, the capability to non-invasively monitor such parameters using appropriate sensors via the cyber-physical system is available. the hybrid partial differential equation (pde) compartment model provides a first-order approximation of average exposure at the room scale. the delay in the transmission conditions between the or and the hall in equations (4) and (5) is not essential to reproduce the result on daily exposure to smoke. in the meantime, the uncertainty of the hvac input/output provides a much larger error. furthermore, deposition of particles on the or's surfaces was not taken into account. the deposition of ufp may be expected to be negligible [22] . a low accuracy model that carries an error of the order of 20% could, however, be conclusive for this study. as a conclusion, it is particularly important to recognize the impact of door design and human behavior when considering hazardous airborne particles spreading throughout a surgical suite. or doors constantly leak air depending on the difference of pressure with the outside hall, and they contribute to the transport of particles throughout the surgical suite. the door opening effect depends on the motion of the door and also the difference of temperature between the or and the hallway. some of these negative impacts can be controlled by a better design of the door and of the temperature control in order to work with a more cost-effective hvac design. the benefit of positive pressure in the or is still canceled by door openings, inducing possible back-flow and contamination from the hallway, especially when the door stays open for several minutes. therefore, efficient movements by personnel may improve indoor air quality and should be quantified. the architectural design of the or suite should optimize the circulation of staff and patient movement activities. the next important step in the modeling to address the complementary aspect of biological transmission versus physical transportation is to correlate the database of staff's pulmonary events with the study's findings to recognize these rare events. we can then translate the quantitative model of surgical smoke transport into a risk assessment for staff's health. the model should be surgery-specific: an efficient cyber-physical infrastructure should non-invasively monitor energy usage and smoke presence to instantly deliver awareness on practices that can improve air quality. a factor that has been neglected is the deposition of surgical smoke in the common storage area, see figure 1 , in which all ors have personal access to via their back-doors. this may offer a different mechanism of propagation of biological material. in the current study, quantification of surgical smoke concentration in the hallway, the duration of exposure along the year, and the mechanism of propagation of hazardous airborne particles from one or to another was feasible. on the practical side, an automatic sliding or door seems to be a better solution over a traditional door's rotation that acts as a pump. the analysis can also be extended to address the problem of the optimum placement of uv lights in the hallway to improve air quality in an efficient and controlled way. finally, the importance of aorn's guideline in the use of a vacuum system during surgery needs to be reinforced at a time when elective surgery may involve asymptomatic covid-19 patients. author contributions: this project is highly interdisciplinary and required all co-authors contributions to establish the concept and reach the goal of the paper. m.g. leads the project, designed the overall framework, including the hybrid model, agent-based clinical model, and matlab code implementation. g.j. did the cfd model at the or scale, participated in the design of the overall method and ran the experiments with air quality sensors required for validation. s.f. participated in the experiments with air quality sensors and with or door activity sensors. all authors contributed to the redaction of this publication. all authors have read and agreed to the published version of the manuscript. airborne transmission of sars-cov-2: the world should face the reality turbulent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of covid-19 airborne transmission route of covid-19: why 2 meters/6 feet of inter-personal distance could not be enough review awareness of surgical smoke hazards 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recent data summary and its importance for medical and dental settings funding: this research received no external funding. the authors declare no conflict of interest. key: cord-254633-7re0k0d1 authors: azarkamand, sahar; wooldridge, chris; darbra, r. m. title: review of initiatives and methodologies to reduce co(2) emissions and climate change effects in ports date: 2020-05-29 journal: int j environ res public health doi: 10.3390/ijerph17113858 sha: doc_id: 254633 cord_uid: 7re0k0d1 ports are important infrastructures for economic growth and development. among the most significant environmental aspects of ports that contribute to the issue of climate change are those due to carbon dioxide emissions generated by port activities. given the importance of this topic, this paper gathers initiatives and methodologies that have been undertaken to calculate and reduce co(2) emissions and climate change effects in ports. after studying these methodologies, their strengths and opportunities for further enhancement have been analyzed. the results show that, in recent years, several ports have started to calculate their carbon footprint and report it. however, in some of the cases, not all the sources of ghg gases that are occurring actually in ports are taken into account, such as emissions from waste treatment operations and employees’ commuting. on other occasions, scopes are not defined following standard guidelines. furthermore, each authority or operator uses its own method to calculate co(2) emissions, which makes the comparison of results difficult. for these reasons, this paper suggests the need for creating a standardized tool to calculate carbon footprint in ports, which will make it possible to establish a benchmark and a potential comparison of results among ports. ports are important infrastructures for economic growth and development. they have strategic importance to a nation, acting as gateways to trade. they also constitute a key node in the global supply chain [1] . at the same time, they are very complex systems, since each port is unique in terms of activities, geography or applicable laws. most of them are regulated by diverse levels of legislation: global, european, national and local. apart from generating positive economic development, ports create negative impacts on the environment due to the range and nature of the activities, products and services carried out in the port area. these may have a direct or indirect impact on air, water, soil and sediment, as well as on the quality of life of local communities. activities such as dredging or the disposal of residues may have negative effects on the movement of water and on the quality of the marine ecosystems, respectively [2] . in general, in ports, almost all the activities can be associated with environmental impacts, such as waste water, emission of gas or particles into the atmosphere, noise, soil contamination, waste production, accidental releases into water or air, etc. [3] . in recent years, several attempts have been made to control environmental impacts in ports. 'going green' is a trend for seaports all over the world, and environmental management has become a critical issue in port operations. the advantages of environmental management are not only for customer satisfaction and corporate image but also for cost saving and environment protection [4] . one of the most important environmental impacts in ports is air pollution [5] . emissions of exhaust gases and particles from ocean-going ships are a significant and growing contributor to the total emissions from the transportation sector. the intensity of air pollution from fuel combustion depends on the activity of the ship. if the ship is in the open sea, maneuvering, or in the dock, the gases emitted will vary, but they always consist of no x , so x , co 2 and suspended particles (pm) [6] . in addition, the generation of co 2 in this area is one of the significant environmental threats in ports, and this is directly related to climate change [5] . the political significance of this issue has increased in recent years, becoming part of the agenda of numerous international organizations. for instance, according to the international association of ports and harbors [7] , growing emissions of greenhouse gases (ghg) have been proved to be the cause of global climate change in port operations. shipping emissions generate approximately 1036 million tons of ghg emissions annually, and account for 2.4% of global carbon emissions for the periods from 2007 to 2012 [8] . another example is the results of the greenport conference, held in valencia (spain) in october 2018, which highlighted the importance of climate change for ports [9] . during this conference, a survey on climate change issues was delivered to the participants, gathering 55 answers from all over the world. from its analysis, it could be stated that climate change occupied the sixth position among the top10 environmental port priorities, and carbon footprint the eighth position. based on the results of this survey, most of the port organizations (81%) believed that climate change had impacts on their organizations, such as via sea level rise. most of the respondents of the greenport survey (86%) considered that ghg emissions from shipping generated in the port area should be included as third-party emission in the carbon footprint calculation of the port. in addition, most of them considered that a common, port-sector carbon footprint scheme would benefit individual port authorities and the port sector as a whole (89%). in 2019, the european sea ports organization (espo) published its annual environmental review, where climate change occupied the third position among the top 10 environmental priorities [5] . this reflects the importance of climate change and carbon footprint in the whole set of environmental priorities at european and international level. climate change impacts, such as the increase in sea level and of storm frequency, will affect seaports and inland waterway infrastructures. as a consequence, due to the economic importance of the ports, their location (in many instances, in the heart of sensitive environments) and the significant existing infrastructure that links them to inland transportation networks, they need special treatment [10] . therefore, the topic of climate change in the maritime industry is getting more important every day. it may reasonably be stated that the environmental issues of air quality and sustainability of industrial activities and operations are set to become of even higher priority and significance post covid-19, given the widely reported improvements in air quality during the "lockdown" period of 2020. such environmental imperatives will focus further attention on the port sector's own initiatives if it is to demonstrate competence in the effective management of such critical topics as carbon footprint. it is timely and topical to review the efforts to date, and to research the pathways that will deliver a generic system appropriate to the widely different circumstances of the maritime world. for this reason, this paper presents a review of different initiatives to reduce climate change effects in general and specifically in the maritime sector. after that, the results of a research conducted on different existing methodologies to calculate co 2 emissions in ports are presented, followed by an analysis of their strengths and opportunities for further development. finally, some conclusions have been drawn. climate change is an important global issue, which has become a major focus of attention because of its potential hazards and impacts on the environment [11] . the on-going global climate change has been related to ghg emissions because of the atmospheric warming effect of these emissions [12] . the main ghgs are carbon dioxide (co 2 ), methane (ch 4 ) and nitrous oxide (n 2 o). in order to measure the potential contribution of human activities to climate change, an environmental indicator can be used: carbon footprint. carbon footprint is an environmental indicator that has been developed over the last decade [13, 14] . based on the parliamentary office of science and technology [15] , carbon footprint is the total amount of co 2 and other ghg emissions which are emitted over the full life cycle of a process or product. the other ghgs are expressed as co 2 equivalent (co 2 eq). the carbon dioxide equivalent of a quantity of gas is calculated by multiplying the mass of the gas (in tons), by the gas global warming potential (gwp). gwp value for co 2 is equal to 1 for a 100-year time horizon, for ch 4 it is equal to 25 and for n 2 o it is equal to 298 [12] . many international initiatives have been taking place for many years in order to control climate change and carbon footprint. some of the most significant ones are summarized in table 1 and explained in more detail after the table. as can be seen in table 1 , in 1979, the world meteorological organization (wmo) sponsored the first major international meeting on climate change in geneva. in this event, concerns about this topic were expressed and first actions discussed [16] . in 1988, the united nations environmental program (unep) and world meteorological organization set up the intergovernmental panel on climate change (ipcc), to provide regular scientific assessments of the current climate change situation and assist policymakers to control it [17] . in addition, ipcc published a set of guidelines for national greenhouse gas inventories in 1995. the revised versions of these guidelines were issued in 2006 and updated in 2019 [18, 19] . this was followed in 1992 by the development of the united nations framework convention on climate change (unfccc) in rio de janeiro to stabilize ghg concentrations in the atmosphere at a level that would prevent dangerous anthropogenic interference with the climate system [20] . after this, in 1997, the kyoto protocol was adopted in kyoto (japan) and entered into force in 2005. this aimed to limit ghg emissions by at least 5% below 1990 levels in the commitment period from 2008 to 2012 [21] . another interesting attempt is the global reporting initiative (gri), an international independent organization that has pioneered corporate sustainability reporting since 1997. gri helps businesses, governments and other organizations understand and communicate the impact of business on critical sustainability issues, such as climate change, human rights, corruption and many others [22] . the development of the greenhouse gas protocol was a very important milestone in the fight against climate change. in 1998, the world resources institute (wri) and the world business council for sustainable development (wbcsd) developed this protocol. it included standards, tools and online training that helped countries and cities to track progress towards their climate goals [23] . in 1998, the epa (u.s. environmental protection agency) developed regulations for ghg emissions, such as regulations related to ghg emissions from new motor vehicles and new motor vehicle engines under section 202 of the clean air act [24] . later on, in 2003, the world wide fund for nature (wwf) and other international ngos developed the gold standard emission allowance. the aim of this project was to ensure that the projects reduced carbon emissions under the un's clean development mechanism (cdm) and also contributed to sustainable development. the next generation of this standard launched in 2017, and allowed climate and development initiatives to quantify, certify, and maximize their impacts on climate security and sustainable development [25] . another important landmark is the development of iso 14064 by the international organization for standard (iso) in 2006. this international standard includes principles and requirements for designing, developing, managing and reporting organization or company-level ghg inventories [26] . the complete and revised version of this standard was published in 2018 [27] . bearing in mind the importance of the carbon footprint, in 2007 the ecological transition ministry (miteco) of the spanish government developed a tool and guidelines to calculate it. the last version of these guidelines was published in 2019 and they aim to calculate emissions of scope 1 and scope 2 [28] . in the same direction, in 2008, the catalan office for climate change (catalonia, spain) developed an excel-based tool to calculate co 2 emissions. the latest version of this tool with its guidelines was published in 2019. the purpose of these guidelines is to facilitate the estimation of ghg emissions [29] . in order to foster training in sustainability issues such as climate change, in 2009, the partnership for learning on climate change (un cc: learn) was launched by the united nations (un). the main function of this collaborative initiative was to provide support to countries that wanted to develop and implement training plans in sustainability, addressing in particular climate change [30] . following the aforementioned kyoto protocol, in 2015, the paris agreement was established. within the framework of the united nations framework convention on climate change, the paris agreement recognized climate change as an urgent threat and set the mitigation goal of limiting the global temperature increase up to 2 • c and ideally up to 1.5 • c [31] . however, ghg emissions have continued to rise [32] . in 2017, in the uk, the carbon trust aimed at developing a common understanding of what the carbon footprint of a product is and circulated a draft methodology for consultation [33] . the carbon trust is a private company set up by the uk government to accelerate the transition to a low-carbon economy. the carbon trust methodology estimates the total emission of greenhouse gases (ghg) in carbon equivalents from a product across its life cycle, from the production of raw material used in its manufacture to disposal of the finished product (excluding in-use emissions). the next step after the paris agreement was the conference of parties (cop 25) of the unfccc gathered in madrid in december 2019. one of the main achievements of this cop was increasing countries' ambitions to meet the goals of paris agreement [34] . discussions on climate change have thus been evolving at an international scale for around forty years, and the issue remains dynamic in terms of science and politics right up to the current period, with future pathways still to be determined. in the post-covid-19 period, it will surely gain further status in terms of multinational collaboration regarding trans-boundary impacts and the goals of sustainability and overall environmental quality. in the next section, specific initiatives for climate change and carbon footprint reduction conducted in the maritime sector are presented. whereas some ghgs are emitted naturally, there is agreement among climate scientists internationally that human activity has significantly increased the ghgs in the earth's atmosphere, leading to accelerating global warming [7] . as is mentioned in the introduction, shipping and port operations are human activities which have an impact on climate change and could be affected by it. activities causing this warming include those that occur in and around a port, such as burning fossil fuels for operations, transportation, heating and electricity [7] . several initiatives from international organizations in the maritime sector have been undertaken in the last few years concerning co 2 reduction and climate change. these initiatives are summarized in table 2 . as it can be seen in table 2 , in 1997, annex vi marpol (the international convention for the prevention of pollution from ships) was adopted by the international maritime organization (imo). the aim of this regulation was to minimize airborne emissions from ships and their contribution to local and global air pollution and environmental problems. annex vi entered into force in 2005 and a revised annex vi with significantly tightened emissions limits was adopted in 2008, which entered into force in 2010 [35] . a very important action took place in 2008: the creation of the world ports climate initiative (wpci). this is a mechanism for assisting ports in controlling climate change, developed by the international association of ports and harbors. the wpci was developed to reduce the threat of global climate change [7] . in 2010, wpci developed guidelines to provide a platform for the exchange of information and to improve ports' ghg emissions inventories [36] . later on, also at international level, in 2011, imo adopted a suite of technical and operational measures to provide an energy efficiency framework for ships. these mandatory measures entered into force in 2013, under annex vi of the international convention for the prevention of pollution from ships (the marpol convention) [8] . in 2014, pianc (the world association for waterborne transport infrastructure) published a guideline for port authorities. this guideline included seven key issues to deal with, and one of them was climate change mitigation and adaptation [37] . more recently, in 2019, pianc's working group 188 investigated the carbon footprint of activities in navigation channels and port infrastructure, including the management of dredged material [38] . after this, in 2020, pianc working group 178 published a technical guidance document to help the owners, operators and users of waterborne transport infrastructure adapt to climate change [39] . opening up the calculations of carbon footprints to port stakeholders was one of the objectives of the clean cargo working group (ccwg). this developed methods to calculate the co 2 footprint for a single shipment or a total transportation company. [40] . concerning ships' measurements, in 2018 the 72nd session of the marine environment protection committee (mepc 72) was held at imo's headquarters in london. in this session, the initial imo strategy on the reduction of ghg emissions from ships was adopted [41] . another interesting initiative to promote climate change measures among ports was the world ports sustainability program (wpsp). this demonstrated global leadership of ports in contributing to the sustainable development goals of the united nations, along five themes. the second of these is related to climate change and energy. based on the output of the wpci, port community actors can collaborate in developing tools to facilitate the reduction of co 2 emissions from shipping, port and landside operations [42] . reductions of port emissions were also promoted by the world ports climate action program (wpcap) launched in 2019 by the world's biggest ports, including the european ports of rotterdam, antwerp, barcelona and hamburg [43] . conferences are also relevant places to gather experts and take decisions. in 2019, the european maritime community met during the green ship technology conference in copenhagen, with the aim to reduce ghg emissions from shipping by 50% until 2050 (compared to 2008) based on the imo decision. they proposed some solutions to reach this goal, such as the implementation of the regulation, compliant fuels and expanding or upgrading existing port infrastructure [44] . in february 2020, espo published its position paper on the european green deal. according to espo, european ports are trying to be the world's first net-zero-emission area by 2050. by 2030, co 2 emissions from ships at berth and in ports should be reduced by 50% on average and across all segments of shipping. in addition, onshore power supply (ops) should be encouraged as an important part of the solution [45] . again, it can be seen after all the initiatives presented in this section that the maritime sector has been very active in the last decades trying to establish limits to ghg emissions or creating guidelines to reduce them. in the next section, research on existing methodologies to calculate co 2 emissions and carbon footprint in ports is presented. as mentioned before, in recent years, many ports have started to calculate their carbon footprint and report it. in this paper, the calculation of co 2 emissions and carbon footprint in ports, port terminals and ships is studied and analyzed. ships' studies are also included since their emissions are contributing to the total port area carbon footprint. more than 20 different methodologies are taken into account. after reviewing all these methodologies, a set of conclusions about their main strengths and opportunities for further enhancement will be extracted in the next section. table 3 presents the ports that were part of this research together with a brief description of their methodologies that will be further explained after the table. as it can be seen, the port of gijón (spain) was one of the first ports in the world to calculate its carbon footprint (2002), having detected all of the direct and indirect emission sources, which made it possible to establish reduction strategies [46] . in the period from 2004 to 2008, the carbon footprint was calculated again in this port [47] . since 2005, the ports of long beach and los angeles (san pedro bay ports-spbp, united states of america) have developed an annual air emissions inventory (ei) report. in november 2006, the ports took joint action to improve air quality in the south coast air basin by adopting the caap (clean air action plan) to ensure that effective air pollution reduction strategies would be commercially available within the five port related source categories: oceangoing vessels, harbor craft, cargo handling equipment, heavy-duty diesel trucks and railroad locomotives [48] . another example is the port of oslo (norway), which calculated its carbon footprint for the first time in 2007 based on iso 14064-1 by an operational control approach. the results showed that most of the emissions were from fossil fuel combustion (direct source-scope 1), and business travel (scope 3) had the smallest share in the carbon footprint [49] . climeport (mediterranean ports' contribution to climate change mitigation) is a european project that involved six ports committed to climate change mitigation. these ports include the port authority of valencia (spain), acting as a leader of the project, alongside other port authorities like algeciras bay (spain), marseille (france), livorno (italy), kopper (slovenia) and piraeus (greece). the objective of this project was to provide a common methodology for port authorities and their collaborators in order to assess their initial situation related to ghg emissions. this methodology provided a way to collect and classify the available information, including questionnaires, invoice data to tenants, and other potential data sources in an ordered way. concerning vessels, only the captive fleet and oceangoing vessels are considered when berthed in the harbor [50] . the calculation has been done for the year of 2008. in this project, a web-based tool was developed to calculate the carbon footprint of ports. the development of this tool was done using iso 14064 standards [51] . the port of rotterdam (the netherlands) is gradually becoming co 2 -neutral via the purchase of gold standard emission allowances. this is an initiative that was established in 2003 by the world wide fund for nature (wwf) and other international ngos to ensure that the projects reduce carbon emissions under the un's clean development mechanism. the aim of rotterdam port is to come in line with the paris climate agreement objectives. port-based companies are encouraged to report their carbon footprint, and the port of rotterdam authority takes steps to reduce its own co 2 emissions as well. the port of rotterdam authority is trying to reduce co 2 emissions by the use of renewable energy, fuel-saving measures for patrol vessels and electric lease cars for employees [52] . in addition, as the energy consumption and production processes need to switch from fossil fuels to an entirely new system from 2030, a radical transition is needed. a necessary step could be handling energy more efficiently in combination with the capture and underground storage of co 2 . in this regard, the port of rotterdam is also already taking measures to reduce emissions as far as possible in the short term, such as the plan to store co 2 below the sea bed in the coming years [53] . another example is the port of stockholm (sweden), which, since 2012, has reported on sustainability issues according to the gri (global reporting initiative) in three scopes [54] . the port of gothenburg (sweden) is also working actively to minimize the environmental impact from shipping and to contribute to sustainable transport. climate and air quality issues are at the top of its agenda. since 2012, this port calculates the three scopes of carbon footprint and reports them in its annual sustainability report. in 2000, the port of gothenburg was the first port to introduce a high-voltage onshore power supply (ops) for cargo vessels. the implementation of ops provides an opportunity not only to improve air quality, but also to reduce emissions of carbon dioxide, one of the main contributors to global warming. by switching from fuel oil to gas as an energy source or, better still, to sustainably generated wind power, co 2 emissions can be curbed [55] . in 2012, the port authority of barcelona (spain) joined the voluntary agreements to reduce ghg emissions promoted by the catalan climate change office (ccco). by signing this agreement, the port committed to gradually reducing the direct and indirect emissions caused by the fuel consumption of its fleet of 120 vehicles, two boats and certain generators, as well as to reduce its electrical consumption [56]. since 2012, ports de la generalitat (catalonia, spain) has joined the voluntary agreements program for the reduction of ghg emissions. in this regard, they started to calculate ghg emissions every year by the use of the tool which was developed by the catalan office for climate change (occc) [57] . the climate action plan (cap) was developed by the san diego unified port district in 2013 (united states of america) to identify, assess and develop strategies to reduce ghg emissions [58] . the carbon footprint of the port of chennai (india) was estimated for the year 2014-2015 based on the wpci guidelines. misra et al. [59] elaborated an inventory of ghg emissions for the port of chennai (india), accounting for the various facilities of the port along with the housing colony and fishing harbor, which come under the management of the port of chennai. in 2007, the port authority of ferrol-san cibrao (spain) implemented its environmental sustainability plan. in 2016, the ferrol-san cibrao port authority started to monitor its environmental aspects through the integrated quality and environmental management system. within this frame, ghg emissions in scope 1 and 2 were calculated by the use of the ecological transition ministry (miteco) tool of the spanish government [60] . in 2016, the carbon footprint report for operational activities of giurgiulesti international free port (moldavia) on an annual basis was developed [61] . the ghg protocol is used to prepare the carbon footprint report [23] . in 2016, the port of taichung (taiwan) created a ghg emissions management and reduction plan by a self-management method. this was approved by the environmental protection bureau (epb) of taichung city. the approach included an inventory and actions to reduce carbon levels and air pollutants. in this regard, the ghg inventory tool (based on iso 14064) was developed by the industrial development bureau (idb) at the ministry of economic affairs and environmental protection agency (epa) of taiwan. following the successful experience of taichung port, the self-management method was adopted in other industries and areas in taichung city [62] . finally, the port of olympia (united states of america), as part of its commitment to environmental sustainability, is voluntarily conducting biennial greenhouse gas emissions inventories. the washington state agencies ghg calculator was used to perform the ghg emissions inventory for the port. scope 1 and scope 2 emissions were calculated for the 2017 inventory. the use of this methodology facilitates in-state comparison and better helps to demonstrate the port of olympia's contribution to the state of washington's overall ghg emissions [63]. besides the studies in ports, research on the methods used to calculate co 2 emissions and carbon footprint in port terminals has also been conducted. as it can be seen in table 4 , the amount of initiatives is not as extensive as in ports. table 4 . existing methodologies in port terminals. the netherlands this calculated the contribution of the processes of container handling and transshipment to the carbon footprint. 2011 this analyzed the three scopes of emission in four container terminals including an assessment of its damage to human health. taiwan this calculated the co 2 emissions per container of two different container terminals. 2017 another study from van duin and greelings [64] provides insight into the processes of container handling and transshipment at the terminals and calculates the contribution of these processes to the carbon footprint of the container terminals in netherlands. an activity-based emission modeling was applied to develop a methodology for the calculation of emissions caused by the container terminals. in research from chowhan et al. [65] , the three scopes of emission in four container terminals in two ports in mumbai were analyzed using the formulae in a spreadsheet developed especially for the computation of carbon footprint based on ipcc guidelines [18] . in this research, a study on the damage of co 2 emissions to human health was also carried out. although the emissions from ships are calculated in chowhan' research, the method is not explained. finally, in research from yang [66] , carbon footprint analysis was employed to calculate the co 2 emissions per container of two different container terminals in the port of kaohsiung (taiwan). the total energy consumption of each type of equipment was calculated as the total working time of that equipment multiplied by the equipment's energy consumption per hour. the average energy consumption of the equipment was calculated as the equipment's total energy consumption divided by the quantity of the equipment. finally, the co 2 emissions of each piece of equipment were obtained from the average energy consumption for that piece of equipment multiplied by the co 2 emission coefficient. as for the port terminals, the initiatives related to the calculation of carbon footprint in ships is reduced. table 5 presents existing methodologies related to ships. a study from chang et al. [67] measured ghg emissions from port vessel operations by considering the case of korea's port of incheon. it provided an estimation of ghg emissions based on the type and the movement of a vessel from the moment of its arrival to its docking, cargo handling, and departure. in a study by winnes et al. [68] , the potential reductions of ships' ghg emissions due to the implementation of different measures by ports were quantified. this research presents a case study of ship traffic in the port of gothenburg in 2010. a case study of the ship traffic at the port of gothenburg was performed. projections of ship emissions in the port area for 2030 with three scenarios were made: alternative fuel use, ship design and operational measures. the port of london authority (pla) and transport for london (tfl) requested that aether. a company that provides consultancy in air quality and climate change emissions inventories, forecasting and policy analysis and tno netherlands organization for applied scientific research on applied science) prepare an inventory of air emissions from shipping on the thames and other navigable waterways in the port of london. this inventory provided a baseline against which policy scenarios can be tested to show their impact on pollution emissions along the thames. the methodology for this study used detailed data on ships and their movements [69] . olukanni and esu [70] estimated the amount of ghgs emitted from port vessel operations in the lagos and tin can ports of nigeria. the emission estimate was carried out based on the type of vessel and its movement from the moment of its arrival. the emission estimate was done using the bottom-up approach based on the characteristics of individual vessels and using data on vessels processed by both ports in the first and second quarters of the year 2017. as it can be seen in the previous section, in recent years, many ports have started to calculate their carbon footprint and report it. however, each port uses its own method and there is no single or unified method to calculate carbon footprint in ports. more than 20 different methodologies used by 15 ports, 3 port terminals and 4 ships were taken into account. a deep analysis was conducted to study the strengths and opportunities for further development of each methodology that has been presented previously. the percentages have been calculated based on the existence of those strengths or opportunities for further development in the studied cases. after reviewing all these methodologies, a set of conclusions about their main strengths and opportunities for further enhancement were extracted. they can be seen in figure 1 . vessel and its movement from the moment of its arrival. the emission estimate was done using the bottom-up approach based on the characteristics of individual vessels and using data on vessels processed by both ports in the first and second quarters of the year 2017. as it can be seen in the previous section, in recent years, many ports have started to calculate their carbon footprint and report it. however, each port uses its own method and there is no single or unified method to calculate carbon footprint in ports. more than 20 different methodologies used by 15 ports, 3 port terminals and 4 ships were taken into account. a deep analysis was conducted to study the strengths and opportunities for further development of each methodology that has been presented previously. the percentages have been calculated based on the existence of those strengths or opportunities for further development in the studied cases. after reviewing all these methodologies, a set of conclusions about their main strengths and opportunities for further enhancement were extracted. they can be seen in figure 1 . as it can be seen in figure 1 , the main strengths of these studies are: in most of the methodologies, vessels' emissions are taken into account. taking into consideration the fact that, in 2012, ghg emissions from international shipping already represented already 2.2% of total co2 emissions [8] and that it is also known that such emissions could grow by between 50% and 250% by 2050, it is a very important sign of the awareness of the port sector to include the calculation of emissions from waterborne vehicles in the existing methodologies.  in around 60% of the methods, not only co2 emissions are calculated, but also other ghg emissions are taken into account such as ch4 and n2o. this is very important, since, as mentioned previously in section 2, the warming potential of ch4 and n2o is much higher than that of co2. therefore, it is really important to take into account all the gases in the carbon footprint calculation to obtain a real estimate. as it can be seen in figure 1 , the main strengths of these studies are: • in most of the methodologies, vessels' emissions are taken into account. taking into consideration the fact that, in 2012, ghg emissions from international shipping already represented already 2.2% of total co 2 emissions [8] and that it is also known that such emissions could grow by between 50% and 250% by 2050, it is a very important sign of the awareness of the port sector to include the calculation of emissions from waterborne vehicles in the existing methodologies. in around 60% of the methods, not only co 2 emissions are calculated, but also other ghg emissions are taken into account such as ch 4 and n 2 o. this is very important, since, as mentioned previously in section 2, the warming potential of ch 4 and n 2 o is much higher than that of co 2 . therefore, it is really important to take into account all the gases in the carbon footprint calculation to obtain a real estimate. in more than half of the cases, the calculation has been done based on standard methods such as the ghg protocol, ipcc, wpci and iso 14064. this makes the calculation more reliable and standard since all these methods should include the same parameters. as it can be seen in figure 1 , the analyzed methods present scope for further development: • in almost all of the studies, all the emission sources mentioned in the standard guidelines (direct or indirect) are not calculated. for example, on some occasions, some sources, like emissions from construction equipment or emissions resulting from energy use in rented out buildings are not calculated. in order to obtain comprehensive and realistic figures on ghg emissions and carbon footprint in ports, all emission sources should be taken into account. in most of the cases, emissions from waste operations that can take place in a port such as incinerators or wastewater treatment plants are not included in the calculation. this is an opportunity for further enhancement of the existing methods. these emissions should be taken into account, where they exist, since they are sources of co 2 emissions that should be counted in the total carbon footprint of a port. in most of the studies, scopes are not defined based on the standard methods. for example, in one port, scopes are divided into inside port emissions, outside port emissions and other emissions. in another method, water consumption is calculated in scope 3. in around 70% of the cases, emissions from employees' commuting are not included. these are a very important source of emissions in scope 3. therefore, their inclusion could help the existing methods to obtain more realistic results of the carbon footprint. in those studies, in which information was available, it has been seen that, in general, estimates are used for the calculation and not real data. in around 65% of cases, some of the recognized scopes or parts of them are excluded. for example, the calculation of the scope 3 emissions is not taken into account in some ports or scope 2 is excluded from the total ghg calculation in others. to obtain a real figure of carbon footprint in ports, it is recommended to calculate emissions of the three scopes. in around 60% of the studies, the whole set of scope 3 emissions (i.e., emissions from tenants, vessels and employees' commuting) are not calculated. therefore, the total amount of co 2 emissions would not present a real figure for the carbon footprint in that particular port. in about 60%of the studies where a tool has been developed (five cases), access to this tool is not possible. in more than half of the studies, the methodology is not fully described. therefore, it is not possible to reproduce it. this could be easily solved, and, in this way, other port agents could use it. ports are strategic nodes for a country's economy. however, given the range of activities, products and services associated with their operations (including those of their tenants), they also generate impacts on the environment which need to be controlled or minimized by effective environmental management programs in order to achieve compliance and sustainability. one of the significant environmental challenges for ports nowadays is to manage their contribution to climate change, mainly due to emissions from mobile sources and stationary sources in ports. emissions from these sources, such as emissions from ships, trucks, cargo handling equipment, power plants and others, are the main cause of climate change in ports. as mentioned before, based on the espo's 2019 survey, climate change occupies the third position among the top 10 environmental priorities [5] . this reflects the importance of climate change in the whole set of environmental priorities at european and international level. in this paper, initiatives to reduce the effects of climate change, carbon footprint and co 2 emissions in ports have been studied to identify function and applicability. the results of this research confirm that a range of international organizations and ports are implementing measures to fight against climate change effects and to reduce co 2 emissions. international organizations such as imo, iaph and pianc have demonstrated commitments to reduce the ghg emissions in ports through different initiatives. examples of this are the revision of the marpol annex vi to include regulations for the prevention of air pollution from ships, the creation of a mechanism to assist ports in the mitigation of climate change and the development of the world ports climate initiative (wpci) working group. the port sector has also decided to combat climate change with initiatives from several individual authorities. the first step was to calculate their carbon footprint. ports such as gijón (spain) and oslo (norway) were the first ones to do so. in recent years, more evolved initiatives consisting of co 2 calculators have also been implemented, such as the washington state agency ghg calculator. concerning the control of co 2 emissions in port terminals, some attempts have been made. for example, the three scopes of emission in four container terminals in two ports in mumbai were analyzed. in some cases, carbon footprint analysis was employed to calculate the co 2 emissions per container, such as two different container terminals at the port of kaohsiung in taiwan. finally, ships' initiatives to reduce ghg gases have also been presented. this includes the case of the study of the ship traffic in the port of gothenburg to quantify potential reductions of ship ghg emissions. the review of different studies shows that, in recent years, many ports have started to calculate their carbon footprint and report it. this is a positive sign in terms of the "greening" of ports. however, there is scope for further enhancement. for example, in most of the cases, all the emission sources mentioned in the standard guidelines (direct or indirect) are not calculated, and emissions from waste treatment operations and employees' commuting are excluded from the total calculation of co 2 . this makes the current calculations in some occasions unrealistic. in addition, in more than half of the studies, no scopes recommended by the standard guidelines are considered and data estimates are used for the calculation and not real data. additionally, the involvement of the port terminals in the final calculation is lower than expected and this is essential to obtain a real value of emissions for the whole port areas. their emissions should be added to the final calculation, although it is complicated to attain this data. an effort in these respects could provide more reliable results. as a general comment, each port uses its own method, and this does not allow establishing a sector benchmark or comparing the results between different ports. there is thus no single or unified method to calculate carbon footprint in ports. all this proves the need for the development a standardized methodology for co 2 calculation in ports. espo's declared environmental policy of compliance through voluntary self-regulation needs a practicable and effective methodology by which to monitor and thereby reduce co 2 emissions. the initiatives flagged in this review demonstrate commitment by the sector but also highlight the challenges of developing and implementing a generic system that may be applicable throughout the sector, as many observers agree that "each port is unique" (in terms of key characteristics including activity profile and geography). analysis of the methods available to date highlights the need for a collaborative approach. this was supported by most of the participants in greenport congress in valencia, as mentioned previously, who consider that a common port-sector carbon footprint scheme would benefit individual port authorities and the port sector as a whole. this is also the view of some of the aforementioned organizations (such as laboratorio de ingeniería sostenible), which also recognize the need for such a tool. therefore, the development of a practicable, user-friendly and easy-to-use tool with a standardized method for the calculation of carbon footprint in ports is highly recommended. this tool should include all the strengths of the existing methods and the opportunities highlighted in this paper for further development. author contributions: s.a. conducted the whole research in the different sources of bibliography. she also wrote a first version of the paper. c.w. reviewed the paper and contributed with valuable comments that were taken in the paper. he also did the english revision of the manuscript. r.m.d. suggested the research topic, structured the paper and reviewed it as a phd supervisor of s.a. all authors have read and agreed to the published version of the manuscript. impacts of climate change on ports and shipping port environmental management: innovations in a brazilian public port the self diagnosis method. a new methodology to assess environmental management in sea ports environmental performance indicators for green port policy evaluation: case study of laem chabang port sea ports organisation) iaph (international association of ports and harbors) imo (international maritime organization) reports on an emissions survey undertaken at greenport congress. greenport magazine. 2019. issue summer climate change impacts and adaptation: knowledge, perceptions, and planning efforts among port administrators climatic drivers of potential 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greenhouse gas emissions carbon footprinting for ports, guidance. 2010. document pianc (world association for waterborne transport infrastructure) envicom 188: carbon management for port and navigation infrastructure pianc (world association for waterborne transport infrastructure) clean cargo working group carbon emissions accounting methodology initial imo strategy on reduction of ghg emissions from ships (imo) cooperation on climate action collaboration maritime industry's path to 2030 espo's roadmap to implement the european green deal objectives in ports 9 years of carbon footprint in a spanish port from the motorways of the sea to the green corridors' carbon footprint: the case of a port in spain ports of long beach and los angeles, clean air action plan technology advancement program annual report co 2 emissions for the calendar year = abacus, a port area energy consumption and c02 footprint calculation tool program co financed by the european regional development fund port of rotterdam authority. co 2 footprint port of rotterdam authority port of rotterdam co 2 neutral annual report and sustainability report climate action plan ghg emission accounting and mitigation strategies to reduce the carbon footprint in conventional port activities-a case of the port of chennai giurgiulesti international free port report on carbon footprint self-management of greenhouse gas and air pollutant emissions in taichung port ghg emissions inventory report estimating co 2 footprints of container terminal port-operations carbon footprinting of container terminal ports in mumbai operating strategies of co 2 reduction for a container terminal based on carbon footprint perspective assessing greenhouse gas emissions from port vessel operations at the port of incheon reducing ghg emissions from ships in port areas report to port of london authority and transport for london estimating greenhouse gas emissions from port vessel operations at the lagos and tin can ports of nigeria this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord-258915-lgee3ers authors: liddle, jennifer; pitcher, nicole; montague, kyle; hanratty, barbara; standing, holly; scharf, thomas title: connecting at local level: exploring opportunities for future design of technology to support social connections in age-friendly communities date: 2020-07-31 journal: int j environ res public health doi: 10.3390/ijerph17155544 sha: doc_id: 258915 cord_uid: lgee3ers social connectedness in later life is an important dimension of an age-friendly community, with associated implications for individual health and wellbeing. in contrast with prior efforts focusing on connections at a distance or online communities where the digital technology is the interface, we explore the design opportunities and role of technology for connectedness within a geographically local community context. we present findings from interviews with 22 older adults and a linked ideation workshop. our analysis identified shared concerns and negative perceptions around local relationships, connections and characteristics of the geographical area. however, local connectedness through technology was largely absent from day-to-day life and even perceived as contributing to disconnection. by uncovering how older adults use and perceive technology in their social lives and combining these findings with their ideas for improving local connections, we highlight the need for thoughtful consideration of the role of technology in optimising social connections within communities. our research highlights a need for design work to understand the specifics of the local context and reduce emphasis on technology as the interface between people. we introduce an amended definition—‘underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community’s physical, social and digital environments and its supporting infrastructure’—to conceptualise our approach. we conclude by suggesting areas for future work in developing digitally connected age-friendly communities. social connectedness in later life is important for health and wellbeing. consequently, making it easy for people to develop and maintain social relationships is a fundamental ambition of 'age-friendly' communities. this local, place-based, policy approach recognises that physical and social environments are key determinants of whether people remain independent, autonomous and healthy in later life. human-computer interaction (hci) researchers are directing increasing attention towards the role of technology in shaping and supporting social relationships in later life. much of this work focuses on online communities or connecting across geographical or generational distances, where digital technology is the interface or infrastructure for connection. in addition, approaches commonly place emphasis on addressing technological inexperience, or on physical or cognitive impairment and decline. in this paper, we are interested in considering technology and connectedness in later life within a specific local context, and exploring how innovation in social connection can be age-friendly and embedded within such physical community settings. we consider older adults as a heterogeneous group, rather than a group marked by singular identities of health, cognitive status, or technological proficiency. nevertheless, our place-based approach aims to identify common values and experiences shared by people living in the same geographical area. life events such as retirement, along with experiences of building and maintaining social connections over the life course, will also have implications for how and why older adults wish to develop and sustain proximate relationships in particular ways. we suggest that considering these topics enables a deeper understanding of how to design for a digitally connected age-friendly neighbourhood, where both the design process and its outputs are age-friendly. our paper presents findings from a study comprising two phases: qualitative interviews with 22 older adults; and a linked workshop ideation process to engage interviewees in beginning to consider how connections within their local area might be enhanced over time. the contributions of our paper centre around a context-specific and bottom-up approach to designing for increased local connectedness in later life. the importance of this topic has since been emphasised by the covid-19 pandemic, heightening awareness of the need to consider ways to maintain and create social connectedness, particularly at a local level. our aim is not to design a technological output. instead, we see our approach as prioritising a crucial, and often neglected, stage in technology design, which provides important insights that would be required for any future stage of a design process that aimed to design or create an actual technology. themes that emerged from our interviews suggest that participants viewed technology as acceptable when it filled a 'gap' and did not have too many negative impacts on everyday life. our starting point for the linked workshop was to consider some of these 'gaps' in local connectedness that interview participants had described. the workshop activities were used to facilitate participants in thinking creatively about addressing specific local challenges, or 'gaps' in connectedness. in drawing together participants' ideas about spaces, processes and mechanisms that might address these local challenges, we conclude the paper with implications that offer scope for further exploration and consideration in terms of how technology might support the operationalisation of local people's ideas for improving face-to-face connections in age-friendly community settings. growing interest in what makes places 'good' to grow old in has led to an increasing focus on the 'age-friendliness' of different types of environments [1] . despite variation in emphasis between models of age-friendly environments, most approaches promote consideration of how policies, services and structures can integrate physical and social environments, supporting social engagement and connection [2] . our work adopts the following conceptual definition, with its emphasis on age-friendliness as commitment to a process rather than a standard to be reached: 'underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community's physical and social environments and its supporting infrastructure' [3] . the adopted definition of age-friendliness shapes our research design and methods, with its emphasis on community engagement and the participation of older people in processes to optimise the environment to support social connections. we also draw on concepts from environmental gerontology, such as 'ageing in place' to understand the importance of the local area in older people's lives. an overarching premise of an age-friendly community is that it is 'friendly for all ages and not just "elder-friendly"' [1] . even so, the argument that older people are 'able to remain more independent by, and benefit from, ageing in environments to which they are accustomed' [4] makes it all the more important to consider how environments can support people 'ageing in place' to optimise their social connectedness within their local area. this has become even more apparent during the 2020 covid-19 pandemic, which has exposed the need for digital connection as an alternative to face-to-face interactions. similarly, finding new ways to connect, even with people in proximate locations, has become a greater priority. there has also been a strong emphasis on tackling the counterparts of social connectednessloneliness and isolation. warnings of the 'loneliness epidemic' and its associated public health implications are prevalent in media discourse [5] [6] [7] , and the uk government appointed the world's first minister for loneliness in 2018 [8] . accordingly, responses to the drive for increased social connection have often focused on mitigating unpleasant experiences, risks and deficits at an individual level [9] . efforts along these lines reflect and uphold persistent ageist stereotypes that fail to acknowledge the roles that older people (can) play in communities, or their potential to contribute innovative ideas or create a voice for themselves [10] [11] [12] . indeed, technology is often presented as the ideal way of solving these 'problems' faced by older adults [13] . ten bruggencate et al. draw our attention to the predominant focus on loneliness and/or isolation in studies about social technology, ageing and relationships [14] . in contrast, a growing body of work on social connectedness in later life challenges the image of older people as lonely and isolated. population ageing is leading to increasing numbers of older people, thereby increasing the number of older people in society who experience loneliness. however, loneliness affects only the minority of older people, including the oldest old [15] [16] [17] . the likelihood of reporting feeling lonely decreases with age, with younger adults (16-24 years) reporting loneliness more often than those in older age groups [18] . while older adults may have smaller social networks, they are often more involved in the community than younger adults-socialising with neighbours, participating in religious organisations and volunteering [19] . however, even if social reciprocity and meaningful interactions are desired and enacted by older people, infrastructural barriers can, and do, impede the quantity and quality of such connectedness [20] . technology offers the potential for scalable and cost-effective interventions to address barriers to connectedness. the design, or adoption, of digital technology to support social relationships in later life often results in technology being the core interface for connection between people, rather than a route to facilitating face-to-face connections by overcoming barriers. for example, online communities are promoted as presenting opportunities for older people to meet and interact with peers [21] [22] [23] [24] . in this interfacing role, technology is a bridge across distances. lindley et al. comment that much hci research related to relationships focuses on ways to maintain feelings of connectedness or express intimacy at a distance [25] . distances being bridged may be geographical, for individuals living in remote areas or wanting to connect with people with whom they share interests, friendship or familial bonds. distances may also be generational, where, despite intentions to the contrary, technology replicates asymmetrical family interactions [23, 26, 27] . growing proportions of older people are now using digital technologies. in the uk, 83% of adults aged 65-74, and 47% of adults aged 75 and over use the internet [28] . thus, the majority rather than a minority of older people are technologically connected, suggesting a need to understand more about how this diverse population uses, and feels about, technology for connecting with others. the few studies that have explored older people's attitudes towards, and perceptions about, communication and connection suggest that rich interactions are valued above lightweight connections offered by newer technologies [14, 25, 29] . again, this work primarily considers the capacity of digital technology to bridge geographical or generational distances, where more traditional technologies such as telephone and email are often preferred. thoughtful and meaningful interactions are the goal, and technology provides the interface. research methods centre around questions about how older adults use, or would choose to use, technology in their social relationships. for instance, sayago et al. report on research with 700 older people (across six studies) that examined situated technology use and the reasons why participants did, or did not, incorporate particular forms into their everyday lives [23] . in this way, technological interfaces are often in-built as fundamental foundations for designing for connection, diminishing considerations of technology in non-interfacing roles. research that has explored ways to improve geographically proximate connections has also tended to concentrate on a prominent role for technology, often studying online community networks. these include bespoke online communities for older adults, or those formed on more widely used social networking platforms. righi et al. focussed on how older people's use of social networking sites could be used to promote their involvement in both online and offline local communities [30] . while participants used, for example, facebook to find out information about the local area, most did not post or share information or send messages to others. instead, these interactions took the form of face-to-face conversations. on this basis, the authors conclude that proximity and face-to-face contacts should be kept in mind when designing online community networks. we would extend this argument further, to suggest reversing the design process. such a process would design for proximity and face-to-face contact in offline communities, with technology kept in mind in a background, less visible, role. the research described above concentrates on technology as the interface for connection between people. while the potential of technology to foster involvement in local communities has been explored, less attention has been paid to understanding and drawing on context-specific factors to develop approaches to promote connection in local areas with, rather than for, older people. this would be a fundamental approach for any community engaged in the ongoing process becoming (more) age-friendly. an effective strategy in one community will not necessarily translate to a community with different geographical, social or structural features. likewise, the attitudes of older people towards technology will vary individually and across communities and countries. in their 'manifesto for change' in age-friendly cities and communities, buffel et al. emphasise the necessity of ensuring the empowerment and recognition of older residents in order to achieve age-friendliness [31] . for these reasons, we adopted a bottom-up, place-based approach that can be responsive to local needs, preferences and resources. we recognise community as an inclusive concept, with the participation and empowerment of members (particularly older people) being fundamental to its creation and functioning [3, 32, 33] . the following sections present the methods and findings of our study. our research design (in-depth interviews followed by an ideation workshop) draws on key concepts, theories, gaps and definitions in the literature outlined above. it is a bottom-up place-based approach that focuses on local needs, preferences and resources. it prioritises the participation of older people in exploring context-specific routes to local connection that present opportunities for future design of technology. we see our participants as crucial to developing ideas to increase or improve connection. as residents within the local area, they have a wealth of knowledge and experience and are best placed to identify resources, ideas and options that can lead to context-specific routes to connection. our overall aim within this study is to begin exploring context-specific routes to local connection that do not start the design process with attempts to design technological interfaces. discovering issues or opportunities for increased connection at a community level is the first step in this process. these opportunities and 'gaps' also need to be considered alongside insights into the current practices and perceptions of older people regarding technology in their social lives. once opportunities for increasing connection have been identified, ways to address these can then be explored by older people with local expertise and knowledge. therefore, in practice, the workshop methods were designed after analysis of our interview data so that we could draw on the interview findings as the starting point for workshop activities and discussions. however, for structural clarity, the methods for both the interviews and workshop are presented first in this paper, followed by the findings from our analyses. the first phase of our study aimed to explore opportunities for designing to improve proximate social connections for older people living within a geographically identified 'community'. we also wanted to know more about how and why research participants were using technology, or not, in their social lives. qualitative interviews were an appropriate method for exploring these two topics, with their potential to elicit personal accounts that help people to 'make explicit things that have hitherto been implicit-to articulate their tacit perceptions, feelings and understandings' about their social lives and technology [34] . the study setting was an electoral ward (district) within a city in the north of england, uk, chosen for its proximity to the research team's institutional location. just over 10% of the around 13,600 people living in this geographical area are aged 60 or over (compared to 23% overall in england and wales). it is also one of the most ethnically diverse and socially deprived wards in the region [35] . following institutional ethical approval (ref. 13284), we recruited 22 older adults (15 women, 7 men) to take part in audio-recorded interviews. sixteen interviews were with individual participants and three interviews were with couples living in the same household who chose to be interviewed together. our only inclusion criterion was that participants were aged 60 or over. however, we also sought to achieve a diverse sample in terms of age, gender, ethnicity, social connectedness and living arrangements. table 1 summarises participant characteristics. participants were aged between 60 and 84 and had been living in the area for between seven months and 84 years. one participant was asian and the remaining 21 participants were white. eight participants were living alone, and the others lived with at least one other person (a spouse/partner ± extended family). with the exception of one participant who was working part-time, all participants were retired. recruitment was via face-to-face conversations at community events and locations (such as a weekly café held in a local church) and contact details shared by community groups and organisations based in the area. we made substantial efforts to achieve a sample with greater ethnic diversity, including seeking assistance from individuals running local organisations and groups for people from non-white backgrounds, and posters in local culturally diverse food and clothing shops. we also made provisions for language translation in interviews. however, in the time available, we were unable to identify additional people from different ethnic groups who were willing to take part in an interview. longer-term development of relationships within the community would likely be needed to increase interest and trust, which was not possible in a study of this scale. all potential participants were given an information sheet about the study and a copy of the consent form to read. interviews were arranged at times to suit participants, and they were offered a choice of location. one participant chose to meet for their interview in a community building and all other interviews were conducted in people's own homes. after completing the consent form and giving an opportunity for the interviewee to ask any questions, we audio-recorded the interview with the participant's agreement. interviews were conducted by jl, hs or np. we initiated the interviews with a narrative approach, asking individuals to tell the story of their social lives since they had been living in the area. this facilitated the exploration of each individual's own concerns, meanings and priorities related to their social lives, rather than these being imposed by predetermined questions [36] . the same question was asked at the beginning of each interview: 'can you please tell me the story of your social life while you've been living in [this area]; your relationships with family, friends, neighbours and other people?'. participants were asked to talk about any events and experiences that were important for them, and invited to take as long as long as they needed to tell their story. this narrative section of the interview was followed by supplementary probing questions to explore areas of particular interest, including the role of technology in their social lives. these questions were not pre-defined in order that interviewers were free to explore anything that they felt was of interest and relevant to the overall aims of the study, maintaining a natural and spontaneous flow within the interview. brief reflective field notes were made by interviewers after each interview. electronic data files were stored in password-protected folders in the university filestore. interview recordings were transcribed and names were anonymised. we then completed initial inductive coding [37] of the data to explore (a) opportunities to improve connections at a local level, i.e., factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction; and (b) participants' engagement with technology in relation to their social lives generally. codes were organised under themes, following the process outlined by braun and clarke [37] . for example, codes such as 'places people used to socialise no longer exist', 'many buildings are not accessible', and 'there are few facilities' were grouped together under the theme 'few local places to socialise'. coding and theme development were completed independently by two researchers (j.l., n.p.) and then discussed and refined with all members of the research team. while all names used in this paper are pseudonyms, participants in photographs gave consent for their images to be included in research outputs. the second phase of the study comprised an ideation workshop. we drew on the following conclusions from our interview analysis when designing the workshop: • there were concerns and perceptions about local community connections and characteristics that offered opportunities for design; • our participants predominantly used technology to connect with family, or friends at a distance; existing local technological connections in their social lives were less obvious; • many participants were actively using a variety of technologies, but their willingness to do so depended on perceptions of unmet needs and balancing the negative aspects (additional work, potential contribution to face-to-face disconnection) in their everyday lives. we designed the workshop to explore and generate ideas to improve and optimise social connections in the local area, focusing on four of the opportunities we identified in our interview analysis. based on the in-depth understanding about participants' use and perceptions of technology that we gained from the interviews, we designed 'playful' workshop activities that deliberately did not ask participants explicitly to consider how technology could address issues in local social connections. instead, we wanted to begin by eliciting participants' thoughts about the best ways to tackle these issues before considering any technological needs that arose from these suggestions. this approach avoids the tendency of previous research to foreground technology at the start of the design process. by deliberately not seeking to design a technology or technological interface in this study, we could instead reflect on the potential needs or roles for technology once we knew what type of interventions our participants had suggested. our approach also fitted well with our desire to draw on participants' knowledge, experience and capacity for creative thinking, and was in keeping with our aim of developing approaches to promote connection with, not for, older people, prioritising their participation in a bottom-up design process. all interview participants were sent a postal invitation to the workshop. eleven individuals initially confirmed their availability and nine attended on the day (6 women, 3 men). these individuals were aged between 68 and 84 and had been living in the area for between 30 and 69 years. the workshop was held in a church hall in the local area and refreshments were provided. participants were asked to read and complete the consent form on arrival. consent to being photographed was optional. the workshop was structured around four opportunities to improve local social connections that we identified as themes through our interview analysis. each theme represented shared concerns and negative perceptions about local relationships, connections and characteristics of the area that participants had talked about. the four themes were 'few local places to socialise', 'not knowing neighbours well', 'absence of a shared community feeling', and 'activities on offer not always conducive to socialising or making new friends'. these themes were chosen to take forward in the workshop based on their content being both appealing and generic enough for all participants to engage with, regardless of their individual circumstances and experiences. in line with age-friendly models, our aim was for a bottom-up approach in which workshop attendees' participation and contributions were fundamental to the resulting design ideas [38] . confronting ageist stereotypes, we also wanted to capitalise on participants' creative abilities and ingenuity along with their knowledge and experience as residents within the local area. in line with these priorities and our aim to explore participants' thoughts about how to improve connections at a local level without a specific focus on technology, we designed a range of playful ideation (idea-generating) activities to scaffold workshop discussions. choosing activities to maintain a 'playful mindset' was a central ambition in our design, as this has been identified as a key enabler when ideating [39] . participants worked in small groups, with each group asked to choose one theme to focus on throughout the activities. we gave groups the option of completing one, some, or all of the activities, depending on which appealed to them and how much time they spent on each activity. all groups tried at least two of the three activities: participants were asked to generate ideas about how to cause the issue/theme or how to make it worse. this generated a list of problems or criticisms that participants were then asked to reverse or convert into positive ideas or solutions ( figure 1 ). an example idea from participants was to remove the internet. they then converted this into an idea to provide free internet access alongside tv licences. mindset' was a central ambition in our design, as this has been identified as a key enabler when ideating [39] . participants worked in small groups, with each group asked to choose one theme to focus on throughout the activities. we gave groups the option of completing one, some, or all of the activities, depending on which appealed to them and how much time they spent on each activity. all groups tried at least two of the three activities: participants were asked to generate ideas about how to cause the issue/theme or how to make it worse. this generated a list of problems or criticisms that participants were then asked to reverse or convert into positive ideas or solutions ( figure 1 ). an example idea from participants was to remove the internet. they then converted this into an idea to provide free internet access alongside tv licences. this activity involved imagining how a famous person or character (fictional or real) with a wealth of skills, resources or power might respond to the issue. one group chose vladimir putin, president of russia, as their inspiration, with ideas that reflected their views on his leadership style, including mandatory socialising (e.g., meeting for a chat over a cup of tea or coffee) at particular times of day with street marshals to monitor and guarantee people's involvement. the third activity began with each group member writing an initial idea on a piece of paper which was then passed around the group for others to contribute to, comment on, or develop the initial idea ( figure 2 ). an example of this process was an initial idea to have more benches and ice cream vans driving round parks to encourage families with children to stay and chat. this resulted in the suggestion that the vans could double-up to provide other services like newspapers or bread, which might attract a wider range of people. this activity involved imagining how a famous person or character (fictional or real) with a wealth of skills, resources or power might respond to the issue. one group chose vladimir putin, president of russia, as their inspiration, with ideas that reflected their views on his leadership style, including mandatory socialising (e.g., meeting for a chat over a cup of tea or coffee) at particular times of day with street marshals to monitor and guarantee people's involvement. the third activity began with each group member writing an initial idea on a piece of paper which was then passed around the group for others to contribute to, comment on, or develop the initial idea ( figure 2 ). an example of this process was an initial idea to have more benches and ice cream vans driving round parks to encourage families with children to stay and chat. this resulted in the suggestion that the vans could double-up to provide other services like newspapers or bread, which might attract a wider range of people. data collection in the workshop comprised ideas written by participants on the templates provided (see figure 1 for example data). all data were stored in a locked filing cabinet within an access controlled workspace. the workshop activities generated an extensive list of ideas and suggestions for facilitating social interaction within the immediate local area. each group wrote down every idea that resulted from the activities they completed. after the workshop, we combined these ideas into one longer list and grouped and organised them under three overarching themes and 12 sub-themes that captured the overall range, content and types of ideas [37] . themes and sub-themes were developed by two researchers (jl, ts) and then discussed with all members of the research team. as described earlier, the interview data were coded to explore a) opportunities to improve connections at a local level, i.e., factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction; and b) participants' engagement with technology in relation to their social lives generally. the following sections outline the main findings in relation to each of these topics. in our interviews with participants, we adopted a place-based approach to focus in on social lives at a geographically local level. it soon became apparent that there were many aspects of the locality that participants were content with, or did not wish to change. for example, some described strong friendships and connections with local friends and neighbours that had endured over time. others were actively involved in attending and/or organising local social events. however, there were shared concerns and negative perceptions around local relationships, connections and characteristics of the area that offered opportunities for further exploration as topics to design around. our analysis of the interview data specifically aimed to identify these opportunities to improve connections at a local level, by pinpointing factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction. we report here on the four of these themes that were taken forward to the ideation workshop. these were chosen from a larger number identified, based on the criteria that they would be both appealing and generic enough for all participants to engage with, whatever their individual circumstances and experiences. table 2 outlines the four themes, along with linked examples from the interview data. data collection in the workshop comprised ideas written by participants on the templates provided (see figure 1 for example data). all data were stored in a locked filing cabinet within an access controlled workspace. the workshop activities generated an extensive list of ideas and suggestions for facilitating social interaction within the immediate local area. each group wrote down every idea that resulted from the activities they completed. after the workshop, we combined these ideas into one longer list and grouped and organised them under three overarching themes and 12 sub-themes that captured the overall range, content and types of ideas [37] . themes and sub-themes were developed by two researchers (jl, ts) and then discussed with all members of the research team. as described earlier, the interview data were coded to explore (a) opportunities to improve connections at a local level, i.e., factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction; and (b) participants' engagement with technology in relation to their social lives generally. the following sections outline the main findings in relation to each of these topics. in our interviews with participants, we adopted a place-based approach to focus in on social lives at a geographically local level. it soon became apparent that there were many aspects of the locality that participants were content with, or did not wish to change. for example, some described strong friendships and connections with local friends and neighbours that had endured over time. others were actively involved in attending and/or organising local social events. however, there were shared concerns and negative perceptions around local relationships, connections and characteristics of the area that offered opportunities for further exploration as topics to design around. our analysis of the interview data specifically aimed to identify these opportunities to improve connections at a local level, by pinpointing factors that had the potential to impact negatively on people's geographically proximate social relationships in terms of quality, quantity or satisfaction. we report here on the four of these themes that were taken forward to the ideation workshop. these were chosen from a larger number identified, based on the criteria that they would be both appealing and generic enough for all participants to engage with, whatever their individual circumstances and experiences. table 2 outlines the four themes, along with linked examples from the interview data. beginning with the first of the four themes, most participants reported that there were few places in the immediate local area that they could use for socialising beyond their own homes. they described how there was no central community centre in the area, and no clearly distinguishable main high street. perceptions about the lack of local options contrasted with participants' opinions about the venues, centres and cafés available in other areas where they felt that community spaces and cafés were prominent and actively used and adopted by people living there. some participants were happy to socialise at home, but others saw this as too much of a burden or did not feel comfortable inviting people into their home. a noteworthy and unique characteristic of the local area highlighted by participants was the historic covenant on the land in the vicinity, preventing any licensed premises or pubs from operating. in the face of limited options in terms of usable spaces, local churches often hosted (or were booked to host) activities and events. however, this itself was a deterrent to some participants who felt uncomfortable attending events that had a religious connection-even if religion was not intended to be part of the event, such as a community café. overall, the perspective was that the community's physical features and built environment did not facilitate face-to-face social activities and interactions. the second theme (not knowing neighbours well) did not apply to all interview participants. in fact, some participants described their neighbours as good friends. these interviewees lived in quieter, more spacious streets, accommodating larger houses with gardens. other interview participants felt very disconnected from their neighbours. those living in particularly 'neighbourly' streets were aware that their situations were unusual in the wider local area where different road and housing types and tenures were more dominant, and fewer longstanding residents were living alongside the same neighbours for extended time periods. population churn, the movement of people in and out of streets, was perceived as a factor influencing the extent to which participants knew their neighbours. growing families and the number of properties available to rent in the area were cited as reasons behind this movement. streets were often busy with traffic-a factor that participants identified as not being conducive to unplanned meetings or chats with neighbours. while the physical proximity of neighbours potentially offered the most geographically close opportunities for social interaction, this had not translated into actual interactions for many participants. in particular, participants indicated that local issues of population mobility and transport routes contributed to the under-development of these relationships. the essence of the third theme (a lack of shared community feeling) was expressed by many participants. some attributed the absence of community to the area's geographical characteristics and location within the wider city, including the proximity of a motorway and the absence of a central focal point, or main high street, in the area. interview participants also commented on the lack of interaction between people of different ethnic and cultural backgrounds, despite the fact that the area was home to a diverse population. some talked about how this had been a longstanding issue, first noticed when their children were at school. together, both the physical environment and the population makeup of the area appeared to contribute to participants feeling that there were physical and cultural divisions within the geographical community. the fourth theme illustrates the complexity of developing new connections and relationships that extend beyond acquaintanceship: activities on offer are not always conducive to socialising or making new friends. even when participants were meeting people and seeking new friendships, these interactions did not often translate into deeper relationships. some participants described attending regular or one-off activities where they felt that the type and format of sessions were not helpful for getting to know people. for example, the focus was on a particular activity so chatting was only possible during brief time periods while setting up or packing away. another barrier was that some participants were more passive than others, and did not initiate conversations or connections themselves. in addition, participants mentioned that the same volunteers or people were often involved in several different groups and activities, resulting in a smaller pool of people to form friendships with. in other instances, it was simply that occasional casual conversations participants had with others did not result in deeper friendships or relationships that were sustained or developed beyond interactions at the events themselves, and individuals, therefore, remained acquaintances. taken together, these themes demonstrate clear barriers in, and characteristics of, local community connections. the themes capture issues that were impacting on the quality and quantity of participants' relationships in the local area, offering opportunities for participatory design processes to address these. alongside identifying opportunities to improve connections at a local level, the other focus of our analysis of the interview data was on understanding more about participants' existing engagements with technology in relation to their social lives. this engagement ranged from minimal (i.e., landline telephone only) to extensive (including social media, real-time audio/video interactions and applications). we use eight central themes to capture participants' accounts of the existing roles that technology played, or did not, play in their social lives. these themes, and examples of the data that support them, are outlined in table 3 . capturing and sharing images marie: "it's got an excellent camera. i use it as a camera because i'm useless at taking photographs otherwise." simon: "see, if marie uses a camera to take somebody's photograph, and eventually either cuts them in half or chops their head off, you know, which is-but, with this phone, it's absolutely brilliant." marie: "yes, yes." simon: "the pictures that she's taken when she's been on holiday and things, absolutely superb." "i get loads of photographs of the children when they're opening birthday presents. their mother takes a photograph and sends it with a comment on what they said when they were trying on things." (lynne) the first theme about the role of technology in interviewees' social lives focuses on its use to connect participants with people in geographically distant locations. in fact, many of the digitally mediated interactions described by participants bridged geographical distances. applications and platforms such as facetime, facebook and whatsapp (along with traditional landline phone calls) were commonly used to keep in touch with friends and family located in geographically separate locations. grandchildren were frequently mentioned as being a priority in seeking to connect face-to-face at a distance. while the financial savings of free long-distance technological connection were noted and appreciated by some, interviewees also reflected on the emotional value of being able to stay visually connected with loved ones. for claire, this connection even changed her perception of the duration of time passing between in-person interactions, making it feel like she had seen her son in person more recently than was the case in reality. in contrast to those using technology to bridge distances in order to maintain existing relationships, deborah was unusual among interviewees in that she had formed long-lasting friendships with people she met initially through the use of an online marketplace. as someone living alone in later life, she was using technology designed for one purpose (financial/accommodation transactions) to initiate and facilitate face-to-face interactions with strangers from geographically distant locations, offering the potential for developing new social relationships. our next theme encapsulates the role of technology in connecting family members and groups. family relationships were frequently discussed as examples of connections that were supported by technology, through informal chatting, sharing photographs or stories and news about day-to-day life events. family connections using technology ranged from group chats to individual messages, and instant short communications as well as ongoing asynchronous conversations. whatsapp was often highlighted in this context, particularly for its usefulness in communicating with a group, and across generations. examples included whatsapp groups with interviewees, their children and partners, and grandchildren. these were sometimes longstanding groups for general communication, but at other times were set-up for a specific purpose, such as organising a birthday party. cross-generational interactions were also perceived as improving the connectedness of family members who had previously felt 'left out' of family communications. john described the example of his sister, who was previously less connected with other members of the family but could now see photographs and hear about what other members of the family were doing, without them needing to make a special effort to include her. technology was seen, in cases like this, as a solution to the barriers to instantaneous communication with family members with diverse and busy lives and routines. however, telephone calls were also important to participants as a way of keeping in touch, particularly with others who were nearer in age such as siblings or friends. in addition, paul expressed his unease at the invasive nature of commonly used apps and platforms which, for example, access lists of contacts from the device they are using or collect data to support targeted advertising. his use of whatsapp was 'reluctant' on this basis, but he acknowledged its usefulness in keeping in touch when his son was abroad, highlighting the trade-off he had to negotiate between privacy and connection. we did not ask participants explicitly about the ways in which they chose to record social interactions or events, but the use of in-built cameras in mobile phones featured in participants' accounts of the role of technology in their social lives. we have described this theme as 'capturing and sharing images'. the ease of taking photographs with a smartphone in comparison to using a camera was noted by some participants, facilitating them in documenting social occasions. moreover, despite his privacy concerns about the invasiveness of technology more generally, paul valued the fact that he was able to recover digital images from an automatic cloud backup after he accidentally deleted photos (documenting an international trip) from his mobile phone. photographs as mementos of experiences in participants' social lives, like paul's trip, were treasured. additionally, the act of sharing and receiving images was a central feature of participants' digital interactions, connecting participants with events and experiences when they were not physically present. after initially dismissing much technology (apart from facetime) as insignificant in her social life, claire later reflected that it did play a large role in how she organised and arranged social events and interactions. the theme of 'sharing information and making arrangements' draws on these organisational uses of technology described by interviewees. information was generally not necessarily shared on social networking sites or more visible platforms, but interactions commonly took place through instant messaging and other technological channels rather than solely in person. in fact, for marie, there were additional benefits to using technology as a tool for organising or making arrangements with people. she preferred the control that it gave her in contrast with the unpredictability and social awkwardness she experienced when talking on the phone. technology was mainly described by interviewees in terms of its role as a tool for connecting, or supporting connections between, people. conversely, several participants noted the ways in which technology itself was a dimension of their social life, offering an alternative to interactions with people. perhaps because of its dominant focus on portraying human lives and activities, jane felt that television was a more 'personal' type of technology. patricia and brenda watched television at times when other company or interaction was inaccessible. for patricia, this was at 'silly hours' of the day or night, whereas brenda described how she might watch television, dvds or listen to cds when she found herself alone or 'down'. there were particular times when others living in her housing development were more likely to be spending time with family, such as weekends, where she used music or television as a strategy to deal with loneliness. at the other end of the spectrum, simon tended to avoid face-to-face social activities and events with other people, preferring to spend time playing games or reading on his computer. there were two main ways that participants described technology as contributing to disconnection in terms of social interactions and events: its prevalence as a platform for information about events; and its disruptive potential during face-to-face interactions. sally used the internet but chose not to engage with social media for privacy and security reasons, but felt that this was increasingly disadvantaging her when it came to finding out about local events. she reflected on her reliance on other people to keep her informed, and the difficulties of being separate from the dominant route of information sharing via social media. for sally, information sharing was happening in a way that excluded her, meaning that she missed out on attending social activities and events that she would have chosen to go to otherwise. in contrast, liz highlighted the capacity of technology to disrupt social interactions themselves. she described both a friend's extensive use of a smartphone, and purely the presence of a phone (in use or not), as disrupting face-to-face interactions and impacting on their quality. sally's and liz's accounts indicated a reluctance to allow technology to become pervasive in everyday life, balanced against a recognition that there were places and circumstances where it could be beneficial. along with concerns about the potential for technology to disrupt relationships, the positive impacts of technology in participants' social lives were also, in some cases, accompanied by additional unwanted work. our penultimate theme, therefore, centres around experiences of technological interaction as an additional 'chore'. sally described being 'bombarded' by messages, and she and others found their perceived continual need to respond and interact electronically to be a burden. the perpetual nature of communicating using interactive technologies such as email, texts and instant messages was also unpopular with some interviewees because of the amount of time it consumed. responding was not perceived as an optional activity. even if emails contained welcome content, the task of checking, opening and reading them was viewed as a compulsory individual task and responsibility. catherine likened this to the responsibility to open letters that came through the post, rather than a choice or pleasurable activity. our final theme sums up participants' thoughts about not needing digital technologies. more traditional technologies such as the telephone or television were commonly accepted as integral to daily life. in fact, their deep-seated role in participants' social lives meant that they were often no longer considered or mentioned (by participants) when talking about technology. instead, participants tended to focus on newer digital technologies such as social media, applications and email. regarding these more modern technologies, there was a sense for some participants that they were unnecessary. for example, when talking about social media, liz explained that she did not 'think there's a gap that i need them.' christopher used the internet and email but did not consider it necessary to go online to find out about local social events as he was exposed to paper-based publicity, such as posters and flyers, as well as information via word-of-mouth. for judith, the whole idea of using a computer or the internet was superfluous when she could instead rely on her family for support, asking them for anything she needed. overall, technological connections were predominantly bridging distances, with existing local technological connections less obvious. technology was mainly seen as a tool to be used to make connecting easier where there were needs, barriers or 'gaps' (geographical or generational distances, difficulties sharing information, capturing images, avoiding uncomfortable face-to-face interactions), but not at the expense of disrupting desired face-to-face interactions or in situations where technology was seen as unnecessary (other strategies would suffice). in addition, the additional work required to use technology as an aid to connection was an unwanted consequence. willingness to use technology depended on balancing the positive and negative aspects. as described earlier, the workshop was designed to build on the findings from our interviews. an extensive list of ideas was generated through our ideation activities, which we combined and organised under themes and sub-themes. table 4 summarises the themes and sub-themes identified in our analysis of the written workshop data. participants commented that the workshop had been enjoyable and thought-provoking-an outcome that supports us in challenging ageist stereotypes of older people as unable or unwilling to engage in creative, disruptive or wild thinking. the second theme brings together ideas that participants had for processes and actions that could play a part in promoting social interactions. these included: prioritising engagement within the wider community to develop ideas; connecting different groups with each other; improving provision of information about events and activities in the local area; connecting people with locations and activities in the city centre; and focusing particularly on making use of proximity as a tool in the process of connection. encouraging people to walk in the local area more often, and setting up hyper-local events such as street meetings, were examples of ideas to facilitate people in connecting with others living in close proximity. participants' ideas emphasise the importance and desire for strong relationships at a local level, particularly building on the existing work and connections of volunteers and groups that they were aware of. the third theme considers what types of mechanism could be used to drive change and engagement by local people, in order that involvement in supporting social connections is seen as an attractive opportunity. participants' ideas included the use of cooperative initiatives to develop or run transport services or community spaces, and incentives for small businesses to make the local area an attractive place to set up or move to. they also suggested that incentive schemes for local residents (such as loyalty cards or credits) to participate in local activities would encourage people to maintain involvement. participants proposed that making a public commitment to community work could not only increase the contributions made by individuals within the local area, but also contribute to an increased sense of community. taken together, these ideas portray a community with actively engaged members working to make positive changes, that directly and indirectly lead to individual connections being strengthened. we take forward one example sub-theme from each of these three main themes for further consideration in the second half of the discussion section of this paper, in order to begin thinking about how technology might contribute to supporting these types of initiative, as well as noting some of the challenges that would need to be addressed in designing such technologies. this paper makes a case for adjusting the design process to accommodate a bottom-up the three main themes we use to understand the workshop data are: social spaces and places; processes to promote social interactions; mechanisms to drive change. these themes capture different dimensions of participants' ideas for facilitating social interactions in the local area. ideas varied in both scale and scope (see table 4 for examples). the first theme describes ideas that related to the physical environment and developing spaces and places to promote interactions. the proposed changes were either to directly provide locations for organised or informal activities to take place, or to change environmental factors to increase the likelihood of people meeting and connecting in their everyday lives. ideas for developing locations for activities included making better use of existing spaces as well as creating new spaces or places. residents suggested taking advantage of the large areas of green space that were nearby and using them in new ways. they also thought that new community premises, such as a community centre, would be helpful. ideas to change other environmental factors included improving the environment for pedestrians and improving security of tenure to increase the length of time that people are resident in the same location before moving home. while some ideas residents suggested were more generic, others were particularly context-specific. participants drew on their local knowledge to consider what resources in the local area could be used, and identified other resources that were lacking. table 4 . themes from workshop data analysis. making better use of existing geographical features and spaces for social purposes, such as large areas of green space (e.g., figure 3 ) longer opening hours e.g., library marquees/undercover spaces in parks etc., for rainy days make better use of open/green spaces for community activities e.g., exercise equipment, open a beach, more benches, ice cream vans to encourage use of parks new transport options to support travel in the immediate local area and into the city centre frequent, small scale local transport e.g., minibus every 10 min extend the metro into the area to improve access to city focusing on proximate relationships i.e., at a street level or between those volunteering at the same events, as well as at the community level encourage greater walking in area e.g., parents taking children to school encourage volunteers to build friendships/relationships outside volunteering activities/context street level interventions e.g., street meetings/cups of tea, annual events community-driven/commissioned or cooperative initiatives around social spaces, information provision, transport and learning/training community/cooperative/volunteer-run hospitality venues buy a property on a co-operative basis and use as community resource/café/party venue community uber-style, tandems/sidecars or other forms of 'fun' transport, bike sharing, motorcycle lessons-teaching/learning/using transport cafes that also operate as training kitchen for cooking healthily, training in basic work skills by involvement in running community hub incentives to: sustain and attract small catering and hospitality businesses to the local area; encourage local people to participate in social activities increase incentives for small catering/hospitality businesses e.g., no rates/taxes for first years after opening happy hours in cafes etc., with free tea/coffee/cake, sponsored by local businesses credits for free attendance at social activities for residents e.g., swimming pool on particular days/times/a month, extra credits could be earned through volunteering dedicated time slots for social and/or physical activity/exercise time finding ways of improving the commitment and contributions of individuals to the local area to create and sustain a sense of community commitment of individuals to community e.g., minimum number of community work hours/community service and strategy to deal with those who do not contribute, volunteers to supervise weekend sporting activities for children, create sense of community between residents/students the second theme brings together ideas that participants had for processes and actions that could play a part in promoting social interactions. these included: prioritising engagement within the wider community to develop ideas; connecting different groups with each other; improving provision of information about events and activities in the local area; connecting people with locations and activities in the city centre; and focusing particularly on making use of proximity as a tool in the process of connection. encouraging people to walk in the local area more often, and setting up hyper-local events such as street meetings, were examples of ideas to facilitate people in connecting with others living in close proximity. participants' ideas emphasise the importance and desire for strong relationships at a local level, particularly building on the existing work and connections of volunteers and groups that they were aware of. the third theme considers what types of mechanism could be used to drive change and engagement by local people, in order that involvement in supporting social connections is seen as an attractive opportunity. participants' ideas included the use of cooperative initiatives to develop or run transport services or community spaces, and incentives for small businesses to make the local area an attractive place to set up or move to. they also suggested that incentive schemes for local residents (such as loyalty cards or credits) to participate in local activities would encourage people to maintain involvement. participants proposed that making a public commitment to community work could not only increase the contributions made by individuals within the local area, but also contribute to an increased sense of community. taken together, these ideas portray a community with actively engaged members working to make positive changes, that directly and indirectly lead to individual connections being strengthened. we take forward one example sub-theme from each of these three main themes for further consideration in the second half of the discussion section of this paper, in order to begin thinking about how technology might contribute to supporting these types of initiative, as well as noting some of the challenges that would need to be addressed in designing such technologies. this paper makes a case for adjusting the design process to accommodate a bottom-up component that precedes design of technological outputs. we begin our discussion of the findings from this study by considering the interview data, and their position in relation to wider debates and literature around technology and social interaction in later life. we then move on to discuss what the ideas generated by workshop participants offer in terms of implications, scope and challenges for future technology design around social connectedness, particularly when considered in the context of the interview findings. we use three sub-themes from the workshop (making better use of existing geographical places and spaces; focusing on proximate relationships; community driven/commissioned or cooperative initiatives) as examples to avoid our discussion of implications and challenges for future technology design being too generic, and to ensure that our focus remains on designing in the particular context of our research community and participants. within an age-friendly context, our analysis of interview data identifies a number of opportunities to design for increased social connectedness within local communities. participants felt that: there were few local places to socialise; they often did not know their neighbours well; there was an absence of shared community feeling; social activities on offer did not always lead to socialising or making new friends. in a policy and practice environment where technology-based initiatives are increasingly perceived as offering huge potential, our findings highlight the importance of age-friendly approaches that are grounded in the local context [1, 2] . this has become even more apparent during the covid-19 pandemic, which has exposed the need for digital connection as an alternative to face-to-face interactions. similarly, finding new ways to connect, including with people in proximate locations, has become even more important in ways we did not anticipate when conducting this study. every community is unique, so designing to optimise social connectedness at a local level requires understanding and recognition of context-specific characteristics. in addition, taking account of the social and structural particularities of places gives insight into meanings and functions that are the result of cumulative experiences over time [40] . in our study, the geographical layout of the community, restrictions on licensed premises and population churn were all factors that participants highlighted as playing a role in disconnection. however, these issues can also be seen as 'leverage points' where interventions could afford the greatest benefits within a specific local context [40] . our interview data also contribute to understanding more about how older people use and perceive technology in their social lives. unlike dickinson and hill's findings in 2009 that older people did not engage with instant messaging or other forms of computer technology aside from email [29] , participants connected using a range of methods and formations of communication. family connections using technology ranged from group chats to individual messages, and instant short communications as well as ongoing asynchronous conversations. participants were not necessarily using social networking sites to share information, as righi et al. [30] also found, but in our study these information-sharing interactions were commonly taking place through instant messaging and other technological channels rather than solely in person. these findings reflect changing levels of digital connection for older people in the uk [28] and emphasise the need for hci to reconsider longstanding stereotypes of older people as digitally inexperienced or uninterested [13] . the covid-19 pandemic has provided further evidence to counter these outdated stereotypes, with many older people embracing technology to facilitate connections with friends and family at a time when face-to-face meetings have been restricted. yet, while participants in our study made regular use of technology to support their connections with others, this use was carefully considered. technology was not, in itself, an attractive prospect unless it was perceived to fill a 'gap' and the 'chore' of using it did not overly impact on everyday life. similarly, lindley et al. reported that older people were cautious of the time commitments required to use technologies, although they also used technology as a way to manage levels of contact and control their own availability to other people [25] . in addition, participants in our study were aware of the potential for technology to contribute to disconnection. waycott et al. [41] reflect that the mismatching of values and assumptions guiding a technology-based social intervention with those of the older adults participating in the evaluation, noticeably contributed to individual decisions not to participate. in an increasingly digital society, our findings again indicate the importance of design processes that are in tune with the perceptions and values of older adults. marston and van hoof draw our attention to the fact that the world health organization's age-friendly cities model does not explicitly consider the role of technology [1, 42] . by adopting a lens of age-friendliness, studies like ours can ensure that methods and processes are rooted in opportunities, concerns and 'gaps' that are relevant and engaging to participants. consequently, we put forward an amended definition that highlights the need for explicit and thoughtful consideration of the role of technology in an age-friendly setting: underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community's physical, social and digital environments and its supporting infrastructure. another contribution of our work comes from its findings about the potential for technology to contribute to building and strengthening connections in geographically-bounded communities. the combination of shared local concerns and opportunities for improving connections, combined with the knowledge that technology was infrequently used to sustain or support local connections, suggests this is a design space worth exploring. participants in this study were comfortable using digital technology to stay in touch with friends and family in geographically distant locations, particularly to maintain close family connections. kharicha et al. also found that engagement with the outside world by landline telephones and computers was an important strategy adopted by older people experiencing loneliness [43] . for this reason, it would seem plausible that technology to facilitate local, proximate, connections and social lives would also be acceptable, should it fill perceived gaps and not lead to unacceptable levels of additional effort. the methods we used in the workshop were intended to encourage 'playful' creativity, and they were successful in their purpose of generating a wide range of ideas as well as being acceptable and enjoyable for participants. in future, we would consider adapting these methods to reduce their paper-based nature, further enhancing their potential for prompting creative thinking by participants. exploring options beyond face-to-face participation may also be important in the context of covid-19 and its aftermath. drawing the interview findings together with one sub-theme from each of the themes we used to organise the ideas generated by workshop participants, we suggest a number of ways in which technology might support greater face-to-face connection in local community contexts and operationalise local people's ideas. by deliberately not placing technology in the foreground in the workshop, we contend that participants' ideas (technological or otherwise) about how to tackle local issues are more likely to align with their own values and perceptions, meaning that any technological needs that arise from these suggestions will be filling 'gaps' rather than technology being introduced as the automatic interface in connection. we maintain that design processes and spaces should be context-specific and bottom-up, but summarise general implications that offer scope for further exploration and consideration in community settings. workshop participants expressed interest in re-purposing spaces in the local area that they felt were underused, or offered potential as social spaces. this ranged from using existing green spaces or buildings on a permanent or temporary basis, to creating new spaces and places for social activities and events. a real-life example of creative use of space by older people that challenges expectations and norms was the transformation (for one night only) of a nightclub in manchester, uk, into a night-time venue reserved for older people [44] . in our study, there were suggestions that spaces could be acquired or managed by groups of local residents as cooperative initiatives. such work is ongoing in virtual spaces by older people in the uk creating a radio network [45] . other adaptations to the built environment were also suggested by participants to improve suitability for pedestrians. however, operationalising these ideas and coordinating the input of the local community presents challenges at many levels. while online platforms to facilitate community commissioning of digital services exist [46] , it is not immediately clear that these tools and processes would translate to local community commissioning of resources and events. moreover, it is unrealistic to expect the required intense interaction with such digital platforms, leading to the need for alternative situated means of participating and engaging in the processes. given the interest by study participants in leveraging local infrastructures and spaces, it is plausible to consider situated artefacts that would mediate between local, physical, and online engagements. for example, postervote is an innovative electronic polling system aiming to provide easy electronic voting for communities [47] . a traditional poster is augmented with buttons that can be pressed by community members to register digital responses to questions on the poster. providing infrastructure for residents to have greater input and control over the provision of their immediate local environments would facilitate their participation in the process of age-friendliness at a community level. while our workshop focussed on connections at a local i.e., electoral ward level, some discussions were about connecting with people who were located very close nearby or even physically 'connected' by living on the same street. in fact, two participants expressed surprise on discovering that they had both been living in the area for many years a few houses apart on adjacent streets, yet they had never interacted before. concerns about safety, privacy and possible lack of interest by others were mentioned as barriers to interventions at a street level. in recent years, we have witnessed a surge in location-based and serendipitous dating/meet-up services and networks (i.e., tinder [48] ). the core functionalities of these technologies are the abilities to discover similar individuals in your local area; privately extend an invitation to initiate a conversation; whilst maintaining a degree of privacy and safety through the network's services (not revealing personal details such as address or phone number). such solutions would have scope to support the hyper-local match-making of friendships within communities. however, our research showed that participants were not using existing online services designed to develop new relationships, indicating that these did not appeal. this is echoed by findings that older people who were lonely did not report using the internet to cultivate new friendships, despite using telephones and computers to engage with the outside world [43] . in fact, one participant, deborah, had instead capitalised on the ability of an accommodation matching platform to facilitate face-to-face interactions in her home with strangers, who then had the potential to become friends. the opportunity for such encounters (through mutually beneficial financial, or other resource, transactions) to result in long-lasting friendships is an area for further exploration. in particular, it would be interesting to consider how these types of interaction could be translated into a purely local context, given that deborah's formation of new friendships contrasts with experiences of those in our study who attended regular local activities but did not find them conducive to making friends. the findings from our study indicate an opportunity for design around community or cooperative ways of addressing local transport gaps. a number of ideas generated by workshop participants related to improving transport in the immediate local area in order to facilitate connection to physical spaces and locations to meet other people. community or cooperative initiatives were suggested as one option, or mechanism, for driving new models of transport in the area. volunteer-run minibus and car transport did exist in the local area, but these prioritised 'essential' travel such as hospital appointments and did not have the flexibility that participants thought important. while existing schemes (e.g., streetbank [49] -a website that facilitates possession sharing and borrowing between neighbours) have been successful in meeting other needs at a very local level, hyper-local journeys in suburban communities outside busy city centres are unlikely to offer sufficient cost/profit ratios to be attractive to existing sharing economy or peer-to-peer services such as uber. a small number of demand responsive transport (drt) schemes are running in the uk, and in theory sound promising. however, it is notable that a drt service actually operated in our study area in the past, but closed in 2011 [50, 51] . similarly, existing bicycle sharing schemes rely on scale of use within large communities or cities to remain profitable, but in contrast, restricted access to a smaller population might reduce the risk of damage and loss experienced by larger scale operations. consideration of what a hyper-local transport system might look like would include questions about who might provide and use the service, and what their incentives would be. participants in this study also suggested teaching, learning and training opportunities as potentially playing a role. this is another avenue for exploration in future technology design which could serve the dual purposes of creating new connections between those learning and teaching, as well as the transport itself facilitating connections between people living in the area. our study adopted an age-friendly, bottom-up approach to explore opportunities for facilitating social connectedness for older adults in a local community context. we focused on specific community issues that could be addressed and considered the physical, social and structural mechanisms (potentially mediated or supported by technology) that might offer routes to tackling these. by understanding more about our participants' current use and perspectives on the role of technology in their social lives, we highlight a need for design work to reduce emphasis on technology as the interface between people. in contrast to previous work, we focus on connection between people in geographically close locations. we also demonstrate the importance of understanding the specific local context within which any technological interventions will take place. our findings reflect changing patterns of technology use among older adults in the uk, suggesting that adoption of new technology is acceptable when it fills gaps and does not create intrusive levels of additional work or contribute to disconnection. our modified definition of age-friendliness highlights a need for the explicit and thoughtful consideration of the role of technology. we identify topics for consideration by those seeking to design with local communities, and make the case for an age-friendly approach to designing (digital) interventions to address social connectedness in later life. world health organization. global age-friendly cities: a guide; world health organization what makes a community age-friendly: a review of international literature exploring the age-friendliness of purpose-built retirement communities: evidence from england evolving images of place in aging and 'aging-in-place how should we tackle the loneliness epidemic is loneliness a health epidemic lonely older people as a problem in society-construction in finnish media prime minister's office; office for civil society; the rt hon theresa may mp. pm commits to government-wide drive to tackle loneliness the firekeepers: aging considered as a resource never too old older voices: supporting community radio production for civic participation in later life researching age-friendly communities: stories from older people as co-investigators an age-old problem: examining the discourses of ageing in hci and strategies for future research friends or frenemies? the role of social technology in the lives of older people an investigation into the patterns of loneliness and loss in the oldest old-newcastle 85+ study being alone in later life: loneliness, social isolation and living alone the high cost of isolation the social connectedness of older adults: a national profile the importance of social connectedness in building age-friendly communities assistive technology, computers and internet may decrease sense of isolation for homebound elderly and disabled persons ethnographic research on the experience of japanese elderly people online tales of the map of my mobile life: intergenerational computer-mediated communication between older people and fieldworkers in their early adulthood multimodal computer-mediated communication and social support among older chinese internet users desiring to be in touch in a changing communications landscape tsunagari-kan" communication: design of a new telecommunication environment and a field test with family members living apart keeping in touch: talking to older people about computers and communication older people's use of social network sites while participating in local online communities from an ethnographical perspective age-friendly cities and communities: a manifesto for change ageing in urban environments: developing 'age-friendly' cities the who global network of age-friendly cities and communities: origins, developments and challenges. in age-friendly cities and communities in international comparison interviewing for social scientists office for national statistics research interviewing: context and narrative using thematic analysis in psychology les villes amies des aînés au québec: un mouvement de changement à large échelle en faveur des aînés experiences of place and neighbourhood in later life: developing age-friendly communities not for me: older adults choosing not to participate in a social isolation intervention who doesn't think about technology when designing urban environments for older people? managing loneliness: a qualitative study of older people's views an alternative age-friendly handbook later life audio and radio network proceedings of the 2016 chi conference on human factors in computing systems good practice guide: transport and social inclusion we thank all participants who took part in this research. our appreciation also goes to cathrine degnen for her involvement in the design, planning and acquisition of funding for the study, and to drake long, meena nanduri and marlo owczarzak for their support in facilitating the workshop. the authors declare no conflict of interest. key: cord-285223-07o9irev authors: malik, usman rashid; atif, naveel; hashmi, furqan khurshid; saleem, fahad; saeed, hamid; islam, muhammad; jiang, minghuan; zhao, mingyue; yang, caijun; fang, yu title: knowledge, attitude, and practices of healthcare professionals on covid-19 and risk assessment to prevent the epidemic spread: a multicenter cross-sectional study from punjab, pakistan date: 2020-09-02 journal: int j environ res public health doi: 10.3390/ijerph17176395 sha: doc_id: 285223 cord_uid: 07o9irev in the current outbreak of novel coronavirus (covid-19), healthcare professionals (hcps) have a primary role in combating the epidemic threat. hcps are at high risk of not only contracting the infection but also spreading it unknowingly. it is of utmost importance to evaluate their knowledge, attitudes, and practices (kap) and the ability to assess the risks associated with the outbreak. a cross-sectional online survey involving physicians, pharmacists, and nurses was conducted. a 39-itemed questionnaire based on the world health organization (who)covid-19 risk assessment tool was shared with healthcare professionals in three purposively selected key divisions of punjab province. out of 500 healthcare professionals, 385 responded to the survey. the majority (70%) were aged 22–29 years; 144 (37.4%) physicians, 113 (29.4%) nurses, and 128 (33.2%) pharmacists completed the survey. overall, 94.8% of healthcare professionals scored adequately (>14) for covid-19-related knowledge; 97.9% displayed an optimistic attitude (>42) and 94.5% had an adequate practice score (>28). kruskal–wallis and jonckheere–terpstra tests showed significant differences (p < 0.05) in kap and risk assessment scores among groups; physicians and nurses scored higher as compared to pharmacists. further research and follow-up investigations on disaster management and risk assessment can help policy-makers better tackle future epidemics. the first-ever cases of novel coronavirus were reported by the world health organization (who) regional office in beijing, china, on 31 december 2019, when a few patients were diagnosed with pneumonia in the city of wuhan in china [1] . the wuhan institute of virology declared a new strain of coronavirus as a causative agent of this new deadly pneumonia and listed it as a novel coronavirus disease (ncov-2019) [2] . later, the disease was officially named as covid-19 by the who [3] . initially reported in china, the disease started being reported in nearby neighboring countries, and until 20 january 2020, new cases were also confirmed in thailand, japan, and south korea. the first situation report by who issued on 21 january 2020 on the novel coronavirus reported 282 confirmed cases of the disease in china and other affected neighboring countries [4] . since then, the disease transmitted to various parts of the world, and on 30 january 2020, the who declared the novel coronavirus disease to be a public health emergency of international concern. soon after, the disease became a global threat to public health and economies, finally transforming into a pandemic disease. on 11 march 2020, the who officially declared covid-19 as a pandemic disease due to the alarming levels of an upsurge in the spread and severity of the disease [5] . the disease spread rampantly, and according to who reports, by 19 july 2020 the disease had shown its notorious presence in around 213 countries with more than 14 million confirmed covid-19 cases and nearly 0.6 million deaths worldwide [6] . healthcare workers have a critical role in lowering morbidity and mortality but in doing so they are directly exposed to patients and the causative agents. preventing nosocomial infections and protecting healthcare workers posed great challenges to the healthcare system during the initial covid-19 outbreak in china [7] . healthcare professionals (hcps) are at a high risk of infection from the patients if they do not have ample knowledge and awareness about the disease or if they do not take adequate precautionary measures. in china, 2050 cases of covid-19 were reported in healthcare workers as of 20 february 2020; the majority of the cases were due to lower awareness and experience of handling the disease [8] . avoiding cross-infection from patients along with effective care delivery can be achieved if the healthcare professionals, including physicians, pharmacists, nurses, and other medical staff, have sufficient knowledge, a positive attitude, and better practices about covid-19. in addition, better preventive policies and risk assessment of healthcare teams are crucial for an effective response to new emerging pandemics such as covid-19 [9] . in pakistan, the incidence of coronavirus disease was initially reported on 26 february 2020 in two persons who returned from the epidemic-affected region of iran [10] . until 14 march 2020, there were only 31 confirmed covid-19 cases. however, afterwards, a dramatic escalation was observed, and the number of cases rose stupendously. by 21 june 2020, the confirmed cases in pakistan had crossed a figure of 174,200 and the new cases were gaining momentum [11] . deaths of healthcare professionals as a result of exposure to covid-19 patients have been reported in countries including the usa, the uk, china, and italy [12, 13] . a recent study reported the deficiencies in the awareness and preparedness of medical professionals regarding covid-19 in pakistan and demonstrated that frontline health workers were not well-prepared to prevent and control the infection [14] . keeping in view the severity of the outbreak and the importance of healthcare professionals working with scarce resources to combat covid-19, it was pertinent to evaluate their knowledge, attitude, practices, and risk assessment skills. a cross-sectional study to examine the knowledge, attitude, practices, and risk assessment of hcps regarding coronavirus and its associated disease (covid-19) was conducted. these data were collected from 21 march 2020 after the covid-19 cases began increasing in pakistan, and were completed on 20 april 2020. pakistan is composed of five provinces, with punjab being the most populous province of pakistan (hosting >50% of total population) having a population of about 110 million [15] . out of nine administrative divisions in the punjab province, three key divisions (lahore, multan, and rawalpindi, representing the north-east, southern, and northern parts of punjab province, respectively) were purposively selected. healthcare professionals working in tertiary and secondary hospitals along with nearby located community pharmacies were chosen as the target population, thus covering both public and private sector hcps (figure 1 ). respectively) were purposively selected. healthcare professionals working in tertiary and secondary hospitals along with nearby located community pharmacies were chosen as the target population, thus covering both public and private sector hcps ( figure 1 ). the study was conducted on doctors (general physicians), hospital and community pharmacists, and nurses who dealt with management and control of the covid-19 disease. these participants included hcps working in various private and public sector (secondary and tertiary care) hospitals and those working at community pharmacies located close to the hospitals. all registered hcps with their respective councils (pakistan medical and dental council, pakistan nursing council, and pharmacy council of pakistan) who were dealing with covid-19 cases, regardless of their experience, age, gender, and socioeconomic status, were included in the study. unregistered hcps and those returning incomplete surveys were excluded during the data analysis phase. participation in the survey was purely on a voluntary basis, and the participants could choose to quit the survey at any stage. in order to obtain robust and complete information, we requested that the participants responded to all questions of the survey. there are 107,112 physicians (including the general physicians and specialists) [16] , 64,846 nurses [17] , and 21,954 pharmacists in punjab province, thus totaling to a population size of 193,912 [18] . raosoft sample size calculator was used to select the sample size with a 95% confidence level, 5% margin of error, and a population size of 193,912. the resultant sample size of 384 was calculated to be a representative of the health care professional population in punjab province. keeping in mind a 20% dropout, in order to achieve an optimal response rate, a total of 500 healthcare professionals were approached online through the whatsapp© application (copyright 2020 whatsapp inc., menlo park, ca, usa) and cellular phone calls by using the purposive sampling method. the questionnaire was designed based on the latest who risk assessment and management of healthcare workers in the context of covid-19 tool [19] and published literature on previously spread viral epidemics in various parts of the world [20, 21] . initially, the questionnaire consisted of the study was conducted on doctors (general physicians), hospital and community pharmacists, and nurses who dealt with management and control of the covid-19 disease. these participants included hcps working in various private and public sector (secondary and tertiary care) hospitals and those working at community pharmacies located close to the hospitals. all registered hcps with their respective councils (pakistan medical and dental council, pakistan nursing council, and pharmacy council of pakistan) who were dealing with covid-19 cases, regardless of their experience, age, gender, and socioeconomic status, were included in the study. unregistered hcps and those returning incomplete surveys were excluded during the data analysis phase. participation in the survey was purely on a voluntary basis, and the participants could choose to quit the survey at any stage. in order to obtain robust and complete information, we requested that the participants responded to all questions of the survey. there are 107,112 physicians (including the general physicians and specialists) [16] , 64,846 nurses [17] , and 21,954 pharmacists in punjab province, thus totaling to a population size of 193,912 [18] . raosoft sample size calculator was used to select the sample size with a 95% confidence level, 5% margin of error, and a population size of 193,912. the resultant sample size of 384 was calculated to be a representative of the health care professional population in punjab province. keeping in mind a 20% dropout, in order to achieve an optimal response rate, a total of 500 healthcare professionals were approached online through the whatsapp© application (copyright 2020 whatsapp inc., menlo park, ca, usa) and cellular phone calls by using the purposive sampling method. the questionnaire was designed based on the latest who risk assessment and management of healthcare workers in the context of covid-19 tool [19] and published literature on previously spread viral epidemics in various parts of the world [20, 21] . initially, the questionnaire consisted of 60 questions on knowledge, attitude, practices, and risk assessment. however, after content and face validity by five experts in clinical practice, pharmacy, and academia (two classified physicians, two pharmacists, and one professor of pharmacy practice), the questionnaire was reduced to 39 questions/items (see supplementary file). initially, a pilot study was conducted and data of 50 participants were used to determine the internal consistency of the questionnaire by calculating the cronbach's alpha value. the cronbach's alpha value of the questionnaire was calculated to be 0.74, which indicated an acceptable level of internal consistency. the final questionnaire had four sections with 39 questions/items. the basic information from all the participants regarding their age, gender, marital status, level of education, occupation, and type of organization was obtained in the demographics section. the second section contained 19 questions about the basic knowledge of coronavirus disease with three options ("yes", "no", and "do not know"). the knowledge was assessed by giving the value 1 to a correct answer and 0 to the wrong answer. the "do not know" response was also processed as 0. the scale measured knowledge score from a maximum of 19 to minimum of 0. scores <9 were taken as poor, 9-14 average, and >14 as adequate knowledge of covid-19. the third section constituted 12 questions on the attitude of healthcare professionals and was rated using a 5-point likert scale varying from "strongly disagree" to "strongly agree". the attitude was assessed by giving value 1 to "strongly disagree" and 5 to the "strongly agree" response. reversed scoring was utilized for negative questions. the scale measuring attitudes ranged from 12 to 60. scores ≤42 were taken as negative while >42 were taken as a positive attitude towards covid-19. the fourth section had 8 questions on covid-19-related practices and risk assessment (4 on practices and 4 on risk assessment) rated on a 5-point likert scale: "always", "mostly", "sometimes", "rarely", and "never". this scale measured practices and risk assessment from a maximum score of 40 to a minimum of 8. scores ≤28 were taken as poor practices while >28 were taken as good practices towards covid-19. keeping in mind the lockdown situation, for the purpose of study, we developed an online google form of the questionnaire that we shared with healthcare professionals. the google form was shared with the participants through the whatsapp platform and the participants were requested via cellular phone calls to fill the online survey. continuous weekly reminders were given both through cellular phone calls and whatsapp to ensure optimal participation. participants were also guided about the aims and objectives of the study and informed consent was obtained verbally to make sure they understand each aspect of the study before filling the survey form. ethical approval was obtained from the human ethics committee at the university college of pharmacy, university of the punjab, lahore, pakistan, no. d/hec/112/ucp2340 and the biomedical ethics committee at xi'an jiaotong university, xi'an, china. the data from the google forms was imported to spss (version 22.0, ibm, chicago, il, usa) and analyzed. descriptive statistics were performed by calculating the frequencies and proportions. the scores on knowledge, attitude, and practices & risk assessment were calculated from a total of 19, 60, and 40 points, respectively. the correct responses for all the questions were determined from the guidelines developed by the who for general public and healthcare workers. data were checked for normality by the kolmogorov-smirnov test and shapiro-wilk's test. these tests indicated that the data were not normally distributed, with a p-value < 0.05 and skewness of −0.702(standard error (s.e.) = 0.124), −0.317 (s.e. = 0.124), and −1.405 (s.e. = 0.124) for scores on knowledge, attitude, and practices, respectively. the kruskal-wallis test was used to evaluate the significant differences among physicians, pharmacists, and nurses and their scores on knowledge, attitude, practices, and risk assessment. the jonckheere-terpstra test was used to confirm the trend of association. out of a total 500 healthcare professionals approached, 385 completed the online survey. the response rate of the survey was 77%. the ages of health care professionals ranged from 22 to 68 years, with a mean age of 28.73 ± 6.31 years. a majority of the participants (69.4%) belonged to the age range of 22-29 years. out of the 385, 144 (37.4%) were physicians, 113 (29.4%) were nurses, and 128 (33.2%) were pharmacists. overall, 53% of all the participants were females. around 51% of participants were from the public sector while 49% came from the private sector. a majority of the participants (88%) belonged to urban regions of punjab province. table 1 shows the baseline characteristics of the respondents. among the 385 participants, 94.8% partakers scored >14, and the average knowledge score of participants was 17.31 ± 1.40. in the current cohort, all of the participants were aware that the disease was a viral infection and were also familiar with the most commonly observed symptoms of covid-19. among them, 99.0% knew that the disease could be transmitted through infected humans and animals; 80% knew that the covid-19 virus is a virus that is related to the severe acute respiratory syndrome coronavirus-2 (sars-cov) and middle east respiratory syndrome coronavirus-2 (mers-cov) family; and 95.8% were aware of the asymptomatic presence of covid-19 in people who recently visited virus-affected areas, with this being a potential source of disease spread. however, 42.1% believed that the disease could be transmitted through contaminated food and 17.9% believed that covid-19 was similar to the normal flu or cold. almost, 37% of healthcare workers believed that antibiotics could be useful in the treatment of covid-19 (see table 2 ). about 96.0% were aware of the fact that virus could survive on different objects such as doors, windows, beds, and tables; 99.7% knew that isolation of the infected patients is a necessity to avoid or prevent disease transfer to other people; and 97.4% knew that the incubation period for symptoms to appear ranges from 1 to 2 weeks. about 97% knew that patients with comorbidities are at a higher risk of getting infected, and 99.7% knew that immune-compromised, old age people, and healthcare professionals working closely with infected people were at increased risk of infection. a total of 84.7% of healthcare professionals believed that they were well prepared to deal with covid-19 in the case of an outbreak in the country (see table 2 ). overall, 97.9% participants scored >42, showing a positive attitude, with a mean score of 50.69 ± 3.96. the majority of the participants (>97%) agreed that the disease could be transmitted by coughing and sneezing and that regular hand washing and the use of sanitizer would help prevent the spread of infection. moreover, around 94% agreed that wearing masks can help prevent covid-19 transmission to other people and 97.6% agreed that isolating infected patients could be beneficial in reducing the risk of cross-infection. more than 98.0% agreed that avoiding frequent touching of the nose, mouth, and eyes could reduce the risk of infection, and 92.2% of participants also agreed that avoiding contact with doors, furniture, and other objects significantly reduce the risk of infection. out of the remaining 7.8%, only 1.1% disagreed on the possibility of transmission through objects, while 6.7% stayed neutral (see table 3 ). more than 92.0% of subjects also expressed that if a vaccine is developed against covid-19, it can significantly prevent the epidemic spread. however, a mixed response was observed for the use of antibiotics in the prevention of the infection. about 39.0% of healthcare professionals agreed antibiotics could be useful in preventing the covid-19 infection, while 7.5% remained neutral and 53.5% disagreed with the statement (see table 3 ). about 94.5% of healthcare professionals scored >28 and showed better practices towards disease management with a mean score of 35.97 ± 4.15. about 93.0% of participants almost always advised their patients to eat properly cooked food and 96.9% advised using soaps and sanitizer for regular hand and face washing. moreover, more than 93% of healthcare professionals in most interactions with people advise them to keep themselves warm and hydrated, and 89% advise avoiding close contact with people with cough and flu-like symptoms. out of remaining population, 5.5% sometimes advised and 2.9% rarely advised patients to avoid close contact with people with flu and cold-like symptoms. the risk assessment revealed that more than 92.0% of healthcare workers almost always preferred to use personal protective equipment (ppe) during interaction with covid-19-suspected patients. more than 91% almost always perform a hand hygiene and washing procedure before or after any medical intervention or procedures. about 89% of participants, in a majority of interactions, perform hand hygiene after touching a patients' surroundings such as beds, doors, tables, and almost 86% of healthcare staff observe social distancing in a majority of interactions and avoid unnecessary contact with the patients. from the remaining 14.0%, 7.0% sometimes avoid unnecessary contact while the other 7.0% rarely or never observe social distancing as it is difficult for them to do so because of the continuous exposure to patients (see table 4 ). the kruskal-wallis test demonstrated significant differences (p-value < 0.05) in the scores on knowledge, attitude, practices, and risk assessment of different healthcare professionals (table 5) . overall, the physicians achieved significantly higher scores on knowledge and attitude as compared to pharmacists and nurses. no significant difference was observed on knowledge and attitude scores between pharmacists and nurses. however, the scores on practices and risk assessment demonstrated that the nurses and physicians scored significantly higher as compared to pharmacists (see figure 2 ). the jonckheere-terpstra test confirmed that knowledge and attitude towards covid-19 were significantly associated (p < 0.001) with occupation. a positive trend was further reported, whereby physicians had more knowledge and carried a positive attitude towards covid-19 as compared to nurses and pharmacists (τ = 0.411 and 0.398, respectively) (see table 6 ). the jonckheere-terpstra test confirmed that knowledge and attitude towards covid-19 were significantly associated (p < 0.001) with occupation. a positive trend was further reported, whereby physicians had more knowledge and carried a positive attitude towards covid-19 as compared to nurses and pharmacists (τ = 0.411 and 0.398, respectively) (see table 6 ). this study exclusively targeted the healthcare staff that would be directly or indirectly in contact with suspected or confirmed covid-19 patients. in current study, more than 94% of hcps had adequate knowledge about covid-19, which is relatively better than earlier reported studies conducted in other countries including egypt, iran, and greece [22] [23] [24] . the clinical symptoms most commonly observed in covid-19 patients in a recent study were fever, cough, fatigue, or myalgia and dyspnea [25, 26] . all of the respondents were well aware of most common symptoms, which showed a considerate level of understanding. moreover, the awareness about the effectiveness of hygienic principles such as regular hand washing, sanitizer usage, isolation of patients, and self-confinement at homes for the prevention of covid-19 is a positive sign. the basic health measures such as washing hands regularly, staying at home, maintaining social distancing, and covering the mouth and nose during coughing and sneezing were effective in controlling and preventing a previously unfolded sars epidemic in china [27] . moreover, these measures have proved to be effective in preventing covid-19 virus transmission [28] . approximately 90% of participants in our study exhibited better practices of hygiene and handwashing before and after interacting with the patients, which is quite high as compared to the findings of a study conducted in greece where only 1 in 4 hcps had a hand-washing routine before and after the patient interaction [23] . dissimilarity was observed between the knowledge, attitude, and practices of healthcare professionals. physicians and nurses, in particular, had significantly higher scores as compared to pharmacists, reflecting a need for improvements in terms of practices and disaster responsiveness. this kind of variation among healthcare workers was also reported in saudi arabia after the outbreak of mers disease in 2016 [20] . however, our findings with pharmacists lacking in covid-19-related knowledge and apt practices were contrary to a recent survey reported from pakistan in which the pharmacists demonstrated better practices as compared to other healthcare colleagues [29] . the respondents' mixed responses about the risk of transmission of the disease through virus-contaminated food and the beneficial and effective role of antibiotics for the treatments of covid-19 reflects uncertainty and misperception among healthcare workers. analytically speaking, until now, no evidence has yet reported the risk of transfer of covid-19 virus to healthy people through contaminated food. the foodborne gastrointestinal viruses often lead to transmission of the virus through food, but covid-19 mainly transmits from person to person, and transmission through food has not been reported from any part of the world [30, 31] . a few antiviral, antimalarial, and anti-inflammatory drugs have shown some benefits in terms of therapy. however, the usefulness of antibiotics as a therapy for covid-19 is still unclear. the footprints of ambiguity about antibiotics were clearly visible in our study, however, a high number of hcps (60.5%) believed that antibiotics are not useful therapy for covid-19, a reasonably high percentage as compared to findings from a study in egypt where only 38% of participants believed so [22] . a few recent studies suggested a supportive and symptomatic treatment approach for disease management and treating secondary bacterial infections [26, 32] . however, antibiotics do not work against any viruses and are only recommended against bacterial infections arising from covid-19 and not as a preventive measure or a treatment for coronavirus infection [33] . following the rumors about the possible use of azithromycin in combination with hydroxychloroquine, the already existing debate about the role of antibiotics in covid-19 escalated [34] . a randomized controlled trial conducted recently has shown that the use of azithromycin in combination with hydroxychloroquine may be effective in eliminating covid-19. however, the trial involved fewer patients [35] and warrants further research to collect evidence on the effectiveness of azithromycin and/or hydroxychloroquine to treat/prevent a viral disease [36] . the current study had certain limitations. the study was conducted in three key divisions of one province and thus the results may not be generalizable to the rest of country. secondly, most of the healthcare professionals came from urban areas. rural areas were not easily accessible during the pandemic outbreak, and therefore not enough responses were achieved from rural parts of punjab. thirdly, healthcare staff other than physicians, nurses, and pharmacists were not involved in the study and their practices went unreported. fourth, the survey was conducted online using whatsapp and, therefore, many of the hcps were not able to be contacted for participation. fifth, the hcps were inquired about their earlier experiences with covid-19 patients, which may have led to recall bias. finally, owing to the exploratory nature of the study, the inherent selection bias cannot be overruled. participants' age may also be one of the potential confounding factors. the study revealed that most of the participants were well primed to deal with the pandemic. pharmacists exhibited relatively lower levels of knowledge and their practices indicated that they were at a higher risk of contracting infections as compared to physicians and nurses. interestingly, due to a lack of evidence, the healthcare professionals were not certain about use of antibiotics to treat or prevent covid-19. it is suggested that the government should take necessary measures to train all healthcare stakeholders for the emergency preparedness and any other environmental or health-related calamity. further research and follow-up investigations are needed to evaluate the readiness of hcps in terms of disaster management and risk assessment to avert future public health crises. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/17/6395/s1, questionnaire, table s1 : section ii-knowledge, table s2 : section iii-attitudes, table s3 : section iv-practices and risk assessment. funding: this research was funded by "young talent support program" of health science center, xi'an jiaotong university. coronavirus infections-more than just the common cold a pneumonia outbreak associated with a new coronavirus of probable bat origin world health organization (who) novel coronavirus situation report-1. 2020 covid-19 a pandemic novel coronavirus situation report-181 clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in report of the who-china joint mission on coronavirus disease 2019 (covid-19) characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china. summary of a report of 72314 cases from the chinese center for disease control and prevention coronavirus cases in pakistan ministry of national health services regulation and coordination, g.o.p. covid-19 pakistan death from covid-19 of 23 health care workers in china italian doctors call for protecting healthcare workers and boosting community surveillance during covid-19 outbreak is pakistan prepared for the covid-19 epidemic? a questionnaire-based survey government of pakistan census registered physicians in punjab punjab public health agency. nurses and midwifery in punjab registered pharmacists in punjab risk assessment and management of exposure of health care workers in the context of covid-19 knowledge and attitudes towards middle east respiratory syndrome-coronavirus (mers-cov) among health care workers in south-western saudi arabia bin saeed, a. knowledge, attitude and practice of secondary schools and university students toward middle east respiratory syndrome epidemic in saudi arabia: a cross-sectional study assessment of knowledge, attitudes, and perception of health care workers regarding covid-19, a cross-sectional study from egypt assessment of knowledge, attitudes, and practices towards new coronavirus (sars-cov-2) of health care professionals in greece before the outbreak period covid-19 and iranian medical students; a survey on their related-knowledge, preventive behaviors and risk perception covid-19-new insights on a rapidly changing epidemic clinical features of patients infected with 2019 novel coronavirus in novel coronavirus-important information for clinicians use of antiviral drugs to reduce covid-19 transmission knowledge, attitude, practice and perceived barriers among healthcare workers regarding covid-19: a cross-sectional survey from pakistan food safety and coronavirus disease covid-19 and food safety: guidance for food businesses review of the clinical characteristics of coronavirus disease 2019 (covid-19) world health organization (who) early treatment of covid-19 patients with hydroxychloroquine and azithromycin: a retrospective analysis of 1061 cases in marseille, france hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial no evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe covid-19 infection we express gratitude and appreciation to all healthcare professionals who participated in the survey. we are thankful to zineb riboua (mccourt school of public policy, georgetown university, washington dc, usa) for rendering her professional services in terms of editing and proofreading the manuscript. the authors declare no conflict of interest. key: cord-262567-gojbccmz authors: lee, seung-man; jeong, hyun-chul; so, wi-young; youn, hyun-su title: mediating effect of sports participation on the relationship between health perceptions and health promoting behavior in adolescents date: 2020-09-16 journal: int j environ res public health doi: 10.3390/ijerph17186744 sha: doc_id: 262567 cord_uid: gojbccmz the aim of this study was to verify the structural relationship between health perceptions, sports participation, and health promoting behavior in adolescents. a total of 507 adolescents living in seoul, republic of korea, in 2020, participated in this study. this study was conducted using a preliminary survey and a main survey. in the preliminary survey, the reliability and validity of the scales used in this study were analyzed, and in the main survey, the relationships between individual variables were verified. specifically, descriptive statistical analysis, path analysis, and mediating effect analysis were conducted in the main survey. the results of the study are as follows: first, health perceptions were found to have a positive effect on sports participation (p < 0.001). furthermore, health perceptions were found to have no direct effect on health promoting behavior (p = 0.554), while sports participation was found to have a positive effect on health promoting behavior (p < 0.001). additionally, sports participation completely mediated the relationship between health perceptions and health promoting behavior. based on the results of this study, suggestions are presented on how to enhance health perceptions in adolescents who are in a critical period for forming healthy life habits, and to prepare measures to encourage sports participation. as of 2020, the world is facing the coronavirus disease (covid19) pandemic. scientists predict that the covid-19 transmission may be at controllable levels over time, but that increasingly more novel viruses will be encountered. the outbreak of new viral infections is accelerating the development of treatment and vaccines at the national global level. people are responding to the new viral infections by strengthening environmental and personal hygiene and enhancing their individual immunity. in addition, people's interest in immunity-related health and related desires is increasing. however, as acquiring healthy life habits takes time, it is necessary to encourage adolescents to develop conscious health perceptions and healthy life habits. while emphasizing that the formation of healthy habits in adolescence is the foundation of lifelong health, it is also necessary to improve adolescents' health interests in various ways. this approach addresses the concept of health perceptions that are likely to be an important factor for determining future health behavior in adolescents. health perceptions refer to a subjective process in which individuals are conscious of external stimuli related to health through sensory organs [1] . however, individuals do not perceive health in the same way, perceptions of health may differ based on how the person views and interprets facts [2] . therefore, previous studies have claimed that the world perceived by each individual is different in similar situations, and the resulting behavior initiated by each individual is different [3, 4] . such health perceptions in adolescents can be naturally linked to health promoting behaviors and habits. health promoting behavior involves an individual's perception of the importance of health for himself/herself and of engaging in preventive behaviors for promoting health. furthermore, it refers to improving health care skills by changing life habits through knowledge, attitudes, and behaviors about health [4] . in addition, because health promoting behavior can reduce the cost of personal health care and is associated with an extended lifespan and improving quality of life, it can bring benefits not only at an individual but also a national level. the relationship between health perceptions and health promoting behavior has been reported in previous studies. the findings suggest that higher health perceptions in middle and high school students were associated with better health behavior [5] . furthermore, an investigation into the relationship between perceived health status and other variables found that people with higher social support evaluated their health status more positively [6] . in addition, the importance of health perceptions have been emphasized because they determine the attitudes and behavioral characteristics of an individual or a group, and have a direct or indirect effect on health [7] . moreover, a study described that health promoting behavior and health perceptions could be enhanced through personalized health care customized to individual characteristics, and adapted to school life, thereby forming healthy life habits and enabling access to health care [7] . furthermore, it focused on the possibility and role of sports participation in the "process" where health perceptions in adolescents affect health promoting behavior. sports participation is a social behavior initiated in connection with various sports phenomena and can be divided into behavioral, cognitive, affective, and social participation [8] . physical activity habits formed through regular sports participation can be regarded as important variables that are highly likely to maintain and promote health, along with eating habits and life habits. previous research [9] [10] [11] [12] has reported a positive causal link between health perceptions and sports participation, this suggests that it can be predicted that adolescents' health perceptions could serve as an antecedent variable affecting sports participation. in addition, considering the results of previous studies [13] [14] [15] regarding the relationship between sports participation and health promoting behavior, it can be assumed that sports participation may be related to health promoting behavior. the results of the aforementioned studies suggest that adolescents' health perceptions may affect health promoting behavior, and that sports participation may act as an explanatory variable in the relationship between health perceptions and health promoting behavior. however, since previous studies mainly involved adults, including older adults, it is difficult to generalize these results to adolescents. in addition, previous studies are limited in that they sporadically report only some of the variables in the relationships among health perceptions, sports participation, and health promoting behavior. in order to overcome these limitations, it is necessary to verify the effects of health perceptions and sports participation on improving health promoting behavior in adolescents, using an appropriate study design. reflecting on these points, this study aims to clarify the structural relationship between health perception, health promoting behavior, and sports participation, and to investigate the mediating effect of sports participation in the relationship between health perceptions and health promoting behavior. in order to clarify the aims of this study, the research hypotheses were established as follows: first, health perceptions will have a positive effect on sports participation (h1). second, health perceptions will have a positive effect on health promoting behavior (h2). third, sports participation will have a positive effect on health promoting behavior (h3). fourth, sport participation will have a mediating effect on the relationship between health perceptions and health promoting behavior (h4). specifically, sports participation will partly mediate the relationship between health perceptions and health promoting behavior (hypothesis model illustrated in figure 1 ) or will fully mediate the relationship between health perception and health promoting behavior (competition model illustrated in figure 2 ). int. j. environ. res. public health 2020, 17, x 3 of 13 participation will have a mediating effect on the relationship between health perceptions and health promoting behavior (h4). specifically, sports participation will partly mediate the relationship between health perceptions and health promoting behavior (hypothesis model illustrated in figure 1 ) or will fully mediate the relationship between health perception and health promoting behavior (competition model illustrated in figure 2 ). the population of this study was adolescents living in the republic of korea in july 2020. a total of 550 korean adolescents were recruited to participate in this study using convenience sampling, a nonprobability sampling method, and were surveyed using google forms to collect the survey. the use of google forms could raise concerns about the accuracy of the answers. however, due to the practice of "social distancing" caused by covid-19, online questionnaires were necessary. a total of 507 survey responses were used in the study, 43 surveys with incomplete information, which were judged to be inadequate for the purpose of data analysis, were excluded. this study was conducted after obtaining ethical approval from the institutional review board of wonkwang university (wkirb-202007-sb-034). the general characteristics of the participants are shown in table 1 . participation will have a mediating effect on the relationship between health perceptions and health promoting behavior (h4). specifically, sports participation will partly mediate the relationship between health perceptions and health promoting behavior (hypothesis model illustrated in figure 1 ) or will fully mediate the relationship between health perception and health promoting behavior (competition model illustrated in figure 2 ). the population of this study was adolescents living in the republic of korea in july 2020. a total of 550 korean adolescents were recruited to participate in this study using convenience sampling, a nonprobability sampling method, and were surveyed using google forms to collect the survey. the use of google forms could raise concerns about the accuracy of the answers. however, due to the practice of "social distancing" caused by covid-19, online questionnaires were necessary. a total of 507 survey responses were used in the study, 43 surveys with incomplete information, which were judged to be inadequate for the purpose of data analysis, were excluded. this study was conducted after obtaining ethical approval from the institutional review board of wonkwang university (wkirb-202007-sb-034). the general characteristics of the participants are shown in table 1 . the population of this study was adolescents living in the republic of korea in july 2020. a total of 550 korean adolescents were recruited to participate in this study using convenience sampling, a nonprobability sampling method, and were surveyed using google forms to collect the survey. the use of google forms could raise concerns about the accuracy of the answers. however, due to the practice of "social distancing" caused by covid-19, online questionnaires were necessary. a total of 507 survey responses were used in the study, 43 surveys with incomplete information, which were judged to be inadequate for the purpose of data analysis, were excluded. this study was conducted after obtaining ethical approval from the institutional review board of wonkwang university (wkirb-202007-sb-034). the general characteristics of the participants are shown in table 1 . this study used scales that were deemed suitable for the purpose of this study selected from scales used in previous studies. the general characteristics of the participants were measured using two items regarding school level and gender on a nominal scale. health perceptions were measured using a scale that was based on the health perception scale developed by ware [2] and was verified for its reliability and validity by kim and choi [1] , kim, kim, and sok [7] , and kwon [16] . specifically, this scale consists of 4 subscales, with a total of 20 items, measuring the importance of health, health interest, confidence in health recovery, and health concern. health promoting behavior was measured using a korean version of the health-promoting lifestyle profile-ii (hplp-ii) originally developed by walker, sechrist, and pender [4] , which was verified for its reliability and validity by kim [13] , kim [17] , and kang [18] . specifically, this scale consists of 5 subscales, with a total of 20 items, measuring personal hygiene and life habits, nutrition and exercise management, eating habit management, stress management, and health responsibility. sports participation was measured using a tool based on a classification model for sports participation developed by snyder and spreitzer [19] , which was verified for its reliability and validity by lee [20] , lee and lee [21, 22] . the scale consists of 3 subscales with a total of 20 items, measuring cognitive participation, behavioral participation, and affective participation. health perceptions, health promoting behavior, and sports participation were independently scored on a 5-point likert scale, ranging from "strongly agree" (5 points) to "not at all" (1 point). a preliminary survey was conducted to verify the reliability and validity of the instruments. the reliability was verified using cronbach's α, which tests the internal consistency of the items, and confirmatory factor analysis was performed to test validity. reliability is related to how consistently and accurately a method measures something and indicates the accuracy of the measurement [23] . the reliability for each variable used in this study is shown in table 2 . generally, cronbach's α cannot be judged to be unreliable until it reaches 0.7 or higher, but some scholars have argued that this scale's reliability can be ensured even if it reaches 0.6 or 0.5 or higher [23] . the cronbach's α values of the observed variables used to measure health perceptions were between 0.526 and 0.787, all of which were more than the reference value of 0.500, indicating that the internal consistency reliability was appropriate [23] . in addition, "alpha if item deleted" eliminated items (health interest #5, confidence in health recovery #1, health concern #4) higher than the total cronbach's α after deleting respective items were deleted. the cronbach's α values of the overserved variables used to measure health promoting behavior ranged from 0.359 to 0.699, and the variable (personal hygiene and life habits) that did not show the desired internal consistency reliability was deleted. all other variables were evaluated as having an appropriate internal consistency reliability with a cronbach's α reference value of 0.500 or above. in addition, items with a cronbach's α value higher than the total cronbach's α (eating habit management #1) after deleting respective items were deleted. in addition, the cronbach's α values of the variables used to measure sports participation ranged from 0.811 to 0.917, and the values for all variables were above the reference value of 0.5, indicating that the internal consistency reliability was at an appropriate level. items with a cronbach's α higher than the total cronbach's α (cognitive participation #4, behavioral participation #3, and affective participation #1) after deleting respective items, were deleted. meanwhile, confirmatory factor analysis was used to test convergent validity, nomological validity, and discriminant validity of the scales. the goodness-of-fit indexes in confirmatory factor analysis were tested for incremental fit index through incremental fit index (ifi) and comparative fit index (cfi), and for absolute fit index through chi-square/degrees of freedom (x 2 /df), root mean square error of approximation (rmsea), goodness of fit index (gfi), and root mean square residual (rmr). the results are shown in table 3 . table 3 . goodness-of-fit indexes in confirmatory factor analysis of proposed and revised models. however, some indexes were found to be below the reference value, and some items (health concern) were removed based on the squared multiple correlation (smc) value. consequently, the goodness-of-fit of the revised model was found to be good overall. the detailed goodness-of-fit indexes in the confirmatory factor analysis of the proposed and revised models are shown in table 3 . in addition, the validity of the model was tested through confirmatory factor analysis and results are presented in table 4 . the convergent validity was verified using three methods: standardized regression coefficient, average variance extracted, and construct reliability. the standardized regression coefficients for all variables ranged from 0.555 to 0.946, and the significance (critical ratio) was 1.965 or higher. in addition, the construct reliability was found to be between 0.547 and 0.985, and the average variance extracted was between 0.917 and 0.955, indicating that the convergent validity was appropriate. the nomological validity was tested. this study predicted the relationship between constructs in a positive (+) direction, and the main relationship between latent variables showed a significant positive (+) relationship (table 4 ), indicating that the nomological validity was secured. the discriminant validity was verified by comparing the correlations between the constructs, and the average variance extracted ( table 5 ). the squared value of the correlation coefficient for "health perception ↔ health promoting behavior" was obtained, and the highest correlation was 0.397, which was lower than the average variance extracted of health perception (0.951) and health promoting behavior (0.955), indicating that the discriminant validity between the variables was secured. the data were collected through two online surveys (a preliminary survey and a main survey) using google forms. the preliminary survey was conducted on 200 korean adolescents in 2020, and a total of 180 survey responses, after excluding 20 survey responses with incomplete information, were finally used for analysis. the main survey was conducted on 350 korean adolescents in 2020, and 327 survey responses, excluding 23 survey responses with incomplete information, were finally used for analysis the data collected were analyzed using spss and amos 18.0 program (ibm corp., armonk, ny, usa). the detailed analyses were as follows. first, frequency analysis was performed to examine the general characteristics of the participants (see section 2.1). second, the reliability of the tools used in this study was tested using cronbach's α (see section 2.3). third, confirmatory factor analysis was performed to test the validity of the tools, and then convergent, nomological, and discriminant validities of the tools were tested (see section 2.3). fourth, a descriptive statistical analysis was performed to examine the perception of each variable by the participants (see section 3.1). fifth, the goodness-of-fit of a hypothesis model was tested to verify the structural relationship between individual variables, and then a path analysis was performed (see section 3.2). sixth, bootstrapping was used to verify the mediating effect of sports participation on the relationship between health perceptions and health promoting behavior in adolescents (see section 3.3). it suggested that because it is difficult to ensure that the distribution of mediating effects is normal, 10,000 bootstrap samples generated by random sampling from raw data are to be used for parameter estimation, and a confidence interval is to be set at 95% [24] . the bootstrap method was used in accordance with the suggestions. in addition, the indirect effects of health perceptions on health promoting behavior through sports participation were examined. to investigate the descriptive statistics of the variables (health perceptions, health promoting behavior, and sports participation) used in this study, all variables and sub-variables were analyzed, and the results are shown in table 6 . the mean values were distributed between 2.58 and 3.83, and the standard deviations were distributed between 0.53 and 1.11. then, the skewness and kurtosis were examined. in general, it was assumed that a skewness value of <3.00 and a kurtosis value of <±10.00 are the bases of the violations of univariate normality assumptions [25, 26] . the analysis results reveal that the absolute value of the skewness was distributed between 0.004 and 0.404, and the absolute value of the kurtosis was distributed between 0.047 and 1.557. these results could be evaluated as satisfying the conditions required for the normality for the structural equation model. the structural equation model developed in this study consisted of three latent variables: health perceptions, sports participation, and health promoting behavior, and 10 observed variables: importance of health, health interest, confidence in health recovery, nutrition and exercise management, eating habit management, stress management, health responsibility, cognitive participation, behavioral participation, and affective participation. a path analysis of the study model was performed, and the goodness-of-fit of the entire study model was determined to analyze direct and indirect effects. the results show that the goodness-of-fit of the proposed model was overall acceptable, as shown in table 7 . the results of verifying the hypotheses that analyzed the causal relationships between the individual variables using the study model showed that hypotheses one and three were supported, but hypothesis two was rejected. the results of testing the hypotheses are shown in table 8 . s.e. = standard error, c.r. = critical ratio; *** p < 0.001, tested by path analysis. first, the results of analyzing hypothesis one (health perceptions will have a positive effect on sports participation) show that the path coefficient was 0.570 (t = 7.885), supporting the hypothesis. second, the results of analyzing hypothesis two (health perception will have a positive effect on health promoting behavior) show that the path coefficient was 0.045 (t = 0.592), rejecting the hypothesis. third, the results of analyzing hypothesis three (health perception will have a positive effect on health promoting behavior) show that the path coefficient was 0.749 (t = 7.159), supporting the hypothesis. analyses were performed to verify the model that explains the structural relationship between the individual variables by verifying the mediating effect of sports participation on the relationship between health perceptions and health promoting behavior in adolescents. first, we comparatively analyzed the goodness-of-fit of a partial mediation model (the hypothesis model) in which health perceptions might directly affect health promoting behavior, while also affecting health promoting behavior through sports participation. the goodness-of-fit of a complete mediation model (the competition model), in which there might be no direct path between health perceptions and health promoting behavior, and health perceptions might affect health promoting behavior through sports participation, was also analyzed. we explored the model that explained the experience data best and was the simplest. the goodness-of-fit indexes of the hypothesis model and the competition model were calculated for comparison, as shown in table 9 . table 9 . goodness-of-fit indices of hypothesis and competition models. since the complete mediation model is an embedded model in the partial mediating model, a x 2 difference test was performed. in the x 2 difference test, which tests the difference in the degrees of freedom between the two models, a goodness-of-fit of 5.99, which is statistically significant with α = 0.05, was revealed. however, the results of the x 2 difference test show that the x 2 difference between the two models was 0.286, and the difference in degrees of freedom between the two models was one, indicating that there was no statistically significant difference. a partial mediation model is selected if the results of the x 2 difference test are statistically significant, and a complete mediation model is selected if they are not [27] . therefore, both the complete mediation model and the competition model can be selected as the final model in this study. in other words, the direct effect of health perceptions on health promoting behavior were found to be not significant, whereas the indirect effect of health perceptions on health promoting behavior through sports participation was found to be significant. in addition, the bootstrap method was used to test the indirect effect of sports participation in the relationship between health perceptions and health promoting behavior [24] . the bootstrap method was used to estimate the standard error of the indirect effect, which may be involved in the existing testing for mediating effects. with the bootstrap method, a confidence interval is provided, and if the confidence interval does not include 0, indirect effects are considered to be statistically significant. as shown in table 10 , the indirect effect (β = 0.454, 95% bias-corrected confidence interval = 0.355-0.551) of health perceptions on health promoting behavior through sports participation was statistically significant. in other words, it was found that higher health perceptions were associated with higher sports participation, thereby leading to higher health promoting behavior. this study aimed to clarify the mediating effect of sports participation on the relationship between health perceptions and health promoting behavior in adolescents, and to determine the importance of sports participation in forming healthy life habits during adolescence. the principal results of this study are as follows: (1) first, health perceptions had a positive effect on sports participation. previous studies regarding the relationship between sports participation and health perceptions [9] [10] [11] [12] 28] have reported that there was a positive causal relationship between the two variables, supporting the results of this study. in particular, a previous study reported that health perceptions improved with participation in exercise [11] , and another study reported that sports activities had a positive effect on subjective health perceptions [1] . as shown in the results of this study and previous studies, adolescents with high health perceptions can be interpreted as actively participating in physical activities, such as sports, in order to maintain and improve their health. accordingly, various measures should be provided to improve health perceptions in adolescence, which is a period that can lay the foundations for lifelong health education. in addition, efforts are needed to improve health perceptions, and to find and facilitate ways for adolescents to voluntarily participate in sports. second, health perceptions had no direct effect on health promoting behavior, but to have an indirect effect on health promoting behavior through sports participation. previous studies have reported a positive correlation between health perceptions and health-promoting behavior, which is supported by the results of this study [3, [29] [30] [31] [32] [33] . in particular, previous studies have reported that there was a positive correlation between health behavior and health perceptions [33] . furthermore, it is argued that help from schools, teachers, and communities is needed to improve the effectiveness of health perception programs for adolescents, and such programs should lead to effective programs in the future [31] . given that as people get older their interest in health generally tends to increase, adolescents are more inclined to have a relatively low interest in health compared to people in other age groups. thus, enhancing health perceptions during adolescence can lead to lifelong health habits, and it is necessary to explore a variety of educational strategies to improve health perceptions among adolescents. third, sports participation had a positive effect on health promoting behavior. a study comparing the health promoting behavior and sports participation of college students in the republic of korea and japan [14] found that the effect of lifestyle factors on health promoting lifestyles and sports activities in japan and korea is different. furthermore, they investigated health promoting behavior in university sports participants and found results that are consistent with the findings of the present study [18] . in addition, a study reported that the experience of participation in program on physical fitness in hungarian older adults had a positive effect on health promoting behavior [15] . from these results, it can be inferred that students' continuous participation in sports activities can effectively affect their health promoting behavior, they can live healthy daily lives, including their schoolwork and school life. therefore, when deciding on health promoting behavior projects and systems for adolescents, it is necessary for educational institutions, such as school authorities and the ministry of education, to consider the results of this study. fourth, sports participation had a complete mediating effect in the relationship between health perceptions and health promoting behavior. the present results show that adolescents with higher levels of health perceptions tend to participate more actively in sports activities, which may lead to increased health promoting behavior in adolescents. active participation in sports activities in adolescence, which is a critical period that can lead to lifelong health, can be seen as a prerequisite for living a healthy life. the results of this study are significant in that they reveal the importance of sports participation as a variable for forming a healthy lifestyle among adolescents. moreover, we believe these results are a theoretical basis for developing various policies and programs for adolescents' sports participation. recently, because of the pandemic phenomenon caused by covid-19, the importance of personal hygiene management and a healthy lifestyle is being emphasized. this experience will make it extremely important for individuals to renew their perception of health. regular participation in sports to improve health from adolescence can be seen as a solid foundation for lifelong health [34, 35] . the results of this study will help provide a theoretical foundation for the development and operation of educational institutions' programs to strengthen awareness of youth health and encourage participation in sports. the aim of this study was to verify the structural relationship between health perceptions, sports participation, and health promoting behavior in adolescents. the results of the study are as follows: first, health perceptions were found to have a positive effect on sports participation. furthermore, health perceptions were found to have no direct effect on health promoting behavior, while sports participation was found to have a positive effect on health promoting behavior. additionally, sports participation completely mediated the relationship between health perceptions and health promoting behavior. based on the findings and limitations of this study, suggestions for further studies are as follows. first, because the participants in this study were limited to korean adolescents, it is difficult to generalize the findings to the entire population. therefore, further studies are needed to involve adolescents in various countries to expand the sample size. second, since adolescents' health promoting behaviors can appear as a complex process involving various variables, it is necessary to conduct further studies using diversified variables that may affect health promoting behaviors based on the results of this study. third, since the scales used in this study were based on self-report, there is a possibility that the participants might respond with defensive attitudes, and their responses might be diminished or exaggerated. therefore, in order to overcome the limitations of the self-report questionnaire, it is necessary to examine various types of tests such as the use of a social desirability scale. fourth, in this study, the measurement of sports participation consisted of a five-point likert scale. in further studies, it will be necessary to conduct research on sports participation by degree (strength, frequency, and duration) and examine the differences in health-related eccentricities according to the level of participation. 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university students effectiveness of universal school-based mental health awareness programs among youth in the united states: a systematic review the association between leisure time physical activity and happiness: testing the indirect role of health perception asociations betwen awarenes of beyond blue and mental health literacy in australian youth: results from a national survey health perception and health status in advanced old age: a paradox of association gender differences in body image misperception according to body mass index, physical activity, and health concern among korean university students the relationship of exercise frequency to body composition and physical fitness in dormitory-dwelling university students this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord-259809-7glw6pir authors: lloyd, helen m.; ekman, inger; rogers, heather l.; raposo, vítor; melo, paulo; marinkovic, valentina d.; buttigieg, sandra c.; srulovici, einav; lewandowski, roman andrzej; britten, nicky title: supporting innovative person-centred care in financially constrained environments: the we care exploratory health laboratory evaluation strategy date: 2020-04-28 journal: int j environ res public health doi: 10.3390/ijerph17093050 sha: doc_id: 259809 cord_uid: 7glw6pir the cost cares project aims to support healthcare cost containment and improve healthcare quality across europe by developing the research and development necessary for person-centred care (pcc) and health promotion. this paper presents an overview evaluation strategy for testing ‘exploratory health laboratories’ to deliver these aims. our strategy is theory driven and evidence based, and developed through a multi-disciplinary and european-wide team. specifically, we define the key approach and essential criteria necessary to evaluate initial testing, and on-going large-scale implementation with a core set of accompanying methods (metrics, models, and measurements). this paper also outlines the enabling mechanisms that support the development of the “health labs” towards innovative models of ethically grounded and evidenced-based pcc. the world health organisation defines universal health care as that 'which all citizens can access without incurring financial hardship' [1] . many nations fail to provide this as a basic human right, health promotion as an approach aims to inform, influence, and support people, communities, and organisations to improve health. supporting people to increase control over their health is in essence health promoting, both for the individual and society [29, 30] . hp activities can work in synchronicity with pcc if developed in partnership with the person, taking into consideration their life context and socioeconomic conditions [31, 32] . cost action 15222 'cost cares' was funded by the eu commission to create the impetus in both the research and development required to design and test innovative exploratory health laboratories (ehls) to implement pcc and hp across the eu. this paper sets out a strategy for evaluating them. to understand how the ehls might work to deliver pcc, hp, and cost outcomes, it was first necessary to develop programme theories (pts). pts describe how interventions (service, treatment, policy) are thought to work by specifying the ways in which they produce outcomes. they are a set of causal relationships often referred to as "if-then" statements. they can also be written or represented graphically to show the relationships between cause and effect. pts are also useful for understanding both the positive and negative impacts that can occur when interventions are implemented. they are often accompanied by logic models, which help plan and evaluate interventions based on their internal logic, and the role of context in supporting successful delivery and evidence acquisition. we created evidenced-based pts to specify how ehls would deliver pcc, hp, and cost outcomes through the critical enablers detailed in the we-care roadmap (see figure 1 ). repeated here for clarity the critical enablers are (1) information technology (it), which describes the use of computers or other computerized devises to store, transmit, and receive data to support pcc planning and care coordination, for handling and communicating health and evaluation data, and for delivering pcc and hp interventions. (2) quality measures, such as organizational processes, that ensure health services increase the likelihood of the desired health outcomes consistent with current scientific knowledge, which take into consideration an individual's preferences, and ensure that health services are effective, affordable and accessible to all citizens. (3) infrastructure to create the necessary resources and structures that support the shift from health systems that are excessively hospital-centric and biomedically-oriented, to those which value continuity, responsiveness, and multidimensionality in community care, e.g., shifts in staffing, training, and delivery of care. (4) incentive systems that reward pcc processes and outcomes, such as personal health goals, pcc plans, improvements in patient self-efficacy and experiences of care, and hp activities. this will require an expansion and critical revision of existing system-based biomedically driven performance indicators. (5) contracting strategies that define and endorse pcc incentive systems and infrastructural support and efficiencies for ehls, purchasing strategies and contracts between payers and providers of healthcare that promote the alignment in organisational goals based on pcc, hp, and cost containment. (6) cultural change that represents shared assumptions, values, and beliefs that govern how people behave in an organisation. receptiveness or readiness to change is considered a prerequisite for ehls. as other critical enablers are modified within a given ehl, cultural change towards pcc, hp, and cost containment may present as either a pre-requisite and/or a natural consequence of development. the addition of this sixth critical enabler represents the importance of organizational culture in achieving pcc and cost stability. upon establishing agreed definitions of the above enablers, the next step was to hypothesize how these might work to support the aims of an ehl. following this step, the literature was searched to detect evidence for the hypothesized statements, referred to as 'if-then' statements. to expedite this process, tables of 'if-then' statements were compiled, which, in keeping with the evaluation methods of critical realism [33, 34] , permitted the compilation of patterns of causal chains within the ehl. for example, if condition x is in place (e.g., practitioners are incentivized to engage in shared decision making with patients), then outcome y might follow (e.g., patients will feel like they are taking an active role in rehabilitation planning), thus improving service user experiences of pcc [35] . this task facilitated exploration of how the critical enablers interacted with pcc and hp to improve quality pcc and cost containment (see figure 1 ). the points at which pcc and hp intersect with each of the critical enablers in figure 1 are referred to as intersection points (e.g., pcc and information technology (it)). this section describes the considerations and necessary steps for evaluating and implementing ehls to improve quality pcc and cost containment. first, the practice of pcc is explored, and then the role of critical enablers is illustrated. a number of controlled studies have been performed comparing pcc to usual care [21, [36] [37] [38] . the core components in the interventions have been to listen carefully to the patient's illness narrative and to mutually agree on a health plan. the true case story (see figure 2 ) previously published in a position paper demonstrates how the patient narrative can open up and reveal information needed for the patient and the professionals to be able to agree on a relevant health plan [39] . this is concordant with the theory and philosophy that pcc is based on starting with each person's capability and wish to take responsibility for their own health. the true case below is a vignette based on a real person to illustrate how pcc can be applied in practice through a worked example. upon establishing agreed definitions of the above enablers, the next step was to hypothesize how these might work to support the aims of an ehl. following this step, the literature was searched to detect evidence for the hypothesized statements, referred to as 'if-then' statements. to expedite this process, tables of 'if-then' statements were compiled, which, in keeping with the evaluation methods of critical realism [33, 34] , permitted the compilation of patterns of causal chains within the ehl. for example, if condition x is in place (e.g., practitioners are incentivized to engage in shared decision making with patients), then outcome y might follow (e.g., patients will feel like they are taking an active role in rehabilitation planning), thus improving service user experiences of pcc [35] . this task facilitated exploration of how the critical enablers interacted with pcc and hp to improve quality pcc and cost containment (see figure 1 ). the points at which pcc and hp intersect with each of the critical enablers in figure 1 are referred to as intersection points (e.g., pcc and information technology (it)). this section describes the considerations and necessary steps for evaluating and implementing ehls to improve quality pcc and cost containment. first, the practice of pcc is explored, and then the role of critical enablers is illustrated. a number of controlled studies have been performed comparing pcc to usual care [21, [36] [37] [38] . the core components in the interventions have been to listen carefully to the patient's illness narrative and to mutually agree on a health plan. the true case story (see figure 2 ) previously published in a position paper demonstrates how the patient narrative can open up and reveal information needed for the patient and the professionals to be able to agree on a relevant health plan [39] . this is concordant with the theory and philosophy that pcc is based on starting with each person's capability and wish to take responsibility for their own health. the true case below is a vignette based on a real person to illustrate how pcc can be applied in practice through a worked example. pcc for mr. g was facilitated via various critical enablers, detailed in the following: information technology: the medical documentation and information (in the patient records) as well as the commonly formulated treatment and health plan are digitalized and accessible to mr. g and his providers in a way that he comprehends and can agree or ask questions about. in formulating the health plan, mr. g was supported by a digital patient decision aid [40] . health information technology (it) systems support the smooth flow of information between services, and to and from citizens and their families. artificial intelligence might facilitate this and help improve interactions with patients [41] . quality measures: mr. g was invited to download an app after his first myocardial infarction where he can follow the development of symptoms and well-being and contact health care services for help and support with formulating his personal health plan. contracting strategies, incentives, and infrastructure: the infrastructure supported cumulative documentation according to the criteria for pcc. this was linked to incentive payments for the whole team. this type of incentive payment includes quality measures (care plans) that are sanctioned and contracted between the provider and commissioner organisation. program theories (pts) are useful ways in which to facilitate an understanding of how complex interventions work; in this case, how the critical enablers could work with pcc and hp interventions to generate cost containment and quality pcc outcomes. table 1 provides 11 worked examples of pts referred to as 'if-then' statements with explanatory 'because' statements and associated suggestions for assessment or measurement. instruments and methods to assess pts should be carefully selected and the use of mixed methods is advised. knowledge base and practical constraints will add to the existing complexity of measurement and evaluation. the type of design employed can help remedy some of these issues. for example, beginning with small-scale and qualitative assessment will help determine what to measure and how to measure it, and what improvements to expect. ensuring measures or assessments capture professional and patient partnership work in care planning is key for emphasizing the importance of this for pcc. the following pts are presented here as examples of a larger body of work (available from the first author) conducted to inform the design and evaluation of ehls. table 1 presents seven different types (a-g) of evidence-based pts that could shape the design of an ehl. type a (contracting strategies for quality and cost outcomes) pts represent how contracting strategies could operate at macro and meso levels to support quality pcc and contain cost. in the two examples provided, 'alliance' or 'partnership' models contract to deliver an ehl based on shared or co-designed pcc and hp objectives to improve quality pcc and costs. this fosters trust and productivity based on collective ownership and the sharing of risk and reward within ehl. a mixture of quantitative and qualitative measures of delivery and management team dynamics, and progress towards aligned goals (e.g., pcc health plans), and costs over time could be used to ascertain the success of the contracting strategy. these enablers provide causal mechanisms for cost and quality outcomes at macro and meso levels within the ehl. type b (incentives and contracting strategies for quality pcc resulting in cultural change) pts represent the potential for contracting strategies combined with incentives to improve cost and quality outcomes by providing incentives at multiple levels across the ehl. for example, if cost effectiveness is measured across the whole care chain with the savings provided to all participants, this creates the potential to act as an incentive towards aligned pcc and cost goals. to combat perceptions of unfairness in the equal distribution of savings across the system, objective measures of effort will need to be employed. these measures, however, should to be balanced against the knowledge of the operational context. for example, settings low on staff resources may seem to have contributed less towards the achievement of savings across the chain. ensuring that contextual knowledge supports objective measurement will help communicate the conditions of contributors towards the savings gained and shared. long-term planning and monitoring, active communication, and shared goals will help mitigate against perceptions of unfairness. redistributing resources based on savings can help achieve the stated organization goals and thus improve the sector's efforts where these are perceived to be lacking. these seemingly radical shifts align to the principles of fair division and social choice [59] . over time, resultant cultural change across the system could be operationalized as permanent transformation of routines/habits. measures of pcc and hp routines/habits, savings distribution, and measures of patient experience of care could help establish if this strategy is beneficial. type c (contracting strategies, incentives, and quality measures for cost and quality) pts combine contracting strategies with incentives and quality measures to effect change in quality and costs. these build on type a and b pts by, for example, suggesting that if contract payments are made at the same time to all providers and tied to measures of pcc and hp, this fosters trust and productivity by reducing the misalignment and unproductive competition between partners and reduces transaction hazards operating at macro and meso levels within the system. type d (incentives for quality pcc) pts work at the micro level with incentives applied equally to all delivery staff irrespective of hierarchy or professional grouping [22, 46] (e.g., patient feedback forms at clinic and ward levels). for quality pcc outcomes to be achievable, incentives must ensure that the reward system motivates individuals to align their own goals with those of the organization (ehl) [60, 61] . as the pcc approach is based on qualitative changes, financial incentives may not be the best type of incentive to test. it has been long recognized that financial incentives are positively related to quantitative performance (e.g., number of tasks completed) but not necessarily with performance quality [62] [63] [64] [65] . thus, ideally, particularly since pcc is based in an aristotelian ethics of virtues, the incentive systems should be a combination of financial and non-financial rewards (e.g., recognition, positive feedback from leaders, promotions, money, as well as target setting and performance evaluation itself) [66, 67] . these rewards would be directed to all ehl members, since in "a complex network of interdependent relationships" [68, 69] necessary for pcc implementation, it is difficult to identify an individual contribution. the success of micro-level incentives can be measured by carefully selected patient experience measures and focus groups. type e (incentives, quality measures for cost, and quality pcc) pts work by combining incentives with quality measures at macro and meso levels. for example, if a pcc quality measure is linked to an ehl accounting system and able to deliver cost containment information resulting from pcc processes, then the measure itself becomes the incentive. quality measures therefore act as both an aligned incentive and measurement of implementation. a pre-and post-comparison of costs associated with pcc quality processes analyzed against quality measure scores would provide an assessment of effectiveness. a benchmarking strategy against non-ehl settings may be an example of a measurement process being itself an incentive. it is important to note that the cost containment may not be immediate, as some costs may be incurred upfront and/or it may take time for outcomes to stabilize or become apparent. ehls employing longitudinal designs can help to account for these potential delays. type f (information technology for quality) pts provide examples of how it has the potential to improve quality. these pts work to support patient self-management through mobile technology, for example, through symptom monitoring or appointment reminders, to help people manage their own health [52] . they may also operate to support the adoption of pcc electronic health records and care plans, which provide teams with the tools to maintain and share pcc information. measurement and evaluation of these mechanisms would be tailored to detect changes in patient self-management activities, team effectiveness, and resultant health system impact (e.g., reviews, appointments attended, etc.). in the current covid-19 context, remote monitoring of patients, video-linked consultations, and e-health interventions could provide an exciting opportunity to test the delivery of person-centred care remotely, with the potential to calculate costs compared to previous standard practice [70] . type g (infrastructure for quality pcc) pts provide examples of how components of an organization's infrastructure could help result in quality care at meso and micro levels. at a meso level, if staff training is provided to enhance professional skills to support patient empowerment and enhance professional communication skills, this then has the potential to improve pcc delivery and experience of care. furthermore, using patient-reported measures to shape care planning and use of the feedback from these measures to improve staff training has the potential to embed the patient voice in quality improvement practices and shape equitable person-centred relationships between professionals and patients [54] . a multitude of measures are available to measure these outcomes [27] and for use in care planning in this way. however, sampling care plans with patient-reported outcome measures (prom) and interviews with professionals and patients would be insightful. these examples of pts are not comprehensive, but they illustrate how those developing ehls can use these and other mechanisms to design their interventions and corresponding evaluation strategies. for further guidance on the use of evaluation metrics and measures, see p3c.org.uk. if "quality measures" are linked to pcc ideas and information systems (e.g., accounting system) and able to deliver information about cost containment or other quantitative indicators improvement against non-ehl settings (benchmarking), then the measurement process itself will be an incentive [51] the measurement process has also the function of ex-ante control applied "quality measures" enabler the evaluation of ehls should address questions that will enable commissioners of health services and delivery organizations to implement, sustain, and scale up the innovations. key evaluation questions for the ehls will include those that probe pcc processes, practices, and patient experiences of pcc care as markers of quality pcc. the health outcomes measured should be relevant to the patient and their family, health care provider, and other decision-makers. key areas of interest in the implementation of pcc are changes in functional ability, experiences of care, self-efficacy, and cost. ehls will also be informed by wilson and cleary's [68] model for integrating concepts of biomedical outcomes and measures of health-related quality of life: (i) biological and physiological factors, (ii) symptoms, (iii) functional status, (iv) general health perceptions, and (v) overall quality of life). specific questions (see figure 3 ) will also probe the mechanistic relationship between the critical enablers and pcc and hp. these are referred to as intersection points. irrespective of the type of intervention, commissioners and policy makers require proof that the additional health care resources needed to make the procedure, service, or program available to those who could benefit from it are justified [71] . the purpose of economic evaluation is to inform such funding decisions. an economic evaluation deals with both inputs and outputs (costs and consequences) of alternative courses of action, and is concerned with choices and consideration of the costs and benefits at multiple levels. ehls will therefore have to evaluate the main costs involved in the change of a healthcare system towards pcc and hp. weinstein [72] identifies costs related to changes in the use of healthcare resources, changes in the use of non-healthcare resources, changes in the use of informal caregiver time, and changes in the use of patient time (for treatment). in a similar way, drummond et al. [71] identifies health sector costs, other sector costs, patient/family costs, and productivity losses. measurement within economic evaluation expands beyond the healthcare system under study. according to weinstein [72] , direct health care costs include all types of resource use, including professional, family, volunteer, or patient time, as well as the costs of tests, drugs, supplies, healthcare personnel, and medical facilities. non-direct health care costs include the additional costs related with the intervention, such as those for childcare (for a parent attending a treatment), the increase of costs required by a dietary prescription, and the costs of transportation to and from the clinic; they also include the time family or volunteers spend providing home care. citizen time costs include the time a person spends seeking care or participating in or undergoing an intervention or treatment. time costs also include travel and waiting times as well as the time receiving treatment. productivity costs include (1) the costs associated with a lost or impaired ability to work or to engage in leisure activities due to morbidity and (2) lost economic productivity due to death. the world health organization (who) recognizes quality health care in those organizations that have a high degree of professional excellence, with minimum risks, good health outcomes for patients, and efficient use of resources [1, 73] . to promote the health of the population, the who recommends key objectives for continuous quality improvement in health care. these include the structuring of health services, the rational and efficient use of both human and financial resources, and the guarantee of professional competence to citizens in order to meet their needs. measures or questions relating to quality are likely to overlap and complement those relevant for cost containment (see figure 4 ). is the ehl coordinating its activities around the person and their carers/family? are carers supported? are community assets are being deployed, including peers, social networks, and the voluntary sector? the evaluation of the ehls must contain the most suitable measures and approaches to answer the questions. quantifiable measures or questions can either be aggregated (single criterion analysis) or handled separately (multi-criteria analysis). careful consideration of the combination of qualitative and quantitative approaches is advised, particularly since different health systems display different capabilities in this regard. in terms of minimum design standards, at least two data collection points-pre-and post-intervention/implementation-are recommended. this is the minimum standard advised. should the availability of knowledge, skills, and resources be forthcoming, more complex experimental and implementation-focused designs could be undertaken upon careful consideration of the amount of preexisting evidence for pcc in that particular context or condition [74] . ideally, monitoring and data collection will be continuous and with feedback to practice, with long follow-up periods to capture lasting changes in care delivery and outcomes. to account for the variance in ehls, a core minimum data set from each site with three categories of data is recommended: routinely collected audit data or similar (e.g., collected at country or hospital level); questionnaire data specifically collected for the ehl; and qualitative data to support implementation development. examples of suitable measures, depending on the focus of the changes in the healthcare system that are implemented, are given in table 1 . as an ehl is scaled out in practice, it may be necessary to add new measurements to capture unanticipated and/or unintended changes. a metrics framework provides the structure for planning the sampling and timing of data collection during the evaluation of an ehl. it is likely that data could flow from different sources, e.g., routinely collected data and quantifiable data, surveys, and qualitative data. the pt will guide the sampling strategies for data collection, the timing of data collection, and the various units of analysis. qualitative approaches will always necessitate careful sampling because they are resource and time intensive. in contrast, an ehl may decide on a questionnaire to measure the experiences of all those using a service to canvas a broad view. the trade-off between qualitative approaches and more structured approaches involves considerations of depth versus breadth; different sampling strategies are required for different forms of data. as qualitative approaches are effective for determining "how and why" the ehl is working, it will be important to consider a range of perspectives. sampling should therefore aim for diversity in terms of ethnicity, social and economic status, age, disability, and health conditions. services may also decide to film or record care interactions for ongoing implementation and quality improvement activities, using purposeful samples or random selection. convenience and pragmatism will also play a role in any sampling procedure, which is common in applied health care research and evaluation, where time and resources are limited. the phasing of data collection will likely include baseline data and follow-up data to mirror the timeframes of the intervention. it might also be necessary (providing sufficient justification and acceptability from practitioners and patients) that focused data capture on a specific element of the delivery is added into the core set of measures at particular times. for example, if communication or shared decision-making was an improvement target, implementing a tool that specifically addresses this issue of relational care could be used as both the intervention and data collection [75] . the potential to link health and social care data to understand an individual's pathway following exposure to an ehl will be determined by local ethical restrictions, data flow, and governance guidelines. linked data sets (or even unified data sets) allow for a longitudinal exploration of the impact of the intervention on service utilization (costs) and health using time series analysis or similar [76] . analysis will be more powerful if compared to a control cohort (tracked by a unique identifier following explicit consent) of people who are part of a health lab. the use of techniques, such as propensity scoring, to identify and match control groups of service users are particularly helpful for this type of evaluation and service development [77] . the analysis plan should be informed by the pts and shaped by the evaluation framework. in principle, three main stages of analysis are envisaged. the first stage will commence with univariate analysis to examine each variable or source of data (for example, acceptability of services as a measure of quality or use of care plans as a measure of it) independently. this could explore the time trends in say routinely collected data and the statistical properties of the data, e.g., the distribution of the data. parallel qualitative analysis could seek to surface emerging themes. in the second stage, for each ehl, the pt will be tested to check if it is functioning as expected. in the third stage, findings both within and across the ehls will be compared to answer the higher-order questions about the relationships between the quality of care and cost containment. working to understand trends in the data and other potential factors influencing outcomes (i.e., closure of a community hospital, or lack of out-of-hours primary care) will be a necessary effort. collaboration between academic and health science partners will facilitate a robust evaluation, linking efforts to capture patient experiences and outcomes with cost indicators. the ultimate result will be a more nuanced story of how the intervention is delivered, experienced, and the extent to which it is achieving change. in this regard, it is important to note that change may not be immediate. even if change is achieved quickly, impact on outcomes may require longer-term follow-up, especially, for instance, to demonstrate the cost-benefit ratio. to convince european societies and key decision-makers at a national and an eu level that the we-care roadmap is viable, reliable evidence from the ehls based on robust evaluation and implementation is required. many barriers and uncertainties may threaten the implementation of pcc. the first is the quality and accuracy of the pt that underpins the ehl model; whether it includes all key aspects needed to provide pcc, if it examines quality care and/or cost, and the extent to which it includes the enablers within the ehl. the model should also be appealing and promise significant benefits, in order to convince key stakeholders of the potential ehl. however, not only is the quality of the theoretical model important, the legitimacy and reliability of the person or organization presenting the model to its future users is also crucial [78] . the engagement of authoritative local leaders who endorse the model to a range of stakeholders will be important to achieve early on in the process. this is likely to affect stakeholders' perception of its quality and validity [79] , as well as its advantage over alternative solutions [80, 81] . the ehls will affect people, their families, health professionals, and employees throughout the organization, including managers. thus, a bundle of incentives for different groups will probably be required. varied incentives, not only financial, as pay-for-performance, but also prospects of increased external recognition or legitimacy for participant organizations should be considered. the title of "the best provider", achieved by public benchmarking, could be an example. this requires accurate outcome measurement. incentive bundles can apply to three enablers of we-care roadmap: incentive systems, quality measures, and contracting strategies. the case-mix systems that are used in many european countries to finance hospital care are motivating providers to admit more patients, because the more patients they serve, the higher their income. if a hospital or a hospital ward agrees to become an ehl, the issue of contradictory incentives is likely to arise and must be overcome. for example, if, by implementation of an innovative community care ehl, more patients are cared for in the community, then the hospital will not receive money from the payer for those patients. the fixed costs of the hospital will remain, creating a deficit in the hospital system. a risk-reward sharing framework between the hospital and community provider could agree to cover hospital losses over the course of the project, but provisions for who will pay the fixed costs afterwards would need to be considered. involving key stakeholders from across the system will be important to provide strategies to overcome these conflicting issues. there should also be a distinction made between the average and the marginal cost of in-patient care. for example, the costs of a hospital ward (e.g., general medicine) are unlikely to differ significantly between a 10-or 20-patient occupancy. this means, that even if a treatment of a group of patients was organized outside of a hospital and the hospital infrastructure remained unchanged, the cost savings would be meagre or illusory. if, after introduction of the innovative care system, the medical infrastructure seemed unnecessary, then ehl employees would need to be motivated to support the ehl to ensure sustainability. the extent to which the organizational climate is favorable for ehl implementation must also be considered [80] . the implementation climate is more evident and less stable than the organizational culture and is thus more susceptible to amendments. policies, procedures, and reward systems are those incentives that may effectively affect the implementation climate [82] . the other fundamental ingredient of a positive implementation climate is the extent to which important actors perceive the current healthcare delivery model as intolerable or unsustainable and are motivated for change, defined as cultural readiness [78] . the proposed model of the ehl should be compatible with stakeholders' own norms and values (culture), as well as with their priorities [78, 83] . to maintain a positive climate for the implementation of ehls, important indicators related to citizen health, well-being, quality, costs, and other important factors should be presented to stakeholders. thus, both the climate for change and incentives and reward systems call for accurate, objective, and verifiable measures viable to reflect the real performance in pivotal areas. if measures do not meet these requirements, this could undermine implementation [84] . measures must clearly communicate pcc goals and feedback to participants indicating the degree of goal achievement. to support pcc implementation and address potential barriers, each pt should be linked to a strategy with its own resources. resources include knowledge, time, money, training, and in some cases physical space. especially important is the access to widely understandable and convincing information and knowledge about pcc implementation, specifically about new work processes for the staff and the nature of care provided to patients and their social environment. if resources are not available, this creates a further barrier to implementation that must be effectively managed. organizational change begins with changes in individual behavior, although as numerous studies have shown, this is complex and challenging [80] . ensuring the main actors do not perceive implementation of ehls as threats to their own interests is a critical issue to address. subjective interests are, however, not often easy to identify. powerful actors, in particular leaders who at multiple levels across the system represent the core activity of the pcc implementation, must include physicians, nurses, allied health and social care professionals, people, and their communities. in ehls, leadership should be transformational and innovative to create teams working to develop a workplace that is person centred. this is a key factor in the delivery and sustainability of pcc [85] . if this is achieved, it will promote cultural change and the upskilling of existing employees. having several key people within the organization take on this role will ensure leadership sustainability. although these groups should support every change to augmenting healthcare quality, such as pcc, in reality, however, explicit or latent resistance can be a common problem [86] . the medical and health professions are built on an ideology to protect and care for humanity over economic profitability and self-reward [87] , but contradictions between altruism and professional self-interest have been established. the excessive self-interest of individual doctors or groups of physicians should be mitigated by professional self-regulation and self-control [88] . since large-scale testing is the ultimate aim, it is assumed that a significant number of enabler elements will be in place when an ehl begins. as suggested earlier, the ehl will be underpinned by the pt that describes how the central work processes and independent actions of actors should be coordinated to deliver high-quality pcc. to be effective, the model, once elaborated, will require continuous adjustment not only to local environment factors but also to external and internal uncertainties emerging over time in each setting. thus, some feedback and regulatory mechanisms should be an integral part of the model. the development and improvement of ehls will be facilitated by a commitment to formative learning in response to the feedback from the evaluation data (data-driven improvement). there is a long tradition of using these methods to improve practice, and good evidence to suggest benefit [89] . learning will vary by organization and setting. however, it will usually require a "plan-do-study-act" (pdsa) cycle or a similar process [90] . this will typically involve action learning sets [91] using quality improvement methodology [92] . action learning sets are particularly suited to iterative complex intervention development as they focus on learning from interactions, thus providing a mechanism to reflect and problem solve. these skills are particularly important for health and social care professionals who are being asked to work in a different way, where this is likely to be challenging. 3.11. co-design and participatory action for pcc emancipatory research designs have been a core feature of community development and strengths-based approaches in social care. such approaches value the lived experience and partnership with patients and the public in developing and evaluating services [93] [94] [95] [96] . research approaches based on these principles have in the past been subject to much derision but are now becoming recognized as critical to citizen-relevant and humanistic healthcare planning and evaluation, and align well with the philosophy of pcc. the uk standards for patient and public involvement in the planning and evaluation of health and social care are supported by academic, research, and government policy. involving patients and the public in the consultation and shaping of ehls is a core and fundamental standard we advocate. this paper laid out a comprehensive plan for the evaluation of exploratory health laboratories that aims to improve the quality of health care in the eu whilst also containing costs. the plan was developed by members of the we-care fp7-funded project and cost cares cost action 15222 from a range of academic and professional backgrounds and different countries. this process identified pcc and hp as the solution, along with critical enablers to facilitate implementation. examination of the intersections among and between these enablers, as well as the impact on quality of care and cost of care, via evidence-based pts provides the justification for the design and incorporation of particular components into an ehl. furthermore, the paper also described how these components and ehls might be evaluated as complex interventions at micro, meso, and macro levels. this work and the resources it produced (www.costcares.eu) are intended to serve as a reference material for those considering setting up ehls or similar initiatives beyond the scope of this cost action. author contributions: h.m.l. was instrumental in leading the work of working group 3. this included development and supervision of the plan of work, data curation, preparation of the original manuscript and subsequent revisions. i.e. was core to working group 3 and supported the writing, reviewing and editing of the manuscript. i.e. led the funding acquisition and contributed to the work of working group 3 and critical development of the manuscript. h.l.r. is a member of working group 3 and was responsible for data curation, manuscript revision with re-conceptualization of some aspects presented, and critical review of the final manuscript. v.r., p.m. and v.d.m. are members of working group 3 and were responsible for data curation, manuscript review and critical revision. s.c.b. read versions of the manuscript and was responsible for reviewing the final manuscript. e.s. contributed to data curation, critical review of the manuscript and was responsible for editing and adding citations. r.a.l. helped to write the manuscript, supported the literature review and subsequent critical revisions of the final version of the manuscript. n.b. supported the work of working group 3 through conceptualization and methodological input and was instrumental to the development and writing the original manuscript and subsequent reviews. all authors have read and agreed to the published version of the manuscript. the 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implement a data-driven quality improvement process to integrate evidence into practice procedures systematic review of the application of the plan-do-study-act method to improve quality in healthcare the kings fund using action learning to develop a more strategic approach to quality improvement at oxleas what is "quality improvement" and how can it transform healthcare? qual. saf. health care bringing user experience to healthcare improvement: the concepts, methods and practices of experience-based design experience-based co-design and healthcare improvement: realizing participatory design in the public sector patients and staff as codesigners of healthcare services point of care foundation ebcd: experience-based co-design toolkit this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-285526-xm9yj5ua authors: gill, balvinder singh; jayaraj, vivek jason; singh, sarbhan; mohd ghazali, sumarni; cheong, yoon ling; md iderus, nuur hafizah; sundram, bala murali; aris, tahir bin; mohd ibrahim, hishamshah; hong, boon hao; labadin, jane title: modelling the effectiveness of epidemic control measures in preventing the transmission of covid-19 in malaysia date: 2020-07-30 journal: int j environ res public health doi: 10.3390/ijerph17155509 sha: doc_id: 285526 cord_uid: xm9yj5ua malaysia is currently facing an outbreak of covid-19. we aim to present the first study in malaysia to report the reproduction numbers and develop a mathematical model forecasting covid-19 transmission by including isolation, quarantine, and movement control measures. we utilized a susceptible, exposed, infectious, and recovered (seir) model by incorporating isolation, quarantine, and movement control order (mco) taken in malaysia. the simulations were fitted into the malaysian covid-19 active case numbers, allowing approximation of parameters consisting of probability of transmission per contact (β), average number of contacts per day per case (ζ), and proportion of close-contact traced per day (q). the effective reproduction number (r(t)) was also determined through this model. our model calibration estimated that (β), (ζ), and (q) were 0.052, 25 persons, and 0.23, respectively. the (r(t)) was estimated to be 1.68. mco measures reduce the peak number of active covid-19 cases by 99.1% and reduce (ζ) from 25 (pre-mco) to 7 (during mco). the flattening of the epidemic curve was also observed with the implementation of these control measures. we conclude that isolation, quarantine, and mco measures are essential to break the transmission of covid-19 in malaysia. covid-19 is a novel pathogen first reported in wuhan, hubei province, china, in december 2019. the world health organization (who) declared it as a global pandemic on 11 march 2020 [1] and the virus had infected more than 275,000 individuals and killed more than 11,000 people as of 22 march 2020 [2] . the cases and deaths are largely centered in china, south korea, italy, and iran [2] . despite intensive public health efforts in early detection, isolation, quarantine, treatment, contact tracing, and social-distancing measures in breaking the chain of transmission, there is a rise in covid-19 cases and deaths worldwide [3] . in addition, reduction in percentages of peak active cases with different control measures instituted were analyzed and described. following a deterministic seir model, the exposed compartment plays an important role in contributing to the potential exponential transmission of covid-19, as has been observed in china [4] . in doing so, we made five important assumptions [23] : (1) we assumed that international travel had introduced transmission into the local setting but then played no further role in local transmissions, assuming a closed population. this was mitigated by travel restrictions and entry/exit point screening, which were enforced on 25 january 2020, limiting importation of cases. (2) malaysia's total population, denoted as n, was divided into an extended seir compartmental model, distinguishing between the traced and untraced populations and incorporating the current control measures and precautions taken. apart from the basic compartments of seir (susceptible (s), exposed (e), infected (i), and recovered (r)), this model had additional three compartments, namely traced close-contact and a negative test result population (t), traced exposed close-contact and positive test result population (e q ), and the infected isolated (i q ). it was assumed that, initially, the entire malaysian population was susceptible, hence s 0 = n. (3) all malaysian residents were assumed to be of equal measure in their likelihood to contract and transmit the virus, assuming there was homogenous mixing within the population; however, we assumed that only 67% of the population would be susceptible based on the concept of herd immunity [24] . current literature on transmission of covid-19 has suggested that there is no strong evidence to support asymptomatic transmission and therefore our model only accounted for symptomatic transmission [24] . (4) a constant population was assumed due to the short time period for the model development and projection, wherein changes of birth and death rates would be negligible. (5) some of the parameters used were developed based on the outbreak data in china. as such, we assumed homogeneity of the disease dynamics between china and malaysia. based on the assumptions outlined above, the transmission model of covid-19 that includes outbreak control measures in malaysia was formulated using the extended seir model, which adopted parameters of control measures instituted during the sars outbreak in japan . a recent paper has also introduced a model that encapsulates the non-pharmaceutical interventions in great detail [48] . the authors demonstrated that high compliance of using face masks may lead to the eradication of covid-19. similar to our model, we introduced two important parameters in the force of infection, which were the number of contacts made per patient per day, denoted as zeta (ζ), and kappa (κ), which was defined as the proportion of exposed people who take effective precautionary measures. thus, the parameter ζ represents the effect of social distancing and the parameter κ reflects the proportion of the exposed people complying to practicing hand-hygiene, use of face masks, and any form of individual effective precautionary measures [24] , which depicts the model in simulating the control measures taken in preventing covid-19 transmission in malaysia. prior to the appearance of symptoms, a covid-19 patient is mobile and free to interact with other susceptible persons. individuals who have made contact with infectious individuals without taking effective precautionary measures will become infected with the probability denoted as beta (β). this means that β signifies the probability of transmission per contact. the identification of the index case would trigger public health authorities to initiate contact tracing, with those identified persons being moved into the e q compartment if they are positive with or without symptoms. however, those identified persons who tested negative would be moved to the t compartment with a probability of transmissibility of 1 − β, and the rate of close contact traced per day was denoted as q. the close contact traced susceptible in t was released back to s after θ days. therefore, the rate of tracing of those contacted with cases, but untraced by the public health, was 1 − q and was considered as exposed and thus moved to the e compartment and transferred to i after the incubation period (ϕ). the i population would be isolated and moved to iq if they were detected with the proportion of the detection, which is denoted as δ and will not contribute further to the disease transmission [2] . therefore, setting the parameters q and δ as zero (0) represents the fact that the no-tracing measure was taken and hence reverted back to the basic seir model. case fatalities from the infection were removed from both the infected i and isolated i q compartments at a rate of ε. infected individuals that survived were transferred into the r compartment at a rate of gamma (γ), which signifies the infectious rate. and hence the model assumes that immunity is attained after the infectious period. the differential equations (equations (1)(7) ) that describe the dynamics of covid-19 in human populations were formulated based on the compartmental diagram described in figure 1 . the description of the parameters and their corresponding values used in the model simulation are described in table 1 . figure 1 . the extended susceptible, exposed, infectious, recovered model depicting the control measures taken in malaysia. the additional compartments are the traced close-contact and a negative test result population (t), the traced exposed close-contact and positive test result population (e q ) undergoing quarantine, and the infected isolated (i q ). the proportion of exposed persons who performed effective precautions 0.05 [24] δ the mean daily rate at which infectious cases are isolated 0.03 [24] department of statistics malaysia (dosm); ministry of health malaysia (moh). this model is based on the mathematical modelling theories for disease epidemics [10] , where, at endemic equilibrium state, we have ds dt = de dt = di dt = dr dt = 0. thus, equating ϕe from equations (3) and (4) and factorizing i gives us therefore, assuming initially that the population attains disease-free equilibrium as (s(0), e(0), i(0), r(0)) = (n, 0, 0, 0), then s/n = 1. in order for the disease to spread in the population, comparing this inequality with the definition of the basic reproduction number, r 0 is thus the transmission model was simulated using r software, foundation for statistical computing, vienna, austria [25] with the desolve package [26] . the model calibration based on the maximum likelihood estimation method utilized the bbmle package, which is written in r language [27] . the ggplot2 package was used to illustrate the simulation in graphs [28] . the parameters chosen to be calibrated were the probability of a susceptible person to become infected per contact (β), the average number of contacts per day per case (ζ), and the proportion of close contacts traced per day (q). other parameter values were obtained from the moh and in the literature, as, during the initial stages of the covid-19 pandemic in malaysia, data availability was limited. furthermore, the use of parameters estimated from literature, such as incubation and infectious period, are specific to the covid-19 pathogen and therefore would have similar pathogenesis across populations; therefore, applying these parameters from existing studies would be appropriate. the reported daily active cases was used to fit the i q from the model simulations. during the first wave of the outbreak (25 january to 26 february 2020), a total of 22 confirmed cases were reported, of which only 4 were local cases. due to this, we disregarded this first wave and set 27 february (t0 = 0) as the start of the simulation. figure 2 shows that the fitting of model (i q ) compared with the total daily active confirmed cases. the calibrated values for the three parameters found were β = 0.052, ζ = 25, and, q = 0.23, determined from the model fit data from 27 february to 17 march 2020, as shown in figure 2 . malaysia imposed a movement control order (mco), starting on 18 march 2020, thus, figure 3 depicts the comparison made between the actual total daily active cases with the model simulation from the 27 february to the first phase of the mco. for this case, the parameter values were kept as they were, except for ζ, which needs to be recalibrated to be 16 as it represents the mco measures taken. in addition, during this period, there were 43 case fatalities reported and hence ε = 0.02. a plateau was observed during the period from 16-26 february 2020 as there were no new cases reported in malaysia. however, from 1 march 2020, the number of cases began to increase rapidly with a total number of cumulative covid-19 cases at 117 on 9 march 2020. in predicting the size of the outbreak, our model requires a longer period of simulation, focusing on the infectious population "i", as active cases in the community will continue to move freely and potentially spread the virus to the susceptible population if no control measures are instituted. this section presents the simulated results of the four phases (pre-mco, mco phases 1-3) based on the parameter values estimated in the model. the results of the simulation using this extended seir model, but without mco measures, was represented by the effect of zeta (ζ), the value of which was calibrated at 25 based on data from 27 february 2020 to 17 march 2020 (pre-mco). based on this simulation, it was estimated that the number of active cases would exponentially rise from may 2020, reaching the peak by mid-june 2020 with a maximum number of 304,907 active covid-19 cases. in addition, the simulation projected the outbreak to progress for well over 8 months, as shown in figure 4 . the results of our model fit with observed active cases during the implementation of mco measures and estimated that the zeta(ζ) value showed a downward trend from ζ = 25 during the pre-mco period (before 18 march 2020) to ζ = 16 during the first mco phase and continued to decrease to ζ = 7 during the second and third mco phases. the observed number of active cases rose exponential from march 2020, reaching the peak by early april 2020 with a maximum number of 2596 active covid-19 cases. in addition, the observed outbreak began to progressively decrease within 3 months from the first cases, as shown in figure 5 . during the pre-mco period, the zeta (ζ) value was estimated to be ζ = 25, wherein with the implementation of the mco phase, the ζ value progressively decreased from 25-7 (phase 1 mco, ζ = 16; phase 2 and 3 mco, ζ = 7). this observation suggests that the number of contacts per case per day significantly reduced with the implementation of the mco, which in turn decreased the disease transmission, as reflected by the observed reduction in number of active cases. in addition, the model simulation with no mco measures showed the estimated peak number of active cases to be 304,907 compared to the observed peak active cases of 2596 during the period where mco measures were implemented. this was an estimated reduction of 99.1% of peak active cases with the implementation of mco measures. the peak of the epidemic was observed to occur earlier by 2 months (from june to april 2020) with the implementation of the mco measures. furthermore, the implementation of the mco measures resulted in the decrease of the epidemic duration, spanning well over 8 months without mco measures to approximately over 3 months with mco measures. this would suggest that the flattening of the curve decreased the peak and reduced the duration of the overall epidemic. most modelling studies of covid-19 outbreaks simulate a forecast of cases occurring during an outbreak without taking into account effects of mco measures. this study extends on a previously developed seir model by labadin and hong (2020) [29] , which now includes traced, exposed, infected, isolated, and quarantined cases. in addition, we utilized data of close contacts, suspected cases (person under investigation), quarantined cases, and isolated cases to develop a more robust model with forecasts of higher accuracy. furthermore, these forecasts were then used to determine the effectiveness of mco measures for the covid-19 outbreak. the model utilized parameters from existing literature and locally calibrated parameters, namely (i) proportion of close contacts traced per day (q), (ii) transmissibility (r t ), and (iii) probability of a susceptible person becoming infected (β) to increase the model representativeness for the malaysian setting [30] . the proportion of close contacts traced per day (q) was 0.23, for which 23% of close contacts were successfully traced in 1 day. as evidence suggests, the ability to trace higher numbers of contacts in a timely manner would increase the chances of detecting cases before they are symptomatic [31] , whereas 50% success rate of contact tracing is sufficient to control an outbreak with a minimum r 0 of 1.5 [32] , hence the ability to control the outbreak successfully [32] . therefore, effective contact tracing measures is crucial in controlling the outbreak by allowing for early case detection, contact tracing, isolation, and quarantine [33] . the estimated r t for the covid-19 outbreak in malaysia was 1.68, which suggests that the outbreak was greater than the epidemic threshold and therefore was self-sustaining unless effective control measures were implemented. existing studies have reported higher r t values that range from 2.50-6.49 [4, [6] [7] [8] 34, 35] . our lower estimates may be accounted for local data used during the r 0 parameter estimation using (κ), (δ), and (q), which is representative of the malaysian outbreak dynamics. in addition, the first outbreak wave comprised of mostly imported cases, allowing for efficient control measures, which had an impact on reducing the r t values in this study. due to the relatively low r t reported in this study, we found that the probability of a susceptible person becoming infected (β) following an exposure was reported at 0.05. this suggests that 5% of exposed individuals in malaysia will ultimately be infected. previous studies have reported higher probabilities of covid-19 infection per exposure at 0.1 [36] . our findings could be affected by the small number of cases reported during the first wave or other exposure-related factors [37] . despite the low (β) value in our study, it is vital that mco measures be instituted to control the outbreak, as was observed with the exponential rise of cases during the second wave of covid-19 in malaysia due to the effect of a mass gathering event. this study shows that the implementation of mco measures would effectively reduce the number of contacts per case per day (ζ) during the mco phase as compared to pre-mco. by reducing ζ, the covid-19 epidemic can be controlled effectively [43, 44] . in addition, it was observed that ζ continued to decrease with the extension of the mco into the second and third mco phases. this finding showed that the mco was effective in decreasing disease transmission and subsequently suppressing the outbreak [45] [46] [47] . with these measures in place, the r t would be reduced to less than 1, therefore resulting in the outbreak to lose its ability to sustain [5] , which supports our findings in this study. furthermore, these findings reflect the compliance of the public towards the mco by practicing social distancing measures. in addition, the findings from our study showed that mco measures would reduce the peak number of active covid-19 cases by 99.1% compared to the pre-mco model simulation, where no mco measures were taken. these measures would effectively flatten the epidemic curve by reducing the peak and reducing the outbreak duration. similar findings on the effectiveness of npi control measures in reducing the number of covid-19 cases has been reported in china [38, 39] and singapore [31] . mco measures would avoid contact and prevent disease transmission, which would eventually break the chain of transmission, therefore ending the outbreak. furthermore, a lower number of infected individuals would reduce the transmission rates of covid-19 infection among the susceptible population and lower the mortality rates. similar results to our study were reported in china and south korea, where mco control measures resulted in the covid-19 outbreak peaking earlier compared to no control measures taken [40] [41] [42] . the observed early peaking of the outbreak in malaysia can also be explained by the occurrence of a mass gathering event in late february 2020, involving more than 16,000 people. this event resulted in the rapid exponential rise of covid-19 cases, which was observed in march 2020. despite the rapid exponential rise of covid-19 cases in malaysia, the institution of effective of outbreak response activities [41, 42] , especially the early implementation of the mco, ensured that the epidemic magnitude was reduced, along with a shorter epidemic duration [43, 44] . this study demonstrates the need for quality surveillance data obtained by health authorities, which is crucial for the modelling of infectious diseases. there are several factors that are essential for the quality of data, which include an efficient surveillance system, laboratory diagnostic capacity, and data reporting and management systems [49] . the capacity to make forecasts in this study is a result of the available data quality by the moh malaysia, as there is a comprehensive infectious disease surveillance system in malaysia, which includes the enotifikasi web-based infectious disease reporting system, which is mandated under the prevention and control of infectious diseases act 1988, which provides an effective system that ensures the collection of quality data [50] . this study recommends the implementation of mco measures, which are effective in controlling the covid-19 outbreak in malaysia, showing an observed reduction of peak active cases by 99.1%. this is evident during the covid-19 outbreak in malaysia, whereby the implementation of the mco measures effectively controlled the outbreak. our findings suggest that existing isolation and quarantine control measures will only be effective with additional mco measures implemented. isolation and quarantine control measures alone are unable to effectively control the outbreak due to issues such as asymptomatic transmission, long transmissibility period, ineffective contact tracing, and isolation practices, and hence mco measures would effectively address these issues [38, 40] . there are several limitations in our model, as covid-19 is a novel pathogen. this model is an extrapolation of a complex problem and many within the field have taken more complex approaches to the question [4, [6] [7] [8] 34] . as such, the forecasts are certainly accompanied by some degree of uncertainty. the limited cases during the malaysian first wave have also made the estimation of parameters difficult. there was a low approximation of the proportion of close contacts traced per day, which was estimated at 23%. practically, this estimation is likely to be much higher when the outbreak progresses and may have caused an underestimation of the effect of control measures. similarly, an average in the number of contacts was used with a large range and a small pool of outliers within the data could have caused an unstable estimate on the number of contacts an infected individual would have. however, with more cases being reported in the second wave, the knowledge exponentiation will certainly improve our understanding of the disease and as such allow more efficient epidemic control. future studies should aim to include more 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crisis china claims peak of coronavirus epidemic has passed as new cases decline and more than 60,000 have recovered china's aggressive measures have slowed the coronavirus. they may not work in other countries china and south korea models seem like only way to contain covid-19. fobes impact of non-pharmaceutical interventions (npis) to reduce covid19 mortality and healthcare demand herd immunity: understanding covid-19 advances on presymptomatic or asymptomatic carrier transmission of covid-19 mathematical assessment of the impact of non-pharmaceutical interventions on curtailing the 2019 novel coronavirus monitoring data quality in syndromic. surveillance: learnings from a resource limited setting prevention and control of infectious diseases act this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we would like to thank the director general of health malaysia for his permission to publish this article. we would like to thank the crisis preparedness and response centre, disease control division, of moh malaysia for providing the relevant data required in this study. we also thank universiti malaysia sarawak for the support rendered for research facilities and postgraduate studies, as well as support from the sarawak multimedia authority. the authors declare no conflict of interest. key: cord-270948-qfsjtflv authors: klosterhalfen, stephanie; kotz, daniel; kuntz, benjamin; zeiher, johannes; starker, anne title: waterpipe use among adolescents in germany: prevalence, associated consumer characteristics, and trends (german health interview and examination survey for children and adolescents, kiggs) date: 2020-10-22 journal: int j environ res public health doi: 10.3390/ijerph17217740 sha: doc_id: 270948 cord_uid: qfsjtflv waterpipe (wp) use is popular among youth worldwide, but epidemiological data from germany are scarce. we aimed to describe prevalence rates of wp use (current, last 12 months, ever) and analysed correlates and trends among 11to 17-year-olds in germany. analyses were based on data from the “german health interview and examination survey for children and adolescents” study during 2014–2017 (n = 6599). changes in wp use prevalence compared with 2009–2012 were used to describe trends. associations with sociodemographic characteristics and cigarette smoking were assessed with multivariable logistic regression models. prevalence of current wp use among adolescents was 8.5% (95% confidence interval (ci) = 7.5–9.6), use in the last 12 months was 19.7% (95% ci = 18.3–21.2), and ever use was 25.8% (95% ci = 24.2–27.5). high prevalence rates were particularly found among 16–17-year-olds. during 2009–2012, these prevalence rates were 9.0%, 18.5%, and 26.1%, respectively. wp use was associated with older age, male sex, migration background, lower educational level, and current smoking status. among current wp users, 66.2% (95% ci = 60.0–71.9) identified themselves as non-smokers, and 38.1% (95% ci = 32.5–44.0) had used wp ≥ three times in the last month. wp consumption is popular among german youth, and prevalence rates have not changed over time. specific prevention strategies to reduce harmful wp consumption among youth should be implemented. in recent decades, there has been a worldwide increase in the prevalence of waterpipe (wp) use among young people. historically, the popularity of wps spread from india, across continents, until its consumption became accepted in the western world as an alternative form of tobacco smoking. regular consumption of wps by broad sections of the population is a phenomenon that was not observed prior to the end of the 20th century [1] [2] [3] . although the name (hookah, shisha, narghile, argileh, boory, goza, or hubble bubble), size, and design of wps vary from region to region, they all function in the same way. the characteristic of this time-consuming (average duration of 47 min) method of tobacco smoking is that the smoke passes through water before being inhaled into the lungs once cooled [4] . figure 1 shows the required components of a wp. to fill the tobacco head, a special, mostly sweet and flavored wp tobacco called maassal can be used, as well as alternative tobacco-free products such as steam stones [5] . to heat the tobacco, wp charcoal (or alternatively, an electronic heat source [6] ) is used. see: figure 1 . components of a waterpipe. int. j. environ. res. public health 2020, 17, x 2 of 16 through water before being inhaled into the lungs once cooled [4] . figure 1 shows the required components of a wp. to fill the tobacco head, a special, mostly sweet and flavored wp tobacco called maassal can be used, as well as alternative tobacco-free products such as steam stones [5] . to heat the tobacco, wp charcoal (or alternatively, an electronic heat source [6] ) is used. see: figure 1 . components of a waterpipe. wp use differs from conventional cigarette use not only with respect to the length of a smoking session; wp tobacco tastes often sweeter due to the added flavors, and the inhalation of cooled smoke seems less irritating to the mucosae and lungs. in addition, wps can be smoked as a group, e.g., at a party, and can therefore create a social experience [7] . these aspects provide insight into why wp use is popular among adolescents, why many wp wp use differs from conventional cigarette use not only with respect to the length of a smoking session; wp tobacco tastes often sweeter due to the added flavors, and the inhalation of cooled smoke seems less irritating to the mucosae and lungs. in addition, wps can be smoked as a group, e.g., at a party, and can therefore create a social experience [7] . these aspects provide insight into why wp use is popular among adolescents, why many wp users do not perceive themselves as "conventional smokers" [8] , and why some users underestimate the health risks of wp consumption [9] [10] [11] [12] . first experiences with the consumption of tobacco typically take place during the period of experimentation during adolescence. the most frequent first tobacco product tried by young people is the cigarette (followed by cigar, smokeless tobacco, and wp) [13] . during this period, adolescents are at special risk of developing dependency, and the risk of early deterioration of health increases [14] . different cultural and socioeconomic backgrounds as well as use of other tobacco products can be determinants regarding the consumption of wp by adolescents [15] [16] [17] . the aromatic taste of wp tobacco (e.g., apple, cherry, melon) appeals to young people and can be associated with a more pleasant, longer smoking experience which leads to increased nicotine exposure and dependence potential [18] [19] [20] . furthermore, the consumption of wp is associated with other harmful health effects similar to those associated with cigarette smoking [21] . in addition to the increased risk of carbon monoxide poisoning, which can result from combustion of the wp charcoal [22] , smoking wp can cause acute to chronic impairment [23] , negative impacts on executive brain function, or carcinogenic changes in various organs including the lungs and cardiovascular system [24] [25] [26] . sharing a wp among different people can also increase the risk of transmission and infection with bacterial or viral diseases [27] , which is particularly relevant during times of acute pandemic such as the present global novel coronavirus disease (covid-19) pandemic. the number of shisha bars (almost 6000) and the consumption of wp tobacco have risen in germany [28] . the increasing number of wp cafés can influence societal acceptance, and these serve as a place of social exchange for adolescents, just like pubs in former generations [12, 29] . in germany, there are legislative measures at the both state and the federal level to regulate wp consumption (bundesnichtraucherschutzgesetz ("federal non-smoker protection act"), jugendschutzgesetz ("youth protection act"), tabakerzeugnisgesetz ("tobacco products act"), nichtraucherschutzgesetz ("non-smoker protection act")). the german tobacco products act regulates ingredients, emission levels and information requirements for tobacco and related products. in 2016, the ingredients of wp tobacco changed (% content of glycerin). the youth protection act regulates the distribution of tobacco products. in 2007, the age limit for the consumption of tobacco products in public has been raised from 16 to 18 years. it is not permitted to sell tobacco products to minors. children and adolescents under the age of 18 are not allowed to smoke in publicly accessible rooms in places open to the public and otherwise in public places. these measures were accompanied by a tobacco prevention program. purchase of wp tobacco and accessories or the entry to a shisha bar are not permitted to people under 18 years of age. apart from regional studies, there are only a few population-based studies on the prevalence of wp consumption among adolescents in germany. the german health interview and examination survey for children and adolescents (kiggs) study and studies of the federal centre for health education (bzga) such as the drug affinity study have collected data on awareness about and use of wp, differentiated according to migration background, frequency of consumption, and combined consumption of tobacco cigarettes, wps, e-products, and tobacco heaters [16, 30] . national and international study findings indicate that male adolescents or youth with a migration background use wp more often than girls or people without a migration background [3, 16, 30] . regarding socioeconomic or educational factors, there seems to be a relationship between wp use and lower educational levels in germany, whereas international studies have reported opposite findings [3, 16, 30] . a study by the german health insurance dak ("dak-präventionsradar") has collected prevalence figures of wp consumption among school children [31] . prevalence rates of 6-14% for current and 22-44% for ever use of wps are reported for adolescents in germany under 18 years of age [16, 27, [30] [31] [32] . regarding international prevalence rates, current wp consumption varies widely, from 2.2% in romania to 36.9% in lebanon [15, 33] . several studies from the united states (us) reported increasing rates of wp use among 11-to 18-year-olds between 2009 and 2017 [34] . smoking a wp is a common form of tobacco use among adolescents in the us [12] . however, little is currently known about the factors associated with wp use. the influence of a one-or both-sided migration background, the socioeconomic status (ses) of the family, and sex, have not yet specifically been investigated in germany. data are also missing on the percentage of wp users who perceive themselves as smokers or non-smokers. this is an important issue, which can influence the perception of health risks of wp tobacco consumption and the creation of prevention programs. we, therefore, aimed to evaluate wp use and associated factors among german adolescents. more specifically, based on data of the second wave of the german health interview and examination survey for children and adolescents (kiggs wave 2), in the present study, we aimed to (i) investigate the prevalence of wp consumption among 11-to 17-year-old boys and girls; (ii) describe the frequency of wp use and the self-assessed smoking status; (iii) examine the associations between sociodemographic factors, smoking status and wp consumption among adolescents; and (iv) to monitor trends between the previous and the current wave of the kiggs study. due to a large study sample, the kiggs study-in contrast to other population-wide studies conducted in germany-allows the surveillance of prevalence figures more detailed (e.g., one-or both-sided migration backgrounds, survey of 11-year-olds, survey 12-month prevalence) and to include statements on self-assessed smoking status. these data can help in the identification of different risk profiles to develop targeted group-specific and gender-sensitive prevention strategies. the kiggs study is part of health monitoring conducted by the robert koch institute (rki) on behalf of the federal ministry of health in germany. kiggs focusses on health status, health behavior, living conditions, protective and risk factors, and healthcare among children, adolescents, and young adults living in germany. cross-sectional data have been collected at three time points: the kiggs baseline study (2003) (2004) (2005) (2006) , kiggs wave 1 (2009-2012) and kiggs wave 2 (2014-2017). the response rate (according to aapor response rate 2) of kiggs wave 2 was 40.1% in total [35] . a multi-step approach was used to include people with a migration background in kiggs wave 2. the share of children and adolescents of non-german nationality in kiggs wave 2 corresponds to the population figures from the federal statistical office [36] . the concept, methodology, and analyses of kiggs are described in detail elsewhere [35, [37] [38] [39] . comparable to the kiggs baseline study, respondents for kiggs wave 2 were selected randomly based on the population registers of 167 representative german municipalities and cities (two steps sampling process). the study population of kiggs wave 1 consists of re-invited participants from the baseline study supplemented by newly invited children aged 0-6 years. kiggs wave 2 (like kiggs baseline study) was comprised of an interview and examination part, whereas kiggs wave 1 was conducted as a telephone interview survey [37] [38] [39] . to achieve an optimal number of respondents and sample composition, a variety of measures were applied (e.g., phone calls or home visits) [35, 36] , resulting in a total of 15,023 respondents aged 0-17 years. the analyses of wp consumption were restricted to data from 11-to 17-year-old respondents (n = 6599), collected using a written questionnaire. to identify trends in comparison with the previous wave, the results from wave 1 were compared with the currently collected prevalence rates from wave 2. the study was approved by the ethics committee of hannover medical school (no. 2275-2014). the prevalence of wp use was assessed with the question "have you ever smoked a waterpipe or shisha?" respondents who affirmed having used a wp were defined as "ever wp user" and were further asked "have you smoked a waterpipe or shisha in the last 12 months?" (yes defined as "last-12-month wp user") and "if you think about the last 30 days, on how many days did you smoke a waterpipe or shisha?" (response options: ≥1 day, defined as "current user" or "none in the past 30 days"). regarding the frequency of use during the past month, we classified responses according to one, two, or ≥three times. to determine the ses of the family, an index was generated based on information of the parents' level of education, occupational status, and income (equivalized disposable income). thus, respondents were classified as belonging to a family with "low", "medium", or "high" ses [40] . school type was surveyed by asking the parents "which type of school does your child go to?", with nine response options: "primary school", "secondary school", "middle school", "school with secondary and middle educational program", "integrated comprehensive school", "academic secondary school", "technical secondary school", "special school", and "other". due to its federal structure, there is no uniform school system in germany. as some federal states now have a two-tier school system, we categorize for the following analyses, two groups for secondary school: "secondary/middle/comprehensive school" and "technical/academic secondary school". young people who no longer attended school were assigned to the corresponding category based on the highest level of education they achieved [41] . to assess migration background, all respondents were asked about their own and their parents' country of origin: "in which country were you born?" and "in which country were your parents born?" a one-sided migration background meant that one parent was not born in germany or had no german citizenship; a both-sided migration background meant that the child himself/herself migrated to germany and had at least one parent who was not born in germany or both parents were born abroad [42] . to assess smoking status, respondents were asked "do you currently smoke?", with the following response options: "no", "daily", "several times a week", "once a week", or "less than once a week". all respondents who answered in the affirmative were defined as a "current smoker". the data collected for kiggs wave 2 are available from the rki research data center (https: //www.rki.de/en/content/health_monitoring/public_use_files/public_use_file_node.html). the descriptive analyses of wp use patterns (current, last 12 months, ever) stratified by sociodemographic characteristics and smoking status are presented, differentiated for female and male respondents, as percentages with 95% confidence intervals (cis). weighting with regard to age, sex, federal state, german citizenship, and the child's parents' level of education was applied to ensure representative data for children and adolescents living in germany. comparison of current prevalence figures and those obtained between 2009 and 2012 was based on descriptive statistics and is presented as percentage with 95% ci. three multivariable logistic regression models were applied to explore associations between different wp use patterns and sociodemographic characteristics and smoking status for girls and boys: model i = current wp use vs. never wp use, model ii = last 12 month wp use vs. never wp use and model iii = ever wp use vs. never wp use. respondents with missing data were excluded from the regression analyses. data were analyzed using stata 15.1 (stata corp., college station, tx, usa). stata's survey procedures were applied to account for the clustered sampling design. the prevalence of current wp use among 11-to 17-year-old adolescents in germany was 8.5% (95% ci = 7.5-9.6; n = 446) in the period 2014-2017. almost every fifth adolescent had used wp within the last 12 months (19.7%, 95% ci = 18.3-21.2; n = 1101), and 25.8% (95% ci = 24.2-27.5; n = 1415) were ever wp users (weighted data). table 1 presents prevalence of different wp use patterns, sociodemographic characteristics, and smoking status, stratified by sex (weighted data, missing data regarding ses (n = 145), education (n = 710), migration background (n = 33), and current smoking status (n = 852)). the pattern of missing values showed a higher amount of missing values among boys with migration background, boys with lower ses and lower education level, and among girls with lower ses and multivariable analyses showed that the odds of missing values are especially high among boys with a both-sided migration background (data not shown). boys were more likely than girls to report current (10.6% vs. 6.3%), last 12-month (22.1% vs. 17.3%), and ever (28.1% vs. 23.4%) wp use. respondents with a migration background and current smokers reported using wp more often than those without a migration background or non-smokers (current, last 12 month, and ever wp use). the results of the three multivariable regression analyses regarding sociodemographic characteristics, current smoking status, and wp consumption are presented in table 2 . the adjusted odds ratios (ors) of current vs. never wp use (model i) were higher in adolescents with older age and current smokers (girls: or = 1.97, 95% ci = 1.69-2.29 and or = 48.27, 95% ci = 24.12-96.59; boys: or = 2.20, ci = 1.92-2.52 and or = 67.57, 95% ci = 18.02-253.32). concerning migration background, we found that boys with a one-sided migration background used wp more often than boys without a migration background (or = 3.03, 95% ci = 1.36-6.77). we found similar associations when comparing wp use in the last 12 months vs. never wp use (model ii). in addition, girls with a both-sided migration background showed a lower or for wp use than girls without a migration background (or = 0.38, 95% ci = 0.22-0.65), and girls with a lower educational level showed a higher or for wp use than girls with higher educational levels (or = 1.82, 95% ci = 1.32-2.51). we also found the above-mentioned associations when comparing ever vs. never wp use (model iii), except that the adjusted or was also higher in girls from a family with low ses compared with girls belonging to a family with high ses (or = 1.66, 95% ci = 1.02-2.71). the numerator for the calculation refers to the total number in the corresponding series (e.g., 50.6% of 17-year-old girls report wp ever use). bold printed indicates the prevalence for the respective group. defined as using wp in the last 30 days. • one-sided indicates children and adolescents having one parent not born in germany or without german citizenship; two-sided indicates children and adolescents who themselves migrated to germany and have at least one parent who was not born in germany, and children and adolescents whose parents were both born in a country other than germany or non-german nationals. * socioeconomic status generated as a household characteristic based on parental levels of education, occupational status, and income. german equivalents to school types: secondary school = hauptschule; middle school = realschule; comprehensive school = gesamtschule; technical secondary school = fachoberschule (fos); academic secondary school = gymnasium. 1 † all listed covariates were included in models i-iii. data are presented as odds ratio (or) 95% confidence interval (ci). * p < 0.05; ** p < 0.01; *** p < 0.001. > age was treated as a continuous variable in the regression analyses. • one-sided indicated children having one parent not born in germany or without german citizenship; both-sided indicates children who themselves migrated to germany and have at least one parent who was not born in germany and children and adolescents whose parents were both born in a country other than germany or non-german citizens. defined as using wp in the past 30 days. ‡ socioeconomic status generated as a household characteristic based on parental levels of education, occupational status, and income. german equival ents to school types: secondary school = hauptschule; middle school = realschule; comprehensive school = gesamtschule; technical secondary school = fachoberschule (fos); academic secondary school = gymnasium. the prevalence rates of wp use in wave 2 (2014-2017) were similar to those identified earlier in wave 1 (2009 wave 1 ( -2012 , as shown in figure 2 . among german 11-to 17-year olds surveyed in the period 2014-2017, 8 .5% reported being current wp users and about 26% reported being ever users. the use of wp seems to be most common in the age group of 16-17-year-olds. a considerable proportion (62%) of current wp users had smoked a wp twice or more in the last month. only one-third of wp users considered themselves smokers. we found positive associations of wp use with older age, male sex, and current smoking status. regarding the associations between wp consumption and education level or migration background, an inverse relationship was observed for both genders in some analyses. as shown in table 2 , the association between lower educational level and the use of wp was more pronounced among girls, whereas the association between the migration background and the use of wp is found primarily among boys. the prevalence rates did not differ much from those obtained during 2009-2012. the prevalence rates found in the present study are highly congruent with data collected in 2015 by the bzga [43] . the two nationwide surveys yielded comparable prevalence rates for both current use (kiggs wave 2 (11-to 17-year-olds): 8.5% vs. drug affinity study (12-to 17-year-olds): 8.9%) and ever use (25.8% vs. 27.3%). the prevalence identified in the european school survey project on alcohol and other drugs (espad) in austria was strikingly higher: in 2019, 21% of 14-to 17-year-olds reported current and 51% reported ever wp use [44] . a possible reason for the difference may be the difference in age groups, as prevalence increases with age. this may also explain the comparatively high prevalence rates for young people (14-to 16-year-olds) living in the german state of bavaria (current wp use: 20.1%; ever use: 48.9%) who also participated in the espad study in 2015 [45] . comparing the prevalence rates reported in germany with those in the us (2009-2017), nationally representative estimates indicate lower prevalence figures (current use among high school students (grades 9 to 12): 4.8%, ever use: 14.3%); however, representative state-wide estimates showed comparable figures (current use: 11.6%; ever use: 22.5%) [34] . within the present study we aimed to explore the frequency of current wp consumption and self-assessed smoking status. most current wp users reported a wp use frequency of no more than twice in the past 30 days. this consumption pattern is also seen in previous studies [32, 46] . reasons for the difference in consumer behavior, for example, in comparison with (daily) cigarette consumption, could be owing to the inflexibility of the stationary tobacco use method and its time-consuming nature. most current wp users identified themselves as non-smokers. thus, wp consumption is not perceived as smoking, a result which has been also reported elsewhere [8] . the results of the kiggs study showed variation in wp use according to sex, age, migration background, and current smoking status. we found higher ors for current and ever use among respondents who were male, older, and who had a one-sided migration background (boys). these findings are in line with prior national and international studies [30, 33, 34, 47] . migration background is a known correlate of wp use described in previous kiggs waves and other studies. whereas in the first wave of the german health survey for children and adolescents (kiggs wave 1, 2009 wave 1, --2012 [48] , boys with a both-sided migration background were found to use wps more often (current and ever) than those without a migration background, we found counterintuitively low prevalence for wp use with a both-sided migration background but high prevalence with a one-sided migration background among boys in kiggs wave 2. hence, we speculate that the particular high amount of missing values among boys with a both-sided migration background might explain their low prevalence of wp use. the case of girls was reversed; we found an association of a both-sided migration background and lower ors for current and ever wp use. similar results have been described for smoking adults (over 18 years) in germany [49] . our findings also point out that young people who regard themselves as current smokers were up to 68 times more likely to use wp than non-smokers. associations regarding this kind of dual use have been reported in other studies [33, 47] . concerning the trend in prevalence figures, our study found stable figures over time. for 12to 17-year-old boys, the bzga reports similar trends in the figures for current wp use. first, these figures decreased from 2007 (16.3%) to 2011 (9.8%), but then remained at this level until 2015. for 12to 17-year-old girls, a similar trend can be seen over time. the prevalence figures for the current use of wp ranged from 7.4% (2011) to 6.4% (2015) [50] . the present study entails the following limitations. owing to the cross-sectional design, it was not possible to make conclusive statements about causality with respect to the results. responses given in kiggs wave 2 are self-reported data, which are always associated with biases. respondents may remember of the corresponding answer categories inaccurately (recall bias) or may give socially acceptable answers (social desirability bias). as there are different terminologies for wp, the use of pictures within the questionnaire would probably have been preferable to ensure that all respondents have the same understanding of the tobacco product. to be able to assess the health risks arising from the consumption of wp tobacco, the ingredients of wp tobacco play an integral part. unfortunately, the composition of wp tobacco or the number of puffs during a session could not be investigated in this study. over the course of the kiggs study, there has been a change in methods: kiggs wave 2 was conducted using self-report questionnaires and kiggs wave 1 using telephone interviews, which are more susceptible to socially desirable response behavior [51] . as with all surveys, the possibility of bias owing to selective non-participation also exists. it is assumed that people who participate in a health study also have greater health awareness and therefore differ from the general population in terms of smoking behavior (selection bias) systematic identification of patterns of missing items was not feasible, but could help to interpret results more accurately in further studies. the described selection effects were partially corrected by weighting. thus, the observed results may be generalizable to 11-to 17-year-olds in germany, which is a strength of the kiggs study. furthermore, it was possible to identify different wp consumption patterns (current, in the last 12 months, and ever), the frequency of wp consumption, and the combined consumption of tobacco cigarettes and wps, as well as the association of wp use with sociodemographic characteristics and cigarette smoking status. older age, male sex, migration background, lower educational level, as well as current cigarette smoking were found to be associated with wp use among german adolescents. wp consumption is popular among adolescents but does not seem to have increased substantially in recent years. continuous monitoring of trends in prevalence and use behavior is important to yield an evidence basis for developing targeted group-specific and gender-sensitive prevention approaches within public health prevention strategies. in addition to preventive programs within schools, it would be also useful to provide information about the health hazards and addiction of wp use in sports clubs or on preferred social networks (e.g., youtube, facebook, twitter) visited by young people. a targeted gender-specific approach could also be made here. the law for the protection of youth, which has been adapted since 2016 and prohibits the sale of wps by mail order to minors, is an important step to reduce the illegal sale to minors. a consistent and frequent age control in shisha bars should continue to be carried out by public authorities. information campaigns (also for parents) may help to decrease the private use of wps. the ban on marketing tobacco with characteristic flavors (e.g., menthol) implemented in germany by § 5 of the tobacco products act in 2020 is an important step to prevent young people from consuming flavored wp tobacco. a further ban on the advertising of tobacco products or combined warnings (consisting of pictures and text) are planned for wp tobacco in germany from may 2024, which will help to increase the awareness about health hazards connected to wp use. further research should explore why many adolescent wp users do not see themselves as smokers, that is, the beliefs and motives that underlie this. more research is needed on the consumption patterns (e.g., number of puffs, duration of a wp session) and on the type of wp use (e.g., types of wp tobacco, use of charcoal). moreover, the association between the consumption of wp and other substances, e.g., cigarettes, should be investigated more in detail. we thank analisa avila, els, of edanz group (https://en-author-services.edanzgroup.com/ac) for editing a draft of this manuscript. the authors declare no conflict of interest. advisory note: water-pipe tobacco smoking: health effects, research needs and recommended actions by regulators estimating the beginning of the waterpipe epidemic in syria the global epidemiology of waterpipe smoking tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic waterpipes. facts about smoking tobacco-free waterpipes can also be a health hazard self-assessment of adolescents regarding water pipe consumption health effects of waterpipe tobacco use: getting the public health message just right adolescents' perceptions of health risks, social risks, and 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sozialforschung key: cord-285513-pkqos0s5 authors: stangvaltaite-mouhat, lina; uhlen, marte-mari; skudutyte-rysstad, rasa; szyszko hovden, ewa alicja; shabestari, maziar; ansteinsson, vibeke elise title: dental health services response to covid-19 in norway date: 2020-08-12 journal: int j environ res public health doi: 10.3390/ijerph17165843 sha: doc_id: 285513 cord_uid: pkqos0s5 we aimed to investigate the management of urgent dental care, the perception of risk and workplace preparedness among dental staff in norway during the covid-19 pandemic. an electronic questionnaire regarding the strictest confinement period in norway (13 march–17 april 2020) was distributed to dental staff. among the 1237 respondents, 727 (59%) treated patients, of whom 170 (14%) worked in clinics designated to treat patients suspected or confirmed to have covid-19. out of them 88% (143) received training and 64% (103) simulation in additional infection prevention procedures, while 27 (24%) respondents reported deviation. in total, 1051 (85%) respondents perceived that dental staff had a high risk of being infected, 1039 (84%) that their workplace handled the current situation well, 767 (62%) that their workplace had adequate infection control equipment and 507 (41%) agreed that their workplace is well equipped to handle an escalation. before an appointment, 1182 (96%) respondents always/often inquired per phone information if a patient experienced symptoms of covid-19, and 1104 (89%) asked about a history of travel to affected areas. twice as many patients on average per week were treated by phone than in a clinic. a lower proportion of dental staff in high incidence counties applied additional infection prevention measures compared to low and medium incidence counties. to conclude, urgent dental health care was managed relatively well in norway. additional training of the dental staff in adequate infection prevention and step-by-step procedures may be needed. these results may be used to improve the dental health service’s response to future outbreaks. coronavirus disease 2019 (covid-19) is a public health emergency of international concern announced by the world health organization on 30 january 2020 and declared a pandemic on 11 march 2020 [1, 2] . covid-19 is caused by a novel coronavirus named "sars-cov-2", which belongs to severe acute respiratory syndrome coronaviruses (sars-covs) [3] . this is the third outbreak of an infection caused by a coronavirus in less than 20 years. the severe acute respiratory syndrome (sars) outbreak in 2002-2003 resulted in more than 8000 cases in 26 countries, and had a mortality rate of approximately 10% [4] [5] [6] [7] . in 2012-2013 the outbreak of middle east respiratory syndrome (mers) spread, and up to date 27 countries reported 2500 confirmed cases with a 34% mortality rate [8] [9] [10] [11] . to date (10 august 2020), there have been 9468 confirmed cases of covid-19 and 256 deaths in norway [12] . sars-cov-2 can be transmitted by two main routes: respiratory and contact. respiratory droplets are generated when an infected person coughs or sneezes. transmission by direct contact occurs through skin contact followed by touching the oral, nasal or ocular mucous membranes. the virus may also be transmitted by indirect contact via objects and surfaces [13] . recent evidence suggests that sars-cov-2 is detected in saliva [14] , can be transmitted by aerosol-generated procedures [15] and from asymptomatic patients [16] . in norway, during the period of containment for covid-19 (13) (14) (15) (16) (17) april 2020) dental health services suspended routine non-urgent dental health care. public dental health services in norway correspond to around 30% of the total dental health service, and twice as many dentists work in private dental clinics. it is unknown how many private clinics complied with the recommendation to suspend non-urgent dental care. health care professionals in both public and private practice are required by the norwegian law to provide emergency health care to all patients. indeed, patients confirmed or suspected to have covid-19 have the same right to emergency care as non-infected patients. however, to provide dental care during the pandemic required an extra focus on protective measures and personal protective equipment (ppe). in the period between 13 march-17 april 2020 there was a shortage of ppe in the health service in norway; consequently, some dental clinics had to be closed or staffed down in this period. on the 14 march 2020, the directorate of health in norwayrequested the dental public sector to establish an emergency service for patients suspected or confirmed to have covid-19. this could be in collaboration with the private sector and/or the universities, however, to our knowledge, the majority of the counties selected a fewpublic clinics in each region that was prepared and designated for this purpose subsequently. dental staff may be at high risk of being infected by covid-19, as the practice of dentistry involves the use of rotary and surgical instruments (e.g., handpieces or ultrasonic scalers) and air-water syringes. these instruments create a visible spray that contains droplets of water, saliva, blood, microorganisms and other debris. aerosols may also be generated [17] . dental staff may become potential carriers of the virus and, if adequate precautions are not taken, the dental office can potentially serve as a cross-infection location [18] . since dental settings have unique characteristics, they warrant specific additional infection control considerations. before the present study was launched, the us centers for disease control and prevention (cdc) had released interim infection prevention and control guidance for dental settings during the covid-19 response [17] and the world health organization (who) had released its guidance for health workers during coronavirus disease (covid-19) outbreak, without specifying dental settings [19] . due to lack of international guidelines, national recommendations had to be devised for additional infection control and urgent dental care. since norway has not been affected by previous coronavirus outbreaks (sars or mers), this emergency was unprecedented for norwegian dental staff. therefore, the aim of this case study was to investigate how urgent dental health care was managed in norway, what additional infection prevention and control measures were employed by dental staff and to assess the dental staff perception of risk and workplace preparedness. the present study comprised a cross-sectional questionnaire survey among dental staff in norway. the questionnaire was sent electronically via questback to chief dental officers in counties who were asked to distribute the questionnaire among dental clinics in norway. all dental staff, including specialists, general dental practitioners, dental hygienists and dental assistants were invited to fill in the questionnaire. invitations to dentists in the private sector were distributed via local associations of the norwegian dental association (nda). the questionnaire was sent out 4 may 2020 to the public sector and 15 of may 2020 to the private sector and asked information related to the strictest confinement period in norway(13 march-17 april 2020). reminder for participation was sent three times and the questionnaire was closed on 26 june 2020. the self-reported questionnaire was based on information provided by cdc, who, norwegian institute of public health, ministry of health in norway, and guidelines provided by the norwegian counties. the questionnaire consisted of four parts: (i) background characteristics, (ii) dental health service management, including treatment of patients suspected or confirmed to have covid-19, (iii) dental staff perception of risk and preparedness, and (iv) psychological impact. the present article intended to report the results from the first three (3) parts of the questionnaire. the background characteristics included information about sex, age, work experience in years, profession (specialist/general dental practitioner, dental hygienist, dental assistant), area of the dental clinic (urban, which had >50,000 inhabitants, peri-urban 5000-50,000 inhabitants, rural <5000 inhabitants), size of dental clinic (large, ≥7 employees and small <7 employees), sector of main workplace (public, private), and if the respondent worked clinically with patients during covid-19 outbreak (yes/no). dental health service management part asked information about triage of patients per phone, additional infection control measures, three (3) most common treated conditions, if a clinic was eligible to treat patients suspected or confirmed to have covid-19, and knowledge of where to refer patients with urgent needs who are suspected or confirmed to have covid-19. questions related to treatment of patients confirmed or suspected to have covid-19 inquired information about the number of patients treated, additional infection control measures and procedures, if dental staff were trained to follow them and if there was a deviation, if scientific information was available and from where. regarding perceptions, dental staff was asked on a 5-point likert scale (1_completely agree, 5_completely disagree) to assess four statements: dental staff risk to be infected; if workplace had adequate infection control equipment; how workplace handled the current situation; if workplace was well equipped to handle an escalation. for statistical analyses the responses were dichotomized into agree (points 1 and 2) and disagree (points 3-5). the questionnaire was face validated by several experts in the field and pre-tested by 10 dentists, which were not included in the analysis. the incidence of cases in counties was retrieved from norwegian institute of public health, and subsequently the counties were grouped into low incidence counties (<100 reported cases per 100,000), medium incidence counties (100-150 reported cases per 100,000) and high incidence counties (>150 reported cases per 100,000) for statistical analyses [20]. statistical package for the social sciences (spss) version 26.0 (ibm spss, armonk, ny, usa) was used for statistical analyses. the chi-square test and analysis of variance (anova) with tukey adjustment were used to identify differences in characteristics between strata. univariable and multivariable binary logistic regression analyses were used to assess the association between the perception of risk and workplace preparedness (four (4) outcomes) and potential determinants. variables significantly associated with the outcome in bivariate analyses at p-value < 0.2 were entered into the regression analyses as independent variables. the results were presented as odds ratios with 95% confidence intervals (ci). the statistical significance was set at p < 0.05. approval was obtained from the norwegian centre for research data (907304). voluntary participation was based on a signed written informed consent. there was an overrepresentation by females, 1106 (89%), and those working in public service, 1134 (92%). out of all the respondents, 590 (48%) were dental specialists/general dental practitioners, 235 (19%) were dental hygienists and 412 (33%) were dental assistants. seven hundred and twenty-seven (59%) respondents worked with patients during the strictest confinement period 13 march-17 april 2020, in norway (413 (70%) dental specialists/general dental practitioners, 66 (28%) dental hygienists and 248 (60%) dental assistants) ( table 1) . table 2 shows the results regarding organization of urgent dental care in oral health service and management of patients not suspected to have covid-19. the majority of the dental staff always/often inquired information per phone if a patient experienced symptoms of covid-19 or had a history of travel to affected areas (1182 (96%) and 1104 (89%), respectively). a significant difference was observed among county incidence categories. dental specialists/general dental practitioners on average per week treated five (standard deviation (sd) 4.6) patients not suspected to have covid-19. on average per week 11 (sd 13.0) patients were clarified per phone out of whom three (sd 4.3) received drug treatment. dental specialists/general dental practitioners were asked to rank three most common conditions the patients had during the period 13 march-17 april 2020. out of 440 (35%) clinicians who responded, the most common urgent conditions were severe dental pain from pulpal inflammation (321, 73%), abscess or localized bacterial infection resulting in localized pain and swelling (264, 60%) and pericoronitis or third-molar pain (233, 53%) (data not shown). when treating patients not suspected to have covid-19, 389 (88%) of dental specialists/general dental practitioners) reported to follow additional infection prevention and control measures. the most common disinfection product was 70% ethyl alcohol; there was a significant difference in the products for disinfection between counties the majority of respondents used mouth rinse and high-volume suction as an additional protective measure while treating patients, while less than half used rubber dam; a significant difference in use of these additional protective measure was observed among county incidence categories (see table 2 ). out of the respondents who were not from clinics designated to treat patients suspected or confirmed to have covid-19 (1067, 86%), 1064 (99%) were aware where to refer a patient suspected or confirmed to have covid-19 for emergency treatment, or where to find such an information; there was a significant difference among county incidence categories (see table 2 ). table 3 shows the results of the organization of urgent dental care for patients suspected or confirmed to have covid-19. out of all the respondents, 170 (14%) were from clinics designated to treat patients suspected or confirmed to have covid-19; out of them 72 (42%) were dental specialists/general dental practitioners, 28 (17%) dental hygienists and 70 (41%) dental assistants. very few patients suspected or confirmed to have covid-19 were treated in the designated clinics. the majority of the dental staff (67, 39%) reported to leave the room between 35 min and 3 h in between such patients; there was a significant difference among county incidence categories. out of the dental staff working in clinics designated to treat patients suspected or confirmed to have covid-19, up to 20% reported not to have available respirators ffp2 or ffp3 standard or equivalent, gowns and aprons in their workplace; there was a significant difference among the county incidence categories. the majority of dental staff received training in additional infection prevention and control procedures either digitally or in a clinic, and mostly guidelines developed by county (84, 49%) and university (59, 35%) were followed. the majority of dental staff reported that their clinic developed step-by-step procedures for treatment; the significant difference observed among county incidence categories. while 88% (143) of dental staff received training in these step-by-step procedures, and 64% (103) in addition received a simulation, 24% (27) still reported deviations. the most popular disinfection product was 70% ethyl alcohol, used by 74% (125) of the respondents. the majority of dental staff did not use extraoral dental radiographs as an alternative to intraoral radiographs; a significant difference was observed among county incidence categories (see table 3 ). all dental staff were asked four attitudinal statements regarding dental staff perception of risk and preparedness. the majority of respondents (1055, 85%) completely agreed/agreed that dental staff were at high risk of being infected by covid-19. sixty-two percent (766) perceived that their workplace had adequate infection control equipment, 84% (1035) experienced that their workplace handled the current situation well, while 41% (501) agreed that their workplace was well equipped to handle an escalation. table 4 shows the results of the multivariable regression analyses exploring associations between perception of risk and preparedness statements and selected independent variables. less experienced dental staff, or 2.0 (ci 1.4; 3.0), and dental staff in public practice, or 2.4 (ci 1.3; 4.4), were more likely to perceive dental staff to have a high risk of being infected, while working in low incidence counties reduced odds, or 0.5 (ci 0.3; 0.8), to perceive this risk. dental staff in public sector, or 0.3 (ci 0.2; 0.5) and those working at clinics not designated to treat patients suspected or confirmed to have covid-19, or 0.6 (0.4; 0.9) were less positive to preparedness of their workplace regarding infection control equipment. dental staff in public sector, or 0.2 (ci 0.1; 0.5), were less positive to how their workplace handled the current situation. dental hygienists, or 1.5 (ci 1.1; 2.2) and dental assistants, or 1.4 (ci 1.0; 1.9), marginally, but statistically significantly associated with being positive to their workplace preparedness to handle an escalation, while dental staff at small clinics, or 0.6 (ci 0.5; 0.9), public sector, or 0.2 (ci 0.1; 0.4), and clinics not designated to treat patients suspected or confirmed to have covid-19, or 0.3 (ci 0.2; 0.4), were less positive to workplace preparedness. ii adjusted for variables that resulted in statistically significant associations according to univariable analyses. iii adjusted for variables that resulted in statistically significant associations according to univariable analyses. iv adjusted for variables that resulted in statistically significant associations according to univariable analyses. the covid-19 pandemic is an unprecedented situation that has affected the population globally, especially healthcare workers, including dental staff. to the best of our knowledge, there are up to date 8 questionnaire studies that investigated covid-19 outbreak and dentistry, summarized in table 5 . none of the questionnaire studies assessed the urgent dental health care management and perception of risk and preparedness among the complete dental team, which includes not only dentists, but also dental hygienists and dental assistants. the appropriate infection prevention and control in order to limit the infection spread is a result of the efforts of the whole dental team. in the present study, there was an over-representation of females and dental staff working in public sector, therefore the results should be interpreted with caution in this respect. in addition, the timing of a questionnaire is an important factor, because of the differences in pandemic peak in different countries and constantly changing guidelines. for example, in march 2020, cdc recommended that dental settings should prioritize urgent and emergency visits and delay elective visits. already in april, some practices in the usa started reopening and providing the full range of dental health care. in norway, from 16 march 2020 health authorities recommended to reduce "one to one contact" in the dental setting by prioritize urgent care and delay elective care. dental health service started gradual re-opening also for elective visits after national recommendations issued by the end of may 2020. the present questionnaire study was commenced 4/15 may 2020 and asked the information about the strictest confinement period in norway, 13 march-17 april 2020. therefore, the results of the present study may not be directly comparable with other studies, as for example the study by kamate and co-workers was conducted much earlier [21] . moreover, the respondents of the global surveys may have experienced different degrees of outbreak during the given survey time which possibly influenced their practices and perceptions. in the present study, the majority of the respondents completely agreed/agreed that dental staff had a high risk of being infected by sars-cov-2. the new york times magazine ranked dental staff among other healthcare workers to have the highest risk to be infected [29] . in italy as well, the majority of respondents agreed that dentistry is a profession at risk [26, 28] . on the contrary, only one out of five dentists perceived covid-19 as very dangerous in jordan [23] . it must be noted that the questionnaire among jordanian dentists was distributed early in the global covid-19 outbreak, when jordan did not have any local cases, in addition to the fact that dentists in jordan has experience with previous similar virus outbreaks. in the present study, the dental staff perception of a dental staff having a high risk of being infected positively associated with working in a public sector and having less professional experience, but negatively with working in low incidence counties. the majority of the dental staff perceived that their clinic handled the current situation well, which negatively associated with working in public sector. however, less than a half of the respondents agreed that their workplace was well equipped to handle an escalation, which negatively associated with small clinics, clinics not designated to treat patients suspected or confirmed to have covid-19 and also public sector. the differences in perceived preparedness between private and public sectors can be partly explained by differences in "locus of control"-while dentists working in private sector were solely themselves responsible for being prepared, while dental staff in public sector were part of a large organization andwere more dependent on decisions of others. as this was a questionnaire study, we do not know if they in fact were better prepared, but it seems they had a better confidence in perceiving their preparedness. there is reason to believe that the level of preparedness facing a virus outbreak like sars-cov-2 in a country or society is influenced by experience with earlier and similar epidemics, like mers and sars. norway has not had a similar virus outbreak in the past and did not even have national recommendations for infection prevention and control in dental practice before 2018. increased internationalization and prevalence of antibiotic resistance did then contribute to the development of recommendations, which were used as a foundation for organizing the activity in the dental health service during the covid-19 outbreak. to reduce the spread of sars-cov-2, the norwegian institute of public health recommended that all patients and accompanying persons should be clarified with regard to infection status and anamnesis per phone prior to their appointment [30] . the majority of the dental staff always/often inquired information per phone about symptoms and about history of travel, showing a high degree of compliance with the recommendations from the authorities. this finding is in line with the global questionnaire study [24] and a study from italy, where phone triage, together with spaced appointments was the most commonly adopted precautionary measure, while deferring treatment in elderly and detecting body temperature in staff and patients were less commonly adopted precautionary measures [26] . the jordanian study revealed limited comprehension of the extra precautionary measures, where a recommended procedure during the outbreak was to measure the temperature of staff and patients [23] . in the present study, the lower proportion of dental staff inquiring about symptoms and travel history were in high incidence counties. in addition, the lower proportion of dental staff in high incidence counties reported not to use prevention measures, such as mouth rinse before procedure, rubber dam and high-volume suction while treating a patient not suspected to have covid-19. these results are in line with the italian survey, where dentists from the highest prevalence areas reported to adopt preventive measures less frequently [26] . the authors suggested that the risk perception is lower in high incidence areas because it is more general. therefore, risk perception in a dental clinic in high incidence areas is also lower. on the other hand, in the present study dental staff working in low incidence counties versus high incidence counties perceived dental staff as having a lower risk of being infected. teledentistry has been proposed only for conditions that could be managed by advice and managed or postponed by medication. it seems to be a useful platform to offer consultations when social distancing is warranted, to minimize direct patient interactions, and to reduce the use of personal protective equipment (ppe) as well as other highly valuable clinical resources during a pandemic [31] . a study evaluating the urgent dental care in north east of england in the first six weeks of the pandemic concluded that the phone triage system used to handle emergency and urgent dental care was both essential and effective [32] . in the present study, on average per week, five patients were treated in a dental office and twice as many received treatment by per phone, out of them one third received drug treatment for their dental condition. thus, treatment per phone may be evaluated as effective also in norway. in the present study, the most common conditions were severe dental pain from pulpal inflammation, abscess, or localized bacterial infection resulting in localized pain and swelling and pericoronitis or third-molar pain. this is in line with a study in beijing, china, which reported that the utilization of emergency dental care decreased during covid-19 outbreak and the distribution of the oral health conditions changed; more dental and oral infections were recorded, but less dental traumas compared to pre-covid-19 period [33] . moreover, the results of the present study are in line with a study from england, where the most frequent dental emergency conditions reported were acute pulpitis or periapical symptoms [32] . during the treatment of these conditions, the most aerosol generating procedures can be avoided. in norway, during the strictest confinement period, several public dental clinics were designated to provide urgent treatment for patients suspected or confirmed to have covid-19. the number of private clinics that provided dental care to patients suspected or confirmed to have covid-19 in norway in this period is not currently known. designated clinics were also implemented in the uk, where local urgent dental care hubs were arranged [34] and in china [35] . this was not the case in italy where private sector provided much of the dental health service, and almost half of the private dentists reported to remain working during the outbreak [26] . in the present study, less than two thirds of the dental staff agreed that their workplace had adequate infection control equipment. dental staff in public sector and those working at clinics not designated to treat patients suspected or confirmed to have covid-19 were less positive to this statement. during the peak of the pandemic, the global stockpile of ppe was insufficient, and the demand for respirators and masks even for health care workers could not be met [36] . the majority of italian dentists reported to have difficulties in finding needed ppe [27] . in the present study, up to 20% of the dental staff working in the clinics designated to treat patients suspected or confirmed to have covid-19 reported not to have available ppe, such a respirators, gowns and aprons at their workplace. even when treating patients not suspected to have covid-19, 88% (389) of the dental staff working during the strictest confinement period in norway applied additional infection control measures, though the who guidelines released 29 june for the health care advise that for patients not suspected to have covid-19 standard precaution should be applied [37] . every fifth responding dentist in jordan reported that additional infection control measures, such as patients wearing masks and washing hands before getting into a dental chair, are not necessary and may create a panic [23] . the newly released (3 august 2020) who interim guidance for the provision of essential oral health services in the context of covid-19 advises that all patients are encouraged to use medical or non-medical masks and practice hand hygiene on arrival and throughout the visit [38] . in the present study, almost all dental staff working in clinics that were not designated to treat patients suspected or confirmed to have covid-19, knew where to refer a patient or where to find an information about it. the highest proportion of dental staff who did not know either clinics or where to find an information, were from high incidence counties. the majority of the respondents in the global survey were aware of the proper authority to contact in case a patient was suspected to have covid-19 [24] . this demonstrates that dental staff were well informed, and thus potentially minimize the risk of infection spread. in the present study, the majority of the dental staff working at the clinics designated to treat patients suspected or confirmed to have covid-19, reported to follow local guidelines for additional infection prevention and control developed by county and university. according to the global survey, 90% of the respondents were updated with the current cdc or who guidelines for infection prevention and control [24] . following guidelines is a crucial aspect in limiting infection spread. dental treatment involves droplets and aerosol generating procedures, such as high-speed drills, dental hand-pieces, ultrasonic and air-flow devices, air-water syringe, ultrasonic scaler and oral prophylaxis cups/rotating brushes. a review has identified that sars-cov-2 may persist in the air in closed unventilated indoor areas for at least 30 min without losing infectivity [39] . therefore, adequate time between patients in the dental office may minimize the risk of cross-infection. in the present study, 84% (144) of the dental staff working in clinics designated to treat patients suspected or confirmed to have covid-19, reported to leave the room before the next patient for 35 min or more. droplets and aerosols may contaminate surfaces, and it has been shown that viruses can sustain on surfaces for various time periods, depending on temperature and humidity, sometimes even up to 28 days [40] . surface disinfection procedures with 62-71% ethanol, 0.5% hydrogen peroxide and 0.1% sodium hypochlorite seem to be the most effective against coronaviruses [40] . in the present study, the most common disinfection agent was reported to be 70% ethyl alcohol. mouth rinse before dental procedures has been shown to reduce microorganisms' load in droplets and aerosols [41] . the most common mouth rinse is 0.02% chlorhexidine digluconate, which seems to be less effective against coronaviruses compared to hydrogen peroxide [40] . the majority of dental staff working in clinics designated to treat patients suspected or confirmed to have covid-19 (93%, 50) reported to use mouth rinse (for example chlorhexidine digluconate or hydrogen peroxide) as an additional protective measure. high-volume suction was reported to be used by 85% (46) and rubber dam by 63% (34) of the dentists as an additional protective measure. according to the global survey, the majority of the respondents neither used mouth rinse nor rubber dam, but a proportion reported to have used high-volume suction [24] . rubber-dam and high-volume suction are considered valid infection control measures during dental procedures and are recommended by american dental association in order to reduce aerosols during dental procedures [42] [43] [44] [45] [46] . intraoral radiographic examination is the most common radiographic technique in dentistry, but as it may stimulate both saliva secretion and coughing, extraoral radiographs may be an appropriate alternative during a virus outbreak, but only a small proportion of dental staff working with patients suspected or confirmed to have covid-19 reported to use extraoral radiographs [35] . the majority of respondents received training in the guidelines either digitally or in the clinics, which included training in putting on and removing ppe. even though, 88% and 67% of the respondents reported to receive training and simulation, respectively, in step-by-step procedures for treatment, including ppe putting on and removing, 24% of the respondents working in clinics designated to treat patients suspected or confirmed to have covid-19 reported the deviation in these procedures. this finding demonstrates that additional infection prevention and control procedures for treatment may not be easy to follow and require extra training. this calls for additional dental staff training in step-by-step procedures for dental treatment during an outbreak in order to minimize infection spread. in general, urgent oral health care was managed relatively well in norway and the majority of the dental staff perceived that their clinic handled the current situation well. however, only less than a half of the respondents agreed that their workplace was well equipped to handle an escalation. in the clinics designated to treat patients suspected or conformed to have covid-19, lack of availability of several ppe was reported. mainly local guidelines developed at a county level or universities were followed. despite training and simulation in additional infection prevention and control step-by-step procedures, there were reported several deviations. fewer dental staff in high incidence counties applied additional infection prevention measures compared to low and medium incidence counties. the results of this study may be used to improve dental health service response to possible 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access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-274774-klystgj4 authors: huang, naizhu; qiu, shaoping; alizadeh, amin; wu, hongchao title: how incivility and academic stress influence psychological health among college students: the moderating role of gratitude date: 2020-05-06 journal: int j environ res public health doi: 10.3390/ijerph17093237 sha: doc_id: 274774 cord_uid: klystgj4 many students suffer from academic stress and uncivil behaviors at colleges and there is a need to identify to what extent these negative phenomena might impact students’ mental health. the main purpose of this study is to examine the relationships between incivility, academic stress, and psychological health, as well as investigate the moderating role of gratitude. the study design of this research is cross-sectional. the final sample consisted of 895 university students in china; the statistical package for the social sciences (spss) version 22 was utilized to conduct statistical analysis. sample t-tests were used to examine whether there were gender differences in terms of four continuous variables: incivility, stress, gratitude, and psychological wellbeing. we also used multiple hierarchical linear regression analysis to test the relationships between the aforementioned four variables and the moderating effect of gratitude. the results of our study indicate that academic stress and incivility are positively associated with psychological distress, and gratitude moderates the relationship between incivility and psychological distress. however, no significant moderating effect of gratitude was found in the relationship between academic stress and psychological distress. the problems of psychological distress are prevalent across the globe and have been the major causes of disproportionately higher rates of disability and mortality [1] . as a set of painful mental and physical symptoms, psychological distress includes anxiety, confused emotions, hallucinations, and depression [2] . statistics on psychological distress are alarming; mental illness accounts for 30% of non-fatal disease burdens worldwide and 10% of overall disease burdens, including death and disability [3] . the proportion of the global population with depression in 2015 was estimated to be 4.4% [4] . the problems of psychological distress are especially prominent among college students, as they are particularly more vulnerable to psychological disorders [5] . for example, in china alone, about 20% of college students suffer from various forms of mental problems, such as depression, anxiety, and stress [6] . therefore, psychological distress of college students has become an issue of utmost concern worldwide [7] . in parallel, the topic of psychological distress has drawn much attention among researchers and practitioners worldwide. research has demonstrated that stress perceived as a personal threat and loss the study design of this research was cross-sectional. data were obtained from students in november 2019 at a large university in south china. since the survey was administered in chinese, and we used instruments originally developed in western countries, we conducted a back-translation to guarantee that the meaning of the instrument items was accurate and culturally appropriate. prior to conducting the survey, a pilot study was carried out using 40 students to assess clarity, length, comprehensiveness, and completion time of the measures. the survey instrument was distributed via the internal email listserv of the university to 19,532 students who came from all provinces of china. a total of 1425 students participated in this study and returned their responses. after excluding incomplete questionnaires, we obtained 895 valid, usable data cases with a response rate of 4.58%. therefore, the final sample consisted of 895 university students. among participants, 695 (77.7%) were female students. the average age was 19.14 years old. in total, 392 students (43.8%) were freshman while 352 (39.3%) were sophomores. in addition, 357 participants (39.9%) reported that their monthly family income was between 3000 to 5000 rmb yuan, while only 37 respondents reported their family earned 11,000 or above rmb yuan per month. most students reported that their father (40.6%) and mother (40.1%) only graduated from middle school. a vast majority of students (493, 55.1%) originally came from the province where the university is located. however, the remaining participants were roughly evenly distributed among other provinces of china except for three autonomous regions. all measures employed were developed and validated and used in previous studies. in addition to ensuring participating students' anonymity and confidentiality, we used a few negatively worded items in the survey to reduce common method variance [29] . incivility was assessed using a sevenitem scale developed by cortina et al. [30] . students were asked to rate the frequency they have been in a situation where any of their classmates exhibited uncivil behavior to them. the rating scale of 1 (never) to 5 (very frequent) was used. an example item was: "how often did my classmates make demeaning or derogatory remarks about me in the last year?". the reliability of this scale was acceptable with an alpha of 0.86. stress was measured using a 10-item scale developed by lepine et al. [31] . students were required to rate the extent to which they experienced academic stress on a scale of 1 (no stress) to the study design of this research was cross-sectional. data were obtained from students in november 2019 at a large university in south china. since the survey was administered in chinese, and we used instruments originally developed in western countries, we conducted a back-translation to guarantee that the meaning of the instrument items was accurate and culturally appropriate. prior to conducting the survey, a pilot study was carried out using 40 students to assess clarity, length, comprehensiveness, and completion time of the measures. the survey instrument was distributed via the internal email listserv of the university to 19,532 students who came from all provinces of china. a total of 1425 students participated in this study and returned their responses. after excluding incomplete questionnaires, we obtained 895 valid, usable data cases with a response rate of 4.58%. therefore, the final sample consisted of 895 university students. among participants, 695 (77.7%) were female students. the average age was 19.14 years old. in total, 392 students (43.8%) were freshman while 352 (39.3%) were sophomores. in addition, 357 participants (39.9%) reported that their monthly family income was between 3000 to 5000 rmb yuan, while only 37 respondents reported their family earned 11,000 or above rmb yuan per month. most students reported that their father (40.6%) and mother (40.1%) only graduated from middle school. a vast majority of students (493, 55.1%) originally came from the province where the university is located. however, the remaining participants were roughly evenly distributed among other provinces of china except for three autonomous regions. all measures employed were developed and validated and used in previous studies. in addition to ensuring participating students' anonymity and confidentiality, we used a few negatively worded items in the survey to reduce common method variance [29] . incivility was assessed using a seven-item scale developed by cortina et al. [30] . students were asked to rate the frequency they have been in a situation where any of their classmates exhibited uncivil behavior to them. the rating scale of 1 (never) to 5 (very frequent) was used. an example item was: "how often did my classmates make demeaning or derogatory remarks about me in the last year?". the reliability of this scale was acceptable with an alpha of 0.86. stress was measured using a 10-item scale developed by lepine et al. [31] . students were required to rate the extent to which they experienced academic stress on a scale of 1 (no stress) to 5 (a great deal of stress). two example items were: "the amount of hassles i need to go through to get projects or assignments done" and "the difficulty of the work required in my classes" cronbach's alpha was acceptable at 0.89. gratitude was evaluated using the gratitude questionnaire-six item form (gq-6) developed by mccullough, emmons, and tsang [32] . participants rated the extent to which they agreed with statements on a scale ranging from 1 (strongly disagree) to 5 (strongly agree). one example item was: "i have so much in life to be thankful for" the measure had an adequate internal consistency (α = 0.83). psychological distress was measured using k6 screening scale developed by kessler et al. [33] . students rated on a scale of 1 (never) to 5 (very often) how often they felt psychologically distressed, such as hopeless. the reliability of this scale was 0.88. control variables included age, gender, and family income. these variables were found to predict psychological distress in previous research [33] [34] [35] . for gender, we coded male as "1" and female as "2". in terms of age, we coded age 18 as "1", age 19 as "2", age 20 as "3", age 21 as "4", age 22 as "5", and age 23 or above as "6". with respect to family income, we coded family monthly income below 3000 rmb yuan as "1", 3000-5000 as "2", 5000-7000 as "3", 7000-9000 as "4", and above 9000 as "5". spss version 22 was utilized to conduct statistical analysis. mplus was used to test convergent and discriminant validities of the main variables. independent sample t-tests were used to examine whether there were gender differences in terms of the four continuous variables: incivility, stress, gratitude, and psychological wellbeing. we also used multiple hierarchical linear regression analysis to test relationships between the aforementioned four variables and the moderating effect of gratitude, controlling for age, gender, grade, and household income. the p-values ≤0.05 were considered throughout as statistically significant. we used harman's single factor test to check whether there was common method variance in the data. results revealed that one single factor only explained 26.86% of the variance, much lower than 50%, indicating no major issues with common method variance. means, standard deviations, reliability, and intercorrelations between study variables are shown in table 1 . as can be seen from table 1 , gender is associated with gratitude (r = 0.15, p < 0.01). however, it has no significant relationship with incivility, stress, and psychological wellbeing. psychological distress is significantly related to incivility (r = 0.37, p < 0.01), stress (r = 0.52, p < 0.01), and gratitude (r = −0.20, p < 0.01), whereas correlation between stress and gratitude is not statistically significant. confirmatory factor analysis (cfa) was performed to test convergent and discriminant validities of main variables (i.e., incivility, academic stress, gratitude, and psychological distress). for this purpose, we compared four measurement models. in the three-factor model, we combined incivility and academic stress because they were two independent variables. in the two-factor model, incivility, academic stress, and gratitude were put together as one variable. the fit indices of all four models are shown in table 2 . as can be seen from this table, the four-factor model provided a good fit with the data and was much better than any other models (χ 2 = 502.17, df = 203, rmsea = 0.04, cfi = 0.96, tli = 0.96, srmr = 0.04). thus, the discriminant validity was established. in addition, the factor loadings in the four-factor model were all greater than 0.50 and all values of average variance extracted (ave) for the four variables were also greater than 0.50. therefore, convergent validities were achieved for all four variables. note: n = incivility; st = academic stress; gr = gratitude; ps = psychological distress. ** p < 0.01. ∆ χ 2 is χ 2 difference between respective and four-factor models. results from independent sample t-tests revealed that there were no statistically significant differences between male and female students in terms of incivility, stress, and psychological wellbeing. however, discrepancies between male and female students were significant, with female participants reporting more gratitude towards others (t = −4.43, p < 0.001). hierarchical multiple regression analysis was performed to examine the relationships between incivility, stress, gratitude, and psychological wellbeing, as well as the moderating effect of gratitude. we mean-centered the values of incivility, stress, and gratitude [36] . results are presented in table 3 . as seen from this table, there was a significant main effect of incivility in both model 2 (β = 0.22, p < 0.01) and model 3 (β = 0.22, p < 0.01), indicating that students feel more psychologically unhealthy under high-level incivility from their classmates. we also found that a significant effect of stress in both model 2 (β = 0.46, p < 0.01) and model 3 (β = 0.46, p < 0.01) revealed that students experience more psychological distress issues under high academic stress. in addition, the effect of gratitude on psychological distress was also negatively significant in both model 2 (β = −0.18, p < 0.01) and model 3 (β = −0.17, p < 0.01), indicating that college students who express more appreciation to others suffer less from psychological distress problems. most importantly, the interaction term between incivility and gratitude was significant in model 3 (β = 0.07, p < 0.05). however, there was no significant moderating effect of gratitude on the relationship between incivility and psychological wellbeing. following the guidelines of aiken and west [36] , we plotted the regression of psychological distress on incivility to assess the moderation effect at two values of gratitude (mean +1 standard deviation and mean −1 standard deviation) ( figure 2 ). as illustrated in this figure, the higher the level of gratitude, the stronger the relationship between incivility and psychological wellbeing. when incivility is low, students with a low level of gratitude experience more severe psychological distress problems. however, as the level of incivility becomes higher, psychological distress issues become less different across these two gratitude groups. following the guidelines of aiken and west [36] , we plotted the regression of psychological distress on incivility to assess the moderation effect at two values of gratitude (mean +1 standard deviation and mean -1 standard deviation) ( figure 2 ). as illustrated in this figure, the higher the level of gratitude, the stronger the relationship between incivility and psychological wellbeing. when incivility is low, students with a low level of gratitude experience more severe psychological distress problems. however, as the level of incivility becomes higher, psychological distress issues become less different across these two gratitude groups. using a sample of 895 students recruited from a university in south china, we investigated the relationships between incivility, academic stress, gratitude, and psychological distress. in addition, using a sample of 895 students recruited from a university in south china, we investigated the relationships between incivility, academic stress, gratitude, and psychological distress. in addition, we examined underlying mechanisms through which incivility and academic stress affect students' psychological distress. that is, we tested how incivility and academic stress interact with gratitude to predict students' psychological distress. moreover, we compared differences between male and female students with respect to incivility, academic stress, gratitude, and psychological distress. results of this study illustrate that incivility is positively associated with psychological distress. our findings are consistent with prior studies [18, 19, 37] . academic stress was also confirmed as related to psychological distress. this conclusion is also in line with previous research that examined the aforementioned relationship [11, 12] . it was also identified that gratitude moderates the relationship between incivility and psychological distress. however, no significant moderating effect of gratitude was found in the relationship between academic stress and psychological distress, which is contrary to our expectations. in low incivility environments, grateful students are less likely to suffer from psychological distress than those with low levels of gratitude. it is sensible because under normal conditions, grateful individuals tend to hold a positive attitude towards life, take more pleasure from benefits in life, and feel happier [38] . as uncivil behaviors or comments become relatively more frequent, grateful students can still keep psychologically healthier. however, as incivility frequency increases, the psychological distress college students experience increases more rapidly for grateful students. a possible reason would be that grateful individuals take uncivil communications more seriously and attempt to resolve conflicts to maintain high-quality interpersonal relationships with others [39] . most probably they attribute sources of these uncivil behaviors and comments to themselves and ruminate on how they could change their thoughts, thus aggravating their psychological problems [40] . in this study, we did not find any gender differences on perceived incivility, perceived level of stress, and reported psychological health. the finding of no gender disparity on perceived stress and psychological distress contradicts the study results of moksnes and lazarewicz [28] . in their research on norwegian adolescents from 13 to 18 years old, they found that boys scored lower than girls on stress and symptoms of depression and anxiety. these inconsistencies may be attributed to the difference of age range. another plausible reason could be the emphasis chinese universities place equally on both male and female students. in our study, the sample participants were chinese college students who were developing or built their own resilience and coping strategies. in chinese universities, there are counselors at both university and department levels dedicated to helping students with personal, emotional, and psychological concerns. when facing stress and adversity, both male and female students are likely to be equipped with the same skills to handle negative situations encountered and to perceive the stress as less severe. however, female college students, compared to male students, were found to be more likely to express gratitude towards others. this finding corresponds with previous studies showing that women tend to report higher levels of gratitude than men [41] [42] [43] . as reasoned by watkins et al. [44] , men generally associate gratitude with weakness in personality. therefore, men tend to avoid expressions of gratitude to protect their masculinity and maintain their social status. this study makes both theoretical and practical contributions. first, research examining the association between incivility, academic stress, and psychological distress in the chinese context is scarce. using chinese college students as a study sample is even more scant. this study adds to the current literature by enhancing our understanding of whether incivility and academic stress influence students' psychological distress in a chinese university setting. additionally, given that little is known about how incivility and stress affect psychological health, testing the moderating effects of gratitude helps us gain an understanding of boundary conditions under which such an association might occur. therefore, this study might fill a theoretical gap in the literature. third, findings of this study could provide insight and timely advice to chinese university students on how to keep psychologically healthy. especially during this difficult time of novel coronavirus outbreak, students are learning online from home. the study of gratitude and stress might offer some useful guidelines to develop positive psychology-based student counseling interventions to help chinese students cope with adversity and hardship. although we used a relatively large sample size and well-validated instrument scales, this study has some limitations. first, the data used in this study were obtained from a single source (i.e., university students). we reduced common method variance by using some negatively-worded items, ensuring anonymity and confidentiality. however, there is still a potential for common method variance to bias our study results. future studies could adopt as many measures as possible, as recommended by podsakoff et al. [29] , to further minimize this issue. second, this study was cross-sectional in nature, which precludes us from making a causal conclusion about the main and moderation effects. if possible, a longitudinal study or experimental design is recommended to interpret the relationships between incivility, academic stress, and psychological distress in a causal way. third, despite the large sample size in this study, most participants came from the province where the university is located and no students from the three autonomous regions participated in this study. this sample distribution, together with a low response rate (4.58%), might bias the study results. future studies could collect more data from other provinces in order to be more representative of the whole chinese student population. next, we only solicited data from one university in china. although students were from all parts of china, the sample may not represent the whole college student population in china. finally, we only used gratitude as a moderator to examine how incivility and academic stress impact students' psychological health, ignoring other possible mediators and moderators. if more variables were examined in the study, such as rumination, personality traits, and students' attribution, we could gain a higher understanding of the underlying mechanisms and boundary conditions about how, whether, and when such effects might be most likely to occur. this study showed that both incivility and academic stress positively affect university students' psychological health. it also demonstrated that gratitude moderates the relationship between incivility and psychological distress after controlling for age, gender, and family income. however, the interaction of gratitude and academic stress does not significantly impact university students' psychological health. for highly grateful students, the relationship between incivility and psychological distress is stronger than those with low levels of gratitude. in addition, female students scored higher on gratitude than male students, whereas there were no differences between these two groups on perceived incivility, perceived academic pressure, and psychological distress. this study contributed insight into the moderating role of gratitude in the incivility-psychological distress relationship. to advance our understanding, future researchers could use more measures to combat common method bias, employ a longitudinal study or experimental design to create causal interpretation, and recruit more representative samples for the study results to be generalized. incivility is a rude or impolite attitude or behavior towards others. considering the vagueness and prevalence of incivility, maintaining civility on campus still remains a great concern for most college administers [45] . incivility interferes with a harmonious and cooperative learning atmosphere, contributing to increased psychological distress among college students. given its widespread effect on both students and college culture, colleges and universities should take measures to tackle this disturbing issue. at the college or university level, administers should create a culture in which each and every student is treated with respect, fairness, and equality. at the department level, college counseling staff and department faculty should make it clear what behaviors students need to follow and what should be avoided. in addition, they should provide counseling to help change students' behaviors. furthermore, students as individuals also need to understand their own roles and assume corresponding responsibilities. they must stand up against any uncivilized behaviors occurring on campus in order to stop such behaviors. in this way, we can facilitate civility and enhance learning effectiveness among college students. psychometric study of depression, anxiety and stress among university students psychological distress: concept analysis making mental health a 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variations by gender the debt of gratitude: dissociating gratitude and indebtedness the level of student incivility: the need of a policy to regulate college student civility this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we would like to thank the students at a chinese university for their participation in this study. the study received no funding from any institutions. the authors declare no conflict of interest. key: cord-281961-5mdiwzvc authors: de las heras-pedrosa, carlos; sánchez-núñez, pablo; peláez, josé ignacio title: sentiment analysis and emotion understanding during the covid-19 pandemic in spain and its impact on digital ecosystems date: 2020-07-31 journal: int j environ res public health doi: 10.3390/ijerph17155542 sha: doc_id: 281961 cord_uid: 5mdiwzvc covid-19 has changed our lives forever. the world we knew until now has been transformed and nowadays we live in a completely new scenario in a perpetual restructuring transition, in which the way we live, relate, and communicate with others has been altered permanently. within this context, risk communication is playing a decisive role when informing, transmitting, and channeling the flow of information in society. covid-19 has posed a real pandemic risk management challenge in terms of impact, preparedness, response, and mitigation by governments, health organizations, non-governmental organizations (ngos), mass media, and stakeholders. in this study, we monitored the digital ecosystems during march and april 2020, and we obtained a sample of 106,261 communications through the analysis of apis and web scraping techniques. this study examines how social media has affected risk communication in uncertain contexts and its impact on the emotions and sentiments derived from the semantic analysis in spanish society during the covid-19 pandemic. the outbreak of the coronavirus disease was first reported by the wuhan municipal health and safety commission (hubei province, china) on 31 december 2019. one month later, the emergency committee of the international health regulations [1] declared the new coronavirus outbreak as a public health emergency of international importance (phei) at its meeting on 30 january 2020 [2] . five months after the official announcement, the virus has infected more than 6, 193 ,548 people worldwide and killed around 372,479 people [3], bringing catastrophic consequences for society [4] , completely collapsing health systems in different countries [5] and generating a strong economic recession worldwide [6] . throughout the history of mankind, societies have been faced with crises of various kinds and of very diverse natures, such as civil conflicts, financial crises, crises caused by the management and export of energy resources or emergencies caused by the impact of diseases and epidemics, among others [7] . it is only necessary to recall some of the events of the past 20th century to be able to appreciate how figure 1 shows the trend in reported cases of covid-19, deaths, and recoveries patients between 25 february 2020 and 29 may 2020. it is verified that the highest level of cases by coronavirus was on 31 march 2020 and deceased people on april 1. after these days, the curve of new infections and deaths trended downward and recovered people were increasing. face masks were a problem, especially at the beginning of the pandemic. initially, they were not available to the general population, so they were only used for those most at risk of infection, such as health care, security forces, and the military. the government of spain was responsible for the purchase and distribution of face masks to the autonomous communities. figure 2 shows the distribution of face masks carried out by the government between march 10 and may 29. madrid and catalonia, with the highest number of infections from covid-19, were where most face masks were distributed. face masks were a problem, especially at the beginning of the pandemic. initially, they were not available to the general population, so they were only used for those most at risk of infection, such as health care, security forces, and the military. the government of spain was responsible for the purchase and distribution of face masks to the autonomous communities. figure 2 shows the distribution of face masks carried out by the government between 10 march and 29 may. madrid and catalonia, with the highest number of infections from covid-19, were where most face masks were distributed. int. j. environ. res. public health 2020, 17, x 3 of 22 figure 1 shows the trend in reported cases of covid-19, deaths, and recoveries patients between 25 february 2020 and 29 may 2020. it is verified that the highest level of cases by coronavirus was on 31 march 2020 and deceased people on april 1. after these days, the curve of new infections and deaths trended downward and recovered people were increasing. face masks were a problem, especially at the beginning of the pandemic. initially, they were not available to the general population, so they were only used for those most at risk of infection, such as health care, security forces, and the military. the government of spain was responsible for the purchase and distribution of face masks to the autonomous communities. figure 2 shows the distribution of face masks carried out by the government between march 10 and may 29. madrid and catalonia, with the highest number of infections from covid-19, were where most face masks were distributed. this research work represents a pioneering challenge in the field of risk communication research. during the months of march and april 2020, various digital ecosystems were analyzed, and a sample of 106,261 communications was obtained through the analysis of apis and web scraping techniques. the study analyzes, through social media, how risk communication management has masks that the spanish government has distributed to each autonomous community from march 10 to may 29 [24] . the communication makes explicit reference to the covid-19 pandemic in spain. the communication is public and can be viewed without the need for a subscription to the data source or explicit permission from the sender of the communication. the author's reported age, when available, was over 18 years old as of the start of the end of the study (30 april 2020). the communication is written in spanish. on the other hand, the exclusion criteria were: • the communication does not come from an advertising campaign. the communication has not been generated by automatic procedural methods (bots, fake posts, among others). one of the most usual problems that we must deal with when using information from digital ecosystems is detecting spammers, fake information generated by bots, which tries to influence or modify the perceived opinion on existing information. to detect and discard this type of information we have implemented different types of algorithms based on support vector machine (svm) techniques which can detect the patterns of this kind of communications, such as the age of the account (in days), the number of comments from the account, follower/following ratio, and the ratio of messages containing urls. to prevent the effect of spammers, in this work we implemented and applied filters previously defined and tested in other scientific works [27, 28] . the emotion information from each communication was extracted employing the natural language analysis tools provided by the ibm watson analytics service [29] . the emotional intensity was measured in a 0 to 1 scale, where 0 represents the complete absence of this emotion; and 1 represents an absolute high intensity of the emotion. in total, this study measured the emotional intensity of four primal emotions-anger, fear, disgust, and sadness. to detect and measure the primary emotions in this study we used the services provided by the ibm watson system. watson is a cognitive computing platform that combines a deepqa architecture, with ai algorithms and big data to solve questions in the domain of natural language. this platform offers a wide range of services including discovery, knowledge studio, language translator, natural language classifier/understanding, and personality insights among others. watson has an overall precision of 97% in natural language processing and has been widely compared with other systems, as well as with humans, and in both cases, it has obtained very satisfactory results. for this reason, this system has been widely used in different scientific works where it has further proved its capabilities on natural language processing (nlp) tasks [30] [31] [32] [33] [34] [35] . in this work, we made use of the natural language understanding service from the ibm watson platform which, given an input text, provides an analysis of syntactic characteristics as well as information on categories, concepts, emotions, entities, keywords, metadata, relationships, and semantic roles. the reliability of the resultant emotion information was tested using the interval majority aggregation operator (isma-owa) [36] , which is designed for decision making in social media with consistent data, leveraged by the combination of computational intelligence and big data techniques [37] . to obtain representative results, when analyzing with information extracted from digital ecosystems, it is important to ensure a correct representation of such information and its quality. when people express opinions in communications, they do not do so in numerical value with a fixed scale, they use natural language expressions such as "this is great" or "this is not so good", so we employed the intervalar representation proposed in [36, 38] instead of a numerical scale. the main advantage of this approach is that intervals represent the information within communication in a way that is more similar to the way people express themselves in digital ecosystems, thus reducing the loss of information associated with forcing linguistic data to a hard-numerical scale. furthermore, regarding information quality, an important aspect that we must consider when assessing the validity of this information is to ensure that such information has been expressed with knowledge of the topic at hand and not at random. another advantage of the usage of an intervalar representation of digital ecosystem data is the availability of consistency indices that can be applied to the matrices obtained from communications to detect inconsistencies derived from uninformed opinions. for this purpose, in this work, we employed the ci+ index defined in [39] . the frequency of the words comprising the sample of communications was calculated using a natural language processing algorithm implemented in python 3, using the natural language toolkit (nltk) [40] . moreover, the emotion polarity (positive or negative) was measured using a multilayer perceptron model, trained to classify the emotional weight of written communications [38, 41] . the python nltk library is an open-source programming library for working with natural language data which incorporate functions that allow for the determination of the frequency of words in a text while discarding stop-words, that is words that are very common to a language but do not convey any significant information such as "the", "a" and "very". furthermore, the nltk library serves as a pre-processing tool to use other artificial intelligence tools such as artificial neural networks such as the multi-layered perceptron that we used in this work to detect the polarity of communications. a multi-layered perceptron (mlp) is a widely used artificial neural network architecture that utilizes a technique known as supervised training to learn how to differentiate data that is not linearly separable. in this case, we trained our mpl with a set of communications created by the spanish society for natural language processing (sepln) which contains over 100,000 natural language texts tagged with the polarity of each communication, that is, each communication contained metadata that indicated if the message was positive or negative. there are other techniques for natural language sentiment analysis, such as naïve bayes, or support vector machines, but we opted for the mlp approach since it can learn complex relationships and it does not enforce any sort of constraint concerning the input data [42] . to further improve the qualitative analysis, the above-mentioned information regarding the volume of communications, the frequency of words and the emotion expressed by each communication was contrasted to determine the information pathways between mass media, government, political parties, employers' confederation, non-governmental organizations (ngos), trade unions, the world health organization (who), among others. this approach provides a graphical representation of the information fluxes about the covid-19 disease in spain. for the analysis of the messages emitted by the spanish government, a content analysis of all press releases during the period of study was carried out. messages were classified as positive, neutral, or negative by selecting the most significant words from them. the frequency of repetition of these words was another objective of this content analysis. the result has been shown through a word cloud representative of the emotions and feelings expressed by the government in its press releases. the analysis of content permits inferences to be reproduced based on specific characteristics identified in the messages [43, 44] . this type of analysis allows for the discovery of tendencies and the revelation of differences in content communication. likewise, this allows the comparison of messages and means of communication, and the identification of intentions, appeals. to this effect, value and frequency analysis were used [45] . since the beginning of the pandemic, the structure organized by the government has involved relations between the spanish government (the health alert coordination center, which is part of the ministry of health) and the governments of the autonomous communities, the national epidemiology center, the national microbiology center and the international organization's world health organization (who), the european disease control center and the european commission [46] . to raise awareness and inform public opinion, the spanish government designed a communication strategy articulated in four actions that had the use of the mass media as channels of transmission of covid-19 information as a main objective: (a) weekly appearances of the president of the government. (b) daily press conferences chaired jointly by the following ministers: minister of health, who is responsible for the state of alarm decreed in the country; minister of defense, who is responsible for the military forces; minister of the interior, who is responsible for the state security forces and minister of transport. all of them were accompanied by experts in each of the areas. the ministers sent out a political message and the experts went into detail about the actions being taken. with a press conference format, online questions from the main spanish and foreign media were admitted. however, this format underwent the first modification after the second week being responsible for the press conferences the so-called "technical committee for monitoring the coronavirus pandemic in spain" consisting only of experts of the different ministries. on 25 april, there was a new restructuring of the press conferences, leaving only the director of the health alert and emergency coordination centre of the ministry of health as the health expert. this last change is censored by the communications media. (c) press release. after the appearance at a press conference, the communication department of the ministry of health sent a press release to all the media. (d) interviews with ministers. another of the government's actions was to make its cabinet available to the media for interviews. to reinforce the previous actions, on march 15 , the state government launched the advertising campaign #estevirusloparamosunidos. this campaign is adapted for television, press, radio, outdoor advertising, and social networks. in a public health crisis like the one spain is experiencing, a transparent and empathetic communication style would generate citizen confidence and would be more effective if politicians and experts unanimously tried to stimulate the population to take a positive stance towards the pandemic and the health and economic alert measures imposed by the government. although the generation of trust must be essential in a crisis, the analysis carried out shows the public's distrust of scientific experts and government representatives for a variety of reasons such as access to conflicting sources of information, contradictions in scientific reasoning, changes in decision-making and, above all, political confrontations. trust and credibility, demonstrated through empathy, experience, honesty, and transparency, are essential elements of public health crisis communication [18] . figure 4 analyzes the messages transmitted by the ministry of health in its press releases between march and april. in green, the positive messages were determined, in black the neutral ones and in red the negative ones. the word size indicates the frequency of repetition in the press releases. as can be seen in the word cloud, the negative word "covid" is the most used by the government in its communications. this is followed at a distance by "coronavirus" and "health crisis" with a dark red color that indicates their use in negative messages, but also in neutral tones. "social networks" is a neutral term used mainly to explain the social network campaigns implemented by the government. it is followed by "patients" and "nursing home". however, the most remarkable thing about this word cloud is its words in the green. the communication made by the communication office of the ministry of health has always wanted to give a positive view in all their messages, with "government" as the most used word, followed by "face masks", "ministry of health" or "test". this could indicate a lack of transparency about the situation the country was going through. none of these press releases refer to either the infected or the dead. attempts are made to give a protagonist role, at times, to all the actions carried out by the government. in spain, the decreed state of alarm requires the total confinement of the population. royal decree-law 10/2020, of 29 march 2020 [47] , establishes the minimum essential services of first necessity such as all those necessary for the supply of food to the population. the minimum distance was made to be one and a half meters. except for these cases, the rest of the population must carry out their work by teleworking, and if this work is not possible, the government approved royal decree-law 8/2020 of 17 march on extraordinary urgent measures to cope with the economic and social impact of covid-19 [48] , which regulates emergency procedures to combat the economic and social impact of the pandemic, denominated as the temporary employment regulation file (terf). the number of workers affected by the terf was two million on 3 april [49] . the high number of terf requests blocks the administration from responding to the citizens with a decrease of the collection of these aids and the decapitalization of these workers in some cases without the possibility of paying the rents of their houses or simply buying the necessary food for the family. non-governmental organizations and food banks have a crucial role to supply the neediest in the population. during confinement, the media are not left out. their workers follow their work from their homes. on televisions, these measures cause programs to be suspended and replaced by new programming offering coronavirus specials. these programs have a structure of news, interviews with experts or politicians, discussion programs or talk shows where covid-19 and the situation that citizens are experiencing are analyzed. due to the uncertainty of the situation and the isolation in their homes, citizens are consuming more television. thus, the month of march and later april became the months with the highest television audience in spanish history. march data show an average consumption of 282 min per person per day (4 h and 42 min). the average number of people who had watched tv for at least one minute a day was 369 min (6 h and 9 min) [50] . the progression in the television audience continued in the month of april with numbers never seen in the conventional spanish television with 302 min (5 h and 2 min) and 395 min (6 h and 35 min) respectively. in addition to television coverage, 33.6 million spaniards consumed this medium daily, representing 74.2% of the population [51] . the serious effects on the economy caused by the crisis determine that new actors acquire an active role in communication by modifying the initial panorama organized by the government. political parties, the confederation of employers and trade unions are configured as sources of information. these new stakeholders also offer interviews to the communication media, organize press conferences, and finally communicate with citizens directly through social media (see figure 1) . therefore, the stakeholder structure created by the government is increased by other social actors who have their own opinion on the management of the pandemic. all of them have in common the use of the media to convey their messages to the citizens, converting these media as the main interlocutors with the population. the high consumption of television makes it the main means of information used by citizens. public and private televisions in spain broadcast the press conferences of the different stakeholders and the appearances of the president of the government. this is referred to in figure 1 as "news". the different ideological tendencies of the television channels in spain mean that their interview programs with experts and television debates do not follow a single argument in support of the government's management. these messages feature contradictory opinions that the media convey to the public as interviews, discussion programs, and talk shows, which increase uncertainty among citizens (figure 3 ). in a public health crisis like the one spain is experiencing, a transparent and empathetic communication style would generate citizen confidence and would be more effective if politicians and experts unanimously tried to stimulate the population to take a positive stance towards the pandemic and the health and economic alert measures imposed by the government. although the generation of trust must be essential in a crisis, the analysis carried out shows the public's distrust of scientific experts and government representatives for a variety of reasons such as access to conflicting sources of information, contradictions in scientific reasoning, changes in decision-making and, above all, political confrontations. trust and credibility, demonstrated through empathy, experience, honesty, and transparency, are essential elements of public health crisis communication [18] . figure 4 analyzes the messages transmitted by the ministry of health in its press releases between march and april. in green, the positive messages were determined, in black the neutral ones and in red the negative ones. the word size indicates the frequency of repetition in the press releases. as can be seen in the word cloud, the negative word "covid" is the most used by the government in its communications. this is followed at a distance by "coronavirus" and "health crisis" with a dark red color that indicates their use in negative messages, but also in neutral tones. "social networks" is a neutral term used mainly to explain the social network campaigns implemented by the government. it is followed by "patients" and "nursing home". however, the most remarkable thing about this word cloud is its words in the green. the communication made by the communication office of the ministry of health has always wanted to give a positive view in all their messages, with "government" as the most used word, followed by "face masks", "ministry of health" or "test". this could indicate a lack of transparency about the situation the country was going through. none of these press releases refer to either the infected or the dead. attempts are made to give a protagonist role, at times, to all the actions carried out by the government. in contrast, figure 5 shows the results of the 106,261 listings made on social media between the same months and shows the feelings and emotions of the population. on this occasion, the word "cases" is the most representative that reflects the number of infections suffered in the country. it is followed by the word "crisis", which represents the public health crisis but also the economic one. the terms "covid" and "coronavirus" are strongly represented, as well as "spain" and "world" which represent the concern of the population in the face of a pandemic of this magnitude. "casualties" is another of the most significant words and is indicative of all those people who have benefited from the terf and who have not yet received the promised aid from the government. the positive messages sent by the government and its experts are counterbalanced by the volume of opinion generated by the media and especially the generalist televisions. some reasons include political parties' criticism of the government's management, contradictions of the experts, the constant increase of infected and dead, spain being among the most affected countries, the state of confinement suffered by society not always in the best conditions, the anxiety of not having financial resources, the population's insecurity in the face of a public health crisis with global effects that are caused by millions of infected people and hundreds of thousands of deaths in the world. all these reasons generate negative feelings and emotions, causing uncertainty and fear among citizens. digital ecosystems reflect this trend in a word cloud with a markedly negative character ( figure 5 ). in contrast, figure 5 shows the results of the 106,261 listings made on social media between the same months and shows the feelings and emotions of the population. on this occasion, the word "cases" is the most representative that reflects the number of infections suffered in the country. it is followed by the word "crisis", which represents the public health crisis but also the economic one. the terms "covid" and "coronavirus" are strongly represented, as well as "spain" and "world" which represent the concern of the population in the face of a pandemic of this magnitude. "casualties" is another of the most significant words and is indicative of all those people who have benefited from the terf and who have not yet received the promised aid from the government. the positive messages sent by the government and its experts are counterbalanced by the volume of opinion generated by the media and especially the generalist televisions. the communications that have the greatest impact on four of the main emotions of the population-fear, sadness, disgust, and anger-are presented. the study has allowed for the some reasons include political parties' criticism of the government's management, contradictions of the experts, the constant increase of infected and dead, spain being among the most affected countries, the state of confinement suffered by society not always in the best conditions, the anxiety of not having financial resources, the population's insecurity in the face of a public health crisis with global effects that are caused by millions of infected people and hundreds of thousands of deaths in the world. all these reasons generate negative feelings and emotions, causing uncertainty and fear among citizens. digital ecosystems reflect this trend in a word cloud with a markedly negative character ( figure 5 ). the communications that have the greatest impact on four of the main emotions of the population-fear, sadness, disgust, and anger-are presented. the study has allowed for the determination of the reaction of the population concerning the covid-19 pandemic and the crisis communication carried out by the government, determining the themes and the feelings of the communications associated with the crisis communication. to this end, the emotion graph corresponding to the period of study is first determined, determining the peaks of emotion that are significant, and those news patterns that generate greater presence and reach in digital ecosystems. secondly, the topics that have most influenced these emotions are analyzed and the patterns that generate them are concluded. figure 6 shows the evolution of the disgust emotion during the study period, where nine peaks can be distinguished where the emotion shows a significant increase. in table 1 , the communications that had the greatest impact on this increase are analyzed in chronological order from 1 march 2020 to 30 april 2020. from these communications, the management of the pandemic is the general theme that most impacts the emotion treated. aspects such as: blaming the pandemic on groups that can be grouped by religion, sex, use of the security forces to censor the population's opinion; lack of care for weak sectors such as the elderly; and the purchase of health material are the conversations that predominate in digital ecosystems. • the religious community is eager for the ministry of health to "point them out" because it leaves them in a "state of defenselessness" and they demand an apology. the evangelicals see it as "very serious" that the ministry of health points to a religious group as a possible focus. 23 march 2020 • a collapse in funeral homes and mortuaries. • spanish health workers are the worst protected. the government is withholding health materials from autonomous communities. the risk of coronavirus is due to gender roles. 14 april 2020 • purchase of masks from opaque companies. the government forces companies to provide workers with protective measures when they cannot buy material. the government spends money on protecting cars when there is a lack of material in hospitals and nursing homes. 20 april 2020 • government members fail to comply with confinement. • government management to protect against future malpractice claims. the political use of pandemic management. use of the guardia civil to minimize the anti-government climate. 23 april 2020 • government control of the media. higher payment for medical equipment by the government. lack of material for workers and they are forced to return to work. the hiring of companies without guarantees to obtain sanitary material. 28 april 2020 • use of the police and confinement to control complaints from the population. the government admits that it lies about the number of tests performed. false count in the number of deaths. finally, in figure 7 , the most relevant topics and their impact value on the emotion of disgust are shown. this shows how the management of masks, censorship in the news, and the transmission of the virus in general and especially in groups of elderly people, predominate in this emotion. figure 8 shows the evolution of the fear emotion during the study period, where five peaks can be distinguished, where the emotion shows a sustained decrease over time. in table 2 , the communications that have had the greatest impact on this temporal progression are analyzed in chronological order from 1 march 2020 to 30 april 2020. of these communications, the rapid growth of the pandemic in spain, the overwhelming social security system, and the economic collapse caused by the covid-19 pandemic are the general themes that have the greatest impact on the emotions addressed. aspects such as border closures, death forecasts, job losses, defective health material, the spanish government being overwhelmed, and deaths in residences are the conversations that predominate in digital ecosystems. finally, figure 9 shows the most relevant issues and their impact value on the emotion fear. this shows how interest in the state of alarm, the transmission of the virus, emergency health material, and deaths of family members predominate in this emotion. figure 10 shows the evolution of the anger emotion during the study period, where eight peaks can be distinguished where the emotion shows sustained growth over time. in table 3 , the communications that had the greatest impact on this temporal progression are analyzed in chronological order from 1 march 2020 to 30 april 2020. from these communications, it can be seen that the loss of employment due to lack of foresight, the delay in activating the health alert, and the opacity in the acquisition of health material by the spanish government during the crisis by covid-19 were the driving themes in this case. aspects such as disinformation for de-escalation, the collapse of the health system, the dubious data on the number of infected and dead people, and the control of the media proposed by members of the spanish government are some of the conversations that predominate in digital ecosystems. finally, figure 11 shows the most relevant topics and their impact value on the anger emotion. this shows how the interest in deaths by a coronavirus, the resources to cure the virus, the diagnosed cases, and the rate of infected, predominate in this emotion. this shows that the lack of prevision predominates in this emotion. figure 11 . the themes related to covid-19 and anger emotion that have impacted most along with its impact value. figure 12 shows the evolution of the sadness emotion during the study period, where eight peaks can be distinguished where the emotion shows sustained growth in time. in table 4 , the communications that had the greatest impact on this temporal progression are analyzed in chronological order from 1 march 2020 to 30 april 2020. of these communications, censorship during covid-19, die of coronavirus, coronavirus patients, infection of coronavirus, and the delay in the incorporation to the labor activity are the general themes that have the greatest impact on the emotion dealt with. aspects such as political interests, entities that the security of the population due to the virus, sale of necessary material by the covid-19 pandemic to foreign countries when it is necessary for spain, healthcare workers exposed to infection by defective health care material are some of the conversations that predominate in digital ecosystems. finally, figure 13 shows the most relevant topics and their impact value on sadness's emotion. this shows how the interest in deaths by covid-19, patients by covid-19, the elderly, and infected workers, predominate in this emotion. as shown in figure 14 , the highest presence of the term covid-19 occurred in the early stages of the pandemic, reaching its highest value on the date when the government of spain announced that it would implement the state of alarm and confinement of the population. from that date onwards, there is a downward trend in the use of this term, until 5 april, when an extension of the state of alarm is announced. the spread of pandemics causes uncertainty and fear among the population. this type of crisis, by not adjusting to specific limits, makes risk communication more critical when designing effective strategies [52, 53] . effective risk communication means that all messages can be presented and shared with the population in a transparent, credible, and easily understood communication process. its main objective is to reduce the knowledge gap between the issuers of information and its recipients to adjust public behavior to proactively address risk [54, 55] . the essential elements for reducing risk and avoiding panic among the population are rapid action by public health organizations and truthful and honest information from governments [56] . even though rodin et al. [57] indicate that in the case of a crisis in public health, stakeholders are structured in international and national public health organizations, national governments, nongovernmental organizations, the media, and citizens, the serious situation experienced in spain has led to new actors taking on a decisive role in communication, modifying the organizational structure originally designed by the government. therefore, the little or no dialogue between the government and the social actors that make up the map of the main publics involved in the covid-19 crisis with different points of view in the face of the pandemic leads to the conclusion that the structure of the stakeholders involved does not determine singular, clear and efficient communication that gives confidence to society. the analysis of the government's communication management shows that the messages emitted, mostly with a positive tone, have been offset by a flow of information from other actors in disagreement with government policies. these are mainly channeled by the media and especially the generalist televisions. in spain, three out of four citizens have used generalist television to keep themselves informed during the pandemic. television is also the medium most used by spaniards to seek out different expert opinions. finally, seven out of ten spaniards say that the diversity of journalists, approaches, and news items on generalist television help them form their own opinions [58] . this information, sometimes contradictory, that reaches the population makes uncertainty and panic be perceived by the citizens through digital ecosystems. there are significant differences between the feelings and emotions of the public about covid-19 analyzed in this study and the tone of the risk communication carried out by the spanish government and the committee of experts represented in figure 4 . risk communication has very close links to the behavioral health issues that affect tens of millions of people. fear and anxiety about a new disease and what could happen can be overwhelming and cause strong emotions in the population. through the monitoring of the emotions and the general sentiment of the people across social media about the covid-19 pandemic reveals that: during this time, the use of the term covid-19 followed a decreasing tendency, motivated by the emotions that the population experienced. if at the beginning, the great concern was the virus, the management carried out by the government, the deaths, the social actions, all caused a change in the terms used in the digital ecosystems, with the virus being a secondary problem about the subjects that influence the emotions. the spread of pandemics causes uncertainty and fear among the population. this type of crisis, by not adjusting to specific limits, makes risk communication more critical when designing effective strategies [52, 53] . effective risk communication means that all messages can be presented and shared with the population in a transparent, credible, and easily understood communication process. its main objective is to reduce the knowledge gap between the issuers of information and its recipients to adjust public behavior to proactively address risk [54, 55] . the essential elements for reducing risk and avoiding panic among the population are rapid action by public health organizations and truthful and honest information from governments [56] . even though rodin et al. [57] indicate that in the case of a crisis in public health, stakeholders are structured in international and national public health organizations, national governments, non-governmental organizations, the media, and citizens, the serious situation experienced in spain has led to new actors taking on a decisive role in communication, modifying the organizational structure originally designed by the government. therefore, the little or no dialogue between the government and the social actors that make up the map of the main publics involved in the covid-19 crisis with different points of view in the face of the pandemic leads to the conclusion that the structure of the stakeholders involved does not determine singular, clear and efficient communication that gives confidence to society. the analysis of the government's communication management shows that the messages emitted, mostly with a positive tone, have been offset by a flow of information from other actors in disagreement with government policies. these are mainly channeled by the media and especially the generalist televisions. in spain, three out of four citizens have used generalist television to keep themselves informed during the pandemic. television is also the medium most used by spaniards to seek out different expert opinions. finally, seven out of ten spaniards say that the diversity of journalists, approaches, and news items on generalist television help them form their own opinions [58] . this information, sometimes contradictory, that reaches the population makes uncertainty and panic be perceived by the citizens through digital ecosystems. there are significant differences between the feelings and emotions of the public about covid-19 analyzed in this study and the tone of the risk communication carried out by the spanish government and the committee of experts represented in figure 4 . risk communication has very close links to the behavioral health issues that affect tens of millions of people. fear and anxiety about a new disease and what could happen can be overwhelming and cause strong emotions in the population. through the monitoring of the emotions and the general sentiment of the people across social media about the covid-19 pandemic reveals that: research shows that the current covid-19 pandemic is creating an added strain on our emotional well-being. topics and themes connected to covid-19 include management, social collaboration, death, safeguarding, and lack of foresight. those are strongly related to health and finances, uncertainty about the length of the quarantine, anger over the loss of control, fear of death, illness, loss of employment, economic instability, loss of loved ones, discontent with the spanish government, transparency, a sense of loneliness and, ultimately, fear of the unknown. research results also demonstrate a lot of mixed feelings. it is observed that the same news, information or media communication generated peaks in different emotions, indicating that they are very mixed between sadness, disgust, anger, and fear. presence analysis reveals that the term covid-19 received the highest presence during the early stages of the pandemic, reaching its highest value on the date when the government of spain announced that it would implement the state of alarm and confinement of the population. from that date onwards, there is a downward trend in the use of the term covid-19. during this time, the use of the term covid-19 has followed a decreasing tendency, motivated by the emotions that the population has experienced. initially, as reflected in the study, only the virus (term covid) was of interest, and later, the consequences and direct impact of the virus on daily life. statement on the second meeting of the international health regulations (2005) emergency committee regarding the outbreak of novel coronavirus (2019-ncov); convened by the w.d.-g. under the i.h.; world health organization the outbreak of coronavirus disease 2019 (covid-19)-an emerging global health threat knowledge system analysis on emergency management of public health emergencies the global economic impact of covid-19: a summary of research the oxford handbook of world history a multidimensional model of public health approaches against covid-19 cartographies of time: a history of the timeline ebola on instagram and twitter: how health organizations address the health crisis in their social media engagement the great convergence: information technology and the new globalization social media use in the united states: implications for health communication what does the public know about ebola? 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philos the public and effective risk communication effective risk communication; routledge: london, uk effective risk communication disentangling rhetorical subarenas of public health crisis communication: a study of the 2014-2015 ebola outbreak in the news media and social media in sweden sobre la percepción social de la televisión en abierto the authors declare no conflict of interest. key: cord-013405-68777jts authors: lu, wenze; ngai, cindy sing bik; yang, lu title: the importance of genuineness in public engagement—an exploratory study of pediatric communication on social media in china date: 2020-09-27 journal: int j environ res public health doi: 10.3390/ijerph17197078 sha: doc_id: 13405 cord_uid: 68777jts there is a growing need for the public to interact with pediatricians through social media in china, and genuineness is a crucial factor contributing to effective communication, but few studies have examined the relationship between genuineness and its effect on public engagement. this study developed a four-dimension framework including self-disclosure, genuine response, functional interactivity, and genuineness in chinese culture to investigate the effect of genuineness in the communication of chinese social media influencers in pediatrics on public engagement. content analysis was employed to examine these dimensions and the related public engagement in 300 social media posts on the largest microblogging site in china. the findings indicate that genuine response was positively associated with the number of comments and positive comments, while negatively related to the number of shares. functional interactivity made the site more appealing, resulting in likes and shares. genuineness in chinese culture was reflected in engagement through sharing posts by the public. this study is the first to develop an integrated framework to measure genuineness in online health communication and contributes to the understanding of the effect of genuineness on chinese public engagement in social media. child health and development has been one of the biggest issues in the world health organization. in recent years, chinese president xi jinping has put public health at the center of the country's policy-making agenda, clarifying the need to include public health in official government policy. "the healthy china 2030 planning outline", issued by the chinese state council, is the first long-term strategic plan of public health developed at the national level in china [1] . one of the aims in the plan is to enhance children's health and reduce children's mortality by the construction of pediatrics and the prevention of pediatric critical diseases [2] . as an important area of study in public health, children health advocates the prioritization of children healthcare in public health community as a basis for the improvement of national health [3] . concerning this great emphasis on children's health, sustainable investment and efforts have been put into relevant fields, especially online. chinese premier li keqiang once put forward a guideline named "internet+," aiming to integrate online resources with other domains including education, logistics, and health care. social media is of particular importance in disseminating health information and promoting health communication as china records the world's largest number of registered social media users [4] [5] [6] . of all the social media in china, sina-microblog (aka weibo) is one of the most popular platforms for health communication, with 516 million active online users at the end of 2019 [4] . in recent years, the number of doctors' the constituent parts of online messages to be employed when they attempt to engage the public in health conversations through social media. moreover, a better understanding of how people view doctors' online health communication would strengthen the value of the principles that guide good communication. among all the driving factors in health communication, genuineness has been suggested as a contributing factor in effective medical communication, especially in patient-centered psychotherapy [21] . norcross and newman [22] pointed out that health practitioners considered doctors' genuineness as "important for significant progress in psychotherapy, and, in fact, fundamental in the formation of a working alliance" (p. 104). likewise, therapists' characteristics, especially genuineness, authenticity and honesty can enhance their credibility which was essential for promoting therapeutic alliance and patients' trust [23] [24] [25] . genuineness has been widely studied in face-to-face communication between doctors and patients. little attention has been paid on the importance of genuineness on health communication in the context of social media. due to the absence of concrete operational dimensions in studying genuineness, we developed an integrated framework that included four dimensions-"self-disclosure", "genuine response", "functional interactivity" and "genuineness in chinese culture", for examining genuineness in social media communication based on previous studies in health communication, dialogic communication, and the study of chinese culture. the first three are universal dimensions that occur regardless of the cultural context while the fourth dimension is a cultural determined dimension which is essential to chinese communication. there is no universally agreed-upon definition of genuineness. however, the common features of genuineness focus on "self-dimension," referring to transparency, realness, and the authenticity of one's mind and behavior. in the medical field, landreth stated, "the most significant resource the therapist brings to therapy relationship is the dimension of self. skills and techniques are useful tools, but therapist's use of their personalities is their greatest asset" ( [26] , pp. 104-105). egan also specified that genuineness is "beyond professionalism and phoniness" ( [27] , p. 55). it refers to an attitude or behavior that can only be expressed if the doctor is self-aware [28] . similarly, studies have noted that doctors' genuineness could be conceptualized as being real, being their true authentic self, and getting rid of dishonest and false behavior [29] . nevertheless, how to concretely perceive genuineness via "self" has been understudied. previous studies once demystified the idea that "self-dimension" of doctors' genuineness could be identified by self-disclosure during the health care process [30] [31] [32] . self-disclosure is defined as being willing to consciously and intentionally reveal personal feelings, life experiences, and professional knowledge in the process of communication to establish a positive relationship [30] . self-disclosure has received extensive attention in medical research because of its benefits to patients' positive health practices and doctor-patient relationships [31] . previous research [30] [31] [32] found three main types of self-disclosure being preferred by the doctors, namely the disclosure of personal thoughts/feelings, disclosure of personal life, and disclosure of personal expertise (e.g., pediatrics, neurology and psychiatry). a study reported [31] that patients liked their doctors more when doctors disclose personal feelings and thoughts. patients viewed an act of expressing feelings and thoughts from doctors as friendly and helpful because it encouraged patients to participate in a dialogue and enhance patient's self-exploration [31] . another study suggested that when a doctor disclosed his/her own lifestyle (e.g., positive health behaviors or daily activities), patients considered the doctor to be more credible and approachable [32] . likewise, patients particularly valued when doctors disclosed the accumulated skills, experience, and specific expertise in the field [28] [29] [30] . expanded on the previous studies, our study aims at investigating these three types of self-disclosure exhibited in the smip communication, and how public responded to different types of disclosure. in addition to self-disclosure, prior studies [33] [34] [35] [36] confirmed that genuineness could be manifested when healthcare workers communicate consistently and provide expertise and emotional support to patients. in the health communication, a consistent response from doctor matters because it reflects "the degree to which one person is functionally integrated in the context of the relationship with another, such that there is an absence of conflict or inconsistency between their total experience, their awareness, and their overt communication in their congruence in the relationship" ( [34] , p. 12). a genuine response is not a response that simply expressed yes or no answer or a simple act of reaction (e.g., smile/cry). it emphasizes on the recognition of interlocutors' concerns, thereby providing professional and emotional support to address their problems [33] [34] [35] [36] . a genuine response to a patient's question or concern, is useful for building a positive therapeutic relationship [35] . yet, an absence of an analytical framework for examining genuine response was noted. as such, we have modified frameworks from previous studies [33, 36] on health communication studies and proposed three main sub-dimensions to measure genuine response: (1) consistency, (2) knowledge, skill, experience and treatment advice, and (3) facilitation of hopefulness. consistency emphasizes on whether patients' concerns are well understood, and the response is on the right track [33, 36] . van et al. [36] noted that healthcare workers often rephrase or repeat the patient's questions or concerns before providing follow-up treatment and explanation to demonstrate their understanding on patients' needs. bottorff et al. [33] pointed out that nurses who responded with expert knowledge, such as treatment and medical advice were able to reduce patients' anxiety and uncertainty. they suggested that such responses enable patients to make informed decision-making and be more actively involved in a dialogue [33] . moreover, previous research [33, 35, 36] indicated that nurses usually communicated emotional support through facilitation of hopefulness with patients during a therapeutic process. bottorff et al. [33] and van et al. [36] found that facilitation of hopefulness that nurses adopted in interactions contributed to reassuring patients and avoiding escalation of emotional instability, thereby leading to positive outcomes of treatment. in view of these, we intend to investigate and reveal genuine responses in smip messages by examining the three sub-dimensions adapted from previous studies on health communication [33, 36] . in addition to health communication studies, this study drew on insights from dialogic communication theory in public relation and communication studies where functional interactivity serves as one of the principle elements in creating a genuine and dialogic communication online [37] . functional interactivity refers to the interface's elements that allow an online user to interact with someone/an organization and build a dialogue between interlocutors [38] . such elements include hyperlinks, multimedia, live-chat rooms, and questions [39] . functional interactivity is of particular importance in social media communication where dynamic, two-way interactive communication is advanced by the proliferation of social media [40, 41] . for a genuine and dialogic communication to emerge [37, 40] , interactive functions including "generation of return visits," "conservation of visitors," and "dialogic loop" were deemed necessary. the "generation of return visits" emphasizes on the return visit of the public while the "conservation of visitors" highlights the importance of connecting the public to the smi. both "generation of return visits" and "conservation of visitors" could be achieved by providing external links and hashtags to engage the public [41, 42] . "dialogic loop" placed much attention on promoting dialogue between smi and the public where strategies including providing frequent responses, asking questions, and using multimedia are most employed [41, 42] . subsequently, this study examines the use of interactive functions for building genuine dialogue in smip communication and their association with public engagement. if the first three dimensions of genuineness are universal dimensions that occur regardless of the cultural context, the fourth dimension can be identified as a cultural determined aspect which is essential in chinese communication. in chinese culture, honesty and kindness are viewed as necessary components for developing genuine dialogue [43] [44] [45] [46] , and therefore, are of particular value to the chinese audience. honesty is the essence of confucianism and has a deep impact on the moral personality development [47] . kindness, along with compassion, care, friendliness, righteousness, and affection, is one of the confucian values about a "good person" in chinese culture [48] . a kind individual is positively related to excellent job performance [49] . zhang et al. [50] also illustrated that the kinder a nurse is, the more satisfied patients are. the genuineness in smip communication that attributes to the portrayal of a positive personality trait [46, 47] , could be measured by the use of lexical indicators for the expression of honesty and kindness [43] [44] [45] [46] . honesty in the chinese culture is denoted as the moral quality of being consistent in words and deeds; opposite to hypocrisy; loyalty and open-mindedness; no lying, no fraud, no exaggeration, no distortion of facts [51] . as such, we postulate that lexical indicators related to (1) reasoning and explanation (e.g., because, so), (2) personal sharing and views (e.g., i think, i contend, i prefer), and (3) truth/facts (e.g., in fact, the truth is, the evidence reveals) are important in expressing honesty. kindness in the chinese culture denotes personalities of being friendly, harmonious, kind-hearted and nice, and behaviors of altruistic, affectionate, righteous, and caring [52, 53] . in smip communication, we expected kindness to be expressed through the use of lexical indicators related to (1) caring (e.g., is that okay, are you satisfied, is this clear for you), (2) friendliness (e.g., hello, could you please, welcome), (3) gratitude (e.g., thanks, appreciate it), (4) blessing (e.g., wish you, no worries, everything will be fine), and (5) compliment (e.g., good question, you are right). in our study, public engagement refers to the public's responses to the content communicated via social media which reflects the public's cognition and attitude on a particular issue [54] . different level of public engagement on social media reveals their trust and relationship with involved members [20, 55] . previous research has studied public engagement in different contexts with varied definitions. in corporate-stakeholder communication, bruce and shelley defined public engagement as "the interaction between an organization and those individuals and groups that are impacted by, or influence, the organization" ( [56] , p. 30). in ceo communication, men et al. conceptualize public engagement "as a behavioral construct focusing on publics' interactions with ceos" ( [57] , p. 87). in government communication, public engagement refers to the involvement of citizens in public affairs [58] . in this aspect, public engagement aims to boost mutual understanding and build up a good relationship between the local government and the public [58] . in recent years, scholars have started to study public engagement and perception in an online context due to the arrival of global social media platforms [59, 60] , such as weibo, youtube, twitter, and facebook, which all include the common feature of real-time public interaction. social media includes a variety of functions to engage with the public (e.g., blogs, photo sharing, video sharing, live chatting, and co-generation of content), and offers the ability to express attitudes via reaction buttons, appearing at the bottom of the relevant content: like, share, and comment [60] . "like" is an indicator to express awareness and interest, which can be used to identify the popularity of messages [61, 62] . "share" provides the opportunity to connect the organizational message to one's social group, and "comment" enables direct dialogue with organizations [61] . these engagement indicators fall into different engagement levels. like is the lowest level of engagement as it requires less cognitive effort and commitment than other indicators [62] . share has a higher engagement level [63] , as it can be viewed not only as an important indicator of user recognition but as user recommendation. this indicates that sharing requires certain time to evaluate the post's value [64] . a comment is the highest level of public engagement, as it requires more effort by the public to figure out the meaning of posts and directly respond to the messages with words or descriptors [61] . the number of likes and shares may indicate an overall positive effect but analyzing constituting parts embedded in comments helps estimate outcomes more concretely and accurately [65] . for instance, fan [66] argued that how people perceive products could be revealed in the comments thread. by studying the comments, the organization will know the weaknesses and affordances of products. public perceptions towards the content can also be amplified or constricted by reviewing other users' comments [67] . therefore, comments can be quite persuasive on affecting public opinions [68] . the present research categorizes comments as the high, shares as the intermediate, and likes as the low level of public engagement indicators. beyond the three engagement indicators, we paid particular attention to the valence of positive user comments. kim and yang [63] found that positive comments towards an organization are more likely to affect how people remember the organization, and further influence the organization's reputation. in tourism, for example, positive e-comments on businesses strongly influence travelers who read e-comments when they decide to select a hotel [69] . in the health field, positive online comments were positively associated with the effectiveness of anti-smoking persuasion on the public's attitudes [70] . given the impact of smip on public views and boosting children's health, we aim to identify the effectiveness of genuineness, one of the most influential driving factors in health communication, in smip's online communication. the paper employs the coding framework of four genuineness dimensions generated from dialogic communication, health communication and chinese cultural studies to examine the association between genuineness and public engagement. further, it provides an in-depth understanding on the relationships between genuineness and public reception indicators (i.e., likes, shares, comments, and positive comments). for the first research question (rq), we aim to investigate the association between the four dimensions of genuineness and public engagement, therefore the following research question is put forward: rq1: what is the association between the four dimensions of genuineness ("self-disclosure", "genuine response", "functional interactivity" and "genuineness in chinese culture") and public engagement? to fully understand the relationship within sub-dimensions in each dimension and public engagement, our second set of research questions is formulated as follows: rq2a: what are the associations within the sub-dimensions of "self-disclosure" ("disclosure of personal life", "disclosure of personal thoughts and feelings", and "disclosure of personal expertise in pediatrics") and public engagement? rq2b: what are the associations within the sub-dimensions of "genuine response" ("consistency", "knowledge, skill, experience and treatment advice", and "facilitation of hopefulness") and public engagement? rq2c: what are the associations within the sub-dimensions of "functional interactivity" ("the generation of return visits and conservation of visitors", and "dialogic loop") and public engagement? rq2d: what are the associations within the sub-dimensions of "genuineness in chinese culture" ("honesty" and "kindness") and public engagement? first, we employed a self-developed python program programmed by our research assistant with a postgraduate degree in computational science to identify the top pediatricians based on their number of followers in weibo, one of the largest microblogging sites in china. the crawler is designed to search and identify verified pediatrician using the keywords "pediatrician" and the label "v-users". "v-users" referred to verified users where doctors need to submit their medical certificates to weibo to prove their authenticity. once approved, the letter "v" with a yellow badge will be assigned to these doctors' profile pictures. verified pediatricians are preferred in our study, as they are much more influential in the social media community than non-verified ones [71] . the identified pediatricians with the highest number of followers in march are recognized as social media influencers in pediatric (smip) in our study as they are well connected and persuasive in their field. as an exploratory study, we scrutinized the number of posts published by these top 10 smip for six months (from march 1 to august 31, 2019), to ensure that they are active communicators online. subsequently, we replaced two inactive users who published fewer than two posts/day on average with the next two smip on the list. table 1 presents the final list of top 10 smip. unlike twitter, weibo tends to change its open api at times for the purpose of data security and timely technical updates. moreover, weibo has a strict "restrictions on the api usage rate and unsolicited data requests" ( [72] , p. 597). therefore, we had to manually collect the smip posts, record the number of comments, likes and shares and analyze positive comments for our study. due to the complexity of the ten sub-dimensions embedded in the four dimensions of genuineness, we decided to code the sub-dimensions manually to ensure an accurate interpretation [54] on the use of genuineness in the smip posts. taking all these into considerations, we decided to harvest a sample size of 300 posts to represent the target population. we have employed the sample size calculator developed by the australian statistics bureau [73] to estimate a sample size of 300, giving a confidence level of 95%, a confident interval of 0.056, and standard error of 0.029. through systematic random sampling, we randomly sampled 30 posts from each smip's weibo account between march 1 and august 31 in 2019 for content analysis. content analysis was employed to examine the four dimensions of genuineness adopted in the 300 posts of the top 10 smip on weibo. content analysis is a widely employed method in the study of media communication [74] and can be applied to "virtually any form of linguistic communication to answer the classic questions of who says what to whom, why, how, and with what effect" ( [75] , p. 268). it is concerned with the context where the occurrences of words, signs, and sentences are examined to provide in-depth understanding [74, 76] . researchers could adapt and integrate framework from previous research for conducting coding in content analysis [74, 76] . in this study, we have drawn insights from health communication, dialogic communication and chinese cultural studies (see sections 1.2.1-1.2.4) to develop a four-dimension framework in genuine communication for pediatricians. a code book that includes the four dimensions of genuineness, the ten sub-dimensions, and descriptors to investigate the genuineness in smip's communication has been developed (see table 2 ). the coding procedure of each dimension is listed below: for the dimension of "self-disclosure", we coded the pediatrician's willingness to disclosure information related to his/her: (1) personal life, (2) personal feelings and thoughts, and (3) personal expertise in pediatrics [30] [31] [32] in the post on sentence basis. for the dimension of "genuine response", we coded to reveal if the pediatrician demonstrates: (1) consistency, (2) knowledge, skill, experience and treatment advice, and (3) facilitation of hopefulness in his/her response in comment thread on sentence basis [33] [34] [35] [36] . for the dimension of "functional interactivity", we coded the number of interactive elements (e.g., links, hashtag, multimedia, responses) used to facilitate: (1) "the generation of return visits and conservation of visitors," and (2) creation of "dialogic loop". refs. [37, 39, 41, 42] in the post and comment thread. for the dimension of "genuineness in chinese culture", we coded the number of lexical indicators that demonstrates pediatrician's personality: of (1) honesty, and (2) kindness [43, 45, 46] ; refs. [50] [51] [52] [53] in the post and comment thread. to ensure a high accuracy of analysis, a face-to-face meeting was held by the first author and the second author before the coding exercise. the authors identified the related descriptors, including lexical indicators and features in each dimension. relevant examples were retrieved from the database collected to guide the coders in the process of coding. the first author and a well-trained research assistant who possesses a ma in communication conducted the coding in this study. table 2 presents the four dimensions, ten sub-dimensions, and descriptors of the code book. the related examples extracted from the database could be found in appendix a. for the evaluation of public engagement, the number of shares, likes, comments, and positive comments were identified. beyond three engagement indicators, we paid particular attention to the valence of positive user comments, as positive comments can contribute to the excellent reputation of social media influencers and enhance public trust [65, 77] . online positive comments are characterized by the expression of compliment and affirmation, admiration and gratitude, usefulness and goodness [78] . in the corpus of this study, the comments, such as "thank you doctor," "beneficial advice," "great," and "feel the same way" were recorded. lexical indicators related to reasoning and explanation, e.g., because, so; lexical indicators related to personal sharing and views, e.g., i think, i contend, i prefer; lexical indicators related to truth/facts, e.g., in fact, the truth is, the evidence reveals expressions of care, e.g., is that okay, are you satisfied, is this clear for you; expressions of friendliness, e.g., hello, could you please, welcome; expressions of gratitude, e.g., thanks, appreciate it; expressions of blessing, e.g., wish you, no worries, everything will be fine; expressions of compliments, e.g., good question, you are right. the coding was conducted by the first author, the primary coder, and a well-trained research assistant who possesses a ma in communication. to ensure inter-rater reliability on the coding of "self-disclosure", "genuine response", "functional interactivity", "genuineness in chinese culture", and public engagement, the coders were highly trained on the coding scheme. any disagreement between the two coders was discussed in the coding process until the agreement was achieved. the measure of interrater reliability was based on the co-coding of 60 posts from the top two smip (20% of the total number of posts studied). for all categories, the average agreement was higher than 0.95, and the average cohen's kappa was greater than 0.9, indicating an almost perfect agreement [79] . please refer to table 3 for the interrater reliability of all categories. since the content in posts and responses in comment threads varied from two words to 140 words, all coded data have been standardized, especially the coding done on sentence basis. as such we have standardized the coding data of the sub-dimensions in "self-disclosure" and "genuine response" by dividing the number of sentences yielded in each sub-dimension in every post by the overall number of sentences in each post. as for the sub-dimensions of "functional interactivity" and "genuineness in chinese culture", we standardized the data by dividing the number of features harvested in each sub-dimension in every post by the total count of features in each post. as likes, shares, comments, and positive comments are count outcomes, poisson regression was employed for statistics analysis. however, we found overdispersion exhibited when testing for assumptions in poisson regression. then we decided to employ negative binomial regression to replace poisson regression as suggested in previous research [80, 81] . negative binomial regression (nb2) fits various types of data arising in communication research [81] , and "the negative binomial model is a more general model compared with the poisson regression model that relaxes the strong assumption that the underlying rate of the outcome is the same for each included participant" [82] (p. 3). moreover, negative binomial regression allows various information to be included [82] ; it is appropriate for the data in this study, especially in the presence of overdispersion. thus, rq1 and rq2 were examined via negative binomial regression in which likes, shares, comments, and positive comments were taken as dependent variables. for the examination of associations between the four dimensions and public engagement in rq1, standardized data in the sub-dimensions were summed up in the related dimension. for instance, the data in "disclosure of personal life", "disclosure of personal feelings and thoughts", and "disclosure of personal expertise" were combined to form the "self-disclosure". as for rq2, we used the standardized data in the sub-dimensions to examine if there was a significant association between sub-dimensions in each genuineness dimension and public engagement. in this section, we aim to reveal the association between the four dimensions of genuineness and public engagement and then identify different levels of impact of sub-dimensions in each genuineness dimension on public engagement. in response to rq1, the nb2 findings indicated the number of "genuine response" was positively associated with the number of comments and positive comments, but negatively related to number of shares. for every extra sentence on "genuine response", 1.344 times more comments were generated, a statistically significant result (p < 0.0001). similarly, there was a 16% increase in the number of positive comments for each extra sentence on "genuine response" (p = 0.0001). likewise, a positive association was found between the occurrence of "functional interactivity" and shares, whereas there was a negative correlation with comment and positive comments. a 19.8% increase in the number of shares is expected for every extra feature in "functional interactivity" found (p = 0.0001). in addition, the frequency of "genuineness in chinese culture" was positively related to the number of shares. for every extra lexical indicator in "genuineness in chinese culture", 1.122 times more shares were generated (p = 0.003). table 4 summarizes the negative binomial regression results on the four dimensions of genuineness and public engagement. the results above show that three sub-dimensions of genuineness, namely "genuine response", "functional interactivity" and "genuineness in chinese culture", have significant associations with public engagement on social media. therefore, we intend to further examine the association between the sub-dimensions in the four genuineness dimensions and public engagement. table 5 summarizes the negative binomial regression results on the sub-dimensions of "self-disclosure", "genuine response", "functional interactivity", "genuineness in chinese culture" and the number of shares, likes, comments and positive comments. in response to rq2a, we found that in the dimension of "self-discourse", "disclosure of personal life" had positive effects on the number of user shares and likes, while "disclosure of personal expertise in pediatrics" is positively associated with number of shares. for every extra sentence in "disclosure of personal life" and "disclosure of personal expertise in pediatrics", 1.23 (p = 0.003) and 1.13 (p = 0.005) times more shares were generated. for every extra sentence in "disclosure of personal life", 1.26 times (p = 0.0003) more likes were expected. however, the "disclosure of personal thoughts and feelings" was negatively associated with the number of comments. for every extra sentence in "disclosure of personal thoughts and feelings", 0.89 times (p = 0.033) fewer comments were expected (see table 5 ). regarding the sub-dimensions in "genuine response" (rq2b), our findings revealed that "consistency" had positive effect on the total number of likes, comments, and positive comments. 1.402 times more likes (p = 0.0003), 1.581 times more comments (p < 0.0001) and 1.347 times more positive comments (p = 0.001) were witnessed for every extra sentence on "consistency" provided. similarly, the sub-dimension of "knowledge, skill, experience and treatment advice" was positively associated with the number of comments and positive comments. for each extra sentence on "knowledge, skill, experience and treatment advice", 1.342 times more comments (p < 0.0001) and 1.166 times more positive comments (p = 0.013) were yielded. however, the sub-dimension of "facilitation of hopefulness" was negatively associated with the number of likes and shares. for every extra sentence on "facilitation of hopefulness", 0.55 times fewer shares (p = 0.001) and 0.742 times fewer likes (p = 0.023) were generated, as presented in table 5 . for the dimension of "functional interactivity" (rq2c), the "generation of return visits and conservation of visitors" had positive effects on the total number of shares and likes, whereas "dialogic loop" had a negative association with the number of comments and positive comments. p < 0.05 *, p < 0.01 **, p < 0.001 ***, p < 0.0001 ****. table 5 . negative binomial regression results on the sub-dimensions of "self-disclosure", "genuine response", "functional interactivity", "genuineness in chinese culture" and the number of shares, likes, comments and positive comments. p < 0.05 *, p < 0.01 **, p < 0.001 ***, p < 0.0001 ****. for every additional "conservation of visitors and the generation of return visits" included, the shares and likes increased by 43% (p = 0.001) and 22% (p = 0.018) respectively while comments and positive comments decreased by 84% (p = 0.005) and 88% (p = 0.015) for every extra feature of "dialogic loop" provided, as shown in table 5 . last but not least, "honesty" in the dimension of "genuineness in chinese culture" (rq2d) had a positive association with the number of shares, likes, and positive comments in contrast to kindness, which showed no significant association. for every extra lexical indicator on "honesty", 1.158 times more shares (p = 0.001), 1.106 times more likes (p = 0.0004), and 1.07 times more positive comments (p = 0.007) were generated, as presented in table 5 . our results revealed that a variety of genuineness dimensions was employed by the smip to communicate with the public on social media. the findings yielded insights into how the "genuine response" alongside "functional interactivity" and "genuineness in chinese culture" played an active role in engaging the public. corroborated with previous studies [33, 36, 83] , our findings revealed that responses with high level of consistency and expert knowledge were positively associated with public engagement (table 5) . a doctor responded by acknowledging the public's need helps develop a trustful relationship [84] , even in online doctor-public communication. furthermore, response with medical knowledge and treatment advice indicates the doctor's understanding of patient's concerns and his/her intention to address the issues [85] . this could be the reasons attributing to the positive association between "genuine response" and the number of likes and comments, especially the positive comments. "genuine response" that aimed to address patients' concerns created more opportunities for the public to express feelings (e.g., grateful, satisfied) in the comment threads, and allowed them to continually ask questions if their concerns were not fully addressed. the phrases "thanks, doctor," "beneficial advice," "learn a lot," "really appreciate your patient guidance" and "what i need to do in the next step" were frequently unveiled under the comment threads. in line with previous studies [37, 40, 42, 57] , our results also revealed the strong effect of "functional interactivity" on public shares (tables 4 and 5) . we found a range of interactive features, in the form of links/hashtags, such as "#simp name+topic#", "@+other online users name" and "link to other weibo pages", employed on the smip posts which foster the public's access to various and detailed information. hashtags lead users to daily hot topics where users can make synchronous conversations, discuss relevant issues with others, and share insightful ideas [57] . links enable users to return the site and increase the time of stay when reading messages [42] . owing to word limit on weibo, the smip messages may not explain the ins and outs of a health problem thoroughly. the offering of external links expands messages in greater detail and strengthens the usefulness of corresponding posts, thereby fostering information sharing. given that the act of sharing can potentially reach out to a large audience, online doctors can adopt interactive elements to express genuineness and extend their influences. noticeably, the sub-dimension "honesty" positively engendered public engagement of likes, shares and positive comments ( table 5 ). the expressions in honesty mainly involve verbs and adverbs related to explanation, personal views, and facts, such as "for instance," "include," "i think," "i suggest," "according to," and "the document shows." tuckett [86] specified that "honesty" is "perceived as truth-telling" (p. 500), and the extent to which truth-telling is preferred is highly related to culture and context. as noted in previous study [86] , "honesty" is a fundamentally ethical principle in doctor-patient relationships. the majority of patients in china demonstrate that they want truthfulness and authenticity about their illness, which could enable them to manage uncertainty and make decisions independently [50] . this might also explain the negative association between sub-dimension of "facilitation of hopefulness" in the "genuine response" and shares and likes. to some extent, expression of hopefulness is intended to comfort patients instead of telling the whole truth [33, 36] , and the truthfulness of such expressions often arises suspicion. also, the shared post represents the user [62] . a previous study [87] found that online self-presentation was a crucial part of impression management, in which the public carefully evaluated someone by how he presented himself. this suggests that sharing requires more cognitive effort [64] . given that "honesty is the traditional morality of chinese nationalities and is regarded as the basis of the making of a man" ( [88] , p. 177), it is not surprising to see the public's willingness in sharing "honest" so as to promote positive personality traits on social media. despite previous studies suggested doctor's "self-disclosure" may have a positive impact on patients' reactions and foster a stronger therapeutic relationship, our results reveal that "self-disclosure" has no significant association with any level of public engagement (table 4 ). beach et al. [89] argued that doctors' personal disclosure to patients have sometimes been regarded as a boundary transgression. doctors should be more careful about disclosing personal information [86] . "self-disclosure" has been viewed as a positive intervention in doctor-patient communication but it could also hinder effective communication and lead to negativity [90] . kelly and achter [91] found that patients concerned the helpfulness and benefits of the disclosure information from doctors for their decision on engagement. if they think the information would be useful for their situations, they are willing to further interact with doctors and listen to their suggestions [92] . however, given that "self-disclosure" messages in this study mainly involve personal life, opinions, and feelings that may not be relevant to the public's concerns and problems, a lower level of public engagement is expected. forest and wood [90] commented that it is not surprising that people may disapprove or doubt the information provided by therapists who share personal opinions and experience frequently. likewise, disclosure of personal expertise may involve the discouraging expressions [92] , which makes the public feel sad and stressful. in addition, mcdaniel et al. [93] found that the frequent statements about the doctor's personal life (e.g., family, habit) and professional information are, occasionally, of little value to impair the doctor-patient relationship because they may result in fewer opportunities for patients to express themselves. general information is prevalent in smip's posts on weibo as each post is limited to 140 words, but there are a variety of followers with different needs. in other words, the posts cannot meet everyone's demands even though smip want to provide detailed information. therefore, the public may not react to some information that is not tailored to their problems. academically, this study contributes to the research of health communication in the following aspects: (1) developed an integrated framework to conceptualize and measure genuineness in social media communication and (2) shed lights in the understanding of effect of genuineness on chinese public engagement in smip online communication. in terms of practical implications, this study provides insights to health information providers such as pediatricians in engaging public on social media communication. for instance, the use of "genuine response" could raise public awareness which in turn facilitates the fostering of a healthy lifestyle. this study also has strong social implications. in recent years, the chinese government has placed public health at the center of the country's entire policy-making agenda and initiated a national long-term strategic public health plan. one of the missions is to improve the well-being of citizens coding items examples genuine response 1. consistency rephrase public's question and concern no 1: mar.10, 06:00 user one: 你好医生, 宝宝9个月，能逗笑，会发妈妈的音，能抓玩具，能扶着腋窝 站立，不能独坐超过7.8秒，要东倒西歪的，趴几秒也要哭就把两只手放两边，请 问这种情况做康复能好吗？ literal translation: hello doctor, my baby is 9 months old. he can laugh, make the voice of "mommy", grasp toys, and stand by armpit, but can not sit alone for more than 7 or 8 seconds. he often comes to cry for a few seconds when he is prostrating. i wonder whether he would recover from this situation? pediatrician: "9个月，能逗笑，会发妈妈音，能抓玩具，能扶着腋窝站立，不能独 坐超过7.8秒，趴几秒也要哭就把两只手放两边。"据叙述，大运动发育落后。"能 扶着腋窝站立"这一定是家长扶着孩子站，不利于大运动发育，反而会有消极作 用。建议看神经康复科医生，是发育问题，还是家长养育问题。 literal translation: "nine months, can make you laugh, can make your mother's voice, can grasp toys, can stand by your armpit, cannot sit alone for more than 7 or 8 seconds, can cry even if you lie down for a few seconds." according to your illustration, it could be said that the development of large motor skills is backward. "can support the armpit to stand" indicates parents was helping the child to stand, which is not conducive to the development of large motor skills and will have a negative effect. i suggest you should consult a neurologist to see if it is a developmental or a parenting problem. provide treatment advice to address public's concern no 2: may.9, 23:11 user one: 您好 吖一岁15天 不吃奶瓶已经十天了 只吃亲喂 奶量肯定不够 什么缘 故？怎么办呢？ literal translation: hello, my son is one year and 15 days old and has not fed by bottle for 10 days. i think the amount of breast-feeding may not be enough. what is the reason and what shall i do? pediatrician: 可以杯子喂奶 同时试试奶酪和酸奶。 literal translation: you can try to feed him by a cup. at the same time, feed him with some cheeses and yogurt. literal translation: as long as the mother has no discomfort after perming and dyeing her hair, she would not affect her children through breastfeeding. just keep in mind that do not let the child lick his/her mother's hair. everyone has a desire for beauty. after giving birth to the baby, most mothers want to recover their body shape and bright skin as soon as possible. thus, hair dyeing, perm, fingernail dyeing can be carried out. mothers will take care of themselves. literal translation: my son has 2 teeth within 8 months. when he was one year and 3 months old, he only had 8 teeth; at present, he is one and a half years old but only with 4 teeth growing. we eat the food, e.g., cod liver oil filled with calcium everyday, so what is wrong? pediatrician: 只要有牙齿出就说明牙齿发育没有问题，耐心等待即可。放轻松。 literal translation: as long as you can see teeth out and growing, there is no problem with tooth development. just be patient and relax. link to the pediatrician's clinic/organization/own weibo page no.3: mar.31, 12:05 哺乳期妈妈生病就要扛吗？还可以喂奶吗？很多妈妈在哺乳期的时候，十分谨慎， 生怕自己生病后不能哺乳，从而影响宝宝生长。有的则是因为家里老人怪自己生 病，怕传染给孩子。这个问题，点击"《我的诊室》"了解更多，网页链接 literal translation: is it necessary for lactation mothers to endure illness with silence? can they still provide breastfeeding? many mothers fear that they may not be able to breastfeed when they are ill in case of affecting the growth of their babies. some concern that the child's grandparents will blame them for being sick and infecting their children. for this concern, click "my clinic" to learn more link to other social networks in which the pediatrician is present no.1: apr.21, 06:22 孩子出现喂养不适很可能与疫苗有关，但不应该是大问题。如果孩子没有新的不 适，家长耐心等待，1-2周会自然恢复。还要关注排便情况。#崔玉涛讲疫苗#。 literal translation: feeding discomfort in children is likely to be related to vaccines, but it is not a big problem. if the child has not emerged new discomfort, the parents need to wait patiently. the child will recover naturally in 1-2 weeks. also, you should pay attention to defecation. #cui yutao talks about vaccines#. healthy china 2030 (from vision to action) outline of healthy china china cdc's chief expert of maternal and child health guizhou province# <the first story of my experience with dongzhai children >, all the things we are insisting on are worthwhile healthy china 2030 (from vision to action) outline of healthy china china cdc's chief expert of maternal and child health weibo monthly active users reach 516 million and barriers to entry remain solid how the public uses social media wechat to obtain health information in china: a survey study a new dimension of health care: systematic review of the uses, benefits, and limitations of social media for health communication china health science popularization alliance officially established the impact of social media influencers on purchase intention and the mediation effect of customer attitude opinion leadership in a computer-mediated environment the network effect on information dissemination on social network sites exploring factors influencing chinese user's perceived credibility of health and safety information on weibo functional interactivity in social media: an examination of chinese health care organizations' microblog profiles social support on weibo for people living with hiv/aids in china: a quantitative content analysis. chin smoking prevention in china: a content analysis of an anti-smoking social media campaign when health information meets social media: exploring virality on sina weibo characterizing depression issues on sina weibo attention, attitude, and behavior: second-level agenda-setting effects as a mediator of media use and political participation let the talk count: attributes of stakeholder engagement, trust, perceive environmental protection and csr. sage open customer agility and responsiveness through big data analytics for public value creation: a case study of houston 311 on-demand services citizen participation, community resilience and crisis-management policy conceptual considerations regarding self-disclosure: a relational psychoanalytic perspective psychotherapy integration: setting the context the significance of therapist genuineness from the client's perspective therapist nonverbal behavior and perceptions of 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measurement processes and preliminary results in the construction of the chinese personality scale (qzps) grappling with the covid-19 health crisis: content analysis of communication strategies and their effects on public engagement on social media public engagement as a means of restoring public trust in science-hitting the notes, but missing the music? public health genom assessing stakeholder engagement social presence and digital dialogic communication: engagement lessons from top social ceos a typology of public engagement mechanisms pandemics in the age of twitter: content analysis of tweets during the 2009 h1n1 outbreak an exploratory study on content and style as driving factors facilitating dialogic communication between corporations and publics on social media in china the like economy: social buttons and the data-intensive web like, comment, and share on facebook: how each behavior differs from the other. public relat analyzing user retweet behavior on twitter the culture of connectivity: a critical history of social media staking reputation on stakeholders: how does stakeholders' facebook engagement help or ruin a company's reputation? public relat research on the external factors of consumers releasing online comments what do others' reactions to news on internet portal sites tell us? effects of presentation format and readers' need for cognition on reality perception word-of-mouth research: principles and applications the impact of positive and negative e-comments on business travelers' intention to purchase a hotel room effects of online comments on smokers' perception of antismoking public service announcements how" big vs" dominate chinese microblog: a comparison of verified and unverified users on sina weibo how ikea turned a crisis into an opportunity. public relat the practice of social research content analysis: a flexible methodology friendship expectations and friendship evaluations: reciprocity and gender effects suggestion analysis for food recipe improvement computing inter-rater reliability for observational data: an overview and tutorial interpreting poisson regression models in dental caries studies some applications of the negative binomial and other contagious distributions do alternative methods for analysing count data produce similar estimates? implications for meta-analyses a model of empathic communication in the medical interview development of the trust in physician scale: a measure to assess interpersonal trust in patient-physician relationships how does physician advice influence patient behavior? evidence for a priming effect truth-telling in clinical practice and the arguments for and against: a review of the literature strategic self-presentation online: a cross-cultural study historical origin of the morality of "honesty" and "honesty" education for college students what do physicians tell patients about themselves? a qualitative analysis of physician self-disclosure when social networking is not working: individuals with low self-esteem recognize but do not reap the benefits of self-disclosure on facebook self-concealment and attitudes toward counseling in university students to seek help or not to seek help: the risks of self-disclosure physician self-disclosure in primary care visits: enough about you, what about me? this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license exemplification of four genuineness dimensions and relevant expression identified in the corpus.coding items examples self-disclosure 1. disclosure of personal life no. 7: may.12, 20:36 上午带小七一起去仙林金鹰广场观看全民营养周启动仪式，仪式活动很棒，小七表 现也很棒，天很热，小七全程很认真地看完。午餐时饿了，吃哈密瓜，鸡翅，意大 利面，还吃了半块含有牛奶和鸡蛋甜点，本来知道她会过敏，不给她吃，抢着要 吃，不过吃了没有出现明显过敏症状。 literal translation: in the morning, i took xiaoqi to xianlin golden eagle square to watch the launching ceremony of national nutrition week. the ceremony was great. xiaoqi performed well. it was scorching, but xiaoqi watched the whole process carefully. i ate cantaloupe, chicken wings, spaghetti, and half of the dessert at lunch. i knew that she would be allergic, so i did not give the food to her. however, she insisted on eating them, and i had not found any obvious allergic symptoms with her after eating. literal translation: experts research shows that from the perspective of health economics, the early childhood investment is the highest ratio of human capital input to output in the whole life cycle. the early return on investment is more than 1:7, so the development of early childhood potential not only determines the development potential of individuals but also profoundly affects the competitiveness of our country's human resources. literal translation: good question! first of all, we should ensure the intake of vegetables for the kids. vegetables contain vitamin k, which is produced by healthy intestinal flora. eating green leafy vegetables has many advantages for both children and adults. there is a mixture of vitamin d3 and vitamin k2 for now. key: cord-262927-mehijkzo authors: guo, shuaijun; yu, xiaoming; okan, orkan title: moving health literacy research and practice towards a vision of equity, precision and transparency date: 2020-10-20 journal: int j environ res public health doi: 10.3390/ijerph17207650 sha: doc_id: 262927 cord_uid: mehijkzo over the past two decades, health literacy research has gained increasing attention in global health initiatives to reduce health disparities. while it is well-documented that health literacy is associated with health outcomes, most findings are generated from cross-sectional data. along with the increasing importance of health literacy in policy, there is a lack of specificity and transparency about how to improve health literacy in practice. in this study, we are calling for a shift of current research paradigms from judging health literacy levels towards observing how health literacy skills are developed over the life course and practised in the real world. this includes using a life-course approach, integrating the rationale of precision public health, applying open science practice, and promoting actionable knowledge translation strategies. we show how a greater appreciation for these paradigms promises to advance health literacy research and practice towards an equitable, precise, transparent, and actionable vision. health literacy underpins everyday health behaviours and health-related decisions. defined as an individual's ability to find, understand, and use health information to promote and maintain good health [1, 2] , the term "health literacy" has been widely used in healthcare, disease prevention, and health promotion since the 1990s [3] . health literacy is a context-and content-specific concept; this means that researchers need to define and measure it within a specific context for a particular purpose [4] . from a public health perspective, health literacy is regarded as a personal asset that evolves over the life course and promotes empowerment in health decision-making [5] [6] [7] . in the context of the coronavirus disease of 2019 (covid19) , an individual's health literacy supports his/her decisions on washing hands, maintaining physical distance, adopting protective behaviours, seeing a doctor, and complying with quarantine policies, thus contributing to a more likely successful public health response strategy [8] [9] [10] . health literacy also helps to navigate the infodemic-the overabundance of valid and invalid information that is circulating on the internet-that is attached to the covid-19 pandemic [11, 12] . low health literacy is a global public health concern. internationally, it is estimated that 28.7% to 92.7% of adults have low health literacy [13, 14] , costing national governments at least $106 billion annually [15] . mounting evidence suggests that low health literacy is associated with adverse health outcomes [16] [17] [18] , including frequent use of emergency care, prolonged hospital stays, and high mortality rates, which in turn lead to health disparities [19] . national and international health programs have shown promising outcomes (e.g., improved health knowledge, healthier behaviours, self-management of chronic illness, access to healthcare) when intervening to improve health literacy [20] [21] [22] . most recently, the world health organization's shanghai declaration on promoting health in the 2030 agenda for sustainable development highlighted health literacy as an integral part of the skills developed over a lifetime and recognized it as a critical driver of achieving an equitable world [23, 24] . enhancing health literacy requires a systems approach to understanding its risk factors and its impact on health outcomes [4, 25, 26] . the social determinants framework suggests that health literacy is an interactive product of an individual's health literacy skills and the broad environment and culture [27, 28] . empirical studies show that health literacy levels differ substantially across age groups and countries. based on the demographic and health surveys, mcclintock et al. [29] found that the prevalence of poor health literacy among respondents aged 15-49 years ranged from 36.1% in namibia to 91.5% in niger across 14 sub-saharan countries. as for children and adolescents, the health behaviour in school-aged children study shows that, in 10 countries (e.g., austria, england, finland), a total of 13.3% of participants have low levels of health literacy, ranging from 6.0% to 17.7% across countries [30] . there is a social gradient in health literacy for children [31] , adolescents [32] , and adults [14] . the lower the socioeconomic status an individual has, the lower the health literacy level is likely to be. health literacy can affect health outcomes at each life stage. prior to childbirth, low health literacy in pregnant mothers has a significant impact on the health and development of their offspring, including prematurity, infancy death, and child vaccination participation [33] . low health literacy in children and adolescents is associated with poor health behaviours, such as smoking, alcohol use, and obesity [34] [35] [36] [37] . when children and adolescents transit into adulthood and older age, health literacy is closely linked with healthcare outcomes, such as prolonged hospitalization and poor medication adherence [17, 38] . while health literacy research has gained momentum in the global context [39, 40] , it is predominated by cross-sectional studies, with less than 8% of all published papers focusing on health literacy interventions, including randomized controlled trials [41, 42] . unlike time-series data, cross-sectional data make it impossible to make a valid statement regarding the change. health literacy is a life-course personal asset [43] , which progresses as a child grows up with different characteristics and health needs at each life stage [7, 44] . for instance, children's and adolescents' health literacy rely heavily on their developmental ability and their parents and peers [45] . when they transition into adulthood, they become more independent in making their own decisions in healthcare, disease prevention, and health promotion [14] . as cognitive function declines with age, older adults are an especially vulnerable group, with low self-management ability for everyday health-related decisions [43, 46, 47] . currently, there is a lack of holistic ways to look at the impact of health literacy over the life-course due to a lack of longitudinal studies. there is promising evidence showing the effectiveness of health literacy interventions on health outcomes at the individual and community level [20, [48] [49] [50] . however, there remain substantial gaps. in practice, health literacy interventions vary in terms of their study designs, measurement tools, and types of outcome measures [21, 22] . besides, there is a lack of specificity in the intervention targets (e.g., individual level, organizational level, community level), content (e.g., functional health literacy, interactive health literacy, critical health literacy), timing (e.g., antenatal, preschool, adolescence), and formats (e.g., universal, intensive, low-threshold). it remains unclear about which interventions are the most effective in improving health literacy, related health behaviours, and associated health outcomes. when translating health literacy evidence into practice, researchers should design interventions that are specifically tailored to people with different health literacy levels and needs [21, 51] . there is a need to use precise and transparent approaches to improving health literacy and reducing health inequities in the end. in response to low health literacy levels in the population, many countries have developed national action plans to strengthen health literacy for achieving sustainable development and health equity (e.g., the national actional plan to improve health literacy in the usa [52] , the national statement on health literacy in australia [53] , the national action plan health literacy in germany [54] ). common features in these policy documents include a response to perceived deficiencies in health literacy, the importance of professional education in improving the quality of communication, and a need for responsive healthcare systems [55, 56] . policy responses to health literacy are important public statements of priorities by governments and provide a mechanism for public accountability [55, 57] . however, in contrast to the increasing number of evidence generated from empirical studies, discussions on the knowledge translation and implementation process are scarce. there remains a lack of specificity in the implementation process and monitoring systems for progress. this perspective is a proposition for four new research paradigms to address the aforementioned knowledge gaps, expecting to move health literacy research and practice towards an equitable, precise, transparent, and actionable vision. this includes using a life-course approach to health literacy [58] , integrating the rationale of precision public health [59] , applying open science practice [60] , and promoting actionable knowledge translation strategies [61] . in what follows, we will discuss the life-course approach to health literacy as a starting point, and then the necessity of integrating the rationale of precision public health. we are calling for a shift of current research paradigms from judging health literacy levels (low versus high) towards observing how health literacy skills are practised and developed over the life-course. based on these new paradigms, we expect a nuanced understanding of how health literacy develops over the life-course, how it influences health behaviour and decision-making, and thus how it informs specific interventional opportunities-especially in the early life stages across educational and healthcare settings-for a precise policy recommendation. we also highlight the importance of applying open science and considering knowledge translation strategies from the beginning of research planning to generate or replicate policy-relevant findings rapidly and cost-effectively across different cultural contexts, and thus facilitate the process of knowledge dissemination. we need to extend the current concept of "health literacy" from cross-sectional to longitudinal studies. health literacy is a personal asset that develops dynamically over time [43] . a life-course approach to health literacy will assist researchers in discovering opportunities for optimizing health development and reducing health inequities, and explaining how health practices and policies can go beyond the avoidance of disease to the promotion of health at the early life stages [7, 42, 43] . as shown in figure 1 , we recognize potential intervention levers (both upstream and downstream) for giving all children the best start to life. a life-course approach to health literacy aligns with national and international health initiatives that aim to reduce inequities (e.g., the national action plan for children and young people in australia [62] ). a life-course approach is well-recognized in public health research and practice to close the gap in health inequities [58, 62] . using life-course data from the wisconsin longitudinal study 1957-2011, clouston et al. [43] found that life-course predictors of health literacy among older adults included parental educational attainment, and adolescent cognitive and non-cognitive skills. findings from this life-course analysis add to our understanding of how health literacy might change over time through adolescent cognitive and non-cognitive skills. depending on the research purpose and available data sources, researchers could also propose other specific research questions using one of the life-course models exemplified in table 1 . for example, early life represents a sensitive period of health and development. exposure to stressors associated with disadvantages during this time can exert adverse effects on health over the life course [7] . using the sensitive period model, researchers can examine and compare the effect of parental health literacy on children's health behaviours and health outcomes at different ages of children (e.g., pregnancy, infancy, toddler age). a life-course approach to health literacy (hl) and its impact on health and social outcomes. table 1 . applying life-course models to health literacy research. the sensitive period model to examine timing effects in which exposures during sensitive periods of development have stronger effects on health, social, emotional, and cognitive development outcomes than they would have at other life stages [63] . • to examine and compare the effect of parental health literacy during pregnancy and infancy on infant and child health outcomes. • to examine and compare the different timing effects of risk or protective factors (e.g., socioeconomic status) in early years on health literacy in later years. the accumulation model to examine the role of persistent advantage or disadvantage over time-in both specific life stages and over life stages-on health and development [64] . • to examine the role of persistent advantage or disadvantage (e.g., socioeconomic status, ethnic minorities) on health literacy in a specific life stage and over the life course. to examine the effect of persistent high or low health literacy (e.g., using the growth-based trajectory modelling method) on health outcomes over the life course. the pathway model to examine the pathway effects whereby early experiences set in motion a chain of events that put individuals on paths differentiated by types and levels of exposures to social and biological factors [65] . • to examine the mediating role of health literacy (e.g., adolescent health literacy) in the relationship between socioeconomic disadvantage and health outcomes. the social mobility model to examine the unique importance of social mobility in explaining the early-life and later-life socioeconomic status and health link [66] . • to examine whether the effect of later-life exposure (e.g., socioeconomic status, immigration status) on health literacy is stronger than the effect of early-life exposure. we are entering an era of "big data" and "precision". big data has enabled extensive and specific research and trials of stratifying and segmenting populations at risk for a variety of health problems, including poor health literacy [67] . in the field of big data and public health, machine learning is a fundamental component of data analytics that provides data-driven insights, decisions, and predictions [68, 69] . machine learning techniques have been broadly adopted for researchers to answer a series of public health research questions (e.g., identifying leading dietary determinants in children [70] , predicting the development of type 2 diabetes [71] ). using different machine learning approaches, researchers can also address health literacy research questions, such as identifying elderly people at high risk of low health literacy. particularly, the breadth of longitudinal data available in existing cohorts enables researchers to generate policy-relevant findings quickly [72] . similar to the precision medicine initiative of providing the right treatment to the right patient at the right time [73] , a precision public health approach to health literacy calls for harnessing the power of resourceful life-course data to inform the right intervention to the right population at the right time [59, 74] . in the context of covid-19 [75] , precision public health is particularly useful to design targeted interventions for populations by person, place, and time to promote better navigation of health care and disease prevention [76] . if a population has a higher proportion of persons with low health literacy, public messages could be provided to educate persons on where to obtain trustworthy information and when to seek health professionals [76] . integrating the rationale of precision public health aligns with the relation-and context-specific nature of health literacy [4, 26] . currently, there is a lack of specificity to inform clear health literacy policy decisions [72] . figure 1 shows that there are substantial opportunities for researchers to generate specific recommendations between personal and social determinants and health literacy (i.e., upstream intervention levers), and between health literacy and health and social outcomes (i.e., downstream intervention levers). for example, the education sector is a critical platform for health literacy interventions, and education for health literacy is a fundamental process and outcome across the life course [40] . precision evidence is needed, such as at which time point, at what dosage, and which delivery approach is likely to have the most significant impact on improving population health literacy and reducing health inequities. we need to identify precise policy levers (either upstream or downstream) and build an evidence base with sufficient specificity to generate actionable policy implications. open science refers to a range of practices that promote transparency, openness, and reproducibility in research [77] . efforts to reproduce published findings have yielded a concerningly high failure rate (e.g., only 62% replicated in nature and science [78] ) [79, 80] . in response to concerns about this "reproducibility crisis", the open science practice has been increasingly recognized across disciplines [60] . [81] . however, in practice, null results are less frequently published than statistically significant results and are more likely to be inaccessible and lost in the "file drawer" [82] . to reduce publication bias, we need to move the current evidence of health literacy from an era of "publish or perish" to "visible or vanish" [83] . transparency, openness, and reproducibility are central principles of open science practice [77] . examples of open science practice include a preregistered report, detailed analytic plan, and publicly shared coding via the open science framework (table 2) [77, 84] . a future vision for health literacy research is to increase its clarity, credibility, and transparency, which can help to provide reliable evidence that can serve as a basis for making decisions about clinical or population-health interventions [85] . for example, the health literacy tool shed is an online, publicly accessible database of health literacy measures [86] . currently, more than 200 measurement tools are available. healthcare providers and researchers can search and select the most appropriate instrument according to a specific research purpose [86] . adoption of open science practice in health literacy research is effective to replicate studies across different cultural contexts. it also provides researchers with a system structure in documenting their work and improving workflows, and offers a path to publication irrespective of the null conclusions [84, 87] . knowledge translation is the exchange, synthesis, and ethically sound application of research findings within a complex set of interactions among researchers and knowledge users [88] . while a number of knowledge translation frameworks has been developed for researchers [89] , there is a well-known gap between research and practice [90, 91] . it is estimated that it takes 17 years for just 14% of medical research to be implemented [83, 92] . this is the same case in the field of health literacy [93, 94] . while the importance of health literacy is increasingly recognized in national and global health initiatives [23, 62, 95] , there is still a long way to go when applying health literacy into current practice [50, 96] . the evidence synthesis shows that, of the 46 existing and developing health literacy policies in european regions, the main barriers influencing the successful implementation of health literacy policy include cultural barriers, budget restrictions, and the difficulty obtaining high-quality evidence. besides, there is also a lack of engagement in policy evaluation by the academic community [20] . translating the best available research evidence into evidence-based practice and policy is a complex process which confronts multiple barriers at the individual, organizational, and political level [97] . there has been a range of efforts to reduce these barriers. for example, the optimizing health literacy and access (ophelia) is a whole-of-system approach to developing and implementing health literacy research [98] . this approach is widely accepted in high-income and low-and middle-income countries, and uses health literacy profiling and community engagement to create and implement health reforms, thus improving health and equity [98] . the ophelia approach has also been adapted for different populations and contexts, such as the healthlit4kids [99] . another well-established whole-of-system approach is organizational health literacy, which is widespread in north america and europe [100] . organizational health literacy is based on the assumption that health literacy is a relational concept in which not only individual skills must be addressed, as well as system-level complexities. this concept has also been used in the helit-schools project, interlinking the organizational health literacy as applied to the school setting with the who health-promoting school framework [101, 102] . there are four main benefits if the above research paradigms are applied in current health literacy research and practice. first, we can monitor and evaluate population health literacy levels over time by implementing routine data collection. this allows us to look at health literacy levels among different age groups as well as vulnerable groups, such as those from different ethnic minorities, backgrounds, and migrants, children and young people, chronically ill, and older people. we can also examine the protective and risk factors of health literacy and its impact on health outcomes from a longer-term perspective, thus informing policy opportunities at the best time. second, we can investigate a specific research question about health literacy from a precision public health perspective. we can use modern epidemiological methods, such as causal inference to explore the ideal time point to intervene in low health literacy of a specific population [103, 104] . when a randomized trial is not available, we can use the emulated target trial to investigate the causal effect of improving health literacy on a specific health outcome [105] . a most valuable approach to better understanding real-life health literacy is to focus on ethnographic research exploring the social practices when health information and knowledge are the action focus [106] [107] [108] . third, through the open science movement initiative, it is cost-effective and time-efficient to measure, collect, and analyze health literacy data via existing or linked datasets. for example, the covid health literacy consortium (covid-hl) is a timely project in the context of covid-19 [109, 110] . covid-hl aims to establish a global network on digital health literacy and increase global awareness on health literacy as a critical tool to help protect from communicable diseases. this international platform makes it possible for a health literacy comparison across countries and enables collaborations and data access for researchers. further examples include the who action network on measuring population and organizational health literacy (m-pohl), which aims at the routine measurement of different types of health literacy in the european adult population [111] . fourth, the knowledge translation and engagement process moves the generated health literacy evidence towards the real world. knowledge end-users, such as policymakers or parents of young children, can benefit from interaction with researchers through reflections on their own daily activities, enhanced health knowledge, and skills to protect health. researchers can also benefit as they gain a nuanced understanding of the practice and policy environment, and develop health literacy research questions that have real-world applicability and benefits [112] . there are also several challenges. first, health literacy measurement is a complex phenomenon across the life stage, even at a particular time point. the assessment of health literacy varies depending on the setting, research purpose, and the scope of health literacy definitions [113, 114] . given that different age groups have different characteristics and health needs, researchers may consider using a core measurement tool plus a variety of add-on modules that target varying age groups [115] . eventually, this will also make the measurement much more complex and time-consuming. second, it is complicated for life-course data planning and analysis using modern epidemiological methods. dropouts, missing data, and other study deviations (e.g., low response rates) are a common occurrence in both population research and clinical studies [116] . it is important to consider the power analysis strategies to estimate the sample size, thus enabling researchers to detect a significant effect of health literacy on the outcome of interest. researchers also need to consider critical questions commonly encountered in longitudinal data analysis, such as confounding bias, selection bias, measurement bias, and whether to include an interaction term in a parametric model [103] . in this case, informed by expert knowledge, researchers can use the directed acyclic graph [117] to visually represent the hypothesized causal pathway from health literacy to a specific health outcome. the lifecourse analysis plan template is another useful toolkit that can strengthen the quality of observational epidemiological studies [118] . as for big data in public health, while it provides opportunities to make causality inferences based on chains of sequence, it also introduces challenges to machine learning, such as high data dimensionality, model scalability, and distributed computing [119] . third, using open science practice in health literacy often requires more time and effort for archiving, documenting, quality controlling of codes, and data security [87] . open science is changing how research and practice are conducted, and it takes time to consolidate in the mainstream [77] . currently, the majority of open-source datasets do not adhere to data principles, such as being findable and accessible [120] . besides, data access and sharing are recurring challenges attributed not only to privacy concerns, but also ambiguous data ownership and unaligned incentives [121] . there is a need for researchers to adhere to principles of research partnership and data governance models to prevent the breaches of privacy that obstruct ethically justified data access. fourth, knowledge translation barriers are common in practice, especially in the context of covid-19 [93] . for example, when disseminating health literacy information in a multi-cultural setting, how could we engage with culturally and linguistically diverse families for the first time and get them to understand the right information? along with challenges related to information overload and an ongoing infodemic [122, 123] , researchers and policymakers should be aware of the main facilitators that drive successful health literacy policy implementation, such as intersectoral working, political leadership, and overcoming cultural barriers [20] . in addition, specific knowledge translation plans are needed in advance when implementing relevant strategies in the real world [54, 124, 125] . there remains much work to be conducted to understand how to implement health literacy evidence into practice. when applying the above paradigms into practice, researchers need to be aware that we are not calling for a "one size fits all" solution to fill the gaps in current research. instead, we are calling for a more equitable, precise, transparent, and actionable way to advance health literacy in research and practice. the four paradigms mentioned above cover a broad range of considerations, ranging from a theoretical approach for individual research to empirical studies generating information using big data for policymaking. researchers can integrate one or two into their research planning and implementation. for example, when a researcher is exploring personal experiences of health literacy at the micro levels, it is more suitable to consider using open science practice and knowledge translation strategies to enhance the rigour of reporting studies and disseminate research findings to a range of stakeholders. health literacy is a crucial driver to health equity. while the evidence base shows a significant impact of health literacy on health outcomes, we need to move this field towards an equitable, precise, transparent, and actionable vision. a life-course approach to health literacy will allow for a better understanding of the mechanisms linking health literacy to health outcomes. a precision public health rationale corresponds with the specific nature of health literacy, and will enable us to generate specific policy recommendations to improve population health. open science practice will assist with minimizing publication bias and motivating researchers to share resources to produce more reliable and cost-effective evidence. 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research is supported by the victorian government's operational infrastructure support program. the authors declare no conflict of interest. key: cord-003612-bp7sray2 authors: hu, guangyu; han, xueyan; zhou, huixuan; liu, yuanli title: public perception on healthcare services: evidence from social media platforms in china date: 2019-04-10 journal: int j environ res public health doi: 10.3390/ijerph16071273 sha: doc_id: 3612 cord_uid: bp7sray2 social media has been used as data resource in a growing number of health-related research. the objectives of this study were to identify content volume and sentiment polarity of social media records relevant to healthcare services in china. a list of the key words of healthcare services were used to extract data from wechat and qzone, between june 2017 and september 2017. the data were put into a corpus, where content analyses were performed using tencent natural language processing (nlp). the final corpus contained approximately 29 million records. records on patient safety were the most frequently mentioned topic (approximately 8.73 million, 30.1% of the corpus), with the contents on humanistic care having received the least social media references (0.43 million, 1.5%). sentiment analyses showed 36.1%, 16.4%, and 47.4% of positive, neutral, and negative emotions, respectively. the doctor-patient relationship category had the highest proportion of negative contents (74.9%), followed by service efficiency (59.5%), and nursing service (53.0%). neutral disposition was found to be the highest (30.4%) in the contents on appointment-booking services. this study added evidence to the magnitude and direction of public perceptions on healthcare services in china’s hospital and pointed to the possibility of monitoring healthcare service improvement, using readily available data in social media. investigating public perception of healthcare services from different perspectives may generate inconsistent results. for example, patient-initiated violence against health workers [1] [2] [3] [4] [5] [6] , and the tension between doctors and patients for their dissatisfaction with the quality of healthcare [7, 8] , were wildly covered in the chinese media. while patient experience surveys on the national level showed that patients were generally satisfied with both in-patient and out-patient services [9] . such differences may result from biases rooted in the survey and media coverage; however, the inconsistency also pointed to the need for additional data sources to monitor public opinions on chinese healthcare services. it has been suggested that social media might be such a data source. rozenblum et al. pointed out that when patient-centered healthcare, the internet, and social media were combined, the current relationship between healthcare providers and consumers might face major changes-thus creating a "perfect storm" [10] . users' posts on the social media platforms would generate a large volume of real-time data regarding public or private issues, among which healthcare related information scatters. therefore, the utilization of social media data for healthcare research becomes a dramatically growing field and already covered various medical and healthcare research fields [11, 12] . sinnenberg and colleagues proposed four ways in which social media data were used in healthcare studies: (1) content analysis, (2) volume surveillance of contents on specific topics, (3) engagement of users with others, and (4) network analysis of users [12] . for the content analysis, most studies focused on measuring public discussion on specific diseases [13] [14] [15] , sentiment analysis for medical interventions (e.g., cancer screening) [16, 17] , identifying safety concerns among health consumers [18] , detecting adverse events of health products [19, 20] . several researchers studied patient experience, based on the comments posted by patients from online health communities in china [21, 22] , but few studies have been conducted to gather information on healthcare services related topics using social media data. meanwhile, although sentiment analysis has been wildly applied to process user sentiments associated with health-related text [23] , the lexical resource and tools designed for doing health-related sentiment analysis in chinese language are few and far between. fast-advancing in technology and economy, social media users and their activities spiked in china, which made social media a promising source for healthcare service monitoring. in china, the internet penetration rate reached 55.8% at the end of 2017 [24] , with local providers dominating the market, rather than facebook and twitter, which are not accessible in china. chinese social media sites have a unique landscape, and it may not only be used as a communication software but also as an entry point for information. as subsidiaries of tencent holdings limited, shenzhen, china, wechat and qzone are two leading social media and networking services platforms. each of them reached more than 938 million and 632 million monthly active user accounts in the first quarter of 2017 [25] . according to the 2016 wechat data report, typical users of wechat were born in the 80s or 90s [26], representing a wide breadth of demographic group in china. besides providing multimedia communication and supporting social networking, wechat also has "official accounts", which serve as channels for publishing articles to the public. any individual or organization can apply for having their own official account to broadcast their ideas and believes. as for qzone, it is a platform bundled with qq, a popular online messaging application in china. qzone allows users to create their own personal page to write blogs and post updates. and users could be able to express their individual opinions and attitudes freely and instantly on the social media platforms. subject to the platforms' terms of service and privacy policy agreed upon by users [27, 28] , three kinds of information were collected, stored, and used by the platforms: (1) personal information; (2) non-personal information; and (3) shared information. the shared information refers to information that is voluntarily shared on the platforms by users freely and instantly, thus providing a valuable perspective and opportunity to gather public opinions on healthcare services. as such, we selected wechat and qzone as the social media platforms to conduct this exploratory study. the objectives of this study are to conduct volume and sentiment analyses base on the extracted social media contents on hospital healthcare services. the study could demonstrate the social media users' perceptions of hospitals healthcare and may shed light on the further utilization of social media as a data source for healthcare research in china. this study consisted of three phases. firstly, we utilized a predefined list of healthcare services categories to devise key words and search strategies accordingly. the data searching strategy would then be used to extract contents from a raw database, which contained publicized posts of wechat and qzone. the extracted materials were then put into a corpus. secondly, we applied natural language processing (nlp) techniques from tencent nlp platform to the corpus and calculated the volume of content concerning different healthcare services topics. thirdly, we conducted sentiment analysis to explore the sentiment polarity of chinese social media users on different healthcare service topics. the detailed process of data collection and analysis is presented in figure 1 the raw databases used for this study come from wechat and qzone of the version only operated in mainland china. the user volumes and data inclusion criteria of the platforms were showed in table 1 . publicly available posted information such as: posted blogs, reviews and articles that are voluntarily shared by individual users from june 2017 to september 2017 were collected from the two platforms. the data collection followed the privacy policy for users of tencent and was subject to the confidentiality and security measures that implemented by the platforms. and the data analyses were supported by technicians in the tencent. the nine healthcare service categories, used in this study, were derived from the objectives of the national healthcare service improvement initiative (2015-2017), which was dedicated to improving patient-centered healthcare and patient experience nationwide by the former national health and family planning commission of p.r. china (nhfpc) [29] . the initiative operated under the leadership of the bureau of medical administration of nhfpc [30] , which suggested that we used nine predefined categories to reflect the healthcare services in hospital (see table 2 ). table 2 . healthcare services categories and corresponding descriptions in the national healthcare service improvement initiative 2015-2017 (nhsii). objectives of nhsii optimize the layout of the facility and build a friendly service environment appointment-booking service promote utilization of clinical appointment services and guide patient flow service efficiency improve service efficiency and effectiveness by rational allocation of resources information technology take advantage of information technology to improve patient experience inpatient service promote inpatient service process reengineering and provide integrated healthcare service nursing service continuously improve quality of nursing care and enhance nursing workforce patient safety ensure patient safety by promoting adoption of standard operating procedures humanistic care strengthen humanistic care and provide medical social worker service doctor-patient relationship harmonize the doctor-patient relationship and reduce medical disputes in this study, we constructed a healthcare services corpus, in the chinese language from the social media data source, to enable further analyses. first, we constructed lexica of keywords and terms in accordance with the predefined service topics. for example, the lexicon for "information technology", used in this study indicate new information dissemination channels, based on information technology provided by hospital to improve patient experience of service information acquisition. and this lexicon contains six information technology service-related terms, namely, "weibo", "wechat", "website", as well as "self-service machine". second, we developed a set of searching strategy to extract the relevant data from the two sources based on the corresponding lexicon of topics. the entire list of search terms for each category and its corresponding searching strategy were provided in supplementary table s1 . finally, we applied the search strategies to the database of publicly posted materials to screen for posts related to the healthcare service categories to construct the corpus. the search and screening process were performed by qcloud. based on the healthcare services corpus, we classified the content to different healthcare services topics that predefined and measured the content volume of the topic. specifically, we used the open application programming interface (openapi) services provided by tencent nlp to analyze the retrieved contents. it is an open platform for chinese natural language processing (based on parallel computing and distributed crawling system) [31] . such services enable us to split reviews and blogs into sentences, and each sentence was filtered to classify whether it contained target service topic keywords and terms. if the sentences, containing certain keywords and terms, belonged to the corresponding topic of healthcare services categories as listed in table s1 , then they would be divided into a certain category. by counting the appearances of each service topic keywords in terms of the number of sentences in the corpus, we can aggregate the counts at the topic level and calculate the proportion of different topics from the social media corpus. for the sentiment analysis tool in chinese, we also select tencent nlp, as its algorithm was trained by hundreds of billions of entries of internet corpus data in chinese and with successful application in other tencent products (https://nlp.qq.com). openapi with function of chinese batch texts automatic summarization and sentiment analysis of tencent nlp enable us to categorize the sentences on certain topic in the social media corpus into a sentiment polarity classification (i.e., neutral, positive, and negative). finally, each sentence was tagged and classified into different sentiment polarity. the social media corpus contained approximately 29 million records from wechat and qzone, spanning the 9 pre-defined categories, related to hospital healthcare services. table 3 presents the content volume of each healthcare services topic by social media channel. among the social media content on healthcare services topics, patient safety was the most commonly encountered topic, both in wechat and qzone. the majority of the content related to patient safety issue, its approximately 8.73 million records and covered 30.1% of the entire corpus. the proportion of contents related to other topics varied in the corpus: information technology (22.2%), service efficiency (17.9%), service environment (10.3%), inpatient service (9.6%), appointment-booking service (3.4%), nursing service (2.5%), doctor-patient relationship (2.5%), and humanistic care (1.5%). the results of the sentiment analysis of contents from the corpus found that, in all nine healthcare services topics, 36.1% of the contents in the corpus have been recognized to reveal a positive disposition, 16 .4% neutral and 47.4% negative. we found that topic comprising most positive contents was service environment (59.6%), followed by patient safety (53.2%). with regard to the topics that contained more negative contents than positive, the most one was doctor-patient relationship (74.9%), followed by service efficiency (59.5%), and nursing service (53.0%). notably, over one third of contents in the appointment-booking service (30.4%) revealed a neutral disposition. additionally, in contrast to the content volume distribution for the nine topics, the sentiment disposition of contents in corresponding healthcare services topics shows differences. for instance, table 3 shows that the nursing service and doctor-patient relationship share an equal proportion (2.5%) of contents in the corpus, however, we observed the disposition of contents from social media users to the two topics varied in figure 2 . to our knowledge, this is the first study that has attempted to explore the public perceptions of healthcare services, using publicly posted materials, of two chinese social media platforms. our results showed that patient safety was the most significant topic for users of chinese social media platforms, followed by information technology and service efficiency. service environment was found to have the highest proportion of positive comments. the research assessed the application of content volume calculation and sentiment analyses on chinese social media data. the study is a crucial step to discovering the methodology on harnessing the social media data in china and an early attempt to track the perceptions of healthcare services in the public by analyzing a unique data source. this study found a large number of information technology and service efficiency, which might reflect the series of efforts made by both the government and the hospital in integrating information technology in healthcare services in china. several researchers have identified that health information technology services were used to enhance patient experience [32] [33] [34] , and as a potential solution to shorten the lengthy waiting time in china's public hospital [22, [35] [36] [37] . humanistic care was the least mentioned topic in the corpus complied by this study. it may suggest that chinese social media users are not very familiar with the idea of humanistic care. those who posted about it basically expressed a positive attitude. an alternative explanation might be this type of care has yet to reach the public only experienced by a few people. further empirical studies or controlled studies may be conducted to provide further insights. our research also explored the sentiment disposition of social media content on healthcare services: 47.4% provided negative feedback. although this was only the initial results, it could be quite alarming to healthcare administrations and policymakers. despite the fact that patient surveys generally had favorable results in china [9] , there was still a significant amount of negative comments to our knowledge, this is the first study that has attempted to explore the public perceptions of healthcare services, using publicly posted materials, of two chinese social media platforms. our results showed that patient safety was the most significant topic for users of chinese social media platforms, followed by information technology and service efficiency. service environment was found to have the highest proportion of positive comments. the research assessed the application of content volume calculation and sentiment analyses on chinese social media data. the study is a crucial step to discovering the methodology on harnessing the social media data in china and an early attempt to track the perceptions of healthcare services in the public by analyzing a unique data source. this study found a large number of information technology and service efficiency, which might reflect the series of efforts made by both the government and the hospital in integrating information technology in healthcare services in china. several researchers have identified that health information technology services were used to enhance patient experience [32] [33] [34] , and as a potential solution to shorten the lengthy waiting time in china's public hospital [22, [35] [36] [37] . humanistic care was the least mentioned topic in the corpus complied by this study. it may suggest that chinese social media users are not very familiar with the idea of humanistic care. those who posted about it basically expressed a positive attitude. an alternative explanation might be this type of care has yet to reach the public only experienced by a few people. further empirical studies or controlled studies may be conducted to provide further insights. our research also explored the sentiment disposition of social media content on healthcare services: 47.4% provided negative feedback. although this was only the initial results, it could be quite alarming to healthcare administrations and policymakers. despite the fact that patient surveys generally had favorable results in china [9] , there was still a significant amount of negative comments on the social media platforms. further and more detailed methodology is necessary to further understand the negative comments. in the 9 topics investigated in this study, we found huge variations in the negative feedback as well as content volumes across topics. for instance, the contents related to doctor-patient relationship only take percentage of 2.5% in the corpus, however 74.9% of the content revealed negative feedback. the varied sentiment polarity distribution of the topics may have important policy implications for healthcare reform in china. for example, 30.4% of the social media references to appointment-booking service reflected neutral feedback, which may suggest that the unsureness of the public on this novel service. patients have yet to be familiar with the services-even though it certainly aims to improve the convenience for patients as well as hospital efficiency. such feedback could be essential for hospitals to improve their service quality by enhancing patient education. further research might focus on what exactly were discussed in those negative posts so that targeted measures can be employed by the hospitals and responsible administrators to improve the services. in line with previous evidence [11, 12] , our results show that social media could be a useful tool for health research in china, as well as english, and could be used to capture the public's perspective of healthcare [23, 38] . however, it appeared that the most concerned issue of healthcare in social media is different from what has been found in patient surveys. findings from a recent qualitative study found that patients cared about the environment and facilities in hospital the most [39] , whereas in our study patient safety issues had the greatest volume. another research examined the online doctor reviews in china revealed that most posts expressed positive attitudes towards the physicians [21] . although the evidence on these issues are still not conclusive, it might suggest the perception difference between general public and patients. our research extends application of the natural language processing techniques to analysis of healthcare services related contents in china's social medial platforms and offers a new perspective of healthcare services in china's hospital. the results would be of benefit to healthcare providers and regulators benchmarking their performance on patient-centered healthcare delivery. this is important because the social media has been considered as a portal of health information acquisition for chinese netizens [40] , the perspective of social media would be supplementary in understanding how consumer views the healthcare services in hospital besides the results from traditional paper-based surveys. this study has the following limitations. first, because the raw material was user-generated data, selection bias may have affected the data. for example, it was observed that most social media users were born in the 80 s or 90 s [26], however we were unable to characterize the users social-demographic information in detail, since the user privacy policy of tencent currently prohibit such practice. moreover, considering the exploratory nature of the study, our study focused only on wechat and qzone as data sources, whereas other social media platforms in china may have the potential to conduct such analyses as well. second, since we derived the healthcare services categories and lexica based on the government document on nhsii and expert consultation, thus the corpus in this study may have failed to include certain amount of healthcare services related data. as a result, we may have underestimated the content volume of healthcare services from the two social media platforms. furthermore, although all the material in the databases are in chinese, and therefore most likely be generated by users from china, we are currently not able to determine whether the posts, containing the key terms on healthcare, were describing the chinese healthcare system or discussing foreign healthcare systems in chinese language. further research may strive to develop searching strategies that enable such distinction and increase the specificity of the results. third, although the consumer health vocabulary (chv) is the gold standard reference for retrieving the target data, it has been used in previous researches [13, 38] , such open source of vocabulary list and its corresponding lexica are not available in chinese language. the accuracy and credibility of the sentiment analysis of this study also await further validation; however, it would require an alternative method to conduct sentiment analyses for chinese language and the possibility to apply such methods on the tencent data, which were publicly posted material but still under strict terms of utilization. another limitation concerned that we have no ability to confirm that the data supplied by tencent completely represent all users' data as there could be undocumented keyword filter on the platforms. these would inflict potential bias and limit the generalizability of our findings. weibo is another popular chinese social media platform considered to be the counterpart of twitter in china. future research could consider extend the analysis process to contents from weibo, to further explore users, and their views, that have not been covered in this study. both the quantitative approach, as shown in our research, and the qualitative approach, such as the face-to-face individual interview method, would be useful to better understand consumer care in healthcare services. there is a scarcity of empirical research exploring the latter issue at present. it has been proposed to complement public perspectives on healthcare services [39] . furthermore, the popularity of consumers' unsolicited comments on healthcare providers in social media, prompts an important avenue for understanding patient experience, and has been demonstrated by previous researches [38, [41] [42] [43] [44] . future research for measuring patient experience based on social media data at hospital level would be help to better understand the landscape of healthcare quality in china. by analyzing shared information from wechat and qzone, this study showed that patient safety was the most concerned topic for users of chinese social media platform, followed by information technology and service efficiency, while the doctor-patient relationship was found to have the highest proportion of negative comments. this study explored the possibility of utilizing social media to monitor public perceptions on healthcare services. the findings provide an overview of public opinion on healthcare services, which could help regulators to set up the benchmark, on a national or regional level, to monitor the progress of healthcare improvements between comparator districts and services domains. it is also a necessary complement to the traditional paper-based consumer survey. the potential differences between social media perception and traditional consumer survey results would help regulators better understand the gap in quality of care services from various perspectives. further studies could also focus on extending the nlp method to a more content-based resource and to expand our understanding of mass opinion on healthcare services. the following are available online at http://www.mdpi.com/1660-4601/16/7/1273/s1, table s1 : list of keywords, terms, and text strings used for data searching. facing up to the threat in china violence against chinese health-care workers the danger of being a doctor in china the frequency of patient-initiated violence and its psychological impact on physicians in china: a cross-sectional study how to decrease violence against doctors in china? workplace violence against medical staff of chinese children's hospitals: a cross-sectional study media contribution to violence against health workers in china: a content analysis study of 124 online media reports changing of china's health policy and doctor-patient relationship consumer satisfaction with tertiary healthcare in china: findings from the 2015 china national patient survey patient-centred healthcare, social media and the internet: the perfect storm? instagram and whatsapp in health and healthcare: an overview twitter as a tool for health research: a systematic review using twitter to measure public discussion of diseases: a case study social big data analysis of information spread and perceived infection risk during the 2015 middle east respiratory syndrome outbreak in south korea characterizing depression issues on sina weibo sentiment analysis of breast cancer screening in the united states using twitter using social media to characterize public sentiment toward medical interventions commonly used for cancer screening: an observational study social media in health-what are the safety concerns for health consumers? utility of social media and crowd-sourced data for pharmacovigilance: a scoping review protocol systematic review of surveillance by social media platforms for illicit drug use the development of online doctor reviews in china: an analysis of the largest online doctor review website in china unhappy patients are not alike: content analysis of the negative comments from china's good doctor website capturing the patient's perspective: a review of advances in natural language processing of health-related text china internet network information center the 41st china statistical report on internet development national health and family planning commission announcement of implementing the healthcare services improvement initiative national health and family planning commission the implementation strategy of the healthcare services improvement initiative social media landscape of the tertiary referral hospitals in china: observational descriptive study a way to understand inpatients based on the electronic medical records in the big data environment what predicts patients' adoption intention toward mhealth services in china: empirical study patient experience with outpatient encounters at public hospitals in shanghai: examining different aspects of physician services and implications of overcrowding discrete event simulation models for ct examination queuing in west china hospital questionnaire survey about use of an online appointment booking system in one large tertiary public hospital outpatient service center in china collecting and analyzing patient experiences of health care from social media what do patients care most about in china's public hospitals? interviews with patients in jiangsu province how the public uses social media wechat to obtain health information in china: a survey study predicting hcahps scores from hospitals' social media pages: a sentiment analysis web-based textual analysis of free-text patient experience comments from a survey in primary care use of sentiment analysis for capturing patient experience from free-text comments posted online harnessing the cloud of patient experience: using social media to detect poor quality healthcare we would like to acknowledge dalu wang and hongda wu from tencent for their technical support in data analysis. the authors declare no conflict of interest. int. j. environ. res. public health 2019, 16, 1273 key: cord-253000-nwbmxepi authors: margină, denisa; ungurianu, anca; purdel, carmen; tsoukalas, dimitris; sarandi, evangelia; thanasoula, maria; tekos, fotios; mesnage, robin; kouretas, demetrios; tsatsakis, aristidis title: chronic inflammation in the context of everyday life: dietary changes as mitigating factors date: 2020-06-10 journal: int j environ res public health doi: 10.3390/ijerph17114135 sha: doc_id: 253000 cord_uid: nwbmxepi the lifestyle adopted by most people in western societies has an important impact on the propensity to metabolic disorders (e.g., diabetes, cancer, cardiovascular disease, neurodegenerative diseases). this is often accompanied by chronic low-grade inflammation, driven by the activation of various molecular pathways such as stat3 (signal transducer and activator of transcription 3), ikk (iκb kinase), mmp9 (matrix metallopeptidase 9), mapk (mitogen-activated protein kinases), cox2 (cyclooxigenase 2), and nf-kβ (nuclear factor kappa-light-chain-enhancer of activated b cells). multiple intervention studies have demonstrated that lifestyle changes can lead to reduced inflammation and improved health. this can be linked to the concept of real-life risk simulation, since humans are continuously exposed to dietary factors in small doses and complex combinations (e.g., polyphenols, fibers, polyunsaturated fatty acids, etc.). inflammation biomarkers improve in patients who consume a certain amount of fiber per day; some even losing weight. fasting in combination with calorie restriction modulates molecular mechanisms such as m-tor, foxo, nrf2, ampk, and sirtuins, ultimately leads to significantly reduced inflammatory marker levels, as well as improved metabolic markers. moving toward healthier dietary habits at the individual level and in publicly-funded institutions, such as schools or hospitals, could help improving public health, reducing healthcare costs and improving community resilience to epidemics (such as covid-19), which predominantly affects individuals with metabolic diseases. chronic inflammation is a central process involved in a high number of metabolic disorders (e.g., obesity, metabolic syndrome, diabetes, dyslipidemia, etc.), including neurodegenerative (alzheimer), malignant diseases, and autoimmune diseases. in most if not all chronic inflammatory conditions, there is an extensively failed resolution of inflammation with high influx of leukocytes, which in their effort to resolve inflammation stimulate the synthesis of pro-inflammatory molecules and establish a highly inflammatory micro-environment, leading to extensive fibrosis and tissue damage [1] . chronic low-grade inflammation has been shown to either induce or aggravate metabolic disturbances, including insulin resistance and dyslipidemia, which contributes to the development of other complications [2] . there is accumulating evidence that, in the case of autoimmune diseases, when the immune system loses self-tolerance and attacks the body's cells and tissues, metabolic disturbances are key contributors to disease progression. results from the type 1 diabetes mellitus (t1dm) prediction and prevention studies on t1dm showed that metabolic disturbances preceded the seroconversion to positive autoantibodies by several months or years in type 1 diabetes mellitus [3, 4] . many chronic inflammatory diseases originate or have their development promoted by an unbalanced diet. although the exact mechanism remains unclear, de rosa et al. suggest that metabolic pressure, as a result of increased caloric intake, leads to an altered adipose tissue homeostasis. this results in the synthesis of adipokines and facilitates the overactivation of nutrient-sensing mechanisms, altering the balance between pro-inflammatory and regulatory t-cells, ultimately resulting in the loss of immunotolerance [5] [6] [7] . in addition, dietary components have the ability to influence the immune response through the modulation of gut bacteria metabolism, impacting the risk of developing chronic diseases either directly in the gastrointestinal tract, or in other more distant organs that impact general metabolism [8] [9] [10] [11] . recent studies have investigated long term exposure to low doses of chemical mixtures that can be a part of modern lifestyles, such as pesticides, food additives, or additives contained in food coating materials, proving that different disturbances appeared from minor biochemical disturbances. these early alterations are generally followed by oxidative stress induction and organ damage depending on the period of exposure [12] [13] [14] [15] [16] [17] . recently, it has been shown that long term exposure to stressors might also have a positive association with increased vulnerability of the population to the microbial and viral infections [18] . metabolomics are an emerging biological field that allow for the identification and simultaneous measurement of a large number of small molecules called metabolites in biological matrixes. it has become the most accurate method to detect metabolic imbalances and is useful for prevention and early detection of diseases. moreover, metabolomics have vast applications in clinical practice [19] . targeted metabolomic analysis provides insights regarding the normal function of endogenous metabolism, dietary intake, microbiota, drug metabolism, and nutrient adequacy [20] . the challenge of chronic inflammatory diseases with respect to early diagnosis can be tackled with metabolomics through the identification of biomarkers that can discriminate high-risk populations. in a group of autoimmune patients, it was found that their fatty acid-based metabolic profile and lifestyle factors including physical activity and alcohol consumption were valuable predictive markers of autoimmune diseases [21] . humans are exposed to a large number of substances from food, water, cosmetics, air, and so forth, each at low levels of exposure, and are able to induce cumulative/synergistic effects. many studies have focused on the effects induced by administering a single substance at medium-high doses to laboratory animals. recently, the concept of real-life risk simulation has emerged, since there is growing evidence that the effects of chemical mixtures at concentrations for which individual components failed to elicit have adverse effects when tested individually [14] . the concept of real-life risk simulation can also incorporate dietary interventions because, in our diets, we expose the human body to myriad substances in diverse doses [14, 22, 23] . the discovery of inflammation regulators opened a new window in therapeutics to clear low-grade chronic inflammation. a large number of physiological processes promote the physiological process of regulating inflammation. the development of such an approach targets the stimulation of endogenous processes that naturally occur during inflammation, which are hampered mainly by the lack of suitable human models and the heterogeneity of inflammatory disorders. another limitation includes the lack of sensitive measurements able to capture the different stages of inflammation and metabolites [24] [25] [26] [27] [28] . the present paper aims to evaluate the impact diet might have on immune response, with special attention as to how lifestyle changes can help mitigate low-grade inflammation. real-life risk simulation (rlrs) concept. this analysis can be highly relevant in the context of the present viral spread of sars-cov-2, since the inflammation is once again in the front line of an acute pathological response. identifying strategies to modulate the immune response might prove useful for reducing the virus's impact on the respiratory tract and thus diminishing its impact on each patient, as well as on the general medical system. the majority of studies that assess dietary habits, metabolism, and nutrient intake are based on food frequency questionnaires. however, food frequency questionnaires (ffq) have several limitations, including inconsistent responses on food choices, mostly because answers depend on responders' memory. moreover, ffq that are filled out by the responder instead of a trained healthcare professional only provide an overview of the macronutrients' intake while not fully capturing the micronutrient status of the person [29] . micronutrient deficiencies are common in both developing and affluent countries, affecting two billion people worldwide, according to the world health organization (who) [30] . the primary cause of micronutrient deficiencies or "hidden hunger" is poor dietary intake of micronutrients while other socioeconomic factors play an important role as well [31] . several diet and nutrients assessment tools have been developed to evaluate inflammation status. the dietary inflammation index (dii) is based on literature data and aims to evaluate if a responder follows a proor anti-inflammatory diet. since its development, there has been an increasing interest in dii, although other indexes are being developed with similar efficacy [32] . an important limitation of these indexes is the lack of causality and direct association to a person's symptoms. thus, the application of these indexes in clinical practice is hampered. a novel empirical, close-ended, and self-administered questionnaire developed by the european institute of nutritional medicine provides an inflammation status score that captures the interaction between the autonomic nervous system and inflammation [33] . there is growing evidence that imbalances in the autonomic nervous system reflect local or systemic inflammation found in various diseases and that diet and lifestyle factors can act as regulators of sympathetic and parasympathetic activity [34] [35] [36] [37] . through a 23-question series, responders provide data on the presence/absence and status of inflammatory response in different body systems. overall, the nutritional medicine exam (numex) consists of 118 questions and assesses the nutritional deficiencies status in seven categories: inflammation, nutrition, perceived stress, oxidation, sugar metabolism, amino acids metabolism, and gut microbiome. designed by medical doctors and nutritionists, the aim of this empirical test is to assist the individual and the healthcare professional to evaluate the overall inflammatory status based on autonomic nervous system changes and track its progression after targeted lifestyle changes. at a molecular level, metabolomics is the only method that can capture small, time-dependent fluctuations in the metabolism, thus indicating ncd-related metabolic imbalances [21] . overall, traditional and well-established diet and nutrient assessment methods including ffq and dii have provided valuable information on the role of specific foods on health and disease, as discussed in the present review. with the advent of advanced tools, metabolomics is complementary to the standard approach to provide tailor-made recommendations depending on an individual's specific needs at a given time. recent literature considers bmi cut-off values to not fully depict metabolic disturbances associated with obesity. the bmi is a mathematical approximation and does not reflect the percentage of total body fat between body fat and total body muscle or bone mass. as such, bmi does not reflect cardiometabolic risk. a more comprehensive classification describes four phenotypes for obese individuals: normal weight obese (nwo), metabolically obese normal weight (monw), metabolically healthy obese (mho), and metabolically unhealthy obese (muo), or "at risk" obese with ms. this classification takes into account bmi, fat mass, and waist circumference, but also general biochemical parameters (e.g., fasting plasma glucose, total cholesterol, ldl, hdl, triglycerides) [38] [39] [40] [41] [42] [43] . all four classes are characterized by impairments of different severity of inflammatory pathways [38, 40] . lifestyle and nutrition are modifiable factors that interact with genetics in regulating chronic inflammation, leading to aforementioned complications. the changes in nutritional patterns in western societies-caused by a high intake of fat and energy-dense, processed foods, as well as a low intake of fibers, fruits, and vegetables-are associated with a rising prevalence of asthma, allergies, and autoimmune diseases involving inflammatory mechanisms [44, 45] . high fat diets determine, among other things: intestinal inflammation, favoring lipopolysaccharides (lps) absorption from gram-negative gut bacteria, and increasing lipoperoxidation that induces insulin resistance and inflammation. saturated fatty acids and lps activate toll-like receptor 4 (tlr4) signaling pathways further contribute to promoting systemic inflammation and consequent metabolic disorders [46] [47] [48] [49] [50] [51] [52] ( figure 1 ). lifestyle-and diet-induced inflammation affects several cellular pathways, which stimulates the synthesis and secretion of various pro-inflammatory molecules. this ultimately maintains the low-grade inflammation state. interestingly, populations that consume a diet rich in fruits, vegetables, and fibers have lower incidences of inflammatory diseases compared to western populations [53, 54] . the mediterranean diet-based on olive oil, fish, vegetables, and fruits, in addition to incorporating myriad beneficial phytochemicals-discourages cardiovascular diseases [55] [56] [57] [58] . sourcing food from organic agriculture could further improve the beneficial health effects of a mediterranean diet, as suggested in a study comparing an organic and nonorganic mediterranean diet on male patients with chronic kidney disease [59] . this was hypothesized to be due to a decreased exposure to pesticides, since animal studies have repeatedly found that exposure to pesticide mixtures can be a source of toxicity [16] . however, although most studies have found that organic food consumers are healthier, it is not clear whether health benefits can be attributed to a decreased exposure to synthetic pesticides [60] . dietary changes that include specific metabolites can modulate gene expression via epigenetic modifications, such as dna methylation or chromatin remodeling (e.g., histone acetylation or deacetylation). for example, a diet rich in folate and methionine can shape the host epigenome with a direct impact on molecular pathways associated with obesity-related inflammation. moreover, global dna hypermethylation in adipocytes derived from obese subjects is correlated with the expression of genes involved in proinflammatory interactions [61, 62] . for example, hypermethylation at 1 kb upstream of the adiponectin gene's promoter site was observed in adipocytes of obese mice fed a high-fat diet, but also in human adipocytes. dna methyltransferase 1 (dnmt1) expression is correlated with the methylation of the adiponectin gene, resulting in decreased expression of adiponectin in obese mice and increased expression in healthy mice. studies on human adipocytes show a correlation between dnmt1 expression and bmi, suggesting that obesity is a cause or cofactor of hypermethylation of adiponectin gene [63, 64] . another factor inducing epigenetic changes is ros overproduction in expanded adipose tissue, influencing histone acetylation/deacetylation equilibrium, thus inducing nfκb activation [65] [66] [67] . on the other hand, nutrient restriction decreases akt (protein kinase b) activity and stimulates foxo (a forkhead box o transcription factor) activity, thus stimulating the expression of proteins involved in cell metabolism, autophagy, and stress-response, contributing to the resolution of inflammation [61, 62] . fasting regimens are correlated with increased insulin sensitivity, improvement of blood pressure, and inflammatory status, regardless if they are associated with weight reduction. for example, 15 days of intermittent fasting induced an increase of glucose uptake rates and a significant increase of anti-inflammatory adiponectin in lean young men (bmi of 25 kg/m 2 ) without a significant decrease in body weight. these results were consistent with data from animal studies [68, 69] . an important causal factor for low grade inflammation influenced mainly by lifestyle is the impairment of gut microbiota. bacteroidetes and firmicutes constitute approximately 90% of the intestinal population, but the equilibrium is fundamentally changing with ageing and depending on diet composition. a decline of microbiota diversity occurs during ageing and obese individuals. gut dysbiosis has been found in several inflammatory pathologies such as obesity, diabetes, cardiovascular, and neurodegenerative diseases. this can be connected to the induction of chronic low-grade inflammation since the gut microbiome is intimately connected to innate immune responses [70] [71] [72] . the relationship between gut microbiome and the host immune system are influenced by lifestyle interventions. for instance, secretory iga levels increase after periodic fasting. this can be linked to changes in gut microbiome composition [14, 73] , with proteobacteria modulating the adaptive humoral local response. some studies showed that microbiota composition and diversity has a great impact on a population's general health status. for example, when comparing the fecal microbiota of european and rural african children (burkina faso), a higher proportion of prevotella and xylanibacter (involved in the digestion of fibers and generation of short chain fatty acids (scfas)) was found in the latter group, which lacked european subjects. these observations could be correlated with the higher prevalence of inflammatory diseases in european populations compared to rural african ones [74, 75] . chronic exposure to environmental pollutants or food additives could also predispose one to chronic pathologies, which promotes inflammation [76] . xenobiotics promotes chronic inflammation, which is thought to be the generation of lipotoxic conditions, i.e., in the development non-alcoholic fatty liver disease [77] . this can be mitigated by lifestyle interventions such as periodic fasting [78] . the exposure to xenobiotics such as heavy metals, pesticides, nanoparticles, polycyclic aromatic hydrocarbons, dioxins, furans, polychlorinated biphenyls, or non-caloric artificial sweeteners can also promote chronic inflammation by disturbing the gut microbiota [77, 79, 80] . decreasing inflammatory burden is more important than ever during the covid-19 pandemic. this can be accomplished through everyday actions (e.g., lifestyle, diet, smoking cessation, weight decrease, sport, etc.). there is a lot of information available in the scientific community regarding the risk of covid-19 complications; even the likelihood of death is highly increased by some chronic diseases, mostly associated with an impaired inflammatory profile (e.g., obesity, type ii diabetes, hypertension, chronic pulmonary disease, etc.) [81, 82] . the literature data shows that people without comorbidities have a much lower risk of severe symptoms as a result of the sars-cov-2 infection [83] . on the other hand, increased levels of inflammatory markers cytokines with pro-inflammatory outcomes constitute predictors of adverse outcome in covid-19 patients [84] . evidence proves that some dietary elements such as zinc or vitamin d might provide protective effects against viral load [84] . as such, this reduces the inflammatory burden through a healthy diet, associating (based on rlrs principles) several protective components (e.g., fiber, polyphenols, pufas, vitamins, etc.) that constantly increase our chance of being better protected against different immune challenges. fermentable dietary fiber are not enzymatically digested in the small intestine; they pass into the colon and are transformed by gut bacteria into scfas [85, 86] . the systemic distribution and generation of scfas-acetate, propionate, and butyrate (the most abundant)-in the distal colon is important to inhibit inflammatory signals. germ-free animal models were characterized by inflammatory flairs, due to the absence of tissue/blood scfas [87] [88] [89] . butyrate is a representative member of scfas and has a high affinity for different g-protein-coupled receptors (gpcrs) found throughout the body: gpr41 is found in adipose tissues and immune cells and gpr43 is found in immune cells. however, gpr109a is present in colonic cells and gpr41 and gpr43 are activated by butyrate, which favors the production of peptide yy (pyy). this contributes to gastric emptying and intestinal transit inhibition, which thereby reduces appetite and promotes glucagon-like peptide 1 (glp-1). these outcomes indirectly stimulate insulin secretion. gpr109a activates the inflammation-associated pathway in colonic macrophages and dendritic cells, inducing the differentiation of il-10-producing t-cells and release of il-18 from intestinal epithelial cells [85, 90, 91] . the presence of fiber in the diet is extremely important ( table 1) as it generates scfas and promotes the proliferation of commensal bacteria, which limits the access of pathogenic bacteria to the gut epithelium. moreover, scfas favor epithelial mucus secretion that increases the protective effect on the intestinal surface and the proper maintenance of the barrier function [92, 93] . scfas have anti-inflammatory effects that bind to the nuclear transcription factor pparγ (peroxisome proliferator-activated receptor γ) and, consequently, inhibit the nf-kb pathway [94, 95] . this ultimately lowers the expression of vcam-1 (vascular adhesion molecule 1) and icam-1 (intracellular adhesion molecule 1), as well as the synthesis of tnfα, il-6, and ifn-γ (interferon γ) [96] . the main physiological role of histones is to interact with dna and stabilize its structure. when they are acetylated, this loosens the contact between histones and dna, uncoiling the dna structure that thus becomes transcriptionally active. the histone acetylation process is a result of the balance between the induction of histone acetyl transferases (hats) and the inhibition of histone deacetylase (hdacs). the same acetylation process causes dna to bind to transcription factors, such as stat3 (signal transducer and activator of transcription 3), nf-kβ (nuclear factor kappa-light-chain-enhancer of activated b cells, and foxp3. consequently, this regulates gene expression, including inflammation proteins [97, 98] . scfas (with butyrate and acetate being the most and least effective, respectively) act as inhibitors for histone deacetylase (hdacs), thus contributing to the inhibition of the transcription for inflammatory proteins [99, 100] . fasting is a process that has been known for thousands of years. it was quite frequent in ancient times, because access to food was difficult and as a result, individuals were obliged to survive without food until it was available again [124] . fasting is a survival mechanism in both animals [125, 126] and humans, especially in countries where food conservation is not widespread [127] . in the rest of the world, fasting has been employed either due to religious convictions or in wellness centers. since 1960, one of the methods used to address morbid obesity and related diseases has been the "zero calorie diet", thus translating into clinical practice the scientific data generated by centuries of fasting. fasting can be divided into three broad categories: • periodic fasting, which lasts from 2 days to a few weeks; • intermittent fasting, which lasts from 16 to 20 h and can be done daily or every second day or twice a week, and • fasting-mimicking diet, the diet that mimics fasting to achieve its beneficial effects, in which restriction of calories and specific foods is necessary (e.g., fat) [128] [129] [130] . there is a lot of research that shows the beneficial effects of fasting on health and also on different pathological conditions. fasting increased lifespan in prokaryotic organisms such as yeast s. cerevisiae and nematode c. elegans [128, [131] [132] [133] [134] , but also on animal models that performed fasting for long periods (e.g., the royal penguin) [135] . other models have shown better brain function [136, 137] , increased lifespan and longevity [138] [139] [140] , and improved maintenance of muscle mass after fasting [141] . studies on animal models reveal the beneficial effect fasting has on cancer as a complementary disease management strategy in concert with drug treatments [142] [143] [144] [145] . studies on animal models show an improvement in neurodegenerative diseases after fasting, while other studies prove that intermittent fasting diets boost the levels of antioxidant defense, neurotrophic factors (bdnfs, h-70 and fgf2), proteins involved in adaptive response (hsp-70 and grp-78), and reduce pro-inflammatory cytokines levels (tnfa, il-1β, and il-6) [146] [147] [148] [149] [150] . it has been found that intermittent fasting can prevent and reverse all aspects of metabolic syndrome in rodents: body fat, inflammation, and blood pressure are reduced; insulin sensitivity is increased; and the functional capacity of the neuromuscular and cardiovascular systems are improved [151] [152] [153] . an intermittent fasting diet has also been found to improve hyper-glycaemia in diabetic rodent models [154] and in myocardial infarction models, as the heart is protected from ischemic damage by this type of regimen [155] . elevated leptin levels usually predict a pre-inflammatory condition, while adiponectin and ghrelin may suppress inflammation and increase insulin sensitivity [150, 156] . fasting can reverse every major abnormality caused by metabolic syndrome, by increasing insulin and leptin sensitivity, suppressing inflammation and stimulating autophagy [157, 158] . there are several studies that show an increased use of fat and ketone bodies for energy [159, 160] , as well as an increase of growth hormone and glucagon secretion [161] [162] [163] , with a decrease in blood sugar, insulin, and igf-1 levels. after intermittent fasting, total fat, abdominal fat, and blood pressure are decreased, while glucose metabolism is improved in obese individuals [69, [164] [165] [166] [167] . in addition, periodic fasting significantly changes the composition of the human gut microbiota [73] . finally, studies of utmost importance show the effect of intermittent fasting mainly in the fight against cancer as a supplement along with the classic treatment, with promising results [168, 169] . below, we analyze the effects of the interrelation between fasting and inflammation as well as the relevant molecular mechanisms. fasting not only results in weight loss but it is a survival mechanism that impacts many metabolic pathways [128, 161, 170] . fasting's many benefits are related to the regulation of key molecular pathways. initially, during fasting, the downregulation of insulin-like growth-factor-1 (igf-1) and mammalian target of rapamycin (mtor) occur. these pathways are upregulated in the presence of food excess as they sense nutrients and therefore activate anabolic metabolism. when there is a lack of food for several hours, catabolic processes are activated. aging appears modulated by changes in the insulin-like growth-factor-1 receptor signaling system, as longevity is enhanced by a decrease in igf-1 signaling [171] [172] [173] . the igf-1 signal induces mtor activation. reduced mtor activity is related to extended lifespan in different organisms [174] , as mtor induces activation of foxo proteins. foxo proteins are transported to the nucleus and activate genes associated with autophagy [175] , which emphasizes the link between autophagy and foxo proteins. when the amp/atp ratio is high, the ampk path is activated [176] ; this results in increased energy production and reduced atp utilization. in addition, the mitochondrial biogenesis and mitophagy repair and replace damaged mitochondria. as a result, the cells have "younger" and more efficient mitochondria. in addition to the aforementioned condition, activation of this path has been associated with increased lifespan in various studies in both c. elegans and drosophila melanogaster [177, 178] . in mammals, fasting does not appear to affect ampk activation, but further studies are needed to be able to draw surer conclusions [179] . like ampk, sirtuins are associated with life [180] and autophagy [181] . some sirtuins are found in the cytoplasm (sirt2), some (sirt1) in the nucleus having dna repair action, and others in mitochondria. in general, sirtuins are associated with mitochondrial biogenesis and mitophagy for damaged mitochondria, thereby enhancing mitochondrial cells without problems and are thus more efficient in energy production [132, 182] . sirt1 is modulated by nad + level and is increased in energy depletion states (such as fasting or exercise) for which nad + is a sensor, which contributes to the reduction of inflammation through nf-kβ down-regulation and related transcription factors [132, 182, 183] . a study on rats showed that inflammation decreased with fasting [184] . other work has shown nf-kβ inhibition and the modulation of nrf2, sirtuins, sod2, and increased lifespan [185] [186] [187] [188] . in a 2017 study, intermittent fasting appears to significantly reduce corticosterone (cort), interleukin 6 (il-6), and tumor necrosis factor-alpha (tnf-α) levels [189] . nrf2 plays a key role in oxidative stress and toxicity; the right balance in ros levels is very important so that mitochondrial and all other pathways can function properly. the absence of ros, however, does not activate nrf2, which in turn does not activate are (antioxidant response). thus, a critical amount of ros ("hormesis hypothesis") is necessary for the upregulation of are, which allows cells and mitochondria to be able to deal with oxidative stress and different kinds of toxins [190] , which consequently increases their lifespan [191] (figure 2 ). during the last decades, many studies have been conducted on the effect of fasting on several markers related to metabolism. most of them determine the effect of fasting on weight. however, there are several studies that identify changes in lipid and carbohydrate metabolism as well as key hormones that affect the above (e.g., insulin). recently, some studies have focused on fasting's effect on inflammatory markers such as tnf-α, interleukins, crp, and bdnf, as well as the hormones adiponectin and leptin. the largest study on fasting's effects is an observational study including 1422 subjects that describes metabolic changes after a 4-to 21-day fasting period [159, 170] . all the participants fasted according to the buchinger wilhelmi fasting guidelines, which include a daily caloric intake of 200-250 kcal together with a variety of lifestyle changes (e.g., dietary advices, physical exercise). a beneficial modulating effect of fasting was observed on blood lipids, glucoregulation, and altogether general health-related blood parameters. additionally, it was associated with a reduction in weight, abdominal circumference, and blood pressure. in another study, which used the same fasting guidelines, improved metabolic markers were observed after periodic fasting, including a decrease in blood glucose levels associated with changes in gut microbiome composition [73] . in this study, the analysis of the gut microbiome after 10 days of periodic fasting showed that fasting caused a decrease in the abundance of bacteria known to degrade dietary polysaccharides such as lachnospiraceae and ruminococcaceae, concomitant to an increase in bacteroidetes and proteobacteria known to use host-derived energy substrates. a study of eight healthy non-obese men discovered that in 15 days of fasting every other day, with 20 h fasting on fasting days, adiponectin increased and leptin decreased, while no changes in il-6 or tnf-α were observed. protocol allowed them to maintain normal exercise but also to consume food in order to keep their weight stable [69] . redman et al., in a two-year study of 34 people who followed a reduced calorie intake diet (15%) observed a reduction in leptin. these individuals lost an average of 8.7 kg while the control group gained an average of 1.8 kg in the same period [192] . another study including eight women and two men, all overweight with asthma, showed that fasting every other day and reducing calories to less than 20% of their normal intake on the days of fasting, for eight weeks, resulted in a reduction in tnf-α and bdnf, but no change in crp. in this study, patients lost 8% of their initial weight during the study. asthma symptoms also improved as well as some indicators of oxidative stress (8-protein carbonyls, isoprostane, nitrotyrosine, and 4-hydroxynonenal adducts) [193] . in 2013, another study [194] found that 12 weeks of reduced calorie intake every other day resulted in reduced crp levels, increased adiponectin levels, and reduced leptin levels in 30 adults who were either overweight or normal weight. on fasting days, they consumed only 25% of the calories they normally consumed each day. in addition, their weight was significantly reduced by 3.6 ± 0.7 kg and the coronary heart disease risk was improved as the concentration of tg reduced. another study [195] found reduced high sensitivity-c-reactive protein (hs-crp) of 27 women with polycystic ovary syndrome (pcos) during the ramadan period in iran and in which participants aged 18 to 40 years old with an average of age 27.5, followed everyday 16.5 h fasting, isocaloric diet, for 29 days. an important study involving 34 men (resistance-trained) who fasted every day 16 h, followed an isocaloric diet for eight weeks, and consumed 100% of their energy needs in the 8-h eating window, showed that there was an increase in adiponectin and a reduction of leptin of il-6 and il-1β [196] . faris' study on 50 healthy volunteers (21 men and 29 women) fasting for 14-15 h each day for 21 days, showed a reduction in il-6, il-1β, tnf-α, total leukocytes, granulocytes, lymphocytes, and monocytes [197] . another study [198] involving 42 patients aged 20 to 50 years old with nonalcoholic fatty liver disease, following ramadan fasting (every day 16-h fasting for 29 days), showed a reduction in il-6 and hs-crp, compared to 41 volunteers who did not fast. these and other studies are presented in detail in table 2 . collectively, an increasing number of studies show that fasting has numerous health benefits and could be used to prevent or manage the development of cardiometabolic disorders, metabolic diseases, and immune diseases. although extended periods of fasting can be challenging without medical advices, recent studies also showed that time-restricted eating can be practiced safely as a routine. for instance, a recent study showed that 10 h of time-restricted eating for 12 weeks improved cardiometabolic health for patients with metabolic syndrome [199] . [194] ns-non-significant; hs-crp-highly sensitive crp; ldl-low density lipoproteins; hdl-high density lipoproteins; gsh-glutathione; tac-total antioxidant capacity; t3-triiodotironine; tg-triglycerides; bmi-body mass index; bf-body fat; sbp-systolic blood pressure; dbp-diastolic blood pressure; 2,3-dinor-ipf(2α)-iii -2,3-dinor-8-iso prostaglandin f 2α; hba1c-glycated hemoglobin; igf-1-insulin growth factor 1. given that a large part of the global population suffers from various metabolic disorders, it is important to look for non-pharmacological ways to deal with these conditions. targeted changes in lifestyle and especially diet can be economical tools to mitigate the development of metabolic disorders when they are at an early stage. these changes include increased fiber and polyphenol intake compared to the current western diets, but also well-structured, personalized fasting protocols, which can reduce the risk of metabolic disorders (figure 3) . this could be implemented in various institutions by improving the nutritional quality of foods served in schools, hospitals, prisons, government buildings, or senior centers. moving toward healthier food options in hospitals might ultimately help improve patient health and reduce healthcare costs. improving diet can have a positive effect on the immune response as a hallmark of rlrs. since inflammation is associated with the acute pathological response to covid-19 and other infectious diseases, improvement of the immune response and inflammatory markers may lead to an improved physiological resilience to disturbances by infectious agents such as viruses and bacteria, and possibly milder symptoms. inflammation in atherosclerosis metabolic syndrome is an inflammatory disorder: a conspiracy between adipose tissue and phagocytes dysregulation of lipid and amino acid metabolism precedes islet autoimmunity in children who later progress to type 1 diabetes circulating metabolites in progression to islet autoimmunity and 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blood cells the effects of italian mediterranean organic diet (imod) on health status limitations in the evidential basis supporting health benefits from a decreased exposure to pesticides through organic food consumption folate and one-carbon metabolism and its impact on aberrant dna methylation in cancer cell-and tissue-specific epigenetic changes associated with chronic inflammation in insulin resistance and type 2 diabetes mellitus obesity-induced dna hypermethylation of the adiponectin gene mediates insulin resistance increased oxidative stress in obesity and its impact on metabolic syndrome dietary polyphenols mediated regulation of oxidative stress and chromatin remodeling in inflammation epigenetic modifications in adipose tissue-relation to obesity and diabetes the spleen in local and systemic regulation of immunity intermittent fasting dissociates beneficial effects of dietary restriction on glucose metabolism and neuronal resistance to injury from calorie intake effect of 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enhances gut homeostasis and oral tolerance by delivering immunoregulatory signals diet, metabolites, and "western-lifestyle" inflammatory diseases short-chain fatty acids stimulate angiopoietin-like 4 synthesis in human colon adenocarcinoma cells by activating peroxisome proliferator-activated receptor gamma butyrate reduces colonic paracellular permeability by enhancing ppargamma activation regulation of inflammation by short chain fatty acids molecular mechanisms of insulin resistance that impact cardiovascular biology immunomodulatory effects of deacetylase inhibitors: therapeutic targeting of foxp3+ regulatory t cells the microbial metabolite butyrate regulates intestinal macrophage function via histone deacetylase inhibition metabolites produced by commensal bacteria promote peripheral regulatory t-cell generation whole grain-rich diet reduces body weight and systemic low-grade inflammation without inducing major changes of the gut microbiome: a randomised cross-over trial a mixture of trans-galactooligosaccharides reduces markers of metabolic syndrome and modulates the fecal microbiota and immune function of overweight adults effects of rye and whole wheat versus refined cereal foods on metabolic risk factors: a randomised controlled two-centre intervention study effects of arabinoxylan and resistant starch on intestinal microbiota and short-chain fatty acids in subjects with metabolic syndrome: a randomised crossover study a high intake of dietary fiber influences c-reactive protein and fibrinogen, but not glucose and lipid metabolism, in mildly hypercholesterolemic subjects effect of 12 wk of resistant starch supplementation on cardiometabolic risk factors in adults with prediabetes: a randomized controlled trial effects of an isocaloric healthy nordic diet on insulin sensitivity, lipid profile and inflammation markers in metabolic syndrome-a randomized study (sysdiet) decreased insulin secretion and incretin concentrations and increased glucagon concentrations after a high-fat meal when compared with a high-fruit and -fiber meal fiber-rich diet with brown rice improves endothelial function in type 2 diabetes mellitus: a randomized controlled trial a diet high in fatty fish, bilberries and wholegrain products improves markers of endothelial function and inflammation in individuals with impaired glucose metabolism in a randomised controlled trial: the sysdimet study dietary supplementation with inulin-propionate ester or inulin improves insulin sensitivity in adults with overweight and obesity with distinct effects on the gut microbiota, plasma metabolome and systemic inflammatory responses: a randomised cross-over trial greater expression of postprandial inflammatory genes in humans after intervention with saturated when compared to unsaturated fatty acids a short-term diet and exercise intervention ameliorates inflammation and markers of metabolic health in overweight/obese children could resistant starch supplementation improve inflammatory and oxidative stress biomarkers and uremic toxins levels in hemodialysis patients? a pilot randomized controlled trial resistant dextrin, as a prebiotic, improves insulin resistance and inflammation in women with type 2 diabetes: a randomised controlled clinical trial strawberries decrease circulating levels of tumor necrosis factor and lipid peroxides in obese adults with knee osteoarthritis low-energy diets differing in fibre, red meat and coffee intake equally improve insulin sensitivity in type 2 diabetes: a randomised feasibility trial effects of increased wholegrain consumption on immune and inflammatory markers in healthy low habitual wholegrain consumers postprandial glucose and nf-kappab responses are regulated differently by monounsaturated fatty acid and dietary fiber in impaired fasting glucose subjects is there any place for resistant starch, as alimentary prebiotic, for patients with type 2 diabetes? inulin controls inflammation and metabolic endotoxemia in women with type 2 diabetes mellitus: a randomized-controlled clinical trial oligofructose-enriched inulin improves some inflammatory markers and metabolic endotoxemia in women with type 2 diabetes mellitus: a randomized controlled clinical trial whole-grain intake favorably affects markers of systemic inflammation in obese children: a randomized controlled crossover clinical trial a time to fast the safety limits of an extended fast: lessons from a non-model organism comparative physiology of fasting, starvation, and food limitation long-term energy balance in child-bearing gambian women fasting: molecular mechanisms and clinical applications effects of intermittent fasting on health impact of intermittent fasting on health and disease processes human bcl-2 reverses survival defects in yeast lacking superoxide dismutase and delays death of wild-type yeast the sir2/3/4 complex and sir2 alone promote longevity in saccharomyces cerevisiae by two different mechanisms replicative and chronological aging in saccharomyces cerevisiae dietary deprivation extends lifespan in caenorhabditis elegans heterothermy in growing king penguins caloric restriction increases learning consolidation and facilitates synaptic plasticity through mechanisms dependent on nr2b subunits of the nmda receptor late-onset intermittent fasting dietary restriction as a potential intervention to retard age-associated brain function impairments in male rats effects of intermittent feeding upon body weight and lifespan in inbred mice: interaction of genotype and age apparent prolongation of the life span of rats by intermittent fasting the effects of infantile stimulation and intermittent fasting and feeding on life span in the black-hooded rat beneficial effects of exercise on growth of rats during intermittent fasting fasting cycles retard growth of tumors and sensitize a range of cancer cell types to chemotherapy starvation-induced activation of atm/chk2/p53 signaling sensitizes cancer cells to cisplatin mitochondrial production of reactive oxygen species and incidence of age-associated lymphoma in of1 mice: effect of alternate-day fasting starvation-dependent differential stress resistance protects normal but not cancer cells against high-dose chemotherapy intermittent fasting and caloric restriction ameliorate age-related behavioral deficits in the triple-transgenic mouse model of alzheimer's disease aberrant heart rate and brainstem brain-derived neurotrophic factor (bdnf) signaling in a mouse model of huntington's disease dietary restriction normalizes glucose metabolism and bdnf levels, slows disease progression, and increases survival in huntingtin mutant mice age and energy intake interact to modify cell stress pathways and stroke outcome the fat-derived hormone adiponectin reverses insulin resistance associated with both lipoatrophy and obesity caloric restriction alternate-day fasting protects the rat heart against age-induced inflammation and fibrosis by inhibiting oxidative damage and nf-kb activation. free radic intermittent fasting and dietary supplementation with 2-deoxy-d-glucose improve functional and metabolic cardiovascular risk factors in rats intermittent feeding and fasting reduces diabetes incidence in bb rats cardioprotection by intermittent fasting in rats the effects of ghrelin on inflammation and the immune system autophagy regulates lipid metabolism cardioprotective effect of intermittent fasting is associated with an elevation of adiponectin levels in rats fasting therapy-an expert panel update of the 2002 consensus guidelines effects of intermittent fasting on glucose and lipid metabolism intermittent metabolic switching, neuroplasticity and brain health flipping the metabolic switch: understanding and applying the health benefits of fasting fasting imparts a switch to alternative daily pathways in liver and muscle alternate day fasting (adf) with a high-fat diet produces similar weight loss and 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genetics of ageing sensing of energy and nutrients by amp-activated protein kinase the amp-activated protein kinase aak-2 links energy levels and insulin-like signals to lifespan in c. elegans a critical role of snf1a/dampkalpha (drosophila amp-activated protein kinase alpha) in muscle on longevity and stress resistance in drosophila melanogaster metabolic adaptations to fasting and chronic caloric restriction in heart, muscle, and liver do not include changes in ampk activity linking sirtuins, igf-i signaling, and starvation deacetylation of nuclear lc3 drives autophagy initiation under starvation sirtuins at a glance regulation of pgc-1alpha, a nodal regulator of mitochondrial biogenesis age-associated development of inflammation in wistar rats: effects of caloric restriction molecular inflammation as an underlying mechanism of the aging process and age-related diseases extending healthy life span-from yeast to humans the hallmarks of aging ramadan diurnal intermittent fasting modulates sod2, tfam, nrf2, and sirtuins (sirt1, sirt3) gene expressions in subjects with overweight and obesity intermittent fasting could ameliorate cognitive function against distress by regulation of inflammatory response pathway role of nrf2 in oxidative stress and toxicity extending life span by increasing oxidative stress. free radic metabolic slowing and reduced oxidative damage with sustained caloric restriction support the rate of living and oxidative damage theories of aging alternate day calorie restriction improves clinical findings and reduces markers of oxidative stress and inflammation in overweight adults with moderate asthma. free radic alternate day fasting for weight loss in normal weight and overweight subjects: a randomized controlled trial effects of ramadan fasting on glucose homeostasis, lipid profiles, inflammation and oxidative stress in women with polycystic ovary syndrome in kashan effects of eight weeks of time-restricted feeding (16/8) on basal metabolism, maximal strength, body composition, inflammation, and cardiovascular risk factors in resistance-trained males intermittent fasting during ramadan attenuates proinflammatory cytokines and immune cells in healthy subjects the effects of ramadan fasting on body composition, blood pressure, glucose metabolism, and markers of inflammation in nafld patients: an observational trial randomized cross-over trial of short-term water-only fasting: metabolic and cardiovascular consequences the effect of short periods of caloric restriction on weight loss and glycemic control in type 2 diabetes alternate day fasting and endurance exercise combine to reduce body weight and favorably alter plasma lipids in obese humans long-term calorie restriction is highly effective in reducing the risk for atherosclerosis in humans the effects of modified alternate-day fasting diet on weight loss and cad risk factors in overweight and obese women the effect of intermittent energy and carbohydrate restriction v. daily energy restriction on weight loss and metabolic disease risk markers in overweight women improvement in coronary heart disease risk factors during an intermittent fasting/calorie restriction regimen: relationship to adipokine modulations key: cord-274459-781by93r authors: khalifa, shaden a. m.; mohamed, briksam s.; elashal, mohamed h.; du, ming; guo, zhiming; zhao, chao; musharraf, syed ghulam; boskabady, mohammad h.; el-seedi, haged h. r.; efferth, thomas; el-seedi, hesham r. title: comprehensive overview on multiple strategies fighting covid-19 date: 2020-08-11 journal: int j environ res public health doi: 10.3390/ijerph17165813 sha: doc_id: 274459 cord_uid: 781by93r lately, myriad of novel viruses have emerged causing epidemics such as sars, mers, and sars-cov-2, leading to high mortality rates worldwide. thus, these viruses represented a challenging threat to mankind, especially considering the miniscule data available at our disposal regarding these novel viruses. the entire world established coordinative relations in research projects regarding drug and vaccine development on the external range, whereas on the internal range, all countries declared it an emergency case through imposing different restrictions related to their border control, large gatherings, school attendance, and most social activities. pandemic combating plans prioritized all sectors including normal people, medical staff politicians, and scientists collectively shouldered the burden. through planning and learning the previous lessons from sars and mers, healthcare systems could succeed in combating the viral spread and implications of these new pandemics. different management strategies including social distance, social awareness and isolation represented successful ways to slow down the spread of the pandemic. furthermore, pre-preparedness of some countries for emergencies is crucial to minimize the consequences of the crisis. . comparison between total deaths and confirmed cases in some countries with different population from jan 21 till 14 april 2020 [10] . most countries were forced to announce emergency measures to protect vulnerable people and block ways of transmission due to the continuous increase in confirmed cases by time as reported in figure 3 [11] [12] [13] [14] [15] [16] . with regard to this escalating situation, governments have begun to develop strategies to resolve the pandemic cooperatively with international health agencies, i.e., centers of disease control (cdc) and world health organization (who) that declared many precautions based on previous lessons from mers and sars diseases, as will be outlined in this section. our review aims to evaluate strategies of the most affected countries from different continents all over the world (china, italy, germany, france, spain, america, canada, brazil, uk, india, japan, singapore, iran, korea, and australia) for confronting the epidemic as it explains the best practices that could help other countries to overcome current or any upcoming pandemic. most countries were forced to announce emergency measures to protect vulnerable people and block ways of transmission due to the continuous increase in confirmed cases by time as reported in figure 3 [11] [12] [13] [14] [15] [16] . with regard to this escalating situation, governments have begun to develop strategies to resolve the pandemic cooperatively with international health agencies, i.e., centers of disease control (cdc) and world health organization (who) that declared many precautions based on previous lessons from mers and sars diseases, as will be outlined in this section. figure 3 . change in numbers of confirmed cases over time [11] [12] [13] [14] [15] [16] . the chinese lunar new year holiday, which synchronized with the outbreak of covid-19, is the most celebrative time of year in china. usually, a large global migration takes place, as individuals travel back to their homes. around five million people had left wuhan [17] . around a third of those people travelled outside the province of hubei. restricting people's social contacts was critical to covid-19 regulation. key elements of such social distancing initiatives included that the chinese government promoted people to stay home, dissuaded mass gathering, postponed or the chinese lunar new year holiday, which synchronized with the outbreak of covid-19, is the most celebrative time of year in china. usually, a large global migration takes place, as individuals travel back to their homes. around five million people had left wuhan [17] . around a third of those people travelled outside the province of hubei. restricting people's social contacts was critical to covid-19 regulation. key elements of such social distancing initiatives included that the chinese government promoted people to stay home, dissuaded mass gathering, postponed or cancelled major events, and closed universities, factories, museums, libraries, schools, and governmental offices. chinese people began to take steps to shield themselves from covid-19, i.e., wearing protective masks, if they had to commute in public. social distancing has been successful in limiting human to human transmission and cutting morbidity and mortality. more stringent steps are introduced such as isolation and quarantine. the lunar new year holiday was expanded by chinese government. the holiday deadline was shifted to 10 march for hubei province and 9 feb for other provinces, so that the holiday duration was long enough to cover the alleged covid-19 incubation time. diagnosed people were segregated in hospitals. in wuhan, in which a large number of infected people resided, people with mild or asymptomatic infections were quarantined at shelters called fang cang hospitals, which were public open areas, i.e., stadiums and convention centers that had been retooled for medical treatment. the chinese government promoted and funded grassroots screening for contact tracking and early detection and encouraged hand-washing and surface sanitization. home-based quarantine of people who were at the epicenters of epidemic and travelled to other places in china to curb the spread of virus to boarder populations. the government avoided panic amongst people by providing the updated information through media. free medical care was introduced by the state to motivate patients to visit doctors as soon as possible and in good time to prevent further deterioration of the condition. the state guaranteed people's daily needs [18] . the state with the second highest numbers of viral deaths worldwide. the government declared a state of emergency lockdown that began in northern italy and spread throughout the world. the fatality rate (7.2) was much higher than that of china (3.8). all italian regions were known as "red zones" with extreme limits imposed on every public event. italy responded to the situation with screening even for those without symptoms. italy faced a persistent shortage of health care staff. the government announced a proposal to recruit 20,000 new doctors, nurses, and health workers to meet demand. retired doctors and students who had finished their medical degree and are in the final year of specialist training, were called upon [19] . coordinated intensive care units were equipped for covid-19 positive patients. continuous training for health care staff was crucial with applying dedicated protocols and full isolation [20] . the rules initially laid down approximately one month for schools' closures and restrictions on people's right to leave homes and two weeks for the suspension of business activities. the italian government proposed an extension of lockdown steps [21] . to curb viral transmission, air travels were banned from china and italian passengers were quarantined in china. suspected cases were moved to pre-defined hospitals where the check for sars-cov-2 was available and infectious disease divisions were willing to isolate confirmed cases. emergency medical system of milan metropolitan area formed covid-19 response team with main goal of resolving the viral pandemic without encumbering regular emergency medical system activities. the response team examined the health and clinical conditions of persons being screened to evaluate the need for hospitalization or home testing and subsequent isolation. this response team designed algorithm to identify covid-19 suspected cases. the algorithm is continuously modified to comply with the regional directives [22] . in a speech about the coronavirus pandemic, german chancellor angela merkel approached the citizens directly. she explained the situation this way "it is serious. take it seriously too!". "since world war ii, there has been no other challenge to the country, where national solidarity was as important as right now", she said. the german chancellor announced stricter steps and declared 9 standards/rules for germany. the main objective was to "reduce public life to the extent warranted". this included restriction of the bare minimum connections, maintenance of a minimum distance to the public of at least 1.5 m, permission for people to go to work, doctors, shops, and play outdoor sports individually. however, gatherings in groups or meeting were no longer permitted [23] . france, like other nations formed their pandemic influenza plan (pip) based on the recommendations for the contagion management by who. president macron clarified that only collective national campaign can prevent the spread of infection, restrict deaths, and avoid the submergence of health service. french pip aimed to alleviate pandemic by minimizing the number of civilian casualties and preserving machinations in particular economic activities. pip included 4 stages: the 1st stage was to impede the introduction of outbreak to the world, 2nd stage to restrict viral growth and distribution in france, 3rd stage to attenuate the potential outbreak to minimum and 4th stage was returning to normalcy. first reported cases were chinese nationals visiting france, so steps were rapidly taken to keep these cases in isolation. contact tracing was held to identify people at risk of infection. the government cancelled all sporting events and schools were also closed. authorities have repeatedly pronounced individual habits and requested protective masks for those who show signs of infections and for health workers so, public and private sectors were mustered to produce masks and disinfectants. to prevent viral transmission, france pressured the european union to close the schengen treaty zone for all non-european citizens. despite the strategy's economic impacts, france scarified the entire society to combat covid-19 [24] . on 14 march, the spanish government started the applications of safety measures, in order to flatten the curve 13 days after the exponential rate of virus start (r0 < 1); the day in which 20 new cases were registered for the first time. all people were forced to stay home through announcing the lockdown. spain has adopted some measures to control spread: social distance, closure of most activities, e.g., cinemas, clubs and schools to avoid crowding [25] . under supervision of the president of the government, pedro sánchez, who described the crisis as: "unprecedented challenge", "a global threat that recognizes no borders, colors or languages", and an "extraordinary challenge that forces us to take exceptional measures". he assured the importance of application of distance learning as much as possible to slow down viral spread. they reduced non-essential work to conserve support to different sectors including the vulnerable categories, the elderly, families with the lowest resources, and small business owners. their strategy included increasing the awareness that each person in the community has a role in combating the virus; elderly people receive intensive care and the young follow the safety measures and social distancing. everyone had to care of others and the sense of social responsibility was increased. moreover, they had a continuously announced transparent data from the beginning beside their steps to prevent infection through following the guidelines and health monitoring protocol [26] . the director-general of the world health organization (who) announced that the covid-19 pandemic had triggered an international public health emergency. the united states department of health and human service secretary announced on 31 january 2020 a u.s public health emergency, and the u.s. president legitimated a "proclamation on suspension of entry as immigrants and non-immigrants of persons that pose a risk of transmitting 2019 novel coronavirus". this regulation restricts the entrance of american citizens and those with legal permanent residents and their families, especially those who have travelled to mainland china. the centers of disease control and prevention (cdc) and other governmental agencies, as well as state and local health centers, introduced proactive steps to limit covid-19 propagation in the u.s. [27] . such steps included the recognition of cases and their contacts, and the suitable care of travelers coming from china to the u.s. the correct actions were taken to (1) slow down virus spread; (2) prepare health care systems and encourage public willingness for pervasive transmission; and (3) clearly define infection and directly report to public health centers in order to make decisions and improve medical safeguards involving diagnosis, therapy, and vaccines [28] . despite the fact that these initiatives were being enforced in anticipation of the virus in the u.s., the continued widespread dissemination of the virus was devastating. usa holds a negative record in regard to the pandemic, with the highest number of infections and deaths recorded worldwide. public health and disease prevention programs in canada were refashioned around guidelines and recommendations of naylor and his group that were used before against sars and entitled "learning from sars". experience with sars affected positively canada's response to the covid-19 outbreak. most notably, correspondence concerning public health was greatly improved and digital media was progressed. there were some technological gaps like contrasting directives on the use of personal protective equipment but this has been mainly resolved. in airports, procurement were organized and rolling tests became faster [29] . previous preparedness before incidence of infection was phenomenal in brazil. on 22 january 2020, the health surveillance secretariat together with the ministry of health activated an emergency health operation center with low alerting level, which was raised later on 27 january when the first suspected corona virus case appeared. national contingency plan (ncp) for the covid-19 and guidelines; based on information received from who were announced to be applied in all states. quarantine law was imposed for protecting people. isolation and exceptional restrictions on travelling was applied even before the appearance of the first case. currently, there is a rapid growth in cases in brazil; 3904 cases and 114 deaths were registered only one month after the first confirmed case [30] . trials to reduce cases were implemented and huge attention was paid towards availability of intensive care units (icus), diagnostic tests and ventilators needed for patients with covid-19 [30] . brazil suffered from political flounder, which constituted distraction in the middle of crisis. the government restricted the use of rt-pcr examinations to people with more severe symptoms leading to higher mortality rates. this was due to high cost of materials and shortage in qualified people and labs able to do the rt-pcr test and the needed transportation for samples to places, where tests are performed. thus, people with mild symptoms or the asymptomatic caused the transmission of infection. dense populations on favelas made it impossible to follow the social distance. moreover, illegal mining and logging in amazon forests may have brought infections to remote areas. scientific organizations, such as the brazilian academy of sciences opposed bolsonaro due to the decreased science budget, general security, and shortage of public services. currently, there is increased production of personal protective equipment, ventilators, and diagnostic kits [31, 32] . the united kingdom (u.k.) government followed health's department direct recommendations for travelling abroad with respiratory infections, especially travelling to wuhan [33] . the u.k. national health service emphasized the importance of using personal protective equipment, obtaining a detailed history of travelling, and rapidly escalating suspicious cases with a dedication to isolate patients. any confirmed cases of covid-19 should be moved to an airborne high impact infectious disease center such as the two major centers in england (royal free hospital in london and newcastle royal victoria infirmary). u.k. chief medical officers told individuals who had toured wuhan or hubei province over the past 14 days to stay at home and call national health service number 111. such recommendations were also applied to people, who have visited japan, thailand, hong kong, singapore, taiwan, macau, and malaysia [34] . the world's second most densely-populated country after china made the situation worse, since population density beside some other factors contributed to the wide viral transmission [35] . poverty and money-related problems complicated combating strategies. if the government imposed social distance (1 m distance), many categories opposed the actions, especially craftsmen. ignorance from indians at first increased the number of infected people [36] . then, the government imposed a strict lockdown for 55 days except for some services such as fire departments, police, and hospitals. diagnostic kits were increased every day and in every state. train coaches were turned to mobile wards for isolation. a phone application was launched called aarogya setu (health bridge) aiming to track people's health [37] . check points were built at borders to check people entering the country, and all borders were shut. the ministry of health and family welfare (mohfw), india, increased awareness, took actions to control covid-19 and guidelines on management; prevention and sample collection were announced. also a hotline was created with a 24 h/7 days-a-week service to help people [38] . a huge budget of about us $2.1 billion was endowed for health sector to combat covid-19. the department of science and technology, government of india tried to promote research in university institutes and started working in various directions to control the virus during the country's lockdown. the indian council of medical research (icmr) launched private labs with suitable safety regulations to test covid-19 samples. icmr reported that about 579,957 tests (as of 25 april 2020) were performed in india. blood plasma therapy using the plasma of recovered patients with immunity against covid-19 was applied to infected individuals. the indian strategies paid the most attention for medical care requirements. thus, the number of infected people is less than other countries due to exerted efforts by authorities to impose the strict lockdown. yet even after lockdown removal (fully or partially) on 3 may 2020, the threats amplified [36] . on 9 june 2020, the ministry of health and family welfare (mohfw) announced that 266,598 confirmed covid-19 cases and 7471 deaths from 32 states especially the states of maharashtra, tamil nadu, delhi, and gujarat. hence, the case-fatality rate became 2.8% [39] . it is not the first time for japanese people to face a national crisis, as they previously experienced two atomic bombings in 1945, the sarin gas in 1995, and the h1n1 epidemic in 2009. thus, fear and anxiety was dominating. images, headlines, rumors and confirmation of human-to-human transmission in nara prefecture played a role. anxiety-related behaviors appeared significantly in shortage of masks and sanitizers in drug stores, social rejection, discrimination against affected people [40] . however, preparedness and learning from previous lessons was effective. japan reported low numbers of covid-19-related deaths due to the following measures. to prevent infection, emergency state was declared on 7 april 2020 and continued for a month. people were asked to stay home and stop un-essential activities. japanese customs suited for social distancing, as they exclude handshaking, hugging, or kissing in greetings [41] . usage of long-term care areas with the most vulnerable residents was temporarily suspended. japanese people were asked to avoid crowded places with bad ventilation and conservation of physical distances according to recommendations of an expert committee [42] . travels were restricted from and to wuhan, and 565 japanese citizens were asked to evacuate china. subsequently, three flights transported them back home. healthy individuals were isolated, prevented to move around and kept under medical observation at designated hotels, while others with disease symptoms upon arrival in japan were admitted to hospitals [43] . singapore, the regional travel center in southeast asia, was one of the first places to be impacted by covid-19. the singapore strategies were based on back experience with sars outbreak. an important lesson was to ensure cohesive response across all sectors, consistent leadership and guidance was crucial. therefore, a multi-ministerial task force was established to provide central leadership for all government crisis management, before singapore had its first covid-19 incident. an intensified surveillance system was developed to monitor covid-19 cases between hospital and primary care pneumonia patients. to promote this system, covid-19 rt-pcr laboratory tests were rapidly expanded to all singapore hospitals with 2200 tests per day for 5.7 million persons. suspected and confirmed cases were isolated in hospitals immediately to avoid further transmission. contact tracing was also started to determine their past locomotion before isolation to identify potential sources of infections. more than 800 public health preparedness clinics has been set up to facilitate the control of primary care of respiratory diseases. incoming travelers were subjected to temperature and health checks at all airports and suspicious cases sent immediately to hospitals. singapore's community approach focused on social responsibilities while precautionary life kept going as usual. social education was a key empowerment strategy and carried out through print, broadcast, and social media. workers are empowered to continuously monitoring temperature and health and organizations are motivated to step forward their business plans. schools remained opened with precautions. even though these precautions were enforced, singapore retained normality of daily life [44] . by 5 march 2020, the viral spread increased, and all 31 provinces were affected. then, by 3 april the number of confirmed cases reached 53,183 with deaths 3294 in iran. the government prohibited many activities: sale and export of face masks to legal entities were limited, commercial movements with china were prevented, and travel was banned. cancelation of all public gatherings, including cinemas, concerts, theaters, postponement of weddings, parties, conferences, seminars, camps and collective sports, school closure, and establishing e-learning, reduced office hours for 2 h/day [45] . people were guided for hand-washing and wearing masks. suspected and infected people with covid-19 were isolated for 14 days [46] . poor people were severely affected by quarantine; hence, the government financially supported them. the supreme council for health and food security together with a special council for covid-19 confessed essential deficiencies in policies regarding food security including delays in bills such as electricity, payment of bank loans. however, reductions in oil prices and oil selling due to sanctions significantly affected the ability of governmental support [47] . the iranian ministry of health and medical education (mohme) compiled the who guidelines for covid-19 prevention and announced them through different platforms. hotlines to answer questions and give advice on nutrition and mental health were available. national campaigns for increasing awareness and information were held to improve public knowledge. a website was launched (salamat.gov.ir) to help people and answer their questions [48] . the political situation in iran impacted the economic infrastructure, which indirectly affected the health sector and the first-line defense against the virus. thus, the burden scaled up. in addition, the weakness of the medical infrastructure, inadequate personal protective equipment and difficulties in importing them are all key factors. quarantining cities was rather ineffective due to viral distribution throughout the country [49] . korea's infection alerting system has four levels: (1) attention to the epidemic as the government began tracking, (2) caution if an epidemic reached the country and the government maintained a program of cooperation, (3) activation of response system that could be alerted regarding to spread of infection, and (4) development of a national response program, as the outbreak progressed and became serious. four days after announcement of new cases in china, korea began screening and enforced quarantine program at the airports. everyone who had visited wuhan during the past 14 days was asked to complete health questionnaire and to have 14 days of self-quarantine. if there was fever or respiratory ailments, they should call korea cdc. early recognition helped korea remove the community infection and limit it to medical facilities which was an integral part of outbreak response. a 6-h rapid test was distributed in all health centers around the country. korea cdc started recording the crisis to provide reliable data. such reports included number and history of suspected cases with public guidance for prevention. travel to china was cancelled. korea goals were accomplished through 3 key strategies: 1st outbreak based on suppression and mitigation, 2nd risk awareness to encourage community involvement, and 3rd science-based and reality driven behavior [50] . australia built its response to covid-19 on the basis of its powerful healthcare system. australia realized that people involved in primary care, elderly care, home care, and disability care need the same degree of support and safety as people working in hospitals in attempt to preserve both public and vital health care system to sustain the workplace of services. good, coherent contact with the primary care staff and general public was very critical for the needed steps. borders were shut down, non-essential facilities were closed, precautionary measures were in the places with infection risk, stringent social distancing were enforced together with quarantining of individuals with suspected infection or confirmed infection. the prime minister of australia stated the implementation of the novel coronavirus emergency response program for australian medical sector. the four strategic goals of the targeted plan were: protecting people from covid-19 effects, maintain health care functional capacity, facilitate the most appropriate treatment of people with symptoms, manage, and control personal protective equipment. the australian government introduced 2.4 billion primary care packages to safeguard all australians. primary care approach has main components: telemedicine services, online infection control training provided to all caregivers, institution of general practice-led primary healthcare respiratory clinics (200 clinic) to transfer affected people away from other general practices [51] . most governmental strategies are summarized in figure 4 . collectively, demographic diversity, standard of living of each country's citizens, political state and health systems in addition to other factors led to various strategies being implemented across the globe trying to cope with the crisis. however, the collaboration and sharing of responsibility for controlling the pandemic through exchange of information between countries was the most important step. taken together, countries facing covid-19 or any other pandemic should consider control or closure periods and whether required or compulsory closure of unneeded workplaces and public entities as a first line of social distance measures can reduce transmission rate. the closure times should be adapted to the unique characteristics of the novel disease, i.e., the incubation duration and transmission routes, and the nature of these outbreaks. the main purpose of the pandemic control closure phase is to avoid the spread of disease by people with asymptomatic infections. governments should use closure times to optimize effect, promotions, group screening, active communication, monitoring, isolation, and quarantine. some countries have promoted their people's consciousness across many channels, e.g., television, newspapers, and conferences. they have been resorting to the use of more modern health and education technologies i.e., e-learning and telemedicine to reduce the urge to go outside. such a hybrid strategy is also backed up by analyses of responses to previous pandemics, which have shown that average attack rate reductions were more noticeable if social distance policies and other disease prevention steps were combined to prevent transmission. sars-cov-2 spreads at an astonishing speed across the globe. on 30 january 2020, who collectively, demographic diversity, standard of living of each country's citizens, political state and health systems in addition to other factors led to various strategies being implemented across the globe trying to cope with the crisis. however, the collaboration and sharing of responsibility for controlling the pandemic through exchange of information between countries was the most important step. taken together, countries facing covid-19 or any other pandemic should consider control or closure periods and whether required or compulsory closure of unneeded workplaces and public entities as a first line of social distance measures can reduce transmission rate. the closure times should be adapted to the unique characteristics of the novel disease, i.e., the incubation duration and transmission routes, and the nature of these outbreaks. the main purpose of the pandemic control closure phase is to avoid the spread of disease by people with asymptomatic infections. governments should use closure times to optimize effect, promotions, group screening, active communication, monitoring, isolation, and quarantine. some countries have promoted their people's consciousness across many channels, e.g., television, newspapers, and conferences. they have been resorting to the use of more modern health and education technologies i.e., e-learning and telemedicine to reduce the urge to go outside. such a hybrid strategy is also backed up by analyses of responses to previous pandemics, which have shown that average attack rate reductions were more noticeable if social distance policies and other disease prevention steps were combined to prevent transmission. sars-cov-2 spreads at an astonishing speed across the globe. on 30 january 2020, who announced the outbreak of covid-19 an international public health emergency which impacted 77 countries (status: 4 march 2020) [52] . the speed and extent of pandemic detection, particularly early diagnosis and notification of new cases, is an important measure to monitor this infectious disease. countries that have previous experience with viral infectious diseases (most commonly sars), powerful primary care systems with helpful infrastructures, guidance rules and instructions, and community awareness with social responsibilities prove to be more effective in controlling the spread of infection and reducing its deleterious impacts. numerous countries endeavor to construct an info-structure of national digital health in order to improve disease surveillance and link public health and clinical intelligence programs. clear and open contact between governments and healthcare staff would be pivotal. it was the time for hospitals or agencies that engage in healthcare delivery to audit its protocols and consumables for all selected patients. heads of state, global health leaders, private sector partners, and other stakeholders have accelerated global partnership to speed up the production of covid-19 diagnostic and preventive tools. all governments should prepare the public for a second wave or another outbreak. national policy discussions about the future of the respective society should be initiated. covid-19 is a tragedy for us all collectively, but it is also an opportunity to ask ourselves what kind of society we want after the pandemic fades away. reproduction numbers of infectious disease models molecular mechanisms of coronavirus rna capping and methylation genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding origin and evolution of pathogenic coronaviruses the novel zoonotic covid-19 pandemic: an expected global health concern systematic review: national notifiable infectious disease surveillance system in china study of surveillance data for class b notifiable disease in china from 2005 to 2014 three emerging coronaviruses in two decades: the story of sars, mers, and now covid-19 covid-19): situation report-85 covid-19): situation report-12 covid-19): situation report-41 coronavirus disease 2019 (covid-19) situation report-72. available online coronavirus disease (covid-19) situation report-102. available online coronavirus disease (covid-19) situation report-133. available online coronavirus disease (covid-19) situation report-163. available online the model of epidemic (covid-19) prevention and control in rural of china covid-19 control in china during mass population movements at new year on the front lines of coronavirus: the italian response to covid-19 hospital surge capacity in a tertiary emergency referral centre during the covid-19 outbreak in italy compliance with covid-19 social-distancing measures in italy: the role of expectations and duration the response of milan's emergency medical system to the covid-19 outbreak in italy merkel announces strict measures and tells germans to stay home in virus fighle adaptation of the national plan for the prevention and fight against pandemic influenza to the 2020 covid-19 epidemic in france effectiveness of the measures to flatten the epidemic curve of covid-19. the case of spain president of the government calls for political and public unity to overcome coronavirus emergencyle proclamation on suspension of entry as immigrants and nonimmigrants of persons who pose a risk of transmitting 2019 novel coronavirus initial public health response and interim clinical guidance for the 2019 novel coronavirus outbreak-united states learning from sars. lancet characterization of the covid-19 pandemic and the impact of uncertainties, mitigation strategies, and underreporting of cases in south korea, italy, and brazil covid-19 in brazil covid-19-6 million cases worldwide and an overview of the diagnosis in brazil: a tragedy to be announced covid-19): situation report-3 world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) projections for covid-19 pandemic in india and effect of temperature and humidity covid 19 in india: strategies to combat from combination threat of life and livelihood investigating the dynamics of covid-19 pandemic in india under lockdown the rise and impact of covid-19 in india covid-19 pandemic in india: present scenario and a steep climb ahead public responses to the novel 2019 coronavirus (2019-ncov) in japan: mental health consequences and target populations why does japan have so few cases of covid-19? clusters of covid-19 in long-term care hospitals and facilities in japan 16 the rate of underascertainment of novel coronavirus (2019-ncov) infection: estimation using japanese passengers data on evacuation flights interrupting transmission of covid-19: lessons from containment efforts in singapore covid-19 pandemic and comparative health policy learning in iran the challenges and considerations of community-based preparedness at the onset of covid-19 outbreak in iran ensuring adequate health financing to prevent and control the covid-19 in iran ir of iran national mobilization against covid-19 epidemic coronavirus disease 2019 (covid-19) outbreak in iran: actions and problems lessons learned from korea: covid-19 pandemic crossref] 52. world health organization. responding to community spread of covid-19: interim guidance the authors declare no conflict of interest. key: cord-272406-h22atwd4 authors: diotaiuti, pierluigi; mancone, stefania; bellizzi, fernando; valente, giuseppe title: the principal at risk: stress and organizing mindfulness in the school context date: 2020-08-31 journal: int j environ res public health doi: 10.3390/ijerph17176318 sha: doc_id: 272406 cord_uid: h22atwd4 background: in recent years the role of school principals is becoming increasingly complex and responsible. methods: this study was voluntarily attended by 419 italian school principals who were administered the psychological stress measurement (msp), mindfulness organizing scale (mos), polychronic-monochronic tendency scale (pmts), and the scale of emotions at work (sew). results: the study has produced a path analysis model in which the relationships between the main predictors of principals’ work discomfort were explained. the effect of depressive anxiety on perceived discomfort (ß = 0.517) found a protective mediator in the mindfulness component that recognizes the sharing as a fundamental operational tool (ß = −0.206), while an increasing sense of effort and confusion could significantly amplify the experience of psychological discomfort associated with the exercise of school leadership (ß = 0.254). conclusions: the model developed in this study suggests that focusing on organizing mindfulness can be a valuable guideline for interventions. research on work-related stress has long identified the school as one of the risk environments, and various studies and publications deal with the stress and burnout of school workers. most of the work produced devotes attention to teachers, and there are few reflections on the psychophysical resistance of the principal, especially considering all the legislative and organizational changes that have taken place [1, 2] . these continuous changes, necessary in a rapidly changing society (well described by the "liquid society" metaphor coined by zygmunt bauman) become a cause of work-related stress for all school staff, especially principals. the ongoing reform of the education system in italy involves various professionals and individuals who have a role in the complex world of school: principal (dg-dirigente scolastico in italian); director of general and administrative services (dsga-it. direttore dei servizi generali e amministrativi), all administrative, technical and auxiliary staff (ata-it. personale amministrativo, tecnico e ausiliario), teachers, students and their parents (or parental figures). each of these players must adapt to regulatory changes, both individually and collectively, with time dictated by political choices, which can be both national and supranational; the educational system, through the schools operating on the territory and the people who effectively act and put into practice the regulatory frameworks decided by the government institutions, must follow and pursue the changes in a short time period, often far from the actual physiological timing that the institution can implement. the principal is an intermediate figure and a link between the institutional organizational framework, represented by the state, the regions, and the municipalities, and the framework of school individuals, represented by the teaching staff, ata staff, parents and students. many of the skills and int. j. environ. res. public health 2020, 17, 6318 2 of 14 competences required of professional staff, but also students, are not part of the training acquired over time and especially put into practice and enriched by personal experimentation and experience, so that even people with a ten-year work experience are forced to become new students learning subjects and skills hitherto untested, and therefore they are unaware of how gifted, capable and effective they are in resolving tasks [3, 4] . the role of principal requires new skills and competences to meet the requirements and objectives defined by the proliferation of school reforms, regulations, and cultural changes [3, 5, 6] . extensive research in various countries has already focused on principal burnout [7] [8] [9] [10] [11] [12] [13] [14] . as sari [8] notes, there may be curiosity and desire to learn and experience new skills and abilities, but the stress related to possible administrative errors and criminal consequences of errors or omissions, or low performance in failing to achieve results, remains high, with emotional drain and possible burnout consequences. moreover, implicitly, the principal may also experience the feeling that his own cultural and cognitive skills, as well as tools and resources, have become obsolete or are no longer suitable for current needs, thus increasing personal insecurity [15] . these elements are sources of elevated stress levels in principals, because they become the point of reference and the catalyst of the stress of all professional and non-professional figures. not only must the principal solve his/her own problems, but he/she must also deal with those of his/her subordinates, in most cases without having adequate leadership experience and training. some countries have experienced a lack of candidates for the role of principal or an increase in resignations, because the teachers know they are not actually capable of fulfilling all the requirements the role calls for [16] [17] [18] . the principal experiences a drastic reduction in his/her educational and pedagogical function and must acquire technical, administrative, cognitive and what we could call management engineering skills: as a principal he/she becomes responsible for the safety of staff and students and a manager of economic resources, with budgetary obligations. to carry out these tasks, he/she must have medical-legal and managerial skills which the teacher who is promoted to the role of principal does not possess. moreover, the change in commitments, as well as responsibilities, can be a source of great stress and a health risk, since the individual might not be able to manage, but above all to identify, the point where he must ask for help and activate a course of treatment. this applies both at the individual level and as the head of the safety and health of subordinate staff, having to decide when it is appropriate to subject a member of staff to a medical examination, especially when the latter does not want to or cannot deal with personal problems. the principal is not alone and employs ata and dsga personnel, but as the person responsible for their work, he/she still must have the ability to evaluate and correct any errors. the above concerns only the legal-administrative part and the school is viewed as a business that must be run efficiently [19] . in addition to this, however, there is the management of the team in the areas of human resources and coordination. principals can contribute to shaping the school climate as they should promote and support students and teachers [20] . this involves managing aspects related to students, social change and the management of a multi-ethnic society in continuous evolution, with changes in customs and processes [21, 22] . for example, the new migratory flows have led some educational institutions to deal with the task of managing adult "students", independent adults and adults with a "different" culture, who are normally obliged to attend school: however, this type of "student" requires cultural and relational skills and management skills that the school staff may not have. the aim of this research is to draw attention to the figure of the principal as a person at risk of burnout and work-related stress for both exploratory, diagnostic and preventive purposes. the principal has to focus on the limit between being engaged in school life and avoiding workaholism, in order to live in a state of health and well-being [23] . chronic stress stimulates negative behaviors and thoughts and problems related to emotions, feelings and physical health that can hinder effective school administration. according to scholars as langer [24] , davidson et al. [25] , vogus and sutcliffe [26] , weick and putnam [27] , and weick and sutcliffe [28] , many positive benefits can be associated with individual and organizing mindfulness, such as health improvement, stress reduction, increased 3 of 14 creativity, and less risk of burnout. more specifically hoy et al. [29] define "school mindfulness" as the extent to which teachers and administrators in a school carefully and regularly look for problems, prevent problems from becoming crises, are reluctant to oversimplify events, focus on teaching and learning, are resilient to problems, and defer to expertise. therefore, we also hypothesized in this work that components of the organizing mindfulness could have a significant role for the school principal in increasing or limiting his/her perceived work discomfort. (1) monitor the stress levels of a large sample of principals belonging to different levels of italian schools; (2) verify the incidence of specific pathologies associated with high levels of school stress; (3) evaluate the relationships between the perceived stress, work discomfort and dimensions of organizational mindfulness; (4) test the fit of a general path model illustrating the influence of the predictors on principals' work discomfort; and (5) identify the role of organizing mindfulness on principal's perceived work discomfort. the study was voluntarily attended by 419 school principals (131 males and 288 females) with an average age of 53.93 (sd = 6.46). they were invited to participate by means of an email indicating the purpose of the study, declaring the guarantee of anonymity and the use of the data collected for scientific purposes only, and therefore were requested to fill in a questionnaire online. approximately 2500 contact e-mails were sent, extracting the addresses from a special national list. the sample size determination was made by setting a 1-alpha confidence level at 95%, therefore with z normal value at the confidence level of 1.96. the following formula was applied: x o = z 2 (p × q)/b 2 , with p as the proportion to be estimated and q the proportion of complementary character and b the desired precision set at 5%. hence: 3.8416 (0.31 × 0.69)/0.0025 = 329. the response rate recorded was 1:6, compatible with the fixed sample size (419 > 329). the average completion time was about 15 min. tools administration took place upon the release and signing of the form for an informed consent of participation in accordance with the declaration of helsinki. the study was approved by the institutional review board of the university of cassino and southern lazio. in order to collect the data necessary to carry out the study, a questionnaire was built up and articulated into the following sections: (1) socio-demographic information: gender; age; type of degree obtained; (2) school environment: (a) how long (in years) have you been a school principal? (b) how many students altogether attend the school(s) you currently manage? (c) how long (in years) have you been a principal at the current location? (d) type of school(s) related to the management (primary/secondary school, technical school, high school, etc.); (3) information on the current health of the subjects: body mass index, high/low blood pressure, possible presence of diabetes, cholesterol, heart disease, respiratory problems (e.g., asthma, bronchitis), migraines, stomach problems, back, neck or joint pain; (4) psychometric measurements: (a) the test m.s.p. (psychological stress measurement) [30, 31] . the test measures the state of subjectively perceived stress, and consists of 49 items with likert response scale 1-4 (from not at all to very much) on the individual's perception of his cognitive-affective, physiological, and behavioral state. the overall test score provides a global index of the psychological stress state. in addition to the overall score, it is possible to calculate six other values that correspond to six different articulations of the way one perceives himself as being stressed: loss of control and irritability (i.e., "i am irritable, my nerves are on edge, i lose patience with people and things."); psychophysiological sensations (i.e., "i feel tense or strained."); sense of effort and confusion (i.e., "i feel overwhelmed, overpowered and overloaded."); depressive anxiety (mixed depression and anxiety symptoms: i.e., "i review the same ideas several times, i brood, i have the same thoughts over and over again, i feel my head full of thoughts."); pain and physical problems (i.e., "i have physical pains: back pain, headache, neck pain, bellyache."); hyperactivity and acceleration (i.e., "i walk quickly"); (b) mindfulness organizing scale (mos) [32, 33] . this is a self-report measure that investigates the safety of the organization, or rather how the worker perceives that safety. it is based on concrete behavior that reflects the employee's relationship with the organization and his colleagues. the measurement is carried out on a three-point likert scale (from not at all to very much). the dimensions included in the items are: concern about failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise. the s9, s5, and s3 scales were used for this study. a total of 9 items make up these three scales. the s9 scale measures the degree of application of group decision-making and comparison with colleagues (awareness of the value of shared problem analysis: i.e., "when a crisis occurs, we rapidly pool our collective expertise to attempt to resolve it"), the s5 scale is designed to assess the organization's reluctance to simplify in the face of critical issues (awareness of the value of a non-rigid climate: i.e., "when discussing emerging problems with co-workers, we usually discuss what to look out for"), the s2 scale is intended to assess the level of organizational awareness (awareness of the value of mutual knowledge: i.e., "we discuss our unique skills with each other so that we know who has relevant specialized skills and knowledge"); (c) scheda per la rilevazione funzionale delle aziende (functional survey module for companies) [34] . for this study, within the module, the scale of emotions at work was used; it consists of 10 items with true/false answers to assess the emotions that prevail during work. the direction of the scale is oriented to specifically assess the work discomfort perceived by the person; (d) polychronic-monochronic tendency scale (pmts) [35] . this measures the subject's ability to perform several tasks during the same time interval (i.e., "i feel at ease when i do several activities at once"). the measurement is carried out on a five-point likert scale (from strongly disagree to strongly agree) including five items. the data were processed using the statistical software spss version 22 (ibm corporation, armonk, ny, usa) and amos ibm version 22 (ibm corporation, armonk, ny, usa). the main analyses performed were: descriptive statistics to illustrate socio-demographic information; pearson and spearman bivariate and partialized correlations for all main measures (psychological stress, organizing mindfulness, work discomfort, polychronic-monochronic tendency) significant at p < 0.005 and at p < 0.001, 2-tailed); kendal's point-biserial correlations between msp, work discomfort and reported physical ailments; cronbach's alpha as scale reliability coefficient; t-test to explore significance in stress score and polychronic tendency relating to gender; anova univariate test with p < 0.05 to explore significances between work discomfort, stress and organizing mindfulness; hierarchical regression to identify the predictors of work discomfort and stress; cohen's d and eta squared as measures of effect size; sem analysis to explore predictors' effects on work discomfort. to test the adequacy of the model the following eight indices were considered: (1) the chi-square; (2) the relationship between the value of the chi-square and the degrees of freedom; (3) gfi (goodness of fit index); (4) agfi (adjusted goodness of fit index); (5) rmsea (root-mean-square error of approximation); (6) rmsr (root mean square residual); (7) cfi (comparative fit index); (8) nfi (normed fit index); (9) rfi (relative fit index); (10) pnfi (parsimony adjustment to nfi); (11) pcfi (parsimony adjustment to cfi); (12) pclose (testing the null hypothesis that the population rmsea is no greater than 0.05). the main characteristics of the sample are illustrated in table 1 below, while table 2 presents the bivariate correlations between the measures used in the study. the corresponding dataset is available as supplementary material s1. it can be observed in table 2 that stress resulted inversely correlated to age, strongly correlated to work discomfort and inversely correlated to organizational awareness. among the components of stress most associated with the perception of work discomfort were depressive anxiety (0.660 **), the sense of effort and confusion (0.601 **), and irritability (0.503 **). as the number of years of service increases, organizational awareness also improves (141 **), while stress (−0.173 **) and the perception of work discomfort (−0.162 **) decrease; at the same time, awareness of the value of mutual knowledge increases (0.149 **) and the person's level of hyperactivity decreases (−0.150 **). the level of discomfort and perceived stress was not associated with the number of students in the administered institution. as seniority increased, there was also an increase in the number of students and therefore in the size of the school administered (0.138 **). partialized correlations with the perception of work discomfort, showed a decrease in the association between the variables (determined by the control variables), which however remained statistically significant with depressive anxiety (0.333 **), the sense of effort and confusion (0.264 **), awareness of sharing analysis (0.151 **), but no longer with irritability (0.041), awareness of no-stiffness (0.144), awareness of mutual knowledge (0.337). partialized correlations with the general measure of stress (msp) showed a reduction of associations with age variables (−0.125 **) and work discomfort (0.098 **), and non-significance with awareness of sharing analysis (0.061), awareness of no-stiffness (0.008), awareness of mutual knowledge (−0.028). table 3 shows the distribution of stress levels among the sample, after the transformation of the raw score into t points and the relative comparison with the italian percentile calibration values of the scale. it can be noted that 27.7% had high levels of stress and almost 60% of the principals were affected by moderate and high levels of stress. figure 1 reports the distribution of stress scores compared to the type of school managed. it can be observed that the regency of the comprehensive schools with multiple age levels (5-13) was accompanied by the highest level of stress for the principals, although the univariate anova and tukey's post-hoc comparisons did not show significant differences between this level of stress and those associated with the other four types of school (p = 0.415). figure 1 reports the distribution of stress scores compared to the type of school managed. it can be observed that the regency of the comprehensive schools with multiple age levels (5-13) was accompanied by the highest level of stress for the principals, although the univariate anova and tukey's post-hoc comparisons did not show significant differences between this level of stress and those associated with the other four types of school (p = 0.415). univariate anova reported, as illustrated in table 4 , a significant inverse association between organizational mindfulness and stress scores; in addition, there was a significant association of the two variables (stress and organizational mindfulness) with the measure of perceived work discomfort. univariate anova reported, as illustrated in table 4 , a significant inverse association between organizational mindfulness and stress scores; in addition, there was a significant association of the two variables (stress and organizational mindfulness) with the measure of perceived work discomfort. table 5 reports point-biserial correlations between msp, work discomfort and the physical ailments the principals claimed to have. it can be noted that the disorders most associated with stress and the perception of work discomfort are: migraine, stomach problems, back and/or cervical pain. stomach problems are sometimes also associated with respiratory problems (e.g., asthma, bronchitis). in order to identify among the components of stress and mindfulness the predictors influencing work discomfort perceived by principals, a hierarchical regression analysis was carried out. hierarchical multiple regressions were run to determine if the addition of the stress and mindfulness components improved the prediction of work discomfort. the preliminary verifications of the regression assumptions excluded the presence of multivariate outliers. mardia's multivariate kurtosis index (160.51) was in fact below the critical value [p (p + 2) = 168]; therefore, the relationship between the variables can be considered substantially linear. low co-linearity was indicated by the low vif values (variance inflation factor) < 2 and high tolerance values >0.60. for verification of the assumptions on the residuals, the average between the standardized and raw residuals was equal to 0; the durbin-watson test had a value of 1.97 and was therefore indicative of the absence of autocorrelation. influential predictors have been identified in depressive anxiety the model is displayed in figure 2 , where it is shown that work discomfort was mainly affected by depressive anxiety (standardized estimate of the regression weight of 0.517 for p < 0.018). the second influential predictor turned out to be the sense of effort and confusion (standardized estimate of the regression weight of 0.862 for p < 0.001), which in turn receives a major influence precisely from depressive anxiety (standardized estimate of the regression weight of −0.248 for p < 0.010). the model has identified the awareness of the value of shared problem analysis as a significant negative predictor of work discomfort (standardized estimates of the regression weights −0.206 for p < 0.001), furthermore this was negatively affected by depressive anxiety (standardized estimate of the regression weight of 0.517 for p < 0.018). subsequently, a sem analysis was performed, combining into one explanatory model the variables that previously revealed significant association with work discomfort. the model showed overall good fit measurements: χ 2 = 271.41 df = 171 p = 0.000; cmin/df = 1.587; rmr = 0.016; gfi = 0.940; agfi = 0.918. baseline comparisons nfi = 0.922; ifi = 0.970; cfi = 0.969. parsimony-adjusted measures pnfi = 0.751; pcfi = 0.789; rmsea: 0.037; pclose: 0.995; rmsea 90% 0.029-0.046. the model is displayed in figure 2 , where it is shown that work discomfort was mainly affected by depressive anxiety (standardized estimate of the regression weight of 0.517 for p < 0.018). the second influential predictor turned out to be the sense of effort and confusion (standardized estimate of the regression weight of 0.862 for p < 0.001), which in turn receives a major influence precisely from depressive anxiety (standardized estimate of the regression weight of −0.248 for p < 0.010). the model has identified the awareness of the value of shared problem analysis as a significant negative predictor of work discomfort (standardized estimates of the regression weights −0.206 for p < 0.001), furthermore this was negatively affected by depressive anxiety (standardized estimate of the regression weight of 0.517 for p < 0.018). table 6 below summarizes the maximum likelihood estimates and regression weights estimates. the corresponding sem with amos is available as supplementary material s2. the state of chronic stress leads to an inability to manage events, both in the sense of not being able to solve the conditions of difficulty that arise and in the sense of inability to prevent them and even of unconscious tendency to intensify and proliferate obstacles and stressful events [36] . numerous studies have demonstrated that chronic stress also directly produces innumerable illness conditions, influenced by the inability to manage and improve one's own health [37] . studies on work-related stress are increasing, as are publications on the difficult condition of school workers [38, 39] . while the focus is on teachers, there are few reflections on the psychophysical fitness of the school manager, especially in light of the latest legislative and organizational changes. school leaders are also exposed to health risks related to work-related stress, but there are different aspects of the problem with respect to teachers and employees in general [40, 41] . this involves an institutional figure thrown into the continuous proliferation of reforms, legal norms, structural changes, conflict management, and radical changes in customs and processes [42] . we are substantially dealing with a figure who is at risk and to whom more research attention should be paid for exploratory, diagnostic and preventive purposes. our study first of all showed that about half of the sample of principals who participated in the research had moderate to high stress levels. this immediately emphasizes how current and critical the problem is. the widespread tendency to merge different school cycles (elementary and junior high schools) in the so-called "istituti comprensivi" (comprehensive schools, ages 5-13), for administrative reasons, was associated with a greater load of tension and pressure for principals, who probably find it difficult to manage with a single approach the problems and differences that arise from educational orientations and professional profiles traditionally characterized by a plurality of visions, different approaches to teaching and evaluation of students, diversity in the level of involvement of families in school life, different propensity and habit of teachers of different cycles (primary and secondary) to work on shared projects. it would seem that the management of these differences, rather than the size of the school (in terms of number of students, and therefore of teachers), is a reason for greater pressure and tension at work [43, 44] . women principals showed significantly higher levels of stress than their male colleagues. in this regard, according to the data, their greater tendency to engage simultaneously in the resolution of several tasks, could indicate a greater resistance to delegation, a strong sense of personal responsibility that would lead them to a total (psychological) involvement which over time can overload the person, limiting the time of physical and mental recovery. in line with these data, studies by kiral [45] have shown that women principals have higher levels of stress than male principals, as women have to reconcile the responsibility for domestic work with the official and public work they do in school. the first analyses of our study have indicated that the general perception of the principal's working discomfort presents on the one hand an association with the level of stress, which contributes to increase the value of the discomfort, and on the other hand an equally significant association with organizing mindfulness, which can substantially limit the negative effects of stress on perceived discomfort. this measure of discomfort includes de-motivational aspects, negative mood, disappointment for the unreliability of the context, negative balance between efforts and results, weight in conducting mediations, pessimistic view of the future, perception of others' insensitivity, doubts about one's self-efficacy. an interesting reflection that emerged from the observation of the data was that relating to the age and period of service of the principals. both the stress level and the perceived general discomfort had an inverse correlation with age and years of service. this suggests that experience can play a significant role in the development of the management and coordination skills required to best perform the complex functions of school leadership. the critical aspect concerns the italian situation where in the last decade there has been a substantial turnover of principals. therefore, only a few years ago, a large number of principals started their service role, in a context of extensive administrative changes imposed by the ministry of education. it is not difficult to hypothesize that in this situation the youngest principal may feel the weight and responsibility of an assignment that no longer finds a frame of reference in past experience. the results of the study confirmed the association between high levels of stress and somatization, which was already evident in the literature on the health implications of a chronic occupational stress condition: migraine, stomach problems, back and/or cervical pains, respiratory problems (e.g., asthma, bronchitis). these data were in line with mariammal et al. [46] who stated that stress manifests itself in the form of chronic disorders or diseases such as hypertension, stroke, headache, and diabetes, as well as regular physical pain. some principals experience symptoms such as suppression of the reproductive system, anxiety, aggression, indigestion, stomach-ache, pain, dizziness, and rapid heartbeat. in addition, chronic stress creates muscle tension, fatigue, constipation, and arthritis [47] . principal stress has even been associated with severe problems such as ischemia and heart problems [48] . further results of the study have identified the predictors of work-related discomfort with greater accuracy in the components of stress and organizational mindfulness. through a regression analysis and then through sem, the effects and influence relationships between the predictors were identified. among the components of the msp, it seemed that depressive anxiety had the main role of influence. the anxiety component is characterized by aspects of recurrent ruminative cognition that amplify the sense of isolation, incomprehension, discouragement, and worry [49] . this negative interpretative framework activates another significant component: the sense of effort and confusion perceived by the person, who develops thoughts of inadequacy, the impression that everything involves a considerable effort and that everything falls on his shoulders. this attitude can naturally encourage a lack of clarity in ideas and decreased attention and concentration. within the model, one of the three components of mindfulness, the awareness of the importance of sharing problem analysis, found a significant place. the effect of the variable limited the dimension of the perceived discomfort. if, on the one hand, the increase in pressure and tension drives the person to intensify their efforts by closing and defensively stiffening themselves, on the other hand, the ability to recognize the value of sharing and involvement of other collaborators and colleagues in order to deepen the understanding of the problems and the identification of the most appropriate management methods, can help one to come out of isolation and discover the value of confrontation and the functional exercise of delegation, reducing the sense of oppression and distrust. the anxiety component that characterizes the principal's stress can be mitigated by training and refresher courses focused on a model of organizing mindfulness. acquiring awareness of the value of sharing practice is the main theme, but two other aspects to be investigated should not be underestimated and which in this study have however shown strong positive correlations with the practice of sharing, and which perhaps constitute the necessary operational preparatory basis: awareness of the value/advantage of a non-rigid climate and awareness of the value of mutual knowledge. a lack of awareness of one's own way of acting can lead to behaviors that are not functional to the work context, to the quality of the interaction with one's colleagues and to the nature of the task required at the time [50] . by investing in one's mindfulness, one can expect to break the old automatisms in favor of new behaviors, effective even in difficult times, as indicated by weick and sutcliffe, who believe it is necessary to rely on a mindfulness-oriented approach when there is a need to make a quick and important decision, giving priority to one's competence (or that of one's co-workers), rather than relying on one's authority. the study by beausaert et al. [51] emphasized the influence of social support in the containment of stress and the burnout of principals. our study points out as a priority, above all, the awareness to which the principal must be individually accountable, i.e., the indispensability of a practice of sharing and mutual recognition of specificities and competences. in this way they move on to a proactive attitude that promotes social support in the first person, before expecting it (in due form) from others. when mindfulness becomes a shared social practice in an organization and permeates the routines, processes and practices among people and teams, and thus affects the organization as a whole, the organization itself becomes more resilient and proactive. even the educational institution has a vital need to promote responsible leaders at all levels, capable of maintaining self-control, a sense of balance and self-determination, despite the informational overload they have to deal with today. data collection through self-reporting measures should be expanded with a methodological design in which judgments about principal stress could be provided also by the staff and teachers of the school, in order to have a more balanced representation by an outside perspective. the cross-sectional approach of the study involved collecting data at a single point in time; instead, the extension of the study could include repeated administration at different times of the school year (beginning, middle, end). the reference hypothesis is that the level of stress and the perception of discomfort could vary in relation to different significant institutional moments, such as the opening and closing of the school year. in this regard it could be useful the novel use of neuroscience-based approaches in education, namely neurodicatics, which is directed to address the educational and psychological well-being of students and staff involved in education as part of the education environment [52] . a further important contribution could be a specific focus on how principals cope with emergencies and on the functionality of their strategies to manage individual and collective stress triggered by the exceptional nature of the problems that the situation entails (e.g., ensuring teaching activities in safe environments after the spread of the covid-19 virus). at the moment, there are also no longitudinal studies that have monitored the evolution of the principal's leadership ability over medium-long intervals. it would therefore be important to understand if and how more mature and functional patterns for the containment and management of pressure in moments of personal tension and discomfort are learned and modeled over the course of his/her career. the results of this study have shown that the levels of stress and work discomfort perceived by principals are high and require both empirical investigation and targeted support and prevention interventions. in fact, the stress experienced by a principal is associated with various physical disorders and serious health risks, such as ischemia and heart problems. the study has produced a path analysis model in which the joint effects between the main predictors of principals' work discomfort were explained. the effect of depressive anxiety on perceived discomfort found a protective mediator in the mindfulness component that recognizes sharing as a fundamental operational tool, while an increasing sense of effort and confusion could significantly amplify the experience of psychological discomfort associated with the practice of school leadership. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/17/6318/s1, file s1: principals stress.sav (dataset); file s2: model work discomfort.amw (model). author contributions: p.d., g.v., and s.m. designed the study. p.d., g.v., and s.m. analyzed the data and discussed the results. f.b. and s.m. drafted the manuscript. g.v. and f.b. revised the manuscript. all authors approved the final manuscript. finally, the authors have agreed to be accountable for all aspects of the manuscript in ensuring that questions related to the accuracy or integrity of any part of it are appropriately investigated and resolved. all authors have read and agreed to the published version of the manuscript. funding: this research received no external funding. symptômes et caractéristiques du burn out [symptoms and characteristics of burnout school burnout and heart rate variability: risk of cardiovascular disease and hypertension in young adult females il nuovo dirigente scolastico preparing leaders to work with emotions in culturally diverse educational communities manuale per dirigenti scolastici e staff di direzione principal burnout: the concept and its components an analysis of burnout and job satisfaction among turkish special school headteachers and teachers, and the factors effecting their burnout and job satisfaction burnout among iranian school principals burnout in school principals: role related antecedents stress and job satisfaction among primary head teachers: a question of balance? a survivor's guide to the principalship: overcoming the challenges occupational stress and job satisfaction among school administrators principal self-efficacy: relations with burnout, job satisfaction and motivation to quit teachers' approaches toward cultural diversity predict diversity-related burnout and self-efficacy principal preparation programs: perceptions of high principals unaccepted accountability: the looming shortage of principals and vice principals in ontario public school boards; working paper 24; school of policy studies where are the principal candidates? perceptions of superintendents shared principalship of schools the school principal as a leader: guiding schools to better teaching and learning strumenti e risorse il dirigente e la scuola multiculturale engaged sì, workaholic no: il ruolo di engagement e workaholism sulla salute e il benessere dei dirigenti scolastici. giornale italiano di psicologia alterations in brain and immune function produced by mindfulness meditation organizational mindfulness and mindful organizing: a reconciliation and path forward organizing for mindfulness: eastern wisdom and western knowledge managing the unexpected: resilient performance in an age of uncertainty theoretical and empirical foundations of mindful schools mesure de stress psychologique (msp): se sentir stressé-e [measurement of psychological stress: to feel stressed the safety organizing scale: development and validation of a behavioral measure of safety culture in hospital nursing units psicologia funzionale per le aziende. scheda di valutazione the polychronic-monochronic tendency model: pmts scale development and validation l'analisi funzionale dello stress. dalla clinica alla psicologia applicata sustaining emotional resilience for school leadership implications of an occupational health perspective for educator stress research, practice, and policy. in aligning perspectives on health, safety and well-being. educator stress: an occupational health perspective occupational stress of academic staff in south africa higher education institutions determinants of kcse examination performance in sda sponsored schools: a key to academic promotion to the next level of learning handbook of school improvement occupational stress among school heads teachers: a case for hwedza district secondary schools' head teachers stress management coping strategies used by female principals in kenya: a case study of rachuonyo north and homa bay sub counties women principals' career paths: difficulties, barriers. in vocational identity and career construction in education work influenced occupational stress and cardiovascular risk among teachers and office workers psychological stress and fibromyalgia: a review of the evidence suggesting a neuroendocrine link ill health and early retirement among school principals in bavaria the influence of morningness-eveningness on anxiety and cardiovascular responses to stress principals and stress: few coping strategies for abundant stressors effects of support on stress and burnout in school principals considering the role of neurodidactics in medical education as inspired by learning studies and music education authors are grateful to all school principals who took part with this study. the authors declare no conflict of interest. key: cord-283771-hh4p7cg3 authors: ku-yuan, lee; li-chi, lan; jiun-hao, wang; chen-ling, fang; kun-sun, shiao title: how to reduce the latent social risk of disease: the determinants of vaccination against rabies in taiwan date: 2014-06-04 journal: int j environ res public health doi: 10.3390/ijerph110605934 sha: doc_id: 283771 cord_uid: hh4p7cg3 to control the latent social risk of disease, the government usually spreads accurate information and attempts to improve the public’s attitude toward adopting prevention. however, these methods with the knowledge, attitudes, and practices (kap) model do not always work. therefore, we used the theory of planned behavior (tpb) to understand dog owners’ behavior and distinguished the knowledge effect as objective knowledge (ok) and subjective knowledge (sk). a total of 310 dog owners completed a questionnaire based on our model. we employed structural equation modeling to verify the structural relationships and found three main results. first, our model was fit, and each path was significant. people with better attitudes, stronger subjective norms, and more perceptive behavioral control have stronger behavioral intention. second, perceived behavioral control, not attitude, was the best predictive index in this model. finally, on perceived behavioral control, subjective knowledge showed more influence than objective knowledge. we successfully extended tpb to explain the behavioral intention of dog owners and presented more workable recommendations. to reduce the latent social risk of disease, the government should not only address dog owners’ attitudes, but also their subjective norms and perceptive behavioral control. indeed, perceptive behavioral control and sk showed the most influence in this model. it is implied that the self-efficacy of dog owners is the most important factor in such a behavior. therefore, the government should focus on enhancing dog owners’ self-efficacy first while devoted to prevention activities. number of infected canines; (2) ineffective canine management; (3) a canine vaccination rate below 80%, including stray dogs; and (4) people's ignorance because of insufficient general knowledge and insufficient education budgets. conversely, the effective investigation of epidemic situations, a high vaccination rate (over 80%), and effective canine management are key factors in successfully controlling rabies infections. according to the report, since 1973, who has widely promoted two rabies prevention measures: broad vaccination programs and strict control of stray dogs. among kap-model promotions, improving knowledge and instilling positive attitudes toward prevention should be the main elements of a taiwanese rabies-prevention campaign. however, taiwan's current vaccination rate is only between 30% and 40% [4, 5] , far below who's 80% recommendation [2] . to close this gap, we focused on owners' intentions to vaccinate dogs and attempted to find the determinants for vaccinating against rabies in taiwan. we had three main purposes: first, we argued that the kap model's attitude concept should be extended to behavioral intention and that the theory of planned behavior (tpb) would be a suitable structural model for behavioral intention of vaccination against rabies because of its wide application in research on forecasting and building rational behavior. tpb has been used to predict, for instance, people's intention to vaccinate against influenza as well as many other health behaviors [6] . we used structural equation modeling (sem) to verify that tpb can explain people's intention to vaccinate dogs against rabies [7] . second, we argued that attitude is not the only key factor, or even the best factor, for understanding dog owners' behavioral intention. according to the low vaccination rate in taiwan, we considered only improving knowledge and instilling a positive attitude are not enough to control the latent risk of rabies in taiwan. by applying tpb to the intention of rabies vaccination, we described relationships among the variables to determine the best predictive index. finally, we argued that the knowledge concept of the kap model should be distinguished into two types, objective knowledge (ok) and subjective knowledge (sk). ok indicates the level of accurate information in one's cognition about the target; sk indicates the level of one's perceptions of what or how much one knows about the target [8, 9] . azjen et al. [10] argued that knowledge, especially objective knowledge, would affect attitude and enhance self-efficacy (perceived behavioral control, pbc), but they did not test the correlation between subjective knowledge and tpb. besides, we thought that especially sk, rather than ok, would be more likely to prompt people to vaccinate their dogs. in conclusion, we proposed to the government rabies prevention policies and suggestions for raising the vaccination rate through tpb, thus not only helping prevent a rabies outbreak in taiwan but also preventing latent risk for similar situations. vaccination is a health behavior that consists of a personal act to preserve or strengthen one's health [11] [12] [13] . many methods have been employed to increase vaccination rates, for example, through increased knowledge and better attitudes, but these strategies have shown only limited success [14, 15] . descriptions of vaccination determinants have been mainly from physician perspectives, and past studies have often ignored those who actually make the decisions [15] . hence, the limited success of these interventions clearly indicates the need for a fresh approach and new methods. besides, vaccinating one's dog is not purely a health behavior. it includes a variety of factors: health, emotions, risk aversion, social perception, and so on. from the human perspective, dogs may be movable property, personal goods, and beloved pets, and those who vaccinate dogs against rabies may do so for one or more of the following motivations: enhancing their dogs' health; loving their dogs; perceiving the risk of rabies; thinking other people hope they will; and others. furthermore, vaccinating dogs is not only a personal act but also a social behavior involving moral perception. at least partly because authorities, such as who and the center for disease control (cdc), have advocated epidemic prevention for several years; for some people, vaccinating dogs has become an ethical and moral act of socialization. applications of certain theoretical frameworks have manifested as well suited to the design of health behavioral change interventions [6, 14, 15] . among theories commonly used to understand health behavior [14] [15] [16] are the theory of reasoned action (tra) and the tpb that have effectively explained inventions and induced health behavior changes [14] [15] [16] . these two theories have increased understanding of the processes involved in vaccination decision-making at the individual level. constructed by ajzen (1991) [17] , the tpb is an especially well established framework for predicting various types of health behaviors [6] . a central element in tra and tpb is the individual's intention to perform a given behavior [17] . previous research shows the instant antecedent of any behavior to be the intention to perform that behavior. people who have a stronger intention to act are more likely to perform the behavior [18] [19] [20] , especially reasoned actions and planned behaviors. developed by fishbein and azjen, the tra is based on two assumptions. the first is that intentions best predict behaviors, and the second is that human behavior is quite rational and employs the limited information available to the individual [21, 22] . in this theory, two independent factors determine one's intention: attitudes and subjective norms. attitudes consist of general evaluations of behavioral performance and beliefs about the consequences of performing the behavior, weighted by an individual's evaluation of each consequence. subjective norms reflect general perceptions of social pressure to perform the target behavior and are affected by the expectations of important referents, weighted by an individual's motivation to comply with each referent. researchers have conducted many empirical studies on this topic over the past 30 years and provided evidence in support of tra to explain health and social behavior [23] [24] [25] [26] [27] [28] . however, although previous studies have successfully verified that tra is helpful in predicting intention and behavior, other studies have revealed its limitations [17, 29, 30] . for the most part, the behaviors investigated through tra have been subject to considerable volitional control [31] . some studies using the health belief model, the source of all health behavior change models [32] , have added self-efficacy to their models [31] [32] [33] . in contrast to tra, tpb contains perceived behavioral control, including the concept of self-efficacy [17, 29] . due to tra's limitations, ajzen developed an enhanced behavior prediction model in which the individual may not have considerable volitional control or be able to perform well [17, 29] . ajzen believed that the construct of perceived behavioral control is belief-based, similar to attitudes and subjective norms in tra [34] [35] [36] . perceived behavioral control represents one's belief about how easy or difficult it is to perform a behavior and is easily measured with a questionnaire [29, 30] . using the tra as a base, ajzen constructed tpb to incorporate perceptions of control over performance of behavior as an additional predictor [17, 29] . he then used tpb to predict behavior that an individual may not be able to perform at will [20] . ajzen also proposed that perceived behavioral control affects behavior not only indirectly through intention but also directly [17, 29] . in fact, many theoretical and empirical studies provide evidence supporting tpb. in 1985, ajzen presented "from intentions to actions: a theory of planned behavior" to open theoretical discussions about tpb. he theorized that the relationship between behavioral intention and behavior is stronger when perceived behavioral control is high. to provide a powerful foundation for tpb, he also presented arguments about social psychology [34] , organizational behavior [17] , self-efficacy [36] , laws of human behavior [37] , and the relationship between consumer attitudes and behavior [38] . in addition to this psychological research, armitage and conner argued that tpb can be applied to health behavior and also disseminated tpb to such fields as moral behavior, technological behavior, and exercise behavior [39] . these researchers found that tpb explained an average of 39% of the variance in intention and 27% of the variance in behavior. the tpb concept has received strong empirical support in applications to a variety of domains. nevertheless, the current study is one of only a few attempts to use tpb as a conceptual framework for vaccination, and more specifically, canine vaccination against rabies. this behavior involves morals, social impressions, and health concepts. researchers have repeatedly used tpb to interpret moral behavior [40] , including behaviors of health promotion [41] , environmental friendliness [42] , and tax compliance [43] . in the social behavior domain, researchers used tpb to examine alcohol abuse [44] , volunteer behavior, substance use [45] , blood donations [18] , and others. in the health domain, tpb has explained various behaviors, for example, smoking [46] [47] [48] , giving up smoking [49] , and drinking [48, 50] . researchers have also used tpb to predict a variety of attendance decisions for many types of health behaviors, including the decision to attend health checks and health clinics [51, 52] , breast cancer screenings [53] , and workplace health and safety courses [54] . therefore, tpb could be the most powerful theory for predicting a rise in the rate of vaccination against rabies. however, despite the fact that tpb has never been applied to explain the behavior of vaccination against rabies, it has been applied to predict of a wide range of other behaviors in previous research, including health behavior, social behavior, and moral behavior, and these behaviors resemble the targeted behavior's concepts. therefore, we employed tpb to construct a theoretical framework for explaining the behavior of owners' ensuring that dogs are vaccinated against rabies. as in the original tra, intention determines actual behavior [17, 29] . intentions are assumed to measure motivational factors that influence a behavior; they are indications of how hard people are willing to try and how much effort they are planning to exert to perform the behavior [17, 29] . furthermore, intention is jointly determined by attitudes, subjective norms, and perceived behavioral control in the tpb model. first, attitudes refer to the degree to which an individual favorably or unfavorably evaluates the behavior in question; second, subjective norms refer to social pressure to perform or not to perform the behavior; and, third, perceived behavioral control refers to whether the individual anticipates the action's performance as relatively easy or difficult. presumably, this third measure reflects past experiences and anticipated hindrances. generally speaking, a person with a more favorable attitude, more positive subjective norms, and higher perceived behavioral control has a stronger intention to perform the target behavior [17, 29] . based on tpb, we argue that behavioral intention is determined by an individual's attitudes toward rabies vaccination, subjective norms about this behavior, and perceived behavioral control, i.e., whether one can control taking a dog to receive the rabies vaccine. in other words, this study hypothesizes that favorable attitudes, high subjective norms, and good perceived behavioral control enhance the behavioral intention of rabies vaccination. beside, ajzen argued that individual behaviors sometimes could be predicted best by self-efficacy, especially while the behaviors need to be controlled [55, 56] . in taking a dog to receive the rabies vaccine, we also considered perceived behavioral control, not attitude, would be the best predictive index: h1: attitude (a) toward the vaccination of rabies positively affects behavioral intention (bi). h2: subjective norms (sn) about the vaccination of rabies positively affect bi. h3: perceived behavioral control (pbc) over vaccination positively affects bi. h3b: the pbc effect is greater than the attitude effect. knowledge changes people's cognition and affects their behavior [57] . knowledge can be defined as a kind of stored information, which people obtain and acquire from processing data [58] . however, in previous studies, knowledge has been discussed according to two concepts, objective knowledge (ok) and subjective knowledge (sk) [8, 9] . ok indicates the level of accurate information in one's cognition about the target; sk indicates the level of one's perceptions of what or how much one knows about the target [8, 9] . the two concepts are related, but must be distinguished: specifically, people cannot actually recognize whether their perceptions of how much they know are correct. in other words, a cognitive gap usually exists between ok and sk. moreover, ok can be measured by objective scales, but sk relates more to one's selfconfidence [8, 59] . in this study, we defined the level of dog owners' accurate information about rabies as ok and the level of dog owners' perceptions of how much they know about rabies as sk. people use their knowledge to develop a cognitive system and to judge whether to perform a specific behavior [10] . in the kap model, people improve their preventive attitudes as they raise their knowledge of disease. when people receive accurate information about prevention of diseases, they know what coping behaviors should be taken and improve their attitudes about performing these behaviors [60] . in this study, we also presumed that owners will have better attitudes about taking their dogs to be vaccinated when they possess greater objective knowledge. people who have higher ok will have more positive attitudes about taking their dogs to be vaccinated. h4: objective knowledge (ok) about rabies positively affects attitude about rabies prevention. perceived behavioral control, including the concept of self-efficacy, is the distinguishing feature of tpb. when people do not have considerable volitional control or are not able to perform well, perceived behavioral control becomes a good predictor for explaining behavioral intention [17, 29] . ajzen argued that perceived behavioral control represents one's belief about how easy or difficult it is to perform a behavior and that the construct of perceived behavioral control is belief-based [34] [35] [36] . an individual with knowledge about specific behavior reduces feelings about impediments and increases perceived behavioral control [17, 29] . in other words, when people have enough knowledge about rabies and about vaccinating their dogs, they add self-efficacy and then feel good about performing the behavior. specifically, both ok and sk can affect the ability to perform a specific behavior but with different mechanisms [9] . ok provides information and skill, reducing the impediment of bringing dogs to be vaccinated; sk enhances dog owners' self-efficacy so that they feel they can perform the behavior well. therefore, we argued that people with higher levels of ok and sk will have higher perceived behavioral control. furthermore, azjen et al. [10] argued that knowledge would positively affect attitude and perceived behavioral control. however, they did not test the correlation between sk and tpb. because sk combines knowledge and self-confidence, it is more important in problem-solving [61, 62] . hence, we also argued that sk could affect dog owners' perceived behavioral control more than ok. figure 1 displays the proposed hypotheses for this study: h5: objective knowledge (ok) about rabies positively affects perceived behavioral control (pbc) about rabies prevention. h6a: subjective knowledge (sk) about rabies positively affects pbc about rabies prevention. h6b: the sk effect is greater than the ok effect. this study administered a questionnaire to assess: (1) attitude; (2) subjective norms; (3) perceived behavioral control; (4) behavioral intention; (5) objective knowledge; (6) subjective knowledge; and (7) basic demographic data. the first four scales were revised from the sample tpb questionnaire designed by icek ajzen. four sections evaluated attitudes, subjective norms, perceived behavioral control, and behavioral intention as to whether owners would take their dogs to receive the rabies vaccine injection. the last two scales (ok and sk) rested on the literature of objective knowledge and subjective knowledge and were revised by the outcome of export pretesting. intention. this study used three items with a 5-point semantic differential scale to measure participants' intentions to have their dogs vaccinated. first, the statement, "i would like to take my dog to have the rabies vaccine injection" was rated on a 5-point semantic differential scale ranging from extraordinarily impossible (1) to extraordinarily possible (5). second, "i will take my dog to have the rabies vaccine injection in the near future (3 months)" was rated on a 5-point semantic differential scale ranging from absolutely incorrect (1) to absolutely correct (5) . lastly, "i plan to take my dog to have the rabies vaccine injection in the near future (1 year)" was rated on a 5-point scale ranging from absolutely incorrect (1) to absolutely correct (5) . attitudes. this study used three items with 5-point scales to assess attitudes toward the behavior. the scales ranged from strongly disagree (1) to strongly agree (5). these items were modified from "constructing a tpb questionnaire" by ajzen and included "for me to take my dog to have the rabies vaccine injection is good," "for me to take my dog to have the rabies vaccine injection is beneficial," and "for me to take my dog to have the rabies vaccine injection is helpful." subjective norms. to assess subjective norms, this study used three 5-point scale items ranging from strongly disagree (1) to strongly agree (5). we not only focused on the opinions of participants' relatives and friends about taking their dogs for the rabies vaccine injection, but considered whether they would like to do so. these items included: "my family thinks i should take my dog to have the rabies vaccine injection," "my friends think i should take my dog to have the rabies vaccine injection," and "my relatives and friends have taken their dogs to have the rabies vaccine injection." perceived behavioral control. this study used three items with 5-point scales to measure perceived behavioral control. these items were also adapted from ajzen's "constructing a tpb questionnaire." the item "to bring my dog to have the rabies vaccine injection every year" was rated on a 5-point semantic differential scale ranging from "i can't make this happen" (1) to "i can make this happen" (5); the item "i have the ability to take my dog to have the rabies vaccine injection" was rated on a 5-point semantic differential scale ranging from completely incorrect (1) to completely correct (5); and the item "to bring my dog to have the rabies vaccine injection" was rated on a 5-point semantic differential scale ranging from "i have no control over this" (1) to "i have control over this" (5) . objective knowledge. aligning with the cdc and who reports [1, 2] , we designed 17 items with key information on rabies. after our pretesting, we performed item analysis and deleted 7 items. finally, 10 items were used to evaluate rabies knowledge in the "the objective knowledge of rabies index." each item employed a dichotomous scale (yes or no question). we summarized ten scores to represent the objective knowledge of dog owners. subjective knowledge. according to the literature, subjective knowledge can be measured as a kind of self-confidence [8, 59] . we took one subjective knowledge item from a self-report and three subjective knowledge items to assess the respondent's self-confidence of rabies knowledge as compared with other dog owners, pet traders, and prevention experts. we used a likert 5-point scale to measure the score, ranging from strongly disagree (1) to strongly agree (5). this study's questionnaire in this study was reviewed by 10 epidemic prevention experts and staff members selected from among veterinary professors in universities and personnel at the bureau of animal and plant health inspection and quarantine. besides that, it was pretested on 133 dog owners in taiwan. according to their suggestions, we revised some items. the geographic scope of this study is taiwan and the kimen district. we distributed the samples around taipei, taichung, kaohsiung, taitung, and kinmen. to increase the response rate, each participant received a questionnaire accompanied by a gift valued at one us dollar. in total, 310 participants completed the questionnaire. the respondents were almost equally male (163; 52.6%) and female (147; 47.4%). their age ranged from 16 to 73, with an average age of 37.6 years old (with a standard deviation of 12.33 years). as for the level of education completed, 12.9% (n = 42) had a junior/senior school degree, 72.6% (n = 225) had a bachelor's degree, 11.9% (n = 37) had a master's degree, and 1.9% (n = 6) had a doctorate degree. for this study, we used sem to verify whether tpb can explain the intention of people to have their dogs vaccinated and whether knowledge of rabies can positively affect people's attitude and perceived behavioral control. besides that, we tried to review the relationships of these variables and find a determinant to explain the dog owners' intention. we employed lisrel 8.7 to achieve this goal. according to the hypotheses, based on tpb and kap, there are six latent variables in this study: objective knowledge (ok), subjective knowledge (sk), attitudes (a), subjective norms (sn), perceived behavioral control (pbc), and behavioral intention (bi). table 1 shows the means and standard deviations of all variables, for which there were no significant differences in gender, age, and education level. to evaluate internal consistency, we used cronbach's α to test the reliability of a, sn, pbc, bi, and sk to obtain rabies vaccines. in this study, the cronbach's α for a was 0.903, for sn was 0.839, and for pbc was 0.940. for the bi scale, it was 0.884, and for the sk scale, 0.945. all values of cronbach's α exceeded 0.80, and are thus well within the commonly accepted range of reliability [7, 63] (table 2) . convergent validity can be determined by reviewing the average variance extracted (ave) and composite reliability (cr) for each construct. this value should exceed 0.5 for average variance extracted and 0.7 for composite reliability [7, 63] . in this study, all values of ave and cr were greater than 0.639 and 0.841, respectively, well within the acceptable range (table 2 ), thus providing evidence that the convergent validity in this study is acceptable. the ave can also measure discriminant validity. discriminant validity is acceptable when the ave score is greater than the squared correlation coefficients among variables. in this study, ave scores, showing in diagonal in table 3 , were all greater than squared correlation coefficients, confirming discriminant validity. this study used sem to examine the structural relationship of our model based on tpb and kap and to determine the factors that are keys for owners' intention to take their dogs for rabies vaccine. besides, ajzen argued that there could be some correlation among attitude, social norm and perceived behavioral control [17, 29] . several literatures also found evidence to support the relations among these variables [64, 65] . hence, according to the modification indices (mi), we opened the correlation among these variables in tpb. finally, all indicators used to test the fitness of sem models were acceptable (table 4 ). it is shown that the fitness of our model was confirmed. figure 2 illustrates the sem results of our model. almost all the paths and relations were significant, and the hypotheses were supported, except h5. for the a-i path (h1), the standardized coefficient was 0.28, with a t-value of 2.60 (p < 0.01). hence, the stronger the attitudes, the stronger the behavioral intention to take a dog to be vaccinated against rabies. for the sn-i path (h2), the standardized coefficient was 0.22, with a t-value of 2.47 (p < 0.05). accordingly, people who felt more social pressure and had higher subjective norms exhibited stronger intention to take their dogs to be vaccinated. for the pbc-i path (h3), the standardized coefficient was 0.43 with a t-value of 6.22 (p < 0.001). in other words, subjects with a higher sense of behavioral control had a higher intention to take their dogs to be vaccinated against rabies. therefore, people who had a more positive attitude, stronger subjective norms, and more perceptive behavioral control would have stronger behavioral intention to take their dogs for vaccination against rabies. additionally, three indices explained 69% of the variance on behavioral intention. social norm positively affected attitude and attitude positively affected perceived behavioral control individually. in knowledge effect on attitude and perceived behavioral control, we also obtained evidence to support our hypotheses. for the ok-a path (h4), the standardized coefficient was 0.14 with a t-value of 3.11 (p < 0.05). in other words, the dog owners with higher objective knowledge had a more positive attitude toward taking their dogs to be vaccinated. for the ok-pbc path (h5), the standardized coefficient was 0.02 with a t-value of 0.50 (p > 0.05); for the sk-pbc path (h6), the standardized coefficient was 0.11 with a t-value of 2.29 (p < 0.05). in other words, people who have more subjective knowledge enhance their perceived behavioral control to perform rabies prevention. therefore, for vaccinating a dog, objective knowledge enhanced an individual's attitude and subjective knowledge enhanced an individual's perceived behavioral control individually. furthermore, according to the path analysis result, perceptive behavioral control was the most obvious predictor of behavioral intention for vaccination against rabies (h3b); subjective knowledge effect on perceived behavioral control was greater than objective knowledge effect (h6b). that is to say that attitude is not the best factor and subjective knowledge must be considerable, for understanding dog owners' behavioral intention. therefore, when we are devoted to raising the vaccination rate against rabies, we need to revise the traditional kap model, which only contains attitude and objective knowledge. vaccinating dogs is the most effective way to prevent an outbreak of rabies. recently, there have been some animal cases but no human cases, in taiwan. however, many latent risks still surround this area, especially those coming from china. with the ecfa deal, more activities between taiwan and china could lead to a higher chance of a rabies outbreak in taiwan. although the administration has tried to improve knowledge and instill positive attitudes, the vaccination rate in taiwan is still between 30% and 40%, far below the 80% rate recommended by the who. hence, it is necessary to better understand and predict owners' behavior about vaccinating their dogs. in this study, we tried to integrate kap and tpb to achieve the main goals. sem results showed all the indices are acceptable and confirmed the fitness of our model. this means that our model is suitable not only for measurement but also for exploring the behavioral intention of vaccination against rabies. to explain behavioral intention through tpb, each path was significant; this supported hypotheses 1-3. in other words, people with more positive attitudes, stronger subjective norms, and more perceived behavioral control have stronger behavioral intention to vaccinate their dogs. through these results, we verified that tpb is a suitable structural model for the behavioral intention of vaccination against rabies and successfully extended tpb to explain the behavioral intention of dog owners. in addition, perceived behavioral control, not attitude, is the most obvious index for predicting the target behavioral intention. in other words, the results confirm our argument that attitude, although important, is not the best index for understanding dog owners' behavioral intention. whether the taiwanese vaccinate their dogs is mostly related to their belief about how easy or difficult it will be to accomplish. to understand the knowledge effect on preventive behavior, sem results also supported hypothesis 4 and 6. people who had more objective knowledge of rabies tended to have more positive attitudes about taking their dogs to be vaccinated. as in the kap model, objective knowledge could strengthen attitudes about prevention and provide the accurate information and skill that reduces impediments to vaccination. at the same time, people who had more subjective knowledge tended to have a better perceived behavioral control toward vaccination. in other words, subjective knowledge could change people's perceptions and considerations about preventing rabies and enhance their self-efficacy so that they feel they perform the behavior well. furthermore, results confirmed our argument that subjective knowledge showed greater influence than objective knowledge on perceived behavioral control: if we want to improve the vaccination rate by raising the dog owners' perceived behavioral control, enhancing their subjective knowledge is more effective than providing greater objective knowledge. according to these findings, we made some contributions in both theory and practice. first, we successfully extended tpb to explain behavioral intention not planned only concerning the individual. this study is the first one to use tpb as a conceptual framework for canine vaccination against rabies. previous authors successfully applied tpb in studies regarding the intention of people to obtain vaccinations for themselves. this study proves that tpb provides adaptability, in that people decide to perform some behavior for their dogs. besides, for the kap model, we also found the evidence to support it can describe the behavior against rabies. however, we found other important factors should be considered at the same time. therefore, we should extend the kap model to the knowledge, intention, practices (kip) model and take care, at least, of perceived behavioral control, attitude, and subjective norms. second, we found that when people decide to perform this kind of behavior, perceived behavioral control might be the most important factor. this result suggests that when people must make a decision outside of their own control, they might not feel that they can have considerable volitional control. their control was a primary determinant of their behaviors [55, 56] . in other word, for the tpb model, we also found evidence to support the argument of ajzen. furthermore, for the kap model, we thought when the owners of dogs, or other animals, try to bring them to be vaccinated against diseases, the perceived behavioral control of owners should be more important than the attitude of them. finally, we found that subjective knowledge more greatly influences perceived behavioral control, the most obvious predictor of behavioral intention for vaccination against rabies, than objective knowledge. ajzen et al. argued that knowledge is positively correlation with attitude and perceived behavioral control [10] . we not only found the evidence to support their argument but also pointed out the mechanism more clearly. we added the concept of subjective knowledge in our model and found the sk-pbc-bi path should be the most effective method for raising the vaccination rate against rabies. in other words, sk-pbc-bi-practices path would be better than the traditional kap model. self-efficacy plays the key factor in such preventive behavior. people with greater self-efficacy feel more subjective knowledge and perceived behavioral control, and then they perform better. therefore, in order to reduce the latent social risk, the government should first focus on raising perceived behavioral control toward behavior. according to our findings, perceived behavioral control was the primary factor influencing behavioral intention. in other words, an effective epidemic prevention policy must be aimed at this factor. to influence perceived behavioral control, the government should provide manageable conditions and a comfortable situation, for instance, a vaccination subsidy, a more convenient location for vaccination, and so on. moreover, social norms and attitude should also be addressed. owners who consider vaccination necessary within a social atmosphere and believe that vaccination against rabies is beneficial will have stronger intentions toward this behavior. at the same time, subjective knowledge plays an important role on positively affecting perceived behavioral control. in other words, when we are devoted to epidemic prevention activities, enhancing dog owners' self-efficacy is more important than confirming their learning. we should first address people's confidence about rabies knowledge, and then confirm how much knowledge they actually have. furthermore, our results not only offer the government a reference for disaster prevention but also present some interesting directions for further research. the tpb model obtained a 69% prediction rate for dog owners' behavioral intention, which still leaves 31% unexplained. in other words, people who tend to vaccinate their dogs are influenced by other factors, including risk perception, good care of dogs, and temporal immediacy. these may affect not only the intention to vaccinate but also the behavior's practical execution. ku-yuan lee: initiated the research, preparation of the text, study conception and design, acquisition of data, drafting of the manuscript; li-chi lan: acquisition of data, analysis and interpretation of statistical data, preparation of the revision; jiun-hao wang: study conception and design, acquisition of data, final approval of the 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feeling of knowing in memory and problem solving feeling of knowing in episodic memory evaluating structural equation models with unobservables and measurement error internet self-efficacy and electronic service acceptance the effect of norms, attitudes and habits on speeding behavior: scale development and model building and estimation the authors declare no conflict of interest. key: cord-277077-kwaiorp8 authors: tița, ovidiu; constantinescu, maria adelina; tița, mihaela adriana; georgescu, cecilia title: use of yoghurt enhanced with volatile plant oils encapsulated in sodium alginate to increase the human body’s immunity in the present fight against stress date: 2020-10-19 journal: int j environ res public health doi: 10.3390/ijerph17207588 sha: doc_id: 277077 cord_uid: kwaiorp8 (1) background: the covid–19 pandemic and the imposition of strict but necessary measures to prevent the spread of the new coronavirus have been, and still are, major stress factors for adults, children, and adolescents. stress harms human health as it creates free radicals in the human body. according to various recent studies, volatile oils from various aromatic plants have a high content of antioxidants and antimicrobial compounds. an external supply of antioxidants is required to destroy these free radicals. the main purpose of this paper is to create a yoghurt with high antioxidant capacity, using only raw materials from romania; (2) methods: the bioactive components used to enrich the cow milk yoghurt were extracted as volatile oils out of four aromatic plants: basil, mint, lavender and fennel. initially, the compounds were extracted to determine the antioxidant capacity, and subsequently, the antioxidant activity of the yoghurt was determined. the 2,2-diphenyl-1-picrylhy-drazyl (dpph) method was used to determine the antioxidant activity; (3) results: the results show that cow milk yoghurt enhanced with volatile oils of basil, lavender, mint and fennel, encapsulated in sodium alginate has an antioxidant and antimicrobial effect as a staple food with multiple effects in increasing the body’s immunity. the antioxidant activity proved to be considerably higher than the control sample. the highest antioxidant activity was obtained on the first day of the analysis, decreasing onwards to measurements taken on days 10 and 20. the cow milk yoghurt enriched with volatile basil oil obtained the best results; (4) conclusions: the paper shows that yoghurts with a high antioxidant capacity were obtained, using only raw materials from romania. a healthy diet, compliance with safety conditions and finding appropriate and safe methods to increase the body’s immunity is a good alternative to a major transition through harder times, such as pandemics. the creation of food products that include natural antioxidant compounds combines both the current great possibility of developing food production in romania and the prevention and reduction of the effects caused by pandemic stress in the human body. according to the food and agriculture organization (fao) of the united states, agri-food production will increase by about 70% in the coming decades [1] . in 2019, romania exported food and animals worth 4.77 billion euros, while imports were over 6.7 billion euros, according to data from the national institute of statistics. the crisis generated by the coronavirus could after several types of research, it was discovered that the volatile oils extracted from different plants bring an extraordinary benefit to the health of consumers. these oils have antiseptic action especially on pathogenic bacteria such as listeria monocytogenes, listeria innocua, salmonella typhimurium. antioxidant activity is another benefit of volatile oils. free radicals cause oxidation of biomolecules, including proteins, amino acids, deoxyribonucleic acid (dna), etc., and eventually cause molecular changes related to ageing, arteriosclerosis and cancer [4] . fennel (foeniculum vulgare) is an aromatic plant that belongs to the apiaceae family and is considered one of the oldest plants cultivated in the world. this is an annual, biennial or perennial plant native to the mediterranean area grown for its aromatic fruits, which are used as culinary spices. it grows especially well in coastal climates and riverbanks [19, 20] . fennel essential oils are used as a flavoring agent in foods such as beverages, bread, pickles, pastries and cheese. it is also used as a component in cosmetics and pharmaceuticals. fennel medicines and fennel essential oils have hepatoprotective effects as well as antispasmodic effects. additionally, volatile fennel oil is known for its diuretic, anti-inflammatory, analgesic and antioxidant activity [21] . the antioxidant and antimicrobial activity of volatile fennel oil is offered by the high content of trans-anethole (63.30%), pinene (11.11%) and fenchone (8.32%) [20] [21] [22] [23] [24] [25] basil (ocimum basilicum) is an aromatic plant that belongs to the lamiaceae family and is considered a rich source of essential oils. the basil plant is native to asia, africa, south and central america [26] . volatile basil oil has antimicrobial, antihistaminic, anti-inflammatory, anthelmintic, antioxidant properties, has an immunomodulatory effect, it is an antidepressant, antidiabetic and anti-hyperlipidemiac, has a hepatoprotective, neuroprotective and cardioprotective effect and it linked to anticancer activity [27] . due to the content of estragole (41.40%), 1,6-octadien-3-ol, 3,7-dimethyl (29.49%), trans-alpha-bergamotene (5.32%), eucalyptol (3.51), citral (3.31%), n-cyano-3-methylbut-2-enamine (3.08%), cis-alpha-bisabolene (1.92%), levomenthol (1.81%), and beta-myrcene (1.11%), volatile oil basil has a good antimicrobial and antioxidant activity [28] [29] [30] [31] [32] [33] . mint (mentha piperita) is an aromatic plant that is part of the lamiaceae family and is widely grown in europe, asia, egypt, south africa and arabia [34] . mint leaves are traditionally used as a tea in the treatment of headaches, fever, digestive disorders and various minor conditions. in modern medicine, mint is widely used in the treatment of gastrointestinal disorders [35] . many studies that have evaluated the antioxidant activities of volatile mint oil have focused exclusively on chemical tests, while the effectiveness of volatile mint oil in preventing oxidative stress at the cellular level or in a living organism has not been characterized [36] . the main components of the mint volatile oil are menthol, menthone, menthofuran, isomenthone, (e)-caryophyllene, 1,8-cineole, linalool, limonene, carvone, pulegone and α-terpineol. they give the volatile mint oil an antioxidant and antimicrobial capacity [37] [38] [39] . lavender (lavandula angustifolia) is an aromatic plant that belongs to the lamiaceae family. lavender is a herbaceous plant native to the mediterranean area and is widely cultivated. the smell of lavender improves mood, reduces mental stress and anxiety, and improves sleep [40] . lavender essential oil is commonly used in aromatherapy and various complementary medicines and cosmetics [41] . numerous studies have shown that volatile lavender oil has antioxidant, antimicrobial and antifungal properties [42] . the antioxidant and antimicrobial capacity of lavender volatile oil is offered by compounds such as the monoterpenoids, linalool, linalyl acetate, 1,8-cineole, β-ocimene, terpinen-4-ol, and camphor [43] [44] [45] [46] . in recent years, romanian entrepreneurs have focused on cultivating aromatic and medicinal plants. they focused especially on plants that are found in the mediterranean area. if until a few years ago we met many crops of vegetables or plants specific to the romanian area, in recent years many crops of lavender, fennel, mint or basil have appeared. the lavender culture is found in the plain and depression area of romania because the plant needs a warm and moderately dry climate. the fennel culture is most often found in the southern part of romania, where it is mostly plain and there is a warm climate. the mint culture is the most common in the depression area of romania because it is a plant that has a moderate tolerance to drought, requiring numerous irrigations. basil crops are most often found in southern romania, more precisely in the plains because the plant prefers a warm climate. basil is in first place at the top of romanians' preferences in terms of cultivating aromatic and medicinal plants [47] [48] [49] [50] [51] . in the study by kokina et al. in 2019 lavender and peppermint volatile oils have been shown to have the highest antioxidant capacity. they combined two methods, dpph and 2,2'-azino-bis-3-ethylbenzthiazoline-6-sulphonic acid (abts), to increase the efficiency of the evaluation of the antioxidant activity of the volatile oils studied. volatile oils were stored for 12 months and a significant decrease in antioxidant activity was observed [52] . in the study conducted by köksal and gülçin in 2008 and 2010, they demonstrated that cauliflower and lintite extracts have strong antioxidant activity [53, 54] . in 2016, aslam et al. conducted a study that demonstrated the antioxidant capacity of spinach leaves [55] . numerous studies conducted in recent years have shown that regular consumption of dairy products can have a protective effect against the development of obesity and cardiovascular disease [5] . yoghurt consumption has increased worldwide due to its nutritional value, therapeutic effects and functional properties [20] . it is very important to know the morphology of the plant and its active substances. from this point of view, the selective use of useful compounds from the plant that can be directed exactly to obtain the expected effect is preferred, and less of the plants that have been proven to produce unwanted and sometimes toxic interactions [56] . the oils obtained, once analyzed and the useful components identified, offer the possibility of their exact dosage in yoghurt so that the antioxidant effect can be ensured without substantially changing the taste and smell of the product [57, 58] . stress in the environment, especially heavy metal pollution, leads to the production of oxidative stress in plants. the population is constantly growing and the problems related to the supply of food are becoming more and more pressing. finding viable solutions for the realization of basic food products, with the widest possible destination, which in addition to a longer life cycle can ensure at the same time a healthy lifestyle, is of utmost importance. plants develop numerous enzymatic and non-enzymatic antioxidant mechanisms for detoxification. aromatic plants are especially rich in antioxidant phenolic compounds. their antioxidant activity is due to the redox properties and chemical structure, which play an important role in neutralizing free radicals and peroxides [20] . in a study conducted in 2019 on a sample of 1000 people in romania, it was shown that 98% of them suffer from diseases caused by stress. work related issues and the insecurity of tomorrow are the main reasons for the respondents' anxiety [59] . as last year in romania, the uncertainty of tomorrow and employment were the most widespread causes of stress, this year the world situation impacted by the covid-19 crisis will only deepen this even more. the large numbers of illnesses reported in the country at the moment, as well as the severely affected economic situation, are the most important causes of stress. social distancing, isolation and lack of certainty at work affects many people, who even reach states of anxiety and depression. stress development is associated with an increase in the number of free radicals, a decrease in the levels of antioxidant enzymes and an increase in oxidative lipids in the brain tissues. this free radical activity is associated with impaired cognitive function. major stress for a single period of eight hours increases the level of oxidative stress and the attack of free radicals on the brain, being accompanied by the weakening of memory and cognitive function. antioxidant nutrients have been shown to alleviate these effects when administered before or after stress-induced circumstances [60] . antioxidants are widely used as food additives to avoid food degradation. antioxidants also play an important role in preventing a variety of lifestyle disorders and ageing conditions, as they are closely linked to active oxygen and lipid peroxidation [54] . vegetable foods contain more antioxidants than those of animal origin, so the world health organization (who, geneva, switzerland) recommends about 400-600 g of vegetables and fruits daily to reduce the risk of cardiovascular disease, cancer, cognitive impairment and other eating disorders [61] . according to studies, it has been shown that the intake of antioxidants in the form of artificial supplements has not always brought the desired effect, so replacing them with natural antioxidants from plants can improve the desired effect. the intake of antioxidants, especially in this period when stress is present at maximum levels, is essential. the creation of food products that include natural antioxidant compounds combines both the current great possibility of developing food production in romania and the prevention and reduction of the effects caused by pandemic stress in the human body. to determine the antioxidant capacity, we used the dpph method. the dpph method measures the radical scavenging activity of antioxidants against free radicals, such as the dpph radical [62] . the main purpose of this work is to create yoghurts with high antioxidant and antimicrobial capacity using only raw materials from romania. external intake of antioxidants is essential to reduce the effects of daily stress. volatile oils are an excellent source of antioxidants, and their use in food production can be a great direction for the current situation. additionally, by using volatile oils, we aim to eliminate artificial preservatives added to yoghurts. according to studies in recent years, food preservatives harm consumer health, so using volatile oils with antimicrobial activity avoids the use of synthetic ones. to achieve this objective, we decided to enrich cow milk yoghurt with volatile oils encapsulated in sodium alginate. we used volatile oils from four aromatic plants: lavender, fennel, mint and basil. to achieve our purpose, we used the dpph method to determinate antioxidant capacity, and the measurements were made on the first day after making yoghurt from cow's milk, after 10 days and after 20 days. for each determination, we had two samples, a test sample (yoghurt with volatile oils) and a control sample (yoghurt without volatile oils). the yoghurt samples were packed in 150g plastic cups and stored in the refrigerator at a temperature between 0-4 • c. during the entire storage period, the glasses were covered with aluminum foil. we used five samples, first called control sample (yoghurt in which no alginate capsules were added with volatile oil), the second one called the yoghurt sample with the addition of volatile mint oil, the third one called the yoghurt sample with volatile basil oil, the fourth one called the yoghurt sample with volatile fennel oil and the fifth one called the yoghurt sample with volatile lavender oil. we used the dpph method to determinate antioxidant capacity, and the measurements were made on the first day after making yoghurt from cow milk, after 10 days and after 20 days. the cow's milk was taken from a farm in the sibiu area. lavender, mint and basil were taken from a culture located in the mures , area, and fennel was taken from a culture in the ialomit , a area. in 2019-before deciding to make a food product with a high content of antioxidants-we conducted a market study and a sensory analysis for these types of yoghurts so that we can conclude whether the products made by us are to the liking of consumers. following the sensory analysis, the tasters stated that the volatile oil added to the yoghurt only slightly influences its taste. the specific taste of yoghurt is predominant, only at the end, stimulating a slight taste of the plant from which the volatile oil is extracted. in addition to these two methods, we determined the ph and the lactic acid content to determine the antimicrobial activity of the yoghurt samples. to verify the antimicrobial activity of volatile oils, we created a mixture of the four oils studied and tested them on different cultures of enterobacteria, yeasts and molds. for the mixture of volatile oils, we used 25% volatile mint oil, 25% volatile lavender oil, 25% volatile basil oil and 25% volatile fennel oil. after obtaining the dilutions, the sowing took place on different culture mediums. the volatile oil mixture had a strong effect on colonies of enterobacteria, yeasts and molds: zero colony-forming units (cfu). no colony developed compared to the comparison plates (standard) [63] . to make the yoghurt enriched with bioactive components extracted from aromatic plants we used raw cow's milk with a physico-chemical composition representative of the lactation period, which we pasteurized, then cooled it and added lactic crops. for the inoculation operation, we used a starter culture from hansen (product name: f-dvs yc-x11 yo-flex). this is a thermophilic culture formed from lactobacillus delbrueckii subsp. bulgaricus and streptococcus thermophillus. the volatile oils did not influence the process of obtaining yoghurt. volatile oil compounds are gradually released into yoghurt due to its encapsulation in sodium alginate. the gradual release of antimicrobial and antioxidant action of volatile oils ensures a longer time of action and an avoidance of losses. for the extraction of volatile oils, we used mint, basil, lavender-dried and crushed aerial parts-and fennel seeds. the volatile oils were extracted by steam entrainment using the neo-clevenger apparatus modified by moritz. the extraction time was five hours for each sample, and for efficient extraction, the plants were soaked the day before. at the end of the extraction, the volatile oil obtained was measured and 1 ml of benzene is added over it. it was then placed in a glass vial containing sodium sulfate anhydrous to remove any traces of water. using a pasteur pipette, we extracted the volatile oil from the glass vial and the benzene evaporated. to preserve the characteristics of the volatile oil until analysis, it was sealed in a dark ampoule and refrigerated. the 4 samples of alginate capsules were obtained from 25 g 2% sodium alginate solution and 30 µl volatile basil, mint, fennel and lavender oil. the alginate solution was added gradually to the calcium chloride solution under centrifugation, thus obtaining the alginate capsules which were then washed with distilled water [63] . for the extraction of the compounds to determine the antioxidant capacity of the yoghurt samples with volatile oils, we used the extraction method adapted after patel et al. (2016) . we weighed 0.5 g of the sample to be analyzed and then extracted it with 10 ml of the mixture methanol:water:hydrochloric acid 0.12 m = 70:29:1 (v/v/v), at room temperature, for 24 h. the mixture was then kept on the ultrasonic water bath for 30 min at a temperature of 25 • c. after the time ran out, the supernatant was collected and centrifuged at 8000 rpm for 10 min. the residue was suspended in 10 ml of solvent to perform a second extraction for 15 min, on the bath of water at 25 • c. the resulting supernatant was centrifuged under the same conditions as the first. the total amount of supernatant was evaporated to the rotary evaporator and the residue was taken up with 10 ml of methanol. we filtered the mixture of supernatant and methanol and filled it to a volume of 10 ml with the same solvent [64] . to determine the antioxidant activity of the yoghurt samples with the addition of volatile oils encapsulated in sodium alginate, we used a method adapted according to the method applied by tylkowski et al. (2011) for the ethanolic extracts of sideritis ssp. l. we prepared a 25 µg/ml dpph solution by solubilizing a quantity of dpph in absolute methanol -stock solution.this mixture needed to be prepared in advance-at least 1-2 h-for complete solubilization. a volume of 970 µl dpph solution 25 µg/ml is measured and added over 30 µl methanol extract from the samples to be analyzed, which we obtained using the extraction shown above. to interpret the results, we measured the absorbance at 515 nm for each sample using the cecil 1021 uv-vis spectrophotometer and the concentration is determined according to the standard curve obtained from different concentrations of the stock solution [65] . the determination of antioxidant activity was performed for each sample of yoghurt. for all these samples, there were 10 spectrophotometer readings, because from each type of yoghurt we made five samples (five containers of 100 g each). after extracting the necessary compounds to determine the antioxidant activity of each extracted container we took two readings. we wanted to eliminate all errors related to equipment, human error and differences in temperature or humidity. all readings were made on the same day of the analysis, to be more exact on the first day, on the 10th day and on the 20th day after the yoghurt samples were made. the results obtained in this research are presented as follows. figure 1a shows the antioxidant activity of the control sample on the first day, the 10th day and the 20th day. on the first day of the analysis, the highest values of the antioxidant activity of the control sample were obtained. on this day, the maximum value obtained was 0.23%, and the minimum value was 0.16%. the value of the antioxidant activity for the control sample decreased on the 10th day compared to the first day. on day 10 of the analysis, the highest value obtained was 0.16%, and the lowest value was 0.10%. the lowest values of antioxidant activity for the control sample were obtained on day 20 of the analysis. on this day, the highest measured value was 0.11%, and the lowest was 0.06%. the average value for each day was 0.20% for the first day, 0.13% for the 10th day and 0.08% for the 20th day. figure 1a shows the antioxidant activity of the control sample on the first day, the 10th day and the 20th day. on the first day of the analysis, the highest values of the antioxidant activity of the control sample were obtained. on this day, the maximum value obtained was 0.23%, and the minimum value was 0.16%. the value of the antioxidant activity for the control sample decreased on the 10th day compared to the first day. on day 10 of the analysis, the highest value obtained was 0.16%, and the lowest value was 0.10%. the lowest values of antioxidant activity for the control sample were obtained on day 20 of the analysis. on this day, the highest measured value was 0.11%, and the lowest was 0.06%. the average value for each day was 0.20% for the first day, 0.13% for the 10th day and 0.08% for the 20th day. in figure 1a , the decline is calculated on day 10 and day 20 compared to the first day for the control sample. the decline on day 10 compared to the first day is smaller than the decline on day 20 compared to the first day. the results obtained on day 20 are lower compared to day 10. the decline from day 10 compared to the first day is between 52-88%. the decline from day 20 compared to the first day is between 27-58%. in figure 1a , the decline is calculated on day 10 and day 20 compared to the first day for the control sample. the decline on day 10 compared to the first day is smaller than the decline on day 20 compared to the first day. the results obtained on day 20 are lower compared to day 10. the decline from day 10 compared to the first day is between 52-88%. the decline from day 20 compared to the first day is between 27-58%. figure 2a shows the antioxidant activity of the yoghurt sample from cow milk with the addition of volatile mint oil encapsulated in sodium alginates on the first day, the 10th day and the 20th day. the strongest antioxidant activity of the yoghurt sample with volatile mint oil was on the first day. the lowest value of this day was 1.57%, and the highest was 1.62%. the value of the antioxidant activity decreased on the 10th day compared to the first day. on day 10 the highest value was 1.23%, and the lowest at 1.17%. for this yoghurt sample, the lowest antioxidant activity was recorded on day 20. the highest value on day 20 was 1.06%, and the lowest was 0.95%. the average value for each day is 1.60% for the first day, 1.20% for the 10th day and 1.00% for the 20th day. figure 2a shows the antioxidant activity of the yoghurt sample from cow milk with the addition of volatile mint oil encapsulated in sodium alginates on the first day, the 10th day and the 20th day. the strongest antioxidant activity of the yoghurt sample with volatile mint oil was on the first day. the lowest value of this day was 1.57%, and the highest was 1.62%. the value of the antioxidant activity decreased on the 10th day compared to the first day. on day 10 the highest value was 1.23%, and the lowest at 1.17%. for this yoghurt sample, the lowest antioxidant activity was recorded on day 20. the highest value on day 20 was 1.06%, and the lowest was 0.95%. the average value for each day is 1.60% for the first day, 1.20% for the 10th day and 1.00% for the 20th day. in figure 2b , the decline is calculated on day 10 and day 20 compared to the first day for the yoghurt sample from cow milk with the addition of volatile mint oil encapsulated in sodium alginates. the decline on day 10 compared to the first day is smaller than the decline on day 20 compared to the first day. the results obtained on day 20 are lower compared to day 10. the decline from day 10 compared to the first day is between 73-78%. the decline from day 20 compared to the first day is between 61-66%. figure 3a shows the antioxidant activity of the yoghurt sample from cow's milk with the addition of volatile basil oil encapsulated in sodium alginates on the first day, the 10th day and the 20th day. on the first day, the yoghurt sample with volatile basil oil showed the highest antioxidant activity, and on the 20th the lowest. the highest value from the first day was 9.65% and the lowest at 9.56%. on day 10 the highest value was 9.33%, and the lowest at 9.26%. on day 10 the antioxidant activity was lower than on the first day, but it was higher than on day 20. day 20 showed the lowest antioxidant activity, and the lowest value was 8.65%. the average value for each day is 9.60% for the first day, 9.30% for the 10th day and 8.70% for the 20th day. in figure 2b , the decline is calculated on day 10 and day 20 compared to the first day for the yoghurt sample from cow milk with the addition of volatile mint oil encapsulated in sodium alginates. the decline on day 10 compared to the first day is smaller than the decline on day 20 compared to the first day. the results obtained on day 20 are lower compared to day 10. the decline from day 10 compared to the first day is between 73-78%. the decline from day 20 compared to the first day is between 61-66%. figure 3a shows the antioxidant activity of the yoghurt sample from cow's milk with the addition of volatile basil oil encapsulated in sodium alginates on the first day, the 10th day and the 20th day. on the first day, the yoghurt sample with volatile basil oil showed the highest antioxidant activity, and on the 20th the lowest. the highest value from the first day was 9.65% and the lowest at 9.56%. on day 10 the highest value was 9.33%, and the lowest at 9.26%. on day 10 the antioxidant activity was lower than on the first day, but it was higher than on day 20. day 20 showed the lowest antioxidant activity, and the lowest value was 8.65%. the average value for each day is 9.60% for the first day, 9.30% for the 10th day and 8.70% for the 20th day. in figure 2b , the decline is calculated on day 10 and day 20 compared to the first day for the yoghurt sample from cow milk with the addition of volatile mint oil encapsulated in sodium alginates. the decline on day 10 compared to the first day is smaller than the decline on day 20 compared to the first day. the results obtained on day 20 are lower compared to day 10. the decline from day 10 compared to the first day is between 73-78%. the decline from day 20 compared to the first day is between 61-66%. figure 3a shows the antioxidant activity of the yoghurt sample from cow's milk with the addition of volatile basil oil encapsulated in sodium alginates on the first day, the 10th day and the 20th day. on the first day, the yoghurt sample with volatile basil oil showed the highest antioxidant activity, and on the 20th the lowest. the highest value from the first day was 9.65% and the lowest at 9.56%. on day 10 the highest value was 9.33%, and the lowest at 9.26%. on day 10 the antioxidant activity was lower than on the first day, but it was higher than on day 20. day 20 showed the lowest antioxidant activity, and the lowest value was 8.65%. the average value for each day is 9.60% for the first day, 9.30% for the 10th day and 8.70% for the 20th day. in figure 3b , the decline is calculated on day 10 and day 20 compared to the first day for the yoghurt sample from cow milk with the addition of volatile basil oil encapsulated in sodium alginates. the decline on day 10 compared to the first day is smaller than the decline on day 20 compared to the first day. the results obtained on day 20 are lower compared to day 10. the decline from day 10 compared to the first day is between 96-97%. the decline from day 20 compared to the first day is between 90-91%. figure 4a shows the antioxidant activity of the yoghurt sample from cow milk with the addition of volatile fennel oil encapsulated in sodium alginates on the first day, the 10th day and the 20th day. the highest antioxidant activity was on the first day and the lowest on the 20th day. on the first day, the highest value was 6.43%, and the lowest value was 6.37%. the antioxidant activity on day 10 is lower than on the first day. the highest value on the 10th day was 6.18%, and the lowest was 6.22%. on day 20, the yoghurt sample with volatile fennel oil had the lowest antioxidant activity. the highest value recorded was 6.04%, and the lowest was 5.95%. the average value for each day was 6.40% for the first day, 6.20% for the 10th day and 6.00% for the 20th day. figure 3 . (a) antioxidant activity of the yoghurt sample from cow milk with the addition of volatile basil oil encapsulated in sodium alginates on the first day, the 10th day and the 20th day; (b) decline on day 10 and day 20 for the yoghurt sample from cow milk with the addition of volatile basil oil encapsulated in sodium alginates compared to day one. in figure 3b , the decline is calculated on day 10 and day 20 compared to the first day for the yoghurt sample from cow milk with the addition of volatile basil oil encapsulated in sodium alginates. the decline on day 10 compared to the first day is smaller than the decline on day 20 compared to the first day. the results obtained on day 20 are lower compared to day 10. the decline from day 10 compared to the first day is between 96-97%. the decline from day 20 compared to the first day is between 90-91%. figure 4a shows the antioxidant activity of the yoghurt sample from cow milk with the addition of volatile fennel oil encapsulated in sodium alginates on the first day, the 10th day and the 20th day. the highest antioxidant activity was on the first day and the lowest on the 20th day. on the first day, the highest value was 6.43%, and the lowest value was 6.37%. the antioxidant activity on day 10 is lower than on the first day. the highest value on the 10th day was 6.18%, and the lowest was 6.22%. on day 20, the yoghurt sample with volatile fennel oil had the lowest antioxidant activity. the highest value recorded was 6.04%, and the lowest was 5.95%. the average value for each day was 6.40% for the first day, 6.20% for the 10th day and 6.00% for the 20th day. in figure 4b , the decline is calculated on day 10 and day 20 compared to the first day for the yoghurt sample from cow milk with the addition of volatile fennel oil encapsulated in sodium alginates. the decline on day 10 compared to the first day is smaller than the decline on day 20 compared to the first day. the results obtained on day 20 are lower compared to day 10. the decline from day 10 compared to the first day was between 96-97%. the decline from day 20 compared to the first day was between 93-95%. figure 5a shows the antioxidant activity of the yoghurt sample from cow milk with the addition of volatile lavender oil encapsulated in sodium alginates on the first day, the 10th day and the 20th day. the highest antioxidant activity of the yoghurt sample with volatile lavender oil was on the first day, and the lowest was on the 20th day. the highest value on the first day was 5.23%, and the lowest was 5.17%. the antioxidant activity on the 10th day was lower than on the first day, but it was higher than on the 20th day. the highest value on day 10 was 5.13%, and the lowest was 5.07%. on day 20, the lowest antioxidant activity was recorded, and the lowest value was 4.67%. the average value for each day was 5.20% for the first day, 5.10% for the 10th day and 4.70% for the 20th day. figure 4 . (a) antioxidant activity of the yoghurt sample from cow milk with the addition of volatile fennel oil encapsulated in sodium alginates on the first day, the 10th day and the 20th day; (b) decline on day 10 and day 20 for the yoghurt sample from cow milk with the addition of volatile fennel oil encapsulated in sodium alginates compared to day one. in figure 4b , the decline is calculated on day 10 and day 20 compared to the first day for the yoghurt sample from cow milk with the addition of volatile fennel oil encapsulated in sodium alginates. the decline on day 10 compared to the first day is smaller than the decline on day 20 compared to the first day. the results obtained on day 20 are lower compared to day 10. the decline from day 10 compared to the first day was between 96-97%. the decline from day 20 compared to the first day was between 93-95%. figure 5a shows the antioxidant activity of the yoghurt sample from cow milk with the addition of volatile lavender oil encapsulated in sodium alginates on the first day, the 10th day and the 20th day. the highest antioxidant activity of the yoghurt sample with volatile lavender oil was on the first day, and the lowest was on the 20th day. the highest value on the first day was 5.23%, and the lowest was 5.17%. the antioxidant activity on the 10th day was lower than on the first day, but it was higher than on the 20th day. the highest value on day 10 was 5.13%, and the lowest was 5.07%. on day 20, the lowest antioxidant activity was recorded, and the lowest value was 4.67%. the average value for each day was 5.20% for the first day, 5.10% for the 10th day and 4.70% for the 20th day. in figure 5b , the decline is calculated on day 10 and day 20 compared to the first day for the yoghurt sample from cow milk with the addition of volatile lavender oil encapsulated in sodium alginates. the decline on day 10 compared to the first day is smaller than the decline on day 20 compared to the first day. the results obtained on day 20 are lower compared to day 10. the decline from day 10 compared to the first day was between 97-99%. the decline from day 20 compared to the first day was between 89-91%. the determination of the antioxidant activity was performed for each sample of yoghurt. for all samples, 10 spectrophotometer readings were performed to eliminate all errors related to equipment, human error and differences in temperature or humidity. all readings were made on the same day of the analysis, to be more exact on the first day, on the 10th day and on the 20th day after the yoghurt samples were made. according to figure 6 , the analytical results obtained show that the highest antioxidant activity was shown by the sample of yoghurt with basil volatile oil encapsulated in sodium alginate, followed by the sample of yoghurt with fennel volatile oil encapsulated in sodium alginate, then the sample of yoghurt with lavender volatile oil encapsulated in the sodium alginate and yoghurt sample with mint volatile oil encapsulated in sodium alginate. the antioxidant activity proved to be considerably higher than the control sample. decline on day 10 and day 20 for the yoghurt sample from cow milk with the addition of volatile lavender oil encapsulated in sodium alginates compared to day one. in figure 5b , the decline is calculated on day 10 and day 20 compared to the first day for the yoghurt sample from cow milk with the addition of volatile lavender oil encapsulated in sodium alginates. the decline on day 10 compared to the first day is smaller than the decline on day 20 compared to the first day. the results obtained on day 20 are lower compared to day 10. the decline from day 10 compared to the first day was between 97-99%. the decline from day 20 compared to the first day was between 89-91%. the determination of the antioxidant activity was performed for each sample of yoghurt. for all samples, 10 spectrophotometer readings were performed to eliminate all errors related to equipment, human error and differences in temperature or humidity. all readings were made on the same day of the analysis, to be more exact on the first day, on the 10th day and on the 20th day after the yoghurt samples were made. according to figure 6 , the analytical results obtained show that the highest antioxidant activity was shown by the sample of yoghurt with basil volatile oil encapsulated in sodium alginate, followed by the sample of yoghurt with fennel volatile oil encapsulated in sodium alginate, then the sample of yoghurt with lavender volatile oil encapsulated in the sodium alginate and yoghurt sample with mint volatile oil encapsulated in sodium alginate. the antioxidant activity proved to be considerably higher than the control sample. the highest antioxidant activity was obtained on the first day of the analysis, before decreasing on day 10 and day 20. in the case of yoghurt samples with volatile basil, fennel and lavender oil, the greatest decreases in antioxidant activity were recorded between the 10th and the 20th day. in the case of the yoghurt sample with volatile mint oil, the greatest decrease in antioxidant activity was recorded between the first and the 10th day. these measurements show us that volatile basil, fennel and lavender oils have a higher antioxidant activity and are more stable during the first 10 days of preservation. in the case of volatile mint oil, it has a lower antioxidant activity and begins to stabilize after 10 days of preservation. all the data obtained show us that the chosen product has a significant antioxidant capacity and can be used as an external source of antioxidants. it was thus demonstrated that there exists a way of the highest antioxidant activity was obtained on the first day of the analysis, before decreasing on day 10 and day 20. in the case of yoghurt samples with volatile basil, fennel and lavender oil, the greatest decreases in antioxidant activity were recorded between the 10th and the 20th day. in the case of the yoghurt sample with volatile mint oil, the greatest decrease in antioxidant activity was recorded between the first and the 10th day. these measurements show us that volatile basil, fennel and lavender oils have a higher antioxidant activity and are more stable during the first 10 days of preservation. in the case of volatile mint oil, it has a lower antioxidant activity and begins to stabilize after 10 days of preservation. all the data obtained show us that the chosen product has a significant antioxidant capacity and can be used as an external source of antioxidants. it was thus demonstrated that there exists a way of increasing both the food and nutritional quality of the yoghurt but also the validation of the method of increasing the shelf life of the yoghurt. acid dairy products are appreciated worldwide because of the benefits they bring to the consumer's health, as well as the possibility of consuming them from an early age [5] . in this case, we used yoghurt as a representative product for consumers, both in terms of favorable intake for the harmonious development of the body at different stages of life, but also in terms of frequency of consumption. enriching it with bioactive components extracted from native herbs mint, basil, fennel and lavender, respectively, by adding volatile oils extracted from these plants and encapsulated using 2% sodium alginate, proved to be a beneficial option to increase the value of the product. the use of sodium alginate capsules also solved the problem of ensuring the stability of the volatile oils added to the food. the statistically processed results demonstrate the validity of the method of obtaining valuable food products, enriched in bioactive components, respectively, of using volatile oils with antioxidant and antimicrobial activity. the amount of volatile oils extracted from mint, basil, fennel and lavender is dependent on the growing conditions, soil and climatic conditions, the extraction method used, but the average values obtained support the potential for their use, especially in terms of the benefits for consumers' health. the creation of foods containing natural antioxidant and antimicrobial compounds must take precedence in food management. the problem of daily stress has become a major health problem in recent years, and the global situation impacted by the covid-19 crisis deepens this further. it is a reality nowadays that social distancing, isolation and the lack of certainty at work affects many people, even reaching states of anxiety and depression. making such foods to increase the body's immunity to viruses or to alleviate many chronic health problems is an effective and safe alternative to ensuring physical and mental health. to get over this period more easily and to reduce-as much as possible the effects-caused by the stress resulted from the pandemic, doctors recommend adopting a healthier lifestyle. therefore, a healthy diet, compliance with safety conditions and especially finding appropriate and safe methods to increase the body's immunity are safe alternatives to an easier passage through harder periods such as the pandemic. the use of volatile oils also ensures the complete elimination of artificial preservatives added to dairy products in this case of yoghurts. food preservatives harm consumer health, often causing food poisoning, so using volatile oils with antiseptic and antioxidant activities ensures an increase in the shelf life of food and attention to toxicology and public health. crossref] 2. #cumreînviembusinessul: industria alimentară merge înainte. producţia de alimente, o piaţă de 50 de miliarde de lei anual, s-ar putea dubla dacă folosim materie primă locală physicochemical, functional, and sensory properties of yogurts containing persimmon antioxidant and antiseptic properties of volatile oils from different medicinal plants: a review dairy consumption at snack meal occasions and the overall quality of diet during childhood. 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nutraceutical potential of psyllium (plantago ovata forsk). front concentration of biologically active compounds extracted from sideritis ssp. l. by nanofiltration. food bioprod. process we would like to express our sincere gratitude to the research center in biotechnology and food engineering (c.c.b.i.a.), lucian blaga university of sibiu for the entire support granted throughout the research period. we also appreciate the editor and the anonymous reviewers for their constructive comments and insightful suggestions on the manuscript. the authors declare no conflict of interest.int. j. environ. res. public health 2020, 17, 7588 key: cord-287196-re4sosff authors: shahzad, fakhar; du, jianguo; khan, imran; fateh, adnan; shahbaz, muhammad; abbas, adnan; wattoo, muhammad umair title: perceived threat of covid-19 contagion and frontline paramedics’ agonistic behaviour: employing a stressor–strain–outcome perspective date: 2020-07-15 journal: int j environ res public health doi: 10.3390/ijerph17145102 sha: doc_id: 287196 cord_uid: re4sosff historically, infectious diseases have been the leading cause of human psychosomatic strain and death tolls. this research investigated the recent threat of covid-19 contagion, especially its impact among frontline paramedics treating patients with covid-19, and their perception of self-infection, which ultimately increases their agonistic behaviour. based on the stressor–strain–outcome paradigm, a research model was proposed and investigated using survey-based data through a structured questionnaire. the results found that the perceived threat of covid-19 contagion (emotional and cognitive threat) was positively correlated with physiological anxiety, depression, and emotional exhaustion, which led toward agonistic behaviour. further, perceived social support was a key moderator that negatively affected the relationships between agonistic behaviour and physiological anxiety, depression, and emotional exhaustion. these findings significantly contributed to the current literature concerning covid-19 and pandemic-related effects on human behaviour. this study also theorized the concept of human agonistic behaviour, which has key implications for future researchers. since december 2019, the global health system has been fighting with the growing number of cases of covid-19, a viral respiratory syndrome that first appeared in china and tentatively named 2019-ncov1 or sars-cov-2 [1] . the world health organization has assessed that the rate of covid-19 spread is expected to be very high and long-lasting [2] . as of 4 july 2020, the confirmed number of patients with covid-19 had reached 11.108 million, causing over 525,790 mortalities worldwide [3] . the rare history and lack of vaccines to control this novel virus may also cause a high level of panic. during a panic, healthcare personnel (in this study, paramedics, defined as "a person who is trained to give emergency medical treatment of sick persons or assist medical professionals") face not only physical challenges but also mental burdens, including psychological distress and fear [4, 5] . a higher sense of social support may be psychologically comforting [17] [18] [19] [20] . of course, social support can have a salutary effect on health. concurrently, the potential moderating effect of pss on human agonistic behaviour has received little interest from scholars. therefore, our study also examined the moderating role of pss on the association between selected strain factors (physiological anxiety, depression, and emotional exhaustion) and the agonistic behaviour of frontline paramedics. in this study context, understanding human agonistic behaviour will help to determine specific characteristics and potential mechanisms of human aggression and violence in a variety of contexts. agonistic behaviour is also known as agonism-survivalist animal behaviour, including defence, avoidance, and aggression. the term agonistic behaviour was first used to describe animal fighting behaviour [21] . it is an adaptive behaviour resulting from conflicts within the same species members [14] . while there is no commonly accepted definition of human agonism, it has usually been defined as the act of triggering psychological or physical harm to other persons or in the destruction of property [15] . moreover, it is further defined as 'the individual's aggressive verbal and physical tendencies and aggressive attitudes' [22] . agonistic behaviour can serve as a tool for distinct antisocial, constructive activities, and destructive acts. in both human and non-humans, agonistic behaviour is significantly influenced by the general principles of operant and classical conditioning learning and social modelling [17] . the biologist who favoured this concept recognised that behavioural stimuli and underlying feelings and approaches are frequently the same; and actual behaviour is dependent on other factors, especially distance to the stimulus [23] . moreover, the term 'agonistic' introduces that the differences between aggressive and agonistic behaviours have been blurred, and these two labels are often used interchangeably in the literature. in humans, aggression is repeatedly related to living conditions [17] . behaviour also depends on the level of awareness among group members when stressful events occur in a social environment because individuals are susceptible to behavioural signals [24] . one primary reaction during the pandemic is fear of contagion. humans react like other animals because they have a similar defence system against ecological threats [25] . negative emotions brought about by threats can be contagious, and fear makes threats more imminent [26, 27] . behaviour has, in part, a genetic basis, which generally is learned in a social context. several factors can cause positive and negative behavioural change. previous literature discussed the change in agonistic behaviour of animals species rather than the human species. this study thus empirically investigated agonistic behaviour in humans and assessed the effect of the perceived threat of covid-19 on agonistic behaviour by employing the sso model. this study will make a significant contribution to the existing theory of agonistic behaviour by elucidating how to measure human psychological cognition and behaviour. our framework is based on the sso model because we examined the influence of the perceived threat of covid-19 (a stressor) on agonistic behaviour [28] . this model divulges how stressors become prominent in individuals' lives, indicating that the stressor source has a direct influence on the strain, which later contributes to outcome variables. stressors are environmental stimuli that individuals experience and transmit stress. strain and outcomes are an individual's personal emotional, and behavioural responses to stressors [13] . summing up, the sso model considers that strain is the result of sensing stressors and the antecedent of the outcome variable. in the past, sso models have been used to comprehend stress in the workplace and behavioural change as an outcome variable [29] [30] [31] [32] . however, in the context of measuring agonistic behaviour among humans, the implementation of the sso model has not been sufficiently investigated. with the rapid rise in covid-19 cases, the severe threat to medical staff is imminent, which increases their physiological and psychosomatic strain [33] . in addition, the availability of equipment and pandemic control preparedness may have a moral effect on medical personnel [34] . however, the threat of getting sick from covid-19 persists, which also puts stress on paramedical personnel. this stress further affects the psychosomatic state of frontline paramedics and increases their agonistic behaviour. recent studies have also confirmed that the perceived fear of covid-19 contagion affects individuals' psychological distress [12, 34, 35] . since outcome factors interact with psychological responses and perceived stressors, the current research model included three valuable and practical individual strains. the first is physiological anxiety-"a level and nature of anxiety, including physiological worry/oversensitivity, social concerns and concentration" [36] . the second is depression-"a mental illness with physiological and psychological consequences, including sluggishness, diminished interest and pleasure, and disturbances in sleep and appetite" [37] . the third is emotional exhaustion-"the extent to which employees feel drained and overwhelmed by their work" [31] . in this study, agonistic behaviour-"adaptive acts which arise out of conflicts between two members of the same species"-was our dependent variable [15] . in prior literature, it was mostly used interchangeably with aggressive behaviour. few scholars have discussed human agonistic behaviour, particularly in the field of marketing and customers' buying behaviour [15, 17] . however, there is no empirical evidence concerning the impact of the perceived threat of covid-19 or any other pandemic-related fears from the perspective of the sso model. this motivated the authors to investigate the possible consequences of human agonistic behaviour. the sso model can be an effective way because it emphasises the positive effect of the environmental stimulus on the internal and external behaviour of frontline paramedics treating patients with covid-19. moreover, the sequential process of the sso model has been used to test the theoretical avowals made in this study, which includes how perceived threat of covid-19 affect the agonistic behaviour of frontline paramedics by creating physiological anxiety, depression, and emotional exhaustion. in this section, we will discuss how threats and risks may be perceived and responded to by people during a pandemic and its aftermath; specifically, fear causes individuals to change their behaviour. intense fear produces the greatest behavioural changes when people experience physical and psychosomatic disorders such as anxiety, depression, and emotional exhaustion [38] [39] [40] ; whereas intense fear can lead to aggressive and defensive responses [26] . therefore, we adapted the previous brief illness perception questionnaire (bipq) [41] to determine the level of perceived threat among frontline paramedics treating patients with covid-19. the concept of illness perception is related to how a person perceives the illness as well as the cognitive structuring of the status of being ill. the model recommends that situational stimuli can produce cognitive and emotional representations of health threats or illness [41] . in other terms, illness perception is the cognitive and emotional representations of patients' viewpoints about the disease [42] . this cognitive and emotional model also includes beliefs about the treatment and control of the situation. the emotional and cognitive interpretation and evaluation about the perception of illness are the determinants of their behavioural reactions, which is shaped by individuals' experiences, knowledge levels, and mental strain [43] . therefore, per prior directions [43] , we divided and validated the scale into two parts based on the emotional and cognitive perception of the threat of illness from covid-19. first, emotional threat is a psychological disorder characterised by uncontrollable and irrational fears, extreme hostility, or persistent anxiety. it identifies the illness consequences and concern that affect individuals' emotions and create anxiety and depression, making them angry, scared, and exhausted [41, 44, 45] . however, it is not the amount of emotions but rather the interpretation of emotional states that is essential for determining an individual's degree of psychological disorder [46] . they confirmed a relationship between the level of distress intolerance, anxiety, and bulimic behaviour in a non-clinical setting [46] . second, cognitive threat refers to the identification of an illness threat from a particular disease, understanding its expected effects, and lacking personal control over the situation [44] . it may also contribute to the creation of anxiety disorders and psychological distress, which ultimately leads to behavioural change [41, 43, 47] . fear of illness is inextricably linked with depression and anxiety [48] . per chinese scholars, a parallel epidemic of depression, anxiety, and emotional exhaustion is triggered by the covid-19 pandemic [4, 49] . in addition, recent studies posited that the pandemic had provoked widespread psychological issues, such as fear, anxiety, and depression, among countries with a high prevalence of viral infections [50, 51] . similarly, we assumed that perceived emotional and cognitive threat concerning covid-19 would create anxiety, depression, and emotional exhaustion among the paramedics treating patients with covid-19, which would ultimately lead to their agonistic behaviour (i.e., outcome). thus, we hypothesised the following: h1a: perceived emotional threat will be positively related to physiological anxiety. h1b: perceived emotional threat will be positively related to depression. h1c: perceived emotional threat will be positively related to emotional exhaustion. h2a: perceived cognitive threat will be positively related to physiological anxiety. h2b: perceived cognitive threat will be positively related to depression. h2c: perceived cognitive threat will be positively related to emotional exhaustion. anxiety disorders are often caused by stressful life events [13] . anxiety is defined as "an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure" [52] . anxiety is also the cause and effect of many psychosomatic diseases and plays a role in the development of emotional psychosis [16] . prior literature described the possible role of stress and fear of sickness in the causation of submissive behaviour owing to anxiety [11, 53, 54] . how long the novel coronavirus will persist and how it will continue to influence the psychological well-being of healthcare staff is unknown. this psychological influence may lead to adverse behavioural change [55] . thus, we posited that physiological anxiety will increase extensively if the pandemic persists, which ultimately will increase frontline paramedics' agonistic behaviour. thus, we also proposed the following hypothesis: h3: physiological anxiety will be positively related to agonistic behaviour. depression refers to a 'psychological state of low mood and aversion to activity that can affect a person's thoughts, behaviour, motivation, feelings, and sense of well-being' [56] . the maladaptive actions in behavioural theories have underlined the occurrence of depression. cognitive behavioural therapy assumes that the root cause of depression is negative thinking patterns, which then lead to negative behavioural patterns [57] . people with depression have extremely negative views about themselves and the world. it is believed that long-lasting emotional stress is the pathogenic factor leading to the development of individual depression that leads to behavioural disorders [16, 58] . generally, during the early stages of a pandemic, people have little information about treatment and mortality, which exacerbates people's fear of infection, leading toward behavioural consequences [59] . consistently, depression rates are higher during the covid-19 pandemic as compared to before [6] . like anxiety, we posited that depression would increase the agonistic behaviours of frontline paramedics: h4: depression will be positively related to agonistic behaviour. emotional exhaustion is a stress-related social issue that may affect individuals' working behaviour [60] . it describes 'feelings of being emotionally overextended' [61] . consequences of emotional exhaustion can lead to behavioural disorders, a preference for remaining at home, and poor work performance [61, 62] . some studies have investigated the causes or consequences of employees' emotional exhaustion in work-related environments [31, [62] [63] [64] [65] . moreover, one study [63] concluded that greater levels of perceived pandemic threat could be used to anticipate increased levels of emotional exhaustion, leading to increased agonistic behaviour. given that the increased threat of the covid-19 pandemic predicts increased emotional exhaustion, it is reasonable to suggest that increased emotional exhaustion will contribute to exacerbated agonistic behaviour among frontline paramedics treating patients with covid-19. like anxiety and depression, we hypothesised the following: h5: emotional exhaustion will be positively related to agonistic behaviour. social support is defined as "social interactions or relationships that provide practical assistance to individuals or embedding individuals into a social system that is considered to provide love, care, or attachment to a valuable social group" [24] . simply, social support refers to all kinds of support that individuals obtain from others. social support is divided into actually received support and perceived support. although the received social support includes the assistance already provided, pss is a faith that these assisting behaviours will occur when needed in the future [66] . increased social support is coupled with better psychological outcomes, and pss (rather than actual social support) seems to indicate healthier psychological behaviours during times of stress [26] . moreover, pss was identified in the sars outbreak and organisational behaviour literature as adversely associated with burnout [67] . therefore, pss was selected as the focus of this research. various aspects of sociocultural background influence the degree and speed of behavioural change. social norms influence employees' behaviours, what they think about others' actions, and what they agree or disagree with at the workplace [68] . in addition, many studies have confirmed the relationship between decreased adolescent social support and increased aggression [69] [70] [71] [72] [73] . moreover, greater levels of perceived pandemic threat predict resulted in increased levels of psychological strain, whereas greater social support predicts a decreased effect of psychological strain on behaviour disorders [63] . increased pss also protects individuals with high levels of victimisation from increased health disorders such as depression, anxiety, emotional exhaustion [19, 69] . the moderating role of pss using the stress-buffering model was also a significant contributor to depressive symptoms among chinese nurses [20] . nonetheless, few studies have explored the impact of pss on the relationship between covid-19-related stress and psychological well-being [74, 75] . consequently, we posited that pss would buffer or moderate the relationship between strain (physiological anxiety, depression, emotional exhaustion) and outcome (agonistic behaviour). specifically, we hypothesised the following: h6a: pss will moderate the positive association between physiological anxiety and agonistic behaviour; i.e., a rise in pss will decrease the relationship strength between physiological anxiety and agonistic behaviour. h6b: pss will moderate the positive association between depression and agonistic behaviour; i.e., a rise in pss will decrease the relationship strength between depression and agonistic behaviour. h6c: pss will moderate the positive association between emotional exhaustion and agonistic behaviour; i.e., a rise in pss will decrease the relationship strength between emotional exhaustion and agonistic behaviour. the proposed model of this study is shown in figure 1 . the threat of covid-19 initially started after the first case was reported in china. regardless of common health issues, developing countries are still in the initial phases of tackling this uncertain situation. the covid-19 pandemic was first verified to have arrived in pakistan in february 2020 [76] and grew to 69,496 confirmed cases by 31 may 2020 [77] . paramedics, working in isolation wards, fever clinics, intensive care units and other related departments with an increased workload and risk of infection. in this study, the targeted population encompassed paramedics treating patients with covid-19 in pakistan who completed a survey. we adapted the survey items (see appendix a) for all constructs from prior literature and refined them to fit the context of this research before final data collection. however, in the preliminary analysis, an item from pss (item number 6) was excluded owing to low factor loadings and to authenticate the results [78] . moreover, to confirm the content validity of the proposed survey, a team composed of one professor and four scholars were requested to verify the wording and face validity of the survey questionnaire. the approved questionnaire was then distributed for data collection. in this study, the brief illness perception questionnaire (bipq) was adapted [41] to measure the perceived threat of covid-19 (0 to 10 scale) among frontline paramedics treating patients during the current pandemic. the initial eight-item questionnaire was divided into two categories as per prior directions [43] : perceived emotional threat and perceived cognitive threat. a sample item for the perceived emotional threat was, "how much does your threat of illness from covid-19 affect you emotionally"? a sample item for the perceived cognitive threat was, "how well do you feel you understand covid-19"? physiological anxiety was measured using 11 items (7-point likert scale) [36] , which were obtained from an earlier measure [53] . a sample item was "i cannot concentrate on a task or job without irrelevant thoughts intruding". the threat of covid-19 initially started after the first case was reported in china. regardless of common health issues, developing countries are still in the initial phases of tackling this uncertain situation. the covid-19 pandemic was first verified to have arrived in pakistan in february 2020 [76] and grew to 69,496 confirmed cases by 31 may 2020 [77] . paramedics, working in isolation wards, fever clinics, intensive care units and other related departments with an increased workload and risk of infection. in this study, the targeted population encompassed paramedics treating patients with covid-19 in pakistan who completed a survey. we adapted the survey items (see appendix a) for all constructs from prior literature and refined them to fit the context of this research before final data collection. however, in the preliminary analysis, an item from pss (item number 6) was excluded owing to low factor loadings and to authenticate the results [78] . moreover, to confirm the content validity of the proposed survey, a team composed of one professor and four scholars were requested to verify the wording and face validity of the survey questionnaire. the approved questionnaire was then distributed for data collection. in this study, the brief illness perception questionnaire (bipq) was adapted [41] to measure the perceived threat of covid-19 (0 to 10 scale) among frontline paramedics treating patients during the current pandemic. the initial eight-item questionnaire was divided into two categories as per prior directions [43] : perceived emotional threat and perceived cognitive threat. a sample item for the perceived emotional threat was, "how much does your threat of illness from covid-19 affect you emotionally"? a sample item for the perceived cognitive threat was, "how well do you feel you understand covid-19"? physiological anxiety was measured using 11 items (7-point likert scale) [36] , which were obtained from an earlier measure [53] . a sample item was "i cannot concentrate on a task or job without irrelevant thoughts intruding". depression was measured using 19 items (7-point likert scale) adapted from an earlier study [79] . a sample item was, "how often was this happen during the past 10 days; you were bothered by things that usually do not bother you? emotional exhaustion was measured using 12 items (7-point likert scale) adapted from an earlier study [31] , which were obtained from an earlier measure [80] . a sample item was, "it is hard for me to relax after dealing with covid-19 patients". perceived social support was assessed using 8-items (7-point likert scale) adapted from an earlier study [81] . a sample item was, "how much do you feel that your family pays extra attention to you during a current pandemic"? an aggression scale was adapted from an earlier study [22] as an objective gauge to assess individuals' agonistic behaviour. we critically analysed several aggression scales; however, we found regoeczi's aggression scale to be the most relevant to our definition of agonistic behaviour. a 5-items scale (7-point likert) was administered to participants. a sample item was, "how often did you feel you were too aggressive toward other people during the past 10 days"? consistent with the focus of this study, data were gathered through a structured questionnaire only from paramedical personnel treating patients with covid-19 in pakistan. in the punjab province of pakistan, there are two separate layers of professionals that support core medical personnel in their healthcare services, namely "paramedics" and "allied health professionals". paramedics are registered with punjab medical faculty (pmf), and allied health professionals are registered with the higher education commission (hec) [82] . in this study, we have collected the data only from the frontline paramedics working in punjab, pakistan particularly dealing with covid-19 patients. for this, we contacted the head of several quarantine centres and hospitals treating patients with covid-19 around punjab province, pakistan. they were informed of the study purpose. all possible questions were answered to their satisfaction, but no official data were collected to assure the privacy of the respondents and the organisations. after getting verbal permission from the concerned authority, we started our data collection process. data collection followed the computer-assisted web interview method-a data-gathering technique in which participants complete questionnaires through an online survey link without the guidance of the interviewer [83] . the expected circulation of the survey was around 1500 using snowball sampling. a total of 372 responses were recorded between 3 march 2020 and 17 may 2020. twenty-seven responses were omitted from final analyses because they were deemed unreliable [84] . moreover, the same size exceeding 200 meant it was reasonable to employ structural equation modelling (sem) [85] . considering the length of the survey (66 questions), utilising sem analyses was rational. moreover, we evaluated the sample adequacy on the advice of [86] , based on cohen's power theory. a post-hoc was applied for all exogenous indicators (significance level was set at 0.05, the effect size was 0.15, and the sample size was 345) to verify the statistical intensity of the study sample using g*power 3.1.9 (heinrich-heine-universität, düsseldorf, germany) [87] . the results of the post-hoc test revealed that the statistical power was 0.9, much higher than the 0.8 thresholds [88] . therefore, the final sample of 345 respondents was analysed by implementing the partial least square sem technique in smart-pls v3.2.9 (smart-pls gmbh, bönningstedt, germany). for our purposes, this was more suitable than covariance-based sem [89, 90] . table 1 outlines participants' characteristics (e.g., sex, age, and work experience): 38.6% were men, and 61.4% were women; 18.3% were aged ≤ 29 years old, 39.4% were aged 30 to 39 years, 40.6% were aged 40 to 49 years, and 1.7% were aged ≥ 50 years; and 20.9% had one to three years of work experience, 25.2% had four to six years of work experience, 26.1% had seven to nine years of work experience, and 27.8% had ≥ 10 years of work experience. [78] . to verify the convergent validity of each item, smart-pls v3.2.9 software was used to conduct a confirmatory factor analysis. table 2 shows the reliability and convergent validity of this study. in addition, cronbach's alpha of all factors ranged from 0.934 to 0.974, which was higher than the threshold value. concerning convergent validity, this study examined the similarity between operationalisation and theory. the composite reliability (cr) was 0.947 to 0.976, and the average variance extracted (ave) was 0.684 to 0.861. the suggested values for cronbach's alpha and cr should be greater than 0.7, and ave should be greater than 0.5; thus, the instrument was efficient and reliable [78, 91] and the data could be used for further structural analysis. to distinguish the extent of empirical variance among the constructs, discriminant validity evaluation has become a widely accepted assumption to analyse the relationship between potential factors [89] . in this study, we used three methods to evaluate discriminant validity. first, by associating the correlation of the factors with the square root of the ave. second, the survey items were checked through the cross-loading criterion to recognise the relevance. third, discriminant validity was measured by the application of heterotrait-monotrait ration (htmt) [89, 92, 93] . as described in table 3 , the correlation between constructs and the square root of ave was linked to quantify the discriminant validity of the instrument. the diagonal values in table 3 suggest that the square root of ave is higher than the correlation coefficients between all variables, a good indication of discriminant validity [93] . prior studies suggested cross-loadings criteria to assess discriminant validity [91, 94] . accordingly, the loading of each item should be higher than its subsequent construct, and the item loadings are also regarded as a threshold. the calculation results of item loadings and cross-loadings (see table 4 ) show that the loadings of each item are higher than the cross-loadings of other subsequent construct items. this shows that it has sufficient discriminant validity by satisfying the cross-loading criteria. finally, the htmt ratio criterion was established to illustrate the insensitivity of fornell and larcker's criterion and cross-loading criterion. the ratio of htmt was close to 1, indicating the lack of discriminant validity [91] . htmt is an estimate of factor correlation (or instead, the upper bound). to make a clear distinction between the two factors, htmt should be less than 1 [92, 95] . therefore, we employed the htmt ratio; the value in table 5 shows that the highest value is 0.75, which is lower than the above threshold, indicating sufficient discriminant validity. after examining reliability and validity, we measured the causal relationship between the factors with smart-pls v3.2.9 software [89, 95] . figure 2 shows the value of the path coefficient. the bootstrap technique was used to measure the significance of the structural model (2000 iterations of resampling). the expressive power of the research model is represented by the illustrative variation of its results (i.e., r 2 ). the r 2 (r-square) value of ab was 0.399, indicating that these selected variables represented 39.9% of the variation. moreover, the r 2 of physiological anxiety was 0.182, indicating that the mutation rate owing to perceived emotional threat (pet) and perceived cognitive threat (pct) was 18.2%. in addition, the r 2 of depression was 0.157 and the r 2 of emotional exhaustion was 0.177, indicating the active participation of perceived threat. after examining reliability and validity, we measured the causal relationship between the factors with smart-pls v3.2.9 software [89, 95] . figure 2 shows the value of the path coefficient. the bootstrap technique was used to measure the significance of the structural model (2000 iterations of resampling). the expressive power of the research model is represented by the illustrative variation of its results (i.e., r 2 ). the r 2 (r-square) value of ab was 0.399, indicating that these selected variables represented 39.9% of the variation. moreover, the r 2 of physiological anxiety was 0.182, indicating that the mutation rate owing to perceived emotional threat (pet) and perceived cognitive threat (pct) was 18.2%. in addition, the r 2 of depression was 0.157 and the r 2 of emotional exhaustion was 0.177, indicating the active participation of perceived threat. the sem results in figure 2 show that all exogenous factors are positively associated with endogenous factors. the p-value confirms the level of significance of the relationship between the proposed relations per the criterion [96, 97] . meanwhile, the value of standardized root mean square residual (srmr) is 0.042, and the value of normed fit index (nfi) is 0.891, showing the good fitness of the model. in figure 2 , the sem analysis results verify the path analysis coefficient between pet and physiological anxiety is (β = 0.267, p < 0.001). pet had a significant positive effect on physiological anxiety, and the beta correlation coefficient between pet and depression was significant (β = 0.221, p < 0.001). the findings further indicated that pet and emotional exhaustion were significantly positively correlated (β = 0.243, p < 0.001). based on these statistical findings, h1a, h1b, and h1c were supported. the sem results in figure 2 show that all exogenous factors are positively associated with endogenous factors. the p-value confirms the level of significance of the relationship between the proposed relations per the criterion [96, 97] . meanwhile, the value of standardized root mean square residual (srmr) is 0.042, and the value of normed fit index (nfi) is 0.891, showing the good fitness of the model. in figure 2 , the sem analysis results verify the path analysis coefficient between pet and physiological anxiety is (β = 0.267, p < 0.001). pet had a significant positive effect on physiological anxiety, and the beta correlation coefficient between pet and depression was significant (β = 0.221, p < 0.001). the findings further indicated that pet and emotional exhaustion were significantly positively correlated (β = 0.243, p < 0.001). based on these statistical findings, h1a, h1b, and h1c were supported. the beta coefficient of pct was significant (β = 0.194, p < 0.01), implying that it positively impacted physiological anxiety; therefore, h2a was supported. pct was positively correlated with depression and emotional exhaustion. pct and depression were also significantly positively correlated (β = 0.209, p < 0.01), as were pct and emotional exhaustion (β = 0.212, p < 0.001). therefore, h2b and h2c were supported. physiological anxiety also had a considerable effect on ab (figure 2 ; β = 0.234, p < 0.001). the coefficient values of depression and ab (β = 0.223, p < 0.001) and emotional exhaustion and ab (β = 0.232, p < 0.001) indicated that the selected strain factors (physiological anxiety, depression, and emotional exhaustion) had a substantial positive effect on the ab. therefore, h3, h4, and h5 are were supported. figure 2 shows the interaction value of the beta coefficient of pss on the association between physiological anxiety and ab (β = −0.242, p < 0.001), the coefficient value of pss on the association between depression and ab is (β = −0.238, p < 0.001), and the coefficient value of pss on the relationship between emotional exhaustion and ab (β = −0.221, p < 0.001). pss significantly and negatively influenced the relationships between physiological anxiety, depression, and emotional exhaustion with ab ( figure 3) . consequently, h6a, h6b, and h6c were supported. figure 3 also illustrates the moderating effect of pss on the relationship between physiological anxiety, depression, and emotional exhaustion with ab. in sum, per the present analyses, the proposed theoretical model was acceptable. h2b and h2c were supported. physiological anxiety also had a considerable effect on ab (figure 2 ; β = 0.234, p < 0.001). the coefficient values of depression and ab (β = 0.223, p < 0.001) and emotional exhaustion and ab (β = 0.232, p < 0.001) indicated that the selected strain factors (physiological anxiety, depression, and emotional exhaustion) had a substantial positive effect on the ab. therefore, h3, h4, and h5 are were supported. figure 2 shows the interaction value of the beta coefficient of pss on the association between physiological anxiety and ab (β = −0.242, p < 0.001), the coefficient value of pss on the association between depression and ab is (β = −0.238, p < 0.001), and the coefficient value of pss on the relationship between emotional exhaustion and ab (β = −0.221, p < 0.001). pss significantly and negatively influenced the relationships between physiological anxiety, depression, and emotional exhaustion with ab ( figure 3) . consequently, h6a, h6b, and h6c were supported. figure 3 also illustrates the moderating effect of pss on the relationship between physiological anxiety, depression, and emotional exhaustion with ab. in sum, per the present analyses, the proposed theoretical model was acceptable. the common method bias (cmb) possibly exposes the efficacy of this study. the survey notes informed participants that there were no right or wrong answers and that their replies would remain anonymous and confidential. moreover, harman's single factor test is usually used to test for the existence of cmb [98, 99] . we used spss v26 (ibm spss inc., chicago, il, usa) software to perform harman's single factor test. the first factor accounted for 40.9% of the variation. in social science literature, a value below 50% is the threshold of the cmb [98, 100, 101] . concurrently, the inner variance inflation factor (vif) was also used to evaluate the cmb problem. according to kock (2015) , inner-vif should be less than 3.3. we discovered that the value varied between 1.09 to 2.01; thus, cmb was not a problem in this study. the values of outer-vif were used for multicollinearity assessment of the survey items. the literature shows that if the vif value of a study is lower than 10, multicollinearity may not be a problem [102] [103] [104] . the highest value of vif was 5.93; thus, there was no severe multicollinearity problem. in sum, the proposed model did not have cmb or multicollinearity problems, indicating that the structural model measured significant differences between the constructs. the global understanding of disease transmission and management has improved during the several pandemics in history. however, covid-19 has limited global health authorities' abilities. as previous studies disclosed, working directly with patients will increase individuals' fear of getting sick and uncertainty about pandemic contagion [63, 105] , which we called perceived threat of covid-19 in this study. therefore, we investigated the impact of perceived covid-19 threat in forecasting greater levels of physiological anxiety, depression, and emotional exhaustion among frontline paramedics, which may boost their agonistic behaviour. another objective was to examine the moderating influence of pss in reducing the adverse consequences of physiological anxiety, depression, and emotional exhaustion on agonistic behaviour owing to the perceived threat of covid-19. the bipq [41] was used to measure the perceived threat of covid-19, which was divided into two constructs: perceived emotional threat and perceived cognitive threat. sem was applied to the data to test the research model under the podium of the sso framework. the results revealed that frontline paramedics in the isolation wards did not think that they were exempt from the peril, which was associated with increased psychological distress. moreover, paramedics worried about the inadequacy of protective measures and vigilance taken by the health department. paramedics' perception of risk contributed to their psychological morbidity and irregular behaviour. based on the empirical results, we postulated that an increased perceived threat of covid-19 would increase the level of paramedics' physiological anxiety and depression, which would ultimately increase their agonistic behaviour. a causal link between the perceived threat of covid-19 and psychological distress was found. after working in isolation for a considerable period, paramedics reported emotional exhaustion. treating patients with covid-19 had become routine, and they were inured to being around death almost every day. however, they also experienced substantial stress owing to the fear of getting ill during the pandemic. the cognitive and emotional threat from covid-19 was positively associated with increased emotional exhaustion at work, which was associated with paramedics' behavioural change. moreover, the results showed that pss reduced the effect of anxiety, depression, and emotional exhaustion on agonistic behaviour. pss is helpful as friends or family members provide social support and express empathy. with the increase in the number of cases of covid-19 infection around the globe, frontline paramedics are required to wear protective masks, protective clothing, and treat many patients with covid-19, which may cause added stress. however, pss can help reduce this stress by reducing the perception of the threat of stressful events and the physiological response and inappropriate behaviour that can result from stress. these results are also supported by prior studies [75, 106] . positive social feedback should thus be provided to frontline paramedics in times of uncertainty to offset potential agonistic behaviour. first, this research offers a more account of the theory of agonistic behaviour from the field of animal biological sciences to human behavioural science. the authors integrated the sso model with the theory of agonistic behaviour to examine the effects of the perceived threat of covid-19 on human agonistic behaviour. this empirical investigation elucidated human behaviour research. second, by using the sso model, this study tested several theoretical-based relationships between the perceived threat of covid-19 and human agonistic behaviour. most of the recent studies concerning covid-19 discussed the consequences and adverse effect on patients' health, daily life, economy, and education [4, 55, [107] [108] [109] [110] ; however, this study mainly concentrated on the perceived threat of covid-19 among frontline paramedics, and how it influenced their psychological strain and increased their agonistic behaviour. therefore, the authors hope that this model can be further extended and used as an ideal platform for future work in a similar context. third, this study further divided the bipq into two major parts-emotional and cognitive threats-and empirically tested it during the current pandemic situation. this significantly contributes to validating the existing scales and can be used in future research. this study also provides some useful insights for practice. first, the findings significantly highlighted the risk of infection that frontline paramedics face, which may cause several mental health problems such as anxiety and depression. health organisations should implement full security measures to protect this at-risk population to mitigate the threat of covid-19. second, the results emphasised the need for healthcare managers to understand the magnitude and sources of psychosocial stress faced by frontline paramedics. providing adequate protection and facilities, communicating effectively, creating transparent guidelines, and implementing appropriate feedback mechanisms for healthcare personnel are essential to reduce the strain in the current pandemic situation. third, this study highlights the significant role of pss in reducing the effect of psychological strain on agonistic behaviour. concerning stress management, it is also essential to strengthen social support in the workplace. for frontline paramedics with severe psychological strain, it is necessary to identify high-risk groups early, and provide counselling, social support, and stress management to mitigate negative behavioural change. some limitations need to be addressed while discussing the outcomes of the current study. first, a cross-sectional design was employed, and the agonistic behaviour of paramedics was measured during the current pandemic. future scholars should employ a multimethod or longitudinal design by comparing the results obtained during and after the covid-19 pandemic. second, this study did not examine sex and age differences. the level of threat may not be the same between female and male paramedics. similarly, those in different age groups will respond to strain differently and may display agonistic behaviour in diverse ways. therefore, multigroup analyses should examine any possible sex or age differences. third, the strain factors discussed in this study are not limited to these particular factors; future researchers could extend the model using several other factors such as scepticism, sadism, and poor sleep quality, which may impact human agonistic behaviour. organisational and government support can also be used as a moderating factor in addition to pss. finally, future researcher should continuously validate the scale used in the current study. our study concludes that the effect of perceived covid-19 threat on predicting greater levels of physiological anxiety, depression, and emotional exhaustion among frontline healthcare paramedics may contribute to their agonistic behaviour. moreover, we have concluded the moderating role of pss in decreasing the adverse effect of physiological anxiety, depression, and emotional exhaustion on agonistic behaviour due to the perceived threat of covid-19. our study provides understanding about human agonistic behaviour will help to identify precise characteristics and probable mechanisms of human aggression and violence in several contexts, which will contribute to the implementation of conflict management practices in the workplace. "you felt sad?" "you felt that people disliked you?" "it was hard to get started doing things?" "you felt life was not worth living?" emotional exhaustion "it is hard for me to relax after dealing with covid-19 patients." "if others speak to me, i will sometimes give an errant reply." "i mostly feel annoyed while dealing with covid-19 patients." "i sometimes act aggressively, although i do not want to do so. " "i feel irritable after dealing with covid-19 patients for hours." "i feel emotionally drained sometimes." "i feel used up at the end of my work." "i feel fatigued when i get up in the morning and being confronted with news of covid-19 patients." "i feel burned out from dealing with covid-19 patients. " "i feel frustrated after work." "i fell, i am working with covid-19 patients for too long." "dealing with covid-19 patients puts too much stress on me." perceived social support "how much do you feel that adults care about you?" "how much do you feel that your employer care about you?" "how much do you feel that your parents care about you?" "how much do you feel that your friends care about you?" "how much do you feel that people in your family understand you?" "how much do you feel that you want to leave home?" (deleted) "how much do you feel that you and your family have fun together during a current pandemic?" "how much do you feel that your family pays extra attention to you during a current pandemic?" agonistic behaviour "how often did you feel, you were too aggressive toward other people during the past 10 days?" "how often did you feel, you influence other people too much to get what you want during the past 10 days?" "how often did you feel, not at all aggressive-aggressive during the past 10 days?" "how often did you feel, you like people to be afraid of you during the past 10 days?" 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"how much do you feel symptoms covid-19 contagion?" "how concerned are you about covid-19 contagion?" "how much does your threat of illness from covid-19 affect you emotionally? (e.g., does it make you angry, scared, upset or depressed)" perceived cognitive threat "how long do you think covid-19 will continue?" "how much control do you feel over covid-19 contagion?" "how much do you think that current treatment is helpful from the recovery of covid-19 contagion?" "how well do you feel you understand covid-19?" physiological anxiety "i picture some future misfortune." "i cannot get some thoughts out of my mind." "i abide on mistakes that i have made." "i think about possible misfortunes to my loved ones." "i cannot concentrate on a task or job without irrelevant thoughts intruding." "i keep trying to avoid uncomfortable thoughts." "i cannot get some pictures or images out of my mind." "i imagine myself appearing foolish with a person whose opinion of me is important." "i am concerned that others might not think well of me." "i have to be careful not to let my real feelings show." "i have an uneasy feeling." depression how often was this happen during the past 10 days: "you were bothered by things that usually do not bother you?" "you did not feel like eating, and your passion was poor?" "you felt that you could not shake the blues, even with help from family and friends?" "you felt that you were just as good as other people?" "you had trouble keeping your mind on what you were doing?" "you felt depressed?" "you felt that you were too tired to do things?" "you felt hopeful about the future?" "you thought your life had been a failure?" "you felt fearful?" "you were happy?" "you talked less than usual?" "you felt lonely?" "people were unfriendly to you?" "you enjoyed life?" key: cord-002184-964tbh7d authors: liu, kui; li, li; jiang, tao; chen, bin; jiang, zhenggang; wang, zhengting; chen, yongdi; jiang, jianmin; gu, hua title: chinese public attention to the outbreak of ebola in west africa: evidence from the online big data platform date: 2016-08-03 journal: int j environ res public health doi: 10.3390/ijerph13080780 sha: doc_id: 2184 cord_uid: 964tbh7d objective: the outbreak of the ebola epidemic in west africa in 2014 exerted enormous global public reaction via the internet and social media. this study aimed to investigate and evaluate the public reaction to ebola in china and identify the primitive correlation between possible influence factors caused by the outbreak of ebola in west africa and chinese public attention via internet surveillance. methods: baidu index (bdi) and sina micro index (smi) were collected from their official websites, and the disease-related data were recorded from the websites of the world health organization (who), u.s. centers for disease control and prevention (cdc), and u.s. national ministries of health. the average bdi of internet users in different regions were calculated to identify the public reaction to the ebola outbreak. spearman’s rank correlation was used to check the relationship of epidemic trends with bdi and smi. additionally, spatio-temporal analysis and autocorrelation analysis were performed to detect the clustered areas with the high attention to the topic of “ebola”. the related news reports were collected from authoritative websites to identify potential patterns. results: the bdi and the smi for “ebola” showed a similar fluctuating trend with a correlation coefficient = 0.9 (p < 0.05). the average bdi in beijing, tibet, and shanghai was higher than other cities. however, the disease-related indicators did not identify potential correlation with both indices above. a hotspot area was detected in tibet by local autocorrelation analysis. the most likely cluster identified by spatiotemporal cluster analysis was in the northeast regions of china with the relative risk (rr) of 2.26 (p ≤ 0.01) from 30 july to 14 august in 2014. qualitative analysis indicated that negative news could lead to a continuous increase of the public’s attention until the appearance of a positive news report. conclusions: confronted with the risk of cross-border transmission of the infectious disease, online surveillance might be used as an innovative approach to perform public communication and health education through examining the public’s reaction and attitude. the ebola epidemic of west africa had been viewed as a public health emergency of international concern by the world health organization (who) on 8 august 2014, attributed to its explosive course and high fatality [1] . ebola virus disease (evd), also known as ebola hemorrhagic fever, was first identified in yambuku and the surrounding areas in zaire and south sudan in 1976 [2, 3] . the largest public reaction, which might provide clues for government and health authorities to reform existing modes of health education. to understand the public reaction in china to the outbreak of evd in west africa, we carried out an innovative network digital epidemiologic study based on the online data retrieved from 20 july to 4 september in 2014, in which the epidemics had aroused significant attention and reaction in china. according to the chinese keyword of "埃博拉 (ebola)", the bdi and smi were collected from the websites of baidu index and sina micro index daily, respectively [19, 30] . all of the ebola-related data, including the number of cases and deaths, were collected from the websites of the world health organization, centers for disease control and prevention and national ministries of health (usa), and netizen data were from the 33rd statistical report on internet development in china [31]. we initiated internet surveillance of cyber citizens' reactions to ebola from 20 july in china. the daily bdi was recognized as a vital data source, which could provide information involving the weighted sum of search frequency for a keyword in light of its daily search volume via the baidu website. we gathered the daily bdi with "埃博拉 (ebola)" as the keyword in cities/provinces to examine the public response. additionally, given internet users in different locations, the average bdi was calculated to identify the mean attention of the netizens (1/100 million) in each province and some cities. also, we used the same strategy to investigate the blogs posted and forwarded daily for the topic of "ebola" by the sina micro index (smi). the headline news reports concerning "ebola" were also collected. these media events were retrieved from two sources: the headlines by the baidu index and baidu news [32] . the former does not carry news headlines of the same topic every day, especially of topics with minor fluctuations of bdi. the latter not only provides the related media events but also sorts focused news by the topic word. finally, the collected media events were abstracted and categorized as positive or negative news. media events were classified as negative if it generated negative sentiments or attitudes towards the topic of ebola, or as positive if it aroused optimistic sentiments or supportive attitudes towards "ebola". these were determined by two individuals, and were eventually decided by the third person if a discrepancy existed. we graphed the curves of the ebola outbreak in west africa to describe the severity of epidemics. to explore the public reaction, the average public reaction of the bdi (average bdi) among internet users from different regions was calculated by the mean or median (p50), in which p50 was used as data distribution did not suffer the test of normality. spearman's rank correlation was employed to check the relationship of epidemic trends with bdi and smi. the autocorrelation analysis included general autocorrelation analysis and local autocorrelation analysis. the general autocorrelation used the global moran's index. according to the value of moran's index, the result would be determined as a clustered distribution, dispersed distribution, or random distribution, respectively [33] . when the p value of the global moran's index was less than 0.05, the local autocorrelation analysis would be carried out by local getis's gi* to identify the potential hotspots. additionally, kulldorff's space-time scan statistics was carried out to recognize the special cities/provinces with high attention to "ebola" [34] . the parameters of the maximum spatial cluster size and maximum temporal cluster size used the default settings (50%). the log likelihood ratio (llr) was calculated through comparing the real average bdi with the expected average bdi, and a monte carlo test (p < 0.05) was utilized to determine the most likely clustered regions. spatial-temporal analysis was done using arcgis software (version 10.1, esri inc., redlands, ca, usa) and satscan software (version 9.1.1, boston, ma, usa). all of the results were considered statistically significant if p < 0.05. this current ebola outbreak started in guéckédou and macenta districts of guinea during december 2013 [35] , and who proclaimed the evd outbreak on 23 march 2014. as the situation deteriorated, from all of the available evidence, director-general margaret chan of who defined the epidemic to be a public health emergency of international concern. figure 1 dbi and smi were used as the indicators for the public attention to the ebola outbreak, and the correlation analysis was used to detect the consistency of the two indices ( figure 2) . the result showed a positive correlation between bdi and smi (spearman's rank correlation coefficient = 0.9, p ď 0.05). the bdi for the keyword of "ebola" increased sharply from 29 july, which peaked at 101,222 on 1 august, and its bdi declined with fluctuations, remaining at a high level above 50,000 between 2 and 9 august. it dropped again on 15 august and reached a lower peak at 79,939. it then steadily decreased to 28,480 with minor fluctuations on 20 august, along with a bdi of 58,360. after that, the bdi of "ebola" stayed at a lower level between 10,000 and 20,000, but higher than that before 29 july ( figure 2 ). the data scale ranged from 399 to 101,222, with a median of 25,421 during the study period. we further collected the daily bdi of different provinces and some municipalities in china between 20 july and 4 september. the overall trend of the bdi in available cities and provinces was similar. considering the diverse frequencies among internet users in different areas, the numbers of netizens were gathered to investigate the average attention as indicated by the average bdi in separated regions ( figure 3 ). the top five cities/provinces in terms of the average bdi were beijing, tibet, shanghai, tianjin, and hainan (table 1 ). the bdi for the keyword of "ebola" increased sharply from 29 july, which peaked at 101,222 on 1 august, and its bdi declined with fluctuations, remaining at a high level above 50,000 between 2 and 9 august. it dropped again on 15 august and reached a lower peak at 79,939. it then steadily decreased to 28,480 with minor fluctuations on 20 august, along with a bdi of 58,360. after that, the bdi of "ebola" stayed at a lower level between 10,000 and 20,000, but higher than that before 29 july ( figure 2 ). the data scale ranged from 399 to 101,222, with a median of 25,421 during the study period. we further collected the daily bdi of different provinces and some municipalities in china between 20 july and 4 september. the overall trend of the bdi in available cities and provinces was similar. considering the diverse frequencies among internet users in different areas, the numbers of netizens were gathered to investigate the average attention as indicated by the average bdi in separated regions ( figure 3 ). the top five cities/provinces in terms of the average bdi were beijing, tibet, shanghai, tianjin, and hainan (table 1) . this map was created by the website of dituhui for free [36] . correlation analysis was carried out to explore potential case-related indicators resulting in the fluctuation of public attention. the associated analyses were performed of the bdi and cumulative fatality rate, bdi and cumulative case, bdi and cumulative death case, bdi and new reported case, and bdi and new reported death case. the results showed no correlation between all case-related influencing indicators and the bdi (spearman's rank correlation, p > 0.05). we also conducted the correlation analysis of the adjusted bdi and new reported case, and adjusted bdi and new reported death case, which took into account the time difference of america and china (the adjusted bdi being the mean bdi of two adjacent days). no correlation was identified between the adjusted bdi and case-related influencing indicators (spearman's rank correlation, p > 0.05). these results are detailed in figures 4a, and 5-7 . smi based on the total microblogs posted and forwarded daily for the keyword "ebola" on the sina microblog were also collected. the smi rapidly increased from 2153 on 29 july to its peak at 88,761 on 30 july 2014, declined to 14,510 with fluctuations on 7 august, and stayed above the primary level before 29 july. the smi reached another peak at about 45,860 on 11 august, which was lower than the first one, and gradually declined from 31,186 on 12 august to 2056 on 2 september (figure 2 ). the data scale ranged from 17 to 88,761 with a median of 7756 during the study period. to explore the potential case-related indicator resulting in the fluctuation of public attention, the correlation analysis was carried out. the associated analyses were performed of the smi and cumulative fatality rate, smi and cumulative case, smi and cumulative death case, smi and new reported case, and smi and new reported death case. no correlation was found between case-related influencing indicators and the smi (spearman's rank correlation, p > 0.05). correlated analyses were also conducted of the adjusted smi and new reported case, and the adjusted smi and new reported death case, which took into account the time difference of america and china (the adjusted smi being the mean smi of two adjacent days). no correlation was identified between the adjusted smi and case-related influencing indicators (spearman's rank correlation, p > 0.05). the results are detailed in figures 4b and 7-9 . in the spatial clustering analysis, the general analysis implied that there was significant spatial clustering for the average bdi of "ebola" in china. the global moran's i index = 0.23 (p < 0.01). a local spatial autocorrelation analysis was then performed to identify the hotspot through local getis's gi*. results of the local autocorrelation analysis showed that the only hotspot to "ebola" was tibet. furthermore, spatio-temporal clustering of public attention to "ebola" in the study time was carried out. the most likely cluster was identified in the 13 regions of china from 30 july-14 august 2014. the llr was 103,962.85 with the relative risk (rr) of 2.26 (p < 0.01). it included 13 cities/provinces, namely, tianjin, beijing, hebei, shandong, shanxi, liaoning, inner mongolia, henan, jiangsu, anhui, jilin, shaanxi, and shanghai. the details are shown in figure 10 . as no direct correlation was detected between case-related influencing indicators and bdi/smi, events possibly related to the fluctuation of public reaction were listed in figure 11 . our results suggested that a series of negative news reports might cause public concern and nervousness, and subsequently induced a raised public reaction as represented by the network retrieval behavior and the number of microblogs posted and forwarded. a case in point was the report concerning one woman who returned to hong kong from africa with the symptoms of ebola disease around 30 july in 2014, an event followed by the first peak of the bdi and smi. another event was the announcement made around 8 august by who, that the ebola outbreak was identified as an international public health emergency along with the second peak of the bdi/smi. on the other hand, positive news reports also influenced public attention. when the who spokesman deemed that chinese people did not need to panic for the epidemic of ebola in west africa, the bdi/smi dropped in the next few days from their first peak. later on, ruling out one suspected case in hong kong led to the decline after the second peak. these observations implied that negative news might increase public reaction while positive news might just do the opposite. as no direct correlation was detected between case-related influencing indicators and bdi/smi, events possibly related to the fluctuation of public reaction were listed in figure 11 . our results suggested that a series of negative news reports might cause public concern and nervousness, and subsequently induced a raised public reaction as represented by the network retrieval behavior and the number of microblogs posted and forwarded. a case in point was the report concerning one woman who returned to hong kong from africa with the symptoms of ebola disease around 30 july in 2014, an event followed by the first peak of the bdi and smi. another event was the announcement made around 8 august by who, that the ebola outbreak was identified as an international public health emergency along with the second peak of the bdi/smi. on the other hand, positive news reports also influenced public attention. when the who spokesman deemed that chinese people did not need to panic for the epidemic of ebola in west africa, the bdi/smi dropped in the next few days from their first peak. later on, ruling out one suspected case in hong kong led to the decline after the second peak. these observations implied that negative news might increase public reaction while positive news might just do the opposite. this paper reported the use of bdi and smi to identify the chinese public's reaction to the ebola outbreak in west africa from 20 july to 4 september in 2014. compared with common network tools, including content analysis, indices such as bdi and smi to investigate public attention possessed unique merits. firstly, these indicators could identify nearly all retrieved information to the specific keywords on the big data platform, while content analysis might only be implemented in limited samples. additionally, bdi and smi could mirror the public attention in a timely manner, whereas conventional methods might cause bias, and even be seriously affected by information deletion in websites. in our study, both indices consistently suggested the tremendous public concern to the ebola event in china. then, included in the study were the centralized tendency of bdi and average public attention to the ebola outbreak as indicated by average bdi in different cities/provinces of china. the highest bdi was observed in guangdong, the province with the largest number of internet users in china. this might be partly attributed to the opportunities brought about by china's booming economy, inducing large numbers of west africans coming to southeast coastal cities including guangdong, which might lead to overreaction by local netizens. additionally, the highest average attention to the ebola outbreak was found in beijing, the political center of china, along with comparable average bdi in shanghai, the economic center of the country. the direct flights from these cities to west africa might contribute to the increase of the average bdi. interestingly, comparable public attention to ebola was captured in tibet, an underdeveloped region, which might be explained by the unique geographical location. tibet has an underdeveloped transportation system, lower population density, and limited communication, all factors probably contributing to the more frequent web access to acquire information. therefore, more attention should be paid in tibet concerning public health education and rumor management. the spatio-temporal analysis had identified 13 clustered regions with higher average attention in china from 30 july to 14 august. during the same period, the daily bdi also indicated higher attention than other periods in china. thus, we thought that the 15 days after the peak of the bdi was a critical period for infectious diseases with imported risk and that necessary health education intervention should be adopted in these clustered regions. this paper reported the use of bdi and smi to identify the chinese public's reaction to the ebola outbreak in west africa from 20 july to 4 september in 2014. compared with common network tools, including content analysis, indices such as bdi and smi to investigate public attention possessed unique merits. firstly, these indicators could identify nearly all retrieved information to the specific keywords on the big data platform, while content analysis might only be implemented in limited samples. additionally, bdi and smi could mirror the public attention in a timely manner, whereas conventional methods might cause bias, and even be seriously affected by information deletion in websites. in our study, both indices consistently suggested the tremendous public concern to the ebola event in china. then, included in the study were the centralized tendency of bdi and average public attention to the ebola outbreak as indicated by average bdi in different cities/provinces of china. the highest bdi was observed in guangdong, the province with the largest number of internet users in china. this might be partly attributed to the opportunities brought about by china's booming economy, inducing large numbers of west africans coming to southeast coastal cities including guangdong, which might lead to overreaction by local netizens. additionally, the highest average attention to the ebola outbreak was found in beijing, the political center of china, along with comparable average bdi in shanghai, the economic center of the country. the direct flights from these cities to west africa might contribute to the increase of the average bdi. interestingly, comparable public attention to ebola was captured in tibet, an underdeveloped region, which might be explained by the unique geographical location. tibet has an underdeveloped transportation system, lower population density, and limited communication, all factors probably contributing to the more frequent web access to acquire information. therefore, more attention should be paid in tibet concerning public health education and rumor management. the spatio-temporal analysis had identified 13 clustered regions with higher average attention in china from 30 july to 14 august. during the same period, the daily bdi also indicated higher attention than other periods in china. thus, we thought that the 15 days after the peak of the bdi was a critical period for infectious diseases with imported risk and that necessary health education intervention should be adopted in these clustered regions. further analyses were performed to explore the correlation between case-related influencing indicators and bdi/smi. contrary to our expectation, no existing statistical correlation was established between case-related influencing indicators and bdi/smi, which was discrepant with our previous findings [18] and other studies [7, 37] . this might be attributable to the fact that ebola epidemics did not occur in china. the public, justifiably, pays more attention to the disease-related data when the outbreak takes place in their location. otherwise, the public focuses more on the news reports and the notices from the authorities. the assumption was partly testified by the observation that the peaks of bdi and smi were usually accompanied with some negative news reports and the decline of the indices followed the positive reports. additionally, the appearance of a suspected ebola case in hong kong might serve as the vital reason for the first peak of bdi and smi. moreover, the particular geographic location and administrative position of hong kong should be considered as influencing factors of the public's attention. previous public health experience, such as sars, indicated that no individual country could single-handedly prevent and protect itself from public health threats. thanks to the worldwide spread of diseases coupled with the easy access to network information, communicable diseases such as ebola, did not only affect the locations of the outbreak but also could cause panic or even major public health events in non-endemic areas. in the public health field, increased internet searching implied the tremendous need of ebola-related preventive knowledge to the public. that is to say, high attention areas could be more susceptible to rumors or false online information if public health authorities did not address the emerging public concerns in a timely manner. to handle the demand warranted by this emerging situation, traditional epidemiological methods and public health education modes were obviously inadequate. online surveillance, with the aid of opinion indices, may have sensitively detected the emergence of serious infectious diseases at their initial stage via the big data platform in previous studies, which could buy time for controlling outbreaks of these diseases and reducing the risk of transmission to humans [28, 38, 39] . that is to say, this modality, different from classic epidemiology questionnaires and telephone interviews developed to know the public reaction after the disease outbreak, enables surveillance beforehand and saves health resources. more importantly, online surveillance can reflect public reactions to emergency public health events and disease outbreaks in a timely manner so that public health interventions can be implemented during epidemic crises to avoid deterioration. additionally, compared to the classical health education mode aimed at high-risk populations in high morbidity regions, our results implied a need for a shift in health education methods to a public-attention-based mode, especially in non-epidemic areas, to identify the regions of high attention. this new mode should be based on the findings of opinion monitoring through public reaction indices like bdi and smi. different interventions, in the future, should be adopted for areas with different indices, more attention being targeted at high-index areas in terms of public propaganda and education. a majority of model studies of the two historical outbreaks of ebola in the democratic republic of congo and uganda involved time series analysis [40] [41] [42] . further investigation was carried out to assess the dynamics of ebola in the aspect of the different transmission sources [43] . however, owning to the complicated influencing factors involved in network transmission dynamics, limited research time and medical informatics, an online surveillance model to identify the public concern about ebola has not been established. several limitations are mentionable for this study. (1) considering the deleted ebola-related blogs, the average smi was not calculated in our analysis, and the average attention, spatio-temporal distribution characteristics as indicated by smi in different regions were not verified; (2) the in-depth correlative analysis was not performed because of the absence of clinically characteristic data and detailed distribution information; (3) our study only focused on chinese websites and netizens from chinese mainland, which could not depict the public reaction from internet users of websites in english or other languages, for instance, twitter and facebook; (4) our findings had not yet been directly applied to identify public health emergency. meanwhile, these findings had not been evidenced with other search engines; (5) due to lack of data, we did not analyze the association of the public attention with the migration population from africa to china and the direct flights from west africa to china; (6) although limited adjustment used in our study, the potential time lag was not considered in our study; (7) traditional media such as tv, newspapers might track well with ebola case data whereas these were not considered in this study. this digital epidemiologic study suggested that online surveillance reflected significant attention in the chinese population to the ebola outbreak, and that bdi and smi were rapid and efficient in identifying and evaluating public reactions. we also identified the regions that paid significant attention to the outbreak. additionally, compared to domestic outbreaks of epidemic diseases, evd, which had not occurred in china, might affect the public reaction through positive and negative news reports. in sum, confronted with the risk of cross-border transmission of the infectious disease, online surveillance based on big data platforms might be an innovative approach to purposefully perform public communication and health education, which was helpful to avoid the occurrence of public panics 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using twitter data early detection of an epidemic erythromelalgia outbreak using baidu search data monitoring influenza epidemics in china with search query from baidu available online: //news.baidu.com/?tn=news notes on continuous stochastic phenomena satscan user guide for version 9.0; department of ambulatory care and prevention the international ebola emergency correlation between reported human infection with avian influenza a h7n9 virus and cyber user awareness: what can we learn from digital epidemiology? media and public reactions toward vaccination during the "hepatitis b vaccine crisis" in china assessing cyber-user awareness of an emerging infectious disease: evidence from human infections with avian influenza a h7n9 in zhejiang, china a likelihood-based method for real-time estimation of the serial interval and reproductive number of an epidemic understanding the dynamics of ebola epidemics estimation and inference of r0 of an infectious pathogen by a removal method potential for large outbreaks of ebola virus disease this study was partly supported by zhejiang provincial medical and health (2016151967 key: cord-271887-blwrpf38 authors: sampa, masuda begum; hoque, md. rakibul; islam, rafiqul; nishikitani, mariko; nakashima, naoki; yokota, fumihiko; kikuchi, kimiyo; rahman, md moshiur; shah, faiz; ahmed, ashir title: redesigning portable health clinic platform as a remote healthcare system to tackle covid-19 pandemic situation in unreached communities date: 2020-06-30 journal: int j environ res public health doi: 10.3390/ijerph17134709 sha: doc_id: 271887 cord_uid: blwrpf38 medical staff carry an inordinate risk of infection from patients, and many doctors, nurses, and other healthcare workers are affected by covid-19 worldwide. the unreached communities with noncommunicable diseases (ncds) such as chronic cardiovascular, respiratory, endocrine, digestive, or renal diseases became more vulnerable during this pandemic situation. in both cases, remote healthcare systems (rhs) may help minimize the risk of sars-cov-2 transmission. this study used the who guidelines and design science research (dsr) framework to redesign the portable health clinic (phc), an rhs, for the containment of the spread of covid-19 as well as proposed corona logic (c-logic) for the main symptoms of covid-19. using the distributed service platform of phc, a trained healthcare worker with appropriate testing kits can screen high-risk individuals and can help optimize triage to medical services. phc with its new triage algorithm (c-logic) classifies the patients according to whether the patient needs to move to a clinic for a pcr test. through modified phc service, we can help people to boost their knowledge, attitude (feelings/beliefs), and self-efficacy to execute preventing measures. our initial examination of the suitability of the phc and its associated technologies as a key contributor to public health responses is designed to “flatten the curve”, particularly among unreached high-risk ncd populations in developing countries. theoretically, this study contributes to design science research by introducing a modified healthcare providing model. beginning at the end of 2019, the covid-19 outbreak was declared a pandemic by who on 11 march 2020 [1, 2] . the main symptoms of covid-19 are fever, cough, sore throat, and respiratory complications [3] . respiratory infections can be transmitted through droplets of different sizes, and according to current evidence, the covid-19 virus (sars-cov-2) is primarily transmitted between people through respiratory droplets (with a particle size of >5-10 µm) when a person comes in close contact (within 1 m) with someone who has respiratory symptoms [4, 5] . moreover, other contact routes, such as the immediate environment around the infected person, may also cause transmission of the virus [6] . in the case of cluster pneumonia of unknown etiology, health workers are recommended droplet and contact precautions when caring for patients and airborne precautions for aerosol-generating procedures conducted by health workers [7] . sars-cov-2 became a pandemic virus due to a multitude of factors such as the early spread of the virus by asymptomatic carriers, uncontrolled social behaviors, and insufficient personal protective equipment (ppe), and both the advanced and developing medical systems appear overwhelmed. public health experts are working at relieving pressure on healthcare facilities so resources can be focused on covid-19 patients. the crisis is even more threatening for developing countries with large underserved populations. as cases multiply, governments, irrespective of developed and developing countries, restricted "nonessential" services by declaring a state of emergency not due to the fear of contagion but as a procedural protocol in order to contain the virus by mandating social distancing. the bangladesh government imposed a nationwide lockdown since 26 march 2020 to curb the spread of the novel coronavirus [8] . bangladesh with its 165 million inhabitants and a density of 1265 people per sq. km is in a great crisis as the outbreak could spread further. in bangladesh, 70% of people live in rural areas where medical facilities are almost absent. recently, the most serious problems in bangladesh are the lack of personal protective equipment (ppe) for doctors or its low quality as well as too many people staying in close proximity and sick people hiding their symptoms. the situation has become more vulnerable as there are an estimated 5.2 healthcare workers (doctors and nurses) available per 10,000 people [9] . as of 13 june 2020, at least 78,052 people have been infected [10] among which more than 4% are the healthcare workers, whereas 2.5% healthcare workers are affected worldwide [11] . most private medical facilities in bangladesh are turning away patients with other health issues amid the coronavirus outbreak even though the government has issued a circular threatening of the annulment of their license to operate [12, 13] . this has deprived many non-covid-19 patients of needed treatment, resulting in death from cough, fever, breathing difficulties, and diarrhoea [14] . older people and people with noncommunicable diseases (ncds) such as cardiovascular disease, diabetes, chronic respiratory disease, and cancer appear to be more vulnerable to becoming severely ill with covid-19. the covid-19 mortality rate in china with the presence of one or more preexisting ncd conditions is represented in table 1 . it shows that almost every fatality is associated with preexisting ncds, while no preexisting medical conditions had a fatality rate of only 0.9%. therefore, preexisting ncd-related illnesses increase the risk of death. according to data from italy, almost 99% of deaths from covid-19 were related to preexisting diseases, and of these, hypertension accounted for 75%. as such, the public health impact of covid-19 will include a significant number of ncd-associated mortalities. the control strategy of large-scale and prolonged lockdowns is bound to increase the morbidity risk for those living with ncds even more. disrupting regular exercise and monitoring check-ups and adding to mental stress may further undermine immune systems among such patients and impact morbidity and mortality rates. many researchers are focusing on the effect of covid-19 on mental health [16] , while there is growing public awareness of the association of ncds with covid-19 mortality rates, and hence, there is also the need to highlight the negative impact of uncontrolled ncds among populations over the long-term. remote healthcare services (rhs) appear well-suited to this purpose, providing ncd patients in remote locations access to critical monitoring services without increasing risk of infection by visiting a hospital. portable health clinic (phc) services, which is an rhs, have proven efficacy in providing necessary information and preventive measures for people without access to healthcare facilities [17] [18] [19] . phc systems have been developed in a preventive healthcare approach with a special focus on noncommunicable diseases. it appears necessary to modify the strategy-of-use of the phc to better respond to the healthcare management needs of ncd patients in an emergency created by the pandemic, particularly in developing countries. in a lockdown situation, this platform can be effectively used to control and manage patient triage, thus relieving pressure on hospitals and healthcare facilities. challenges of remote healthcare systems during an emergency like disasters, pandemics, etc. implies unique challenges to healthcare delivery [20] . in the context of developing countries, the scenario of using ehealth technology is completely different, especially for rural people who are typically low health-literate and are more at risk for ncds. nearly every one of the 205 countries affected by covid-19 has instituted social distancing measures. many, including bangladesh, china, france, india, italy, korea, pakistan, singapore, spain, taiwan, and thailand, have enforced large-scale lockdowns to avoid spikes in cases and to buy time to set up appropriate responses. during such emergencies, rhs platforms assume even greater relevance, especially for ncd patients who may be turned away from hospitals treating acute patients. the real challenge is providing primary care services to ncd patients within the context of social distancing. leveraging the phc and attendants of ehealth technologies already successfully deployed in support of rural and remote patients makes this challenge surmountable [21] . some previous research already confirms the effectiveness of ehealth in emergency response situations, primarily for urban areas in developed countries. however, healthcare planners agree on the need to monitor ncd patients in rural populations of developing countries in the pandemic situation [22] . however, some questions remain unanswered: how to redesign rhs such as the phc platform to achieve the goal more effectively in a pandemic situation like covid-19? • how to ensure coverage of underserved rural populations who have comparatively less access to healthcare facilities? • how can the rhs platform like phc be adapted to accommodate emergency response situations like covid-19? therefore, this paper tries to answer the above research questions and presents the process of designing and developing an rhs based on the general requirements to tackle communicable diseases for allowing both covid-19 patients and non-patients in bangladesh. no previous study to date has examined the scopes of designing and developing an rhs based on the general requirements to facilitate primary screening and triaging covid-19 and primary healthcare services for preventing covid-19 and controlling ncds. however, such screening and triaging covid-19 by an rhs is important for cost-effective check-ups and for reducing the risk of transmission for unreached communities with various needs. extensive research works are conducted only on the hospital information systems to construct the hospital management information system of infectious diseases. to improve the efficiency and level of infectious disease management of the hospital, those research investigate their risk factors, the rules of emergence, and the control measures for infectious disease management [23] [24] [25] . however, a challenge during the pandemic in progress is to identify the determinants underpinning the spatial and temporal patterns of the epidemic for making preventive strategies by the decision-makers [26] . along with these, health services for reducing transmission and triaging is also a necessity. the provision of effective ehealth services likely enhances patients' own abilities to manage their ncds during the covid-19 outbreak, especially in places where lack of sanitation or availability of ppe increases the risk of contagion. more importantly, ehealth solutions minimize direct contact between the public and healthcare providers and thus promote social distancing without affecting the strength of patient support [27] . consultancy over video communications has become useful for the delivery of preventive and consultation services. remote consultancy over phone or video communication has already shown social, technical, and commercial benefits for the management of ncds. the important benefits of telemedicine for the health systems for handling covid-19, especially on monitoring, surveillance, and detection and the potential for machine learning and artificial intelligence, have been focused very well in many articles starting from one of the very first ones but an opinion from the patients' side is not reported well yet, though it is of importance to draw attention to the ongoing importance of patient involvement when it comes to urgent ehealth solutions for covid-19 [20, 28, 29] . during public health emergency like covid-19 pandemic, the digital infrastructures remain intact and doctors can still be in touch with patients but yet no large-scale telemedicine services for monitoring acute and chronic patients' health status and for allowing continuity of care have been considered in the highly affected countries like italy [30] . with the importance of ehealth becoming formally recognized, several governments are reinterpreting regulations to enable remote medical services by licensed practitioners. the governments are supplementing healthcare budgets to counter the impact of the pandemic, such as the medicare benefits schedule [31] and medicare in the united states, expanding the coverage range for the testing and treatment of covid-19 without subscribers' expense [32] . this allocation can support a range of ehealth services during the covid-19 phase, enabling more people to receive healthcare at a significantly lower cost compared to hospital-centric services, including telehealth consultations with general practitioners and specialists. doctors or nurses manning the ehealth service will be able to guide patients over video communication. healthcare systems have had to adapt rapidly to the evolving situation for three main reasons: firstly, there is a need to triage and treat large numbers of patients with respiratory illness [27] ; secondly, there is a need to protect the healthcare workforce to ensure they can treat the sick [33, 34] ; and thirdly, we need to shield the elderly and most vulnerable from becoming infected [35] . this study used the who guidelines to tackle covid-19 as a theoretical basis of the designed service to satisfy the general requirements in the service and also followed the information system research (isr) framework to involve the people in the service design and evaluation phase. the guidelines of who explains the key components of required healthcare services for covid-19 disease. according to who guidelines [36] [37] [38] , the following are the key components of required healthcare services for covid-19 disease: who recommends screening and isolation of all patients with suspected covid-19 at the first of point of contact with the health care system, such as outpatients and emergency departments/clinics. early detection of suspected patients allows for the timely initiation of appropriate prevention and control measures [36, 37] . isolation is a long-established containment response that is designed to prevent further transmission from an individual suspected of exposure to a contagious disease. suspected infectious individuals not in immediate need of medical attention may be effectively quarantined at home instead of a hospital. in pandemics, it is often impossible to accurately identify cases and carriers of the disease, and hence, the closure of premises such as schools, markets, theatres, etc. are declared to physically limit further transmission. physical contact, direct or indirect, is the most important channel for the transmission of infectious disease. contact tracing involves identifying everyone who may have had exposure to an initial case and tracing it to all possible contacts. the privacy of the patients' needs to be maintained to avoid any sort of discrimination to the patient or his/her family. to design a useful information system-based healthcare service based on the who guidelines, we resorted to following the directions and guidelines as proposed in information system research (isr) framework [39] . theorizing in design science research (dsr) is different than other types of science. it has two general modes of dsr activity and theorizing: (i) the interior mode, where theorizing is done to formulate a theory for design and action with the prescriptive statement about the way to design the artifact, and (ii) the exterior mode, where analyzing, describing, and predicting are done on what happens to the artifacts in the external environment [39, 40] . we designed our phc following the theories of the dsr framework. in phc architecture, all artifacts or medical devices are organized following the prescriptive roles provided by who. a portable health clinic (phc) system (shown in figure 1 ) has been developed as an rhs system for the unreached communities with a special focus on noncommunicable diseases [41, 42] . a health worker visits a patient with the phc box to measure vital information and to upload the data with the medical history of the patient to an online server by using the gramhealth client application. the remote doctor gets access to this data and makes a video call to the patient for further verification. finally, the doctor creates an online prescription and preserves it on the online server under the patient's profile. the health worker accesses the system, prints the prescription from the server, and passes it to the patient with detailed explanation instantly. the whole process takes about 15 to 30 min per patient. the phc system introduces a triage system to classify the subjects in four categories, namely, (i) green or healthy, (ii) yellow or suspicious, (iii) orange or affected, and (iv) red or emergent, based on the gradual higher risk status of health. the subjects under orange and red who are primarily diagnosed as in the high-risk zone need a doctor's consultation. phc was initially designed to provide primary health screening services to the unreached community in remote areas. it is time to test its compatibility in emergencies to lessen the mortality and morbidity due to ncds in developing countries. the prevalence of ncds such as diabetes, blood pressure, and chronic diseases may rise due to mental stress, fear, income loss, physical inactivity, and more food consumption and during the lock-down situation at home. in the spread of covid-19, people can neither go out for physical exercises such as morning or evening walking nor visit a hospital for ncds during the lockdown situation. this phc system is modified to be used for addressing communicable diseases like covid-19. the steps are explained in figure 2 . at first, a potential patient can place a call to the nearby health worker. the health worker can ask questions as per the standard protocol. a patient with a smartphone can fill in a self-check form through the web, which ultimately goes to the nearby community health worker. the health worker checks the data and visits the patient with the phc box for clinical measurements. although the original phc box contains various medical sensors, only covid-19-related sensors will be used. these are (i) thermometers (omron) for measuring body temperature; (ii) pulse oximeters (oxi meter) for measuring oxygenation of blood (spo2); (iii) digital blood pressure (bp) machines (a&d) for measuring blood pressure, pulse rate, and arrhythmia; and (iv) glucometers (terumo) for measuring blood glucose in the case of diabetic patients. after taking the measurements, the triage algorithm at the phc client device will run to classify the patient into four categories. table 2 shows the proposed logic set for covid-19. the orange and red marked patients will be connected with the remote doctor. the doctor will have a video conversation with the patient for further verification of their status. phc was initially designed to provide primary health screening services to the unreached community in remote areas. it is time to test its compatibility in emergencies to lessen the mortality and morbidity due to ncds in developing countries. the prevalence of ncds such as diabetes, blood pressure, and chronic diseases may rise due to mental stress, fear, income loss, physical inactivity, and more food consumption and during the lock-down situation at home. in the spread of covid-19, people can neither go out for physical exercises such as morning or evening walking nor visit a hospital for ncds during the lockdown situation. this phc system is modified to be used for addressing communicable diseases like covid-19. the steps are explained in figure 2 . at first, a potential patient can place a call to the nearby health worker. the health worker can ask questions as per the standard protocol. a patient with a smartphone can fill in a self-check form through the web, which ultimately goes to the nearby community health worker. the health worker checks the data and visits the patient with the phc box for clinical measurements. although the original phc box contains various medical sensors, only covid-19-related sensors will be used. these are (i) thermometers (omron) for measuring body temperature; (ii) pulse oximeters (oxi meter) for measuring oxygenation of blood (spo 2 ); (iii) digital blood pressure (bp) machines (a&d) for measuring blood pressure, pulse rate, and arrhythmia; and (iv) glucometers (terumo) for measuring blood glucose in the case of diabetic patients. after taking the measurements, the triage algorithm at the phc client device will run to classify the patient into four categories. table 2 shows the proposed logic set for covid-19. the orange and red marked patients will be connected with the remote doctor. the doctor will have a video conversation with the patient for further verification of their status. note: "3 days *" should be replaced by "1 day" and "4 days **" should be replaced by "2 days" for 65 years old or older patients with ncds such as diabetes, heart failure, copd, etc. who are using hemodialysis, immunosuppressants, and anticancer agents. no. 8, spo 2 is optional. unlike the conventional phc for ncds, the local health worker collects the primary symptoms of a patient through a standard questionnaire. if the patient is identified as a potential patient, the phc covid-19 box will be sent to the patient's home temporarily together with an operation manual so that they can check themselves under the guidance of the health worker. this will save both parties from infection. now, if a patient is identified as a potential covid-19 carrier by this primary screening using the triage system, as shown in table 2 , the patient will be immediately advised to see the nearby hospital for further investigation and follow-up as needed. otherwise, the health worker will provide a guideline to stay safe at home. since the community health workers are already known to the patients, patients feel more comfortable and safer under their guidance. the privacy of sensitive information of patients will be protected and secured because it is required by an increasing body of legislative provisions and standards [43] . table 3 shows the functionalities of a portable health clinic to meet general requirements. the high-risk potential patients are dealt with by the hospital, and they can go under treatment or isolation in hospital or home quarantine as per the result of the polymerase chain reaction (pcr) test. on the other hand, the health worker can also guide the remaining patients if they need home quarantine based on the primary screening. thus, the spread of the highly contaminating covid-19 can be efficiently controlled with the utilization of local health workers. in phc service policy, the health workers are usually from the respective localities. therefore, they know their communities and are in a position to trace with ease and speed those exposed to direct or indirect contact. since the phc reaches people at their doorstep, only those referred by the doctor online need to go to the hospital. this process helps maintain privacy as well. in its existing functional form, deploying the phc and related rhs technologies for socially distanced populations during a public health emergency, such as the covid-19 pandemic, is beneficial in reducing the risk of transmission to frontline healthcare professionals. moreover, findings indicate that frontline medical staff experience heightened levels of stress when coming into direct contact with covid-19 patients. the impact of stress on cardiovascular function is well-established experimentally, independent of known risk factors associated with ncds [44] [45] [46] [47] [48] . the phc service may create an effective physical separation between the caregiver and the patient without materially diminishing the quality of care or the reliability of care management responses. in bangladesh, medical staffs such as doctors, nurses, and volunteers who are fighting the coronavirus are being socially excluded, driven from the flats or rooms they rent and banned from his or her buildings. official reports from china indicate that 71.5% of the frontline healthcare providers treating covid-19 patients experience high levels of mental stress. also, 50.4% show signs of depression, 44.6% exhibit anxiety states, and 34.0% suffer from insomnia [49] . fatalities among healthcare professionals reported from china, korea, pakistan, and the united kingdom may well be causally linked to reduced efficiency as a result of anxiety-induced stress as well as lack of sleep and depressive states [50] . in japan too, healthcare staff treating the new covid-19 patients report higher mental stress compared to routine care assignments [51] . phc and attendant rhs technologies can create the required physical distancing that increases the sense of safety among medical staff and is likely to reduce stress. the most conclusive method for determining covid-19 infection utilizes pcr techniques, which require running the patients' dna sample through specialized equipment in a laboratory environment. at present, therefore, the remote diagnosis of covid-19 is not possible. however, the phc can reliably triage individuals presenting with symptoms associated with covid-19 using a checklist released by the centers for disease control (cdc) [52] . this way, the phc can help stem the unbridled flow of concerned citizens to healthcare facilities. this reduces the burden on already overextended healthcare staffs and facilities but still allows the concerned citizen to receive reliable well-being information from the phc worker and retains human contact essential to medical care [53] . while conventional telemedicine applications only offer live contact with a medical professional, the phc system incorporates diagnostic testing for screening ncds and nutritional status. a unique aspect of the phc system is its built-in algorithm that compares up to 17 diagnostic parameters in real-time and generates a triage plan that is relayed to the doctor manning the telemedicine call-point. this eliminates any interference by the phc worker attending the patient by providing the attending doctor with direct control over patient management decisions. phc can reduce the risk of transmission to frontline healthcare workers, can reduce psychosocial stress on frontline healthcare staff, and can optimize healthcare resources for more patients who need them most. as part of its covid-19 response, the united states congress has promulgated public law no: 116-123, which provides for the temporary removal of restrictions on telehealth services for medicare beneficiaries [54] . these developments indicate that the phc system can be adapted to regulatory and best practice parameters, either by securing the clinical role of the licensed medical practitioner within the delivery model or by modulating the level of service provision in ways that do not impinge on best practice guidelines. in summary, the phc, even in its present form, can be effectively deployed to eliminate the risk of transmission among frontline healthcare staff and to contribute significantly towards reducing pressure on healthcare services and resources. with considered realignment of its technical configuration, the phc can be deployed as an ancillary resource supporting large-scale public health emergencies, exemplified by the covid-19 pandemic. the phc system can be effective in providing the following: (1) a primary-level screening mechanism that can demonstrably reduce the burden of ncd-related complications among covid-19 patients and that can directly contribute to the reduction of the incidence of ncds by timely advice and treatment; (2) a primary healthcare service platform for underserved populations in remote regions of developing countries and now mature enough to be adapted to respond to large-scale public health emergencies such as covid-19 to impact the reduction of associated mortality and morbidities; (3) a reliable platform for early detection of ncds and associated comorbidities among target populations and for effectively contributing to a tangible reduction in the burden of disease; (4) a key ancillary mechanism for controlling patient-to-caregiver transmission of covid-19 by creating physical distance between all except diagnosed cases and attending clinical staff; (5) evidence for health authorities to choose ehealth technologies, such as a phc service, to provide primary healthcare services simultaneously for covid-19 and ncds, including video consultation with physicians, preventive health education, and awareness at the grassroots, and to encourage well-being behaviors; (6) an effective outreach tool for controlling ncds and for decreasing the burden of disease on the target community; (7) a new approach to responding to large-scale public health emergencies like covid-19 and to contributing directly to building adaptive resilience among populations at risk. if the paraprofessional worker visiting homes is not well-trained in self-disinfection or access to disinfection facilities is not available between one visit and another, then the contagion can be transmitted by the paraprofessionals. this is indeed what has happened in nursing homes and assisted living facilities across the united states and japan. this may potentially facilitate the spread of the virus rather than containment. however, the main challenge for deploying the phc during large-scale public health emergencies such as covid-19 is ensuring that the patient is amenable to self-checking, guided by the phc health worker. initial screening requires 3 simple tests for which a manual is provided. health workers can also guide online. another challenge is to ensure access to a facility equipped for a definitive diagnostic test, such as the pcr test in the case of covid-19 so that the diagnosed patient can be triaged to a hospital for treatment. this paper touched upon relevant current and future public health implications arising from the covid-19 outbreak. it provided an overview of how several centralized initiatives have emerged to tackle the situation. our initial examination of the suitability of the phc and its associated technologies as a key contributor to public health responses designed to "flatten the curve", particularly among unreached high-risk ncd populations in developing countries, indicates the strong possibility of affirmative impact. in this paper, we redesigned the existing phc for the containment of the spread of covid-19 as well as proposed corona logic (c-logic) for the main symptoms of covid-19, such as fever, cough, sore throat, respiratory complications, etc. through modified phc service, we can help people to boost their knowledge, attitude (feelings/beliefs), and self-efficacy to execute preventative measures. knowledge about covid-19 means what are the causes, sources of infection, symptoms, ways of transmission, and prevention. as it is a new disease and has become a pandemic within a short period, there is a lack of knowledge, especially among rural people. therefore, it is very important to fill these knowledge gaps timely to prevent and control the spread, which will lead to better practice for prevention and control of the contagious disease. portable health clinics introduce an affordable, usable set of sensors with the transmission facility to convey clinical data to the remote doctor so that the doctor can make an accurate decision. phc with its new triage algorithm (corona logic) classifies the patients on whether the patient needs to move to a clinic for a pcr test. as mentioned in the previous sections, the new model can reduce the risk of transmission and psychological stress on frontline healthcare staff and can optimize healthcare resources for more patients who need them the most. the consultancy service is mostly on introducing nearby hospitals, providing doctor appointments, and interpreting prescriptions. the salient point is that the same model can work in other countries both rural or urban to bring similar benefits for an emergency to reduce the transmission of diseases. therefore, governments and other healthcare sectors can take initiative to use rhss such as the phc service, to provide primary healthcare services simultaneously for triaging susceptible covid-19 and for supporting ncd patients isolated in various geographical locations. theoretically, 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stressed heart. insights from studies in rodents study finds psychological burden in frontline medical workers. 2020. available online medical workers face coronavirus mental health crisis from fine to flailing: rapid health declines in covid-19 patients jar doctors and nurses. the japan times criteria to guide evaluation and laboratory testing for covid-19 keeping the human touch in medical practice. lippincott williams and wilkins coronavirus preparedness and response supplemental appropriations act this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license acknowledgments: global communication centre in grameen communications provided essential covid-19-related information on bangladesh. the authors declare that there is no conflict of interest. key: cord-013385-6nq4yzvz authors: yang, fan; jiang, yao title: heterogeneous influences of social support on physical and mental health: evidence from china date: 2020-09-18 journal: int j environ res public health doi: 10.3390/ijerph17186838 sha: doc_id: 13385 cord_uid: 6nq4yzvz employing a national representative survey (the china labor-force dynamics survey 2016, clds2016) data (n = 14246), this paper examines the heterogeneous influences of social support on individual physical and mental health in china. social support is characterized by four dimensions: emotional support, tangible or instrumental support, interaction or exchange support, and community support. physical health is measured by self-rated health and body mass index (bmi), while mental health is measured by depression, hopelessness, failure, fear, loneliness, and meaninglessness. the results indicate that different dimensions of social support have heterogeneous effects on individual physical and mental health. specifically, the correlation between emotional support and individual physical health is not significant, but emotional support is significantly related to some mental health variables. tangible or instrumental support is significantly related to individual self-rated physical health but not to bmi or mental health. interaction or exchange support is significantly correlated with individual self-rated health and some mental health variables. in general, there are significant correlations between community support, and individual physical and mental health. the results also suggest that the influences of social support on physical and mental health of individuals at different ages (<60 years and ≥60 years) are heterogeneous. the results of this study provide direction for the dimension selection of social support to promote individual health. individuals are embedded within a society, and social support affects multitudinous aspects of individuals, including health. individual good health is a valuable aspect of life and social development, and the relationship between social support and individual health is receiving increased academic attention [1] [2] [3] . while social support can affect both individual physical and mental health [4] , it is unclear which is more closely related to social support. this paper investigates whether there is any heterogeneity in the effects of multidimensional social support on physical and mental health. further, the influences of multidimensional social support on health at various ages are investigated. answers to the above issues have not reached academic consensus, as evidenced by a literature review conducted in this study. social support refers to the care and support that social members can receive from others [5] . it can improve individual social adaptability [6] and is a potential social factor affecting individual health [7] . as early as the 1940s, the world health organization (who) presented a multidimensional definition of health, which was a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity [8] . as can be seen from this definition, health is a multidimensional concept, including not only physical health but also mental health. from 1990 to 2016, the burden of mental disorders globally was enormous, with an estimated 1.1 billion population affected by mental or substance use disorders [9] . a growing body of literature has demonstrated that the amount and quality of social support from relatives, friends, neighbors, and the community are pivotal factors in positively affecting a person's physical and mental health [10] [11] [12] and acts as a form of prevention against harmful behaviors and distressing emotions [13] . social support is one of the well-documented factors influencing physical health outcomes [14, 15] . the most compelling evidence on the physical health outcomes of social support is a meta-analysis of the existing literatures that found that social support significantly lowers the risk for mortality [16] . studies have shown that, the stronger a person's social support network, the more likely they are to obtain more wealth, higher social status, as well as medical resources to prevent diseases and to maintain good physical health [17, 18] . these individuals with strong social support networks can use these supports to receive good treatment when faced with disease [19] . conversely, those who do not have much social support may not have enough resources to remain healthy. when they are suffering from disease, it is also challenging for them to obtain good medical resources or to pay for treatment, which causes their health to further deteriorate [19] . previous studies have argued that social support is a factor affecting mental health, and these studies have shown that there are two primary ways that social support affects individual mental health [20, 21] . the first is main (or additive) effects of social support on health [22] . it is argued that social support has a generally beneficial effect. when the amount of social support increases, the level of individual mental health improves [22] . the second is stress-buffering (also termed moderating or interactive) effects of social support on mental health [23] . in this case, research suggests that social support only plays a role in mental health under stress. social support minimizes the impacts of stress from negative life events on psychological health [24] . however, empirical studies do not reach a consensus on the two ways that social support affects individual mental health. some studies have found evidence of the main or stress-buffering effect of social support on health [25] [26] [27] [28] . for example, a study on the mental health of incarcerated offenders showed that perceived social support helps safeguard the mental health of offenders [29] . further, a study of college students with disabilities showed that both the main and buffering effects of social support effectively relieve their financial pressure [30] . conversely, other studies have shown that the effect of social support on mental health is not significant [31, 32] . for example, a five-year longitudinal study has found that social support does not uniformly mitigate the effects of stressors on health for individuals living in urban poverty [33] . in conclusion, previous researchers have mainly studied the correlations between social support and health from the two perspectives of physical and mental health [34, 35] . these two perspectives should be compared, but the results of the presented works may be incomplete if analyzed from one perspective alone. social supports are multifaced [36, 37] . previous studies mainly used functional and global functional concepts to measure it. functional social support refers to the functions performed for individuals by significant others or secondary group members. the most frequently noted functions are emotional, informational, and instrumental assistance [36] . the measurement of global functional social support combines the functional social supports mentioned above into a single index [38] . in this paper, under the consensus that total social support influences individual health, we do not intend to combine varying functional social supports into a single index. instead, we investigate the heterogeneous influences of various functional social supports on individual physical and mental health. based on previous studies, we divided social support into four dimensions: emotional support, tangible or instrumental support, interaction or exchange support, and community support [39, 40] . emotional support plays a protective role in individual physical and mental health. for physical health, studies have demonstrated that individuals who lack emotional support are twice as likely to commit suicide and to suffer from myocardial death and cardiac disease compared to individuals who have emotional support [41, 42] . for mental health, emotional support is associated with a reduction in psychological distress and anxiety [43, 44] . tangible or instrumental support refers to giving individuals practical support, such as financial assistance [45] . effective tangible or instrumental support can help individuals maintain their general health or recover from illness [22] . from the perspective of psychology, productive interaction or exchange support involves having people who can discuss important personal issues. not only does this release individual anxiety and pressure but also this kind of support enables collaborative solutions to be reached. [46] . in china, with the improvement of rural and urban community management, the grassroots community plays an increasingly vital role in people's lives, which includes their health [47] . members of a community often form an intimate group. through mutual acquaintance, trust-building, and mutual assistance, they can become a source of social support for each other [10] . in terms of specific measurement indicators, the number of friends a person has is used to measure emotional support [48] . tangible or instrumental support is commonly measured by the number of people that an individual can borrow money from [49, 50] . interaction or exchange support is usually measured by the number of people who can discuss important personal issues together [51] . community members' familiarity, trust, and mutual assistance is used to measure the level of community support [52] . in addition to social support, individual health is also affected by other factors. gender, age, religion, marital status, health habits, and socioeconomic status are individual characteristics that are intimately related to health [53] . gender is a widely documented determinant of health. studies have indicated that feminine and undifferentiated gender roles are related to poor self-rated health and that the average health status of men is better than that of women [54] . it is recognized that individual health declines with age [55, 56] . regarding an individual's marital status, single people experience higher mortality and poorer health than married people [57] . studies on the link between religion and mental health have consistently revealed that spiritual people turn to their religious beliefs as one of the first resources when faced with traumatic life events or significant stressors [58, 59] . multiple studies of the factors influencing individual health have found compelling evidence concerning damaging health habits and behaviors such as smoking, drinking, and beneficial habits like regular physical activity [60] . an individual's socioeconomic position involves the indicators of income, occupational prestige, and attaining education, which are intimately linked to health care accessibility and health literacy [61, 62] . studies have consistently documented that individuals with high incomes and good education are healthier than poorer, less educated people [63] [64] [65] . apart from individual characteristics, the environment in which the person is located also influences individual health. a growing, global body of literature has focused on the negative impacts of environmental pollution, especially air pollution, on individual health [66] [67] [68] [69] [70] [71] . studying the health of chinese people has great social significance for both the general public and for the chinese government. first, according to data released by the chinese government, about 40% of the poverty experienced by china's rural population is caused by health problems [72] . this means that, with increased social support, improving people's health can play a role in alleviating poverty. second, there was a large seasonal and internal migrant population in china, consisting of around 250 million people at the end of 2019 [73] . they migrated from rural areas where their household was registered to urban places to seek work. in this process, whether social support is available may affect individual income as well as health. additionally, the first blue book of chinese mental health (2017-2018), released by the chinese academy of sciences institute of psychology, shows that an increasing number of individuals experience psychological problems in china [74] . the chinese government is committed to building a healthy population in china. citizens' health is a symbol of national prosperity. the government is gradually improving national health policies to provide people with comprehensive health services. improving individual social support is part of these policies. in conclusion, it is of great pragmatic significance to study the effect of social support on the health of chinese people. this paper aims to fill some of the gaps in current studies on individual health. based on big data from china, this study adopts quantitative research methods to analyze the heterogenous affecting of social support on individual physical and mental health. first, this study attempts to give a description of the influence of multidimensional social support on both individual physical and mental health. second, this study shows a comparison of each dimension of social support on individual physical and mental health, which strongly proves the varied effects of social support on health. finally, this study expands the heterogeneity to age and effectively identifies the heterogeneous influence of each dimension of social support on different ages' mental health. the data of this paper comes from the china labor-force dynamics survey 2016 (clds2016) carried out by sun yat-sen university in 2016. the survey covers education, work, migration, health, economic activities, and other interdisciplinary aspects. in this survey, a multi-stage, multi-level probability sampling method proportional to the size of the labor force is adopted. to ensure national representation, the samples cover 29 provincial administrative units (hong kong, macao, taiwan, tibet, and hainan are not included). therefore, this dataset is highly representative of china. it is a public dataset that all researchers can use by applying to sun yat-sen university. the survey is conducted by computer assisted personal interviewing (capi) technology. in order to reduce the estimation bias as much as possible, this paper removes invalid samples in the original data table. specifically, the samples with the following characteristics have been deleted: refusing to answer key questions or answering "inapplicable, unclear" and obvious logical contradictions. finally, 14,246 valid samples were used in this paper. therefore, the data this paper employed can be regarded as big data in terms of both the national representation of the survey scope and the absolute number. two dimensions, physical health and mental health, of respondents were measured. for the first dimension, physical health, survey participants were asked, "how do you evaluate your current health (variable named self-rated health)?" the answer was measured using a five-point likert scale ranging from "1" to "5". an answer of "very bad" was coded as "1", "bad" was coded as "2", "normal" was coded as "3", "good" was coded as "4", and "very good" was coded as "5". considering the subjectivity of self-rated health, this paper also used body mass index (bmi) to measure the physical health of respondents. in the standards provided by the world health organization (who), 18.5 ≤ bmi < 24 refers to a normal weight range [75] . however, according to a study published in the lancet by who experts, a normal bmi between 18.5-23 may be more appropriate for asians [76] . therefore, we chose the range of bmi from 18.5 to 23 as normal weight. if 18.5 ≤ bmi < 23, it was coded as "1"; otherwise, it was coded as "0". individuals who develop mental health problems may experience feelings of depression, hopelessness, failure, fear, loneliness, and meaninglessness [77] . therefore, for the second dimension, mental health, respondents were asked six questions: "how often do you feel depressed (variable named depression)?", "how often do you feel like there is no hope (variable named hopelessness)?", "how often do you feel you have failed (variable named failure)?", "how often do you experience fear (variable named fear)?", "how often do you feel lonely (variable named loneliness)?", and "how often do you feel life is meaningless (variable named meaninglessness)?" the answers were coded from "1" (very low frequency) to "4" (very high frequency), which meant that the individual mental health status was ranked from good to poor [78, 79] . explanatory variables in social support include four dimensions: emotional support, tangible or instrumental support, interaction or exchange of support, and community support. for the first dimension, emotional support, respondents were asked two questions: "how many friends do you have locally (variable named friends)?" and "how many people can you speak your mind to (variable named speaking one's mind)?" the answers to both questions were numerical. in other words, emotional support was defined by two variables: friends and speaking one's mind. for the second dimension, tangible or instrumental support, respondents were asked, "how many people can you borrow money from (variable named borrowing money)?" the answer to the question was also numerical. it meant that tangible or instrumental support was defined by the variable of borrowing money. for the third dimension, interaction or exchange of support, respondents were asked, "how many people can you discuss important personal issues with (variable named discussion)?" the answer was still numerical. in other words, interaction or exchange of support was defined by the variable of discussion. for the fourth dimension, community support, respondents were asked three questions: "how familiar are you with the members in your community (variable named familiarity)?" the answer was measured by a five-point likert scale ranging from "1" (very unfamiliar) to "5" (very familiar). "to what extent do you trust the members in your community (variable named trust)?" the answer was also measured using a five-point likert scale ranging from "1" (very distrustful) to "5" (very trustful). the final question of the fourth dimension was "do you have mutual aid with the members in your community (variable named mutual aid)?" the answer was again measured by a five-point likert scale ranging from "1" (very little) to "5" (very much). it meant that community support was defined by three variables: familiarity, trust, and mutual aid. according to the analysis in the introduction section, the control variables of this paper included gender, age, education, marital status, religion, income, working time, smoking, drinking, exercise, and region. gender was a dummy variable. male was coded as "1", and female as "0". age was a continuous variable. education referred to the number of years of schooling, which was also a continuous variable. marital status was a dummy variable, which was divided into "single", "married", "divorced", and "widowed". religion was a dummy variable, which was clustered into "western religion (including catholicism, christianity, and the eastern orthodox church)", "eastern religion (including southern buddhism, tibetan buddhism, taoism, islam, and folk religions)", and "no religion". income was a continuous variable, which referred to the total income of respondents in 2015, mainly composed of wage income, operating income, property income, and transfer income. in regression analysis, we took the logarithm of income. working time was measured by the average number of days respondents worked in one month ranging from "0" to "31". smoking and drinking both were dummy variables with "1" representing "yes" for each of the two variables. exercise was measured by asking the question, "do you exercise regularly in your daily life?", with "1" representing "yes". region was a dummy variable and was measured by the provinces where respondents were located. the eight measures of outcome, (1) self-rated health, (2) bmi, (3) depression, (4) hopelessness, (5) failure, (6) fear, (7) loneliness, and (8) meaninglessness, were used as the dependent variables. the ordered probit (oprobit) regression models were used to estimate the results of (1) self-rated health, (3) depression, (4) hopelessness, (5) failure, (6) fear, (7) loneliness, and (8) meaninglessness, due to these dependent variables being ordered discrete data. the logistic regression model was used to estimate the result of (2) bmi, due to the bmi being measured as binary. the statistical software stata version 13.1 mp was used to implement the analysis (statacorp. lp., college station, tx, usa). there are two main limitations of this paper. one is in research and design. our data is second-hand data collected by other research institutions. health and social support are only part of this dataset. in addition, mental health is a complex concept, so it is extremely difficult to quantify accurately. therefore, we only use six indicators to measure mental health, which is obviously not enough to represent its complexities. future research can cautiously expand the dimensions of mental health. the second limitation of this paper is in the methods used. this is also related to the data. due to the cross-sectional nature of the data, this paper does not explore the internal mechanisms of social support for physical and mental health. future research can continue to expand on this point. in terms of physical health, the average value of self-rated health is 3.65 (sd = 0.97). bmi shows that 46.1% of the respondents' weights were within the normal range. in terms of mental health, the mean values of six indicators are all less than 2, among which, the mean value of depression is when reviewing social support factors that may influence physical and mental health, on average, respondents had 12.33 friends, 4.88 respondents had people with whom they could speak their mind, 5.08 people from whom they could borrow money, and 4.01 people with whom they could discuss important personal issues. in terms of community support, the average degree of familiarity of the respondents and other members of the community is 3.81, the average degree of trust of the respondents and the other members of the community is 3.68, and the average value of mutual aid between the respondents and the other members of the community is 3.36. the influences of the social support factors on the two physical health dimensions, self-rated health and bmi, are estimated separately by an oprobit regression model and a logistic regression model. the results are shown in table 2 . the number of samples used in the estimations is 14,246. varied technical diagnostic tests were conducted [80, 81] , and the results show that the two models are good fits. it can be observed from table 2 that the influences of social support on self-rated health and bmi are heterogeneous. specifically, the two indicators of emotional support (friends and speaking one's mind) do not significantly affect self-rated health and bmi. tangible or instrumental support (borrowing money) significantly and positively affects self-rated health but not bmi. this result means that, with the increase of tangible or instrumental support (borrowing money), individual self-rated health level is correspondingly higher on average. similarly, interaction or exchange support (discussion) affects self-rated health significantly and positively but not bmi. on average, individuals with more people to discuss important personal issues with have higher self-rated health. in terms of community support, the respondents' degree of familiarity with other members of the community has a significant and positive effect on the self-rated health of the respondents and has a significant and negative effect on bmi. the degree of trust that the respondents have with the other members in their community has a significant positive effect on both self-rated health and bmi. the frequency of mutual aid behavior of the respondents and community members significantly and positively affects the self-rated health of the respondents but not their bmi. for the results of the control variables, on average, the older the respondent is, the lower their self-rated health level is. similarly, the older the respondent is, the lower the probability that their weight is within the normal range. for education, the more years of schooling the respondent has, the higher their self-rated health level is. in terms of income, the self-rated health level of the respondent increases with the increment of annual income. finally, people who adhere to regular exercise have higher self-rated health levels compared with those who do not exercise regularly. oprobit regression models are used to estimate the influences of social support factors on the six mental health dimensions in this study (depression, hopelessness, failure, fear, loneliness, and meaninglessness). the results are shown in table 3 . the number of samples used in the estimations is also 14,246, and the models are found to be a good fit [80] . notes: standard errors in parentheses; *** p < 0.01, ** p < 0.05, * p < 0.1. table 3 shows that the more friends the respondents have, the higher frequency they feel depression, failure, and fear; the more people the respondent has to discuss important personal issues with, the less likely respondents will experience feelings of hopelessness, failure, and loneliness; and the more familiar the respondents are with members of their community, the better their mental health is, that is, the less likely the respondents will feel depressed, hopeless, afraid of failure, fearful, lonely, and meaningless. similar results appeared as the respondents were more trusted within their community. the more mutual aid behaviors the respondents have with other members of their community, the better their mental health is, and respondents thus experience less frequent feelings of hopelessness, failure, loneliness, and meaninglessness. in the control variables, on average, compared with women, men's mental health is better. they spend less time feeling depressed, hopeless, like a failure, fearful, lonely, and meaningless than women do. the amount of time that respondents feel these variables increases with age. the higher the level of education of the respondents, the lower the frequency of depression, hopelessness, failure, fear, loneliness, and meaninglessness they feel. regarding marital status, compared with single people, married respondents have better mental health. they spend less time feeling the above variables than single people do. the more income the respondents earn, the less likely they are to feel depressed, hopeless, failed, feared, lonely, and meaningless. respondents who exercise regularly are also less likely to feel these variables. age is significantly associated with mental health [82] . as such, we grouped the samples into two subgroups-respondents below 60 and those 60 and over-to check the heterogeneous influence of emotional, tangible or instrumental, interaction or exchange, and community support on individual mental health at different ages. the results are reported in table 4 . it can be observed from table 4 that not all the variables (friends and speaking one's mind) related to emotional support have significant effects on individual mental health across the two different age subgroups. specifically, the number of friends that respondents have has significant negative effects on the mental health variables of depression, failure, and fear in the below-60 subgroup. the variable of speaking one's mind shows a significant positive effect on easing the feeling of failure in the 60-and-over subgroup, while it has no significant effects on the other mental health variables. for tangible or instrumental support, the variable of borrowing money only has a significant positive effect of relieving feelings of depression, hopelessness, and loneliness in the 60-and-over subgroup. the variable did not affect the mental health of those aged below 60. in terms of interaction or exchange support, the coefficients of variables of discussion are insignificant across the two subgroups, demonstrating that the interaction or exchange of support does not affect respondents' mental health status positively or negatively. overall, community support is the most crucial dimension of social support affecting individual mental health. the degree of familiarity respondents share with the other members of their community has significant, positive influences on every assessed mental health status in the below-60 subgroup. in contrast, in the 60-and-over subgroup, the degree of familiarity lessens the feelings of depression and fear significantly. the degree of trust that the respondents share with the other community members improves overall mental health across the two different subgroups significantly. alternatively, the trust between community members shows that there is a strong association of mental health with community support among individuals. the mutual aid behaviors of the respondents and other community members is significantly and positively correlated with alleviating feelings of hopelessness, failure, and meaninglessness but significantly exacerbates the feeling of fear in the 60-and-over subgroup. for the below-60 subgroup, the effects of mutual aid are significantly positive and help alleviate loneliness and meaninglessness. notes: standard errors in parentheses; *** p < 0.01, ** p < 0.05, * p < 0.1. by analyzing updated and representative survey big data from china, this paper examines the influence of social support on individual health. different from previous studies, we examine the influences of social support on individual physical and mental health and attempt to find heterogeneity between them. we find that the number of friends that respondents have has no significant influence on their own physical health (self-rated health and bmi). however, the number of friends has a significant influence on some aspects of respondents' mental health (depression, failure, and fear). we questioned why people with more friends feel more depressed, failed, and fearful. we speculate that this is related to the comparative effect. to a large extent, the psychological problems of individuals come from people close to them, such as family members and friends, rather than strangers [83, 84] . the more friends a person has, the more people the person can compare themselves with. generally, the more friends a person has, the greater the probability of having more highly accomplished friends. comparing oneself with those talented friends may induce depression, a sense of failure, and fear. this is not the fault of the friends but instead how people think about the role of friends in their lives. the number of people that the respondents could borrow money from significantly affects the respondents' self-rated health but does not significantly affect bmi and mental health. based on these results, we can argue that the influence of tangible or instrumental support on individual health, especially mental health, is limited. therefore, these results above provide evidence for future studies to reconsider the heterogeneous effects of different dimensions of social support on individual health. additionally, there is the potential for future studies to consider whether tangible or intangible support has the most significant effect on individual health. having more people with whom the respondent can discuss important personal issues not only can improve the self-rated health of respondents but also can make them feel less hopeless, failed, and lonely. the importance of discussion is reflected in that it can reduce the cognitive limitations of an individual, can open one's mind, can find solutions to problems, and can create a sense of hope. helping individuals find others to discuss things with will be a potential way that government and nongovernmental organizations (ngos) can provide social support for individuals. specifically, the government and ngos can set up community-based advice agencies to provide constructive suggestions on the problems that individuals encounter in daily life to increase their social support. the more familiarity the respondents have with other community members, the higher their self-rated health level is but the greater the probability that their bmi is within an abnormal range. although it is difficult to give a reasonable explanation for the above results, it shows that different choices of health indicators may produce different results. whether to choose subjective or objective indicators to measure physical health is worthy of further study. however, the influence of this variable (familiarity) on the mental health of respondents is consistent. it has a significant positive effect on the six variables (depression, hopelessness, failure, fear, loneliness, and meaninglessness) of mental health. the more familiar the respondents are with other community members, the better their mental health is and the less depressed, hopeless, failed, fearful, lonely, and meaningless they feel. this is evidence that community support has a significant effect on individual mental health, consistent with previous studies [85] . this result suggests that community involvement should be emphasized when strengthening social support. specific measures may include holding communal activities for promoting fellowship, so that community residents can be well acquainted with each other. there is a significant correlation between the degree of trust of respondents with the other community members and the respondents' mental health. the more trust the respondents have with other community members, the better their mental health is. trust is the foundation of mental health [86, 87] . against the social background of the trust crisis in china [88] , this result reminds us again that we cannot ignore the role of trust in people's mental health. positive measures should be taken to maintain interpersonal trust, which is not only beneficial to the mental health of social members but also beneficial to the healthy development of the whole society. mutual aid behavior has a significant correlation with hopelessness, failure, loneliness, and meaninglessness. the more the members of a community help each other, the less time members experience hopelessness, a sense of failure, loneliness, and meaninglessness. however, the frequency of mutual aid behavior within a community significantly affects the self-rated health of respondents but not bmi. the results remind us again that, in the process of measuring health, choosing different indicators may produce different results. additionally, the above results suggest that mutual aid behavior is beneficial to people's mental health. therefore, it is necessary for the community to establish a set of effective mechanisms to stimulate community members to help each other. to conclude, community support plays a prominent role in the four dimensions of social support. our study shows that age plays a moderating role in the impact of social support on mental health. people under the age of 60 and people aged 60 and above have heterogeneous perceptions about the effects of various social support dimensions on different mental health indicators. therefore, the social support measures provided to these two age groups to help them improve their health must also be heterogeneous and targeted. specifically, according to the results of this paper, community support is needed by both age groups (<60 and ≥60), tangible or instrumental support is needed more by the age group over 60 (including 60) , and more emotional support should be given to the age group below 60. for the control variables, the results are mostly consistent with previous studies. in particular, we find that the influence of gender on mental health is heterogeneous. on average, compared with women, men's mental health is better. in addition to the psychological and physiological differences of gender, it may also be related to the different social division of labor between men and women in china. although the status of women has been greatly improved in china, generally, most women are still in a subordinate position in a family. household chores are dealt with mainly by women, which can easily lead to mental health issues [89] . therefore, women's mental health problems deserve further attention. reasonable family division of labor may help to alleviate this problem. in addition, we find that marriage is a way to alleviate mental health problems. compared with single people, those who are married enjoy better mental health. they spend less time feeling depressed, hopeless, like a failure, fearful, lonely, and meaninglessness than single people. good interaction and communication between a husband and wife are beneficial to one's mental health [90] . in conclusion, this paper has shown that different social support dimensions have heterogeneous effects on individual physical and mental health. specifically, tangible or instrumental support (borrowing money), interaction or exchange support (discussion), and community support (familiarity, trust, and mutual aid) are significantly correlated with individual self-rated health. community support (familiarity and trust) is significantly correlated with individual bmi. compared with the other three dimensions, community support plays the most important role in individual mental health. this paper finds that friends do not play a positive role in the depression, failure, and fear dimensions of individual mental health. the results also suggest that the effects of social support on the physical and mental health of individuals at different ages (<60 years and ≥60years) are heterogeneous. in addition, this study reminds us that different health measurement methods may produce different results. therefore, scientific measurement of health is the key to achieving more accurate results on this topic in future research. this paper has contributed to the literature on the heterogeneous influence of social support on individual physical and mental health in china. author contributions: f.y. proposed the idea of this paper and wrote most of the text including the literature review, methods, results, discussion, and conclusions. y.j. performed the theoretical and data analysis and edited the paper. all authors have read and agreed to the published version of the manuscript. the effect of social support on mental health in chinese adolescents during the outbreak of covid-19 social contact, social support, and cognitive health in a population-based study of middle-aged and older men and 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supporting child mental health assertiveness and organizational trust as predictors of mental and physical health in a romanian oil company epa guidance on building trust in mental health services trust collapse caused by the changsheng vaccine crisis in china urban/rural and gender differentials in suicide rates: east and west does marriage have positive effects on the psychological well-being of the individual? key: cord-270796-ixpt6jnr authors: khurshid, zohaib; asiri, faris yahya ibrahim; al wadaani, hamed title: human saliva: non-invasive fluid for detecting novel coronavirus (2019-ncov) date: 2020-03-26 journal: int j environ res public health doi: 10.3390/ijerph17072225 sha: doc_id: 270796 cord_uid: ixpt6jnr the breakthrough of novel coronavirus (2019-ncov) in wuhan, a city of china, has damaged the status of health and quality of life. in the sequel of this epidemic or contagious disease, the patient experiences fever, chest paint, chills, a rapid heartbeat, breathing difficulties, pneumonia, and kidney failure. it has been suggested that this disease can spread through human-to-human transmission or by super spreading. by the help of the non-invasive fluid “saliva”, it is easy to detect the virus. this can help with the comfort of the patient as well as healthcare personnel. under this perspective, we discuss the epidemic situation of 2019-ncov and its relationship with human saliva. in december 2019, patients with pneumonia of unknown cause reported to hospitals in wuhan, hubei, china. this unknown cause of pneumonia provoked fear, stress, and panic in china. within a day, this condition spread to other provinces in china, and health authorities started immediate investigation to characterize and isolated the virus, which, by 7 january 2020, was named the novel coronavirus (ncov) [1] . on 12 january 2020, the world health organization (who) named this new virus 2019-novel coronavirus (2019-ncov). the infectious disease was named covid-19 by who on 11 february 2020. this virus is part of a diverse family of viruses, consisting of four viral genera (alpha-, beta-, gamma-, and delta-coronaviruses) [2] . they infect different body systems of human and vertebrates like the respiratory, central nervous, hepatic, and gastrointestinal systems [3] . figure 1 shows the essential events related to the 2019-ncov outbreak. the clinical features of covid-19, as determined from 99 patients in wuhan city, china are fever (83%), cough (82%), shortness of breath (31%), muscle pain (11%), confusion (9%), headache (8%), sore throat (5%), rhinorrhea (4%), chest pain (2%), diarrhea (2%), and nausea and vomiting (1%) [4] . a study revealed that reported patients tended to be older males who had the fatal condition of acute respiratory distress syndrome (ards) [4] . as of 28 february 2020, the day on which this perspective was finalized, a total of 46 countries other than china have reported to have 2019-ncov cases (source who situation report-38). according to the who situation report, globally, 179,000 thousand cases have been confirmed and the number is increasing every hour. understanding the disease etiology, epidemics, genomics, clinical findings, and treatment options requires extensive data from sampling, laboratory work, and clinical trials [5, 6] . rapid findings can help to control the disease spread as well as further outbreaks of contagious viruses. covid-2019 transmission occurs person-to-person, either through direct transmission by sneeze, cough, or droplet inhalation, or contact transmission such as ocular contact or through mucous membranes of the eyes and nose and saliva [7, 8] . in this perspective, we highlight the hidden capability of saliva for the early detection of any viral, bacterial, or systemic disease [9] . in the past, saliva was proven to be an ideal role for the isolation of proteins, peptides, and sheds of viruses via many molecular assays [10] . the composition of saliva is very informative for analysis or to compare the physiology or pathology of the human body. currently, salivary biomarkers are helping in the detection of oral cancer, dental caries, periodontal diseases, diabetes, breast cancer, and lung cancer [9, 10] . the oral cavity is kept wet by salivary flow, and the normal physiological activities of the oral cavity are maintained by a saliva washout mechanism [9] . a study revealed a large amount of rna isolation from the saliva of a severe acute respiratory syndrome (sars)-associated coronavirus patient in national taiwan university hospital [11] . in this study, quantitative real-time reverse transcription-polymerase chain reaction (rt-pcr) assay was used to investigate the load of sars-cov in the saliva samples. samples of saliva from 17 patients were confirmed to have lymphopenia, elevated levels of creatine kinase, and thrombocytopenia. on 9 january 2020, who published guidelines for the detection of 2019-ncov using respiratory materials (nasopharyngeal and oropharyngeal swab in ambulatory patients and sputum (if produced) and endotracheal aspirate or bronchoalveolar lavage in patients with more severe respiratory disease) and serum for serological testing (https://www.who.int/publications-detail/laboratory-testing-for-2019novel-coronavirus-in-suspected-human-cases-20200117 accessed on 28 february 2020). testing at these sites is painful, uncomfortable, and invasive for the patients, but there is strong evidence for its use in detecting the virus's presence. a recent paper reported only one case as part of a diagnostic evaluation of sputum from a 2019-ncov patient, and it was a lower respiratory tract sample [12] . nasopharyngeal and oropharyngeal swabs are not suitable for monitoring the viral loads compared with saliva samples [11] . on 12 february 2020, a breakthrough was reported regarding the accuracy of a human saliva sample from eleven covid-19 patients in a hong kong hospital [13] . in this study, consistent detection of coronavirus was reported in the saliva of patients admitted from the first day of hospitalization. the sampling of saliva in this study was done by instructing the patient to cough out saliva from the throat into a sterile container, and this was transported to the laboratory for further analysis. this study demonstrated the advantage of saliva sampling comfortability in an epidemic situation such as covid-2019 [13] . further exploring the use of saliva or oral fluid will bring new treatment strategies in the prevention and early detection of covid-19 [14] . by using saliva as a form of liquid biopsy, healthcare providers, doctors, nurses, and paramedic staff will be safe from the transmission of disease. this method of sampling is advantageous compared with the use of nasopharyngeal aspirates, oropharyngeal swabs, and nasopharyngeal swabs. previously, it has been reported that the sars-cov rna can be detected from saliva and throat wash [11] . there are many saliva collection devices available in the market for safe and sterile collection without compromising the quality and quantity [15] . figure 2 shows commercially available saliva sampling devices and their company names, which can be accessed by all researchers, healthcare providers, doctors, microbiologists, and virologists for the handling of samples. further investigation on salivary biomarkers related to covid-2019 will open a corridor for optimizing cost-effective point-of-care (poc) technology [16, 17] . further investigation should investigate the diagnostic capability of human saliva for identifying covid-2019, sars-cov, mers, zikv, and other viruses in the home, city, airport immigration counter or check-in, hospitals, and busy clinics in a few seconds with the cost-effective point-of-care (poc) technology. saliva collection is quite comfortable for patients as well as being easy, cheap, and non-invasive with minimal equipment required. it should also minimize the nosocomial transmission of 2019-ncov to healthcare workers. right now, in this controllable pandemic situation, all research centers, health agencies, and health care providers must explore the diagnostics opportunity and rapidly develop automated molecular point-of-care assays. this write-up will help epidemiologists, virologists, and clinicians to understand the importance of saliva in diagnostic testing as well as the transmission of the disease. a novel coronavirus outbreak of global health concern emerging coronaviruses: genome structure, replication, and pathogenesis a tale of two viruses: the distinct spike glycoproteins of feline coronaviruses epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study a new microchannel capillary flow assay (mcfa) platform with lyophilized chemiluminescence reagents for a smartphone-based poct detecting malaria real-time tentative assessment of the epidemiological characteristics of novel coronavirus infections in wuhan, china, as at 22 the impact of the covid-19 epidemic on the utilization of emergency dental services covid-19): emerging and future challenges for dental and oral medicine role of salivary biomarkers in oral cancer detection human saliva can be a diagnostic tool for zika virus detection detection of sars-associated coronavirus in throat wash and saliva in early diagnosis clinical features of patients infected with 2019 novel coronavirus in consistent detection of 2019 novel coronavirus in saliva coronavirus covid-19 impacts to dentistry and potential salivary diagnosis human saliva collection devices for proteomics: an update saliva as a diagnostic specimen for testing respiratory virus by a point-of-care molecular assay: a diagnostic validity study yahya ibrahim asiri, f. advancing point-of-care (poc) testing using human saliva as liquid biopsy we want to acknowledge the pakistan human salivary research group (phsrg) for helping and guiding us in the preparation of this manuscript. the authors declare no conflict of interest. int. j. environ. res. public health 2020, 17, 2225 key: cord-265937-f39md0vk authors: cachón-zagalaz, javier; sanabrias-moreno, déborah; sánchez-zafra, maría; zagalaz-sánchez, maría luisa; lara-sánchez, amador jesús title: use of the smartphone and self-concept in university students according to the gender variable date: 2020-06-12 journal: int j environ res public health doi: 10.3390/ijerph17124184 sha: doc_id: 265937 cord_uid: f39md0vk the university stage comprises a very important and vital period in the modification of students’ lifestyles, and these changes can affect their self-concept. the excessive use of technology today can also influence the formation of their identity. the aim of this study is to analyze the relationship between self-concept and the use of the smartphone by university students in terms of gender. the sample included 253 students (mean age 21.39 ± 3.27) of the primary education degree of the university of jaén (106 men and 147 women). a questionnaire was used to unify several instruments: a sociodemographic questionnaire, a self-concept form-5 questionnaire (af-5), and a questionnaire on cell phone-related experiences (cerm). the results show the existence of significant differences between both genders in the academic, emotional, and social dimensions of self-concept, with women showing a greater academic self-concept and men showing an emotional and physical one. regarding the use of the smartphone in relation to self-concept, significant differences are found in the academic and emotional dimensions depending on the degree of use. in addition, in relation to the use of the smartphone, it has been detected that half of the students present potential problems. it is concluded that there is a relationship between both constructs, especially the academic and emotional self-concept. the university stage coincides with what some authors describe as emerging adulthood, a period of life in which people between the ages of 18 and 29 have passed through adolescence but have not yet fully assumed the role of an adult [1] [2] [3] [4] [5] [6] . this cycle also coincides with a total change in lifestyle, since it involves interaction with a new group of people, the abandonment of the family nucleus in many cases, and the possible combination of studies and work. it is a time that can cause certain instability, since it is the moment when the subject strengthens his personality [7] . related to these cognitive and psychological processes arises the term self-concept, a construct of high importance in this stage of change and consolidation of personal identity which is defined as the perception that an individual has of himself, taking into account limitations, characteristics, and personal relationships [8] [9] [10] . this self-perception is flexible and modifiable-that is, it is not the same throughout an individual's life and is influenced by all the changes that the subject experiences in the different areas of his or her day-to-day life and furthermore, is influenced by the reinforcements, positive or negative, that other people exert on the individual [11] . some authors argue that there are differences in some dimensions of self-concept according to gender, as indicated, for example, in the study by cachón et al. (2015) [8] . the concept has also undergone several changes in its definition over the last few decades. in the seventies of the last century, the self-concept had a one-dimensional character-it was a single factor. in this line, the rosenberg self-esteem scale [12] , which measured this single dimension, became popular. over the years, the deepening of the study of this construct led the scientific community to consider its multidimensional nature. in this sense, the study by shavelson et al. (1976) [13] already defined self-concept as a hierarchical model formed by several factors or dimensions, so that a person can have a high self-concept in several aspects of his life and a low one in others. currently, the model that divides the self-concept into five dimensions is formally accepted: physical, related to body image and physical factors; emotional, understood as the ability to manage emotions that the individual has; family and perception about the role within the family; academic, in his role as a student; and social, conditioned by the quantity and quality of social relationships [14] [15] [16] [17] . the self-concept form-5 questionnaire by garcía and musitu (1999) [18] is the most widely used in this regard. on the other hand, it cannot be ignored that today's society is technological and constantly changing. technological advances have a great impact on people's lives, on the activities they carry out, and on their socialization [19] . mobile phones or smartphones (terms that will be used interchangeably in this paper) are currently one of the most famous products, are within the reach of almost all subjects, and are part of their lives. the use of these devices has become widespread, and it is common to manipulate them at any time of day, walking on the street, on public transport, at home, or even in class or at work. according to the ditrendia report [20] , which analyses various aspects of mobile phone use, there were more than five billion users in 2019. in the specific case of spain, 96% of the population uses them to access the internet. in 2018, it has been estimated that users worldwide spent an average of 800 h using their smartphones to surf the internet, and this figure is expected to increase to 930 h in 2021. the covid-19 pandemic has broken these forecasts, with mobile phone use skyrocketing in 2020 during periods of confinement. for example, in spain during the second week of march and coinciding with the beginning of the state of alarm, mobile phone use increased by 38.3% compared to the last week of february. in general, the use of communication applications has increased by more than 50%, social networks by 20.9%, and television and cinema by a similar percentage. among the most used applications in the communication sector are "hangouts"; "whatsapp"; and "calls", especially video calls, while in the social network sector are "twitter", "facebook", and "instagram". the television and film applications that have increased their use the most are "megadede", "netflix", and "prime video" [21] . returning to the use of mobile phones, 85% of spanish users use messaging applications, with whatsapp being the most widely used, especially among young people between 14 and 24 years old. the second most applied activity by the spanish is related to the display of videos (82%), and the third is the display of mobile mapping programs (75%). the favorite applications are games, social networks, entertainment, and photography [20] . as we have maintained, the smartphone is now a must-have for many people. throughout the history of mankind, there are few elements that have been so influential in the lives of human beings, so the problem of dependence that it manages to create in its users is generated, and this can even affect relationships with other people. it is at this point that we talk about social problems related to the use of mobile phones [22] , which are complemented by others that are also derived from this excessive use, such as lack of sleep, loss of the notion of time, obsession with what is happening on social networks, or the failure to do other important activities. despite the fact that this device is used by both genders, some authors report that women spend the most time using it [23] . the use of the smartphone is especially noticeable among young people. the group of university students, along with teenagers, is one of the most likely to suffer from addiction problems, since the mobile phone is a first and indispensable object for them, and they consider it a fundamental tool to relate to and socialize with others [24] . the media is an essential tool for young people, but at this age its use is dangerous as it can influence people and change their behavior without them being aware [25] . the excessive use of the smartphone can cause health problems affecting sleep, increase the risk of having a traffic accident or influence academic results. in relation to this term, the concept of "phubbing" arises, understood as the fact of neglecting other people by continuously using the smartphone [26] . it should be noted that the two main constructs of this research (self-concept and the use of the smartphone) can influence each other, since one of the transcendental uses that young people give to the mobile phone is access to social networks in which they continually interact by publishing photographs with the intention of showing a lifestyle, real or imaginary. this digital individual is changeable and usually responds to the desires of the real subject, to how he wants to be seen or how he wants to see himself. it is essential to educate students about the dangers that can be caused by social networks, reminding them that the information they see published is usually subject to filters that transmit unreal information or with a very biased truth [27] however, this process may not always be negative; the problem arises when the real self is lost and an identity crisis appears, influencing its self-concept [28] . especially in the adolescent stage, it is very important to acquire and maintain a good body image, since this is directly related to the person's general health [29] . likewise, studies such as pedrero et al. (2012) [30] state that the excessive use of mobile phones can make it even more difficult for people with a low self-concept to socialize openly and directly or even to speak of depressive symptoms. some people with low self-esteem and self-concept have trouble interacting with other subjects face-to-face, causing them to prefer to communicate with others through the smartphone, which makes them feel more confident. therefore, people with this low self-concept may have an excessive use of the smartphone [31] . twenge et al. (2018) [32] also comment that teenagers who spend less time using technological devices are happier than those who use them continuously. based on the information found, the hypothesis is that mobile phone use directly affects the self-concept of university students. therefore, the main objective of this study is to analyze the relationship between the self-concept of university students and the use they make of their mobile phones, also analyzing the gender variable. the sample is made up of 253 university students (n = 253) of the primary education degree of the university of jaén (spain). a non-probabilistic sampling of accidental or casual type has been used. the distribution of participants according to gender is as follows: 106 men (41.9%) and 147 women (58.1%). the mean age of the sample subjects is 21.39 (±3.27); the minimum age of the participants is 18 and the maximum is 42 (range = 24 years). (4, 9, 14, 19, 24 and 29) , and physical (5, 10, 15, 20, 25 and 30) . an example of an item is: "it's difficult for me to make friends". the type of response is a likert scale of between 1 and 5 points, with 1 being "never" and 5 being "always". in the participants of the study, the initial reliability (including all items) of the scores obtained (cronbach's alpha) was 0.64 for the total of the scale, for the academic dimension 0.81, for the social dimension 0.79, for the emotional dimension 0.65, for the family dimension 0.86, and for the physical dimension 0.78. in the study, item number 8, or "many things make me nervous", has been eliminated because it interfered with the reliability of the scale. excluding this item from the analyses, the total reliability of the scale was 0.87. -questionnaire on cell phone-related experiences (cerm-cuestionario de experiencias relacionadas con el móvil), by beranuy et al. (2009) [33] : scale made up of 10 items answered on a four-point likert scale, with 1 being "almost never" and 4 being "almost always". an example of an item is "do you get angry or irritated when someone bothers you while using your mobile phone?". following authors such as carbonell et al. (2012) [34] , the results have been analyzed by grouping the participants into three groups: "no problems" (10 to 15 points), "occasional problems" (16 to 23 points), and "severe problems" (24 to 40 points). the reliability of the scale (cronbach's alpha) was 0.75. firstly, a questionnaire was developed by linking the above instruments and applying them collectively and voluntarily to participants in their classrooms. at the beginning, they were informed of the nature of the study and were assured of the anonymity of the responses and results. this research also meets the international ethical standards set by the world medical association (wma), which issued the declaration of helsinki in 1964 [35] , although it has undergone subsequent revisions, the latest in 2017. it also complies with the spanish legislation required for this type of work. the spss 22.0 (ibm corps., armonk, ny, usa) statistical program was used for data analysis. a descriptive study was performed to report the characteristics of the sample subjects (means and standard deviations) and various non-parametric tests (spearman's rho correlation, mann-whitney u test, h kruskall wallis), since the assumption of normality was based on the results obtained in the kolmogorov-smirnov test (n > 30) was not met. table 1 shows the results when bivariate correlations are made between the different dimensions of the self-concept, as well as the mean (m) and standard deviation of each one of them. when the u mann-whitney test was performed to relate the dimensions of self-concept with the gender variable (table 2) , statistically significant differences (p < 0.01) were obtained in favor of girls in academic self-concept (z = −3.286, p = 0.001, r = 0.020) and of boys in emotional (z = −5.456, p = 0.000, r = 0.35) and physical self-concepts (z = −5.640, p = 0.000, r = 0.34). in relation to the size of the effect, the values obtained in the variables in which significant differences have been found are of medium size (r < 0.50, r > 0.30). it can be observed that those dimensions with statistically significant differences according to gender have a higher statistical power. as can be seen in table 3 , most university students are classified between those who do not have problems related to mobile phone use (n = 102, 40.3%) and those who may have them (n = 142, 56.1%). only nine students present severe problems (3.6%). in terms of gender differentiation, girls show less problems than boys (n = 59 vs. n = 43), but at the same time they are the ones that show more potential difficulties (n = 84 vs. n = 58). in terms of severe problems, both genders are equal, with the male being slightly superior (n = 5 vs n = 4). table 4 shows the relationship between the dimensions of self-concept and the three categories of mobile phone use. statistically significant differences (p < 0.05) were obtained in the academic dimension (χ 2 = 7.003, p = 0.030, r = 0.027) and in the emotional dimension (χ 2 = 17.351, p = 0.000, r = 0.082), being in both the mean of the category "no problems" the highest (m = 22.38, sd = 3.44 vs. m = 16.47, sd = 2.87). it is observed that the statistical power is higher in those variables in which there are statistically significant differences. sig., significance. * statistically significant differences at the 0.05 level. the results obtained show that of the five dimensions into which the self-concept is divided, the one that scores most is the family one, followed by the social one. these data agree with bustos et al. (2015) [36] and baptista et al. (2012) [14] , for whom the family relationship is a key factor in the lives of people that can affect, positively or negatively, other key aspects of the lives of individuals. this is even more important at the university stage, because most students leave the family nucleus and losing family closeness can affect other aspects of their lives. therefore, it is a very positive fact that the subjects surveyed show high scores in this dimension. with regard to social self-concept, it is important to remember that university students create social bonds with people they meet during their years of study at this institution. a high social self-concept implies, in most cases, that they have no problems in creating new relationships with their peers [37] . the order in which these dimensions are scored continues with the physical and academic dimensions, with the emotional one being the one with the lowest score. logically, the physical self-concept is closely related to physical activity practice, so one way to increase it would be to perform physical exercise regularly [17, 38] . some authors indicate that academic self-concept is influenced by some variables, such as student involvement in the teaching process or the relationship between the teacher and student [9] . it is perhaps for this reason that university students score lower on the academic dimension than on others, given that the relationship between students and teachers at the university is not as close as it is at other educational stages. finally, as for the emotional dimension, which is the one that presents the lowest scores, it has been found that it is closely related to the social one. this is due to the fact that people who consider themselves emotionally strong have more facility when it comes to strengthening ties with other subjects [39] . according to the results, there are statistically significant differences (p < 0.01) between both genders in the academic, emotional, and physical dimensions. women present a higher academic self-concept than men, possibly because they get better grades than men by having better study habits [40] . in contrast to this idea, the article by jiménez-caballero et al. (2015) [41] concludes that gender is not a variable that influences the academic performance of university students. with regard to the emotional and physical dimension, it is men who have higher scores, data which is consistent with chacón-cuberos et al. (2020) [7] . suárez and wilches (2015) [42] claim that men perceive and regulate their emotions better than women. it is important to pay attention to your emotions, because not doing so can lead to some symptoms of depression. in terms of the physical self-concept, linares-manrique et al. (2016) [43] states that men have a superior appreciation of themselves in terms of physical ability, physical condition, strength, and physical attractiveness. as for the use of mobile devices, more than 50% of the sample presents potential problems. it should not be forgotten that most of the university students surveyed belong to what is known as the digital native generation, understood as the people who were born when they switched from the analog to the digital world [19] . in terms of gender differentiation, girls are the group that stands out in the "no problem" category, although they outnumber boys with potential complications related to their use. these results coincide with those of lópez-rosales and jasso-medrano (2019) [23] , who found differences between the time of use of mobile phones between both genders but not addictive behaviors. according to these authors, girls use social networks more frequently to express themselves through them and boys to meet other people. zagalaz et al. (2019) [44] also state that women use their smartphones more, especially to access social networks, and that men prefer to use them to surf the internet or play video games. when analyzing the results obtained in the relationship between the dimensions of self-concept and the use of the smartphone, it is found that there are statistically significant differences (p < 0.05) in the academic and emotional self-concepts, with those subjects who have severe problems with the use of the mobile phone scoring in both dimensions lower. the students are aware that the excessive use of smartphones can reduce their university performance and, as a consequence, their academic self-concept. according to the data obtained by herrera et al. (2014) [45], more than 50% of the young participants in their research stated that they were distracted in class when using their mobile phone. in terms of emotional self-concept, the results are reinforced by olivencia-carrión et al. (2016) [22] , who state that the use of mobile devices can create situations of dependency and emotional attachment, and that they are used to deal with negative emotional situations, such as boredom. finally, as the main conclusion, it should be noted that university students show a high degree of family self-concept, followed by the social and physical self-concepts. the academic and emotional dimensions score the lowest. as for the differentiation by gender, this are found only in the academic self-concept in favor of women and in the emotional and physical dimensions in favor of men. regarding the use of smartphones, more than half of the students surveyed present potential problems related to their use, with a small percentage having severe problems. finally, the relationship between self-concept and mobile phone use is remarkable in the academic and emotional dimensions, being the only ones in which significant differences appear depending on the degree of use of smartphones. 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our smartphones? the vital roles of smartphone activity in smartphone separation anxiety anabolic steroids and their effects on health: a case study of media social responsibility autoconcepto y autoestima en la adolescencia. desarrollo de la identidad personal en las nuevas realidades sociales body image and obesity by stunkard's silhouettes in 14-to 21-year-old italian adolescents adicción o abuso del teléfono móvil. revisión de la literatura how does self-esteem affect mobile phone addiction? the mediating role ofsocial anxiety and interpersonal sensitivity decreases in psychological well-being among american adolescents after 2012 and links to screen time during the rise of smartphone technology validación de dos escalas breves para evaluar la adicción a internet y el abuso de móvil problematic internet and cell phone use in spanish teenagers and young students declaration of helsinki ethical principles for medical research involving human subjects validación del autoconcepto forma 5 en universitarios peruanos: una herramienta para la psicología positiva relaciones sociales y escolares de alumnos universitarios diferencias del autoconcepto físico en practicantes y no practicantes de actividad física en estudiantes universitarios habilidades sociales y autoconcepto en estudiantes universitarios de la región altos sur de jaliso importancia de los hábitos de estudio en el rendimiento académico del adolescente: diferencias por género factores determinantes del rendimiento académico universitario en el espacio europeo de educación superior habilidades emocionales en una muestra de estudiantes universitarios: las diferencias de género the relation of physical self-concept, anxiety, and bmi among mexicam university students acknowledgments: this article has counted with the collaboration of the group hum-653 of the university of jaén. likewise, we would like to thank the students of the university of jaén for their collaboration. the authors declare no conflict of interest. key: cord-284272-68ykes60 authors: suso-ribera, carlos; martín-brufau, ramón title: how much support is there for the recommendations made to the general population during confinement? a study during the first three days of the covid–19 quarantine in spain date: 2020-06-18 journal: int j environ res public health doi: 10.3390/ijerph17124382 sha: doc_id: 284272 cord_uid: 68ykes60 background: recommendations on lifestyles during quarantine have been proposed by researchers and institutions since the covid–19 crisis emerged. however, most of these have never been tested under real quarantine situations or derive from older investigations conducted mostly in china and canada in the face of infections other than covid–19. the present study aimed at exploring the relationship between a comprehensive set of recommended lifestyles, socio–demographic, and personality variables and mood during the first stages of quarantine. methods: a virtual snow–ball recollection technique was used to disseminate the survey across the general population in spain starting the first day of mandatory quarantine (15 march 2020) until three days later (17 march). in total, 2683 spanish adults (mean age = 34.86 years, sd = 13.74 years; 77.7% women) from the general population completed measures on socio–demographic, covid–related, behavioral, personality/cognitive, and mood characteristics. results: in the present study, depression and anger were higher than levels reported in a previous investigation before the covid–19 crisis, while vigor, friendliness, and fatigue were lower. anxiety levels were comparable. the expected direction of associations was confirmed for the majority of predictors. however, effect sizes were generally small and only a subset of them correlated to most outcomes. intolerance of unpleasant emotions, neuroticism, and, to a lesser extent, agreeableness, sleep quality, young age, and time spent internet surfing were the most robust and strongest correlates of mood states. conclusions: some recommended lifestyles (i.e., maintaining good quality of sleep and reducing internet surfing) might be more important than others during the first days of quarantine. promoting tolerance to unpleasant emotions (e.g., through online, self–managed programs) might also be of upmost importance. so far, recommendations have been made in general, but certain subgroups (e.g., certain personality profiles and young adults) might be especially vulnerable and should receive more attention. the world health organization (who) declared, in january 2020, the outbreak of covid-19, a new coronavirus disease. the who indicated that there was an elevated risk of coronavirus spreading globally and, indeed, in march 2020 the situation was characterized as a pandemic [1] . in spain, the government declared the state of alarm late on 14 march 2020. as a consequence, since march 15 an absolute quarantine was imposed and individuals were only allowed to leave their homes under certain circumstances, such as to buy medicines, food, or travel to health centers. this also implied closing all non-essential services and stores, including restaurants [2] . it has been recently argued that quarantine will boost mental health problems in the population and several authors have anticipated that anxiety, depression, and anger will be frequent [3, 4] . thus, since quarantine and mobility restrictions have become more and more frequent globally, institutions, researchers, and clinicians have made an effort to provide the population with guidelines on how to manage quarantine in a more effective manner for their mental well-being. an example of the previous was a rapid review published in the lancet as early as march 14, in which past research on the psychological consequences of quarantine due to similar circumstances (e.g., severe acute respiratory syndrome, influenza, ebola, and middle east respiratory syndrome-related coronavirus) and their correlates were investigated [5] . the authors concluded that quarantine has important psychological effects on individuals and pointed to a number of stressors, such as mobility restriction duration, fear of infection, frustration, boredom, inadequate supplies, and inadequate information. however, the cross-cultural generalizability of the findings and applicability to the covid-19 situation was put into question because previous sample sizes were generally small, the majority of studies had been conducted in canada and china, and many only included specific populations (i.e., students or health-care workers). while acknowledging the aforementioned stressors, many local and global entities and agencies have provided their own psychological recommendations to better manage the quarantine. for instance, in march 18, the who addressed a message to the population and suggested some best practices, such as minimizing seeking news about covid-19 that increased anxiety or distress and being supportive to others (e.g., checking by telephone on people in the community) [1] . other entities, such as the centers for disease control and prevention, the american psychiatric association, the national health service, and spanish institutions (spanish government and general council of the official college of psychologists), to name some examples, have made similar efforts [6] [7] [8] [9] . in general, these guidelines have recommended limiting covid-19 news exposure, taking care of the body (e.g., exercising, eating healthy and at regular times, getting enough sleep, avoiding drug and alcohol use), planning a daily routine, getting involved into pleasant activities, and connecting with trusted others to share concerns and feelings, which is consistent with recent opinions from researchers in the field [10] [11] [12] . to what extent are these and other recommendations that have been frequently posted in the media associated with a successful adaptation to quarantine in the current covid-19 crisis? psychological interventions in the face of the covid-19 crisis should be based on sound scientific advice [13] . however, current evidence is insufficient to confirm to what extent the recommended lifestyles reviewed in the previous paragraphs are associated with a more successful adaptation to the quarantine in the present pandemic. additionally, because research in the field has been conducted in china, the cross-cultural generalizability of findings is unclear. therefore, the goal of the present study is to investigate the emotional impact of the covid-19 pandemic, as well as to the extent to which a comprehensive set of socio-demographic, behavioral, and personality/cognitive correlate with well-being just at the beginning of the quarantine in spain (first three days). according to the reviewed literature, we expect to find low mood as a result of the first days of quarantine. we also hypothesize that we will replicate most of the proposed correlates of well-being indicated in guidelines, expert opinions, and the scarce literature from china. this is a cross-sectional, observational investigation with 2683 participants who completed an online qualtrics © survey disseminated using a virtual snow-ball sampling approach with different social media resources (e.g., twitter, whatsapp, instagram, and facebook). specifically, social media accounts were used to disseminate the study online and respondents were asked to disseminate the study in their own social media. this is a non-probabilistic sampling strategy that can help increase the number of responses and the representativeness of the sample, yet with some bias (e.g., only people who have access to the internet can respond and certain online populations might be more likely to participate). survey dissemination started late in the evening on 15 march 2020, the day the quarantine officially started in spain (even though it was officially announced the day before). this means that the population in spain knew about the quarantine onset already on 14 march. responses were obtained during the first three days of quarantine: 15 march (n = 713), 16 march (n = 1332), and 17 march (n = 638). the fact that data was obtained during three consecutive days should not be interpreted as this being longitudinal data. data represents responses from different individuals and is the study is therefore cross-sectional. data was obtained from all 17 regions in spain. the exact details are not provided for readability reasons, but the proportion of responses per region was consistent with the population in that region (e.g., the majority of responses, that is 58.6%, were obtained from the four most populated regions in spain, which represent 57.8% of the adult population in the country). all obtained responses were anonymous and no personal data was collected from any of the participants. the informed consent was obtained for all participants in the same online platform, qualtrics © , before allowing participants to complete the survey. first, the online survey showed an information sheet for the study and then informed consent had to be provided by clicking on a button where they confirmed that they were over 18 years of age and were willing to voluntarily participate in the investigation. the study and its procedures were approved by the ethics committee of the university of murcia. the study was conducted in accordance with the declaration of helsinki. eligibility included being over 18 years of age, understanding spanish, living in spain, and consenting to participate in the online consent form. the primary outcome was mood, which was measured with the reduced 30-item version of the profile of mood states [14] . this questionnaire evaluates six dimensions of mood, namely depression, anxiety/tension, anger, vigor, fatigue, and friendliness. the selection of predictors was based on the literature review and the recommended lifestyles from several institutions described in the previous paragraphs. these included socio-demographic and clinical characteristics, quarantine-related behavior, and personality/cognitive factors (see tables 1 and 2 for details) . socio-demographic, covid-related, and behavioral factors were created ad hoc and were dichotomous, ordinal, or continuous, depending on the content assessed. all behavioral variables referred to behavior in the past 24 h. for the measurement of frustration intolerance, the 7-item emotional intolerance scale from the frustration discomfort scale was used because this is the scale that mostly correlates to negative mood states [15] . for personality, the ten item personality inventory was selected because it is a valid and very brief measure of the big five personality dimensions [16] . high scores in these scales should be interpreted as indicating poorer tolerance to unpleasant emotions/cognitions and higher neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. following a descriptive analysis of items/scales, the levels of the main outcome (mood) will be compared against previous scores from the general population in spain obtained before the covid-19 epidemic [17] . an independent t-test was computed and the cohen's d estimate was calculated as a measure of effect size. finally, a set of linear regressions was calculated for each predictor and each outcome separately to obtain a measure of the strength of the relationship between every predictor with an outcome (table 3) . similar to recent research [18] , univariate regressions are presented first to show the relationship between each predictor and outcomes. additionally, though, we also propose an additional multivariate model that can help identify the more relevant predictors for each outcome. due to the large number of predictors and the risk of multicollinearity problems, a back-elimination procedure was selected in the multivariate regression. in this type of regression, all variables are entered in a first step and then variables are sequentially removed based on partial correlation. this provides a parsimonious model based on the data, but not on theory. linear regressions assume that the relationship between the predictor and the outcome is linear. thus, we first tested whether this type of relationship was feasible for the ordinal variables. we calculated a series of analyses of variance (anovas) and investigated whether mean scores in outcomes across categories in the ordinal predictors suggested a linear relationship between both variables. this was the case for all predictors, except for "exercising frequency". the anova findings suggested that those that exercised were generally in a better mood, irrespective of the amount of exercise they performed. therefore, a dichotomous version of this variable, which was labeled as "exercised", was created. because the administration of measures was completely online, we checked the time spent to complete the survey and included several control items to control for fake or inconsistent responding to the survey (i.e., "select option never true in the current item"). due to the large number of analyses made and to reduce the risk of false positives and unimportant associations, the alpha level was corrected for multiple testing and set to 0.001. in total, 3608 respondents consented to participate into the study after reading the online information sheet. of these, 653 were eliminated because they did not provide any information and 272 were removed because they completed less than half of the survey, which did not include the mood questionnaire. thus, the final sample comprised 2683 respondents. an analysis of the control items and the time spent completing the survey did not suggest the need to eliminate further participants from the sample. the results of the descriptive analyses are either presented in tables 1 and 2 (behavioral/coping) or described in the following lines for readability reasons. the average age of participants was 34.86 years (sd = 13.74, range = 18 to 80). the majority of them were women (77.7%). at the time of assessment, most respondents were in a relationship (76.4%) and had completed postsecondary education studies (63.5%). a significant number of individuals indicated having lost their job due to the covid-19 pandemic (23.7%), while 45.8% of respondents reported working at the time of assessment. the representation of students in the sample was high (27.7%). only a small percentage of participants did not cohabitate at the time of assessment (8.8%) and cohabitation with an infected person was even more infrequent (0.8%). the majority of participants did not cohabitate with children (28.9%). house size and income were relatively similarly distributed across the sample. monthly home income was very diverse and ranged from less than 1000€ (8.8%) to more than 3500€ (17.6%). the percentage of individuals reporting a monthly income of 1001€-1500€, 1501€-2000€, 2001€-2500€, and 2501€-3000€ was 17.3%, 17.4%, 12.6%, and 9.4%, respectively. house sizes also largely varies across participants, with some living in homes of ≤ 70 m 2 (21.0%) or 71-90 m 2 (22.3%) and other living in houses of 91-110 m 2 (23.9%), 111-130 m 2 (13.3%), or >130 m 2 (19.5%). the majority of respondents perceived that they had a moderately or extremely low risk of covid-19 infection (68.0%) and indicated that they did not have a relative that would be considered as vulnerable to the covid-19, such as patients with immunosuppression, cancer, or severe respiratory conditions (74.3%). only 1.8% of participants reported taking psychotropic medication at the time of assessment. more than half of participants reported having changed their usual sleeping patterns due to the quarantine (54.9%). however, the majority of participants were somewhat-to-completely satisfied with the quality of their sleep in the previous night (67.5%). participants reported having slept an average of 7.31 h (sd = 1.25) the previous night. participants interacted with an average of 2.40 individuals (sd = 1.78) in person and 1.71 individuals (sd = 1.95) using videoconferences daily. certain activities (i.e., sitting/laying, text messaging, internet surfing, seeking covid-19 information, and watching tv/series/movies) were very frequent and were only never performed by less than 6% of respondents. other behaviors, such as exposing to sunlight (none = 19.0%) and exercising (none = 48.4%) were less common. when trying to cope with emotional distress and boredom, the most frequent activities were eating (not at all = 1.5%), watching tv (not at all = 11.4%), and cleaning/tidying (not at all = 13.5%). working/studying (not at all = 38.3%), videoconferencing (not at all = 39.4%), playing games with others (not at all = 51.3%), and exercising (not at all = 56.6%) were less frequently used as coping strategies. almost half of participants did not plan or only slightly planned their daily activities in advance (49.4%). up to 48.4% of respondents did not exercise at all during the past 24 h. see tables 1 and 2 for more details on behavioral/coping items and responses. status during the beginning of the quarantine (first three days) and comparison with data from the general population before the quarantine as indicated in table 3 , participants in the present study reported more depressed mood (t = 5.79, p < 0.001, d = 0.30) and anger (t = 4.81, p < 0.001, d = 0.25), as well as less vigor (t = −12.49, p < 0.001, d = 0.69) and friendliness (t = −9.41, p < 0.001, d = 0.47) compared to data from the general population previous to the current covid-19 crisis [17] . by contrast, the fatigue levels were lower in the present study sample (t = −5.75, p < 0.001, d = 0.34). anxiety levels were comparable across samples (t = −0.29, p = 0.774, d = 0.02). the results of the univariate regression analyses are reported in table 4 . some variables were significantly associated with all or almost all (four out of six) outcomes. these included younger , poor sleep quality (2.9 ≤ r 2 ≤ 10.9%), changes in usual sleep patterns (1.2 ≤ r 2 ≤ 2.9%), time spent sitting/laying (0.6 ≤ r 2 ≤ 6.3%), time spent internet surfing (2.1 ≤ r 2 ≤ 5.4%), eating to cope with distress (0.7 ≤ r 2 ≤ 2.5%), frustration intolerance (3.5 ≤ r 2 ≤ 2 0.2%), and neuroticism (6.5 ≤ r 2 ≤ 15.8%), which were overall associated with poor mood states. on the contrary, exercising (0.3 ≤ r 2 ≤ 5.3%), exercising to cope with distress (0.2 ≤ r 2 ≤ 6.3%), planning daily activities (0.2 ≤ r 2 ≤ 3.8%), extraversion (0.3 ≤ r 2 ≤ 4.9%), openness to experience (0.7 ≤ r 2 ≤ 4.6%), agreeableness (2.0 ≤ r 2 ≤ 12.3%), and conscientiousness (0.8 ≤ r 2 ≤ 3.3%) were associated with better outcomes in at least four out of six mood states. the use of videoconferencing to cope with distress was singular, as it was sometimes associated both with poor (i.e., depression and anxiety) and positive mood states (i.e., vigor and friendliness). the remaining variables were less consistently associated with mood states and are not described here in detail due to space limitations (see table 4 ). only a reduced number of variables were not related to any of the mood state (i.e., job loss due to the covid-19 crisis, number of pets, and cohabitation with a covid-infected person). as shown in table 5 , the results obtained with the results of the multivariate analyses were in the same direction as those reported in the univariate regression analysis. in particular, the majority of variables that were consistently and more strongly (larger r 2 ) associated with outcomes in a bivariate manner (i.e., age, sleep quality, time spent internet surfing, frustration intolerance, and neuroticism) were also uniquely associated with several outcomes even after controlling for the contribution of the remaining predictors. in all dichotomous variables, except gender and education, the reference value is "yes". for gender and education, the reference values are "female" and "≥12 years", respectively. among all categorical, non-dichotomous variables, only "exercising" was dichotomized because an analysis of differences in outcome scores across categories suggested that a linear association was adequately represented the relationship between the remaining ordinal variables and outcomes. * p < 0.001; in the r 2 columns, significant r 2 estimates at p < 0.001 are presented in bold. a categorical (dichotomous); b categorical (ordinal); c continuous. in all dichotomous variables, except gender and education, the reference value is "yes". for gender, the reference value is "female". among all categorical, non-dichotomous variables, only "exercising" was dichotomized because an analysis of differences in outcome scores across categories suggested that a linear association was adequately represented the relationship between the remaining ordinal variables and outcomes. * p < 0.001; the r 2 estimates are from the final model with the predictors that were retained after the backward elimination procedure. only variables that were retained for at least one predictor are included in the table for readability reasons. several calls for mental health investigation during the covid-19 pandemic have been made and numerous behavioral guidelines have been developed to try to minimize the emotional impact of the current crisis on the population [1, 19] . thus, this study aimed at investigating the emotional impact of the covid-19 pandemic and included an important comprehensive set of socio-demographic, behavioral, and cognitive correlates of well-being. a key strength of the current study refers to the fact that data was obtained just after the onset of the covid-19 quarantine in spain (first day during the evening to the end of the third day of quarantine). as anticipated, the mood of a sample of individuals at quarantine onset was generally poorer compared to a sample of individuals from the general population recruited before the current covid-19 [17] . additionally, we generally confirmed the majority of expected associations between socio-demographic, clinical, behavioral, and cognitive/personality factors and individual differences in mood status during the early phase of adaptation to quarantine (first three days). so far, most studies on the mental health consequences of quarantine and its correlates have been letters to the editor or commentary articles and a reduced number of original investigations have been conducted in china [19] . these studies suggest that the covid-19 crisis is indeed impacting negatively on the mental well-being of individuals. for example, one study with 1210 chinese respondents revealed moderate to severe depression, anxiety, and stress in 16.5%, 28.8%, and 8.1% of respondents, respectively [18] . another investigation during the covid-19 outbreak in wuhan (china) reported prevalence rates of depression, anxiety, or both of 48.3%, 22.6%, and 19.4%, respectively [20] . it is important to note that the aforementioned prevalence rates of mental distress do not imply that depression and anxiety problems were a consequence of covid-19 and could have existed before the crisis. to address this limitation, the present study compared mood levels of participants in the present study with those from past research before the covid-19 crisis began. our findings support the aforementioned idea that the current crisis or at least quarantine might exert a negative influence on the severity of depressed mood in the general population, although the obtained between-group differences were only small. in relation to anxiety and anger, the results only support the impact of quarantine on the latter. while this is only speculative, it is possible that anxiety, which could have been higher before quarantine due to infection risk, was actually reduced when confined at home (i.e., when risk of infection was low). in fact, note that only 10.7% of respondents perceived that they had a higher-than-average risk of infection. on the contrary, while the onset of quarantine might mitigate the impact of the covid-19 crisis on anxiety levels, it has been repeatedly shown that quarantine negatively impacts on anger [5] , which might be explained by the frustration associated with the consequences of restricted mobility in achieving important personal goals. the present study also evidenced that vigor and, to a lesser extent, fatigue, and friendliness might be diminished during the onset of quarantine or as a consequence of the covid-19 crisis. at first glance, the results on vigor and fatigue might seem contradictory. of course, it is possible that the sample used for comparison was very fatigued at the time of assessment, which might explain why our sample indicated being less fatigued. however, a distinction between fatigue (e.g., tired, exhausted, and weak) and vigor items (e.g., full of energy, lively, and active) might also shed light on the rationale behind the different direction of findings. in this sense, note that the most frequent activities indicated by individuals in the present study during quarantine onset were largely passive (i.e., sitting/laying, text messaging, internet surfing, seeking covid-19 information, and watching tv/series/movies). this, together with the fact that quarantine onset started on a sunday and imposed resting at home for many participants (note that half of them were not working), might explain why participants in our sample might have been less fatigued, but also less energetic (vigorous). one last finding in relation to mood status was that friendliness was lower in our sample than in the comparison group. friendliness is composed of adjectives like kind, considerate of others, and sympathetic. thus, the fact that this mood state was low in our sample might be problematic in a situation where pro-social behavior (e.g., respecting governmental recommendations in attempt to decrease the risk of spreading the disease) is of utter importance. while one would expect that this should have been enhanced in the face of the current situation, our results indicate that this mood state might be challenged during quarantine, which could explain why so many antisocial behaviors have occurred since the quarantine onset in spain (over half a million fines issued and almost 2000 arrests for violating confinement in one month only) [21] . regarding the correlates of well-being, it has been argued that collecting high-quality data during the current covid-19 crisis is crucial to update existent guidelines [22] . the present study might be an important step in this direction. overall, our results supported the majority of recommended lifestyles indicated by guidelines and experts (e.g., sleep self-care, exercising, planning some daily activities, and minimizing the time spent seeking covid-19 information and emotional eating) [6] [7] [8] [9] [10] [11] [12] . we also replicated the results from a study in china indicating that students and women were at higher risk for low mood [18] . overall, however, the contribution of these variables on mood states was modest (generally less than 5% explained variance by a single variable). exceptions to this were cognitive/personality characteristics, namely frustration intolerance and neuroticism, which explained up to 20.2% and 15.8%, respectively, of mood states. on the one hand, frustration intolerance refers to an inability to acknowledge ("cannot stand") the existence of discomfort in life [23] . in particular, the intolerance of emotions component taps into the difficulties in accepting difficult thoughts and feelings [15] . on the other hand, neuroticism is a personality trait characterized by a tendency to experience negative emotions in the face of threat, loss, or frustration [24] . both psychological factors have been consistently associated with poor mental and often physical health status of individuals and argued to predispose individuals to psychopathology [25, 26] . in the light of the previous and the large explained variance obtained in the present study, both frustration intolerance and neuroticism might be important factors to be considered to detect vulnerable individuals to quarantine onset. while changing neuroticism might require more structured interventions, one straightforward recommendation for the general population in the direction of increasing tolerance of emotions might be to acknowledge difficult emotions as part of the current situation (i.e., quarantine) without trying to get rid of them (e.g., by eating emotionally or seeking covid-19 information excessively). the present study limitations include the focus on cross-sectional data only, the limited number of days (i.e., only three), and the fact that analyses are based on linear regressions, which poses the question of whether we are leaving out of sight possible non-linear or interaction effects. however, none of the guidelines take non-linearity into account when making their recommendations, but this exceeds the scope of this paper and should be addressed in future studies. additionally, answers from three consecutive days were collapsed, which prevents us from exploring whether the correlation between study variables differed across days. this was done to reduce the already large number of statistical comparisons and because measures were obtained in three consecutive days as opposed to very different moments during quarantine. however, an important question for future research might be to explore whether the importance of correlates of mood remains unchanged or not at different stages during quarantine (e.g., whether frustration tolerance is not only important at the beginning of quarantine but also when individuals have been under quarantine for several weeks). note also that data from the general public used to compare average mood in the present study was obtained in 2013 and in a single region of spain. therefore, it is possible that the differences in time and place of data collection might have affected the results. in relation to generalizability of findings, it is also important to note that, despite answers were obtained from almost 2700 participants from all 17 regions in spain and the proportion of responses per region were consistent with the population numbers per region, the overrepresentation of females and young adults in the sample should be taken into account when considering the generalizability of the results. finally, it is important to consider that in the study we present correlates between several socio-demographic, behavioral, and personality/cognitive factors and mood status during the first three days of quarantine only. thus, because the strength of the obtained correlations was not compared against data before the quarantine or before the covid-19 crisis we cannot assume that the correlations found are due to quarantine or the covid-19 crisis. therefore, it is possible that the correlations found are a general phenomenon rather than a consequence of confinement or the covid-10 crisis. while acknowledging the previous shortcomings, the present study might as well add to the existing literature on the impact of the covid-19 crisis or quarantine on well-being and its correlates. an important finding was that the majority of recommendations made by renowned institutions and experts for adaptation to quarantine were supported, even though not all of them might be related to all mood states or, at least, to the same extent. in this sense, the study pointed to frustration intolerance and neuroticism as the most important vulnerability factors for low mood during quarantine onset. additionally and consistent with guidelines, behaviors like having a good quality of sleep, exercising, and planning daily activities were found to be associated with better mood, while the opposite relationship was found with spending a lot of time internet surfing, seeking coronavirus-related information, and sitting/lying for long periods. also, interestingly, a novel finding was that younger participants (young adults) presented poorer mood status. as a final remark, it is important to note the contribution of the majority of these variables on outcomes, particularly age, sleep quality, internet surfing, videoconferencing, frustration intolerance, and neuroticism, remained significant even after controlling for the role of all the other factors. this suggests that the previous variables might be relevant risk/protective factors to be considered together for prevention and treatment purposes. ultimately, these results might be important to guide psychological interventions in the face of the covid-19 in a more effective way, which is crucial in the current situation [13] . world health organization. mental health and psychosocial considerations during covid-19 outbreak; world health organization royal decree 463/2020, of march 14th, declaring the state of alarm for the management of the health crisis situation caused by covid-19. boe number 67 of march 14th the emotional impact of coronavirus 2019-ncov (new coronavirus disease) timely mental health care for the 2019 novel coronavirus outbreak is urgently needed the psychological impact of quarantine and how to reduce it: rapid review of the evidence american psychiatric association taking care of ourselves during infectious disease outbreaks simple recommendations to manage the quarantine the outbreak of covid-19 coronavirus and its impact on global mental health the consequences of the covid-19 pandemic on mental health and implications for clinical practice covid 19: impact of lock-down on mental health and tips to overcome psychological interventions for people affected by the covid-19 epidemic a shortened version of the profile of mood states the frustration discomfort scale: development and psychometric properties a very brief measure of the big-five personality domains abbreviated spanish version of the {poms} questionnaire for adult athletes and the general population immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china covid-19 and mental health: a review of the existing literature the psychological impact of the covid-19 epidemic on college students in china half a million fines and arrests made for violating confinement in one month multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science there's more than catastrophizing in chronic pain: low frustration tolerance and self-downing also predict mental health in chronic pain patients economic costs of neuroticism frustration intolerance: therapy issues and strategies benet-martínez, v. personality and the prediction of consequential outcomes this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord-012515-dxu7ajse authors: kim, sookyung; lee, hyeonkyeong; lee, hyeyeon; loan, bui thi thanh; huyen, le thi thanh; huong, nguyen thi thanh title: prioritizing training needs of school health staff: the example of vietnam date: 2020-08-01 journal: int j environ res public health doi: 10.3390/ijerph17155563 sha: doc_id: 12515 cord_uid: dxu7ajse competencies of school health staff (shs) members, including school nurses, are crucial to improving child and adolescent health. in vietnam, although shs members are dispatched to schools, they have limited training opportunities. this study identified shs members’ training needs in a province of vietnam. a cross-sectional, online survey was conducted with 204 shs members. the performance and importance of shs members’ competencies were measured using 59-items and rated by a 5-point likert scale. shs members’ training priorities were analyzed using the borich needs assessment and the locus for focus model. controlling infectious disease was the highest training priority while implementing health promotion programs was of relatively low priority. the high-priority training needs identified could be rendered mandatory in policy for continuing education of shs members. awareness of the importance of health promotion, which has been emphasized globally, should also be promoted via school health policy. these findings could guide development of future training programs for shs members. establishing children and adolescents' engagement in self-care is crucial to ensure their health in adulthood and ultimately reduce global health inequality [1] . earlier studies have provided evidence that risky behaviors established during adolescence can continue into adulthood, thereby becoming several leading causes of mortality and morbidity [2] . attention has been directed toward adolescence in low-and middle-income countries (lmics) as part of their commitment to achieve the 2030 sustainable development goals (sdgs) of ensuring healthy lives and promoting well-being for all, at all ages, and decreasing the incidence of non-communicable diseases, which represents the leading cause of preventable mortality [3] . as schools provide care and education for students for long periods, school is an important setting within which to promote adolescents' health [1] . well-designed school-based health interventions enable students to build competencies to prevent disease and promote health [4, 5] . however, the school health staff (shs) members responsible for school health service and education in lmics have limited capacity. therefore, global collaborative efforts are essential to improve key human resources on the frontline of ensuring students' health; implementation of best practices across countries could represent an improved strategy. shs members play a key role in identifying unmet health needs of school-aged children and promoting health in schools. it is essential to strengthen the ability of shs members to perform their roles adequately. shs members in lmics rarely have opportunities to engage in systematic education and training, and there is considerable variation in their competency [6] . in many countries, school nurses play an important role in promotion and prevention programs for school health, but in lmics, the proportion of shs members who are skilled health professionals is low [7] . in vietnam, shs members, including assistant doctors or nurses, are assigned to individual schools and usually attend a 1-day training session annually, but this does not occur regularly (tien le thi huong, personal communication, 26 july 2018). the role of shs members in vietnam is specified as "health records management of students and teachers, health education, first aid, care of general illness, and management of health equipment" [8] . however, systematic school health education and activities would likely be inadequate for students unless the practical competencies of shs members are developed through continuing training. thus, it is necessary to identify shs members' training needs prior to the development of training programs to improve their capacity. accordingly, the purpose of this study was to identify shs members' training needs in a province of vietnam through a global collaboration project. this study used a cross-sectional, descriptive design. it was conducted in quang tri province, one of 58 provinces in vietnam with a population of approximately 650,000 and an area of 4746 km 2 . quang tri province is located in central north vietnam and consists of two urban towns and eight rural districts. as the corresponding author's university had previously collaborated with a college in quang tri province for several years, this study was conducted in the province to develop a future training program for shs members. an shs member qualified as an assistant doctor or nurse is assigned to each school. in some schools, non-health professionals are responsible for practical work as shs members. the study targeted an entire sample of 243 shs members of all schools, including non-health professionals, responsible for school health in primary and secondary schools in quang tri province in vietnam. out of 243 shs members, 233 who had valid email addresses provided by department of education training (doet) in quang tri province were targeted in this study. the response rate was 96.1% (n = 224). twenty shs members were excluded because of missing data, outliers, or duplicate submissions. ultimately, the data of 204 shs members were included in the analysis. the training needs assessment questionnaire (tnaq) developed for the current study consists of three parts: perceived importance of competency for shs members (59 items), perceived performance of competency for shs members (59 items), and sociodemographic information (14 items). the competency items for shs members were developed in multiple steps ( figure 1 ): organizing initial items pertaining to shs members' competencies according to a literature review, back translation, expert review using a content validity index, pretest, and finalization. the items were scored using a five-point likert scale ranging from 1 (not important/confident) to 5 (very important/confident). the cronbach's alpha value assessing internal consistency reliability was 0.98 in this study. initial items pertaining to shs members' competencies in vietnam were developed using eight domains from the health teachers' job analysis [9] , which is consistent with roles of shs member proposed by school health law in korea and vietnam. one domain of "establishing healthy and safe physical environment" based on the monitoring and evaluation guidance for school health programs [10] . the initial questionnaire consisted of 59 items pertaining to shs members' training int. j. environ. res. public health 2020, 17, 5563 3 of 11 needs in nine domains: providing emergency care (domain 1), providing health education (domain 2), operating the school health room (domain 3), implementing health screening for students (domain 4), controlling infectious diseases (domain 5), establishing a healthy and safe physical environment (domain 6), providing health counseling (domain 7), implementing health promotion programs (domain 8), and developing professionalism (domain 9). initial items pertaining to shs members' competencies in vietnam were developed using eight domains from the health teachers' job analysis [9] , which is consistent with roles of shs member proposed by school health law in korea and vietnam. one domain of "establishing healthy and safe physical environment" based on the monitoring and evaluation guidance for school health programs [10] . the initial questionnaire consisted of 59 items pertaining to shs members' training needs in nine domains: providing emergency care (domain 1), providing health education (domain 2), operating the school health room (domain 3), implementing health screening for students (domain 4), controlling infectious diseases (domain 5), establishing a healthy and safe physical environment (domain 6), providing health counseling (domain 7), implementing health promotion programs (domain 8), and developing professionalism (domain 9). back translation was used to develop culturally appropriate measurements [11] . a bilingual translator, who was fluent in english and vietnamese and understood school health in vietnam, translated the english version into vietnamese. another english-vietnamese translator, who had not seen the original version, translated the vietnamese version back into english. research team members compared both versions in the original language for inconsistencies, mistranslations, and meaning. in the final step, a committee meeting was held between the research team members and another english-vietnamese translator who was not involved in the previous steps. content validity was assessed by three school health experts in korea and three school health experts in vietnam, consistent with the criteria outlined by lynn [12] . items with a content validity index of less than 0.80 were reviewed by three authors (sk, hl, and hyl) to determine whether the item was necessary for the purpose of the study. two items were deleted ("teaching cardiopulmonary resuscitation and first aid" and "providing group education," as they overlapped with other items), and two items were added ("providing counseling to students with mental or psychological trauma," as proposed by the doet in quang tri province, and "planning health promotion programs," as suggested by a korean expert). one item was modified from "providing counseling to students with abnormal health problems" to "providing counseling to students with health problems." this resulted in a total of 59 items for a pretest. back translation was used to develop culturally appropriate measurements [11] . a bilingual translator, who was fluent in english and vietnamese and understood school health in vietnam, translated the english version into vietnamese. another english-vietnamese translator, who had not seen the original version, translated the vietnamese version back into english. research team members compared both versions in the original language for inconsistencies, mistranslations, and meaning. in the final step, a committee meeting was held between the research team members and another english-vietnamese translator who was not involved in the previous steps. content validity was assessed by three school health experts in korea and three school health experts in vietnam, consistent with the criteria outlined by lynn [12] . items with a content validity index of less than 0.80 were reviewed by three authors (sk, hl, and hyl) to determine whether the item was necessary for the purpose of the study. two items were deleted ("teaching cardiopulmonary resuscitation and first aid" and "providing group education," as they overlapped with other items), and two items were added ("providing counseling to students with mental or psychological trauma," as proposed by the doet in quang tri province, and "planning health promotion programs," as suggested by a korean expert). one item was modified from "providing counseling to students with abnormal health problems" to "providing counseling to students with health problems." this resulted in a total of 59 items for a pretest. a pretest was conducted with five shs members who were working in schools in the research area, via an online survey [11] . no items were considered difficult to understand in a vietnamese context. ultimately, 59 items probing shs members' competencies were included in the final tnaq. in cooperation with quang tri medical college and the doet, an online survey was conducted. survey announcements were sent to all shs members via email. after reading an explanation of the study that was provided when accessing the online survey, shs members who wished to participate clicked a button to provide consent. twenty days later, the doet sent a reminder email to consenting shs members. data were collected from july 5 to 28, 2019. data were analyzed using ibm spss statistics for windows, version 25.0 (ibm corp., armonk, ny, usa). participants' characteristics were analyzed using means, standard deviation (sds), frequencies and percentages. a t-test was performed to compare shs member' performance levels according to general characteristics. perceived performance and perceived importance ratings provided by shs member were analyzed using means, sds, and paired t-tests. shs member' training needs were identified using the borich needs assessment [13] and the locus for focus model [14] . borich needs assessment identified the "what is" (performance level) and "what should be" (importance level), and weighted the "what should be" (importance level) of each item to determine the priority of items [13] . the priority of training needs was represented by an x-y plane using the locus for focus model [14] . the median value of the x axis shows the average score of the importance level, while that of the y axis shows the average score of discrepancy between the importance and performance level (i.e., first quadrant is higher than the average importance level and higher than the average discrepancy between the two levels). the number of items having priority in the borich needs assessment can be decided using the number of items included in the first quadrant (in the right upper quadrant) of the locus for focus model. top ranking consistent items of the borich needs assessment and items in the first quadrant from the locus for focus model represented the highest priority of training needs for shs members [15] . the study was approved by the institutional review board at the institution with which the first author was affiliated (irb no. y-2019-0004). before the online survey began, the study purpose, anonymity, and confidentiality were explained. participants were advised that clicking the "next" button indicated consent to participate. participants' mean age was 34.28 years (sd = 6.76). approximately 45.1% of participants were assistant doctors or nurses, and 54.9% reported other professions (e.g., accountant and librarian); 55.9% and 44.1% were primary and secondary school staff members, respectively. about 15.7% of the participants worked in schools in urban towns in quang tri province, and 28.9% of schools contained minority students. regarding characteristics related to school health, 66.7% of health education providers were shs members and 91.2% of schools provided regular heath education. of the participants, 17.2% did not receive training regarding school health within the past two years (table 1) . perceived performance levels of nurses or physicians' assistants (mean = 3.78) were significantly higher than those of non-health professionals (mean = 3.21; t = 5.06, p < 0.001). perceived performance levels of participants working in secondary schools (mean = 3.64) were significantly higher than those of participants working in primary schools (mean = 3.34; t = −2.59, p = 0.01). participants who received training in school health within the past two years (mean = 3.55) reported significantly higher performance than those who had not received such training (mean = 3.09; t = 2.92, p = 0.004). there was no significant difference in shs members' performance according to district (t = 0.33, p = 0.744) or whether schools contain minority students (t = −0.21, p = 0.837; table 1 ). participants' mean performance score over all items was 3.48 (sd = 0.86), whereas the overall average importance score was 4.35 (sd = 0.50). the average scores significantly differed between performance and importance (t = 13.65, p < 0.001) and all 59 items exhibited statistically significant differences between ratings of performance and importance ( table 2) . the average score for shs members' training needs was 3.79 according to the borich needs assessment. borich needs scores for all items in domain 5 (controlling infectious disease) were higher than the average borich needs score. borich needs scores for ≥ 50% of items were higher than the average score for domains 1 (providing emergency care), 4 (implementing health screening for students), and 9 (developing professionalism; table 2 ). there was considerable discrepancy in importance and performance in the locus for focus model ( figure 2 ). the first quadrant represented the highest priority, as the importance and discrepancy between importance and performance were higher than average. in total, 19 priority training needs were included in the first quadrant and eight of nine domains (all but domain 8, implementing health promotion programs). domain 5 (controlling infectious diseases), domain 1 (providing emergency care), and domain 4 (implementing health screening for students) included numerous items pertaining to priority training needs (table 3) . fourteen items were both in the 19 top priority items in the borich needs assessment and in the first quadrant of the locus for focus model. ten items, which were derived from only one of the borich needs assessment or the locus for focus model, were not given high priority in training needs (table 3) . were included in the first quadrant and eight of nine domains (all but domain 8, implementing health promotion programs). domain 5 (controlling infectious diseases), domain 1 (providing emergency care), and domain 4 (implementing health screening for students) included numerous items pertaining to priority training needs (table 3) . fourteen items were both in the 19 top priority items in the borich needs assessment and in the first quadrant of the locus for focus model. nine items, which were derived from only one of the borich needs assessment or the locus for focus model, were not given high priority in training needs (table 3 ). priority of training needs in the locus for focus model. figure 2 . priority of training needs in the locus for focus model. an online consensus development panel was assembled to obtain agreement regarding training needs and share the survey results. in total, 93 shs members who attended the 2019 annual shs members' training responded. all of the top 10 training needs for shs members were agreed upon through consensus, with percentages ranging from 92.5% to 98.9%. this was a nurse-led global health project that aimed to identify the priority of training needs to strengthen the capacity of shs members, who rarely have opportunities to continue professional development. it is worth mentioning that the cooperation of researchers from both countries was beneficial in conducting this needs assessment prior to designing a vietnam-specific training program, as integrating the needs and circumstances of shs members in vietnam and would benefit from evidence accumulated pertaining to korean school health teachers. as part of a global commitment to achieve sdg 3, the findings provide data to help establish training programs for shs members, who play key roles in providing quality school health service and improving health knowledge and healthy behaviors of students in lmics. the tnaq will be useful in future research in lmics to provide valid and reliable assessments of the performance and importance of shs members' activities. the domain of "controlling infectious diseases" was identified as a top priority area for shs members' training, as lower performance than average was reported while the domain was considered of higher than average importance for all competency items but one. specifically, "building a system of infectious disease control" and "monitoring and managing students with infectious diseases" represented the highest priority training needs. as suggested by kim and colleagues [16] , it is important to establish systems and action plans in schools that address outbreaks of pandemic diseases. in korea, school health teachers plan and take action in response to infectious diseases in schools appropriately according to the situation, by following an infectious disease manual [17] distributed by the ministry of education. for example, in general cases of infectious disease, school health teachers confirm vaccination completion of students and encourage vaccination for unvaccinated students; provide preventive education regarding infectious disease for students, parents, and school personnel; and monitor students at-risk of infectious disease and report infected students to public health centers [17] . during infectious disease outbreaks such as the middle east respiratory syndrome (mers), school health teachers are required to coordinate school health services, develop plans for distributing infection-control supplies, construct referral systems to public health centers and local clinics for screening, and provide health education for both parents and students for preventing infectious disease [18] . in resource-limited communities in lmics, shs members are expected to play a vital role in responding to both infectious diseases in general and outbreaks, which highlights the need for training programs. providing emergency care (domain 1) included the three top-ranking items requiring priority training. according to recommendations on the role of school nurses during emergencies by the national association of school nurses (nasn) [19] , training content for school nurses should include identifying hazards, serving on planning groups, building emergency response plans, and coordinating first aid response teams; these were identified in the current study as items that should be prioritized in shs members' training. where resources and accessibility of medical facilities are limited in lmics, it would be necessary to strengthen the capacity of shs members to appropriately manage medical emergencies in schools. nasn emphasized shs members as key persons to act as liaisons between community resources [19] . thus, shs members should be trained to organize community networks and link community transportation resources for urgent patient transfers. in a previous study [20] , school nurses who were well-trained in medical emergency response plans were confident when managing head/neck injury of students and determining the availability of emergency equipment. note that more than half of the shs members in the current study were non-professionals who reported low competency in several skills. therefore, considerable education regarding how to address emergencies should be provided to shs members. in addition to infectious and emergency care, the shs participants in this study exhibited high training needs in the areas of health screening, counseling students with mental or psychological trauma, and protecting children from danger from road traffic, animals, and fire. according to the american academy of pediatrics on school health [21] , schools should provide regular and developmental health screening for vision, oral health, hearing, height, and weight for secondary prevention in schools. it is interesting to consider counseling students with mental or psychological trauma and protecting children from danger from road traffic, animals, and fire. in a recent study of vietnamese adults, 46.9% had been exposed to a traumatic event in their life [22] . children of parents who have experienced traumatic events are likely to experience psychological problems, as evidenced by findings that children of war veterans with post-traumatic stress disorder (ptsd) experience more psychological issues than do children of veteran fathers without ptsd [23] . in addition, motorcycles are a major form of transportation in vietnam, and mortality of children and adolescents due to motorcycle accidents is high [24] . further, road traffic injuries are common among older adolescents and those who consume alcohol before riding motorcycles [24] . this suggests that training for shs members should include strategies to educate adolescents regarding the risks associated with motorcycling. no items were identified as being of high priority in "implementing health promotion programs" (domain 8) in the current study. the results are consistent with low levels of awareness of the importance of health promotion [25] and promoting healthy behaviors among adolescents [26] in lmics. however, the who has emphasized that schools are of strategic value for guiding preventive health behaviors as a key to health promotion [27] . the who has further stated that children and adolescents are the most important population for fostering the adoption of healthy lifestyles in the future [28] . in addition, as school-based health promotion programs exert positive effects on children's and adolescents' health [29, 30] , consideration should also be given to efforts to increase awareness about these issues among shs members in the process of developing the training program. providing continuous training for health professionals in areas with shortages of, and low accessibility to, medical resources is crucial [31] and would ultimately exert a significant effect on children's and adolescents' health [21] . the current study showed that non-health professionals (e.g., accountants and librarians) in charge of school health demonstrated significantly poorer performance than did health professionals, indicating an urgent need to develop the capacity of the former to provide school health. it is noteworthy that increased training and opportunities for continuous professional development could reduce variation in competency among types of shs professional [7] . the study was subject to some limitations. it is difficult to generalize the results regarding training needs to all shs members in lmics because the study was conducted in a single province of vietnam. in addition, training needs were examined only via an online survey. further research involving qualitative needs assessment is required to explore the training context in-depth. the current findings support the need for a policy of mandatory training for school health professionals, including nurses. training needs for health promotion were of low priority, but there is a need for political support for long-term health promotion programs for young people and efforts to increase awareness regarding the importance of this issue. this study was conducted to identify training needs of all shs members of a province in vietnam, one of the lmics, in close cooperation with a local college and provincial education department. therefore, this study's strength is that the results can be practically applied to training programs for shs members in the future. it is important to assess shs members' performance in each country at a local level and provide them with needs-based appropriate training. the current findings could be of utility for other developing countries in research and policy pertaining to shs members. this study consisted of a korean-vietnamese collaborative project to identify high-priority training needs of shs members in a province in vietnam. the findings provide empirical evidence that could inform the development of a vietnam-specific training program for shs members. shs members' competencies in lmics with limited resources could exert a significant effect on young people's health. training content should be organized to control infectious diseases and enhance the ability of shs members to manage emergency care in school settings. in addition, long-term health promotion should receive focus. variations in schools' commitment to health and implementation of health improvement activities: a cross-sectional study of secondary schools in wales youth risk behavior surveillance-united states the importance of a life-course approach to health: chronic disease risk from preconception through adolescence and adulthood universal school-based prevention for illicit drug use school-based education programmes for the prevention of child sexual abuse in urban and rural india, a standardized patient study showed low levels of provider training and huge quality gaps global overview of school health services: data from 102 countries. health behav join circular: regulations on school health work dacum job analysis on elementary health teachers' roles united nations educational, scientific and cultural organization world health organization. management of substance abuse-process of translation and adaptation of instruments determination and quantification of content validity a needs assessment model for conducting follow-up studies developing and managing open organizations: a model and method for maximizing organizational potential exploring how to 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supports in six low-and middle-income countries mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low-and middle-income countries standard for health promoting schools effects of the cope cognitive behavioral skills building teen program on the healthy lifestyle behaviors and mental health of appalachian early adolescents decreasing in-home smoking of adults-results from a school-based intervention program in vietnam school-based intervention programs for preventing obesity and promoting physical activity and fitness: a systematic review training needs assessment of health care professionals in a developing country: the example of saint lucia this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we express our appreciation to quang tri medical college and department of education training in quang tri province for their constant effort in this study. the authors declare no conflict of interests. key: cord-259149-svryhcgy authors: su, yue; xue, jia; liu, xiaoqian; wu, peijing; chen, junxiang; chen, chen; liu, tianli; gong, weigang; zhu, tingshao title: examining the impact of covid-19 lockdown in wuhan and lombardy: a psycholinguistic analysis on weibo and twitter date: 2020-06-24 journal: int j environ res public health doi: 10.3390/ijerph17124552 sha: doc_id: 259149 cord_uid: svryhcgy many countries are taking strict quarantine policies to prevent the rapid spread of covid-19 (corona virus disease 2019) around the world, such as city lockdown. cities in china and italy were locked down in the early stage of the pandemic. the present study aims to examine and compare the impact of covid-19 lockdown on individuals’ psychological states in china and italy. we achieved the aim by (1) sampling weibo users (geo-location = wuhan, china) and twitter users (geo-location = lombardy, italy); (2) fetching all the users’ published posts two weeks before and after the lockdown in each region (e.g., the lockdown date of wuhan was 23 january 2020); (3) extracting the psycholinguistic features of these posts using the simplified chinese and italian version of language inquiry and word count (liwc) dictionary; and (4) conducting wilcoxon tests to examine the changes in the psycholinguistic characteristics of the posts before and after the lockdown in wuhan and lombardy, respectively. results showed that individuals focused more on “home”, and expressed a higher level of cognitive process after a lockdown in both wuhan and lombardy. meanwhile, the level of stress decreased, and the attention to leisure increased in lombardy after the lockdown. the attention to group, religion, and emotions became more prevalent in wuhan after the lockdown. findings provide decision-makers timely evidence on public reactions and the impacts on psychological states in the covid-19 context, and have implications for evidence-based mental health interventions in two countries. the covid-19 (corona virus disease 2019) pandemic is a global health emergency that is having a profound impact on the physical and mental health of people [1] [2] [3] . many countries have taken strict quarantine measures as an intervention: cities locked down, school closure, mass gathering ban, public event prohibition, and self-isolation. a study conducted in china shows that lockdown has been effective in postponing the spread of covid-19 [4] . however, strict quarantine interventions may have negative impacts on mental health [5, 6] . it is essential to investigate the psychological effects of the lockdown which could make an influence on the execution of measures on epidemic containment. studies find that public reactions to sars (severe acute respiratory syndrome) in 2003 and the ebola virus disease in 2014 have impeded infection control to an extent [7, 8] . moreover, quarantine measures are making psychosocial impact on individuals more severe [9] . this study intends to explore how the lockdown affects the psychological states. the "first case" of covid-19 was identified in wuhan [10] , which was the epicenter of the coronavirus outbreak in china. to stop the spread of covid-19, china declared the lockdown of wuhan on 23 january 2020, which was the first city placed on lockdown during this pandemic in china and affected over 11 million people [11] . in europe, italy was the first country facing the pandemic [12] and taking actions (e.g., banned flights) [13] . lombardy in italy was the most affected area by covid-19 [14] . on 8 march 2020, the italian government announced a quarantine zone that covered most of northern italy, including lombardy. lombardy had a population of over 10 million, which was comparable with wuhan. this quarantine measure was considered as the most aggressive response taken in any region beyond china [15] . taken all these together, we chose wuhan and lombardy as research regions to investigate the impacts of the lockdown. recent studies used the self-report questionnaire approach to examine the psychological responses during the lockdown in different countries, including italy, india, and china [12, 16, 17] . however, these studies rely on retrospective and time-lagged surveys and interviews. these approaches have limitations in accessing psychological statuses before the lockdown. that is, there is recall bias inevitably when people are required to recall a past period in the retrospective study. social media plays a vital role in recording the reactions, opinions, and mental health features of social media users [18] previous studies suggest that the language use and psychosocial expressions on social media data provide indicators of mental health [19] [20] [21] . in china, sina weibo is the leading social media service provider. upon the end of 2019, the number of daily active users of sina weibo reached 222 million. twitter is one of the most-used social media platforms in italy. weibo and twitter provide vast amounts of user's online behavioral records for researchers. although there are some differences between weibo and twitter when comparing the functions and other features of platforms, they both serve as the online environment of expression and communication, providing us features of contents related to this study. thus, we collected chinese social media data from weibo and used twitter to acquire italian social media data. existing studies have widely used the language inquiry and word count (liwc) and confirmed it as a valid tool for psychometric analysis [22] . the liwc dictionary has multiple versions of different languages, including english [23] , french [24] , italian [25] , and dutch [26] . the liwc dictionary includes many word categories of linguistic features that are related to mental processes and human behaviors [22] . for example, the word category of personal pronouns reflects attentional allocation [22] . in this study, we used the simplified chinese version of liwc and italian liwc to measure people's psychological status before and after the lockdown in wuhan and lombardy, respectively. by using psycholinguistic analysis, we aim to identify the psychological effects of the lockdown on individuals in wuhan and lombardy. we downloaded active user's posts from weibo and twitter as our dataset. the research protocol was approved in advance by the ethics committee of the institute of psychology, chinese academy of sciences (approved number: h15009). we extracted the linguistic features using the simplified chinese liwc dictionary (scliwc) [27] and the italian liwc dictionary [25] . given both scliwc and italian liwc share liwc dictionary structure, there are many common words in scliwc and liwc. to make the result of wuhan and lombardy comparable, we only analyzed the common word categories between scliwc and italian liwc. the selection procedure of common categories is as follows: a native italian speaker who is fluent in english translated the names of italian liwc word categories into english. we translated the chinese names of scliwc word categories into english. 3. we selected the common names between two translation versions. as for the names sharing similar meanings, such as "tentative" from scliwc and "possibility" from italian liwc, we checked the meaning of words belonging to this word category in italian liwc and scliwc to determine whether the two names represented the same kind of word category. some word categories are unique in scliwc or italian liwc. by comparing, there are 26 word categories only existing in scliwc, such as quantity unit, interjunction, and tense mark words. in italian, people conjugate verbs when they follow different subjects. moreover, people can infer the subject of the sentence from verb conjugation. as the subject in a sentence is dropped sometimes, conjugations (i_verb, we_verb, you_verb, you_plural_verb, heshe_verb, they_verb) can reveal the use of pronouns more accurately compared to pronouns (i, we, you, you plural, heshe, them). thus, we regard the use of conjugations, the same as pronouns in our study. additionally, we found that 28 word categories only exist in italian liwc. in this study, we kept the common word categories in both scliwc and italian liwc and got 51 common word categories for further analysis. the chinese samples are from the weibo data pool containing 1.16 million active weibo users [28] . in this study, we selected active weibo users from the data pool by the following criteria: 1. published at least one original post on average each day from 9 january 2020 to 5 february 2020 (i.e., two weeks before and after the lockdown); 2. individual users only, excluding any organizations; 3. locate at "wuhan, hubei" by the geo-location in the user profile. we finally got 850 weibo users and downloaded their posts published from 9 january 2020 to 5 february 2020. for each weibo user, we divided the posts into two groups. for example, all posts published before the date 23 january 2020, are labeled as "before lockdown" group. in contrast, those posts published after the data 23 january 2020 (23 january included) are labeled as "after lockdown" group. we employed the textmind system to extract linguistic features [29] in each of the two groups for all sampled weibo users. then, we used the liwc dictionary containing 51 common word categories to extract psycholinguistic features and calculated word frequencies of each word category in the dictionary. the final dataset included the word frequencies of two groups from 850 weibo users. we sampled italian twitter users' messages as our twitter data. we downloaded tweets of users whose location authentication is lombardia, italy. there are 3,650,380 tweets acquired. we then selected italian twitter users as follows: 1. published at least one original tweet (not retweet) from 23 february 2020 to 21 march 2020 (that is, two weeks before and after the lockdown); 2. all tweets in italian only. we acquired 14,269 tweets from 188 unique twitter users. we divided these tweets into two groups as well. we gathered each user's tweets and labeled the tweets posted before 8 march 2020, as "before lockdown" tweets and tweets posted after 8 march 2020 (march 8 included) as "after lockdown" tweets, respectively. we filtered out the users if only emoji, numbers, web links, "@" and "#" were published in either "before lockdown" or "after lockdown" tweets. we finally acquired 120 twitter users. then, we extracted every user's linguistic features from "before" and "after" tweets by using the same dictionary used in weibo data and calculated word frequencies of each word category. we conducted wilcoxon tests to examine the differences between linguistic characteristics before and after the lockdown. spss (statistical product and service solutions) 26.0 (international business machines corporation, armonk, ny, usa). released 2019. ibm spss statistics for macintosh, version 26.0. was used during data analysis, which was published by ibm (international business machines corporation, armonk, ny, usa). in this study, we compared the word frequencies of 51 liwc categories before lockdown with after lockdown in wuhan. results showed that the frequencies of 39 word categories were statistically significantly different before and after wuhan lockdown. we identified 16 out of 39 significant categories with absolute values of effect size greater than 0.2, including function words (e.g., i, we), relative words (motion, time), personal concerns words (home, money, religion), affective process words (negative emotion, affect), social words (humans, social), and cognitive mechanism words (e.g., certain, inhibition). as shown in table 1 , the first-person plural pronoun is of high effect size (p < 0.001, effect size d = 0.674), which means users used more words of the first-person plural pronoun significantly after the lockdown. in addition, weibo users mentioned more in religion, social, negative emotion, home, affect after wuhan lockdown. meanwhile, we found significant decreases in the frequencies of some word categories, such as motion, i, money, and time after the lockdown. table 1 . word categories with significant differences between "before" and "after" in weibo (n = 850). dictionary; m1-the mean of the "before lockdown" group; sd1-the standard deviation of the "before lockdown" group; m2-the mean of the "after lockdown" group; sd2-the standard deviation of the "after lockdown" group. we compared the word frequencies of the 51 liwc categories before and after lombardy lockdown (8 march 2020) . results showed that the frequencies of 10-word categories were significantly changed. among them, the number of word categories with absolute values of effect size greater than 0.2 is five-word categories, including personal concerns words (leisure, home), affective process words (anxiety), and cognitive mechanism words (discrepancy, possibility). as shown in table 2 , there are increases in the frequencies of discrepancy, home, leisure, and possibility. meanwhile, we observed significant decrease in the frequency of anxiety after the lockdown. table 2 . words with significant changes between "before lockdown" and "after lockdown" in lombardy (n = 120). english liwc-language inquiry and word count; m1-the mean of the "before lockdown" group; sd1-the standard deviation of the "before lockdown" group; m2-the mean of the "after lockdown" group; sd2-the standard deviation of the "after lockdown" group. we presented the word categories whose frequencies significantly changed after the lockdown both in wuhan and lombardy in table 3 , including home and discrepancy. in both wuhan and lombardy, the frequencies of home and discrepancy words increased after a lockdown. the present study uses the chinese version of liwc and italian version of liwc to extract the psycholinguistic features from social media users' posts. examinations of the features allow us to access the changes of psychological status before and after the lockdown in wuhan and lombardy. the frequencies of some word categories increase in both wuhan and lombardy after the lockdown, including discrepancy and home words. these linguistic features imply that social media users' psychological states were impacted after the covid-19 lockdown, in both wuhan and lombardy. the increased use of home words is related to mobility control after the lockdown in wuhan and lombardy. researchers estimated that mobility and social contacts in china during the lockdown dropped about 80%, concerning a baseline set on 1 january 2020 [30] . moreover, google reported a 23% increase in residential location activity in lombardy during lockdown compared to baseline [31] . these reports indicate people spend more time at home and spend less time outdoors during a lockdown, which is consistent with more use of home words. the frequency of discrepancy words increases after the lockdown in wuhan and lombardy. besides, we observe the increased use of inhibition and certain words after the lockdown in wuhan. previous study suggests that the uses of discrepancy, inhibition, and certain words reflect the change of degree of cognitive processing [32] . furthermore, cognitive processing indicates that individuals make efforts to make sense of the environment [32] . residents in wuhan and lombardy attempt to figure out what has happened after the lockdown. thus, they could adjust their attitudes and lifestyles to accommodate new circumstances during the covid-19 pandemic. we observe there are some differences between wuhan and lombardy after a lockdown in the use of liwc word categories. we find significant changes in three-word categories in lombardy, including tentative, anxiety, and leisure words. the use of tentative words increases after a lockdown in lombardy. the previous study shows that people may use tentative language (e.g., maybe, perhaps, guess) when they feel uncertain or insecure about their topic [22] . our findings suggest that people tend to use tentative words during the lockdown. losing direct social contacts during the lockdown contributes to make residents feel losses of recreation, freedoms, and supports [1] . such a sense of loss means losing control of their healthy life, and people are likely to feel uncertain about the upcoming situation. tweets reveal that people in lombardy express such feelings on social media. however, we do not observe such change in wuhan, suggesting that people in wuhan do not convey the emotions of uncertainty in their posts on weibo. our results show that twitter users in lombardy use more leisure words in their posts after the lockdown. the increased use of leisure words implies more focus on leisure activities after a lockdown in lombardy. according to the news reports from cnbc (consumer news and business channel), italians turn to music to boost morale during lockdown [33] , which might be expressed in the use of leisure in tweets. on the contrary, we do not find the same change in the use of leisure words in wuhan. with the rapid growth of the pandemic, some people might focus more attention on the latest news of this disease on weibo and discuss less about leisure after the lockdown. moreover, some people may talk more about leisure and recreation after the lockdown, considering that the lunar new year holiday was in the lockdown period (25 january 2020, is the spring festival in china). considering these two facets, we may find it reasonable to observe no change in the use of leisure words in wuhan. the use of anxiety words decreases in lombardy. anxiety reveals self-reported stress [34] . our results imply that people feel less stressed after lombardy lockdown. however, people do not experience any change of stress in wuhan. researchers find that unrealistic optimism is more evident for european north americans [13] , which might be related to the different responses in the level of stress between lombardy and wuhan after the lockdown. however, our results are not consistent with existing studies [12, 35] . rossi and colleagues consider that the strict measures of the lockdown in italy serve as an unprecedented stressful event [12] . besides, ahmed and colleagues find that 29% of respondents report different levels of anxiety related to lockdown at home in china [35] . such differences could be due to different research methods, design, measurements, and timeframe used in the study. some word categories are changing significantly after the lockdown only in wuhan. the uses of first-person plural pronouns, second-person plural pronouns, religion, social, negative emotions, humans, certainty, affect, inhibition, and prepositions words increase. in contrast, the uses of motion, first-person singular pronouns, time, and money words decrease after the lockdown in wuhan. in wuhan, the uses of the first-person plural pronouns, second-person plural pronoun increase after a lockdown, while the use of first-person singular pronoun decreases. previous reports confirm that first-person singular pronouns show attention to the self, whereas most other pronouns suggest attention to other individuals [36] . moreover, "we" implies a sense of group identity sometimes [37] . results suggest that people switch their attention from themselves to others and the communities after the lockdown. besides, the increased use of "we" indicates that people focus more on the group, become more united, and share more group identity after a lockdown, which is consistent with some researchers' opinions [1] . china has a collectivistic culture, and italy has an individualistic culture [38] . results show that the increased use of other pronouns and decreased use of first-person singular pronouns suggest a collectivistic culture in china. at the same time, the absence of such a consequence in lombardy might be related to the individualist culture. researchers find that people sharing collectivist values stress more communal coping as a resource to cope with collective traumatic events [39] , which is consistent with our research conducted in the context of the lockdown. holmes and colleagues find that higher levels of the use of emotion words indicate more immersion in the negative event [40] . in the study, we find that a higher degree of immersion [22] evidenced by the frequent use of emotion words (negative emotion and affective process words). therefore, people in wuhan might get more emotional and are at a deeper level of immersion in negative emotions after the lockdown. however, we do not observe such a situation in lombardy. besides, we also find a decrease in the use of motion words after a lockdown in wuhan. our results are consistent with the previous mobility study of wuhan [41] , suggesting that stringent mobility control leads to the reduction of movement in wuhan. google's location mobility report in lombardy shows an 85% decrease in activities at transit stations, a 57% drop in activities at workplaces, an 86% drop in activities at parks, and a 94% drop in activities at retail and recreation from 15 march 2020 to 26 april 2020. however, our results do not identify a significant change of mobility in the use of motion words in lombardy. the increased use of social words in wuhan after the lockdown suggests the focus on social concerns and social support [22] . social support can make people feel better about their situation and reinforce the belief that they have access to support resources [16, 42] . thus, seeking social support is considered adaptive for people during a lockdown. in contrast, we do not observe such a change in lombardy. table 1 shows increases in the uses of religion and humans words, while decreases in the uses of money and time words after wuhan lockdown. content word categories explicitly reveal where individuals are focusing, including death, sex, and money [22] . moreover, our results suggest people focus more on humans and religion, while less on money and time during the lockdown. the previous study finds that religion can bring more positive and comforting emotions, and people tend to use it when suffering from emergencies such as stress or death [43] . the increases in the use of religion words suggest an adaptive behavior during the lockdown. moreover, the decreased use of money words may relate to fewer transactions under strict restrictions. in contrast, we do not identify any changes in these word categories among lombardy tweets. this result in lombardy tweets suggests that residents in lombardy do not change their focus level on religion, human, time, and money after lockdown. besides, we find an increase in the use of prepositions. previous research shows that prepositions signal more complex expression and detailed information about a topic [44] . the increased use of prepositions in wuhan indicates broader and more in-depth discussions that occurred on weibo after lockdown. however, such a change is not identified in lombardy. study findings have implications for decision-makers, public health authorities, and practitioners. first, considering the efforts of adjusting to the changing environment in both wuhan and lombardy after the lockdown, decision-makers should ensure the supply chain functions as usual to ensure people's confidence in having the control of their lives. besides, public health authorities and practitioners could adjust their focus of service given the changes in residents' attention after lockdown. for example, people in wuhan expressed more stress and negative emotions, public health authorities and practitioners should take interventions to comfort them and relieve stress, such as the online consulting service and indoor activities. notably, the support for individuals with pre-existing mental or physical health issues is also needed. meanwhile, people did not show significant stress in lombardy. public health communities and practitioners might focus more on the popularization of pandemic prevention knowledge and the reinforcement of protection awareness. there are several limitations. first, our samples were from selected active social media users only. the results have a limitation in generalizing to the whole population. second, language differences exist between chinese and italian. while processing italian text, some inevitable errors may occur because of the apostrophe. third, we do not have access to the users' ip, and location authentication is self-reported. there are some studies also applying self-reported location authentication to identify users' locations [45] . fourth, the bias existing in two different platforms possibly influences the results of our study. twitter users generally use more hashtags than weibo users, which shows that twitter users seem to be more eager to publicize their posts [46] . in addition, weibo users have a stronger tendency to post positive content compared to twitter users [46] . considering these differences between twitter and weibo, future studies should find methods to deal with these differences to avoid biases when employing data from weibo and twitter. this study examined the changes in psycholinguistic features before and after a lockdown in wuhan and lombardy. we compared the differences in frequencies of liwc word categories before and after lockdown and found that the number of word categories whose frequencies were significantly changed is more in wuhan than in lombardy. we found significant changes in the use of function words, relative words, personal concerns words, affective process words, social words, and cognitive mechanism words among wuhan users' posts. we also found significant changes in the frequencies of personal concerns words, affective process words, and cognitive mechanism words in lombardy. individuals focus more on home and express more levels of the cognitive process after a lockdown in both wuhan and lombardy. in lombardy, the level of stress decreases, the use of leisure increases. in wuhan, people convey more emotion expressions, more feelings of uncertainty, and more focus on groups after the lockdown. results inform decision-makers, public health authorities, and practitioners the potentially different impacts of city lockdown on individuals in the two countries, and contribute to the cultural-based psychological responses. author contributions: t.z., j.x., and y.s. were responsible for study design. x.l., j.c., and w.g. were responsible for data collection. y.s., p.w., c.c., and t.l. were responsible for data analysis. y.s., j.x., and t.z. were responsible for data interpretation. y.s. wrote the first draft of the manuscript. y.s., j.x., and t.z. contributed to the final draft. all authors have read and agreed to the published version of the manuscript. multidisciplinary research priorities for the 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web-based survey machine learning on big data from twitter to understand public reactions to covid-19. arxiv 2020 covid-19 disease outbreak forecasting of registered and recovered cases after sixty day lockdown in italy: a data driven model approach covid-19 pandemic in italy. available online a descriptive study of indian general public's psychological responses during covid-19 pandemic lockdown period in india immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china using social media to explore the consequences of domestic violence on mental health a multi-label, semi-supervised classification approach applied to personality prediction in social media using linguistic features to estimate suicide probability of chinese microblog users discovering shifts to suicidal ideation from mental health content in social media the psychological meaning of words: liwc and computerized text analysis methods the development and psychometric properties of liwc2007; liwc la version française du dictionnaire pour le liwc: modalités de construction et exemples d'utilisation the italian liwc dictionary de nederlandse versie van de 'linguistic inquiry and word count'(liwc) developing simplified chinese psychological linguistic analysis dictionary for microblog predicting active users' personality based on micro-blogging behaviors improving user profile with personality traits predicted from social media content covid-19 outbreak response: a first assessment of mobility changes in italy following national lockdown covid-19 community mobility reports analyzing songs used for lyric analysis with mental health consumers using linguistic inquiry and word count (liwc) software. theses diss coronavirus italy: italians are singing songs during lockdown detecting well-being via computerized content analysis of brief diary entries epidemic of covid-19 in china and 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twitter the authors thank fiorella foscarini at university of toronto for fruitful discussions in the analysis of italian texts, and sijia li at institute of psychology, chinese academy of sciences for helpful suggestions in the data analysis. the authors declare no conflict of interest. key: cord-012022-r3xkpwte authors: keeble, matthew; adams, jean; sacks, gary; vanderlee, lana; white, christine m.; hammond, david; burgoine, thomas title: use of online food delivery services to order food prepared away-from-home and associated sociodemographic characteristics: a cross-sectional, multi-country analysis date: 2020-07-17 journal: int j environ res public health doi: 10.3390/ijerph17145190 sha: doc_id: 12022 cord_uid: r3xkpwte online food delivery services like just eat and grubhub facilitate online ordering and home delivery of food prepared away-from-home. it is poorly understood how these services are used and by whom. this study investigated the prevalence of online food delivery service use and sociodemographic characteristics of customers, in and across australia, canada, mexico, the uk, and the usa. we analyzed online survey data (n = 19,378) from the international food policy study, conducted in 2018. we identified respondents who reported any online food delivery service use in the past 7 days and calculated the frequency of use and number of meals ordered. we investigated whether odds of any online food delivery service use in the past 7 days differed by sociodemographic characteristics using adjusted logistic regression. overall, 15% of respondents (n = 2929) reported online food delivery service use, with the greatest prevalence amongst respondents in mexico (n = 839 (26%)). online food delivery services had most frequently been used once and the median number of meals purchased through this mode of order was two. odds of any online food delivery service use were lower per additional year of age (or: 0.95; 95% ci: 0.94, 0.95) and greater for respondents who were male (or: 1.50; 95% ci: 1.35, 1.66), that identified with an ethnic minority (or: 1.57; 95% ci: 1.38, 1.78), were highly educated (or: 1.66; 95% ci: 1.46, 1.90), or living with children (or: 2.71; 95% ci: 2.44, 3.01). further research is required to explore how online food delivery services may influence diet and health. according to global estimates from 2016, 11% of men and 15% of women were living with obesity, which has been associated with multiple co-morbidities [1, 2] . whilst the drivers of obesity are complex, the role of excess calorie intake through consumption of food prepared away-from-home has been recognized in previous research [3] [4] [5] . food prepared away-from-home is often energy dense, high in fat and salt, and less healthy than food prepared at home, and more frequent consumption has been associated with elevated bodyweight [6] [7] [8] [9] [10] . food prepared away-from-home is typically served ready to consume and has become a major contributor to overall dietary intake [11, 12] . in the usa, for example, food prepared away-from-home accounted for over 50% of total food expenditure in 2018 [13] . traditionally, this food may have been purchased through 'conventional' modes of order whereby customers would visit food outlets in-person or contact food outlets directly to place orders before collection or delivery. third-party platforms that facilitate online ordering and delivery, referred to throughout as 'online food delivery services', provide an alternative mode of order that appears to have grown in popularity [14] . whilst business models vary, online food delivery services typically operate as intermediaries between customers and food outlets [15] . customers place orders through online platforms, their orders are forwarded to food outlets where meals are cooked, and once ready, meals are delivered to customers by couriers working for the food outlet or the online food delivery service [14, 16] . in 2020, prominent online food delivery services just eat (including subsidiaries) and uber eats, were available in 13 countries, deliveroo was available in 12 countries, and grubhub was established in many cities across the usa [17] [18] [19] [20] . online food delivery service availability has been forecast to increase, which could lead to greater use. in turn, this could increase the purchase and consumption of food prepared away-from-home [21] . to our knowledge, there is currently a limited understanding about the nutritional quality of food items sold through online food delivery services. nonetheless, given that food sold through online food delivery services is primarily prepared in existing food outlet facilities [15] , it may have a similar nutrient profile to food prepared away-from-home ordered in conventional ways. as such, online food delivery services could contribute to excess calorie intake and adverse health outcomes [6, 7, 22] . accordingly, interventions to reduce online food delivery service use or to improve the nutritional quality of food that is available, may be called for in the future. previous research into online food delivery services is limited. a narrative review identified business reports stating that convenience and choice of food outlet were potential drivers of online food delivery service use, supporting findings from malaysia and indonesia [16, 23] . a further study investigated the availability of food outlets through an online food delivery service in one city in each of australia, the netherlands, and the usa [24] . in each city, a diverse range of food types were available and the number of food outlets that were available differed by area level deprivation. to date, the prevalence and frequency of online food delivery service use and the sociodemographic characteristics of online food delivery service customers have not been investigated, and thus remain poorly understood. understanding how often online food delivery services are used and the sociodemographic characteristics of current online food delivery service customers will establish a baseline against which future use can be compared, allow any future interventions to be targeted towards frequent users, serve as an indicator of potential public health harm and of the need for further research. in this study, we aimed to describe the prevalence and frequency of online food delivery service use, investigate associations between online food delivery service use and sociodemographic characteristics, and describe how online food delivery service customers used other modes of order to purchase food prepared away-from-home, in and across five upper-middle or high-income countries. we used cross-sectional data from the international food policy study (ifps), conducted in australia, canada, mexico, the uk, and the usa in november 2018. data collection methods have been described elsewhere [24] . briefly, data were collected via self-completed online surveys from adults aged 18 years or over, recruited through nielsen consumer insights global panel and their partners' panels. panelists were screened for eligibility and quota requirements based on device screen size, age, and sex. email invitations containing links to an online survey in national languages were sent to a random sample of eligible panelists in each country. respondents provided consent prior to survey completion. the ifps was reviewed by and received ethics clearance through a university of waterloo research ethics committee (ore# 21460). all respondents were asked: "during the past 7 days, how many meals did you get that were prepared away-from-home in places such as restaurants, fast food or takeaway places, food stands, or from vending machines?". a similar question has been asked in previous research [25, 26] . respondents who had purchased at least one meal prepared away-from-home reported the number of meals ordered: "using a food delivery service (e.g. country specific examples) and delivered", "directly from a restaurant and delivered", "at a restaurant/food outlet within 5 minutes of your home", and "at a restaurant/food outlet more than 5 minutes away from your home". country-specific examples of online food delivery services available in each country included uber eats (all countries), just eat (canada, mexico, uk), deliveroo (australia, uk), foodora (australia), skipthedishes (canada), and grubhub (usa). in our analyses, we collapsed "at a restaurant/food outlet within 5 minutes of your home" and "at a restaurant/food outlet more than 5 minutes away from your home" into a single category: 'directly from food outlets in-person'. we included sex, age, ethnicity, education, body mass index (bmi), and living with children aged under 18 years as independent variables. age was reported in years (continuous). ethnicity was reported as the group that best described racial or ethnic backgrounds. we dichotomized responses into 'majority' (white, predominantly english speaking or not indigenous) and 'minority' (all other responses). education was reported as the highest level completed. we categorized respondents as having: 'low' (high school completion or lower), 'medium' (some post-high school qualifications), or 'high' (university degree or higher) levels of education, and used this variable as a marker of socioeconomic status [27] . height and weight were reported in either metric or imperial units. we calculated bmi (kg/m 2 ) and grouped respondents by world health organization categories: 'underweight' (bmi < 18.5), 'normal weight' (bmi 18.5-24.9), 'overweight' (bmi 25.0-29.9), or 'obesity' (bmi ≥ 30) [28] . we collapsed the 'underweight' and 'normal weight' categories into a 'not overweight' category (bmi < 25.0), and as individuals with greater bmi may not always report their height and weight, we included respondents with missing data for this variable and categorized them as 'missing' [29, 30] . living with children aged under 18 years was reported as a binary variable. in total, 22,824 respondents completed the online survey. we excluded respondents with missing data for variables of interest (except for bmi), when the total number of meals purchased away-from-home and the number of meals purchased through each mode of order summed did not match, or when the total number of meals purchased away-from-home in the past 7 days exceeded 21 (n = 2164). we considered 21 to be the maximum number of meals that could be purchased away-from-home based on daily consumption of three meals in the past 7 days. the final analytical sample included 19,378 respondents. to reduce non-response and selection bias, we applied post-stratification sample weights. weights were constructed using population estimates from the census in each country based on age, sex, region, ethnicity (except in canada) and education (except in mexico) [24, 31] . in each country, we determined the prevalence of online food delivery service use by identifying respondents who reported that they had used an online food delivery service at least once in the past 7 days. for these 'online food delivery service customers' we identified the frequency of online food delivery service use and calculated the number and proportion of all meals purchased away-from-home for each mode of order ('online food delivery services', 'directly from food outlets for delivery' and 'directly from food outlets in-person'). for respondents who had purchased at least one meal prepared away-from-home directly from food outlets for delivery or in-person but had not used an online food delivery service ('non-online food delivery service customers'), we calculated the number and proportion of all meals purchased away-from-home 'directly from food outlets for delivery' and 'directly from food outlets in-person'. in analyses, we used online food delivery service use as our dependent variable. as data were not normally distributed, we dichotomized respondents into any online food delivery service use in the past 7 days or not. we used pearson's χ 2 to compare differences in sociodemographic characteristics of online food delivery service customers in each country. to investigate associations between our dependent variable and sex, age, ethnicity, education, bmi, and living with children aged under 18 years, across all countries combined, we used logistic regression following a sequential modelling strategy. model 0 was unadjusted, model 1 was adjusted for all independent variables except education, to investigate variation by individual-level socioeconomic status, and model 2 was maximally adjusted [32, 33] . to investigate differences in online food delivery service use between countries, we used separate, maximally adjusted, logistic regression models with each country as the reference category. we investigated differences in prevalence of online food delivery service use and independent variables between countries by adding a two-way interaction term (country x independent variable) to separate maximally adjusted logistic regression models and used post-estimation wald tests to determine interaction term significance. when interaction terms were significant, we stratified analyses by country. we used stata version 15.1 (statacorp llc., college station, tx, usa) to complete analyses in 2019, with a significance threshold of p < 0.05 used throughout. amongst our sample, 78% (n = 15,093) had purchased at least one meal prepared away-from-home in the past 7 days; 15% (n = 2929) had used an online food delivery service at least once, and 63% (n = 12,163) had purchased food prepared away-from-home directly from food outlets for delivery or in-person, but had not used an online food delivery service. overall, more than half of our sample were female or identified with an ethnic majority, most had low education, over 20% were living with obesity, the median age was 47 years, and less than 30% lived with children aged under 18 years (supplementary material: table s1 ). overall, more than half of the 2929 online food delivery service customers were male, identified with an ethnic majority, were highly educated, or were living with children aged under 18 years, while around 40% were living with overweight or obesity, and the median age was 33 years (table 1) . sociodemographic characteristics of respondents that had purchased at least one meal prepared away-from-home directly from food outlets for delivery or in-person, but had not used an online food delivery service (n = 12,163), are shown in supplementary material (table s2) . around half of respondents that reported any online food delivery service use in the past 7 days, had used this mode of order once (supplementary material: figure s1 ). table 2 reports the modes of order used to purchase meals prepared away-from-home. overall, online food delivery service customers ordered a median of two meals prepared away-from-home through an online food delivery service, which represented 36% of all meals purchased away-from-home. online food delivery service customers also ordered a median of one meal directly from food outlets for delivery and two meals directly from food outlets in-person. overall, the median number of meals that non-online food delivery service customers ordered directly from food outlets for delivery was two, which was the same as the median number of meals ordered directly from food outlets in-person. note: a -unless specified, data reported as n (%). b -p values from pearson's χ2 test. c -online food delivery service customers had purchased at least one meal prepared away-from-home through an online food delivery service in the past 7 days. table 2 . modes of order used in the past 7 days to purchase meals prepared away-from-home. note: a -p value from pearson's χ 2 test. b -online food delivery service customers had purchased at least one meal prepared away-from-home through an online food delivery service in the past 7 days. c -data reported as median (interquartile range (iqr)) number of meals, and median (iqr) proportion of all meals purchased away-from-home, per person. d -non-online food delivery service customers had purchased at least one meal prepared away-from-home directly from food outlets but not through an online food delivery service, in the past 7 days. sociodemographic correlates of any online food delivery service use in the past 7 days from unadjusted and partially adjusted models are reported in supplementary material (table s3 ). figure 1 reports findings from the maximally adjusted model. overall, there were greater odds of online food delivery service use amongst respondents who were male (or: 1.50; 95% ci: 1. 35 figure 1 . associations between prevalence of any online food delivery service use in the past 7 days and sociodemographic characteristics (n = 19,378). data are from 2018, collected through the international food policy study, analyzed using adjusted logistic regression a . note: a -reference groups: ethnicity-majority, education level-low, body mass index (bmi) category-not overweight. the greatest prevalence of any online food delivery service use in the past 7 days was amongst respondents in mexico (n = 895 (26%)). respondents in canada had lower odds of online food delivery service use compared to respondents in all other countries, whilst respondents in the uk and mexico had greater odds compared to respondents in all other countries (table 3) . amongst online food delivery service customers in australia, mexico, and the usa, the median number of meals ordered through online food delivery services per person, was two, whereas in canada and the uk, the median number, per person, was one ( table 2) . there were significant between-country interactions. the association between online food delivery service use in the past 7 days and each of age (p < 0.0001), living with children aged under 18 years (p = 0.037), sex (p < 0.0001), and education (p < 0.0001) varied between countries (supplementary material: table s4 ). the greatest prevalence of any online food delivery service use in the past 7 days was amongst respondents in mexico (n = 895 (26%)). respondents in canada had lower odds of online food delivery service use compared to respondents in all other countries, whilst respondents in the uk and mexico had greater odds compared to respondents in all other countries (table 3) . amongst online food delivery service customers in australia, mexico, and the usa, the median number of meals ordered through online food delivery services per person, was two, whereas in canada and the uk, the median number, per person, was one ( table 2) . there were significant between-country interactions. the association between online food delivery service use in the past 7 days and each of age (p < 0.0001), living with children aged under 18 years (p = 0.037), sex (p < 0.0001), and education (p < 0.0001) varied between countries (supplementary material: table s4 ). figures 2-5 report country-stratified findings. odds of online food delivery service use in the past 7 days were lower per additional year of age amongst respondents in all countries. respondents who lived with children aged under 18 years had greater odds of online food delivery service use in all countries, with the strongest association observed amongst respondents in the usa (or: 3.22; 95% ci: 2. 49, 4.20) . there was no difference in odds of online food delivery service use by sex amongst respondents in mexico (or: 1.02; 95% ci: 0.85, 1.23), whereas males in all other countries had greater odds of online food delivery service use. respondents with high (versus low) levels of education had greater odds of online food delivery service use in all countries except the uk (or: 0.87; 95% ci: 0.67, 1.13). to our knowledge, this is the first study in the published international literature that has examined the prevalence and frequency of online food delivery service use and identified sociodemographic characteristics of online food delivery service customers. our findings from multiple countries provide knowledge about the individual and wider contextual factors that may relate to online food delivery service use. overall, 15% of respondents across australia, canada, mexico, the uk, and the usa reported online food delivery service use in the past 7 days, however, almost two thirds of respondents had purchased food prepared away-from-home directly from food outlets but had not used an online food delivery service. online food delivery services were most frequently used once in the past 7 days. overall, online food delivery service customers ordered a median of two meals through an online food delivery service, and the median proportion of all meals purchased away-from-home ordered through an online food delivery service was more than 30%. respondents who were male, younger, with higher education, lived with children aged under 18 years, or that identified with an ethnic minority had greater odds of online food delivery service use. respondents in mexico and the uk had greater odds of online food delivery service use compared to respondents in other countries, and whilst correlates of online food delivery service use were similar in each country, the strength of associations varied. as the first study to investigate the prevalence and frequency of online food delivery service use in and across multiple countries, we are unable to conclude that the levels we identified are relatively high or low. nonetheless, our findings regarding the modes of order used to purchase food prepared away-from-home provide novel insight into how multiple ways of purchasing food prepared away-from-home may coexist. when having food delivered, those who reported any online food delivery service use in the past 7 days appeared to favor this mode of order compared to ordering directly from food outlets. our observation could support the suggestion that online food delivery services have the capacity to disrupt conventional and established purchasing formats within food retail, which in turn, could influence how individuals interact with the built food environment [34] . however, a high proportion of online food delivery service customers reported that they also visited food outlets in-person, indicating that the traditional practice of visiting neighborhood food outlets persisted regardless of online food delivery service use. therefore, promotion of healthier neighborhood food environments, for example through the use of urban planning or 'zoning' continues to be a potentially effective public health intervention [35] . importantly, using multiple modes of order to purchase food prepared away-from-home may lead to greater total consumption, increased risk of excess weight and adverse health outcomes [36, 37] . the full extent to which using multiple modes of order, and in-particular online food delivery service use, increases consumption of food prepared away-from-home, is unclear without longitudinal data. consistent with our finding that men had greater odds of online food delivery service use, men reportedly purchase food prepared away-from-home more frequently and cook at home less than women [38, 39] . it is unclear how reasons for purchasing food prepared away-from-home might differ based on mode of order used, and how these reasons may vary by sex. respondents that identified with an ethnic minority had greater odds of online food delivery service use. analyses of data from the national health and nutrition examination survey completed in the usa indicated that black respondents cooked at home less frequently than other groups [40] . however, further research from the usa [41] and uk [42] concluded that individuals that identified with an ethnic minority allocated more time to home food preparation and consumed more home cooked food than individuals that identified with an ethnic majority. online food delivery service use could reduce home cooking, which might have implications for the overall diet quality of customers. whilst it is possible to meet dietary guidelines through consumption of food prepared away-from-home, it may be more difficult and more expensive than through food prepared at home [42, 43] , and bound by the types of food outlet available [44] . in our study, online food delivery service customers were likely to be younger, have higher education, or live with children aged under 18 years. similarly, marketing companies and online food delivery services suggest that individuals with these sociodemographic characteristics often report online food delivery service use [45] . older individuals may be disinclined to order food online due to lacking familiarity with technology and a loyalty towards conventional modes of order, whilst individuals who are younger, highly educated, or parents, often report having limited time and may purchase food prepared away-from-home to offset pressure stemming from having limited time resources [46] [47] [48] [49] . as previously described, reasons for using one mode of order over another are currently unclear [50] . future research should engage with online food delivery service customers to better understand their reasons for online food delivery service use. analysis of the uk's national diet and nutrition survey identified that living with obesity was associated with greater consumption of food from fast-food outlets but not restaurants or cafés [51] . in our study, online food delivery service use was not associated with weight status. to some extent, this may be due to our cross-sectional study design and the simultaneous measurement of our exposure (online food delivery use) and outcome (weight status). however, it is also possible that this reflects the potential for online food delivery services to offer food from different types of food outlets, including restaurants, which may offer healthier food than is traditionally served away-from-home [45] . in our analysis it was not possible to disaggregate online delivery service use by the type of food outlet that meals were ordered from. future research investigating which food outlets are ordered from when using online food delivery services, and the nutritional composition of foods sold, would provide greater insight into associations between food delivery service use and weight status. this understanding would serve to inform the need for development of public health interventions. the prevalence of online food delivery service use, the proportion of all meals prepared away-from-home purchased through online food delivery services, and the number of meals purchased directly from food outlets in-person by non-online food delivery service customers, were each greatest for respondents in mexico. together, these findings may reflect cultural norms aligned with frequent purchase of food prepared away-from-home in this country [52] . individuals with greater access to food outlets through online food delivery services could be inclined to use them more frequently. this may explain plans from just eat, branded as skipthedishes, to increase the number of food outlets in canada who are signed up to accept orders through their platform [19] . indeed, our finding that respondents from canada had lower odds of online food delivery service use compared to respondents in all other countries could indicate that there is currently limited access to food outlets through this mode of order. future research could investigate the extent to which access to food outlets signed up to accept orders through online food delivery services is associated with online food delivery service use. sociodemographic characteristics of online food delivery service customers were similar between countries, however, the strength of associations varied. notably, higher education was associated with greater odds of online food delivery service use in all countries except the uk. food outlets signed up to accept orders through online food delivery services in the uk may not sell food that accommodates the needs of individuals with higher education, possibly limiting use. the type of food available through online food delivery services in the uk is currently unclear. whilst the uk may be different, amongst food outlets signed up to accept orders through an online food delivery service in australia, the netherlands, and the usa, common food labels used to describe the type of food sold included 'burgers', 'pizza', and 'italian', with 'healthy' food labels less common [53] . however, labels selected by food outlets may not always reflect the food they sell and the nutritional quality of food available through online food delivery services remains unclear. given the apparent lack of 'healthy' food choices, further work to develop an understanding about how well self-selected labels reflect the types of food that outlets sell, and the nutritional quality of this food, is warranted. this study represents the most comprehensive description of online food delivery service use to date. nonetheless, the findings are subject to limitations, including those common to survey-based research. respondents were recruited using nonprobability-based sampling. thus, findings are not necessarily nationally representative. we applied post-stratification sample weights to improve representativeness, yet respondents in mexico had higher levels of education than census estimates and average bmi scores were lower than national averages for respondents in all countries [24] . recruitment may have been biased towards individuals with internet access. in 2016, however, internet penetration rates ranged between 67% (mexico) and 93% (australia), with rates of 88% or higher in canada, the uk, and the usa [54] . analyses were based on cross-sectional data, limiting the ability to draw causal inference. additionally, data were self-reported and collected through online surveys. social desirability bias may have led to the number of meals purchased away-from-home, online food delivery service use, and body weight being under-reported. this risk may have been reduced by use of online surveys that offer respondents a sense of anonymity when reporting sensitive information [55, 56] . finally, we used education as our marker of socioeconomic status which may not be internationally comparable [39, 57] . it is possible that the global covid-19 pandemic has accelerated changes in consumer behavior with regards to use of online modes of order [58] . at least in terms of the research contexts studied here, individuals that may have previously visited food outlets in-person to purchase food prepared away-from-home are likely to have found that this option has been restricted, and may therefore have adopted online modes of order. whilst there is much uncertainty, it is possible that short-term changes in consumer behavior persist long term. research is required to fully understand short-and long-term changes in online food delivery service and in-person food outlet use. we found that 15% of adults across australia, canada, mexico, the uk, and the usa had purchased food prepared away-from-home through online food delivery services in the past 7 days. online food delivery service use was associated with being male, from an ethnic minority, younger, highly educated, or living with children aged under 18 years. sociodemographic characteristics of online food delivery service customers were consistent across countries, yet there was variation in the strength of associations. norms surrounding the purchase of food prepared away-from-home, stressors on time that limit the opportunity for home meal preparation, and the number and type of food outlets that can be accessed through online food delivery services may vary internationally and could help explain observed differences between countries. whilst we identified sociodemographic characteristics of online food delivery service customers, which is important information for future intervention development, further research is needed to understand the extent to which use of an online food delivery service contributes to overall purchasing and consumption of food prepared away-from-home, whether online food delivery services are used in place of, or in addition to, traditional modes of order, and associated implications for public health. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/14/5190/s1, table s1 : sociodemographic characteristics of analytic sample, table s2 : sociodemographic characteristics of non-online food delivery service customers, figure s1 : frequency of online food delivery service use in the past 7 days amongst online food delivery service customers, table s3 : associations between prevalence of any online food delivery service use in the past 7 days and 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convenience as care in the australian obesity debate socioeconomic disadvantage and the purchase of takeaway food: a multilevel analysis why eat at fast-food restaurants: reported reasons among frequent consumers utilization of away-from-home food establishments, dietary approaches to stop hypertension dietary pattern, and obesity nutrition transition in mexico and in other latin american countries a cross-sectional comparison of meal delivery options in three international cities internet penetration rates are high in north america determinants of social desirability bias in sensitive surveys: a literature review analysis of the over 65 uk national diet and nutrition survey indicators of socioeconomic position (part 1) covid-19: impact on the urban food retail system, diet and health inequalities in the uk the authors thank the participants from wave two of the international food policy study. the authors declare no conflict of interest. key: cord-255119-l82o5fif authors: passerini, giorgio; mancinelli, enrico; morichetti, mauro; virgili, simone; rizza, umberto title: a preliminary investigation on the statistical correlations between sars-cov-2 spread and local meteorology date: 2020-06-05 journal: int j environ res public health doi: 10.3390/ijerph17114051 sha: doc_id: 255119 cord_uid: l82o5fif the statistical correlation between meteorological parameters and the spread of coronavirus disease-2019 (covid-19) was investigated in five provinces of italy selected according to the number of infected individuals and the different trends of infection in the early stages of the epidemic: bergamo and brescia showed some of the highest trends of infections while nearby cremona and mantova, showed lower trends. pesaro–urbino province was included for further investigation as it was comparably affected by the epidemic despite being the area far from the po valley. moving means of the variables were considered to take into account the variability of incubation periods and uncertainties in the epidemiological data. the same analyzes were performed normalizing the number of new daily cases based on the number of checks performed. for each province, the moving mean of adjusted and unadjusted new daily cases were independently plotted versus each meteorological parameter, and linear regressions were determined in the period from 29th of february 2020 to 29th of march 2020. strong positive correlations were observed between new cases and temperatures within three provinces representing 86.5% of the contagions. strong negative correlations were observed between the moving means of new cases and relative humidity values for four provinces and more than 90% of the contagions. on 31th of december 2019, pneumonia of unknown etiology was first reported by the offices of the world health organization (who) in china [1] . this disease was labelled as coronavirus disease-2019 (covid-19) [2] . based on phylogeny, taxonomy, and established practice, gorbalenya et al. [3] have marked the related virus of covid-19 disease as severe acute respiratory syndrome coronavirus 2 (sars-cov-2). sars-cov-2, as in the case of another zoonotic coronavirus originated in the early 2000s with pandemic potential [4] , was first transmitted from animals to humans [1] . at present, the human-to-human transmission of the covid-19 virus has been reported via close unprotected contact with infected droplets and fomites, whereas the airborne transmission is considered possible only for specific circumstances and settings in the hospital context [5] . in the early 2000s, sars transmission was controlled through quarantine, social distancing, travel restrictions, and contact precautions since no specific vaccines or drugs existed for this new pathogen to human beings [6] . building on the experience of the chinese government, the italian government adopted control measures for the containment of the covid-19 epidemiological emergency. in order to prevent the virus from extending beyond a few affected areas in italy, various activities and daily life were regulated with a series of decrees of the president of the council of ministers (dpcm) (mainly [7] [8] [9] ). since the covid-19 outbreak became much more severe, the italian government imposed a nationwide lockdown through another dpcm [10] . since little is known about covid-19 disease and its causative virus, the scientific community responded to the dramatic emergency posed by the covid-19 pandemic shifting research focus to the covid-19 related issues. environmental constraints are expected to influence human coronavirus outbreaks, as environmental survival factors have been defined for other viruses in the past [11, 12] . therefore, a number of studies have examined the relation between the incidence of covid-19 and atmospheric variables such as surface temperature, relative humidity, air pressure, ultraviolet radiation, wind speed, and atmospheric particles [13] [14] [15] [16] [17] [18] . considering air temperature and relative humidity, both the 2002 and 2019 sars epidemics originated during cold and particularly dry winters in china [19] . sajadi et al. [16] have observed that seven cities around the globe with latitudes in the range 30-50 n and affected by the early onset of covid-19 pandemic had similar average values of temperature (5-11 • c) and relative humidity (47-79%) both monitored at 2 m height. several authors [15, 17, 20] , have found linear relationships between climatic variables (i.e., relative humidity and temperature) and covid-19 incidence. based on the analysis of more than 100 countries, islam et al. [15] have observed that temperature and relative humidity were inversely associated with the incidence rate of covid-19, thus suggesting that cold and dry climate favors virus survival. wang et al. [17] analyzed the early onset of the covid-19 outbreak in 100 chinese cities considering mean values of temperature and relative humidity in the range from −21 to 21 • c and from 47% to 100%, respectively. these authors have found negative relationships between relative humidity, temperature, and the daily effective reproductive number for covid-19, although with coefficient of determinations of about 20%. rahman et al. [20] have confirmed a negative correlation between the positive cases of 12 chinese provinces and median daily temperature, whereas no clear trend can be observed for the number of infected versus relative humidity. ficetola and rubolini [14] reported nonlinear relationships between covid-19 growth rates and climatic variables such as temperature and absolute humidity, with peaks in regions with mean temperature of about 5 • c and absolute humidity in the range of 0.6-1 kpa. a nonlinear relationship between temperature and sars-cov-2 transmission was reported also by wang et al. [21] . according to chen et al. [13] , the optimal climate conditions for sars-cov2 transmission occur at a temperature of around 8 • c and relative humidity in the range 60-90%. a similar value of the average temperature (8.7 • c) was identified as optimal for sars-cov2 transmission also in the work of wang et al. [21] . however, yao et al. [18] have reported no significant associations between daily mean temperatures and the spread ability of sars-cov-2 in chinese cities, thus concluding that temperature is not a driving factor of sars-cov-2 transmissibility. o'reilly et al. [22] have observed that the countries with reported local sars-cov-2 transmission had a wide range of temperature and relative humidity, thus excluding seasonality as key modulating factor of sars-cov-2 transmissibility. furthermore, there is a risk for misinterpreting the covariance between the incidence of infectious diseases and noncausal phenomena because of their similar seasonal pattern [23] . other factors such as human population density may better explain the spatial distribution pattern of covid-19 cases [24] . the aim of the present work is to investigate the statistical correlation between meteorological parameters (i.e., daily mean temperature, and relative humidity) and the incidence of covid-19 in italy. the time period considered was from 29th of february 2020 to 29th of march 2020. in this time period, italy was the hardest hit country around the globe with more than 90,000 reported positive cases [25] . the emotional impact of the situation posed by the covid-19 emergency recall the line ''no man is an island entire of itself; every man is . . . , a part of the main" by john donne [26] . five provinces were selected according to the number of infected individuals in the early stages of the covid-19 epidemic in italy. furthermore, these provinces represent three different climatic areas of italy. the fact that this study is limited to the analysis of meteorological parameters does not imply that these are considered as main driving factors of the covid-19 incidence. it is likely that several factors, other than the meteorological ones, concur in determining the incidence of covid-19. in the present study, we considered four provinces located in northwest italy within the lombardy region: bergamo (bg) brescia (bs), cremona (cr), and mantova or mantua (mn) (figure 1 ). we also considered one province located in central italy within marche region: pesaro-urbino (pu). the five provinces were selected according to the number of infected individuals in the early stages of the covid-19 epidemic in italy. in particular, bg and bs showed some of the highest trends of contagion, while cr and mn showed rather lower trends and were selected to check statistical evidence under different conditions (table 1) . finally, pesaro-urbino province was included for further investigation as it was comparably affected by the epidemic despite being the area far from the po valley. here, the orography is more complex, and the province includes a mountainous area and a valley-coastal environment. however, most of the population lives near the coast, so for this study, we employed temperatures observed near the city of pesaro, located on the coast. four cities for each province, collecting a total number of 24 points (figure 1 ). the physical parameterization of the wrf model for this domain was set following rizza et al. [31] . for each province, the average of such values were calculated as arithmetic means, resulting in single daily values to be compared with the daily mean values measured at the monitoring stations of the respective capitals (table 2) . figures 2 and 3 show comparisons between measured and modelled daily mean temperature and relative humidity for the five provinces. monitored data and model results show very similar trends although, especially for relative humidity, few discrepancies are readily evident. however, in almost all cases, the trends of the two sets of time series are very similar. therefore, the selected monitoring stations can be considered representative for the daily average temperature and relative humidity were downloaded from the web sites of regional agency for the environmental protection of lombardy [28] and the regional agrometeorological service of marche [29] . in each province, a single monitoring site, located nearby the related capitals, was considered representative of the meteorology of the whole area ( table 2 ). this was considered important to avoid weakening of experimental statistics. however, to confirm such representativeness, a meteorological simulation was carried through the weather research and forecasting (wrf) model version 4.1.3 [30] . the wrf model was applied from 1 february 2020 (00:00 utc) to 1 april 2020 (00:00 utc), with a simulation domain covering the entire italian peninsula having 240 × 270 grid points with a horizontal grid spacing of 10 km for both directions (west-east and south-north) and 40 vertical levels up to 50 hpa. the simulated daily mean temperature and relative humidity were evaluated in at least four cities for each province, collecting a total number of 24 points (figure 1 ). the physical parameterization of the wrf model for this domain was set following rizza et al. [31] . for each province, the average of such values were calculated as arithmetic means, resulting in single daily values to be compared with the daily mean values measured at the monitoring stations of the respective capitals ( table 2) . figures 2 and 3 show comparisons between measured and modelled daily mean temperature and relative humidity for the five provinces. monitored data and model results show very similar trends although, especially for relative humidity, few discrepancies are readily evident. however, in almost all cases, the trends of the two sets of time series are very similar. therefore, the selected monitoring stations can be considered representative for the meteorology of the whole area of each province for the time period considered. to the 29th of march 2020. moving means were calculated over 5 days and 8 days, since the statistics of the new daily positive cases may be affected by the length of the incubation period and discrepancies in the epidemiological data. a five-day moving mean was adopted for all statistical variables as 5 days is the average incubation period for covid-19 disease [1] . in fact, who [1] reported a mean incubation period of 5-6 days, and a range 1-14 days. however, according to lauer et al. [33] , 97.5% of the individuals that develop symptoms will do so within 11.5 days (confidence interval, 8.2-15.6 days) of infection. thus, also an 8-day moving mean was adopted in order to take into account possible longer time required for symptoms to appear, possible delays between the arising of symptoms and testing for the disease, possible discrepancies in the epidemiological data from the covid-19 outbreak because of variations in the daily number of specimen collected, possible diverse testing criteria, and the possible discrepancies from the date of specimen collection and the release of the test result. as pointed out in previous studies regarding the onset of covid-19 outbreak in italy [34, 35] , the epidemiological data could be affected by errors both at regional and at national level. previous studies [13, 15] have considered a time lag of 7-14 days between the meteorological variables and the incidence of covid-19. however, we considered the moving mean a better option for the analysis of data subject to the abovementioned uncertainties. the number of cases was considered both as a raw variable and "adjusted" by the number of checks performed during the same period. to take into account the time needed to carry out the tests, the related values were computed shifting the time period one day back. for example, the number of individuals infected between 10th and 15th of march was normalized by the number of checks performed between 9th and 14th of march. the use of the term "adjusted" instead of the more customary "normalized" or "biased" is due to the unfortunate circumstance that the number of tests performed daily is not available at province level but only for each italian region. thus, we opted for the following procedure in order to adjust the number of new daily positive cases based on the daily number of specimens collected at region level. by considering per each province the ratio between the new daily positive cases within the related region and the total number of tests performed within the same region, the adjusted new daily cases (n-day moving mean, with n = 5, or n = 8) was calculated for each province as follows: epidemiological data were downloaded from the italian civil protection web site [32] . original data, published day by day, consisted of the overall amount of infected individuals for each province and the total number of individuals checked, and individuals infected for each region. from such data, we determined the number of new infected individuals within each province and the number of individuals checked and infected within each region for each day from the 29th of february 2020 to the 29th of march 2020. moving means were calculated over 5 days and 8 days, since the statistics of the new daily positive cases may be affected by the length of the incubation period and discrepancies in the epidemiological data. a five-day moving mean was adopted for all statistical variables as 5 days is the average incubation period for covid-19 disease [1] . in fact, who [1] reported a mean incubation period of 5-6 days, and a range 1-14 days. however, according to lauer et al. [33] , 97.5% of the individuals that develop symptoms will do so within 11.5 days (confidence interval, 8.2-15.6 days) of infection. thus, also an 8-day moving mean was adopted in order to take into account possible longer time required for symptoms to appear, possible delays between the arising of symptoms and testing for the disease, possible discrepancies in the epidemiological data from the covid-19 outbreak because of variations in the daily number of specimen collected, possible diverse testing criteria, and the possible discrepancies from the date of specimen collection and the release of the test result. as pointed out in previous studies regarding the onset of covid-19 outbreak in italy [34, 35] , the epidemiological data could be affected by errors both at regional and at national level. previous studies [13, 15] have considered a time lag of 7-14 days between the meteorological variables and the incidence of covid-19. however, we considered the moving mean a better option for the analysis of data subject to the abovementioned uncertainties. the number of cases was considered both as a raw variable and "adjusted" by the number of checks performed during the same period. to take into account the time needed to carry out the tests, the related values were computed shifting the time period one day back. for example, the number of individuals infected between 10th and 15th of march was normalized by the number of checks performed between 9th and 14th of march. the use of the term "adjusted" instead of the more customary "normalized" or "biased" is due to the unfortunate circumstance that the number of tests performed daily is not available at province level but only for each italian region. thus, we opted for the following procedure in order to adjust the number of new daily positive cases based on the daily number of specimens collected at region level. by considering per each province the ratio between the new daily positive cases within the related region and the total number of tests performed within the same region, the adjusted new daily cases (n-day moving mean, with n = 5, or n = 8) was calculated for each province as follows: the pearson correlation coefficient (pcc) was calculated to evaluate possible relations between the moving means of the meteorological parameters (i.e., temperature, and relative humidity) and the moving mean of adjusted/unadjusted new daily cases. pcc is a number between −1 and 1 (following the cauchy-schwarz inequality) that determines the possible linear correlation between two variables. when pcc = 1, there is a complete positive linear correlation; when pcc = 0, there is no linear correlation; and when pcc = −1, there is complete negative linear correlation. when checking the linear correlation between two data sets having the same number of samples (e.g., time series of experimental variables x and y, randomly collected in the number of n), the pcc, often labelled as 'r', may be seen as: x and y being the 'expected' (mean) values of the two variables, while σ x and σ y are the standard deviations as, for example, in simple terms, pcc assumes positive values whenever, within two time series, high values of the first series mostly correspond to high values of the second series. on the other hand, pcc assumes negative values whenever, within two time series, high values of the first series mostly correspond to low values of the second series. finally, pcc assumes values close to zero whenever no such conditions are verified. it is important to avoid confusing correlation with causation. when two variables are correlated, there may or may not be a causative connection, and this connection may moreover be indirect. correlation can be interpreted in terms of causation only when the variables under investigation provide further logical, biological, or physical foundations for such interpretation. to validate the statistical correlation of two variables or time series, the 'p-value' (probability value) is customarily employed. in a statistical investigation, the p-value can be seen as the probability of obtaining statistics at least as significant as the ones obtained, assuming that the so-called 'null hypothesis' is correct. the 'null hypothesis' is a statement that theorizes no statistical relationship between two observed phenomena and, thus, between the two related time series. in simple terms, the null hypothesis implies that no linear relationship exists between variables, and the p-value can be seen as the probability that the current results would be found if the correlation were, in fact, null (which is exactly within the null hypothesis). conventionally, if the probability value is lower than 5% (p-value < 0.05) the correlation coefficient may be called statistically significant [36] . for this study, pearson's analyses were performed over moving mean of meteorological parameters as the first time series x and the moving mean of "unadjusted" new daily cases or "adjusted" new daily cases as the second time series y. most of statistical analyses were carried out using the 'r project for statistical computing' version 3.3.4 [37] . we checked several meteorological parameters, namely outdoor temperature, relative humidity, wind speed and wind direction. however, statistical analysis of wind data was not significant, which was likely due to the narrow range of wind speed values (namely 0.5-2 ms −1 ) and the sparse distribution of wind direction data. therefore, here we present the results of pearson's analysis related to outdoor temperature and relative humidity. in fact, only for these meteorological parameters, results showed significant statistical correlations, and in most cases related probability values were much lower than 5% [36] . here, we present pearson's analyses performed over eight couples of experimental data series. the most inclusive and impressive results are the values of pcc found for the time series related to the number of new daily infected individuals within the five selected italian provinces, the daily mean temperatures as monitored at the related capitals, and the daily mean relative humidity values observed at the same stations. as above outlined, we chose to use actual data monitored nearby province capitals, but we checked by means of a meteorological model the representativeness of such data within most populated areas of the entire related provinces. the time series are related to a 30-day time period from 29th of february 2020 to 29th of march 2020 and were averaged through 5-day moving mean and 8-day moving mean. each dot corresponds to the situation on a certain time period (5 days or 8 days) and the last day of such period is reported through the corresponding label. thus, each dot represents a couple of values (x, y) belonging to the two related time series. for instance, x could be the average number of new infections during five days while y could be the mean daily temperature averaged over the same days. as already outlined, the number of cases was considered both as a raw variable and "adjusted" by the number of checks performed during the same period. each figure also shows the regression line related to those two data sets, the value of pcc as 'r', and the related p-value as 'p'. model the representativeness of such data within most populated areas of the entire related provinces. the time series are related to a 30-day time period from 29th of february 2020 to 29th of march 2020 and were averaged through 5-day moving mean and 8-day moving mean. figures 4-11 show on the abscissa axis a meteorological variable and on the ordinate axis the number of new infections. , belonging to the two related time series. for instance, x could be the average number of new infections during five days while y could be the mean daily temperature averaged over the same days. as already outlined, the number of cases was considered both as a raw variable and "adjusted" by the number of checks performed during the same period. each figure also shows the regression line related to those two data sets, the value of pcc as 'r', and the related p-value as 'p'. pu. all panels of figure 4 show positive correlations, namely, the pccs (r) of bg, bs, and cr in the range of 0.65-0.75 with p-values much lower than 0.05 corroborating such results. on the other hand, mn and pu show much lower pearson correlation values (namely 0.21 and 0.26, respectively) associated with p-values much higher than previous ones. this allows us to assume that the related results cannot be considered of statistical importance. individuals, adjusted against the number of individuals checked in the corresponding regions, and the 5-day moving mean of outdoor daily mean temperatures. all pcc are positive and the values of bg, bs, and cr are very similar, in a range of 0.71-0.75 with p-values all much lower than 0.05 but also very similar, in the range 1.6-4.7 × 10 −5 . this time pu shows a pcc = 0.52 and a p-value now down to 0.0063. observed pcc are negative except for the pu one, which turns positive probably due to the concentration of almost all the experimental points within an even narrower humidity range. pcc values of cr, bs, and bg are in the range −0.55 to −0.83. all p-values are much lower than the 0.05 except for the bg one, which is equal to 0.0051. this time mn shows a very strong correlation, the pcc being −0.94 with an impressing p-value of 10 −9 order of magnitude. as already outlined, pu shows a positive correlation but its p-value shows a very weak statistics. figure 11 shows pearson's analyses regarding the 8-day moving means of daily new infected individuals, normalized against the number of individuals checked, and outdoor daily average pearson correlation coefficient is reported as 'r' while probability value is reported as 'p'. table 3 shows the correlations between the moving mean of new daily cases and the meteorological parameters. in the time period considered, the five provinces had a mean daily temperature of 9.8 °c, and mean relative humidity of 70.9%. for all the five provinces, positive correlations were observed between the moving means of new daily cases and the moving means of outdoor temperatures in the range 5-14 °c. however, most correlations were not statistically significant for mn, and pu. on the other hand, mn and pu show much lower pearson correlation values (namely 0.21 and 0.26, respectively) associated with p-values much higher than previous ones. this allows us to assume that the related results cannot be considered of statistical importance. however, mn and pu registered lower amounts of infections and a different approach to patients' checks, so we decided to adjust the daily number of individuals found infected in each province by the number of checks performed in the respective region. a first conclusion may be raised here. both analyzing new cases and analyzing adjusted new cases, linear correlations exist and are always positive in the temperature range 5-14 • c, and statistically significant at least in three most infected provinces. when normalizing the number of infected people by the number of checks performed, results tend to equalize and become very similar, almost equal, for the three most infected provinces (bg, bs, and cr). pu is now much closer to the padania's statistics, but the significance of the related analysis is much lower with its p-value only one order of magnitude lower than the acceptable value. mn's statistics are very close to the null hypothesis. figure 6 shows the pearson's analyses employing the 8-day moving mean both for outdoor temperatures and for new infections. all pcc are positive in the temperature range 5-14 • c. as expected, all values remain very similar to those obtained applying the 5-day moving mean. for bg, bs, and cr pccs are in the range 0.73-0.83 with very good p-values. mn and pu keep their behavior and remain very close to the null hypothesis. figure 7 shows the pearson's analyses employing the 8-day moving mean both for outdoor temperatures and for adjusted new infections. all pcc are positive in the temperature range 5-14 • c. pccs of bg, bs, and cr are in the range 0.77-0.83 with very good p-values. pu has now a fair pcc = 0.45 but the p-value = 0.03 is just below the significance level. mn keeps a low pcc = 0.33 associated with p-value much higher than the significance level, implying that the data distribution cannot be linearly correlated. figure 8 shows the pearson's analyses performed over daily average relative humidity time series and recently infected individual time series both averaged by the 5-day moving mean. the mean amounts of infections obviously remain up to about 500/day in bg and bs, up to 150/day in cr and up to 100/day in mn and pu while average humidity ranges are 50-95%, but for pu that shows a narrower range about 65-75%. all observed pccs are negative in the relative humidity range 50-95%. the pccs of bg, bs, cr, and mn are between −0.54 and −0.82 while all the p-values are much lower than 0.05, with that of bg being lower only by one order of magnitude. pu remains within null hypothesis with its pcc = −0.11 and its p-value = 0.59. figure 9 shows pearson's analyses regarding the 5-day moving means of daily new infected individuals, adjusted against the number of individuals checked in the respective region, and outdoor daily average humidity. all observed pccs are negative in the relative humidity range 50-95%. the pccs of bg, bs, cr, and mn are between −0.56 and −0.77 while all the p-values remain lower than 0.05, with those of bg and cr being lower only by one order of magnitude. pu remains within null hypothesis with its pcc = −0.24 and its p-value = 0.23. for both previous pearson's analyses (humidity against new daily cases, and humidity against adjusted new daily cases) linear correlation trends are always negative in the relative humidity range 50-95%. during the analyses against the outdoor temperatures, normalizing against the number of checks led to a smoothing and a general improvement of results. here the same analyses do not show a homogeneous improvement of the correlations, and for cr, bs, and mn, there is a drop in the correlation coefficient from −0.68, −0.81, and −0.82 respectively to −0.57, −0.75, and −0.77. bg only shows a slight increase in pcc going from −0.54 to −0.56. pu always remains uncorrelated. figure 10 shows the pearson's analyses performed over daily average relative humidity time series and recently infected individual time series both averaged by the 8-day moving mean. all observed pcc are negative except for the pu one, which turns positive probably due to the concentration of almost all the experimental points within an even narrower humidity range. pcc values of cr, bs, and bg are in the range −0.55 to −0.83. all p-values are much lower than the 0.05 except for the bg one, which is equal to 0.0051. this time mn shows a very strong correlation, the pcc being −0.94 with an impressing p-value of 10 −9 order of magnitude. as already outlined, pu shows a positive correlation but its p-value shows a very weak statistics. figure 11 shows pearson's analyses regarding the 8-day moving means of daily new infected individuals, normalized against the number of individuals checked, and outdoor daily average humidity. this time, all observed pcc are negative, including pu's one. the pccs of bg, bs, cr, and mn are between −0.57 and −0.91 while all the p-values remain lower than 0.05 with those of bg and cr being lower by one order of magnitude only. pu remains within null hypothesis with its pcc = −0.33 and its p-value still unacceptable. table 3 shows the correlations between the moving mean of new daily cases and the meteorological parameters. in the time period considered, the five provinces had a mean daily temperature of 9.8 • c, and mean relative humidity of 70.9%. for all the five provinces, positive correlations were observed between the moving means of new daily cases and the moving means of outdoor temperatures in the range 5-14 • c. however, most correlations were not statistically significant for mn, and pu. multiple regression analysis was also performed with case rate as the dependent variable and temperature plus relative humidity as independent variables. here we only summarize results in table 4 . the table shows multiple r, intercept stat t, temperature stat t, relative humidity stat t, and the related p-values for the "unadjusted" infection-rate time series. results are in good agreement with those of pearson's analyses. statistical correlations are evident in bg, bs, cr, and mn while pu still shows values very near to null hypothesis condition. mn now shows multiple r much closer to those of bg, bs, and cr but the p-values related to temperature are rather high, while those related to relative humidity are very good. this seems to confirm that mn statistics are close to those of other lombardy provinces but not equivalent. results for "adjusted" infection-rate time series are very similar. regarding f-test results, f-stat values are in the range 20 to 40 for bg, cr, and mn while peak up to 260 for bs but fall down to 1 for pu. accordingly, the related significances are in the range 10 -10 -10 -6 for bg, cr and mn, in the range 10 −15 -10 −11 for bs and in the range 10 −2 -10 −1 for pu. the positive correlations calculated between covid-19 incidence and the outdoor temperatures were in line with previous studies about covid-19 pandemic in new york (united states) [38] , jakarta (indonesia) [39] , and various cities and regions around the world [21] . the range of outdoor temperatures (5-14 • c), that was observed in the present study for the five provinces of italy, is in the range of temperatures (3-17 • c) that was reported by bukhari and jameel [40] for the countries with more than 90% of covid-19 new cases across the world. bashir et al. [38] have reported significant positive correlations between covid-19 total daily cases and mean daily temperature in the range 1.8-15.2 • c. furthermore, tosepu et al. [39] have pointed out similar findings, with a significant positive correlation between the new daily cases and mean daily temperatures in the range 26.1-28.6 • c. in various cities and region around the world, new daily positive cases significantly increased with increasing mean daily temperatures of up to 8.7 • c [21] . our results are in contrast with some previous studies [15, 17, 41, 42] regarding a negative linear relationship between outdoor temperature and covid-19 incidence. yet, comparisons with previous studies should take into account the different meteorological conditions, since the occurrence of sars-cov-2 outbreak has been observed for a wide range of temperatures around the globe. for example, rahman et al. [20] have observed negative correlations between outdoor temperature and sars-cov-2 infectivity statistically significant for provinces with a median temperature of −2.9 • c. moreover, increases in daily mean temperature between 3 and 21 • c did not affect the containment of the covid-19 outbreak in wuhan (china) [43] . negative correlations were observed between the moving means of new daily cases and the moving means of outdoor relative humidity in the range 50-95% for more than 90% of the infected. the correlation between the pu new daily cases, thus for about 6.8% of the total number of infected, and relative humidity were not statistically significant. negative relationships between relative humidity and covid-19 incidence have been reported also in previous studies about several chinese cities [17] and countries around the globe [15] . according to chen et al. [13] , the trend of new daily positive is better reproduced by the models that combine several meteorological parameters (e.g., air temperature, wind speed, visibility, and relative humidity) rather than correlations with a single meteorological variable. the pcc, the related p-values and the results of multiple regression analyses associated with the three central provinces of lombardy (bg, bs, and cr) and, in most cases those of mn, show strong correlations between the selected meteorological parameters and the trend of covid-19 new infections. this strong correlation is positive for temperature and this means that infections were more likely to occur at higher temperatures in the range about 5-14 • c. such temperature range refers to the 5-day moving mean and the 8-day moving mean, so the actual range is slightly wider. the same strong correlation is negative for relative humidity and this means that infections were more likely to occur at low levels of humidity in the range about 50-95%. again, such range of humidity refers to the 5-day moving mean and the 8-day moving mean, so the actual range is slightly wider. as already stressed, correlation does not imply causation, so it remains difficult to find a possible explanation for such statistical evidence. a simple possible explanation could be the need of a close contact for the infection to occur combined with the tendency of most people, especially elderly people, to gather more frequently when the weather is fair. thus, we can expect more narrow contacts and infections in warmer dry days. as an example, italian news reported about records of victims within bocce-ball players, who are mostly elderly people often playing outdoor. the pu province did not show such strong statistical evidence. correlations between temperatures and infections exist and are still positive, but the degree of confidence is much lower. the correlation between humidity and infections is simply null for pu. however, such statistics might have been weakened by the reduced temperature range and the very narrow humidity range. in fact, after averaging, almost all relative humidity values were in the range 65-75%. the first limitation of this study is represented by the reduced number of provinces considered. all the provinces showing significant statistics belong to the central-upper po valley. a comparison with other regions showing similar trends of infections and comparable meteorological conditions is crucial for validating our results. the second limitation of this study is represented by the short time span considered. as a matter of fact, temperatures tend to increase steadily in march and so the trend of infections also increased during the entire month. however, at the end of the month a sharp decrease in temperature and humidity occurred due to a penetration of artic cold and dry air masses. this decrease is visible in figures 2 and 3 . since we had already developed statistical analyses, we were concerned about this point. however, once the new data were introduced, to our surprise, we did not find a significant decrease in pccs and p-values. another possible source of errors derives from the assessment of covid-19 victims. we know that many victims were not included within statistics since they did not have the time or the possibility of being checked for sars-cov-2. some researchers postulate an overall much higher number of victims. furthermore, within the three most infected areas, records of infections happened within residences for the elderly and chronically ill, and this might have altered statistics. more in general, epidemiological data could be affected by errors both at the regional and national level as pointed out in previous works [34, 35] . additionally, the so-called "adjusted" number of infections was extrapolated somehow combining the number of infections within provinces with the number of tests performed in the same region. this was inevitable since we do not have the latter data collected at province level. such data will probably never be published as there are problems in identifying precisely the areas of samplings given that, in most cases, patients were asked to reach collection sites and the samples were sent to laboratories often far from there. the present study investigated the statistical correlation between meteorological parameters, namely, daily mean temperature and mean relative humidity, and the incidence of covid-19 for a 30-day time period (from 29th of february 2020 to 29th of march 2020) in italy. five provinces were selected according to the number of infected individuals in the early stages of the covid-19 epidemic. in the time period considered, these provinces reported 23,184 new cases of covid-19. in particular, bergamo and brescia showed some of the highest trends of infections, while nearby cremona and mantova, showed lower trends and were selected to check statistical evidence under different conditions. finally, pesaro-urbino province was included for further investigation as it was comparably affected by the epidemic despite being the area far from the po valley. furthermore, the selected provinces represent three different climatic areas of italy. in the time period considered, these provinces had a mean daily temperature of 9.8 • c and mean relative humidity of 70.9%. moving means were calculated at 5 days and 8 days, since the statistics of the new daily positive cases may be affected by the length of the incubation period and by uncertainties in the epidemiological data. for a second set of experiments, the number of new daily positive cases was adjusted considering possible variations in the daily number of specimens collected, biasing per each province the number of new daily positive cases for the ratio between the new daily positive cases and the total number of tests performed in the respective region. for each province, adjusted and unadjusted new daily cases were plotted versus the meteorological parameters, and linear regressions were determined. for the five provinces of italy, strong positive correlations were observed between the moving means of new daily cases and the moving means of daily temperatures. however, most correlations were not statistically significant for mn and pu. strong negative correlations were observed between the moving means of new daily cases and moving means of relative humidity for more than 90% of the infected. the correlation between the pu new daily cases and relative humidity were not statistically significant. this seems to indicate a general positive correlation between covid-19 rates of contagion and the outdoor temperatures in the range 5-14 • c, and a general negative correlation between covid-19 rate of contagion and outdoor humidity in the range 50-95%. this study is limited to the analysis of meteorological parameters for a 30-day time period. it is likely that several other factors concur in determining the incidence of covid-19. therefore, it is not possible to consider outdoor temperature and relative humidity as driving factors of the covid-19 incidence. a robust model linking all the driving factors to the experimental evidence would be useful to support the statistical analyses. in this context, we did not consider any forecasts regarding the propagation of the sars-cov-2 to be suitable and/or realistic. funding: this research was partially funded by marche regional authority. report of the who-china joint mission on coronavirus disease 2019 (covid-19) who-world health organization. novel coronavirus(2019-ncov) situation report-22 the species severe acute respiratory syndrome-related coronavirus: classifying 2019-ncov and naming it sars-cov-2 infectious diseases emerging from chinese wet-markets: zoonotic origins of severe respiratory viral infections who-world health organization. modes of transmission of virus causing covid-19: implications for ipc precazution recommendations emerging 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spatial modeling cannot currently differentiate sars-cov-2 coronavirus and human distributions on the basis of climate in the united states the works of john donne. vol iii climate and pedoclimate of italy request for measured data sensitivity analysis in wind and temperature fields simulation for the northern sahara and the mediterranean basin department of civil protection of the presidency of the council of ministers-covid19 epidemiological data the incubation period of coronavirus disease 2019 (covid-19) from publicly reported confirmed cases: estimation and application the covid-19 infection in italy: a statistical study of an abnormally severe disease covid-19: recovering estimates of the infected fatality rate during an ongoing pandemic through partial data predictive models using regression. in applying predictive analytics r: a language and environment for statistical computing; r foundation for statistical computing correlation between climate indicators and covid-19 pandemic in new york correlation between weather and covid-19 pandemic in jakarta will coronavirus pandemic diminish by summer? ssrn electron impact of meteorological factors on the covid-19 transmission: a multi-city study in china the role of absolute humidity on transmission rates of the covid-19 outbreak nexus between covid-19, temperature and exchange rate in wuhan city: new findings from partial and multiple wavelet coherence this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we are grateful to the regional agency for the environmental protection of lombardy for providing meteorological data and to the italian civil protection agency for making epidemiological data readily available. far out of the conventional scope of this section, we wish to thank all the healthcare personnel, the officers, and all the volunteers who have helped and continue to help fighting covid-19. we wish to remember the ones who sacrificed their lives during the fight: this study is for them. the authors declare no conflict of interest. int. j. environ. res. public health 2020, 17, 4051 key: cord-013401-yh8cu1hx authors: hitachi, mami; wanjihia, violet; nyandieka, lilian; francesca, chepkirui; wekesa, norah; changoma, juma; muniu, erastus; ndemwa, phillip; honda, sumihisa; hirayama, kenji; karama, mohammed; kaneko, satoshi title: improvement of dietary diversity and attitude toward recommended feeding through novel community based nutritional education program in coastal kenya—an intervention study date: 2020-10-05 journal: int j environ res public health doi: 10.3390/ijerph17197269 sha: doc_id: 13401 cord_uid: yh8cu1hx community-based nutritional intervention to improve the practice of dietary diversity and child nutrition by community health workers (chws) involving nyumba kumi as small neighborhood units (snus) in communities has not yet been explored. this study was conducted in two villages in rural kenya between 2018 and 2019. in total, 662 participants (control vs. intervention: n = 339 vs. n = 323) were recruited. the intervention group received education on maternal and child nutrition and follow-up consultations. the custom-tailored educational guidelines were made based on infant and young child feeding and the mother and child health booklet. the educational effects on household caregivers’ feeding practice attitude and child nutritional status were analyzed using multiple linear regression. after the intervention, a total of 368 household caregivers (187 vs. 181) and 180 children (113 vs. 67) were analyzed separately. between the groups, no significant difference was found in their background characteristics. this study successfully improved the dietary diversity score (β = 0.54; p < 0.01) and attitude score (β = 0.29; p < 0.01). the results revealed that the interventions using chws and snus were useful to improve dietary diversity and caregivers’ attitudes toward recommended feeding. this research has the potential to be successfully applied in other regions where child undernutrition remains. abstract: community-based nutritional intervention to improve the practice of dietary diversity and child nutrition by community health workers (chws) involving nyumba kumi as small neighborhood units (snus) in communities has not yet been explored. this study was conducted in two villages in rural kenya between 2018 and 2019. in total, 662 participants (control vs. intervention: n = 339 vs. n = 323) were recruited. the intervention group received education on maternal and child nutrition and follow-up consultations. the custom-tailored educational guidelines were made based on infant and young child feeding and the mother and child health booklet. the educational effects on household caregivers' feeding practice attitude and child nutritional status were analyzed using multiple linear regression. after the intervention, a total of 368 household caregivers (187 vs. 181) and 180 children (113 vs. 67) were analyzed separately. between the groups, no significant difference was found in their background characteristics. this study successfully improved the dietary diversity score (β = 0.54; p < 0.01) and attitude score (β = 0.29; p < 0.01). the results revealed that the interventions using chws and snus were useful to improve dietary diversity and caregivers' attitudes toward recommended feeding. this research has the potential to be successfully applied in other regions where child undernutrition remains. keywords: education; intervention; child nutrition; dietary diversity; attitude; community health workers; small neighborhood units; nyumba kumi undernutrition associates with nearly half of the deaths among children under the age of five, which means approximately three million young lives are unnecessarily lost in the world [1] . furthermore, it increases the morbidity risks from several diseases among young children in the short term; in the long-term, it causes stunting and impaired cognitive development, which results in poor school performance and social development [2] . although several efforts and measures have been taken to improve the nutritional status among children worldwide, it is still estimated that twenty-one percent of children still have a stunting condition or chronic undernutrition, especially in south asia and sub-saharan africa [2] [3] [4] . rich dietary diversity is an essential component to reduce undernutrition among children; however, less than 30% of children in sub-saharan africa are fed a "minimally acceptable" diet based on the global guidelines [5] [6] [7] [8] . kenya is one of 34 countries experiencing the highest burden of child undernutrition [9] . approximately one in four children (26.2%) is estimated to be stunted in kenya [10] . tanaka et al. reported that the traditional diet pattern had low dietary diversity in their research in kenya, and children fed by the traditional diets had a higher risk of stunting compared with those who were fed by non-traditional diet patterns [11] . since dietary diversity for children depends on caregivers' knowledge, attitude, and practice [12] , it is essential to provide caregivers enough information about the appropriate feeding of children, including dietary diversities by health staff members during antenatal and postnatal care. however, those opportunities to receive such information are limited due to inadequate access to health facilities [13] . under such limited situations to access health facilities, it is proven that community-based educational programs using community health workers (chws) improve the nutritional status of children in low-income and middle-income countries [9] . however, the effect on dietary diversity by a community-based approach with chws has not been well investigated. although intervention with chws can have the potentiality to improve diet diversity, it would be challenging because of the chws' low motivation, community supports for the chws, and cooperation with existing community organizations [14] . additionally, there is another community-based structure, "nyumba kumi," small neighborhood units (snus), in kenya, which means ten households in the swahili language. it is a mechanism introduced to achieve political stability and shared values in 2013 in kenya by the presidential order. it is the smallest social unit located at the lowest governmental community policing structure [15, 16] . the combined activities of chws and nyumba kumi might have synergistic effects regarding health education in the community; however, there has been no study on this matter to date. this study aimed to prove the hypothesis that community-based nutritional educational programs cooperating with chws and nyumba kumi might effectively change the attitudes of caregivers toward feeding practices and dietary diversity for their children. this study was conducted in the kwale district of kenya, where a health and demographic surveillance system (hdss) is being supervised under nagasaki university and kenya medical research institute (figure 1 ). the hdss monitors the population dynamics every three months, and the system covers nearly 43,000 individuals in an area of 390 square km that includes ten villages [17] . of the ten villages, two villages, dumbule and miatsani, were selected and assigned to a control and an intervention group. these two villages were chosen because of the similar backgrounds in terms of (i) climate settings, (ii) ethnicity (durumas) and culture, and (iii) healthcare services (health facility and staff). furthermore, we considered the geographical distance (30 km) to avoid intervention information "cross-over" from the intervention group to the control group. for the participant selection, 662 potential participants (control: n = 339; and intervention: n = 323) were recruited from the hdss records. the study period was between february 2018 and june 2019 ( figure 2 ). information "cross-over" from the intervention group to the control group. for the participant selection, 662 potential participants (control: n = 339; and intervention: n = 323) were recruited from the hdss records. the study period was between february 2018 and june 2019 ( figure 2 ). based on the pre-intervention survey, we found 649 pairs (control: n = 329; and intervention: n = 320) of caregivers and children who were potentially eligible for the educational intervention trial. the subjects were children aged 6-59 months and their caregivers ( figure 2 ). the trial had two groups: (i) control: caregivers did not receive any education on maternal and child nutrition, and (ii) intervention: caregivers received the education between june and august 2018, and a follow-up consultation was done between september 2018 and february 2019. the educators were locally recruited qualified nutritionists, and they were trained to follow the custom-tailored educational guidelines based on the who recommended indicators of infant and young child feeding and instructions written in the mother and child health booklet [18] . the custom-tailored guidelines contained general information on maternal and child nutrition and health, considering local situations and traditional practices: (i) maternal nutrition during pregnancy and lactation, (ii) early initiation of breastfeeding, (iii) exclusive breastfeeding and duration of breastfeeding and expressing breast milk, (iv) age-appropriate complementary feeding, (v) diverse diet and food groups, (vi) proper hygiene and sanitation practices, (vii) nutrient components of foods and supplements under the maternal and child health program, and (viii) malaria and soil-transmitted helminth and family planning. the education intervention was given in the local language using teaching aids like charts, pamphlets, and models to promote participants' uptake of the materials. during the follow-up consultation, either a chw or a member of the snu visited the households in the intervention group, and they observed the households according to the list to confirm the practice they learned during the educational session. if their practices were improper, suggestions were provided as part of the educational program to follow the educational guidelines by discussing challenges and problems. our data collectors, a chw, or a member of the snu who was given training in advance, administrated a structured questionnaire survey at each caregiver's household once in the pre-and post-intervention in february 2018 and june 2019, respectively. the training sessions were given and qualified by the trained nutritionists to keep the quality of the surveys. the questionnaire was designed to investigate household status (socioeconomic and demographic variables), household caregiver situation (attitudes toward recommended feeding and diet practice), and child status (age, sex, weight, and height). for the socioeconomic status (ses), the possession or use of the following contents were asked as a binomial variable (0/1): bedrooms (<2 or 2≤); cooking fuel (firewood or other); home electrical appliances (either phone, refrigerator, or t.v. set); mobile phone; bicycle; cart; car; and house (owner-occupied or not). the ses was divided into lower and higher statuses using a median threshold of ses. besides, the household population, questions about religion (islam or others), and delivery place (home or facility) were added to the demographic variables. the household population was categorized into two groups (<5 or 5≤) based on the average household population in kwale county [19] . as asked in the household caregiver situation section in the questionnaire, caregiver attitude was assessed based on nine items corresponding to the tailored educational guidelines, and each item was scored one if the caregiver agreed (table s1 , supplementary materials). this attitude score ranged from zero to nine. the diet quality and food consumption in the previous 24 h were also asked of each caregiver. after the interview, food items were classified into 15 categories based on the fao guidelines [20] : starchy staples (grains, white tubers, and roots); vitamin a-rich vegetables (vitamin a-rich vegetables and tubers); dark green leafy vegetables; other vegetables; vitamin a-rich fruits; other fruits; legumes and nuts; dairy products (milk, yogurt, and cheese); eggs; fresh meats; organ meats; fish and seafood; oil; sweets; and spices. based on the classification, each category was binomially classified (0/1) and the sum was calculated (a.k.a. dietary diversity score (dds)). the dds ranged between zero and 15, with the higher score indicating higher diversity. moreover, the body weights of children were measured using a digital scale (seca gmbh & co.kg, hamburg, germany), and heights were scaled using a unicef length measure (available online: https://www.unicef.org/supply/documents/height-length-measuring-boards). both anthropometric scales were taken twice, and averages were recorded to minimize measurement errors in the field. z-scores for height-for-age (haz), weight-for-age (waz), and weight-for-height (whz) were calculated based on the mean according to the child growth standards published by the who in 2006 to evaluate child nutritional status [21] . responses from household caregivers who remained in the post-intervention survey were analyzed to understand caregivers' attitudes toward recommended feeding and the practice of dietary diversity. effects on child nutrition were evaluated for children who attended both pre-and post-surveys. the chi-square test was performed for categorical variables to test background differences between treatment groups: household population, ses, place of delivery, and child sex, statistically. mann-whitney u test was used for the continuous variable of child age. to assess the variable changes per treatment group at the pre-and post-intervention periods, the mean differences of household caregiver situation (dds and attitude score) and child nutritional status (haz, waz, and whz) were tested using the wilcoxon signed-rank test for matched pairs. in contrast, multiple linear regression (mlr) was performed to understand the linear relationship between the treatment groups and dependent variables. the differences (post-and pre-intervention) for household caregiver situation and child nutritional status were set as outcomes or dependent variables, and the independent variable was the treatment group. the effect of the intervention was evaluated with and without adjustments for background covariates showing p-values less than 0.2 in baseline characteristics, along with pre-intervention scores of the outcome. all statistical analyses were performed using stata 14 (statacorp llc, college station, tx, usa). adjusted coefficients with the p-value were reported. p-values less than or equal to 0.05 were considered statistically significant. qgis (3.14, 64 bit) (open source geospatial foundation, available online: qgis.osgeo.org) was used to create the study site map, and world countries were drawn using natural earth (1:50 m cultural vectors) (available online: www.naturalearthdata.com). community boundaries were based on the gadm database (available online: gadm.org). this study was approved by the kemri scientific ethics review unit (seru) (kemri seru no. 3570) and the institutional review board of the institute of tropical medicine, nagasaki university (irb # 171207184-2). the study was conducted in two villages in kwale county, kenya (figure 1 ). according to the hdss registration, the villages had 662 eligible households for nutritional education (figure 2 ). after the trial process, a total of 368 household caregivers (control vs. intervention: 187 vs. 181) and 180 children (113 vs. 67) met the eligibility criteria for the analysis (table 1) . between the groups, differences in household population (p = 0.09), ses (p = 0.43), religion (p = 0.40), and place of delivery (p = 0.66) were not significant. additionally, there was no significant difference in child characteristics in age (p = 0.18) and sex (p = 0.72). the total drop-out cases included participants who were absent at the post-intervention survey and had missing and contradictive data. significant differences in household characteristics listed in table 1 and child sex were not observed between participants who dropped out and completed both pre-and post-intervention surveys. table 2 shows within-group improvements in household caregiver situations for both control and intervention groups. from pre-to post-intervention, the means of dds increased similarly in both groups, 1.97 ± 0.45 in the control and 1.94 ± 0.53 in the intervention group (p < 0.01). likewise, the means of the attitude score by group were significantly improved (control improved: 0.46 ± 0.15; p < 0.01; intervention improved: 0.49 ± 0.41; p < 0.01). concerning child nutritional statuses, the means of haz, waz, and whz for each group had no evident changes between pre-and post-intervention ( table 2 ). the differences between pre-and post-intervention in attitude towards recommended feeding within the group are shown in table s2 (supplementary materials). in table 3 , the difference in household dds (β = 0.54; p < 0.01) and attitude score (β = 0.29; p < 0.01) between the groups demonstrated significant educational effects on the intervention group in the adjusted analysis, although no differences were shown in unadjusted modeling. no educational effects between the treatment groups were identified in child nutritional status. regarding the factors associated with the difference, pre-intervention scores of each outcome negatively related to each corresponding difference (p < 0.01). besides, significant decreases in dds were observed in the household with the population equal to or more than five members (β = −0.46; p < 0.01) and child age (β = −0.02; p < 0.01). table 3 . the effects a of educational intervention and participants demographic variables for household diet practice and child growth between pre-and post-intervention. the results indicate a significant positive impact of nutritional education with the help of chws and snus (i.e., nyumba kumi) on household caregivers' attitudes toward recommended feeding and practices of dietary diversity (table 3) . these improvements can be explained by shi and zhang's review on educational intervention for feeding practice, which identified four critical elements for successful interventions [22] . indeed, our tailored education with snus met the first essential element of cultural sensitivity, accessibility, and integration with local resources. the second key element, effective interpersonal communication, was satisfied with our educational strategy of home visit follow-ups. thirdly, snus matched the required key element of community member involvement. lastly, enrollments of chws in education met the fourth essential element, which recommended the use of existing healthcare services. furthermore, the success of this study could be better explained by the use of snus. it is well known that getting advice from someone known and who is knowledgeable about appropriate feeding practices is more likely to lead to the desired behavior changes of household caregivers [13, 23] . in this study, household caregivers had the opportunity to listen to knowledgeable advice from close known community members in the snu. recently, the kenya government adapted the snu framework or "nyumba kumi" for covid-19 control, which requires flexible and quick responses in local settings. this government action took advantage of the usefulness of using snus across the country [24] . while within-group improvements in dds and attitude scores were observed for both the control and intervention groups (table 2) , the reason could not be explained in our study. these improvements might be due to the effects of the difference in the agricultural seasonality according to the schedule for pre-and post-intervention data collection considering the reports from other studies [25] [26] [27] . however, it is difficult to conclude that the improvements were due to the seasonality because households in the areas grow several crops for cashing regardless of the season in the study areas. although neither the control nor intervention groups immediately improved child nutritional status, studies have demonstrated that educational interventions require a longer duration to observe a significant impact on child nutrition [28, 29] . therefore, successfully improved attitudes and practices of household caregivers should lead to enhancements in child nutrition status in the long term. regrettably, this study was unable to observe such long-term effects on child nutrition because of the limit of the study period, although we observed the improvement of dds and attitude scores. we need to extend the study period to have positive associations between dietary diversity and haz shown in the previous study [30] . moreover, households with more than five members had a smaller difference in dietary diversity though it was not detected in the attitude score. it may be challenging to increase dietary diversity with the limited household budget for larger families regardless of how much nutritional information they receive; therefore, educational intervention combined with other supports is required to promote behavior changes. the results revealed that the interventions using chws and nyumba kumi (snus) were useful to improve dietary diversity and caregivers' attitudes toward recommended feeding; however, we could not identify the effect on child nutritional status in the short observation period of the study. similar small neighborhood frameworks with chws can be expected to bring positive effects in other regions where similar problems of child nutrition remain. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/19/7269/s1, table s1 : nine question items used to assess caregivers' attitudes, table s2 : differences between pre-and post-intervention in attitude towards recommended feeding within the group, respectively. the faces of malnutrition global nutrition targets 2025: policy brief series world bank joint child malnutrition estimates regional classifications maternal participation in a nutrition education program in uganda is associated with improved infant and young child feeding practices and feeding knowledge: a post-program comparison study low dietary diversity is a predictor of child stunting in rural bangladesh consumption of animal source foods and dietary diversity reduce stunting in children in cambodia food variety-a good indicator of nutritional adequacy of the diet? a case study from an urban area in mali, west africa evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? lancet ministry of health/kenya; national aids control council/kenya; kenya medical research institute; national council for population and development/kenya. kenya demographic and health survey relationship between dietary patterns and stunting in preschool children: a cohort analysis from kwale food and nutrition: growing well in a changing world perceptions of caregivers about health and nutritional problems and feeding practices of infants: a qualitative study on exclusive breast-feeding in kwale community health workers in low-and middle-income countries: what do we know about scaling up and sustainability? conflict resolution and crime surveillance in kenya: local peace committees and nyumba kumi nyumba kumi strategy of community policing and its impact on curbing crime; empirical assessment from kenya health and demographic surveillance system in the western and coastal areas of kenya: an infrastructure for epidemiologic studies in africa world health organization. indicators for assessing infant and young child feeding practices, part i: definition guidelines for measuring household and individual dietary diversity; food and agricultural organization of the united nations world health organization. who child growth standards: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: methods and development recent evidence of the effectiveness of educational interventions for improving complementary feeding practices in developing countries correlates of exclusive breastfeeding practices in rural and urban niger: a community-based cross-sectional study ministry of health kenya. kenya report 167 new cases of covid-19 nairobi variations between post-and pre-harvest seasons in stunting, wasting, and infant and young child feeding (iycf) practices among children 6-23 months of age in lowland and midland agro-ecological zones of rural ethiopia seasonality affects dietary diversity of school-age children in northern ghana attitudes and practices on child feeding and care: preliminary insights from the project on linkages between child nutrition and agricultural growth. food security international development policy syntheses an integrated microcredit, entrepreneurial training, and nutrition education intervention is associated with better growth among preschool-aged children in rural ghana effectiveness of an educational intervention delivered through the health services to improve nutrition in young children: a cluster-randomised controlled trial differential effects of dietary diversity and maternal characteristics on linear growth of children aged 6-59 months in sub-saharan africa: a multi-country analysis. public heal the authors thank all our participants, field workers, and the program for nurturing global leaders in tropical and emerging communicable diseases, graduate school of biomedical sciences, nagasaki university. further, we wish to gratefully appreciate tomonori hoshi and todd saunders for great supports to edit this article and abdulatif mohamed for assistance with data collection. the authors declare no conflict of interest. key: cord-032625-u8qces3r authors: park, se-won; yoon, ra gyoung; lee, hyunwoo; lee, heon-jin; choi, yong-do; lee, du-hyeong title: impacts of thresholds of gray value for cone-beam computed tomography 3d reconstruction on the accuracy of image matching with optical scan date: 2020-09-01 journal: int j environ res public health doi: 10.3390/ijerph17176375 sha: doc_id: 32625 cord_uid: u8qces3r in cone-beam computed tomography (cbct), the minimum threshold of the gray value of segmentation is set to convert the cbct images to the 3d mesh reconstruction model. this study aimed to assess the accuracy of image registration of optical scans to 3d cbct reconstructions created by different thresholds of grey values of segmentation in partial edentulous jaw conditions. cbct of a dentate jaw was reconstructed to 3d mesh models using three different thresholds of gray value (−500, 500, and 1500), and three partially edentulous models with different numbers of remaining teeth (4, 8, and 12) were made from each 3d reconstruction model. to merge cbct and optical scan data, optical scan images were registered to respective 3d reconstruction cbct images using a point-based best-fit algorithm. the accuracy of image registration was assessed by measuring the positional deviation between the matched 3d images. the kruskal–wallis test and a post hoc mann–whitney u test with bonferroni correction were used to compare the results between groups (α = 0.05). the correlations between the experimental factors were calculated using the two-way analysis of variance test. the positional deviations were lowest with the threshold of 500, followed by the threshold of 1500, and then −500. a significant interaction was found between the threshold of gray values and the number of remaining teeth on the registration accuracy. the most significant deviation was observed in the arch model with four teeth reconstructed with a gray-value threshold of −500. the threshold for the gray value of cbct segmentation affects the accuracy of image registration of optical scans to the 3d reconstruction model of cbct. the appropriate gray value that can visualize the anatomical structure should be set, especially when few teeth remain in the dental arch. with the widespread use of the cone-beam computed tomography (cbct) in the dental field, three-dimensional (3d) reconstruction images of the jaws and critical anatomical structures were applied in the diagnostic and treatment modalities in oral implantology, maxillofacial surgery, and orthodontics [1] [2] [3] [4] . cbct uses a cone-shaped x-ray beam and a flat detector providing a high-resolution image with lower radiation doses and cost than those from multi-slice ct [5, 6] . the development of digital impression and dental computer-aided design/computer-assisted manufacturing (cad/cam) technologies enhanced the accuracy of implant placement and the convenience of the fabrication of surgical guides reducing the manual work [7] [8] [9] [10] [11] [12] [13] . accordingly, these 3d image reconstructions and computerized manufacturing have accelerated to optimize implant treatments to be more predictable and evidence-based, from both a surgical and a prosthodontic perspective [14] . image registration in computer-guided surgery superimposes the optical scan of the oral cavity and the corresponding cbct data with the same coordinate system [15] . image merging is a prerequisite for accurate virtual surgical planning, because the surface information of teeth and mucosal tissues in the cbct is replaced with optical scans, to compensate for the inaccuracy of the cbct data [16] . the method of image registration is selecting evenly-dispersed anatomical landmarks shown in both cbct and optical scan images, and further automatic alignment is then processed using adjacent image areas with the automatic best-fit algorithm in planning software [17] . to match cbct and optical scan images, the digital imaging and communications in medicine (dicom) images are transformed from a 2d image to a 3d mesh model using medical modeling software. in each of the 2d images of dicom, the teeth and jaw bone are defined radiopaque images, and the amount of anatomical morphology shown in gray-scale values is designated by controlling the minimum threshold of gray value of segmentation in the software [18] . the gray value is a standard index used in cbct for representing the detected radiation intensity by quantitative measurement of tissue absorptivity as the hounsfield unit (hu) of multi-slice ct [19] . through the setting of the minimum threshold of gray value of segmentation, the shape of the 3d reconstruction image is determined because it is created by computing the voxels that have higher gray values than the minimum threshold. when the matching areas are deficient or different in shape between the two images in the registration process, image matching could either be failed or not precise. deviations in the image alignment influence errors in implant position through an inaccurate guide template and cause unavoidable critical complications [20, 21] . the control of the gray-value threshold is an important parameter in the segmentation process that directly affects the quality of 3d reconstruction. depending on the threshold of the gray value of segmentation, scattered radiopaque images in cbct are rendered different in the 3d reconstruction, which could interfere with the point-based automatic best-fit algorithm. however, there has been limited research on the effects of the minimum threshold of the grey value in the 3d reconstruction of cbct on the accuracy of image registration of optical scan to the 3d reconstruction models. the objective of this study was to assess the accuracy of image registration of the optical scan to 3d cbct reconstructions with different thresholds of grey values of segmentation in partial edentulous jaw conditions. the null hypothesis was that the threshold of the gray value of segmentation in cbct and the number of residual teeth would not result in a different image registration accuracy between the optical scan and the cbct 3d reconstruction model. the workflow of this study is presented in figure 1 . from the patients programmed for orthodontic diagnosis, a dentate case with no metallic prosthesis was selected. the study workflow was approved by the institutional review board of the kyungpook national university dental hospital (no 2020-06-02-00), and written informed consent for the use of imaging data was obtained. a hemisphere radiopaque fiducial marker with a diameter of 3 mm was made in the posterior area of the hard palate using a light-curing composite resin (charmfil flow, denkist, gunpo, korea) for supplying a measurement point in this study, and then the image data of the underlying hard tissue and the surface of the oral cavity were obtained. the radiographic data were acquired using a cbct scanner (pax-i3d smart; vatech, hawseong, korea) with a field of view of 100 × 80 mm, 0.2 mm voxel size, 85 kvp, 8 ma, and 24 s pulsed scan, and the image slices were saved in the digital imaging and communications in medicine (dicom) format. the surface data of the oral cavity were digitized using an intraoral optical scanner (cs3600, carestream, rochester, ny, usa) and saved in the standard tessellation language (stl). the study variables of this experiment were the threshold of gray value that was set in the process of the 3d model reconstruction of radiographic data and the number of remaining teeth. the dicom data were converted to the 3d mesh models using three different minimum thresholds of gray value (−500, 500, and 1500) in the image-control software (mimics, materialise, leuven, belgium). image segmentation of tooth images was followed in the 3d mesh models using imageanalysis software (geomagic designx, 3d systems, rock hill, sc, usa) to make models with different numbers of remaining teeth (4, 8, and 12) . accordingly, a total of nine 3d reconstructed models were made according to the radiographic threshold and the number of remaining teeth ( figure 2 ). the stl image of the surface of the oral cavity was also modified and saved in different files to make scan models with different numbers of remaining teeth ( figure 3 ). a hemisphere radiopaque fiducial marker with a diameter of 3 mm was made in the posterior area of the hard palate using a light-curing composite resin (charmfil flow, denkist, gunpo, korea) for supplying a measurement point in this study, and then the image data of the underlying hard tissue and the surface of the oral cavity were obtained. the radiographic data were acquired using a cbct scanner (pax-i3d smart; vatech, hawseong, korea) with a field of view of 100 × 80 mm, 0.2 mm voxel size, 85 kvp, 8 ma, and 24 s pulsed scan, and the image slices were saved in the digital imaging and communications in medicine (dicom) format. the surface data of the oral cavity were digitized using an intraoral optical scanner (cs3600, carestream, rochester, ny, usa) and saved in the standard tessellation language (stl). the study variables of this experiment were the threshold of gray value that was set in the process of the 3d model reconstruction of radiographic data and the number of remaining teeth. the dicom data were converted to the 3d mesh models using three different minimum thresholds of gray value (−500, 500, and 1500) in the image-control software (mimics, materialise, leuven, belgium). image segmentation of tooth images was followed in the 3d mesh models using image-analysis software (geomagic designx, 3d systems, rock hill, sc, usa) to make models with different numbers of remaining teeth (4, 8, and 12) . accordingly, a total of nine 3d reconstructed models were made according to the radiographic threshold and the number of remaining teeth ( figure 2 ). the stl image of the surface of the oral cavity was also modified and saved in different files to make scan models with different numbers of remaining teeth ( figure 3 ). to combine the cbct-based reconstructed 3d image and the optical scan image, an imageregistration process was performed in the image-analysis software (geomagic designx, 3d systems). in each group, the optical scan images were registered to the corresponding reconstructed 3d images using the point-based best-fit algorithm ( figure 4 ) [22] . three matching points in pairs were designated to dental structures discernible in both images with a wide-spread pattern: teeth 11, 12, 22 for the four-teeth condition; teeth 11, 14, 24 for the eight-teeth condition; and teeth 11, 17, 27 for the 12-teeth condition. the anatomic structures, such as the incisal edge or buccal cusp tip of the tooth, were used for reference-matching points. after the point designation, the optical scan images were moved to the closest fit with the corresponding reconstructed images using an iterative closest points (icp) algorithm in the software programs [17] . the image registration procedure was conducted 5 times for each group by a qualified operator, who had experience in image matching to minimize the human error involved in the selection of matching points. the sample size was determined with power analysis of f tests using results of a preliminary test (number of groups = 3, α = 0.05, power = 0.8, effect size f = 0.919, standard deviation = 0.18). to combine the cbct-based reconstructed 3d image and the optical scan image, an imageregistration process was performed in the image-analysis software (geomagic designx, 3d systems). in each group, the optical scan images were registered to the corresponding reconstructed 3d images using the point-based best-fit algorithm ( figure 4 ) [22] . three matching points in pairs were designated to dental structures discernible in both images with a wide-spread pattern: teeth 11, 12, 22 for the four-teeth condition; teeth 11, 14, 24 for the eight-teeth condition; and teeth 11, 17, 27 for the 12-teeth condition. the anatomic structures, such as the incisal edge or buccal cusp tip of the tooth, were used for reference-matching points. after the point designation, the optical scan images were moved to the closest fit with the corresponding reconstructed images using an iterative closest points (icp) algorithm in the software programs [17] . the image registration procedure was conducted 5 times for each group by a qualified operator, who had experience in image matching to minimize the human error involved in the selection of matching points. the sample size was determined with power analysis of f tests using results of a preliminary test (number of groups = 3, α = 0.05, power = 0.8, effect size f = 0.919, standard deviation = 0.18). to combine the cbct-based reconstructed 3d image and the optical scan image, an image-registration process was performed in the image-analysis software (geomagic designx, 3d systems). in each group, the optical scan images were registered to the corresponding reconstructed 3d images using the point-based best-fit algorithm ( figure 4 ) [22] . three matching points in pairs were designated to dental structures discernible in both images with a wide-spread pattern: teeth 11, 12, 22 for the four-teeth condition; teeth 11, 14, 24 for the eight-teeth condition; and teeth 11, 17, 27 for the 12-teeth condition. the anatomic structures, such as the incisal edge or buccal cusp tip of the tooth, were used for reference-matching points. after the point designation, the optical scan images were moved to the closest fit with the corresponding reconstructed images using an iterative closest points (icp) algorithm in the software programs [17] . the image registration procedure was conducted 5 times for each group by a qualified operator, who had experience in image matching to minimize the human error involved in the selection of matching points. the sample size was determined with power analysis of f tests using results of a preliminary test (number of groups = 3, α = 0.05, power = 0.8, effect size f = 0.919, standard deviation = 0.18). the accuracy of image registration was assessed by means of the positional discrepancy between the 3d reconstructed radiographic image and the registered optical scan image. the positional discrepancy was recorded by measuring the distance between the center points of inserted fiducial markers (3d linear deviation) shown in both images in the image-analysis software ( figure 5 ). to detect the center point, a virtual circle of a marker outline that was perpendicular to the long axis of the marker was set, and the center point was determined based on the circle. the error measurements were performed by an investigator who was blinded to the purpose of this experiment. all continuous measurement data were reported as mean ± standard deviation. statistical analyses were performed using statistical software (ibm spss statistics, v25.0; ibm corp, chicago, il, usa). the kruskal-wallis test and the post hoc mann-whitney u test with the bonferroni correction were used to compare the results between groups with a different minimum threshold of gray values and number of remaining teeth. the interaction between the experimental factors on the image registration accuracy was statistically calculated using the two-way analysis of variance (anova). statistical significance level was set at 0.05. the accuracy of image registration was assessed by means of the positional discrepancy between the 3d reconstructed radiographic image and the registered optical scan image. the positional discrepancy was recorded by measuring the distance between the center points of inserted fiducial markers (3d linear deviation) shown in both images in the image-analysis software ( figure 5 ). to detect the center point, a virtual circle of a marker outline that was perpendicular to the long axis of the marker was set, and the center point was determined based on the circle. the error measurements were performed by an investigator who was blinded to the purpose of this experiment. the accuracy of image registration was assessed by means of the positional discrepancy between the 3d reconstructed radiographic image and the registered optical scan image. the positional discrepancy was recorded by measuring the distance between the center points of inserted fiducial markers (3d linear deviation) shown in both images in the image-analysis software ( figure 5 ). to detect the center point, a virtual circle of a marker outline that was perpendicular to the long axis of the marker was set, and the center point was determined based on the circle. the error measurements were performed by an investigator who was blinded to the purpose of this experiment. all continuous measurement data were reported as mean ± standard deviation. statistical analyses were performed using statistical software (ibm spss statistics, v25.0; ibm corp, chicago, il, usa). the kruskal-wallis test and the post hoc mann-whitney u test with the bonferroni correction were used to compare the results between groups with a different minimum threshold of gray values and number of remaining teeth. the interaction between the experimental factors on the image registration accuracy was statistically calculated using the two-way analysis of variance (anova). statistical significance level was set at 0.05. all continuous measurement data were reported as mean ± standard deviation. statistical analyses were performed using statistical software (ibm spss statistics, v25.0; ibm corp, chicago, il, usa). the kruskal-wallis test and the post hoc mann-whitney u test with the bonferroni correction were used to compare the results between groups with a different minimum threshold of gray values and number of remaining teeth. the interaction between the experimental factors on the image registration accuracy was statistically calculated using the two-way analysis of variance (anova). statistical significance level was set at 0.05. table 1 shows the image registration error of each condition using the 3d linear deviation values. of all the thresholds of gray value of segmentation, the registration errors were lowest with the threshold of 500. in the arch image with 4 remaining teeth, the registration error with the threshold setting of −500 was significantly higher than those with the threshold settings of 500 and 1500 (table 2 ). in the arch images with 8 and 12 remaining teeth, the registration errors were the lowest with the threshold of 500, followed by those with the thresholds of −500 and then 1500; furthermore, there was a significant difference among the groups in terms of errors. table 3 ). the registration errors were lowest in the arch image with twelve teeth, followed by in the arch images with eight teeth, and then those with four teeth. the biggest error of 1.89 ± 0.32 mm was observed when the arch image with four teeth was reconstructed with a minimum threshold of −500 gray values, whereas the smallest error of 0.13 ± 0.02 mm was observed when the arch image with the 12-teeth model was reconstructed with a minimum threshold of 500 gray values. the two-way anova test revealed a significant interaction between the minimum threshold of gray value factor and the number of remaining teeth on the registration accuracy (f = 53.6, p < 0.001; table 4 ). although the trend line of image-registration error had a similar tendency in all arch images having the lowest error values at the threshold of 500, the error was markedly high in the arch image with four remaining teeth and −500 gray-value threshold ( figure 6 ). the two-way anova test revealed a significant interaction between the minimum threshold of gray value factor and the number of remaining teeth on the registration accuracy (f = 53.6, p < 0.001; table 4 ). although the trend line of image-registration error had a similar tendency in all arch images having the lowest error values at the threshold of 500, the error was markedly high in the arch image with four remaining teeth and −500 gray-value threshold ( figure 6 ). this study was designed to evaluate the impacts of thresholds of gray value of cbct segmentation on the accuracy of image registration of optical scans on the 3d reconstruction model of the cbct. for the purpose, the optical scan was registered to 3d reconstruction cbct models created by different thresholds of gray value of segmentation and number of remaining teeth, and the 3d linear deviations of the registered optical scan were measured. the deviation values were significantly different according to the 3d reconstruction models made by different thresholds of gray value. the deviation values were significantly higher when few teeth remained in the arch in all conditions of thresholds of gray value for cbct 3d reconstruction. thus, based on the findings of this study, the proposed null hypothesis, the thresholds of gray value of segmentation in cbct, and the number of residual teeth would not influence the accuracy of image registration of the optical scan to the cbct data, was rejected. the main variables in this study were gray-value thresholds of segmentation and the number of residual teeth in the image registration. the quality of 3d reconstruction image models obtained by this study was designed to evaluate the impacts of thresholds of gray value of cbct segmentation on the accuracy of image registration of optical scans on the 3d reconstruction model of the cbct. for the purpose, the optical scan was registered to 3d reconstruction cbct models created by different thresholds of gray value of segmentation and number of remaining teeth, and the 3d linear deviations of the registered optical scan were measured. the deviation values were significantly different according to the 3d reconstruction models made by different thresholds of gray value. the deviation values were significantly higher when few teeth remained in the arch in all conditions of thresholds of gray value for cbct 3d reconstruction. thus, based on the findings of this study, the proposed null hypothesis, the thresholds of gray value of segmentation in cbct, and the number of residual teeth would not influence the accuracy of image registration of the optical scan to the cbct data, was rejected. the main variables in this study were gray-value thresholds of segmentation and the number of residual teeth in the image registration. the quality of 3d reconstruction image models obtained by cbct is dependent on acquisition parameters such as tube voltage, tube current, voxel size, the type of the device, the signal-to-noise ratio, the position of the object, the field of view, and anatomic variations [23] . all these factors affect the results of the density of gray-value voxel and further 3d reconstruction. to control these image acquisition factors in the present study, the one set of dicom data with a fully dentate case was used to create 3d reconstruction models with different thresholds of gray value. afterward, dental images were selectively removed to make subgroup models with different remaining teeth. the errors in 3d matching between the reconstructed cbct image and the optical scan image may be due to discrepancies in shape. in this study, the volume of the 3d reconstruction model was increased with a decrease in the minimum threshold settings. the halation around the mandible can be induced by the scatter and nonlinear partial-volume effect [23, 24] . the scattering of photons deteriorates the image, blurring the image borders, and eventually leading to artifacts [25] . although several strategies have been proposed to reduce the scatter by using physical instruments as anti-scatter grids [26] , imaging corrections based on system simulation [27] , calibration of the cbct system [28] , and higher scatter levels in cbct is basically related to the cone-beam projection geometry, that is much higher than in multi-slice ct [29] . meanwhile, according to the theory of partial-volume effects, the gray value of voxel on the ct image represents the average density value of the corresponding unit when a voxel lies on the borders of two objects of different densities [28] . in larger voxel sizes and lower thresholds for segmentation, the volume of a reconstructed bone could be larger than its real size, and the margin of a reconstructed bone is relatively vague because of the surface-surrounding artifacts [30] . accordingly, the partial-volume effect can produce deformations in the reconstruction image. low minimum-threshold settings of gray value visualize more existing artifact images that degrade the quality of cbct images [25, 31] . in the present study, the artifact images were changed to 3d surface polygons in the reconstruction process in the low minimum threshold, causing deformed and irregular surfaces, whereas with increased minimum-threshold settings of segmentation, low gray-density pixels were excluded to be converted to 3d reconstruction images. some artifacts were hidden, but porous surface images were created in the 3d mesh model, and the loss of surface area needed for the automatic image matching process was also involved. therefore, an optimal threshold of gray value of segmentation is required to diminish the artifact image involvement and obtain enough area of intact anatomical structure image in 3d reconstruction. the use of surface-based image matching is known to be advantageous for computer-guided implant surgery because this workflow is clinically feasible and time-efficient [17, 32] . the surface-based matching uses the computer algorithm of iterative closest points (icps) that locates paired images in optimal positions by computing the 3d coordinates of the geometrical shape of 3d object surfaces to align images [17, 22] . when the image surface point clouds that are used for matching are widely spread in the oral cavity, the matching condition is favorable, and the whole accuracy of image registration can be increased [15, 33] . in the present study, a significant correlation was found between the threshold of gray value factor and the number of remaining teeth on the registration accuracy. the deviation error was markedly high in the arch image with four remaining teeth that were created using the −500 threshold of gray value. that is to say, when few teeth remained, low thresholds of gray value of segmentation in cbct incurred inaccurate image registration of optical scan images. this finding implies that, in the case of extensive tooth loss, particular care should be taken in reducing the creation of adverse artifact images in the 3d reconstruction likely to influence the image matching by not using low thresholds of gray value of segmentation. the establishment of accurate virtual 3d space visualizing the oro-maxillary anatomical structures brings new diagnostic possibilities, which make the entire treatment procedure more predictable and precise [34, 35] . the authors do not know of a previous study that evaluated the relationship between the threshold of gray value of segmentation for cbct 3d reconstruction and the accuracy of image-matching with an optical scan image. knowledge of the effects of the image operation factor on the results of image registration can contribute to clinically improve the accuracy of computerized treatments. a limitation of this study was that the radiographic and optical scan data were derived from just one clinical case. the quality of cbct and optical scan images may vary depending upon the related factors and settings involved. although this study design was intended to control other confounding factors, multiple and diverse clinical cases should be included in further studies considering the anatomical variations of the dental arch shape, dental morphology, and other influencing factors. more related research on image denoising and artifact suppression methods is required. within the limitations of this study, the accuracy of image registration of optical scan with the 3d reconstruction model of cbct could be different depending on the threshold of gray value of cbct segmentation. the accuracy was higher in the case that a high enough number of teeth remained and the set gray value reconstructed the shape of the teeth properly. particular care should be taken in minimizing the artifact images in the 3d reconstruction when few teeth remain in the dental arch. further studies are required to confirm the findings of this study in diverse clinical cases and anatomical variations. assessing mandibular body changes in growing subjects: a comparison of cbct and reconstructed lateral cephalogram measurements available technologies, applications and benefits of teleorthodontics. a literature review and possible applications during the covid-19 pandemic three dimensional reliability analyses of currently used methods for assessment of sagittal jaw discrepancy cad/cam-guided implant surgery and fabrication of an immediately loaded prosthesis for a partially edentulous patient what is cone-beam ct and how does it work? dent study of the scan uniformity from an i-cat cone beam computed tomography dental imaging system dynamic navigation in dental implantology: the influence of surgical experience on implant placement accuracy and operating time. an in vitro study a simple and safe approach for maxillary sinus augmentation with the advanced surgical guide influence of intra-oral scanner (i.o.s.) on the marginal accuracy of cad/cam single crowns milled versus moulded mock-ups based on the superimposition of 3d meshes from digital oral impressions: a comparative in vitro study in the aesthetic area 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hounsfield unit values from multidetector computed tomography scans bone classification: an objective scale of bone density using the computerized tomography scan fusion of computed tomography data and optical 3d images of the dentition for streak artefact correction in the simulation of orthognathic surgery clinical application of stereolithographic surgical guides for implant placement: preliminary results impact of matching point selections on image registration accuracy between optical scan and computed tomography accuracy of in-vitro tooth volumetric measurements from cone-beam computed tomography reliability and accuracy of cone-beam computed tomography dental measurements artefacts in cbct: a review antiscatter grids in mobile c-arm cone-beam ct: effect on image quality and dose a practical cone-beam ct scatter correction method with optimized monte carlo simulations for image-guided radiation therapy an evaluation of techniques for dose calculation on cone beam computed tomography evaluating the scattered radiation intensity in cbct detection of alveolar bone defects with three different voxel sizes of cone-beam computed tomography: an in vitro study artifacts: the downturn of cbct image integration of digital dental casts in cone beam computed tomography scans-a clinical validation study the effects of distribution of image matched fiducial markers on accuracy of computer-guided implant surgery three-dimensional evaluation of maxillary sinus changes in growing subjects: a retrospective cross-sectional study assessment of condylar volume and ramus height in jia patients with unilateral and bilateral tmj involvement: retrospective case-control study key: cord-266239-l0ulr2ep authors: freeman, shannon; marston, hannah r.; olynick, janna; musselwhite, charles; kulczycki, cory; genoe, rebecca; xiong, beibei title: intergenerational effects on the impacts of technology use in later life: insights from an international, multi-site study date: 2020-08-07 journal: int j environ res public health doi: 10.3390/ijerph17165711 sha: doc_id: 266239 cord_uid: l0ulr2ep as the use of technology becomes further integrated into the daily lives of all persons, including older adults, it is important to investigate how the perceptions and use of technology intersect with intergenerational relationships. based on the international multi-centered study technology in later life (till), this paper emphasizes the perceptions of older adults and the interconnection between technology and intergenerational relationships are integral to social connectedness with others. participants from rural and urban sites in canada and the uk (n = 37) completed an online survey and attended a focus group. descriptive and thematic analyses suggest that older adults are not technologically adverse and leverage intergenerational relationships with family and friends to adjust to new technologies and to remain connected to adult children and grandchildren, especially when there is high geographic separation between them. participants referenced younger family members as having introduced them to, and having taught them how to use, technologies such as digital devices, computers, and social networking sites. the intergenerational support in the adoption of new technologies has important implications for helping older persons to remain independent and to age in place, in both age-friendly cities and in rural communities. the findings contribute to the growing literature in the fields of gerontology and gerontechnology on intergenerational influences and the impacts of technology use in later life and suggest the flexibility and willingness of older persons to adopt to new technologies as well as the value of intergenerational relationships for overcoming barriers to technology adoption. from monitoring personal health and wearable devices to playing online games and using social media to connect with friends and family, technology has become a valued component of daily life for many individuals. interest in technology has steadily increased over the past decade, associated with unprecedented growth and innovation in information and communication technologies (icts) [1, 2] . there has been an increase in the proportion of older adults (persons aged over 65 years) in countries across the world utilizing technology [3] . as the use of technology and associated icts increases, there is a greater need to expand the understanding of the intersection of technology, ageing, and intergenerational relationships. a particular gap in knowledge exists regarding the role of intergenerational elements in motivating older adults to learn how to use technology and associated icts. across the globe, societies are aging rapidly due to increased life expectancy as a result of better health and social care, and lower birth rates [4] . recent united kingdom (uk) population estimations suggest the proportion of those aged 65+ years in rural and urban environments will increase by 50% between 2016 and 2039, whilst those aged <65 years are projected to increase by eight percent in urban areas and to stagnate in rural locations [5] . in 2014, 15.6% of the canadian population, equating to over 6 million persons, were aged 65, and it is predicted that by 2030, older adults will exceed 9.5 million persons, accounting for 23% of the canadian population [6] . in canada, the majority of older adults (56.4%) lived with a spouse or a common-law partner in 2011 while about one-quarter (24.6%) lived alone [6, 7] . the increase in the migration of younger cohorts from rural to urban areas and of older adults from urban to rural areas leaves an increased proportion of older adults in rural areas who prefer to "age in place" [8, 9] . research focused on aging in urban areas has emphasized the challenges older adults face in accessibility, especially in access to public transportation, shopping, and green space [10] . as geographic separation between family members increases, the role of icts in helping to strengthen and maintain family bonds becomes more important [11] . however, the extent to which older adults use technologies for this purpose remains unclear. although, in the future, aged cohorts may be more "tech savvy" [12] , having used technologies regularly across their life course, new technologies may still arrive that could be disproportionately challenging for older people to adopt. technology (e.g., digital devices, the internet, digital gaming, and mobile apps) use in later life is a growing field of research, with much new exploration and study [13] [14] [15] [16] . technology and associated icts are often aimed towards improving the health, wellbeing and quality of life of older adults, whether through applications for home healthcare and connected health services [17] , medication reminders [18, 19] , mirrors that display health data [20] , or wearable technology [21] . technology use to enhance communication is routine practice for many older adults, with home computers being used to create a common interest among older and younger family members and improve family ties [22] . technology use among older adults is growing [3] . for example, in canada, between 2007 and 2016, internet use increased from 32% to 68% among those aged 65 and older [23] . in 2016, 85% of people aged 65-69 used the internet compared to 62% of those aged 70-79 and 40% of those aged 80 years and older [23] . challenges with technology have been linked to age, evidenced by differences in use [24, 25] and variation in the learning of technology (computers and internet) between older and younger adults [12, [26] [27] [28] [29] [30] [31] . older adults in canada were less likely than younger adults to perceive technology as useful for communicating with others, making informed decisions, and saving time [23] . several studies reported that internet use is lower among older-aged cohorts than younger cohorts [32] [33] [34] ; however, there is evidence of a cohort effect as there has been an increase in technology use within older-aged cohorts over time [2] . older adults who do use the internet report lower confidence in their ability to do so than younger adults [35] , which may be tied to challenges older adults experience with technology use (e.g., visual difficulties and cognitive declines) [36, 37] . older adults are likely to make more errors and require assistance when learning computer systems and software [36, 37] . previous research suggests that older adults may be "technophobic" [38, 39] and struggle to use technology [2] , as they embrace technology differently and at a slower pace than younger adults [2] , [32, 40] . as the canadian and uk populations age, differences in technology adoption and use across age cohorts may increase, amplifying the "generational gap" [41] . while learning to use technology serves as a rite of passage for today's youth, playing an important role in the self-definition of young adults [42] , this may not be the case for older generations. individuals not born into the current rapidly evolving digital age, sometimes referred to as "digital immigrants", must find ways to adapt to a changing society [43] . rama noted that each "technology generation" may have been affected by common experiences during their formative years that influence behaviours towards and the use of technology [44] . however, these notions are challenged by bennett and maton, who note the diverse range of experience and engagement with technology among youth, as well as by loos, who describes technology use as a spectrum affected not only by life stage but also by socialization and degree of age-related functionality [16, 45] . technology use is complex and can no longer simply be split into user vs. non-user groups. instead, the heterogeneity in the use of technology includes not only use of the technology for an intended purpose but also the meaning and value that the use of technologies has in mediating social relationships and connection to the external world [46] . existing research highlights differences in technology use between the generations; however, research on the connection between intergenerational factors, social variables, and technology use among older adults is less prevalent, with notable exceptions including [26] [27] [28] . however, other research suggests that age is not a consistent driving factor associated with aversion to technology such as computer anxiety [24] . as such, it remains less clear how factors such as intergenerational intelligence, solidarity, and adaptiveness apply to the learning and use of technology, especially by older adults [47] [48] [49] [50] [51] . younger generations are the dominant early users and adopters of social networking sites [12, 52] , with few older adults (between 10% and 27%) using this form of technology [2, 3] . social networking and other technologies present opportunities for older generations to connect with younger generations and individuals in diverse geographic locations [22, [53] [54] [55] . technology has been shown to enhance an older adult's quality of aging [56] , independence [57] , social status [56] , interpersonal relationships, control, self-esteem, and integration into society [57, 58] . to understand how to meet the needs of an aging population in a technology-suffused society, it is useful to understand why older adults choose (or not) to use technology and whether (or not) they perceive the reasons driving their choice as constraints requiring negotiation or benefits to everyday life. the challenges to acquiring new technology skills and strategies for connecting with younger generations to overcome them suggest the importance of intergenerational influences on older adults' understanding and use of technology, which must be further explored. the above findings are concerning in light of research reports that older adults are more likely to experience loneliness and isolation [34] . there is, to date, a growing body of scholarly work exploring the relationships between intergenerational relationships and technology [27, 28] , offering insight into how technology and associated icts lay within and across intergenerational networks. taipale and colleagues [27] discuss ict use through various lenses including both older and younger adults-a generational perspective, the family, and the home. to further extend research in this area, we describe further the relationship between technology use and interpersonal relationships-more specifically, the how older adults' understanding and use of technology is affected by their intergenerational relationships. the technology in later life (till) study examined the experiences of older adults aged 70+ years with technology, exploring how they adopted, accepted, and used various types of technology. subsequently, the team sought to identify the implications of using icts for current and future aging populations in rural and urban locations. the technology in later life (till) study was an exploratory study conducted in canada and the uk across four study sites. canada and the uk were selected for this study as they both have aging populations and exposure to technology and contain different rural and urban populations. in each country, two sites were selected: one rural and one urban. the rural site in canada was the town of mcbride (bc), and the urban site selected was the city of regina (sk). the rural sites in the uk included the village of cwmtwrch and the village of ystalyfera in wales, and the urban site was the town of milton keynes (buckinghamshire) in england. participants were recruited through the use of posters and mailing list scripts tailored to each site distributed to local organizations including the older people's forum, seniors' centers, public libraries, seniors' community newsletters, and local public radio. participants were also recruited through word of mouth in the community. participants each voluntarily contacted the lead investigator for the research site closest to them to request to participate in the study. upon contact, the participants were sent an email containing a link to the online survey, information on the study and a request for written consent to participate, and an invitation to set a date to join a focus group interview. all participants completed the online survey prior to participation in a focus group. the survey was an iteration of an earlier survey [14, 59] , which covered eight domains: (1) technology use, (2) internet ownership and use, (3) social networking, (4) digital device ownership, (5) purchasing patterns, (6) quantified self-and life-logging, (7) information sharing and privacy issues, and (8) demographics. bivariate analyses of the survey data were conducted using spss version 24. an inductive approach was taken to generate new knowledge from the qualitative data. a descriptive approach is beneficial for an initial study, as such an approach allows the researchers to richly describe the phenomenon being studied. focus group discussions, led by the lead researcher from each site, lasting between 40 and 60 minutes, were digitally audio-recorded and then transcribed verbatim in microsoft word by a uk-based transcription company. all the lead researchers were experienced in conducting qualitative research analyses and in leading focus groups. a semi-structured interview guide containing questions and probes was used to facilitate discussion (supplementary materials). the questions examined several areas including the ownership of technology, the purpose for using technology, internet social media use, life-logging, privacy issues and the sharing of information (e.g., what type of information and rationale for sharing), and willingness to embrace new technology (supplementary materials). content and inductive analyses [60] were conducted across all the transcripts. given the exploratory nature of this analysis, the transcriptions were read closely for familiarization with the data, coded, and analyzed thematically. the data were classified into categories as a way of describing key themes [61] . in addition, areas of concordance and discordance were examined through the analysis. specifically, open coding, with the creation of categories and abstraction, was undertaken. coding was first conducted independently by a research assistant, trained in qualitative research methodologies and experienced in conducting analysis, and by a co-investigator, both of whom then came together to come to a consensus on the coding. discrepancies were addressed by recoding areas of discordance, and then, the transcripts were reanalyzed by the research assistant and reviewed by a co-investigator of the study to promote accuracy and trustworthiness [62] . ethics approval was granted by all four institutions. thirty-seven participants both completed an online questionnaire and attended a focus group discussion. this included 20 rural participants (mcbride, canada, n = 10, cwmtwrch and ystalyfera, uk, n = 10) and 17 urban participants (regina, canada, n = 6 and milton keynes, uk, n = 11) from 2015 to 2016. most participants were female (67.6%), retired/not employed (86.5%), and in their late 70s (mean age, 77.4 years). five themes were identified relating to intergenerational relationships. three themes focused on the benefits of intergenerational relationships to support use of technology including 1) motivation for older adults to use technology, 2) use of technology as a facilitator of intergenerational connection and 3) technology use for safety reasons. additionally, two themes focused on the impediments of intergenerational relationships to use of technology including 1) using technology to appease younger family members; and 2) learning how to use technology in later life. all participants used technology, the majority of whom did so on a regular basis (table 1) . nearly all participants used a computer (97.3%) and owned a computer (89.2%). most participants had used a computer for at least 10 years (75.7%) and used a computer more than once per day (62.2%). all participants used a digital device, typically a mobile/cell phone (70.3%), and to share information (82.7%). nearly all participants identified having internet at home (94.3%) and most had used the internet for more than 10 years (75.8%). participants used technology for a variety of tasks including e-mail, word processing, playing games, making telephone calls, online shopping, online banking, sharing information, social networking, searching/checking information, instant messaging, reading, uploading content, and lifelogging. over half reported using social media (54.1%, n = 20) with more canadian participants' self-reporting use of social media when compared to participants from the uk (62.5% vs. 47.6%) ( table 2 ). a primary motivation for participants to use technology was as a "digital gathering place" to communicate with family, especially adult children and grandchildren, and friends. participants communicated through technology in a variety of ways including skype, facetime, e-mail, social networking sites (e.g., facebook), and texting through cellular networks or whatsapp. interestingly, it was common that participants who used technology were taught how to do so by younger family members. the value of digital communication was enhanced when participants' children and/or grandchildren lived far away. "skype is brilliant. i've got a daughter in spain, i've got a granddaughter in spain, i've got a son in the west indies and a daughter in london, and skype is one of the most brilliant things that's happened because you can see, you can talk." [mk6, male]. "i've used skype because my daughter lives in south africa, but it's an atrocious service because south african broadband is atrocious. we now use apple facetime and that is far superior." . it is also useful to note that participants adjusted the platforms they used not only due to personal preferences but also in response to the variance in the infrastructure and broadband support across the locations. older adults reported using technology to connect with friends and family members, and to share information, also likely with family members. participants often used computers for email (85.3%) and social networking (38.2%), most often in their own home (97.1%) and occasionally at an adult child's home (17.1%). social networking sites were used to stay connected with children and/or grandchildren and friends, to share photos and information with friends and/or family, and to keep up to date with news. the internet was used for sending/receiving e-mails, social media, making phone calls through skype/viber, and instant messaging. older adults both created and sent content (e.g., photos and emails), as well as receiving content. it was both older adults and their family members/friends who took turns initiating contact. most participants identified that they used technology to write or speak with other family members; there were a few instances where participants reported using technology to partake in and share the hobbies of younger family members. older adults were keen to try new things with their grandchildren such as interactive videogames and immersed themselves in the flow of the games. one participant noted, "[ . . . ] jumping up and down to the things that they've got on the screen when you play tennis or jump up and down and dance, or whatever you're chasing, something. yes. video games, i suppose. childish ones." [mcb2, female]. another participant used her daughter and granddaughter's ipad to take pictures of the community garden. participants suggested that technology is not only used to connect and communicate with younger family members but also to learn about and actively participate in activities with younger generations. of the participants using technology to stay in contact with family, some also acknowledged having started using a digital device for safety reasons at the suggestion of another family member, commonly an adult child. most participants reported owning a mobile device or cell phone, many of whom owned these devices for "safety" [regina2, female] and "emergencies only" [mk5, female]. one participant living in rural british columbia described how they started using a digital device specifically for driving purposes as well as feeling the need to maintain a sense of peace with their adult children. "i got the cell phone because my kids kept thinking something was going to happen to me. i said, "well you know if i have a breakdown on the highway, we managed for 70 years for god's sake by just stopping someone and they'd help you. but now, "oh my god they could murder you." so, this was supposed to be a safety element to keep peace in the family." [mcb1, female]. this participant further described displeasure with the cell phone because it cost them money each month and they never used the device. several participants identified that they got digital devices at the suggestion of an adult child after having suffered a health scare. for example, when asked why they got a cell phone, one participant replied, "oh, well it was the bright idea of my son. i had a mini stroke . . . ever since, but they're [kids] always frightened . . . of a recurrence. so, my son gave me a cell phone, his old one, which i used right away, or more or less. i think, they decided that i should have one, because i did get a few dizzy spells. so, now i just use it" [mcb2, female]. even though it was often a younger family member, such as an adult child, who suggested the participant carry a digital device for safety-related reasons, most participants had positive perceptions of using technology for such reasons. for example, one participant spoke positively of how they wore a certain piece of technology that they can press in an emergency situation to notify a family member or emergency service that help is needed. while it seems that most participants use technology to keep in touch with younger family members, the reasons for this contact vary, from safety and emergency situations to routine check-ins with children and grandchildren. in some instances, participants seemed to use technology to make a younger relative happy even if they did not seem to need the technology. for example, "i don't even have an iphone or ipad so i'm really out of date . . . i will get more modernized so that my children will be happy" [regina2, female]. another participant stated, "i've got a tablet that i was to take away with me because my grandchildren said it would be useful to have and i wouldn't be using theirs whenever i'm away on holiday with them. i don't get on terribly well with a tablet . . . " [mk2, female]. common responses for why participants owned technology included similar motivations, stemming from the children: " . . . the kids decided we should have one [computer]" [mcb4, male] and that their grandchildren were putting pressure on them to keep up with the latest technology. furthermore, one participant explained that they were learning technology because the " . . . grandchildren push me and they go, 'oh nana, you're so far behind, you should be up to date and you should be doing this and doing that.' so, they want me to be up to date with all the latest technology and i'm not." [regina3, female]. in certain cases, younger family members purchased technology for older family members as gifts. one participant reflected on a life logging device they owned, explaining, "my daughter bought it for my birthday . . . " [wales1, female] after her husband began experiencing a health decline. these examples illustrate, across the different study sites, how the respective participants felt about technology and how digital devices had been implemented into their lives without consideration of their respective feelings, needs, and choice. many participants used computers as integral components of their jobs decades ago and were among the early adopters of computing technologies. one participant who was familiar with computers explained that they used to do it at milton keynes college. similarly, a participant from mcbride learned the fundamentals of using a computer for their accounting position, explaining that they learned about spreadsheets. however, with the rapid pace of technology development, the technological skills participants had employed prior to retirement became quickly outdated. participants described that the challenges in keeping up with the rapid pace of changes in the technology itself were compounded by their frustrations in keeping up to date on the expanded language used to describe the technologies. participants described the complexity in language and terminology used in technology tutorial classes and instruction manuals as too complicated and inhibiting their ability to adopt new technologies. one participant identified that instructors at computer classes "go way too fast for me. i can't keep up; there is too much new information . . . the language like computer and technological language is totally different from what we were raised with" [mcb2, male]. another participant identified similar grievances about learning to use technology, such as the fact that they "can't understand technology words" [mcb1, female] in instruction manuals and that when speaking with information technology (it) specialists, the it specialist would explain too quickly. although participants noted how they were confused about how to use technology, they still managed to do so, most commonly with assistance from younger family members. participants were frequently introduced to digital devices and to social networking sites by a relative or adult child. participants alluded to younger family members playing a key role in the learning process, saying things such as "my son set it [skype] up . . . " [mk2, female] and "oh, my daughter is the one that does all the computerizing. she helps . . . " [mcb2, female]. they emphasized that they were not technophobic or averse to use of the technology itself but felt outpaced by the speed of change of technology. for many, they were unable to overcome the language barriers created to adapt and adjust to changes in technology on their own or with those of a similar age. instead, they would connect with younger generations for help. where confusion over technology existed, younger family members took on a teaching role, especially for newer technologies such as digital devices and social networking programs. "i ask my grandchildren. 'okay, how do i do this?' they say, 'don't you know?' but they will help me eventually" [regina3, female]. younger generations were able to bridge the technology gap and communicate complex language in lay language that was non-threatening. "anything i want to know, i have to phone up my sons or my grandchildren because they're a lot more knowledgeable than i am . . . " [mk1, female]. even after being introduced to technology and learning how to use it, participants continued to contact their adult children and other relatives for assistance when faced with difficulties. for instance, one participant stated that "my son is an it expert. if i have any problems, 'can i speak to the it man please.' he knows it's me. he sorts my problems" [mk3, female]. some participants seemed to solely rely on younger family members for information when necessary. for instance, one participant concluded, "if i need to know something, i will get my daughter to look it up on her, whatever thing she packs in her pocket" [mcb4, male]. for many older adults, intergenerational relationships are leveraged to support the understanding and use of technology. the challenges in the adoption of and adaptation to the rapid developments in digital technologies facilitate opportunities and meaningful purposes for participants to connect and communicate with younger generations. the leveraging of technologies, including social media and virtual communication platforms, supported older adults in maintaining and enhancing social connections, especially with adult children and grandchildren who lived in different cities and countries. these findings support the idea that the use of digital technologies can enhance social connectedness across generations; as taipale noted, "[ . . . ] distributed families can today nevertheless remain connected and feel a sense of togetherness, even when their members are not physically close to one another" [28] . the benefits of intergenerational relationships for technology, including motivation for older adults' use of technology and the use of technology as a facilitator of intergenerational connections, underlie each domain of the who checklist of essential features of age-friendly cities [63] . furthermore, this reinforces the need for a revised smart age-friendly ecosystem framework as coined and posited by marston et al. [10] , who proposed an extension, noting that these features also apply to the rural, and non-urban, context. the desire to mitigate the digital divide fuels older adults' motivation to invest time in building and fostering intergenerational digital connections. previous research similarly suggests that computers are commonly used by older adults as a method of communication with younger generations, serving as a gateway to the world of younger family members and a means to strengthen relationships [64] . studies show that individuals will often play games, not because of enjoyment of the game itself, but because of the social interaction with others with whom they are playing [65] . therefore, when creating an age-friendly environment or helping older persons to age in place, it is worthwhile to challenge those designing built environments to consciously address how they may seize opportunities to effectively and efficiently leverage icts to facilitate intergenerational engagement. older adults leveraged technology to connect, communicate, and actively participate in the interests and hobbies of their adult children and grandchildren in online formats, including digital gaming and photography. participants encouraged and enjoyed interacting with younger family members to learn about different technologies (e.g., digital games) as a way of immersing themselves in the culture of younger generations. as previous research illustrates, participants in this study were using digital games as a "computational meeting place" that supported meaningful social interactions and shared motivation for group gaming [66] . further evidence shows that gaming technologies foster intergenerational group interactions of up to four generations, including adult children and extended families [67] . our study revealed findings similar to those noted above but for multiple digital technologies, which suggests a more universal and generalizable use of technologies among older adults to increase intergenerational family social interactions as a "digital gathering place". health limitations, the costs of transportation, and social isolation can create barriers for travel, all of which might explain why communication technologies such as skype were often used to connect with family members. these technologies can come close to replicating the face-to-face experience of conversing with another person and are an effective communication method to use when travel is not an option. the extended value of the support of intergenerational connection may be further amplified given the context of covid-19 and in the post-covid-19 context. language and terminology often impede the ability of older adults to learn how to use technology. this disconnect and incomplete understanding of technological language could explain why few respondents identified using social media/networking sites but went on to further indicate they do in fact use this form of technology. this discrepancy in responses may stem from a lack of clarity in the question about what social networking entails for the respective participants, or this may reflect a lack of recognition by older adults that they did in fact use social media/networking platforms. despite these complications, participants were able to use technology and associated icts by learning to do so with their adult children and grandchildren, who were able to translate the jargon and technical terms used in information technology courses into a language that older adults could understand within the context of intergenerational relations. this is consistent with the findings from previous studies showing that adult children often initiate the technology use process for older adults and that extended family members (such as grandchildren) are important educators for older adults as they learn to use technology [64] [65] [66] [67] [68] [69] . intergenerational informal education between those with existing relationships may be more effective for knowledge/information exchange. when considering why adult children and grandchildren were common educators, there are a few ways to explain this finding. first, older adults might feel more comfortable learning from family members due to feelings of trust. second, as it was often adult children and other relatives who introduced participants to technology, it makes sense that they would be the ones providing the lessons and education. third, participants may have been learning from younger generations because they may have a greater knowledge of technology, having grown up in the information age. fourth, older adults might choose to learn from younger family members as they use less confusing terminology (compared to user manuals or classes) and they are comfortable enough to ask questions. many older adults in the present study used technology comfortably and were among the early adopters of computers and technology. the role younger generations play in guiding and motivating older adults to use technology may contribute to family cohesion and strengthen relationships. this supports the notion of the "change in family roles" put forward by taipale [28] , who highlighted the variance of perception between italian and slovenian contexts. nearly all participants reported using a computer at their own home, but other locations such as an adult child's home were also identified. studies have shown that, among older adults who use computers, a majority do so in the comfort of their own home, although computers are also used in public locations such as at work, in a library, or at a friend's/family member's home [14, 37, 53, 70] . computers might be used at an adult child's home because this is where the learning and introduction to technology take place. however, this pattern of usage could also be indicative of locational convenience, access to computers, privacy issues, what the computer is being used for, or another combination of variables. these preliminary findings point to the importance of investigating further how these intergenerational factors influence the location of technology use. even though participants highlighted the many benefits and uses of technology, some participants remarked on the drawbacks and risks of living in the digital age. the finding that older adults often chose to use computers for leisure to share information and communicate, whereas cell phones were often used to appease worried children, suggests both positive and negative associations of technology. for instance, surveillance and privacy issues, along with digital crime, are risks of using certain technologies [71] . despite the existence of privacy legislation, there exist privacy threats with the use of technology, such as the tracking of personal information, profiling, and privacy-violating interactions [72] . despite voiced concern over privacy issues, participants continued to use technologies because of the benefits, such as bridging geographical distances to communicate with younger family members. as such, it seems the rewards outweigh the risk for older adults to use technology. nonetheless, the acknowledgment of such risks by participants draws attention to the importance of providing clear education communicated in lay language on how to safely use technology. this research specifically addressed intergenerational elements of technology use among individuals in both rural and urban areas in two countries. research often overlooks social elements of technology use, viewing technology engagement as a solo activity. a strength of this study is the combination of an in-depth online survey and focus groups, which allowed for a deeper understanding of the topics being studied. upon further validation, the survey could be used in future studies as a standard measure of technology use, social media habits and behaviour, information sharing, and privacy issues. given the exploratory nature of the study, a small sample was acceptable as the aim was for each site to recruit 10 participants. although our sample sizes enabled us to reach saturation of information, a larger sample is needed to confirm our findings. differences in the recruitment methods across sites may have contributed to the difficulties of achieving the targeted number of participants. future studies should recruit participants who use and who do not use technology to compare and contrast their behaviours and identify further barriers to and enablers of technology use in later life. further investigations may extend this work to examine the intersection of technology and intergenerational relationships among older adults who are aging without family to expand the understanding of the roles that peers, friends, or even siblings play in comparison to that of adult children [73, 74] . at a time when technology development and population aging research are prevalent, it is vital to capitalize on opportunities to learn about how technology can be used and deployed to increase social connectedness, improve the quality of life of older adults, and support aging in place. with rapid technological developments occurring, there are great opportunities to expand the understanding of gerontechnology and human-computer interaction from a multi-disciplinary standpoint. technology has the potential to play an integral role in ensuring all attributes complement each other and keep knowledge up to date. many participants used technology to maintain social connectedness with younger family members who were geographically dispersed. the findings from this study provide insight into the strengths and opportunities that technologies provide to older adults. understanding how intergenerational relationships impact technology use in later life can inform further research and technological and social practices. tech adoption climbs among older adults. pew research center media use in the european union older adults and technology use world 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processes of learning to use computers internet use among midlife and older adults: an aarp bulletin poll digital crime and digital terrorism privacy in the internet of things: threats and challenges the lived experience of older involuntary childless men ageing without children, gender and social justice we would like to thank all participants who agreed to take part in this study across the different study sites. the authors declare no conflict of interest. key: cord-256636-z14anp3h authors: muennig, peter; mcewen, bruce; belsky, daniel w.; noble, kimberly g.; riccio, james; manly, jennifer title: determining the optimal outcome measures for studying the social determinants of health date: 2020-04-27 journal: int j environ res public health doi: 10.3390/ijerph17093028 sha: doc_id: 256636 cord_uid: z14anp3h americans have significantly poorer health outcomes and shorter longevity than citizens of other industrialized nations. poverty is a major driver of these poor health outcomes in the united states. innovative anti-poverty policies may help reduce economic malaise thereby increasing the health and longevity of the most vulnerable americans. however, there is no consensus framework for studying the health impacts of anti-poverty social policies. in this paper, we describe a case study in which leading global experts systematically: (1) developed a conceptual model that outlines the potential pathways through which a social policy influences health, (2) fits outcome measures to this conceptual model, and (3) estimates an optimal time frame for collection of the selected outcome measures. this systematic process, called the delphi method, has the potential to produce estimates more quickly and with less bias than might be achieved through expert panel discussions alone. our case study is a multi-component randomized-controlled trial (rct) of a workforce policy called mygoals for healthy aging. aristotle postulated that the social environment is an important determinant of human health [1] . in the mid-nineteenth century, rudolf virchow conducted the first epidemiologic investigation showing the relationship between social conditions and health, documenting what would later come to be known as the "social determinants of health" [2, 3] . the 20th century saw social policy and health policy begin to converge in europe and latin america [4, 5] , with the world health organization formally recognizing the social determinants of health as "the conditions in which people are born, grow, live, work and age" [3] . the affordable care act in the united states led to billions of dollars spent on the social determinants of health in the hope of preventing disease before it occurs [6, 7] . one way to address the social determinants of health is to make investments in proven social policies in an attempt to improve the social circumstances of low-income families and individuals [8] . were it possible to make even a small dent in the burden of disease associated with poverty, enormous gains in health and longevity could be realized [9] . unfortunately, very few experimental tests of social policies have been conducted [10] , and fewer still contain health outcomes [11] [12] [13] . only three randomized-controlled trials (rcts) to date have attempted to collect objective biological measures of health using laboratory or medical examination data [13] [14] [15] [16] . this is in part because there is a good deal of uncertainty surrounding which measures to use [12, 17] . this uncertainty arises from three challenges. first, the process of biological "wear and tear" associated with living in poverty begins from the time of conception [18, 19] , but most anti-poverty programs are targeted toward older children and adults [13] . as a result, it is necessary to devise a sensitive measure of health-a "yardstick"-that will change within the time frame of the study. a second challenge is that there is a latency between the time that one is exposed to a social policy and the point at which measurable changes in health occur [20] . while income support programs can immediately lift a family out of poverty, it takes time for that family to invest the money in healthy food, housing, and health care. even after these investments are made, the effects of these investments take time to manifest as measurable changes in health [14] . a third challenge lies in the nature of the available objective biomarkers of chronic disease [21] . these can be difficult to collect, are sometimes statistically noisy, and may have an inadequate empirical base linking the measure to tangible health outcomes in humans. they also must be conceptually aligned with the expected mechanisms through which a given social policy influences health. what is needed is a sensitive but broad biological measure that can serve as a yardstick of changes in health over a relatively short period of time. in the absence of such a measure, those who study the effect of social policy on health face an enigma. how should we operationalize what the intervention does vis-à-vis changes in human physiology, and how do we know how far in the future we need to measure these changes given the nature of the intervention? this question is underscored by a recent meta-analysis of 38 experimental social policy rcts, which found that most lacked adequate statistical power to detect a change in the outcome of interest [13] . had a sensitive measure been available, the statistical power would have been higher. the authors set out to build a conceptual model for an ambitious social policy experiment called mygoals for healthy aging. prior to the exercise, each expert submitted their own conceptual model and relevant outcome measures anonymously. we were surprised to find that each expert in the room had a very different idea about how the intervention might influence health, and how to measure the changes in health that might arise from the intervention. in this paper, we describe our journey toward coming to a consensus about the correct way to measure health outcomes for this health policy experiment. given that a very long time must pass between changes in one's social circumstances and distal disease outcomes (like heart disease), measure selection is limited to outcomes than can reasonably change over a short period. these might include psychological stress, mental health, and biological measures of disease risk ("biomarkers"). biomarkers can include blood assays, such as cholesterol levels, or medical examination data, such as blood pressure. biomarkers are appealing endpoints for social policy rcts because they are objective, they have established links to disease, and they change over a relatively short period [22, 23] . however, biomarkers must be selected carefully. the challenge is to match the biomarkers to the intervention of interest [12, 17] . one approach to rule-in or rule-out a large number of candidate biomarkers is to build a team of experts, often backed up by research staff, to compile and summarize the existing literature. the stress measurement working group [24, 25] and the targeting aging with metformin (tame) [21] provide two examples of this approach. the stress measurement working group was tasked with selecting measures for several social surveys of aging populations, the health and retirement study in the united states, the english longitudinal study of ageing in england, and the survey of health, ageing and retirement in europe [17] . the tame rct is designed to investigate whether a drug can slow human aging. social policy experiments are thought to affect health in a way that is very similar to this drug from a biological standpoint-they alter a cascade of biological events that lead to "wear and tear" on the body's physiological systems [26] . this process (which we might call the "quantitative shotgun approach") can be very resource intensive, as a good deal of background work must be done to decide how to include or exclude measures, to conduct an extensive literature review, and to manage the information produced by experts over many months of meetings [17, 21] . beyond these logistical challenges, there is also a need to manage bias. the bandwidth of leading experts can be limited, so they might not have the time to read literature that falls outside of their specific area of expertise (which can sometimes be limited to a single biomarker or biological pathway). open discussions can result in senior, charismatic, or otherwise forceful experts overpowering the ideas of those who are less expressive or who fear professional repercussions of disagreeing with their colleagues [27] . an alternative to the quantitative shotgun approach is the delphi method. the delphi method also leverages expertise from multiple researchers to identify a consensus on a set of measures. it also uses introductory materials and research as a foundation upon which experts make decisions. however, it has a specific structure designed to overcome some limitations of the quantitative shotgun approach. one advantage is that it is highly structured, thereby reducing tangential discussions [27] . the delphi method is led by a moderator, and can effectively be conducted over the phone or by email [27] . a much bigger advantage is that key parts of the process are anonymized, so that the ideas of senior researchers are less likely to dominate the discussion. deciding which "experts" to select for a given delphi process really depends on one's overarching objectives [28] . if the objective is to obtain a collective guess at a parameter in particle physics, then one would draw experts from a very narrow area of physics. however, if one's objective is to guess at the number of years needed before a given country developed a nuclear bomb, one may wish to draw not just from atomic scientists, but also experts on national security and possibly even anthropologists. thus, experts might be selected from a very narrow field, more broadly across a given field, or across a broad array of disciplines. after an initial briefing that includes an overview of the delphi method and the problem to be solved, a moderator guides experts through various "rounds" or iterations of the estimate to be obtained ( figure 1 ). the result is incrementally modified over several sessions. this iterative process allows experts to quickly identify problems in logical thinking or missing information as they constantly reformulate their ideas, ideally arriving at a consensus. 4 obtained ( figure 1 ). the result is incrementally modified over several sessions. this iterative process allows experts to quickly identify problems in logical thinking or missing information as they constantly reformulate their ideas, ideally arriving at a consensus. in the delphi method, experts anonymously discuss a problem over various rounds, with each round, the estimate is refined until consensus or near consensus is reached. our case study outlines this process for a unique rct called mygoals for healthy aging, which is a piggyback health study on an innovative welfare intervention called mygoals for employment success [29] . the parent intervention assigned 1,798 unemployed recipients of government housing subsidies (section 8 voucher or public housing) to mygoals (the treatment group) or to a control group that did not have access to mygoals. the treatment group is offered three years of employment coaching that uses an explicit methodology for helping participants set and achieve goals across four domains (employment, education/training, financial management, and personal and family wellbeing) with an explicit focus on identifying and addressing "executive function" challenges that get in the way of goal-achievement in these domains [30] . this coaching is coupled with a package of cash payments that includes a monthly stipend for engaging in substantive coaching sessions plus incentives for achieving certain employment outcomes. executive function refers to the selfregulation capacities that are essential for successful execution of tasks and include such cognitive skills as stress tolerance, emotional control, time management, metacognition, mental flexibility, task initiation, sustained attention, and others [31−33] . if mygoals increases participants' earnings and fringe benefits, that increased compensation combined with the financial incentives (which are disregarded in government transfer benefit calculations) and benefits associated with employment, such as the earned income tax credit and, in our case, funding for the coronavirus aid, relief, and economic security (cares) act, will improve participants' net disposable income and reduce their likelihood of being poor or the extent of their poverty relative to the control group. (these benefits arise because the participant is more likely to be employed and therefore filing taxes.) we first contacted a number of other investigators of social policy rcts to ask how they had selected measures in their previous studies. standard practice, we learned, is to simply query experts, who then provide input as to a range of survey, medical examination, and blood measures to fit the conceptual model of the intervention [34] . the initial conceptual model for mygoals for healthy aging ( figure 2 ) was simply drawn out by a handful of experts in the social determinants of health. measures were then selected for each component of the model and tested to statistical power to determine whether they were feasible. this model was included in a grant to the national institute on aging, but reviewers disliked the structure and raised questions about the measures we collected as well as the timing of measure collection. our team was awarded funding to refine the structure, and we decided to deploy the delphi method to address these reviewer concerns. in the delphi method, experts anonymously discuss a problem over various rounds, with each round, the estimate is refined until consensus or near consensus is reached. our case study outlines this process for a unique rct called mygoals for healthy aging, which is a piggyback health study on an innovative welfare intervention called mygoals for employment success [29] . the parent intervention assigned 1798 unemployed recipients of government housing subsidies (section 8 voucher or public housing) to mygoals (the treatment group) or to a control group that did not have access to mygoals. the treatment group is offered three years of employment coaching that uses an explicit methodology for helping participants set and achieve goals across four domains (employment, education/training, financial management, and personal and family well-being) with an explicit focus on identifying and addressing "executive function" challenges that get in the way of goal-achievement in these domains [30] . this coaching is coupled with a package of cash payments that includes a monthly stipend for engaging in substantive coaching sessions plus incentives for achieving certain employment outcomes. executive function refers to the self-regulation capacities that are essential for successful execution of tasks and include such cognitive skills as stress tolerance, emotional control, time management, metacognition, mental flexibility, task initiation, sustained attention, and others [31] [32] [33] . if mygoals increases participants' earnings and fringe benefits, that increased compensation combined with the financial incentives (which are disregarded in government transfer benefit calculations) and benefits associated with employment, such as the earned income tax credit and, in our case, funding for the coronavirus aid, relief, and economic security (cares) act, will improve participants' net disposable income and reduce their likelihood of being poor or the extent of their poverty relative to the control group. (these benefits arise because the participant is more likely to be employed and therefore filing taxes.). we first contacted a number of other investigators of social policy rcts to ask how they had selected measures in their previous studies. standard practice, we learned, is to simply query experts, who then provide input as to a range of survey, medical examination, and blood measures to fit the conceptual model of the intervention [34] . the initial conceptual model for mygoals for healthy aging (figure 2 ) was simply drawn out by a handful of experts in the social determinants of health. measures were then selected for each component of the model and tested to statistical power to determine whether they were feasible. this model was included in a grant to the national institute on aging, but reviewers disliked the structure and raised questions about the measures we collected as well as the timing of measure collection. our team was awarded funding to refine the structure, and we decided to deploy the delphi method to address these reviewer concerns. int. j. environ. res. public health 2020, 17, x for peer review 5 of 10 this increases income thereby reducing psychological stress [13] . reductions in psychological stress influence physical and mental health via allostatic load [22] while also producing synergies with the executive function training program to reduce neural damage and improve executive function, thereby improving work performance and behavioral risk factors [30, 31] . here, executive function (e.g., the ability to plan and execute those plans) was separated from broader cognitive function to show how employment can enhance broader cognitive skillsets, such as math [31] . the experts were carefully selected to ensure: (1) comprehensive expertise in the domains of the intervention, (2) the social determinants of health, and (3) familiarity with social policy or experimental research designs. this required not only selecting interdisciplinary experts, but also those who had specifically applied their work across disciplines. the principal investigator and the national institute on aging program officer were both familiar with experts who met these characteristics. six experts were invited, but one could not attend in person, leaving a total of 5. the in addition to these 5 experts, james riccio was present. dr. riccio, the pi for the parent mygoals demonstration, has led numerous multi-center social policy rcts and was therefore invaluable to the de-anonymized discussions as were other mdrc staff. experts were first distributed a 3-page description of the mygoals rct, including its sample size, locations, and details of the intervention. the description was followed by a task (sketching out figure 2 . the conceptual model used prior to the delphi method. when this model underwent review in the national institute on aging, reviewers were concerned about the sequencing of events, and asked that it be revised. in this model, income is derived from incentive payments and employment. this increases income thereby reducing psychological stress [13] . reductions in psychological stress influence physical and mental health via allostatic load [22] while also producing synergies with the executive function training program to reduce neural damage and improve executive function, thereby improving work performance and behavioral risk factors [30, 31] . here, executive function (e.g., the ability to plan and execute those plans) was separated from broader cognitive function to show how employment can enhance broader cognitive skillsets, such as math [31] . the experts were carefully selected to ensure: (1) comprehensive expertise in the domains of the intervention, (2) the social determinants of health, and (3) familiarity with social policy or experimental research designs. this required not only selecting interdisciplinary experts, but also those who had specifically applied their work across disciplines. the principal investigator and the national institute on aging program officer were both familiar with experts who met these characteristics. six experts were invited, but one could not attend in person, leaving a total of 5. the in addition to these 5 experts, james riccio was present. dr. riccio, the pi for the parent mygoals demonstration, has led numerous multi-center social policy rcts and was therefore invaluable to the de-anonymized discussions as were other mdrc staff. experts were first distributed a 3-page description of the mygoals rct, including its sample size, locations, and details of the intervention. the description was followed by a task (sketching out the conceptual model), two quantitative questions, and another task (linking survey or biological outcome measures to each component of the conceptual model). prior to the meeting, the facilitator re-drew pen and paper images of each pathway presented by the participants to help preserve the anonymity of the participants and to provide consistency in the presentation. participants were brought together to an in-person, 5 h meeting. mdrc staff reviewed the intervention and took questions that came up regarding the experiment. after this introduction, participants discussed the questions from the prior round. a majority opinion was reached among 4 out of the 5 participants during this round, even though the in-person meeting was not meant to develop a consensus. participants were contacted following the meeting and asked to anonymously confirm their individual responses. one participant disagreed with the results of the first round. the moderator relayed individual responses and concerns to this participant over 3 additional rounds of email, and the final model was sent to the entire panel for a final vote. income is thought to be a key pathway. four out of five participants thought that income was important for health (one participant felt that income was the only important mediator in the pathway between intervention and health outcomes). three out of five thought that employment was important for health and an equal number thought that the executive function coaching was important for health. a range of biomarker measures are proposed as potential endpoints. with respect to outcomes, four out of five of the figures the experts submitted had depicted stress reduction as a mechanism through which mygoals for healthy aging would improve physical and mental health outcomes. three out of five recommended the perceived stress scale and an equal number recommended a biological measure of stress (blood pressure, hair cortisol, or c-reactive protein). three out of five thought that cognition (measured both using the behavior rating inventory of executive function (adult version) and tasks from the nih toolbox, a set of tests available from the national institutes of health) as well as mental health/well-being (measured using the patient health questionnaire 9 and beck anxiety inventory) would be enhanced by the intervention. two participants thought that body-mass index (bmi) and blood pressure would be decreased and one thought that sleep would be improved. the pathways that all 5 of the participants initially sketched out were sequential (e.g., income leads to reduced stress which then leads to increased sleep). for the second round, which was held face-to-face, the facilitator presented tabulated data from the first round of anonymous inputs. after this, each participant's anonymized conceptual model was reviewed in front of the group. a more in-depth discussion was then undertaken regarding each pathway. this portion of the discussion was for idea generation and was not anonymized. it was meant to exploit the power of free association within the group before returning to anonymized input. executive function coaching and health: evaluating potential mechanisms suggests new outcome measures. after the question and answer session, all participants agreed that executive function was important for health in theory, but most felt that the executive function coaching component of the intervention would only be beneficial for some participants. this led the participants to probe the mdrc staff regarding the nature of the intervention. participants were told that the coaches were trained to be supportive rather than prescriptive. that is, rather than saying, "i have the perfect job for you," they would ask, "are you interested in looking for a job?" they also learned that the coaches were from similar backgrounds as the participants (e.g., had also been recipients of public housing), and were provided an example that one participant had identified the coach as his only "real friend." they also learned that some participants sought additional coaching sessions for which they were not compensated. these factors led the experts to believe that having a "friendly face" with whom to talk about life's challenges would potentially have an impact on measures of stress, anxiety, and depression. it was therefore postulated that the coaching had both the effect of addressing some of the executive function deficits of some participants and also serving to provide social support for others. measures not identified at the outset of the process were raised as relevant, including sleep quality and perceived discrimination in the workforce. with respect to the latter, all participants came to the conclusion that employment could produce both positive and harmful effects. on the positive side, it affords new opportunities for cognitive engagement, development of social skills (e.g., with co-workers and customers), and to build social capital. on the other hand, participants felt that some aspects of all work, and low-wage work especially, tended to be stressful, and that exposing participants to the employment market would also expose them to discrimination (particularly if they are women or racial/ethnic minorities). occupational safety was brought up as a potential health hazard specific to being employed. timing and model building. a final issue concerned timing of outcome collection. all experts suggested the same general follow-up range: 5−6 years. therefore, this was not discussed in additional rounds. however, the experts pointed out that it is not possible to actually sequence these events in time, and that sequencing should not be built into the conceptual model ( figure 3) . the group came to the conclusion that the best approach would be to consider the intervention to include executive function, a friendly face, income support, and employment. it was decided that the study should include a measure of stress, a measure of anxiety, a measure of depression, a measure of sleep, and a set of biomarker measures that reasonably serve as intermediate for stress, inflammation, and future disease. the experts argued for established measures that have been traditionally used in social determinants research rather than those that reflect newer research or ideas that might be more controversial for a nih review panel. for cognitive outcomes, it was felt that both validated survey instruments and data from tasks should be collected. the final rounds were conducted by email, with each participant providing their final vote. one participant disagreed with the other four with respect to the physiological measures. this expert expressed the desire to use hair cortisol and telomere length as outcome measures. the moderator and other experts then discussed these ideas by emails. concerns included: 1) difficulty obtaining hair from bald people or women who are concerned about cosmetic changes [35] , and 2) concerns that cortisol levels will be suppressed in some people with chronic stress but elevated in others, leading to results that are difficult to interpret. at that point, participant 5 agreed that hair collection would be an issue. this reviewer also suggested that a waist-to-hip ratio be obtained as a measure of obesity, noting recent evidence that body-mass index was an incomplete measure of obesity [36, 37] . this participant also suggested a long-term measure of life trauma in order to better understand whether trauma altered participants' responses to the intervention [38] . the final model appears in figure 3 . sequencing, including all of the measured outcomes, and to consider enhancements to broader cognitive function as a part of the outcome, rather than part of the intervention (figure 2 ). in addition, after learning about the experiences that the executive function coaches have had with the clients, the expert panel felt that part of the intervention entailed adding a "friendly face," or a friend to talk with about the participants' problems. 1) measured using the three-item loneliness scale; 2) measured using the insomnia severity index; 3) measured using the beck anxiety inventory; 4) measured using the patient health questionnaire 9; 5) measured using the perceived stress scale; 6) blood pressure, c-reactive protein, interleukin-6, hemoglobin a1c; 7) measured by trained examiner three times; 8) measured using the eating at america's table survey; 9) measured using questions taken from the behavioral risk factor surveillance system; 10) measured height, weight, waist circumference, hip circumference, waist-tohip ratio; 11) measured using the behavior rating inventory of executive function (brief) and the flanker + dimensional card sort tasks from nih toolbox; 12) measured using the national death index. note: serum will be banked for possible future biomarker analyses such as conserved transcriptional response to adversity, gene x environment studies, biological clock studies, and metabolomic studies as these are rapidly evolving fields of study that will undoubtedly change over the period of performance of the grant. we demonstrate a process by which a conceptual model and outcome measures (along with other useful estimates, like timing for data collection) can be quickly accomplished via the use of expert input. while there is no counterfactual "ideal" against which the results of the delphi process can be compared, it is worthy to note that the experts produced a significant alteration to the way that the intervention was perceived to work, produced major alterations to the presentation of the conceptual model, and altered four of the original outcome measures. our model has now been incorporated into the research plan for mygoals for healthy aging, and it will be used to determine the selection and timing of the outcome measures if the study is funded by the national institute on aging. we also hope that our study will serve two uses for the greater scientific community. first, we hope that it will provide a foundation for thinking through the ways that social policies might impact health. second, we hope that it provides a scaffolding and method for the rapid and inexpensive development of future social policy research that includes health outcomes. funding: this study was funded with a grant from the national institute on aging r56 ag062485-01a1. the authors declare no conflict of interest. about the original model by removing temporal sequencing, including all of the measured outcomes, and to consider enhancements to broader cognitive function as a part of the outcome, rather than part of the intervention (figure 2 ). in addition, after learning about the experiences that the executive function coaches have had with the clients, the expert panel felt that part of the intervention entailed adding a "friendly face," or a friend to talk with about the participants' problems. (1) measured using the three-item loneliness scale; (2) measured using the insomnia severity index; (3) measured using the beck anxiety inventory; (4) measured using the patient health questionnaire 9; (5) measured using the perceived stress scale; (6) blood pressure, c-reactive protein, interleukin-6, hemoglobin a1c; (7) measured by trained examiner three times; (8) measured using the eating at america's table survey; (9) measured using questions taken from the behavioral risk factor surveillance system; (10) measured height, weight, waist circumference, hip circumference, waist-to-hip ratio; (11) measured using the behavior rating inventory of executive function (brief) and the flanker + dimensional card sort tasks from nih toolbox; (12) measured using the national death index. note: serum will be banked for possible future biomarker analyses such as conserved transcriptional response to adversity, gene x environment studies, biological clock studies, and metabolomic studies as these are rapidly evolving fields of study that will undoubtedly change over the period of performance of the grant. we demonstrate a process by which a conceptual model and outcome measures (along with other useful estimates, like timing for data collection) can be quickly accomplished via the use of expert input. while there is no counterfactual "ideal" against which the results of the delphi process can be compared, it is worthy to note that the experts produced a significant alteration to the way that the intervention was perceived to work, produced major alterations to the presentation of the conceptual model, and altered four of the original outcome measures. our model has now been incorporated into the research plan for mygoals for healthy aging, and it will be used to determine the selection and timing of the outcome measures if the study is funded by the national institute on aging. we also hope that our study will serve two uses for the greater scientific community. first, we hope that it will provide a foundation for thinking through the ways that social policies might impact health. second, we hope that it provides a scaffolding and method for the rapid and inexpensive development of future social policy research that includes health outcomes. the historical origins of the basic concepts of health promotion and education: the role of ancient greek philosophy and medicine notes on the typhoid epidemic prevailing in upper silesia closing the gap in a generation: health equity through action on the social determinants of health: commission on social determinants of health final report; world health organization inequalities in health. the black report: a summary and comment medicine, socialism, and totalitarianism: lessons from chile the delivery system reform incentive payment (dsrip) program beyond a traditional payer-cms's role in improving population health us health in international perspective: shorter lives, poorer health the income-associated burden of disease in the united states show me the evidence: obama's fight for rigor and results in social policy money, schooling, and health: mechanisms and causal evidence national research council; commission on behavioral and social sciences and education. biosocial opportunities for surveys can social policies improve health? a systematic review and meta-analysis of 38 randomized trials neighborhood effects on the long-term well-being of low-income adults early childhood investments substantially boost adult health the oregon experiment-effects of medicaid on clinical outcomes elastic powers: the integration of biomarkers into the health and retirement study health disparities across the lifespan: meaning, methods, and mechanisms health selection vs. causation in the income gradient: what can we learn from graphical trends? j. health care poor underserved the effect of small class sizes on mortality through age 29 years: evidence from a multicenter randomized controlled trial a framework for selection of blood-based biomarkers for geroscience-guided clinical trials: report from the tame allostatic load as a marker of cumulative biological risk: macarthur studies of successful aging socioeconomic status and health in industrial nations: social, psychological and biological pathways the benefits and challenges of collecting physical measures and biomarkers in cross-national studies measures of stress in the health and retirement survey (hrs) and the hrs family of studies protective and damaging effects of stress mediators how expert are the experts? an exploration of the concept of 'expert' within delphi panel techniques mygoals for employment success a manual for executive skills coaching with adults affected by conditions of poverty and stress socioeconomic status and executive function: developmental trajectories and mediation participation in work: the necessity of addressing executive function deficits executive function moderates the intention-behavior link for physical activity and dietary behavior anonymized personal communication socioeconomic status is associated with stress hormones income and psychological distress: the role of the social environment history of socioeconomic disadvantage and allostatic load in later life socio-economic differentials in peripheral biology: cumulative allostatic load mcewen was a mentor and hero to us all. he helped us see the invisible world linking our day-to-day experiences to how our bodies and minds thrive and remain healthy. he passed away weeks after making his final contribution to this manuscript and will be dearly missed. the authors declare no conflict of interest. int. j. environ. res. public health 2020, 17, 3028 key: cord-262637-crqw59k1 authors: kwon, sophia; riggs, jessica; crowley, george; lam, rachel; young, isabel r.; nayar, christine; sunseri, maria; mikhail, mena; ostrofsky, dean; veerappan, arul; zeig-owens, rachel; schwartz, theresa; colbeth, hilary; liu, mengling; pompeii, mary lou; st-jules, david; prezant, david j.; sevick, mary ann; nolan, anna title: food intake restriction for health outcome support and education (firehouse) protocol: a randomized clinical trial date: 2020-09-09 journal: int j environ res public health doi: 10.3390/ijerph17186569 sha: doc_id: 262637 cord_uid: crqw59k1 fire department of new york (fdny) rescue and recovery workers exposed to world trade center (wtc) particulates suffered loss of forced expiratory volume in 1 s (fev(1)). metabolic syndrome increased the risk of developing wtc-lung injury (wtc-li)(.) we aim to attenuate the deleterious effects of wtc exposure through a dietary intervention targeting these clinically relevant disease modifiers. we hypothesize that a calorie-restricted mediterranean dietary intervention will improve metabolic risk, subclinical indicators of cardiopulmonary disease, quality of life, and lung function in firefighters with wtc-li. to assess our hypothesis, we developed the food intake restriction for health outcome support and education (firehouse), a randomized controlled clinical trial (rct). male firefighters with wtc-li and a bmi > 27 kg/m(2) will be included. we will randomize subjects (1:1) to either: (1) low calorie mediterranean (localmed)—an integrative multifactorial, technology-supported approach focused on behavioral modification, nutritional education that will include a self-monitored diet with feedback, physical activity recommendations, and social cognitive theory-based group counseling sessions; or (2) usual care. outcomes include reduction in body mass index (bmi) (primary), improvement in fev(1), fractional exhaled nitric oxide, pulse wave velocity, lipid profiles, targeted metabolic/clinical biomarkers, and quality of life measures (secondary). by implementing a technology-supported localmed diet our firehouse rct may help further the treatment of wtc associated pulmonary disease. metabolic syndrome (metsyn) is defined as having at least three of five risk factors (abdominal obesity, insulin resistance, hyperglycemia, dyslipidemia, and hypertension) that increase the likelihood of cardiovascular disease [1] . metsyn afflicts more than 30 percent of adults (>47 million americans) and is associated with impaired lung function [2, 3] . our group has focused on defining the development of world trade center-particulate matter (wtc-pm) associated lung disease in the context of metsyn in the well-phenotyped fire department of new york (fdny) cohort [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] . nearly half of chronic obstructive pulmonary disease (copd) patients demonstrate the presence of metsyn phenotypic characteristics [12] [13] [14] . systemic inflammation, which is often seen in metsyn, is implicated in lung function loss, the development of chronic obstructive airways dysfunction (oad), vascular disease, and cancer [15] [16] [17] [18] [19] . additionally, longitudinal investigations indicate that lower baseline forced expiratory volume in one second (fev 1 ) was an independent predictor of metsyn [10, 11] . our recent investigations indicate that metsyn components, most strongly dyslipidemia and abdominal obesity, are significant predictors of world trade center-lung injury (wtc-li), as defined by fev 1 less than the lower limit of normal (lln). although one major contributor to poor lung mechanics is from mechanical load-induced stress secondary to abdominal obesity, our prior work shows near equivalent contribution from dyslipidemia in those with wtc-li [2, 10, 11] . inflammatory profiles from serum samples collected within three months of 9/11 showed that dyslipidemia predicted wtc-li even after adjusting for body mass index (bmi), and was in fact a stronger predictor than obesity [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] 15, 20, 21] . in light of these findings, we focused our work on the inflammatory effects of lipids in the development of particulate matter (pm)-induced lung injury [22] to investigate the potential reversibility of wtc-li by direct impact on metsyn risk factors, we focus on calorie-restricted (cr) mediterranean diets based on recent studies showing their ability to attenuate lipid levels [20, 23, 24] . modifying metsyn through diet and exercise has been used successfully in other studies to directly impact lung disease. dietary interventions in oad patients improved fev 1 and forced vital capacity (fvc) by as much as 22 percent in as little as 15 days [25, 26] . using a low calorie diet, investigators achieved a 20 kg loss over a 6-month period, and found that every 10 percent relative loss of weight led to significant improvement of fvc by 92 ml and fev 1 by 73 ml [27] . it has been documented that patients with decreased bmi from 37 to 32 kg/m 2 also had increased fev1 and fvc [28] . technology-supported behavioral interventions have shown enhanced data collection and improved adherence to diet plans [29, 30] . mobile technology allows clinicians to deliver targeted behavioral interventions and deliver counseling remotely, increasing scalability. we have previously developed an innovative weight loss intervention involving: (1) cloud-based self-monitoring of behavior (diet and physical activity) with automated feedback; (2) theory-based behavioral counseling delivered via webex (cisco webex, milpitas, ca, usa) group sessions; (3) standardized education to minimize calorie intake and enhance energy expenditure [29] . in the context of our prior findings, as well as the previously discussed literature linking nutritional modification to health benefits, we have chosen to explore the therapeutic potential of ameliorating metsyn phenotype in our wtc-exposed cohort [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] 21 ]. in the current study, we are implementing a technology-supported, low calorie mediterranean (localmed) dietary intervention to improve metabolic risk factors in subjects with wtc-li. we hypothesize that our dietary intervention will have a therapeutic effect on the clinical endpoints of body mass index (bmi), fev 1 , fractional nitric oxide (no) concentration in exhaled breath (feno), pulse wave velocity (pwv), lipid profiles, targeted biomarkers and quality of life measures. firehouse is a 6-month randomized, controlled, two-arm, parallel, un-blinded, exploratory clinical trial, with 1:1 allocation, in overweight (specifically for this study our inclusion criteria was a bmi > 27 kg/m 2 ) fdny firefighters with documented wtc-li (defined as fev 1 < lln post exposure). while overweight is defined as having a bmi of 25.0 to <30.0 kg/m 2 , and subjects are considered obese if there bmi is ≥30.0 kg/m 2 [31] , for the purposes of our study we wanted to enroll subjects that were overweight with a bmi that was greater than 27 kg/m 2 . this was by design since our power analysis and primary outcome assessment was targeting at least 1-2 units of bmi change in the intervention group [32] [33] [34] [35] . ethics: the trial and all proposed analysis will be performed in accordance with the new york university (nyu)-institutional review board, protocol 17-00127. firehouse is a 6-month randomized, controlled, two-arm, parallel, un-blinded, exploratory clinical trial, with 1:1 allocation, in overweight (specifically for this study our inclusion criteria was a bmi > 27 kg/m 2 ) fdny firefighters with documented wtc-li (defined as fev1 < lln post exposure). while overweight is defined as having a bmi of 25.0 to <30.0 kg/m 2 , and subjects are considered obese if there bmi is ≥30.0 kg/m 2 [31] , for the purposes of our study we wanted to enroll subjects that were overweight with a bmi that was greater than 27 kg/m 2 . this was by design since our power analysis and primary outcome assessment was targeting at least 1-2 units of bmi change in the intervention group [32] [33] [34] [35] . ethics: the trial and all proposed analysis will be performed in accordance with the new york university (nyu)-institutional review board, protocol 17-00127. inclusion and exclusion criteria for study enrollment detailed in table 1 . in brief, participants are eligible for inclusion if they are fdny firefighters with documented wtc exposure, enrolled in the fdny wtc-health program (wtc-hp), and have wtc-li as defined by an fev1 < lln after exposure, table 1 and figure 1 . this firehouse trial will be performed in accordance with the declaration of helsinki and good clinical practice and the protocol is approved by the new york university irb #17-00127. bmi, body mass index; copd, chronic obstructive pulmonary disease. table 1 includes descriptions of both the inclusion and exclusion criteria that we will use to qualify potential study participants. participant recruitment will include: (1) direct mailings; (2) telephone contact; (3) email; (4) self-referral. recruitment efforts will be supported by a study website that provides general information about the study and answers frequently asked questions. the website will also facilitate study activities during the intervention period. participants will be randomized to either usual care (control arm) or localmed diet plus technology-assisted nutrition education and behavior modification (intervention arm), figure 2 . each study arm is active for six months following enrollment. participants will return after six months for a repeat of all measures. all participants will be informed of pertinent clinical assessment conclusions and offered all of the intervention materials at the study's conclusion, table 2 and table s1 . study design of firehouse trial. all participants will be enrolled during the enrollment period at visit 0. at visit 1, cohort will complete the dietary assessment/food frequency questionnaire, receive routine medical care, and obtain baseline measurements. randomization will then occur and groups will be assigned to either localmed or usual care groups. localmed dietary and intervention group will receive weekly or biweekly technology-driven nutrition visits as scheduled, whereas usual care group will receive quarterly flyers to perform routine medical care. follow-up measurements at visit 2 will be collected at the end of the 6-month intervention for both groups. the world trade center-health program (wtc-hp) will be available throughout the time period to all participants to provide other medical care. table 2 . schedule of enrollment, intervention, and assessment. timepoint (visit) 0 1 t/n 2 f/u enrollment eligibility screen x informed consent x interventions localmed x x usual care x assessments physical exam x x phlebotomy x x ekg/pwv feno x x spirometry x x genome x x microbiome questionnaires x x x technology training x x nutrition consultation x x pwv, pulse wave velocity; feno, fractional nitric oxide (no) concentration in exhaled breath; t/n, technology and nutrition visit. table 2 outlines the schedule we will follow during the study pertaining important benchmarks of enrollment, baseline visit (done pre-randomization), post visit (done after randomization), and closing out, or placing the participant off-study. the table is arranged according to the type of data collected (enrollment, interventions, assessments, instructive components). all follow-up components will be available to both intervention groups. . study design of firehouse trial. all participants will be enrolled during the enrollment period at visit 0. at visit 1, cohort will complete the dietary assessment/food frequency questionnaire, receive routine medical care, and obtain baseline measurements. randomization will then occur and groups will be assigned to either localmed or usual care groups. localmed dietary and intervention group will receive weekly or biweekly technology-driven nutrition visits as scheduled, whereas usual care group will receive quarterly flyers to perform routine medical care. follow-up measurements at visit 2 will be collected at the end of the 6-month intervention for both groups. the world trade center-health program (wtc-hp) will be available throughout the time period to all participants to provide other medical care. table 2 outlines the schedule we will follow during the study pertaining important benchmarks of enrollment, baseline visit (done pre-randomization), post visit (done after randomization), and closing out, or placing the participant off-study. the table is arranged according to the type of data collected (enrollment, interventions, assessments, instructive components). all follow-up components will be available to both intervention groups. the usual care group serves as a control (reference) arm, with target enrollment of n = 70. in addition to standard care from their wtc-hp primary provider, participants in the usual care group will receive newsletters every five weeks during the intervention from study staff related to: (1) mindfulness; (2) sleep; (3) staying healthy year-round; (4) disease self-management. as an added incentive for remaining in the study, usual care participants will be provided access to educational and behavioral materials upon completion of their 6-month measurement visit. the localmed group will be enrolled in a 6-month, technology-supported, educational-behavioral program designed to promote a calorie-restricted, mediterranean-style diet and regular, moderate-intensity physical activity. at baseline, participants will be provided in-person, group-based technology training, and will receive handouts with the following study goals: (1) weight loss of ≥seven percent at 6-months; (2) saturated fat intake ≤seven percent of kcal; (3) ≥150-min per week of moderate-intensity physical activity. after the initial technology training session, all intervention-related activities will be delivered remotely via smartphones. the localmed program will consist of two main parts: (1) mobile self-monitoring with feedback; (2) remote group-based education and behavioral counseling. participants will be provided a 6-month subscription for the commercial diet diary application mynetdiary (mnd, mynetdiary, inc., marlton, nj, usa) and directed to record their body weight weekly, all food and drink consumption, and any physical activity as it occurs. if needed, participants are provided with a digital bathroom scale for monitoring body weight during the intervention. self-monitoring of health behaviors (e.g., diet) and outcomes (e.g., body weight) is thought to promote behavioral change in part by bringing these factors to individuals' conscious attention, thereby enhancing vigilance. in addition to providing a digital platform for self-monitoring, mnd generates real-time feedback on nutrient intakes across foods, meals, and meal-days, as well as daily and weekly summaries of recorded physical activities. the multi-level organization of data in mnd assists with information processing, which may reduce information burden that can lead to oversimplified heuristics (aka "food rules") and burnout. to further limit information burden, mnd nutrient output will be restricted to track only calories and macronutrients (carbohydrates, protein, and total, saturated, monounsaturated, and polyunsaturated fats). mnd summary reports are updated with new entries, they will permit ecological momentary assessment (ema) of behaviors at the time, which is thought to augment the effectiveness of self-monitoring. adding to the automated feedback provided by mnd, the study dietitian will review the participants' mnd accounts weekly for the first four weeks and every second week thereafter during the intervention, and they will provide feedback reports via the participant's personal (or a study-provided) email account. reports will contain three parts: (1) adherence to self-monitoring; (2) body weight; (3) saturated fat intake. feedback on saturated fat is graded as green (≤seven percent of kcal), yellow (>7-10 percent of kcal) or red (>10 percent of kcal), and it includes tailored advice on restricting saturated fat based on participants' mnd records. within the program, reported body weights are plotted on a personalized weight loss trajectory line graph that is modeled with 95 percent confidence intervals to achieve a seven percent weight loss over six months [36] . in our experience, participants are motivated by the additional accountability that is provided by external monitoring of health behaviors and outcomes by study staff. participants will receive group-based education and behavioral counseling (~1-h) each week for the first four weeks, and every other week thereafter during the intervention via the videoconferencing application, webex (cisco webex, milpitas, ca, usa). group sessions are facilitated by the study dietitian, and anchored by brief animated videos (powtoon, london, uk), table 3 . after each session, videos will be posted on the study website, which participants can access via a password-protected brainshark link (brainshark, inc., waltham ma, usa). brainshark is a video viewing platform that records time spent watching videos and will help assess intervention dose. problem solving: coping with lapses and setting new goals. table 3 provides a breakdown of the schedule and learning goals for the intervention group. this is organized by the week in the study, as well as the title of the lesson and the social cognitive theory aiming to be achieved. during the first month, the localmed study group subjects receive weekly education and coaching remotely, which changes to bi-weekly in remaining months 2-6. table 3 were designed to provide intervention subjects materials for following a calorie-restricted, mediterranean-style diet, and engaging in regular moderate-intensity physical activity, table 3 . the mediterranean diet was selected as the dietary pattern for this intervention because of the emphasis on healthy fats. previous metabolomics analysis of fdny 9/11 first responders with and without wtc-li suggested that metabolic pathways affected by dietary fats were risk factors for the condition [22] . this dietary pattern, which promotes whole fruits and vegetables, whole grains, nuts, legumes, fish, healthy oils (namely olive oil), and a limited amount of lean meat and low-fat dairy products, is largely consistent with dietary patterns that are commonly used in weight loss. to assist participants in restricting energy intake, additional education is provided on portion control, meals away from home, meal skipping, and avoiding empty calories (e.g., sugar-sweetened beverages), table 3 . behavioral counseling and videos are based on social cognitive theory (sct), which focuses on the roles of self-referent thought and self-efficacy (i.e., confidence) in adopting and maintaining healthy behaviors. according to sct, self-efficacy can be derived from four factors: (1) mastery experiences: goal-setting, prior successes, and problem-solving; (2) social modeling: learning by observing others; (3) verbal persuasion: encouragement from others; (4) physiological benefits: improvements in health outcomes (e.g., weight loss), table 3 . primary outcome assessment is a seven percent decrease in total body weight with a subsequent drop in bmi of roughly 1-2 kg/m 2 depending on the individual's height. secondary outcome measures include a 7-10 cc increase in fev 1 after trial intervention compared to control subjects, as well as an increased lean body mass relative to fat percentage on body-impedance analysis (bia), reduction in pwv and feno, and improved perceived health status as measured by the short form 36 (sf-36) and the st. george's respiratory questionnaire (sgrq), which are both validated quality of life assessment tools available for public use. details of the primary and secondary endpoints of the firehouse trial are shown in table 4 . additionally, we will collect clinical measurements such as routine vital signs, electrocardiograms (ecgs), routine chemistries, complete blood counts (including white blood cell differentials), liver function tests, and blood lipid profiles. furthermore, we will collect saliva and stool samples for genomic (oragene-discover; ogr-500; dnagenotek) and microbiomic analysis (omnigenegut; omr-200 dnagenotek), respectively. primary statistical modeling will be performed based on the change in outcomes from baseline to 6-months post-intervention between the two randomized groups. descriptive analysis of all data collected, using typical graphic and numerical exploratory data techniques, is planned. an intention to treat approach will be used to avoid bias from noncompliance and missing outcomes for primary analyses of the treatment effect between two groups. regression models will be used for modeling treatment effects while adjusting other covariates. post hoc multiple comparisons tests are applied to adjust for pairwise comparisons. the primary objective is to compare the change in bmi in the two groups from pre-intervention to post-intervention after six months (intervention completion). the analysis for this primary objective will be based on the multivariate linear regression with adjustment for potential confounders. the difference for the change of bmi between the two groups will be estimated, and a corresponding 95 percent confidence interval will be calculated. the sample size of the firehouse trial was estimated by the power analysis for the primary outcome of the change in bmi predicted between the start and end of the intervention, which was based on a two-sample test to compare the outcome between two groups under 1:1 randomization. according to the preliminary data, we assumed sd = 2 kg/m 2 and the means of two groups "usual care" and "localmed" to be 0 and −1 kg/m 2 , respectively. furthermore, 6-month interventions with similar calorie targets and behavioral modification with exercise produce a 7-10 percent weight loss [37, 38] . a total sample of 128 subjects (64 subjects in each arm) can achieve 80 percent power at α = 0.05. we will recruit 140 subjects accounting for potential loss of around 20 percent drop out. the interim analysis plan will incorporate two interim looks and one final look, with all looks named as formal interim analysis, table 5 . this study will not be monitored for futility. the first look will be conducted at the completion of 6-month intervention or observation for 30 subjects in each group. this look will use 2-sided α < 0.001. the second look will be one formal interim look, which will be conducted at the completion of 50 subjects in each group with a 2-sided α = 0.007. the final analysis will take place at completion of all subjects in each group, with an o'brien fleming boundary for a 3-look design with 2-sided α = 0.033, table 5 and figure s1 . table 5 describes the statistical measures which will be the basis for our interim analysis. coronavirus disease 2019 (covid-19), caused by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), emerged in wuhan, china, in late 2019 and has since developed into a pandemic. during the firehouse rct's enrollment period, new york state emerged as an epicenter of the global health emergency [39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] . in response to this novel respiratory pathogen, nyu paused face-to-face clinical research for many studies in order to assess, address and minimize any potential covid-19-related risks. this impacted our in-person baseline visits as well as final study visits. meetings with our nutritionist continued for subjects already enrolled since these were designed to be on a video platform. once safe to resume these activities, we implemented a covid-19 pre-visit screening with subjects. this "research participant information sheet: covid-19 updates" informs both newly screened/enrolled subjects as well as subjects returning for their follow-up evaluation about the safeguards that have been put into place to protect against the risk of covid-19 transmission while restarting certain in-person research activities. specifically, subjects were informed that since some study visits need to be conducted in person, participation in these study activities may increase their risk of exposure to the covid-19 virus. we also discussed that nyu, as with nearly all public venues, has implemented a number of safety policies to protect subjects and to reduce exposure risk. these policies include, among other requirements, screening all persons involved in research visits (staff and study subjects), use of personal protective equipment (ppe), following social distancing guidelines when possible, and cleaning and sanitizing rooms and equipment. these protective measures are similar to those most doctors' offices have implemented in response to this participant information document also informs subjects that their participation is completely voluntary. additionally, subjects are provided with the principal investigator (pi)'s contact information and given the opportunity to ask any questions that may arise. a copy of this information sheet is also provided to the patient. due to the pause, the final study visit timeframe, to the extent to which it could be performed, was extended for at least three additional months. since spirometry and feno assessment may lead to aerosolization, we also suspended their assessment for the purposes of research during the covid-19 pandemic. the impact on quality of life and financial burden of wtc-li are public health concerns. despite treatment, new cases continue to be identified, and those affected continue to experience morbidity. our work fits into broader literature that explores the association of poor metabolic health and oad in those exposed to pollution. although the mechanisms that lead to lung disease in the context of pollution and metabolic syndrome remain poorly understood, we have shown that modifiable risks such as bmi and dyslipidemia can predict development of wtc-li. in the firehouse rct, we will investigate dietary intervention as a treatment of wtc-li. our prior investigations, from which the firehouse rct stems, allowed us to discover and validate a metabolomic signature of wtc-li, while investigating the effects of confounders found in the entire fdny cohort such as smoking, obesity, and diet. since dietary habits have a direct relationship to metsyn and the metabolome, we propose to alter the subjects' nutritional status using a mediterranean style diet. our current wtc portfolio lacks insight into dietary patterns and quality of life measures as they pertain to metabolic risk. furthermore, it lacks direct vascular injury measures and assessments of feno and pwv. in the context of our preliminary findings, and due to a clinical need, we propose an rct to assess the effect of dietary modification on bmi, lung function, vascular injury, and quality of life measures. we measure pwv, a marker of central aortic stiffness, which has implications in cardiovascular disease [50] [51] [52] [53] [54] . a meta-analysis of 20 studies showed that modest weight loss (eight percent of the initial body weight) caused a reduction in pwv measured in all arterial segments [55, 56] . a systematic review and meta-analysis of rcts looking at the effect of dietary interventions found that polyunsaturated fatty acids (pufa) supplementation improved pwv [57, 58] . pulmonary vascular injury occurs early in obstruction, prior to the development of abnormal fev 1 [59, 60] . we have published that enlarged pulmonary artery/aorta ratio by ct scan and dyslipidemia are biomarkers of wtc-li [61] . feno, a clinically accepted, indirect biomarker of lung disease activity, will be a valuable measure in our population. feno is associated with airway hyperreactivity, and several studies show that feno increases during obstructive exacerbations [62] . we propose to sample, bank, and measure serum and plasma for biomarker assessment before and after the dietary intervention. biomarkers are powerful predictors of disease that are useful in defining the efficacy of our intervention. this biorepository will not only allow us to complete and evaluate our current clinical trial but will be valuable to future epigenetic studies of wtc disease. assaying biologically relevant biomarkers allows for the identification of relevant pathways involved in wtc-li and helps guide therapies targeting these mediators. we will also obtain peripheral blood mononuclear cells from collected blood that will allow us to assess the genomic and microbiomic signatures pre/post intervention. there are limitations to this study, and a few will be discussed in this protocol paper. first, the study population is male and largely caucasian, which may limit generalizability. to limit bias in this un-blinded study, we will randomize after visit one. however, there is a chance that the main research team (not including the nutritionist and technology support providers) will be privy to subject identities and experimenter bias. given the tightly knit nature of the fdny community, we also surmise that there could be some sharing of information regarding the protocol between participants in opposing treatment arms. furthermore, as a behavioral and educational intervention, there is marked variability among individuals with regard to technologic savviness, educational background, willingness to alter diet and exercise, social support, economic means for a healthier diet, and physical ability to exercise. this variability will be equally prevalent in both groups. similarly, subjects unwilling to participate fully will not pass the inclusion criteria. the fdny cohort is highly motivated to improve their disease burden and quality of life. rescue workers receive routine screening and have an excellent recall of at least 90 percent in prior clinical studies. in addition, there is a strong commitment at the fdny for this proposed collaborative nyu/fdny effort to improve the health of these brave individuals. many participants are aware of our previous findings and have asked for ways to modify their lifestyle with hopes of changing disease outcomes. hence, it is logical to provide this much-affected cohort with interventions that they may benefit from. this intervention, once validated, may yield meaningful findings for populations exposed to ambient and other occupational particulates. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/18/6569/s1, figure s1 : interim monitoring bounds. interpolated stopping boundaries-z-score critical values for the 3-look design. table s1 : study procedures. funding: cdc/niosh u01-oh011300 funds this work. additional funding from nhlbi r01hl119326. the funding agencies did not participate in the study design; collection, analysis and interpretation of data; in the writing of the report; in the decision to submit the article for 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with special reference to vascular changes lysophosphatidic acid and apolipoprotein a1 predict increased risk of developing world trade center-lung injury: a nested case-control study exhaled nitric oxide in chronic obstructive pulmonary disease key: cord-264629-kuknvemy authors: sáez, gemma; ruiz, manuel j.; delclós-lópez, gabriel; expósito, francisca; fernández-artamendi, sergio title: the effect of prescription drugs and alcohol consumption on intimate partner violence victim blaming date: 2020-07-01 journal: int j environ res public health doi: 10.3390/ijerph17134747 sha: doc_id: 264629 cord_uid: kuknvemy intimate partner violence (ipv) is a public health problem with harsh consequences for women’s well-being. social attitudes towards victims of ipv have a big impact on the perpetuation of this phenomenon. moreover, specific problems such as the abuse of alcohol and drugs by ipv victims could have an effect on blame attributions towards them. the aim of this study was to evaluate whether the external perception (study 1) and self-perception (study 2) of blame were influenced by the victims’ use and abuse of alcohol or by the victims’ use of psychotropic prescription drugs. results of the first study (n = 136 participants) showed a significantly higher blame attribution towards female victims with alcohol abuse compared to those without it. no significant differences were found on blame attributed to those with psychotropic prescription drugs abuse and the control group. results of the second study (n = 195 female victims of interpersonal violence) showed that alcohol consumption is associated with higher self-blame and self-blame cognitions among ipv victims. however, results did not show significant differences on self-blame associated to the victims’ use of psychotropic prescription drugs. our findings indicate that alcohol consumption, but not prescription drugs use, plays a relevant role in the attribution of blame by general population and self-blame by victims of ipv. intimate partner violence (ipv) is defined as the violence committed by a current or former partner [1, 2] and it includes any behavior "that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviors" [3] . worldwide, almost one third of women who have been in a romantic relationship report having experienced some form of physical and/or sexual victimization by their partner in their lifetime [4] . in fact, the 2030 agenda of sustainable development goals (sdgs) encourages all countries to eradicate ipv, since violence can negatively affect women's physical, psychological and sexual wellbeing, increasing the risk of a poorer health, and it is associated with childhood trauma [5, 6] . the most severe consequence of ipv is death, and 38% of the female murders are currently attributed to this form of violence [4] . moreover, ipv can also have a negative impact on women's economic and social outcomes [7] , as well as on mental health (e.g., depression; [8] ), which might eventually turn into alcohol and drugs abuse [9] . ipv victims blame themselves for the violence they have experienced [10] . moreover, they are judged as more blameworthy by the society when they have violated gender roles [11] . such feelings of blame have an important role on the perpetuation of this phenomenon, and they are related to adversely negative mental health consequences, including substance abuse [12] . however, the relation between ipv and substance use and abuse remains understudied. data indicates that, among welfare recipients, victims of recent physical partner violence show higher rates of alcohol dependence (8%), compared to those who experienced physical partner violence in the past (2.6%) and those who have not experienced physical partner violence (1.1%) [13] . women exposed to ipv have also shown to be more likely to use psychotropic drugs, even after controlling for mental health [14] . according to research, substance use might become a coping strategy for facing continuous violent experiences [15, 16] since victims expect that substances will alleviate the negative physical and psychological impact of ipv [17] . moreover, psychological violence has shown to undermine adaptative coping strategies such as social support among victims of ipv, leading to drug abuse problems [18] . gezinki, gonzalez-pons and rogers [9] concluded that survivors use alcohol and self-medication as a coping mechanism while abuse is occurring, in order to reduce pain; and after the relationship, victims use alcohol and self-medication as a way of coping with the trauma and the stress of building a new life. however, kaysen and collaborators [19] have shown that the use of alcohol as a coping strategy may act as a mediator in the relation between alcohol use and trauma symptoms among ipv victims. in accordance with this approach, alcohol and drugs have been commonly understood as a consequence of the violence [17, 20] . one additional factor aggravating the negative consequences of ipv is social attitudes. as flood and pease [21] asserted: "attitudes play a role in the perpetration of this violence, in victims' responses to victimization, and in community responses to violence against women (p. 125)". these authors assert that women's response to intimate personal violence is determined by their attitudes towards ipv as well as by the attitudes of those around them. social attitudes towards intimate partner violence influence women's perception of support and help in an ipv situation [22] . stereotypic beliefs about intimate partner violence influence people's evaluation of the victim, and "cultural beliefs around ipv de-legitimize individuals who have experienced partner abuse, often blaming those who have experienced ipv for their own victimization" [23] (p. 3). more specifically, one critical attitude towards ipv victims in the general population is victim-blaming, which is defined as the process in which the victim is overtly or covertly attributed fault for their actions or inactions as the reason for the negative outcome [24] . victim-blaming provokes that women not fitting into the traditional gender roles are negatively judged for the violence they are suffering [25] . since the stereotypical features of an ipv victim are passivity and weakness [26] , any deviation of such stereotypical view increases victim-blaming. accordingly, empirical evidence has shown that women are judged more harshly in situations of sexual violence if they are behaving against traditional gender norms [21, 27, 28] . viki and abrams [29] demonstrated that female victims of sexual violence who have violated traditional gender roles are highly blamed by individuals who endorse sexism. therefore, gender norms are limiting women's acceptable behaviors and individual choices [11] . victim-blaming is also important given its effect on external support provided in ipv situations. victim-blaming has shown to be the mediator in the relationship between social attitudes and intervention in ipv situations [30] . when ipv victims are blamed for the violence experimented, they will encounter more obstacles when asking for help. firstly, because they might self-blame themselves. secondly, because they will anticipate that such social victim-blaming will turn into lower help. moreover, female victims not fitting in the traditional gender roles are negatively judged in terms of blame [31] : "women who fail to conform to traditional expectations, either based on their occupations or their actions, are perceived as less warm and this lack of warmth leads to more blame and negativity in a psychological abuse context" [31] (p. 849). self-blame is defined as the attribution of the cause of a traumatic event to one's own actions, assuming the responsibility of the event [32] and hindering recovery [32, 33] . self-blame is a criterion for post-traumatic stress disorder (ptsd) in the diagnostic statistic manual fifth version (dsm-5) [34] and plays an important role on intimate partner victimization (physical, psychological and sexual abuse). according to andrews and brewin [35] , attribution of blame in individuals that have suffered traumatic violent experiences is a learned process where they may be more likely to blame their character, which is linked to lower levels of self-esteem. reich and collaborators [32] have confirmed that self-blame has negative psychological consequences on ipv victims. in addition, according to the transtheoretical model of behavior change [36] internal blame attribution has been associated with the pre-contemplation phase in ipv victims. moreover, women focused on feelings of guilt and self-blame have higher substance abuse and stay in the abusive relationship for a longer period of time [12] . as a consequence, internal attribution of blame enhances the mental health negative effects of ipv among victims, including higher levels of depression and lower levels of self-esteem, damaged psychological adjustment [12, 32, 37] and lower perceived social support. being male or female entails different expectations about social behaviors [38] . gender has shown to be a crucial variable determining drug use as socially acceptable or unacceptable [39, 40] . in this line, brabete, sánchez-lópez, cuéllar-floresa and rivas-diez [41] showed a negative relation between alcohol consumption and traditional female gender norms. although a traditional feminine gender role might work as a protective factor for adverse health habits, it might also be detrimental for social perception and victim blame. in fact, previous studies have shown that women who use drugs report high levels of self-blame, shame, depressive mood, anxiety and tend to use substances more frequently alone and in private rather than in public settings [42] . moreover, according to capezza and arriaga [31] , non-traditional women are blamed more when they are attributed a lack of warmth. following the stereotype content model [43] , drug users would be considered low in competence and low on warmth, labeled as completely cold [44] . this means that women using substances would face an increased stigma since they go against expected female roles. in this direction, since a man drinking alcohol is more socially acceptable than a woman drinking alcohol [45] , drinking among ipv victims will increase victim blame. romero-sánchez et al. [46] showed that the victim's alcohol consumption influences victim blaming to a higher extent than the use of physical strength by the perpetrator. moreover, victims who use substances are perceived as less truthful, leading to higher victim blaming [47] . another study by stewart and maddren [48] showed that drunk victims of family violence were blamed more than non-drunk victims. however, despite previous studies suggesting the effect of drinking on ipv victim-blaming, no previous research has explored the differential effect of alcohol intake and other psychotropic drugs use on victim-blaming among ipv victims. the current study aims to explore the effect of prescription drugs and alcohol use on intimate partner violence victim blaming. our study has two different goals: (1) to assess the perception of the general population of women victims of ipv that use either alcohol or prescription drugs and (2) to determine whether there is a relationship between the use of alcohol/prescription drugs and self-blaming among ipv victims. with this design, we took a two-sided approach to examine how alcohol and prescription drugs influence intimate partner violence victim blaming. given that substantial research has shown the importance of social perception in the use of both legal and illegal drugs [49] , the first study used an experimental design to explore the detrimental effect of alcohol abuse and prescription drugs abuse on the social perception of the ipv victim. considering gender roles on drinking and drugs is of great importance [50] , in the second study, we took a needed gender perspective because "the gender lens asks us to study substance use more carefully and to recognize the impact of social and cultural constructions of masculinity and femininity on individual and group drug use" [51] (p. 286). this gender perspective is necessary since alcohol use is significantly higher among men [50] whereas psychotropic drugs use is higher among women [52] [53] [54] . therefore, a correlational study was carried out among victims of intimate partner violence to evaluate whether alcohol and psychotropic drug consumption are positively related to self-blaming. in order to understand the role of alcohol and psychotropic prescription drugs on ipv victim blaming from a social and victim perspective, two studies were carried out, with two different samples and two different recruitment strategies. the first experimental study was carried out with a paper-and-pencil technique, which allows for a better control of confounding variables and environmental distractors by the experimenter. the second study used an online sampling method for recruiting women meeting the established inclusion criteria. in this case, the online sampling method facilitated a higher perception of anonymity, which was crucial for the study given the sensitivity of the topic [55] . the hypotheses of the first study are: victim-blaming would be higher when an alcohol abuse problem existed in comparison to a control condition without an alcohol abuse problem. victim-blaming would be higher when the victim was an abuser of prescription drugs compared to a control condition without prescription drug abuse. the hypotheses of the second study are: hypothesis 3 (h3). victims of ipv that have an alcohol abuse problem would report higher levels of self-blaming (hypothesis 3a) and higher self-blame cognitions (hypothesis 3b) than those women without an alcohol abuse problem. alcohol consumption is positively related to self-blaming (hypothesis 4a) and self-blaming cognitions (hypothesis 4b) among ipv victims. victims of intimate partner violence who have ever used prescription drugs would self-blame themselves more (hypothesis 5a) and would have higher self-blaming cognitions (hypothesis 5b) compared to women who do not report any prescription drugs use. there is a positive correlation between prescription drugs use duration and self-blaming (hypothesis 6a) and self-blaming cognitions (hypothesis 6b) among ipv victims. a total of one hundred and fifty-five participants participated in the study. nineteen of them were excluded from the analysis due to invalid data, leaving a total of 136 participants. the majority of participants self-identified as heterosexual (94.9%), and 52.2% were women. on average, participants were 30.40 years old (sd = 13.61). modal education was a university degree (58.1%). the research study entitled "psychosocial factors related to the perception of intimate partner violence" was approved by the ethical committee of loyola university previous data collection. following an incidental sampling procedure in different crowded places (e.g., libraries) of a spanish city, a researcher requested the participants' collaboration answering a paper-and-pencil study. all participants were volunteers and provided informed written consent, and no monetary incentives were provided for participation. a between-subjects manipulation was used, where two identical ipv scenarios were created, except for the manipulation of the alcohol or prescription drug abuse problem reported by the victim of the interpersonal violence. after a random assignment of the manipulation, victim-blaming was assessed embedded within a larger series of questionnaires. interpersonal violence scenarios: three scenarios were created to incorporate the experimental manipulation from nguyen et al. [56] second scenario. this scenario described a fictitious dating violence situation between carlos and ana, who were involved in a romantic relationship. the scenarios varied exclusively in the information regarding ana's substance abuse (psychotropic prescription drug abuse condition, alcohol abuse condition and control condition). the scenario provided to participants was as follows: "carlos and ana have been dating for about four years, both are students at the university (alcohol condition: and ana has alcohol abuse problems) (psychotropic prescription drug condition: and ana has psychotropic prescription drug abuse problems). one day, ana went out with her friends and then came over to see carlos. carlos had been working hard on a project for one of his classes. he had wanted ana to help him with this task and was very angry at ana her for going out with her friends. he was quite upset and slapped her fairly hard. she fell and broke a bone in her hand. this required a visit to the emergency room to reset the hand and to get pain pills" (adapted from nguyen et al.; scenario 2 [56] ). victim blame: six questions from romero-sánchez, megías and krahé [57] were used to assess victim blame: "do you believe ana should feel guilty for what happened at the end of this story?" "do you believe ana incited carlos to act like he did at the end of this story?" "do you believe ana could have behaved differently to change the outcome of this story?" "do you believe ana got what she deserved?" "do you believe ana could have prevented what happened at the end of this story?" and "do you think that ana's behavior provoked what happened at the end of this story?" the scale response format was a 7-point likert-scale form, with responses ranging from (1) strongly disagree to (7) strongly agree. higher scores indicated more blame attributed to the victim. there was strong internal consistency in the present study (cronbach's α = 0.81). all analyses were conducted using spss (statistical package for the social sciences version 26.0, ibm corp., armonk, ny, usa) software. to evaluate the effect that experimental manipulation (control, prescription drug and alcohol) has on victim blaming, one-way anovas with welch's test procedure was conducted. additionally, pairwise comparison tests were used to examine descriptive data. regarding the anova for victim blaming with the different conditions (control, psychotropic prescription drug and alcohol), levene's test for heterogeneity of variance indicated that responses to victim blame questionnaire violated the homogeneity of variance assumption (f (2, 133) = 10.59, p < 0.001). accordingly, we conducted welch's test procedure [58] . welch's test held a significant effect f welch (2, 80.63) = 5.62, p = 0.005 (see table 1 ). our results confirmed hypothesis 1, and pairwise comparisons indicated that participants who read the alcohol abuse scenario scored higher on victim-blaming compared to the control condition (t (59.97) = −3.19, p = 0.002). however, results did not confirm hypothesis 2, and there were no significant differences on victim-blaming among participants who read the psychotropic prescription drug abuse scenario and the control scenario (t (78.56) = −1.78, p = 0.08). means are presented in table 1 . results did not yield a significant effect of the psychotropic prescription drug on the blame attribution to the victim. there was, however, a clear tendency among participants to attribute a higher blame to women who have a prescription drug problem compared to the control condition. victims of intimate partner violence are targets of a double source of blaming, namely: the social judgement about their victim status and their own perception of their responsibility of such violence. results from the first study showed the importance of victim's alcohol consumption on victim blaming among general population; the second study aims to explore the effect that alcohol and prescription drug use have on the victim's self-blaming and self-blaming cognitions. the study entitled "alcohol and prescription drug consumption and its effect on interpersonal relationships" was approved by the institutional ethical committee of loyola university previous data collection and participants were recruited from an online survey. inclusion criteria were: (1) self-identifying as a woman, (2) being older than 18, (3) currently in a heterosexual relationship, (4) correctly answering two attentional checks and (5) the woman abuse screening tool (wast-short): this tool was utilized to evaluate the inclusion criteria of self-identifying as victims of ipv. the spanish-language version of this scale has shown good specificity (76.2%) and good sensitivity (91.4%) [59] . the wast-short is composed of two items that assess the degree of relationship tension and the difficulty that the couple reports in solving arguments on a scale from 1 (no tension/no difficulty) to 3 (a lot of tension/great difficulty) [60] . following plazaola-castaño et al. [59] a response of 2 or 3 on any of the two items was coded as positive (1) whereas a response of 1 was coded as negative (0). the total score, calculated by summing both items, ranges from 0 to 2, with 2 being the cutoff (participants scoring 0 or 1 were excluded). consequently, participants in the study included those experiencing some or great difficulty and some or a lot of tension on their relationship. this way of calculating the final score is the recommended for spanish population [59] . the alcohol use disorders identification test (audit) [61] is a 10-item self-report screening measure assessing alcohol use disorders (aud) and harmful alcohol use. the current study utilized the total score to measure alcohol use problems, with a cut-off of 7 points for problem drinking as suggested by babor and collaborators [62] to be used by women. there was strong internal consistency in the present study (cronbach's α = 0.81). prescription drugs: in the absence of an existing validated measure of the extent to which participants use prescription drugs, we adapted four items from a larger measure used by antich and collaborators [63] . specifically, we asked participants: "have you ever taken psychotropic prescription drugs for depression, anxiety or sleep disorders?" with a response format including 0 (no consumption) or 1 (consumption). two participants have missing data in this question. among participants reporting any psychotropic drug use, three different questions were presented to explore the length of time that they had been using prescription drugs for (a) depression, (b) anxiety and (c) sleep disorders. with this purpose, a likert scale was used with responses including 1 (less than 1 month), 2 (from 1 to 3 months), 3 (more than six months) and 4 (more than one year). the final timeframe of prescription drug consumption was the average of the time reported for depression, anxiety and sleep disorders (m = 2.43; sd = 1.04). this result indicates that among participants who reported any prescription drug use, they had done so for between three and six months in average. a total of eight responses were coded as missing on these two measures because of the inconsistent responses of participants to the items (e.g., reporting no previous psychotropic prescription drug use in the first question but then providing details on the specific features of their prescription drug use). self-blame: in order to evaluate the self-blame that women feel as a consequence of being victims of interpersonal violence, the combination of two instruments was used. firstly, the items of the psychological violence (e.g., my partner demands obedience to his whims) from the reduced spanish version of the index of spouse abuse were used (isa) [64] , and afterwards, the level of self-blame that female participants felt towards these items was assessed. secondly, we listed the items referring to behaviors of physical violence (e.g., my partner becomes abusive when he drinks) from the isa scale and immediately asked participants about the level of self-blame regarding those items. specifically, after reading the items on physical or non-physical violence, we asked participants: "how guilty do you feel?". the response format is a 6-point likert ranging from 0 (not guilty) to 5 (totally guilty). we calculated the total score by averaging the score reported for both items. there was strong internal consistency of this measure in the present study (cronbach's α = 0.85). self-blame cognitions: the subscale from the posttraumatic cognitions inventory (ptci) [65] was translated (and back-translated) into spanish and adapted for the study purpose. self-blame subscale is a self-reported measure to assess self-blame as part of the traumatic cognition, and it was adapted to evaluate female perception of having acted wrongly with regards to the violence they have experienced (e.g., "it happened because of the way i acted"; "it happened to me because of the sort of person i am"). the response format is a 7-point likert from 1 (totally disagree) to 7 (totally agree). the total score was calculated as the mean of the five items [66] . there was strong internal consistency in the present study (cronbach's α = 0.87). the self-blame questions of the trauma questionnaire were presented immediately after the items from the reduced spanish version of the index of spouse abuse [64] . the self-blame cognition subscale was adapted in order to ask participants to answer these questions with regards to the victimization items they had just read. independent samples t-tests were conducted for testing hypothesis 3, predicting significant differences on self-blame (hypothesis 3a) and self-blame cognitions (hypothesis 3b) depending on their alcohol problematic consumption. to test hypothesis 4, which predicts that alcohol consumption will predict self-blame (hypothesis 4a) and self-blame cognition (hypothesis 4b) among ipv victims, regression analyses were run to evaluate the predicting role of self-blame and self-blame cognitions on alcohol use. to test hypothesis 5, which predicts differences on self-blame (hypothesis 5a) and self-blame cognition (hypothesis 5b) among ipv victims depending on their prescription drug use, independent samples t-tests were conducted. lastly, in order to test hypothesis 6, predicting a relation between prescription drugs use duration and self-blaming (hypothesis 6a) and self-blaming cognitions (hypothesis 6b), correlation analysis between drug use duration and both measures of self-blaming were conducted. tables 2 and 3 . hypothesis 3, which predicts higher self-blame (hypothesis 3a) and self-blame cognition (hypothesis 3b) on ipv victims with an alcohol abuse problem, is partially supported (see table 3 ). in accordance with hypothesis 3a, female participants who reported having problematic alcohol consumption scored higher on self-blame (t (43.26) = −2.22, p = 0.03). women scoring above the alcohol problematic cutoff scored higher on self-blame (m = 0.81, sd = 1.31) compared to women below the cutoff (m = 0.31, sd = 0.81). however, and contrary to hypothesis 3b, female participants who reported having a problematic alcohol consumption did not report higher self-blaming cognitions (t (177) = −0.99, p = 0.33) (see table 4 ). note: * p < 0.05, significant difference; the difference in sample size is due to missing data on some scales. our results confirmed hypotheses 4a and 4b, since higher alcohol consumption was related to higher self-blame (b = 0.22, t = 2.97, p = 0.003) and self-blame cognitions (b = 0.17, t = 2.23 p = 0.03) (see table 5 ). finally, our results did not allow us to confirm hypotheses 5a and 5b (see table 4 ). there were no significant differences between female participants on their self-blame (t (175) = 0.09, p = 0.93) and their self-blame cognitions (t (173) = −1.53, p = 0.13) depending of their prescription drug consumption. moreover and contrary to hypothesis 6, which predicts a positive relation between the prescription drug duration and self-blame (6a) and self-blame cognition (6b) among ipv victims, there was not a significant association between time consumption of prescription drugs and self-blame (r = 0.13, p = 0.27) and self-blame cognitions (r = −0.04, p = 0.71) reported by victims of intimate partner violence. the present work examined the effect of alcohol and prescription drug use on victim-blaming. particularly, we have focused on female victimization since the world health organization report [3] states that women are frequent targets of violence, whereas men are more likely to be perpetrators. moreover, social perception in intimate partner violence phenomena is determinant [67] . with these considerations in mind, the present study had two goals in different populations. firstly, we examined the social perception of victim-blaming depending on the victim's alcohol or prescription drug abuse. secondly, and focusing on intimate partner violence victims, we evaluated whether the reported consumption of alcohol and prescription drugs would be related to self-blame and self-blaming cognitions. study 1 revealed that presenting an alcohol abuse problem but not a prescription-drug abuse problem was related to higher victim-blaming compared to a control condition among general population. this result might be explained because women who use alcohol are considered to violate social gender norms, whereas prescription drug abuse is in accordance with the stereotypical view of women as emotionally weak [26] . this result replicates previous studies reporting that "drinking by domestic violence victims would lead to increased victim blame and derogation" [45] (p. 1054) because alcohol consumption has a detrimental effect on the attribution of empathy and compassion. alcohol abuse causes women to be perceived as behaving inappropriately, which decreases the perpetrator's attribution of blame and increases the female's responsibility of the violence [68, 69] . from the perspective of the just world theory [70] , which states that bad things happen just to bad people and people who deserve it, victim blaming in intimate partner violence situation is one of the strategies that allow people to believe that the world is a just and fair place [71] . valor-segura, expósito and moya [72] found that people who endorse to a higher extent the belief in a just world attribute higher victim-blaming to the victim when there is not a cause for the violence, because people tend to think that the victim must have done something to deserve such violence. our experimental manipulation gave participants a pretext to attribute blame to the victim, i.e., she has an alcohol problem. moreover, the current work extends previous literature revealing that there are no differences on victim blame associated to the victim's psychotropic prescription drugs abuse problem. this result might be explained because the stereotype of women abusing prescription drugs would be that of weakness and overemotional among other characteristics [73] , which is in accordance with the submissive stereotypical position hold by intimate partner violence victims. this result is in line with findings from little and terrance [74] , supporting that female victims described as more feminine are considered less blameworthy. merging results from capezza and arriaga [31] and the findings presented here, we can assert that women with an alcohol abuse problem are violating their gender role, and turning into higher victim-blaming in case they experience ipv violence. does social stigma towards female victims of ipv with alcohol abuse problem affect their own perception and attitudes toward the violence they experience? based on the fact that women with substance abuse problems perceive lower levels of social support in the context of ipv experiences [75] , we hypothesized that among victims of ipv with higher drugs and alcohol consumption, the internalization of social blaming would be higher compared to ipv victims with lower substance use. with this goal in mind, the second study using a specific sample of ipv victims aimed to explore the effect that alcohol and prescription drugs have on self-blaming attribution for the violence they had experienced. results of study 2 concluded that victims with higher alcohol consumption or an alcohol use disorder endorse submissive and self-blaming beliefs. this result is in line with previous studies indicating that victims of intimate partner violence with addiction problems have a lack of personal autonomy [76] . this result is highly relevant because alcohol abuse is significantly higher among those women who have experienced intimate violence compared to non-victims [77] . if experiencing violence is a risk factor for alcohol abusive problem, and this abusive behavior leads to self-blaming among ipv victims, self-blaming is a perpetuating phenomenon among women who use alcohol as a coping strategy for ipv situations. according to the trans-theoretical model, self-blaming cognitions and feelings might contribute to the victims' emotional distress and hinder victims' progression through the ttm-based stages. the use of alcohol by ipv victims might aggravate this situation. moreover, it might be that alcohol consumption is used by female victims as a way of enhancing the bond with their partner [78] , given the high emotional dependence on their partners [79] . another alternative is that their perception of lack of mate alternatives because of their addiction would decrease their readiness to leave the abusive relationship [78, 80] . this might in turn increase their self-blame for not leaving the abusive relationship. lastly, another alternative is that self-blaming cognitions might be explained because women are aware that they are violating the gender norm due to their alcohol consumption. this perception comes from social stigmatization to female drinkers [81] . however, they would not be aware of such violation if they use psychotropic prescription drugs since its consumption is perceived as normalized and harmless, because they might be prescribed by a doctor [82] . despite the significant findings in our study about the role of alcohol and prescription drugs use on blame and self-blaming attribution among ipv victims, this study is not without limitations. firstly, the current studies focused solely on one side of the phenomenon. while gender violence is a gendered phenomenon where women are mostly victims and men are perpetrators of the violence, it would be important to evaluate the level of male alcohol consumption to control for relations found between self-blaming and alcohol consumption in study 2. secondly, the manipulation in the first study has been carried out through a scenario method, which might have limitations regarding external validity. additionally, it was carried out with a convenience sample, and the level of victimization or perpetration of participants was not evaluated. even though this level of victimization should be randomly distributed across the three conditions, future studies should explore the role of experiencing violence on victim blame attribution. thirdly, the correlational nature of study 2 avoids any interpretation of causality. accordingly, longitudinal studies should be conducted that examine the long-term and reciprocal associations between ipv victim blaming on alcohol and prescription drugs use. fourthly, the use of different samples for each study compels us to be cautious regarding the interpretation of possible relationships between studies. further studies should evaluate both the effect of contextual and internal variables in the same sample of ipv victims and their social network. fifthly, previous research indicates that variables such as depressive symptoms [83] or dysphoric symptoms [84] might also have a significant impact on self-blame and self-blaming cognitions. in our study, and due to time limitations, no further information was collected on possible control variables. results from ols regression should then be interpreted with caution. finally, an important limitation of the second study is the use of the wast. in our study, we have used the criterion scoring for spanish population to create the cut-off recommended by plazaola-castaño et al. [59] due to its higher sensitivity. we must note though that this cut-off level has been shown to detect a high number of false positives, meaning that some of the women who are considered as battered by the instrument might be erroneously classified as such. however, in our study, we are not particularly interested in an exhaustive detection of intimate partner violence, and our interest is to analyze the effect of alcohol and prescription drug use on self-perception among women experiencing any kind of violence. this investigation is designed as a potential contributor to the attainment of the fifth goal of the sustainable development goals (sdg) adopted by the united nations member states, which aims to achieve gender equality and empower all women and girls. specifically, we have adopted a dual approach that integrates social and individual perspectives on the victim's blame attribution analysis. this allows us to attain a comprehensive understanding of the role of alcohol and drugs on victim blaming that contributes to expand our knowledge on the role of victim's behaviors on attributions. in particular, results revealed that alcohol consumption, but not prescription drug consumption, increases blame attribution among observers and self-blame attribution among victims. both results are closely related because of the fact that people perceive women with an alcohol abuse problem as responsible for the violence they experience, it is manifested in everyday discriminant and non-helping behavior [85, 86] causing the victim to internalize such blame. present findings and future studies in this line of research have implications for interventions with victims who are alcohol users and for policy intervention. on the one hand, the consideration of blaming attribution and self-attribution is crucial for mental health professionals working with ipv victims, since self-blame moderates the relation between physical abuse and ptsd severity [36] . drinking problems on ipv victims need to be understood as a way of coping with self-blaming cognitions. on the other hand, policymakers working on awareness campaigns might find the results from study 1 useful for creating preventive programs aiming to reduce ipv by modifying individual attitudes towards victims with alcohol abuse problems. lastly, since the current covid-19 pandemic situation has shown to exacerbate ipv victimization [87] , as well alcohol and drug problematic consumption [88, 89] , we encourage researchers to explore the effect that covid-19 pandemic might have on the use of alcohol as a way of coping with ipv situations, due to the lack of social support. intimate partner violence surveillance uniform definitions and recommended data elements version 2.0; national center for injury prevention and control national center for injury prevention and control costs of intimate partner violence against women in the united states world health organization. preventing intimate partner and sexual 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acceptance, gender role conformity and substance use on victim blaming violent victimization among women with alcohol problems. in recent developments in alcoholism: alcoholism and women; recent developments in alcoholism family violence and covid-19: increased vulnerability and reduced options for support world health organization. mental health and covid-19; world health organization collision of the covid-19 and addiction epidemics the authors acknowledge the collaboration of maría ruiz (m.r.) who was involved on data collection of the first study, and ayan ahmed (a.a.) for proofreading. the authors declare no conflicts of interest. key: cord-011536-rb8g5llp authors: jiang, dong; wang, qian; bai, zhihua; qi, heyuan; ma, juncai; liu, wenjun; ding, fangyu; li, jing title: could environment affect the mutation of h1n1 influenza virus? date: 2020-04-29 journal: int j environ res public health doi: 10.3390/ijerph17093092 sha: doc_id: 11536 cord_uid: rb8g5llp h1n1 subtype influenza a viruses are the most common type of influenza a virus to infect humans. the two major outbreaks of the virus in 1918 and 2009 had a great impact both on human health and social development. though data on their complete genome sequences have recently been obtained, the evolution and mutation of a/h1n1 viruses remain unknown to this day. among many drivers, the impact of environmental factors on mutation is a novel hypothesis worth studying. here, a geographically disaggregated method was used to explore the relationship between environmental factors and mutation of a/h1n1 viruses from 2000–2019. all of the 11,721 geo-located cases were examined and the data was analysed of six environmental elements according to the time and location (latitude and longitude) of those cases. the main mutation value was obtained by comparing the sequence of the influenza virus strain with the earliest reported sequence. it was found that environmental factors systematically affect the mutation of a/h1n1 viruses. minimum temperature displayed a nonlinear, rising association with mutation, with a maximum ~15 °c. the effects of precipitation and social development index (nighttime light) were more complex, while population density was linearly and positively correlated with mutation of a/h1n1 viruses. our results provide novel insight into understanding the complex relationships between mutation of a/h1n1 viruses and environmental factors. influenza viruses possess an rna genome and belong to the orthomyxoviridae family [1] . segmenting genes attributed to influenza viruses, when two or more different influenza virus strains infect the same host or cell an antigen shift may occur due to gene recombination. theoretically, recombination of two different strains of influenza virus will produce a variety of influenza viruses. therefore, gene recombination is an important reason for the diversity of the virus. replacement and accumulation of surface glycoprotein genes leads to antigenic drift and, thus, the outbreak and epidemic of influenza each year. this diversity enables the rapid evolution of influenza viruses, their adaptation to new host environments, their evasion from the host's immune response, and the accelerated generation of drug-resistant strains [2] . of course, the evolution of influenza viruses has required constant changes in the composition of vaccines for seasonal influenza and for the continued development and preparation of candidate vaccine strains for pandemic prevention and control [3, 4] . h1n1 subtype influenza a viruses have a major impact on the epidemiology of humans by causing seasonal epidemics of different degrees of severity and two pandemics in 1918 and 2009 [5] . though complete genome sequences have recently been reported, the evolution, epidemiology, transmission dynamics, and other aspects of a/h1n1 viruses remain unknown to this day. over the past few decades, global climate change and the integration of economic development in urban and rural areas have greatly impacted earth's ecology. climate change has significant impacts on both human migration and population health, especially infectious disease. it has not only a direct impact on the ecology of infectious diseases, but also a remote impact on the ability of society to control and prevent diseases [6, 7] . christine et al. demonstrate the strong regulating effect of temperature on microbial diversity through 16s rrna gene sequencing [8] . although the change in diversity at the gene level is of greater concern, the effect of these factors on the gene mutation of the influenza viruses is still not clear. according to the research of aitor nogales et al., the h3n2 virus encoding the ns1-v194i protein displays a temperature-sensitive phenotype, providing an assumption of the effect of environmental factors such as temperature on the genetic mutation of influenza viruses [9] . furthermore, as urbanization and population density have increased, seasonal infectious diseases are more difficult to prevent and treat [10] . in terms of social factors, chris et al. used the theory of games to study the impact of social collaboration and human vaccination on epidemics. human social behavior is closely related to the emergence of influenza virus resistance and the occurrence of infectious diseases [11, 12] . jan proposed that the fitness penalty of pathogens could be used as a predictor of the durability of disease resistance genes [13] . however, there are still many unknowns surrounding the safety of antiviral drugs and effectiveness of that strategy. it is important to collect data on climate, urbanization, socio-economic conditions, and virus incidence rate, which is helpful in understanding the interaction between climate change, urbanization and public health, as well as in adequately planning for the future. in the present study, the location information (i.e., latitude and longitudes) of 11,721 reported cases of h1n1 were collected and we explored if h1n1 genomic diversity was subject to the direct effects of temperature, precipitation, and other natural factors or the indirect effects of population density, urban development, and other social factors. the h1n1 influenza data reported on the chinese mainland from the world health organization (who)'s global influenza program (gip, http://who.int/influenza/) were collected. the h1n1 dataset included 12,401 records from the first case reported in 1931 to the last case reported in 2019. the datasets included the basic information (reported province, reported date, latitude, and longitude) for each case (supplementary table s1 ). the sequences of influenza virus strains were compared with those of the earliest reported strain and the sequences of other strains to obtain the location and number of different sequences. the number of differentially expressed genes was taken as the numerator, and the total number of strains with the earliest reported was taken as the denominator to calculate the difference rate, i.e., the mutation rate of the ha gene. biological experiments and epidemiological evidence indicate that variations in environment have important effects on the occurrence and transmission of epidemic influenza. there are many reports demonstrating that the spread of influenza virus is closely related to the two climatic factors of temperature and precipitation: low-temperature dry environments are conducive to the spread of the virus, and high-temperature environments can largely prevent the virus from spreading in aerosols. however, there are few studies on how these two factors affect the mutation of the virus. the temperature and precipitation data used in this experiment were downloaded from the worldclim database (version 2.0, http://www.wordclim.org) with a spatial resolution of 1 × 1 km 2 ( table 1 ). the temperature and precipitation values were obtained corresponding to each case point by arcgis processing. population density, urban accessibility, and nighttime light were chosen as social factors simulating the impact of mutation, and urbanicity was added as a fixed factor of the model. population, economy, and transportation are three important factors that reflect social conditions, and urbanicity is a more direct factor for distinguishing the level of social development. to a certain extent, urban accessibility reflects the spatial distribution and traffic conditions of an area. many studies show that, as an effective representation of human activities, nighttime light data has a significant correlation with gdp and can be used to invert regional gdp development. as the host of the virus, the higher the population density is, the faster the virus spreads, so this is reason to believe that population density has a certain relationship with virus transmission and mutation. the urban accessibility data was obtained with a spatial resolution of 1 km × 1 km from the european commission joint research center global environment monitoring unit, (https://ec.europa. eu/info/departments/joint-research-centre_en). the population density data was downloaded from socioeconomic data and applications (table 1) , https://sedac.ciesin.columbia.edu/. the dmsp-ols nighttime light data was used from the earth observation group, noaa, and the fixed factor urbanicity data from the national aeronautics and space administration (nasa). the spatial resolution of all these social variables was 1 km × 1 km, and these data were included in our case dataset by using both the geographical locations assigned and the temporal period at a decadal resolution via arcgis 10.2 made by environmental systems research institute of america. the years variable was obtained by using the year in which a case occurred minus the year 1931 in which h1n1 was first reported, and this variable ranged from 69 to 88. all data coordinates were unified as wgs-84. glm with a gaussian distribution was used to study the association between environment and social conditions and h1n1 mutation (table 2 , column a). it was found that most of the elements were not significantly related to mutation, so a more flexible model (with nonlinear parameters) was required. to address this nonlinearity, a gam using the r package mgcv and a thin-plate spline for several factors were estimated ( table 2 , column b). this specification allowed factor coefficients to vary over the values within their distributions, and it enabled us to explore the nuances of the relationship between our measurements and ha mutation. since these spline variables do not have a single coefficient estimate, the coefficients for some factors were presented graphically ( figure 1) . for both the glm and gam versions of the models, we controlled for residual unmeasured regional differences by using the urban-rural partition variable. this urban-rural variable was included as a fixed, instead of random, effect attributed to the fact that several of the predictor variables are reported differently in rural and urban areas. therefore, they are correlated at that spatial scale. the total number of virus strains was also included as another fixed factor to avoid different response power to environmental factors caused by different virus strains. the gam version of the model has the following functional form: where i = case, t = time, y is ha mutation, parameter a is the overall intercept, x is the independent variable, f ( ) is the thin-plate spline function, urban is the fixed effect term urban-rural variable, m is the fixed factor total number of virus strains, and ε is the error term. table 2 , column b. non-overlap between the confidence interval and dashed zero line indicates a statistically significant effect. figure 2 shows the spatial distribution of h1n1 cases from 2000-2019, totaling 11,721 reported infections. the cases spatially clustered in three major areas of the world during this timeframe: the southern portion of north america; central europe; and southeast asia. meanwhile, there was sporadic distribution in oceania, south america, and africa. in north america, cases were mainly distributed in the usa, the country with the most cases in the world, accounting for 57.7% of the total. the united kingdom, finland, and new zealand were the main affected areas in europe. in asia, cases were concentrated in the southeast, such as singapore, thailand, and china's southeastern cities. in terms of ha mutation value, in all 11,721 cases the boundary of the variability was very obvious: 46 were > 0.75, two were between 0.55 and 0.60, and all of the remaining were < 0.22. at the country level, cases with high mutation value occurred only in two countries, the united states (44/46) and the united kingdom (2/46). cases with low values, < 0.01, were mostly distributed in europe and russia, and 26 of the 37 were located in the netherlands. for h1n1's ha mutation from 2000-2019, a simple generalized linear model (glm) shows that, of all the seven independent variables, most variables displayed a strong significance with ha mutation, including maximum temperature, minimum temperature, nighttime light, population density, and years fixed factor. precipitation and urban accessibility were not statistically significant in the basic glm model ( table 2 , column a). to capture any possible coefficient variations over the variable range, estimates in a generalized additive model (gam) were allowed to vary ( table 2 , column b). the results of the gam model show that the relationship of the five above variables and ha mutation was still significant, and the connection between nighttime light and mutation became very significant. at the same time, two variables (precipitation and urban accessibility) displayed significant association with mutation in the gam but not glm model. here, aic (akaike information criterion) and explained deviance were used to consider the simulation effect of the model. the aic of gam is lower than that of glm, −68,857.5 vs. −67,655.2. the deviance explained of gam is 90.5%, while that of glm is 89.4%. these results indicate that the simulation capability of the gam model is better for this experimental process. figure 1 shows the impact of four variables on mutation, with precipitation (a) and minimum temperature (b) being selected as representatives of environmental factors, and nighttime light (c) and population density (d) as representative social factors. in terms of the relationship between precipitation and mutation ( figure 1a) , the mutation rate does not change much with an increase of precipitation within about 2000 mm. above 2000 mm, the rate of mutation first increases and then decreases with the increase in precipitation, but overall the effect is not significant. minimum temperature displayed a nonlinear, rising association with ha mutation, with a maximum around 15 • c ( figure 1b) . the curve as a whole is first stable, then increases, and after maintaining a stable period suddenly rises and then falls. the broad effect of nighttime light on ha mutation forms an undulating wave with three troughs and two peaks ( figure 1c ) and reached a minimum around 35. the impacts of the rising section are 15-25, 35-45, and > 50, with a maximum around 25. the association of population density with mutation is simpler than the above three factors, displaying a linear, positive association with mutation ( figure 1d ). the dependence of influenza virus transmission on environmental factors, including temperature, humidity, and atmospheric pressure, has been documented by many previous studies [14] [15] [16] [17] . therefore, the question arises as to whether these climatic factors are related to influenza virus mutations. in this study, the correlation between climatic factors and ha protein mutation of h1n1 was examined. as for the relationship between precipitation and mutation, the result was shown that the effect on mutations only occurred when precipitation was > 2000 mm, though the relationship was not linear. however, the average annual precipitation of many countries with high rates of h1n1 subtype influenza a virus mutation, especially the united states and united kingdom, did not exceed 2000 mm [18, 19] . thus, precipitation is not associated with ha protein mutations in a practical sense. another climatic factor was the minimum temperature, which is slowly rising due to the influence of human activities. in recent years, multiple studies have proposed that global warming will likely influence the life of all living species, including the evolution of influenza a virus [20, 21] . furthermore, yan et al. found that global warming affects many different levels of biological evolution; even intracellular proteins are subject to global warming [22] . it is understandable that all biological functions are interconnected from the macro to micro level. in contrast, from the perspective of cross-species transmission of avian influenza, our previous studies on the correlation between climate factors and avian influenza infection found that there were significant relationships between climate factors and h5/h7 influenza infection, especially temperature variables [23] . herein, the minimum temperature showed a nonlinear, rising association with ha mutation, with a maximum around 15 • c. interestingly, diana et al. found that the maximum values of the weekly influenza proxy coincided with the minimum temperature (10-15 • c) in the 2010-2015 influenza seasons in spain [24] . this suggests that the highest mutation rate of ha protein at 15 • c could be related to the high incidence and transmission rate of influenza virus at~15 • c. aside from meteorological factors, many other factors also affect influenza mutation rates. in terms of socioeconomic factors, nighttime light and population density were selected as the test criteria. as is known, there is less research providing information on the correlation between flu mutation rates and nighttime light. nighttime light data can reflect comprehensive information, and depends not only on population density but also per capita energy consumption and, hence, economic activity [25] . surprisingly, nighttime light and influenza mutations did not display a positive correlation as predicted but, rather, an unstable fluctuation. considering the influence of a variety of social factors, the one potential explanation for this result is that the effect of nighttime light on ha mutation is not direct but indirect or combined with other auxiliary factors. however, these trends cannot be ignored. a better understanding of the complex effects of nighttime light will enable better prediction and manipulation of the course of influenza evolution in social contexts, so more detailed classification and analysis of various social factors are needed. the association of population density with mutation is simpler than the above three factors, displaying a linear, positive association with mutation. this is to be expected as an excessive population can contribute to the spread of the epidemic. notably, the continuous infection and propagation of the virus could yield genetic mutation and also affect pathogenicity and virulence [26, 27] . these results indicate that interventions with a focus on municipalities with greater flows and densities of people, especially those with a higher human development index and the presence of municipal air and road transport, could play an important role in mitigating the impact of future influenza pandemics on public health. it is well known that influenza viruses display a remarkable genetic flexibility based on their high mutation rate under different selective pressures [28, 29] . our study provides an environmental perspective for understanding mutation in the evolution of the h1n1 subtype of influenza viruses. due to its crucial role in receptor recognition and attachment, the ha protein is considered to be a principal determinant of influenza virus invasion [30, 31] . consequently, the association between ha mutations and environmental factors has been sought. in this study, a complex non-linear relationship had been found between minimum temperature, nighttime light, and ha protein mutations. simultaneously, population density was positively correlated with ha protein mutations. these results suggest the possibility of using temperature and population density to approximate the effects that environmental factors have on h1n1 ha mutation. however, we have not analyzed and predicted the influence of these factors on the direction of ha protein mutation. notably, much statistical data demonstrates that correlation does not mean a cause-consequence relationship. therefore, even if correlations between two trends have not been found, whether there is any direct or indirect causation remains to be determined. thus, wider and deeper research needs to be done. in addition, our findings showed that mutation rates of h1n1 subtype viruses were higher in the united states and the united kingdom than in other countries, suggesting that there may be a greater risk for the emergence of novel pathogenic h1n1 strains in the us and uk. the climate and social economic risk delineated in this study should be considered as important monitoring references for the guidance of h1n1 epidemics caused by mutations. however, it should be noted that there are several limitations in this study. for instance, the environmental variables are annual average data, which does not exactly match the virus dataset on the time scale. in the future research, we will collect macro and micro data on the same time scale as far as possible. in addition, the environmental covariates adopted in this study may not be comprehensive enough due to the availability of data. in the future research, several variables (i.e., the distance to migratory bird migration routes and the distance to water body) will be added to the statistical analysis. our findings show that environmental factors systematically affect the mutation of a/h1n1 viruses. minimum temperature displayed a nonlinear, rising association with mutation, with a maximum~15 • c. the effects of precipitation and social development index (nighttime light) were more complex, while population density was linearly and positively correlated with mutation of a/h1n1 viruses. this study provides a novel insight into understanding the complex relationships between mutation of a/h1n1 viruses and environmental factors, which enhances our capacity to target the potential risk areas, to develop disease control strategies and to allocate medical supplies. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/9/3092/s1, table s1 : basic information (reported province, reported date, latitude, and longitude) for 12401 h1n1 influenza case from 1931 to 2019. influenza virus evolution 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climatologic investigation of the sars-cov outbreak in beijing mapping spread and risk of avian influenza a (h7n9) in china european rainfall patterns trends in global warming and evolution of nucleoproteins from influenza a viruses since 1918 public debates driven by incomplete scientific data: the cases of evolution theory, global warming and h1n1 pandemic influenza trends in global warming and evolution of matrix protein 2 family from influenza a virus identification of climate factors related to human infection with avian influenza a h7n9 and h5n1 viruses in china climatic factors and influenza transmission regional variations in spatial structure of nightlights, population density and fossil-fuel co2 emissions evolution of influenza a virus by mutation and re-assortment clinical and epidemiological characteristics of a fatal case of avian influenza a h10n8 virus infection: a descriptive study the evolution and characterization of influenza a (h7n9) virus under the selective pressure of peramivir evolutionary dynamics and global diversity of influenza a virus influenza hemagglutinin protein stability, activation, and pandemic risk molecular epidemiology of the hemagglutinin gene of prevalent influenza virus a/h1n1/pdm09 among patient in iran this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no competing financial interests. key: cord-283398-wplz8o2k authors: sanders, chris; burnett, kristin; lam, steven; hassan, mehdia; skinner, kelly title: “you need id to get id”: a scoping review of personal identification as a barrier to and facilitator of the social determinants of health in north america date: 2020-06-13 journal: int j environ res public health doi: 10.3390/ijerph17124227 sha: doc_id: 283398 cord_uid: wplz8o2k personal identification (pid) is an important, if often overlooked, barrier to accessing the social determinants of health for many marginalized people in society. a scoping review was undertaken to explore the range of research addressing the role of pid in the social determinants of health in north america, barriers to acquiring and maintaining pid, and to identify gaps in the existing research. a systematic search of academic and gray literature was performed, and a thematic analysis of the included studies (n = 31) was conducted. the themes identified were: (1) gaining and retaining identification, (2) access to health and social services, and (3) facilitating identification programs. the findings suggest a paucity of research on pid services and the role of pid in the social determinants of health. we contend that research is urgently required to build a more robust understanding of existing pid service models, particularly in rural contexts, as well as on barriers to accessing and maintaining pid, especially among the most marginalized groups in society. personal identification (pid) serves multiple and frequently contradictory purposes within the context of the modern state. establishing the identity of individuals by connecting them to key information such as age, sex/gender, birthdate, nationality, and residence, pid has the potential to confer certain rights and privileges on individuals. common forms of pid, like birth certificates, passports, driver licenses, and government-issued health cards, grant access to important benefits, such as health and social services, while non-government pid (e.g., private club membership card, credit cards) typically allow situational access or benefits to the bearer. however, the loss and misuse of personal identity can have devasting consequences for individuals. state record keeping also makes individuals visible to the polity and, thus, governable and subject to the loss of freedoms. recent conversations about the significance of pid and identification security processes, especially since the events of 9/11 and the ongoing collection and sale of personal data through large online social media platforms, have largely centered on fears about increased state and corporate surveillance, as well as identity theft and fraud [1] [2] [3] . while it is extremely important to acknowledge that these circumstances have had and continue to have enormous and detrimental impacts on the lives and well-being of individuals and communities, largely overlooked in these conversations is the central role played by pid in accessing essential state services, particularly among people who are socially and economically disenfranchised. taylor and colleagues have astutely described this phenomenon as the inherent ambiguity of viewing citizens as both a "risk to be managed, and thereby an object for surveillance (and) a consumer deserving the best possible public service" [4] (p. 152). after all, without pid it is nearly impossible to access health care, housing, income maintenance, education, banking services, employment, and pension benefits, among other essential programs and services. it is also frequently impossible to access something as simple as emergency food services, like a food bank, without providing government-issued pid and proof of residence. while access to and possession of pid does not of itself guarantee education, health, protection, and participation in society for marginalized people, not having certain forms of government-issued pid ensures that access to essential health, social, and financial services is nearly impossible [5] . possession of pid, in effect, becomes the gateway to accessing the social determinants of health, particularly in rural settings [6] . thus, what we refer to as the "problem of personal identification" occurs when populations that are already marginalized and underserved are made further vulnerable because they lack forms of official identification that enable them to secure vital benefits and resources, effectively making them invisible to health and social services. literature on pid in the north american context that does not examine this issue from a security/governmentality perspective tends to focus on populations that are precariously housed or homeless and living in urban spaces. barriers to pid associated with people living in rural and northern settings in north america have not been adequately explored. additionally, relatively little attention is paid to the particular pid challenges experienced by people who are racialized and indigenous, and further, how those identities operate alongside space and gender. these multiple and intersecting identities are important to explore with regard to pid because, as audre lorde points out, "we do not live single-issue lives," [7] meaning that it behooves us to understand the dynamic ways that lived identities and structural systems intersect to the detriment of the most marginalized individuals and social groups. through this scoping review, we seek to enter into this conversation regarding barriers to obtaining pid by highlighting the ways in which the problems posed by a lack of pid are particularly pronounced for people living in rural, northern, and remote access communities-people whom we already know experience poorer health outcomes than residents in metropolitan and suburban areas, and whom to date have been largely ignored in the scholarship [8] . further, in canada, indigenous people are more likely to reside in the provincial north and territories than non-indigenous people [9] [10] [11] . given the higher proportion of indigenous people and communities located in rural and remote areas, we contend that health disparities and a lack of access to health and social services resulting from a lack of pid exacerbate inequalities between indigenous and non-indigenous people, broadly speaking. a better understanding of the problem of pid is needed, particularly as it pertains to accessing health and social services for the most marginalized people and groups in society. the aims of this scoping review are as follows: first, to provide readers with a clear understanding of the current research on this topic by providing a comprehensive review and analysis of the academic and gray literatures on the barriers to attaining pid in north america. second, this review aims to show the significance that a lack of pid has for people's ability to access health and social services. third, this review aims to identify gaps in the existing research, particularly in regards to rural and indigenous peoples and communities. fourth, we discuss the implications for rural and indigenous communities and identify future directions for research on pid. scoping reviews aim to provide a survey of studies on or related to a topic rather than to assess the quality of each study. a scoping review was considered an appropriate strategy for this research topic because it was not previously comprehensively reviewed [12] . this scoping review was conducted following guidelines for scoping studies outlined by colquhoun and colleagues involving a stepwise process of search, selection, extraction, and synthesis of the literature [13] . a separate protocol for this review does not exist; below, we provide a detailed roster overview of the review process. to ensure the quality of scoping review reporting, we used a checklist developed by tricco and colleagues [14] . other than the assessment of and secondary analysis of the studies, this scoping review complies with the preferred reporting items for systematic reviews and meta-analyses (prisma) statement and checklist. we use the term "pid" to refer to all types of government-issued personal identification used to recognize citizens and denizens for the purposes of granting access to vital services. common forms of pid include "identity documents" (e.g., birth certificates, passports) and "identity cards" (e.g., driver licenses, provincial health cards, hunting licenses). by contrast, the term "id" includes non-government issued forms of identification (e.g., student body card, private club membership, employment id cards) and may not grant access to vital services provided by the government. we only use the term "id" when quoting studies or in reference to specific identification cards. because existing studies sometimes use these terms interchangeably, or simply use the more common term id, our search strategy employed the term "identification" to search databases. a search string was developed (table 1 ) and used to search the following citation databases: web of science™ (clarivate analytics, philadelphia, pa, usa), core collection (ebsco, ipswich, ma, usa), medline ® (national library of medicine, bethesda, md, usa), cabdirect© (cabi, wallingford, uk), and ebscohost© (ebsco, ipswich, ma, usa). these databases cover health, sociology, anthropology, and psychology disciplines, thereby providing the opportunity to capture the broad literature, as well as approach the research question from different perspectives. no search restrictions were placed (e.g., language, date, publication type). a complementary search for gray literature documents, such as government research reports, was also conducted using a series of simple search strings in google (e.g., "barriers to obtaining identification in north america"). as google returns results based on relevance criteria related to the search term entered, only the first 100 hits of each search were examined [15] . the reference list of all relevant studies was also hand-searched to identify any further relevant studies not captured in the search. records were uploaded into endnote x7 ® and de-duplicated. table 1 . search strategy to identify peer-reviewed articles on barriers and facilitators to obtaining identification. identification ("photo identification" or "personal identification" or "government-issued identification" or "civil identification" or "birth identification" or "birth certificat *" or "birth registration" or "photo id") and barriers and facilitators ((barrier * or challenge *) or (facilitator * or opportunit *)) * boolean operator symbol for truncation used to broaden search by capturing all variations of words. the titles and abstracts of studies were screened according to a priori inclusion criteria. to be included in the scoping review, studies needed to report on barriers or facilitators to obtaining pid in the north american context. studies were excluded if they were not relevant to this topic or were not in the english language. in some cases, a full-text review was conducted in order to assess suitability. sources of evidence included primary studies published in english as journal articles, books, research reports, dissertations and theses, or conference proceedings. to ensure the availability of data for charting purposes, we excluded newsletters, news articles, and summaries. we developed and used a charting form to capture data from each study. key information extracted included author, year of publication, country of origin, purpose, publication type, study scale, study population, methodology/methods, and key findings that related to the scoping review question. charting followed an iterative process in which the data were extracted and the charting form was updated continuously. of note, study screening and data charting were done by one author (s.l.), presenting possible concerns over reviewer bias. to address this bias, this author discussed challenges and uncertainties related to the reviewing strategy with the co-authors and refined the approach in the process. the data analysis included quantitative analysis and qualitative analysis. for quantitative analysis, we used descriptive statistics to present the characteristics of the study, methodology, and findings. to characterize and summarize factors which act as barriers to and facilitators of obtaining identification, we used thematic qualitative analysis following a process outlined by braun and colleagues [16] . first, studies were read in full and notes were written to facilitate data familiarization. then, codes were assigned to portions of the text that discussed identification. we used an inductive approach to coding, with no pre-formulated assumptions of how codes should be defined. similar codes were then grouped into descriptive themes that illuminate patterns in the data across studies. we selected quotations that exemplified these themes and presented them in the results to provide a rich and nuanced description of the data [16] . to ensure the validity of the qualitative analysis, we held regular discussions among the authors surrounding the developed themes. data were stored in a spreadsheet (excel 2013, microsoft corporation, redmond, wa, usa) to facilitate analysis. the initial search returned 1401 studies; after the removal of duplicates and non-relevant studies, a total of 31 studies were included ( figure 1 ). a summary of the descriptive characteristics of these studies is shown in table 2 . the median publication year of relevant studies was 2005 (range 2000-2018). there was a near equal balance of publications from canada (51%) and the united states (49%). most of the studies were from the academic literature, though a significant portion (30%) were from the gray literature. many of the 31 studies (45%) were purely qualitative and used interviews to collect qualitative data from participants. most studies focused on homeless youth, adults, or people in general (58%, n = 18). a detailed summary of the 31 studies, including relevant findings, can be found in appendix a. three descriptive themes were identified across the 31 relevant studies that capture barriers to, and facilitators for, obtaining identification: (1) gaining and retaining identification, (2) access to health and social services, and (3) facilitating identification programs and services. these themes are described in detail below and are supported by illustrative quotations from study participants and/or study authors. one of the biggest challenges identified in the literature that individuals faced was the acquisition and retention of pid. according to many studies (32%, n = 10), the main reason people reported for not having identification was that it had been either lost or stolen (e.g., [17] [18] [19] ). this is particularly true for many people who are precariously housed or homeless. campbell and colleagues, for example, conducted one-on-one interviews and focus groups with individuals in calgary that were homeless and health and social services providers in which one participant without housing identified pid as a key barrier: "one of the things i just thought of that could be a potential barrier is missing or stolen id" [17] (p. 7). further support is provided by a survey of 1169 people who were homeless in toronto, which found that 315 (27%) were not in possession of their health card [18] , and in the united states, an estimated 11% of voting-age citizens lacked identification, with estimates higher among those experiencing homelessness [20] . additionally, it is common in homeless shelters to have one's personal belongings, where ids and other personal documents are typically stored, taken if left unattended for even a short period of time or while sleeping [21] [22] [23] . consequently, whether living on the streets or staying in a shelter, maintaining possession of one's belongings requires constant vigilance, which is challenging for many people living in precarious circumstances. in addition, many people experiencing homelessness do not possess the means of replacing their pid (e.g., money for fees, knowledge of application process, competency with bureaucratic forms). other studies (16%, n = 5) highlighted the requirement of an address or an existing piece of identification in order to apply for additional identification (e.g., [24] [25] [26] ); yet, many homeless people frequently are unable to provide either of these. gordon interviewed 102 people visiting identification clinics in edmonton, alberta, and reflected: "nine people spontaneously told me 'you need id to get id,' or similar words" [27] (p. 256). in a study exploring the lived experiences of 20 adolescent women in seattle who were homeless, the authors reported: [the young women] claimed that the biggest structural barriers to care [that they identified] at many hospitals or clinics not designed for homeless youth were questions over consent for care, being asked to provide addresses and an identification (id) card, and source of insurance or payment [28] (p. 169). still more studies (16%, n = 5) emphasized the high cost of obtaining identification (e.g., [25, 26, 29] ). for example, one study from toronto, canada finds: even a modest fee can make it difficult for a homeless young person to obtain identification-and in many states, the cost of obtaining an id card is far from modest [25] (p. 18). for people who are economically marginalized and/or precariously housed, even seemingly minor fees constitute a financial hardship that makes the acquisition of pid prohibitive. in the province of ontario, for example, higher fees are charged for replacement birth certificates, and if people go through "third party" providers rather than state agencies to obtain this form of id, additional service fees are incurred. this means that people who have little or no money and who are likely to lose or have their pid stolen due to being precariously housed are further burdened with higher replacement fees. ultimately, people regularly prioritize the immediate needs of food, transportation, or rent rather than the costs of replacing a lost or stolen document. furthermore, additional costs are required if individuals must take public transportation or live in rural or remote locations and have to travel to service centers. according to a united nations report, the "greater the distance to the registration center the higher the financial costs to the family" [30] . other scholarship outlined those barriers to obtaining identification that were unique to specific social groups. for example, a lack of legal identity is a barrier among immigrants who are undocumented [31] . in some us states and canadian provinces, youth are required to obtain the consent of their parents or legal guardians and need to be a certain age in order to apply for identification. for instance, in ontario, youth have to be at least thirteen years of age to apply for many forms of pid on their own behalf, and for youth who are minors and estranged from parents or guardians, age-related restrictions present significant barriers [25, 32] and potential danger for those individuals trying to avoid foster care or the return to a less than safe environment. young women who are homeless reported facing judgement and censure from health care providers [28] . one study also reported stigmatizing attitudes towards people who were homeless in general [18] . for female sex workers in miami, a lack of space for the storage of identification posed a problem; without storage space for possessions, "women are often assaulted or otherwise robbed of the few goods they own," including their ids [33] (p. 353). in some canadian provinces (e.g., ontario, british colombia, new brunswick), there is a three-month waiting period for a provincial health card for newcomers [34] , leaving people in a vulnerable position should they require emergency services during the window of no coverage. a few studies (10%, n = 3) also reported barriers in the accurate and complete reporting of personal information, like date of birth and the incorrect recording of names and place of birth [35] [36] [37] . a study by melnik and colleagues explored the accuracy of birth data collected in new york state facilities, and found barriers including incomplete information provided by medical staff, birth data located in multiple systems, conflicting birth data from different sources, and inadequate staff resources [36] . in california, smith and colleagues found the misclassification of ethnicity and race in administrative records in 23.1% and 33.6% of children, respectively [37] . the authors reported two major causes of this misclassification, including missing information in administrative records and the classification of children of multiple races based on information from only one parent. while many studies (55%, n = 17) included the socio-demographic characteristics of participants, such as age, gender, and ethnicity [18, 38, 39] , few attempted to differentiate people's experiences and perspectives that result from these characteristics. for example, 385 adults in toronto who were homeless that participated in a survey included, but were not limited to, 63% white, 12% black, and 9% indigenous [38] . however, while the study found that 34% of participants had a health card, it did not indicate whether this outcome corresponded with a particular racial identity. information on which ethnic groups possessed a health card would help inform more nuanced efforts to increase access to identification and health care more generally. a notable exception where this information was included is a qualitative study in edmonton, where 40% of interviewees (n = 41) were estimated to be indigenous, with the majority being men [27] . the study found that indigenous men and women experienced more barriers to identification on average compared to non-indigenous men and women. in a different study from california, smith and colleagues found that children of minority groups are more likely than non-minority groups to experience the misclassification of ethnicity and race in administrative records, presenting possible consequences for data misinterpretation and over/underestimated health disparities, as well as presenting further difficulties later in life if and when people have to replace their pid [37] . the challenge posed by pid was further exacerbated for sexual minorities, particularly transgender individuals [25, 39] . in a study exploring the lived experiences of 27 transgender youth that were homeless in new york city, many either did not have identification or had identification documents that did not match their self-designated gender and presentation, resulting in "transgender and gender expansive young people facing harassment and discrimination when applying for jobs" [39] (p. 16). following from the inability to acquire or maintain pid are the social and health consequences that directly result. the lack of identification was reported by many studies (42%, n = 13) as a factor impacting the ability of individuals to access health services (e.g., [17, 40, 41] ). for example, one provider in calgary, canada reported: identification is something that you often need when you go to clinics and a lot of our [clients] do not have id-whether or not they even have alberta health care cards with them or have even applied for their alberta health care cards. we have a lot of out-of-province clients that come through, a lot of immigrants that come through so then that whole issue is do they even get access to certain types of care just due to not having the proper documents [17] (p. 7). a lack of pid becomes both a direct and indirect barrier to accessing services. in ontario, for example, residents must present an ontario health card in order to receive benefits through provincially funded health coverage [24] . to receive a health card, however, an individual must provide three key documents (proof of citizenship, proof of ontario residency, and some form of personal identification from a specified list), which poses significant difficulties for people with precarious housing. bureaucratic structures with onerous requirements for applying for pid can further complicate matters for many people. in a qualitative study involving 54 youth in los angeles who were homeless and drug-dependent, the authors reported: perhaps surprisingly, structural barriers cited by the youth stemmed not from a paucity of agencies or resources but conversely from the presence of too many agencies with endless bureaucratic requirements involving interagency referrals, the need for identification cards, time-consuming paperwork, and lack of continuity of care [42] (p. 158). this was also echoed in a qualitative study involving 20 young women in seattle experiencing homelessness: so you have to go to a regular clinic and they take forever to register you and they want to know why you don't have insurance and then they make you sit there another 45 minutes until they call someone to figure out what it is. i've had so many bills from places like that so many notices. i always told them from the beginning, 'i'm homeless. i don't have an id. you can't call my parents; they will not say they're my guardians. they will not take responsibility for me. i don't have insurance.' you know-it's like, 'can you please? i'm bleeding here -can you help me'? [28] (p. 169). according to some studies (26%, n = 8), government-issued identification is also required to access food banks (e.g., [19, 20, 26] ). a survey of service providers across 16 us states found that when individuals who were homeless could not provide photo identification, 53% were denied food stamps [29] . another survey of homeless adults in downtown toronto reported that 15% of adults that were homeless were unable to access the food bank due to a lack of identification [43] . in new york city, 29 out of the 47 (62%) food pantries surveyed had an identification requirement [44] . in an unnamed city in the us, individuals living with mental health disabilities and facing homeless were found to face further challenges to accessing services as a result of the lack of pid: returning offenders who have mental illness are often eligible for several public assistance programs, including general assistance, food stamps, and medicaid. in the state where the study site is located, all such programs are administered by the state's public assistance department, which also oversees the application process and thereby controls access to services. identification requirements are a central feature of the application process, and these requirements emerged early in the study as a source of problems for clients" [19] (p. 117). indeed, a lack of pid was identified by several studies (13%, n = 4) as a serious barrier to accessing social housing and income support (e.g., [43, 45, 46] ). for example, the lack of personal identification was reported as a barrier of many people who were either homeless or precariously housed that were applying to the ontario disability support program [46] . in a survey of 368 adults in toronto that were homeless, 22 (6%) reported that the lack of pid was the main reason for remaining homeless [43] . suggestions for reducing barriers to accessing health and social services include: welcoming other forms of identification (e.g., non-government issued identification) [20] , providing alternative verification processes for proof of identity or residence (e.g., allowing people who were homeless to use the address of a shelter as their mailing address) [25, 32] , building mechanisms to improve access to services that do not require individuals to present identification (e.g., databases that transfer medical data between sites) [38, 42] , building the cultural competencies of health care providers [18, 28, 33, 47] , and improving the access and availability of information on how to obtain identification and reducing or eliminating fees [31, 32] . finally, a number of studies exploring pid facilitators (13%, n = 4) recommended funding programs at social service agencies to support the replacement and storage of identification [25, 38, 48, 49] . kopec and cowper-smith described four organizations in canada that provide a space to store identifications (sometimes referred to as "id banks") [50] . most of these organizations also help clients apply for their identification and cover the associated fees. similarly, goldblatt and colleagues described two identification programs that provide a mix of support services at no fee [45] . in one case, the regional municipality of york region in ontario provides a mailing address for clients when necessary, delivers identification to clients, and connects individuals with other services such as housing, food resources, and financial support. in the second case, the city of toronto provided funding to support the id bank located at street health. other studies argued that id fees for people who were homeless should be waived [29] [30] [31] [32] . in one state, south carolina, people that were homeless were not required to pay fees associated with pid: in order to get a fee waiver, a homeless person provides a letter from a shelter employee or other service provider indicating that he is homeless and requesting a fee waiver [29] (p. 21). within the modern bureaucratic state, personal identification serves many, often contradictory, purposes. on the one hand, establishing identity can connect individuals to vital health and social services, while, on the other hand, the theft and misuse of identity can have devastating consequences, ranging from breaches in personal privacy and financial fraud to the loss of democratic freedoms when governments use personal data to surveil individuals and populations. recent conversations about pid have tended to focus on the latter issues, precipitated mainly by the events of 9/11 and recent high-profile cases of cybertheft and the sale of personal data by major corporations. while it is important to acknowledge the validity of these concerns, this scoping review focuses on the former issue by drawing attention to the central role played by pid in accessing essential state services, particularly among the most socially and economically marginalized people and groups in society. we started this research prior to the outbreak of, and public health response to, the covid-19 global pandemic, an event that makes it more apparent than ever how a lack of pid impacts access to the social determinants of health for the most marginalized people in society. at the time writing, local emergency food banks require valid identification, not only for the individual directly receiving the food, but for everyone living in the household [51] [52] [53] . many people simply do not have access to pid documents and information at this tumultuous time, let alone are they able to afford the cost of a pid application at the moment. marginalized people without pid are unable to travel home by air or bus, nor can they access many emergency housing supports, as these options all require pid, leaving some with no alternative but to live on the streets where physical distancing and other protective measures, like hand-washing, cannot be practiced [54] . government service centers that normally process pid applications have limited both their business hours and their provision of services [55] , and while these measures are important in helping to flatten the curve of covid-19, they also further marginalize people in need of emergency services by making it exceedingly difficult to obtain pid at a time when it is needed most. the results of this scoping review illustrate the paucity of research on what may be termed the "problem of personal identification," especially in regards to the barriers and facilitators faced by groups that are particularly marginalized in the acquisition and retention of pid. our review also finds that the existing research, while limited, focuses primarily on people who are either homeless or precariously housed; to a lesser extent, the review also finds that sex workers and select sexual minorities face significant pid challenges, namely transgender people. it is also worth pointing out that almost one-third of our results come from the gray literature, in the form of reports and policy briefs produced by nonprofit organizations, like street health in toronto, canada. this suggests that a significant portion of the work on pid is being conducted by frontline organizations and that more academic involvement could support these organizations to study the issue more comprehensively. among the most common barriers to pid, the scoping review finds that homelessness creates obstacles to the acquisition of pid, as often an address is required to apply for pid, as well as to maintaining the possession of pid, as theft of and damage to personal belongings is an ever-present problem. another key barrier associated with a lack of pid is an inability to access social and health services, which, in turn, makes people who are marginalized further vulnerable by limited access to the social determinants of health; this problem is particularly marked among women and youth. finally, regarding facilitators, the review finds that identification programs, such as "id banks," are positively associated with people's ability to acquire and maintain pid. these findings highlight important sociological interactions, ranging from economic deprivation and homelessness to gender and sexual identity, that contribute to people's ability to acquire or maintain key forms of pid that are the gateway to accessing vital services. another notable finding of the scoping review was a pointed statement shared by several interviewees of one study: "you need id to get id . . . you can't do anything without id" [27] (p. 256). this reality speaks to the importance of birth registration and maintaining the possession of a birth certificate. in canada, for instance, a birth certificate is required to acquire most forms of identification, such as a social insurance number (sin) or an indian status card, which is required under the indian act to confirm the indian status of indigenous people. even for forms of pid that do not directly require a birth certificate, such as an ontario health card or driver license, a birth certificate is necessary to get the prerequisite identification needed to apply for a health card or driver license. thus, in canada, as in many other nations, the birth certificate becomes the foundational piece of pid that enables access to all other identification documents. that many pid applications require a permanent residence in order to be issued becomes a "catch 22" situation of sorts, wherein people who are precariously housed require a home in order to obtain pid that will enable them to access housing or health and social services. conspicuously absent from the existing literature was research that focused on northern and rural populations, indigenous people, and the relationship between the two. in canada, for instance, indigenous people make up a significant proportion of the population in the rural and provincial north, and further clarity is needed on the unique pid problems facing this population, such as birth registration and the acquisition of birth certificates, as well as the difficulties of obtaining pid in areas with extremely limited access to state social and health services [6] . our preliminary work, for example, has shown that 73% of the clients seeking birth certificates and other forms of pid in thunder bay and the surrounding district identify as indigenous [56] , indicating that this is an important area of further study. likewise, the structural barriers that exist in fly-in and road access first nations have not been addressed, nor is there any sustained analysis of the historical and ongoing impacts of settler colonialism on access to and the meaning of pid. although a few studies identified the reporting of inaccurate birth information by medical staff or other administrative personnel as a barrier to acquiring pid, the particular experiences of indigenous peoples in the north and the implications have not yet been fully fleshed out. for instance, indigenous children forced to attended residential schools frequently had their names changed, misspelt, or dates of birth recorded incorrectly [57] . records of these activities, which would help substantiate claims of identity, have often been lost to fires and flooding that frequently occur in rural settings. that this is a historical problem, dating back to the 1800s, means that elders from rural areas are even less likely to have access to original documentation required to acquire pid. furthermore, these problems have persisted for indigenous children, who continue to be removed from their families and communities at alarming rates by child welfare agencies. in canada, indigenous children account for 48% of the children in foster care, while constituting only 4.3% of the canadian population [58] . the fear of possible child apprehension may also pose a further barrier to birth registration for indigenous peoples, if parents are afraid to report new births [59, 60] . long histories of settler violence enacted through systems of education, health care, policing, and child welfare have ensured that indigenous people and communities have been over-policed and under-serviced by the state. as a result, mechanisms, like birth certificates and other forms of pid, which make citizens visible to state structures and services, can often be problematic and fraught with anxiety and distrust for indigenous people. more research is also needed on the implementation and use of "id banks" as a facilitator for acquiring and maintaining pid. storage programs are particularly promising for people who are homeless, especially as the conditions of living unhoused frequently leads to the damage and permanent loss of pid [61, 62] . such programs exist in different forms in urban areas, offering a variety of storage options for pid. options include the storage of original copies of pid, official duplicates, and unofficial photocopies, as well as the storage of digital copies on secure servers. in some instances, an unofficial photocopy of pid may be adequate to prove personal identity or, at least, to begin the process of applying for certain services contingent upon the client returning with the original identification document to complete the process. in other cases, agencies that host id banks can also be contacted to vouch that the photocopy is accurate and on file; this model can be particularly effective among partnering agencies or those with a memorandum of understanding (mou) for specific issues. importantly, there are examples of agencies that work with people who are homeless to create their own form of "agency id card" for clients, which is recognized by local law enforcement due to the agency's reputation (e.g., street health in toronto, on, canada). furthermore, some agencies with id banks have staff with registered notary status, enabling them to make notarized copies of pid on site. a staff member who can serve as a notary alleviates one more complicated, if not costly, step, as notary services can be prohibitive for people who are economically disadvantaged. using an id bank service means that clients know their pid is safely stored and can be accessed during agency business hours (or whatever access schedule is in place). some agencies also serve as a mailing address where clients may have identification documents sent for official receipt and safe storage. id banks may be one way that frontline service agencies with extremely limited resources can begin to address the pid problem among their clientele. research on this topic should focus on the structure and design of id banks, common/best practices, who uses them and why, which agencies have established them and to what effect, and barriers to implementation. it is also important to further explore the ways in which different national and provincial/state jurisdictions and policies affect the implementation and design of id banks. if the process of instituting an id bank is too costly or bureaucratically onerous, many community agencies with limited resources will be deterred from attempting to provide this important service. finally, it is important to better understand the implementation and use of id banks in rural areas, as the current literature deals exclusively with urban settings. it is important to consider the potential risk of bias within this review. first, this scoping review was limited to english-language articles, which most obviously biases findings toward higher income western nations but also, in the case of canada, excluded francophone areas like quebec. while many of the themes identified in the literature are likely national and therefore also exist in quebec, pid barriers and facilitators that are particular to that province require further investigation prior to the development and implementation of federal policy. second, in general scoping reviews, including this one, do not evaluate the methodological quality of the studies nor the quality of the evidence, but rather focus more broadly on the outcomes presented by the studies [63] . third, a further limitation of this study was the decision to limit the scope of analysis to pid in north america. this decision was anchored in our particular research project that examines the pid experiences of indigenous people in canada and the us-nations that have similar policies and practices. undoubtedly, expanding the scope of the analysis to include places like europe and australia, for example, would shed additional valuable light on the experiences of other marginalized groups, including ethnic minorities and refugee and migrant communities, as well as the bureaucratic practices of other nations with respect to pid. finally, as with any scoping review, some literature may have been missed as a result of the keyword search strategy and the limitations of the selected databases, which may, for instance, limit the ability to locate key gray literature. the google search alone, for example, might not capture all of the relevant gray literature [15] . for a more comprehensive analysis, future analyses might look at websites of key organizations or contact organizations to inquire if they have unpublished sources available. nevertheless, this scoping review is rigorous and provides insights into some of the pid key barriers and important facilitators in north america. this scoping review is the first step toward investigating the problem of pid through an intersectional lens. our findings indicate that pid is an important influence on the ability of people who are marginalized to acquire and maintain pid that, among other things, enables access to the social determinants of health. it is our position that a more complete understanding of the barriers and facilitators to pid is imperative, particularly in different local, regional, and national contexts, as well across a diverse range of social identities. such research will benefit multiple disciplines in the social and health sciences and nursing, as well as policy-oriented fields. interweaving this understanding with a more sophisticated understanding of the social determinants of health would further highlight ways that poverty and social factors, like racism and colonialism, help reproduce one another. this would not only provide a more nuanced understanding of the problem of pid, but contribute to evidence-informed policy aimed at ameliorating the problem and improving health outcomes among people that are the most underserved and marginalized in society. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. 1 appel explore common sources of advice, health-seeking behaviors, and access to care issues of homeless adolescent women participants said that the biggest structural barriers to care at many hospitals or clinics not designed for homeless youth were questions over consent for care, being asked to provide addresses and an id card, and source of insurance or payment identity crisis: how identification is overused and misunderstood playing the identity card: surveillance, security and identification in global perspective protecting and proving identity: the biopolitics of waging war through citizenship in the post-9/11 era identification practices in government: citizen surveillance and the quest for public service improvement birth registration: right from the start. innocenti dig a case study in personal identification and social determinants of health: unregistered births among indigenous people in northern ontario sister outsider: essays and speeches health in rural canada the embodiment of inequity: health disparities in aboriginal canada indigenous health part 1: determinants and disease patterns social transformations in rural canada: community, cultures, and collective action scoping studies: towards a methodological framework scoping reviews: time for clarity in definition, methods, and reporting prisma extension for scoping reviews (prisma-scr): checklist and explanation applying systematic review search methods to the grey literature: a case study examining guidelines for school-based breakfast programs in canada thematic analysis. in handbook of primary healthcare needs and barriers to care among calgary's homeless populations universal health insurance and health care access for homeless persons it takes id to get id: the new identity politics in services restrictive id policies: implications for health equity risk factors, endurance of victimization, and survival strategies: the impact of the structural location of men and women on their experiences within homeless milieus perspectives of homeless people on their health and health needs priorities more sinned against than sinning? homeless people as victims of crime and harassment meeting the health care needs of female crack users: a canadian example expanding id card access for lgbt homeless youth policy brief on government identification community, use it or lose it? anthropologica barriers and bridges to care: voices of homeless female adolescent youth in national law center on homelessness & poverty. photo identification barriers faced by homeless persons: the impact of the 'rights' start to life: a statistical analysis of birth registration healthcare access and barriers for unauthorized immigrants in el paso county national network for youth. a state-by-state guide to obtaining id cards barriers to health and social services for street-based sex workers i spent nine years looking for a doctor': exploring access to health care among immigrants in association of missing paternal demographics on infant birth certificates with perinatal risk factors for childhood obesity barriers in accurate and complete birth registration in new york state. matern health plan administrative records versus birth certificate records: quality of race and ethnicity information in children access to primary health care among homeless adults in toronto, canada: results from the street health survey transgender youth homelessness: understanding programmatic barriers through the lens of cisgenderism barriers to enrollment in drug abuse treatment and suggestions for reducing them: opinions of drug injecting street outreach clients and other system stakeholders the health bus: healthcare for marginalized populations attitudes of homeless and drug-using youth regarding barriers and facilitators in delivery of quality and culturally sensitive health care the street health report. the street health report. the health of toronto's homeless population food insecurity: limitations of emergency food resources for our patients final report: systemic barriers to housing initiative failing the homeless: barriers in the ontario disability support program for homeless people with disabilities; street health barriers to care: the challenges for canadian refugees and their health care providers physician payment for the care of homeless people toronto report card on housing and homelessness; city of toronto guelph-wellington taskforce for poverty elimination: avenues for creating an id bank greater vancouver food-bank users will soon need to prove low-income status food bank deals with location change. the chronicle journal sudbury food bank updates guidelines for new users can't go home: no id strands indigenous man on vancouver's downtown eastside. cbc ottawa shuts service canada centres after employees refuse to work. the globe and mail the challenges of accessing personal identification in northwestern ontario national centre for truth and reconciliation (nctr) aboriginal peoples in canada: first nations people, métis and inuit, part 3 living arrangements of aboriginal children province reports 1st decrease in child welfare numbers in 15 years child apprehension laws to be amended so kids can't be taken because of poverty the struggle to end homelessness in canada: how we created the crisis, and how we can end it. open health serv can i see your id? the policing of youth homelessness in toronto advancing scoping study methodology: a web-based survey and consultation of perceptions on terminology, definition and methodological steps harm reduction through a social justice lens key: cord-002438-b8t4a57r authors: cheng, wei; yu, zhao; liu, shelan; zhang, xueying; wang, xiaoxiao; cai, jian; ling, feng; chen, enfu title: comparison of influenza epidemiological and virological characteristics between outpatients and inpatients in zhejiang province, china, march 2011–june 2015 date: 2017-02-22 journal: int j environ res public health doi: 10.3390/ijerph14020217 sha: doc_id: 2438 cord_uid: b8t4a57r given the rapid rate of global spread and consequently healthcare costs related to influenza, surveillance plays an important role in monitoring the emerging pandemics in china. however, the characteristics of influenza in southeast of china haven’t been fully studied. our study use the surveillance data collected from 16 sentinel hospitals across zhejiang province during march 2011 through june 2015, including the demographic information and respiratory specimens from influenza-like illness (ili) patients and severe acute respiratory illness (sari) patients. as analysis results, most sari and ili patients were in the age group of 0–4 years old (62.38% of ili and 71.54% of sari). the respiratory specimens have statistically significantly higher positive rate for influenza among ili patients than that among sari patients (p < 0.001). the comparison between ili patients and sari patients shows no statistically significantly difference in detecting influenza virus type and influenza a virus subtype. the sari and ili patients were found to be positively correlated for overall positive rate (r = 0.63, p < 0.001), the weekly percentage of a(h1n1)pdm09 (r = 0.51, p < 0.001), influenza b virus (r = 0.17, p = 0.013), and a/h3n2 (r = 0.43, p < 0.001) among all the positive numbers. our study demonstrated that the activities of influenza virus, including its subtypes, had a similar temporal pattern between ili and sari cases. influenza virus is estimated to cause 3 to 5 million cases of severe illness and 250,000 to 500,000 deaths each year, while 5%-10% of adults and 20%-30% of children are infected with the influenza virus worldwide [1] . in lower and middle-income countries, influenza could result in large economic burden encompassing direct costs to the health service and households, and indirect costs of productivity losses [2, 3] . vaccination is a cost-effective way to reduce the public health and economic impacts caused by influenza. because of the antigenic shift and drift of the virus, the influenza vaccine composition needs regular updates. currently, the selection of strains for the annual influenza vaccine are primarily 2 of 12 based on the predominant strain of influenza virus detected in influenza-like illness (ili) [4] . however, ili only represents a proportion of acute respiratory infections with mild clinical manifestations. severe acute respiratory illness (sari) surveillance is another type of surveillance for severe influenza-associated disease. it is recommended to be monitored with established surveillance systems with ili according to the guidelines of the world health organization (who) [5] . in china, patients meeting with the definition of sari are required to have inpatient observation and necessary treatment. due to the emerging high healthcare cost and severe consequences of sari, effective vaccination is needed to reduce the incidence of sari caused by influenza [6] [7] [8] . therefore, whether influenza epidemiological and virological characteristics among sari patients were consistent to those of ili patients is critical to the effectiveness of current vaccination plan. zhejiang province located in the southeastern china, featuring by its blooming economy and high density of population. it has over than 55 million permanent residents, which are distributed in 11 metropolitan areas. influenza surveillance in zhejiang province launched at the same time with national surveillance in the year of 2001, and expanded to 16 ili and four sari sentinel hospitals by the year of 2011. both ili and sari are monitored in the surveillance system. although studies describing influenza surveillance with both ili and sari are well documented in the northern and southern hemispheres [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] , few studies have fully compared the influenza epidemiological and virological characteristics between ili and sari cases. in this study, we used four-year continuous surveillance data to compare the epidemic and virological characteristics of influenza virus between ili cases and sari cases in zhejiang province. the influenza surveillance network in zhejiang province is a part of the national influenza surveillance system [20] . the ili surveillance in zhejiang province was initially launched in 2001. as to 2009, the ili surveillance has been expanded into 16 sentinel hospitals that cover all of the 11 metropolitan areas in zhejiang province. the types of sentinel hospitals include general hospital, specialized clinic as well as maternal and children hospital. the sari surveillance started in 2009. as to march 2011, the surveillance has expended to four sentinel hospitals including three general hospitals and one children's hospital. all four sari sentinel hospitals were selected from the existing ili surveillance network ( figure 1 ). ili is defined as any person with sudden onset of fever >38 • c and cough or sore throat in the absence of other diagnosis [21] . the definition of sari is varied by ages. a patient >5 years old is defined as having sari if, upon or during admission, presenting an acute onset of elevated temperature (axillary temperature ≥38 • c) and cough or sore throat, as well as tachypnea (respiratory rate ≥25/min) or dyspnea (difficulty breathing). a patient ≤5 years old is defined as having sari if, upon or during admission, presenting with acute onset of cough or dyspnea, and at least one of the following six signs or symptoms: (a) tachypnea(respiratory rate >60/min for ages <2 months, respiratory rate >50/min for ages 2 to <12 months, and respiratory rate >40/min for ages 1 to ≤5 years); (b) inability to drink or breastfeed; (c) vomiting; (d) convulsions; (e) lethargy or unconsciousness; (f) chest in-drawing or stridor in a calm child [4] . ili is defined as any person with sudden onset of fever >38 °c and cough or sore throat in the absence of other diagnosis [21] . the definition of sari is varied by ages. a patient >5 years old is defined as having sari if, upon or during admission, presenting an acute onset of elevated temperature (axillary temperature ≥38 °c ) and cough or sore throat, as well as tachypnea (respiratory rate ≥25/min) or dyspnea (difficulty breathing). a patient ≤5 years old is defined as having sari if, upon or during admission, presenting with acute onset of cough or dyspnea, and at least one of the following six signs or symptoms: (a) tachypnea(respiratory rate >60/min for ages <2 months, respiratory rate >50/min for ages 2 to <12 months, and respiratory rate >40/min for ages 1 to ≤5 years); (b) inability to drink or breastfeed; (c) vomiting; (d) convulsions; (e) lethargy or unconsciousness; (f) chest in-drawing or stridor in a calm child [4] . each week, physicians from departments of pediatrics and respiratory, as well as emergency rooms in all of the 16 ili sentinel hospitals were required to report the number of total visits to outpatient, as well as the number of outpatients who presented with non-specific symptoms that meet a case definition of ili. as for four sari sentinel hospitals, the number of sari and total admissions from pediatrics ward, the respiratory medicine ward and the intensive care unit were also reported. all of the reported numbers in the above-mentioned departments were required to record by age classified as 0-, 5-, 15-, 25-, and 60-years old. nasopharyngeal or throat swabs were required to collect from all of sari cases and 5-15 ili cases of each sentinel hospital on every week. the collection of swabs was conducted by trained nurses from who had not received antiviral each week, physicians from departments of pediatrics and respiratory, as well as emergency rooms in all of the 16 ili sentinel hospitals were required to report the number of total visits to outpatient, as well as the number of outpatients who presented with non-specific symptoms that meet a case definition of ili. as for four sari sentinel hospitals, the number of sari and total admissions from pediatrics ward, the respiratory medicine ward and the intensive care unit were also reported. all of the reported numbers in the above-mentioned departments were required to record by age classified as 0-, 5-, 15-, 25-, and 60-years old. nasopharyngeal or throat swabs were required to collect from all of sari cases and 5-15 ili cases of each sentinel hospital on every week. the collection of swabs was conducted by trained nurses from who had not received antiviral drugs. in addition, a standardized case report form containing demographic and sample information was also required to complete among whose biological samples had been collected. due to the outbreak of avian influenza a(h7n9) in april 2013, ili surveillance was strengthened by increasing the weekly number of the biological samples collected in each hospital from 5-15 to 20. the biological samples were collected and saved in cryovial tubes, stored at 4 • c at the sentinel site, and then sent to regional center for disease control and prevention (cdc) within 48 h after the sample collected. the regional cdc laboratory tested influenza using real-time reverse transcription polymerase chain reaction (rrt-pcr) assay following the standard protocols. specimens tested as positive for influenza a were further tested for subtypes (i.e., a(h1n1), a(h3n2), a(h1n1)pdm09, and a(h7n9)) using specific rrt-pcr. once the laboratory complete, regional cdc submitted the laboratory results to the online surveillance system. data obtained from the surveillance system were reported weekly by the staff of the sentinel hospitals and laboratories. the mean and standard deviation or median and interquartile range (iqr) were calculated for continuous variables, and percentages were calculated for categorical variables. chi-squared test and fisher's exact test were used to assess the differences of age, sex, season, influenza virus type/subtype, and influenza positive rate between all the sampled ili and sari cases. the weekly number of positive influenza by subtype and the percentage of specimens tested positively were plotted to describe seasonality and circulation of influenza types/subtypes among sari and ili cases. spring, summer, autumn, and winter were defined from week 11 to 21, 22 to 38, 39 to 48, and 49 to 10 of the next year, respectively [22] . cochran-armitage trend test was used to analyze the trend change of influenza virus positivity with the increase of age. spearman correlation was applied to analyze the linear relationship of the influenza virus positive rate, weekly percentage of influenza virus subtypes accounted for all the positive numbers between sari and ili patients. ili percentage was calculated as the percentage of total outpatient visits that were due to ili and sari percentage was calculated as the percentage of total admissions that were due to sari. to compare ili percentage and sari percentage of which can better reflect the activity of influenza virus among outpatients and inpatients, spearman correlation analysis was used to assess the linear relationship between weekly ili influenza-positive rate and ili percentage, as well as weekly sari percentage and sari influenza-positive rate. a two-sided p-values were considered as statistically significant if it was found less than 0.05. all the statistics were conducted using sas version 9.2 (sas institute, cary, nc, usa). verbal consent was obtained from all patients in prior to survey and specimen collection. for children aged under 15 years old, verbal consent was obtained from at least one parent or legal guardian. the influenza surveillance were a national-wide, governmental public health activity. therefore, institutional review board approval was not required in china. in this study, the personal identifiers (e.g., names, address, occupations and so on) were not disclosed in order to maintain patient confidentiality, all the patient information was analyzed anonymously. during the study period, 52,293 patients completed both the standardized case report and laboratory sample test, of which 46,868 (89.63%) were ili patients and 5425 (10.37%) sari patients. the median age of the tested patients was 15 years (iqr: 3-34), and the median age of ili patients was significantly older than it of sari patients (p < 0.001). in addition, the group of sari patients had higher proportion of children at 0-4 years old (71.54% for sari versus 27.82% for ili), male during the study period, 52,293 patients completed both the standardized case report and laboratory sample test, of which 46,868 (89.63%) were ili patients and 5425 (10.37%) sari patients. the median age of the tested patients was 15 years (iqr: 3-34), and the median age of ili patients was significantly older than it of sari patients (p < 0.001). in addition, the group of sari patients had higher proportion of children at 0-4 years old (71.54% for sari versus 27.82% for ili), male (61.25% for sari versus 50.67% for ili), and patients enrolled in the winter (34.14% for sari versus 28.32% for ili) than those of ili patients (table 1) . the most identified influenza virus were influenza a virus (61.97% among ili, and 63.05% among sari), followed by influenza b virus (37.92% among ili, and 36.95% among sari), and mixed type virus (0.11% among ili; 0.00% among sari), with no statistical significance between the two groups (p = 0.774). for influenza a virus in the ili group, a(h3n2) was the most identified subtype (75.00%), followed by a(h1n1)pdm09 (24.87%), a(h7n9) (0.10%), and a(untype) (0.04%). those proportions were correspondent to that in the sari group-a(h3n2) (73.49%), a(h1n1)pdm09 (25.58%), a(h7n9) (0.93%), and a(untype) (0.00%) with p-value 0.067 (table 1) . influenza viruses were found in the specimen of 8601 of 52,293 (16.44%) all patients, with 8260 of 46,868 (17.62%) ili patients and 341 of 5425 (6.29%) sari patients. table 2 shows the specific positive rate of influenza virus by age groups, genders, and seasons. for ili patients, the highest (24.74%) rate is in the 40-59 years age-group, followed by >60 years age-group (23.01%). meanwhile, the positive rate of influenza viruses of sari patients was highest in the >60 years age-group (11.07%), followed by 5-14 years age-group (10.06%). among both ili and sari cases, influenza virus was found in all age groups, and cochran-armitage trend test showed that the influenza virus positive rates tend to be higher at older ages (figure 3) . the positive rate was highest in the winter, and lowest in the autumn. overall, the influenza virus positive rate among ili cases was significantly higher than that among sari cases across different groups of age, sex and season ( table 2 ). mixed type virus (0.11% among ili; 0.00% among sari), with no statistical significance between the two groups (p = 0.774). for influenza a virus in the ili group, a(h3n2) was the most identified subtype (75.00%), followed by a(h1n1)pdm09 (24.87%), a(h7n9) (0.10%), and a(untype) (0.04%). those proportions were correspondent to that in the sari group-a(h3n2) (73.49%), a(h1n1)pdm09 (25.58%), a(h7n9) (0.93%), and a(untype) (0.00%) with p-value 0.067 (table 1) . influenza viruses were found in the specimen of 8601 of 52,293 (16.44%) all patients, with 8260 of 46,868 (17.62%) ili patients and 341 of 5425 (6.29%) sari patients. table 2 shows the specific positive rate of influenza virus by age groups, genders, and seasons. for ili patients, the highest (24.74%) rate is in the 40-59 years age-group, followed by >60 years age-group (23.01%). meanwhile, the positive rate of influenza viruses of sari patients was highest in the >60 years age-group (11.07%), followed by 5-14 years age-group (10.06%). among both ili and sari cases, influenza virus was found in all age groups, and cochran-armitage trend test showed that the influenza virus positive rates tend to be higher at older ages (figure 3) . the positive rate was highest in the winter, and lowest in the autumn. overall, the influenza virus positive rate among ili cases was significantly higher than that among sari cases across different groups of age, sex and season ( table 2 ). due to the outbreak of avian h7n9 virus in april 2013, ili surveillance was strengthened by increasing the number of samples for testing from 5-15 to 20. figure 4 shows that although the weekly number of the samples tested has increased since the week 14 of year 2013, the weekly number of all ili patients remained at similar level from year 2011 to 2014 (figure 4 ). due to the outbreak of avian h7n9 virus in april 2013, ili surveillance was strengthened by increasing the number of samples for testing from 5-15 to 20. figure 4 shows that although the weekly number of the samples tested has increased since the week 14 of year 2013, the weekly number of all ili patients remained at similar level from year 2011 to 2014 (figure 4) . figure 5a ). consistently, this influenza activity was also observed among sari patients ( figure 5b ). seven a(h7n9) viruses (five in the ili group and two in the sari group) were detected during the early year of 2014 ( figure 5 ). we found that the weekly percentage of influenza virus types/subtypes among all the identified influenza cases were significantly correlated between sari and ili patients, with a(h1n1)pdm09 (r = 0.51, p < 0.001), influenza b virus (r = 0.17, p = 0.013), and a(h3n2) (r = 0.43, p < 0.001) ( table 3) . table 3 . correlation analysis of weekly influenza virus type/subtype constitution among total positive numbers between influenza-like illness (ili) and severe acute respiratory illness (sari). figure 5a ). consistently, this influenza activity was also observed among sari patients ( figure 5b ). seven a(h7n9) viruses (five in the ili group and two in the sari group) were detected during the early year of 2014 ( figure 5 ). we found that the weekly percentage of influenza virus types/subtypes among all the identified influenza cases were significantly correlated between sari and ili patients, with a(h1n1)pdm09 (r = 0.51, p < 0.001), influenza b virus (r = 0.17, p = 0.013), and a(h3n2) (r = 0.43, p < 0.001) (table 3 ). 3.6. correlation analysis between weekly ili influenza-positive rate and sari influenza-positive rate, ili percentage and ili influenza-positive rate, sari percentage and sari influenza-positive rate table 4 shows the results of spearman correlation analysis among influenza virus positive rate and percentage of people with ili or sari. the positive rate for influenza virus of ili cases and those of sari cases was statistically significantly correlated (r = 0.63, p < 0.001). the percentage of ili cases and ili influenza-positive rate was statistically significantly correlated (r = 0.53, p < 0.001), which was higher than it of sari (r = 0.19), whose coefficient was statistical significant though (p < 0.001). to our knowledge, this is the first study to compare the epidemic characteristics of influenza between outpatients and hospitalized inpatients in zhejiang province. children less than 5 years of age were found to be the largest group of both ili and sari patients, which was consistent with those reported by other studies [10, 16, 17] . besides, we found a good agreement between sari and ili patients for the weekly proportion of samples tested positively for influenza virus and the distribution of the influenza virus types/subtypes among all the identified patients. this demonstrated that the seasonal pattern and predominant circulation types of influenza were similar between ili and sari patients. finally, we found that the correlation between the weekly influenza positive rates and percentages of patients meeting the definition of ili and sari is higher among ili patients than it among sari patients, which indicated that compared to ili, influenza may less important in causing sari. although the largest age groups were same (0-4 years old) among ili patients and sari patients, this age group had higher proportion within sari patients than it within ili patients. this difference might be caused by the different behaviors when a child or an adult is found to be sick. compared to adults, children are more likely to be taken to hospital, especially for sari cases. therefore, children have sari were more likely to be involved in the surveillance. similar results have been obtained in mongolia [10] , philippines [11] , jordan [23] . our findings further demonstrated that young children are vulnerable for both mild and severe respiratory infection, and the low influenza detection rate among 0-4 years age-group in both sari and ili patients foreshadow the need of expand the respiratory illness surveillance to more types of pathogens [12, 24] . being consistent with other studies, influenza virus was detected in all age groups among both ili and sari cases [10, 14] . and overall, the proportion of samples tested positively for influenza viruses in different age groups presented to be higher with the increase of age. therefore, all persons aged 6 months and older are recommended for vaccination and elders should be considered with priority [25] . to understand the temporal characteristics of influenza epidemics is essential for planning influenza vaccination programmes because vaccine effectiveness wanes over time, a boost of vaccine is essential to prevent the spread of diseases [26] . the simple and preferred measure to assess and compare seasonality patterns was the proportion of influenza positives [27] . the highly correlated influenza virus positive rate between sari and ili patients demonstrated the similar temporal pattern of influenza activity in the two groups. similar findings were recently reported in a description of influenza surveillance in egypt, which showed that the seasonality of influenza among ili cases and sari cases was consisted in november-february [19] . moreover, the comparison between ili patients and sari patients shows no statistically significantly difference in detecting influenza virus type and influenza a virus subtype, which was similar to the findings from nigeria [16] . finally, the correlation of weekly percentage of influenza virus type/subtypes accounted for all the positive numbers between sari and ili patients indicated that the predominant influenza types/subtypes among ili and sari cases was corresponded. these findings are essential for planning influenza vaccination programmes for those severe cases given recommendations for strain inclusion within the vaccine are based on the ili surveillance system. our results were consistent to the study conducted by peng et al. in the year of 2015 [4] . but in that study, the detailed analyses such as correlation analysis between weekly ili influenza-positive rate and sari influenza-positive rate, ili percentage and ili influenza-positive rate, sari percentage and sari influenza-positive rate were not performed. therefore, we believe the present study can provide more comprehensive information on the comparison of influenza epidemiological and virological characteristics between outpatients and inpatients. in line with the findings of other studies [11, 13, 14] , we also found higher influenza detection rate among ili patients compared to that among sari patients. moreover, we also found the correlation coefficient of ili percentage and ili influenza-positive rate was higher than that of sari percentage and sari influenza-positive rate. these phenomena may due to the higher specificity of the ili diagnosis compared to the sari diagnosis [28] . some studies have demonstrated that influenza played an important role in the viral aetiologies of ili cases [29] [30] [31] , while other respiratory virus such as respiratory syncytial virus, rhinovirus, human bocavirus were essential for the cause of sari, especially in children [32, 33] . this indicated that it is more necessary to conduct pathogen spectrum test for sari cases so as to accurately understand the cause of those severe cases. of note, we detected seven cases of a(h7n9) viruses (five in the ili group and two in the sari group) during early year of 2014, when this virus was outbreak in zhejiang province [34] . the detection rate of a(h7n9) virus in the sari patients was higher than that in the ili patients because this strain frequently cause severe syndromes. however, our study found that the surveillance network has low sensitivity on the capture of patients infected with a(h7n9) virus. although one of the critical functions of influenza surveillance is to detect novel strains of influenza, the rapid detection of emerging novel influenza strains or outbreaks of respiratory disease calls for other surveillance with standardized methodology [5] . this study has several limitations. first, although sari surveillance was required to catch all patients in accordance with the definition, sometimes the cases may not be fully recorded because of physicians' oversights and absenteeism. in the ili surveillance, to get all ili patients surveyed was impossible due to the limited amount of resources and personnel. therefore, the subject chosen for ili sampled may prone to sicker patients or younger patients. second, compared to ili surveillance, sari surveillance may be less representative due to its sparse surveillance sites. in the future, we should consider to expand and to enhance the coverage of the surveillance network, with priority to choose hospitals from ili surveillance. third, we did not test for pathogens other than influenza, which made us unable to exclude other viral, bacterial, and fungal pathogens that could be the causes of ili and sari. this study demonstrated circulating types/subtypes of influenza strains and seasonality pattern of ili cases were similar to that of sari cases in zhejiang providence. this reassured the effectiveness of influenza vaccine as strain selection based upon ili surveillance. our study results suggest that compared to ili patients, it is more necessary to conduct pathogen spectrum detection among sari patients. in the future, the expanded and enhanced ili and sari surveillance in the province may contribute to identify the novel virus, detect pandemics at early stage, and then improve the understanding of the etiology of ili and sari. a systematic review of the social and economic burden of influenza in low-and middle-income countries the economic burden of influenza-associated outpatient visits and hospitalizations in china: a retrospective survey characterizing the epidemiology, virology, and clinical features of influenza in china's first severe acute respiratory infection sentinel surveillance system global epidemiological surveillance standards for influenza the burden of influenza-associated hospitalizations in oman direct medical cost of influenza-related hospitalizations among severe acute respiratory infections cases in three provinces in china determining the provincial and national burden of influenza-associated severe acute respiratory illness in south africa using a rapid assessment 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circulating subtypes among cases of influenza-like illness and severe acute respiratory infection influenza-associated mortality in temperate and subtropical chinese cities characterization of regional influenza seasonality patterns in china and implications for vaccination strategies: spatio-temporal modeling of surveillance data method for four seasons division in zhejiang province influenza hospitalization epidemiology from a severe acute respiratory infection surveillance system in jordan influenza surveillance among outpatients and inpatients in morocco cdc. summary recommendations: prevention and control of influenza with vaccines: recommendations of the advisory committee on immunization practices (acip)-united states temporal patterns of influenza a and b in tropical and temperate countries: what are the lessons for influenza vaccination? expert group meeting on seasonal influenza vaccine composition for tropics and subtropics what are the most sensitive and specific sign and symptom combinations for influenza in patients hospitalized with acute respiratory illness? results from western kenya viral etiology of influenza-like illnesses in cameroon the clinical and etiological characteristics of influenza-like illness (ili) in outpatients in laboratory surveillance of influenza-like illness in seven teaching hospitals viral etiology and clinical profiles of children with severe acute respiratory infections in china identification of viral and bacterial pathogens from hospitalized children with severe acute respiratory illness in lusaka, zambia epidemiology of human infections with avian influenza a(h7n9) virus in the two waves before and after october 2013 in zhejiang province acknowledgments: this work was financially supported by grants from zhejiang province (major science and technology programme, grant number 2014c03039), (medical research programme, grant number 2015rcb011, 2016rca008). we would like to thank physicians and staff in the 16 influenza surveillance hospitals across zhejiang province for their dedication in completing the countless numbers of data forms that made this work possible. we also want to thank physicians and staff of hangzhou, ningbo, huzhou, shaoxing, jiaxing, quzhou, taizhou, zhoushan, wenzhou, jinhua, lishui and yiwu centers for disease control and prevention for their invaluable assistance with samples collection and detection. the authors declare no conflict of interest. key: cord-266257-hp11at50 authors: zhang, yao; zhang, haoyu; ma, xindong; di, qian title: mental health problems during the covid-19 pandemics and the mitigation effects of exercise: a longitudinal study of college students in china date: 2020-05-25 journal: int j environ res public health doi: 10.3390/ijerph17103722 sha: doc_id: 266257 cord_uid: hp11at50 (1) background: the novel coronavirus disease 2019 (covid-19) is a global public health emergency that has caused worldwide concern. vast resources have been allocated to control the pandemic and treat patients. however, little attention has been paid to the adverse impact on mental health or effective mitigation strategies to improve mental health. (2) purpose: the aim of this study was to assess the adverse impact of the covid-19 outbreak on chinese college students’ mental health, understand the underlying mechanisms, and explore feasible mitigation strategies. (3) methods: during the peak time of the covid-19 outbreak in china, we conducted longitudinal surveys of sixty-six college students. structured questionnaires collected information on demographics, physical activity, negative emotions, sleep quality, and aggressiveness level. a mixed-effect model was used to evaluate associations between variables, and the mediating effect of sleep quality was further explored. a generalized additive model was used to determine the dose-response relationships between the covid-19 death count, physical activity, and negative emotions. (4) results: the covid-19 death count showed a direct negative impact on general sleep quality (β = 1.37, 95% confidence interval [95% ci]: 0.55, 2.19) and reduced aggressiveness (β = −6.57, 95% ci: −12.78, −0.36). in contrast, the covid-19 death count imposed not a direct but an indirect impact on general negative emotions (indirect effect (ie) = 0.81, p = 0.012), stress (ie = 0.40, p < 0.001), and anxiety (ie = 0.27, p = 0.004) with sleep quality as a mediator. moreover, physical activity directly alleviated general negative emotions (β = −0.12, 95% ci: −0.22, −0.01), and the maximal mitigation effect occurred when weekly physical activity was about 2500 mets. (5) conclusions: (a) the severity of the covid-19 outbreak has an indirect effect on negative emotions by affecting sleep quality. (b) a possible mitigation strategy for improving mental health includes taking suitable amounts of daily physical activity and sleeping well. (c) the covid-19 outbreak has reduced people’s aggressiveness, probably by making people realize the fragility and preciousness of life. the novel coronavirus disease 2019 (covid19) has swept across the world, causing a global pandemic [1] . on 30 january 2020, the world health organization (who) declared covid-19 an international public health emergency. until april 15, 2020, nearly 2 million confirmed covid-19 cases, including 123,010 deaths, have been reported worldwide. with respect to the covid-19 outbreak online surveys, we posted recruitment information for the longitudinal surveys on the internet via wechat moments and wechat pushes. since we intended to explore the mitigation effects of exercise on negative emotions, the participation selection criteria in this study were that college students, who stayed at home in a social distancing status, should be physically healthy and non-disabled. after seeing the recruitment information, sixty-six college students from several provinces participated voluntarily in the survey. all of them met the enrolled criteria, and none of them were diagnosed with covid-19 disease by the end of the online survey. as per national policy, participants stayed at home to implement physical distancing to stop disease transmission. they were instructed to complete the online questionnaires every half month, and the three examined times were 9:00 a.m.-12:00 p.m. on february 19, 2020, 9:00 a.m.-12:00 p.m. on march 5, 2020, and 9:00 a.m.-12:00 p.m. on march 20, 2020 . the language of all the online questionnaires was chinese, and all the questionnaires used in this study have been validated among chinese populations in previous studies. participants were asked to complete and submit the online questionnaires on time. ethical approval was obtained from the institutional review board of tsinghua university (id number: 20190091) . detailed information about this study was posted at the top of the questionnaires. survey participants were asked to sign a consent form before completing the structured questionnaire each time. a total of 70 yuan (equivalent to 10 dollars) was offered to each participant upon receiving all completed questionnaires. before the longitudinal surveys, a total of 66 college students were invited to this study. during the investigations, 66 participants who volunteered to participate in this study completed the online questionnaires twice, and 59 of them completed the surveys three times. in order to explore longitudinal evidence, the survey data for participants who filled online questionnaires at least twice were used to analyze. hence, the final sample size included in the study analysis was 66 participants. information on physical activity (pa) was collected via the short version of the international physical activity questionnaire (ipaq-s), which is suitable for people aged between 15 and 69 years and is primarily used for population surveillance of physical activity levels. the ipaq-s (7 items) has been validated in chinese with good reliability [20, 21] . participants were asked to classify their weekly pa during the recent half month into three categories: light, moderate, and vigorous. total minutes of vigorous physical activity in the last week were constructed based on two questions: "during the last seven days, how many days did you spend on vigorous physical activities like lifting, fast cycling, and fast swimming?" and "how much time did you usually spend each time on these vigorous physical activities?" total minutes of vigorous pa were computed by multiplying the daily average minutes of vigorous pa by the corresponding intensity days. likewise, the total minutes of moderate and light pa in the last week were calculated in the same way. according to ainsworth et al. [22] , the ratio of work metabolic rate to a standard resting metabolic rate (met) was used to estimate the weekly energy expenditure. energy expenditure in met-minutes per week (mets) can be estimated for specific activities by type and intensity [22, 23] . referring to previous studies [22, 23] , the average met coefficients of light, moderate, and vigorous pa in ipaq-s are 3.3, 4, and 8, respectively. the final light, moderate, and vigorous physical activity were computed by multiplying the corresponding met coefficient with the total minutes (e.g., moderate met minutes/week (mets) = 4.0 × moderate-intensity activity minutes × moderate days). the mets of total pa were calculated by adding vigorous pa, moderate pa, and light pa. sedentary behavior was defined as pa less than 1.5 mets [22, 23] . subjective sleep quality was measured using the widely used pittsburgh sleep quality index (psqi), which assesses the overall weekly sleep quality in the last month [24] . we used 19 self-rated items of the validated chinese version of the psqi (c-psqi) in this study [25] . the c-psqi used in this study includes seven sleep components: subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. each component was rated on a scale of 0-3. the global psqi score, ranging from 0 to 21, is the sum of all the component scores, and a higher global psqi score indicates poorer sleep quality. according to a previous study, global psqi with a score greater than 5 scores indicates some degree of poor sleep disorder [26] . negative emotions and mental health during the last week were measured using the depression anxiety stress scale, with 21 self-reported items (dass-21) [27] , which has been validated in the chinese population [28, 29] . this structured questionnaire was previously used to assess the immediate and sustained psychological distress of healthcare workers during the sars period [30] . the dass-21 consists of three components of stress, anxiety, and depression, each of which includes seven items. in terms of stress, participants were asked to answer questions like "i found myself getting quite upset by trivial things." with regard to depression and anxiety, participants were asked to answer questions such as "i felt that life was not worthwhile" and "i found myself in a situation which made me so anxious and i was most relieved when they ended." each item was rated on a scale of 0-3, corresponding to "totally disagree," "partially agree," "mostly agree," and "totally agree." the score of each component was calculated as the sum of scores for seven related items, with values ranging from 0 to 21. the global dass score is the sum of the three components and is used as a general indicator of mental distress. the score for each component ranges from 0 to 21, and the global dass score, which the sum of the three components, serves as a general indicator of mental distress. in addition, higher scores of stress, anxiety, depression, and global dass represent more serious negative emotions. scores greater than 10, 7, and 9 on stress, anxiety, and depression, respectively, may indicate significant levels of the corresponding negative emotions [31] . aggressiveness was measured using the buss-perry aggressive questionnaire (bpaq), which assesses aggressive emotions, intentions, or behaviors [32, 33] . the bpaq has been demonstrated to be a reliable measure of aggressiveness in the chinese population [34, 35] . the bpaq consists of four components: physical aggression, verbal aggression, anger, and hostility, with 5, 6, 3, and 8 items, respectively. each item was rated on a scale of 1 (totally disagree) to 5 (totally agree). the score of each component was the sum of scores for the corresponding items, and the overall aggressiveness score was the sum of the four components. a higher score indicates a higher aggressive level. the covid-19 disease data were extracted from the open-source git-hub packages "canghailan/wuhan-2019-ncov" and "guangchuangyu/ncov2019," which comprise cumulative numbers of confirmed, suspected, cured, and death cases at the provincial level from january 1, 2019, to the present day. we extracted the number of cumulative death cases one day before as the indicator of covid-19 outbreak severity for each province and then matched provincial-level covid-19 death cases to each participant based on home address. considering longitudinal measurements and inter-person variation, we employed a mixed-effect model with a random effect on individuals to examine the relationship between covid-19 death cases, sleep quality, physical activity, negative emotions, and aggressiveness. variables that did not change over time were controlled using this analytic approach. we used the mediation package of r software to explore the mediation effect of sleep quality on the association between covid-19 death count and negative emotions in order to discover the possible underlying influence mechanism. in addition, we examined the mitigating effects of pa on negative emotions and then explored the dose-response relationship between the global dass score, covid-19 death count, and physical activity by fitting a generalized additive model with splines. statistical analysis was performed using r software, version 3.6.3 (r project for statistical computing) and a two-tailed p < 0.05 was considered statistically significant. a summary of participants' demographic information and health behaviors at baseline is shown in table 1 . a majority of the sample comprised female participants (62.12%) and most participants were around 20 years old (20.70 ± 2.11), and only a few of the participants were from non-han minorities. most of the participants lived in urban areas during the covid-19 outbreak. with regard to health behaviors, participants exerted 354.55 mets (sd = 613.41) of vigorous physical activity every week on average. the amount of physical activity was significantly higher in male participants than female ones. likewise, male participants consumed more energy in light pa (p = 0.005), vigorous pa (p < 0.001), and total pa (p < 0.001) than did female participants. however, no significant differences were observed in terms of moderate pa and total minutes of weekly sedentary behavior, and no gender difference was observed in the groups with good sleep quality (psqi ≤ 5) and poor sleep quality (psqi > 5). it is worth mentioning that nearly 85% of respondents reported worries or concerns about covid-19 disease, and 28.79%, 45.45%, and 22.73% of them reported stress, anxiety, and depression emotions. in addition, the percentage of female young adults reporting abnormal levels of every negative emotion was higher than in male respondents, even though the differences were not statistically significant. moreover, all enrolled participants were non-smokers according to the demographic information. this may be because all of the participants were college students and the sample size in this study was not too big. trends of the covid-19 in china from january 23 to march 20, 2020 figure 1 shows the development trend of the covid-19 pandemic in china from january 23 to march 20, 2020 for the cumulative numbers of cases of confirmed, suspected, and cured patients and of deaths. the numbers of cumulatively confirmed cases and deaths continued to climb for two months, with a sharp increase in the number of cumulatively confirmed cases in the first month. during the period of repeated online surveys, from february 19 to march 20, 2020, the severity of covid-19 continued to increase and gradually reached its peak. figure 1 shows the development trend of the covid-19 pandemic in china from january 23 to march 20, 2020 for the cumulative numbers of cases of confirmed, suspected, and cured patients and of deaths. the numbers of cumulatively confirmed cases and deaths continued to climb for two months, with a sharp increase in the number of cumulatively confirmed cases in the first month. during the period of repeated online surveys, from february 19 to march 20, 2020, the severity of covid-19 continued to increase and gradually reached its peak. note: the subgraph of (a-d) refer to the relationship between date and cumulative confirmed, suspected, cured, and death counts, respectively. the chinese government declared a lockdown in wuhan on january 23, which then entered the level-1 emergency response. all provinces across china entered a state of blockade. thus, we regard january 23, 2020 as the starting point (date 1) of our study and a total of 58 days (from date 1 to date 58) were recorded until the last day of the online survey, march 20, 2020. the subgraph of (a-d) refer to the relationship between date and cumulative confirmed, suspected, cured, and death counts, respectively. the chinese government declared a lockdown in wuhan on january 23, which then entered the level-1 emergency response. all provinces across china entered a state of blockade. thus, we regard january 23, 2020 as the starting point (date 1) of our study and a total of 58 days (from date 1 to date 58) were recorded until the last day of the online survey, march 20, 2020. table 2 shows the relationships between covid-19 deaths and physical activity, along with sleep quality, aggressiveness, and negative emotions. local covid-19 death cases were negatively associated with participants' general sleep quality. every 1000 increase in local covid-19 deaths was associated with a rise of 1.37 (95% confidence interval [95% ci]: 0.55, 2.19) units in the global psqi score, indicating a decline in sleep quality. among the seven components of psqi, sleep efficiency was significantly associated with covid-19 death cases, with a 1000 increase in local death cases corresponding to a 0.29 (95% ci: 0.15. 0.44)-unit increase in sleep efficiency score, indicating reduced sleep efficiency. in addition to sleep efficiency, covid-19 death cases were also associated with decreased sleep quality and sleep duration and increased sleep disturbance and daytime dysfunction, although these associations were insignificant. however, negative emotions, global dass scores, stress, anxiety, and depression did not show any directly significant associations with the covid-19 death count. in contrast to negative emotions, the aggressiveness score was negatively associated with the local covid-19 death count. every 1000 increase in local covid-19 deaths was significantly associated with a change of −6.57 units (95% ci: −12.78, −0.36) in the aggressiveness score, indicating a declined aggressiveness level. furthermore, negative emotions can be significantly alleviated by physical activity. each 100-unit increase in mets of total physical activity corresponded to a change of −0.12 (95% ci: −0.22, −0.010) in the global dass score. physical activity also significantly alleviated depression (p = 0.040); however, the alleviation effects on stress were insignificant (p = 0.090, table 2 ). unlike negative emotions, physical activity, sleep quality, and aggressiveness was not significantly associated. based on the relationships between variables, we further explored the mediation effect of sleep quality on covid-19 and negative emotions (figure 2 ). the effects of the covid-19 death count on young adults' stress (indirect effect (ie) = 0.40, p < 0.001), anxiety (ie = 0.27, p = 0.004), and global dass score (ie = 0.81, p = 0.012) were significantly mediated by decreased sleep quality, and the mediation effect on depression was not significant (p = 0.180). however, while physical activity did not show an indirect influence on negative emotions, it did show a direct impact without mediating the effect of sleep quality (figure 3 ). quality on covid-19 and negative emotions (figure 2 ). the effects of the covid-19 death count on young adults' stress (indirect effect (ie) = 0.40, p < 0.001), anxiety (ie = 0.27, p = 0.004), and global dass score (ie = 0.81, p = 0.012) were significantly mediated by decreased sleep quality, and the mediation effect on depression was not significant (p = 0.180). however, while physical activity did not show an indirect influence on negative emotions, it did show a direct impact without mediating the effect of sleep quality (figure 3 ). we used a generalized additive model to examine the dose-response associations between the covid-19 death count, physical activity and aggressiveness, and negative emotions ( figure 4 ). as figure 4 shows, the relationship between the covid-19 death count and negative emotions as well as aggressiveness was linear with no sign of threshold or plateau, although the trends were different. moreover, the dose-response curve between negative emotions and physical activity exhibited a ushaped relationship, indicating that either an inadequate or excessive amount of physical activity worsened negative emotions. a suitable amount to minimize negative emotions occurred when weekly physical activity was about 2500 mets, corresponding to 108 min of light, 80 min of moderate, or 45 min of vigorous physical activity every day. we used a generalized additive model to examine the dose-response associations between the covid-19 death count, physical activity and aggressiveness, and negative emotions ( figure 4 ). as figure 4 shows, the relationship between the covid-19 death count and negative emotions as well as aggressiveness was linear with no sign of threshold or plateau, although the trends were different. moreover, the dose-response curve between negative emotions and physical activity exhibited a u-shaped relationship, indicating that either an inadequate or excessive amount of physical activity worsened negative emotions. a suitable amount to minimize negative emotions occurred when weekly physical activity was about 2500 mets, corresponding to 108 min of light, 80 min of moderate, or 45 min of vigorous physical activity every day. the focus of this longitudinal study is twofold: (1) to investigate the impact of the covid-19 severity on chinese college students' mental health and life status and explore the underlying mechanisms of this effect during the peak time of the covid-19, from february 19 to march 20, 2020; and (2) to assess the mitigation effects of exercise on negative emotions and advance a suitable physical activity level as a psychological intervention strategy to improve mental health. our findings suggest that the severity of the covid-19 outbreak could significantly increase people's negative emotions through declining sleep quality. in additional, maintaining regular exercise was helpful to alleviate negative emotions, and 2500 mets of pa every week was the optimal load. the focus of this longitudinal study is twofold: (1) to investigate the impact of the covid-19 severity on chinese college students' mental health and life status and explore the underlying mechanisms of this effect during the peak time of the covid-19, from february 19 to march 20, 2020; and (2) to assess the mitigation effects of exercise on negative emotions and advance a suitable physical activity level as a psychological intervention strategy to improve mental health. our findings suggest that the severity of the covid-19 outbreak could significantly increase people's negative emotions through declining sleep quality. in additional, maintaining regular exercise was helpful to alleviate negative emotions, and 2500 mets of pa every week was the optimal load. in this study, nearly 85% of respondents reported their worries about covid-19, and over 20% reported at least one form of mental distress in line with previous acute emergencies [7] [8] [9] . the prevalence of negative emotions, especially anxious emotions, was higher in this study than in previous studies, which were conducted mainly among chinese university students in the initial phase of covid-19 [11, 12] . the development trend of negative emotions may imply that the adverse impact of covid-19 on public mental health will continue to increase as covid-19 spreads across the world. furthermore, females suffered a greater psychological impact from the covid-19 outbreak, with higher but insignificant scores in stress, anxiety, and depression. the lack of significant results probably reflects the limited sample size. this finding is in line with previous epidemiological studies, which found that women were more vulnerable to developing depression or ptsd [36, 37] . we found that the covid-19 outbreak could significantly reduce young adults' sleep quality and thereby increase their global negative emotions, especially stress and anxiety. this finding was consistent with a previous study revealing that individuals with better sleep quality or lower frequency of early awakenings showed reduced morbidity rates of ptsd during the covid-19 outbreak [36] . thus, the covid-19 outbreak demonstrates an indirect influence on young adults' mental health, with sleep quality playing an important mediating role. considering that all colleges in china have shut down and may stay closed until september, chinese college students will stay at home and keep social distancing for a long time. under such circumstances, they might adopt irregular lifestyles with poor sleep quality, stress, and anxiety over their academics or future employment [1] , as well as loneliness due to the lack of communication [38] . however, unexpectedly, covid-19 might significantly reduce aggressiveness levels. we propose that this phenomenon probably results from people beginning to realize the fragility of life and cherishing every moment. furthermore, regular exercise is a good treatment for poor mental health and may directly reduce negative emotions within a certain range. this finding is in accordance with previous studies showing that daily physical activity was associated with a lower risk of psychiatric distress, regardless of form and intensity [39, 40] , that could improve immunity and maintain mood stability [41] . some indoor exercises have been recommended during the disease outbreak, such as high-intensity interval training (hiit), which helps facilitate metabolism, and yoga or relaxation training, which helps promote sleep quality and calm the mood [18, 19] . furthermore, it should be noted that the gym may be a high-risk infection area due to crowding [42] . thus, staying at home and maintaining ventilation are as important as regular exercise during the covid-19 period [42] . more importantly, the relationship between physical activity and mental health is nonlinear. in our study, 2500 mets of weekly physical activity appeared to minimize negative emotions during the covid-19 outbreak, which is equivalent to about 108 min of light, 80 min of moderate, or 45 min of vigorous physical activity every day. the recommended pa load during this special period is slightly higher than in previous studies, in which 60 min of moderate-to-vigorous pa every day is recommended to maintain physical and psychological heath [43] . this is probably because of the special period of the covid-19 outbreak: people need additional pa to offset the psychological burden and negative emotions caused by the disease outbreak and social distancing. this study has several limitations. first, considering the physical distancing status and difficulty of collecting longitudinal survey data, the sample size in our longitudinal study was not large enough and the study was performed on a relatively small group of exclusively chinese college students as respondents. this study population may not be representative of the overall mental distress pattern of ordinary people of different ages, education levels, and countries. however, the findings in this study might to some extent reflect the psychological problems and intervention needs of the public during the covid-19 disease period. second, the study participants were predominantly females, who might tend to exercise less and be more vulnerable to negative emotions than their male counterparts. thus, the associations between the covid-19 outbreak, physical activity, and psychological health may be different between females and males. in addition, the preferred methods of coping with negative emotions, such as stress, anxiety, and depression, are different in females and males. females may prefer to handle psychological distress based on avoidance and looking for social contacts. therefore, further studies with larger samples are needed to explore the differences in the effectiveness of different forms of physical activity (e.g., group video exercise or interesting online sports) by gender. third, we mainly focused on the impact of the local increases in covid-19 death counts on the negative emotions of college students in social isolation status, and we did not exclusively focus on the effects of lengthened social distancing time. however, it was possible that the relationship between the results of psychological tests and the number of covid-19 death counts might reflect the relationship between negative emotions and lengthened social distancing times. hence, more studies are needed in the future to analyze the main impact of social distancing and the interactive effects of social isolation and the covid-19 outbreak on public mental health. furthermore, due to the physical distancing status across the whole country, we only used the validated self-reported dass-21 questionnaire to measure the adverse impact of covid-19 severity on negative emotions without having psychological consultants assess their mental health status as a form of third-party verification. this limitation might have resulted in self-report bias, but the results are generally reliable and consistent with the previous applications of dass-21 in sars-related and mers-related studies. moreover, due to restrictions of sample size, we did not compare the differences in variables between serious covid-19 disease areas (e.g., inside hubei province) and non-serious covid-19 disease areas (e.g., outside hubei province). we hope that other researchers from different countries or different areas will collect data in the future to analyze the regional differences in the impact of the covid-19 on public mental health. this study also has several strengths. first, this study conducted longitudinal surveys to assess the adverse impact of the covid-19 outbreak on chinese college students' mental health, sleep quality, and aggressiveness during the peak epidemic time. in addition, unlike cross-sectional studies, this longitudinal study used a mixed-effect model with random effects on individuals to control for inter-person variation. to the best of our knowledge, this study is the first to investigate the underlying mechanism whereby covid-19 influences public mental health. most importantly, our study found mitigation effects of regular exercise and good sleep on the public's negative emotions without additional social medical burden. in addition, our study advances a suitable range of physical activity to maintain psychological health of 108 min of light, 80 min of moderate, or 45 min of vigorous physical activity daily, which we recommended for psychological interventions during the covid-19 period. in summary, during the peak phase of the covid-19 outbreak in china, the severity of the covid-19 outbreak has had an indirect effect on local young adults' negative emotions, with sleep quality playing a mediating role. to deal with negative emotions during the disease outbreak, increasing physical activity and developing good sleeping patterns are cost-effective and practical mitigation strategies for ordinary people who are forced to stay at home. developing a regular exercise habit with approximately 2500 mets of weekly physical activity is recommended during this special 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china hardest-hit areas: gender differences matter prevalence of depression in the community from 30 countries between 1994 and rules on isolation rooms for suspected covid-19 cases in gp surgeries to be relaxed dose-response relationship between physical activity and mental health: the scottish health survey objectively measured light and moderate-to-vigorous physical activity is associated with lower depression levels among older us adults debunking the myth of exercise-induced immune suppression: redefining the impact of exercise on immunological health across the lifespan infection risk in gyms during physical exercise american college of sports medicine american college of sports medicine position stand. appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we would like to thank all the participants who participated in this study. the authors declare no conflict of interest. the institutional review board of tsinghua university (id number: 20190091) approved this research.participants' consent for publication: consent form was obtained from every participant in our study. detailed information about this study was posted on the top of the questionnaires. survey participants were asked to read all study information and sign a consent form online (answer yes/no and write signature) before completing the online structured questionnaire each time. key: cord-277228-zk4arqw5 authors: suleiman, aiman; bsisu, isam; guzu, hasan; santarisi, abeer; alsatari, murad; abbad, ala’; jaber, ahmad; harb, taima’a; abuhejleh, ahmad; nadi, nisreen; aloweidi, abdelkarim; almustafa, mahmoud title: preparedness of frontline doctors in jordan healthcare facilities to covid-19 outbreak date: 2020-05-02 journal: int j environ res public health doi: 10.3390/ijerph17093181 sha: doc_id: 277228 cord_uid: zk4arqw5 the number of covid-19 (coronavirus disease of 2019) cases in jordan is rising rapidly. a serious threat to the healthcare system appears on the horizon. our study aims to evaluate preparedness of jordanian frontline doctors to the worsening scenario. it has a questionnaire-based cross-sectional structure. the questionnaire was designed to evaluate preparedness according to knowledge about virus transmission and protective measures, adherence to protection guidelines, and psychological impacts affecting doctors. institutional factors affecting doctors’ readiness like adopting approach protocols and making protection equipment available were investigated; 308 doctors from different healthcare facilities participated (response rate: 53.9%). approximately 25% of doctors (n = 77) previously took care of covid-19 patients, and 173 (56.2%) have institutional covid-19 approach protocols. only 57 doctors (18.5%) reported all ppe (personal protective equipment) available. the self-reported score of preparedness to deal with covid-19 patients was 4.9 ± 2.4. doctors having institutional protocols for dealing with covid-19 cases and those with sustained availability of ppe reported higher scores of preparedness (5.5 ± 2.3 and 6.2 ± 2.1 with p < 0.001, respectively). correlations with knowledge score, adherence to ppe score, and psychological impacts were investigated. the study revealed multiple challenges and insufficiencies that can affect frontline doctors’ preparedness. policy makers are urged to take these findings into consideration and to act promptly. covid-19 (coronavirus disease of 2019) is a new type of virus that has the potential to cause severe respiratory disease [1] . the first encounter of the disease was in the city of wuhan, china, in december 2019, after which a pandemic emerged and spread all over the world [1] . on 12 march 2020, the world health organization (who) announced that covid-19 is categorized as a pandemic [2] . as of 30 march 2020, more than 750,000 positive cases were identified across 170 countries with more than 36,000 reported deaths [3] . the virus may have originated in bats [4] . in most severe cases, patients can develop pneumonia that progresses to acute respiratory distress syndrome (ards) requiring mechanical ventilation [5] . in jordan, the first case of covid-19 was identified on 2 march 2020 in a traveler who had returned from italy two weeks before quarantine procedures [6] . as of march 23, the starting date of our study, officials announced that the number of cases had reached 127 and that the country had yet to move into the acceleration phase of the epidemic curve. jordan is a middle-income country with a population exceeding 10 million [7] . advanced medical care is provided in over 106 tertiary hospitals distributed across the country with about 12,081 beds capacity (1.8 beds per 1000 people) [8] . jordan is considered a leading country in healthcare services in the middle east with many global ranks and awards [9, 10] . since march 16, one of the world's strictest lockdowns took place in the country and five tertiary hospitals were designated to provide medical care for suspected/diagnosed covid-19 patients [11] . since the number of covid-19 cases in jordan is rising rapidly, a serious threat to the healthcare system appears on the horizon. adding to availability of equipment, the preparedness of frontline doctors to the impact of the outbreak is what guarantees the system to function properly and efficiently. our study aims to evaluate the awareness and readiness of these doctors to the worsening scenario in jordan, a limited-resources country. to the best of our knowledge, this is the first study to evaluate the preparedness of frontline doctors to covid-19 outbreak in jordan and in the middle east. this is a questionnaire-based cross-sectional study. our target sample was jordanian doctors who might be in first contact with covid-19-positive patients. we identified 571 doctors that were assigned to missions that deal directly with covid-19 patients. the sample included general practitioners, resident doctors, and specialists. the specialties allocated to first contact with covid-19 patients were emergency medicine and accidents, anesthesia and intensive care, internal medicine, ent (ear, nose, and throat), and family medicine. all healthcare sectors which were or might be involved in taking care of covid-19 patients were involved; these included university hospitals, governmental hospitals, military hospitals, and private hospitals. our questionnaire was designed to evaluate awareness and readiness of frontline doctors to deal with covid-19 patients. it was web-based and filled using google forms we collected data regarding three main aspects of preparedness. firstly, knowledge and awareness of transmission routes, protection guidelines, and emergency approaches were assessed using five questions, with four points per question. the overall score was then converted to a ten-point score. secondly, adherence to the ppe (personal protective equipment) guidelines by the cdc (centers for disease control and prevention) [12] was evaluated using three questions, with an overall score of 12 that was then converted to a ten-point score. in addition, we studied the availability of ppe and the application of institutional protocols for dealing with covid-19-positive or suspected patients. we also investigated psychological impacts and interactions affecting the preparedness of involved doctors. moreover, a self-reported 11-point score of preparedness to deal with covid-19-positive or suspected patients was filled by the participating doctors, where a score of 10 represented "fully prepared" while 0 represented "not prepared at all". for ethical considerations, names of doctors and institutional information were not collected and data was used solely for statistical analysis. the study design and its questionnaire were approved by the institutional review board (irb) committee at the university of jordan (reference number: 10/2020/7409). data was collected in the period between march 23 to march 27. based on phone and email communications with the designated institutes, the team of the study was able to identify 571 doctors as frontline doctors. all 571 doctors were approached by phone and email; 308 doctors filled the questionnaire and the consent form attached, marking a response rate of 53.9%. the authors analyzed the data using statistical package for social science program (spss) version 23.0 (spss inc., chicago, ill., usa). we used pearson's chi-squared (χ2) test for categorical variables. independent t-test was used to investigate for significant associations between self-reported preparedness score, knowledge score, and adherence score with gender, presence of institutional protocol for dealing with covid-19 patients, availability of ppe, psychological interactions, institutional support, and previously dealing with covid-19-positive or suspected patients. one-way anova (analysis of variance) followed by post hoc analysis of the least significant difference was used to compare between different workplaces, departments, and job descriptions in the preparedness score. moreover, linear regression analysis and pearson's correlation coefficient (pearson's r) were used to explore the association between self-reported preparedness score and age, knowledge score, and adherence score. the statistical significance level was considered as a p-value less than 0.05. for questionnaire validation, the questionnaire was reviewed by seven anesthesiologists and by one doctor from the department of infectious diseases and was modified based on their comments. calculated cronbach's alpha value was 0.81, marking a good level of internal consistency [13] . overall, 308 doctors with a mean age of 30.3 ± 5.8 were enrolled in the study, of which 195 (63.3%) were males and 113 (36.7%) were females. most of the included frontline doctors were resident doctors (n = 174; 56.5%), followed by general practitioners (n = 73; 23.7%) and specialists (n = 61; 19.8%). eighty-nine doctors (28.9%) were from emergency medicine and accidents departments, 87 (28.2%) were from anesthesia and intensive care departments, 74 (24%) were from internal medicine departments, 37 (12%) were from family medicine departments, and 21 (6.8%) were from ent departments. seventy-seven doctors (25%) previously took care of a positive or suspected covid-19 patient, and their most trusted source of information was articles published in scientific journals (n = 267; 86.7%). the knowledge and adherence scores of these doctors were 8 ± 1.3 and 8.4 ± 1.5, respectively (table 1) . moreover, the doctors' psychological interactions and institutional support are explored in table 2 . the self-reported score of preparedness to deal with covid-19-positive or suspected patients was 4.9 ± 2.4 ( table 2 ). upon analyzing the effect of demographic factors, knowledge score, and adherence score on the self-reported preparedness score of frontline doctors, we found that males had higher preparedness scores (5.2 ± 2.4) when compared to females (4.5 ± 2.4; p = 0.019). moreover, those who have an institutional protocol for dealing with covid-19 suspected and confirmed cases at their institution scored 5.5 ± 2.3 (p < 0.001), and those who have sustained availability of ppe had significantly higher preparedness scores (6.2 ± 2.1; p < 0.001). additionally, preparedness scores of doctors who previously took care of positive or suspected covid-19 patients followed the same trend (p = 0.021), with a mean score of 5.5 ± 2.3 (table 3 ). doctors who were concerned about dealing with covid-19 patients had higher knowledge scores (8.2 ± 1.3; p = 0.004). likewise, those who feel anxious regarding the possibility of the spread of covid-19 and the increase in number of positive patients had also higher scores (8.1 ± 1.3; p = 0.033) (table 4) . remarkably, those who have an institutional protocol for dealing with covid-19 suspected and confirmed cases at their institution had a significantly higher percent of satisfaction with the infection control policy at their institutions, with feeling safe at their work, with feeling safe for their colleagues at work, and with feeling that current infection control practices at their institution will decrease the risk for them and their colleagues to contract covid-19 (p < 0.001) ( table 5 ). doctors who reported full availability of ppe followed the same positive trend for those four factors (p < 0.001) ( table 6 ). on the other hand, doctors who do not have all ppes available at their institutions were significantly more concerned about dealing with covid-19-positive or suspected patients (n = 177; 70.5%) when compared to those who always have ppes available (n = 32; 56.1%; p = 0.036). as mentioned earlier, the full availability of ppes was associated with higher self-reported preparedness scores (6.2 ± 2.1; p < 0.001). table 3 . an analysis on the effect of demographic factors, knowledge score, and adherence score on the self-reported preparedness score of frontline doctors. frontline doctors' preparedness relies on two main pillars: self-preparedness and institutional preparedness. self-preparedness depends on the amount of knowledge about the virus and the safe approach to patients and the amount of adherence to safety measures. institutional preparedness is reflected by making safety measures available for doctors and by providing clear protocols to deal with covid-19 patients. psychological health and impacts on doctors during outbreaks should be targeted as an important factor of preparedness. the study evaluated self, institutional, and psychological preparedness of frontline doctors. studies conducted on healthcare system preparedness to outbreaks have long encouraged policy makers to modify policies based on findings and recommendations. in jordan and many other countries, disease control and prevention committees are in charge of responding to public crises caused by viruses like covid-19 [14] . along with the ministry of health, they are also responsible for the fortification of capabilities of healthcare workers. committees employ data of relevant studies to formulate these recommendations. recently, with the covid-19 pandemic, many studies are conducted worldwide to evaluate the readiness and the action measures applied to deal with pandemics [15] . previous studies on the awareness of covid-19 in healthcare workers worldwide showed that a significant proportion had poor knowledge about the virus yet positive perceptions about its control [16] . our study included 308 doctors from all healthcare sectors across the country. correlations regarding the job description were not valid as we assume all doctors who might be in first contact with a covid-19 patient should have the same degree of preparedness. institutional differences were omitted as many doctors might change their workplace according to needs during pandemics. scientific journals are believed to be the most trustful source of scientific information across all scientific communities; 59.7% of jordanian doctors believe that officials are a trustful source, which reflects an adequate mutual trust between officials and frontline doctors. only 16.9% of doctors identified social media as a safe source of information, which reflects the spread of fake science and news across jordanian social media. considering medical news, studies showed that at least 40% of information shared on social media is fake, of which 20% is "dangerously" fake [17] . for knowledge, a score of five fundamental questions was built to evaluate the knowledge needed to approach covid-19 patients safely. frontline doctors achieved satisfactory numbers with a mean of 8 ± 1.3. the biggest defect in terms of choices was that 58.1% of doctors do not consider the fecal-oral route as a possible route of disease transmission [18] . the biggest defect in terms of questions was in the "measures related to cpr" question, which can be attributed to the involvement of only specific specialties in the cpr team. nevertheless, frontline doctors should acquire knowledge about all emergency situations [19] . as covid-19 is an emerging disease, researches continue to fortify knowledge about it and institutions are recommended to update their healthcare workers on any new information [20] . regarding adherence to safety measures, a score of three fundamental questions was built based on measures practiced before, during, and after work. the mean score of doctors was 8.4 ± 1.5, which is satisfactory; 65.6% of doctors are not adherent to any sport activity. there is a tremendous evidence in the literature linking healthy lifestyles to boosted immunity [21] , which should be encouraged in healthcare communities. as the number of positive cases is rising worldwide, the burden on healthcare systems is enlarging, which will increase the demand on medical supplies. many facilities worldwide are suffering shortage in equipment supplies [22] . only 18.5% of frontline doctors in jordan reported that all protective measures are available, which reflects that the rest are at very high risk of catching the disease if ppe measures are not fully met [12] . most shortage was in protective facemasks (66.2%). alternative methods shared throughout social media do not meet the proper standards and are not of proven safety [23] . facemasks are frequently reported to be the most important measure in ppe for healthcare workers [24, 25] . the aim of the study was to evaluate frontline doctors' preparedness. on a score out of 10, doctors' self-reported preparedness mean was 4.9 ± 2.4. as the mean is unpleasantly low, correlations to understand the reason were established. male doctors felt more prepared, and this could be regarded to female doctors worrying about being at childbearing age, having more family concerns or more anxiety thoughts, which might affect females more than males naturally [26] . differences in relation to job description, specialty department, healthcare sector, and knowledge and adherence scores were not significant. doctors who reported the availability of clear institutional protocols to approach covid-19 patients and the availability of all ppe measures had the highest preparedness scores. there are many potential benefits of having clear institutional guidelines for doctors, which include improvement of the quality of clinical decisions, reduction of uncertainty in approaching patients, avoidance of outdated practices, and reassurance of practitioners' treatment policies [27] . availability of equipment is an essential factor in proper application of protocols and thus strongly affects preparedness [22] . doctors who previously dealt with positive patients felt much more prepared than other doctors, which reflects the important role experience can play. outbreaks carry many psychological impacts on healthcare workers. these impacts can influence the quality of the healthcare provided. doctors experiencing anxiety and distress might develop unfavorable mental health outcomes that might affect their preparedness to provide proper care [28] . our study showed worrying results regarding the psychological health of jordan frontline doctors. only 28.2% of doctors are satisfied with the infection control policy at their institution, and only 19.8% feel safe at their workplace. more than 90% of doctors are concerned about the probability of transmitting the disease to their noninfected patients or their families. considering previous figures, it would be expected that 67.9% of sampled doctors are concerned about dealing with covid-19 patients. knowledge can significantly affect psychological impact. in our case, doctors with higher knowledge scores were more concerned about dealing with covid-19 patients and more anxious regarding the increase of positive cases. this can be attributed to the proper understanding of the genuineness of the virus and to the lack of effective treatment policies till present time [29] . this also goes in line with findings in other studies that prove that poor knowledge is associated with less concerns [16] . the availability of clear protocols and full ppes significantly improved figures of psychological impacts in terms of feeling safe at work and satisfaction about institutional plans; this emphasizes the importance of adopting international and local protocols at the institutional level and ensuring their proper application to avoid endangering the doctors [22] . doctors without full ppes were significantly more concerned about dealing with covid-19 patients, which further expands the effect of shortage of ppe to fear and anxiety. with progressing shortage in ppe, doctors may battle the indicated situations to adopt full ppes; however, this should not be at the expense of doctors' safety [30] . different healthcare sectors have different capabilities to provide doctors' needs, but in the case of an outbreak, unified protocols adopted by the highest healthcare authorities should be obligatory and frequently monitored for efficiency all over the country. as many countries are employing all healthcare sectors in the care of covid-19 patients, preparedness of doctors in these sectors should be at the head of all priorities. in 2009, avian influenza and pandemic influenza took place in jordan and other countries around the world. according to the who (world health organization) regional office for the eastern mediterranean report, jordan's response to the pandemic had strong national communication and surveillance strategies and its national influenza center has become a regional reference laboratory in the region [31]. nevertheless, many gaps have been identified in the policies and practices of the ministry of health in regard to effective risk communication with the public and healthcare workers during outbreaks [31] . in the new covid-19 outbreak, major governmental efforts relying on who guidelines were made to fill these gaps, some of which had clearly contributed to the flattening of the epidemic curve, but the deficiencies recognized by this study may lead to a loophole that can overthrow these efforts. the main limitation of this study is that the number of physicians interacting with covid-19 patients is dynamically changing, which will have a continuous impact on their knowledge, their adherence to infection control policy, and their social and institutional support. however, the study illustrated the need for plans to take place for the current pandemic, and for actions that need to take place to prepare for future pandemics. the study revealed multiple challenges and difficulties that can significantly affect frontline doctors' preparedness. policy makers in jordan are urged to take these 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and clinical therapies on coronavirus disease 2019 (covid-19) outbreak-an update on the status clinicians face harassment, firing for self care -medscape -26 this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord-256004-rqdeac7h authors: wilcox, elizabeth s.; chimedza, ida tsitsi; mabhele, simphiwe; romao, paulo; spiegel, jerry m.; zungu, muzimkhulu; yassi, annalee title: empowering health workers to protect their own health: a study of enabling factors and barriers to implementing healthwise in mozambique, south africa, and zimbabwe date: 2020-06-23 journal: int j environ res public health doi: 10.3390/ijerph17124519 sha: doc_id: 256004 cord_uid: rqdeac7h ways to address the increasing global health workforce shortage include improving the occupational health and safety of health workers, particularly those in high-risk, low-resource settings. the world health organization and international labour organization designed healthwise, a quality improvement tool to help health workers identify workplace hazards to find and apply low-cost solutions. however, its implementation had never been systematically evaluated. we, therefore, studied the implementation of healthwise in seven hospitals in three countries: mozambique, south africa, and zimbabwe. through a multiple-case study and thematic analysis of data collected primarily from focus group discussions and questionnaires, we examined the enabling factors and barriers to the implementation of healthwise by applying the integrated promoting action on research implementation in health services (i-parihs) framework. enabling factors included the willingness of workers to engage in the implementation, diverse teams that championed the process, and supportive senior leadership. barriers included lack of clarity about how to use healthwise, insufficient funds, stretched human resources, older buildings, and lack of incident reporting infrastructure. overall, successful implementation of healthwise required dedicated local team members who helped facilitate the process by adapting healthwise to the workers’ occupational health and safety (ohs) knowledge and skill levels and the cultures and needs of their hospitals, cutting across all constructs of the i-parihs framework. health workers (hws) are in short supply worldwide. it is estimated that by 2030, the global health workforce will be short approximately 18 million workers, primarily in low-and middle-income countries (lmics) [1] . in high-risk settings, where disease prevalence is high and health systems are stretched to provide basic health services, hws are at an elevated risk of contracting infectious diseases such as hepatitis, human immunodeficiency virus (hiv), tuberculosis (tb), and novel emerging threats from occupational exposure, including covid-19. they also suffer stigma and discrimination at work, in their communities, and at home from bearing these increased risks. effective coverage by the health workforce depends on availability, accessibility, acceptability, and quality of hws [2] . one of the top three factors reducing supply, along with migration and retirement, is the "risk of violence, illness or death" [3] . strategies to address the hw shortage ought to therefore include protecting hws by promoting their health and safety at work, particularly in high-risk settings. international organizations have developed tools to improve the occupational health and safety (ohs) of hws. one of these is healthwise, a participatory, quality improvement tool, jointly developed by the international labour organization (ilo) and the world health organization (who) [4] . in 2010, a tripartite group consisting of workers', employers', and governments' representatives, as well as specialists from the ilo and who, convened and agreed on a framework for improving the ohs of hws. based on principles from the original work improvement in small enterprises (wise) training program created by the ilo, healthwise was then developed to help support the implementation of this framework [4] . healthwise aims to improve working conditions, performance, and workplace safety through training and empowering hws with the ability to identify workplace hazards and areas requiring improvement in their work environments and to conduct processes for developing and implementing low-cost solutions to address them. healthwise consists of two workbooks, one for participants and one for trainers, with content organized into eight modules (figure 1 ). the workbooks are available online in five languages. as with addressing the supply of hws, the availability of the tool is only part of the solution. it is also important to understand the implementation of healthwise and to improve upon implementation processes to maximize the tool's potential. novel emerging threats from occupational exposure, including covid-19. they also suffer stigma and discrimination at work, in their communities, and at home from bearing these increased risks. effective coverage by the health workforce depends on availability, accessibility, acceptability, and quality of hws [2] . one of the top three factors reducing supply, along with migration and retirement, is the "risk of violence, illness or death" [3] . strategies to address the hw shortage ought to therefore include protecting hws by promoting their health and safety at work, particularly in high-risk settings. international organizations have developed tools to improve the occupational health and safety (ohs) of hws. one of these is healthwise, a participatory, quality improvement tool, jointly developed by the international labour organization (ilo) and the world health organization (who) [4] . in 2010, a tripartite group consisting of workers', employers', and governments' representatives, as well as specialists from the ilo and who, convened and agreed on a framework for improving the ohs of hws. based on principles from the original work improvement in small enterprises (wise) training program created by the ilo, healthwise was then developed to help support the implementation of this framework [4] . healthwise aims to improve working conditions, performance, and workplace safety through training and empowering hws with the ability to identify workplace hazards and areas requiring improvement in their work environments and to conduct processes for developing and implementing low-cost solutions to address them. healthwise consists of two workbooks, one for participants and one for trainers, with content organized into eight modules ( figure 1 ). the workbooks are available online in five languages. as with addressing the supply of hws, the availability of the tool is only part of the solution. it is also important to understand the implementation of healthwise and to improve upon implementation processes to maximize the tool's potential. implementation science is growing in the field of global health. madon and colleagues [5] called on researchers to (i) "develop theoretical models and new analytic methods that apply to resource poor settings" such as areas where hws are in short supply, (ii) build capacity and strengthen research institutions in lmics in regard to implementation science, in part to learn from valuable local knowledge and insights that influence implementation processes, and (iii) increase collaboration with governments, non-governmental organizations, and communities to incorporate research into implementation processes in order to improve upon them. implementation science is growing in the field of global health. madon and colleagues [5] called on researchers to (i) "develop theoretical models and new analytic methods that apply to resource poor settings" such as areas where hws are in short supply, (ii) build capacity and strengthen research institutions in lmics in regard to implementation science, in part to learn from valuable local knowledge and insights that influence implementation processes, and (iii) increase collaboration with governments, non-governmental organizations, and communities to incorporate research into implementation processes in order to improve upon them. this paper overviews the implementation of three healthwise modules in seven hospitals (designated the letters a through g) in mozambique, south africa, and zimbabwe. using the integrated promoting action on research implementation in health services (i-parihs) framework (described in "research methods" below), it aims to better understand the enabling factors and barriers to the implementation of healthwise in these hospitals and, considering previous implementation science research, to discuss how these might be leveraged or overcome in future implementations of healthwise. an existing north south partnership involving researchers and technical teams from canada and south africa [6] was expanded to include team members from mozambique and zimbabwe due to plans and interest to implement healthwise in those countries. this enabled a comparison of its implementation in different contexts. the three countries are in close proximity in the southern african region and represent high-risk settings where the ohs of hws is at different stages and resource levels and has yet to be fully given the importance that it is due. according to 2018 world bank classifications based on gross national income (gni) per capita, mozambique is a low-income country (gni per capita of us$460), south africa an upper-middle-income country (gni per capita of us$5750), and zimbabwe a lower-middle-income country (gni per capita of us$1790) [7] . total health expenditures per capita (and as a percentage of gross domestic product) from 2017 reflect this trend, with mozambique spending us$21.07 (4.94%), south africa us$499.24 (8.11%), and zimbabwe us$110.15 (6.64%) [8] . mozambique, south africa, and zimbabwe are amongst 30 high burden countries with regard to tb, tb and hiv co-infection, and multi-drug resistant tb [9] . in 2018, the incidence of tb per 100,000 people was 551 in mozambique, 520 in south africa, and 210 in zimbabwe. the total prevalence of hiv among their populations aged 15-49 was 12.6% in mozambique, 20.4% in south africa, and 12.7% in zimbabwe [8] . a planning meeting with representation from all countries was held in zimbabwe in february 2016. at this meeting, it was decided that the focus would be restricted to specific, related priority areas: biological hazards and infection control (module 3) and discrimination, harassment, and violence (module 4). over the following eight months, local team leads sought any necessary local, provincial, and national approvals and selected hospitals in which to implement healthwise. a total of seven hospitals participated: three in mozambique, two in south africa, and two in zimbabwe. implementation refers to the ensuing activities, including the introduction of healthwise, by training groups of hws at participating hospitals and the activities carried out by participants from this point through to the final capstone meeting. observation focused on if and how participants used healthwise in their hospitals and included the activities conducted by research team members, such as focus groups and questionnaires, to inquire into the enabling factors and barriers to its uptake and resultant activities. implementation was observed over 20 months, beginning with three training-of-trainers (tot) workshops (one per country) in october and november 2016. the three-day program was developed and carried out by local team members. in brief, the focus of day 1 was on introducing healthwise and modules 1 and 3. the focus of day 2 was on module 4. day 3 was devoted to developing healthwise action plans (activities to be carried out by trainees in their health facilities). throughout, participatory training techniques, including role plays and an interactive exercise on the topic of stigma [10] , were demonstrated, which might be useful for participants to help engage workers and disseminate new information in their workplaces. following the training, participants were expected to create healthwise teams and based on the healthwise principle of finding simple, low-cost solutions to workplace issues within their local contexts, carry out healthwise activities in their hospitals. based on budgets determined by the action plans, a small amount of project funds was made available for healthwise activities. additional practical training sessions were held in mozambique in july 2017 and in zimbabwe in february 2018. the healthwise teams trained during the tot workshops conducted walk-through assessments with the lay hws in one or more departments, helping to identify hazards and how they might be mitigated with low-or no-cost solutions. one year after the tot workshops, six follow-up workshops were held (one per hospital, with hospitals a and c in mozambique combined). during these workshops, participants presented on healthwise activities that had taken place in their facilities to date and participated in focus groups on the perceived enabling factors and barriers to implementing healthwise. participants were asked to individually brainstorm their own lists of enabling factors and barriers and to then read these out one-by-one and explain them to the group. questions and discussion were encouraged. participants in mozambique and south africa also completed an anonymous questionnaire. due to resource constraints within the hospitals, these questionnaires were unable to be administered in zimbabwe. shortly after the follow-up workshops, one representative from each hospital from all three countries attended a dissemination meeting in south africa to present on their progress implementing healthwise. the research focus of the project culminated in a final meeting in may 2018 in zimbabwe ( figure 2 ). one representative from each hospital presented on healthwise activities that had taken place to date and provided feedback on the implementation process and preliminary findings from the research. available for healthwise activities. additional practical training sessions were held in mozambique in july 2017 and in zimbabwe in february 2018. the healthwise teams trained during the tot workshops conducted walk-through assessments with the lay hws in one or more departments, helping to identify hazards and how they might be mitigated with low-or no-cost solutions. one year after the tot workshops, six follow-up workshops were held (one per hospital, with hospitals a and c in mozambique combined). during these workshops, participants presented on healthwise activities that had taken place in their facilities to date and participated in focus groups on the perceived enabling factors and barriers to implementing healthwise. participants were asked to individually brainstorm their own lists of enabling factors and barriers and to then read these out one-by-one and explain them to the group. questions and discussion were encouraged. participants in mozambique and south africa also completed an anonymous questionnaire. due to resource constraints within the hospitals, these questionnaires were unable to be administered in zimbabwe. shortly after the follow-up workshops, one representative from each hospital from all three countries attended a dissemination meeting in south africa to present on their progress implementing healthwise. the research focus of the project culminated in a final meeting in may 2018 in zimbabwe. one representative from each hospital presented on healthwise activities that had taken place to date and provided feedback on the implementation process and preliminary findings from the research. a multiple-case study, in which each hospital was treated as a single case, was used to examine the enabling factors and barriers to the implementation of healthwise [11] . within the case study, thematic analysis, "a method for identifying, analysing and reporting patterns (themes) within data", was used [12] . the integrated promoting action on research implementation in health services (i-parihs) framework was employed in this study [13] . the i-parihs framework was published in 2016, based on an earlier iteration from 1998 [14] and continues to be developed and refined. the framework describes four constructs related to implementation: (i) the 'innovation', or new knowledge informed by evidence-based research, that is being introduced; (ii) the 'recipients', or the individuals and teams who are involved in or affected by the implementation; (iii) the 'context', referring to three levels of local, organizational, and external health system settings in which the innovation is being implemented; and (iv) 'facilitation', or the strategies and actions performed by the facilitator(s) to enable implementation in response to the innovation and its recipients within their given context. the earlier version was classified as an explanatory framework that specified the relationship between the constructs [15] and while the integrated version maintains these linkages, the i-parihs framework is also descriptive as it breaks-down the constructs to further describe characteristics important to implementation. descriptive and explanatory frameworks are used to understand factors that might have positively or negatively influenced implementation processes [16] and given a multiple-case study, in which each hospital was treated as a single case, was used to examine the enabling factors and barriers to the implementation of healthwise [11] . within the case study, thematic analysis, "a method for identifying, analysing and reporting patterns (themes) within data", was used [12] . the integrated promoting action on research implementation in health services (i-parihs) framework was employed in this study [13] . the i-parihs framework was published in 2016, based on an earlier iteration from 1998 [14] and continues to be developed and refined. the framework describes four constructs related to implementation: (i) the 'innovation', or new knowledge informed by evidence-based research, that is being introduced; (ii) the 'recipients', or the individuals and teams who are involved in or affected by the implementation; (iii) the 'context', referring to three levels of local, organizational, and external health system settings in which the innovation is being implemented; and (iv) 'facilitation', or the strategies and actions performed by the facilitator(s) to enable implementation in response to the innovation and its recipients within their given context. the earlier version was classified as an explanatory framework that specified the relationship between the constructs [15] and while the integrated version maintains these linkages, the i-parihs framework is also descriptive as it breaks-down the constructs to further describe characteristics important to implementation. descriptive and explanatory frameworks are used to understand factors that might have positively or negatively influenced implementation processes [16] and given its continuing evolution, the i-parihs framework was chosen to explore the implementation of healthwise. it ought to be noted that several tools have been developed based on the original parihs framework to more thoroughly assess the context construct, including the context assessment for community health (coach) tool, specifically for use in lmics [17] . while the dimensions described therein were considered during this analysis, they are captured in the more recent i-parihs framework and the characteristics of the latter were therefore used. data were drawn from dissemination and capstone meeting presentations (powerpoint presentations), focus group transcripts (word documents generated from audio-recordings), and open-ended responses to completed anonymous questionnaires (paper and electronic pdf copies). using an inductive approach, three focus group transcripts, one from each country, were first open coded to generate a list of enabling factors and barriers. these codes were then compared and categorized according to the i-parihs constructs and characteristics to generate a draft codebook. the remaining three focus group transcripts were then coded using the draft codebook. some characteristics were subsequently removed or combined to refine the constructs and characteristics to those listed in tables 2-5 , which are the themes and sub-themes for the final codebook. using this codebook, all data were coded using nvivo 12 and excel to better understand the enabling factors and barriers to the implementation of healthwise. this study was approved by the behavioural research ethics board, university of british columbia, canada (h17-00286, h17-00039), the research ethics committee, university of pretoria, south africa (159/2017), and the medical research council of zimbabwe, zimbabwe (mrcz/a/2240). participants who were involved in the follow-up workshop focus groups, questionnaires, and dissemination and capstone meetings were provided with written information about the research objectives and processes prior to their involvement and individual informed consent was obtained. participation was voluntary and individuals were informed of their right to withdraw from the study at any time. all data was collected anonymously or de-identified before analysis to protect confidentiality. the seven participating hospitals ranged in size from 36 to 1652 beds and from approximately 139 to 4407 workers. in all hospitals, the workers were predominantly female. characteristics of the seven hospitals are presented in table 1 . results for the four constructs-innovation, recipients, context, and facilitation-are presented below, with quotes that help to reflect what was an enabling factor or barrier in the implementation of healthwise in each of the participating hospitals in mozambique, south africa, and zimbabwe. it is important to note that not all constructs or characteristics were explicitly mentioned by participants at each of the hospitals. this absence does not necessarily mean that a specific characteristic was or was not an enabling factor or barrier; while this could be the case, it could instead indicate that further questioning on specific characteristics of interest may be warranted in future studies. where a characteristic is designated as both an enabling factor and barrier (ef/b) within the tables, further information on how the implementation of healthwise was helped or hindered is provided in the ensuing description. the innovation construct included characteristics related to healthwise, the intervention being implemented. three of the seven characteristics of the innovation construct from the i-parihs framework were mentioned; whether they were enabling factors and/or barriers in each of the hospitals is shown in table 2 . table 2 . innovation construct characteristics and whether they were enabling factors (ef) and/or barriers (b) to the implementation of healthwise in each participating hospital (a-g). "clarity" about healthwise-what the tool was and why and how it was going to be used-was a key enabling factor in nearly all of the hospitals: "when personnel have been trained and they know . . . what is expected of them and what is going to be done, they are more cooperative than when they do not know" (hospital e, focus group). the "relative advantage" of healthwise-how it would be of benefit compared with existing interventions-particularly that the tool aimed to benefit workers and their working environment (as opposed to being focused solely on patients), helped to spur the implementation of healthwise in one hospital in mozambique and one hospital in south africa where the "anticipated positive results/effects of [the] healthwise project" (hospital d; capstone meeting) were an enabling factor. "observable results" were also mentioned as enabling the implementation of healthwise by one hospital in each country. in opposition, one barrier of the innovation construct, mentioned by all the hospitals in mozambique, was a lack of clarity or "lack of knowledge about exactly what to do" (hospital a, questionnaire). for some hospitals, there was also an inability to raise awareness about healthwise among hospital staff: "...we did not have much time to publicize this project to colleagues to understand what it was all about" (hospital b, focus group). one hospital in south africa echoed this lack of clarity and awareness, as represented by one comment of "supervisors not understanding the project" (hospital e, questionnaire). the recipients construct included characteristics related to the individuals and teams involved in, or affected by, the implementation of healthwise. the 11 characteristics of the recipients construct and whether they were enabling factors and/ or barriers in each of the hospitals are shown in table 3 . the "time, resources, support" characteristic from the i-parihs framework was split into four: "project funding", "human resources", "material resources", and "personal protective equipment (ppe)" to better capture their different impacts on the implementation of healthwise. two characteristics from the i-parihs framework, "values and beliefs" and "presence of boundaries", did not emerge during this analysis. table 3 . recipient construct characteristics and whether they were enabling factors (ef) and/or barriers (b) to the implementation of healthwise in each participating hospital (a-g). "motivation", or the "willingness of staff to participate in healthwise activities" (hospital c, capstone meeting), was mentioned as an enabling factor by hospitals c and f, where workers "showed much interest in this program" (hospital f, focus group). a lack of external incentives was mentioned as a barrier by both zimbabwe hospitals f and g, where "there is in most cases lack of incentives for trainers to keep their motivation high" (hospital f, dissemination meeting). lack of clear "goals and expectations" related to the implementation of healthwise was mentioned as a barrier by the three mozambique hospitals a, b, and c, where there was "difficulty of perception of some professionals about the objectives of the project" (hospital b, dissemination and capstone meetings) as well as "failure to comply with agreed deadlines" (hospital a, dissemination meeting). on the other hand, having clear "goals and expectations" was an enabling factor for both hospitals d and e in south africa and for hospital g in zimbabwe. goals came in different forms, such as an "attainable objective that was set by the team member" (hospital d, focus group), as well as "an action plan that served as our guiding point of reference" (hospital e, focus group). individual "skills and knowledge" related to ohs was both an enabling factor and barrier mentioned by hospitals a, b, and c in mozambique, depending on whether recipients were perceived as having or lacking ohs knowledge. there was some overlap with the culture characteristic in the context construct, which was discussed to a greater extent in zimbabwe and south africa. lack of "project funding" was mentioned as a barrier by all but one hospital in mozambique. "lack of resources for implementation" (hospital a, dissemination meeting), "financial constraint" (hospital e, questionnaire), and "lack of funding for full implementation of healthwise" (hospital f, capstone meeting) were some of the ways that this barrier was mentioned. since this initially proved to be a major constraint, it was addressed by local team members in all three countries through communication and practical training sessions that helped to redirect workers towards no-cost solutions. for example, a patient consultation room was rearranged to improve ventilation and reduce the risk of workers being exposed to airborne pathogens and, in the same area, ripped flooring that created a fall hazard was cut out and removed, as opposed to being replaced with new flooring (figure 3 ). workers involved in the practical training sessions expressed that "the search for solving problems that do not require financing was a great gain" (hospital a, focus group). where funding for larger project activities was available, it was an enabling factor. hospital c in mozambique was able to draw from external funding sources to begin construction of a new tb consultation and testing unit and laboratory when the old infrastructure was identified as a hazard by the healthwise team. one hospital in zimbabwe, which used project funds to purchase some equipment for their training sessions, indicated that the "allocation of funds" (hospital f, dissemination meeting) was an enabling factor to implementation in their hospital. "human resources" were a barrier mentioned by all hospitals except a and c in mozambique. all hospitals seemed to experience some degree of staff shortages, "when the departments are so shortstaffed, they are reluctant to take part in some of the activities and to attend some of the meetings" (hospital e, focus group); turnover, "staff movement, some people are exiting the system, others might be on night duty, you know, on leave" (hospital d, focus group); overwhelming "workload from the department" (hospital d, focus group); and lack of time, "we always have quite demanding tasks that we do every day, our jobs are quite demanding, so the lack of time maybe is one of the major barriers to the implementation" (hospital f, focus group). "material resources", including the availability of reference, training, and other materials for the practical application of healthwise were mentioned by all participating hospitals. where material resources were available, they were an enabling factor; where they were unavailable, they were a barrier. there was also an issue with the "scarcity of surgical medical material with an emphasis on personal protective equipment" (hospital b, capstone meeting) mentioned by the three hospitals in mozambique, however there were indications from one hospital in each south africa and zimbabwe that the process of implementing healthwise was helping to secure "some improvements in procurement e.g. availability of appropriate ppe for linen bank staff and food services personnel and respirators" (hospital e, capstone meeting) and that "if we procure that [ppe] then it will be, the healthwise program will be effective" (hospital g, focus group). where active and engaged, the "local opinion leaders", referring to the existing ohs teams or newly created healthwise teams, were an enabling factor. this was particularly the case at both hospitals in south africa, where ohs teams were in place before the implementation of the project. one was commended as a "knowledgeable, skilled, reliable and committed ohs team" (hospital d, capstone meeting) and the other as a diverse "healthwise team comprising of members from different departments e.g. hr [human resources], staff development, cleaning, ipc [infection prevention and control] and linen bank" (hospital e, capstone meeting), which helped contribute to their success. the smaller hospital in zimbabwe also noted their "dedicated healthwise champions" (hospital g, capstone meeting). the barrier was due to "peripheral involvement of medical doctors and the nurses' representative member" (hospital f, capstone meeting), again indicating that engagement of diverse teams was one of the keys to successful implementation. "collaboration and teamwork" were mentioned as enabling factors or, where lacking, as barriers by the three hospitals in mozambique. similar to the motivation characteristic or the willingness of the workers to engage in the healthwise project, this characteristic referred to the involvement and inclusion of workers. hospitals a and c felt that there was both "good participation and adherence from employees" as well as that "there must be greater involvement of employees in the healthwise project" (hospital a/c, focus group). "existing networks", referring to collaboration and communication within and between hospitals, was generally an enabling factor mentioned by six of the seven hospitals. communication, figure 3 . before (not shown), the physician's desk was positioned next to the window, with the patient to their right. after, the patient is positioned next to the window and the physician is seated on the opposite side of the desk, allowing the air to flow from the door outside. ripped flooring has been removed. "human resources" were a barrier mentioned by all hospitals except a and c in mozambique. all hospitals seemed to experience some degree of staff shortages, "when the departments are so short-staffed, they are reluctant to take part in some of the activities and to attend some of the meetings" (hospital e, focus group); turnover, "staff movement, some people are exiting the system, others might be on night duty, you know, on leave" (hospital d, focus group); overwhelming "workload from the department" (hospital d, focus group); and lack of time, "we always have quite demanding tasks that we do every day, our jobs are quite demanding, so the lack of time maybe is one of the major barriers to the implementation" (hospital f, focus group). "material resources", including the availability of reference, training, and other materials for the practical application of healthwise were mentioned by all participating hospitals. where material resources were available, they were an enabling factor; where they were unavailable, they were a barrier. there was also an issue with the "scarcity of surgical medical material with an emphasis on personal protective equipment" (hospital b, capstone meeting) mentioned by the three hospitals in mozambique, however there were indications from one hospital in each south africa and zimbabwe that the process of implementing healthwise was helping to secure "some improvements in procurement e.g., availability of appropriate ppe for linen bank staff and food services personnel and respirators" (hospital e, capstone meeting) and that "if we procure that [ppe] then it will be, the healthwise program will be effective" (hospital g, focus group). where active and engaged, the "local opinion leaders", referring to the existing ohs teams or newly created healthwise teams, were an enabling factor. this was particularly the case at both hospitals in south africa, where ohs teams were in place before the implementation of the project. one was commended as a "knowledgeable, skilled, reliable and committed ohs team" (hospital d, capstone meeting) and the other as a diverse "healthwise team comprising of members from different departments e.g., hr [human resources], staff development, cleaning, ipc [infection prevention and control] and linen bank" (hospital e, capstone meeting), which helped contribute to their success. the smaller hospital in zimbabwe also noted their "dedicated healthwise champions" (hospital g, capstone meeting). the barrier was due to "peripheral involvement of medical doctors and the nurses' representative member" (hospital f, capstone meeting), again indicating that engagement of diverse teams was one of the keys to successful implementation. "collaboration and teamwork" were mentioned as enabling factors or, where lacking, as barriers by the three hospitals in mozambique. similar to the motivation characteristic or the willingness of the workers to engage in the healthwise project, this characteristic referred to the involvement and inclusion of workers. hospitals a and c felt that there was both "good participation and adherence from employees" as well as that "there must be greater involvement of employees in the healthwise project" (hospital a/c, focus group). "existing networks", referring to collaboration and communication within and between hospitals, was generally an enabling factor mentioned by six of the seven hospitals. communication, expressed as "the exchange of information among workers and from workers to patients; reciprocal information sharing" (hospital a/c, questionnaire) was key, as was the "easy implementation and dissemination of information to colleagues" (hospital b, dissemination and capstone meetings). one participant from south africa mentioned that "hr has been absolutely amazing. having a member of hr in our healthwise team was the best thing" (hospital e, focus group), due to the improved communication between departments and with management that enabled more project activities to receive approval and take place. finally, the "collaboration between [hospital a] and [hospital c] -exchanged experiences and helped to overcome difficulties that were encountered" (hospital a/c, dissemination meeting) was particularly helpful. the barrier in this regard was "poor communication" (hospital d, capstone meeting). "power and authority" were identified as enabling factors for hospitals a, c, and g. this generally related to workers feeling empowered to take charge of their own health and safety. during the focus group, one participant mentioned the idea of greater ownership over their own safety: "for me the project came to change my way of thinking... i realized that i am able to improve . . . my safety in the workplace and not wait for the bosses to come to control something within the sector, and so it was positive for me" (hospitals a/c, focus group). this sentiment was shared by a participant in zimbabwe: "...when we started it was your program but now slowly it is becoming our program so if everyone is involved at that level then we are going to succeed" (hospital g, focus group). these feelings also manifested as achievements; at hospital c in mozambique, one team member used material from module 5, which was not part of the initial training, and worked and negotiated with management and the local municipality to more routinely dispose of waste that piled up on the hospital grounds. a "lack of authority to implement certain activities" (hospital e, capstone meeting) was a barrier mentioned by one hospital in south africa. the context construct included characteristics related to the setting in which the innovation was to be implemented. characteristics related to the local and organizational levels from the i-parihs framework were combined as these were difficult to piece apart and included six characteristics. the external health system level included three of five characteristics from the i-parihs framework, leaving out "policy drivers and priorities" and "incentives and mandates". identified enabling factors and/or barriers in each of the hospitals are shown in table 4 . "senior leadership and management support" was an enabling factor mentioned by all seven hospitals through comments such as "support from the management... and the participation of those in charge of the sectors" (hospital b, focus group), "buy-in from senior management" (hospital d, focus group), and "management acceptance of the program" (hospital g, focus group). "lack of support from some middle managers" (hospital d, capstone meeting) where, for instance, heads of departments were at times not willing or able to release workers from their duties to participate in healthwise activities, was a barrier in hospitals d, e, and f. elements of the "culture" characteristic were mentioned by five of the participating hospitals. where workers were perceived to have greater "commitment to work", with descriptions such as "strong workforce" (hospital g, focus group), this was designated as an enabling factor. in mozambique, "one of the barriers [was] that information [had] to be oral" since workers were "not in the habit of stopping to read" (hospital b, focus group). here, there were overlaps with the willingness of workers to participate and learn and the degree of teamwork and collaboration described in the recipients construct above. where difficulties were raised in regard to "knowledge application", this was designated as a barrier. in the two hospitals in south africa, a "lack of safety culture; lack of knowledge about the importance of ohs matters and the healthwise program" (hospital e, capstone meeting) was discussed as a barrier, referring to the idea that workers have ohs "knowledge but they are not interested [in applying it]" (hospital e, focus group). "negative hospital staff attitudes" (hospital d, capstone meeting) and "resistance to change" (hospital b, questionnaire) were also perceived as a barrier in several hospitals. one hospital in zimbabwe that had expanded the services of their regular staff wellness clinic as part of the implementation of healthwise also mentioned "fear to uptake services . . . due to fear of stigma and discrimination" (hospital g, capstone meeting). competing "organizational priorities" and programs were mentioned as a barrier by hospitals d, f, and g. hospital a seemed to have priorities and programs that served to support, instead of compete with, healthwise activities, indicating "reinforcement of the ongoing ipc activities; synergies have been built among healthwise and ipc" (hospital a, dissemination meeting). in regard to "structure and systems", infrastructure was a barrier mentioned by all hospitals. infrastructure was generally older and difficult to change and participants seemed to feel that "some infrastructure hinders the proper functioning of the project" (hospital a/c, focus group), such as the "lack of ramps to move trolleys" (hospital b, dissemination and capstone meetings) at one hospital in mozambique and that "buildings were not constructed in such a way that they allow for proper ventilation" (hospital f, focus group) at one hospital in zimbabwe. hospital g expressed that the "infrastructure . . . might not be ideal but we are going to work with what we have" (hospital g, focus group). "lack of a specific project space" (hospital a/c, focus group) was mentioned by one hospital in mozambique, while in south africa, both hospitals perceived the lack of a dedicated ohs clinic "where you can see your employees when they are sick" (hospital d, focus group) or "lack of equipment at our ohs clinics" (hospital e, questionnaire) as barriers as well. institution size, specifically in relation to the number of workers trained on healthwise, was also a barrier specifically mentioned by hospital f in zimbabwe. regarding "history of innovation and change", resistance to change was mentioned as a barrier by participants at hospitals a, b, c, e, and g. one participant from south africa indicated that "anytime there is a new project there will always be resistance . . . because people are used to the norm of how they usually do things" (hospital e, focus group) and another from mozambique indicated that "resistance to change on the part of some colleagues was a challenge in the past" (hospital b, questionnaire). "evaluation and feedback processes" were perceived to be both enabling factors and barriers to the implementation of healthwise. improvements to reporting procedures were an enabling factor in hospital a, demonstrated by the increased "willingness of staff to communicate accidents in the workplace" (hospital a, capstone meeting), however "lack of understanding and knowledge of procedures, e.g., incident reporting procedure" (hospital d, capstone meeting) and "poor reporting of incidents" (hospital e, capstone meeting) remained barriers elsewhere. lack of feedback was a barrier mentioned by hospitals b, d, and e. hospital b indicated the "need to find a way to get worker feedback" (hospital b, focus group) and hospital d felt that "if you don't give feedback to the unit . . . it may compromise participation at the later stage" (hospital d, focus group) . in regard to external context, existing ohs "regulatory frameworks" were mentioned as an enabling factor by the two hospitals in south africa, such as the existence of an "occupational health and safety act that we need to adhere to" (hospital d, focus group) . the "instability of the health system environment" was mentioned as a barrier by hospital f in zimbabwe, where significant political and socioeconomic changes and challenges occurred during the course of the project. having good "inter-organizational networks/relationships", particularly with trade unions that play more prominent roles in south africa, was mentioned as both an enabling factor and, where lacking, a barrier by hospitals d and e. the facilitation construct included characteristics related to the strategies and actions performed by the facilitator(s) to enable implementation by adapting healthwise in response to the workers who were asked to use it within the contexts of their hospitals and countries. two characteristics and whether they acted as enabling factors and/or barriers in each of the hospitals is shown in table 5 . table 5 . facilitation construct characteristics and whether they were enabling factors (ef) and/or barriers (b) to the implementation of healthwise in each participating hospital (a-g). at least one hospital in each country declared that the "healthwise trainings" were key enabling factors to the implementation of healthwise-that the tool would not have been implemented solely based on the workbooks being available. in the hospitals in mozambique, an identified barrier was that the "training time was too short" (hospital a/c, focus group) and was therefore insufficient to support the implementation process. the practical training sessions in mozambique and zimbabwe also helped participants with relatively less ohs experience better identify workplace hazards and solutions: "...what helped was a second meeting [implementation training]... when we realized what in theory we had to do in practice" (hospital a/c, focus group). ongoing "communication and support from the research team" was an enabling factor in five of the participating hospitals. the research team was available, however participants at the different hospitals reached out to varying degrees. in the hospitals in south africa, one member of the research team was more accessible to participants and was therefore able to more quickly answer questions and on occasion, help to troubleshoot issues that arose. at the same time, key participants at hospitals a and f in mozambique and zimbabwe, respectively, were also more engaged and would reach out more often if queries or problems arose and would, in turn, receive desired engagement. for instance, one worker expressed that "we had a permanent contact with the team that trained us . . . i would email him, and he would respond quickly" (hospital a, focus group). the research team was therefore accessible, however was used in different ways and amounts by participants at each hospital. where "continued interaction between the hospital and the research team" (hospital f, dissemination meeting) took place, it was perceived as an enabling factor. many programs and tools available for health facilities focus on measuring and improving patient health, quality of service, and safety culture and have been reviewed in several publications [18, 19] . the few that have been developed and studied related to hws include online infection control tools [20] and a seasonal influenza vaccination rate improvement tool [21] . healthwise is a widely available quality improvement tool that addresses a variety of ohs concerns encountered in health facilities, containing information and activities that are particularly suitable to areas with few resources and little ohs experience. while it has been piloted in several countries, including in senegal, the united republic of tanzania, and thailand, and has since been implemented in the united states [22], china [23] , and the gambia, few publications and reports discussing or evaluating these experiences are publicly available. this paper is therefore one of the first to detail the implementation of healthwise and provide an analysis of enabling factors and barriers encountered in different lmics during the process. applying the i-parihs framework enabled an identification of key enabling factors as characteristics of the "recipients" and "context" constructs and included the willingness of workers to engage in implementation, the presence of diverse teams that championed the implementation process, and supportive senior leadership. barriers were reported in all constructs and included a lack of clarity about how to use healthwise, insufficient funds, stretched human resources, older buildings, and lack of incident reporting infrastructure. overall, successful implementation of healthwise called for dedicated local research and technical team members who helped facilitate the process by adapting healthwise to the workers' ohs knowledge and skill levels and the cultures and needs of their hospitals, cutting across all constructs of the i-parihs framework. healthwise was well-received in all participating hospitals, demonstrating the importance of the innovation itself. workers in hospital a seemed especially interested in a tool that was aimed at their own needs as opposed to solely those of patients. in the majority of hospitals, even those that did not mention it explicitly, there was difficulty in fully understanding healthwise and how to use it, as well as how to spread awareness regarding its implementation throughout the hospital. the anticipated benefits or the results that were being observed over the course of the implementation spurred several hospitals forward. the research team felt there was room to improve the messaging related to healthwise, and future implementations might further explore how information related to the innovation impacts the implementation process. questions could explore what factors made healthwise more acceptable, such as its development by the ilo and who, the quality or contents of the materials, and its fit within existing hospital practices and values in order to explore additional aspects of the innovation construct. healthwise activities were accomplished in all hospitals due to the active efforts of healthwise recipients, the individuals and teams who were overall key to the implementation. barriers described in this study, including staff shortages, high workloads, and limited material resources, have been identified among common barriers to evidence implementation across clinical areas in lmics [24] . despite these issues, workers possessed a wealth of knowledge related to their hospitals and colleagues and therefore knew best when it came to implementing healthwise. while participants at hospitals in mozambique and zimbabwe mentioned feeling empowered and taking ownership over healthwise, more might have been done to help all teams recognize earlier on that their local insights and initiatives were what would make healthwise more successful. literature on team innovation and implementation points to the need for varied team composition to promote creativity and action [25] . where teams were more diverse, particularly where members helped link frontline workers to management, more activities seemed to receive approval and were able to move forward. having established ohs teams in both hospitals in south africa, along with the accompanying knowledge and skills, also enabled them to accomplish a variety of tasks. it seemed that healthwise was a catalyst to the implementation of available ohs policies and allowed workers to take ownership of their own health and safety, with the ohs professionals providing oversight. the importance of opinion leaders-"people who influence the opinions, attitudes, beliefs, motivations, and behaviors of others" [26] -has been shown in other examples of successful implementation processes and was similar here [27] . promoting collaboration and exchange between sites that are implementing the same innovation might be interesting to explore, since this was an enabling factor for hospitals a and c who worked together in mozambique and was of particular interest to participants in zimbabwe who expressed a desire to visit other sites and learn from them during the implementation process. implementing healthwise in hospitals in different countries enabled the exploration of several characteristics of the context construct, which in these low-resource settings were more often barriers to the implementation of healthwise rather than enabling factors. context has repeatedly been discussed as an important factor in regard to implementing various interventions, one that deserves more thorough definition and analysis [28] . findings from this study may help to better identify which characteristics are most important to the implementation of healthwise and, to some degree, other similar projects in lmics. in terms of the context construct, local and organizational factors were more often discussed than external health system ones. while senior management were supportive of the project in all hospitals and welcomed its implementation, middle management were perceived as a barrier at several sites. engaging more actively with middle management to explore strategies that would have allowed workers to be involved in healthwise activities, such as being relieved from their duties for a short time on a regular basis-perhaps one hour per week-to examine and improve their working environments, while also ensuring that their tasks remained fulfilled and that their departments ran smoothly, might have been one way to overcome this barrier. taking time to explain the longer-term potential of healthwise to the departments might have been another. the resistance by middle management highlighted the importance of communication and consultation across all levels of the hospital and all stakeholders when introducing new interventions to protect hws. birken and colleagues [29] developed a theory of the role of middle management in healthcare innovation implementation. engle and colleagues [30] expanded on this theory and found that middle management in organizations with "high change potential" promoted bidirectional communication and independent thinking and overall supported staff to facilitate implementation. emphasizing the goal of working within limits-of older infrastructure, inadequate human and material resources due to hiring freezes and health budgets, and manual incident reporting-might also have helped to avoid some blockages in the implementation process. also, given limited data collection and reporting procedures and mechanisms, understanding what type of feedback would have been attainable and useful might also have been helpful, as would have been pointing out synergies with existing organizational priorities and programs and external system regulatory frameworks and legislation. for the most part, workers were enthusiastic and engaged, although some negative attitudes and resistance to change were mentioned. a study by bergström and colleagues [31] that examined the organizational context construct of the earlier parihs framework found that hws' commitment to their work, or an "individual's devotion to the organization," had an impact on the implementation of knowledge translation interventions in uganda. change was less likely where commitment levels were lower and a shortage of human resources contributed to lower levels of commitment. this indicates that where human and possibly other resources are a barrier, organizational culture might need to be addressed and improved for implementation to be successful, particularly in low-resource settings. there is important interplay between constructs, particularly between "recipients" and "context". for instance, incentives that contribute to the motivation of participants and project funding for specific equipment and activities might be more effective in some contexts than others. a systematic review by liu and colleagues [32] found a range of macro, meso, and micro level context factors that influenced the types and impacts of incentives on the recruitment and retention of hws in multiple countries. in our study, participants from zimbabwe, where macro level political and socioeconomic factors were straining the country, mentioned that incentives might have been helpful for full participation. they were also initially focused on needing project funding to move forward with any activities and hospital f was the only facility to indicate that the allocation of funds enabled the implementation of healthwise. while our study did not specifically study the effects of externally funded projects, we got the impression that some participants were expecting extra incentives to motivate their participation. we acknowledge, however, that the local conditions and previous experiences with externally funded projects might contribute to this seeming dependency and expectation in lmics. harvey and colleagues [33] conducted a concept analysis of facilitation and presented the role of the facilitator as one of "supporting people to change their practice". this healthwise study used appointed facilitators, external to the hospitals, who focused on building capacity in ohs in order to enable change, all which fit within the defining characteristics of facilitation that they describe. hospital a, b, and c in mozambique considered the healthwise trainings useful, but too short, compared with hospitals d and g in south africa and zimbabwe, respectively, which alluded to them only as enabling the implementation of healthwise. all tot workshops were conducted in english; in mozambique, simultaneous audio translation using headsets and all materials, including the healthwise manuals, were available in portuguese. additional time may have been warranted due to the language difference, since interpretation demanded a slower pace and longer explanations. for hospitals a, c, d, e, and f, where participants communicated with the research team, this was perceived as an enabling factor. the process of communication, including tools for translation, ought to have been made clear to participants and questions encouraged, particularly following the tot workshops to help the initial implementation gain momentum, as opposed to waiting six months for check-in meetings. overall, the actions carried out by local team members were key to the implementation of healthwise. other studies have demonstrated the critical role of external facilitators and shown links between the different constructs of the parihs framework. a study by ellis and colleagues found that "good facilitation appears to be more influential than context in overcoming the barriers to the uptake of [evidence-based practice]" [34] . this experience helps to show that the roles of the facilitators were key and that improved facilitation across the different constructs could enhance the implementation. for example, facilitators could emphasize both the knowledge and practical aspects of the tool, improving its clarity; they could adapt the training based on workers' levels of knowledge and skills in regard to ohs; they could demonstrate how the tool fits within the workplace in relation to the hospital's mission and to other programs and priorities, and help participants advocate for its implementation to improve both worker and patient safety and to better align with existing ohs legislation. a key strength of this project was the existing north-south partnership, which enabled the collaboration between multiple countries, one in the global north and three in the global south [6] . according to landau [35] , "international research partnerships enact and expose the inequalities, structural constraints, and historically conditioned power relations implicit in the production of knowledge". caution is needed and care must be taken to mitigate factors that could exacerbate inequalities and inequities. in this study, local research partners and team members were instrumental in initiating, carrying out, and sustaining the project. one specific measure that was taken was to provide as much direct budget control to the southern partners as the funder permitted. some limitations were related to administrative issues, such as delays securing approvals from multiple countries and facilities. data collection instruments ought to also have been piloted, particularly following translation to portuguese, and streamlined to avoid overburdening participants. this may also have helped to reduce the missing data from incomplete questionnaires; as it stands, further research is required to fully understand the more nuanced aspects of certain constructs, particularly context, where responses were not specific or detailed enough to comprehend how minor differences affected implementation. understanding how healthwise-related changes affected the ohs of hws was a desired yet difficult-to-capture aspect of this study, particularly due to insufficient existing incident reporting procedures and data collection systems at the participating hospitals. therefore, while we were able to describe some improvements that were made, we were limited in assessing ohs outcomes and focused instead on enabling factors and barriers to implementation. as a final reflection on our experience, it is worth noting that the research team initially intended to participate as mere observers to the implementation of healthwise, to understand how a standalone tool to improve the health and safety of workers, introduced via a single training session, was implemented in different hospitals in different countries. this hands-off approach was also used to discourage dependency on local teams, whose resources and time are limited, and on international funds, of which there are less and less. however, the capacities of the countries to implement healthwise were limited by their differing knowledge and skill levels in regard to ohs; while hospitals in south africa had workers who specialized in ohs and existing committees, hospitals in mozambique and even more so in zimbabwe needed to start with more basic training. implementation was also limited by resources, which were undeniably scarce in all three countries, but again, especially so in mozambique and zimbabwe, as well as by the expectation that external funds were the solution. the team gradually increased their level of facilitation, providing additional practical training and encouraging larger hospitals to start small by focusing on one department instead of being overwhelmed by the whole hospital. this shows that in some contexts, a standalone tool is insufficient and a more robust toolbox that addresses the need to build capacity in implementation science is needed. future work is focused on developing and testing preparation strategies and materials that might make it easier for individuals and teams who are keen to improve the ohs of their health facilities to do so independently using healthwise. documenting experiences implementing healthwise and other tools, including any adaptations made, and making these available via publication or central repository ought to also be encouraged. the effort to develop tools for protecting hws must be accompanied by comparable attention to the way in which these instruments are implemented in settings of need. our study of the implementation of healthwise in seven hospitals in the southern african region provides clear documentation of how a variety of enabling factors and barriers can influence success. building on methods, such as the application of the i-parihs framework which we pursued, a valuable evidence base can be built to support efforts for ensuring that improved work environments for hws are part of strengthened health systems. with this vision, future implementations ought to focus on areas such as providing clarity about the tool and helping participants to develop clear goals and expectations based on their ohs knowledge and skill levels and on the amount of resources and time available to them. securing support from senior leadership and middle management and assembling a dedicated and diverse healthwise team would also be beneficial. emphasizing the need to work within existing constraints and find no-or low-cost solutions is also key in resource-poor areas. future research might focus on examining construct characteristics in further detail and on testing ways to overcome obstacles, as well as on what additional materials might help to create a toolbox, as opposed to a standalone tool, to enable facilities to implement healthwise on their own. promoting and improving the health and safety of hws at work is part of the solution to increasing recruitment and retention of these essential workers and curbing current and projected shortages in the global health workforce. 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attribution (cc by) license we would like to acknowledge the dedicated health workers who participated in the implementation of healthwise at each of the participating hospitals. we would also like to acknowledge the in-kind contributions from team members and staff at the international labour organization and the national institute for occupational health for their time and expertise in ohs. sincere thank you to ana tina titos mutola jemuce, jonathan ramodike, and shamiso muteti fana for their contributions to this project. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-268176-tb12txdf authors: garcia de avila, marla andréia; hamamoto filho, pedro tadao; jacob, francine letícia da silva; alcantara, léia regina souza; berghammer, malin; jenholt nolbris, margaretha; olaya-contreras, patricia; nilsson, stefan title: children’s anxiety and factors related to the covid-19 pandemic: an exploratory study using the children’s anxiety questionnaire and the numerical rating scale date: 2020-08-09 journal: int j environ res public health doi: 10.3390/ijerph17165757 sha: doc_id: 268176 cord_uid: tb12txdf the repercussions of the covid-19 pandemic on children’s lives deserve attention. this study aimed to assess the prevalence of anxiety among brazilian children and its associated factors during social distancing during covid-19. we used a cross-sectional design with an online survey from april to may 2020 in brazil. we included children aged 6–12 years and their guardians. the children’s anxiety questionnaire (caq; scores 4–12) and the numerical rating scale (nrs; scores 0–10) were used to measure anxiety. we enrolled 157 girls and 132 boys, with a mean age of 8.84 (±2.05) years; 88.9% of respondents were mothers. based on caq ≥ 9, the prevalence of anxiety was 19.4% (n = 56), and higher among children with parents with essential jobs and those who were social distancing without parents. in logistic regression, the following variables were associated with higher caq scores: social distancing without parents; more persons living together in home; and education level of guardians. based on nrs > 7, the prevalence of anxiety was 21.8% (n = 63); however, no associations with nrs scores were found with the investigated variables. these findings suggest the necessity of implementing public health actions targeting these parents and their children at the population level. coronaviruses are a large family of enveloped, single-stranded, zoonotic rna viruses. a novel form of the coronavirus-sars-cov-2-causes covid-19, which was first reported in china, and has caused a global pandemic [1] . the spread of covid-19 infection requires continually improving knowledge about its epidemiology [2] . in brazil, sars-cov-2 has greatly influenced children nationwide; events such as school closures have affected daily life [1] . however, groups have expressed the importance of maintaining the educational opportunities of children, despite the covid-19 int. j. environ. res. public health 2020, 17, 5757 2 of 13 pandemic [3] . it is important that children have access to peers to maintain social and cognitive development. additionally, the lack of access to such services can be particularly harmful for vulnerable children and/or families; notably, there has been an increase in physical, emotional, and sexual violence against children reported during the covid-19 pandemic [4] . the covid-19 symptoms in children are milder than in adults; children have a better prognosis, and deaths are extremely rare [5] . a systematic review reported that children with covid-19 often recovered within 1-2 weeks after disease onset. at that time, no cases of death from covid-19 had been reported in the age range of 0 to 9 years, and only one death in the age range of 10 to 19 years [2] . although most children appear to experience less severe physical illness and have much lower mortality rates than other age groups from covid-19 infection, they remain at substantial risk for negative outcomes given the widespread economic and societal disruption resulting from the pandemic [6] . the consequences of covid-19 on children are vast in terms of their health, safety, and well-being [7] . the influence of changes in the daily lives of children should not be underestimated. other family members' health and emotional states will affect children, and negative influences from the environment could greatly impact their health. the covid-19 pandemic has led to isolation and restrictions, which are significantly disrupting for children; they are not well understood, and have been shown to be both confusing and frightening [7] . studies have consistently concluded that quarantine was an important public health measure to reduce the number of people infected and the number of deaths [8] . however, the social distancing that has been imposed on children has caused massive upheaval [7] . children have received home schooling under the guidance of their parents or carers, whose attention was divided among taking care of the children, the home, and the home office. most publications about people´s anxiety levels in conjunction with covid-19 have focussed on adults; attention should also be paid to children's situations. an increase in the prevalence of depression, insomnia, post-traumatic stress disorders, and feelings of anger and frustration was observed in a population from the city of wuhan, china [9] . a population-based study in hong kong during the covid-19 pandemic showed that 14% had anxiety [10] . the majority of the respondents in a chinese study during covid-19 were women, and 28.8% reported moderate to severe anxiety [11] . children´s development has been influenced by the covid-19 pandemic; their health is influenced by their experiences, as well as that of the adults around them [12] . the world health organisation has presented recommendations for facing the psychological and mental consequences of the pandemic, which is essential for children. they must also have opportunities to express their fears and doubts in their own ways. it was therefore important to measure the experiences of children at the height of the pandemic of the century. it was necessary to listen to how children described their experiences, anxiety levels, and perspectives during the covid-19 pandemic [13] . the present study highlights children´s perspectives by using a questionnaire adapted for children. the aim of the study was to assess the prevalence of anxiety among brazilian schoolchildren and study the anxiety factors associated with social distancing during the global covid-19 pandemic. a cross-sectional study using non-probability and convenience sampling methods was conducted between 25 april and 25 may 2020 in brazil. we used an online survey to collect information (https://forms.gle/qhkt4hxqbuntz4pc6). the study sample consisted of brazilian children between 6 and 12 years of age and their guardians, all of whom were social distancing. guardians under 18 years of age were excluded from this study. the children´s anxiety questionnaire (caq, scores range from 4 to 12) and the numerical rating scale (nrs, scores range 0 to 10) were used to measure anxiety in the children. the authors of the caq, a swedish instrument, aimed to develop a questionnaire that would be easy to administer, had solid psychometric measures, and could be used to assess self-reported anxiety in young children [14, 15] . it is based on the state-trait anxiety inventory [16] . the caq contains four items with four images of facial expressions, with three response options, each representative of a different level of emotional intensity [14, 15] . the children give their responses based on the four facial expressions, one at a time, and then choose between three steps (i.e., a little (1), some (2) , and a lot (3)). the faces of happy/content and calm/relaxed are measured as 3-2-1, and the faces of tense/nervous and worried/afraid are measured as 1-2-3. the range for this instrument is 4 to 12 points, with 4 points signifying no anxiety and 12 points signifying the highest level of anxiety. recently, the caq in brazilian portuguese was validated, as demonstrated by satisfactory results among professionals and children; however, these data are unpublished. the caq has previously shown construct validity in conjunction with out-patient surgery [14, 17] . the nrs is an 11-point scale that is scored from 0 to 10. in the past few decades, the nrs has been validated for the evaluation of pain intensity in children [18] and assessing unpleasantness. however, there are no agreed upon nrs anchors for measuring unpleasantness in children [19] . in this study, anxiety was assessed using the nrs, wherein 0 was equivalent to 'calm', and 10 meant 'very anxious'. mild anxiety is expressed with scores of 1, and 2; moderate anxiety: 3, 4, 5, 6, and 7; and intense anxiety 8, 9, and 10 [20] . the nrs is easy to administer, and there is good evidence for its construct validity [19] . similar forms of self-reports have previously been validated for use in school-aged children who have undergone care in hospitals [21, 22] . an online survey using the google forms platform was distributed by three researchers through social media (twitter, facebook, instagram) and personal contacts (whatsapp) that expanded through snowballing. a brief written description of the study and its objectives was sent to guardians. we instructed the guardians and children about how to participate and guided the guardians on how to fill in their data and conduct the interview with their children. the online survey evaluated the sociodemographic profiles and current conditions regarding the social distancing and isolation of the children and their guardians. the guardians used the caq and the nrs following the survey instructions; the survey had a total of 25 questions. the quantitative variables measured for children were: gender; age; if they were on vacation; if they were home schooling; social distancing with the father, mother, both, or others; if the parents had an essential job; if they had a chronic disease or disability; how many people were in the same house; suspected or confirmed diagnosis of covid-19 in the house; for how long the children had been social distancing; and the size of their home. the quantitative variables for guardians were: relationship with the children (mother, father, and others), schooling (elementary school, high school, college, or postgraduate degree); income reduced during the pandemic (yes or no); and guardians were asked about how much they thought their children understood the pandemic (a lot, some, a little, or nothing). to test the normal distribution of the data, the shapiro-wilk test was used. comparisons between the groups were performed using the mann-whitney-u test for unpaired data that were not normally distributed. for multiple-group comparisons, the kruskal-wallis tests, followed by dunn's tests, were performed. the scores were handled as ordinal data, and thus, the spearman´s rho correlation coefficients were calculated between the caq and nrs scores. the chi-square test, as a two-tailed test (n > 30), and fisher´s exact test were employed to compare proportions in the different groups. odds ratios (or) were calculated to test the association between the outcome variables, such as the dependent variable (nrs or caq), as binary categories defined (</>): for the caq, a score higher/lower than the mean value plus a standard deviation, the cut-off value was set at the level [low < 9 or high ≥ 9]); scores of 9 and higher than 9 indicated intense anxiety. for the nrs, the cut-off value was set at the level [low ≤ 7 or high > 7]; thus, scores of 8 or higher indicated intense anxiety. a logistic regression was performed to test associations between the dependent variable (i.e., high (≥9) or low anxiety scores of the caq and (>7) nrs, respectively) and the independent variables. for all tests, the level of statistical significance was set at 5%. for the statistical analyses, we used ibm spss statistics for macbook, version 24 (ibm corp., armonk, n.y., usa). this research was approved by the research ethics committee of brazil (caae: 30547320.0.0000.0008 and opinion n • 4.128.847) and complied with resolution no. 510/2016, which establishes the guidelines and regulatory rules for research involving humans. the guardians and children agreed to participate in the research through an electronic record/register. of the 289 children and their guardians who were included in this study, 54.3% (n = 157) were girls, and 45.7% (n = 132) were boys, with a median age of 9 years (interquartile range = 4). most of them (45.7%, n = 132) were social distancing with both parents; 27% (n = 77) were with their mothers; 8% (n = 24) were with their fathers, and 19% (n = 56) were with someone else. few children had a suspected or confirmed diagnosis of covid-19 (1.7%, n = 5 and 5.9%, n = 17, respectively). over half of the children were on vacation (53%, n = 153), and 90% (n = 261) of the children were being home schooled; they did not attend physically. nearly sixty percent (58%, n = 168) of the guardians reported that their children understood the actual pandemic situation relatively well. among the guardians, 257 (88.9%) were mothers, 11 (4%) were fathers, and 20 (7%) had another type of relationship with the children. they had a mean age of 38.97 (±6.54) years. of the guardians, 46.4% (n = 134) had completed postgraduate studies, 31.1% (n = 90) had graduated from university, 16.3% (n = 47) had finished high school, and 6.2% (n = 18) had completed elementary school. on average, roughly four people (±1.38) were living at home, the house size was 212.02 m 2 (±sd 402.85), and the hours spent social distancing was 22/day (±7.71). over half (53%, n = 153) said their normal income had decreased, and 18% (n = 51) replied that the mother or father had maintained an essential job. according to the descriptive analyses, the girls scored higher on caq than the boys did (p = 0.047, median test); however, these differences were not found for the nrs (p = 0.929). children who were maintaining social distance with both their parents had lower scores on the caq than those who were isolated with a person other than their parents (p = 0.002). there were no significant differences in the scores of caq or nrs in terms of whether the child was on vacation, was being home schooled, or had an immediate connection to someone with a covid-19 diagnosis, the level of the child's comprehension, or a decrease in household income. there were no statistical differences between the prevalence of anxiety, for caq (p = 0.879), or for nrs by the age of the children (p = 0.408) ( table 1) . table 2 shows the prevalence of anxiety according to both scales by the associated variables. according to caq (caq ≥ 9), the prevalence of anxiety was 19.4% (n = 56). for girls, the prevalence was 21% (n = 33) and, for boys, 17.4% (n= 23), without statistical difference. the prevalence of anxiety according to nrs (nrs > 7) was 21.8% (n = 63), and there were no statistically significant differences in the prevalence between the girls 22.3% (n = 35) and boys 21.2% (n = 28) ( table 2 ). according to the caq scores, the prevalence of anxiety was higher among the children with parents with essential jobs, 31.4% (n = 16) vs. 16 .8% (n = 40), and when keeping social distance without parents (35.7%, n = 20). this was followed by social distancing only with the mother (20.8%, n = 16). lower scores were found among children who were staying only with their fathers or with both guardians. there were no statistically significant differences for nrs and the studied variables, but the prevalence of anxiety was highest among the children who maintained social distance with someone other than the parents (28.6%, n = 16). regarding the age of the guardians (figure 1) , there was an inverse association between the age of the caregiver and the children's scores on the caq (p = 0.002). this association did not reach statistical significance for the nrs scores (p = 0.078). furthermore, the correlation between the caq and nrs scores was weak but significant (r = 0.461; p < 0.001). the prevalence of anxiety was highest among the children who maintained social distance with someone other than the parents (28.6%, n = 16). regarding the age of the guardians (figure 1) , there was an inverse association between the age of the caregiver and the children's scores on the caq (p = 0.002). this association did not reach statistical significance for the nrs scores (p = 0.078). furthermore, the correlation between the caq and nrs scores was weak but significant (r = 0.461; p < 0.001). as shown in table 3 , children with guardians who had a higher educational level exhibited more comprehension of the pandemic than did children whose guardians received less education. among the six children with no comprehension of the situation, three were cared for by guardians with the lowest level of education. figure 2 shows the respective caq and nrs scores of the children and their perceived comprehension of the pandemic categorised as a lot, some, a little, and nothing. there was no association between the children's perceived comprehension of the situation and their scores on caq (p = 0.416) or nrs (p = 0.283). the children who understood the pandemic situation did not exhibit more anxiety than those who did not understand it at all (figure 2 ). as shown in table 3 , children with guardians who had a higher educational level exhibited more comprehension of the pandemic than did children whose guardians received less education. among the six children with no comprehension of the situation, three were cared for by guardians with the lowest level of education. we found that age distribution differed between the education level groups (p = 0.002). post hoc analysis showed that the difference was between high school and postgraduate; postgraduates were older than those who had only finished high school (p = 0.001). table 3 shows the association between caq scores and the independent variables included in the study. higher levels of anxiety (caq ≥ 9) were associated with social distancing, the number of persons at home, guardians' age, and education level of the guardians. children keeping social distance without their parents had higher levels of anxiety than children with both parents at home (p = 0.029). the greater the number of persons at home, the greater the anxiety score (p = 0.024). regarding the guardians' education level, children whose guardians had a postgraduate (p = 0.019) or university education level (p = 0.024) had lower anxiety scores on the caq than those whose guardians had only elementary school (reference category). in line with the descriptive analyses, a positive statistical significance was found for the interaction between the guardians' age and education level (p = 0.022). children whose guardians were among the youngest and with the lowest levels of education among the participants had higher caq scores than children whose guardians were older and more educated (for postgraduate b = 0.996, for university graduate b = 0.995, p < 0.05; table 4 ). we found that age distribution differed between the education level groups (p = 0.002). post hoc analysis showed that the difference was between high school and postgraduate; postgraduates were older than those who had only finished high school (p = 0.001). table 3 shows the association between caq scores and the independent variables included in the study. higher levels of anxiety (caq ≥ 9) were associated with social distancing, the number of persons at home, guardians' age, and education level of the guardians. children keeping social distance without their parents had higher levels of anxiety than children with both parents at home (p = 0.029). the greater the number of persons at home, the greater the anxiety score (p = 0.024). regarding the guardians' education level, children whose guardians had a postgraduate (p = 0.019) or university education level (p = 0.024) had lower anxiety scores on the caq than those whose guardians had only elementary school (reference category). in line with the descriptive analyses, a positive statistical significance was found for the interaction between the guardians' age and education level (p = 0.022). children whose guardians were among the youngest and with the lowest levels of education among the participants had higher caq scores than children whose guardians were older and more educated (for postgraduate b = 0.996, for university graduate b = 0.995, p < 0.05; table 4 ). table 5 shows the results of the binary logistic regression for nrs and the independent variables included in the study. no association was found between the nrs scores and the studied variables. independent of the selected cut-off value of nrs > 6, > 7, or ≥ 9, there was no association between the nrs scores and the covariates, or when using logistic regression or multinomial regression analyses. multinomial regression analysis revealed that when the dependent variable was set as a group of anxiety (mild, moderate, and intense), unlike the caq score, none of the variables was guardians for the anxiety reported with the nrs scores, except for confirmed covid-19 cases at home, which was guardians for a difference between mild and moderate anxiety (data not shown). the present study assessed children's anxiety during the covid-19 pandemic in order to assist healthcare professionals in understanding children´s reports of anxiety. comprehending children's emotions was quite challenging, because the situations they experienced may not have characteristics in common with any previous event in their lives. thus, giving them a voice was an essential strategy. in the present study, the prevalence of anxiety among children was between 19.4% (n = 56), using the caq, and 21.8% (n = 63), using the nrs. compared to previous research, this study found a high prevalence of anxiety. the worldwide prevalence of any anxiety disorder among children according to diagnostic and statistical manual (dsm) and international statistical classification of diseases and related health problems (icd) was shown to be 6.5% [23] . in brazilian preadolescents (aged 11-12 years), the prevalence of anxiety was 6.2% according to the icd-10 classification [24] . in the united states, a study that analysed data from the 2016 national survey of children's health (nsch), reported that the prevalence of anxiety was 7.1% among children aged 3-17 years (6.6% in children aged 6-11 years and 10.5% in children aged 12-17) [25] . however, the criteria for dsm and icd were not used in our study. previous research suggested an association between seropositivity for coronaviruses and a history of mood disorders [26] . it is also thought that the severity of a stress reaction is related to the degree of exposure to a disaster. for example, earthquakes that damaged houses and family members were associated with more severe fear, anxiety, depression, or physical symptoms. young schoolchildren and girls were especially vulnerable [27] . another study demonstrated that these anxiety symptoms were more often associated with girls [28] . in our study, greater levels of anxiety were also exhibited by girls than boys. our data collection was based on children's self-reports of anxiety. it is important to use validated instruments that can gauge what they are intended to measure. the caq is a newly developed instrument that needs further validation. for example, the appropriate cut-off score has not been confirmed. however, the caq has been used in a couple of studies [14, 17] . as for the children's characterisation, the mean age group was approximately 8.8 years, with a slight increase in girls. among their guardians, most had university and postgraduate levels of education. according to the instituto brasileiro de geografia e estatística (ibge), the level of education of the brazilian population over 25 years old was distributed as follows: 6.4% had no schooling, 40.2% had incomplete or complete elementary school, 31.9% had incomplete or complete high school, 4.0% were incomplete graduate, and 17.4% were complete graduate [29] . the possibility of selection bias should be considered because of the exclusion of digital illiterates who were not involved in this study. this has been reported previously [30] . however, the use of digital environments for data collection was the most suitable for the current pandemic, and internet research was safer and more convenient for participants. the present study shows that guardians´education levels affect their children's perceived comprehension of the situation but not their anxiety levels. however, the guardians´age in combination with their education level directly affect their children's anxiety level. guardians with higher education could probably offer more support to their children in several ways. they could invite their children to speak about covid-19, could listen with the aim of understanding what their children knew, and explain misunderstandings. these parents may be providing further information about the prevention of virus contagion. they could be creating a safe environment where emotions can be freely expressed so that they can pay attention to their children's anxiety levels and filling evenings/after-dinner time with pleasant activities [31] . the lowest education level in parents corresponds to the highest prevalence of obese school children (aged 8 to 9 years) [32] , and an association has been found between parental education and parent-reported child mental health (for children aged 4 to 11 years old) [33] . children have the right to understand what is happening around them as it can affect them. covid-19 is a global threat, which children can hear about even as it affects them and their loved ones. the rights of children [34] continue to matter even during covid-19, including the articles of the child convention in terms of development, democratic rights education, protection, right to one's own family, and right to support. children's perceived comprehension can be a positive aspect during the pandemic. according to unicef, children might find it difficult to understand what they are seeing online or on tv, and they are vulnerable to anxiety, stress, and sadness. the guideline 'how to talk to your child about covid-19 recommends that parents ask their children open questions and that they listen to the answers. other recommendations include that parents be honest and use age-appropriate language, watch their children's reactions, show sensitivity to their anxiety levels, and close conversations with care [35] . play is an essential part of children's physical and social development; however, during isolation and social distancing, the world is relying on technology to learn, live, and stay connected [36] . the most important thing for children is to have adults around them to meet their needs and to help them feel secure, calm, and supported in their own sense of control [37] . children feel better when they can communicate their feelings in a supportive environment. adults need to be authentic about the uncertainty and psychological challenges of the pandemic, without overwhelming children with their own fears. this honesty should encompass a coherent explanation for what the children are observing and grant permission for children to safely talk about their feelings [38] . the majority of the guardians in this study were older (mean age: 38.97 years); however, we found that the younger the guardians were, the higher the anxiety levels exhibited by the children. it may be a question of the resilience of the guardians; perhaps, it was a question of the stability of their professions and finances when exhibiting worries to the child. another factor to consider was that young guardians in this socioeconomic group had fewer children; it was possible that these children did not have other children to play together with. neither possibility was investigated in this study. these findings were in line with previous studies of how the age of parents, especially the mother, affect the mental health of children, among other health conditions and outcomes. remmerswaal and muris [39] found during the previous swine flu that children aged 7-12 years had a significant relationship between their level of fear and their parents' level of fear. in another study, children whose mothers had a high level of education, compared to children with uneducated mothers, showed a reduced risk of suffering from emotional difficulties [40] . similar results have also been reported during the covid-19 pandemic; a correlation was found between mothers' state of anxiety scores and the trait anxiety scores of their children (ages 9 to 12 years old) [41] . children who were keeping social distance with both their mother and father had lower caq scores than those who were isolated with a person other than their parents. this finding confirmed the important role of parents in children's lives, perhaps especially in this pandemic. a study conducted in china reported the presence of psychological difficulties in children during the covid-19 pandemic, with fear, clinging, inattention, and irritability as the most severe symptoms for younger children [42] . parents and other family members are encouraged to increase their communication with children to address their fears and concerns, play games, engage in physical activity, and use music therapy in the form of singing to reduce the worry, fear, and stress that children may feel [43] . another interesting result in the present study showed the opposite: parents who kept their jobs had children who experienced more anxiety. this result highlights children´s insecurity when their parents are not with them during the crisis. the serious implications of this finding and experiences from the covid-19 pandemic highlight the need for effective strategies to strengthen families and help them protect the children [44] . parents' presence is important for children, and children need to feel safe within their families. if children lack emotion-focused conversations with their parents, it can lead to anxiety about the emotional state of their parents [32] . the significance of the correlations between children´s anxiety levels and other factors was only shown in caq scores, not in the nrs scores. the caq considers different feelings/domains in measuring a child's anxiety than the nrs. the focus of the caq on anxiety-compared to the nrs, which only has one item on anxiety-may explain this difference; however, further studies are needed to investigate the causes of this difference. however, the prevalence of anxiety found in this group was similar between the caq and nrs. minimising children's anxiety may depend on addressing children's restriction from engaging in their regular activities. other aspects of the pandemic will appear with time. intensive research to find a vaccination will provide new research questions among children. the experience of benefits and risks with vaccination, and accessibility to vaccination will prompt repeating this study on children´s reported anxiety. this study had several limitations. first, the data collection occurred online; this excluded participants without the computer skills necessary to access the survey, and probably there was a selection bias arising from the social media interpersonal connections through which the survey was circulated. second, we guided participants on how to use the caq and nrs with their children, but we are unsure if they filled in the instruments according to our recommendations. third, we did not investigate how many children were in the same house; we did not exclude guardians who participated twice, since they had two children. finally, the questionnaire did not capture how well the children actually comprehended the situation, but the adults' opinion on this. there was no objective measurement of the children's understanding; the adult respondents were asked their subjective opinion of the extent to which the children understood the pandemic, taking age into consideration. therefore, caution should be taken in generalising the results to the brazilian population. the prevalence of anxiety among the children during the covid-19 pandemic in this group was 19.4% (n = 56), according to the caq, and 21.8% (n = 63), according to the nrs. these results are higher than the prevalence reported for children under normal conditions (6.5%). higher levels of anxiety were associated with social distancing without parents, a higher number of persons living at home, and a low education level reported for the parent or guardian. the highest levels of anxiety were found among children with both young and less educated guardians. these findings suggest the necessity of implementing public health actions targeting these parents and their children at the population level. severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection in children and adolescents: a systematic review supporting the continuation of teaching and learning during the covid-19 pandemic annotated resources for online learning challenges and burden of the coronavirus 2019 (covid-19) pandemic for child and adolescent mental health: a narrative review to highlight clinical and research needs in the acute phase and the long return to normality systematic review of covid-19 in children 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kobe earthquake and post-traumatic stress in school-aged children anxiety symptoms among children after the wenchuan earthquake in china factors associated with people's behavior in social isolation during the covid-19 pandemic children and the covid-19 transition: psychological reflections and suggestions on adapting to the emergency relationship between 8/9-yr-old school children bmi, guardians' bmi and educational level: a cross sectional survey how to talk to your child about coronavirus disease 2019 (covid-19) the covid-19 pandemic: technology use to support the wellbeing of children talking to children about the coronavirus|breeze-children's rights in society protecting the psychological health of children through effective communication about covid-19 children's fear reactions to the 2009 swine flu pandemic: the role of threat information as provided by guardians influence maternal background has on children's mental health effect of the covid-19 pandemic on anxiety among children with cystic fibrosis and their mothers behavioral and emotional disorders in children during the covid-19 epidemic mitigate the effects of home confinement on children during the covid-19 outbreak parenting in a time of covid-19 the authors declare no conflict of interest. key: cord-271853-wexe9gq0 authors: lu, quan; cai, zehao; chen, bin; liu, tao title: social policy responses to the covid-19 crisis in china in 2020 date: 2020-08-14 journal: int j environ res public health doi: 10.3390/ijerph17165896 sha: doc_id: 271853 cord_uid: wexe9gq0 the 2020 coronavirus pandemic has catapulted china into a serious social and political crisis. this article focuses upon how chinese social policy has responded to the covid-19 crisis. it reveals that the chinese welfare state has woven a comprehensive social safety net to mitigate the social suffering of chinese society in the midand post-crisis periods. different types of social policy programs have been combined and synthesized, including social insurance, social assistance, and social welfare arrangements. facing the challenges of the new risks caused by the pandemic, the collaboration of the chinese state and intermediary social welfare organizations has played a crucial role in providing both cash benefits and social services (benefits in kind). for the first time, social policy in china has acted as a major player for coping with the negative outcomes of a pandemic. this article concludes that the pandemic-related crisis has justified an interventionist approach and logic, driven by the state’s welfare system, which favors a model of “big government”. however, this model also requires justification and legitimation. the covid-19 pandemic represents the most serious public health crisis in china since the founding of the people's republic of china (prc), with the fastest spread and the widest infection range, challenging the country's socioeconomic development and people's daily life. facing these challenges, chinese governments have established strong command-and-control mechanisms, reminiscent of war times, to respond to this crisis and control the virus [1] . these measures appear to have worked sufficiently, and the pandemic in china seems to have been brought under control. the central government has played a proactive role by issuing a number of key policies in the field of social security, effectively relieving the anxiety of patients infected with covid-19 and their families from the financial burden of medical treatment, and also fully mobilizing social resources to effectively support the resumption of work and production. china has witnessed a rapid expansion of social security programs over the past decades, especially since 2000, and has established the world's largest comprehensive social protection network [2] . currently, the social security system in china consists mainly of three types of social programs: contributory social insurance, non-contributory social assistance, and tax-financed social welfare. employment injury insurance, and maternity insurance, and all of these programs are extended to urban employees. at the same time, it also includes basic pension insurance and basic medical insurance for urban and rural residents who do not fall under the category of urban employees. according to a report released by the ministry of human resources and social security, the total number of persons covered by pension insurance is 943 million (419 million are urban employees and 524 million are urban and rural residents). the total number covered by medical insurance is 1.344 billion (317 million are urban employees and 897 million are urban and rural residents). more than 95 percent of chinese citizens are covered through this program. medical expenses in conformity with the drug catalogue, diagnosis and treatment items and medical care service facility standards for medical insurance and medical expenses for emergency treatment or rescue are paid from this program. the current reimbursement rate is around 60 percent of the total expenses for insured urban employees and about 50 percent for insured urban and rural residents. further, at the end of 2018, 196 million employees had been covered by unemployment insurance, 239 million employees had been covered by work accident insurance and 204 million employees had been covered by maternity insurance. for china's social assistance system, the most important program is the minimum living standard scheme (mlss, known as dibao), which covers residents whose per capita income/annual net income falls under the threshold of the local minimum living standard in both urban and rural areas. according to the statistical report on the development of civil affairs issued by the ministry of civil affairs in 2019, 10 .07 and 35.02 million people received benefits from the mlss in urban and rural areas, respectively. in addition, medical assistance, educational assistance, housing support, legal assistance, and a relief system after natural disasters are also important ingredients of china's social assistance system. the country's social welfare program provides funds and social care services to ensure the livelihood of the elderly, children, and persons with disabilities who experience extraordinary difficulties [3] (see figure 1 ). however, interventions through social protection policy and questions that must be reconsidered in relation to disease-related crises have been largely neglected in academic research. therefore, this article will specifically analyze how different types of current social security programs have responded to the outbreak and the outcome of the pandemic-related crisis and highlight the however, interventions through social protection policy and questions that must be reconsidered in relation to disease-related crises have been largely neglected in academic research. therefore, this article will specifically analyze how different types of current social security programs have responded to the outbreak and the outcome of the pandemic-related crisis and highlight the shortcomings of these measures. the remainder of this article is organized as follows. section 2 constructs an analytical framework for the study. section 3 presents the research findings, including reflections on policies in areas such as unemployment insurance, welfare institutions, social insurance, and social assistance. section 4 offers a discussion and concludes the paper. within modern capitalist welfare systems, social policy is considered an institutional response to the negative effects of free-market competition and the rising and contingent risks that occur during market fluctuation [4] [5] [6] . in particular, state-organized social protection programs have corrected the primary distribution mechanism, mitigating social problems in the capitalist market economy. social policy dovetails with the long-term institutional policy intervention by welfare states in the field of production and reproduction [7] , having been established in the continuing transformation of the capitalist economy from a laissez-faire model to a market economy increasingly regulated by welfare states [8] . although the formation of modern state-organized social policy represents a long-range transitionary process, it is necessary to take another aspect of social policy into consideration-the social policy and social protection adopted and stimulated by short-term events and shocks. in particular, special attention should be paid to social crises and socially and economically anomic developments that deviate from the state of social normality, challenging and jeopardizing regular and consistent socioeconomic development within a short-term or medium-term period [9, 10] . social crises often alter the "normal" state of a society, creating a critical juncture posing an acute threat to the status quo of the current social and political system. the nexus between crises and social policy has not been investigated sufficiently in academia. commonly, crises have been regarded as negative events that can overshadow the regular functioning of welfare states, causing dysfunctionality and disruption of the existing social order. moreover, historically, social crises are closely related to welfare state retrenchment. for instance, the oil crisis in the 1970s and the subsequent stagflation in the western world had precipitated the end of the golden age of capitalism and the postwar economic boom, resulting in the reduction of social expenditures during the reagan and thatcher administrations [11, 12] . however, the intuitive assumptions concerning the nexus between crisis and welfare retrenchment have been upended by empirical developments in various welfare states and welfare regimes. usually, social crises have increased the suffering and the poverty gap in a society and precipitated social protests and social turmoil, challenging the current social political order and endangering the legitimacy of governments. against this backdrop, many state administrations have been inclined to expand public revenues and state social investments to circumvent social disorder and sharply increasing social and economic problems. in some cases, crises have fostered new opportunities for the extension of welfare state intervention and the expansion of social protection programs. conflict theories have generally verified that social conflicts such as social protests, social movements, and struggles among different social classes for resources have benefited and accelerated social policy expansion in welfare states [6, 13] . social crises represent a special type of social conflict. during the outbreak of crises, social conflicts usually intensify, social grievances are raised, and the battle among different social classes for subsistence and resources escalates. all this tremendously jeopardizes social cohesion; thus, social and political responses are urgent for the survival of governments. if governments do not act in time, social discontent may transform into destructive protest. for instance, the roosevelt-administration initiated welfare state arrangements in the united states in the 1930s after the shocking (after-) effects of the great depression began to unfold [14] . hort and kuhnle have verified empirically that after the asian financial crisis of 1997-1998, social expenditures in the region of east and southeast asia were not reduced as usually assumed; on the contrary, in nearly all of the 10 selected examples in this region, social protection programs remarkably expanded, during and even after the crisis [15] . these counterexamples demonstrate that crises do not always cause austerity and the state's retreat from public investment. under certain conditions, crises and the subsequent pressure imposed upon governments may unintentionally become driving forces for elite groups to change and respond to critical demands from society. in other words, the suffering during periods of crises can be transformed into positive assets for welfare state extension and expansion. this paradoxical development concerning welfare expansion during economic crises has also been traced in the developmental trajectory of the korean welfare state [16] . historical examples, along with the current pandemic crisis in 2020, have unveiled a trend in which state administrations from various countries are inclined to expand their capacities and intensify state intervention in society to lessen social tensions and calm the social discontent and public anger emerging from the outbreak of crises. in major global crises, such as the great depression, the global financial crisis of 2007-2008, as well as the covid-19 crisis, "big government" represents a model for coping with social problems and social conflicts [17] ; accordingly, the myths of market omnipotence and neoliberal ideology have been substantially diluted [18] . counter to assumptions concerning the retreat of welfare states, these substantial crises have strengthened the power of the state, disenchanting the "laissez-faire model". facing a crisis of acute existential survival, ordinary working populations and residents, as well as enterprises short on liquidity must seek assistance and bailouts from the state. in turn, the state must devote considerable resources to society to ensure a threshold of existence. otherwise, widespread malnutrition or famine, or the demise of many small-and medium-sized enterprises, would very likely endanger the state's basic functioning, causing enormous loss of human resources and financial drain, and leading to danger and risk for the survival of the state itself. crises have provided stimuli for governments to assume the role of the ultimate guarantor and provider of public goods for their citizens. thus, crises are somehow related to "big government" and an active interventionist state. in the chinese case, the pervasive model of "big government" may shift rapidly into a quasi-war state to respond to crisis. however, many emergency measures and acts need special justification and legitimation, since personal freedoms and right of free mobility may be constrained, as they have been during the pandemic-related lockdowns and curfews. the social security system has been designed and built to cope with risks. however, the covid-19 pandemic is a sudden public health event, which by itself is a risk of a new type. it therefore brings substantial challenges to the existing social security system. during the covid-19 pandemic, china's social security system has largely functioned well in many aspects, but some serious problems have also been exposed that call for further improvement. this study applies the method of event analysis with a special focus on social and political responses to this special crisis event. the trajectory and chronological development of covid-19 from february through june of 2020 has been intensively observed and consequently integrated into our analysis of the social policy responsiveness to this crisis-related event. the pandemic-related crisis has been divided into three primary stages-the pre-crisis, during crisis, and post-crisis periods. regular social policy arrangements before the outbreak of covid-19 have previously been introduced. some hallmark subevents in the arena of chinese social protection during the outbreak of the pandemic and in the post-crisis period have been identified and analytically discussed and reflected, including policy measures and strategies adopted in the areas of health insurance, unemployment insurance, social assistance, and social welfare, among others. to complement our event-centered policy analysis, we have collected different kinds of secondary data such as policy documents and data published by the state administration, including the ministry of human resources and social security (mhrss) and the ministry of civil affairs (mca), which characterize the coping strategies of the chinese state and society in relation to covid-19. secondary documents issued by different state administration and public media have uncovered the urgency and exigency created by pandemic and presented an assemblage of emergency measures, formal and institutional policies implemented during the crisis. through the process tracing crisis-related events, using various data sources, we reconstruct the panorama of social policy responses to the critical juncture that chinese society experienced amid the pandemic. the impact of the covid-19 pandemic on employment might be short-term, but it is more serious and complicated than the situation of sars in 2003 [19] . therefore, helping enterprises to overcome difficulties is still an important measure to stabilize employment and the economy. governmental departments have formulated various policies for different regions and different types of enterprises to reduce social insurance contributions. for example, in hubei province, where the pandemic has been most severe, the government has exempted certain employers (except for the public sectors) from paying social insurance fees for no more than five months. for other regions, the social insurance contributions of large enterprises may be halved for a period of no more than 3 months, not exceeding 5 months for small-and medium-sized enterprises. finally, enterprises with difficulties in production and operation may apply for deferred payment of social insurance premiums for no more than 6 months. (the above contributions refer to the portion paid by the employer; payments by individuals must be made on time. it is noteworthy that none of the above policy adjustments affect personal entitlements.) using unemployment insurance to help employers and reduce the unemployment rate is another important measure. specifically, for small-and medium-sized enterprises, if the unemployment rate is not higher than that in the national survey of the previous year, part of the unemployment insurance benefits may be refunded to stabilize employment. meanwhile, enterprises were encouraged to implement training programs for those affected by the pandemic, which could be subsidized if they organized employees to participate in offline or online vocational training during the shutdown period. according to a spokesperson from the ministry of human resources and social security, the pension insurance, unemployment insurance, and employment injury insurance contributions reduced in february reached 123.9 billion yuan ($17.5 billion). the total amount of deductions in contributions from february to june was estimated to be more than 500 billion yuan ($70.6 billion), effectively supporting the resumption of work and production. at the same time, 1.46 million enterprises received unemployment insurance refunds, amounting to 22.2 billion yuan ($3.1 billion), benefiting 49.51 million employees [20] . notwithstanding the achievements outlined above, some problems have also been exposed with regard to supporting enterprises by fully utilizing unemployment insurance policy. the functions of the unemployment insurance system are twofold: one is to maintain the basic livelihood of the unemployed and their families, and the other is to actively create conditions for their reemployment through professional training, job referrals, and other means. at present, the main function of this system in china is to maintain the livelihood of the unemployed; however, the promoting and preventing functions have not been fulfilled. it is mandated that employees shall participate in unemployment insurance, and the premiums should be jointly paid by employers and employees; however, statistics reveal that the number of people participating in this insurance program stands at 196 million, accounting for only 45 percent of urban workers. this is the lowest insured rate among all types of social insurance, because a large number of migrant workers and informal employees are not included in this program. at the same time, the cumulative balance of unemployment insurance funds reached 581.7 billion yuan ($82.1 billion), 6.4 times of its expenditure of 91.5 billion yuan ($12.9 billion) in 2018 [21] . in other words, even if unemployment insurance fees are no longer collected, the funds can still be used for more than 6 years, suggesting that the amount of cash benefits paid out is low, and other unemployment benefit programs should be added. it is worth noting that, in this pandemic, some companies in china have adopted innovative forms of employment such as "shared employees", with individuals working in multiple companies at the same time, to reduce their own expenditure burden by lowering wages and/or not paying social security fees; however, the government has also required these companies to reduce the layoff rate and pay basic wages. therefore, a responsibility-sharing mechanism should be established to finance the expenditures. in this sense, the unemployment insurance funds can shoulder the task by paying a portion of the wages for workers who have not returned to work, and thereby reducing the burden on the enterprise. these measures will better allow the enterprises to weather the storm. the practice of the unemployment insurance system has exposed another problem: according to current regulations, insured persons will not be qualified to receive unemployment insurance benefits after being laid off, unless they have contributed to the system for no less than one year. in the pandemic, a new special policy has been introduced to provide unemployment subsidies for laid-off employees who have contributed for less than one year. however, this subsidy is lower than the usual unemployment insurance benefits. we believe that the special policy should become part of the formal unemployment insurance system and be incorporated into the current regulations. welfare organizations, such as nursing houses for people in need, tend to be higher-risk areas in terms of emergency management, as these are places where elderly people, dependent children, people with disabilities, etc., live in close quarters. in the event of emergencies (including the covid-19 pandemic), high-density living spaces and collective actions cause a chain reaction of infection, making residents even more vulnerable [22] . indeed, specific demographic groups living in welfare organizations are susceptible to covid-19 because of their underlying health conditions, making special protection policies during the pandemic more significant and urgent than ever. in the early stages of the areas with high incidence of covid-19 in china, there were clustered cases within nursing homes. on 21 february 2020, according to the notice of the wuhan civil affairs bureau, as of february 19, social welfare agencies in wuhan had a total of 12 confirmed cases; 11 were elderly residents (including one deceased) and one employee [23] . in response to this, the relevant departments implemented three measures: (1) several anti-pandemic guidelines were issued for different types of welfare agencies based on the risk level of the region, followed by stricter closed management for these agencies to accommodate the elderly, persons with disabilities, and their service staff. (2) cross-regional caregivers were arranged to provide necessary support. there were more than 20,000 elderly residents in the old-age care agencies in wuhan, but only 3000 local care staff. in addition, some of these caregivers were infected or self-isolated, so there was a shortage of care staff in general. thus, the ministry of civil affairs of the central government coordinated cross-regional care and nursing staff to offer support to wuhan [24] . (3) care services for stay-at-home elderly residents whose families were isolated and/or sick were provided. daily life became more complicated for elderly residents living alone due to the pandemic, and their routine caregivers were not always available to serve in a timely manner. moreover, some caregivers were being treated or medically isolated because of the pandemic, which forced vulnerable groups to stay at home. to address this situation, welfare agencies would provide door-to-door services or arrange for these residents to be cared for in-house. however, the protection for some caregivers and volunteers in this case was, to some extent, less focused. in the process of prevention and control of the covid-19 pandemic, in addition to medical workers, some volunteers were infected or even passed away at work, but technically, volunteers cannot be identified as beneficiaries of work-related accident benefits; similar cases also applied to caregivers as informal workers without work-related accident insurance. therefore, establishing a social compensation system is necessary. social compensation refers to the compensation by the state and society for the loss of interests (physical disability or a sharp decrease in income, and so on) of relevant stakeholders, when is caused by uncontrollable risks (such as natural, societal, or policy-related events). germany and the taiwan region have built relatively complete social compensation legal systems, but mainland china has not yet established such a system. unlike the civil compensation caused by torts, the administrative compensation brought by wrong administrative acts and state compensation brought by judicial misconduct, social compensation is mainly to pay for losses caused by wars, natural disasters, and other uncontrollable social risks. this includes not only compensation for the direct victims of such disasters, but also praise for the staff and volunteers involved in disaster relief. in china, the social insurance system is primarily composed of five sub-programs: medical insurance, employment injury insurance, unemployment insurance, pension insurance, and maternity insurance. the first three in particular have played a major role in providing economic support for the insured during the covid-19 pandemic. 3.3.1. medical insurance and related policies: programs that bear the brunt as mentioned above, there are two kinds of medical insurance system in china: one for urban employees, and the other for urban and rural residents other than urban workers. the former is paid by employers and employees (6 percent and 2 percent of wages, respectively), and the latter is paid by residents and subsidized by the government (in 2020, the individual contributions are 280 yuan, and the central and local financial subsidies are not less than 270 yuan). the medical insurance fund is principally used for in-hospital and substantial medical expenses of the insured, and the current average reimbursement rate is more than 70 percent of the total expense for urban employees, and around 60 percent for urban and rural residents who participate in the scheme. effective medical security measures, mainly medical social insurance, were taken in a timely manner during the covid-19 crisis in china, so that patients and their families are relieved from worrying about treatment costs, specifically: (1) shortly after the outbreak, the state issued a policy to include drugs and medical services for the treatment of the new coronavirus as part of the payment range for the medical insurance fund. (2) furthermore, the personal medical burden is borne by fiscal resources of the government, thus achieving free treatment for patients with covid-19. the policy was initially limited to confirmed cases, but was later expanded to suspected ones. (3) simultaneously, when people seek medical treatment within one's coordinated areas of the social medical insurance fund, it is mandated that treatment must be provided first, with the fee to be settled later. (4) for medical institutions admitting a large number of patients, social medical insurance would prepay funds to ensure that the effectiveness of treatment from hospitals is not impaired due to payment policies. the above policies may be summarized as "two guarantees", first to ensure that no patient is rejected or treated in an untimely manner due to medical expenditure or cost problems, and, second, to guarantee that no designated medical institution is impaired from treating patients due to budget management regulations from the medical insurance fund. for foreign patients, if they have participated in china's basic medical insurance or any commercial insurance, their fee will be paid by the corresponding insurance funds; alternatively, they must bear the cost themselves. however, whether insured or not, medical institutions will treat first and charge later to ensure that everyone can receive medical treatment in time. the total cost of confirmed and suspected covid-19 cases in china was about 1.486 billion yuan ($0.21 billion) as of 6 april 2020. the per-capita medical cost of diagnosed inpatients reached 21,500 yuan ($3035), and of the severe ones, more than 150,000 yuan ($21,176). the medical insurance fund paid 990 million yuan ($139.8 million), accounting for 66.6 percent of the total medical cost. the total cost of diagnosed inpatients involved was 1.118 billion yuan ($0.16 billion), 746 million yuan ($105.3 million) of which was paid by the medical insurance fund, accounting for 66.7 percent. the total cost of the suspected patients was 368 million yuan ($52 million), with the medical insurance fund paying 66.6 percent of it (245 million yuan) [25] . overall, the medical insurance fund paid about two thirds of the total cost, and the remaining one third was borne by fiscal funds at various levels. however, these medical security measures were not without constraints. many of the medical security policies issued during the covid-19 pandemic were interim measures, which made them difficult for some local medical funds to implement in an orderly fashion [26] . one question yet to be clarified concerns the ultimate responsibility for payment: between public finance and the medical security fund, which one should eventually bear the medical expenses, or how they should be shared on the basis of specific principles? that is, in this pandemic, the medical security funds and fiscal funds work together to provide free medical care to patients. however, according to the social insurance law (the third paragraph of article 30), the basic medical insurance funds should not pay expenses that should be borne by public health funds. therefore, it is necessary to rethink the relationship between public finance and medical security funds in major pandemics like covid-19. to address this problem, the first step is to take the perspective of the comprehensive process of public health emergency management. according to china's emergency response law, the emergency management process includes four phases: prevention and preparation; monitoring and early warning; rescue and disposal; and rehabilitation and recovery. on the one hand, the beneficiaries of the public health funds include the entire population, so these funds should be mainly used in the prevention and preparation phase, for vaccination, tracking, and service provision for people who test with underlying health conditions. on the other hand, medical insurance helps diversify risks among insured persons, so it should mainly target the medical expenses of patients. furthermore, the impact of major public health events on different regions is often disproportional. according to the latest information, among 84,614 confirmed cases recorded nationwide, 68,135 were diagnosed in hubei province, accounting for more than 80 percent of the total cases. however, at present, the overall planning level of medical insurance funds in china is only at the municipal level, inevitably resulting in a larger burden of medical expenses in areas with severe pandemics, which cannot be shared on a larger scale. faced with such a contradiction, limited by the reality of the situation, medical insurance cannot achieve national pooling in a short period of time; it is still necessary to establish a sharing mechanism between the medical insurance and the public finance for medical expenses, especially in areas with severe pandemics. the responsibility-sharing mechanism between public finance and the medical insurance system also concerns the issue of due beneficiaries, or more specifically, foreigners in china and chinese students overseas. for foreigners in china, as long as they have participated in medical insurance, they are entitled to benefits; and if they also fulfill their tax obligations, they should also benefit from public financial subsidies. for overseas students, in the context of the global spread of the covid-19 pandemic, a large number of students want to return to china. in response, the chinese government has issued a policy stating that if they return, they will be responsible for their accommodation and boarding expenses during the period of quarantine. whether their medical expenses will be paid depends on whether they have participated in medical insurance. this practice is in line with the basic principles of medical insurance. however, if the medical expenses are mainly to be borne by public finance at the national level, these students should enjoy free treatment, regardless of whether they are insured or not, paying taxes or not. other insurance sub-programs have also contributed to the battle against the covid-19 crisis. as far as unemployment insurance and work-related injury insurance are concerned, although the contribution rates have continued to decline over the past five years, and the scope and level of expenditures have increased, the accumulated balances have continued to rise [27] . (there may be many factors contributing to the increasing accumulated balance. first, and likely foremost, more workers have participated in the social insurance system. according to the ministry of human resources and social security, the number of participants in the unemployment insurance system increased from 170.43 million in 2014 to 196.43 million in 2018. second, on the expenditure side, the total number of beneficiaries has remained stable, fluctuating around just above 2 million people during 2014-2018, despite the relatively higher level of benefits and larger scope of compensation projects for qualified insured persons. moreover, the level of overall planning in the unemployment insurance system has been low, reducing the efficiency of unemployment insurance funding, which also helps explain the situation. relatively developed regions usually enjoy more advantages in the labor market such as more local and immigrant workers, and thus more contributions to the unemployment insurance program, while unemployment rates are relatively low, in contrast to underdeveloped regions. these developed regions have contributed the most to the accumulated balance on a national scale, but this surplus cannot be properly shared by other regions if they are not in the same overall planning area.) this has provided a solid foundation for expanding expenditures related to the pandemic. employment injury insurance was adjusted in time to recognize and thus protect caregivers on the front line. to begin with, it was made clear that medical care staff and other related staff, who were infected with covid-19 or died from it in the course of their work to prevent and control the pandemic, would be recognized as work-related injuries cases, and their legitimate entitlements and interests would be protected. given that the covid-19 outbreak in china was mainly concentrated in wuhan, the central government mobilized medical care staff from other administrative areas to support wuhan city. from 24 january (a traditional chinese holiday, the eve of the spring festival) to 8 march, approximately 42,600 staff members from 346 medical teams across the country arrived in wuhan and hubei province to participate in medical treatment. however, as of 11 february, 1716 medical care staff, accounting for 3.8 percent of the national confirmed cases, had been confirmed as infected with covid-19 nationwide [28] . in addition, as of 8 march, 53 community workers perished in the line of duty during the epidemic prevention and control [24] . in order to ensure the basic entitlements for these employees, the relevant authorities opened a "green channel" to simplify the procedure for identifying work-related injuries. at the same time, if the requirements are met, deceased medical care staff and other pandemic prevention workers are eligible to be recognized as martyrs. according to the regulation on honoring martyrs, the state has established a reward system for martyrs. the reward standard is 30 times the per capita disposable income of urban residents in the previous year. meanwhile, the state grants preferential treatment to the survivors of martyrs to ensure that their quality of life is not lower than the average living standards of local residents, and the state will also provide support for their children's education and parents' pension. furthermore, the unemployment insurance system, by nature, works counter-cyclically in the sense of economics. as the pandemic caused a large number of enterprises to fail in resuming a timely production schedule, workers were thus unable to return to work, which adversely affected both the employers and employees. as a policy response, a series of regulations have been issued by various governmental departments to broaden the scope of beneficiaries. for insured persons who lost their jobs due to the pandemic in hubei and other pandemic-stricken areas, if they do not meet the basic requirements for receiving unemployment insurance (e.g., participating in and contributing to the insurance fund for no less than one year), they will be offered an unemployment subsidy. the standard is no higher than 80 percent of the local unemployment insurance premium, and it is only paid for six months. for those who had not contributed to unemployment insurance, the unemployment assistance benefit would be paid, in an amount equivalent to 120 to 150 percent of the social relief amount prescribed by the local civil affairs department, and the specific amount is determined by the provincial government. in most countries, social assistance acts as a bedrock and functions as a last resort of social protection, which aims to contribute to the prevention and alleviation of poverty. china issued the interim measures for social assistance (imsa) in 2014, which initially established a social assistance system consisting of the minimum subsistence security system and eight specific social assistance programs. (the eight specific social assistance programs include the minimum living standard scheme, the relief and support system for people living in dire poverty, medical assistance, educational assistance, housing support, legal assistance, a relief system after natural disasters and the temporary-assistance scheme.) with the target of "precise poverty alleviation" to be achieved in 2020, the goal of the social assistance system will shift from eliminating absolute poverty to alleviating relative poverty [29] . following the outbreak of the covid-19 pandemic, a range of social assistance measures were taken to guarantee a basic livelihood for the poor. during the period of epidemic prevention and control, vulnerable groups, such as families receiving subsistence allowances (i.e., the dibao households), low-income groups, vagrants, beggars, and workers who could not return to their workplace, encountered many difficulties as a result of regional closures, self-isolation, or quarantine. to address this situation, chinese civil affairs departments adopted a series of measures: (1) for the dibao households, the family means test could be carried out remotely, and the means test and dynamic adjustments could be suspended in areas with severe pandemics. (2) the amount of cash benefits for the impoverished increased. for instance, hubei province stipulated that 500 yuan ($70.6) should be added to the amount received by people in need in urban areas, and 300 yuan ($42.4) in rural areas. (3) temporary assistance would be given to those who have difficulty in life due to self-isolation, quarantine, or infection. (4) in principle, china's social assistance is mainly for people with local household registration (hukou). however, during the covid-19 outbreak, temporary accommodation, food, clothing, and other help was provided to non-local residents in need. despite the success in constraining the covid-19 pandemic, at present, one of the major problems with social assistance in china is that each specific sub-program is based on the minimum subsistence security system. in many regions, only those households with low-income are qualified to apply for benefits from other specific assistance programs. during the covid-19 pandemic, there were many laborers who could not return to their hometowns in time for the new year's holiday. urban residents' incomes dropped, and they experienced temporary difficulties due to their employers failing to resume work in time. these fragile groups are undergoing hardship and need temporary assistance. however, according to china's imsa, the objectives and standards of temporary assistance are not clear. in practice, it is mainly aimed at the homeless. but it should be also targeted at fragile groups whose lives have been severely constrained during major crisis events like the covid-19 pandemic. since china's social assistance is tied to local household registration, workers and residents from other administrative areas cannot apply, which may be reasonable under normal circumstances, but in the context of major emergencies, household registration restrictions should be softened. this scenario represents another problem in the existing social assistance system that has been exposed during the covid-19 pandemic. many people in need of social assistance benefits might not be living in their local household registration location, and thus cannot possibly apply in a timely manner. thus, it is crucial to reflect on the current social assistance system in china and extend social assistance benefits to all residents in the face of sudden public health events. furthermore, the current social assistance system operates mainly by providing cash benefits. however, in this pandemic, most communities have adopted the strategy of closed management, and cash benefits alone might not enable the beneficiaries to purchase goods or services in time. therefore, during the covid-19 pandemic, social assistance must provide in-kind benefits and services and ensure the basic livelihood of chinese residents. at the same time, special emphasis should be placed on employment assistance, as it helps people who have temporarily lost their jobs due to the pandemic become more employable as soon as possible and become self-reliant workers again. in modern society, social security systems represent an important institutional arrangement in responding to individual risks through collective organization. with the proper utilization of techniques and digitalization in public services, the efficiency and effectiveness of the social security can be substantially enhanced. first of all, a number of charitable organizations actively carry out various fundraising activities to make up for the shortage of public resources. during the pandemic prevention and control periods, charitable organizations fully utilized their advantages in terms of fundraising, social services, and mental health interventions. various foundations mobilized social donations and purchased pandemic materials for prevention, effectively making up for the lack of materials in some significant areas in the early stages of the crisis. as of 24:00 on 8 march, charitable organizations and the red cross system at all levels across the country had received about 29.29 billion yuan ($4.14 billion) in donations and donated about 522 million items [24] . among them, the wuhan red cross society (rcs) received more than 1.697 billion yuan ($0.24 billion) by 24:00 on 3 april, according to the announcement on its official website [30] . in addition, the closed management of residential areas in many regions brought great inconvenience into the daily lives of residents. many charitable organizations have launched services such as centralized purchase of daily necessities for residents and the provision of mental health counseling to help residents survive the pandemic period. in addition, efforts to promote and practice online activities not only improved the efficiency of the services, but also reduced the risk of pandemic spread. after the pandemic occurred, various social security agencies actively promoted online processing. business that previously was undertaken on a face-to-face basis could be moved online, thus reducing the crowding of people, the chances of infection for various fund-contributing companies, charitable organizations, etc. moreover, the efficiency and quality of such services were also improved. for example, the departments of human resources and social security announced an online application platform for claiming unemployment insurance benefits, notifying each recipient about their benefits online. it is believed that after the pandemic, more beneficiaries of social insurance will be accustomed to handling social security procedures or formalities online. nevertheless, looking back at the performance improvement of the social security system reveals some urgent and necessary adjustments. the larger and broader the impact of the public health emergency, the more actors are involved in the response, and more effective cooperation between different parties is required [31] . among them, the most important is the cooperation between the government and charitable organizations. as the third sector, charitable organizations can provide more precise, differentiated, and high-quality services. over the course of the pandemic prevention and control, charitable organizations not only demonstrated a strong capacity to draw resources, but also exposed problems such as insufficient credibility, untimely information disclosure, and unfair resource distribution. for example, the wuhan rcs did not distribute donated materials to hospitals in time, there was unfairness in the process of distribution, and the information about donated and distributed materials was not disclosed in time, all of which led to a wave of questioning by the public. charitable organizations in china are largely still immature; therefore, to strengthen their capacity, china should focus on the following three aspects: (1) strengthen the role of hub-type charitable organizations such as the charity federation, the rcs, etc., at all levels, and utilize them as a link between governments and charitable organizations to coordinate social resources in response to major public crises. (2) acknowledge the shift in charitable organizations' functions from financing to service provision. charitable organizations in china are currently divided into social groups, foundations, and private non-enterprise units. among them, foundations can both raise funds and provide social services; private non-enterprises can only provide social services and are unable to raise funds. in accordance with the principle of the social division of labor, it is recommended to establish a new pattern, with funds raised by foundations, professional services provided by social service agencies, and a connection between these two types of organizations through a bidding mechanism. (3) information disclosure should be well implemented. in the event of a major crisis, in particular, charitable organizations should promptly release information about fundraising and material distribution through various channels and accept public supervision. only in this way can public maintain confidence in charitable organizations. the unexpected and sudden outbreak of covid-19 in wuhan and its prompt spread nationwide have created a special situation and state of exigency and urgency, challenging the status quo of the socio-economic order within and outside hubei province. the crisis precipitated by the pandemic has quickly led to a critical juncture at which the chinese administration must quickly and effectively respond. the negative effects of the crisis have created strong pressure and an incentive for a quick administrative response and effective action in the part of the chinese state. the explosiveness and severity of the pandemic crisis and its unpredictable as well as astronomical social costs have strengthened the model of "big government" in the chinese case [32] , with massive state intervention in society and the economy. besides the usual intervention methods such as lockdowns, curfews, travel bans, the use of big data for tracing and breaking infection chains, the creation of health-related codes via smartphones, and nationwide mobilization of medical assistance for wuhan and hubei province, social policy intervention has also become especially relevant. in both the mid-crisis and post-crisis periods, we have observed an increase in social welfare and social protection programs. however, this topic has been largely neglected, both in academic research and public perception. social policy intervention is deeply connected with the social fact that modern society is a risk society [33] , and some social risks, such as environmental pollution and global warming, have evolved into global risks that challenge all nation states. social policy must circumvent new global risks like global pandemics, and the social protection programs of nation states must find an effective way to mitigate the social risks and hazards caused by newly emerging infectious diseases such as covid-19. these programs are not only targeted at national citizens, but also at international migrants such as tourists, foreign visitors, guest workers, etc. how modern social policy responds to pandemics has become a new and urgent research question for all nation states. the adopted social protection programs in china include a wide range of policy areas, such as health insurance, unemployment insurance, and accident insurance, among others. from the perspective of system types, we can differentiate social protection programs amid the covid-19 crisis into social insurance, social assistance, social welfare, and enterprise-related special subsidies and policy measures. existing social insurance programs, the mlss, and some special temporary policy arrangements have been combined to circumvent the sharp increase in social suffering. within the portfolio of different benefits, we have noted: (1) cash payments such as unemployment allowances and unemployment subsidies, benefits from the chinese social assistance program (mlss), ensuring the material security of millions of people and employees who have suffered from temporary layoffs, shortened work hours, or mandatory breaks imposed by employers; (2) benefits in kind, including service programs like testing, diagnosis, and therapy for covid-19 patients, free of charge, either financed by health insurance programs or subsidized by state revenues. also included are special social protection and social services for elderly people in nursing homes and social welfare units who constitute one of the highly vulnerable groups exposed to the virus; (3) favorable policy measures, such as the alleviation of income tax burdens and the granting of special loans for small-and medium-sized enterprises who face challenges in existential survival owing to a lack of liquidity because of the drastic freeze in economic and commercial activities. with regard to targeted welfare clients, we can also distinguish two types of program-individual-related and collective-related benefits. the first includes benefits that target individual demands, delivered to each citizen in case of need. the second is delivered to collective units such as households and enterprises. in sum, different interventionist forms, including monetary intervention, service-related intervention, policy-related intervention, and legal intervention have been combined and synthesized to help residents and social and economic units to traverse the "valley of tears" [34] amid the covid-19 crisis. the unprecedented covid-19 crisis has indeed stimulated rigorous state intervention in the areas of livelihood, welfare, and wellbeing for millions of people who have suffered directly and indirectly from its negative effects. as with various historical examples, the crisis derived from the coronavirus has stimulated public expenditures and a model of "big government". it has further legitimated hyper-normal and, in some cases, nationwide and large-scale extralegal intervention policy to lessen the intensity and severity of soaring social problems and escalating social conflicts. however, this kind of special intervention within and beyond the regular legal and institutional framework has also reached its limits, leaving many problems unresolved, such as the question of who should take responsibility for the medical treatment of residents that have dropped out from the regular health insurance system and who should finance diagnosis and therapy for overseas chinese and foreigners returning to chinese territory, and to what extent. the tacit problems of coverage loopholes in the chinese social security system have become explicit during the development of the crisis. even in cases of monetary compensation and intervention, impoverished residents or the unemployed who have received cash benefits, either from social assistance or from unemployment insurance, have been unable to purchase enough daily necessities and basic commodities due to the lockdown and curfew that has constrained the normal functioning of physical stores and brick-and-mortar businesses. charitable organizations have played a vital role in providing benefits in kind for individuals and families in need. ensuring material security and social safety encompasses more than one single area of social policy and requires much more coordinated policy intervention from different arenas, including economic policy, employment policy, fiscal policy, and social policy. coproducing responses to covid-19 with community-based organizations: lessons from zhejiang province the social protection system in ageing china china's social assistance: in need of closer coordination citizenship and social class and other essays vom armenhaus zum wohlfahrtsstaat: analysen zur entwicklung der sozialversicherung in westeuropa; campus: frankfurt am main the three worlds of welfare capitalism herausforderungen des sozialstaates; campus: frankfurt am main the political economy of the welfare state a grounded theory of construction crisis management fractal crises-a new path for crisis theory and management ending welfare as we know it (again): welfare state retrenchment dismantling the welfare state? reagan, thatcher and the politics of retrenchment toward a theory of social conflict america's welfare state: from roosevelt to reagan the coming of east and south-east asian welfare states the korean welfare state: a paradox of expansion in an era of globalisation and economic crisis global financial crisis and government intervention: a case for effective regulatory governance the financial and economic crisis of 2008: a systemic crisis of neoliberal capitalism impact of covid-19 on china's employment protection and social security system accelerate the implementation of periodic tax and fee reduction to stabilize employment how to revive 600 billion unemployment insurance funds with the benefit rate has been declining for ten years? available online evolution mechanism of safety accidents and rule of law path of risk management and control in old-age care institutions 12 confirmed covid-19 and 1 death in wuhan social welfare home. the beijing news epidemic prevention and control and livelihood security in civil affairs. china news the per-capita medical cost of patients with severe covid-19 exceeds 150000 yuan, being reimbursed in accordance with regulations reform and high-quality development of the medical security system with chinese characteristics social security fee reduction from the perspective of "tax wedge": fighting the epidemic and long-term reform national health commission. care for the health of medical staff and improve working conditions theoretical and policy focus of relative poverty: establishing a governance system for relative poverty in china innovation and development of national emergency management institution and mechanism in the new era bring back big government from industrial society to the risk society: questions of survival, social structure and ecological enlightenment crossing the valley of tears in east european reform . special thanks to two anonymous referees for their insightful, valuable, and very helpful comments, which contributed to improving the text significantly. the authors declare no conflict of interest. key: cord-288184-fa1niz51 authors: kwon, chan-young; kwak, hui-yong; kim, jong woo title: using mind–body modalities via telemedicine during the covid-19 crisis: cases in the republic of korea date: 2020-06-22 journal: int j environ res public health doi: 10.3390/ijerph17124477 sha: doc_id: 288184 cord_uid: fa1niz51 the coronavirus disease 2019 (covid-19) pandemic affected the world, and its deleterious effects on human domestic life, society, economics, and especially on human mental health are expected to continue. mental health experts highlighted health issues this pandemic may cause, such as depression, anxiety, obsessive compulsive disorder, and post-traumatic stress disorder. mind–body intervention, such as mindfulness meditation, has accumulated sufficient empirical evidence supporting the efficacy in improving human mental health states and the use for this purpose has been increasing. notably, some of these interventions have already been tried in the form of telemedicine or ehealth. korea, located adjacent to china, was exposed to covid-19 from a relatively early stage, and today it is evaluated to have been successful in controlling this disease. “the covid-19 telemedicine center of korean medicine” has treated more than 20% of the confirmed covid-19 patients in korea with telemedicine since 9 march 2020. the center used telemedicine and mind–body modalities (including mindfulness meditation) to improve the mental health of patients diagnosed with covid-19. in this paper, the telemedicine manual is introduced to provide insights into the development of mental health interventions for covid-19 and other large-scale disasters in the upcoming new-normal era. the coronavirus disease 2019 (covid-19) was first reported as "a cluster of cases of pneumonia" on 31 december 2019 at the wuhan municipal health commission in china. on 30 january 2020, world health organization (who) director-general declared the novel coronavirus outbreak as a public health emergency of international concern (pheic) and eventually declared covid-19 as a pandemic on 11 march [1] . the optimal treatment for infection of this coronavirus, which has the official name of severe acute respiratory syndrome coronavirus 2 (sars-cov-2), has not yet been established, and symptomatic treatment and supportive treatment are mainly performed [2] . therefore, front-line health care providers and health authorities around the world had great difficulties during this pandemic. antiviral agents approved for treatment of common influenza, such as favilavir, are being tried on covid-19 patients, but the established clinical evidence is lacking, and clinical trials of the first vaccine against sars-cov-2 are unlikely to be conducted this year [3] . korea, an adjacent country to china, was affected by covid-19 from a relatively early stage, and today it is evaluated to have been successful in extinguishing covid19 although strategies to cope with the physical health impact of covid-19 were gradually explored, the impact of this pandemic on human families, society, economics, and especially on the mental health of individuals, are expected to continue [5] [6] [7] . first, the impact of the pandemic on mental health started with the ambiguity and anxiety that arose from the absence of a cure or vaccine for sars-cov-2 infection, and the rapid spread of infection brought panic to the public with limited quarantine resources [8] . many people had to watch themselves or beloved family and friends suffer from the disease. moreover, many people lost the freedom of everyday life due to social distancing and/or quarantine. furthermore, some argue individuals must prepare for the "new-normal" [9] . in addition to the negative psychological effects of disease-related factors, the worldwide economic contraction caused by this epidemic is considered a major threat to the survival of the general public from an economic perspective [10] . one encouraging factor is the use of telemedicine during the pandemic [11] . since covid-19 makes it impossible for patients with various diseases to visit a clinic directly for face-to-face care due to concerns over the spread of the virus, several healthcare providers are looking for ways to use telemedicine instead [12] . mental health management is one of the areas that is making rapid progress in the field of telemedicine. mindfulness, a type of mind-body modality, may be defined as one being non-judgmentally aware in every moment. in the field of mental health care, the combination of telemedicine or e-health has been tried along with mindfulness [13] . korea has a dualized medical system called western medicine and korean medicine (km) and "the covid-19 telemedicine center of km" has treated more than 20% of confirmed covid-19 patients in korea with telemedicine since 9 march ( figure 2) . initially, the telemedicine center was established by the association of korean medicine (akom), a representative organization of all km doctors established in the early 1950s, at daegu korean medicine hospital, daegu, korea, where the number of covid-19 patients increased rapidly. after the outbreak was controlled in daegu and gyeongbuk, akom set up a second covid-19 telemedicine center of km in seoul. the center uses herbal medicine (mainly qing-fei-pai-du-tang) with established protocols based on multidisciplinary expert discussions and empirical evidence [14] , and the center also used telemedicine in conjunction with mind-body modalities (including mindfulness meditation) to improve the mental health of covid-19 patients in korea. the aim of this paper is to introduce the km doctor's mental health instruction manual in telemedicine for covid-19 and to provide insights although strategies to cope with the physical health impact of covid-19 were gradually explored, the impact of this pandemic on human families, society, economics, and especially on the mental health of individuals, are expected to continue [5] [6] [7] . first, the impact of the pandemic on mental health started with the ambiguity and anxiety that arose from the absence of a cure or vaccine for sars-cov-2 infection, and the rapid spread of infection brought panic to the public with limited quarantine resources [8] . many people had to watch themselves or beloved family and friends suffer from the disease. moreover, many people lost the freedom of everyday life due to social distancing and/or quarantine. furthermore, some argue individuals must prepare for the "new-normal" [9] . in addition to the negative psychological effects of disease-related factors, the worldwide economic contraction caused by this epidemic is considered a major threat to the survival of the general public from an economic perspective [10] . one encouraging factor is the use of telemedicine during the pandemic [11] . since covid-19 makes it impossible for patients with various diseases to visit a clinic directly for face-to-face care due to concerns over the spread of the virus, several healthcare providers are looking for ways to use telemedicine instead [12] . mental health management is one of the areas that is making rapid progress in the field of telemedicine. mindfulness, a type of mind-body modality, may be defined as one being non-judgmentally aware in every moment. in the field of mental health care, the combination of telemedicine or e-health has been tried along with mindfulness [13] . korea has a dualized medical system called western medicine and korean medicine (km) and "the covid-19 telemedicine center of km" has treated more than 20% of confirmed covid-19 patients in korea with telemedicine since 9 march ( figure 2 ). initially, the telemedicine center was established by the association of korean medicine (akom), a representative organization of all km doctors established in the early 1950s, at daegu korean medicine hospital, daegu, korea, where the number of covid-19 patients increased rapidly. after the outbreak was controlled in daegu and gyeongbuk, akom set up a second covid-19 telemedicine center of km in seoul. the center uses herbal medicine (mainly qing-fei-pai-du-tang) with established protocols based on multidisciplinary expert discussions and empirical evidence [14] , and the center also used telemedicine in conjunction with mind-body modalities (including mindfulness meditation) to improve the mental health of covid-19 patients in korea. the aim of this paper is to introduce the km doctor's mental health instruction manual in telemedicine for covid-19 and to provide insights into the development of mental-health interventions for covid-19 patients and large-scale disasters in the upcoming "new-normal" era. into the development of mental-health interventions for covid-19 patients and large-scale disasters in the upcoming "new-normal" era. to better manage the mental health of covid-19 victims and survivors, the covid-19 telemedicine center of km requested specialists in oriental neuropsychiatry to develop the km doctor's mental health instruction manual in telemedicine for covid-19 in a written format. specifically, the manual was developed by professors, professor jong woo kim who is also the corresponding author of this article and professor sun-yong chung, at the department of oriental neuropsychiatry at kyunghee university in korea. moreover, they practice the hwa-byung and stress clinic at the kyunghee university korean medicine hospital at gangdong and have used mindfulness meditation in their clinical practice for over 10 years. professor kim, the primary author of this manual, is also the president of the korean society for meditation [15] . as is the case in other countries, the covid-19 pandemic caused an unprecedented crisis in korea and there were no previously reported cases of using telemedicine for mental health during such catastrophes. in addition, due to the urgency of developing the manual there was not sufficient time to conduct a comprehensive systematic review of the literature regarding the development of such a manual and intervention for human subjects. instead, the two professors and an assistant, dr. hui-yong kwak who is one of author of this article, developed this manual using empirical evidence obtained from not-systematic review methodology as well as clinical experiences from their clinical settings. this manual was intended to enable km doctors to provide appropriate guidance and counseling for individuals who needed mental health care via a novel method of telemedicine. specifically, it provided guidance on managing psychological problems, such as anxiety, depression, fear, and anger, and related physical symptoms such as pain, digestive problems, and insomnia. throughout the manual, km doctors categorized the potential psychological condition of individuals, and explained the symptoms that may happen in this stressful situation and guided potentially useful mind-body interventions. the target population of the manual was primarily confirmed covid-19 patients. in addition, it could be applied to people who were self-contained in contact with the confirmed patient, the family and acquaintances of the confirmed patient, and the general public complaining of anxiety related to covid-19. to better manage the mental health of covid-19 victims and survivors, the covid-19 telemedicine center of km requested specialists in oriental neuropsychiatry to develop the km doctor's mental health instruction manual in telemedicine for covid-19 in a written format. specifically, the manual was developed by professors, professor jong woo kim who is also the corresponding author of this article and professor sun-yong chung, at the department of oriental neuropsychiatry at kyunghee university in korea. moreover, they practice the hwa-byung and stress clinic at the kyunghee university korean medicine hospital at gangdong and have used mindfulness meditation in their clinical practice for over 10 years. professor kim, the primary author of this manual, is also the president of the korean society for meditation [15] . as is the case in other countries, the covid-19 pandemic caused an unprecedented crisis in korea and there were no previously reported cases of using telemedicine for mental health during such catastrophes. in addition, due to the urgency of developing the manual there was not sufficient time to conduct a comprehensive systematic review of the literature regarding the development of such a manual and intervention for human subjects. instead, the two professors and an assistant, dr. hui-yong kwak who is one of author of this article, developed this manual using empirical evidence obtained from not-systematic review methodology as well as clinical experiences from their clinical settings. this manual was intended to enable km doctors to provide appropriate guidance and counseling for individuals who needed mental health care via a novel method of telemedicine. specifically, it provided guidance on managing psychological problems, such as anxiety, depression, fear, and anger, and related physical symptoms such as pain, digestive problems, and insomnia. throughout the manual, km doctors categorized the potential psychological condition of individuals, and explained the symptoms that may happen in this stressful situation and guided potentially useful mind-body interventions. the target population of the manual was primarily confirmed covid-19 patients. in addition, it could be applied to people who were self-contained in contact with the confirmed patient, the family and acquaintances of the confirmed patient, and the general public complaining of anxiety related to covid-19. to identify the potential psychological condition of individuals, the following three steps were used. the majority of these questions are leading, since this manual was applied to all individuals receiving telemedicine services at this center and the number of staff (mostly volunteers) was limited. therefore, questions were constructed to quickly and efficiently assess the need for mental health care and identify the presence of related symptoms (table 1) . table 1 . history taking: 3-step approach. step 1 "do you feel distressed or need psychological support for symptoms such as overstrain, dyspepsia, and insomnia?" step 2 "if so, can you quantify it? please express it as a number between 0 and 10. set the most severe level as 10 and answer 0 when there are no symptoms at all." step 3 overstrain "do you think that you have been more nervous in your daily life than necessary?" fear "are you struggling with fear or fear of the coronavirus?" anxiety "do you have a lot of worries or thoughts that constantly make you feel restless and anxious?" lethargy/depression "do you feel depressed without having fun, or are you feeling lethargy?" insomnia "are you suffering because you haven't been sleeping well these days? if you don't sleep easily, wake up often in the middle night, or wake up too early in the morning, making you feel tired throughout the day, that means you are not sleeping well." dyspepsia "is it uncomfortable when you eat food these days? are you reluctant to eat with reduced appetite or indigestion?" pain "do you have new pain whenever you feel bad? or do you feel more unpleasant pain in the areas where you felt pain before? " anger/irritability "have you easily become angry or annoyed these days?" in the telemedicine of the km center, km doctors explained the mechanism of symptom occurrence that individuals complain about, and each recommended modality. all counseling required an explanation of the current situation and empathy for the individual ( table 2) . table 2 . guidance for symptom management. overstrain tension is a natural phenomenon of the human body to survive in the stress response theory (fight or flight reaction). the constant rumination creates overstrain, even in non-existent events. notice the thoughts that make you nervous. imagine the thought of relaxing yourself repeatedly, and if this is difficult, focus on the physical stimulus to relax your body (e.g., half body bath, listening to music, walking, etc.) table 2 . cont. the reaction of fear appears when the stress response to protect our body from danger is extremely severe. fear is easily learned, and when a circuit of thought is formed for the fearful situation, the emotion can be reproduced whenever the situation appears or a related thought arises. if you experience panic, you may develop a fear (expected anxiety) that the symptoms will occur again. once panic is experienced, expectation anxiety may follow. in case of an excessive fear reaction, prevent hyperventilation and induce parasympathetic activity through exhalation-oriented deep breathing. repeatedly reaffirm the sense of security that can cope with fear. if you are relaxed and calm enough, try exposing yourself to the usual stimuli that triggered your fear response. acutely, anxiety appears with the reaction of fear. anxiety is closely related to the thought process. when a person falls into the thought that triggers anxiety, more and more thoughts are continually generated, and in this process, anxiety can be strengthened. notice that you are anxious. this is the first step in laying down the thoughts that cause anxiety. instead of turning your attention to other thoughts, it is helpful to focus on your body sensations instead. reactive depression can occur when an acute emotional reaction occurs, but the situation persists unchanged, and the mental energy that an individual can consume has reached a limit. in addition, individual vulnerability is a risk factor that easily causes lethargy and depression. decreasing physical activity exacerbates depression. find out your own new rhythm in a small space called "home." discover and expand positive energies like charity, empathy, loving-kindness, and mercy that exist in your mind. depression, anxiety, and decreased physical activity can cause insomnia. insomnia has a close relationship with cognitive factors, and if insomnia causes anxiety, this anxiety can exacerbate insomnia again. bad sleep hygiene and sleep habits can also cause insomnia. the solution to insomnia is based on the recovery of biorhythm. that is, a rhythm that is sufficiently active during the day and rests during the night should be restored. in case of worries, anxiety, and tension that persists insomnia, apply methods of relaxing the body and attempt mental distraction methods. please observe good sleep hygiene. if you are taking sleeping pills, you need guidance and management on how to take the correct sleeping pills. depression can reduce appetite. if a person eats only similar foods in a limited space, and the number of people who can eat together is limited, depression and loss of appetite become more severe. if the sympathetic activity continues to be elevated, the movement of the digestive system is not smooth. this leads to a decrease in gastric motility, causing some symptoms, including dyspepsia. imagine the memory of eating something delicious before the current eating situation and promote your appetite. eat meals regularly, and after eating, help the gastrointestinal tract to digest enough through physical activities, such as walking lightly. it is better to eat even a small amount of fun and delicious food, rather than eating it excessively and vigorously. local pain can be caused primarily by muscle tension in the area. body pain is closely related to cognitive factors. worries about the pain, psychological tension, anxiety, and depression can amplify the pain condition. it is important to know that thoughts, feelings, and pain are closely related. try some work or activity that reminds you of thoughts other than pain or that may make you forget about pain. observe the pain from the point of view that it is not just a bad thing or an unpleasant event, but simply a signal or sensation from your body. anger/irritability anger emotion suggests the resistance to the irrational and absurd reality from the thought that you have been harmed by the current situation. anger induces a state of tension in the short term, so it instantly boosts the body's metabolism and activates the immune system. chronic anger and tension, however, can depress the immune system and lead to depression, lethargy, and some somatic symptoms. understand that current anger is a natural reaction to the situation. find other activities or ways to express this intense energy. some relaxation modalities may be appropriate methods. it is important to be an objective third-party observer of this situation that is damaging to me. this manual consists of care algorithms for individuals that included the symptom, education on each symptom, basic modalities, and individual mind-body modalities. based on this care algorithm, three basic modalities including simple breathing, mindful breathing, and walking meditation were suggested twice a day for overall mental health improvement. for each symptom that an individual complained of, individual mind-body modalities were suggested to improve the symptom (table 3) . in the case of "basic modalities," it is recommended the modalities be carried out regularly, such as once in the morning and evening, whenever possible. in the case of "individual modalities," it is recommended to perform the suggested modalities when symptoms occur. a description of the mind-body modalities for symptom management is provided in table 4 . individuals may achieve efficient self-management of their symptoms through youtube videos in which detailed instructions for each modality are provided [16] . table 4 . mind-body modalities for symptom management. simple breathing repeat your inspiration and exhalation to find your original rhythm. find the most stable, comfortable, and balanced one. breathe and feel safe and comfortable. observe your breath. let us observe the inspiration and exhalation. try to feel cool air coming into your body and turbid air coming out of your body. breathing confirms that your body is clear and healthy. try to feel that your body is clear and healthy throughout this breathing exercise. walking meditation step on the ground and make sure it is stable and firm. while walking slowly, check that it is stable-unstable-stable again. walk to your own rhythm and find yourself comfortable and balanced. even in a small space, you can see the vitality of movement. divide the body parts and try to repeat the local tension and relaxation. tension your muscles while you breathe in and relax your muscles while you exhale. this process begins with your hands and spreads to each part of the body. throughout this process, make sure that your body is sufficiently relaxed. try to create the most stable and relaxed state. notice that both hands are warm. notice that both hands are heavy. notice that your heart beats regularly. notice that your breathing is comfortable. notice that your lower abdomen is warm. notice that the forehead is cool. breathe with the numbers to focus more on your breathing. each time you breathe in and out, count backwards starting with 10 to 1. focus only on breathing and numbers, and if you have other thoughts, try to focus on the breathing again. as you breathe comfortably, notice your body sensations, thoughts, and emotions. if a disturbing thought or emotion occurs, just observe it with tranquility. observe how it changes. it is important to take a non-judgmental attitude, rather than resisting or interpreting its meaning. let us check the warm heart we originally had. think about the sadness that a mother feels when seeing a sick child, or the wish that the child will be cured. let's extend that warmth to me, to my family, to my friends, and to my health care provider. try to be mindful when eating. do not rush food automatically, see it with your eyes, take it with the nose, taste it with the tongue, chew it with the teeth, swallow it with the throat, pass it through the esophagus, fill the stomach, and eventually feel satisfied. also, imagine that the energy generated in this process is supplied to the whole body. observe your body closely. identify the sensations, feelings, or pains felt in each area and accept it as it is. just accept it while looking. in the process of scanning the whole body, make sure that your body and mind are gradually relaxed. feel the warm energy in your palms. use that warm energy to deliver it to places where your body is uncomfortable or where you are in pain. make sure that the warmth is relaxing your symptoms and pain. when you are done, put your hands on top of your belly and deliver the warm energy to your body. km doctors explained why immunity plays an important role in the prevention and recovery of virus infection, including sars-cov-2 infection, to the individuals [17] . in addition, the impact of mind health on immunity was also explained. question 1. why is immunity important in the covid-19 era? answer 1. currently, no cure or vaccine for the new coronavirus has been developed. although no such treatments or vaccines have been developed, there are thousands of covid-19 patients who are self-healing. this is because the most important weapon against viruses is the body's immunity. since sars-cov-2 inhibits cells involved in immunity when it enters the human body, it is best to maintain and regulate immune function before the infection. question 2. does our mind or mood affect immunity? answer 2. depression or anxiety can decrease the activity of immune cells and increase the level of inflammation, thereby increasing the risk of preventing the body from responding appropriately to viral infections. short-term stress causes the human body to produce more immune cells, but long-term stress rather causes an accumulation of inflammatory substances, disrupting the immune system homeostasis. are there any recommended actions to improve immunity? answer 3. eating foods rich in antioxidants; getting enough sleep; exercising regularly; and it is important to get away from excessive psychological stress. simple activities such as singing, exercising, foot bathing, or even watching comedy movies, can help boost the release of immune-related molecules. question 4. are there any contraindications that can impair immunity? answer 4. eating junk food; breaks in life rhythms including sleep cycles; decreased physical activity; anxiety, repeated psychological stress, among others, have a detrimental effect on immunity. in particular, the sleep cycle plays a very important role in regulating the cycle of the immune system, and chronic sleep deprivation affects the balance of inflammatory cytokines, causing vulnerability to hypersensitivity reactions. in addition, excessive anxiety about the future and regret about the past can exacerbate negative emotions and physical symptoms, which can act as a burden on the immune system. answer 5. as a result of measuring the inflammation level and activity of the immune system in various studies, it was reported that when meditating, the body's inflammation level was lowered and the immune system activity was increased. representatively, there are some studies of mindfulness meditation and loving-kindness meditation. what is the principle of relaxation? answer 6. relaxation can be applied as a simple means to reduce physical and mental tension. the scope of relaxation is very comprehensive, and the breathing method is also used as a preparation step before starting a full-scale meditation. in relaxation, focusing on body sensations is a key concept. the most effective way to stay in the 'here and now' is to focus on the body sensations. answer 7. mindfulness is 'observing what is, as it is.' it is to create a state of staying here after putting down a lot of thoughts that arise automatically, such as certain preconceptions and stereotypes. in mindfulness, one's mind is not deceived by thoughts or other body sensations and can focus on a specific object or phenomenon itself. in fact, if you look at your body and mind excluding "interpretation" and "prejudice" among others, you will notice that you are in a clearer mind and more comfortable body than before. answer 8. loving-kindness meditation is often called social meditation. loving-kindness is the desire for people to be peaceful and happy, and compassion is the desire for people to escape from suffering. in a situation of disconnected and lonely alienation, you will be able to fill the natural energy and solidarity of human beings by having a warm heart and by practicing passing it on to others or to yourself. with the introduction of this manual, we look forward to the widespread use of mind-body medicine, including mindfulness-based interventions, to improve mental health in other disaster areas. however, in order for this manual to be applied in other environments, some limitations must first be taken into account. first, simple mental health measures should be introduced to simplify the evaluation of individuals' mental health in the telemedicine environment. since the creation and implementation of our manual was conducted during a pandemic, and not for the purpose of a study, it was insufficient to consider it as a proper outcome indicator. some indicators, such as the beck depression inventory, the beck hopelessness scale, the hamilton anxiety rating scale, and the pittsburg sleep quality index may be considered [18] , but considering the nature of telemedicine at disaster sites, it may be necessary to consider a simpler format. also, in combining telemedicine and measurement of mental health, the digital privacy of patients must be considered [19] . second, although the mind-body modalities introduced in our manual were provided through youtube videos, youtube videos have one-way characteristics. based on our clinical experience of mindfulness meditation, we believe the application of mind-body modalities, including mindfulness meditation, is more effective in an interactive communication environment. specifically, a sufficient feedback process is required following each practice, and this may be achieved by using programs such as zoom meetings. in the digital interactive communication environment, such as via zoom technology, it is possible to consider the construction of an online community-based meditation practice that may contribute to improving public mental health via web-based social interaction. third, although mindfulness meditation is a popular mind-body modality that is widely accepted, not only in eastern cultures, but also in western cultures, the cultural, ethnic, and religious/spiritual characteristics of patients should still be considered and respected. for example, in countries like china, tai chi or qigong may be a more familiar movement to cultivate mindfulness [20] , while in the united states, although not considered in our manual, spiritual meditation or mantra meditation may be good options [21] . fourth, mental health telemedicine interventions for front-line healthcare providers also need to be developed. our manual has been established for the general public or for infected patients, but today covid-19 poses a serious risk for first-line medical staffs' mental health [22] . therefore, a revised manual may include strategies to improve mental health and relieve psychological stress for medical staff. fifth, more specific scripts are needed for each stressful situation. for example, individual modalities could be developed according to events that may be applied to specific cases, such as family discord, social conflicts, helplessness, and despair. finally, although our manual is limited, mindful movements such as yoga, tai chi, and qigong may be useful strategies for mental health interventions through youtube videos or software like zoom meetings. importantly, because these movements transcend language barriers, they are likely to be helpful to foreigners residing in korea, as well as other citizens residing outside korea. in view of these above limitations, future studies on mental health management using telemedicine for covid-19 might consider the following issues. researchers should consider adopting a validated and simple form of mental health assessment tool for the initial and follow-up assessments of individuals. a comprehensive review by beidas et al. (2015) is helpful in developing the evaluation strategy [8] . also, mental health interventions based on smartphone applications are increasing today, and some of these applications evaluate the emotional psychopathology of users through assessment tools such as the 9-item patient health questionnaire or 7-item generalized anxiety disorder scale [1] . therefore, if the policy makers and information technology (it) experts can consider and authorize the linkage of information between telemedicine and existing mental health applications, mental health assessment in the field of telemedicine is likely to improve. for the use of mind-body modalities in telemedicine, bidirectional communication between the individual and practitioner could be emphasized. youtube videos or communication software, such as zoom may facilitate bidirectional communication; such recent advances in online video technologies have increased the potential utilization of mindful movements such as yoga, tai chi, and qigong. the fear and social distancing caused by covid-19 emphasized the importance of recognizing the mental health of all individuals. here, mindfulness is a promising intervention that may be combined with telemedicine. many attempts, such as telephone-adapted mindfulness-based stress reduction [23] and mhealth mindfulness intervention [24] have already been made. in this short paper, we introduced the "km doctor's mental health instruction manual in the telemedicine for covid-19" as a pilot manual used by the patients attending the covid-19 telemedicine center of km in korea. in this manual, a mindfulness-based intervention was introduced and may play an important role in assisting individuals faced with a pandemic or other emergency-situations. based on our experience, we propose health authorities in other countries consider the establishment of telemedicine-based mental health management strategies and further share their experiences and potential research. for mental health care in the upcoming "new-normal" era, mindfulness-based interventions are promising mind-body modalities. who timeline-covid-19 evidence based management guideline for the covid-19 pandemic-review article recent progress and challenges in drug development against covid-19 coronavirus (sars-cov-2)-an update on the status emerging evidence for neuropsycho-consequences of covid-19 covid-19 pandemic and impending global mental health implications effects of covid-19 pandemic in daily life psychosocial impact of covid-19 choices for the "new normal multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science turning the crisis into an opportunity: digital health strategies deployed during the covid-19 outbreak virtual health care in the era of covid-19 effectiveness of mindfulness-and relaxation-based ehealth interventions for patients with medical conditions: a systematic review and synthesis traditional chinese medicine for covid-19 treatment youtube channel of the association of korean medicine the trinity of covid-19: immunity, inflammation and intervention rapid response reports: summary with critical appraisal. in telehealth for the assessment and treatment of depression, post-traumatic stress disorder, and anxiety: clinical evidence; canadian agency for drugs and technologies in health digital privacy in mental healthcare: current issues and recommendations for technology use chi as exercise among middle-aged and elderly chinese in urban china prevalence and patterns of use of mantra, mindfulness and spiritual meditation among adults in the united states mental health care for medical staff and affiliated healthcare workers during the covid-19 pandemic telephone-adapted mindfulness-based stress reduction (tmbsr) for patients awaiting kidney transplantation: trial design, rationale and feasibility a randomized controlled trial of mhealth mindfulness intervention for cancer patients and informal cancer caregivers: a feasibility study within an integrated health care delivery system this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors are grateful for the support and cooperation with covid-19 telemedicine center of korean medicine and the association of korean medicine. the authors declare no conflict of interest. key: cord-296669-1md8j11e authors: li, xin; lu, peixin; hu, lianting; huang, tianhui; lu, long title: factors associated with mental health results among workers with income losses exposed to covid-19 in china date: 2020-08-04 journal: int j environ res public health doi: 10.3390/ijerph17155627 sha: doc_id: 296669 cord_uid: 1md8j11e the outbreak and worldwide spread of covid-19 has resulted in a high prevalence of mental health problems in china and other countries. this was a cross-sectional study conducted using an online survey and face-to-face interviews to assess mental health problems and the associated factors among chinese citizens with income losses exposed to covid-19. the degrees of the depression, anxiety, insomnia, and distress symptoms of our participants were assessed using the chinese versions of the patient health questionnaire-9 (phq-9), the generalized anxiety disorder-7 (gad-7), the insomnia severity index-7 (isi-7), and the revised 7-item impact of event scale (ies-7) scales, respectively, which found that the prevalence rates of depression, anxiety, insomnia, and distress caused by covid-19 were 45.5%, 49.5%, 30.9%, and 68.1%, respectively. multivariable logistic regression analysis was performed to identify factors associated with mental health outcomes among workers with income losses during covid-19. participants working in hubei province with heavy income losses, especially pregnant women, were found to have a high risk of developing unfavorable mental health symptoms and may need psychological support or interventions. at the end of december 2019, the chinese city of wuhan reported a novel pneumonia caused by coronavirus disease 2019 (covid19) , an infectious disease caused by an acute severe respiratory syndrome coronavirus, which is rapidly spreading both domestically and internationally [1, 2] . on 30 january 2020, the world health organization (who) held an emergency meeting and declared the worldwide covid-19 outbreak a public health emergency of international concern [3] . the emergence and rapid increase in the number of covid-19 cases has posed and continues to pose complex challenges for global research, public health, and medical communities [4, 5] . as of 1 june 2020, there were more than 6.15 million confirmed cases of covid-19 across more than 215 countries and regions, including more than 372,130 deaths. with the rapid spread of covid-19, the local government in wuhan immediately adopted a city closure policy, encouraging citizens to work at home and teach online, and shut down non-essential services to mitigate the impact and risks of the disease. then, the governments of other provinces with low numbers of infected people in china and many other countries around the world entered states of emergency for the health response and issued a series of policies, including ordering citizens (regardless of having symptoms of infection or not) to self-isolate at home, and maintaining social distance from other people. however, concerns have arisen about the potential psychological impact of these measures [6] [7] [8] . studies proved that covid-19 has caused a high prevalence of mental health problems in china [8] [9] [10] [11] [12] and other countries around the world [13] [14] [15] [16] . some researchers have attempted to understand the outbreak of this novel coronavirus from a global health perspective [17] [18] [19] . however, most studies focused on the psychological effects of people who were infected with covid-19, medical workers, or people in specific regions [10] [11] [12] [13] [14] [15] 20] . studies showed that the economic impact caused by severe acute respiratory syndrome (sars) will produce psychological morbidities in individuals who are directly or indirectly exposed to life-threatening situations [21] . the occurrence of such psychological morbidities among workers can impact their daily functions and lead to immediate economic and physiological consequences, such as lost job productivity, depression, and anxiety [22, 23] . to the best of our knowledge, no previous study focused on mental health problems among people with income losses caused by covid-19. to address this gap, the aim of our study was to evaluate the mental health of chinese workers with income losses exposed to covid-19 by quantifying the degrees of depression, anxiety, insomnia, and distress, and analyze the potential risk factors related to these symptoms. in this study, besides age, sex and other demographic characteristics, participants from hubei province and outside hubei province were taken as the research objects for comparison of regional differences. the ultimate goal of this study was to assess the mental health burden of people with income losses during covid-19 and to provide guidance for the promotion of mental well-being among this population. this was a cross-sectional study conducted using an online survey and face-to-face interviews to assess mental health problems and their associations with income losses among chinese citizens who were exposed to coronavirus disease 2019 (covid-19) from 25 april to 9 may 2020. eligibility criteria included (i) currently living in china, (ii) aged 18 years or older, and (iii) with income losses caused by covid-19. participants were encouraged to participate in online surveys or complete offline questionnaires. a total of 421 of 600 contacted individuals completed the survey for a participation rate of 70.2%, and 23 people with no loss of income were excluded from the study. the final sample included 398 respondents, with a response rate of 66.3%. this study was approved by the ethics committee and institutional review board of wuhan university, wuhan, china (ref: 20200411), and conducted in accordance with the ethical guidelines of the declaration of helsinki of the world medical association. all data were deidentified before being provided to the investigators. consent from each participant was obtained at the beginning of the survey. the questionnaire consisted of 37 factors to record demographic indicators and symptoms of depression, anxiety, insomnia, and distress caused by covid-19 of the participants (see appendix a). the following demographic data were included in this study: sex (male or female), age (18-25, 26-30, 31-40 and >40 years old categories), educational level (<undergraduate, college, masters, and higher), marital status (married and other including unmarried, widowed, and divorced), working location (hubei province, and outside hubei province), loss of income caused by covid-19 (light, middle, or heavy, >0% to 25%, 25-50%, and >50% less than pre-epidemic income, respectively), and place of residence (urban or rural). mental disorders, including depression, anxiety, insomnia, and distress, caused by covid-19 were assessed in our study by chinese versions of validated measurement tools [24] [25] [26] [27] : the patient health questionnaire-9 (phq-9; the total score ranged from 0 to 27) [24] , the generalized anxiety disorder-7 (gad-7; the total score ranged from 0 to 21) [25] , the insomnia severity index-7 (isi-7; the total score ranged from 0 to 28) [26] , and the revised 7-item impact of event scale (ies-7; the total score ranged from 0 to 28) [27] . the response options are: 3 = nearly every day, 2 = more than half the days, 1 = several days, and 0 = not at all for phq-9 and gad-7; 4 = always, 3 = often, 2 = sometimes, 1 = rare, and 0 = never for isi-7 and ies-7. the total scores of these survey scales are interpreted as follows: phq-9, extremely severe (22-28), severe (15) (16) (17) (18) (19) (20) (21) , moderate (10) (11) (12) (13) (14) , mild (5) (6) (7) (8) (9) , and normal (0-4) depression; gad-7, severe (15) (16) (17) (18) (19) (20) (21) , moderate (10) (11) (12) (13) (14) , mild (5) (6) (7) (8) (9) , and normal (0-4) anxiety; isi-7, severe (22-28), moderate (15) (16) (17) (18) (19) (20) (21) , subthreshold (8) (9) (10) (11) (12) (13) (14) , normal (0-7) insomnia; and ies-7 severe (22-28), moderate (15) (16) (17) (18) (19) (20) (21) , subthreshold (8) (9) (10) (11) (12) (13) (14) , and normal (0-7) distress. the cutoff score for detecting possible major symptoms of depression, anxiety, insomnia, and distress caused by covid-19 are 10, 10, 15, and 15, respectively. a higher score indicates participants with greater self-reported severe symptoms [24] [25] [26] [27] . the psychometric properties and internal reliabilities of the 4 scales have been previously confirmed in chinese populations [24] [25] [26] [27] . in [24] , statistical tests were performed to determine the reliability and validity of phq-9. results showed that the internal consistency value of phq-9 was 0.854 and the test-retest reliability value of phq-9 was 0.873, proving the phq-9 is a valid and reliable tool to evaluate depression in chinese people. he [25] tested the reliability and validity of chinese version of gad-7. the results show that the cronbach 'α coefficient of gad-7 is 0.898, and the test-retest reliability coefficient is 0.856, proving the chinese version of gad-7 has good reliability and validity in the application of evaluating anxiety. doris s.f. yu [26] tested the reliability and validity of chinese version of isi-7, finding that cronbach's alpha of the chinese version of the isi-7 was 0.81, with item-to-total correlations in the range of 0.34-0.67. in [27] , chan reported that the cronbach 'α coefficient of ies-r is 0.89, which proved the ies-r is a valid and reliable tool to evaluate distress among chinese people. in our study, the cronbach's alpha coefficient of our questionnaire is 0.97. the cronbach's alpha coefficients of the chinese versions of phq-9, gad-7, isi-7 and ies-7 were 0.920, 0.945, 0.879 and 0.909, respectively. first, we used descriptive statistics to describe the socio-demographic characteristics of these participants. second, the prevalence rates of depression (phq-9 score ≥ 5), anxiety (gad-7 score ≥ 5), insomnia (isi-7 score ≥ 8), and distress (ies-7 score ≥ 8) were estimated. finally, multivariable logistic regression models were used to explore factors associated with depression, anxiety, insomnia, and distress among workers with income losses exposed to covid-19 in china, and the associations between risk factors and outcomes are presented as adjusted odds ratios (aors) with a 95% confidence interval (ci), after adjustment for confounders, including sex, age, marital status, educational level, working position, place of residence, degrees of income losses. data analysis was performed by spss statistical software (version 25.0, ibm corp., armonk, ny, usa,), with p-values < 0.05 indicating statistical significance. the significance level was set at α = 0.05, and all tests were two-tailed. as shown in table 1 , the proportion of men to women was close, at 50.5% and 49.5%, respectively, and the proportion of marital status (recoded into married and other including unmarried, widowed, and divorced) was similar to that of sex, at 49.5% and 50.5%, respectively. we classified their income losses caused by covid-19 as one of the demographic variables. response options were slightly affected (>0% to 25%), moderately affected (25-50%), and heavily affected (>50%). table 1 shows that the proportions of light, middle, and heavy income loss (>0% to 25%, 25-50%, and >50% lower income than pre-epidemic income, respectively) caused by covid-19 were 33.9%, 17.6%, and 48.5%, respectively. as hubei was most severely affected province by covid-19 in china, all 398 participants were grouped by their geographic location. the proportions in hubei province, and places outside hubei province were 44.2%, and 55.8%, respectively. most of these participants were aged from 26 to 40 years, lived in urban areas, and had a college degree or above. generally consistent with the existing covid-19 research results [8] [9] [10] , the prevalence rates of our participants who had symptoms of depression, anxiety, insomnia, and distress cause by covid-19 were 45.5%, 49.5%, 30.9%, and 68.1%, respectively. as shown in table 2 , multivariable logistic regression analyses showed that, after controlling for covariates, the adjusted odds of depression, anxiety, insomnia and distress were lower among participants who under 30 years (e.g., depression among participants aged 26-30 years: or = 0.228, 95% ci: 0.097-0.535, p < 0.001; depression among participants aged 18-25 years: or = 0.187, 95% ci: 0.072-0.489, p < 0.001) compared with who aged over 40 years, and greater among those working in hubei province (e.g., depression: or = 2.647, 95% ci: 1.662-4.217, p < 0.001) than outside hubei province. for the population whose income was heavily affected by covid-19, they were prone to experiencing mental symptoms of depression, anxiety, and insomnia (e.g., depression among participants with light income losses: or = 0.215, 95% ci: 0.124-0.371, p < 0.001). those from urban area had lower adjusted odds of depression anxiety, insomnia and distress than those from rural area (e.g., depression: or = 0.391, 95% ci: 0.226-0.675, p = 0.001). at the same time, being married (or, 3.348; 95% ci, 1.896-5.911; p < 0.001) was associated with a greater risk of feeling depressed than being unmarried. in sex statistics, we set an additional question (if you are a woman, please indicate whether you are pregnant). in this study, as shown in table 3 , multivariable logistic regression analyses showed that, after controlling for covariates, we found that pregnant women with income losses during covid-19 were associated with a greater risk of feeling depressed and anxiety (depression: or = 2.956, 95% ci: 1.208-7.229, p = 0.018; anxiety: or = 3.146, 95% ci: 1.217-6.133, p = 0.018) than unpregnant women (table 3) . table 2 lists the detailed results of phq-9 from multivariable logistic regression analysis; the results for the other scales are presented in supplementary materials (tables s1-s3). abbreviations: na = not available; aor: adjusted odds ratio; ci: confidence interval. phq-9: the patient health questionnaire-9. according to lai, j et al. [10] , the cutoff scores for detecting possible major symptoms of depression, anxiety, insomnia, and distress caused by covid-19 are 10, 10, 15, and 15, respectively. thus, the prevalence rates of our participants who had severe mental symptoms of depression, anxiety, insomnia, and distress were 19.1%, 21.9%, 7.8%, and 25.9%, respectively. similar to findings regarding prevalence of mental symptoms, as shown in table 4 , multivariable logistic regression analyses showed that, after controlling for covariates, the adjusted odds of severe symptoms of depression, anxiety, and distress were lower among participants who aged 26-30 years (e.g., severe depression: or = 0.243, 95% ci: 0.091-0.645, p = 0.005) compared with who aged over 40 years, greater among those with heavy income losses than light and middle income losses (e.g., severe depression among participants with light income losses: or = 0.246, 95% ci: 0.121-0.502, p < 0.001), and lower among those from urban area than those from rural area (e.g., severe depression: or = 0.337, 95% ci: 0.185-0.615, p < 0.001). for those working in hubei province, they were more prone to experiencing severe mental symptoms of anxiety and distress than those working outside hubei province. we enrolled 398 respondents and found a high prevalence of mental health symptoms among workers with income losses caused by covid-19 in china. this latest national sample indicated the prevalence rates of any disorder (excluding dementia), anxiety disorders, and depressive disorders were 16.6%, 7.6%, and 6.9% in china, respectively. compared with national data, we found much higher prevalence rates of participants with symptoms of depression, anxiety, insomnia, and distress caused by covid-19, at 45.5%, 49.5%, 30.9%, and 68.1%, respectively. our findings are consistent with those of previous covid-19 studies, including a study in mainland china that found that the prevalence of depression as measured during the covid-19 pandemic was 48.3% [8] and a study in hong kong that found that the prevalence of depression caused by covid-19 was 49.8% [9] . mental disorders, including depression, anxiety, insomnia, and distress, caused by covid-19 were assessed in our study by chinese versions of validated measurement tools [24] [25] [26] [27] : phq-9, gad-7, and isi-7. in our study, the cronbach's alpha coefficient of our questionnaire is 0.97. the cronbach's alpha coefficients of the chinese versions of phq-9, gad-7, isi-7 and ies-7 were 0.920, 0.945, 0.879 and 0.909, respectively, proving these scales have good reliabilities and validities in the application of evaluating mental disorders among chinese worker with income losses. by reviewing the literature, we found that these chinese scales are widely used in the study of psychological problems. especially recently, these four scales have been used to study covid-19. for example, researchers used them to assess the magnitude of mental health outcomes among healthcare workers treating patients exposed to covid-19 in china [10] , phq-9 and gad-7 were used to evaluate depression and anxiety in hong kong during the covid-19 pandemic [9] , and gad-7 was used to assess the prevalence of mental health problems and examine their association with social media exposure [8] . in this study, besides age, sex and other demographic characteristics, participants from hubei province and outside hubei province were taken as the research objects for comparison of regional differences. the proportions of respondents from hubei province and places outside hubei province were 44.2% and 55.8%, respectively. the proportions of light, middle, and heavy losses of income (>0 to 25%, 25-50%, and >50% less income than pre-epidemic levels, respectively) caused by covid-19 were 33.9%, 17.6%, and 48.5%, respectively. most of these participants were aged from 26 to 40 years, lived in urban areas, and had a college degree or above. we found that workers with heavy income losses caused by covid-19 reported more symptoms of depression, anxiety, and insomnia. compared with participants outside hubei province, those in hubei province reported higher scores on all four scales. the prevalence rates of our participants who had severe mental symptoms of depression, anxiety, insomnia, and distress were 19.1%, 21.9%, 7.8%, and 25.9%, respectively. our findings further indicated that pregnant women scored higher than non-pregnant women on phq-9 and gad-7 measuring symptoms of depression and anxiety. these findings are consistent with the previous studies' findings that exposure to a public health emergency can cause mental health problems. this study has several limitations. first, it was limited in scope. almost half of the participants (44.2%) were from hubei province, limiting the generalization of our findings to less affected regions. this survey was mainly conducted online, so some respondent bias, such as few elder citizens' participation, may have affected the results. second, the survey was conducted over two weeks and lacked longitudinal follow-up. it was hard to determine whether the mental health symptoms of workers with income losses could become more severe, so the long-term psychological implications of this population are worth further investigation. last, although the response rate of this study was 70.1%, response bias may still exist if the non-respondents were either too stressed to respond or not at all stressed and therefore not interested in this survey. in conclusion, our findings showed that relatively high prevalence rates of symptoms of depression, anxiety, insomnia, and distress were caused by covid-19. the prevalence of mental health problems among workers caused by covid-19 in china is high, especially those working in hubei province with heavy income losses. in addition, pregnant women with income losses were associated with a greater risk of feeling depressed and anxiety than other women, and may need psychological support or interventions. these results further indicate that the long-term psychological implications of this population are worth further investigation. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/15/5627/s1, table s1 : prevalence of anxiety and associated factors, table s2 : prevalence of insomnia and associated factors, table s3 : prevalence of distress and associated factors, table s4 : prevalence of severe anxiety and associated factors, table s5 : prevalence of severe insomnia and associated factors, table s6 : prevalence of severe distress and associated factors. the authors declare no conflicts of interest. the questionnaire consisted of 37 questions to record demographic indicators and symptoms of depression, anxiety, insomnia, and distress of all participants. demographic data the following demographic data were included in this study: sex (male or female), age (18-25, 26-30, 31-40, or >40 years categories), educational level (<undergraduate, college, masters, or higher), marital status (recoded into married or other including unmarried, widowed, and divorced), working location (hubei province or outside hubei province), loss of income caused by covid-19 (light, middle, and heavy, being >0 to 25%, 25-50%, and >50% less income than the pre-epidemic level, respectively), and place of residence (urban or rural). the english versions of the phq-9, gad-7, isi-7, and ies-r-7 scales were used in this study to measure the degree of symptoms of depression, anxiety, insomnia, and distress of our participants. early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia a novel coronavirus from patients with pneumonia in china emergency committee regarding the outbreak of novel coronavirus (2019-ncov) outbreak of pneumonia of unknown etiology in wuhan, china: the mystery and the miracle characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: 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among college students in china reliability and validity of a generalized anxiety scale in general hospital outpatients insomnia severity index: psychometric properties with chinese community-dwelling older people the development of the chinese version of impact of event scale-revised (cies-r) this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-254471-4lomiv5d authors: kupcewicz, ewa; grochans, elżbieta; mikla, marzena; kadučáková, helena; jóźwik, marcin title: role of global self-esteem in predicting life satisfaction of nursing students in poland, spain and slovakia date: 2020-07-27 journal: int j environ res public health doi: 10.3390/ijerph17155392 sha: doc_id: 254471 cord_uid: 4lomiv5d background: this study analyzed the role of global self-esteem and selected sociodemographic variables in predicting life satisfaction of nursing students in poland, spain and slovakia. methods: the study subjects were full-time nursing students from three european countries. a diagnostic survey was used as a research method, while the rosenberg self-esteem scale (ses) and the satisfaction with life scale (swls) were used to collect data. results: the research was performed on a group of 1002 students. the mean age of those surveyed was 21.6 (±3.4). the results showed significant differences both in the level of the global self-esteem index (f = 40.74; p < 0.0001) and in the level of general satisfaction with life (f = 12.71; p < 0.0001). a comparison of the structure of results demonstrated that there were significantly fewer students with high self-esteem in spain (11.06%) than in poland (48.27%) and in slovakia (42.05%), while more students with a high sense of life satisfaction were recorded in spain (64.90%) than in poland (37.87%) or in slovakia (47.44%). a positive, statistically significant correlation was found between global self-esteem and satisfaction with life in the group of slovak students (r = 0.37; p < 0.0001), polish students (r = 0.31; p < 0.0001) and spanish students (r = 0.26; p < 0.0001). furthermore, a regression analysis proved that three variables explaining a total of 12% output variation were the predictors of life satisfaction in polish students. the regression factor was positive (ßeta = 0.31; r(2) = 0.12), which indicates a positive correlation and the largest share was attributed to global self-esteem (9%). in the group of spanish students, global self-esteem explained 7% (ßeta = 0.27; r(2) = 0.07) of the output variation and 14% in the group of slovak students (ßeta = 0.38; r(2) = 0.14). conclusions: the global self-esteem demonstrates the predictive power of life satisfaction of nursing students, most clearly marked in the group of slovak students. the measurement of the variables under consideration may facilitate the planning and implementation of programs aimed at increasing self-esteem among young people and promoting the well-being of nursing students. the literature explores various approaches to self-esteem. according to rosenberg, self-esteem is a positive or negative attitude towards oneself, a kind of global self-assessment. at the same time, the author points out that high self-esteem is a belief that one is "good enough", a valuable person, while low self-esteem means dissatisfaction with oneself, a kind of self-rejection [1] . self-esteem is a complex and multifaceted concept, often used interchangeably with self-evaluation [2, 3] . by its very nature, it is a subjective construct, based on personal perception and assessment. it involves not only the emotional, but also the performative aspect of functioning. it is a representative indicator of health and well-being, as well as a variable explaining human behavior [3, 4] . research shows that people with high self-esteem experience more positive emotions and are very active, persistent and healthier. on the other hand, people with low self-esteem experience more negative emotions and show less activity and even an attitude of avoiding difficulties, challenges and risks [3] . there are theoretical assumptions and empirical evidence that global self-esteem is a feature or state. according to mark leary's theory, self-esteem reflects the sociometric position of a person in a group. in turn, self-esteem as a state reflects the level of social approval and acceptance, as well as the sense of group membership and is susceptible to changes under the influence of mood or effort put into the task [5] . studies show that self-esteem changes during human life, increases between late childhood and adolescence and then increases during late adolescence and early adulthood [6] . this is a period related to a young person's education and the formation of new competences with regard to their personal vision of life. it is important that positive feelings, a lack of negative feelings and the level of satisfaction with life should be part of the subjective well-being in the life of every person [7] . the literature offers numerous studies on the evaluation of life satisfaction as a result of comparing one's own situation against the standards set by a given person. the evaluation of life satisfaction is expressed in the sense of satisfaction with one's own achievements and conditions [8, 9] . as the research shows, the level of self-esteem and satisfaction with life among nursing students (as well as among active nurses) varies and it is usually at a moderate level [10] [11] [12] [13] . many researchers have indicated that the variables in question reveal important relationships proving, among other things, the level of individual activity [14] [15] [16] [17] [18] . farwa et al. searched for a link between self-esteem and life satisfaction and socioeconomic status in a group of nursing students at the university of lahore. the results showed a positive correlation between socioeconomic status and self-esteem and student life satisfaction, which, according to the authors of the research, will translate into a more effective study [14] . other studies conducted among a group of 348 chinese students (214 men and 134 women) showed a close relationship between self-esteem and life satisfaction for both women and men. furthermore, the impact of the socioeconomic status on the life satisfaction of the students was observed [15] . an interesting study was conducted at the university of cyprus to determine the relationship between religiousness, self-esteem, stress and depression among students of nursing, social care and early education. self-esteem in that study played a significant role because higher levels of self-esteem in students were associated with lower levels of depression, while the strength of religious and spiritual beliefs negatively correlated with depression [16] . the links between self-esteem and student health were also confirmed by karaca et al. self-esteem, academic satisfaction, stress and negative events over the past year have been shown to have a strong link to mental health in a group of 516 turkish nursing students [17] . other turkish studies at the foundation university in istanbul attempted to determine the impact of four years of nursing studies on the self-esteem and assertiveness of academic youth. it was found that the level of self-esteem in the examined students increased in the fourth year of studies, while the level of assertiveness in the students varied depending on the year of studies, increasing in the second and third year of studies [18] . the relationship between global self-esteem and sociodemographic variables such as age, marital status, level of education and professional experience of nursing students is also evident, as was shown by shresth et al. [19] . the research results also show the relationship between emotional intelligence and self-esteem. the results of a study carried out on a group of 400 nursing students at kafrelsheikh university in egypt can provide an example here. significant positive correlations between variables were observed and it was shown that emotional intelligence and self-esteem are important factors determining student progress. most the examined students demonstrated low and moderate self-esteem [20] . other studies, in turn, show that self-esteem is significantly related to social functioning and plays a significant role in shaping the image of the nursing profession [11] . based on the literature review, it can be concluded that self-esteem shows predicted relationships with emotional dispositions, predispositions determining readiness to take action, as well as aspects of task-oriented and social functioning [6] . in line with the presented theoretical assumptions, the main objectives of this study were established: • the following research hypotheses were put forward: • it is assumed that nursing students have different levels of global self-esteem and life satisfaction depending on their country of origin; • there is a relationship between global self-esteem and selected sociodemographic variables, i.e., age, year of study and gender and satisfaction with life in nursing students from different countries. between may 2018 and june 2019, a diagnostic survey was carried out with the participation of 1002 students enrolled in first degree-undergraduate, full-time studies in the nursing program at the university of warmia and mazury in olsztyn, the pomeranian medical university in szczecin (poland), the university of murcia in murcia (spain) and the catholic university in ružomberok (slovakia). the criteria for inclusion in the study included having the status of a nursing student, age up to 30 and expressed consent to participate in the study. the criteria for exclusion from the study were the period of the examination session and the absence of consent to participate in the study. the research was carried out at the place where the teaching classes for students are held, after obtaining permission from the teacher conducting the classes. one of the researchers delivered the prepared sets of questionnaires to the universities where the research project was carried out. students were provided with information about the purpose of the study and instructions on how to fill in the answer sheet and they had the opportunity to ask questions and receive explanations. after expressing informed consent to participate in the study, students were given a set of questionnaires. on average, it took about 20 min to complete the questionnaire. the research was anonymous and voluntary and the students could withdraw from the study at any time. a total of 1017 sets of questionnaires were distributed. after collecting the data and eliminating defective questionnaires, 1002 (i.e., 98.5%) correctly completed questionnaires were qualified for further analysis. the collected material was entered in excel software and the results were analyzed collectively. the study involved 1002 students, including 404 (40.3%) from poland, 208 (20.8%) from spain and 390 (38.9%) from slovakia. the mean age of all the respondents was 21.60 years (±3.40). the distribution of women and men in different countries was significantly different (p < 0.001). women accounted for 91.32% (n = 915) of all surveyed persons and men only 8.68% (n = 87). the distribution of the number of students in particular years of studies in the analyzed groups was similar. the number of first-year students was 329 (32.83%), the second year: 458 (45.71%) and the number of third-year students was 215 (21.46%). the age of the respondents was analyzed in three age groups: ≤20 years, 21-22 years and ≥23 years. the distribution of age groups by country was significantly different (p < 0.001). among spanish students, 73.08% were 20 and below (table 1 ). the research applied the diagnostic survey method and two research tools (validated and available for general use in the mother tongue in each of the countries) were used to measure variables: a self-constructed questionnaire was used to collect sociodemographic data, such as place of residence (country), gender, age, level of education, form and year of study. rosenberg ses self-esteem scale is made up of 10 statements that relate to beliefs and are diagnostic in their nature. the examined person indicates the extent to which he/she agrees with each of them by providing answers on a four-point scale from 1 to 4, which indicate: 1-strongly agree, 2-agree, 3-disagree, 4-strongly disagree. following the assumed method of evaluating the answers, statements that are positively formulated are reversed: 1, 2, 4, 6, 7, so that the highest score is awarded for answers expressing a higher level of self-assessment. the result is the sum of points, which is an indicator of the overall self-esteem level. the range of possible results is from 10 points to 40 points. a higher score reflected higher self-esteem. raw results were converted into standard units on the sten scale. the ses scale has good psychometric properties, with cronbach's alpha ranging from 0.81 to 0.83 [3,4,6]. the satisfaction with life scale (swls) contains five statements and is used to measure life satisfaction expressed in the sense of satisfaction with one's achievements. the respondent indicates to what extent each of the statements refers to his/her previous life, providing a response on a seven-point scale from 1 to 7, which indicate: 1-strongly disagree, 2-disagree, 3-slightly disagree, 4-neither agree nor disagree, 5-slightly agree, 6-agree, 7-strongly agree. the result is a sum of points, which is an overall indicator of the sense of satisfaction with life. the range of results is from 5 points to 35 points. a higher score indicates greater satisfaction with life. raw results were converted into standard units on the sten scale. the swls scale has good psychometric properties and a reliability factor (cronbach's alpha) is 0.87 [9] . the data generated during the study were subjected to statistical analysis using the polish version of statistica 13 (tibco, palo alto, ca, usa). socio-demographic data are presented as the number of cases and as the percentage values and the distribution of variables in groups for individual countries was checked with the chi-squared (χ 2 ) test. the overall indicator of global self-esteem was converted to standardized units, which were interpreted according to the characteristics of the sten scale. it contains 10 units and the scale jump equals 1 sten. sten scores between 1 and 4 were considered low, between 5 and 6 were considered average and between 7 high and 10 high [6, 9] . differences in average global self-esteem and life satisfaction results among students by country of origin were tested with the anova (f) test, while intergroup differences were tested with the post hoc test. the r-pearson correlation coefficient was used to determine the relationship between the variables. multiple regression analysis was used to build a model of estimation of a random variable from explanatory variables. the interpretation of the strength of the relationship between the variables was based on guilford's classification. in all tests, the significance level p < 0.05 was assumed [21] . the presented research results are part of a larger international research project [22] . the research meets the criteria for a cross-sectional study [23] , and the project received approval (no. 4/2020) from the senate committee on ethics of scientific research at the olsztyn university. the results of research on global self-esteem and life satisfaction conducted in poland, spain and slovakia indicate that global self-assessment is related to the subjective well-being of nursing students. taking into account the cultural conditions in individual countries, significant differences were observed in nursing students both for overall global self-esteem index (f = 40.74; p < 0.0001) and for overall life satisfaction (f = 12.71; p < 0.0001) ( table 2 ). detailed analyses with the post hoc test (nir test) showed that the level of global self-esteem among spanish students was significantly lower than among polish (p < 0.0001) and slovak students (p < 0.0001). however, no significant differences in the level of the overall global self-esteem index were found between students from poland and slovakia (table 2 ; figures 1 and 2) . subsequent analyses with a post hoc test showed that the general level of life satisfaction among nursing students in poland was significantly lower than in slovakia (p < 0.03) and lower than in spain (p < 0.0001). in turn, students from slovakia demonstrated a significantly lower rate of satisfaction with life than students from spain (p < 0.002) ( table 2 , figures 1 and 2) . within a given country, no significant differences in the average results for global self-esteem or sense of satisfaction with life were noted in relation to selected sociodemographic characteristics such as age, gender and year of study. after converting the raw results into sten-scale standardized units, it was found that the distribution of low, average and high global self-esteem in nursing students varied significantly from country to country (χ 2 = 103.66; p < 0.0001). as shown by the analyses, the number of respondents with low self-esteem was significantly higher in spain (37.02%) than in poland (27.97%) and slovakia (26.15%). on the other hand, students with high self-esteem were significantly less numerous in spain (11.06%) than in poland (48.27%) and slovakia (42.05%) ( figure 3) . after converting the raw results into sten-scale standardized units, it was found that the distribution of low, average and high global self-esteem in nursing students varied significantly from country to country (χ 2 = 103.66; p < 0.0001). as shown by the analyses, the number of respondents with low self-esteem was significantly higher in spain (37.02%) than in poland (27.97%) and slovakia (26.15%). on the other hand, students with high self-esteem were significantly less numerous in spain (11.06%) than in poland (48.27%) and slovakia (42.05%) (figure 3 ). after converting the raw results into sten-scale standardized units, it was found that the distribution of low, average and high global self-esteem in nursing students varied significantly from country to country (χ 2 = 103.66; p < 0.0001). as shown by the analyses, the number of respondents with low self-esteem was significantly higher in spain (37.02%) than in poland (27.97%) and slovakia (26.15%). on the other hand, students with high self-esteem were significantly less numerous in spain (11.06%) than in poland (48.27%) and slovakia (42.05%) ( figure 3) . subsequent analyses were associated with the calculation of pearson's linear correlation coefficients (r) between the overall global self-esteem index and life satisfaction of nursing students, determining the strength and direction of the relationship. in the group of slovak students, a statistically significant positive correlation (r = 0.37; p < 0.0001) between global self-esteem and satisfaction with life was observed on an average level ( figure 5 ). the same direction and a similar strength of relationship at the average level were found for polish students. the correlation coefficient was r = 0.31 (p < 0.0001) ( figure 6 ). the lowest correlation coefficient (r = 0.26; p < 0.0001) was observed among spanish students (figure 7) . these results indicate that nursing students with higher global self-esteem are significantly more satisfied with life, regardless of their country of residence. spain slovakia subsequent analyses were associated with the calculation of pearson's linear correlation coefficients (r) between the overall global self-esteem index and life satisfaction of nursing students, determining the strength and direction of the relationship. in the group of slovak students, a statistically significant positive correlation (r = 0.37; p < 0.0001) between global self-esteem and satisfaction with life was observed on an average level ( figure 5 ). the same direction and a similar strength of relationship at the average level were found for polish students. the correlation coefficient was r = 0.31 (p < 0.0001) ( figure 6 ). the lowest correlation coefficient (r = 0.26; p < 0.0001) was observed among spanish students (figure 7) . these results indicate that nursing students with higher global self-esteem are significantly more satisfied with life, regardless of their country of residence. determining the strength and direction of the relationship. in the group of slovak students, a statistically significant positive correlation (r = 0.37; p < 0.0001) between global self-esteem and satisfaction with life was observed on an average level ( figure 5 ). the same direction and a similar strength of relationship at the average level were found for polish students. the correlation coefficient was r = 0.31 (p < 0.0001) ( figure 6 ). the lowest correlation coefficient (r = 0.26; p < 0.0001) was observed among spanish students (figure 7) . these results indicate that nursing students with higher global self-esteem are significantly more satisfied with life, regardless of their country of residence. further analyses attempted to determine the predictors of life satisfaction among the examined nursing students in individual countries. when constructing the multiple regression model, life satisfaction was assumed as the explained (dependent) variable and a range of sociodemographic variables, i.e., age, gender, year of study and global self-esteem, were used as explanatory (independent) variables. regression analysis showed that three variables explaining a total of 12% output variation were the predictors of life satisfaction in polish students ( table 3) further analyses attempted to determine the predictors of life satisfaction among the examined nursing students in individual countries. when constructing the multiple regression model, life satisfaction was assumed as the explained (dependent) variable and a range of sociodemographic variables, i.e., age, gender, year of study and global self-esteem, were used as explanatory (independent) variables. regression analysis showed that three variables explaining a total of 12% output variation were the predictors of life satisfaction in polish students ( table 3 ). the regression further analyses attempted to determine the predictors of life satisfaction among the examined nursing students in individual countries. when constructing the multiple regression model, life satisfaction was assumed as the explained (dependent) variable and a range of sociodemographic variables, i.e., age, gender, year of study and global self-esteem, were used as explanatory (independent) variables. regression analysis showed that three variables explaining a total of 12% output variation were the predictors of life satisfaction in polish students ( table 3 ). the regression factor was positive (ßeta = 0.31; r 2 = 0.12), indicating a positive correlation, with the largest share attributed to global self-esteem (9%). the other two variables, year of study and gender, demonstrated a small share in the prediction of life satisfaction among polish students (3%). in nursing students in spain and slovakia, only one variable-global self-esteem-proved to be a predictor of life satisfaction. in the group of spanish students, global self-esteem explained 7% (ßeta = 0.27; r 2 = 0.07) of the output variation and 14% in the group of slovak students (ßeta = 0.38; r 2 = 0.14). in both cases, the regression index was a positive value, which means that global self-esteem is positively linked to subjective well-being, which is an important element of health. = 0.14; corrected r 2 = 0.14 statistically significant: p < 0.01; p < 0.001. explanation: r-correlation coefficient; r 2 -multiple determination coefficient; ßeta-standardized regression coefficient; ß-non-standardized regression coefficient; ß error-non-standardized regression coefficient error; t-t-test value; ses-global self-esteem. the authors of this study have attempted to define the role of global self-esteem in the lives of nursing students in poland, spain and slovakia, recognizing that self-esteem is based on self-knowledge, which affects satisfaction with life. there are numerous factors that determine how nursing students perceive themselves. the image they create of themselves and the attitude they have towards themselves have a strong influence on a wide range of personal and social behaviors. in this study, significant differences were observed in the level of the overall global self-esteem index among nursing students. students from spain obtained lower average values (26.03) of global self-esteem than nursing students from poland and slovakia (29.69 vs 29.10). comparing the mean values obtained in own research with the mean results (30.85) obtained for the data collected in 53 countries by other researchers, it can be concluded that, as in most countries, most the examined nursing students obtained results higher than the arithmetic midpoint of the scale [22] . the average results of the second examined variable, i.e., life satisfaction, were distributed slightly differently. the highest average value was obtained by students from spain (24.04), while lower values were obtained by students from slovakia (22.40) and poland (21.46 ). when reviewing the results obtained by other researchers, it can be observed that they indicate different levels of global self-esteem and life satisfaction among the groups of respondents, sometimes being quite diverse [10, [24] [25] [26] [27] [28] [29] [30] . velmurugan et al. proved that 65.3% of the surveyed nursing students revealed moderate self-esteem, while 22.9% had low and only 11.9% had high levels of self-esteem [10] . as demonstrated in the analyses of own research results, students with high self-esteem were significantly less numerous in spain (11.06%) than in poland (48.27%) or slovakia (42.05%). in contrast, more than half (64.90%) of the surveyed students from spain described their sense of life satisfaction as high, which may indicate that in addition to self-esteem, other factors have a significant impact on their well-being. in turn, in a study in cyprus, average levels of global self-esteem were found for the majority (71.3%) of nursing students [27] . the results of numerous studies indicate that global self-esteem correlates with life satisfaction [28] [29] [30] . to confirm this thesis, it is worth citing the results of research carried out by patel et al., who found a significant impact of self-esteem on the satisfaction with life of indian students [28] . similarly, in the research presented in this study, the results of linear correlation indicate that the higher global self-esteem among students is correlated with increased satisfaction with life. the presented study also showed that global self-esteem is a predictor of satisfaction with life (from 7% to 14%) of nursing students, and the strongest predictive power was shown in the slovak group. however, sociodemographic variables, i.e., age, gender and year of studies did not play a significant role in predicting the satisfaction of the studied students. several researchers also sought individual determinants of subjective well-being in early adulthood. it was found that students' self-esteem, physical appearance and positive everyday events were indicators of satisfaction with life among spanish youth [29] . in contrast, williams et al. conducted an interesting study to determine the relationship between daily life satisfaction of nursing students and the body mass index (bmi) and the consumption of food and drink. the study group consisted of 215 students, of whom approximately 44.9% were overweight, obese or extremely obese. it was found that the increase in individual satisfaction with everyday life predicted a 36% decrease in the probability of overweight/obesity [30] . self-esteem is a personal resource related to the well-being of working nurses and it makes sense to develop it in the next stages of education. a study by perez-fuentes et al. of a group of 1073 nurses found that global self-esteem correlates strongly with health behavior. the results of these studies have shown that poor sleep quality and the type of food consumed affect the self-esteem of nurses [31] . in other studies, using a group of 1094 nurses, it was found that global self-esteem had a direct and indirect effect on uncontrolled eating [32] . abnormal eating behavior often signals problems with self-esteem, acceptance of one's own body and difficulties with adaptation in the group [33] . research shows that self-esteem has strong links to the dimensions of emotional functioning. consequently, it is important to promote the well-being of students. an illustration of this is a project aimed at promoting the mental health of first-year nursing students at the university of minify (egypt). as a result of the actions taken, there was an increase in self-esteem and a decrease in the level of student anxiety in relation to the initial parameters [34] . korean researchers, on the other hand, evaluated a short program for nursing students that focused on promoting positive self-esteem and ego development, as these two variables are related to academic achievement and students' life satisfaction. as indicated by the authors of the study, the results of self-identity and self-esteem increased significantly in the group of participating students, while the results in the control group remained at the same level [35] . in subsequent korean studies, an attempt was made to identify factors affecting the learning outcomes of nursing students under simulated conditions. it was found that the self-esteem and collective effectiveness of nursing students during team classes in simulated conditions affects their educational effects [36] . there is evidence suggesting that other variables that are expected to be related to the level of self-esteem are key attributes of healthcare workers, such as interpersonal communication, emotional intelligence and empathy [25] . it is worth highlighting that it is impossible to present all directions in which scientific research on self-esteem and satisfaction with life is developing. the authors of the study have only reviewed the most important findings, which may be helpful in interpreting the results of their own research and comparing them with the results of other researchers, as well as outlining the area of future research on the development of global self-esteem and quality of life of academic youth as future employees of the medical services sector. it is also worth considering the new situation recently caused by the covid-19 pandemic, at least in view of the factors related to restrictions which have forced quite a radical change in the functioning of young people, especially in social contacts. in further scientific deliberations, it can be assumed that nursing students with low global self-esteem and low life satisfaction may experience negative emotional states of dissatisfaction in their relationships with others, which may lead, among others, to feelings of loneliness. the results of the research presented in this study show that global self-esteem is a predictor of life satisfaction for nursing students, and its measurement can help to plan and implement programs aimed at increasing the sense of self-esteem of young people and promoting the well-being of students. the authors of the study indicated some limitations, related to the fact that the research did not exclude students experiencing (at that time) family related, financial or emotional problems, not related to studying. since the presented study is the first on the international scene in selected european countries, such as poland, spain and slovakia, it requires replication with a larger study group, as well as verification of the relationships established here in other situational contexts. significant differences in the level of overall global self-esteem and life satisfaction of nursing students based on the country of residence were found. students from spain achieved lower average values of global self-esteem than nursing students from poland and slovakia, but they achieved higher values of satisfaction with life than other students. the percentage shares of low, average and high global self-esteem and life satisfaction among nursing students in particular countries were significantly different. there were fewer students with high self-esteem in spain than in poland or slovakia, while more highly satisfied students were reported in spain than in poland or slovakia. although global self-esteem demonstrates the predictive power of life satisfaction of nursing students in all of the analyzed countries, it is most clearly marked in the group of slovak students. in the polish group, two sociodemographic variables (year of study and gender) slightly influenced the prediction of life satisfaction in nursing students. society and adolescent self-image does high self-esteem cause better performance, interpersonal success, happiness, or healthier lifestyles? skala samooceny ses morrisa rosenberga-polska adaptacja metody the rosenberg self-esteem scale: translation and validation in university students commentary on self-esteem as an interpersonal monitor: the sociometer hypothesis subjective well-being abbreviated three-item versions of the satisfaction with life scale and the harmony in life scale yield as strong psychometric properties as the original scales self-esteem among 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between emotional intelligence and self-esteem among nursing students. egypt analysis of the relationship between stress intensity and coping strategy and the quality of life of nursing students in poland, spain and slovakia strengthening the reporting of observational studies in epidemiology (strobe): explanation and elaboration simultaneous administration of the rosenberg self-esteem scale in 53 nations: exploring the universal and culture-specific features of global self-esteem the relationship between self-esteem, emotional intelligence, and empathy among students from six health professional programs analysis of sociodemographic and psychological variables involved in sleep quality in nurses religious and spiritual beliefs, self-esteem, anxiety, and depression among nursing students self-esteem and life satisfaction among university students of eastern uttar pradesh of india: a demographical perspective prosociality and life satisfaction: a daily-diary investigation among spanish university students nursing student satisfaction with daily life: a holistic approach association with the quality of sleep and the mediating role of eating on self-esteem in healthcare personnel the reasons for doing physical exercise mediate the effect of self-esteem on uncontrolled eating amongst nursing personnel the effect of body dissatisfaction on disordered eating: the mediating role of self-esteem and negative effects in male and female adolescents impact of counseling on self-esteem and anxiety levels among nursing students evaluation of a program on self-esteem and ego-identity for korean nursing students associations of stress, self-esteem, and collective efficacy among nursing students: a descriptive cross-sectional study this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflicts of interest. key: cord-272497-ww9o1kjr authors: al-anzi, bader s.; alenizi, mohammad; al dallal, jehad; abookleesh, frage lhadi; ullah, aman title: an overview of the world current and future assessment of novel covid-19 trajectory, impact, and potential preventive strategies at healthcare settings date: 2020-09-25 journal: int j environ res public health doi: 10.3390/ijerph17197016 sha: doc_id: 272497 cord_uid: ww9o1kjr this study is an overview of the current and future trajectory, as well as the impact of the novel coronavirus (covid-19) in the world and selected countries including the state of kuwait. the selected countries were divided into two groups: group a (china, switzerland, and ireland) and group b (usa, brazil, and india) based on their outbreak containment of this virus. then, the actual data for each country were fitted to a regression model utilizing the excel solver software to assess the current and future trajectory of novel covid-19 and its impact. in addition, the data were fitted using the susceptible–infected–recovered (sir) model. the group a trajectory showed an “s” shape trend that suited a logistic function with r(2) > 0.97, which is an indication of the outbreak control. the sir models for the countries in this group showed that they passed the expected 99% end of pandemic dates. group b, however, exhibited a continuous increase of the total covid-19 new cases, that best suited an exponential growth model with r(2) > 0.97, which meant that the outbreak is still uncontrolled. the sir models for the countries in this group showed that they are still relatively far away from reaching the expected 97% end of pandemic dates. the maximum death percentage varied from 3.3% (india) to 7.2% with usa recording the highest death percentage, which is virtually equal to the maximum death percentage of the world (7.3%). the power of the exponential model determines the severity of the country’s trajectory that ranged from 11 to 19 with the usa and brazil having the highest values. the maximum impact of this covid-19 pandemic occurred during the uncontrolled stage (2), which mainly depended on the deceptive stage (1). further, some novel potential containment strategies are discussed. results from both models showed that the group a countries contained the outbreak, whereas the group b countries still have not reached this stage yet. early measures and containment strategies are imperative in suppressing the spread of covid-19. today's world is changing rapidly at different levels during the current technological and medical renaissance due to research and development (r&d) that has resulted in innovative technologies and outcomes. sometimes such developments may lead to disastrous consequences causing adverse effects on the environment, which could be reflected on the health of living organisms at different levels such as global warming as a part of air pollution, water pollution, and even cancer. some of the advancements could be in the medical field, as well some new antibiotics and vaccines to fight new diseases and outbreaks. as a result, some microorganisms/pathogens have mutated to develop resistance to existing treatments causing many epidemics and outbreaks. disease and sickness have tormented humanity since the beginning of life on earth. human beings, along with plants and vegetables, have had to face challenges from microorganisms during their evolution. the mankind history has seen epidemics characterized by mortality and morbidity [1] . however, the scale of these diseases has increased notably since the advent of globalization. with the rise in global trade, expansion of civilization, contact with populations across the globe, new opportunities for human interactions have become more common, resulting in the proliferation of such epidemics. the early years witnessed the onset of several diseases such as malaria, smallpox, tuberculosis, influenza, leprosy, whose cure has eventually been discovered [2] . the scientific efforts made during the mid-20th century has reduced the spread of epidemics in the world, mainly due to the advances in medical services, improvements in health care and the urban environment, and availability of vaccines and antibiotics [1, 3] . however, the widespread outbreaks have again returned to the world in the 21st century, possibly due to pollution, overpopulation, global transportation network, and poverty in some parts of the world. hence, the recurrence and emergence of potential infectious diseases that may cause epidemics is most likely to continue [3] . in fact, the world health organization (who) has claimed that approximately 15 million deaths due to these infectious diseases takes place each year. in developing countries with the least economic resources, such diseases are the major causes of deaths. certain diseases such as tuberculosis and malaria, have reappeared due to the emergence of drug resistant microorganism strains. lastly, the perception of "deliberately emergent" pathogens (such as anthrax and smallpox), and the possibility of their use for bioterrorism in the contemporary world cannot be ruled out [4] . recently, the world has gone through an intermittent communicable disease outbreak that led to unprecedented epidemics, which have significantly impacted humanity claiming many innocent lives and the economy. such epidemics are sever acute respiratory syndrome (sars), middle eastern respiratory syndrome (mers), and of course the current novel coronavirus that has been classified as a pandemic . table 1 lists the historic and recent epidemics/pandemics [3, 5] that have occurred in the world. no one can overlook what the world is going through these days as a result of the covid-19 pandemic that has already spread through the 213 countries affecting 13,000,000 people and, unfortunately, killing around 600,000 people over a short timeframe (5-7 months), still with an accelerated pace and notable upward trend [6] . as aforementioned, this has affected the world economy, the humans' life, and has spread panic all around. on 31 december 2019, there was a cluster of pneumonia cases in wuhan, hubei province, china, whose investigation revealed that these cases were associated with the novel coronavirus or covid-19, as it is called today [7] . viruses are not from the plant or animal kingdom, and are neither bacteria, but are the typical parasites of the living kingdoms. viruses are not living organisms because they cannot live without a host cell. all viruses contain a core, made of a genetic material-nucleic acid, either dna or rna-and a protein shell, which encases the nucleic acid [8] . coronaviruses are a large group of viruses [9] surrounded by an envelope with protein spikes, which gives the appearance of a crown (or, in latin, corona) from where it derives its name. [10] . there are different types of coronaviruses that cause respiratory and gastrointestinal problems [11] . respiratory diseases can range from pneumonia and in most people the symptoms can generally cause a mild disease [12] . however, there are some types of coronaviruses that can cause several diseases such as sars: the coronavirus sars-cov identified in table 1 . historic and recent epidemics/pandemics [3, 5] . the current novel coronavirus (covid19) was first found through a group of chinese people who tested positive for pneumonia [7] . this was at the end of year 2019 in wuhan city. the disease then spread to their family members and the surrounding people including their health care staff. the contagious nature of this disease resulted in its spread to other 213 countries over few months [6] . the coronaviruses circulate in a range of animals. this virus can "spill over" meaning they can jump from animal to human probably due to a range of factors such as mutation or increased contact between human and animals [15] ; for example the mers-cov came from camels [13] and the sars_cov from civet cats [12] . the animal reservoir of coronavirus (2019-ncov) is not known yet. in general, respiratory viruses are usually transmitted through droplets from an infected person's cough or sneeze or by touching a surface that has been contaminated with the virus [16] . people at most risk of the coronavirus infection are those who work at an animal market, health care workers treating coronavirus patients, as well as family members caring for infected coronavirus members [17] . the most common symptoms of this coronavirus (2019-ncov) are fever, tiredness, respiratory symptoms such as cough, sore throat, and shortness of breath, and rare intestinal symptoms such as diarrhoea [18, 19] . unluckily, this covid-19 virus has some features that contributed to its global spread at a relatively short time. the virus has spread all over asia and reached the united states (snohomish county, washington) on 19 january [20] and in germany on 24 january [21] through different routes from china. facts about this virus are still new, and what we know about this may change in the future. zhao et al. verified that the initial growth phase of the coronavirus in china was the exponential growth [22] . they used the serial intervals (si) of infection caused by mers and sars as approximations for the si of the coronavirus and estimated the r 0 [22] . iwato et al. conducted simulations using the seir model to assess the impact of secondary outbreaks outside china, assuming that one infected patient travelled to an outside community [23] . while applying the seir compartmental model, kuniya t. predicted the epidemic peak for the coronavirus in japan using real data from january to february 2020 [24] . al qaness et al. developed a novel forecasting model that forecasted and estimated the covid-19 cases for the upcoming ten days using the adaptive neuro-fuzzy inference system (anfis), which uses the enhanced flower pollination algorithm (fpa) and the salp swarm algorithm (ssa) [25] . roosa et al., in their study, generated forecasts based on two popular models used previously for forecasting infectious diseases outbreaks, i.e., richards growth model, and a sub-epidemic wave model [26] . jung et al. modeled the epidemic growth using two methods, scenario-1, from a single case recorded on 8 december 2019, and scenario-2, using the growth rate fitted along with the other parameters based on data from 20 exported cases reported by 24 january 2020 [27] . the current study aims to assess the trajectory of the recent pandemic due to the covid-19 outbreak utilizing a new splitting methodology of the selected countries into two groups and developing regression-based and sir-based statistical models and tools that depict the actual recorded data of covid-19. different modeling techniques potentially provide different prediction results. we considered two modeling techniques that adopt two different prediction approaches to show that although the modeling techniques exhibit different detailed results, they lead to the same general conclusions. this study covers the entire world with emphasis on extreme cases based on the disease containment. such models will be useful in projecting the covid-19 trajectory to estimate the daily infection and death rates of the world and selected countries in advance. in addition, this study introduces new factors to be used directly to compare the countries' responses towards covid-19. this will help the authorities take the necessary measures and proper action plans to minimize the covid-19 impact ahead of time. furthermore, the article also covers some novel potential strategies to contain the virus spread at healthcare settings. actual data (country wide population number, number of infected cases in a country, number of deaths in a country, number of new cases) for the entire world and a few selected countries were obtained from the worldometer website [6] . according to the website, the data mentioned have been collected from the countries' health ministry, government institutions, or government authorities' social media accounts [6] . the data were recorded daily where the day was reset after midnight gmt+0. all the countries recorded new cases for the current day while in progress except china who displayed the previous day cases. certain countries were chosen to conduct this study based on their outbreak containment and responses. then, a new splitting methodology was used in the current study to divide the selected countries into two groups (a) group a: that succeeded in containing the covid-19 outbreak, where its behavior was split into 3-4 subperiods and (b) group b: that failed and is still struggling in containing the outbreak, where its behavior was split into two subperiods. logistic and exponential growth statistical models were used to fit the actual model into regression equations utilizing the excel solver software. in addition, the susceptible-infected-recovered (sir) model [28] was applied, which is a compartmental model that has been widely utilized in the literature to predict the spread of infectious diseases. in this model, the population (n) is categorized into three compartments including susceptible (s), infected (i), and recovered (r). the model assumes that the population and both infection and removal rates are constant during the whole epidemic period. in addition, it assumes that the population is well-mixed. during the epidemic period, susceptible cases become infected with a rate β and infected cases become recovered with a rate γ. the rate of change for the three compartments is estimated by the following three differential equations: this model is considered because it requires simple data that is available for the public. furthermore, its implementation is provided as an open source code. to obtain covid-19 prediction results for the selected countries, we applied an already existing matlab sir modeling tool [29, 30] . the tool takes the daily new infection cases as an input and optimizes the model parameters by minimizing the difference between the actual and estimated number of cases and it considers the possibility of having multiple sub-waves. the number of daily new infection cases were collected from a publicly available repository [31] on 11 july 2020. in this study, an assumption was made that all the data reported by the selected countries were accurate and up-to-date. it is important to note that the results of the prediction models might be inaccurate due to the fact that such models do not consider some affecting factors such as the containment strategies and other related governmental interventions. the considered pandemic prediction models assume that all such related factors remain the same. the prediction results are useful to assess whether more strict interventions must be applied to reduce the estimated number of infections and deaths and relieve the healthcare system. figure 1 was generated to show the recorded daily total infected cases of the world over a certain timeframe (22 january 2020 until present), which shows that the covid-19 disease started to increase slowly until about 11 march and then accelerated at a faster speed afterwards. this means that the infected number of cases after 11 march are significantly higher than the numbers before this date. to illustrate this further, the change in new infected cases for the first 49 days (from 22 january until 10 march) is between 532 to 115,597 cases, whereas the change for a similar period of time (10 march until 26 april)) varied between 115,579 to 2,837,407 cases, which is a 24-fold increase in the new infected cases than that of the first interval. mathematically, this means that the change in the y over time (∆y/∆x) experienced a relatively drastic jump as opposed to the first interval. in other words, the slope of the second interval is steeper than the first interval ( figure 1 ), which is also called the tangible line of the graph. this clearly means that the infection is spreading through the world in a faster change rate over a short timeframe. interventions. the considered pandemic prediction models assume that all such related factors remain the same. the prediction results are useful to assess whether more strict interventions must be applied to reduce the estimated number of infections and deaths and relieve the healthcare system. figure 1 was generated to show the recorded daily total infected cases of the world over a certain timeframe (22 january 2020 until present), which shows that the covid-19 disease started to increase slowly until about 11 march and then accelerated at a faster speed afterwards. this means that the infected number of cases after 11 march are significantly higher than the numbers before this date. to illustrate this further, the change in new infected cases for the first 49 days (from 22 january until 10 march) is between 532 to 115,597 cases, whereas the change for a similar period of time (10 march until 26 april)) varied between 115,579 to 2,837,407 cases, which is a 24-fold increase in the new infected cases than that of the first interval. mathematically, this means that the change in the y over time (δy/δx) experienced a relatively drastic jump as opposed to the first interval. in other words, the slope of the second interval is steeper than the first interval ( figure 1 ), which is also called the tangible line of the graph. this clearly means that the infection is spreading through the world in a faster change rate over a short timeframe. looking at the selected countries based on containment rates, the countries were classified into two groups: (a) countries that contained (had controlled) the covid-19 disease, and (b) those that failed to do so (uncontrolled), as follows ( table 2) : china is taken as an example for group a where after the outbreak china managed to control the spread of the covid-19 virus, as shown in figure 2 . china is the origin of covid-19 where the first cases were recorded in wuhan city on 22 january 2020. this virus started to spread in china with a short-term (interval 1 in figure 2 ) slow rate of infection for about 5 days (22 to 29 january) followed looking at the selected countries based on containment rates, the countries were classified into two groups: (a) countries that contained (had controlled) the covid-19 disease, and (b) those that failed to do so (uncontrolled), as follows ( table 2) : china is taken as an example for group a where after the outbreak china managed to control the spread of the covid-19 virus, as shown in figure 2 . china is the origin of covid-19 where the first cases were recorded in wuhan city on 22 january 2020. this virus started to spread in china with a short-term (interval 1 in figure 2 ) slow rate of infection for about 5 days (22 to 29 january) followed by a faster infection rate in the second interval that lasted for 17 days (26 january to 11 february). then, the total infected cases continued to increase with a slow rate until it reached the maximum and levelled off thereafter (interval 3). china went through three intervals where interval 1 and 2 represent the breakout stage, and interval 3 the control stage. the slopes for intervals 1 and 2 increased from small to significant and then decreased until they became negligible in interval 3 ( figure 2 ). int. j. environ. res. public health 2020, 17, x 6 of 21 by a faster infection rate in the second interval that lasted for 17 days (26 january to 11 february). then, the total infected cases continued to increase with a slow rate until it reached the maximum and levelled off thereafter (interval 3). china went through three intervals where interval 1 and 2 represent the breakout stage, and interval 3 the control stage. the slopes for intervals 1 and 2 increased from small to significant and then decreased until they became negligible in interval 3 ( figure 2 ). an example of group b is brazil, where the covid-19 spreading rate went through two distinct intervals. interval 1 where the slope of the curve was negligible indicating small increases in the new cases (3 march to 1 april) and interval 2 represented by a sudden upward shift in the graph as a result of a massive increase in the newly infected cases each day from 20 april onwards ( figure 3 ). the daily increase rate for interval 1 was from 0 to 5717 new cases, whereas the same rate for interval 2 was from 6836 to 1,839,850, which is significantly higher than that of interval 1 with a notable upward trend. again, this is due to the drastic change in daily new cases as represented by the changing direction of the slope from a small slope to a steeper one. an example of group b is brazil, where the covid-19 spreading rate went through two distinct intervals. interval 1 where the slope of the curve was negligible indicating small increases in the new cases (3 march to 1 april) and interval 2 represented by a sudden upward shift in the graph as a result of a massive increase in the newly infected cases each day from 20 april onwards ( figure 3 ). the daily increase rate for interval 1 was from 0 to 5717 new cases, whereas the same rate for interval 2 was from 6836 to 1,839,850, which is significantly higher than that of interval 1 with a notable upward trend. again, this is due to the drastic change in daily new cases as represented by the changing direction of the slope from a small slope to a steeper one. by a faster infection rate in the second interval that lasted for 17 days (26 january to 11 february). then, the total infected cases continued to increase with a slow rate until it reached the maximum and levelled off thereafter (interval 3). china went through three intervals where interval 1 and 2 represent the breakout stage, and interval 3 the control stage. the slopes for intervals 1 and 2 increased from small to significant and then decreased until they became negligible in interval 3 ( figure 2 ). an example of group b is brazil, where the covid-19 spreading rate went through two distinct intervals. interval 1 where the slope of the curve was negligible indicating small increases in the new cases (3 march to 1 april) and interval 2 represented by a sudden upward shift in the graph as a result of a massive increase in the newly infected cases each day from 20 april onwards ( figure 3 ). the daily increase rate for interval 1 was from 0 to 5717 new cases, whereas the same rate for interval 2 was from 6836 to 1,839,850, which is significantly higher than that of interval 1 with a notable upward trend. again, this is due to the drastic change in daily new cases as represented by the changing direction of the slope from a small slope to a steeper one. generally, the death rate is proportional to the infection rate but at a smaller scale that varies from country to country, depending on many factors such as population, awareness, health care system, hospital building capacity, demographics, and location. as shown in figures 5-7 , the death rates for the world and each selected country depict a similar trend as that of the infection rate. for example, figures 5 and 6 show the world and the usa death rates, respectively where they are still increasing continuously without reaching a maximum value. in switzerland, however, the death rate exhibited a similar trend as its infection rate behavior (figure 7 ). generally, the death rate is proportional to the infection rate but at a smaller scale that varies from country to country, depending on many factors such as population, awareness, health care system, hospital building capacity, demographics, and location. as shown in figures 5-7 , the death rates for the world and each selected country depict a similar trend as that of the infection rate. for example, figures 5 and 6 show the world and the usa death rates, respectively where they are still increasing continuously without reaching a maximum value. in switzerland, however, the death rate exhibited a similar trend as its infection rate behavior (figure 7) . figure 8 is plotted to show the total deaths of the selected countries so far, which shows that usa recorded the highest total deaths due to the covid-19 infection. however, it would not be accurate to use such data to directly compare the death rates between the countries. therefore, the next section is dedicated to calculate the death percentage for the selected countries and the world. figure 8 is plotted to show the total deaths of the selected countries so far, which shows that usa recorded the highest total deaths due to the covid-19 infection. however, it would not be accurate to use such data to directly compare the death rates between the countries. therefore, the next section is dedicated to calculate the death percentage for the selected countries and the world. figure 8 is plotted to show the total deaths of the selected countries so far, which shows that usa recorded the highest total deaths due to the covid-19 infection. however, it would not be accurate to use such data to directly compare the death rates between the countries. therefore, the next section is dedicated to calculate the death percentage for the selected countries and the world. a simple equation (4) is used to calculate the percentage of the deaths for each selected country for the sake of direct comparison. a simple equation (4) is used to calculate the percentage of the deaths for each selected country for the sake of direct comparison. since population (p) is proportional to the number of infected cases (inf), then: where a is the infected cases per capita, which is the infection percentage of the population. similarly, another factor b that relates the total deaths (d) to the total infected cases is described below: although, china has the largest population in the world, it had the least infection percentage of population (a) compared to the other selected countries (figure 9 ). furthermore, the death percentage (b) of the selected countries up to this date varies between 3.9% (brazil) to 6.8% (ireland). the world's death percentage of 4.45% is within the foregoing values ( figure 10 ). figure 11 shows the accumulated daily death percentages of the foregoing countries in comparison with the world death percentage, which shows that the world experienced a sharp increase in the total death cases after 7 march until it reached a maximum of 7.3% on 25 april and decreased afterwards until this moment with 4.5%. group b showed a similar trend to that of the world with slightly less death percentages. this is due to the decline of the daily deaths in comparison figure 11 shows the accumulated daily death percentages of the foregoing countries in comparison with the world death percentage, which shows that the world experienced a sharp increase in the total death cases after 7 march until it reached a maximum of 7.3% on 25 april and decreased afterwards until this moment with 4.5%. group b showed a similar trend to that of the world with slightly less death percentages. this is due to the decline of the daily deaths in comparison with the continuous daily increase in the infected cases. group a, on the other hand, exhibited a similar behavior at the beginning until it reached a maximum and then levelled off as an indication of containing the outbreak (negligible new infected cases with zero deaths). as stated in the previous sections, the trend of covid-19 outbreak varies between countries at different levels (e.g., death rates, total infected cases, and containment). this section focuses on fitting the actual data of the selected countries into regression-based equations/models that help in understanding the covid-19 trajectory for a better projection. once an accurate model is developed (r 2 > 0.9) for each case, it was used to project the future behavior of covid-19 to provide potential statistics. this will help in developing proactive action plans and the necessary strategic measures to contain such pandemics in the future too. starting with group a, selected countries such as switzerland and ireland, a good regression fit for both countries was obtained from the logistic model with r 2 > 0.97 ( figure 12 ) to fit the "s" shaped trend. the fitted model of total covid-19 cases (tcov) for both countries is expressed by equation we have not carried out a sensitivity test in the current study to investigate the effect of each parameter of the logistic model (m and k) on the infection rate because it is not of our interest at this stage. given that, they are generally defined as follows, m is the amount after growth and k is the constant of proportionality (continuous growth). the values of the coefficients for each country are listed in table 3 . as stated in the previous sections, the trend of covid-19 outbreak varies between countries at different levels (e.g., death rates, total infected cases, and containment). this section focuses on fitting the actual data of the selected countries into regression-based equations/models that help in understanding the covid-19 trajectory for a better projection. once an accurate model is developed (r 2 > 0.9) for each case, it was used to project the future behavior of covid-19 to provide potential statistics. this will help in developing proactive action plans and the necessary strategic measures to contain such pandemics in the future too. starting with group a, selected countries such as switzerland and ireland, a good regression fit for both countries was obtained from the logistic model with r 2 > 0.97 ( figure 12 ) to fit the "s" shaped trend. the fitted model of total covid-19 cases (tcov) for both countries is expressed by equation (8): we have not carried out a sensitivity test in the current study to investigate the effect of each parameter of the logistic model (m and k) on the infection rate because it is not of our interest at this stage. given that, they are generally defined as follows, m is the amount after growth and k is the constant of proportionality (continuous growth). the values of the coefficients for each country are listed in table 3 . the trajectory projection of group a consistently suggests that the pandemic will continue to be contained for all of the group a countries. the group b countries' trajectory is different from the group a countries, and therefore a different model was sought to fit such trend. the regression fit that best described the group b behavior is an exponential growth model with r 2 ≥ 0.97 as expressed below: = 1 (9) where the values of the coefficients for each country in this group are listed in table 4 . generally, the exponential growth is deceptive because it starts off slowly and after a few days it jumps to enormous numbers. unfortunately, this is what exactly happened to some of the countries during the covid-19 pandemic. a set of graphs in figure 13 shows the current and future trajectory of brazil and india in group b. over the same timeframe, all countries experienced a very slow increase on each day and continued to do so for a few days. this means that the change in y-axis was close to zero (slope of the curve). however, after a few doublings the total daily covid-19 infected cases was increasing with a sharp slope recording higher changes of new cases (δy) until it reached enormous numbers. the group b countries' trajectory is different from the group a countries, and therefore a different model was sought to fit such trend. the regression fit that best described the group b behavior is an exponential growth model with r 2 ≥ 0.97 as expressed below: where the values of the coefficients for each country in this group are listed in table 4 . generally, the exponential growth is deceptive because it starts off slowly and after a few days it jumps to enormous numbers. unfortunately, this is what exactly happened to some of the countries during the covid-19 pandemic. a set of graphs in figure 13 shows the current and future trajectory of brazil and india in group b. over the same timeframe, all countries experienced a very slow increase on each day and continued to do so for a few days. this means that the change in y-axis was close to zero (slope of the curve). however, after a few doublings the total daily covid-19 infected cases was increasing with a sharp slope recording higher changes of new cases (∆y) until it reached enormous numbers. if this is not controlled sooner, the total recorded new cases of covid-19 for these countries will further double claiming more precious lives. for example, the total predicted total covid-19 infected cases for brazil, india, and usa by 15 august is expected to be around 6,000,000, 3,259,917, and 5,800,000 with the number of deaths expected to be equal to 200,000, 60,000, and 1,600,000, respectively. despite the fact that the usa is leading the world in the total recorded infected cases, brazil will slightly pass the usa by 15 august as predicted by the model. this is due to the fact that the coefficient of the exponential term for brazil is higher suggesting that the exponential growth stage of brazil is severer than that of usa. having said that, the total deaths in the usa will continue to be higher than the rest of the countries. actual observations proofed that the future actual statistics would be less than the predicted values due to the implementation of physical measures such as social distancing, wearing masks, lock-down, disinfection, and travel restrictions. currently, there are many countries exhibiting a similar trend to group b that caused the world trajectory to follow an exponential growth model ( figure 14 ) with r 2 = 0.99. the world's total covid-19 infected cases trajectory was suited more for the exponential growth model (equation (10)) in the second interval (after 11 march). if the pandemic is not contained, the model (tcovw) predicts that the world's total new infected cases would reach 28,000,000 by 15 august with total deaths equal to 1,500,000. if this is not controlled sooner, the total recorded new cases of covid-19 for these countries will further double claiming more precious lives. for example, the total predicted total covid-19 infected cases for brazil, india, and usa by 15 august is expected to be around 6,000,000, 3,259,917, and 5,800,000 with the number of deaths expected to be equal to 200,000, 60,000, and 1,600,000, respectively. despite the fact that the usa is leading the world in the total recorded infected cases, brazil will slightly pass the usa by 15 august as predicted by the model. this is due to the fact that the coefficient of the exponential term for brazil is higher suggesting that the exponential growth stage of brazil is severer than that of usa. having said that, the total deaths in the usa will continue to be higher than the rest of the countries. actual observations proofed that the future actual statistics would be less than the predicted values due to the implementation of physical measures such as social distancing, wearing masks, lock-down, disinfection, and travel restrictions. currently, there are many countries exhibiting a similar trend to group b that caused the world trajectory to follow an exponential growth model ( figure 14 ) with r 2 = 0.99. the world's total covid-19 infected cases trajectory was suited more for the exponential growth model (equation (10)) in the second interval (after 11 march). if the pandemic is not contained, the model (tcov w ) predicts that the world's total new infected cases would reach 28,000,000 by 15 august with total deaths equal to 1,500,000. if this is not controlled sooner, the total recorded new cases of covid-19 for these countries will further double claiming more precious lives. for example, the total predicted total covid-19 infected cases for brazil, india, and usa by 15 august is expected to be around 6,000,000, 3,259,917, and 5,800,000 with the number of deaths expected to be equal to 200,000, 60,000, and 1,600,000, respectively. despite the fact that the usa is leading the world in the total recorded infected cases, brazil will slightly pass the usa by 15 august as predicted by the model. this is due to the fact that the coefficient of the exponential term for brazil is higher suggesting that the exponential growth stage of brazil is severer than that of usa. having said that, the total deaths in the usa will continue to be higher than the rest of the countries. actual observations proofed that the future actual statistics would be less than the predicted values due to the implementation of physical measures such as social distancing, wearing masks, lock-down, disinfection, and travel restrictions. currently, there are many countries exhibiting a similar trend to group b that caused the world trajectory to follow an exponential growth model ( figure 14 ) with r 2 = 0.99. the world's total covid-19 infected cases trajectory was suited more for the exponential growth model (equation (10)) in the second interval (after 11 march). if the pandemic is not contained, the model (tcovw) predicts that the world's total new infected cases would reach 28,000,000 by 15 august with total deaths equal to 1,500,000. this section considers fitting the actual data for the infection cases of the selected countries using sir modeling and obtaining the prediction results in terms of total number of infection cases and end of pandemic dates. the results given in table 5 and figures 15-20 show that the countries in group a are at the end state of the pandemic, which indicates an outbreak control. all these countries already passed the expected 99% end of pandemic dates. the prediction curves for the countries in group b show that they have just passed the inflection point of the curve and started the deacceleration phase. this indicates that the outbreak is still uncontrolled, and it is expected that these countries reach the outbreak control sometime in august. the prediction curve shows that some of the group b countries, especially usa, went through several sub-waves of the disease spread. this section considers fitting the actual data for the infection cases of the selected countries using sir modeling and obtaining the prediction results in terms of total number of infection cases and end of pandemic dates. the results given in table 5 and figures 15-20 show that the countries in group a are at the end state of the pandemic, which indicates an outbreak control. all these countries already passed the expected 99% end of pandemic dates. the prediction curves for the countries in group b show that they have just passed the inflection point of the curve and started the deacceleration phase. this indicates that the outbreak is still uncontrolled, and it is expected that these countries reach the outbreak control sometime in august. the prediction curve shows that some of the group b countries, especially usa, went through several sub-waves of the disease spread. this section considers fitting the actual data for the infection cases of the selected countries using sir modeling and obtaining the prediction results in terms of total number of infection cases and end of pandemic dates. the results given in table 5 and figures 15-20 show that the countries in group a are at the end state of the pandemic, which indicates an outbreak control. all these countries already passed the expected 99% end of pandemic dates. the prediction curves for the countries in group b show that they have just passed the inflection point of the curve and started the deacceleration phase. this indicates that the outbreak is still uncontrolled, and it is expected that these countries reach the outbreak control sometime in august. the prediction curve shows that some of the group b countries, especially usa, went through several sub-waves of the disease spread. applying the previous studies on local data for the state of kuwait resulted in the trajectory depicted in figure 21 . the actual data was fitted to an exponential growth model with an r 2 > 0.96 as expressed in equation (5) . one can clearly visualize that the slope of the curve has changed since the end of april indicating the start of the exponential growth second stage/interval (2) as those in group b and the world. this suggests that the state of kuwait has done a commendable job in reacting right away with this covid-19 outbreak and took all the necessary measures to control it, which resulted in delaying stage 2 as much as possible. with the current trend, the model predicted that the total infected cases in the state of kuwait by 15 august would be about 120,000. applying the previous studies on local data for the state of kuwait resulted in the trajectory depicted in figure 21 . the actual data was fitted to an exponential growth model with an r 2 > 0.96 as expressed in equation (5) . one can clearly visualize that the slope of the curve has changed since the end of april indicating the start of the exponential growth second stage/interval (2) as those in group b and the world. this suggests that the state of kuwait has done a commendable job in reacting right away with this covid-19 outbreak and took all the necessary measures to control it, which resulted in delaying stage 2 as much as possible. with the current trend, the model predicted that the total infected cases in the state of kuwait by 15 august would be about 120,000. as shown in figure 22 , the results for sir-modeling for the infection cases in kuwait show that kuwait went through two main sub-waves of the disease spread and passed the inflection point of the second sub-wave by the beginning of july. the model predicts the pandemic to end 97% by 29 july 2020 and 99% by 10 august 2020. the total infected cases are predicted to be 62,757, which might be more realistic than the corresponding result of the regression model. as shown in figure 22 , the results for sir-modeling for the infection cases in kuwait show that kuwait went through two main sub-waves of the disease spread and passed the inflection point of the second sub-wave by the beginning of july. the model predicts the pandemic to end 97% by 29 july 2020 and 99% by 10 august 2020. the total infected cases are predicted to be 62,757, which might be more realistic than the corresponding result of the regression model. applying the previous studies on local data for the state of kuwait resulted in the trajectory depicted in figure 21 . the actual data was fitted to an exponential growth model with an r 2 > 0.96 as expressed in equation (5) . one can clearly visualize that the slope of the curve has changed since the end of april indicating the start of the exponential growth second stage/interval (2) as those in group b and the world. this suggests that the state of kuwait has done a commendable job in reacting right away with this covid-19 outbreak and took all the necessary measures to control it, which resulted in delaying stage 2 as much as possible. with the current trend, the model predicted that the total infected cases in the state of kuwait by 15 august would be about 120,000. as shown in figure 22 , the results for sir-modeling for the infection cases in kuwait show that kuwait went through two main sub-waves of the disease spread and passed the inflection point of the second sub-wave by the beginning of july. the model predicts the pandemic to end 97% by 29 july 2020 and 99% by 10 august 2020. the total infected cases are predicted to be 62,757, which might be more realistic than the corresponding result of the regression model. the main pathways of covid-19 spread are through respiratory droplets either coughing, speaking or sneezing, body fluid contact, or touching contaminated surfaces [32] . the prevention/containment of the virus at healthcare settings is more important because it will not only ensure the safety of healthcare workers but will prevent the transmission and spread of the virus. it has also been reported that conventional face masks and ordinary clothing do not provide 100% protection [33] . therefore, development of new strategies to prevent virus transmission through common pathways is critical. below we describe current and potential strategies of prevention. the virus filtering capability of masks depends on the design and materials they are made up of and on the size of the particulates. the current masks have limited ability to protect against aerosol and smaller droplets with surgical and n95 masks having the best protection. therefore, development of masks with antiviral capabilities can substantially reduce transmission of the virus. furthermore, current masks from fossil fuel based polymeric materials do not degrade and will create a potential pollution threat to the environment. therefore, biodegradable antimicrobial masks could be a great potential option. the contaminated surfaces are another contributor to the spread and covid-19 is reported to remain present on surfaces for several hours to days [34] . the current surface cleaning and disinfection methods are not highly effective where a single wiping of the surfaces becomes dry within 3 min and recovery of the bacteria and viruses is reportedly high [35] . therefore, efforts should be made to new preventive measures for surface decontaminations. one such method is nano-coating, which can enhance the effectiveness up to several folds compared to current technologies. the emerging self-cleaning nano-coatings have a great future potential to prevent surfaces against such microbial threats. other countries should learn from those who preceded them in the present covid-19 pandemic. in general, most of the developed countries went through a tough time in dealing with this outbreak. the trajectory of the covid-19 pandemic, for some countries, went through three critical stages depicting a logistic behavior, as shown in figure 23 . the deceptive stage (1) from the start of the outbreak that varied from one week (in china) to about a month (in usa). then, it was followed by an uncontrolled exponential increase stage that lasted in some countries for about 20 days (in china, switzerland, and ireland) and the rest of the countries unfortunately still experiencing it (usa, brazil, spain, and india). the third stage (containment stage) applies to the countries in group a that controlled the outbreak. the maximum impact of this covid-19 pandemic occurred during the uncontrolled stage (2), which mainly depended on the deceptive stage (1). the shorter the deceptive stage, the shorter the controlling stage and hence the less damage occurred, and vice versa. that is why the countries performance of group a was better than that of group b because they took serious measures right from the beginning of the covid-19 infections (short deceptive stage 1) that resulted in a shorter and less steep uncontrolled stage followed by a controlled stage. amongst the group b countries and based on regression modeling, brazil could potentially lead the world in the total infected cases in the next few weeks if the circumstances remain the same. however, the sir-modeling results predict that the usa will continue leading the world in terms of the total infected cases. the state of kuwait covid-19 trajectory is similar to that of group b (uncontrolled). both regression and sir-modeling results lead to the same general conclusion that countries in group a reached the controlling stage, whereas countries in group b are still far away from reaching this stage. the maximum impact of this covid-19 pandemic occurred during the uncontrolled stage (2), which mainly depended on the deceptive stage (1). the shorter the deceptive stage, the shorter the controlling stage and hence the less damage occurred, and vice versa. that is why the countries performance of group a was better than that of group b because they took serious measures right from the beginning of the covid-19 infections (short deceptive stage 1) that resulted in a shorter and less steep uncontrolled stage followed by a controlled stage. amongst the group b countries and based on regression modeling, brazil could potentially lead the world in the total infected cases in the next few weeks if the circumstances remain the same. however, the sir-modeling results predict that the usa will continue leading the world in terms of the total infected cases. the state of kuwait covid-19 trajectory is similar to that of group b (uncontrolled). both regression and sir-modeling results lead to the same general conclusion that countries in group a reached the controlling stage, whereas countries in group b are still far away from reaching this stage. what needs to be done is to limit the spread of the disease as much as possible. this results in delaying the second stage, and the sharp increase would happen over a longer period instead of on a daily basis that results in reducing the slope of the curve to be less steep ( figure 24 ). this will spread the new cases over a longer period enabling the health care system to accommodate the existing patients instead of having enormous new cases in a short timeframe. this can be achieved by taking the right measures at the government and individual levels, such as quarantine, personal hygiene, lock-down, curfew, etc. this is what is happening now in some of the countries. what needs to be done is to limit the spread of the disease as much as possible. this results in delaying the second stage, and the sharp increase would happen over a longer period instead of on a daily basis that results in reducing the slope of the curve to be less steep ( figure 24 ). this will spread the new cases over a longer period enabling the health care system to accommodate the existing patients instead of having enormous new cases in a short timeframe. this can be achieved by taking the right measures at the government and individual levels, such as quarantine, personal hygiene, lock-down, curfew, etc. this is what is happening now in some of the countries. all the selected countries in both groups recorded lower death percentages than that of the world during the outbreak timeframe. the exponent value (b) of the exponential growth model determines the severity (slope) of the covid-19 trajectory. that is why the usa is leading the world in the total infected new cases now and brazil may surpass the usa in the next few weeks if the severity of the exponential remains the same. since the model did not consider effects such as containment strategies and other related governmental interventions taken by countries, this limitation could cause slight inaccuracies in the results of the prediction models. all the selected countries in both groups recorded lower death percentages than that of the world during the outbreak timeframe. the exponent value (b) of the exponential growth model determines the severity (slope) of the covid-19 trajectory. that is why the usa is leading the world in the total infected new cases now and brazil may surpass the usa in the next few weeks if the severity of the exponential remains the same. since the model did not consider effects such as containment strategies and other related governmental interventions taken by countries, this limitation could cause slight inaccuracies in the results of the prediction models. emerging and re-emerging viruses in the era of globalization visualizing the history of pandemics, visual capitalist epidemics: past, present and future-what are the risks? from pasteur to genomics: progress and challenges in infectious diseases as ebola death toll rises, remembering history's worst epidemics covid-19. coronavirus outbreak. world meters. 2020. available online 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compared with sars-cov-1 residual viral and bacterial contamination of surfaces after cleaning and disinfection this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord-281741-wzsrqc7p authors: xu, bo; tian, huaiyu; sabel, clive eric; xu, bing title: impacts of road traffic network and socioeconomic factors on the diffusion of 2009 pandemic influenza a (h1n1) in mainland china date: 2019-04-05 journal: int j environ res public health doi: 10.3390/ijerph16071223 sha: doc_id: 281741 cord_uid: wzsrqc7p the 2009 pandemic influenza virus caused the majority of the influenza a virus infections in china in 2009. it arrived in several chinese cities from imported cases and then spread as people travelled domestically by all means of transportation, among which road traffic was the most commonly used for daily commuting. spatial variation in socioeconomic status not only accelerates migration across regions but also partly induces the differences in epidemic processes and in responses to epidemics across regions. however, the roles of both road travel and socioeconomic factors have not received the attention they deserve. here, we constructed a national highway network for and between 333 cities in mainland china and extracted epidemiological variables and socioeconomic factors for each city. we calculated classic centrality measures for each city in the network and proposed two new measures (sumratio and multicenter distance). we evaluated the correlation between the centrality measures and epidemiological features and conducted a spatial autoregression to quantify the impacts of road network and socioeconomic factors during the outbreak. the results showed that epidemics had more significant relationships with both our new measures than the classic ones. higher population density, higher per person income, larger sumratio and multicenter distance, more hospitals and college students, and lower per person gdp were associated with higher cumulative incidence. higher population density and number of slaughtered pigs were found to advance epidemic arrival time. higher population density, more colleges and slaughtered pigs, and lower multicenter distance were associated with longer epidemic duration. in conclusion, road transport and socioeconomic status had significant impacts and should be considered for the prevention and control of future pandemics. the 2009 influenza a (h1n1) pandemic posed one of the most serious global public health challenges in recent years [1] . with the ease and speed of global travel in the 21st century, the world is now a global village in terms of epidemic transmission [2] . the influenza a (h1n1) virus can transmit from humans to humans by direct body contact or respiratory droplets. the infectious disease can spread widely as people carrying pathogens travel and commute between cities by multiple means of transport. thus, intercity travel is important for the diffusion of viruses [3] [4] [5] . in this study, we constructed a national highway network including 333 prefecture-level cities in mainland china and extracted three epidemiological variables (cumulative incidence, onset week, and duration of epidemics) and 14 socioeconomic factors (related to population, income level, medical condition, livestock breeding, and school education) in each city. we calculated four classic centrality measures (degree, betweenness, closeness, and eigenvector centrality) for each city in the network and proposed two new measures (sumratio and multicenter distance). we first evaluated the correlation between the centrality measures and epidemiological features, and then used spatial autoregressive models to investigate the impacts of road network and socioeconomic factors on the diffusion of the 2009 influenza pandemic. the suspected and laboratory-confirmed cases of influenza a (h1n1) used in this study were obtained from the surveillance system of the chinese center for disease control and prevention, with dates ranging from week 19 (may) in 2009 to week 53 (december) in 2010. every data entry represents a case with attributes, such as the date of onset, date of birth, and address together with a corresponding administrative area number. matlab [23] and arcgis desktop [24] were used to extract information concerning the cumulative incidence which is the cumulative number of daily reported cases during the above time period divided by the population at risk, the onset week which is defined here as the week when the first case in a city was reported, and the duration which is the time from onset to the first epidemic peak, all in a certain prefecture-level city. statistical data for prefecture-level cities in 2009 were collected from the china economic and social development statistical database (http://tongji.cnki.net), including highway passenger capacity, urbanization ratio (denoted as urban ratio), population density (popdensity), per person gross domestic product (pgdp), average wage of employees (income), number of hospitals per 10,000 population (hospital), number of hospital beds per 1000 population (hos-bed), number of doctors per 10,000 population (doctor), number of colleges (college), number of middle schools (midschool), number of primary schools (prischool), number of college students per 100 population (collegestu), number of middle school students per 100 population (midschoolstu), number of primary school students per 100 population (prischoolstu), and number of slaughtered pigs (pig). the network of national highways in china consists of nodes (representing prefecture-level cities) and links (representing national highway lines). every link is connected to two nodes, to which the two corresponding prefecture-level cities are connected by a section of national highways. there are seventy national highway lines in china. we calculated the actual distance between any pair of adjacent prefecture-level cities along the national highways and assigned a unique number to each city. two symmetric matrices (matrix a and d1) were constructed. matrix a is an adjacency matrix. if city i and j are adjacent along a national highway, then the value of element a (i, j) is one, else it is zero. matrix d1 is an adjacent distance matrix and element d1 (i, j) is the actual distance between city i and j if they are adjacent to each other along national highways (if not, d1 (i, j) equals zero). an unsymmetrical matrix d2 was generated from matrix d1 using the floyd algorithm [25] to store the shortest distances between cities along the national highways. we calculated four common network node centrality measures for each city node, including the degree, which is the number of nodes directly adjacent to it; the betweenness, which is the number of shortest paths that pass through the node; the closeness, which is the sum of the shortest distances (geodesic paths) between that node and all other nodes in the network; and the eigenvector centrality, which is a measure of the influence of a node in a network [26] . these node centralities are calculated with the igraph package [27] in the r program [28] . inspired by the method of dominant flow analysis [29] , we propose a new node centrality measure called sumratio, which is a synthetic indicator combining the number of passengers and the spatial distance, measuring the global importance of a node to all others in a network. higher values of sumratio relate to more frequent exchanges of people and economic trade, which makes it easier for viruses to spread among individuals. sumratio can be calculated as follows. where g(i, j) represents the gravity coefficient between cities i and j; n is the outflow highway passenger capacity; d is the shortest distance between two cities along national highways; and m, β, δ, and γ are constants. gp(i, j) represents the ratio of gravity coefficient between cities i and j to the sum of gravity coefficients between city i and any other cities in the network and measures the relative importance of city j to city i. sumratio(j) is the sum of the gravity coefficient ratio, which measures the integrated importance of city j to all other cities in the network. the two matrices (matrix g and gp) are generated using a gravity model [30, 31] based on the demographic data. matrix g is a symmetric matrix while gp is unsymmetrical [32] . n is the total number of cities in the national highway network (n = 333). m, β, and δ are set to be 1, 1, and 1, respectively, as estimated by reference [32] . γ is set to be 1 according to the result of reference [31] . n can be estimated as follows: because the "highway passenger capacity" figures found in the statistical yearbook consisted of three parts, including the highway passenger capacity within a city, the inflow passenger capacity, and outflow passenger capacity of a city, we assumed that the inflow and outflow passenger capacities of a city are equal to each other and that they both could compose "the passenger capacity between cities". among the 104,096 nonzero values of the distance stored in matrix d2, more than 98% were larger than 200 km. hence, we assumed that the highway passenger capacity within a city can be represented by the number of passengers transported within the range of a circle whose center is a certain city with a radius of 100 km. it has also been reported that the highway passenger volume occurred within a distance shorter than 100 km accounted for more than 90% of the total highway passenger volume. therefore, we assumed that the highway passenger capacity within a city accounted for 90% of the total highway passenger volume and that the outflow highway passenger capacity accounted for 5%. we propose another new node centrality measure called multicenter distance, which refers to the shortest distance along national highways from a certain city to one of the eight center cities (chengdu, jinan, beijing, guangzhou, shanghai, fuzhou, wenzhou, and changsha city) where the epidemics arrived the earliest (before may 22, 2009 ). all the first cases in these eight cities were imported into china by planes from other countries. the spatial locations of the eight cities are shown in figure 1 . the multicenter distance of city i (sd i ) is calculated as follows. sd i = min {d ij , i = all cities, j = center cities}, where i = 1, 2, 3, . . . , n; n is the total number of cities; j = 1, 2, 3, . . . , m; m indicates the number of central cities; and d ij is the distance along the national highways between a certain city i and a center city j. a correlation analysis was performed to assess the associations between disease variables (cumulative incidence, onset week, and duration from onset to the first epidemic peak) and highway network node centralities (adjacent degree, betweenness, closeness, eigenvector centrality, sumratio, and multicenter distance) using the pearson correlation coefficient and to figure out the significant explanatory variables for the following spatial regression analysis. to investigate the quantitative relationships between epidemic characteristics (e.g., cumulative incidence, onset week, and duration) and socioeconomic factors, including urban ratio, popdensity, pgdp, income, hospital, hos-bed, doctor, college, midschool, prischool, collegestu, midschoolstu, prischoolstu, and pig, as well as the network structure parameters of the city vertices calculated above and to quantify the contribution of road transportation and the spatial distance to the spread of the influenza virus, we used spatial autoregressive models [33] performed in matlab. in the models, epidemic characteristics were set to be response variables, while the selected network node centrality measures and socioeconomic factors were included as explanatory variables. we were able to collect the records of all these variables in 273 cities where influenza a (h1n1) cases had been reported. before the regression analysis, we calculated the variance inflation factor (vif) of each explanatory variables to detect collinearity. a general version of the spatial model including both the spatial lag term and a spatially correlated error structure is shown as where y denotes an n × 1 vector of response variable observations collected at n cities; x is an n × k matrix representing explanatory variables; ε is an n × 1 vector of normally distributed (with constant a correlation analysis was performed to assess the associations between disease variables (cumulative incidence, onset week, and duration from onset to the first epidemic peak) and highway network node centralities (adjacent degree, betweenness, closeness, eigenvector centrality, sumratio, and multicenter distance) using the pearson correlation coefficient and to figure out the significant explanatory variables for the following spatial regression analysis. to investigate the quantitative relationships between epidemic characteristics (e.g., cumulative incidence, onset week, and duration) and socioeconomic factors, including urban ratio, popdensity, pgdp, income, hospital, hos-bed, doctor, college, midschool, prischool, collegestu, midschoolstu, prischoolstu, and pig, as well as the network structure parameters of the city vertices calculated above and to quantify the contribution of road transportation and the spatial distance to the spread of the influenza virus, we used spatial autoregressive models [33] performed in matlab. in the models, epidemic characteristics were set to be response variables, while the selected network node centrality measures and socioeconomic factors were included as explanatory variables. we were able to collect the records of all these variables in 273 cities where influenza a (h1n1) cases had been reported. before the regression analysis, we calculated the variance inflation factor (vif) of each explanatory variables to detect collinearity. a general version of the spatial model including both the spatial lag term and a spatially correlated error structure is shown as where y denotes an n × 1 vector of response variable observations collected at n cities; x is an n × k matrix representing explanatory variables; ε is an n × 1 vector of normally distributed (with constant variance σ 2 ) stochastic disturbances; n is the total number of cities; k is the number of explanatory variables incorporated into the regression model; w 1 and w 2 are n × n spatial weight matrices, usually containing contiguity relations; the parameter ρ is a coefficient on the spatially lagged response variable (w 1 y); β represents the regression coefficients to be estimated to reflect the influence of the explanatory variables x on the variation of the response variable y; the parameter λ is a coefficient on the spatially correlated error µ; and i n is an n × n unit matrix. the earliest onset was week 19 and the latest was week 44 in 2009. the earliest epidemic peak in all cities arrived in week 35, and the last one arrived in week 52. as shown in figure 2a , the weekly incidence curve rose slowly from may 10 to august 30. then, it ascended quickly and arrived in the first peak (5853 cases) on september 27. during the period from october 18 to december 20, the weekly incidence was larger than 7000 cases and reached the second peak (18,989 cases) on november 29. as shown in figure 2b , the cumulative number of cities where cases had ever been reported increased moderately before august 23. thereafter, it climbed up quickly and decelerated after september 27. it reached a plateau in december 1, when nearly all chinese cities had been exposed to the emerging influenza virus. the national highway network had a mean degree of 3.06, an average clustering coefficient of 0.102, a diameter of 26, and an average path length of 10.645. in figure 3a -c, histograms of the road passenger volumes, sumratio, and multicenter distance of all the cities in the national highway network are displayed, respectively. as shown in table 1 , each of the two newly proposed centrality measures (sumratio and multicenter distance) was significantly correlated with all three epidemiological features (cumulative incidence, onset week, and duration). while the correlations between classic centrality measures (degree, betweenness, and eigenvector centrality, except for closeness centrality) and any of the three epidemiological features were not statistically significant. in addition, sumratio and multicenter distance performed even better than closeness centrality. multicenter distance was positively correlated with the cumulative incidence (r = 0.258, p < 0.001) and onset week (r = 0.320, p < 0.001) but negatively correlated with the duration from onset to the first epidemic peak (r = −0.369, p < 0.001). a positive correlation between closeness centrality and onset week (r = 0.208, p < 0.001) was identified, as well as a negative association between closeness and duration (r = −0.126, p < 0.05). sumratio was positively associated with the cumulative incidence (r = 0.354, p < 0.001) and duration (r = 0.265, p < 0.001), but negatively associated with the onset week (r = −0.348, p < 0.001). the pearson correlation coefficients between the number of slaughtered pigs and cumulative incidence, onset week, and duration of epidemics were −0.096 (p = 0.175), −0.259 (p < 0.001), and 0.271 (p < 0.001), respectively. therefore, the number of pigs would not be taken as an explanatory variable of the regression model when the cumulative incidence was taken as the response variable. as shown in table 1 , each of the two newly proposed centrality measures (sumratio and multicenter distance) was significantly correlated with all three epidemiological features (cumulative incidence, onset week, and duration). while the correlations between classic centrality measures (degree, betweenness, and eigenvector centrality, except for closeness centrality) and any of the three epidemiological features were not statistically significant. in addition, sumratio and multicenter distance performed even better than closeness centrality. multicenter distance was positively correlated with the cumulative incidence (r = 0.258, p < 0.001) and onset week (r = 0.320, p < 0.001) but negatively correlated with the duration from onset to the first epidemic peak (r = −0.369, p < 0.001). a positive correlation between closeness centrality and onset week (r = 0.208, p < 0.001) was identified, as well as a negative association between closeness and duration (r = −0.126, p < 0.05). sumratio was positively associated with the cumulative incidence (r = 0.354, p < 0.001) and duration (r = 0.265, p < 0.001), but negatively associated with the onset week (r = −0.348, p < 0.001). the pearson correlation coefficients between the number of slaughtered pigs and cumulative incidence, onset week, and duration of epidemics were −0.096 (p = 0.175), −0.259 (p < 0.001), and 0.271 (p < 0.001), respectively. therefore, the number of pigs would not be taken as an explanatory variable of the regression model when the cumulative incidence was taken as the response variable. based on the results of correlation analysis, we incorporated three network node centrality measures (closeness, sumratio, and multicenter distance) into spatial autoregressive models as explanatory variables. the vif of each explanatory variable except for closeness centrality (17.128) was less than 10 ( table 2) , so all the explanatory variables but closeness were able to enter the regression model. w c , w 2 w 2 , w w, w 2 a cuminc is the same as that in table 1 . b the closeness centrality was not included in the models as an explanatory variable because its vif was larger than 10. c w is the adjacent matrix a in the materials and methods section. *, **, and *** the regression coefficients are significant at the 0.05 level, at the 0.01 level, and at the 0.001 level, respectively. when we took the cumulative incidence as the response variable in the spatial autoregressive model, the spatial dependence coefficient ρ of the response variable was statistically significant (ρ = 0.104, p =0.001). the cumulative incidence can increase 0.205%, −0.140%, 0.286%, 0.141%, 0.147%, 0.190%, and 0.326%, with a 1% increase in popdensity, pgdp, income, hospital, collegestu, sumratio, and multicenter distance, respectively (table 2 ). when we took the onset week as the response variable in the spatial autoregressive model, the spatial dependence coefficient of the response variable was statistically significant (ρ = 0.216, p < 0.001). onset week can be delayed by 0.413% and 0.510% when popdensity and pig decreased by one percent, respectively (table 2 ).when we took the duration from onset to the first epidemic peak as the response variable in the spatial autoregressive model, the spatial dependence coefficient of the response variable was also statistically significant (ρ = 0.237, p < 0.001). duration can be lengthened by 0.803%, 0.541%, 0.472%, and −0.277%, with a 1% increase in popdensity, college, pig, and multicenter distance, respectively (table 2 ). in this study, we evaluated the impacts of road traffic and other socioeconomic factors on the nationwide spread of influenza a (h1n1) across china in 2009. we constructed a national highway network and proposed two new centrality measures: sumratio and multicenter distance. both new measures were significantly correlated with all three epidemiological features in question (cumulative incidence, onset week, and epidemic duration). based on the positive association between onset week and multicenter distance, we understand the transmission process of influenza a (h1n1) as follows: at the very beginning, internationally infected individuals quickly arrived in the eight center cities and other cities in eastern china with frequent international communications [34] , most of which are spatially distant from each other, after long distance travel by plane [6] . by this means the virus was quickly introduced into new regions. this pattern was important for virus spread in the early stage of an epidemic, especially before strict control measures were taken [13] . the virus then diffused over short-range connections as infectious individuals moved to neighboring areas by ground-based transport along highways [6] . the epidemic followed the classic distance decay theory, starting earlier in the cities which are closer to their nearest center cities, and this was partly supported by the findings in reference [22] . to verify our discoveries and explanations quantitatively and to acquire quantitative relationships between road traffic, as well as socioeconomic factors and the spread of influenza a (h1n1), we conducted spatial regression analyses. when the cumulative incidence was taken as a response variable in the spatial autoregressive model, the results could be interpreted as follows: people had more chances to contact each other and transmit infectious diseases with a higher base probability in cities of a higher population density [21, 22, 35] , which resulted in a higher cumulative incidence at the end of epidemics. the income level in these cities was also higher [21] , and more workers would be attracted to come. it has been previously reported that the density of medical facilities was not significantly associated with the arrival time of the first confirmed influenza a (h1n1) case in each chinese county in 2009 [10] . our findings elaborate on this, showing that the density of hospitals has a significant effect on the cumulative incidence at the city level. as we know, cities with more (high-level) hospitals would attract more patients seeking medical treatment [20] . moreover, many symptomatic patients gathered in hospitals where the space was confined, and cross infection and nosocomial infection by means of virus droplet and aerosol could be facilitated [36] , which would also result in a higher incidence. previous research [37] reported that people between 5-24 years old were most affected by the 2009 influenza a (h1n1) in china. therefore, our positive association between the proportion of college students and cumulative incidence is consistent with previous works. cities with a higher sumratio were more likely to be traffic hubs in the national highway network, and the cumulative incidence would be higher. the larger the multicenter distance of a city, the lower the medical treatment level would be, and the cumulative incidence could not be reduced quickly and would remain relatively high. as for cities with a high gdp, they would tend to conduct stronger intervention measures to control the infectious disease, reducing the cumulative incidence. when the onset week was taken as a response variable in the spatial regression, we found that the population density and the number of pigs had negative effects on the epidemic onset in cities. a higher population density meant that the corresponding city was more central and it might have been more likely to have a large airport or train station, and then, the imported cases which could start an epidemic in the city might arrive earlier. the "first" reported case may not be the true first person who was infected by the influenza virus in a given city. it is possible that an infected individual arrived in a city and infected others around him/her, but the public health authority did not receive an infection report, and then, the epidemic started silently and developed freely. thus, the "first" case was not announced to the public until the underlying infected population had taken place. as the reservoir of the 2009 pandemic h1n1 influenza virus, pigs can carry this virus, can transmit it to human beings, and may be a magnifier of the population of virus and potentially infected people. hence, the "first" case would be reported earlier in a city where more pigs were fed. when the duration from onset to the first epidemic peak was taken as the response variable in the spatial regression, the results can be interpreted as follows and be supported by the finding in reference [21] that the periods of epidemics in smaller cities are shorter than those in larger cities. a city with a high population density would have a high proportion of susceptible people who are fuel for epidemics [38, 39] , which would prolong the duration of an epidemic. it was reported that school students were more susceptible to the 2009 influenza a (h1n1) than other age groups in china [37] and that schools were high-risk areas for influenza outbreaks and should be the focus for prevention [22, 40] . therefore, the result that the number of colleges was positively associated with the epidemic duration is consistent with the real situation. moreover, cities with a larger value of multicenter distance would have a smaller population, and the number of susceptible people would also be less. as a result, the epidemic duration would be shorter. intervention measures of public health authorities in china could shorten the epidemic duration, but these measures were taken upon human beings instead of pigs, which played a role of viral reservoir. the virus might spill over from pigs to the human population continuously, which would prolong the epidemic period. it may be an explanation for the significantly positive association between the number of slaughtered pigs and epidemic duration. in addition, it has been reported recently that the presence of airports and railway stations in prefecture-level cities did not have significant impacts on epidemic duration [41] . our results complement previous findings and reveal that both road transport and socioeconomic factors had a significant influence on epidemic duration. among all means of transport, herein we emphasize the role of road transportation in the spatial diffusion of the 2009 influenza a (h1n1) virus in mainland china. it has been reported recently that both aviation and road travel have a significant association with the epidemic arrival day in each prefecture-level city during the whole viral diffusion period, but the role of rail travel was only significant after august 1st 2009 [41] . although air travel is a significant factor in the global spread of the influenza virus, short-range daily travel on the ground is more important at the regional scale [6] , which our results support. to the best of our knowledge, most chinese people do not travel by air very often (at least in 2009, except for businessmen). airplanes bring virus carriers to areas that are far from each other and disease-free before landing, which may lead to a spatially random dispersal of viral pathogens. in daily commuting, an infectious individual is likely to infect anyone with whom he/she is in contact, with the probability of infection associated with spatial distance and time length of contact, which may result in a spatially structured viral population [6] . in our spatial regression analyses, the spatial dependence coefficient ρ of three epidemiological features are all significant and positive, which means that the epidemic in a city was positively correlated with those in neighboring cities and indicates that road travel would be more important than air travel for the spatial transmission of the 2009 influenza a (h1n1) virus in china. unlike some countries in europe and america which experienced two infection peaks of influenza during 2009, china had only one autumn-winter wave in 2009, which could be attributed to the strict prevention and control strategies conducted by china at the early stage of the pandemic [34] . for example, fever screenings performed in airports and railway stations could be expected to detect most symptomatic passengers with a fever, but the expected efficiency of fever screenings in long-distance highway passenger stations should be much lower because a bus is allowed to pick up passengers along the way and they need not gather in a specifically designated station before boarding and because a considerable number of highway passengers would choose private vehicles. therefore, it is much more difficult to restrict the diffusion of influenza virus by road travel. in this respect, the role of highway passenger transport in dispersing viruses spatially is more important than air and railway modes. we also suggest that the socioeconomic conditions themselves not only have direct impacts on the development of an influenza pandemic but also indirectly exert an influence by stimulating human domestic travel and by changing the patterns of human aggregation, which is congruent with previous research [10, 19, 21] . it has been reported that people in a wealthy region travel farther than people in a relatively poor region in china due to the difference in basic facilities or people's living standard, and a pandemic emerging in less developed regions might diffuse more slowly [42] . interestingly, health disparities of people in less developed and developed areas in china might be reduced by the interaction of epidemiological and socioeconomic factors in the face of a newly emerging influenza pandemic, especially in the early stages. for instance, although medical treatment in developed areas is better than that in less developed areas, the epidemic arrival time would be earlier in developed areas with a longer epidemic duration. with the reduction of airfares, the opening of more domestic airlines, and the promotion and popularization of high-speed trains in china, the time cost of the journey is greatly decreased in recent years, and passengers tend to think more about the attractiveness of certain places which are mostly determined by the places' socioeconomic and environmental conditions and think less about the length of trip distance when they choose destinations for travel. therefore, the impact of spatial distance on the diffusion of infectious diseases may become smaller in the future, while that of socioeconomic factors will be more and more important. it is interesting to note that the number of newly reported cases peaked at a time point later than the peak of the number of newly affected cities ( figure 2 ). our explanations of this finding is that before week 34 (until 23 august) in 2009, the number of cases was quite small and increased very slowly (255 cases per week); the number of affected cities increased steadily (10 cities per week), which was most likely to be driven by the sporadic importation of overseas cases into china, because the majority of new cases before week 30 (until 26 july) were imported cases [34] . from week 35 to week 44 (until 1 november), the increase in the number of new cases sped up significantly (6126 cases per week) and reached its first peak on 27 september, and the large amount of existing cases greatly facilitated the invasion of the virus into unaffected cities; hence, the number of affected cities increased more quickly (18 cities per week) than in the prior period. this could be explained by two possible reasons. the first may be that almost all the new cases were local cases after week 36 (until 6 september), which meant the community transmission of the virus within a city had started, so the number of weekly newly affected cities arrived in its peak on 6 september and the rate of increase dropped afterwards. the second reason could be that the chinese government took strict prevention and control measures before september 2009, but the measures were relaxed from september [34] , which could also partly explain the sharp rise in the number of new cases and newly affected cities at the end of august and the beginning of september. the curve of new cases did not rise continuously but dropped to a local minimum in early october, which may be explained by the reduced case reporting during chinese national holidays [37] and could further enlarge the time delay between its peak and the peak of the number of newly affected cases. from week 45 to week 53 (until 31 december), no city was newly affected because almost all prefecture-level cities (except for yushu city in qinghai province) in mainland china had already reported cases in the prior period, and the increasing velocity of the number of new cases was nearly twice of that in the earlier period. there are some limitations in this study. although the trend of case reporting was consistent with that of the percentage of respiratory specimens tested positive for the influenza virus, the number of reported cases was much less than the real size of infected individuals [34] . it was observed globally in many influenza outbreaksthat not all cases were reported to the medical services. therefore, data from virological and serological surveillance should be taken into consideration for further information. additionally, even though there were several socioeconomic factors which were not significantly associated with all three epidemiological features, there still existed other effective factors that were not included in this research, such as climate conditions. as an ecological study, the results of this study cannot provide evidence for causal relationships but merely suggest probable associations. in future research, a meta-population epidemiological model driven by road travel should be constructed to investigate the diffusion process of the 2009 influenza a (h1n1) under the effects of socioeconomic factors. in summary, our study provides two major contributions to the literature. first, we propose two new node centrality measures for a national highway network: sumratio and multicenter distance, and both perform better than classic node centralities for statistically significant correlations with 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influenza a(h1n1) 2009 in mainland china the clustering and transmission dynamics of pandemic influenza a (h1n1) 2009 cases in hong kong aerosol transmission of influenza a virus: a review of new studies transmission dynamics, border entry screening, and school holidays during the 2009 influenza a (h1n1) pandemic discovering the phylodynamics of rna viruses the effect of public health measures on the 1918 influenza pandemic in u.s. cities closure of schools during an influenza pandemic roles of different transport modes in the spatial spread of the 2009 influenza a(h1n1) pandemic in mainland china travel patterns in china we would like to thank jun cai, ruiyun li, zhe sun, sen zhou, and yao pei for their assistance in the epidemiological data preparation. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of the data; in the writing of the manuscript; or in the decision to publish the results. key: cord-304780-lbq70q11 authors: han, changwoo; hong, yun-chul title: decrease in ambient fine particulate matter during covid-19 crisis and corresponding health benefits in seoul, korea date: 2020-07-22 journal: int j environ res public health doi: 10.3390/ijerph17155279 sha: doc_id: 304780 cord_uid: lbq70q11 both domestic emissions and transported pollutants from neighboring countries affect the ambient fine particulate matter (pm(2.5)) concentration of seoul, korea. diverse measures to control the coronavirus disease 2019 (covid-19), such as social distancing and increased telecommuting in korea and the stringent lockdown measures of china, may reduce domestic emissions and levels of transported pollutants, respectively. in addition, wearing a particulate-filtering respirator may have decreased the absolute pm(2.5) exposure level for individuals. therefore, this study estimated the acute health benefits of pm(2.5) reduction and changes in public behavior during the covid-19 crisis in seoul, korea. to calculate the mortality burden attributable to pm(2.5), we obtained residents’ registration data, mortality data, and air pollution monitoring data for seoul from publicly available databases. relative risks were derived from previous time-series studies. we used the attributable fraction to estimate the number of excessive deaths attributable to acute pm(2.5) exposure during january to april, yearly, from 2016 to 2020, and the number of mortalities avoided from pm(2.5) reduction and respirator use observed in 2020. the average pm(2.5) concentration from january to april in 2020 (25.6 μg/m(3)) was the lowest in the last 5 years. at least −4.1 μg/m(3) (95% ci: −7.2, −0.9) change in ambient pm(2.5) in seoul was observed in 2020 compared to the previous 4 years. overall, 37.6 (95% ci: 32.6, 42.5) non-accidental; 7.0 (95% ci: 5.7, 8.4) cardiovascular; and 4.7 (95% ci: 3.4, 6.1) respiratory mortalities were avoided due to pm(2.5) reduction in 2020. by considering the effects of particulate respirator, decreases of 102.5 (95% ci: 89.0, 115.9) non-accidental; 19.1 (95% ci: 15.6, 22.9) cardiovascular; and 12.9 (95% ci: 9.2, 16.5) respiratory mortalities were estimated. we estimated that 37 lives were saved due to the pm(2.5) reduction related to covid-19 in seoul, korea. the health benefit may be greater due to the popular use of particulate-filtering respirators during the covid-19 crisis. future studies with daily mortality data are needed to verify our study estimates. the world is facing one of its gravest challenges due to the coronavirus disease 2019 . after the first unknown pneumonia cases detected in wuhan, china, in december 2019, scientists identified new species of the zoonotic coronavirus, severe acute respiratory syndrome coronavirus 2 (sars-cov-2), causing covid-19 [1, 2] . covid-19 may lead to a fatal respiratory disease in the elderly and in persons with preexisting chronic diseases, but the symptoms can be mild in young and healthy individuals [3] . according to the report from the chinese center for disease control using the 44,672 filtering respirator. based on this assumption, we estimated the acute health benefits of pm 2.5 reduction and changes in public behavior (wearing of a respirator) during the covid-19 crisis using the health impact assessment methodology. the aim of this study was to use currently available data to estimate the acute health benefits of pm 2.5 reduction and changes in public behavior, which were changes experienced by korean citizens in their daily lives during the covid-19 crisis. the health impact assessment requires data on exposure, mortality, and the population. although korea shares the real-time air pollution monitoring data with the public, the mortality data are not shared simultaneously. therefore, we estimated the mortality rates over the last 2 years (2019 and 2020) based on the mortality rates of earlier years. with the pm 2.5 monitoring data, population data, and estimated mortality rates in seoul, we estimated the health benefits based on the pm 2.5 reduction levels in 2020. by using previous respirator intervention study results [21] , we estimated the health benefits of decreased pm 2.5 and respirator use in 2020. to estimate the pm 2.5 decrease in year 2020, we first calculated the average pm 2.5 concentration during the first 4 months of 2020 and compared it with the concentration in the same months, each year, from 2016 to 2019. by using the attributable fraction (af) method [22] , we estimated the mortality burden attributable to the acute ambient pm 2.5 exposure in the first 4 months of each year, and the number of mortalities avoided due to the observed pm 2.5 reduction in 2020. to calculate the mortality burden attributable to pm 2.5 , we obtained the population, mortality, and air pollution monitoring data of seoul from publicly available databases. the relative risks (rr) derived from previous time-series studies, which evaluated the association between ambient pm 2.5 exposure and cause-specific mortalities were reviewed to retrieve the beta estimates of the concentration-response functions [23, 24] . to consider the effects of public respirator use, we referred to previous intervention study, which evaluated the difference between individual pm 2.5 exposure level by the particulate respirator use [21] . several important assumptions were made for our study. because mortality data were unavailable for the last two years (2019 and 2020), we assumed that mortality rates in seoul from january to april had not changed in the last 5 years. in korea, the daily mortality data for a typical year become publicly available at least 1.5 years after the year ends. therefore, we estimated the mortality rates of seoul from january to april in 2019 and 2020 by averaging the mortality rates of the same months from 2016 to 2018. because the mortality rates are closely related to the structure of the population, we also assumed that the composition of the population by age groups had not changed during our study period. second, we assumed that the effects of pm 2.5 were limited to a single day, ignoring the delayed effect of pm 2.5 . pm 2.5 is known to have lag effects of several days after the exposure [25] . however, because the daily mortality counts were unavailable for the years 2019 and 2020, it was impossible to estimate the daily levels accounting for lag effects of pm 2.5 . therefore, we regarded the 4-month period as a whole and calculated the mortality burden for each year using the 4-month averages of pm 2.5 concentrations and the estimated mortality rates of seoul. assumption focusing on a single day effect of pm 2.5 may underestimate the overall mortality burden attributable to pm 2.5 . however, the avoided number of mortalities due to pm 2.5 reduction during the covid-19 crisis may not be biased because we focused on the changes in pm 2.5 levels with the assumption of a linear concentration-response function. third, we assumed that the effects of pm 2.5 concentration on health outcomes did not change during the study period, despite the changes in personal behaviors (i.e., social distancing and decreased outdoor activities) due to the covid-19 crisis. we adopted the rrs from the previous time-series studies conducted both in seoul and that in 652 cities around the globe [23, 24] . however, despite assuming that the slope of concentration-response function between pm 2.5 and mortality remained unchanged, we assumed that wearing a particulate filtering respirator would decrease the absolute level of pm 2.5 exposure of an individual. this study was exempt from review by the institutional review board of the seoul national university hospital, korea (irb no.: 2006 -122-1133 , because data used in our study were de-identified and publicly available. the yearly residents' registration data for january during the study period (2016 to 2020) and the cause-specific mortality data for january to april (2016 to 2018) were acquired from the publicly available databases, the korean statistical information service website, and the korean statistical information service microdata integrated service website [26, 27] . we used the international classification of disease, 10th revision codes to define the following cause-specific mortalities: non-accidental and specific disease mortality (a00-r00), cardiovascular disease mortality (i00-i99), and respiratory disease mortality (j00-j99). the number of deaths due to these disease categories during the 4 months (january to april) of each year was calculated and divided by the number of registered residents in january of the corresponding year, to calculate the 4-month average in mortality rates of seoul. ambient pm 2.5 data of seoul from january 2016 to april 2020 were accessed through the airkorea website, which provides real-time air pollution monitoring data of korea [28] . korea operates 25 air pollution monitoring stations in seoul, covering 25 basic administration districts. we acquired the hourly pm 2.5 monitoring results from each station, and calculated seoul's daily and 4-month average of pm 2.5 exposure levels for january to april each year from 2016 to 2020. daily meteorological data such as ambient temperature, relative humidity, and wind speed from january 2016 to april 2020 were accessed through the national climate data center website. the map of seoul and the locations of the ambient pm 2.5 as well as the weather monitoring stations are presented in figure s1 . the beta estimates of the concentration-response functions were retrieved from the rrs of the previous time-series studies that evaluated the association between ambient pm 2.5 exposure and cause-specific mortalities (supplementary table s1 ). we selected two recently published studies-one analyzing the data from cities around the globe, and the other limited to seoul. in brief, the multi-city multi-country (mcc) collaborative research network gathered the daily mortality rates and pm 2.5 data from 499 cities in 16 countries. the researchers found that a 10 µg/m 3 increase in a 2-day moving average of ambient pm 2.5 was associated with 0.68% (95% confidence interval (ci): 0.59, 0.77); 0.55% (95% ci: 0.45, 0.66); and 0.75% (95% ci: 0.53, 0.95) increase in the daily non-accidental, cardiovascular, and respiratory mortalities, respectively [23] . the study conducted in seoul used the daily pm 2.5 concentrations and mortality data of the city from 2006 to 2012. a 10 µg/m 3 increase in ambient pm 2.5 was associated with an increase in non-accidental mortality (0.33% (95% ci: 0.01, 0.66)), cardiovascular mortality (0.76% (95% ci: 0.12, 1.41)), and respiratory mortality (1.77% (95% ci: 0.55, 3.01)) on the same day in seoul [24] . in a previous intervention study with 21 female elderlies in korea, we evaluated the effects of a particulate-filtering respirator on cardiopulmonary function by using the crossover study design [21] . the subjects were instructed to use (intervention period) or not use the respirator (control period) for six consecutive days and had a medical examination on the last day of each period. by using the disposable particulate respirators (capable of filtering 80% of the 0.6 µm nonoil particulates), we found that the average level of personal exposure to pm 2.5 had decreased by 27.4% (9.0 µg/m 3 reduction) during the respirator use, and even the outdoor (27.4-28.8 µg/m 3 ) and 24-h personally monitored pm 2.5 levels (18.7-20.1 µg/m 3 ) were similar between intervention and control periods. by referring to this value, we estimated that the effects of respirator use during covid-19 crisis decreased the personal pm 2.5 exposure level by 27.4% in addition to the decrease in ambient pm 2.5 levels observed during 2020. with the estimated number of mortalities and monitored pm 2.5 concentrations from january to april each year, we used the af method to estimate the mortality burden attributable to ambient pm 2.5 levels [22] . excess deaths by pm 2. β is the coefficient derived from the rrs in the previous time-series studies and ∆c refers to the changes in the pm 2.5 concentrations under different counterfactual scenarios. the number of deaths from january to april for the years 2016 to 2018 was obtained from the mortality database, while those of 2019 and 2020 were calculated by multiplying the number of registered residents with the mortality rates estimated based on the mortality rates of 2016 to 2018. to calculate the number of excess deaths attributable to the acute pm 2.5 exposure from january to april each year from 2016 to 2020, we defined 2.4 µg/m 3 as the concentration with the minimum health risk, which is the theoretical minimum risk exposure level, indicating no health benefits for reducing pm 2.5 below the level based on prior epidemiological studies [29] . therefore, ∆c in the equation indicates the difference between average pm 2.5 concentrations monitored each year from january to april and 2.4 µg/m 3 . on the other hand, to calculate the avoided mortality due to pm 2.5 reduction in 2020, we defined ∆c as the estimated reduction in pm 2.5 from january to april in 2020 compared to the same months in 2016-2019. to calculate the reduction in pm 2.5 in 2020, we used the linear regression models assuming the normal distribution of pm 2.5 levels. in model 1, the amount of reduction was estimated based on a simple comparison of the average value for 2020 with the average for the years 2016-2019. in model 2, we adjusted for meteorological variables (daily average temperature, relative humidity, and wind speed), and in model 3, we adjusted for the meteorological variables, years (as a continuous variable), and the months (as a categorical variable). in model 4, we adjusted for the meteorological variables and assumed that the average level of personal exposure to pm 2.5 had decreased by 27.4% in 2020, to account for the widespread use of particulate filtrating respirator. all analyses were conducted with sas version 9.4 (sas institute inc., cary, nc, usa), and figures were drawn using the r statistical software (version 3.6.1; r foundation for statistical computing, vienna, austria). the level of statistical significance was set at a p-value of less than 0.05. table 1 and figure 1 show the 2016 to 2020 seoul data for the daily pm 2.5 concentrations, ambient temperature, relative humidity, wind speed, and the number of days that the pm 2.5 concentration was above the who and korea 24-h average standards. the average ambient temperature from january to april in 2020 was the highest compared to those of the previous 4 years, while the relative humidity and wind speed of 2020 were similar to that of 2016 and 2017. the average pm 2.5 concentration from january to april in 2020 (25.6 µg/m 3 ) was the lowest in the last 5 years. overall, the pm 2.5 concentrations above the who (25 µg/m 3 ) and the korean standards (35 µg/m 3 ) in 2020 were for 55 days (45.5%) and 25 days (20.7%) respectively, which were the least number of days in the past 5 years. figure 1 shows the dramatic decrease in the daily pm 2.5 concentrations as well as the number of days with spiking pm 2.5 concentrations in 2020 compared to the previous 4 years. table 2 shows the number of registered residents, estimated number of deaths, and mortality rates used in the study. the average number of registered residents in seoul in january each year was 9,860,115. the average non-accidental, cardiovascular, and respiratory mortalities per 100,000 persons in seoul were 139.2, 32.0, and 16.1 from january to april in 2016 to 2018, respectively. we used these mortality rates to estimate the number of deaths for 2019 and 2020 assuming that these rates remained unchanged. we estimated that 13,549; 3115; and 1567 persons died in seoul from january to april in 2020 due to non-accidental, cardiovascular, and respiratory diseases, respectively. rates remained unchanged. we estimated that 13,549; 3115; and 1567 persons died in seoul from january to april in 2020 due to non-accidental, cardiovascular, and respiratory diseases, respectively. table s2 , and figure s2 show the number of mortalities attributable to pm 2.5 exposure in seoul from january to april each year from 2016 to 2020. by using the mcc study's rrs, the daily exposure to pm 2.5 in 2020 caused 211.4 (95% ci: 183.7, 239.0); 39.4 (95% ci: 32.3, 47.2); and 26.6 (95% ci: 19.1, 34.0) deaths due to non-accidental, cardiovascular, and respiratory diseases, respectively (table s2 ). the mortality attributable to the daily pm 2.5 exposure was the lowest in 2020 compared to those of the previous 4 years (figure 2 ). the results using rrs from the seoul study are summarized in table s2 and figure s2 . table s2 , and figure s2 show the number of mortalities attributable to pm2.5 exposure in seoul from january to april each year from 2016 to 2020. by using the mcc study's rrs, the daily exposure to pm2.5 in 2020 caused 211.4 (95% ci: 183.7, 239.0); 39.4 (95% ci: 32.3, 47.2); and 26.6 (95% ci: 19.1, 34.0) deaths due to non-accidental, cardiovascular, and respiratory diseases, respectively (table s2 ). the mortality attributable to the daily pm2.5 exposure was the lowest in 2020 compared to those of the previous 4 years (figure 2 ). the results using rrs from the seoul study are summarized in tables s2 and figure s2 . table 3 shows the estimated pm2.5 reduction levels and the avoided mortality due to the pm2. table 3 shows the estimated pm 2.5 reduction levels and the avoided mortality due to the pm 2.5 exposure in 2020 compared to those from 2016-2019. by simply comparing the average values, a −5.6 µg/m 3 (95% ci: −9.0, −2.3) change in ambient pm 2.5 was observed in seoul from january to april in 2020 compared to the same months in the previous 4 years (model 1). by adjusting for meteorological variables, a −4.1 µg/m 3 (95% ci: −7.2, −0.9) change in ambient pm 2.5 was estimated (model 2). by further adjusting for years and months, a −15.1 µg/m 3 (95% ci: −27.1, −3.2) change in ambient pm 2.5 was estimated (model 3). with the conservative estimation of a 4.1 µg/m 3 decrease in pm 2.5 and rrs from the mcc study, we found that 37.6 (95% ci: 32.6, 42.5) non-accidental; 7.0 (95% ci: 5.7, 8.4) cardiovascular; and 4.7 (95% ci: 3.4, 6.1) respiratory mortalities were avoided because of the reduction in pm 2.5 from january to april in 2020 compared to those of the previous 4 years. table 3 . estimated pm 2.5 reduction levels and avoided mortality due to pm 2.5 exposure in january to april of 2020 compared to same month each year from 2016 to 2019. reduction avoided cause-specific deaths we observed at least a 4.1 µg/m 3 decrease in ambient pm 2.5 concentration in seoul from january to april in 2020 compared to the same months in 2016-2019. we estimated that 37 persons were saved due to the reduction in pm 2.5 during the 4-month period. because using a particulate-filtrating respirator may decrease the absolute level of pm 2.5 exposure for an individual, the health benefit related to air pollution during the covid-19 crisis may be larger than our current estimation of 37 persons. there are several possible explanations for the decrease in pm 2.5 in seoul. first, public behavioral changes such as social distancing and reduced outdoor activities to limit covid-19 transmission may have decreased the air pollution levels. according to the mobility data based on the map navigation application on smartphones, both walking and driving by the public were decreased in seoul after the covid-19 crisis ( figure s3 ). the daily amount of traffics entering the highways and the number of citizens using the seoul metropolitan area subway from january to april in 2020 dropped by 6.1% and 28.4%, respectively, compared to the same months in the period 2016-2019 (table s3 ). in addition, industrial activities such as the number of operating factories may have decreased due to the limited consumer demand during covid-19 crisis, which may have resulted in decreased domestic emissions [30] . similar improvements in air quality were observed around the world since the covid-19 crisis, with an estimated reduction of 9%, 29%, and 11% of ambient pm 2.5 , no 2 , and ozone levels, respectively [18] . the reductions in carbon monoxide and no 2 levels were observed after the partial lockdown (school closure, work from home, avoiding gatherings, shutting down commerce, and limiting public transportation) in the city of rio de janeiro and são paulo state [16, 17] . during the movement control order (work from home and suspend industrial activities) to isolate the source of covid-19 in malaysia, up to a 58.4% decrease in pm 2.5 was observed [15] . by analyzing air quality monitoring data of 22 cities in india, 43% and 18% decreases in pm 2.5 and no 2 were observed during the covid-19 crisis [31] . the air pollution levels in seoul cannot be evaluated without considering the effects of the neighboring countries, china and north korea. by evaluating the source contribution of pm 2.5 on days with severe pm 2.5 concentrations (with 24-h average pm 2.5 concentration of over 100 µg/m 3 ) in seoul, china contributed to the pm 2.5 concentrations by up to 70% while the domestic contribution was 21% [20] . in addition, around 15% of pm 2.5 concentration in seoul is affected by the emission from north korea [32] . among the 1638 mortalities attributable to the acute exposure to high levels of pm 2.5 in korea in 2016, at least 258 and 26 deaths were estimated to have been due to the emissions from china and north korea, respectively [33] . because the air quality in china improved dramatically during the covid-19 quarantine (10 february to 14 april 2020) [12] [13] [14] 34] , and considering the fact that china's contribution to seoul's pm 2.5 concentration is generally greater in the spring and winter [33] , the decrease in pm 2.5 observed in seoul from january to april 2020 may partially be explained by the effects of china's rigorous quarantine measures and decreased industrial activities during the covid-19 crisis. if the observed decrease in pm 2.5 levels in seoul in 2020 is indeed due to the changes related to domestic responses as well as china's response against covid-19, the estimated mortality benefit from the lowered pm 2.5 levels (37 persons) outweighs the number of the direct casualties from covid-19 in seoul (2 persons till 30 april 2020). similar paradoxical phenomena, and a massive decrease in air-pollution-related mortalities and morbidities during the covid-19 crisis are expected worldwide [14] . another plausible explanation for the decrease in pm 2.5 concentration in seoul in 2020 is the governmental effort to reduce the domestic sources of pm 2.5 [19] . with consultations with relevant ministries, a comprehensive set of measures to control the particulate matter in 2020 to 2024 was finalized on 1 november 2019 [35] . one of the measures is the seasonal management of the domestic sources of pm 2.5 from december to april, when pm 2.5 levels are usually high [36] . efforts to reduce the domestic emission of pm 2.5 include the shutting down of the coal-fired power plants, voluntary reduction in emissions from business sites, nationwide surveillance of emission sources, designation of low-sailing zones, and transition to low sulfur fuels for ocean vessels. in addition to these comprehensive measures, an increase in rainfall and the number of days with high wind velocity may also help to explain the decrease in pm 2.5 observed in seoul from january to march 2020 [19] . however, the relative humidity and wind speed in 2020 were similar to those of 2016 and 2017; limiting the effects of meteorological factors on pm 2.5 reduction. we may not be able to distinguish the effects of diverse governmental measures from those of domestic and international changes related to covid-19 on the reduced pm 2.5 levels in seoul. however, it is reasonable to assume that the domestic measures (social distancing and avoidance of outside activities in korea) and international effects (decreased pm 2.5 levels during the quarantine in china) related to covid-19 may have played a significant role at the same time. we may be able to confirm the effects of covid-19 by observing the air pollution levels after the covid-19 measures are lifted and by evaluating whether the effects (decrease in air pollution) cease after the treatment (measures against covid-19) ends [37] . although not formally published as a journal article, several reports posted on medrxiv are showing the health benefits of reduced pm 2.5 levels after the covid-19 crisis. one report estimated that the pm 2.5 and no 2 levels dropped by 18.9 and 12.9 µg/m 3 in china during the covid-19 quarantine period, which led to a decrease of 3214 pm 2.5 -related deaths and a decrease of 8911 no 2 -related deaths [13] . by analyzing the air pollution data from over 10,000 monitoring stations around the globe, a 9%, 29%, and 11% reduction in ambient pm 2.5 , no 2 , and ozone levels was estimated during february to april 2020, just after the global lockdown in response to covid-19 [18] . the corresponding health benefits related to the decrease in air pollution levels were 7400 deaths and 6600 pediatric asthma cases. after the first confirmed case of covid-19 in korea on 20 january 2020, the panic buying of particulate filtrating respirator led to instability in supply and demand. to tackle this issue, the korean government adopted a "5-day rotation system for respirator" to provide equal opportunity for individuals to purchase two particulate-filtering respirators (particulate respirators capable of filtering at least 80% of the 0.6 µm nonoil particulates) per week. as the korean government instructed its citizens to wear a respirator outside the house to control covid-19, personal level of exposure to ambient pm 2.5 may have decreased from wearing a particulate respirator. with the results of the previous intervention study, we estimated that the effects of respirator use during covid-19 crisis decreased the personal pm 2.5 exposure level by 27.4% in addition to the decrease in ambient pm 2.5 levels. we estimated that this decrease led to 102 averted deaths related to pm 2.5 during the 4-month period; this is higher compared to the conservative estimation of 37 lives saved with a 4.1 µg/m 3 decrease in ambient pm 2.5 concentration during the covid-19 crisis estimated in our study. we believe that using a particulate filtrating respirator not only help to block the transmission of covid-19, but also helped to limit the adverse health effects of pm 2.5 . we have previously estimated that around 12,000 premature deaths were attributable to chronic pm 2.5 exposure in korea in 2015, when the annual average of pm 2.5 concentration was 24.4 µg/m 3 [38] . we have also estimated that 1763 deaths solely occurred in seoul. however, our study is different from the previous study in terms of the fact that it addressed the acute effects of pm 2.5 exposure by using the rrs from previous time-series studies. with the yearly mortality information and pm 2.5 measurement data for the entire year, we may be able to estimate the chronic pm 2.5 exposure burden for 2020 and compare the difference with previous years. if reduced pm 2.5 levels are maintained throughout 2020, we may be able to see a marked decrease in pm 2.5 -related burden. several limitations should be noted for this study. first, we adopted the rrs from previous time-series studies and ignored the possibility that the association between pm 2.5 and health outcomes may have changed during the covid-19 crisis. the korean government instructed its citizens to avoid outdoor activities or crowded areas, and to use a respirator outside the house. due to social distancing and the use of a respirator, the beta coefficient of exposure-response relationship may have changed. if the daily mortality data become available in the future, we may be able to confirm the changes in beta coefficient by comparing the estimates from the time-series analyses before and during the covid-19 crisis. in addition, although we tried to adjust for the effects of respirator by using the results from previous intervention study, we also assumed that the entire public were using the particulate respirator during the covid-19 crisis, which is unlikely. second, we ignored the daily lag effect of pm 2.5 . because mortality data are not disclosed simultaneously, we were unable to conduct a day-to-day analysis accounting for the lag effects of pm 2.5 . with the full mortality data of 2020, a more precise estimation can be conducted by using the daily data rather than using the 4-month (january to april) data as a whole. due to insufficient data and assumptions used in our study, our study estimates may be biased. assumptions regarding mortality rates and concentration-response functions have to be validated with a daily number of mortality data and pm 2.5 monitoring data in the future. however, based on the currently available data, our study may offer a glimpse into the acute health benefits of pm 2.5 reduction and changes in public behaviors, which are the tangible changes experienced by the citizens in their daily lives during the covid-19 crisis. we observed at least 4.1 µg/m 3 decrease in ambient pm 2.5 in seoul from january to april 2020, and this decrease is believed to be the results of the changes related to covid-19 crisis. with our conservative estimation, a total of 37 lives were saved due to the pm 2.5 reduction in seoul from january to april 2020 compared to the same period in previous years. however, the health benefits related to the decrease in pm 2.5 may be greater because of the popular use of the particulate respirator by the public during the covid-19 crisis in korea. we may need to verify our study findings by observing the pm 2.5 levels after the covid-19 crisis and conducting studies with a full set of daily mortality data. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/15/5279/s1, table s1 : concentration-response functions used in the study; table s2 : estimated number of mortalities attributable to pm 2.5 exposure from january to april in each year from 2016 to 2020; table s3 : the daily average amount of vehicles entering the seoul metropolitan area highways and number of citizens who used subways of seoul metropolitan area from january to april each year from 2016 to 2020; figure s1 : locations of 25 pm 2.5 monitoring stations (red circle) and meteorological station (blue circle) covering seoul; figure s2 : average pm 2.5 concentration of seoul from january to april and estimated number of mortalities attributable to pm 2.5 exposure (rrs from the seoul study were used for the estimation); figure 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particulate matter event effects of particulate respirator use on cardiopulmonary function in elderly women: a quasi-experimental study spatial and temporal trends in the mortality burden of air pollution in china ambient particulate air pollution and daily mortality in 652 cities short-term effects of ambient pm2. 5 and pm2. 5-10 on mortality in major cities of korea time series regression studies in environmental epidemiology estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the global burden of diseases study covid-19 outbreak: migration, effects on society, global environment and prevention effect of restricted emissions during covid-19 on air quality in india pm 2.5 simulations for the seoul metropolitan area:(v) estimation of north korean emission contribution source country-specific burden on health due to high concentrations of a preliminary assessment of the impact of covid-19 on environment-a case study of china comprehensive measures for fine particulate matter special measures for high concentration fine particulate matter period experimental and quasi-experimental designs for generalized causal inference spatial and temporal trends of number of deaths attributable to ambient pm2. 5 in the korea key: cord-288394-h9hozu9j authors: kheirallah, khalid a.; alsinglawi, belal; alzoubi, abdallah; saidan, motasem n.; mubin, omar; alorjani, mohammed s.; mzayek, fawaz title: the effect of strict state measures on the epidemiologic curve of covid-19 infection in the context of a developing country: a simulation from jordan date: 2020-09-08 journal: int j environ res public health doi: 10.3390/ijerph17186530 sha: doc_id: 288394 cord_uid: h9hozu9j covid-19 has posed an unprecedented global public health threat and caused a significant number of severe cases that necessitated long hospitalization and overwhelmed health services in the most affected countries. in response, governments initiated a series of non-pharmaceutical interventions (npis) that led to severe economic and social impacts. the effect of these intervention measures on the spread of the covid-19 pandemic are not well investigated within developing country settings. this study simulated the trajectories of the covid-19 pandemic curve in jordan between february and may and assessed the effect of jordan’s strict npi measures on the spread of covid-19. a modified susceptible, exposed, infected, and recovered (seir) epidemic model was utilized. the compartments in the proposed model categorized the jordanian population into six deterministic compartments: suspected, exposed, infectious pre-symptomatic, infectious with mild symptoms, infectious with moderate to severe symptoms, and recovered. the gleamviz client simulator was used to run the simulation model. epidemic curves were plotted for estimated covid-19 cases in the simulation model, and compared against the reported cases. the simulation model estimated the highest number of total daily new covid-19 cases, in the pre-symptomatic compartmental state, to be 65 cases, with an epidemic curve growing to its peak in 49 days and terminating in a duration of 83 days, and a total simulated cumulative case count of 1048 cases. the curve representing the number of actual reported cases in jordan showed a good pattern compatibility to that in the mild and moderate to severe compartmental states. the reproduction number under the npis was reduced from 5.6 to less than one. npis in jordan seem to be effective in controlling the covid-19 epidemic and reducing the reproduction rate. early strict intervention measures showed evidence of containing and suppressing the disease. the number of newly reported covid-19 cases in jordan fluctuated between three and 42 daily cases (mean number of daily reported cases was 15 cases). as of may 1, the number of reported cases was 459 cases, including eight deaths. cases seem to have clustered among persons within the same family and a limited number of cases have been identified to be of unknown origin. testing, taking place during the time at which this manuscript was prepared, has been conducted randomly, regardless of symptoms, within each of the 12 jordanian governorates and a limited number of cases have been identified using this approach. in early may, the number of local cases reached zero for about 10 days. at this stage, it is necessary to simulate the covid-19 epidemic curve in jordan, especially for those with mild symptoms, as this will give an indication of the actual national situation. without proper simulation of cases by clinical manifestation, decisions to re-open businesses will be arbitrary and not data driven. from this perspective, the current research attempted to mathematically simulate the ongoing trajectory of the covid-19 outbreak in jordan and to model the effect of national interventions utilizing real-time scenarios. the simulation of the covid-19 outbreak could be of added value for public health response planning and future expectations. the current research will also advance our knowledge about covid-19 in developing countries and the effect of publicized responses implemented with widespread adherence and support in jordan. a modified susceptible, exposed, infected, and recovered (seir) epidemic model [24] to simulate the spread of covid-19 in jordan was utilized. the seir model simulates the spread of an infectious disease, assuming that no births or deaths occur and that no new individuals are introduced. as such, each individual is initially assigned to each of the following disease states (deterministic compartments): susceptible (s), exposed (e), infectious (i) or recovered (r). the deterministic compartments in the seir model are fairly sophisticated quantitative mathematical models, yet are easily run utilizing public data and known disease characteristics [24] . we have modified the standard seir model by adding compartmental states that reflect the compartmental population and research needs. our modified model categorized the jordanian population into six deterministic compartments: susceptible, exposed, infectious pre-symptomatic (representing the total number of infections in jordan), infectious with mild symptoms (i.e., not needing hospitalization), infectious with moderate to severe symptoms (i.e., needing hospitalization), and recovered. in designing the modified simulation model, we assumed that an exposed individual may become infectious, pre-symptomatic, and then may progress to recovered, or progress to become either a mild or moderate to severe symptomatic individual, both of whom may then progress to recovered. the following brief shows the compartmental states applied in our study: susceptible: all of the non-immune population in our study (the entire jordanian population). pre-symptomatic: population producing or showing no covid-19 symptoms yet, albeit infectious [11] . symptomatic (mild or moderate to severe): population showing covid-19 symptoms. recovered: population recovered from covid-19 infection. the modified model predicts the number of simulated covid-19 cases by each compartmental state in jordan. it also has the potential to distinguish hidden (asymptomatic or mild, not seeking hospital care) from identified infected cases needing hospitalization (moderate to severe cases). indeed, standard seir models are estimated by assuming that all infected people are reported. such an assumption for the novel covid-19 pandemic is largely unreasonable, as many infected people show no symptoms or mild symptoms and, as the testing procedure is not available in mass, many remain undetected [25] . the model also accounts for hospitalization of moderate to severe cases by adjusting the contact rate. it is assumed that such cases will be detected and quarantined within a healthcare setting as they will be seeking medical services. hence, their contact rates will decrease tremendously. we have utilized the gleamviz client desktop application version 7 simulator [26] that combines world data such as country population and human mobility. the gleamviz elaborates compartmental stochastic models [27] for disease transmission in a pandemic event. our analysis assumes that the first case entered jordan on february 1, and the initial simulation started as such. a population size of 10.2 million was built into the client simulator. moreover, the model allows for the limitation of mobility within the population and the restriction of travel as built-in functions within the designed models. the simulator provides rates within each compartment which were converted into numbers based on population size. to run the simulation model, we utilized a series of parameters, as indicated by the simulator (table 1 ) [26] . these parameters are as follows: beta (β) describes the transmission rate and the spread of disease in the community. the β varies according to public health policies that are enforced or applied in communities such as pandemic containment, social distancing, remote working, closing schools, etc. since jordan's culture is homogeneous, and people follow traditional forms for greeting, we have set the standard contact rate (β) to 0.37 [16, 28, 29] . to reflect the status of measures in jordan, we added an extra layer (exception) to designate the non-pharmaceutical interventions (npis) that took place on march 17. as such, the contact rate value (β) was reduced from 0.37 to 0.06 [30] between march 17 and april 24. the contact rate value (β) was set to 0.2 between april 25 and may 15, reflecting the partial lifting of the curfew and partial reopening of selected businesses. after that, the contact rate value (β) was set to its original value of 0.37. alpha (α) denotes the reduction in the transmission rate of hospitalized (moderate to severe) cases. we have used the value of α = 0.5 to reflect the negligible transmission rate of hospitalized patients. epsilon (ε): the incubation period from the point of exposure to the disease becoming infectious. it is set to 5.2 days [9, 10, 31] . ps: the probability of developing severe covid-19 symptoms. this value was set at 0.01 [32] . recovery rate (mu or µ), which indicates the time until an infectious case becomes recovered. previous research [33] reports that the recovery time for covid-19 is 14 days (µ = 1/14 days). hence, we have used this value as the recovery rate (µ = 0.07) in our model. r 0 : the reproduction number for covid-19. based on the above values, r 0 was calculated as 5.6 (see supplementary table s1 for formula). the basic reproduction number (r 0 ) measures the transmission (contagious) potential of covid-19 and describes the average number of secondary infections caused by a typical primary infection in a completely susceptible population. an r 0 value of 5.6 was reported in other similar global simulations [34] . the literature reported that r 0 ranges between 2.3 and 6.5 [28, [35] [36] [37] and a re-analysis of chinese data provided an updated estimate of 5.7 (95% ci 3.8-8.9) [37] . other published studies reported that, for social gathering events such as wedding parties in jordan, the r 0 value was five [38] . our model does not provide estimates for the proportion requiring intensive care units (icu) within hospitals nor the estimated number of covid-19-related deaths. providing these estimates requires details of the clinical fraction of infected people, the likelihood of clinical cases being severely ill, as well as a detailed understanding of the capacity of the health services in jordan. two basic models were run to simulate the estimated numbers of covid-19 cases by clinical manifestation, assuming two separate scenarios: the npi scenario (s1), which was implemented in jordan, and the no action scenario (s2). the former considered npi implementation dates (starting march 17 and ending may 15), while the latter assumed no npis took place (see supplementary table s1 ). for each compartmental state, the number of simulated daily new covid-19 cases was plotted. accordingly, the epidemic curves are presented along with the duration of the epidemic (in days) and the time to the peak (in days). each s1 curve was also fitted against the reported daily number of cases. figure 1 presents the number of daily new covid-19 cases in the pre-symptomatic compartmental state, simulated under the s1 and s2 curves using the same scale. the s1 curve is demonstrated as a "baby" curve under the s2 curve that started after february 1 and ended before april 20. the simulation model, under s1, predicted that on march 20 the highest number of daily new cases in the pre-symptomatic compartmental state would be 65 cases, after which the number of simulated daily new cases started to decrease. by april 24, the predicted daily new cases had leveled out to zero. considering that the simulation was set to start on february 1, and the npis commenced on march 17, it took the epidemic curve 49 days to grow to its peak and the total duration of the epidemic curve was predicted at 83 days. the cumulative number of cases was predicted at 1048. for the hypothetical scenario of no action (s2), the epidemic took a total of 147 days to reach its peak of 238,142 daily new cases by june 27, and the cumulative number of cases reached about 9.5 million around december 1. our model does not provide estimates for the proportion requiring intensive care units (icu) within hospitals nor the estimated number of covid-19-related deaths. providing these estimates requires details of the clinical fraction of infected people, the likelihood of clinical cases being severely ill, as well as a detailed understanding of the capacity of the health services in jordan. two basic models were run to simulate the estimated numbers of covid-19 cases by clinical manifestation, assuming two separate scenarios: the npi scenario (s1), which was implemented in jordan, and the no action scenario (s2). the former considered npi implementation dates (starting march 17 and ending may 15), while the latter assumed no npis took place (see supplementary table s1 ). for each compartmental state, the number of simulated daily new covid-19 cases was plotted. accordingly, the epidemic curves are presented along with the duration of the epidemic (in days) and the time to the peak (in days). each s1 curve was also fitted against the reported daily number of cases. figure 1 presents the number of daily new covid-19 cases in the pre-symptomatic compartmental state, simulated under the s1 and s2 curves using the same scale. the s1 curve is demonstrated as a "baby" curve under the s2 curve that started after february 1 and ended before april 20. the simulation model, under s1, predicted that on march 20 the highest number of daily new cases in the pre-symptomatic compartmental state would be 65 cases, after which the number of simulated daily new cases started to decrease. by april 24, the predicted daily new cases had leveled out to zero. considering that the simulation was set to start on february 1, and the npis commenced on march 17, it took the epidemic curve 49 days to grow to its peak and the total duration of the epidemic curve was predicted at 83 days. the cumulative number of cases was predicted at 1048. for the hypothetical scenario of no action (s2), the epidemic took a total of 147 days to reach its peak of 238,142 daily new cases by june 27, and the cumulative number of cases reached about 9.5 million around december 1. the simulated daily new mild covid-19 cases under s1 reached their peak on march 21 with 36 cases and a total duration of 49 days (figure 2) , after which the simulated daily new mild case as seen in figure 3 , the simulated daily new moderate to severe cases, under s1, reached a maximum number on march 24 with a total of 46 cases (a total of 53 days). the number then decreased to zero cases on april 27 (the total number of days for the epidemic was 87 days). in figure 4 , we plotted the actual reported daily new cases in jordan against the simulated cases in our model (s1). the curves representing the simulated number of daily new covid-19 cases, in both the mild and moderate to severe compartmental states, had good pattern compatibility with those depicting the number of reported cases in jordan, with a peak of new cases on march 24. as seen in figure 3 , the simulated daily new moderate to severe cases, under s1, reached a maximum number on march 24 with a total of 46 cases (a total of 53 days). the number then decreased to zero cases on april 27 (the total number of days for the epidemic was 87 days). as seen in figure 3 , the simulated daily new moderate to severe cases, under s1, reached a maximum number on march 24 with a total of 46 cases (a total of 53 days). the number then decreased to zero cases on april 27 (the total number of days for the epidemic was 87 days). in figure 4 , we plotted the actual reported daily new cases in jordan against the simulated cases in our model (s1). the curves representing the simulated number of daily new covid-19 cases, in both the mild and moderate to severe compartmental states, had good pattern compatibility with those depicting the number of reported cases in jordan, with a peak of new cases on march 24. in figure 4 , we plotted the actual reported daily new cases in jordan against the simulated cases in our model (s1). the curves representing the simulated number of daily new covid-19 cases, in both the mild and moderate to severe compartmental states, had good pattern compatibility with those depicting the number of reported cases in jordan, with a peak of new cases on march 24. under s1, the simulated cumulative recovery was 1044 cases by june 30. out of the total cumulative cases, 695 cases were in the moderate to severe compartmental state, i.e., needing hospital care, while 795 were in the mild compartmental state, i.e., mostly hidden cases within the community. moreover, based on the s1 model, the simulated reproduction number (r 0 ) for covid-19 after implementing npis in jordan was estimated at 0.9. further comparisons between the s1 and s2 simulated models are presented in the supplementary figures (see supplementary figure s1 ). under s1, the simulated cumulative recovery was 1044 cases by june 30. out of the total cumulative cases, 695 cases were in the moderate to severe compartmental state, i.e., needing hospital care, while 795 were in the mild compartmental state, i.e., mostly hidden cases within the community. moreover, based on the s1 model, the simulated reproduction number (r0) for covid-19 after implementing npis in jordan was estimated at 0.9. further comparisons between the s1 and s2 simulated models are presented in the supplementary figures (see supplementary figure s1 ). with covid-19 imposing global public health and socioeconomic uncertainties, governments are counting on their people to adapt to npis in an effort to reduce the impact of the epidemic. the combined efforts of both the government and the people are then necessary to bring the epidemic under control. how people react and respond to the implemented npi measures are critical to the epidemiological presentation of the epidemic. in this context, the current study assessed the effect of npis implemented in jordan on the covid-19 outbreak, utilizing simulation techniques. the simulated epidemic curves for covid-19 provided evidence that jordan may have successfully implemented npi measures that facilitated suppressing (containing) the spread of the epidemic by reducing the number of daily new reported cases and the total duration of the epidemic. the effects of the adopted npis in jordan on the number of daily new cases and the duration of the epidemic are even more appreciated when compared to the catastrophic effects of the hypothetical scenario of no action (see supplementary figure s1 ). our results suggest that swift, intensive, and targeted lockdowns in jordan may have caused new covid-19 cases to plummet and the health system to be with covid-19 imposing global public health and socioeconomic uncertainties, governments are counting on their people to adapt to npis in an effort to reduce the impact of the epidemic. the combined efforts of both the government and the people are then necessary to bring the epidemic under control. how people react and respond to the implemented npi measures are critical to the epidemiological presentation of the epidemic. in this context, the current study assessed the effect of npis implemented in jordan on the covid-19 outbreak, utilizing simulation techniques. the simulated epidemic curves for covid-19 provided evidence that jordan may have successfully implemented npi measures that facilitated suppressing (containing) the spread of the epidemic by reducing the number of daily new reported cases and the total duration of the epidemic. the effects of the adopted npis in jordan on the number of daily new cases and the duration of the epidemic are even more appreciated when compared to the catastrophic effects of the hypothetical scenario of no action (see supplementary figure s1 ). our results suggest that swift, intensive, and targeted lockdowns in jordan may have caused new covid-19 cases to plummet and the health system to be protected. our research therefore suggests that a strong containment policy implemented early on can combat the spread of a covid-19 epidemic. a recent study, which utilized statistical modeling based on google reports on social distancing, assessed lockdown efficiency for 13 countries. jordan, italy, and indonesia were categorized as countries with very high-level lockdowns. when correlating lockdown procedures and the infection rates, to assess the impact of lockdown policies on r 0 , jordan was reported as a country with high lockdown efficiency for the period between february 15 and april 11. however, italy and indonesia were categorized as medium lockdown efficiency countries for the same period. similarly, germany and spain were reported as "not gaining any productive results out of the lockdown procedures" for the same period, yet their efficiency levels improved between may and july. india, on the other hand, was reported to have a very strict lockdown policy yet was categorized, initially, to have a low lockdown efficiency. later on, india was categorized to have a medium efficiency (between may and july). late lockdown procedures detected in brazil and the united states were reported to have a major impact on large outbreaks and to inversely contribute to elevated infection rates [39] . these results are in line with our simulated model for jordan and suggest that the country has presented a successful strategy that allowed for the "snuffing" out of the covid-19 pandemic at an early stage. such success may be attributed to early adaptation to a complete national lockdown, early isolation of all arrivals and travelers for two weeks, and effective contact tracing through the already established crises management center, which facilitated centralized decision making. the jordan ministry of health is currently conducting a national seropositivity (immunoglobulins m (igm) and immunoglobulins g (igg)) study to assess the effect of its measures in combating the spread of covid-19. this comes as a continuation of the random pcr testing conducted earlier by the ministry after the first wave that we are simulating. the positivity rate of the pcr test for about 700,000 randomly collected samples was less than 0.03%, while the positivity rate for sars-cov-2 antibodies is less than 1% for about 500,000 tests performed so far (jordan's population is estimated at 10.2 million). the results of the latter are still being updated but the positivity rate seems to be in line with the reported national numbers and the random pcr testing results. both results seem to point to the effectiveness of state measures in combating covid-19 and to support our findings as well. strict npi measures implemented in jordan, which lasted for more than six weeks, appear to have reduced covid-19 transmission and likely reduced the reproduction number to less than one. a similar discussion was presented for the uk, for example [13] , where, in the absence of control measures, the epidemic would quickly overwhelm the healthcare system. a combination of moderate interventions (school closures, shielding of older groups and self-isolation) was predicted to be unlikely to prevent an epidemic that would far exceed the available icu capacity in the uk. more intensive lockdown-type measures, however, predicted an effective protection of the healthcare system from being overwhelmed. importantly, the lockdown scenario for the uk effectively reduced r 0 to near or below one [13] . our results are significant not only for public health decision makers, but also for risk communication and lessons learned. in case a new wave of the epidemic hits, the notion to initiate strict measures is supported by this model's outcomes and would strengthen public messages to enhance the proper implementation of strict measures. this data-driven approach is vital to ensure population commitment and to, perhaps, aid the ongoing efforts of other countries with similar resources and culture. in infectious disease epidemiology, sensitivity analysis provides an insight into how the uncertainty of the model inputs affects the model output, and which input tends to lead to variation in the output. the gleamviz simulation software application does not provide compartment modeling in the form of accessible algorithms. therefore, the inputs of the compartments are the only parameters that can be controlled by the end user. this limited our abilities to examine the algorithm of gleamviz and to conduct sensitivity analyses. in a future study, our simulation could be further improved by introducing epidemiological compartmental models in the form of computational algorithms to be evaluated with a suitable sensitivity analysis. however, the susceptible, infected, and recovered (sir) original model is a standardized one that has been in use for several years in epidemic investigation. importantly, when we were optimizing the model parameter values to facilitate a proper agreement between the simulated and reported covid-19 cases (as presented in figure 4 ), we were improving the validity of the model. a combination of npis, isolation and contact tracing has been reported to present a synergistic effect that increased the prospect of containment of covid-19 [40] . knowing that jordan has implemented strict contact tracing and isolation of contacts limits our ability to clearly compare the actual reported numbers to those presented under s1. until detailed information about cases identified via contact tracing and isolation are made available, the presented model (s1) is the only available method to meet the objective of the current study. moreover, the numbers presented under s2 seemed to be high values, as the scenario assumed that no prevention and control measures were implemented. their interpretation, therefore, should be limited to a comparison with s1 and should be seen as mostly hypothetical. the simulation presented in the current study has limitations. it was designed to monitor the evolution of the covid-19 epidemic spread in jordan utilizing parameters presented about the disease from the experience within developed countries. however, at this stage of the epidemic, country-specific parameters are not available. furthermore, the contact rates used in the current simulation were generalized for the whole population and did not consider variability within households or local communities. the assumption of a universal contact rate used in the proposed model was, however, adjusted for all cases with moderate to severe clinical manifestations. considering that these cases are most likely to be detected within healthcare settings and be hospitalized, we reduced their contact rate to its minimum to overcome this limitation. furthermore, recognizing co-morbidities within the population structure of jordan and incorporating them within the compartmental states is assuredly of added value in this simulation. however, the reports from jordan did not specify co-morbidities and only stated the number of cases. this is a limitation to the proposed model and limits our abilities to assess and compare, as stated before. however, our aim was to evaluate state measures and compare simulated numbers to reported ones. future research should consider this population structure of comorbidities and fine tune the results to reflect such factors within simulation models. npis in jordan seem to be effective in controlling the covid-19 epidemic and reducing the reproduction rate. early 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technology. the authors declare no conflict of interest. key: cord-292173-95t89yee authors: villani, federico alcide; aiuto, riccardo; paglia, luigi; re, dino title: covid-19 and dentistry: prevention in dental practice, a literature review date: 2020-06-26 journal: int j environ res public health doi: 10.3390/ijerph17124609 sha: doc_id: 292173 cord_uid: 95t89yee sars-cov-2 is a member of the family of coronaviruses. the first cases were recorded in wuhan, china, between december 2019 and january 2020. italy is one of the most affected countries in europe. covid-19 is a new challenge in modern dentistry. new guidelines are required in dental clinics to avoid contagion caused by cross-infections. a narrative review was performed using both primary sources, such as scientific articles and secondary ones, such as bibliographic indexes, web pages, and databases. the main search engines were pubmed, scielo, and google scholar. twelve articles were selected to develop the bibliographic review by applying pre-established inclusion and exclusion criteria. precautionary measures should be applied to control covid-19 in clinical practice. several authors have highlighted the importance of telephone triage and/or clinic questionnaires, body temperature measurement, usage of personal protective equipment, surface disinfection with ethanol between 62% and 71%, high-speed instruments equipped with an anti-retraction system, four-handed work, and large-volume cannulas for aspiration. clinically, the use of a rubber dam is essential. ffp2 (or n95) and ffp3 respirators, if compared to surgical masks, provide greater protection for health workers against viral respiratory infections. further accurate studies are needed to confirm this. this article is a narrative review. zoonotic diseases constitute a large group of infections that can be transmitted from animals to humans, regardless of the presence of vectors [1] . approximately 80% of viruses, 50% of bacteria, and 40% of fungi are capable of generating a zoonotic infection [2] . bats are considered important reservoirs and vectors for the exponential spread of zoonotic infectious diseases; they are associated with sars and ebola, the latter of which was responsible for an epidemic with its epicenter in sub-saharan africa in 2014 [3] . sars coronavirus in 2003 and 2019, and h1n1 flu in 2009 have demonstrated how a zoonotic infection can spread rapidly among humans, causing potentially irreversible global repercussions, from an economic, social, and health-related standpoint [2] . compared to previous eras, globalization and the intensification of international movements have greatly facilitated the spread of viruses [1] [2] [3] [4] . coronaviruses are a subfamily of viruses [5] . all viruses contain nucleic acids, either dna or rna, and a protein coat which encases the nucleic acid. some viruses are also enclosed by an envelope of fat and protein molecules [5, 6] . towards the last week of december 2019, cases of abnormal pneumonia with unknown etiology were recorded in wuhan, the capital of the hubei province, in the geographical heart of the people's republic of china [11] . in the second half of january, the chinese competent authorities confirmed 6000 cases of patients infected with sars-cov-2, although 80,000 cases were estimated at that time [21] . however, unlike sars-cov-1, sars-cov-2 has shown a greater tendency for rapid human-to-human transmission, with an r0 varying between 1.4 and 6.5, and an incubation period ranging from 2 to 14 days, with an average of 7 days [10] . on 31 january 2020, 213 deaths had been confirmed globally in 19 different countries [11] . according to the data of 14 march 2020, italy was the most affected european country, followed by spain [22] . on 3 may 2020, the number of people currently positive in italy was 100,179, with 28,884 deaths [23] . the average age of people who died of covid-19 was 78.5 years, while, the average age of diagnosis was 65 [22] . the age group with the highest mortality rate was 80 to 89 years, with a male predominance (67%). the mortality rate in the male population increased by 10% (77%) in the 70-79 age group [22] . forty-eight percent of patients deceased from sars-cov-2 exhibited three or more comorbidities, two comorbidities (26%), one comorbidity (23%) and no comorbidity (1.2%). hypertension, diabetes, and ischemic heart diseases are among the main preexisting pathologies. only 1% of deaths from covid-19 occurred in patients under the age of 50 years. lombardy was the most affected region, accounting for 68% of the national cases, followed by emilia romagna (16.4%) and veneto (4.3%) [24] . these data prompted authors to investigate the existence of a possible link between the exponential transmission of covid-19 in certain italian regions and the pollution of atmospheric particulate matter, the latter acting as a vector of the virus [25] . however, this is a spurious association because there are systematic errors that determine the lack of correlation between these two factors. according to that reported by the new york times [26] , dentistry is one of the most exposed professions to the covid-19 contagion. it is necessary to establish a clinical protocol to be applied in the working environment to avoid new infections and progressive virus spread. in daily clinical practice, the patient's oral fluids, material contamination, and dental unit surfaces can act as sources of contagion both for the dentist and the assistant, and for the patient himself or herself. saliva and blood droplets that are deposited on the surfaces or aerosol inhalation generated by rotating instruments and ultrasound handpieces constitute a risk for those who occupy or will occupy those environments. therefore, the use of disinfectants and personal protective equipment (ppe) remain essential for the proper development of the dental profession [27] . the sudden spread of sars-cov-2 has determined the need to modify both preventive and therapeutic protocols in dental practice. consequently, the need to analyze the available sources in the literature to update clinical practice is crucial. the aim of this narrative review is to investigate preventive measures in dental practice by assessing the operator and patient health protection during the new covid-19 emergency by considering past experiences in terms of prevention, as the virus was only recently discovered. special attention is devoted to personal protection equipment, such as respirators and surgical masks, due to the major exposition of dental workers to the coronavirus. the authors carried out a narrative review and not a systematic review, as the topic is based on a recent event, and there are still several aspects pending to be analyzed. the process of selecting scientifically valid sources took place over five weeks, between 1 april and 4 may 2020. the search engines used were pubmed, scielo, and google scholar. the boolean operators used "and" and "or". the mesh terms for the research were: "dental care", "dentistry", "dental offices", "masks", "coronavirus", "dental equipment", and "disinfectants". non-mesh words were "sars-cov-2" and "ppe" the following terms were used with boolean operators to combine searches: "covid-19" or "sars-cov-2" or "coronavirus" and "dental care" or "dental office" or "dentistry" with no limitation to the year of publication. in addition, a second search was made: "masks" or "disinfectants" or "ppe" or "dental equipment" and "covid-19" or "coronavirus" or "sars-cov-2". included in the study were bibliographic reviews, systematic reviews, meta-analyses, randomized controlled trials, cohort studies, case reports, and studies in english, italian, spanish, and portuguese. the exclusion criteria were as follows: articles not related to the topic, animal studies, full-text not available, and articles in other languages. no time limits were applied during the screening phase of the scientific articles ( figure 1 ). given the heterogeneous results, the selected articles were divided into two main groups according to the treated topic: sars-cov-2 guidelines in dentistry ( table 1 ) and analysis of preventive masks used for protection against sars-cov-2 (table 2) . a third group, on disinfectants, was analyzed. the results obtained demonstrate compliance and homogeneity between the authors. in studies done by rabenau et al. [37] and kampf et al. [38] , ethanol proved to be one of the first-choice disinfectants in percentages ranging from 80 to 95% (used as a hand rub gel) [37] or 62 to 71% (used as a surface disinfectant) [38] . the coronavirus is reduced to below recording levels in a variable lapse of time between 30 and 60 s. in the study by rabenau et al., similar results were observed with disinfectant based on 45% iso-propanol, 30% n-propanol, and 0.2% mecetronium ethyl sulfate. furthermore, the use of surface disinfectants such as mikrobac forte (containing benzalkonium chloride and laurylamine), khorsolin ff (containing benzalkonium chloride, glutaraldehyde, and didecyldimonium chloride), and dismozon (containing magnesium monoperphthalate) can be valid options, even if the desired effect is obtained after 30-60 min [37] . with all tested preparations, sars-cov-2 was inactivated to below the limit of detection, regardless of the type of organic load (0.3% albumin, 10% fetal calf serum, and 0.3% albumin with 0.3% sheep erythrocytes). kampf et al. in carrier tests demonstrated the disinfectant action of ethanol at 62-71% against the sars coronavirus in 60 s, of sodium hypochlorite between 0.1-0.5% in one min, and glutaraldehyde at 2%. in contrast, 0.04% benzalkonium chloride, 0.06% sodium hypochlorite, and 0.55% ortho-phtalaldehyde were less effective [38] . the percentages varied in the suspension tests, where ethanol (between 78 and 95%), 2-propanol (70-100%), the combination of 45% 2-propanol with 30% 1-propanol, glutardialdehyde (0.5-2.5%), formaldehyde (0.7-1%) and povidone iodine readily inactivate the coronavirus; hypochlorite is effective at a concentration greater than 0.21% [38] . fundamentally, the authors agree ( table 1 ) that it is essential to perform an accurate telephone triage, a subsequent triage in dental clinics, and a complementary questionnaire to collect as much information as possible about the patient and his or her family members, specifically regarding symptoms and movements in the previous 14 days [27] [28] [29] [30] [31] . temperature measurement is recommended when the patient enters the dental office; if the body temperature exceeds 37.3 • c, it is suggested the treatment be postponed [30] . in patients with a cured covid-19 infection, the american dental association (ada) guidelines propose to reschedule dental treatment at least 72 h after the resolution of the symptoms, or 7 days after the appearance of initial symptoms, such as fever controlled without antipyretics and spontaneous improvement of breathing [39] . meng et al., in a precautionary way, set the necessary recovery period to 30 days before performing non-deferrable dental care in patients who have been infected [28] . for medical-legal issues, a patient's self-certification is also required with regard to what he/she claims during the telephone and clinical triage phase. the ada and the centers for disease prevention and control (cdc) recommend keeping the waiting room empty, without magazines, and avoiding the overlap of two or more appointments. if this is not possible, the minimum distance between one patient and the other must be 2 m (6 feet) in each direction. in extreme situations, for health protection, it is reasonable to ask patients to wait in their vehicle, if possible, or nearby to the dental clinic, and advise them by telephone call or message when it is their turn [40] . as far as pediatric dentistry is concerned, persons accompanying minor age patients are asked to come to the appointment in the smallest possible number, wear a protective mask, wait in the waiting room, and not attend the patient's treatment to avoid the risk of aerosol inhalation [27] . further accurate studies have been carried out to demonstrate the importance of oral rinses just before dental treatment; costa et al., in a study in 2019, highlighted how the use of chlorhexidine at 0.12% and 0.20% alters the amount of bacteria, viruses, and fungi present in the oral biofilm, reducing the risk of cross-contamination due to aerosol [29] . since covid-19 is sensitive to oxidation, peng et al. proposed rinsing with 1% hydrogen peroxide or, alternatively, with 0.2% povidone-iodine [30] . this must be interpreted with caution: saliva is constantly and cyclically renewed by the salivary glands, making the virus available again. regardless of the type of treatment planned, healthcare professionals, especially dentists, hygienists, and dental assistants, must follow rigid protocols related to dressing and personal protective equipment. hair caps, protective goggles, surgical masks or n95, disposable surgical gowns, special footwears, and protective visors are essential [27] [28] [29] [30] [31] . according to the "en iso 374-5.2016" regulation, for medical protection gloves to be considered functional against microorganisms, such as bacteria and fungi, must pass the penetration test, which analyzes air and water transition through material pores, seams, holes, and other structural imperfections [41] . "iso 16604: 2004 method b" is an additional test that is necessary to certify the specific protection of the gloves against viruses [42] . the ppe should be used as asserted in the instructions in the user manual and must be disposed of as special waste. it is always recommended to check the integrity of the ppe, and if any negative findings, eliminate the ppe immediately [43] . there are several articles in the scientific literature on the effectiveness of surgical masks in comparison to respirators ( table 2 ). the distance and length of time in which particles remain suspended in the air are determined by particle size, settling velocity, relative humidity, and air flow [36] . the european standard classifies filtering facepiece respirators (ffp) into three categories: ffp1, ffp2, and ffp3 with minimum filtration efficiencies of 80%, 94%, and 99%. consequently, ffp2 respirators are approximately equivalent to n95, and therefore recommended for use in the prevention of airborne infectious diseases in the us and other countries [44, 45] . both long et al. [32] and radonovich et al. [34] , in their respective analyses did not find significant differences between the n95 and surgical masks in terms of protection from the influenza virus. similar results were also observed in the study by offeddu et al., which was performed two years before the current covid-19 health emergency. on one hand, there is an equal effectiveness between the two types of masks on the influenza virus. however, compared to nonspecific respiratory tract infections, the n95 masks give slightly better results [33] . macintyre et al. instead obtained diametrically opposing results; they showed, through a randomized controlled clinical study on 3591 subjects, that health workers who used n95 masks continuously during the shift or in situations considered to be at high risk, presented an 85% chance of not contracting a viral infection transmitted via droplets [36] . in addition, the n95 mask group compared to the control group was associated with a significantly lower risk of contracting influenza, as confirmed by the laboratory. the authors suggest updating the classification of infectious transmissions; they consider that focusing only on aerosols and droplets is an oversimplification. in a recent study, ma et al. analyzed the degree of protection of surgical masks, n95, and home masks (four layers of paper and polyester) against the virus; n95 masks showed greater reliability [35] . lee et al., focused on particles between 0.093 and 1.61 µm, and demonstrated that the ffp respirators provided better protection than the surgical masks, suggesting that such surgical masks are not a good substitute for ffp respirators in the case of airborne transmission of bacterial and viral pathogens [44] . the principal limitation of surgical masks is due to the poor face fit and the consequential possibility of aerosol aspiration [43] . in spain, the dentists council (consejo de dentistas) reports a maximum of 4 h of use, and if kept in good condition, ffp2 or n95 masks can be sterilized through various techniques: hydrogen peroxide vapor, dry heat at 70 • c for 30 min, or in humid heat at 121 • c; however, not for more than 2-3 times [45] . the who protocol recommendations suggest the use of ffp3 masks according to the european nomenclature or n100, according to the united states nomenclature [46] . hand hygiene is considered the first step in limiting the spread of the virus; who guidelines impose scrupulous hand-washing before and after any contact with the patient [46] . being previously considered an essential tool for correct operating practice, the rubber dam has become even more so after the viral epidemic of 2020. various authors underline the utility of the rubber dam on containment and protection from oral fluids; it reduces the particles present in the aerosol by 70% [30] and also drastically reduces the risk of cross-infection [27, 28, 30 ]. if it is not possible to position it, peng et al. recommend the use of the carisolv and an excavator for conservative treatments [30] . high-speed rotating instruments, such as the turbine and the contra-angle, must be equipped with an anti-retraction system, which prevents the release of debris and fluids that can accidentally be inhaled by healthcare professionals during clinical procedures [29, 30] . meng et al. suggests minimizing the use of these tools; if this is not possible, the last appointment of the day should be intended for those patients who need dental treatments requiring the use of high-speed rotating instruments [28] . they also recommend not to use intraoral radiographs; therefore, they propose the use of orthopantomography or ct if strictly necessary. the authors agreed on the need for four-handed work to reduce the risk of spreading the virus in the dental care unit, to manipulate the water-air syringe with extreme caution, and to use large-volume aspirators [27, 28, 30] . concerning potentially deferred dental emergencies, luzzi et al. recommend remote telephone or assistance support from the dentist. in the case of pulp pain, therapy with non-steroidal anti-inflammatory drugs, such as ibuprofen, and antibiotics, such as beta-lactams, are recommended, if the patient does not have allergies [27] . alharbi et al. classified therapeutic dental procedures into five groups: emergencies, emergencies manageable through invasive or non-invasive procedures (minimum aerosol), non-emergencies, and elective treatments, depending on the dentist. among the emergencies, the authors highlight maxillofacial fractures that compromise the respiratory tract, uncontrolled post-operative bleeding, and bacterial oral soft tissues infections with intra-or extra-oral swelling that negatively affect the patient's respiratory capacity [47] . orthodontists are suggested to stop activating the rapid palate expander; parents are instructed to reposition the ni-ti arch if it should go off-axis and cause a contact ulcer on the oral mucosa. any non-urgent treatment must be postponed; if this is not possible, the dentist must follow strict protocols to avoid contagions. peng et al., advise the elimination of waste using special yellow double-layer bags for special waste and mark them to facilitate their elimination [30] . various disinfectants available on the market, can effectively inactivate the sars-cov-2. the italian dentists association recommends covering all surfaces, where possible, with polyethylene wrap [48] . the results obtained demonstrate compliance and homogeneity between the authors. rabenau et al. [37] and kampf et al. [38] illustrated that various groups of disinfectants, such as propanol, sodium hypochlorite, and ethanol, in percentages ranging from 80 to 95% (as a hand rub) [37] or 62 to 71% (as a surface disinfectant) [38] , can reduce sars-cov-2 load to below recording levels in a variable lapse of time. pertinent papers on this topic are limited. the who guidelines recommend the use of 5% sodium hypochlorite, with a 1:100 dilution, to be applied on surfaces for an average action time of 10 min; constant ventilation of the dental surgery room is also recommended [46] . studies have shown that other biocidal agents such as 0.05-0.2% benzalkonium chloride or 0.02% chlorhexidine digluconate probably have lower efficiency [49] . the spanish dentists council suggests the use of 1% sodium hypochlorite for the disinfection of the impressions. the action time of the disinfectant varies depending on the material used: 10 min for alginate, and 15-20 min for elastomers [45] . as reported by kyun-ki et al., it is necessary to establish preventive policies in clinical and hospital settings to avoid the high risk of nosocomial infections, as with mers [50] . sabino-silva et al., starting with the assumption that covid-19 may be present in saliva through major salivary gland infection or through the crevicular fluid, suggest more accurate studies in order to evaluate the possibility of early and non-invasive virus diagnosis using saliva samples [51] . the possibility of the role of salivary gland cells in the initial progress of the infection and as a source of the virus should be considered and validated [8] . dentistry remains one of the most exposed professions to sars-cov-2; each individual clinical situation must be adequately controlled and pondered by the healthcare professional; defaults in protocols cannot be tolerated. however, there are indications in the literature on how to deal with emergencies. currently, the swab represents the only system of diagnosis, and it requires a laboratory procedure that cannot be implemented in the dental clinic. however, rapid immunoglobulin tests, which are not considered for diagnosis, can report whether a healthcare professional has had the disease and been immunized. the development of new diagnostic tools will provide a reasonable hope for greater protection from the virus in the future. two types of rapid tests are currently being developed for covid-19: the first one directly detects sars-cov-2 antigens by nasopharyngeal secretions, while the second indirectly records the antibodies present in the serum as part of the autoimmune response against the virus [52] . ahmed et al. conducted a cross-sectional study on 699 dental practitioners from 30 different countries using an online survey between the second and the third weeks of march 2020; 87% of participants were afraid of becoming infected with covid-19 from either a patient or a co-worker. a considerable number of dentists (66%) wanted to close their dental cabinets until the number of covid-19 cases declined [53] . the fear that dentists have regarding becoming infected by covid-19 could be less if dentists and dental healthcare workers conscientiously follow the relevant recommendations [53] . looking ahead, it is necessary to increase research efforts in aerosol control during dental treatments, including improving engineering control in dental office design. the covid-19 pandemic has exposed important gaps in the collective response of global healthcare systems to a public health emergency [54] . dentistry as an integral part of the health care system should be prepared to play an active role in the fight against future emerging life-threatening diseases. preventive measures against covid-19 in dental practice include telephone and clinical triage supported by a questionnaire on recent symptoms and movements, body temperature measurement, oral rinses with 1% hydrogen peroxide, and the use of specific ppes. pragmatic and technical recommendations for correct clinical practice are the implementation of anti-retraction dental handpieces, four-handed work, the use of a rubber dam, and large-volume cannulas for aspiration. ffp2 (or n95) and ffp3 respirators, if compared to surgical masks, provide greater protection to health workers against viral respiratory infections. ethanol between 62% and 71% and sodium hypochlorite between 0.1% and 0.5% are considered to be the best among the surface disinfectants. this narrative review has some limitations. as there is a current emergency, in the literature there is a limited and heterogenous number of primary sources directly related to the repercussion of sars-cov-2 on the dental discipline. further studies are needed in the future. author contributions: authors equally contributed to conceptualization, methodology, validation, investigation, writing-original draft preparation, writing-review and editing, supervision. all authors have read and agreed to the published 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received no external funding. the authors declare no conflict of interest. key: cord-292409-hz5qj1fw authors: viterbo, lilian monteiro ferrari; costa, andré santana; vidal, diogo guedes; dinis, maria alzira pimenta title: workers’ healthcare assistance model (wham): development, validation, and assessment of sustainable return on investment (s-roi) date: 2020-04-30 journal: int j environ res public health doi: 10.3390/ijerph17093143 sha: doc_id: 292409 cord_uid: hz5qj1fw the present study aimed to present and validate the worker´s healthcare assistance model (wham), which includes an interdisciplinary approach to health risk management in search of integral and integrated health, considering economic sustainability. through the integration of distinct methodological strategies, wham was developed in the period from 2011 to 2018, in a workers’ occupational health centre in the oil industry in bahia, brazil. the study included a sample of 965 workers, 91.7% of which were men, with a mean age of 44.9 years (age ranged from 23 to 73 years). the kendall rank correlation coefficient and hierarchical multiple regression analysis were used for the validation of wham. the assessment of sustainable return on investment (s-roi) was made using the wellcast roi™ decision support tool, covering workers with heart disease and diabetes. wham can be considered an innovative healthcare model, as there is no available comparative model. wham is considered robust, with 86% health risk explanatory capacity and with an 85.5% s-roi. it can be concluded that wham is a model capable of enhancing the level of workers’ health in companies, reducing costs for employers and improving the quality of life within the organization. more than ever, life, as we know, will never be the same. the world is currently experiencing the coronavirus pandemic (covid-19) [1] , an unforeseeable health development that is affecting the entire global population, and consequently healthcare assistance models across the globe. there is now an urgent need to look at human health through the "one health" lens [2] , to design and implement programs, policies, legislation, and research in a cooperative manner among all sectors of society to achieve better public health outcomes. in addition to the recognition of the success of the current healthcare models in the relief of pain and the treatment of multiple pathologies, several criticisms are gaining support, pointing out the limitations relating to the attention to patient health. these issues include approaches that take an undifferentiated view of the individual, which is focused exclusively on the part of the body that is sick; the focus on the curative actions of diseases, injuries, and damages; the advancement of medicalization; and the generalization of hospital care using technology. in the past, if a medical doctor was seen as a figure possessing the knowledge necessary to cure the patient, nowadays that figure is seen as one part of a team, with the patient being the final decision-maker in their health outcomes. the world health organization has chosen to strengthen people-centred care and integrated health services as priority strategies to transform health services to meet the health challenges of the 21st century [3] . this favours the emergence of integrated care models, which are seen as possible solutions to the growing demand for improvement in the patient experience, especially in patients with chronic conditions. considering economic sustainability in the search for integral and integrated health, this study aims to present and validate a model of workers' healthcare, the workers´healthcare assistance model (wham), which embraces an interdisciplinary approach towards health risk management. in light of the literature review, the following three research hypotheses were formulated: hypotheses (h1). wham promotes integral and integrated care; hypotheses (h2). wham is robust and has greater explanatory capacity for workers' health risks; hypotheses (h3). wham is economically sustainable and provides a significant return on investment. a review of the literature in the field of occupational health highlights discussions relating to "assistance models", a term that varies based on the conceptualization, which can include "assistance modalities or technological models" [4, 5] ; "ways to promote health" [6] ; "assistance models" [4, 6, 7] ; "technical, techno-assistance, and technical assistance models" [4, 8] ; "modes of intervention" [7] ; "attention models" [9] [10] [11] ; and "care models". the result of this diversity of terms is the already identified difficulty in conceptualizing assistance models. healthcare assistance models are understood as technological combinations with different purposes, which are used to solve problems and meet needs within a given context and population and in a given territory (individuals, groups, or communities), to organize health services or to intervene in situations, depending on the epidemiological profile and investigation of health problems and risks [12] . these logical systems organize the functioning of care networks, articulating the relationships between network components and health interventions. in turn, these are defined according to the prevailing view of health, demographic and epidemiological situations, and social determinants of health at a given time and in a given society and place [13] . according to campos [5, 6] , the conceptualization of an assistance model, technological model, or assistance modality must go beyond mere organizational and technical design, showing a new way of producing assistance actions anchored in the organization of the state. according to silva [14] , biomedicine has become the hegemonic model in the provision of health services in brazil and other countries around the world, influenced by accumulated knowledge and the paradigm of science. in this process, the daily requirements in the health sector stand out, such as the relationships between people; the involvement and co-responsibility of managers, health professionals, and patients in healthcare; as well as the bond, reception, and humanization of healthcare assistance practices [15] . from a technological point of view, there is a predominance of the use of the so-called "hard technologies" (equipment), to the detriment of light technologies (professional-patient relationships) [8, 16] . thus, diagnostic tests are a priority, but patients are not necessarily considered in terms of their suffering. this approach has been the target of criticism at the international level, starting from the 1970s and gaining greater importance in the second half of the 1980s [11, 17] . in terms of the biomedical model, there is a certain neglect of the importance of the determinants of the health-disease process; that is, the focus on the disease and not on the elements that contribute to health promotion, underestimating that cultural, ethical, and social aspects condition lifestyles and that these are also determinants in the same process [13, 14, 18] . merhy [8] contributes to the debate about the need to change the hegemonic assistance model, arguing that it is necessary to impact the core of care. in this sense, it is necessary to invest in relational-type light technologies, focusing on the needs of users and reversing the investment in hard or light-hard technologies, which can be translated into standards, equipment, and materials. thus, light technologies are used and combined with people and resources to achieve certain objectives, which are gathered in an organized manner and consolidated as essential elements of health services [19] . regardless of the scope, health services are always complex. the processes are standardized by regulatory bodies, service providers, and class representatives, among others. they have highly specialized and qualified workers who, belonging to different class councils, have interests that do not always converge [20] . team composition characteristics in health services must be highlighted, recognizing these team members as the main actors responsible for the implementation of technologies aligned to a healthcare assistance model. faria [21] draws attention to the fact that actions performed in a given place to deal with a certain problem may not apply to other situations, considering the historical-political context that influences a situation. therefore, the use of healthcare assistance models invariably requires the selection of certain constructs that support them. thus, they can be used in an alternative or adapted way, as long as they enable the achievement of similar results. to incorporate new health needs, healthcare assistance models can be considered to have influenced the organization of care models, being more focused on specific populations, such as the chronically ill. a comprehensive care model defines how health services are offered, providing the best care and service practices for a person or population group as they evolve through a condition, injury, or event, aiming for people to receive the right care, at the right time, by the right team, and in the right place [22] . the field of occupational health is a fertile environment for the development of interdisciplinary practices [23] [24] [25] [26] , as it encompasses knowledge from different disciplines, requiring constant and complex interactions between professionals in the fields of epidemiology, the environment, engineering, and healthcare, among others. the framing of occupational health in a biomedical healthcare assistance model favours the development of disjointed and ineffective interventions regarding the needs presented by workers, while the biopsychosocial model is often used in their work environments. according to annadale [27] , the biomedical healthcare assistance model only focuses on the physical processes, i.e., the pathology, biochemistry, and physiology of a disease, neglecting the roles of social factors or individual subjectivity. in this context, it is necessary to discuss a model of assistance in occupational health that is capable of reviewing the central characteristics of the biomedical healthcare assistance model, including: (i) organization of practices focused on the identification of signs and symptoms and the treatment of diseases, with health promotion not being a priority; (ii) assistance is organized based on individual spontaneous demand, with an emphasis on specialization and the use of hard technologies; (iii) the work is developed in a fragmented, hierarchical manner and with inequality across different professional categories; (iv) difficulty in implementing the integrated care due to the lack of understanding of the individual as a multidimensional human being, as well as the lack of communication and integration between the services involved; (v) health planning is seldom used as a management tool; (vi) the training of health professionals is specialized, based on the hegemony of scientific knowledge; and (vii) themes such as interdisciplinary, people-centered care, attachment, and welcoming are not prioritized. another aspect of great relevance in the current global context of scarcity of resources, particularly in the current context of covid-19, is the prioritization of investments ineffective, integral, and integrated interventions, which can be achieved through a model that contemplates the management of occupational health risks, considering the social health determinants [28, 29] , global disease burden [30] , environmental aspects [31, 32] , sustainable development goals [33, 34] and in particular, working conditions that affect an individual's health [35] . in the current context, the effectiveness of a healthcare assistance model must include economic sustainability in addition to health gains, to know how much the company has earned due to investments made in a certain area, with the sustainable return on investment (s-roi) being a very important metric for this assessment. measuring the s-roi [36] [37] [38] of preventive programs is not an easy task, due to the large number of variables that influence this calculation. the main variable is patient health, which can improve or worsen unpredictably. analyzing the s-roi in preventive programs identifies the financial impact a program generates concerning the amount invested, which must be considered in the long term. disease prevention actions bring future returns, mainly to the reduction of healthcare assistance costs. if the individual participates in preventive programs, the probability of developing diseases or discovering them in advanced stages decreases. over the past 20 years, several studies [39] [40] [41] [42] [43] [44] [45] [46] [47] have addressed this issue and there is growing evidence that workplace programs can generate acceptable financial returns for employers investing in them. a study of johnson and johnson employees [39] showed a difference in the increase in the average annual costs of internment between workers involved and not involved in lifestyle improvement programs and changes in the workplace, representing $43 and $76, respectively, thus representing a considerable increase in percentage terms. the study by munir et al. [45] aimed to conduct a cost-benefit analysis of the stand more at work (smart) workplace intervention, designed to reduce sitting time. a net saving of $2.18813 (95% ci; $−4.3804; $4.8143) per employee was found as a result of productivity increase. peik and others [46] applied the research and development (rand) europe model, a program designed to expand access to up to 40 evidence-based clinical preventive services for all employees and eligible family members, as part of a unique global health initiative at the country level to estimate the return on investment over a five-year timeframe. the study concluded that this program generates a global return of $4.28-$11.88 (after investment cost). gao and co-workers [47] assessed the economic performance of a workplace-delivered intervention to reduce sitting time among desk-based workers. the incremental cost-efficacy ratios ranged from $6.28/minute reduction in workplace sitting time to $8.45/minute reduction in overall sitting time. the intervention was cost-effective over the lifetime of the cohort when scaled up to the national workforce, and provides important evidence for policy-makers and workplaces regarding the allocation of resources to reduce workplace sitting. the present study was carried out from 2011 to 2018, in a workers' occupational healthcare centre in the oil industry in bahia, brazil. it involved the integration of distinct methodological strategies for the development of wham, such as the development of a conceptual model, action research, statistical validation, and s-roi analysis. the study involved two experts who had been working in the field of occupational health for fifteen years, with an emphasis on ergonomics and health management, an interdisciplinary approach, and a database composed of a population group and sample of workers, numbering 1275 and 965 individuals, respectively (table 1) . data analyses were carried out using spss version 25 for windows (ibm corporation, new york, ny, usa). diagnostics and intervention prevalence were presented as absolute and relative frequencies. correlations among modifiable health risk factors and health outcomes were performed through the kendall rank correlation coefficient. correlations among health indicators and the interdisciplinary risk coefficients were also performed using the kendall rank correlation coefficient. hierarchical multiple regression analysis was used to calculate the independent contributions of occupational medicine interdisciplinary, dentistry interdisciplinary, physical education interdisciplinary, nursing interdisciplinary, and nutrition interdisciplinary risk coefficients, to provide an estimate of incremental variance accounting for the workers' health risk index (whri) [48] . this index had already been published, resulting from the classification of workers into three risk ranges-"low", "moderate", and "high". the durbin-watson test was applied to detect the presence of autocorrelation at lag 1 in the residuals (prediction errors), through which the hierarchical multiple regression analysis multicollinearity was verified. to lead the application of the wham, the "guidelines for implementing the workers' healthcare assistance model (wham)" were developed, which are presented in the supplementary materials (word s1). the "workers' healthcare assistance model" is understood as the organization of the conditions necessary to carry out a person-centred care process, about the method, staff, and instruments. the term "process" used in the context of healthcare makes it possible to identify, understand, describe, explain, and predict the needs of a person, family, or community at a given moment in the health and disease process, demanding professional care by health specialists. therefore, wham presupposes a set of actions, through certain means of action, regulated by a course of thinking; that is, through a conception of workers' health, wham's origin and its potential to transform itself or to be transformed. to compose the wham, the interdisciplinary workers' health approach instrument (iwhai) [49] , a tool that had already been published, was used as a data collection instrument, aiming to collect data from 43 health indicators. to map the diagnoses, the health taxonomies were used, while the whri [48] was used to prioritize the health risks of the workers. figure 1 shows the main stages of integrating the wham. int. j. environ. res. public health 2019, 16, x 5of18 through the kendall rank correlation coefficient. correlations among health indicators and the interdisciplinary risk coefficients were also performed using the kendall rank correlation coefficient. hierarchical multiple regression analysis was used to calculate the independent contributions of occupational medicine interdisciplinary, dentistry interdisciplinary, physical education interdisciplinary, nursing interdisciplinary, and nutrition interdisciplinary risk coefficients, to provide an estimate of incremental variance accounting for the workers' health risk index (whri) [48] . this index had already been published, resulting from the classification of workers into three risk ranges-"low", "moderate", and "high". the durbin-watson test was applied to detect the presence of autocorrelation at lag 1 in the residuals (prediction errors), through which the hierarchical multiple regression analysis multicollinearity was verified. to lead the application of the wham, the "guidelines for implementing the workers' healthcare assistance model (wham)" were developed, which are presented in the supplementary materials (word s1). the "workers' healthcare assistance model" is understood as the organization of the conditions necessary to carry out a person-centred care process, about the method, staff, and instruments. the term "process" used in the context of healthcare makes it possible to identify, understand, describe, explain, and predict the needs of a person, family, or community at a given moment in the health and disease process, demanding professional care by health specialists. therefore, wham presupposes a set of actions, through certain means of action, regulated by a course of thinking; that is, through a conception of workers' health, wham's origin and its potential to transform itself or to be transformed. to compose the wham, the interdisciplinary workers' health approach instrument (iwhai) [49] , a tool that had already been published, was used as a data collection instrument, aiming to collect data from 43 health indicators. to map the diagnoses, the health taxonomies were used, while the whri [48] was used to prioritize the health risks of the workers. figure 1 shows the main stages of integrating the wham. the data collection stage aimed to identify health problems, as well as the efficient and targeted recording of the workers' needs in its broadest sense. for this, the iwhai [49] was chosen. it allows structured data collection, covering the disciplines of medicine, dentistry, nursing, nutrition, and physical education, as well as environmental, occupational, behavioural, personal, and metabolic the data collection stage aimed to identify health problems, as well as the efficient and targeted recording of the workers' needs in its broadest sense. for this, the iwhai [49] was chosen. it allows structured data collection, covering the disciplines of medicine, dentistry, nursing, nutrition, and physical education, as well as environmental, occupational, behavioural, personal, and metabolic factors. it is composed of in 5 dimensions with 43 indicators, totalling 215 sub-indexes with closed response coding, where zero represents non-existent or inadequate control of risk and four represents optimal control of risk, arranged in the following scale: 0 = non-existent or inadequate; 1 = tolerable; 2 = reasonable; 3 = good; 4 = excellent. for the diagnostics mapping stage, it was necessary to define taxonomies that encompass the complexity of the workers' health field, especially those related to the health, environment, and work triad. the following codes were used for medical, dental, nursing, nutritional, and physical education factors: (i) international classification of diseases (icd 11) [50] ; international classification of nursing practice (cipe ® ) [51, 52] ; international dietetics and nutritional terminology (idnt) [53] ; and the international classification of functioning, disability, and health (icf) [54] . for the intervention design stage, it was necessary to define classifications that encompass proposals for interventions, which include ecological and occupational care. for each mapped diagnosis, an intervention must be associated. during the attendance of the worker, priority is given to diagnoses for health indicators that are classified as control or health conditions: 0 = non-existent or inadequate; 1 = poor; 2 = reasonable. this consists of a discussion amongst the interdisciplinary health team to validate the perceptions [55] raised by professionals in each area during the attendance of workers, sharing the diagnoses and interventions proposed by each discipline. the iwhai [49] was used as a guiding instrument for data collection. for support of the team decisions regarding the hierarchy of priority interventions, the whri [48] was used, allowing multidisciplinary (by dimension) and interdisciplinary (association of all dimensions) risk classifications. the classifications comprise three ranges: "low", "moderate", and "high". since 64% of the sample age is above 40 years and the gender proportion of male to female is very high, the effects of these factors were controlled in this step by the whri [48] assessment. as the workers' ages increase, the risk indicator also increases; the same happens for male and female workers for some sex-related diseases, such as the higher susceptibility by men to develop cardiovascular diseases and alcohol abuse. for this reason, when whri [48] is applied, each worker will have two risk indicators influencing the indicators of health behaviours and outcomes: a risk indicator related to the workers' age, whereby the older the worker, the higher their risk indicator; and another risk related to their sex, whereby female or male gender will have different impacts on health behaviours and outcomes. the final whri [48] score is mediated by the workers' age and sex. the whri [48] dimension that has the greatest weight in the interdisciplinary context is designated as the worker case manager (wcm) and will assume technical responsibility concerning care management. the care plan (cp) is an interdisciplinary document, composed of relevant iwhai indicators with their respective diagnoses and associated interventions, in addition to the definitions of the implementation and deadline. for the implementation of the cp, the wcm must bring together the interdisciplinary intervention team (iit), ratify the cp, and proceed with the treatment of the proposed actions through interdisciplinary assistance, group work, and collective and environmental interventions. after validation of the cp by the iit, the workers are involved in discussing the cp and implementing it at the individual level. the assessment stage deals with the follow-up and monitoring of the workers to the effectiveness of the implemented health interventions. for this, it is necessary to systematically reassess the whri [48] . the attendance took place in a single period (shift) by each member of the interdisciplinary team, with an average time of 40 min for each consultation and a total time of 3.5 h for each worker in the health service. to validate the wham, the data collected in 2018 were used in a representative sample of the population of 965 workers, where attendance by the interdisciplinary team occurred at the same time. through statistical tests, the intention was to identify the prevalent diagnoses and interventions, how the modifiable factors are related to health outcomes in this sample, and the impact each dimension has on the whri [48] , i.e., if the joint use of these dimensions contributes to greater robustness and explanatory capacity of the wham. to assess the cost-benefit (cb) relationship of implementing wham, interventions directed at workers with coronary heart disease (chd) and diabetes in the period ranging from 2011 to 2018 were analyzed. the effectiveness of the intervention was based on the results of epidemiological studies over this period. brazilian national data were used to estimate the average annual benefits of preventing direct medical costs for diseases. the analytical tool wellcast roi™ [56] , developed to justify the approval of disease prevention and management programs, was used to calculate the s-roi. for this, the following steps were taken: (i) determine the incidence of the pre-program disease; (ii) determine all costs associated with the disease, either medical costs (for chd patients, the framingham model [57] was used to calculate incidence pre and post-program for a period of 10 years, assuming changes in low-density lipoprotein (ldl) cholesterol, and systolic and diastolic pressure risk factors; for patients with diabetes mellitus, the reduction in the progression of diabetes comorbidities over 10 years was calculated, based on the reduction of glycemia, considering the retinopathy, kidney disease, neuropathy, and microangiopathy comorbidities) or economic costs (monthly salary data, loss of daily productivity, medical inflation rate, among other rates estimated by wellcast roi™); (iii) define the program and its cost; (iv) determine the effectiveness of the program in reducing costs; (v) subtract post-program costs from pre-program costs to determine reductions; and (vi) apply the concepts of net present value (npv), internal rate of return (irr), and cb to determine the s-roi. in all stages of the study, the recommendations and guidelines of resolution 466/2012 [58] of the brazilian ministry of health on ethical aspects regulating research with human beings, approved by the research ethics committee of the bahia school of medicine and public health and certificate of presentation for ethical consideration (caae) 84318218.2.0000.5544, were followed. all subjects gave their informed consent for inclusion before participating in the study. the prevalent diagnoses and their respective interventions by dimension are presented in detail in table 2 . in the physical education dimension, the most prevalent diagnosis is "regular aerobic capacity" (76.3 %), with the most prevalent intervention being "encourage thinking about starting a physical activity program, warning about the harm of physical inactivity" (84.8 %). in the field of nursing, the "impaired ability to perform leisure activities" (100.0 %) stands out as the most prevalent diagnosis, followed by the need to "promote ergonomic comfort" (99.0 %) as the most necessary intervention. in the field of medicine, "primary essential hypertension" emerges as the diagnosis with the highest prevalence among workers (87.2 %), preceded by "encourage health-seeking behaviour" (95.5 %) as the intervention with the greatest application within this sample. at the nutritional level, "excessive alcohol intake" is the most prevalent (99.0 %), with the intervention with the greatest application focusing on the need for "adequate macronutrients" (87.6 %). finally, in the field of dentistry, the most prevalent diagnosis is identified as "other somatoform disorders related to stressful events-bruxism" (97.1 %), with the predominant intervention being "guide to restorative treatment with external dentist" (72.9 %). table 3 shows the statistically significant correlations between modifiable health behaviours and health outcomes. moderate correlations in table 3 (τb ≥ 0.30) are identified as follows: between diabetes mellitus and altered blood glucose (τb = 0.65), energy balance intake (τb = 0.48), and the level of food knowledge (τb = 0.46); between arterial hypertension and the contemplation stage for physical activity (τb = 0.31); between the musculoskeletal pathology and the feeling of pain (τb = 0.40); between psychiatric pathology and energy balance intake (τb = 0.36); between triglycerides and energy balance intake (τb = 0.32); between caries and oral hygiene quality (τb = 0.30); between periodontal disease and periodontal condition (τb = 0.76), oral hygiene quality (τb = 0.58), level of food knowledge (τb = 0.31), altered blood glucose (τb = 0.45), energy balance intake (τb = 0.44), and simple carbohydrate intake (τb = 0.33). the results are shown in table 4 show which indicators are most correlated with each coefficient of each dimension of interdisciplinary risk. the values presented in table 4 make it clear which indicators are most correlated with multidisciplinary risk; the worse an indicator is, the more the risk increases. thus, in the field of physical education, it appears that the indicator of the contemplation stage for physical activity is the one that is most strongly correlated (τb = 0.59). in nursing, the physical aspects of ergonomic risks have the most significant correlation (τb = 0.44). in the field of medicine, diabetes mellitus is the most disturbing indicator (τb = 0.60). in nutrition, alcohol consumption presents the strongest correlation (τb = 0.45). finally, the highest correlation of all is for oral lesion on soft or hard tissue, which is the most significant indicator in the field of dentistry (τb = 0.82). hierarchical regression analysis was applied to understand whether the variables or dimensions under analysis explain a statistically significant amount of the variance of the dependent variable to be tested-in this case, the whri [48] ( table 5) . a comparison of stages is made by gradually adding each independent variable in each stage, to understand if the combination of the dimensions explains more than considering them separately. table 5 . hierarchical multiple regression analysis scheme. step 1 step 2 step 3 step 4 step 5 after analyzing the robustness of wham, its economic sustainability was assessed using the wellcast roi™ tool. for the analyzed time period and based on the npv of usd 23,363.29/per worker, the irr of 85.5%, and the cb of 1.85:1, the s-roi was determined, suggesting that wham is economically sustainable. given its complexity, the field of healthcare requires the mobilization of specialists from different areas, with the aim of promoting comprehensive and integrated care for workers. based on an approach aimed at changing behaviors and adopting healthier lifestyles, going beyond the mere medicalization or treatment of diseases, the interdisciplinary care on which the wham model is based resulted in the data presented in table 2 . in view of the most prevalent diagnoses identified for each of the integrated dimensions, an intervention was generated that promotes worker autonomy and the maintenance of healthy lifestyles and behaviors, such as physical activity, healthy eating, non-consumption of alcohol and tobacco, good oral hygiene, balanced social and environmental relations, and decent work habits [55] . at this level, hypertension or diabetes mellitus diagnosis is highlighted, suggesting healthy behaviors or healthier eating habits interventions. as eng and collaborators [59] state, the workplace is a key space for guidance around healthy behaviors and the reduction of non-communicable diseases (ncds), such as diabetes mellitus and arterial hypertension. viterbo and co-authors [23] report that long-term interdisciplinary practice has had very positive and significant effects on reducing ncds. hochart and lang [60] also mention in their study that the implementation of a comprehensive care program in the workplace with the aim of modifying health risk behaviors resulted in a decrease in workers in the high and medium risk ranges and in the maintenance of health for those that were in the low risk range. the same is true for the issue of oral health, a problem that is related to other serious diseases [61, 62] , and which is solved through the implementation of regular programs for the adoption of oral hygiene behavior among workers, as reported by viterbo and collaborators [63] . supporting these results, and in order to reinforce the importance of an integral look at workers' health, table 3 presents the results between the behaviors (modifiable factors) and the results for workers' health. an overview of these results makes the connections between behaviors and health outcomes even more evident, as well as between the results themselves. in this case, an individual look at a worker would not allow one to understand them as a whole, contributing to fragmentation. certain associations exemplify this idea, namely between the level of food knowledge and the type of food, identified by the energy balance intake, altered blood glucose, and diabetes mellitus. a similar relationship was identified in a review by sami and co-authors [64] , in which guidance towards healthier eating practices reduced the level of diabetes and prevented associated complications. the study by holynska and colleagues [65] showed that the level of food knowledge is effectively related to nutrient intake, as this study also demonstrated. in line with this, breen et al. [66] argued that the level of food knowledge enhances the choice of food, thus optimizing the quality of life of people with diabetes. table 4 shows the results of the indicators that are most correlated with the risk of each analyzed dimension, making it possible to identify those that contribute most to the increased risk in that dimension. the strongest correlation belongs to the field of dentistry, more specifically for oral lesions increasing the health risk of these workers. according to warnakulasuriya et al. [67] , conducting screening programs using valid visual inspection method to detect potentially malignant oral disorders within a workplace is not only feasible, but also effective. in terms of physical activity, the indicator that has the strongest correlation is that of the contemplation stage for physical activity; that is, the predisposition to start a physical activity. in the review by jirathananuwat and pongpirul [68] , the 48 studies analyzed demonstrated that the workplace can play an important role in promoting regular physical activity among workers. ergonomic risks in the workplace are, in this context, assumed to be the most correlated with risk in the field of nursing. this has been documented in several studies, namely by skovlund et al. [69] and welch et al. [70] . since workers spend long hours of their day at the workplace, an additional concern regarding workplace ergonomics must be considered, as correct adaptation will result not only in promoting the well-being of workers, but also in reducing medical costs for employers, as reported by munir et al. [45] , gao et al. [47] , and welch et al. [70] . in terms of pathologies, diabetes mellitus is the indicator that most contributes to risk in the dimension of medicine. in the reviews by hafez [71] and gan [72] , the workplace is an important space for effective reduction of diabetes mellitus. some of the results in this study will have a direct implication in the workplace context, thus a more detailed specific analysis is necessary. the results regarding the wham robustness (table 5 ) make it clear that the combination of technical and scientific knowledge in the work context results in a better understanding of the workers' global health. this result makes it possible to effectively verify that the interdisciplinary approach translates into gains in health, and that it must be adopted as a matrix in all work contexts, particularly those referring to a higher exposure risk and greater number of employees, as already identified in the studies by viterbo et al. [23] , clark et al. [73] , and costa et al. [74] . considering that health promotion and prevention actions can influence the health habits and behaviors of workers, they can also reduce health costs. the literature review [38, [75] [76] [77] suggests that programs based on behavior change theory and using personalized communication and individualized counselling for high-risk individuals are likely to produce a positive return on the amount invested in these programs. the assessment of s-roi in the specific model under investigation (wham) corroborates other studies carried out in the workplace [41, 44, 45, 47] , showing positive financial results and reinforcing the advantages of applying wham, which in addition to directing investment in health strategies that are proven to be a priority, enables the optimization of financial resources, resulting in an s-roi of 85.5% for interdisciplinary, integral, and integrated interventions for the community of workers with a high risk level. the search for a healthcare model for workers that is oriented towards integrated care, expanded health needs, economic sustainability, and which overcomes the problems arising from the hegemony of the biomedicine paradigm, such as the excessive use of technologies and focus on curative actions of diseases, is one of the great challenges of the brazilian health system today. this scenario is strongly present in brazilian scientific production and is reflected in national and international policies through legislation and public initiative. the results obtained with the practical application of wham in the oil industry in bahia, brazil, demonstrated the potential of the model, where the articulated and hierarchical management of the various indicators of workers' health makes it possible to direct practices aimed at the cause and not at the effect or symptom. at the individual level, the model presented an interdisciplinary diagnosis of the health conditions of each worker, correlating the modifiable health factors and their respective impacts. the presentation of information to individuals promoted autonomy and empowered workers to change behaviors that negatively interfere with health conditions. at the collective level, the application of the model demonstrated the correlation between health indicators and interdisciplinary risk in the studied context, encouraging the creation of strategies aimed at the most critical conditions, as well as the design of preventive interventions. the robustness of the model highlights this same potential, in addition to the related optimization of financial resources of 85.5% for interdisciplinary interventions. the absence of a similar model in occupational health is a limitation of this study since comparative analyses in the context of this work are not possible. the application of wham in different healthcare contexts is suggested in future studies, as well as carrying out analyses of the model's effectiveness by comparing the population's epidemiological results and studying the s-roi. the different theoretical contributions to the theme of this study, as well as the results found, lead to the understanding that wham can be considered as a model capable of encompassing the complexity of the field of occupational health, considering the interdisciplinary approach, risk management, and comprehensive and integrated care, in addition to accounting for economic sustainability for companies investing in healthcare. the proximal origin of sars-cov-2 the one health concept-the health of humans is intimately linked with the health of animals and a sustainable environmen health services delivery programme division of health systems and public health duas faces da mesma moeda: microrregulação e modelos assistenciais na saúde suplementar. in [national agency for supplementary health. two faces of the same coin: microregulation and care models in supplementary health modelos assistenciais e unidades básicas de saúde: elementos para debate [care models and 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world health organization health behaviors as a mediator of the association between interpersonal relationships and physical health in a workplace context the framingham heart study and the epidemiology of cardiovascular disease: a historical perspective approves regulatory norms of research involving human beings; national health council resolution no 466 of december 12 impact of a workplace health promotion program on employees' blood pressure in a public university impact of a comprehensive worksite wellness program on health risk, utilization, and health care costs periodontitis and diabetes: a two-way relationship the association between oral hygiene and periodontitis: a systematic review and meta-analysis. int effectiveness of an oral health program among brazilian oil workers. in occupational and environmental safety and health ii effect of diet counseling on type 2 diabetes mellitus the level of nutrition knowledge versus dietary habits of diabetes patients treated with insulin diabetes-related nutrition knowledge and dietary intake among adults with type 2 diabetes is workplace screening for potentially malignant oral disorders feasible in india? promoting physical activity in the workplace: a systematic meta-review association between physical work demands and work ability in workers with musculoskeletal pain: cross-sectional study process evaluation of a workplace-based health promotion and exercise cluster-randomised trial to increase productivity and reduce neck pain in office workers: a re-aim approach workplace interventions to prevent type 2 diabetes mellitus: a narrative review shift work and diabetes mellitus: a meta-analysis of observational studies developing and evaluating an interdisciplinary clinical team training program: lessons taught and lessons learned communication of environmental risks to potentially exposed workers: an experience in the oil industry, bahia, brazil. in occupational and environmental safety and health ii financial impact of health promotion programs: a comprehensive review of the literature meta-evaluation of worksite health promotion economic return studies: 2005 update a review and analysis of the clinical and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite: update vi 2000-2004 key: cord-289378-ghmqd3yv authors: wang, peng-wei; ko, nai-ying; chang, yu-ping; wu, chia-fen; lu, wei-hsin; yen, cheng-fang title: subjective deterioration of physical and psychological health during the covid-19 pandemic in taiwan: their association with the adoption of protective behaviors and mental health problems date: 2020-09-18 journal: int j environ res public health doi: 10.3390/ijerph17186827 sha: doc_id: 289378 cord_uid: ghmqd3yv this study aimed to determine the proportion of individuals who reported the deterioration of physical and psychological health during the coronavirus disease 2019 (covid-19) pandemic in taiwan. moreover, the related factors of deterioration of physical and psychological health and the association between deterioration of health and adoption of protective behavior against covid-19 and mental health problems were also examined. we recruited participants via a facebook advertisement. we determined the subjective physical and psychological health states, cognitive and affective construct of health belief, perceived social support, mental health problems, adoption of protective behavior and demographic characteristics among 1954 respondents (1305 women and 649 men; mean age: 37.9 years with standard deviation 10.8 years). in total, 13.2% and 19.3% of respondents reported deteriorated physical and psychological health during the covid-19 pandemic, respectively. participants with higher perceived harm from covid-19 compared with severe acute respiratory syndrome (sars) were more likely to report the subjective deterioration of physical and psychological health, whereas respondents who were older and perceived a higher level of social support were less likely to report a deterioration of physical and psychological health. the subjective deterioration of psychological health was significantly associated with avoiding crowded places and wearing a mask. both subjective deteriorations of physical and psychological health positively related to general anxiety. the coronavirus disease 2019 (covid19) pandemic has been raging globally. as a novel respiratory infectious disease that is highly contagious, the covid-19 pandemic has impacted int. j. environ. res. public health 2020, 17, 6827 2 of 18 physical [1] and mental health [2, 3] , the economy [4] , education [5] , quality of life [6] , occupations [7] , and the interpersonal relationships [8] of humans. the first covid-19 case in taiwan was confirmed on 21 january 2020 [9] . due to proactive containment and comprehensive contact tracing, the number of covid-19 cases in taiwan has remained lower than in other countries [10] . by 21 august 2020, taiwan had tested 129,009 individuals. a total of 486 confirmed cases were identified, of which 55 were domestic and 7 had died [9] . therefore, taiwan did not impose a social lockdown. however, the pandemic has impacted the economy and unemployment rate profoundly [11] . in 2012-2013, taiwan experienced a major outbreak of severe acute respiratory syndrome (sars). the covid-19 outbreak rekindled memories of sars and caused fear among the people of taiwan. covid-19 is a threat to the physical health of both infected individuals and the general public. a study in canada found that 36% of the population was very or extremely concerned about the impact of covid-19 to their health [12] . an online-based study on the general public in china found that 19% of the participants experienced physical pain or discomfort on the euroqol-5d evaluating health-related quality of life [13] . the psychological health of the public has also been deeply affected by the covid-19 pandemic. a review study found that both specific populations such as children, elderly, and medical personnel and the general population were harmed psychologically by imposition of strict isolation during the covid-19 pandemic [14] . the covid-19 pandemic might also threaten individual bodily integrity and autonomy and subsequently result in psychiatric comorbidity representing as atypical pictures, such as functional movement disorders [15] . these studies examined the cross-sectional status of physical and psychological health among people during the covid-19 pandemic. given that covid-19 has impacted human lives rapidly and unprecedentedly, examining the deterioration of physical and psychological health since the pandemic began may provide insights into changes in health status during the covid-19 pandemic. several individual and environmental factors may correlate with the physical and psychological health problems evident during the covid-19 pandemic, such as pre-existing physical and mental health conditions [12, 13, [16] [17] [18] , low income [13, 18] , and experiencing the profound influence of the pandemic on daily activities [13, 19, 20] . determining the modifiable factors predicting the deterioration of physical and psychological health during the covid-19 pandemic may provide evidence to develop prevention and intervention programs for the public affected by the covid-19 pandemic. the health belief model (hbm) can serve as a theoretical basis for determining the predictors of deteriorating physical and psychological health during the covid-19 pandemic. the hbm proposes cognitive and affective constructs that predict whether an individual will adopt health-promoting behaviors. these include perceived susceptibility to and severity of a health problem, perceived benefits of and barriers to engaging in recommended action, and the belief in one's ability to successfully perform a behavior [21, 22] . several studies have examined the association of cognitive and affective constructs of health beliefs with physical and psychological health during the covid-19 pandemic. for example, perceived high vulnerability for contracting covid-19 [23, 24] , perceived low survival likelihood [24] , anxiety regarding contracting covid-19 [13] , and the distress caused by the uncertainty of the endpoint of the covid-19 pandemic [25] predict physical and psychological health during the covid-19 pandemic. however, hbm-based assessment is inadequate. liao et al. [26] proposed cognitive and affective constructs of health beliefs concerning the risk of contracting (1) influenza a/h1n1 in 2009 and (2) respiratory infectious diseases in future epidemics or pandemics. these can be used to examine the cognitive and affective constructs of health beliefs predicting physical and psychological health during the covid-19 pandemic. studies have found that levels of social support were significantly associated with self-efficacy and sleep quality and negatively associated with the degree of anxiety and stress among medical staff in china who were treating patients with covid-19 [27] . however, the association between perceived social support and deteriorating physical health has not been well examined. studies on the association between demographic characteristics and physical and psychological health during the covid-19 pandemic have revealed mixed results. one study found that aging individuals had a higher risk of physical pain or discomfort and depression or anxiety [13] , whereas other studies have found that young people were more likely to report mental health problems during the covid-19 pandemic [17, 18, 28] . moreover, several studies have confirmed that women are more likely to report poor mental health during the covid-19 pandemic than men are [17, 18, 24, 29] ; however, gender difference in determining physical health during the covid-19 pandemic has not been examined. further study is needed to examine whether demographic factors relate to the deterioration of physical and psychological health during the covid-19 pandemic. adopting protective behaviors, such as avoiding crowded places, washing hands frequently, and wearing a mask, are essential to prevent contracting covid-19 and staying healthy. a two-wave study in china indicated that precautionary measures, such as maintaining hand hygiene and wearing a mask, were associated with a lower psychological impact from the outbreak and lower levels of stress, anxiety, and depression in both the initial stage of the covid-19 outbreak [24] and four weeks later [30] . however, studies on people during the sars epidemic have reported that respondents with a moderate level of anxiety were most likely to take comprehensive precautionary measures against the infection [31] . moreover, the use of personal protective equipment increases the discomfort level and causes difficulties in communication [32] . there is a need of further research into the roles played by deteriorating physical and psychological health in the adoption of protective behaviors against covid-19. physical symptoms and poor self-rated health status were significantly associated with a higher incidence of post-traumatic stress disorder and symptoms of stress, anxiety, and depression [30] . both sleep problems [28] and suicidal ideation [33] are serious mental health problems in the era of covid-19. it is reasonable to hypothesize that the deterioration of psychological health is significantly associated with sleep problems and suicidal ideation that have become more prevalent during the covid-19 pandemic, whether the deterioration of physical health is significantly associated with sleep problems and suicidal ideation bears further exploration. this study had three aims: (1) to determine the proportion of individuals who reported the deterioration of physical and psychological health during the covid-19 pandemic in taiwan, (2) to examine the association between cognitive and affective constructs of health beliefs and demographic characteristics and the subjective deterioration of physical and psychological health, and (3) to examine the association between subjective deterioration of physical and psychological health and adoption of protective behavior against covid-19 and mental health problems. the current investigation was based on the dataset of the survey of health behaviors during the covid-19 pandemic in taiwan, which was comprehensively described elsewhere [34] . briefly, a facebook advertisement was deployed between 10 april 2020 and 23 april 2020. we targeted the advertisement to facebook users by location (taiwan) and language (chinese), where facebook's advertising algorithm determined which users to show our advertisement to. facebook users who were 20 years or older and resided in taiwan were eligible for this study. participants reached the research questionnaire website through the facebook advertisement, which was composed of a headline, main text, pop-up banner, and weblink. a total of 2031 respondents completed the research questionnaire; of them, 77 respondents were excluded due to missing data on any variable or being younger than 20. data from 1954 respondents were analyzed. figure 1 demonstrates the flowchart of study design. the institutional review board (irb) of kaohsiung medical university hospital that is responsible for ethical review approved this study (kmuhirb-exempt(i) 20200011). as participation was voluntary and survey responses were anonymous, written informed consent was waived based on the approval of irb. the participants were given no incentive for participation. we provided links to taiwan centers for disease control, kaohsiung medical university hospital, and medical college of national cheng kung university for participants to learn more about covid-19 at the end of the online questionnaire. the analyses of information sources [34] , sexual behaviors [35] , and sleep and suicidality [36] using the dataset have been published elsewhere. facebook advertisement was deployed between 10 april 2020 and 23 april 2020. we targeted the advertisement to facebook users by location (taiwan) and language (chinese), where facebook's advertising algorithm determined which users to show our advertisement to. facebook users who were 20 years or older and resided in taiwan were eligible for this study. participants reached the research questionnaire website through the facebook advertisement, which was composed of a headline, main text, pop-up banner, and weblink. a total of 2031 respondents completed the research questionnaire; of them, 77 respondents were excluded due to missing data on any variable or being younger than 20. data from 1954 respondents were analyzed. figure 1 demonstrates the flowchart of study design. the institutional review board (irb) of kaohsiung medical university hospital that is responsible for ethical review approved this study (kmuhirb-exempt(i) 20200011). as participation was voluntary and survey responses were anonymous, written informed consent was waived based on the approval of irb. the participants were given no incentive for participation. we provided links to taiwan centers for disease control, kaohsiung medical university hospital, and medical college of national cheng kung university for participants to learn more about covid-19 at the end of the online questionnaire. the analyses of information sources [34] , sexual behaviors [35] , and sleep and suicidality [36] using the dataset have been published elsewhere. the four-item self-perceived health questionnaire was developed by ko et al. [37] to evaluate the physical and psychological health of the public during the sars epidemic. for this study, the four questions were modified to evaluate the self-rated physical and psychological health of the respondent compared with those of other people before the covid-19 outbreak and during the week before filling out the questionnaire ("how is the state of your physical/psychological health compared with other people before the covid-19 pandemic/in the recent week?"). the questions are listed in table s1 . the rating for each question ranged from 1 (much worse), 2 (mildly worse), 3 (the same), 4 (mildly better), and 5 (much better). then, the self-reported physical and psychological health states were compared between before and during the covid-19 pandemic. respondents whose self-rated physical health score in the preceding week was lower than that before the covid-19 outbreak were classified as having a deterioration of physical health during the covid-19 pandemic. the respondents whose self-rated physical health score in the preceding week was the same as or higher than that before the covid-19 outbreak were classified as having no deterioration 2031 respondents completed the research questionnaire 1954 respondents who were 20 years or older and resided in taiwan completed the questionnaire without missing data data from 1954 respondents were analyzed 77 respondents were excluded due to missing data or being younger than 20 the four-item self-perceived health questionnaire was developed by ko et al. [37] to evaluate the physical and psychological health of the public during the sars epidemic. for this study, the four questions were modified to evaluate the self-rated physical and psychological health of the respondent compared with those of other people before the covid-19 outbreak and during the week before filling out the questionnaire ("how is the state of your physical/psychological health compared with other people before the covid-19 pandemic/in the recent week?"). the questions are listed in table s1 . the rating for each question ranged from 1 (much worse), 2 (mildly worse), 3 (the same), 4 (mildly better), and 5 (much better). then, the self-reported physical and psychological health states were compared between before and during the covid-19 pandemic. respondents whose self-rated physical health score in the preceding week was lower than that before the covid-19 outbreak were classified as having a deterioration of physical health during the covid-19 pandemic. the respondents whose self-rated physical health score in the preceding week was the same as or higher than that before the covid-19 outbreak were classified as having no deterioration in physical health. the respondents with or without a deterioration of psychological health during the covid-19 pandemic were classified according to the same rules. we examined the cognitive and affective constructs of health beliefs in the context of covid-19, according to the particularization of the hbm to respiratory infectious disease pandemics [26] . the four cognitive constructs included perceived relative susceptibility to covid-19 ("what do you think are your chances of contracting covid-19 over the next 1 month compared with others outside your family?"), perceived severity of covid-19 relative to sars ("how serious is covid-19 relative to sars?"), sufficiency of knowledge and information about covid-19 ("do you think you have sufficient knowledge and information on covid-19?"), and perceived self-confidence in coping with covid-19 ("how confident are you that you can cope well with covid-19?"). the affective construct included worry about covid-19 ("please rate how worried you are toward covid-19"). the questions, response scales, and dichotomous scales for statistical analysis are listed in table s1 . three questions developed in the study of tardy [38] were used to assess the levels of perceived social support from families, friends, and colleagues during the preceding week ("in the past 7 days, were you satisfied with the support from your (1) family, (2) friends, and (3) colleagues or classmates?). the questions and response scales are listed in table s1 . the total score for the three questions indicates the level of perceived social support. higher scores represent higher perceived social support. the internal reliability (cronbach's î±) of the measure was 0.813 in this study. as the scores of perceived social support were not normally distributed (skewness = â��0.138, kurtosis = â��0.056, p of kolmogorov-smirnoff test <0.05), we used the median score of 9 as the cutoff, and respondents whose score of perceived social support was lower than 9 and whose score was 9 or higher were classified as the groups of low and high perceived social support, respectively. we assessed whether the participants avoided crowded places, washed their hands more often, or wore a mask more often in the preceding week to protect themselves from contracting covid-19 ("in the past week, did you (1) avoid going to crowded places, (2) wash your hands more often, and (3) wear a mask more often?") [26] . the questions, response scales, and dichotomous scales for statistical analysis are listed in table s1 . respondents' level of general anxiety was assessed with the previously validated state-anxiety scale of the chinese version of state-trait anxiety inventory (c-stai), wherein respondents rate their feelings in response to 10 general statements (for example, "i feel rested") [26, 39, 40] . a previous study found that the state-anxiety scale of c-stai had a high internal consistency (cronbach's alpha = 0.90, split-half reliability = 0.89) and high item-total correlations (r = 0.42-0.62) [36] . two questions adopted from the revised 5-item brief symptom rating scale were used to assess sleep problems ("in the past week, did you have sleep problems?") and suicidal ideation ("in the past week, did you ever have suicidal thoughts?") in the preceding week [41, 42] . previous studies confirmed that both questions had acceptable test-retest reliability (paired sample correlation coefficients = 0.73-0.78) and significant correlations with suicidal risk in general population (p < 0.001) [41, 42] . the questions, response scales, and dichotomous scales for statistical analysis are listed in table s1 . data on gender (women vs. men), age, and education level (university qualifications or above vs. high school qualifications or below) were collected. as age was not normally distributed (skewness = 0.485, kurtosis = â��0.218, p of kolmogorov-smirnoff test < 0.05), we used the median age int. j. environ. res. public health 2020, 17, 6827 6 of 18 (37 years old) as the cutoff, and respondents who were younger than 37 and who were 37 or older were classified as the younger and older groups, respectively. data analysis was performed using spss 22.0 statistical software (spss inc., chicago, il, usa). demographic characteristics, cognitive and affective constructs of health beliefs related to covid-19, and perceived social support were compared between respondents who did or did not exhibit a subjective deterioration in physical and psychological health during the covid-19 pandemic using univariate logistic regression with the crude odds ratio (cor). furthermore, all potential predictive variables identified from the first step were eligible for inclusion in the multivariate logistic regression models with an adjusted odds ratio (aor) to determine the independent predictors of the subjective deterioration of physical and psychological health. the association between the deterioration of physical and psychological health and adoption of protective behaviors against covid-19 (avoiding crowded places, washing hands, and wearing a mask) and mental health problems (general anxiety, sleep problems, and suicidal ideation) was examined using multivariate logistic regression after controlling for the effects of gender, age, and educational level. moreover, p values, odds ratios (ors), and 95% confidence intervals (cis) of or were used to indicate significance. a two-tailed p value of <0.05 indicated statistical significance. we also used the standard criteria proposed by baron and kenny [43] to examine whether the associations of the deteriorated physical and psychological health and related factors (cognitive and affective constructs of health beliefs, perceived social support, adoption of protective behaviors, and mental health problems) were moderated by demographic characteristics that were significantly associated with the deterioration of physical and psychological health. the interactions (demographic characteristics ã� related factors) were selected into the logistic regression analysis to examine the moderating effects. data from 1954 respondents (1305 women and 649 men) were analyzed. the mean age was 37.9 years (standard deviation [sd] = 10.8 years; range: 20-74), 1029 (52.7%) participants were classified as the older group, and 1736 (88.8%) participants had university qualifications or above. the mean scores for worry and self-confidence were 6.2 (sd = 2.2; range: 0-10) and 3.1 (sd = 0.8; range: 1-5), respectively. regarding the cognitive and affective constructs of health beliefs related to covid-19, 346 (17.7%) respondents reported high perceived susceptibility to covid-19; moreover, 1379 (70.6%) perceived that covid-19 was more harmful than sars, 1763 (90.2%) reported having sufficient knowledge and information about covid-19, 1686 (86.3%) reported having high confidence in coping with covid-19, and 1228 (62.8%) reported having a high degree of worry about covid-19. the mean level of perceived social support was 8.6 (sd = 2.0; range: 0-12), and 1189 (60.8%) participants were classified as the group of high perceived social support. table 1 shows the proportions of the respondents with various levels of subjective physical and psychological health and changes in health from before to during the covid-19 pandemic. most of the respondents reported their health the same as other people before (physical: 46.1%; psychological: 43.1%) and during the covid-19 pandemic (physical: 55.4%; psychological: 48.2%). regarding the changes in health from before to during the covid-19 pandemic, 69.2% and 69.8% of the respondents reported no change in physical and psychological health, respectively. of those who had changes in physical and psychological health, most reported mild deterioration (physical: 10.8%; psychological: 15.2%) or improvement (physical: 15.4%; psychological: 9.2%). in total, 257 (13.2%) and 377 (19.3%) respondents reported that their physical and psychological health deteriorated during the covid-19 pandemic, respectively. table 2 presents the results of the univariate logistic regression model examining the associations between demographic characteristics, cognitive and affective constructs of health beliefs related to covid-19, perceived social support, and the subjective deterioration of physical and psychological health. participants who reported higher perceived harm with respect to covid-19 than to sars all variables that were significantly associated with the subjective deterioration of physical and psychological health during the covid-19 pandemic in the univariate logistic regression model were included in the multivariate logistic regression models ( table 3 ). the results indicate that participants with higher perceived harm from covid-19 compared with sars (b = 0.421, aor = 1.524, 95% ci: 1.107-2.099, p = 0.010) and sufficient knowledge and information about covid-19 (b = 0.763, aor = 2.146, 95% ci: 1.247-3.692, p = 0.006) were more likely to report the subjective deterioration of physical health during the covid-19 pandemic because both b values were larger than zero. the moderating effects of age on the associations between perceived harm of covid-19 relative to sars, sufficiency of knowledge and information about covid-19, confidence in coping with covid-19, and perceived social support with the deterioration of physical health were further examined based on the criteria proposed by baron and kenny (1986) . the results demonstrate that the interaction between age and sufficiency of knowledge and information about covid-19 was significantly associated with the deterioration of physical health (b = â��1.316, aor = 0.268, 95% ci: 0.079-0.912, p = 0.035), indicating that age moderated the association between the deterioration of physical health and sufficiency of knowledge and information about covid-19. further analysis found that the significant association between the deterioration of physical health and sufficient knowledge and information about covid-19 existed only in younger respondents (b = 1.564, aor = 4.776, 95% ci: 1.705-13.381, p = 0.003) but not in older ones (b = 0.249, aor = 1.283, 95% ci: 0.662-2.486, p = 0.461). the moderating effects of gender and age on the associations between perceived harm of covid-19 relative to sars, worry about covid-19, and perceived social support with the deterioration of psychological health were also examined. the results demonstrate that the interactions between age and other factors were not significantly associated with the deterioration of psychological health, indicating that age did not moderate the associations between the deterioration of psychological health and other factors. regarding the adoption of protective behaviors against covid-19, 1587 respondents (81.2%) reported avoiding crowded places, 1511 (77.3%) washed hands more often, and 1511 (77.3%) wore a mask more often. table 4 demonstrates the results from examining the association between the deterioration of physical and psychological health and the adoption of protective behaviors against covid-19. the results indicate that after controlling for the effects of demographic characteristics, the subjective deterioration of psychological health was associated with more adoption of two protective behaviors, including avoiding crowded places (b = 0.411, aor = 1.508, 95% ci: 1.088-2.092, p = 0.014) and wearing a mask (b = 0.525, aor = 1.690, 95% ci: 1.238-2.308, p = 0.001). the interactions between demographic characteristics and the deterioration of psychological health were not significantly associated with avoiding crowded places, indicating that demographic characteristics did not moderate the associations between the deterioration of psychological health and avoiding crowded places. no significant association was found between the deterioration of physical health and adoption of protective behaviors against covid-19. regarding mental health problems, 943 respondents (48.3%) had a high level of general anxiety, 1089 (55.7%) had sleep problems, and 206 (10.5%) had suicidal ideation. the results from examining the association between the deterioration of physical and psychological health and mental health problems are shown in table 5 . the results show that after controlling for the effects of demographic characteristics, the deterioration of both physical and psychological health was associated with more general anxiety (physical: b = 0.687, aor = 1.989, 95% ci: 1.499-2.639, p < 0.001; psychological: b = 0.497, aor = 1.643, 95% ci: 1.295-2.084, p < 0.001). the deterioration of psychological health and not physical health was associated with more sleep problems (b = 0.271, aor = 1.312, 95% ci: 1.033-1.665, p = 0.026). the interactions between gender and the deterioration of physical and psychological health were not significantly associated with general anxiety. the interaction between age and the deterioration of psychological health was not significantly associated with sleep problems. the results indicate that neither gender nor age moderated the association between the deterioration of health and general anxiety and sleep problems. the deterioration of physical or psychological health was not significantly associated with suicidal ideation. before discussing the results, some issues related to the method of recruiting participants using the facebook advertisement warrants discussion first. recruiting participants through facebook can deliver large numbers of participants quickly, cheaply, and with minimal effort as compared with mail and phone recruitment [44] . facebook is a platform that provides the opportunity to assess the general public during fast-moving infectious disease outbreaks. however, facebook users may not be representative of the population. a review of a study that recruited respondents through facebook reported a bias in favor of women, young adults, and people with higher education and incomes [45] . the gender disproportion of the respondents also existed in the present study. to control the effect of gender, gender was used as the covariate when we examined the associations between the deterioration of health and the adoption of protective behaviors and mental health problems. moreover, the present study examined the moderating effects of gender. however, the nonrepresentation of the population in the study should be cautiously considered, and is a consequence of using social media to recruit the participants. this study found that 13.2% and 19.3% of respondents reported experiencing a deterioration of physical and psychological health during the covid-19 pandemic, respectively. according to the statistics of the national health insurance administration, taiwan, the numbers of patients visiting health care facilities during the period of april to june in 2020 reduced 12.9% when compared with the same period in 2019 [46] . people with chronic illnesses may worry about contracting covid-19 in hospitals and doctor's offices and therefore not seek medical assistance and delay treatment. people with anxiety may interpret changes in perceived bodily sensations as symptoms of being ill, related or unrelated to covid-19, and complain of deteriorating physical and psychological health [14] . although taiwan was not placed under lockdown, people may have reduced outdoor activities or stopped routine exercise due to the worry of contracting covid-19 and the burden of physical and psychological health problems may have therefore increased [47] . the results of this study indicate that in addition to monitoring health states of people who are quarantined or have contracted covid-19, it is necessary for the governments and health professionals to early detect health problems of and timely deliver medical assistance to the public in the pandemic. introducing novel methods of clinical interaction, such as telemedicine and the use of electronic devices for covid-19 education, self-assessment, and maintenance of a symptom diary may assist in overcoming the mounting challenges of the covid-19 pandemic [20, 48] . health promotion strategies directed at adopting or maintaining positive health-related behaviors should be utilized to address the increase in psychological distress during the pandemic [18] . moreover, promoting community-supported interventions for stress and anxiety due to covid-19 is recommended [2] . this study found that the perceived harm from covid-19, more than that from sars, was significantly associated with the subjective deterioration of physical and psychological health during the covid-19 pandemic. the perceived risk of contracting covid-19 may cause stress, which may compromise physical and psychological health [49] . the public evaluates the risk of covid-19 relative to sars based on the information they receive from the media and social networks. this study also found that self-rated knowledge and information about covid-19 were positively associated with the deterioration of physical health. the provision of timely and accurate information on covid-19 is fundamental to mitigating the disease [50] and for rationally understanding covid-19. moreover, high confidence in coping with covid-19 was negatively associated with deterioration of physical health. helping build confidence to successfully cope with the pandemic by delivering information through traditional and social media should be a priority for governments and health professionals. however, controlling misinformation on covid-19 remains a challenge. this study found that perceived social support was negatively associated with the deterioration of physical and psychological health. good social interactions not only provide emotional support but also daily necessities, which may contribute to the maintenance of physical and psychological health. for example, social support can increase individual capacity to maintain health behaviors [51] . a study on women's sport practice in spain found that brothers/sisters, best friends and workmates encourage women to practice exercise; in particular, the presence of supportive friends increases with age [52] . social support may be attenuated due to social distancing according to the health policy requirement and the fear of contracting covid-19. social support can be offered through telecommunication instead of physical contact to those who have been quarantined to prevent mental health problems. the governments should take an initiative to provide support for those who were socially isolated before the pandemic. this study found that the respondents who reported deteriorated psychological health were more likely to avoid crowded places and wear masks. the results of previous studies were mixed. a study in cyprus found that higher anxiety was positively associated with the adoption of measures related to personal hygiene, whereas higher depression was negatively associated with higher compliance with precautionary measures [53] . a study in china during the initial outbreak of covid-19 demonstrated that the adoption of precautionary measures was associated with a lower psychological impact from the outbreak of covid-19 and lower levels of stress, anxiety, and depression [24, 30] . another study in china found that people's perceptions that the outbreak can be controlled by protective behaviors were associated with lower prevalence of depression and anxiety [54] . the results of the present and previous studies indicate that there might be factors such as the timing of survey, severity of the pandemic and definition of psychological health influencing the association between psychological health and adoption of protective behaviors. this study found that the deterioration of both physical and psychological health was significantly associated with general anxiety and that of psychological health with sleep problems. general anxiety is closely connected to dysfunction of interoception, which can disturb the process by which the nervous system senses, interprets, and integrates signals originating from within the body, providing a moment-by-moment mapping of the body's internal landscape across conscious and unconscious levels [55] . somatic discomfort, such as increased muscle ache and heart rate, and psychological discomfort, such as excessive worry and irritability were also the core symptoms of generalized anxiety disorder [56] . therefore, general anxiety and the perception of deteriorating health may occur together. moreover, the present study found that deteriorated psychological health was significantly associated with sleep problems. sleep disturbance is the core symptom of several mental disorders; for example, depression and anxiety disorders [56] . sleep problems may be used as an indicator of psychological health and may warrant psychological intervention during the covid-19 pandemic. the present study has some limitations in addition to the gender nonrepresentation of the participants recruited by the facebook advisement. first, there might be recall bias for the health state before the covid-19 outbreak. second, the cross-sectional design of this study limited causal inference between changes in health state and related factors. third, some factors such as chronic diseases that might influence deteriorated health in the covid-19 pandemic were not examined in the present study. fourth, the psychometric measures used in the present study for evaluating perceived social support warrants further examination. this facebook-based online study on the general public in taiwan found that 13.2% and 19.3% of respondents reported deteriorated physical and psychological health during the covid-19 pandemic, respectively. both subjective deteriorations of physical and psychological health positively related to general anxiety. the results indicate that the physical and psychological health of the public, but not only those who were contracted with covid-19, should be focus of health professionals' concern. the present study identified several health belief constructs, social support and demographic characteristics that were significantly associated with deteriorated physical and psychological health. these factors can be used to screen for the individuals who need intervention for physical and psychological health problems. the subjective deterioration of psychological health was significantly associated with avoiding crowded places and wearing a mask. further study is needed to examine the mechanism accounting for the association and provide reference for developing strategies to promote adoption of protective behaviors against respiratory infectious diseases. funding: this research did not receive any specific grant from funding agencies in the public, commercial, or nonprofit sectors. the authors declare no conflict of interest. the outbreak of covid-19 coronavirus and its impact on global mental health preventing suicide in the context of the covid-19 pandemic the socio-economic implications of the coronavirus pandemic (covid-19): a review covid-19-related school closings and risk of weight gain among children impact of the covid-19 pandemic on mental health and quality of life among local residents in liaoning province, china: a cross-sectional study the traumatic impact of job loss and job 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can increase physical inactivity and the global burden of cardiovascular disease using ehealth to support covid-19 education, self-assessment, and symptom monitoring in the netherlands: observational study covid-19 related stress exacerbates common physical and mental pathologies and affects treatment (review) infodemic" and emerging issues through a data lens: the case of china theoretical explanations for maintenance of behaviour change: a systematic review of behaviour theories estudio de la relaciã³n del entorno psicosocial en la prã¡ctica deportiva de la mujer prevalence and predictors of anxiety and depression symptoms during the covid-19 pandemic and compliance with precautionary measures: age and sex matter public behavior change, perceptions, depression, and anxiety in relation to the covid-19 outbreak â© 2020 by the authors key: cord-295543-nj4a640t authors: castañeda-babarro, arkaitz; arbillaga-etxarri, ane; gutiérrez-santamaría, borja; coca, aitor title: physical activity change during covid-19 confinement date: 2020-09-21 journal: int j environ res public health doi: 10.3390/ijerph17186878 sha: doc_id: 295543 cord_uid: nj4a640t background: the lockdown and social distancing caused by covid-19 may influence common health behavior. the unprecedent worldwide confinement, in which spain has been one of the most affected—with severe rules governing confinement—may have changed physical activity (pa) and sedentary habits due to prolonged stays at home. purpose: the aim of this study is to evaluate how self-reported pa and sedentary time (st) have changed during confinement in the spanish population. methods: 3800 healthy adults (age 18–64 years) residing in spain answered the international physical activity questionnaire short (ipaq-s) twice between 23 march and 1 april (confinement). data analysis was carried out taking into consideration meeting general pa recommendations before confinement, age and gender. results: self-reported pa decreased significantly during confinement in our sample. vigorous physical activities (vpa) and walking time decreased by 16.8% (p < 0.001) and 58.2% (p < 0.001), respectively, whereas st increased by 23.8% (p < 0.001). the percent of people fulfilling the 75 min/week of vpa recommendation decreased by 10.7% (p < 0.001) while the percent of people who reached 150 min/week of moderate activity barely changed (1.4%). the group that performed the most vpa before confinement showed the greatest decrease (30.5%, p < 0.001). men reduced time in vpa more than women (21% vs 9%, respectively) who even increased time in moderate pa by 11% (p < 0.05) and reported less increase in st than men (35% vs 25.3%, respectively). conclusion: the spanish adult population, especially young people, students and very active men, decreased daily self-reported pa and increased st during covid-19 confinement. on 11 march 2020, the world health organization (who) [1] declared a global pandemic caused by severe acute respiratory syndrome coronavirus (sars-covid-2), which has become a public health emergency of international concern. during its first phase of expansion outside china, italy and spain were the most affected countries reporting most cases and deaths. thus, they were the first nations to declare a state of emergency in europe. in spain it was declared on 17 march and the government ordered a lockdown to restrict travel and cancel non-essential services in order to stop the spread of coronavirus disease (covid-19) [2] . social distancing and confinement are fundamental in tackling the spread of coronavirus. however, the ongoing lockdown across the country has no precedent and it is unknown how this may affect the general population's health and wellbeing. in these circumstances, the sudden and stressful situation in addition to prolonged stays at home may imply a radical change in lifestyle behavior such as physical activity (pa), eating habits, alcohol consumption, mental health, quality of sleep, etc. [3] [4] [5] [6] [7] . likewise, there is a general concern about the negative health implications of inactivity and sedentary behavior [8] . the general recommendation for considering an adult to be physically active is to attain at least 150 min of moderate or 75 min of vigorous intensity activity per week or an equivalent combination of both [9] , and sedentary behavior is defined as any waking behavior practiced while lying down, reclining, sitting or standing, involving an energy expenditure ≤ 1.5 metabolic equivalents [10] . while the disease spreads around the world, healthy people are being requested to stay at home for prolonged periods of time and, as a consequence, covid-19 has radically modified the determining factors (individual, interpersonal, environmental, regional or national policies and global) [11] of both types of behavior thus, due to isolation and limitations in engaging in regular and common activities, fulfilling pa recommendations and reducing sedentary behavior during lockdown may pose a significant challenge, especially during the first weeks when the population has limited chances to find alternatives to ensure they remain active even at home. hence, although individuals were encouraged to remain physically active in their homes [12], the unprecedented confinement may give rise to two situations. (1) the active population may decrease their activity and (2) the inactive population may not be likely to increase their daily pa. despite the fact that lockdown has affected several countries, data are scarce about how people have changed their pa and sedentary behavioral patterns because of the specific cases of isolation in each country. therefore, the aim of this study was to analyze self-reported pa and sedentary behavior before and during lockdown caused by covid-19 in a spanish healthy adult population. healthy adults (age 18-64 years, age category defined by who) living in spain were asked to participate in this cross-sectional study. all the subjects were informed about the objective of the study and their free participation in it, being able to leave it whenever they wanted. ethics approval was obtained from the deusto university human ethics advisory group, and informed consent was obtained from participants. sociodemographic data (age, height, weight, gender, whether working and/or studying) and self-reported pa data were collected by questionnaires sent between 23 march and 1 april, just 10 days after the state of emergency was declared in spain. two questionnaires were sent together to be answered consecutively at the same time. the first collected retrospective data about habits during a normal week before lockdown, and the second asked about the following one or two weeks. the questionnaire used was the ipaq short version validated in spanish [13] . the ipaq short version asks about three specific types of activity undertaken during the previous 7 days in the four domains (leisure time, work, household activities and transport); items are structured to provide separate scores for walking, moderately intense and vigorously intense activities. the ipaq version also contains a question about the time spent on sedentary activity. the invitation to participate in the study was issued via social media, e-mail and mobile phone from the physical activity and sports sciences department, university of deusto. moreover, a national sports store (forumsport s.a.) and a biomechanical laboratory (custom4us) also sent the questionnaire to their customers by e-mail. the primary outcome was the change in time and intensity of self-reported pa and the sedentary time prior to the confinement situation and after it. the secondary outcome was the change in the percentage number of participants who fulfilled general pa recommendations according to age, gender, working status and baseline pa levels. a total of 4160 healthy subjects answered the questionnaire. a total of 360 were excluded due to exclusion criteria: not resident in spain (n = 16), age < 18 or ≥65 (n = 110) and extreme scores in vigorous, moderate and walking activities (≥6 h per day, 7 days a week). the exact number of participants excluded was as follows: n = 81 were excluded because the sum of the total active time was >6 h per day (vigorous + moderate + walking). within the pre-covid data, n = 17, n = 31 and n = 62 were excluded because they exercised > 180 min per session at a vigorous level of intensity, >180 at moderate intensity and >21 h (3 h per day, 7 days of week) walking, respectively. finally, within the during-covid data, n = 17, n = 9 and n = 17 were excluded because they exercised >180 min per session at vigorous intensity, >180 at moderate intensity and >21 h (3 h per day, 7 days of week) walking, respectively. a univariate analysis with paired t-tests was used to compare the differences in primary outcomes before and during confinement. furthermore, a chi 2 frequency test was used to assess secondary outcomes, which refer to the change in the percentage number of participants who fulfilled the amount of self-reported pa in the subgroups. a subgroup analysis was performed on different age groups (18-24, 25-34, 35-44, 45-54, 55-64) , gender (m, f), working status (students, active workers, people that study and work, those that reported they did nothing), and self-reported pa, categorized into vigorous activity groups (0-75, 75-150, 150-225, more than 225 min/week) and moderate activity groups (0-150, 150-300, 300-450, >450 min/week). the pa subgroup categories are based on world health organization (who) recommendations. we divided the data into different groups following in accordance with who recommendations for activity of moderate (150 min per week) and vigorous (75 min per week) intensity. within each of the two categories we divided the data into 4 groups as follows: (1) under the amount recommended (less than 150 min of moderate intensity or less than 75 min of vigorous intensity), (2) following recommendations (150 to 300 min of moderate intensity or 75 to 150 min of vigorous activity), (3) twice the amount recommended and (4) three times the amount recommended. this categorization was made to extrapolate the results to the amount of self-reported pa fulfilled by participants in the study, with α level set at 0.05. statistical analysis was performed using the spss data analysis version 23 (spss, inc., chicago, il, usa). table 1 shows the demographic characteristics of 3800 participants who were mostly male, (54%) active workers (78%) and aged 42.7 ± 10.4 years (mean ± sd). (5) data presented as mean ± sd, n (%) using the who stratification, we divided the sample into five bmi groups with n = 77 (2.1%) being the underweight group, n = 2621 (70.0%) normal; n = 897 (24.0%) overweight; n = 144 (3.8%) obese and n = 4 (0.1%) extremely obese (<18.5 kg/m 2 ; 18.5-24.9; 25-29.9; 30-39, 9 and ≥40 groups of bmi score, respectively). during confinement, the amount of time spent on moderate and vigorous activities by all the population decreased by 2.6% (p = 0.102) and 16.8% (p < 0.001), respectively. in addition, walking time was reduced by 58.2% (p < 0.001) whereas sedentary time increased by 23.8% (p < 0.001) ( table 2) . men reported a higher decrease in vigorous activities than women (21% and 9%, respectively) and both reduced walking time to a similar extent (58.5% men, 59.6% women) ( table 2 ). however, sedentary time was reported to have a higher increase in men (35%, p < 0.001) than in women (25.3%, p < 0.001) and accordingly, men significantly reduced moderate activities by 8.2% (p < 0.001) while women increased these activities by 11% (p < 0.05). the student group showed the highest decrease in moderate (16.1% p < 0.05), vigorous (24.3%, p < 0.001) and walking activities (66.9% p < 0.001), whereas unemployed or non-students were proved to be the most sedentary during confinement (47.7%, p < 0.001) ( table 2 ). the adult population (age 55-65 years) decreased the amount of time they spent on vigorous activities the most (22.1%) whereas for moderate activities and walking time it was the youngest subjects (18-24 years) who also evidenced the greatest increase in sedentary time (47.7% p < 0.001). regarding meeting pa recommendations, the number of subjects who failed to complete 75 minutes' activity of vigorous intensity per week before confinement increased by 10.7% (p < 0.001) during lockdown. (table 3 ). in addition, the most active population (>225 min/week of vigorous activity) decreased their activity significantly by 7.7% (p < 0.001). nevertheless, meeting 150 min of moderate activity per week barely changed (1.4%, p value 0.117). in the subgroup analysis, the most active subjects showed the highest decrease in vigorous activity time (30.5%, p < 0.001) ( table 2 ). however, the less active population increased the time they spent on these activities by 34% and this trend is also evidenced in the case of moderate activities. furthermore, walking time declined similarly for all self-reported pa levels, while in terms of sedentary time, the most active group reported the highest increase (40.3%, p < 0.001). self-reported pa decreased significantly during confinement in all the population, in which vigorous and walking activities declined the most and moderate activities barely changed. there were more inactive people who failed to fulfil the 75 min/week of vigorous activities during lockdown and sedentary time also increased considerably. the impact on active and sedentary behavior was particularly high in men, young people, students and the physically very active population. to our knowledge, there are limited previous studies that have analyzed the effect of confinement caused by a pandemic on self-reported pa. thus, it is difficult to assess whether the population we studied has reduced the amount of self-reported pa to a smaller or larger extent. the only available data we found about self-reported pa during confinement comes from activity trackers, where it has been shown that in europe the country with the greatest step count decrease recorded was spain, with 38% less, followed by italy with 25%. this reduction is similar to the falling trend in walking time shown in our study. in this regard, other studies carried out in similar lockdown situations (confinement during seasons with adverse weather conditions-cold winter or heat waves) also reported pa decrease during confinement, whereas sedentary time increased because poor or extreme weather becomes an environmental barrier to going outdoors [14] [15] [16] [17] . sedentary time increased considerably, most likely due to the exchange between common daily active behavior (walking, cycling or transport to work, etc.) and the prolonged stay at home. young people and students spent more time seated during confinement and this may be due to the forced e-learning which encourages sedentary behavior related to excessive time on screen-based activities [18] . likewise, according to the socioecological model [11] , in a comparable framework where social or environmental barriers promote an inactive lifestyle (social isolation, loneliness and, when season changes), more sedentary behavior and less time being spent on light, moderate and vigorous pa have been reported [19] [20] [21] . hence, an involuntary prolonged stay at home may encourage sedentary behavior as well as during confinement caused by covid-19. the most active subjects showed the highest decrease in vigorous activity time and this may be explained by two main reasons: the forced sudden inaccessibility to community resources (e.g., sports facilities, urban trails, parks, green spaces, etc.) and the lack of time to react during the first weeks of confinement to gather fitness resources, in order to continue engaging in regular activities at home. regarding moderate activities, our data showed that it barely changed in all the population and this could be attributed to the fact that some people may have been maintaining the minimum recommended time doing alternative activities at home. in this regard, the less active population increased vigorous and moderate activities during confinement, which could be related to the promotion of such activities by health institutions, fitness centers, the internet and television by posting daily online workout routines. to our knowledge, there are no scientific articles supporting the benefits of promoting pa established during confinement. some specific examples of such activities are spanish national television (morning workouts), the free online classes offered by several institutions and fitness centers (using online platforms such as zoom or google meet) and the recommendations made by health associations. our results showed that there are people who found new ways of being more active during this lockdown, which could become best practices in the future, should a pandemic of similar characteristics hit again. active behavior changed according to gender. both genders reduced walking time to a similar extent, although men reported a higher decrease in vigorous activities that may be related to the greater pa prevalence reported in women over the years. [22] [23] [24] [25] . in terms of sedentary behavior, sitting time increased more highly in men who also significantly reduced moderate activities, while women increased these activities. this could be attributed to the gender gap by historically demonstrated female inequality in household and child care tasks, in which men have shown a low level of involvement in spain [26] [27] [28] . regarding meeting pa recommendations, the global age-standardized prevalence among the inactive population was 27.5% in 2016 [23] . according to the eurobarometer (eurobarometer, 2014), 33.6% of the spanish adult population did not attain minimum levels of pa, and 36% spent most of the day sitting down (national health surveys in spain). in our population, our inactive population before confinement is lower (25.3% corresponding to 75 min/week vigorous pa) than that of the eurobarometer. that may be explained by the fact that the population recruited for the study was particularly more active as shown in the data for people undertaking >225 min/week of vigorous activities, and this could be attributed to the fact that the questionnaire was shared by institutions linked to sport, exercise and biomechanics. therefore, it is to be expected that we recruited a population that is commonly more active than the general population. a limitation of the current study is that we selected the ipaq short version instead of the ipaq-long one because of concerns that the length of the questionnaire would result in significant participant burden. in addition, although the questionnaire collects data about the last seven days, in our study we requested information beyond a week, which may be justified due to the unprecedented situation and the lack of time available to manage more appropriate study design and methods. in order to obtain as many participants as possible, sharing the questionnaire was sent to customers involved in sports and biomechanical issues in addition to being shared on social networks. therefore, a sampling selection bias may have occurred in the population analyzed due to their natural active habits. another limitation could be the cross-sectional design of the study since directionality of the associations cannot be established. finally, the way in which the data were collected in this study can be in itself considered a limitation, since participants reported data in a subjective way when answering self-rated questionnaires. on the other hand, one of the strong points of the study is that the questionnaire was sent just when the population started confinement (during the first two weeks), and so it is likely participants had their common activities in mind before confinement in a fresh and realistic way. to our knowledge, this is the first study carried out on a confined large sample size, which may be useful in designing different strategies in order for the confined population to reduce sedentarism and increase pa. in conclusion, healthy adults reduced daily self-reported pa and increased sedentary time during covid-19 confinement in spain. the impact was particularly high in men, young people, students and the very active population. strategies should thus be employed to increase pa and decrease sedentary behavior. in this study, we tried to ascertain the influence of confinement on the lifestyle of the population. this study may serve to show the effect of an extraordinary measure, such as confinement, on this lifestyle, as well as a greater awareness of the effect of confinement. moreover, the results may help design and target interventions aimed at increasing physical activity and reducing unhealthy levels of sedentary time associated with pandemic mitigation efforts. who director media briefing on covid-19. available online alcohol use and misuse during the covid-19 pandemic: a potential public health crisis? lancet public health 2020, 5, e259 a prospective study of holiday weight gain who mental health. mental health and psychosocial considerations during the covid-19 outbreak dealing with sleep problems during home confinement due to the covid-19 outbreak: practical recommendations from a task force of the european cbt-i academy physical exercise as therapy to fight against themental and physical consequences of covid-19 quarantine: special focus in older people a tale of two pandemics: how will covid-19 and global trends in physical inactivity and sedentary behavior affect one another? on behalf of sbrn terminology consensus project participants. sedentary behavior research network (sbrn)-terminology consensus project process and outcome correlates of physical activity: why are some people physically active and others not? validation of the international physical activity questionnaire-short among blacks the effect of season and weather on physical activity: a systematic review. public health physical activity levels of community-dwelling older adults are influenced by winter weather variables influence of seasonal variations on physical activity in older people living in mountainous agricultural areas comparison of summer and winter objectively measured physical activity and sedentary behavior in older adults: age, gene/environment susceptibility reykjavik study covid-19): the need to maintain regular physical activity while taking precautions associations between social isolation, loneliness, and objective physical activity in older men and women social isolation, loneliness, and health behaviors at older ages: longitudinal cohort study loneliness predicts reduced physical activity: cross-sectional & longitudinal analyses the active living gender's gap challenge: 2013-2017 eurobarometers physical inactivity data show constant higher prevalence in women with no progress towards global reduction goals worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1.9 million participants worldwide variability in physical inactivity a 51-country survey shifting the physical inactivity curve worldwide by closing the gender gap the gender revolution: a framework for understanding changing family and demographic behavior parentalidad y división del trabajo doméstico en españa el impacto de cuidar en la salud y la calidad de vida de las mujeres the authors gratefully acknowledge those who participated in this study and forumsport and custom4us for helping to disseminate the questionnaire. the authors declare no conflict of interest. key: cord-293117-hkkbqorv authors: hernández-garcía, ignacio; giménez-júlvez, teresa title: characteristics of youtube videos in spanish on how to prevent covid-19 date: 2020-06-29 journal: int j environ res public health doi: 10.3390/ijerph17134671 sha: doc_id: 293117 cord_uid: hkkbqorv objective: to analyze the characteristics of youtube videos in spanish on the basic measures to prevent coronavirus disease 2019 (covid-19). methods: on 18 march 2020, a search was conducted on youtube using the terms “prevencion coronavirus” and “prevencion covid-19”. we studied the associations between the type of authorship and the country of publication with other variables (such as the number of likes and basic measures to prevent covid-19 according to the world health organization, among others) with univariate analysis and a multiple logistic regression model. results: a total of 129 videos were evaluated; 37.2% were produced in mexico (25.6%) and spain (11.6%), and 56.6% were produced by mass media, including television and newspapers. the most frequently reported basic preventive measure was hand washing (71.3%), and the least frequent was not touching the eyes, nose, and mouth (24.0%). hoaxes (such as eating garlic or citrus to prevent covid-19) were detected in 15 videos (10.9%). in terms of authorship, papers produced by health professionals had a higher probability of reporting hand hygiene (or (95% ci) = 4.20 (1.17–15.09)) and respiratory hygiene (or (95% ci) = 3.05 (1.22–7.62)) as preventive measures. conclusion: information from youtube in spanish on basic measures to prevent covid-19 is usually not very complete and differs according to the type of authorship. our findings make it possible to guide spanish-speaking users on the characteristics of the videos to be viewed in order to obtain reliable information. internet access has increased worldwide in recent years. by the end of 2017, 3.58 billion people were online, equivalent to 48.0% of the global population [1] . youtube is the second most visited website and the second biggest search engine in the world [2] . in particular, youtube, with more than one billion users worldwide and more than 100 million videos, is becoming an increasingly important source of health information [1, 3] , and it has the capacity to influence its users (for example, regarding their vaccination habits [3] or patient decision-making regarding screening and prevention on colorectal cancer [4] or buying a drug [5] ). however, it has no policy of filtering videos according to their potency or effectiveness; for this reason, there are many videos online, and while some may be useful, others may be misleading [6] . in this context, infodemiological studies are becoming increasingly necessary, since they can provide valuable insights into health-related behaviors of populations. infodemiology is the science of distribution and determinants of information on the internet or in a population, and it has the aim of informing public health and public policy [7] . examples of infodemiology applications include the identification and monitoring of public-health-relevant publications on the internet, measuring information diffusion, and analyzing how people search and navigate on the internet for health-related information as well as how they communicate and share this information [7, 8] . during the previous zika [9] and ebola [10, 11] public health emergencies, youtube videos on such infections were viewed millions of times [9] [10] [11] . this extraordinary audience makes youtube a double-edged sword in times of epidemic crises, because while appropriate youtube content can benefit health organizations in ensuring that the population properly implements measures to control the spread of the disease, misleading videos can contribute to failure to contain the infection [12] . on 11 march 2020, the world health organization (who) considered coronavirus disease 2019 to have a pandemic status [13] . according to the who situation reports, as of 18 march 2020, 191,127 cases had been confirmed worldwide, of which 11,178 were in spain and 701 cases were in 16 spanish-speaking countries of america [14] . as in other similar situations, people wanted to know what they could do to prevent and treat the disease [15] . since there is currently no vaccine or specific antiviral treatment, the application of basic preventive measures is essential [16] . the objective of this study was to evaluate the characteristics of the youtube videos that provide information in spanish on the basic measures for preventing covid-19. on 18 march 2020, a cross-sectional study of the data was conducted by entering the terms "prevencion coronavirus" and "prevencion covid-19" into the youtube search engine. the videos were sorted according to the number of views, and their full names and urls were recorded. after applying the exclusion criteria (not available for viewing, language other than spanish, not providing information on covid-19, and duplicate video), the 129 most viewed videos were selected. this sample size was estimated from the total number of videos that met the selection criteria (379 videos, after having discarded 39 for being duplicates, 5 for using a language other than spanish, and 1 for not providing information on covid-19; all were available for viewing), considering an accuracy level of 5%, an alpha error of 5%, and an expected proportion of finding information on how to prevent covid-19 according to the who of 15% [17] . the information corresponding to the following variables was extracted: date and country of publication, number of views, comments, likes and dislikes, duration, and type of authorship (represents the person or organization that produced the video and was classified into 4 categories: "mass media", including television and newspapers; "health professionals", including healthcare professionals, medical centers, or public health official organizations; "individual users", a lay person's opinion about the issue; and "others", videos that did not belong to any other category [3] ). in addition, we recorded whether they provided information on the following basic measures to prevent covid-19 according to the who: (a) wash your hands frequently; (b) respiratory hygiene (when coughing or sneezing, cover the mouth and nose with a bent elbow or tissue, and then dispose of the used tissue immediately and wash your hands); (c) social distance (keep at least 1 m away from other people, particularly those who are coughing, sneezing, or have a fever); and (d) avoid touching your eyes, nose, and mouth) [18] . a descriptive analysis of the variables was performed, and we studied which variables were associated with the videos providing information on the basic measures to prevent covid-19. for this purpose, the countries of origin of the videos were categorized according to the type of transmission existing in each country at the time of data collection, as follows: (a) local transmission, locations where the source of infection is within the reporting location; (b) imported cases only, locations where all cases have been acquired outside the location of reporting; and (c) no transmission, countries where no cases have been reported) [14] . the chi-square test, or fisher's exact test, was used for qualitative variables. the magnitude of each association was quantified with the odds ratio (or) and its 95% confidence interval (ci) obtained with a univariate logistic regression analysis. for quantitative variables, after checking with the kolmogorov-smirnov test that none followed a normal distribution, the mann-whitney u-test was used. a multivariable logistic regression analysis was performed with all variables associated (p < 0.05) with the videos providing information on basic measures to prevent covid-19. the agreement between the two reviewers regarding the basic protective measures in the videos was analyzed using the kappa index. all statistical analyses were performed using spss v25 (ibm corp, chicago, usa) and epiinfo (centers for disease control and prevention, atlanta, usa). as in similar studies, videos publicly available on youtube were assessed, and no human participants/animals were included. therefore, ethics committee approval was not required for this study [19] . the oldest video was dated 13 january 2020, and the most recent was dated 18 march 2020. a total of 41.9% of the videos were published on or after 11 march 2020, and 37.2% (48/129) were produced in mexico or spain (table 1) . a percentage share of 78.3% of the videos were produced by the mass media (56.6%) and health professionals (21.7%). only one video was produced by the who. the videos had been viewed 15,589,902 times. the number of views ranged from 10,053 to 1,933,567 (median: 45,284). the number of comments ranged from 0 to 2639 (median: 85). in terms of likes and dislikes, the figures ranged, respectively, from 0 to 48,367 (median: 394) and from 0 to 2711 (median: 32). the median duration was 187 s (range: 30-6485 s). there were no discrepancies between the authors regarding the basic protective measures reported in the videos (kappa = 1). the most frequently reported basic preventive measure was hand washing (71.3%), and the least frequent was not touching the eyes, nose, and mouth (24.0%) ( table 1) . hoaxes were detected in 15 videos (10.9%). in particular, seven videos indicated that certain foods (such as garlic, citrus, zinc-containing foods, parsley, ginger tea with curcuma, or fennel tea) or the consumption of multivitamin supplements, magnesium chloride, sodium bicarbonate, water with bicarbonate plus lemon, alkaline water, n-acetyl cysteine tablets, or zinc tablets serve to prevent covid-19. one video also indicated that "orange juice with kiwi and a spoonful of pollen is more important than hand hygiene to prevent covid-19". one video indicated that with rising temperatures in the spring, heat will help to control covid-19. two videos indicated that natural sunbathing serves to prevent covid-19; one of them also indicated how hot/cold contrast baths serve to prevent covid-19. five videos referred to conspiracy theories about the origin of the virus (created in a laboratory to be used as a biological weapon or because of the interest of the pharmaceutical industries to make a new treatment or a new vaccine). in addition, one of these videos questioned the usefulness of recommending hand hygiene or respiratory hygiene practices because in spain and latin american countries, people will not comply because of their culture/way of being. significant differences were detected in the number of video views reporting hand washing as a measure to prevent covid-19 (median: 49,972; interquartile range: 21,690-122,269) compared to those not reporting such information (median: 29,359; interquartile range: 14,775-70,115) (p = 0.039). significant differences were also detected in the number of comments on the videos reporting respiratory hygiene as a measure to prevent covid-19 (median: 49.5; interquartile range: 14.75-169.75) compared to those not reporting such information (median: 128; interquartile range: 36-251.5) (p = 0.023). according to the author, those produced by health professionals showed, compared to the rest of the videos, a higher probability of reporting on washing hands frequently (or (95% ci) = 4.23 (1.19-15.01); p = 0.018), respiratory hygiene (or (95% ci) = 3.39 (1.42-8.14); p = 0.005), and avoiding touching the eyes, nose, and mouth (or (95% ci) = 3.24 (1.32-7.96); p = 0.009) as measures to prevent covid-19. in particular, videos produced by health professionals showed, compared to those made by the mass media, a higher probability of reporting on washing hands frequently, respiratory hygiene, and avoiding touching the face as measures to prevent covid-19 (table 2) . moreover, significant differences were detected in the frequency with which the videos produced in countries with local transmission (spain, the united states of america, argentina, colombia, ecuador, germany, chile, peru, costa rica, dominican republic, china, the united kingdom) provided information on washing hands frequently (or = 2.29) and respiratory hygiene (or = 2.26) compared with other countries (table 3) . no other associations were found in the univariate analysis. in the multivariate analysis, the only variable that maintained a significant association with the video reporting on hand hygiene and respiratory hygiene as measures to prevent covid-19 was the type of authorship. videos produced by health professionals showed, compared to the rest of the videos, a higher probability of reporting on washing hands frequently (or (95% ci) = 4.20 (1.17-15.09); p = 0.028) and respiratory hygiene (or (95% ci) = 3.05 (1.22-7.62); p = 0.017). this study is the first to evaluate the characteristics of youtube videos that provide information specifically in spanish on the basic measures indicated by the who to prevent the transmission of covid-19. the most frequently reported basic preventive measure was hand washing (71.3%), and the least frequent was not touching the eyes, nose, and mouth (24.0%). hoaxes were detected in 15 videos (10.9%). the videos in this study had accumulated a total of 15,589,902 views. this number, together with the median number of views obtained (45,284), is lower than those recorded in studies that have analyzed the information on youtube on recent pandemics, such as ebola, in which the total number and the median number of views in the 100 most viewed videos were 73 million times and 401,162 views, respectively [10] . it is a surprising result, given the greater global spread of covid-19 than ebola. moreover, this is a very worrying finding (given that 483 million people have spanish as their mother language [20] ), and it could indicate that, on the day of the data collection (on 18 march 2020), the spanish-speaking population had little interest in and concern about how to prevent covid-19, despite the fact that a week earlier, the who had declared covid-19 to be a pandemic [13] . another disturbing finding was that three of the four basic prevention measures of the who appeared in less than 42% of the videos. it is difficult to control the spread of a virus if people have little information and are not very interested in how it can be prevented. perhaps all of this may have contributed to the fact that, in spanish-speaking countries, the number of cases multiplied in just two weeks, which corresponds to the incubation period of covid-19 [21] . for example, spain went from 11,178 cases on march 18 to 94,417 cases on 1 april, chile from 156 to 2738 cases, ecuador from 58 to 2240 cases, and peru from 86 to 1065 cases [14, 22] . unfortunately, this trend has been increasing in latin america, and at the end of may, the who declared that central and south america have emerged as the new epicenter of the coronavirus pandemic [23] . in this regard, the presidents of several governments (including those of peru and chile) have stated that this pandemic has taught them that the priority must be education [23] . it may also be a lesson to be learned for the management of future pandemics, as using youtube to educate early represents an opportunity and a means to this goal [2] . timely education is a fundamental element of any prevention policy; prevention is either reached earlier or not at all [24] . knowledge regarding infectious diseases is related to the level of adherence to all control measures, which may limit the spread of those diseases [25] . the difficulty of obtaining information on youtube on the basic measures for the prevention of covid-19 according to the who is congruent with studies by other authors that have described the difficulty of finding measures promoted by the who to prevent other infectious diseases, such as influenza, on the internet [26] . in fact, this limited availability of information was also described by basch [17] , who, after evaluating 100 youtube videos on covid-19 (86 in english and 14 in spanish), stated that the videos reported maintaining social distance, hand washing, and respiratory hygiene as fundamental prevention measures in only 31, 26, and 14 videos, respectively [17] . however, the fact that this study did not provide disaggregated information according to the language of the video limits the validity of making comparisons with our results, given that, as previously discussed in other works, it is common for videos in english to provide information on preventive measures against infectious diseases less frequently than videos in spanish [27] . our study is the first to provide data on infodemics related to the prevention of covid-19 detected specifically in youtube videos in spanish. in particular, hoaxes were detected in 10.9% of the videos. such findings could be used in educational campaigns to correct misinformation about covid-19 in spanish. the fight against this pandemic is also a fight against infodemics. nowadays, misinformation is an important problem; people do not tend to critically assess the information they read [5] . dispersing misinformation can create agitation; can cause fear, panic shopping, and taking drugs without a medical prescription; and can ultimately diminish preventive measures [5, 28] . misinformation on covid-19 is rife, especially on social media [29] . studies on this have been done on twitter and the internet. in particular, kouzy [30] analyzed 673 tweets related to covid-19 and found misinformation in 24.8%. cuan [5] compared information about the new coronavirus available on 36 websites with information from a medical bibliography, finding that 15 websites gave true information, 16 gave partially true information, and 5 gave false information compared to the medical literature present in pubmed. the study of misinformation about covid-19 in youtube videos has also been carried out, although only from videos in english. li [31] evaluated 69 youtube videos in english and detected that 19 (27.5%) contained misinformation. however, this author did not specify examples of misinformation related to the preventive measures of covid-19 in his publication, a fact that limits the possibility of making detailed comparisons with the findings of this study. social media providers are trying to filter out fake news, but this has not stopped the conspiracy theorists, swindlers, and liars on the internet [5] , as we have detected in our study. scientific information about covid-19 flows freely in the networks, but it must be accompanied by proper interpretation by the media and internet users. however, for users with nonmedical education, it is difficult to judge the reliability of health information on the internet [5] . for these reasons, and in this context, the who has recently provided information on its website to counteract various hoaxes about covid-19, explaining, for example, that exposing yourself to the sun or to temperatures higher than 25°c does not prevent covid-19, taking a hot bath does not prevent transmission of the new coronavirus disease, and that there is no evidence that eating garlic has protected people from the new coronavirus [32] . in any case, to combat misinformation in social media, more ambitious strategies must be adopted. according to bastani and bahrami [33] , such strategies would include the following: supervision of online content via regulation setting and the creation of a legal framework, identification of acommunity's information needs related to covid-19, participation of specialists and providers of health institutions in generating valid and credible information, and facilitation of the dissemination of evidence-based information [33] . with regard to authorship, the finding that the majority of videos were produced by mass media (60.0%) supports what has been found in previous studies carried out to date on covid-19 in youtube videos, in which the mass media were found to have produced 85.0% [17] and 75.4% [34] of the videos evaluated. given that our work found that, in general, the probability of finding information on the basic preventive measures of covid-19 is lower in videos produced by mass media, mass media must be urged to assume responsibility for providing correct and complete information and creating understanding among citizens [35] . in addition, since the highest probability of obtaining information on basic prevention measures for covid-19 was obtained from videos by health professionals, which confirms findings in other studies regarding the reliability of information in the videos of such professionals [2, 36] , spanish-speaking users should be encouraged to consult videos produced by health professionals when looking for information on youtube on how to prevent covid-19. furthermore, implementing and evaluating the effectiveness of this behavior could be the subject of future research. no specific differences were found according to the country of origin of the video. this could be explained by the fact that although the local situation in terms of the type of transmission of covid-19 was variable [14] , the basic prevention measures studied are recommended to be applied worldwide. among the limitations of our study, one that stands out is that it is intrinsic to the internet, since online information is constantly changing, and this type of research is limited to the information available at the specific time it is analyzed [3, 9, 10, 17, 27, 34] . in addition, the search terms were chosen by the authors on the assumption that a spanish-speaking user would probably use one of them to perform simple searches on youtube regarding covid-19 prevention measures. the number of videos evaluated, although somewhat less than that used by some other authors (142) [37] , is greater than that used in most studies of this type [6, [9] [10] [11] 17, 19, 31, 34] , in which less than 114 videos are usually included. in any case, our sample was sufficient to obtain accurate results (with narrow confidence intervals). this work shows that, a week after covid-19 was considered a pandemic, the information in youtube videos in spanish about the basic measures to prevent covid-19 according to the who was incomplete and differed according to the type of authorship. in addition, such videos had rarely been viewed. this represents an alarming finding, given that a key element in controlling the spread of this disease is that people know what to do to prevent it, since people cannot implement disease control measures if they do not know them. this is perhaps a lesson to be learned from this crisis. thus, for future pandemics, there is an urgent need for early training of the population in basic prevention measures. the key to this is to disseminate information on prevention measures recommended by the who more frequently and to promote its consult with particular emphasis on spanish-speaking users consulting youtube videos produced by health professionals. international telecommunications union/unesco. the state of broadband 2017: broadband catalyzing sustainable development covid-19: the doctors turned youtubers what arguments on vaccinations run through youtube videos in italy? a content analysis youtube videos as a source of information on colorectal cancer: what 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attribution (cc by) license key: cord-003640-psnec2qp authors: mbareche, hamza; veillette, marc; pilote, jonathan; létourneau, valérie; duchaine, caroline title: bioaerosols play a major role in the nasopharyngeal microbiota content in agricultural environment date: 2019-04-16 journal: int j environ res public health doi: 10.3390/ijerph16081375 sha: doc_id: 3640 cord_uid: psnec2qp background: bioaerosols are a major concern for public health and sampling for exposure assessment purposes is challenging. the nasopharyngeal region could be a potent carrier of long-term bioaerosol exposure agents. this study aimed to evaluate the correlation between nasopharyngeal bacterial flora of swine workers and the swine barns bioaerosol biodiversity. methods: air samples from eight swine barns as well as nasopharyngeal swabs from pig workers (n = 25) and from a non-exposed control group (n = 29) were sequenced using 16s rrna gene high-throughput sequencing. wastewater treatment plants were used as the industrial, low-dust, non-agricultural environment control to validate the microbial link between the bioaerosol content (air) and the nasopharynxes of workers. results: a multivariate analysis showed air samples and nasopharyngeal flora of pig workers cluster together, compared to the non-exposed control group. the significance was confirmed with the permanova statistical test (p-value of 0.0001). unlike the farm environment, nasopharynx samples from wastewater workers did not cluster with air samples from wastewater treatment plants. the difference in the microbial community of nasopharynx of swine workers and a control group suggest that swine workers are carriers of germs found in bioaerosols. conclusion: nasopharynx sampling and microbiota could be used as a proxy of air sampling for exposure assessment studies or for the determination of exposure markers in highly contaminated agricultural environments. the microbial flora of aerosols, referred to as bioaerosols, consists of a combination of viable and non-viable microorganisms (e.g., bacteria, fungi and viruses) and derived compounds of biological origin (e.g., animal and plant debris, endotoxins, exotoxins, and other microbial metabolites) [1] [2] [3] . bioaerosols are ubiquitous in indoor and outdoor environments and are generated from various natural and/or anthropogenic sources. composed of particles ranging in size from a few nanometers to 200 µm in diameter, bioaerosols remain suspended in the air for long periods of time and may travel many kilometers depending on the size of the particle [1, [4] [5] [6] [7] [8] . therefore, the dispersal of bioaerosols may impact the air quality of extensive areas that are far from the source and can create public health issues, due to the presence of highly diverse and dynamic microbial communities. beyond affecting the time that particles remain suspended and the distances they travel, particle size plays a role in human diseases, as it dictates which pathway the particle follows in the respiratory tract after inhalation [9] . for example, particles with a size of 4 µm to 10 µm tend to get deposited in the upper airways, while larger particles may remain in the nasal cavity [10, 11] . bioaerosols can be a transmission vector for infectious diseases and are responsible for a variety of health problems, principally through inhalation [9, [12] [13] [14] [15] . human exposure to bioaerosols is associated with a wide variety of acute and chronic diseases ranging from allergies, asthma, rhinitis, sinusitis and bronchitis, mostly due to occupational exposure [4, [16] [17] [18] [19] . however, health risks from bioaerosols also exist just from living in close proximity to an intensive source of airborne biological particles [20, 21] . additionally, other health problems linked to bioaerosols include fatigue, headache, mucous membrane irritation syndrome, nasal congestion, sore throat, and irritation of the nose and eyes [17, 22, 23] . the industrial environment is the main source of occupational health issues, due to the presence of raw organic materials, the prevalence of operations releasing harmful bioaerosols (e.g., mechanical operations such as wood planning, straw chopping, animal bedding, hay handling, and compost pile turning) and the eventual large amounts of bioaerosols present in confined spaces. for example, biowaste facilities are characterized by notable concentrations of bioaerosols, due to the intense microbial activity involved in waste degradation and the activities performed by workers [24] [25] [26] [27] . wastewater treatment plants (wwtps) represent another environment where workers are subject to bioaerosol exposure, due to the steps required for the treatment of discharged municipal and industrial effluents [28, 29] . intensive animal farming practices in confined buildings that hold a large number of animals (e.g., pigs, poultry, cattle) are also associated with extreme exposure to airborne microbes. the variety of possible sources (e.g., animals, feces, feed, litter) present at farms leads to the emission of complex mixtures of biological particles [30] [31] [32] [33] [34] [35] . moreover, the dynamic nature of the microbial composition makes health risk evaluation complicated for farm workers and nearby residents [36, 37] . environmental hygienists continue to insist that insufficient exposure assessments are a primary reason for the absence of bioaerosol exposure limits and strategies to mitigate risk [35, 38] . there are several challenges and limitations to measuring bioaerosol exposure. the type of sampler, time and duration of sampling, meteorological conditions [39] , and geographical positions all affect bioaerosol sampling efficiency, making it difficult to compare studies and limiting collaboration efforts in bioaerosol exposure studies. an added challenge in terms of measuring microbial diversity is that culture-dependent analytical approaches recuperate the cultural/viable portion of bioaerosols exclusively. in contrast, high-throughput sequencing (hts) methods are associated with a more in-depth characterization of the microbial content of a sample [26, 27, [40] [41] [42] [43] . to overcome the aforementioned challenges, the scientific community that studies aerosols has identified the need to explore new alternatives and complementary approaches for assessing bioaerosol exposure, such as identifying markers that can help classify environments based on human health risks [44] [45] [46] . the upper respiratory tract, which includes the nasal cavity and the nasopharynx and is a primary pathway for inhaled air, is an important niche for transient environmental bacteria and for colonization. previous studies have already used nasopharynx or nasal cavity samples to look for specific microorganisms, using culture-based approaches [11, 47] , or revealed the presence of bacterial resistance genes, using molecular biology approaches [33] . recently, an hts approach was used on samples from the anterior and posterior cavity of the nose to study the bacterial diversity of individuals [48] . however, because the microflora in the nasal cavity is dynamic and fluctuant [49] , a region like the nasopharynx may represent a more long-term reservoir of inhaled bioaerosols. to the best of our knowledge, no study has ever used a 16s rrna amplicon-based hts approach to investigate the microbial diversity of nasopharyngeal flora, in order to assess occupational exposure. microbiome studies that use upper respiratory tract tissue and focus on specific pathologies (such as asthma, chronic obstructive pulmonary disease and chronic rhinosinusitis) may underestimate the effect of occupational exposure on the microbiomes of the subjects examined in those studies. we hypothesis that the microbiome of patients with respiratory disease is most likely affected by exposure to their work environment in addition to disease, rather than to disease alone. this study aims to contribute to the development of a new alternative method for assessing bioaerosol exposure, by linking the nasopharyngeal flora of pig farm workers to the bioaerosol microbial composition of their occupational environment, and to explore the role of bioaerosols in the nasopharyngeal microbial content. the 16s rrna amplicon-based hts approach was used to determine bacterial diversity, while qpcr was used to evaluate the presence of human pathogenic agents and bacterial resistance genes in bioaerosols and in nasopharyngeal samples from pig workers. additionally, wwtps were used as the industrial, low-dust, non-agricultural environment control to validate the microbial link between the bioaerosol content (air) and the nasopharynxes of workers. although the experiment focused on pig farmers and the buildings that they work in, the results may have implications for a wider population of agricultural workers. consequently, nasopharynx samples could be used as proxies for air samples in exposure assessment studies and for the determination of exposure markers in agricultural settings. in addition, the study advocates for the need of systematic bioaerosol exposure study when evaluating the nasopharyngeal microbiota. air samples were collected from eight confined pig buildings in eastern canada during fall/winter 2015. inside each farm building, a sampling site was designated based on worker activities and bioaerosol exposure. the buildings visited were mechanically ventilated and contained between 800-1200 pigs each weighing between 90-120 kg. there were no obvious signs of illness affecting the animals. air samples were collected from eight wwtps in the province of quebec, located in eastern canada, the during summer and winter seasons. summer visits occurred between september 2015 and july 2016, and winter visits occurred between february 2015 and march 2016. four sampling sites were chosen depending on the wastewater treatment process (screening, de-gritting/degreasing, settling tank, and bio-filtration), workers' daily tasks, and the level of confinement of the space. a liquid cyclonic impactor coriolis µ biological air sampler (bertin corp., rockville, md, usa) was used for collecting air samples. the samplers were set at 300 l/min for 10 min (3 m 3 of air per sample), placed within 1-2 m of the bioaerosol source and away from any turbulent air flow (e.g., away from building exhaust fans). fifteen milliliters of a phosphate buffer saline (pbs) solution (0.0067 m, ph 7.4, lonza, walkersville, md, usa) were used as the collecting solution. nasopharyngeal samples were taken from 29 controls (university students and staff never exposed to animal farms), 25 pig farmers and 12 wwtp workers between the fall of 2015 and spring 2017. all controls, pig farmers, and wwtp workers were non-smokers and none were taking antibiotics. the protocol was approved by the ethics committee of the institut universitaire de cardiologie et de pneumologie de québec (cer21221). nasopharyngeal samples were collected by a nurse using swabs (puritan ® hydraflock ® collection devices, guilford, ma, usa) with a dry secure transport system. briefly, a swab was inserted into the nose until a resistance was felt and then turned a few times before it was removed. samples were transported to the laboratory at 4 • c. from the 15 ml collecting solution of the coriolis µ biological air sampler (bertin corp.), a 1.5 ml aliquot was centrifuged for 10 min at 14,000× g (j. pilote protocol = 3 ml aliquot, 10 min, 21,000× g). the supernatant was discarded and the pellets were kept at −20 • c until dna extraction. likewise, the tips of the swabs were cut and vortexed thoroughly in 1 ml pbs (lonza) and discarded. suspensions were then centrifuged for 10 min at 21,000× g, the supernatants were discarded and the pellets were stored at −20 • c until dna extraction. total genomic dna from air and nasopharyngeal samples was extracted with a powerlyser ® powersoil isolation dna kit (mo bio laboratories, carlsbad, ca, usa) following the manufacturer's instructions. dna samples were stored at −20 • c until subsequent analyses. the amplification of targeted genes, equimolar pooling, and sequencing were performed at the plateforme d'analyses génomiques (ibis, université laval, québec, qc, canada). the 16s rrna v6-v8 region was amplified using the sequence-specific regions described in comeau et al. 2011 using a two-step dual-indexed pcr approach, specifically designed for illumina ® instruments, san diego, ca, usa [50] . the gene-specific sequence was first fused to the illumina ® truseq sequencing primers and pcr was carried out in a total volume of 25 µl containing 1 × q5 buffer (neb, ipswish, ma, usa), 0.25 µm of each primer, 200 µm of each of the dntps, 1 u of q5 high-fidelity dna polymerase (neb) and 1 µl of template dna. pcr thermoprotocol began with an initial denaturation at 98 • c for 30 s followed by 35 cycles of denaturation at 98 • c for 10 s, annealing at 55 • c for 10 s, extension at 72 • c for 30 s and a final extension at 72 • c for 2 min. the pcr reaction was purified using the axygen pcr cleanup kit (axygen ® , waltham, ma, usa). the quality of the purified pcr product was checked on a 1% agarose gel. a fifty to 100-fold dilution of the purified product was used as a template for a second round of pcr in order to add barcodes (dual-indexed) and for missing sequences required for illumina sequencing. the thermoprotocol for the second pcr was identical to the first one but with 12 cycles. pcr reactions were purified again in the same way as above, checked for quality on a dna7500 bioanalyzer chip (agilent ® , santa clara, ca, usa) and then quantified spectrophotometrically with the nanodrop ® 1000 (thermo fisher scientific, waltham, ma, usa). barcoded amplicons were pooled in equimolar concentrations for sequencing on the illumina ® miseq machine. the oligonucleotide sequences that were used for pcr amplification are presented in table 1 . briefly, after de-multiplexing the raw fastq files, the reads generated from the paired end sequencing were combined using the make.contigs script from mothur [51] . quality filtering was also performed with mothur, using the screen.seqs script to discard homopolymers, reads with ambiguous sequences, and reads with suspiciously short lengths. similar sequences were gathered together in order to reduce the computational burden, and the number of copies of the same sequence was displayed to monitor the abundance of each sequence. this de-replication step was performed with vsearch [52] . the sequences were then aligned with the bacterial reference silva core alignment using the qiime script align_seqs.py [53] . operational taxonomic units (otus), with a 97% similarity cut-off, were clustered using the uparse method implemented in vsearch. uchime was used to identify and remove the chimeric sequences [54] . qiime was used to assign taxonomy to otus based on the silva database reference training dataset for taxonomic assignment and to generate an otu table. a metadata-mapping file was produced that includes information about air and nasopharyngeal samples. the microbial diversity analyses, including statistical analyses, conducted in this study, were achieved using qiime plugins in version 1.9.0 as described in qiime scripts (http://qiime.org/scripts/). the names of the scripts used are mentioned in the results section of each analysis. pcr was performed with cfx-96 and cfx-384 touch™ real-time pcr detection systems (bio-rad laboratories, mississauga, on, canada) to evaluate the presence of six human pathogens (clostridium difficile, listeria monocytogenes, mycobacterium avium, salmonella spp., staphylococcus aureus, and methicillin-resistant staphylococcus aureus (mrsa)), and antibiotic and metal resistance genes (cephalosporin, colistin, zinc). the pcr mixture contained 2 µl of dna template, 150-300 nm for each primer, 100-125 nm probe and 10 µl of 2 × iq™ supermix or iq™ sybr ® green supermix (bio-rad laboratories) in a 20 µl reaction mixture. the results were analyzed using bio-rad cfx manager software, version 3.1 (bio-rad laboratories). positive control and standard curves ranging from 1 × 10 6 to one copy of the targeted genes were used for each protocol using genomic dna or synthetic genes as templates (integrated dna technologies, coralville, ia, usa). negative controls were included in the plates as ntc (non-template controls). all primers and probes were purchased from integrated dna technologies. the primers, probes, hybridization temperatures, amplicon sizes and original references for all targeted genes are listed in pilote et al. 2019 [55] . for alpha diversity measures, the normality was verified using the d'agostino and pearson omnibus normality test. the assumption of data normality was not fulfilled. non-parametric mann-whitney u tests (two-tailed) were performed to highlight that there are significant differences in diversity measures between the groups of samples. a p-value ≤0.05 was considered statistically significant. all of the results were analyzed using the software graphpad prism 5.03 (graphpad software, inc., san diego, ca, usa). to determine the statistical significance of the variation in the observed microbial community composition with multivariate analyses (pcoa), a permanova test was performed on the unweighted unifrac matrix. the compare_categories.py qiime script was used to generate the statistical results. because permanova is a non-parametric test, significance is determined through permutations. in this case, 999 permutations were used. a p-value ≤0.05 was considered to be statistically significant. detailed information about the performance of the test is presented in the multivariate section of the results. the non-parametric mann-whitney u test was used to ascertain whether or not differences in otu abundances were statistically significant between the controls and pig farmers. to test otu differential abundance, the null hypothesis was that the populations that the two groups of samples were collected from have equal means. the range of p-values obtained for the 30 most differentially abundant otus between the control samples and the pig farmer samples are presented in the differential abundance section of the results. this study used both positive and negative controls. the negative controls include unused swabs that underwent the same extraction protocol as the swabs collected from the subjects of this study. a pcr amplification targeting the 16s rrna genes allowed us to confirm the very low biomass of the negative controls compared to the nasopharyngeal swabs from the pig workers and non-exposed controls. for this reason, negative controls did not pass the next step of illumina hts. additional negative controls consisted of outdoor air samples that were taken outside the pig buildings sampled in this study. these samples showed enough concentration of bacterial biomass with the pcr amplification. thus, outdoor negative controls were sequenced. however, the number of reads and subsequent otu clustering was low compared to the indoor air samples. during the rarefaction step, the negative controls were not included in the analyses due to a low number of sequences. the goal is to have a number of sequences per sample deep enough to cover most of the bacterial diversity. positive controls consisted of a mock community containing equal concentrations of 20 bacteria purchased from atcc (20 strain even mix genomic material atcc ® msa-1002 tm ). sequencing of the mock community showed a taxonomic profile resembling the expected microbial community, but with different relative abundances. in total, 8 air samples from pig buildings, 25 nasopharynx samples from farmers and 29 nasopharynx samples from the non-exposed control group resulted in 2,942,265 sequences (air samples = 39,425; farmers = 1,900,800, controls = 1,002,040). following quality filtering and the discarding of singletons, 1,425,981 unique sequences clustered into 6060 otus. representing the non-agricultural control environment (wwtps), 1,190,166 sequences came from 8 air samples (98,285) and 12 nasopharynx samples (1,091,881) from plant workers. after quality filtering and the removal of singletons, 51,969 unique sequences clustered into 2188 otus. a rarefaction analysis was performed to validate the sequencing depth and to confirm the effective sampling of the microbial diversity using the alpha_rarefaction.py qiime script. the lowest-depth sample parameter was used for the rarefaction analyses, allowing equal numbers of sequences for all samples. therefore, the samples with a sequencing depth lower than the reference sample were excluded from the analyses. the higher the sequencing depth, the more likely that the full diversity coverage is attained. the sequencing depth was 15,000 sequences for all the groups of samples: the air samples from pig buildings, the nasopharyngeal samples of pig farmers and non-exposed controls. the points shown in figure 1 were calculated as follows: ten values from 10 to 15,000 analyzed sequences were randomly selected. for each of these values, the corresponding number of otus observed, was noted for all of the samples. then, the average number of otus observed, plus or minus one standard deviation, were calculated for each of the ten values. the samples were divided into three groups: air from pig buildings, pig farmers and non-exposed controls. the slope of the curves shows sufficient sequencing depth and good bacterial coverage in all samples. moreover, pig farmers and air samples showed the highest average number of otus compared to non-exposed controls. four indexes were used to measure alpha diversity using the alpha_diversity.py script: chao1 richness estimator (the higher the number of otus in a sample, the higher the value of the chao1 index). for a more detailed explanation about richness estimate calculation, please refer to http://chao.stat.nthu.edu.tw/wordpress/paper/119.pdf. in shannon and simpson diversity measures, richness is combined with abundance to obtain an evenness measure. simpson values are bounded between 0 and 1, where 1 represents the most diverse case. shannon values are bounded between 0 and 10, where 10 represent the highest diversity) and phylogenetic diversity (pd) whole tree (quantitative measure of phylogenetic diversity; the higher the value, the higher the diversity; no limit value). the nasopharynx samples from pig farmers consistently showed the highest richness estimates and diversity measure values, whereas non-exposed controls displayed the lowest values (figure 2a-d) . the difference between the two groups of samples was significant (chao1 p = 0.000001; shannon p = 0.000009; simpson p = 0.00004; pd whole tree p = 0.000006). the richness estimates and diversity measures in the air samples were nearly as high as the pig farmer nasopharynx samples, although the measures from the pig farmer samples were statistically higher (chao1 p = 0.00001; shannon p = 0.0002; simpson p = 0.001; pd whole tree p = 0.00002). the difference between the air samples from pig buildings and non-exposed controls (nasopharynx) was significant as well (chao1 p = 0.00005; shannon p = 0.00001; simpson p = 0.00007; pd whole tree p = 0.000009). four indexes were used to measure alpha diversity using the alpha_diversity.py script: chao1 richness estimator (the higher the number of otus in a sample, the higher the value of the chao1 index). for a more detailed explanation about richness estimate calculation, please refer to http://chao.stat.nthu.edu.tw/wordpress/paper/119.pdf. in shannon and simpson diversity measures, richness is combined with abundance to obtain an evenness measure. simpson values are bounded between 0 and 1, where 1 represents the most diverse case. shannon values are bounded between 0 and 10, where 10 represent the highest diversity) and phylogenetic diversity (pd) whole tree (quantitative measure of phylogenetic diversity; the higher the value, the higher the diversity; no limit value). the nasopharynx samples from pig farmers consistently showed the highest richness estimates and diversity measure values, whereas non-exposed controls displayed the lowest values (figure 2a-d) . the difference between the two groups of samples was significant (chao1 p = 0.000001; shannon p = 0.000009; simpson p = 0.00004; pd whole tree p = 0.000006). the richness estimates and diversity measures in the air samples were nearly as high as the pig farmer nasopharynx samples, although the measures from the pig farmer samples were statistically higher (chao1 p = 0.00001; shannon p = 0.0002; simpson p = 0.001; pd whole tree p = 0.00002). the difference between the air samples from pig buildings and non-exposed controls (nasopharynx) was significant as well (chao1 p = 0.00005; shannon p = 0.00001; simpson p = 0.00007; pd whole tree p = 0.000009). an ecological analysis was conducted to reveal the variation in the community composition between the three sample groups (nasopharynx of pig farmers and non-exposed controls and air from pig farms). the weighted unifrac distance metric was used to calculate the pairwise distances between samples using the beta_diversity.py script. the distance matrix was then transformed into coordinates using the principal_coordinates.py script and inter-samples distances were represented in a two-dimensional (2d) space using ordination. the samples closer to one another were more similar than those ordinated further apart. the principal coordinate analysis (pcoa) was used to visualize bacterial community variation (make_2d_plots.py). figure 3a shows the two principal coordinate axes capturing a total of 35.48% of the variation observed. a distinct clustering of pig farmers, nonexposed controls, and air samples from pig buildings is also illustrated in that figure. the profiles of pig farmers were more similar to the profiles of air samples than to the profiles of non-exposed controls. the distinct clustering was confirmed by the per-mutational multivariate analyses of variance (permanova p = 0.0001). the same statistical test was used to confirm the non-significant clustering of air and pig farmer (nasopharynx) samples, as the test showed a non-significant difference (permanova p = 0.08). interestingly, air samples from the pig buildings seemed to display less dispersion amongst its individuals than the farmers and non-exposed groups, indicating a more homogenous bacterial community structure. we used a phylogram that displays sample clustering, using the unweighted pair group method, with arithmetic mean to confirm the sample clustering observed with the pcoa analyses ( figure 3b ). an ecological analysis was conducted to reveal the variation in the community composition between the three sample groups (nasopharynx of pig farmers and non-exposed controls and air from pig farms). the weighted unifrac distance metric was used to calculate the pairwise distances between samples using the beta_diversity.py script. the distance matrix was then transformed into coordinates using the principal_coordinates.py script and inter-samples distances were represented in a two-dimensional (2d) space using ordination. the samples closer to one another were more similar than those ordinated further apart. the principal coordinate analysis (pcoa) was used to visualize bacterial community variation (make_2d_plots.py). figure 3a shows the two principal coordinate axes capturing a total of 35.48% of the variation observed. a distinct clustering of pig farmers, non-exposed controls, and air samples from pig buildings is also illustrated in that figure. the profiles of pig farmers were more similar to the profiles of air samples than to the profiles of non-exposed controls. the distinct clustering was confirmed by the per-mutational multivariate analyses of variance (permanova p = 0.0001). the same statistical test was used to confirm the non-significant clustering of air and pig farmer (nasopharynx) samples, as the test showed a non-significant difference (permanova p = 0.08). interestingly, air samples from the pig buildings seemed to display less dispersion amongst its individuals than the farmers and non-exposed groups, indicating a more homogenous bacterial community structure. we used a phylogram that displays sample clustering, using the unweighted pair group method, with arithmetic mean to confirm the sample clustering observed with the pcoa analyses ( figure 3b) . the clustering (air from pig buildings and pig farmers together, versus the non-exposed controls) was statistically significant as confirmed by the permanova test (p-value = 0.0001). given the observed difference in the number of bacterial otus, evenness, and evolutionary distance (alpha diversity) and in the bacterial community composition (beta diversity) in samples of the nasopharyngeal flora of farmers and non-exposed individuals and bioaerosols, collected in pig buildings, the next step was to reveal the taxonomic profiles of the three groups. figure 4 shows the taxonomic distribution of the bacterial phyla across the three groups of samples. overall, actinobacteria, proteobacteria, bacteriotedes, and firmicutes dominated the three profiles, representing more than 95% of the taxonomic abundance. however, major differences distinguished the pig farmer samples from the non-exposed controls. in the latter, actinobacteria and proteobacteria were the most abundant phyla (relative abundances of 35%, and 24%, respectively). however, in farmers, firmicutes and bacteriotedes were the most dominant phyla with relative abundances of 40%, and 24%, respectively. consistent with the previous analyses, air samples from pig farms had different relative abundances values, but comparable profiles (with the same conclusions) to the nasopharyngeal flora of farmers, with a dominance of firmicutes (83%), followed by bacteriotedes (11%). actinobacteria, and proteobacteria had a relative abundance of less than 5% in bioaerosol samples. notably, spirochaetes, tenericutes, and verrumicrobia were detected only in farmers and the air from pig buildings. the clustering (air from pig buildings and pig farmers together, versus the non-exposed controls) was statistically significant as confirmed by the permanova test (p-value = 0.0001). given the observed difference in the number of bacterial otus, evenness, and evolutionary distance (alpha diversity) and in the bacterial community composition (beta diversity) in samples of the nasopharyngeal flora of farmers and non-exposed individuals and bioaerosols, collected in pig buildings, the next step was to reveal the taxonomic profiles of the three groups. figure 4 shows the taxonomic distribution of the bacterial phyla across the three groups of samples. overall, actinobacteria, proteobacteria, bacteriotedes, and firmicutes dominated the three profiles, representing more than 95% of the taxonomic abundance. however, major differences distinguished the pig farmer samples from the non-exposed controls. in the latter, actinobacteria and proteobacteria were the most abundant phyla (relative abundances of 35%, and 24%, respectively). however, in farmers, firmicutes and bacteriotedes were the most dominant phyla with relative abundances of 40%, and 24%, respectively. consistent with the previous analyses, air samples from pig farms had different relative abundances values, but comparable profiles (with the same conclusions) to the nasopharyngeal flora of farmers, with a dominance of firmicutes (83%), followed by bacteriotedes (11%). actinobacteria, and proteobacteria had a relative abundance of less than 5% in bioaerosol samples. notably, spirochaetes, tenericutes, and verrumicrobia were detected only in farmers and the air from pig buildings. the relative abundance of taxa was more thoroughly analyzed by examining the most abundant bacterial classes across the three groups of samples ( figure 5 ). similar to the phyla profiles, the class profiles showed notable differences between non-exposed controls and farmers/air from pig buildings. in the former, actinobacteria (39%), saprospirae (23%), bacilli (11%), gammaproteobacteria (10%) and betaproteobacteria (8%) represented more than 90% of the taxonomic profile. however, the profile from farmers was more evenly distributed. clostridia had the highest relative abundance (24%) followed by saprospirae (19%), bacilli (18%) and actinobacteria (11%). unlike the non-exposed control group, gammaproteobacteria and betaproteobacteria represented less than 10% of the profile, whereas bacteroidia represented 10% of the relative abundance. in the non-exposed control group, bacteroidia represented 0.7% of the taxonomic profile. in air samples, clostridia, bacilli and bacteroidia dominated the profile representing more than 90% of the relative abundance, thus confirming the previous observations about the similarity between the flora from pig farmers and air samples. interestingly, the presence of coriobacteria, erysipelotrichi, spichaetes, mollicutes, sphyngobacteria, epsilonproteobacteria, and verruco-5 was exclusive to samples from the nasopharynx of pig farmers and sampled bioaerosols. the relative abundance of taxa was more thoroughly analyzed by examining the most abundant bacterial classes across the three groups of samples ( figure 5 ). similar to the phyla profiles, the class profiles showed notable differences between non-exposed controls and farmers/air from pig buildings. in the former, actinobacteria (39%), saprospirae (23%), bacilli (11%), gammaproteobacteria (10%) and betaproteobacteria (8%) represented more than 90% of the taxonomic profile. however, the profile from farmers was more evenly distributed. clostridia had the highest relative abundance (24%) followed by saprospirae (19%), bacilli (18%) and actinobacteria (11%). unlike the non-exposed control group, gammaproteobacteria and betaproteobacteria represented less than 10% of the profile, whereas bacteroidia represented 10% of the relative abundance. in the non-exposed control group, bacteroidia represented 0.7% of the taxonomic profile. in air samples, clostridia, bacilli and bacteroidia dominated the profile representing more than 90% of the relative abundance, thus confirming the previous observations about the similarity between the flora from pig farmers and air samples. interestingly, the presence of coriobacteria, erysipelotrichi, spichaetes, mollicutes, sphyngobacteria, epsilonproteobacteria, and verruco-5 was exclusive to samples from the nasopharynx of pig farmers and sampled bioaerosols. a non-parametric mann-whitney u test, was used to analyze count data and determine the species most significantly associated with farming. the test compares otu frequencies in groups of samples and ascertains if there are statistically different otu abundances between the two groups of samples. the mann-whitney u test uses absolute data counts rather than relative abundances. more specifically, the output of the test contains the test statistic, the p-value corrected for multiple comparisons, and a mean count for each otu in the given sample group. this test was used following instructions from the group_significance.py qiime script. the thirty taxa (identified to the species or genera) with the greatest significant differences in counts between samples from pig farmers and non-exposed controls are presented in figure 6 . however, to better visualize and emphasize the most striking cases of differential abundance, the list is not exhaustive. the complete results output of differential abundance is presented in additional file 1 (supplementary material). it represents the results of the mann-whitney u test to determine the statistical differential abundance of taxa in nasopharynx of workers and non-exposed controls. the test was applied to sequences using qiime script (group_significance.py) with the mann-whitney u test option. the taxonomy represent bacteria from the nasopharynx samples. notably, some taxa were identified only to class or family, as those were the highest levels of identification possible using the silva database. p-values were corrected for multiple comparisons using the bonferroni correction. values ranged from 0.0000007 to 0.0001 for the 15 differentially abundant taxa, from pig farmer samples, and from 0.000002 to 0.0005 for the 15 differentially abundant taxa, from non-exposed controls. the most notable imbalance was observed for the class clostridia with a mean count of more than 800 sequences in pig farmer samples and less figure 5 . taxonomic profile showing the relative abundance of each bacterial class across nasopharyngeal flora samples from pig farmers, non-exposed controls and air samples from pig buildings. taxa written in bold type were specific to farmers and air from pig buildings. a non-parametric mann-whitney u test, was used to analyze count data and determine the species most significantly associated with farming. the test compares otu frequencies in groups of samples and ascertains if there are statistically different otu abundances between the two groups of samples. the mann-whitney u test uses absolute data counts rather than relative abundances. more specifically, the output of the test contains the test statistic, the p-value corrected for multiple comparisons, and a mean count for each otu in the given sample group. this test was used following instructions from the group_significance.py qiime script. the thirty taxa (identified to the species or genera) with the greatest significant differences in counts between samples from pig farmers and non-exposed controls are presented in figure 6 . however, to better visualize and emphasize the most striking cases of differential abundance, the list is not exhaustive. the complete results output of differential abundance is presented in additional file 1 (supplementary materials). it represents the results of the mann-whitney u test to determine the statistical differential abundance of taxa in nasopharynx of workers and non-exposed controls. the test was applied to sequences using qiime script (group_significance.py) with the mann-whitney u test option. the taxonomy represent bacteria from the nasopharynx samples. notably, some taxa were identified only to class or family, as those were the highest levels of identification possible using the silva database. p-values were corrected for multiple comparisons using the bonferroni correction. values ranged from 0.0000007 to 0.0001 for the 15 differentially abundant taxa, from pig farmer samples, and from 0.000002 to 0.0005 for the 15 differentially abundant taxa, from non-exposed controls. the most notable imbalance was observed for the class clostridia with a mean count of more than 800 sequences in pig farmer samples and less than 10 sequences in the non-exposed controls. staphylococcus epidermis was present with a mean count of 1000 sequences in non-exposed individuals and less than 100 sequences in pig farmers. other important examples related to human health include, the greater differential abundance of haemophilus influenzae in non-exposed controls (950 sequences in non-exposed control samples vs. 5 in samples from pig farmers), and the differential abundance of klebsiella in samples from pig farmers (400 sequences in pig farmer samples vs. 3 in non-exposed controls). than 10 sequences in the non-exposed controls. staphylococcus epidermis was present with a mean count of 1000 sequences in non-exposed individuals and less than 100 sequences in pig farmers. other important examples related to human health include, the greater differential abundance of haemophilus influenzae in non-exposed controls (950 sequences in non-exposed control samples vs. 5 in samples from pig farmers), and the differential abundance of klebsiella in samples from pig farmers (400 sequences in pig farmer samples vs. 3 in non-exposed controls). figure 6 . taxa identified to highest possible taxonomic level with statistically significant differential abundances across pig farmers and non-exposed controls. from the bottom to the top: the first 15 taxa were the most abundant in samples from farmers and the last 15 were more abundant in nonexposed controls. the taxa written in bold type affect human health. a non-agricultural low-dust control environment (wwtps) was used as a control to validate the link between the microbial composition of nasopharyngeal flora of exposed workers and that of bioaerosols released in the workplace. the nasopharynx samples of the non-exposed controls figure 6 . taxa identified to highest possible taxonomic level with statistically significant differential abundances across pig farmers and non-exposed controls. from the bottom to the top: the first 15 taxa were the most abundant in samples from farmers and the last 15 were more abundant in non-exposed controls. the taxa written in bold type affect human health. a non-agricultural low-dust control environment (wwtps) was used as a control to validate the link between the microbial composition of nasopharyngeal flora of exposed workers and that of bioaerosols released in the workplace. the nasopharynx samples of the non-exposed controls (subjects not previously exposed to any animal farm) were again used for comparison with the nasopharynx samples from wastewater workers and air samples from wwtps. the distances between the groups of samples were compared and visualized using the pcoa approach. similar to the pig farm environment, the pairwise distances were calculated using the weighted unifrac distance metric. figure 7 shows the two principal coordinate axes capturing a total of 24.96% of the variation observed. unlike the farm environment, the nasopharynx samples from wastewater workers did not cluster with air samples from wwtps. in fact, nasopharyngeal flora of wastewater workers and non-exposed controls had similar microbial compositions. the difference between air and nasopharynx samples (controls and wastewater workers) was statistically significant (permanova p = 0.0006). as shown in figure 7 , the difference between non-exposed controls and wastewater workers was not significant (permanova p = 0.1). (subjects not previously exposed to any animal farm) were again used for comparison with the nasopharynx samples from wastewater workers and air samples from wwtps. the distances between the groups of samples were compared and visualized using the pcoa approach. similar to the pig farm environment, the pairwise distances were calculated using the weighted unifrac distance metric. figure 7 shows the two principal coordinate axes capturing a total of 24.96% of the variation observed. unlike the farm environment, the nasopharynx samples from wastewater workers did not cluster with air samples from wwtps. in fact, nasopharyngeal flora of wastewater workers and non-exposed controls had similar microbial compositions. the difference between air and nasopharynx samples (controls and wastewater workers) was statistically significant (permanova p = 0.0006). as shown in figure 7 , the difference between non-exposed controls and wastewater workers was not significant (permanova p = 0.1). principal coordinate analysis plot. the plot shows the distances for the microbiota of three groups of samples: nasopharynx samples from wastewater workers and from non-exposed controls and bioaerosols from wastewater treatment plants (wwtps). the pairwise distances were calculated using the weighted unifrac distance metric. the presence of human pathogens was investigated in the nasopharynx of pig farmers. as noted in table 2 , all of the pathogens were more frequently detected in the pig farmer nasopharynx samples, compared to non-exposed controls, with the exception of salmonella spp. striking examples include, mrsa and clostridium difficile, which were present in the nasopharyngeal flora of 60%, and 12% of pig farmers, respectively. they were found in 10%, and 0% of the non-exposed controls, respectively. principal coordinate analysis plot. the plot shows the distances for the microbiota of three groups of samples: nasopharynx samples from wastewater workers and from non-exposed controls and bioaerosols from wastewater treatment plants (wwtps). the pairwise distances were calculated using the weighted unifrac distance metric. the presence of human pathogens was investigated in the nasopharynx of pig farmers. as noted in table 2 , all of the pathogens were more frequently detected in the pig farmer nasopharynx samples, compared to non-exposed controls, with the exception of salmonella spp. striking examples include, mrsa and clostridium difficile, which were present in the nasopharyngeal flora of 60%, and 12% of pig farmers, respectively. they were found in 10%, and 0% of the non-exposed controls, respectively. listeria monocytogenes was detected in 3% of non-exposed controls and in 24% of pig worker samples. mycobacterium avium was not detected in the nasopharynx samples of either group. likewise, antibiotic and zinc resistance genes were present at a higher frequency among pig farmers compared to non-exposed controls. moreover, cephalosporin, and colistin resistance genes were exclusively detected in the nasopharyngeal flora of pig farmers. table 2 . human pathogens and antibiotic and zinc resistance genes in the nasopharyngeal flora of pig workers compared to non-exposed controls. given the many potential microbial sources, animal farmers inhale a variety of aerosolized bacteria that impact their health [18, 56, 57] . in this study, the bacterial populations in bioaerosols from pig buildings were compared to those of the nasopharyngeal flora of farmers using bioinformatics tools to determine if nasopharynx sampling could be used as a proxy for air sampling in exposure assessment studies. systemic microbial ecology analyses led to unequivocal results with identical conclusions throughout the analyses. the alpha diversity of bacterial species in the air from pig buildings and the nasopharyngeal flora of farmers were not statistically different. the evaluation of species diversity was introduced by whittaker and defined as the number of species and their proportional abundance within one sampling site [58] . there are different ways to measure alpha diversity and an extensive list of indexes has been presented by magurran and mcgill [59] . in addition to the usual chao1 richness estimates and shannon/simpson diversity measures [60] [61] [62] [63] , pd whole tree was also used to analyze the alpha diversity in samples in this study. pd stands for phylogenetic diversity and is defined as the minimum length of all phylogenetic branches required to span a given set of taxa on the phylogenetic tree [64] . all four of the alpha diversity measures revealed greater bacterial richness and diversity in the nasopharyngeal samples from pig farmers compared to non-exposed individuals. the observed similarity between bioaerosols from pig buildings and the nasopharyngeal flora from farmers is indicative of occupational exposure and, consequently, a transient presence and/or possible colonization of the upper respiratory tract regions by environmental bacteria. these findings are even more interesting given that the majority of pig farmers recruited for this study do not work in the eight pig buildings selected for air analysis. this suggests that airborne bacteria associated with pig buildings can take over the microbiota in farmers' nasopharynxes. the establishment of this "new" microbial community could represent a microbial signature for the nasopharynx of pig farmers. also, a higher prevalence of viruses in the nasopharynxes of farmers compared to the non-exposed control group could play a role in the increased alpha-diversity [65] . beta diversity analyses revealed that long-term exposure, such as occupational exposure to bioaerosols in the air of pig buildings, appeared to modify the nasopharyngeal microbiota of farmers. common approaches to evaluating changes in the community composition (beta diversity) rely on the creation of a (dis)similarity matrix to calculate the distance between samples. dis(similarity) matrices may be calculated using different methods depending on the type of dataset, analyses, and the objectives of the study, as some metrics are more suitable than others [66] [67] [68] [69] . the unifrac distance metric was used as efficacy was proven with 16s rrna bacterial genes [70] . in addition, pcoa coupled with permanova offers a robust statistical significance of sample grouping using distance matrices. this non-parametric multivariate analysis of variance separates the distance matrix into sources of variation to describe the robustness and significance of a variable in explaining the variations observed between samples. it is based on the anova experimental design but analyzes the variance and determines the significance by permutations, as it is a non-parametric test [71] . whereas, anova/manova assumes normal distributions and a euclidean distance, permanova can be used with any distance measure. the two analyses led to the same conclusions for this study. therefore their usefulness when used together as a tool to visualize and evaluate sample clustering was confirmed. the distinct clusters formed between the combination of pig farmers, and the air from pig buildings, and non-exposed individuals, is clearly linked to a strong divergence in the nasopharyngeal microbiota of farmers compared to other non-exposed individuals. mechanical deposition of <100 µm diameter inhaled particles on nasopharyngeal surfaces by inertial impaction [72] , represents a continuous source of environmental bacteria to the nasopharynx. this continuous source of bacterial exposure may therefore be responsible for the establishment of a reservoir of bacteria reflecting long-term exposure (e.g., occupational exposure). a thorough understanding of the established bacterial community may then lead to a better evaluation of the risks associated with an environment. for example, domestic animals share some of their microbiota with their human cohabitants, supposedly through frequent and direct contact [73, 74] . song et al., (2013) mention that airborne microbiota plays an important role in microbial transfer to the human upper respiratory tract. ten thousand litres of air are inhaled daily and the bioaerosols in the air may have an effect on the human nasal microbial community [75] . finally, as different farm animals are associated with different microbiota, the normal nasopharyngeal flora of farmers may be differently disturbed. in other words, farmers working with different animals may have a different disturbances of their natural nasopharyngeal flora. therefore, the microbial fingerprint of the nasopharynx may be directly linked to a specific type of farming environment and the potential long-term health effects on farmers. the high abundance of firmicutes and bacteriotedes in pig buildings has been shown [76] [77] [78] . interestingly, the results of this study are consistent with the literature, but with the added information indicating that, these same phyla colonize the nasopharynxes of farmers. more particularly, other studies have previously shown clostridia to be the most abundant class of bacteria in bioaerosols from pig buildings [30] . this study not only confirmed the abundance of clostridia in air samples, but also that this class was the dominant class found in nasopharynx samples, while it was practically absent in non-exposed individuals. clostridium spp., identified as differentially abundant in the farmer nasopharyngeal samples in the present study, comprise potentially pathogenic species [79] . specifically, clostridium butyricum, also differentially abundant in samples from farmers, has been identified as an emerging pathogen by public health authorities. some c. butyricum pathogenic strains were associated with the occurrence of necrotizing enterocolitis, a bowel disease [80] . in addition, prevotella spp., which was strikingly more abundant in nasopharynx samples, is a well-known agent involved in upper respiratory tract infections [81] [82] [83] . moraxella is another genus identified by the differential abundance analyses as being predominant in the nasopharynxes of farmers. like for other taxa identified in this study, strains of moraxella spp. were previously detected as airborne bacteria in pig buildings [84] . the rate of colonization of moraxella spp. in healthy adult populations is around 3% [85] . species of this genus are opportunistic pathogens responsible for upper and lower respiratory tract infections [86] . taxa identified exclusively in nasopharyngeal samples and air samples from pig buildings could be candidates for new markers to assess exposure to bioaerosols in pig farming environments. although, actinobacteria are most abundant in the non-exposed controls, no pathogen was identified in the most abundant taxa presented in figure 6 (except haemophilus influenza). an example of the most abundant actinobacteria in non-exposed control is micrococcus luteus that was differentially more abundant in controls compared to farmers. another example of firmicutes is staphylococcus epidermis that was more abundant in the controls compared to the farmers. the respiratory health of farmers has been of great interest for testing the hygiene hypothesis that stipulates that exposure to microbes from intensive farming during early life could be beneficial to health in adulthood [87, 88] . however, the acceptance of the hygiene hypothesis is not unanimous in the scientific community [89] . in this study, taxa identified as differentially abundant among farmers could hypothetically play a role in the prevention of allergy and the development of atopic diseases. indeed, some bacteria identified through this investigation (e.g., pedobacter, pelomonas, and megasphaera) have been linked to healthy respiratory conditions [90] . a recent study, conducted by kraemer and colleagues, also found a distinct clustering between samples from the nasal cavities of pig farmers and air samples from their workplace, when compared to the nasal cavities of non-exposed individuals [48] . moreover, samples from the nasal cavities of cow farmers clustered separately from pig worker samples and air samples from pig buildings [48] . although the nasal cavity is a more transient environment for environmental bacteria than the nasopharynx, it confirms the hypothesis of a microbial fingerprint specific to the farming environment. it supports the idea of creating a worldwide database, that lists potential markers specific to certain environments, and to the nasopharynxes of the people working in them. this database could represent an important asset for associating bioaerosol exposure with health problems [91] . the lack of a correlation between the nasopharynx of wastewater workers and bioaerosols from wwtps could be explained by the nature and duration of exposure. workers wear personal protective devices (e.g., masks) at certain working sites (e.g., biofiltration), which may affect the establishment of a 'new' environmental microflora. supporting this idea, the most abundant bacteria, shared by non-exposed controls and wastewater workers, are naturally occurring skin bacteria like propionibacterium, corynebacterium, staphylococcus, streptococcus, and cutibacterium. these taxa were not present (relative abundance less than 1%) in air samples from wwtps (data not shown). farmers do not usually wear respiratory protection and, moreover, they often live in the farming environment (e.g., in a house located near farms) and are consequently continuously exposed to the microbes generated from farming activities (occupational and residential exposures). therefore, the exposure that farmers are subjected to is more likely to modify their natural nasopharyngeal flora. the agricultural/non-agricultural hypothesis presented in this work regarding the nasopharyngeal flora of exposed workers should be validated in other agricultural and industrial environments. recent studies of the microbiome of the upper respiratory tract may have underestimated the influence of occupational exposure when considering the effect of a particular disease on the natural flora of upper respiratory tract tissue [92] [93] [94] . the fact that the work environment may affect the natural flora of an exposed person on a long-term scale is a crucial consideration when he/she becomes a patient whose upper respiratory tract microbiota is the target of the disease. the results obtained in this work emphasize the importance of considering the environment of the nasopharyngeal flora of exposed workers, who are or could become patients suffering from chronic respiratory diseases. in the same way that recent advances in methods for identifying microbes has helped implicate the upper respiratory tract microbiome in inflammatory respiratory diseases, evaluating bioaerosol exposure can help us support the roles of resident microbes in both healthy and diseased tissues. specific human pathogens and antibiotic and zinc resistance genes were detected in the nasopharynxes of pig farm workers as well as in bioaerosols of pig buildings [55] . for bacterial diversity analyses, the qpcr approach supports the use of the nasopharynx as an alternative to air sampling. the presence of zinc and antibiotic resistance genes, in the nasopharynxes of farmers, is explained by the use of zinc and antibiotics in animal farming (for therapeutic or sub-therapeutic use, such as for growth promotion) and implies possible human health risks. extensive use of zinc in pig feed is responsible for the proliferation of zinc-resistant bacterial communities at farms [95] . cephalosporin is a commonly used antimicrobial drug in human infections and the spread of its resistance constitutes part of the antibiotic resistance crisis [96] . finally, the mcr-1 gene was found in the nasopharynxes of half of the pig farmers in this study, although the use of colistin is extremely regulated in north america and limited to multi-drug resistant microbes [97] . future studies should include detailed health information on the sampled individuals to investigate the nasopharynx microbiota associated with certain occupational health problems. additionally, a longitudinal study of the bacterial diversity, in the nasopharynxes of farmers and in bioaerosols from pig buildings, could unveil a long-term variation in microbial content. finally, information about the diet of exposed human (or animal) and antibiotic use could be added to the analyses as important factors influencing the microbiota. this is the first study to link the nasopharyngeal flora of exposed humans with the source of the exposure in an agricultural setting, using bacterial diversity analyses and the detection of specific pathogens and resistance genes. the results suggest that workers are carriers of bioaerosol-associated bacteria and that nasopharynx sampling could be used as a proxy for air 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staphylococcus aureus isolates the antibiotic resistance crisis: part 1: causes and threats colistin: an update on the antibiotic of the 21st century this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-011818-z89m8dur authors: ki, jison; ryu, jaegeum; baek, jihyun; huh, iksoo; choi-kwon, smi title: association between health problems and turnover intention in shift work nurses: health problem clustering date: 2020-06-24 journal: int j environ res public health doi: 10.3390/ijerph17124532 sha: doc_id: 11818 cord_uid: z89m8dur shift work nurses experience multiple health problems due to irregular shifts and heavy job demands. however, the comorbidity patterns of nurses’ health problems and the association between health problems and turnover intention have rarely been studied. this study aimed to identify and cluster shift work nurses’ health problems and to reveal the associations between health problems and turnover intention. in this cross-sectional study, we analyzed data from 500 nurses who worked at two tertiary hospitals in seoul, south korea. data, including turnover intention and nine types of health issues, were collected between march 2018 and april 2019. hierarchical clustering and multiple ordinal logistic regressions were used for the data analysis. among the participants, 22.2% expressed turnover intention and the mean number of health problems was 4.5 (range 0–9). using multiple ordinal logistic regressions analysis, it was shown that sleep disturbance, depression, fatigue, a gastrointestinal disorder, and leg or foot discomfort as a single health problem significantly increased turnover intention. after clustering the health problems, four clusters were identified and only the neuropsychological cluster—sleep disturbance, fatigue, and depression—significantly increased turnover intention. we propose that health problems within the neuropsychological cluster must receive close attention and be addressed simultaneously to decrease nurse’s turnover intentions. nurses often work irregular shifts and bear high physical and psychological job demands that may, in turn, jeopardize their health status. specifically, shift work may cause a variety of physical and mental health problems [1] . the deterioration of nurses' health status could not only lead to a decline in their quality of life but could also affect the quality of care provided by them [2] . in addition, health problems may affect nurses' turnover, which is a serious issue worldwide [3] . the high turnover rate of nurses has led to an increase in both direct and indirect costs in the health system and could further protract the shortage of nurses that has lasted for the past several years [4] . a recent survey of korean nurses reported that about 10% of shift work nurses cited health problems as their main reason for resigning [5] . prior studies also show that nurses complained of two or more health problems simultaneously, which may be interrelated [2, [6] [7] [8] . musculoskeletal pain in nurses has been reported in many studies [9, 10] , and poor dietary habits due to irregular shift work were reported to cause gastrointestinal disorders [11, 12] . sleep disturbance, which is most frequently reported in studies of shift nurses, could lead to mood disorders, such as depression, both of which lead to chronic fatigue [13] [14] [15] . although nurses experience various health problems, there is relatively little research on the relationships between complex health problems in nurses [2] . moreover, few studies have investigated the relationship between concomitant health problems and turnover intention. because the burden may vary depending on the number and the kind of health problems shift work nurses have [16] , it may be important to identify specific comorbidity patterns of nurses' health problems through clustering and determine which clusters most affect turnover intention, where a cluster-that is, a comorbid pattern of health problems-can be defined as a group of concurrent or related health problems that can be distinguished from other clusters [17] . therefore, the purpose of this study was to first characterize shift work nurses' health problems. we then determined the pattern of symptom modalities by clustering the health problems through the hierarchical clustering method. lastly, we identified the impact of health problem clusters on turnover intention. this cross-sectional study was part of the shift work nurses' health and turnover (swnht) study, which is a prospective cohort study designed to investigate the longitudinal relationships between shift work nurses' health and turnover. it was supported by the national research foundation of korea (nrf) grant funded by the korea ministry of science and information and communications technologies and approved by the institutional review board (irb) at two tertiary hospitals in seoul, south korea. data collection was performed from march 2018 until april 2020. in the swnht study, we recruited 594 female nurses (294 novice nurses who had no exposure to rotating shift work, and 300 nurses with exposure to 8-hour rotating work, including night shifts, for at least 1 month) ( figure 1 ). because health problems can vary according to sex [18, 19] and the swnht study included a survey of nurses' menstrual and gynecological symptoms, the swnht study was limited to female nurses. data were collected three times for novice nurses: before exposure to shift work (novice registered nurse (nrn) t0, n = 294), after six months of work (nrn t1, n = 204), and 12 months after t1 (nrn t2, n = 204). for experienced registered nurses, data were collected twice: baseline (experienced registered nurse (ern) t1, n = 300) and 12 months after t1 (ern t2, n = 269; see details in section 2.2 data collection). int. j. environ. res. public health 2020, 17, x 2 of 13 could lead to mood disorders, such as depression, both of which lead to chronic fatigue [13] [14] [15] . although nurses experience various health problems, there is relatively little research on the relationships between complex health problems in nurses [2] . moreover, few studies have investigated the relationship between concomitant health problems and turnover intention. because the burden may vary depending on the number and the kind of health problems shift work nurses have [16] , it may be important to identify specific comorbidity patterns of nurses' health problems through clustering and determine which clusters most affect turnover intention, where a cluster-that is, a comorbid pattern of health problems-can be defined as a group of concurrent or related health problems that can be distinguished from other clusters [17] . therefore, the purpose of this study was to first characterize shift work nurses' health problems. we then determined the pattern of symptom modalities by clustering the health problems through the hierarchical clustering method. lastly, we identified the impact of health problem clusters on turnover intention. this cross-sectional study was part of the shift work nurses' health and turnover (swnht) study, which is a prospective cohort study designed to investigate the longitudinal relationships between shift work nurses' health and turnover. it was supported by the national research foundation of korea (nrf) grant funded by the korea ministry of science and information and communications technologies and approved by the institutional review board (irb) at two tertiary hospitals in seoul, south korea. data collection was performed from march 2018 until april 2020. in the swnht study, we recruited 594 female nurses (294 novice nurses who had no exposure to rotating shift work, and 300 nurses with exposure to 8-hour rotating work, including night shifts, for at least 1 month) ( figure 1 ). because health problems can vary according to sex [18, 19] and the swnht study included a survey of nurses' menstrual and gynecological symptoms, the swnht study was limited to female nurses. data were collected three times for novice nurses: before exposure to shift work (novice registered nurse (nrn) t0, n = 294), after six months of work (nrn t1, n = 204), and 12 months after t1 (nrn t2, n = 204). for experienced registered nurses, data were collected twice: baseline (experienced registered nurse (ern) t1, n = 300) and 12 months after t1 (ern t2, n = 269; see details in section 2.2. data collection). in this study, we used data collected from october 2018 to january 2019 (nrn t1, n = 204) and from march 2018 to may 2018 (ern t1, n = 300) to analyze the association between health problems and turnover intention among shift work nurses. in this analysis, we defined shift work as a in this study, we used data collected from october 2018 to january 2019 (nrn t1, n = 204) and from march 2018 to may 2018 (ern t1, n = 300) to analyze the association between health problems and turnover intention among shift work nurses. in this analysis, we defined shift work as a combination of day, evening, and night shifts; therefore, we excluded four nurses, including three nurses who worked only daytime hours and one nurse who worked from midday to 8 p.m. the primary purpose of the swnht study was to investigate health problems, presenteeism, and turnover intention in shift work nurses. to enroll novice nurses without shift work experience, we distributed and collected survey envelope packages that included survey instructions, consent forms, and a questionnaire on the third day of their work orientation before ward placement. to enroll experienced shift work nurses, we attached a recruitment notice to the ward bulletin boards, and nurses who wished to participate in the study voluntarily contacted the research team. we maximized voluntary participation by protecting confidentiality, ensuring anonymity, and no hospital-associated researchers took part in the data collection process. we collected the follow-up data through an online survey program; their response rates were 69.4% (nrn t1, nrn t2) and 89.7% (ern t1). the swnht study questionnaire included questions regarding general and job-related characteristics, health-related variables (e.g., dietary habits, menstrual symptoms, exposure to blood and body fluid, sleep, fatigue, depression, physical activity, etc.), occupational stress, presenteeism, and turnover intention. to objectively verify the sleep scale data, we also obtained actigraphy data from the subjects who consented to wear the actigraphy. the examined demographic characteristics included age (years), education (bachelor's degree or lower/master's degree or higher), marital status (single/married), having children (yes/no), and body mass index (kg/m 2 ). the examined job-related characteristics included work unit (general ward, intensive care unit, delivery room, and emergency room), months of shift work experience, and the average number of night shifts per month. we measured turnover intention since it is the most predictive measure of actual turnover [20] . in a longitudinal study in europe, nurses who had turnover intentions were more likely to leave their jobs [21] . in this study, the subjects were asked to choose one of four options (strongly agree, agree, disagree, or strongly disagree) to answer the question: "i plan on staying for the next year" [22] . the nine health problems in this study were selected by two professors at a nursing college and two nurses in a research team, and were based on reviews of the literature about shift work nurses' health problems [10, 18, [23] [24] [25] [26] [27] . these were (1) upper musculoskeletal pain (including neck, shoulder, and back pain), (2) leg or foot discomfort, (3) sleep disturbance, (4) fatigue, (5) depression, (6) menstrual disorders (including dysmenorrhea and menopause symptoms), (7) gynecological disorders (including disease of the uterus or ovary), (8) headaches (including migraine, dizziness, and chronic headaches), and (9) gastrointestinal disorders (including gastric ulcer, diarrhea, constipation, and stomachache). among the nine health problem categories, sleep disturbance, fatigue, and depression were measured using the instruments described below. for the other six health problem categories, the subjects were asked to indicate the health problems they experienced during the last month with "yes" or "no." to assess the quality of sleep, we used the korean version of the insomnia severity index (isi), which was developed by morin and translated by the korean sleep research society. the insomnia severity scale consists of seven questions related to sleep disorders measured on a 5-point scale (0-4 points) for each item. the score ranges from 0 to 28; higher scores indicate a lower quality of sleep. a score above 10 indicates sleep disturbance [28] . the cronbach's alpha value of the korean version of isi was 0.928 in our study. fatigue was measured using the fatigue severity scale (fss). the fss consists of nine questions about the degree of fatigue during the past week and is scored from 1 (strongly disagree) to 7 (strongly agree). a higher average score indicates higher fatigue. the criterion for fatigue is more than four points on average [29] . the cronbach's alpha value of the fss was 0.917 in our study. we measured depression using the shortened center for epidemiological studies depression scale (ces-d). the shortened ces-d consists of 10 questions about depressive feelings and thoughts during the past week and is scored from 0 (less than 1 day) to 3 (about 5-7 days). higher total scores indicate more depressive symptoms. a total score of 10 or above indicates depression [30] . the cronbach's alpha value of the shortened ces-d was 0.877 in our study. all analyses were performed using sas version 9.4 (sas institute inc., cary, nc, usa) and r project for statistical computing software version 3.4.4 (cran, soule, korea). we confirmed that there were no missing data. the descriptive statistics (frequency, percentage, mean, and standard deviation) for the demographic characteristics were analyzed. pearson's chi-squared test, fisher's exact test, and an analysis of variance were used to identify general characteristics associated with turnover intention. hierarchical clustering was used to group the health problems reported by participants. hierarchical clustering is a statistical method for grouping objects or variables according to the similarity between clusters using a bottom-up approach. in the field of nursing, this technique has been used mainly for symptom clustering of cancer patients; however, it has recently become more widely used in various studies [31] . the method used for measuring the distance between variables was the squared euclidean distance and the linkage method used for measuring the distance between clusters was the average linkage. the number of final clusters is usually determined by the researchers by taking into account clinical suitability [32] . multiple ordinal logistic regressions that included covariates, such as education, marital status, having children, body mass index (kg/m 2 ), work unit, months of shift work experience, and the number of night shifts per month, was used to investigate the association of single health problems and clusters of health problems with turnover intention. the four categories of "strongly agree," "agree," "disagree," and "strongly disagree" used for the turnover intention variable satisfied the proportional odds assumption at p > 0.050 with the covariates and variables of interest. this study was approved by the institutional review board (irb) at seoul national university hospital (irb no. h-1712-094-907) and the samsung medical center (irb no. 2017-12-075-002). after agreeing to participate in the study, all nurse participants signed a consent form and completed the baseline questionnaire. the participants were 500 female nurses working shifts, including night shifts. the nurses' mean age was 26.7 years (standard deviation (sd) = 4.20), and 19.8% were over 30 years old. there were no differences in demographic and job-related characteristics between the participants in the two tertiary hospitals. most nurses were single (88.2%) and had no children (94.0%). the average body mass index (bmi) was 20.19 kg/m 2 ; 22.8% of the subjects were underweight and only one subject was obese. the shift work length was 35 months on average, which was highly correlated with age (r = 0.92, p < 0.001). therefore, we excluded age from the covariates of the multiple ordinal logistic regressions (table 1) . one hundred and eleven nurses (22.2%) had a turnover intention and 12 nurses (2.4%) strongly intended to leave. the turnover intention was statistically higher in subjects who were younger (f = 5.70, p = 0.001), had no children (χ 2 = 10.14, p = 0.030), had a lower bmi (f = 4.24, p = 0.006), and had shorter periods of shift work (f = 6.83, p < 0.001). the mean number of health problems was 4.5 (range 0-9), with 95.2% (n = 476) of participants having more than two health problems. the most frequently reported health problem was upper musculoskeletal pain (82.4%), followed by leg or foot discomfort (67.8%), fatigue (65.0%), and sleep disturbance (62.4%). the associations between single health problems and turnover intention using multiple ordinal logistic regressions are provided in table 2 . fatigue (odds ratio (or) = 3.4, 95% confidence interval (ci) = 2.21-5.24), depression (or = 1.79, 95% ci = 1.22-2.62), leg or foot discomfort (or = 1.69, 95% ci = 1.12-2.56), sleep disturbance (or = 1.61, 95% ci = 1.10-2.37), and a gastrointestinal disorder (or = 1.51, 95% ci = 1.03-2.19) were significantly related to turnover intention. based on the hierarchical clustering analysis, four clusters were identified ( figure 2 ): the pain cluster (upper musculoskeletal pain and leg or foot discomfort), the neuropsychological cluster (depression, sleep disturbance, and fatigue), the gynecological cluster (menstrual disorder and gynecological disorder), and the gastrointestinal cluster (headache and gastrointestinal disorder). as a result of our multiple ordinal logistic regression analyses, only the neuropsychological cluster (depression, sleep disturbance, and fatigue) was found to be significantly related to turnover intention. in the neuropsychological cluster, if the participant had only one health problem, it did not relate to turnover intention. if the participant experienced two (or = 3.35, 95% ci = 1.90-5.92) or three (or = 5.73, 95% ci = 3.17-10.33) health problems in the cluster simultaneously, the odds ratio of the turnover intention increased linearly, which was statistically significant (f = 5.84, p < 0.001; table 3 ). based on the hierarchical clustering analysis, four clusters were identified (figure 2 ): the pain cluster (upper musculoskeletal pain and leg or foot discomfort), the neuropsychological cluster (depression, sleep disturbance, and fatigue), the gynecological cluster (menstrual disorder and gynecological disorder), and the gastrointestinal cluster (headache and gastrointestinal disorder). we investigated the prevalence of shift work nurses' health problems and characterized the patterns of symptom modalities by clustering health problems. we then investigated the association of single health problems and clusters of health problems with turnover intentions. we found that most shift work nurses experienced multiple health problems at the same time. we also found that having more than two health problems in the neuropsychological cluster was significantly related to turnover intention. this study was the first to attempt the clustering of nurses' health problems and explore the relationship between the clusters and turnover intention in shift work nurses. we found that 22.2% of nurses had turnover intention. in previous studies, turnover intention varied from 4% to 54% [33] [34] [35] . the first reason for the difference in turnover intention between existing studies and our study could have been the different measurement tools used in each study. while our study asked about future plans regarding turnover, such as "i plan on staying for the next year," other studies asked how often they thought about turnover in the past [36, 37] . some studies measured turnover intention with various questions, such as whether they were seeking another job or whether they thought about leaving the nursing profession forever [33, 38] . the second reason that turnover intention in our study was higher than in previous studies may be due to different hospital environments. the hospitals where our study was performed were tertiary hospitals in seoul, which had a higher patient severity and higher nurse labor intensity than other hospitals in korea. third, we measured turnover intention and not actual turnover, which is reported to be higher than actual turnover rates [21] . in 2018, the annual average nurse turnover rate was 13.9% in korea [5] . we found that fatigue was common in our subjects, highly related to turnover intention, and had the highest odds ratio (or = 3.4, 95% ci = 2.21-5.24). our results were consistent with a previous study that reported a positive correlation between fatigue and turnover intention [39] . although we could not determine with certainty how long they had suffered from fatigue, it appeared that fatigue was one of the common disabling health problems that lead to turnover intention. fatigue may exert a direct effect on turnover intention since nurses' fatigue has been reported to interfere with work efficiency and concentration and increase the risk of medical error and injury [40, 41] . although the direction of causality was not identified, nurses' fatigue was reported to be related to sleep disturbance, poor health, and depression [18, 25] . not surprisingly, we found that about 50% of nurses complained of fatigue and sleep disturbance at the same time and sleep disturbance was associated with turnover intention as a single health problem (or = 1.61, 95% ci = 1.10-2.37). sleep disturbance has received the most attention as a cause of turnover intention among nurses' health problems [42, 43] . irregular and insufficient sleep time due to shift work may often cause sleep disturbance, which may affect nurses' physical and mental health [1] . another finding of interest was that about 28% of nurses had all three interrelated symptoms of fatigue, sleep disturbances, and depression; this was associated with turnover intention as a single health problem (or = 1.79, 95% ci = 1.22-2.62). depression in nurses is prevalent in many studies, and in one study, the prevalence of depression among nurses was almost twice as high as in other professions [26, 44, 45] . depression may decrease concentration, which reduces the productivity of nursing and affects nurses' judgment, thus increasing occupational injury and turnover intention [26, 43] . our study revealed that fatigue, sleep disturbance, and depression may play important roles in increasing turnover intention as a cluster and as individual symptoms. approximately one-third of nurses experienced all three health problems; these findings suggest fatigue, sleep disturbance, and depression in the neuropsychological cluster were correlated with each other. despite the fact that biological and behavioral mechanisms in the development of depression, fatigue, and sleep disturbances are unknown, several studies have reported that these three health problems are related and co-occur [46, 47] . most importantly, 80% of nurses experienced one or more health problems in the neuropsychological cluster and this cluster was associated with turnover intention. moreover, their odds ratio of turnover intention increased linearly as the number of health problems increased within this cluster. future studies should probe the comorbidity of sleep disturbance, depression, and fatigue of shift work nurses and develop comprehensive health promotion to alleviate these three health problems. we found that having a gastrointestinal disorder was another common health problem, which was consistent with the result of a previous study of 20,000 korean nurses [12] . this high prevalence of gastrointestinal disorders among shift work nurses may, first, be due to disturbed circadian rhythm. the gastrointestinal system, like sleep, has a circadian rhythm, which controls bowel movement and the secretion of gastric juices [48] . second, it might be due to irregular meal times and skipped meals [49] . although not shown in the result, most of the nurses in our study reported eating irregularly (92.8%) and they ate breakfast twice a week, which was lower than the average number of times korean adults eat breakfast [50] . the most common reason for skipped meals in our study was irregular work times (64.8%). considering that having a gastrointestinal disorder was common among shift work nurses and was a single health problem that increased turnover intention, special attention needs to be paid to having regular and sufficient mealtimes as much as possible. in our results, gastrointestinal disorders and headaches formed the gastrointestinal cluster. this connection could be explained by the association between the brain and the stomach through neural, endocrine, and immune pathways and the high prevalence of headaches in patients with a gastrointestinal disorder [51, 52] . however, the gastrointestinal cluster was not related to turnover intention. it is possible that headaches, as an individual health problem, had no significant association with turnover intention, which could have decreased the effect of the cluster. furthermore, we presume that headaches as a single health problem were not shown to be associated with turnover intention because headaches are often easily relieved by medication and may not have been as severe as a gastrointestinal disorder. upper musculoskeletal pain, which had the highest prevalence, formed a pain cluster with leg or foot discomfort. nurses work most of the time in a standing position, walking an average of 8747 steps (4.1 miles) per shift [53] , and high physical demands have been associated with musculoskeletal problems in nurses [54] . additionally, multi-site musculoskeletal pain has been shown to be more common than single-site pain, especially in women [55] . unexpectedly, this cluster was not related to turnover intention, although leg or foot discomfort was related to turnover intention. this might be because most nurses (82%) suffered upper musculoskeletal pain regardless of turnover intention and, similar to the gastrointestinal cluster, the association of the pain cluster with turnover intention was reduced by the effect of upper musculoskeletal pain. although the pain cluster did not relate to turnover intention, given that these health problems in the pain cluster had a high prevalence and cause sickness and absence from work and decreased work productivity [24] , there is a need to investigate the prevalence of musculoskeletal disorders in nurses by workplace and to provide appropriate prevention and treatment programs. although our study provides a new perspective on nurses' health problems, it has some limitations. first, this study relied on self-report measures of health problems, except for three health problems (sleep disturbance, depression, and fatigue). second, we surveyed only the presence of health problems, but not the severity; however, as the participants were nurses with medical knowledge, their judgment of the presence of health problems might be more reliable than that of the general public [56] , which would partially compensate for the fact that some health problems were not assessed with standardized tools. third, we could not infer the causal relationship from the cross-sectional design of the study. the fourth significant limitation is that this study did not measure how many nurses actually leave their job; therefore, the findings of our study may not apply to actual turnover, as turnover intention does not always lead to actual turnover. fifth, the shift work nurses who participated were all female and from two tertiary hospitals in seoul in korea. therefore, the generalizability of the results is limited. future studies on the comorbidity of sleep disturbance, depression, and fatigue in shift work nurses from various hospitals in various regions, along with the inclusion of male nurses, are recommended. in this study, the association of single health problems and clusters of health problems with turnover intention differed. although fatigue, sleep disturbance, depression, gastrointestinal disorders, and leg or foot discomfort were related to turnover intention as single health problems, after clustering, only the neuropsychological cluster-including fatigue, sleep disturbance, and depression-was related to turnover intention. given that nurses had more than two health problems and turnover intention increased linearly within the neuropsychological cluster, these problems must receive close attention and be addressed to decrease the nurse turnover rate. future studies should implement longitudinal research to determine the effect of the neuropsychological cluster on turnover. author contributions: j.k. developed the concept of this manuscript, analyzed the data, and prepared this manuscript. j.r. and j.b. were responsible for the data collection and contributed to the manuscript revision. i.h. developed the study protocol and advised on the data analysis. s.c.-k. developed the study protocol and concept, and revised this manuscript to its final version. all authors have read and agreed to the published version of the manuscript. health consequences of shift work and insufficient sleep we cannot 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clinical data warehouse comorbidity of headache and gastrointestinal complaints. the head-hunt study how far do nurses walk? medsurg nurs perceived physical demands and reported musculoskeletal problems in registered nurses chronic musculoskeletal pain rarely presents in a single body site: results from a uk population study the nurses' health study: lifestyle and health among women this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-313356-ninzeazy authors: fiorillo, luca; cervino, gabriele; matarese, marco; d’amico, cesare; surace, giovanni; paduano, valeria; fiorillo, maria teresa; moschella, antonio; la bruna, alessia; romano, giovanni luca; laudicella, riccardo; baldari, sergio; cicciù, marco title: covid-19 surface persistence: a recent data summary and its importance for medical and dental settings date: 2020-04-30 journal: int j environ res public health doi: 10.3390/ijerph17093132 sha: doc_id: 313356 cord_uid: ninzeazy recently, due to the coronavirus pandemic, many guidelines and anti-contagion strategies continue to report unclear information about the persistence of coronavirus disease 2019 (covid-19) in the environment. this certainly generates insecurity and fear in people, with an important psychological component that is not to be underestimated at this stage of the pandemic. the purpose of this article is to highlight all the sources currently present in the literature concerning the persistence of the different coronaviruses in the environment as well as in medical and dental settings. as this was a current study, there are still not many sources in the literature, and scientific strategies are moving towards therapy and diagnosis, rather than knowing the characteristics of the virus. such an article could be an aid to summarize virus features and formulate new guidelines and anti-spread strategies. coronavirus disease 2019 (covid19) is an infectious respiratory disease caused by the virus called severe acute respiratory syndrome coronavirus 2 (sars-cov-2), belonging to the coronavirus family. an infected person may experience symptoms after an incubation period that could vary from about 2 to 14 days (there have rarely been cases of incubation periods of 29 days), during which time the person could still be contagious. to limit transmission, precautions should be taken, such as adopting careful personal hygiene, washing hands frequently and wearing masks. coronavirus mainly affects the lower respiratory tract and causes a number of symptoms described as flu-like, including fever, cough, shortness of breath, muscle pain, tiredness and gastrointestinal complaints such as diarrhea. in severe cases, pneumonia, acute respiratory distress syndrome, sepsis and septic shock could occur, up to the death of the patient. among the collective preventive measures, it should be noted that in 2003, during the sars epidemic, the major collective catering companies in china and hong kong adopted the obligation to wear surgical masks for their service personnel to protect both the workers of companies and the public. this professional category is particularly exposed to potentially infectious contacts, both active and passive. in the same way, a person in charge of equipment who is not equipped with the appropriate personal protective equipment (ppe) will find themselves exposed to contact with the dirty dishes and recent food remains of a large number of customers. further interventions in the restaurant sector may include a prohibition on the distribution of buffets for both food and dishes [1] [2] [3] [4] . in recent weeks there has been about a great deal of discussion about the contamination and decontamination of inanimate surfaces. in fact, the duration before inactivation of the covid-19 virus on surfaces (liquid, solid or gaseous) is still debated. in most cases, the spread between people occurs through the respiratory droplets emitted by an infected individual through coughing or sneezing, which, are subsequently inhaled by a healthy person who is nearby. this also caused an initial diffidence on the part of people in purchasing products of any kind coming (including by post) from the areas affected by the epidemic, leading to economic damage. it is possible to become infected by touching surfaces or objects where the virus is present and then bringing your hands towards your mouth, nose or eyes [5] [6] [7] [8] [9] [10] . in ideal conditions, the virus can in fact persist on different surfaces for hours or days. the surfaces most exposed to this type of transmission include, for example: public transport handholds [11] [12] [13] [14] . the viral titration, viral assay or viral count is the count, made in the laboratory, of the number of viral particles of a given virus under examination present in a biological sample. it is used in microbiological research, diagnostics and in the production of antiviral vaccines-all situations that require knowledge of the amount of virus being analyzed or used. we used tissue-culture infectious dose (tcid) per milliliter for covid-19 persistence evaluation [15] [16] [17] [18] [19] . the aim of this article is to evaluate, through the analysis of the current literature, how long this virus can remain active on different surfaces. it is too early to be able to carry out a review with meta-analysis of the literature given the incredible relevance of this topic, but it is certainly a step to clarify this pandemic. the following questions were used to develop the study framework according to the pico (population/intervention/comparison/outcomes) guidelines: • what is the persistence of sars-cov-2 on surfaces? • what is the mean persistence of coronaviruses compared to sars-cov-2? an investigation methods protocol was used, according to the prisma statement; the aim of the prisma statement is to help authors improve the reporting of systematic reviews and meta-analyses. it can be used as a basis for reporting reviews of other types of research. the use of checklists like prisma is likely to improve the reporting quality of a systematic review and provides substantial transparency in the selection process of papers in a systematic review. furthermore, pico guidelines have been used to prepare summary questions [20] [21] [22] . the full texts of all studies related to the main revision topics were obtained for comparing the inclusion parameters: • sars-cov-2 features articles; the persistence of other coronaviruses. the following were the exclusion criteria: • not enough information regarding the topic; • articles published prior to 1 january 2010; • no access to the title and abstract. research was conducted in five electronic databases, including medline, pubmed, and embase. in addition, a manual search was conducted for relevant studies published. digital and manual searches were then performed. the data search was performed in order to add significant studies and to increase the sensitivity of this study. for the search we used keywords according to medical subject headings (mesh). (sars-cov-2 or coronavirus) and (persistence or surface) terms were investigated on information sources, as specified in section 2.3. first, the manuscript titles list was highlighted to exclude irrelevant publications and search errors. the final selection was performed by reading the full texts of the papers in order to approve each study's eligibility based on the inclusion and exclusion criteria. data selection and revision was performed by independent reviewers of three different affiliations (luca fiorillo, messina; giovanni surace, reggio calabria; alessia la bruna, milan). they singularly analyzed the obtained papers. results obtained were compared and discussed with a fourth independent reviewer (gabriele cervino, university of messina) when a consensus could not be reached. for the stage of the full-text articles' revision, a complete independent analysis was performed. results were singularly analyzed and items about viruses' persistence on different materials were evaluated and shown. we created a table to show a summary of inherent virus features. the grade of bias risk was independently considered, as reported in [23] [24] [25] . potential causes of bias were investigated: • selection bias; • performance bias and detection bias; • attrition bias; • reporting bias; • examiner blinding, examiner calibration, standardized follow-up description, standardized residual graft measurement, standardized radiographic assessment. we conducted a manual synthesis of article results. during the first search, 25 studies were obtained. after applying inclusion and exclusion criteria, only the remaining 5 articles were further analyzed. then, articles were manually selected, and finally 4 articles were obtained ( figure 1 ). • performance bias and detection bias; • attrition bias; • reporting bias; • examiner blinding, examiner calibration, standardized follow-up description, standardized residual graft measurement, standardized radiographic assessment. we conducted a manual synthesis of article results. during the first search, 25 studies were obtained. after applying inclusion and exclusion criteria, only the remaining 5 articles were further analyzed. then, articles were manually selected, and finally 4 articles were obtained ( figure 1 ). results of individual studies were shown after an accurate analysis in table 1 . the aim of this table is to summarize coronaviruses' persistence time. van doremalen et al. [26] evaluated the stability of sars-cov-2 and sars-cov-1 in aerosols and different surfaces. they evaluated these viruses' decay rates using bayesian linear regression. they conducted their experiment using aerosols (< 5 µm) containing sars-cov-2 (105.25 50% tissue-culture infectious dose (tcid50) per milliliter) or sars-cov-1 (106.75-7.00 tcid50 per milliliter) generated by a nebulizer. ten different experimental conditions involving sars-cov-1 or 2 were evaluated. results on infectious titer reduction are shown in table 1 . the data were expressed as 50% tissue-culture infectious dose (tcid 50 ). it is important to specify that the limit of detection for this experiment was 3.33 × 10 0.5 tcid 50 per liter of air for aerosols; 10 0.5 tcid 50 per milliliter of medium for plastic, steel, and cardboard; and 10 1.5 tcid 50 per milliliter of medium for copper. kampf et al. [27] showed how different coronaviruses could persist on different types of inanimate surfaces. they also evaluated some environmental characteristics, such as temperature or humidity. they showed how human coronavirus could be influenced by temperature, as 30 or 40 • c reduced the duration of persistence of coronaviruses on inanimate surfaces. however, at the temperature of 4 • c, the persistence could be greater than or equal to 28 days. another important result is that the persistence was longer with higher inocula. warnes et al. [28] evaluated coronaviruses' persistence on metal and non-metal samples. they inoculated 10 3 plaque forming units (pfu) on different materials: polyfluorotetraethylene (teflon; ptfe), polyvinyl chloride (pvc), ceramic tiles, glass and stainless steel. coronaviruses' persistence was at least 5 days (and 3 days for silicon rubber) at 21 • c. despite this, it could be rapidly inactivated by brass and copper nickel surfaces in less than 60 min. copper nickel surfaces were effective but less than brass copper; in these cases, the inactivation time was up to 5 min in the fingertip contamination model. warnes et al. demonstrated how a higher percentage of copper could lead to superior antiviral properties. another important factor reported in this study was that the release of ions from copper and the formation of reactive oxygen species (ros) take part in the deactivation of the virus. furthermore, the authors report that following an analysis carried out with a transmission electron microscope (tem), the virus was normally present on common surfaces such as stainless steel, but on copper surfaces it appeared to be damaged and intact particles were few. it was not possible to conduct a bias risk analysis according to the prisma statement as specified in the previous section. unfortunately, the limited number of articles obtained does not allow for the realization of a systematic review. the individual studies were analyzed, and the experiments leading to the results shown in table 1 were rigorously conducted and are repeatable analyses [29] . the literature concerning the characteristics of these viruses is still scarce, especially if one considers only covid-19. the aspects related to the persistence of the virus on surfaces not only represent an environmental and public health problem concerning schools, roads, offices. it is a much bigger problem if hospitals, operating theaters, and sanitary waiting rooms are considered, especially in the new and continuously increasing "covid departments". knowing how the virus behaves in contact with surfaces and with different disinfectants could be important for the sanitization of medical environments. in particular, some authors deal with the optimization of infection control in operating rooms. some devices are used in hospital operating rooms for single use only, but other devices, surfaces, handles and cords could be transmission vehicles [30] . ong et al. 2020 [31] evaluated the presence of coronavirus in a hospital room of covid-19 patients. some surfaces, such as the toilet bowl and the sink, were positive. room air samples and samples collected after cleaning were negative. the time span varied according to the characteristics of the type of surface: the less-porous ones like plastic and steel were the worst because they absorb droplets less easily, preserving the active virus. additionally, the different environmental conditions could affect the amount of ventilation of the rooms and the humidity [26] . according to van doremalen et al. [26] , aerosol and surface virus transmission is plausible, since it can remain viable and infectious for hours or days. kampf et al. [27] showed how human coronaviruses can remain infectious on surfaces for up to 9 days at room temperature. this is an important factor about coronaviruses' spread. from this, it is easy to see that if someone tends to touch the environment often-especially if not properly disinfected-the possibility of becoming infected increases. furthermore, the droplets present in the form of an aerosol of an infected patient can not only easily spread, but also easily settle and last for several hours on a surface. kampf et al. [27] investigated different biocidal agents on coronaviruses. they demonstrated how ethanol (78%-95%), 2-propanol (70%-100%), the combination of 45% 2-propanol with 30% 1-propanol, glutardialdehyde (0.5%-2.5%), formaldehyde (0.7%-1%) and povidone iodine (0.23%-7.5%) readily inactivated coronavirus infectivity by approximately 4 log 10 or more. sodium hypochlorite required a minimal concentration of at least 0.21% to be effective. hydrogen peroxide was effective with a concentration of 0.5% and an incubation time of 1 min. an important finding is the ineffectiveness of chlorhexidine. within 10 min, a concentration of 0.2% revealed no efficacy against coronavirus. it is a result that does not support some guidelines for dentistry [32] . kampf et al. [27] concluded that these viruses can remain on surfaces up to 9 days and that surface disinfection could be performed with 0.1% sodium hypochlorite or 62%-71% ethanol for 1 minute. according to warnes et al. [26] , coronavirus persists in an infectious state on surfaces for several days. warnes et al. [26] demonstrated the survival of coronaviruses on different surfaces for up to 5 days. concerning the persistence of the virus on different surfaces, and in particular on metals containing copper, these findings are interesting and could lead to the development of new surfaces with viricidal or bactericidal properties. in confined environments, especially if poorly ventilated, viral particles of less than 0.1 µm in size may remain in the environment as a secondary aerosol. studies on the topic indicate that a sneeze could release up to 2 million droplets into the air, less than a million from a cough and about 3000 from speaking out loud. the droplets eliminated from the airways, if larger than 100 µm, from a height of 2 m settle on flat surfaces in 3-6 s and reach horizontally about 1.5 m away, then evaporate rapidly, dry and become solid material. this material reaches a size of 2-3 µm. studies on tuberculosis have shown that this material, maintaining its infectious capacity, could be inhaled and, thanks to its size, reach the most peripheral parts of the lungs, becoming a secondary biological aerosol [26] . there has not been much discussion about the importance of ventilating environments to prevent sars-cov-2 infection, and although the viral particles have not been studied sufficiently for their ability to achieve dangerous concentrations from a distance in confined environments, increased ventilation in an environment is believed to reduce the cross-infection of airborne diseases. therefore, existing recommendations could be amended to include ventilating public spaces, including means of transport, with suitable means. it is essential to focus on preventing infection by using ventilation suitable to reduce the infectious capacity of the coronavirus. it has been widely demonstrated that natural ventilation causes better air exchange compared to mechanical ventilation-up to 69 changes per hour of rooms when the windows are completely open [33] . most international guidelines recommend about 12 changes per hour for isolation rooms in case of infections. medical and dental staff will have to work safely, and this is complicated by the fact that there are still no official guidelines that tell them how to behave. moreover, as suggested by spagnuolo et al., dentists should avoid the scheduling of any patient: only such urgent dental diseases can be considered during the covid-19 outbreak. the waiting time of patients in dental offices could highly predispose patients to be infected. when dentists treat patients, they should intercept potentially infected persons before they reach the operating areas; for example, identifying those with a fever measuring >37.5 • c and posing a few questions about the patient's general health status in the last 7 days, and about the risk of having been in contact with other infected persons. dentists as well as medical office employees should always be covered by facial masks, and they should remind patients to maintain the 1-m distance with each other during their waiting time [34, 35] . disinfecting surfaces is one of the aspects to which to give greater attention, being done with the detergents already in use today, along with the washing of hands and the use of suitable ppe. in regards to ppe, surgical masks must be used by those who could transmit the virus, but those who work in contact with the patient's aerosol must use ffp2 and ffp3 (filtering facepiece particles) masks. there should only be one patient in waiting rooms. this is also true in clinical areas; in the case of minors who need an escort, the escort must be at a distance from operators, and must wear a surgical mask. at the end of each session, the surfaces will then have to be cleaned, and the air exchanged. the same procedures should be adopted in the waiting room and in other areas where the patient might pass or touch objects. certainly, some tools, such as quick tests (once validated), can become useful in the hands of the doctor/dentist to understand if the patient, or some member of their team, is potentially infected. we are aware of the limitations of this article; it is not possible to make a review of the literature due to the lack of data. so, this is only a summary of the available information. further studies are needed in order to verify the persistence times of coronavirus on surfaces more precisely. however, we have considered proceeding with the creation of this summary, while respecting the guidelines of systematic reviews and also not having sufficient numbers. the reason for this choice lies in the incredible topicality and reliability of the data obtained, with the hope that this work could be widely and immediately used to contain the pandemic. the purpose of this summary is to draw a line and clarify the characteristics of sars-cov-2 with regard to its persistence on surfaces. this article is of great interest and could be used to write new guidelines by epidemiologists, having a clear summary of the current situation. from our analysis it is possible to deduce some aspects. the virus can reach surfaces in the form of an aerosol. therefore, following nebulization through people (sneezing or coughing) or electromedical machinery, infection via surfaces should be considered, since the latter could remain viable and infectious for hours or days. on average, the different coronaviruses persist in an infectious state on surfaces for several days, even up to nine. surface disinfection could be performed with 0.1% sodium hypochlorite or 62%-71% ethanol for 1 minute. copper has shown antiviral properties-so much so that the virus appears damaged or altered on copper surfaces. other experiments are certainly needed, on different surfaces or even on biological surfaces, to better understand the persistence times of this virus and promote adequate standards. a novel coronavirus (covid-19) outbreak: a call for action suspending classes without 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of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations the cochrane collaboration's tool for assessing risk of bias in randomised trials association between risk-of-bias assessments and results of randomized trials in cochrane reviews: the robes meta-epidemiologic study robis: a new tool to assess risk of bias in systematic reviews was developed aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents human coronavirus 229e remains infectious on common touch surface materials risk of bias assessment: (1) overview. zhonghua liu xing bing xue za zhi perioperative covid-19 defense: an evidence-based approach for optimization of infection control and operating room management surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient covid-19 transmission in dental practice: brief review of preventive measures in italy assessing the dynamics and control of droplet-and aerosol-transmitted influenza using an indoor positioning system covid-19 outbreak: an overview on dentistry 3d printing beyond dentistry during covid 19 epidemic: a technical note for producing connectors to breathing devices acknowledgments: in this covid-19 emergency period, thanks go to all clinicians and researchers who every day risk their lives for research. the authors declare no conflict of interest. key: cord-314539-6vvgov43 authors: chen, zhongxiang; yang, jun; dai, binxiang title: forecast possible risk for covid-19 epidemic dissemination under current control strategies in japan date: 2020-05-29 journal: int j environ res public health doi: 10.3390/ijerph17113872 sha: doc_id: 314539 cord_uid: 6vvgov43 covid-19 has globally spread to over 4 million people and the epidemic situation in japan is very serious. the purpose of this research was to assess the risk of covid-19 epidemic dissemination in japan by estimating the current state of epidemic dissemination and providing some epidemic prevention and control recommendations. firstly, the period from 6 january to 31 march 2020 was divided into four stages and the relevant parameters were estimated according to the imported cases in japan. the basic reproduction number of the current stage is 1.954 (95% confidence interval (ci) 1.851–2.025), which means covid-19 will spread quickly, and the self-healing rate of japanese is about 0.495 (95% ci 0.437–0.506), with small variations in the four stages. secondly, the results were applied to the actual reported cases from 1 to 5 april 2020, verifying the reliability of the estimated data using the accumulated reported cases located within the 95% confidence interval and the relative error of forecast data of five days being less than [formula: see text]. thirdly, considering the medical resources in japan, the times the epidemic beds and ventilators become fully occupied are predicted as 5 and 15 may 2020, respectively. keeping with the current situation, the final death toll in japan may reach into the millions. finally, based on experience with covid-19 prevention and control in china, robust measures such as nationwide shutdown, store closures, citizens isolating themselves at home, and increasing pcr testing would quickly and effectively prevent covid-19 spread. since the first covid-19 case was diagnosed in december 2019, covid-19 had quickly spread to all chinese provinces by 28 january 2020 [1] . on 1 april 2020, the world health organization (who) reported 823,636 confirmed cases and 40,598 deaths globally [2] . among these countries, the most serious epidemic situations were occurring in the united states, italy, china, spain, germany, france, and iran, which each exceeded 50,000 infected people. in particular, the number of cases in the united states has grown quickly, with the number of reported cases increasing from 15 to 288,721 over 82 days. contemporaneously, the first covid-19 case was reported on 15 february 2020 in japan and the number of accumulated reported cases was 3858 on 5 april 2020. the undocumented infected individuals will facilitate the rapid dissemination of covid-19 [3] . therefore, estimation of current infected cases plays an essential role in controlling epidemic development and will help us to evaluate the strategies that should be implemented to adjust the prevention and control measures for mitigating the spread of covid-19 in japan. from 15 to 30 january 2020, the reported cases in japan were due to imported cases. for instance, the first reported case was a person from wuhan on 6 january, who had been experiencing symptoms on 3 january. this means that the covid-19 starting time in japan was 6 january due to the first imported case not being diagnosed and isolated. some imported infected or exposed people were in a state of natural transmission until confirmed. according to news reports, the first 10 imported cases, with their serial number, imported days, the symptom days, and confirmed days, are listed in table 1 . 19 january 2020 14 january 2020 24 january 2020 7 21 january 2020 21 january 2020 28 january 2020 3 18 january 2020 21 january 2020 25 january 2020 8 12 january 2020 26 january 2020 28 january 2020 4 22 january 2020 23 january 2020 26 january 2020 9 13 january 2020 25 january 2020 30 january 2020 5 12 january 2020 22 january 2020 28 january 2020 10 22 january 2020 23 january 2020 30 january 2020 the predominant route of transmission of covid-19 is person-to-person and dynamic methods can better reflect epidemic law from the aspect of the disease transmission mechanism. to provide theoretical and quantitative bases for making prevention and control decisions, we aimed to establish a mathematical model that reflects the dynamics of covid-19 propagation, and to qualitatively and quantitatively analyze and numerically simulate the dynamics of the model to show the development process of the disease, reveal the epidemic law, predict the development trend, and analyze the causes and key factors of the epidemic. recently, toshkazu [5] predicted the epidemic peak of covid-19 in japan based on a susceptible-exposed-infected-recovered (seir) model. this work forecasted that the epidemic peak would be reached in the early to mid-summer and the peak number of confirmed cases in a single day would be 2.053 × 10 6 . the works [6, 7] on the diamond princess cruise ship helped officials to make strategic decisions to prevent covid-19 from spreading from the ship. these works have a limited impact on future disease prevention and control in japan and cannot directly explain the key tasks of disease prevention and control. the current state estimation generated by the right model can be useful to govern the epidemic battle in japan. in this paper, we establish a seven-compartment dynamic model, and adopt the piecewise method and nonlinear least squares to obtain the parameters in the epidemic model. according to the calculation results, we analyze the key factors that affect the covid-19 outbreak in japan. through numerical examples, we forecast the time when medical resources are scarce and the number of deaths without improving the current situation. we divided the total human population into seven compartments, as shown in figure 1 , named the seihrd model: the susceptible (s), the exposed (e), the infected (i), the hospitalized (h), the recovered by self-healing (r i ), the recovered by hospital curing (r h ), and the deaths (d). the mathematical model is given by: where s(t), e(t), i(t), h(t), r i (t), r h (t), and d(t) denote the proportion of susceptible, exposed, infected, hospitalized, removed by hospital cure, removed by self-healing, and deaths in the total populations at time t, respectively. thus, the following equation holds: where β se and β si denote the transmission rates from the exposed and infected, respectively. because covid-19 is an infectious person-to-person virus, the growth of exposed and infected cases increases the transmission rates β se and β si . therefore, effective isolation measures and medical screening with the polymerase chain reaction (pcr) test can reduce β se and β si . the exposed individuals become infected after incubation period 1/µ. in reality, a proportion ζ r recovers from infection through self-cure; ζ h is the confirmed rate from an infected individual. the hospital cure recovery rate is and d is the proportion of deaths. based on previous research [8, 9] , 1/µ = 5, and hence µ = 0.2. in [10] , β se = κβ si where κ = 0.2. we assume 0.2 ≤ κ ≤ 0.4 because the transmission rate of infected individual is more powerful than that of exposed individuals. due to the different national fitness and medical conditions of different countries, the hospital cure rate and disease-related mortality rate are also different. according to reported data in figure 2 , we estimated the cure and death rates as = 0.2057 (95% confidence interval (ci), 0.1987-0.2127) and d = 0.0291 (95% ci 0.0279-0.0304), as exhibited in figure 2 . we assumed that the total population is n = 1.26 × 10 8 in japan [5] . the basic reproduction number r 0 , which is the expected number of secondary cases produced by one infected individual [11] , is described as: the basic reproduction number r 0 is independent of the hospital cured rate and the covid-19-related death rate d. from equation (1), the number n × (h(t) + r i (t) + d(t)) is the accumulated reported cases, which can be called the documented cases at time t. n × i(t) is the undocumented infection cases at time t. we used data from the ministry of health, labor, and welfare, which reports the data related to covid-19 in japan [2] . we also collected reported cases from news reports containing more details to guarantee the validity of the data. in table 1 , covid-19 spread started in japan on 6 january 2020, which was set as t = 0. we assumed that no. 1, no. 2, and no. 7 are the unconfirmed imported infected individuals, and that nos. 3-6 and 8-10 are imported exposed individuals. we assumed the uniform distribution of the 45 imported exposed individuals that landed from the diamond princess cruise ship from 19 to 26 february [3] . thus, the states of e(t) and i(t) should be updated by the following equations: and whereē(t) ands(t) indicate the imported proportion at time t. because the spread of covid-19 is affected by many factors, different interventions produce different results. therefore, we estimated the parameters of the model for different stages of the epidemic. we divided the period from 6 january to 31 march into four stages to estimate the model parameters. the first dividing point is 26 february [12] , the second dividing point is the implementation of the school suspension order on 6 march [13] , and the third is the landing of the diamond princess. 2.3. estimation of the parameters β se , β si , ζ h , and ζ r covid-19 is a new type of coronavirus, and its detection methods and diagnostic techniques are limited, thus we could not guarantee the integrity of the documented data. thus, the nonlinear least square method was used to estimate the parameters, and random simulations under isometric observations were used to obtain the confidence intervals of the parameters. we appointed y(t), t = 0, 1, · · · , 85 as the accumulated reported cases of covid-19 in japan from 6 january to 31 march 2020. we solved the following least-square-based optimization problem: for given parameters β se , β si , ζ h and ζ r , the numerical value of y(t) is: by employing the model in equation (1) and the assumption in section 2.2. we constructed the objective function as: then, based on the previous statement, the optimization problem is given by: subject to: and: by solving the above nonlinear optimization problem employing the lsqnonlin toolbox in matlab (mathworks, natick, ma, usa) [14] , the parameters β se , β si , ζ h , and ζ r can be determined. however, the approximations cannot reflect the error ranges, and the estimation intervals need to be given to confirm that the true values of the unknown parameters are included in these intervals. based on the bootstrap method [15] , we constructed isometric random observations as: where χ(t) denotes random variables from a normal distribution with a mean of zero and variance σ 2 i in the ith stage. y(t) and χ(t) are calculated by applying β se , β si , ζ h , and ζ r . after 1000 simulations, we obtained the calculation results shown in figure 3 and table 2 . r 0 was calculated according to equation (3). the root-mean-square error (rmse) is 12.264 and the goodness of fit (gof) r 2 is 0.9994 from 6 january to 31 march. as assumed in section 2.2, the first dividing point was 26 february and the people disembarked from the diamond princess cruise ship were required to isolate for 14 days. this aroused public attention and strengthened self-protection awareness. the transmission rates β se and β si slightly decreased from the first to the second stage. the second dividing point was the implementation of the decree suspending school and provision of financial assistance to parents. the transmission rates β se and β si dramatically decreased and the basic reproduction number was close to 1. this measure strengthened the isolation measures and effectively prevented the spread of covid-19. after the third dividing point, the transmission rates and confirmed rate substantially changed. during the nine days of the third stage, the number of pcr tests and documented cases were 5550 and 397, respectively. during the 16 days of the last stage, the number of pcr tests and documented cases were 19,471 and 1474, receptively. we defined an average index υ for the daily pcr tests as: where ∆n pcr , ∆h, and t denote the number of pcr tests, the number of documented cases, and the days of the different stages, respectively. we calculated the values of υ in the last two stages as 1.553 and 0.826, respectively, which showed the confirmed rate decreased sharply and resulted in the growth of transmission rates. the self-healing rate is within [0.479, 0.495] with small variations, showing that this parameter relies on the national constitution. from the trend of the basic reproduction number r 0 in table 2 , direct and indirect isolation and pcr medical screening measures are effective prevention and control strategies. with the development of the epidemic, the implemented prevention and control strategies are changing daily. we applied the accumulated reported cases of five days to examine the reliability of our approach. employing the model in equation (1) and the parameters in table 2 , the numerical accumulated reported cases and their confidence intervals are 2493 (95% ci 2437-2548), 2780 (95% ci 2700-2860), 3116 (95% ci 2999-3232), 3505 (95% ci 3342-3667), and 3957 (95% ci 3734-4181). all real reported cases exist within the 95% confidence intervals, as proven in figure 4a . as demonstrated in figure 4b , the largest relative error of the five-day forecast data is less than 2.5%, which means the forecast data have high reliability under the current measures. in comparison with the results in [5] , the relative errors of forecast data are around 25%, indicating the model and method in this paper are closer to the actual situation. to show that the current control strategies may lead japan to a massive crisis, we combined the existing epidemic bed statistics and the number of ventilators to predict the future medical state. according to a previous investigation [16] , the number of existing epidemic beds is about 272,255 and we assumed 45% of the beds are used for other epidemic cases. the number of all kinds of ventilators on standby is about 18,322 including 1255 ecmo devices. according to the real data, we estimated that the proportion of severe cases of covid-19 in japan is 5% of the reported cases [16] . when the use of ventilators and/or epidemic beds is saturated, the mortality rate will increase dramatically. consequently, we estimated the ventilator and epidemic bed saturation times. as estimated in figure 5a ,b, the hospital cases would reach 156,114, with epidemic beds being insufficient on 8 may and the respirator shortage occurring on 15 may, with about 19,434 critical patients. the results show that makeshift hospitals and shelter hospitals should be arranged in late april at the latest. if we continue with the current situation and adjust the death rate to 3%, 4%, and 5% after the saturation, the number of deaths, as exhibited in figure 5c , would reach 1.4 × 10 6 , 1.6 × 10 6 , and 1.8 × 10 6 , respectively. to avoid this serious situation, some prevention and control measures that could change the current situation were simulated to predict the epidemic trend. in this section, we discuss some effective strategies for mitigating covid-19 dissemination. from equation (3), some parameters affect the value of the basic reproduction number, such as β se , β si , and ζ h . the parameters µ and ζ r are subject to the characteristics of covid-19 and the national physique. hence, we can adopt some appropriate control strategies to impact the transmission rate and the confirmed rate via β se , β si , and ζ h . given china's experience, the implementation of nationwide shutdowns can effectively reduce the values of β se and β si . increasing the number of pcr tests and enhancing the investigation of those with direct or indirect contact history can quickly increase the percentage of diagnoses ζ h . we assumed that nationwide shutdown, store closures, and citizens isolating themselves for at least 28 days are implemented, and that the β si decreased to 0.2 starting from march 31. the numerical result exhibited in figure 6a shows that the peak value decreases and the peak is delayed to 25 august. with the parameters set to β se = 0.067 and β si = 0.2, covid-19 would be extinct on 14 august in japan. the above measures appear to be valid strategies for restricting covid-19 dissemination in japan. essentially, the transmission rate β si is decreased when the confirmed rate ζ h increases. therefore, in the second numerical example, we changed the parameters β se , β si , and ζ h simultaneously. figure 6b shows that this effectively shortens the peak time and reduces the peak size, resulting in the earliest covid-19 virus extinction. compared with the first simulation, the end of the epidemic would occur on 7 july with β se , β si = 0.067, and ζ h = 0.665, whereas the limited value ζ h in china is 62% [16] . we applied the seihrd model to analyze the development of the covid-19 epidemic situation in japan. to eliminate the impact of the uncertainty in the early data, the first 10 imported cases were extracted based on news reports. table 1 details the days the 10 cases appeared in japan as infected or exposed individuals. the parameters of the seihrd model were estimated by dividing the period from 6 january to 31 march into four segments, and the basic regeneration number r 0 in the first segment was estimated as 1.614 (95% ci 1.449-1.649), as illustrated in table 2 . on 26 january, due to the landing of the diamond princess cruise ship, the officials began to pay attention to the epidemic and introduced relevant isolation measures, which reduced the infection rate and the basic reproduction number r 0 to 1.484 (95% ci 0.926-1.860). with japan's large-scale suspension of schooling on 6 march, the transmission rates weakened to β se = 0.105 (95% ci 0.088-0.202) and β si = 0.325 (95% ci 0.088-0.202). the basic number of r 0 became 1.053 (95% ci 0.885-1.641). we constructed an index of pcr testing and the proportion of diagnoses ζ h degraded to 0.065 (95% ci 0.035-0.199) when the index reduced from 1.553 to 0.826. the transmission rates β se and β si increased as the index decreased. these results show that strengthening the isolation measures and increasing pcr medical screening would help to effectively mitigate covid-19 spread. to examine the validity of our approach, applying the seihrd model, we generated five-day forecast data and compared the results with the actual accumulated reported cases. the five days of accumulated reported cases exist within the 95% confidence intervals, as shown in figure 4a . the five-day relative error of the forecasted accumulated reported cases is less than 2.5%, which means this seihrd model and the piecewise estimation method can be effective applied to covid-19. according to the existing medical resources [17] , we predicted the time of medical saturation under the current situation and forecast the number of deaths, as shown in figure 5a . numerical examples proved that the suspension of production and business, school shut downs, and large-scale implementation of pcr testing for individuals who may have directly or indirectly come into contact with confirmed cases are the success strategies for preventing the further spread of covid-19. it may be possible to end the epidemic in early or mid-july by combining isolation measures and increasing pcr testing, as shown in figure 5b . in conclusion, there is the possibility of a large-scale outbreak of covid-19 in japan given the current situation. some control strategies such as strengthening the isolation measures and increasing pcr medical screening should be taken to prevent the covid-19 further spreading, as shown in section 3. the authors declare no conflict of interest. the latest situation of the pneumonia epidemic infected with new coronavirus as of 24:00 on coronavirus covid-19 global cases by the center for systems science and engineering (csse) at johns hopkins university (jhu). available online substantial undocumented infection facilitates the rapid dissemination of novel coronavirus (covid-19) prediction of the epidemic peak of coronavirus disease in japan transmission potential of the novel coronavirus (covid-19) onboard the diamond princess cruises ship estimating the asymptomatic proportion of coronavirus disease 2019 (covid-19) cases on board the diamond princess cruise ship incubation period and other epidemiological characteristics of 2019 novel coronavirus infections with right truncation: a statistical analysis of publicly available case data tracking and predicting covid-19 epidemic in china mainland modified seir and ai prediction of the epidemics trend of covid-19 in china under public health interventions reproduction numbers and sub-threshold endemic equilibria for compartmental models of disease transmission the japan times. nearly all prefectures in japan shut schools amid coronavirus outbreak passengers disembarking from diamond princess need to be quarantined for 14 days nonlinear observer using mean value theorem and lsqnonlin matlab algorithm exact bootstrap confidence intervals for regression coefficients in small samples characteristics of and imoprtant lessons from the coronavirus disease 2019 urgent investigation on the number of respirators and ecmo devices handled key: cord-317449-xjo6r6yc authors: mota, gustavo r.; dos santos, izabela aparecida; arriel, rhaí andré; marocolo, moacir title: is it high time to increase elite soccer substitutions permanently? date: 2020-09-25 journal: int j environ res public health doi: 10.3390/ijerph17197008 sha: doc_id: 317449 cord_uid: xjo6r6yc rules determine how team sport matches occur. match-induced fatigue is specific to each sport, and may be associated with injury incidence. for example, the injury rate in soccer is distinctly higher during matches than in training sessions. understanding the differences between team sports rules might be useful for enhancing rules (e.g., safer sport). therefore, this study aimed to evaluate the impact of the rule-induced physical demands between soccer, futsal, basketball, and handball, focusing on substitution rules. data from the elite team sports’ rules (e.g., absolute and relative court dimensions; the number of players, substitutions allowed, total game time, time-outs) were collected, including the changes due to the coronavirus disease (covid-19) pandemic in soccer substitutions, and comparisons were performed. the data showed that soccer has higher rule-induced physical demands: e.g., substantially lower substitution rate, higher dimensions in absolute (eight to fifteen times), and relative (four to eight times) values. simulations also showed that soccer has extremely large differences, even considering covid-19 substitution changes (from three to up to five). we conclude that elite soccer has remarkably higher overall rule-induced physical demands than elite futsal, basketball and handball, and increasing soccer substitutions permanently (e.g., unlimited) might mitigate overall soccer demands. the overall load of soccer matches (i.e., cognitive decision making, tactical and technical proficiency inside a set of well-advanced physical capacities) results in postmatch fatigue which is associated with high match-induced muscle damage and inflammatory responses, dehydration, and glycogen depletion [1] [2] [3] . a systematic review concluded that a period of~3 days postmatch, for example, is insufficient to fully recover homeostatic balance caused by a soccer match load [1] . compared to basketball, volleyball, and handball, soccer is the most demanding sport with much higher muscle damage and inflammatory markers than the other sports [4] . indeed, another systematic review showed that soccer has the largest total running distances, including high-intensity running and sprinting in comparison with futsal, basketball, and handball [5] , and increments in soccer demands have been recognized through the years [6] . barnes et al. investigated physical and technical soccer performance across a 7-season period in the english premier league. their data confirmed an increment of "only" 2% in total distance covered per match, however they reported impressive increments in distances covered in high-intensity running distance (~30%), actions (~50%), sprint distance (~35%), and the number of sprints (~85%) [6] . this high-intensity increment may be a concern because there is a strong association between high-speed running and injuries [7, 8] . additionally, due to commitments for economic and entertainment reasons, soccer has presented congested schedules (i.e., multiple games within 72-96 h), which is a relevant issue for medical staff [9, 10] . for instance, data over 11 seasons (from 27 teams) exhibited that matches with short recovery (≤four days) were related to augmented muscle injury rates when compared with longer recovery periods (≥six days) [11] , generating the average cost of an elite player injured of~€500,000 (~1 month) [12] . soccer is also associated with long-term sequelae due to the high loading on hip and knee joints [13] , early osteoarthritis and poor quality of life after retirement [14] . additionally, soccer injuries may produce a meaningful loss of time from participation, or even early retirement [15] . to confront the issues aforementioned, several studies have investigated strategies to improve recovery, and to minimize soccer-induced muscle damage and fatigue [2] . for example, compression garments [16, 17] , cold water immersion [2] , myofascial release [18] , etc. the literature has a myriad of studies seeking to find smarter training programs or better control of the training load [8] , nutritional aids [19] , sleep hygiene [20] , and other strategies. surprisingly, there are no scientific studies investigating the potential issues caused by the rules of the game itself. reasoning scientifically, the rules of any sport are the "cause", and the "way to play" is the effect. the injury rate is noticeably higher (~10 times) during soccer matches than during training sessions [21] . therefore, rule evaluation to manage the main causes of issues (i.e., match) is necessary, since rules should often be updated to enhance any sport for safety (e.g., shin guards), prevention (e.g., time for hydration), entertainment, cleaner (e.g., video referee), etc. on 11 march 2020, the world health organization announced the coronavirus disease (covid-19) outbreak as a pandemic, and the regular sports season worldwide was interrupted. after months of interruption (~3 or 4 months), most sports leagues have resumed the season. due to the overlap of competition schedules caused by the covid-19 interruption, most soccer teams will face very congested schedules on returning (e.g., games every sunday and wednesday), which potentially increase the risk of injuries (e.g., muscle and ligament injuries) [10, 11] . thus, the fédération internationale de football association (fifa) has changed the substitution rule (temporarily) increasing it from three substitutions to up to five for each team (each match), aiming to minimize the impact on player welfare [22] . there is no research regarding a deep investigation on the impact of potential rule-induced physical demands in soccer (e.g., area per player and fewer substitutes forced by the law of the game), and none comparing different sports in this context. understanding the potential differences between the rules which may impact sport-specific fatigue and eventually injury risk [10] might be useful for practical applications (e.g., updating and enhancing rules for a safer/healthier sport). therefore, this study aimed to evaluate the impact of the rule-induced physical demands among soccer, futsal, basketball and handball, focusing on the substitution rules (including changes due to . we hypothesized that soccer would have potentially higher rule-induced physical demands than other team sports, even considering the changes due to covid-19. in order to meet the aims of this study, first, rule-specific information for the international top men (elite) was obtained from each team sport selected. two authors independently highlighted which rules (in each sport) might have an impact on the physical demands of the players (e.g., total distance covered). for example, the size of the goal (or basket) has a minimal potential effect on physical demands. on the other hand, the dimensions of the court/field (absolute area and relative area per player), time of playing, and the number of substitutes (absolute and relative) logically impact the demands of the sport. after a consensus between the two authors, the data were collected. then, data were organized in excel sheets for calculations (e.g., percentage of players available-relative substitutions allowed/total players available). quantitative and qualitative analyses were performed and confronted with the literature already existent on physiological (e.g., muscle damage and inflammatory markers) and time−motion (e.g., number of sprints, jumps, distances covered in several speed zones) sport demands. four invasive team sports (i.e., soccer, futsal, handball, and basketball) were selected because these sports have several similarities, and are popular worldwide. all are invasive intermittent team sports, have body contact, require quick (and accurate) decision making and optimum scanning (reading the game), and the purpose is to score a goal or a basket on the opponent's territory [23, 24] . the specific rule information of each team sport was obtained from official websites in june of 2020: soccer, futsal [25] , basketball [26] , and handball [27] . to meet the current research aims, specific information from the rules which may impact the physical demand of the players was collected. for instance, information about the number of players on the field (soccer) or court (other team sports), availability of substitutes on the bench area and when they are allowed to play (including the substitutions changes due to covid-19), time load of each team sport, time-outs, field/court dimensions and the relation between and among that information. the number of games per season (2018-2019) from the top four teams (international, men, elite) of each sport were obtained from websites of each team or official federation. the teams for each sport are presented as a table in the supplementary document (table s1 ). this study developed a descriptive, cross-sectional design, therefore quantitative data presentation is essentially descriptive in nature. due to the nature of this study (i.e., there is only one rule for each sport), the data were not judged from a traditional statistical point of view (e.g., p value, mean values, and standard deviation). alternatively, a qualitative analysis was performed, conducted by two authors focusing on the potential practical implications. all other authors read this analysis carefully, and edits have been combined. such kind of data analysis (e.g., progressive statistics and case research) has been used in sports medicine and sports science fields [28, 29] . data about the number of players, substitutions, time (total, breaks, time-outs), and dimensions of the field/court are presented in table 1 . overall, soccer rules demand higher dimensions of the field and lower substitutions, both in absolute and relative values. soccer has no time-out during the game, but futsal, basketball, and handball do not have this rule. the offside rule may increase the physical demand (please, see discussion). table 2 shows simulations to equate the soccer dimension, changing the current court dimensions. * international and official competitions-minimum dimensions (for soccer); maximum allowed by rules; ** soccer has changed number of maximum substitutions allowed from 3 to 5, due to postponing the regular calendar caused by the covid-19 pandemic; *** unlimited, using total players available (c). simulations to equate soccer to other team sports by decreasing the number of players of the other team sports or increasing the number of soccer players are shown in figures 1 and 2 simulations to equate soccer to other team sports by decreasing the number of players of the other team sports or increasing the number of soccer players are shown in figures 1 and 2 . basketball presented the highest number of matches per season, followed by soccer and futsal (similar), and lately handball in top clubs (table 3) . basketball presented the highest number of matches per season, followed by soccer and futsal (similar), and lately handball in top clubs (table 3) . the proportion between dimensions of the field/courts, number of players, the ratio between total match time and number of matches/season and substitutions simulations are shown in figure 3 . the proportion between dimensions of the field/courts, number of players, the ratio between total match time and number of matches/season and substitutions simulations are shown in figure 3 . table 1 ); * c-19 means the increased maximum substitutions allowed for soccer (from 3 to 5), due to postponing the calendar caused by the covid-19 pandemic; ** s100% represents a hypothetical simulation if soccer could make unlimited substitutions (i.e., using total players available in a game (i.e., 23 each team)). so, 6400 m 2 (soccer area)/46 players (23 × 2 teams) = 139 m 2 /player. panel (c) shows a ratio between total game time x number of matches (e.g., soccer 90 min × 62.5 matches/season [ table 3 ] = ~5625 min/season). panel (d) presents the load time using the maximum substitutions allowed in each sport. note that for soccer we added the c-19 * and s100% ** simulations to equate (like panel b explanation). table 1 ); * c-19 means the increased maximum substitutions allowed for soccer (from 3 to 5), due to postponing the calendar caused by the covid-19 pandemic; ** s100% represents a hypothetical simulation if soccer could make unlimited substitutions (i.e., using total players available in a game (i.e., 23 each team)). so, 6400 m 2 (soccer area)/46 players (23 × 2 teams) = 139 m 2 /player. panel (c) shows a ratio between total game time x number of matches (e.g., soccer 90 min × 62.5 matches/season [ table 3 ] =~5625 min/season). panel (d) presents the load time using the maximum substitutions allowed in each sport. note that for soccer we added the c-19 * and s100% ** simulations to equate (like panel b explanation). this study shows for the first time that elite soccer presents remarkably higher overall rule-induced physical demands than futsal, basketball, and handball, and increasing elite soccer substitutions permanently (e.g., unlimited) might mitigate the overall soccer demands. our findings corroborate our hypothesis, and also studies involving time−motion and physiological demands [4, 5] . the principal reason is the higher surface area of the soccer field, in both absolute (eight to fifteen times) and relative terms (per player; four to eight times), than those of the other sports here studied. the restricted possibility to replace players during the games (i.e., only three substitutions according to the regular rule) is crucial; the other team sports (i.e., futsal, basketball and handball) can limitlessly replace players. even considering the increased number of substitutions during the match due to the covid-19 changes (i.e., from three to up to five substitutions), the discrepancy in the soccer rule-induced physical demands is still too big (figure 3 ). the current data (see h, i, n, o, p and q in table 1 and figure 3b ,d) support that soccer rule-induced physical demands may cause an overload (overall demands) on the players compared with the other team sports here investigated. as the injury rate is clearly higher (~10 times) during the matches than during the training sessions [21] , the rule change due to covid-19 seems not to be enough. recently a study concluded that nonstarters (i.e., substitutes who played) had a lower internal and external load, considering matches and training sessions, during congested schedules [30] , confirming that matches are a crucial training component (i.e., substitutes might be detrained). allowing soccer to increase substitutions permanently across the games, would potentially be a "game changer". this would be easier to implement in comparison to other actions; e.g., reducing the number of competitions, since soccer has a huge economic impact [31] . because the congested schedules in soccer are a relevant concern, and it is related to accumulated fatigue and higher risk of injuries [9] [10] [11] 32] , unlimited substitutions might be an intelligent decision. allowing soccer unlimited substitutions (e.g., only three opportunities to make substitutions to avoid disruption or allowing the turnover of players like futsal), would likely prevent the drop in the intensity of the matches, especially in the second half [1, 33, 34] . evidence exists for an improvement. for example, substitutes covered a greater high-intensity-running distance [35] , and midfield substitutes covered a greater overall distance and distance at high-intensity compared to other midfield team-mates who remained on the pitch for the same period of the game [36] . additionally, hill et al. [37] concluded that substitutes may provide physical and/or tactical impetus, corroborating a basketball study that showed better scoring after substitutions [38] . although a comparison among different sports is limited for obvious reasons (i.e., they "really" are different sports), the disparity between the soccer load (due to its rules) and the others is enormous. it could be considered as "villain", the current rule of substitutions (regular and covid-19 alteration). for example, from all players available in a match (soccer: 11 playing and 12 on the bench), the soccer coach can use only 13% or 21.7% (three players according to the regular rule and five during covid19) against 100% in the other sports (table 1) . besides, in all other sports here investigated, a replaced player can play again. a long time ago, a study compared the epidemiology of injuries between soccer and handball concluding that a modification in soccer rules concerning substitutions was a must [39] . the author showed that 80% of the soccer players had to wait on the field despite an injury because all the substitutions had already been done, probably worsening the injury [39] . if, in 1984, it already was nonsensical, nowadays we cannot find an adjective to mention, since soccer matches are now much more demanding [1, 4, 6] , and the number of games per season probably also. unlimited substitutions potentially would reduce the injury risk during a soccer match/season, which can improve team performance since an 11-year follow-up of the uefa champions league concluded that injuries affect team performance negatively in soccer [40] . recently due to the covid-19 pandemic, two more substitutions per match were allowed (up to five total) in soccer. the contradiction is that the reason is to "protect" the physical integrity of the players [22] . why not release the substitutions regularly, if the reason is to prevent injuries? in the same way that coaches change the rules during small-sided games (e.g., different number of players, smaller area per player) during training to target specific effects [41] , why not change the substitution rule in elite official matches to obtain the benefits? beside the substitution limitations, elite soccer is the only sport (here investigated) which does not allow the substituted player to return to the same match, has no time-out (i.e., no chance for brief recovery), and has the offside rule (which obligates the players to move back and forth). such conditions require even more physical effort from elite soccer players. in this sense, it is interesting to note that the time load would be reduced by~40% if soccer could use all players available (table 1 , q). in our data, we performed simulations to equate soccer to other sports by increasing the court dimensions ( table 2 , figures 1 and 2) . it is relevant to realize the huge changes that are necessary to have similar conditions. for instance, it does not make sense a basketball match "1 vs. 1" (figure 1) , or a soccer match with 76 vs. 76 players on the field (figure 2) . our data showed that basketball has the highest number of matches during a season, while soccer and futsal are similar, and handball has the lowest number of matches per season (table 3) . although soccer has fewer matches per season than basketball, when we investigated the ratio of matches and time load exposure, soccer shows around a two-fold greater time played (matches and season) than the other sports ( figure 3c ,d). even assuming together (i.e., futsal plus basketball plus handball) the soccer relative load time is higher ( figure 3d ). when the covid-19 changes in substitutions is considered, the scenario is better, but still, soccer alone is most demanding (i.e., higher time load per season). however, when allowing unlimited substitutions in soccer (simulation), then, soccer would have lower load time per season than the other three team sports "together" ( figure 3d ). therefore, it seems crucial to increase the number of substitutions in elite soccer, beyond the covid-19 changes. the same reasoning would apply to the dimension of each team sport ( figure 3a,b) . although the field area would not be equal, the increment on soccer substitutions would make elite soccer less physically stressful. it has been shown that soccer promotes higher metabolic demands [1] , and causes greater inflammatory responses and muscle damage, compared with handball, basketball and volleyball [4] . lastly, but not least, beside the higher overall physical demand from elite soccer, especially on the lower limbs (to run, sprint, jump), all the technical skills are performed (e.g., passes) by the "same" lower limbs. although the lower limbs are fully in demand (e.g., runs, sprints, accelerations, decelerations) during a basketball or handball game, they may not kick the ball. soccer-induced fatigue worsens the quality of skills such as passing and shooting [42] , which are decisive for soccer. indeed, lower extremities are more injured in soccer [43] . those facts are additional points to suggest unlimited substitutions during elite soccer games (permanently) as a strategy to improve recovery, prevent injuries, and improve performance. one limitation of the current study is that it is difficult to compare different sports, since they are naturally different. we also cannot confirm that all players participate in all the matches during a season. however, the same might happen for other sports too. thus, such limitations do not obscure our conclusions. although the increment in substitutions might be an interesting strategy to mitigate the high overall fatigue from elite soccer, we acknowledge that many substitutions during a game may influence a team's tactics. therefore, the coaches should handle it to take advantage of this possibility. another potential limitation of the current study is that we did not consider the surfaces. the playing surfaces of the field (soccer) and courts (futsal, basketball, and handball) of these sports are different and may influence the physical demands. we conclude that elite soccer has remarkably higher overall rule-induced physical demands than futsal, basketball, and handball, even acknowledging the change in substitutions due to the covid-19 pandemic. as a practical application, allowing the increase of elite soccer substitutions permanently (e.g., unlimited) across the game is a simple strategy to improve recovery and to mitigate the enormous overall soccer demands. since soccer injury rate is much higher during matches (vs. training sessions [21] ), this rule change may help to face congested schedules and benefit injury prevention. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/19/7008/s1, table s1 : top four teams to obtain the number of games per season (2018-2019), international, men, elite of each sport. acute and residual soccer match-related fatigue: a systematic review and meta-analysis recovery in soccer relationships between match activities and peak power output and creatine kinase responses to professional reserve team soccer match-play comparison of inflammatory responses and muscle damage indices following a soccer, basketball, volleyball and handball game at an elite competitive level activity demands during multi-directional team sports: a systematic review the evolution of physical and technical performance parameters in the english premier league injury rate and prevention in elite football: let us first search within our own hearts the training-injury prevention paradox: should athletes be training smarter and harder? the effects of a congested fixture period on physical performance, technical activity and injury rate during matches in a professional soccer team a congested football calendar and the wellbeing of players: correlation between match exposure of european footballers before the world cup 2002 and their injuries and performances during that world cup muscle injury rates in professional football increase with fixture congestion: an 11-year follow-up of the uefa champions league injury study keeping your top players on the pitch: the key to football medicine at a professional level are there long-term sequelae from soccer? early osteoarthritis and reduced quality of life after retirement in former professional soccer players why are stress injuries so common in the soccer player? can compression stockings reduce the degree of soccer match-induced fatigue in females? compression stockings used during two soccer matches improve perceived muscle soreness and high-intensity performance effects of foam rolling as a recovery tool in professional soccer players the efficacy of acute nutritional interventions on soccer skill performance sleep interventions designed to improve athletic performance and recovery: a systematic review of current approaches epidemiology of injuries in professional football: a systematic review and meta-analysis five-substitute option extended into 2021 in response to covid-19 pandemic-fifa teaching invasive team sports in the school environment: from theory to practice from the perspective of a hybrid model the effects of ball possession status on physical and technical indicators during the 2014 fifa world cup finals fédération internationale de football association fifa. futsal laws of the game fédération internationale de basketball fiba international handball federation ihf. rules of the game progressive statistics for studies in sports medicine and exercise science the application of single-case research designs to study elite athletes' conditioning: an update workload monitoring in top-level soccer players during congested fixture periods the economic effects of the soccer world cup 2006 in germany with regard to different financing perspectives in football medicine match performance and physical capacity of players in the top three competitive standards of english professional soccer high-intensity acceleration and deceleration demands in elite team sports competitive match play: a systematic review and meta-analysis of observational studies evaluation of the match performances of substitution players in elite soccer work-rate of substitutes in elite soccer: a preliminary study practitioner perceptions regarding the practices of soccer substitutes exploring the effects of substituting basketball players in high-level teams epidemiology of injuries in typical scandinavian team sports injuries affect team performance negatively in professional football: an 11-year follow-up of the uefa champions league injury study physiology of small-sided games training in football: a systematic review the effects of fatigue on soccer skills performed during a soccer match simulation soccer injury in the lower extremities we acknowledge l. bruce gladden (auburn university, al, usa) for his assistance with english editing. we also acknowledge gilson l. volpato (igvec institute and sao paulo state university-unesp, botucatu, sp, brazil) for his scientific advice during the peer-review process. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-312094-czuw4t7i authors: radic, aleksandar; lück, michael; ariza-montes, antonio; han, heesup title: fear and trembling of cruise ship employees: psychological effects of the covid-19 pandemic date: 2020-09-16 journal: int j environ res public health doi: 10.3390/ijerph17186741 sha: doc_id: 312094 cord_uid: czuw4t7i the current covid-19 pandemic has evolved to unprecedented proportions. this research aimed to gain a deeper understanding of the psychological effects of the covid-19 pandemic on cruise ship employees stuck at sea. using an inductive qualitative approach, a synchronous online focus group was conducted with nine cruise ship employees who were stuck at sea during covid-19 pandemic. the findings revealed that covid-19 pandemic has managed to erase the feeling of joy from cruise ship employees who were stuck at sea while exposing weakness of cruise line companies such as poor human resource management leadership. moreover, covid-19 pandemic demonstrated that it is of paramount importance that cruise line companies create a comprehensive strategy in assisting their employees who are experiencing an anxiety disorder and depression. the managerial implications are outlined. up until 2020, cruise tourism was the fastest-growing sector within the tourism industry [1] ; however, on 14 march 2020, members of the cruise line international association (clia) voluntarily suspended their cruise ship operation due to the covid-19 pandemic, and on 12 april 2020 a no sail order issued by the centers for disease control and prevention (cdc) suspended all cruise operations until 30 september 2020 [2] . the cruise line international association (2020) [3] outlines that 1.17 million jobs worldwide will be in danger due to the suspension of cruise operations caused by the covid-19 pandemic. furthermore, major cruise lines are experiencing enormous financial losses [4] , and fears from the covid-19 cruise tourism crisis have induced a devastating crash of major cruise lines stocks [5] . thus, 122 new ocean-going ships that are on order until 2027 with a total value of 68.4 billion usd$ [6] , are at risk due to the shrinking liquidity of the extremely fragile cruise line industry. due to this poor liquidity and being on the verge of bankruptcy: • carnival corporation has laid off 502 and furloughed 28 employees from their miami-based office [7] , laid off 450 from their uk-based office [8] , and tapped into various financial agreements, raising 6.4 billion usd$ in liquidity [9] ; • royal caribbean cruises ltd. has laid off or furloughed approximately 26% of their 5000 employees in the united states [10] and raised over $3.6 billion usd$ in liquidity [11] ; • norwegian cruise line holdings ltd. furloughed about 20% of its workforce including 4000 shore side employees and roughly 32,000 shipboard workers [12] , and raised close to 3.5 billion usd$ in liquidity [13] . with suspended cruise ship operations and without revenue, cruise line companies are draining their funds at a fast rate. balboa [14] predicts that from 15 may 2020, carnival corporation can sustain itself for 9 more months, royal caribbean cruises ltd for 11 more months and norwegian cruise line holdings ltd for 18 more months. with such predictions, at least 250,000 crew members worldwide [15] are in danger of losing their jobs. studies on well-being and life satisfaction of cruise ship employees are scarce; however, studies that are related to the psychological effects of being unemployed and isolated at sea due to the covid-19 pandemic are to the authors' best knowledge non-existent. thus, the purpose of this research is to obtain a deeper understanding of the psychological effects of the covid-19 pandemic on cruise ship employees stuck at sea. to accomplish this task, the following research question is addressed: "what are the psychological effects of the covid-19 pandemic on cruise ship employees stuck at sea?" this study is exploratory in nature and the present work addresses a major research gap. the aim of this research will be addressed by utilizing an inductive approach to data collection and an online synchronous focus group with cruise ship employees stuck at sea during the covid-19 pandemic. hence, to answer the research question and to fulfill the aim of this study, the specific objectives were to: (a) explore if cruise ship employees are experiencing certain worries, fears and sleep disturbances; (b) investigate how the lack of onboard social cohesion and lack of family and friends social support is affecting cruise ship employees; (c) assess components associated with perceived stress of cruise ship employees; and (d) evaluate the state of hope and sense of belonging of cruise ship employees. in light of the current covid-19 pandemic, the results of this study provide valuable contributions to the theory of cruise tourism. cruise tourism is a socio-economic system based on maritime transport with a sole purpose of creating tourism experiences founded on interaction between people, organizations, and geographical entities [16] [17] [18] [19] [20] . as such, cruise ship employees have a crucial role in delivering quality service [21] in a multi-sensory cruise experience [1] . thus, the service quality and cruise experience are heavily dependent on the well-being and life satisfaction of cruise ship employees. looking at cruise ship employees' well-being, radic et al. [22] argue that cruise ship employee well-being is a synthesis of happiness and pleasure. similarly, the life satisfaction of cruise ship employees can be understood as an individual's psychological aspects rooted in their hedonic satisfaction [23] . considering the well-being and life satisfaction of cruise ship employees, bardelle and lashley [24] outlined how a large number of crew members are experiencing homesickness and sadness while working on a cruise ship. while investigating onboard experiences of cruise ship employees, bolt and lashley [24] found considerably stressful constraints that place pressure on cruise ship employees. furthermore, larsen at al. [25] found how life satisfaction of cruise ship employees was strongly influenced by respect, social atmosphere, and quality of food and living quarters. hence, in a recent study on occupational health and safety of cruise ship employees, radic [26] concluded how work-related injuries have profound negative effects on the well-being of cruise ship employees, creating a perception of unattractive and unfavourable working conditions among crew members. interestingly, cruise ship employees who resigned from cruise line companies to start a new beginning with a land-based job, exhibit a certain degree of nostalgia with a romanticized feeling about well-being and life satisfaction while being onboard [27] . however, while being onboard, cruise ship employees are exposed to prolonged harsh working conditions in the form of constant time pressure and heavy workload coupled with the everlasting uncertainty about their next contract assignment [28] . moreover, unfavorable working conditions combined with the inability of psychological detachment from the work creates a negative impact on cruise ship employees' well-being [29] . thus, cruise industry news [21] argues how poor well-being of cruise ship employees can affect their mental health, which leads to high employee turnover, absenteeism, and increased expenses due to health care costs. hence, it appears that cruise ship employees are trapped in what moore [30] calls "misery machines". peculiar work and life conditions of cruise ship employees affect their well-being to the point of the alarming rise of suicide rates in recent years [31, 32] . the shipowners' club [33] briefly outlines that cruise ship employees' mental and physical health and relationships at home and onboard were evidently affected by the covid-19 pandemic. in summary, although aforementioned studies have provided a glimpse of cruise ship employees' well-being and life satisfaction, currently there exists a research gap on the psychological effects of a pandemic, in particular the covid-19 pandemic on cruise ship employees stuck at sea. because of the observational nature of the study, and in the absence of any involvement of therapeutic medication, no formal approval of the institutional review board of the local ethics committee was required. nonetheless, all subjects were informed about the study and participation was fully on voluntary basis. the study was conducted in accordance with the helsinki declaration. this research is explorative as it analyzes new and unprecedented areas of the covid-19 pandemic. the goal of this study is to explore the psychological effects of the covid-19 pandemic on the cruise ship workforce stuck at sea. taking into consideration that the covid-19 pandemic has led to a health and epidemiological type of crisis in cruise tourism, this novel situation needs to be explored in-depth, and qualitative research with an interpretivist paradigm was adopted. interpretivism argues that social phenomena should be studied from the perspective of involved social actors [34] . communication and social relationships are comprised of diverse expositions and individual responses, and, as such, interpretivist-qualitative lenses provide a meticulous understanding of the connection between implication and action [35] . furthermore, the interpretivist paradigm creates opportunities for accessing diverse expressions and points of view since this paradigm seeks to raise the voices of the community in the appraisal process [36] . this study took an inductive approach and a qualitative method where an online synchronous focus group was conducted. the synchronous online focus group is a peculiar situation where the moderator and somewhere between four to nine participants are in an online chat room where everyone simultaneously types comments that are visible to all group members [37] . possible participants were invited to take part in the research via the crew center facebook group that connects cruise ship employees. participants for this study were chosen using a convenience sampling method. to participate in the synchronous online focus group, the participants had to meet the following criteria: (1) being stuck at sea on a cruise ship during the interview; (2) being on a cruise ship since 14 march 2020, the day when members of the clia voluntarily suspended their cruise ship operation; (3) being without a contract and not being paid while being stuck at sea; and (4) not knowing their repatriation date. data were collected from nine cruise ship workers employed by four major cruise lines and who were on nine different cruise ships during the covid-19 pandemic. these cruise ship employees are members of various onboard departments. given the aim of examining the psychological effects of the covid-19 pandemic on cruise ship workforce stuck at sea, cross-sectional research was conducted. the major strength of a cross-sectional design is convenience, as such studies are quick to complete and relatively inexpensive [38] , and they provide a picture of a situation related to a particular population within a specific time [39] . in this study, a synchronous online focus group was conducted via the well-known text and voice messaging cross-platform whatsapp. this option ensured participants' anonymity since they are not visible to the group and the recent popularity of chat emoticons buffered the disadvantage of not having visual cues [35] . the study was conducted on 22 may 2020 and the online synchronous focus group lasted 68 min. one of the authors who works on the cruise ship and was stuck at sea since 14 march 2020 when members of the clia voluntarily suspended their cruise ship operation, acted as a moderator. at the end of the discussion, the moderator downloaded the entire script. written data were coded using open and axial coding techniques grounded in procedures outlined by strauss and corbin [40] . online synchronous focus groups are not without shortcomings, however, rigor was achieved by following higginbottom's [41] recommendations, carefully recruiting participants based on their experience and knowledge. validity was enhanced by facilitating a lavish data set as recommended by morse [42] . reliability was ensured by following richard et al.'s [43] recommendations with a skilled and experienced researcher (one of the authors) acting as moderator, which was instrumental in overcoming the disadvantages of lack of non-verbal cues, minimizing disturbing conduct of some of participants, and minimizing various errors and biases. in summary, an inductive approach and a qualitative method with an online synchronous focus group are commonly used for topics that are not well understood so the new insights could be discovered. this study aims to explore the psychological effects of the covid-19 pandemic on cruise ship employees stuck at sea. its explorative nature made online a synchronous focus group a suitable method for this study. furthermore, as an exploratory study on the psychological effects of the covid-19 pandemic, the portrayal of the sample as part of a specific entity is not a considerable worry as the method aims to investigate the aspects and provide a structure instead of variables estimation and their description. respondents from the synchronous online focus group were cruise ship employees who were on board since 14 march 2020; they were without a contract and not being paid, and they did not know their repatriation date. the respondents' age ranged from 26 to 43 years; five respondents were from asia, followed by three respondents from europe, and one respondent from south america. the sample was evenly distributed in terms of gender, with five females and four males. looking at the participants' working departments, the sample had seven respondents from the hotel department, one participant from the marine and technical department, and one participant from the entertainment department (table 1) . the maritime labour convention 2006 [44] "seafarers' bill of rights" was extended to cruise ship seafarers in 2013, and under the "seafarers' bill of rights", cruise line companies are obliged to provide for their crew members repatriation at the end of their contract. however, on 12 april 2020, due to the covid-19 pandemic, the cdc issued a no sail order, which has prohibited cruise line companies to use any form of commercial transportation for crew member repatriation purposes [2] . the cdc's no sail order in combination with poor liquidity of cruise line companies due to the covid-19 cruise tourism crisis has created an unprecedented event leaving 100,000 cruise ship employees stuck at sea for months without any certainty when they will be repatriated to their homes [45] . consequently, like song and li [46] argue, the uncertainty of what future might hold can lead to anxiety. during the discussion, all participants have outlined that they are experiencing certain worries while being stuck at sea. my contract was until july 2020. the company unilaterally stopped it on 30 march and since then (today is 22 may) they are holding me onboard without pay. my family needs financial support and i am unable to provide them financial support because my company doesn't want to pay for the charter flight, and the cdc is not allowing the company to send me home with a commercial flight. (cruise ship employee no. 4) cruise ship employees' worries are related to not being able to provide financial support to their families, not being able to see their family and friends, and ultimately they are left with a feeling that they do not have any control of their life. they are experiencing negative economic and social effects of being unemployed and isolated at sea due to the covid-19 pandemic. thus, the aforementioned conditions can lead to anxiety, where house and stark [47] define anxiety as a comprehensive adaptive reaction when the individual is facing an unknown danger. moreover, due to the covid-19 pandemic, government-issued isolations will have an enormous negative effect on mental health for many, especially on those individuals who are peripheral members of the society, because they are more likely to face financial deprivation and lower quality of life [48] . although cruise ship employees come from various countries around the globe, the majority of them are from undeveloped or developing countries [49] , thus, cruise ship employees' mental health will be most likely affected by the covid-19 pandemic. the anxiety of cruise ship employees stuck at sea is growing as they fear an uncertain future and an economic mega-crisis that lies ahead. increased anxiety and fear-associated traits within human behavior are related to the fearful stimuli and increased activity in the amygdala. it is well documented that fear spreads extremely fast and that no one is immune to fear [50] . during the discussion, all respondents outlined that their biggest fears were related to not being able to see their family, not being able to go home, not getting paid, the uncertainty of what future holds, and knowledge of forthcoming financial deprivation. i fear that my son won't recognize me when i come home. i am already 9 months onboard. i have to wear a mask while i talk to my son, and he always asks me to remove my mask because he can't see me. i can't hold off my tears when he tells me this. (cruise ship employee no. 2) seafaring is an occupation that carries hardship [51] , and the covid-19 cruise tourism crisis illustrated that cruise ship employees feel afraid, lonely, unprotected, and financially enslaved. living in fear is what makes one "being a slave" [52] and since cruise ship employees are low paid, mobile, and under "maltese contract," "cyprus contract," or "swiss contract", they fit well in what mann [53] describes as wage slaves. nevertheless, cruise ship employees come onboard with hopes that their work efforts will in return provide them and/or their family considerable financial benefits [49] . furthermore, the covid-19 cruise tourism crisis has shattered, both in ethical and aesthetic nature, cruise ship employees' dreams and ideals of a brighter future. however, kierkegaard [54] argues how such destruction leads only to the remolding of dreams and ideals on new grounds. sleep is a process that incorporates neurobiological, neurochemical, and psychological systems [55] . moreover, an optimal period of quality sleep plays an important function as a safeguard for individuals' mental health and everyday performance [56] . abysmal sleep quality can lead to quite a few psychological disorders including depression, anxiety, and paranoia [57] . thus, sleep disturbances are one of the symptoms of anxiety [58] . gillespie [59] discusses how isolation and coronavirus anxiety lead to insomnia. during the discussion with the participants, every single one of the participants described in an individual way how their quality of sleep was poor. i am constantly tired although i am not working. with too much pressure on my shoulders, too much free time to think about all the possible things that can go wrong, locked inside my cabin, when night comes i can't fall asleep. i force myself to sleep, only to wake up every 2-3 h. looking at my watch asking myself when will this agony come to an end. (cruise ship employee no. 9) a clear sign of cruise ship employees' growing anxiety is their sleep pattern. as days onboard become weeks, and weeks become months, cruise ship employees experience insomnia and when they fall asleep, nightmares wake them in distress. sleep disturbances are a common factor in anxiety disorders where complaints related to insomnia and even nightmares are fundamental in defining generalized anxiety disorder and even posttraumatic stress disorder [60] . worries, fears, uncertainty, isolation in small cabins, lack of opportunity to share one's concerns, and loud noise from maintenance were just some of the factors that have led to sleep disturbance and anxiety of cruise ship employees. moreover, due to the cdc's no sail order [2] , cruise line companies are failing to meet obligations related to cruise ship employees' living conditions, recreational areas and amenities set in the maritime labour convention 2006 [44] "seafarers' bill of rights". depression is a profound medical illness that negatively affects how an individual feels, thinks, and acts, which ultimately leads to sadness and/or a deprivation of delight in previously pleasurable activities [61] . seafarers are susceptible to diverse mental health disorders including depression [62] . bearing in mind that social isolation is a robust contributor to depression [63] , cruise ship employees that are stuck at sea for months [45] due to the covid-19 pandemic are at risk to aggravate depressive symptoms. during the discussion, all respondents clearly outlined some traits of depression. this hopelessness, confusion, sadness, and longing. some of us have finished our contracts two months ago and since then we are not paid. there are people on board who are here for more than 7 months. it's very hard for all of us and none of psychologist and none of that nonsense talk will help us. just look at the people who have committed suicide in the last 10 days. i think there were 4 or 5 suicides by crew members who were stuck at sea. this is terrible. people are on the edge and most of the people are broken beyond repair. (cruise ship employee no. 7) prolonged isolation, despair, deterioration of well-being, and impossibility to return to their homes so they can be reunited with their loved ones have seriously affected how cruise ship employees feel, think, and act. although evidence on seafarers' depression and suicide rates are scarce and fragmented [64] , while being stranded at sea due to the covid-19 pandemic, four crew members have died under unclear circumstances and not related to the covid-19 virus [65] . cruise ship employees who embark on the cruise ship in pursuit of a brighter future found themselves in what kulzer et al. [66] describe as a world where fear survives. cruise ship employees are facing a transformational experience that rogell et al. [67] pronounce as the journey of a lifetime. humans are social beings that are constructing the hierarchical structure of society to obtain and maintain resources [68] . to comply with the maritime labour convention 2006 [44] "seafarers' bill of rights", cruise line companies are in obligation to provide recreational facilities and amenities for socializing purposes of their crew members. however, the cdc's no sail order [2] has specifically forbidden the usage of recreational facilities and amenities for socializing purposes. consequently, the cdc's no sail order [2] has created both objective and subjective social isolation. subjective social isolation from both family and friends is associated with higher depressive symptoms [69] . participants have made a clear statement that it is impossible to socialize due to the cdc's no sail order [2] . by some law, we should have recreational space and space for socializing like crew bar or similar space. the cdc forbids the usage of crew gym, crew bar, or anything where we can group for socializing. i come from a society where we live in small and large groups caring for each other. this is also how we behave while we are on the ship. now we can't do that, so i fell very lonely, sad, and depressed. cruise ship employees socialize with one another in specially designated bars, while they are at the gym, on the rare occasion when they go ashore, and some of the crew members even engage in casual intimacy [49] . however, while being stuck at sea due to the covid-19 pandemic, cruise ship employees feel alone, isolated, depressed, and detached because they are unable to enjoy onboard socialization due to the cdc's no sail order [2] . the liminality of the cruise ship and rigid managerial hierarchical structure erase a clear line between private life and workplace of crew members [70] , thus, while being stranded at sea, cruise ship employees have lost all points of reference except daytime and nighttime. human beings are social animals [71] in need of relatedness to friends and family. however, cruise ship employees understand that to the cruise line companies they are nothing more than a number on their identification card, thus, for the cruise ship employees' perceived social support and relatedness to friends and family needs satisfaction is of paramount importance [49] . furthermore, the quality of family interactions is of utmost importance for understanding the development process of depressive symptoms in adolescents [72] . depressive symptoms decrease significantly with those individuals who enjoy strong family and spousal support [73] . during the discussion, participants used every opportunity to stress how much they are missing their friends and family at home. under normal circumstances cruise ship employees leave their family and friends at home and the mental pressure of such decision weighs heavy on them. crew members cope with such hard decisions by psychologically preparing themselves that their sacrifice will provide them and/or their families with considerable financial benefits [49] . however, in a case when cruise ship employees are stuck at sea due to the covid-19 pandemic, where the majority of them are not getting paid or are paid a minimal salary, the uncertainty of when they will go home, if they will find another job and what would be a new reality when they eventually go home, is crushing them. human functional brain networks is a system that organizes various assignments such as planning, anticipating, analyzing (executive control network), reflecting on previous experience (default mode network), determining the importance of the current environment (salience network), and focusing attention to the issue at hand (ventral attentional networks) [74] . on 11 april 2020, cruise ship seafarers went to sleep with hopes that they will soon go to their homes and loved ones, however, they woke up on 12 april 2020 in a completely different world where the cdc's no sail order [2] was not allowing them to use any form of commercial transportation for repatriation purposes. thus, since that point in time, cruise ship employees have been under chronic stress, due to situations where salience brain network activity (scanning the environment for threat) has taken control and executive control brain network (analyzing current conditions) has been deactivated. fear is a mind killer [75] , and being afraid of something suppresses the ability to think straight [74] . as a consequence, sep et al. [76] conclude how extrapolation of fear is a frequent indication of anxiety and trauma-related disorders. during the discussion, participants clearly outlined how they feel agitated due to the uncertainty of what the future holds. the covid-19 cruise tourism crisis managed to erase the feeling of joy from cruise ship employees, thus, it does not come as a surprise when they speak in an almost passive participant voice about their relentless complaints against diminished control of their own life. it appears as though fear of what might come has spread across the cruise ships. thus, melancholy prevents cruise ship employees from feeling any positive emotions. as the uncertainty of future events keeps on suffocating cruise ship employees, they grow agitated, confused, and depressed. for inexperienced seafarers, cruise ships appear as delightful ocean-floating hotels with never-ending entertainment, and a wonderful way to obtain monetary gain while being able to visit exotic places. however, cruise ship employees work and live on board for a prolonged period of time, and during their stay on board, they are often exposed to various stressful events that affect their life satisfaction [77] . in light of the covid-19 pandemic, cruise ship employees that are stuck at sea are experiencing particularly high levels of stress that may develop mental health disorders such as anxiety and depression. during the discussion, all participants but one expressed how they feel stressed and nervous. i feel stressed and furious. if the president of the imo, cdc, or whatever had a kid or spouse stuck on a ship would they not do everything to get them home? it's common sense to allow crew members to go to their homes. did you know that 5 crew members committed suicide in the last 10 days? do you know why they did it? because they couldn't cope with stress, so what do you think will happen if this drags for another two months or until 24 july 2020 when the no sail order comes to an end?! governments around the world need to step up and help their citizens who are crew members, and the cdc needs to come forward towards an agreement with an international organization and various governments. (cruise ship employee no. 4) while being stuck at sea, cruise ship employees are caught in no man's land between: (1) cruise companies on verge of bankruptcy that are trying to consolidate their liquidity; (2) a distant cdc administration who are inhumanly insisting on noncommercial transportation for crew members' repatriation purposes; and (3) quite a few government bureaucracies who are not allowing their crew members to come back home. due to the fear of uncertainty, stress builds up and it appears that on the high seas no one can hear crew members' silent screams of existential despair. lastly, as reconstructions in fear neurocircuitry influence anxiety disorder, chronic stress manifestation reorganizes fear neurocircuitry, triggering structural degeneration in the prefrontal cortex and hippocampus, thereby restricting dominance over the stress response [78] . the covid-19 pandemic changed the world, and each human being has changed in their own way. when it comes to cruise ship employees, the covid-19 cruise tourism crisis showed that major cruise line companies do not have a contingency plan in case of a health and epidemiological type of crisis and that many governments do not have coherent leadership. consequently, cruise ship employees found themselves alone in a chaotic situation. during the discussion, the majority of participants shared the opinion that they cannot cope with all the things that are happening in the world during the covid-19 pandemic. every question we asked we get an answer "we don't know" or "we are not sure". we are really worried about our future and our mental health because this is a situation without a solution. we are not getting paid, we can't buy drinks, the gym is closed, and there are no activities that would relax us here onboard. when you want to buy morning coffee you need to wait in line for 1 h, because the ship is understaffed. of course all of us are very stressed in this situation. today security called us in cabins to ask for the names of people who were protesting yesterday. it is serious retaliation and this is against human rights. it feels like none of us have a right to say our opinion. we just want the world to hear us because all of us just want to go home to be with our families. (cruise ship employee no. 1) cruise ship employees who are stuck at sea have found themselves in a peculiar situation that they cannot change because they depend on multilateral dialog and agreements between cruise line companies, the cdc, airlines, and various governments. as uncertainty crawls in every pore of cruise ships, causing waves of stress, depression, anxiety, and panic, cruise ship employees are in need to create a common sense from what appears to be a hopeless situation. the covid-19 pandemic is having an overwhelming effect on all life aspects of cruise ship employees, including mental and physical health. thus, as frankl [79] concludes, when a person finds themselves in a situation that they cannot change, the only thing the person can do is to embrace the opportunity to change themselves. while cruise line companies are dealing with the covid-19 cruise tourism crisis, their leadership needs to look further and make contingency plans on how to prevent the next pandemic crisis and pending climate change crisis. cruise line companies' leadership should, therefore, ask themselves how the covid-19 cruise tourism crisis did happen in the first place, and diligently work to change everything that went wrong. the covid-19 pandemic has created a unique opportunity for cruise line companies to revise their corporate culture, reinvent their business models, enhance their human resource management, develop and embrace the risk and crisis management strategies, and adopt sustainable development. based on the respondents' answers, there are mixed opinions if there are positive ways how cruise line companies can get out of the covid-19 cruise tourism crisis. we should not only look into the cruise companies and what they are doing. have faith and hope. talk to each other about what's good. somebody out there anywhere in the world is battling for their life in this pandemic. come to think of the other perspective. after all of this darkness and rain, there will be light and rainbow and a brighter future. one day all of this will be the history which we will tell to our grandchildren. it would be a story of how we coped with a crisis and survived. all this will probably help us to be better people. (cruise ship employee no. 6) to those people who are saying that we need to wait, put yourselves in our shoes, that is come on the ship that has a covid-19 outbreak. this is day 61 of our isolation excluding the days when we were at sea before we started isolation. almost 2.5 months without contact with other people. we are only asking for one thing, send us back home to our families. (cruise ship employee no. 4) the covid-19 pandemic has exposed the unsustainable business model of cruise line companies. although under normal circumstances working conditions onboard do not dehumanize cruise ship employees, the covid-19 pandemic has certainly shown that for cruise line companies and the cdc, cruise ship employees do not matter in some profound way. the aforementioned condition is rooted in a systemic failure of cruise line companies' leadership to understand what is happening with the covid-19 pandemic, aggravated by the capitalism of the neoliberal era. thus, as cruise line companies claim they are doing their best for the crew members' repatriation, there is a dividing perception among cruise ship employees in regards to positive ways how cruise line companies can get out of the covid-19 cruise tourism crisis. while some cruise ship employees see the light at the end of tunnel as the cdc's no sail order [2] expires on 30 september 2020, others think that the long-awaited 30 september 2020 and the light at the end of the tunnel is nothing more than what žižek [80] (pp. xi-xii) describes as: "probably the headlight of another train approaching from the opposite direction". on 3 february 2020, princess cruises confirmed that 10 people on the ship diamond princess had tested positive for covid-19 [81] and on 11 march 2020, the world health organization officially declared covid-19 a pandemic. at that time, there were 121,564 people infected, 4373 dead and 66,239 recovered including nearly 800 people aboard four cruise ships [82] . shortly after that on 14 march 2020, members of the clia voluntarily suspended their cruise ship operations, followed by the cdc's no sail order issued on 12 april 2020, which suspended all cruise operations until 30 september 2020 [2] . lastly, on 17 may 2020, there were around 100,000 cruise ship employees stuck at sea without any certainty in regards to their repatriation to their homes [45] . all respondents but one were quite skeptical about the leadership of cruise line companies and their energetical pursuit to do everything in their power to get them home. no, i don't think that office people are doing everything in their power to get us home. crew members should be respected way more than they have been. if the company continues this horrible management of their crew members, the day will come when no one will work for them and they will fail as a company. everything starts at the top. horrible leadership! i have lost all faith in this company. i am just tired of all the lies and their failure to care about people. true colors came out in tough times. this is no way to treat anyone. so sad! (cruise ship employee no. 8) while being stuck at sea, cruise ship employees' doubts in regards to cruise line companies' leadership capabilities and their sincere efforts in pursuing crew members' repatriation are boiling up. thus, as despair, anxiety, depression and stress accumulate across various cruise ships, it appears that trust in cruise line companies' leadership is diminishing, and as walker [83] points out, some crew members are organizing protests, while others go even further by performing a hunger strike [84] . thus, while cruise line companies' leadership is battling the covid-19 cruise tourism crisis, and they are looking into ways to tap into liquidity so they can stay afloat and avoid bankruptcy, they must not neglect their obligations outlined in the maritime labour convention 2006 [44] "seafarers' bill of rights". all participants expressed an opinion that even when cruise line companies get bad publicity, they hope that they will find a way to solve the covid-19 cruise tourism crisis yes, they are doing their best. i don't understand why media is bad mouthing cruise lines and they can't understand that some countries are not accepting their crew members coming from cruise ships. beside me, my sister is working on a cruise ship and we are from trinidad and tobago, and my sister's boyfriend who also works on a cruise ship is from nicaragua. all of us are not allowed by our countries to come back home. however, all you read is how cruise companies are bad and no one is accusing countries like ours who are not allowing us to come back home. this is hypocrisy! i can tell you that our company is looking after us while we are on board. (cruise ship employee no. 9) crew ship employees believe that sometimes they are being used by media who are attracted to stories related to the covid-19 pandemic and cruise tourism since, as pooley [85] said, "if it bleeds, it leads." nevertheless, the covid-19 pandemic should awaken cruise line companies' leadership to the realization that exploitation of crew ship employees should be abandoned and replaced by social bonds between cruise line companies' leadership and cruise ship employees. the bad publicity of the cruise line companies' leadership during thecovid-19 pandemic is a direct result of poor leadership skills, poor human resource management, nonexistent contingency plans, nonexistent crisis management, and nonexistent crisis communication strategies. lastly, as cruise line companies' leadership are delaying crucial decisions and continue to weigh the costs of crew members' repatriation using charter flights and/or cruise ships while meeting the cdc's no sail order [2] , they are putting hardship on their crew ship employees. onboard working conditions under normal circumstances do not dehumanize cruise ship employees, however, the covid-19 pandemic has managed to erase the feeling of joy from cruise ship employees while exposing the weakness of cruise line companies such as poor human resource management strategies, nonexistent contingency plans, and nonexistent crisis management. accordingly, this study attempted to answer the question: what are the psychological effects of the covid-19 pandemic on cruise ship employees stuck at sea? the results of this study revealed that cruise line companies have poor human resource management strategies and that they did not have a contingency plan to manage this health and epidemiological type of crisis. moreover, cruise line companies do not have a strategy for managing various negative psychological effects of the covid-19 pandemic on cruise ship employees who are stuck at sea. thus, since cruise line companies have to develop a comprehensive contingency plan for managing onboard covid-19 outbreaks as a mandatory requirement set by the cdc's no sail order [2] , cruise line companies have to look further and develop strategies for managing anxiety, depression and stress of cruise ship employees during a pandemic and/or crisis. cruise line companies need to embrace the philosophy defined by mitroff [86] as "thinking about the unthinkable". regarding the worries, fears and sleep disturbances experienced by cruise ship employees stuck at sea, it appears that they are related to fears of not being able to see their family and friends, not being able to provide financial support to their families or significant other and the feeling that they have lost control of their lives. anxiety within cruise ship employees stuck at sea was inflated due to the fear of an uncertain future and economic recession. these findings are in line with shigemura et al. [87] who argue that during a pandemic, worries and fears surge the anxiety levels in particularly healthy persons, and boost the manifestations of those with pre-existing mental disorders. as days become weeks and weeks become months, cruise ship employees experience sleep disturbances. the sleep disturbances of cruise ship employees stuck at sea were related to the combination of worries, fears, and anxiety, which ultimately affected their sleep quality. this finding is in line with alvaro et al. [88] who in their systematic review on sleep disturbances, anxiety, and depression point to causality between anxiety and sleep quality due to a specific condition where anxious individuals experience difficulties to fall asleep and they wake up frequently during their sleep. during the covid-19 pandemic, cruise ship employees experience a lack of onboard social cohesion and lack of family and friends' social support, which leads to the development of depression. without an opportunity to socialize with fellow crew members due to restrictive social distancing, each cruise ship employee was left alone to face their worries and fears of uncertainty. fear is an adaptive defense mechanism essential for survival with several biochemical processes as a response to potential threats [89] . moreover, despair, a decline in well-being, combined with a loss of hope that the day of final repatriation is in sight has seriously affected how cruise ship employees feel, think, and act, causing the development of depression. these findings are supported by garcia [90] who argues how chronic or disproportionate fear can harm individuals' mental health and as it progresses it can lead to the development of various psychiatric disorders. hence, as melancholy sweeps over cruise ship employees, their silent screams of existential despair go unheard by cruise line companies, the cdc, airlines, and national governments. uncertainty of what the future holds, distress, and neurosis coupled with not being able to cope with the covid-19 pandemic were the main components associated with the perceived stress of cruise ship employees. unbearable uncertainty of what the future holds paralyzes cruise ship employees as they are preoccupied with the day of their final repatriation and loss of their only source of income. peculiar conditions of cruise ship employees who are stuck at sea leave them with limited, if any strategies to manage their negative emotions. thus emotion regulation strategies described by diefendorff et al. [91] such as: (a) connecting with others so one could feel good; (b) working or keeping oneself busy; (c) enjoying pleasurable activities to improve one's mood; (d) doing one's best to solve a problem; are not applicable to cruise ship employees who are stuck on the sea due to the cdc's no sail order [2] . hence, cruise ship employees speak in an almost passive participant voice about their relentless complaints against diminished control of their own life. these findings are in line with stein [92] who points out how the uncertainty of what the future holds, coupled with distress, and an inability to cope with the covid-19 pandemic creates worries and anxiety among many people, leaving them with nothing but dread and despair. this study showed that a state of hope and sense of belonging of cruise ship employees is hitting an all-time low. cruise line companies' leadership failed on multiple levels of human resource management, as they reached the point of being perceived by cruise ship employees as inauthentic and untrustworthy. moreover, cruise line companies' leaderships' poor crisis communication strategies left the cruise ship employees almost without any hope in regards to their repatriation. the covid-19 pandemic demonstrated that for cruise line companies and the cdc, cruise ship employees do not matter in some profound way. even though it appears that hope has abandoned the cruise ship employees, there is a glimmer of a sense of belonging as cruise ship employees are willing to defend the image of cruise line companies under the ruthless judgment of mainstream media. hence, as crises create opportunities, the covid-19 pandemic has provided a unique opportunity for cruise line companies to revise their corporate culture and enhance their human resource management strategies. the covid-19 pandemic demonstrated that it is of paramount importance that cruise line companies create a comprehensive strategy in assisting their employees who are experiencing anxiety disorder and depression. in the case of a pandemic and/or crisis, cruise ship companies need to employ onboard psychologists who could assist employees with anxiety disorder and depression. the anxiety of cruise ship employees could be solved by fairburn's [93] cognitive behavior therapy. cognitive behavioral therapy (cbt) is a well-established psychological treatment with robust effectiveness in treating depression and anxiety disorders [94] . onboard leaders have to be approachable and they have to recognize crew members who are experiencing anxiety and depression. during the open conversation with cruise ship employees, onboard leaders have to be authentic and emphatic as they listen to worries, fears, and troubles of their crew members. it is a duty of onboard leaders to explain to cruise ship employees that it is normal to feel worried and anxious as uncertainty and loss of control are two key factors associated with stress and anxiety. additionally, onboard leaders have to be supported by shore-side cruise line companies' leaders with appropriate video content and digital cbt. in their study on the mental health burden of covid-19, da silva lopes and jaspal [95] concluded that digital cbt can address all aspects of stress management and the management of worry and fear. furthermore, murphy et al. [96] suggest that delivering enhanced cbt remotely by video-calls delivers strong results in treating anxiety disorder. practical aspects of cbt that onboard leaders can perform every day are: engaging crew members in the novel ways of protection against covid-19; showing crew members reasons and positive ways to overcome despair; arranging outdoor activities that do not violate the cdc's no sail order [2] (e.g., walks on the open decks, yoga and breathing classes with prescribed social distance); and engaging crew members in solving problems such as contacting their embassies for potential charter flights and final repatriation and sharing the information with shore-side leaders related to individual countries lockdown measures. cruise line companies need to be transparent in their communication with cruise ship employees by providing them with accurate information in a timely manner. cruise ship employees understand that during the covid-19 cruise tourism crisis, cruise line companies' leadership is struggling to keep companies afloat, while at the same time preventing potential takeovers by protecting the stock value. however, lack of information and/or inaccurate information can only boost the crisis. the covid-19 pandemic demonstrated poor crisis communication of cruise line companies, since the main source of information and loudest spokespeople during the covid-19 cruise tourism crisis was social media and mainstream media. it appears that cruise line companies neglect the fundamentals of crisis communication strategies, which is, as per fink [97] , managing the perception of reality by framing the public opinion. although some cruise line companies created the slogan (e.g., "we will be back"), unfortunately, the slogan failed to capture a feeling of security so that cruise ship employees' reaction was cold. onboard leadership needs to understand who their crew members are and what they want to hear. in particular, cruise line employees are interested in: (a) their repatriation home; (b) financial support while they are away from home; and (c) their employment status. thus, onboard leadership must communicate to them such information with empathy and compassion. the cruise industry will certainly experience an exponential drop in employment due to the covid-19 pandemic; however, this issue of unemployment will affect cruise ship employees' family members as well. while being stuck at sea, cruise ship employees who are not getting paid cannot engage in activities such as searching for another job, looking into ways to increase their visibility on the labor market, rearranging their family finances by decreasing expenses, and outsourcing alternative resource for existential purposes. to soften the negative impact on cruise workers, cruise ship companies should provide a minimum basic salary for at least 3 months to all cruise ship employees who were affected by the covid-19 pandemic, as well as support laid-off cruise ship employees in finding another job or allowing them to return to work if cruise line companies resume their operation. due to its qualitative nature, this study cannot be generalized. it would be interesting to conduct similar research with additional online synchronous focus groups over time, to elicit in-depth information evolving during the course of the covid-19 pandemic. the second limitation is the cross-sectional time horizon utilized in this study; thus, there is space for potential causality and reciprocal relationships among components [98] . future studies should use a longitudinal time horizon to understand the complexities of the psychological effects of the covid-19 pandemic on cruise ship employees stuck at sea. moreover, a quantitative follow up study that is built on findings from this study would help improve our understanding of the psycholotablgical effects of the covid-19 pandemic on cruise ship employees stuck at sea. lastly, future studies can address the shortcomings of this study to gain a deeper understanding of the psychological effects of the covid-19 pandemic on cruise ship employees stuck at sea. funding: this research received no external funding. the authors declare no conflict of interest. towards an understanding of a child's cruise experience. curr. issues tour cruise ship no sail order extended through recollection of the sea cruise: the role of cruise photos and other passengers on the ship using a choice experiment (ce) to value the attributes of cruise tourism assessing the 'poverty of cruise theory' hypothesis using twitter data for cruise tourism marketing and research economic impact of cruise activity: the case of barcelona managing context to improve cruise line service relationships. cornell hosp connected at sea: the influence of the internet and online communication on the well-being and life satisfaction of cruise ship employees the effect of internet use on well-being: meta-analysis pining for home: studying crew homesickness aboard a cruise liner working onboard -job perception, organizational commitment and job satisfaction in the cruise sector. tourism manag occupational and health safety on cruise ships: dimensions of injuries among crew members new kids on the ship: organisational socialisation and sensemaking of new entrants to cruise ship employment talent management and the cruise industry identity construction in transient spaces: hospitality work on-board cruise ships succeeding in literature reviews and research project plans for nursing students researching interpersonal relationships: qualitative methods, studies, and analysis participatory evaluation in youth and community work: theory and practice conducting focus groups for business and management students orthopaedic basic science: foundations of clinical practice cross-sectional study basics of qualitative research: techniques and theory for developing grounded theory sampling issues in qualitative research critical analysis of strategies for determining rigor in qualitative inquiry online focus groups: a valuable alternative for hospitality research? no way off. 100,000 crew members remain in cruise ship limbo for months locus of control and trait anxiety in aged adults: the mediating effect of intolerance of uncertainty anxiety in medical patients adaptive anxiety job demands-job resources (jd-r) model, work engagement, and well-being of cruise ship employees contributory to stress and fatigue of filipino seafarers the state, race, and 'wage slavery' in the forest sector of the pacific north-west united states fear and trembling; 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penguin random house medical news today stuck-at-sea-protest-erupts-on-royal-caribbeans-majesty-of-the-seas grins, gore and videotape: the trouble with local tv news crisis leadership: planning for the unthinkable public responses to the novel 2019 coronavirus (2019-ncov) in japan: mental health consequences and target populations a systematic review assessing bidirectionality between sleep disturbances, anxiety, and depression pandemic fear" and covid-19: mental health burden and strategies neurobiology of fear and specific phobias linking emotion regulation strategies to affective events and negative emotions at work covid-19 and anxiety and depression in 2020 cognitive behavior therapy and eating disorders an oasis in the wilderness understanding the mental health burden of covid-19 in the united kingdom dalle grave, r. challenges and opportunities for enhanced cognitive behaviour therapy (cbt-e) in light of covid-19 crisis communications: the definitive guide to managing the message games researchers play: extreme-groups analysis and mediation analysis in longitudinal occupational health research key: cord-301348-h21rnyww authors: gherghina, ștefan cristian; armeanu, daniel ștefan; joldeș, camelia cătălina title: stock market reactions to covid-19 pandemic outbreak: quantitative evidence from ardl bounds tests and granger causality analysis date: 2020-09-15 journal: int j environ res public health doi: 10.3390/ijerph17186729 sha: doc_id: 301348 cord_uid: h21rnyww this paper examines the linkages in financial markets during coronavirus disease 2019 (covid-19) pandemic outbreak. for this purpose, daily stock market returns were used over the period of december 31, 2019–april 20, 2020 for the following economies: usa, spain, italy, france, germany, uk, china, and romania. the study applied the autoregressive distributed lag (ardl) model to explore whether the romanian stock market is impacted by the crisis generated by novel coronavirus. granger causality was employed to investigate the causalities among covid-19 and stock market returns, as well as between pandemic measures and several commodities. the outcomes of the ardl approach failed to find evidence towards the impact of chinese covid-19 records on the romanian financial market, neither in the short-term, nor in the long-term. on the other hand, our quantitative approach reveals a negative effect of the new deaths’ cases from italy on the 10-year romanian bond yield both in the short-run and long-run. the econometric research provide evidence that romanian 10-year government bond is more sensitive to the news related to covid-19 than the index of the bucharest stock exchange. granger causality analysis reveals causal associations between selected stock market returns and philadelphia gold/silver index. with globalization, urban sprawl, and ecological transformations, contagious disease outbursts turned out to be worldwide risks demanding a joint reply [1] . according to the international monetary fund (imf), coronavirus disease 2019 (covid-19) generated an economic crisis different from the others [2] for the reason that it is much more multifaceted (interconnections between the economy and the health system), uncertain (the related treatment is established gradually, alongside the measures concerning how to streamline isolation and the means to start over the economy), and has a worldwide character. both supply and demand reductions occur since individuals work and consume lower, whereas companies diminish their productivity and investment [3] . hence, erokhin and gao [4] explored 45 developing states and established that food security status of individuals and the strength of food supply chains are impacted by consequently, governments have taken unprecedented actions, respectively fiscal measures figuring to around $8 trillion, whereas central banks injected liquidity getting up to over $6 trillion [5] . the imf has implemented exceptional measures by doubling its emergency loaning volume to $100 billion and deferring debt outflows for poor nations [6] . preparing for the economic recovery raised a number of issues such as the way to maintain fiscal stimulus and unconventional monetary policy, managing high unemployment, low interest rates, and preserving financial stability [7] . hence, market inefficiencies to acquire abnormal returns [73] . on the contrary, yan, et al. [74] recommended the tourism industry, technology sector, leisure industry, and gold as suitable investments. li, et al. [75] endorsed health sector in line with chong, et al. [76] which suggested over sars to buy medical stocks and sell tourism stocks. in terms of cryptocurrencies, chen, et al. [77] argued that augmented concerns of the coronavirus caused negative bitcoin returns and large trading volume, whereas conlon and mcgee [78] advised that it does not perform as a hedge. with reference to the influence of the pandemic on the enterprise's activities, mazur, et al. [79] contended that companies reply in various means to the covid-19 revenue shock because many sectors were locked throughout the quarantine stage. hence, xiong, wu, hou and zhang [9] evidenced that companies belonging to sectors that are exposed to the pandemic have significantly lower cumulative abnormal returns, but enterprises with good financial conditions endure less opposing effect of the disease. nguyen [80] established that energy segment experienced the utmost abnormal negative returns amid all sectors. fallahgoul [81] established that the financial segment is the most doubtful, whereas health is the most hopeful over the covid-19 pandemic. he, sun, zhang and li [15] claimed that manufacturing, information technology, education and health-care chinese sectors remained stable to covid-19. gu, et al. [82] found that chinese manufacturing sector was hardly hit by corona crisis, but construction, information transfer, computer services and software, and health care and social work were positively influenced by covid-19. financial markets worldwide confronted with the flight-to-safety phenomenon which engendered a severe deterioration in asset appraisals and amplified volatility around the world [11] . baker, bloom, davis, kost, sammon and viratyosin [30] stressed that there was no prior illness that determined such daily stock market jumps. albulescu [83] emphasized that the fatality rate has a positive and very significant influence on financial volatility, whereas albuquerque, koskinen, yang and zhang [31] found that green stocks are highly valued and register lower volatility and larger trading volumes than the rest of stocks. markets are a function of government, hence responding reliant on authority reply [84] . alfaro, chari, greenland and schott [32] confirmed that a doubling of projected contaminations is linked with a 4 to 11 percent deterioration of aggregate market value. alber [85] showed that stock market return is influenced by covid-19 cases more than deaths, as well as by aggregate measures more than new ones. however, attributable to local features, the influence of novel coronavirus may diverge across equity markets [86] . onali [33] revealed that variations in the amount of cases and deaths in the usa and other highly impacted nations by the coronavirus do not influence stock market returns out of usa, except the number of cases for china. the spread of covid-19 globally driven an upsurge of yields on sovereign securities more than proportionally in developing and emerging states [36] . nozawa and qiu [35] noticed that corporate bonds supplied by companies showing a strong link with china respond more to the quarantine of wuhan at early 2020. hence, m.al-awadhi, alsaifi, al-awadhi and alhammadi [29] concluded that the covid-19 disease negatively influence stock market returns of the companies covered in the hang seng index and shanghai stock exchange composite index. adenomon, maijamaa and john [34] strengthened that the coronavirus disease negatively influences the stock returns in nigeria. on the contrary, there was proved that everyday cases of new contagions have a low adverse effect on the crude oil quotations in the long-term [37] . albulescu [38] explored whether the covid-19 and crude oil influence the economic policy uncertainty of the united states and observed no impact when considering the global coronavirus data, but a positive effect when assessing the condition outside china. sharif, et al. [87] established a unique responsiveness of stock market of usa, related economic policy uncertainty, and geopolitical risk to the joint shocks of the coronavirus and oil instability. for the case of colombia, cardona-arenas and serna-gómez [26] argued that the depreciation of national in addition, we have included a wide range of variables that allow us to achieve our goal, such as covid-19 measures, commodities, currencies, and 10-year government bond spreads. in order to gain insights towards the linkages in stock markets during covid-19 pandemic outbreak, we will use the autoregressive distributed lag (ardl) model similar albulescu [37, 38] , erokhin and gao [4] , as well as granger causality test alike mamaysky [88] . checking for unit root in ardl approach is not fundamental in as much as it can examine for the occurrence of cointegration among a set of variables of order i(0) or i(1) or a mixture of them. hence, the leading benefit of ardl model consist in its versatility. however, the ardl methodology impose that no variable should be integrated of second order or i (2) . therefore, in line with prior research [26, 34, 59] , the augmented dickey-fuller (adf) test will be applied for unit root testing. the null hypothesis of the adf test claims the presence of unit root in the time series. the adf test involves estimating the following equation: where t denotes the time trend, t signifies the length of the sample, while k is the length of the lag in the dependent variable. further, ardl model examines the long and short-term cointegration, being specified as a sole equation framed with adaptable choice of lag extents. the general form of an ardl (p, q) model is as follows: the lag orders p and q are established by means of the akaike information criteria and may differ over the explanatory variables covered in our quantitative framework. the granger causality test can be applied to analyze the causality between variables, as in mamaysky [88] . the null hypothesis is that w does not granger-cause z and that z does not granger-cause w. the following bivariate regressions will be estimated: w t = α 0 + α 1 w t−1 + · · · + α p w t−p + β 1 z t−1 + · · · + β p z −p + u t (4) the descriptive statistics of the variables are provided in table 2 . the distributions of all stock market returns, as well as most of included commodities are negatively skewed. thus, negative returns are more prevalent than positive returns, supporting a greater likelihood for very high losses. kurtosis shows the thickness of the tail and highlights a high level of risk for selected stock markets, especially spain and italy. in addition, except eur/cny and natural gas futures contract 1, the jarque-bera test provides evidence that selected series are not normally distributed. figure 1 shows the evolution of the number of new cases due to covid-19, whereas figure 2 reveals the progress of the number of new death due to covid-19. there is noticed that usa registers the highest figures in this regard. source: authors' own calculations. notes: for the definition of variables, please see table 1 . figure 1 shows the evolution of the number of new cases due to covid-19, whereas figure 2 reveals the progress of the number of new death due to covid-19. there is noticed that usa registers the highest figures in this regard. figure 3 shows the evolution of stock market returns amongst the explored period. there is reinforced the significant volatility, especially for ftse mib on march 9, 2020 and march 12, 2020, as well as for dow jones industrial average on march 16, 2020. in the first two months of 2020, dax declined by 10.2 percent, cac 40 dropped by 11.2 percent, whereas ftse 100 plunged 12.7%. in the same vein, dow jones throw down by 11 percent and s&p 500 by 8.6 percent. the bucharest stock exchange also encountered instabilities and registered a decay of 8.6 percent [89] . capelle-blancard and desroziers [90] contended that prior to february 21, stock markets disregarded the pandemic, but over february 23-march 20, the reaction to the rising number of diseased people was strong. as such, mazur, dang and vega [79] emphasized that the failure of stock quotes in march 2020 marked one of the major financial market collapses in history. baiardi, et al. [91] developed a three-regime switching model and concluded that in 2020 the most common state for the dow jones industrial average was turbulent. figure 3 shows the evolution of stock market returns amongst the explored period. there is reinforced the significant volatility, especially for ftse mib on march 9, 2020 and march 12, 2020, as well as for dow jones industrial average on march 16, 2020. in the first two months of 2020, dax declined by 10.2 percent, cac 40 dropped by 11.2 percent, whereas ftse 100 plunged 12.7%. in the same vein, dow jones throw down by 11 percent and s&p 500 by 8.6 percent. the bucharest stock but over february 23-march 20, the reaction to the rising number of diseased people was strong. as such, mazur, dang and vega [79] emphasized that the failure of stock quotes in march 2020 marked one of the major financial market collapses in history. baiardi, et al. [91] developed a three-regime switching model and concluded that in 2020 the most common state for the dow jones industrial average was turbulent. table 1 . figure 4 reveals the evolution of oil futures. there is noticed the sharp decline registered on 21 april 2020. figure 5 shows the progress of philadelphia gold/silver index returns. therewith, high volatility is prevailing. table 1 . figure 4 reveals the evolution of oil futures. there is noticed the sharp decline registered on 21 april 2020. figure 5 shows the progress of philadelphia gold/silver index returns. therewith, high volatility is prevailing. table 1 . table 1 . for the definition of variables, please see table 1 . table 3 reveals the correlations among selected variables. there are acknowledged high negative correlations (below −0.7) between the number of new cases and new deaths due to covid-19 in italy and crude oil, wti, as well as nymex light sweet crude oil. in case of the number of new cases and table 1 . table 3 reveals the correlations among selected variables. there are acknowledged high negative correlations (below −0.7) between the number of new cases and new deaths due to covid-19 in italy and crude oil, wti, as well as nymex light sweet crude oil. in case of the number of new cases and new deaths due to covid-19 in china, there are not recorded high correlations with the included measures. therewith, high positive correlations (over 0.7) are registered amongst the stock market returns, except sse 100 (china). non-stationary variables lead to inadequate results, which means insignificant results. the verification of the stationarity of the selected data is performed through adf stationarity test. this test is most commonly used to confirm the stationarity of a data series. table 4 shows the results of the adf test at the level and in the first difference, as well as the level of integration of the stock indices. the outcomes of adf test provide support that all covered stock indices are stationary at the first difference, showing an integration order of i(1), except the stock market index from the shanghai stock exchange. we also notice that the indicators related to the evolution of covid-19 for the most affected regions, china and italy, show a mixed integration order (i(0)and i(1)). after studying the stationary of the data series and due to the mixed results, we conclude that the ardl model is the most appropriate for exploring the linkages between variables. further, the purpose is to assess whether new cases and new deaths due to covid-19 in china and italy, along with chinese and italian stock market returns, several commodities, and currencies are related to the romanian stock market as measured by bet index return and romania 10-year bond yield. the ardl (autoregressive distributed lag) model is used especially when the variables i(0) and i(1) are integrated. for the accurate choice of the ardl model that would allow us to research the relationships that are established between variables, it is imperative to choose the correct number of lags. therefore, we will analyze the akaike information criteria (aic) to select the optimal lags for the variables included in the ardl model. we will apply the criteria graph, which will indicate the suitable lags for the ardl model and the lowest value is preferred. figure 6 shows the results of criteria graph for the ardl model that takes into account the number of new cases and new deaths in china, both for the bet stock index return and for the romanian government bond (10y). according to the results, in total, 1,562,500 ardl model specifications were considered for each of the four cases given the information related to covid-19 in china. the top 20 results are presented in the criteria graph. further, table 5 summarizes the selected lags for the model romania and covid-19 (china) according to criteria graph out of figure 6 . table 1 . according to the results, in total, 1,562,500 ardl model specifications were considered for each of the four cases given the information related to covid-19 in china. the top 20 results are presented in the criteria graph. further, table 5 summarizes the selected lags for the model romania and covid-19 (china) according to criteria graph out of figure 6 . figure 7 shows the results of criteria graph for the ardl model that takes into account the number of new cases and new deaths in italy, both for the bet stock index return and for the romanian government bond (10y). likewise, in case of italy, in total, 1,562,500 ardl model specifications were considered for each of the four cases. table 1 . table 6 exhibits the selected lags for the model romania and covid-19 (italy) in line with criteria graph out of figure 7 . the results reported in tables 7 and 8 provides the ardl bound test for cointegration. if the f-statistic is greater than the upper bound, then the variables comprised in the model are cointegrated and a long-run relationship befall. with reference to new cases in china models (see table 7 ), the f-statistic for bet_r (18.06988) and ro_bond (4.523219) models is greater than the upper bound of bounds value at 5%, which is suggesting that long-run relationship occur between the variables. the same result is achieved in the case of new deaths in china models, where the value of the f-statistic is greater than the upper bound critical value. hence, the null hypothesis is rejected, meaning that the variables in the model are cointegrated. figure 7 . the results reported in tables 7 and 8 provides the ardl bound test for cointegration. if the fstatistic is greater than the upper bound, then the variables comprised in the model are cointegrated and a long-run relationship befall. with reference to new cases in china models (see table 7 ), the fstatistic for bet_r (18.06988) and ro_bond (4.523219) models is greater than the upper bound of bounds value at 5%, which is suggesting that long-run relationship occur between the variables. the same result is achieved in the case of new deaths in china models, where the value of the f-statistic is greater than the upper bound critical value. hence, the null hypothesis is rejected, meaning that the variables in the model are cointegrated. table 1 . regarding italy, in all four estimated ardl models the existence of cointegration is confirmed (see table 8 ) since the f-statistic is significantly higher than the critical values in i(0) and i(1). consequently, the examined variables are cointegrated and will move together in long-run. further, we will analyze the results of the long-term linkages between selected measures. table 9 shows the outcomes regarding the long-run causal connections among variables for the model romania and covid-19 (china)-new cases. the short-run estimates of ardl approach are presented in table s1 . in the first model, the number of new infection cases from china have no effect on the bet index return. however, a decrease of crude oil price leads to a higher uncertainty, consistent with salisu, ebuh and usman [23] , suggesting the necessity for policymakers to diminish fears in financial markets. in addition, the exchange rate negatively influences stock market return in the long-run. the philadelphia gold/silver index coefficient is positive and significant at the 5% level of significance. hence, the coefficient of xau_r indicates that an increase of one unit in philadelphia gold/silver index leads to over 0.2983 units increase in bet index return in the long-run. the error correction term or adjustment speed provides evidence regarding the rate of convergence to equilibrium, being highly statistically significant. the adjustment speed of −1.017783 shows that deviations from the long-term equilibrium in bet index return are corrected the following day by approximately 101.7783 percent. regarding the second model from table 9 , similar to the first model, the new infection cases from china does not influence romania 10-year bond yield in the long-run. unlike the previous model, the ro_bond is negatively affected by xau_r and indicates that an increase of one unit in philadelphia gold/silver index leads to over 0.3718 units decrease in ro_bond return in the long-term. besides, in the long-run, the return of stock market index sse 100 negatively influences romania 10-year bond yield. the coefficient of the error correction term is highly statistically significant. hence, the romanian 10-year bond will reach equilibrium with a speed of 185.3068 percent in next day. as well, the short-run results strengthen the lack of impact regarding new infection cases of covid-19 from china on ro_bond. table 10 reveals the outcomes of the long-term connection amongst variables for the model romania and covid-19 (china)-new deaths. the short-run results are shown in table s2 . the empirical findings reveal that the impact is stronger in this case as compared to the model that depends on the number of new cases in china due to covid-19 (see table 9 ). however, both models shows that the number of new deaths in china due to covid-19 has no influence on the bet index return, respectively, on the romania 10-year bond yield, neither in the short-term, nor in the long-term. therefore, both research hypotheses are rejected for chinese covid-19 figures, similar topcu and gulal [86] which established that emerging european countries experienced the lowest influence of the outbreak. tables 11 and 12 reveals the results of serial correlation and heteroscedasticity tests for the models romania and covid-19 (china)-new cases and romania and covid-19 (china)-new deaths. the results support that the models are free from autocorrelation and heteroscedasticity. in the case of models that take into account the effects of new cases and new deaths in italy, unique relationships are identified between the selected variables, as opposed to the models that explored the impact of coronavirus from china. table 13 exhibits the outcomes of the long-term causal associations between variables for the model romania and covid-19 (italy)-new cases. the short-run outcomes are exhibited in table s3 . in the long-run, the results of the first model show the lack of any effect from the number of new cases of covid-19 in italy on bet index return. in contrast, the return of milan stock market index ftse mib has a positive long-term impact on the bet index return. as well, the short-run results reveal no impact of new infection cases of covid-19 from italy on the bet index return. in contrast to covid-19 figures from china, in case of italian new cases of coronavirus, the first hypothesis is still rejected, but the second hypothesis is confirmed. moreover, in the second model, several statistically significant relationships are identified. there is found a positive impact of the number of new cases in italy on the romania 10-year bond yield in the long-term. in addition, a natural gas futures contract has a positive effect on ro_bond, while the wti oil and philadelphia gold/silver index has a negative impact in the long-run. another outstanding outcome is that new infection cases of covid-19 from italy negatively influence ro_bond in the short-run, consistent with sène, mbengue and allaya [36] . therefore, the related uncertainty triggered by the health emergency may determine investors to get rid of their securities. table 14 exposes the findings towards long-run linkages between variables for models related to romania and covid-19 (italy)-new deaths. the results of short-run estimates are presented in table s4 . the first model out of table 14 exhibits that the number of new deaths from italy have no effect on the bet index return in the long-run. the philadelphia gold/silver index coefficient is positive and significant at the 5% level of significance. hence, the coefficient value of xau_r indicates that an increase of one unit in philadelphia gold/silver index leads to over 0.1574 units increase in bet index return in the long-term. however, the short-run results show a negative impact of new deaths cases of covid-19 from italy on the bet index return, in line with okorie and lin [58] which underlined a transitory contagion effect in the stock markets due to novel coronavirus. in addition, erdem [55] claimed that the index returns decline and volatilities rise due to corona crisis. hence, the first hypothesis is confirmed. the second model shows a negative effect of the new deaths' cases from italy on the romania 10-year bond yield in the long-run. in addition, the philadelphia gold/silver index and the ok crude oil future contract negatively influence ro_bond in the long-term. besides, in the long-run, the returns of the stock market index ftse mib has no impact on the 10-year romanian bond. nevertheless, in the short-run, results show a negative impact of new deaths cases of covid-19 from italy on the ro_bond. therefore, the second hypothesis is established. tables 15 and 16 exhibit the outcomes of breusch-godfrey serial correlation lm test and breusch-pagan-godfrey heteroscedasticity test for the models romania and covid-19 (italy)-new cases and romania and covid-19 (italy)-new deaths. hence, the models are not threatened by autocorrelation and heteroscedasticity. with the purpose of exploring the causality between included variables, the granger causality test is employed. in order to be able to apply the granger causality test, the data series must be stationary and therefore they were turned it into stationary series. table 17 displays the results of granger causality test for the stock market returns and covid-19 measures. there were identified some bidirectional causal relations between bet_r and ftmib_r (1st lag), as well as among bet_r and ibex35_r (1st lag). besides, some unidirectional causal relations arise from ftse_r (1st lag), djia_r (1st lag and 3rd lag), sse100_r (1st lag, 2nd lag, and 3rd lag), and xau_r (1st lag, 2nd lag, and 3rd lag) to bet_r. nevertheless, no relationship was found between bet_r and the covid-19 variables. table 18 shows the outcomes of causalities for the variables concerning commodities, currencies, governmental bonds, and covid-19. the causalities for the whole world stock indexes, commodities, currencies, and covid-19 variables are reported in table s5 . some bidirectional relationships were found merely for the 1st lag between the 10-year romanian bond and few stock market indices returns, namely cac40, dax, and ibex 35. besides, unidirectional relationships for 1st lag, 2nd lag, and 3rd lag occurred from returns of djia, s&p 500, ftse 100, ftse mib, sse 100, and the number of new cases in italy due to covid-19 to the 10-year romanian bond. one of the most severe stock market crashes was registered in march 2020 [79] due to the occurrence of the novel coronavirus covid-19 pandemic [55] . the research contributions are twofold. first, we investigated whether the romanian stock market is affected by the covid-19 pandemic outbreak. second, our paper explored the causalities among covid-19 and major stock market returns, as well as between pandemic measures and several commodities. in this regard, we used daily stock market returns over the period december 31, 2019-april 20, 2020 for the following economies: usa, spain, italy, france, germany, uk, china, and romania. we have selected a wide range of variables that allow us to achieve our goal, such as stock market indices, new number of cases of illness, new number of deaths in china and italy, exchange rate, commodity indices, romanian bonds. as far as we know, this is the first study addressing the impact of the covid-19 from both china and italy crisis on the romanian capital market and the 10-year romanian bond. after examining the stationarity of the selected data series and due to the mixed results, we conclude that the ardl model is the most appropriate to explore the short-term and long-term causal associations among romanian stock market and novel coronavirus. in the case of the model that includes the number of new deaths in china due to covid-19, it is found that the impact of the coefficients is stronger compared to the model that depends on the number of new cases in china due to covid-19. at the level of these two models, no effect was identified from the number of new deaths in china due to covid-19 on the bet index return, respectively on the romania 10-year bond yield, neither in the short-term, nor in the long-term. with reference to the model that cover the new cases of coronavirus from italy, short-run results provide support for a negative impact of new italian covid-19 cases on the romania 10-year bond yield. taking into account the number of new deaths in italy we found that it has no effect on the bet index in the long-term, but the short-run results exposes a negative effect. besides, the ardl models showed a negative effect of the new deaths' cases from italy on the romania 10-year bond yield both in the long-run and short-run. granger causality test exhibits bidirectional causal relations between returns of bet and ftse mib, ibex, as well as a unidirectional causal relation from ftse 100, djia, sse 100, and philadelphia gold/silver index to bet index return. however, no relationship was found between the bet index return and the covid-19 variables. some bidirectional relationships were found between the 10-year romanian bond and a few stock market indices (cac 40, dax, and ibex 35). unidirectional relationships occurred from returns of djia, s&p 500, ftse 100, ftse mib, sse100, and the number of new cases in italy due to covid-19 to the 10-year romanian bond. therefore, the empirical findings from ardl model and granger causality test confirmed both the presence of a long-term and short-term relationship between romanian capital market and covid-19 variables. the findings show that the chinese covid-19 numbers have no impact on the romanian financial market. in addition, it was found that the 10-year romanian bond is more sensitive to the news related to covid-19 than the index of the bucharest stock exchange, similar to pavlyshenko [39] , mamaysky [88] . the paper may have some policy implications. as long as the bet index is not influenced by covid-19 variables, this may suggest evidence of an inefficient market, in line with beck, flynn and homanen [52] , mensi, sensoy, vo and kang [72] . there are required policies to increase market efficiency though longstanding and sustainable growth rather than administering short-term interest rates [73] . the investors should seek long-term horizons of investing since the monetary and fiscal policies set by governments will alleviate the harmful effects of covid-19. the policymakers should be aware that corona crisis may be an occasion to improve the discrepancy among romania and developed nations of european union. in this regard, a substantial share of the budget should be expended to alleviate this pandemic [59] . a suitable clinical stream is vital so as to ensure a reliable supervision of patients [92] . rearrangement of public expenditure to enlarge the absorptive volume of healthcare organizations is essential [46] . therefore, public health expenditures should be increased, along with offering direct income funding to exposed populations via cash transfers, support to affected manufacturing areas and corporations through transient tax cuts, deferral on debt reimbursements, and interim credit lines [3] . supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/18/6729/s1, table s1 : ardl short-run coefficient estimates for the model romania and covid-19 (china)-new cases, table s2 : ardl short-run coefficient estimates for the model romania and covid-19 (china)-new deaths, table s3 : ardl short-run coefficient estimates for the model romania and covid-19 (italy)-new cases, table s4 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market, geopolitical risk and policy uncertainty nexus in the us economy: fresh evidence from the wavelet-based approach financial markets and news about the coronavirus. ssrn electron the stock market and the economy: insights from the covid-19 crisis the dynamics of the s & p 500 under a crisis context: insights from a three-regime switching model the exponential phase of the covid-19 pandemic in central italy: an integrated care pathway this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord-318528-yc0jw3s1 authors: romero-blanco, cristina; rodríguez-almagro, julián; onieva-zafra, maría dolores; parra-fernández, maría laura; prado-laguna, maría del carmen; hernández-martínez, antonio title: physical activity and sedentary lifestyle in university students: changes during confinement due to the covid-19 pandemic date: 2020-09-09 journal: int j environ res public health doi: 10.3390/ijerph17186567 sha: doc_id: 318528 cord_uid: yc0jw3s1 regular physical activity is related to many factors in a university student’s environment. the coronavirus pandemic and the resulting lockdown have restricted many elements of our environment. the aim of this study was to evaluate students’ physical activity and sedentary behaviour at two points in time: before and during the coronavirus lockdown. as a secondary aim, we also wanted to look at changes resulting from other factors (alcohol, tobacco, diet, stages of change, symptoms of anxiety/depression and sociodemographic characteristics). we conducted an observational, cross-sectional, pre-post study with two cut-off points. two hundred and thirteen students took part in the study. the main dependent variables were physical activity and sitting time, measured using the international physical activity questionnaire—short form (ipaq-sf). parametric and non-parametric tests were used for paired and unpaired data, as well as group-stratified analysis. during lockdown, both weekly physical activity (md: −159.87; ci: −100.44, −219.31) and weekly sitting time increased (md: −106.76; ci: −71.85, −141.67). in the group analysis, differences were observed in relation to gender, year of study, bmi, alcohol consumption, tobacco use, symptoms of anxiety/depression, mediterranean diet, living situation and stage of change. the results showed an increase in both physical activity and sitting time globally and by group. a healthy lifestyle should be promoted among all ages, but the earlier a habit is formed, the more likely it is to become rooted [1] . regular physical activity is one of the most effective ways of preventing premature death [2, 3] . the world health organization (who) recommends at least 150 min of moderate physical activity, 75 min of vigorous activity, or a combination of the two, per week [4] . independently of the physical activity carried out, it is important to assess sedentary behaviour (sb) as this is related to increased morbidity and cardiovascular risk factors [5] . by 2030, the who aims to reduce the prevalence of physical inactivity by 15% worldwide [6] . in spain, the amount of physical activity carried out by university students is low [7] and is in many cases linked to other healthy habits such as eating fruit and not smoking [8] . meanwhile, sedentary behaviour is a health problem in the child and youth population, which is aggravated with age [9] . in university students, sitting time can exceed 9 h a day [10] . it is known that individual factors such as age, sex and health status affect the physical activity that individuals do [11] . other factors associated with physical activity are motivation, lack of time and aspects related to body image or physical appearance [12] ; some of the beneficial effects of physical activity are reduced anxiety and depression [13, 14] . however, there are several factors that come into play throughout an individual's lifetime that can either facilitate or impede a behaviour, with the transition from secondary education to university being a decisive moment [15] . it is at this time that young adults form their behavioural habits, so the role of healthy universities and the healthy habits they acquire at this stage are fundamental in maintaining this behaviour in the years to come [16] . when it comes to making physical activity a regular habit, the elements that may be related have been studied in depth [17] . ecological models are considered one of the most significant theoretical approaches when it comes to analysing habit formation [18] . these models establish that in addition to individual factors, social and environmental factors are determinant in forming and maintaining physical activity habits [19] . the covid-19 pandemic led to the population being confined to their homes [20] . in spain, from march to april 2020, there was a prohibition on going outside to engage in sporting or social activities. during this period, elements of the built environment and other factors related to individuals' environments were restricted due to the state of alarm. this created a valuable opportunity to assess physical activity without taking these factors into account. experts' recommendations to prevent sedentary behaviour during lockdown included taking active breaks, getting up and walking around the house, and doing online workouts [21] . however, during the pandemic, an overall negative effect on physical activity intensity was observed, as well as a rise in the consumption of less healthy food and a 28.6% increase in sedentary behaviour [22] . a reduction in physical activity was also observed in university students [23] , along with increased levels of anxiety among 18-to 34-year-olds [24] . spanish university students had to continue attending classes online, and their social lives were limited due to the prohibition on going outside. during lockdown, physical activity could have been an opportunity to pass the time, or, conversely, sedentary behaviour could have increased. the other characteristics of each individual (gender, motivation, eating habits, mental state etc.) could have either facilitated or interfered with the decision to exercise. the hypothesis put forward was that students' sedentary behaviour would have increased during lockdown since they were confined to their homes, and that their physical activity would have decreased since they could not go outside to exercise. in this study, we aimed to analyse the physical activity university students did before and during lockdown. to broaden our approach, as a secondary aim, we also wanted to look at changes in physical activity and sedentary behaviour resulting from other factors such as alcohol and tobacco consumption, adherence to a mediterranean diet, motivation, symptoms of anxiety/depression and sociodemographic characteristics. we aimed to evaluate whether there were any differences when certain factors affecting individuals' environments were restricted. this was an observational, cross-sectional, pre-post study on health sciences students, with two cut-off points. the first cut-off point was between 15 and 30 january 2020, prior to the state of alarm being put in place, and the second sample point was between 1 and 15 april 2020. this study received the approval of the ethics and clinical research committee of ciudad real, in spain, with protocol number (c-291, 11/2019). this study was carried out within the context of another study that we conducted on healthy habits and lifestyles, with an estimated follow-up period of 9 months. due to the state of alarm and lockdown, recruitment of subjects was temporarily suspended and a decision was made to study the impact of lockdown on the population already participating. there were no exclusion criteria, other than failure to fully complete the questionnaire. to estimate the sample considering a bilateral hypothesis, the following criteria were used: variance in the pre-lockdown control group of 33,929.60, obtained using the total minutes of physical activity [25] , a beta risk of 20% (power = 80%), a confidence level of 95% and a clinically important difference of 60 min with respect to the control group. it was therefore estimated that a minimum of 148 study subjects would be needed. considering a missing values ratio of 20%, the resulting sample size would be 185 subjects. the students invited to take part were first-to fourth-year students who agreed to respond to the questionnaire at both time points. the questionnaires were administered during the second university semester. the first data collection point was two weeks after the end of the exam period, while the second data collection point was four weeks into lockdown. at the second data collection point, students could not leave their homes except for essential purposes such as buying food or going to hospital. outdoor exercise was prohibited across spain; anyone breaching the rules faced a 600 euro fine. during lockdown, university classes continued online with the same schedule as usual. the university provided internet access or technological devices to any students who requested them so that they could continue attending classes. online classes did not contain any recommendations for students to carry out physical activity. an ad hoc self-administered questionnaire was used, collecting sociodemographic information such as sex, age, weight, height, place of residence during the academic year, smoking habits (yes/no and number of cigarettes per day) and alcohol consumption (yes/no and number of drinks per week). for perceived health status and the existence of problems with anxiety/depression, the euroqol 5d (eq-5d) questionnaire was used [26] . to assess adherence to the mediterranean diet, the predimed questionnaire [27] was used, which uses 14 questions to assess the frequency of food consumption and eating habits. each question has a possible score of 0 or 1. the result allows classification into low adherence or high adherence. stages of change (soc) in physical activity were assessed using prochaska and diclemente's transtheoretical model (ttm) [28] . five stages of motivation for change were evaluated: pre-contemplation (i don't exercise and i don't intend to), contemplation (i don't exercise, but i'd like to), preparation (i exercise sometimes), action (i have been regularly exercising for less than 6 months) and maintenance (i have been regularly exercising for more than 6 months). physical activity was measured using the international physical activity questionnaire-short form (ipaq-sf), which contains 7 questions [29] . the questionnaire was used to obtain the total minutes of physical activity per week and sitting time per day. first, descriptive statistical analysis was performed using absolute and relative frequencies for categorical variables and mean with standard deviation (sd) for the quantitative variables. next, bivariate analysis was performed on the whole sample for paired data between weekly minutes of physical activity for the two sample points (pre-lockdown and lockdown). we used the kolmogorov-smirnov test to verify the normality of the quantitative variables. since there were variables that were not normally distributed, we then used the non-parametric wilcoxon signed-rank test. we also used the parametric student-fisher t-test to evaluate whether there were statistical differences in some comparisons and to obtain an approximation of the differences found. finally, the same analyses were performed again, but this time stratified for different sub-groups. mean differences (md) were obtained with a confidence interval of 95% (ci). all calculations were done using the program spss v24.0 (ibm corp, new york, ny, usa). two hundred and thirteen health sciences students participated in this study. the mean age was 20.5 years (sd = 4.56). of the participants, 80.8% (172) were women, 76.5% (163) were normal weight and 9.9% (21) were smokers. the rest of the demographic characteristics and health parameters are shown in table 1 . then, the results of the ipaq questionnaire were analysed: days and minutes of physical activity per week, as well as time spent sitting per week at both time points studied ( table 2) . we observed a significant increase in the number of days on which students engaged in physical activity, both vigorous we then analysed physical activity by group (table 3 ). when we looked at the differences in average minutes of physical activity, all groups analysed spent more time doing physical activity during lockdown (although not all of them significantly). groups that showed significant differences were women; first, second and third year of study; normal or low bmi; and those who did not eat a mediterranean diet. average physical activity time reduced during lockdown for participants in the pre-contemplation (md: 37.50; 95% ci: −115. 33, 190.33) and contemplation (md: 31.08; 95%ci: −15.87, 78.03) stages. in other words, they spent less time on physical activity, although this difference was not significant. conversely, for those in the preparation (md: −75.59; 95%ci: −0.92, −150.25) and action (md: 322.69; 95%ci: −214.84, −430.55) stages, significant differences (p < 0.05) were observed. in the rest of the groups analysed, statistically significant differences were observed between the two time points, except for men, final-year students, those that were overweight or obese and those that ate a mediterranean diet. finally, the analysis by group (table 4 ) showed significant differences (p < 0.05) in sitting time before and during lockdown in all groups except first-year students, those that were overweight or obese, smokers and those in the pre-contemplation stage. sitting time increased in all groups of the variables gender, alcohol, symptoms of anxiety/depression and mediterranean diet. it also increased in the following groups: second, third and fourth year of study; normal and underweight bmi; non-smokers; those living in a university residence, shared apartment or with family; and those in the contemplation, preparation, action and maintenance stages. this study aimed to evaluate physical activity and sedentary behaviour in health sciences students before and during the lockdown. at the first time point, students were in their normal study environment, while at the second, their social and environmental setting was limited due to lockdown. the results showed changes in physical activity and sedentary behaviour patterns both globally and by group. overall, students spent more time doing physical activity and spent more time sitting when their usual environment was limited. in the analysis by group, minutes of physical activity increased significantly during lockdown among the following groups: women; all years of study except final year; normal or low bmi; those who did not eat a mediterranean diet; and those in the preparation or action stage of change. sitting time increased in all groups of the variables gender, alcohol, symptoms of anxiety/depression and mediterranean diet. the groups that did not experience differences were: first year of study, overweight or obese, smokers and those in the pre-contemplation stage. these four groups spent the most time sitting at the first data collection point when compared with the rest of their cohort; in other words, sedentary behaviour was already high before lockdown and there were no significant differences at the second data collection point. some researchers believed that lockdown would cause inactivity and an increase in sedentary behaviour and that measures would need to be taken to prevent these effects [30] . in fact, during lockdown, people modified their lifestyles, with an increase in sitting time due to people spending more time at home, and there was also a reduction in the amount of time spent on physical activity [22] . in our study, the initial hypothesis was partially confirmed: there was an increase in sitting time, but unexpectedly, there was also an increase in both the amount of time spent doing physical activity and the number of days on which participants were active. we expected to find an increase in sitting time due to the restrictions on movement; however, we also thought that the increase in screen time would reduce physical activity time, since in previous studies conducted in the spanish university population, more screen time was associated with higher inactivity levels [31] . we do not know the exact reasons why physical activity increased, and we do not know if the effects on physical activity habits would have been maintained if the lockdown had gone on for longer. the environment in which students live affects their sedentary behaviour patterns [32] , and it seems that the characteristics of health sciences students' environments do not facilitate physical activity. rather than being an obstacle, restricted social relations and not having access to the built environment in their community increased the number of days and minutes students spent doing physical activity. in the case of health sciences students, another factor to consider is that their training in promoting healthy habits may have influenced their decision to exercise at home. no changes in physical activity were found in men. perhaps men and women had different motivations and the environment influences one gender more strongly. in previous studies on motives for physical activity by gender [33] , some variables that motivated men but not women were elements related to the environment, such as competition or social recognition, while weight control was the main motivation for women. in our study, women accounted for more than 80% of the sample, so the lack of results may also be due to the fact that there were fewer male participants. the effect of the built environment is yet to be determined for those with a high bmi [34] . the data in this study show that in overweight or obese students, there were no changes in time spent doing physical activity or sitting time. as we have seen, healthy habits that are ingrained in the population are not affected by the lockdown: this is the case of the mediterranean diet [35] . in this study, we observed that students that ate a mediterranean diet spent more time doing physical activity and that their physical activity patterns did not change significantly. this suggests that those that lead a healthy lifestyle pay attention to both diet and exercise and persist with their habits regardless of the environment. conversely, those with unhealthy habits stick to them and experience no changes during lockdown. this is the case for smoking and sedentary behaviour. grouping of healthy and non-healthy factors is habitual in university students [8, 25] : those that are more sedentary are also more likely to smoke or spend a lot of time watching screens, while those that exercise regularly tend to eat more fruit and vegetables and drink less alcohol. contrary to what we expected, smokers did spend more time doing physical activity during lockdown. it would be interesting to investigate the reasons for this. in our sample of the population, the percentage of smokers was very low, and the number of cigarettes smoked per day was also low, so we believe more research is needed in a sample with more smokers. in our results, we also found differences based on year of study. among final-year students, physical activity did not vary significantly. this group also spent the least time doing physical activity at both time points analysed. in their meta-analysis, keating et al. indicate that with regard to year of study, the majority of studies find no differences in physical activity, but that some studies suggest that higher years of study are less active [36] . as for sedentary behaviour, it was observed that first-year students spent more time sitting and that lockdown did not bring about any significant changes. some studies, contrary to the findings of our study, observed that students in higher years of study were more sedentary due to a higher workload [10] . in health sciences students, most of the theoretical workload is in the first year, while in their final year students spend most of their time on placement. another possible factor could be that first-year students might have practiced sport in secondary school and kept up the habit. it would have been interesting to ask students about their sports histories. in this study, we evaluated stages of change, one of the central concepts of the transtheoretical model of change. this model was initially used to treat tobacco and alcohol problems, but it was later adapted to other aspects of health such as physical activity and sedentary behaviour [37] [38] [39] . the analysis of the stages of change and how they affected the participants was very interesting. participants in the first two stages did not experience any changes, and neither did those in the last stage. the behaviour of participants that exercised as part of their routine remained practically the same, as did the behavior of those that did not do any exercise. however, for those that were motivated but had not yet made exercise a regular habit, lockdown was a good opportunity to increase their dedication. in line with these findings, di renzo et al. [35] observed in a recent study that lockdown increased activity among people that did sport occasionally because they had more time at home, but those that did not do any exercise did not use the situation as an opportunity to start. overall, the results show that minutes of physical activity increased, as did minutes of sitting time. although the results during lockdown are positive in terms of physical activity, it is necessary to recognise that this population might suffer from health issues in the future due to an increase in sedentary behaviour. it would be interesting to find out what the reasons were for students having this behaviour. perhaps they realised that their sitting time increased (they were not walking to class, walking to their car, going shopping, standing up, going to their jobs etc.) and compensated for this with some high-intensity exercise. another aspect that could have affected the results is that the students were involved in the health sciences field, so they may have been more prone to exercising during the pandemic than students in other majors such as engineering or literature. this is why we cannot exclusively consider the limitation of the environment during lockdown to be the cause of the changes in physical activity and sedentary behaviour. it would be interesting to continue studying the elements related to university students' physical activity/sedentary behaviour and their surroundings in order to plan strategies that promote an increase in physical activity levels in this group. our study has various limitations that should be considered. firstly, it is an observational study and all study subjects volunteered to participate in the questionnaire, so there may be a selection bias. secondly, we did not measure whether there was any risk of exposure to covid-19 infection, a factor that could have influenced our assessment of physical activity and sedentary behaviour. another limitation is the use of a self-administered questionnaire to evaluate physical activity and sedentary behaviour. it would have been more interesting to perform a real assessment of physical activity using accelerometry and also investigate their sports history. this could be a future line of research. finally, the lack of significance in some of the strata analysed could be due to a lack of statistical power because of the low number of subjects in some groups. furthermore, we do not know if these changes in physical activity would have been maintained if lockdown had gone on longer. as for the strengths, this is the first study to look at physical activity and sedentary behaviour in university students studying health sciences both before and during lockdown. in this study, we observed the behaviour of health sciences students when deprived of their usual social and community environment. participants spent more time doing physical activity and also spent more time sitting. university students' social environment may be a barrier to building an exercise habit, especially among women, and motivation seems to have a significant bearing on whether university students engage in physical activity. more efforts should be made to create strategies that motivate students to lead a healthy lifestyle in all aspects (diet, avoiding harmful substances, mental health etc.), with a particular emphasis on engaging in physical activity and reducing sitting time. programs and policies that promote positive youth development and prevent risky behaviors: an international perspective health benefits of physical activity: the evidence health benefits of physical activity: a systematic review of current systematic reviews world health organization. global recommendations on physical activity for health sedentary behavior and cardiovascular morbidity and mortality: a science advisory from the american heart association world health organization. global action plan on physical activity 2018-2030: more active people for a 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consumption, physical activity and diet quality the spanish version of euroqol: a description and its applications a 14-item mediterranean diet assessment tool and obesity indexes among high-risk subjects: the predimed trial stages and processes of selfchange of smoking:toward an integrative model of change validation of three short physical activity questionnaires with accelerometers among university students in spain how to deal with covid-19 epidemic-related lockdown physical inactivity and sedentary increase in youth? adaptation of anses' benchmarks cluster analysis of health-related lifestyles in university students neighborhood built environment and socioeconomic status are associated with active commuting and sedentary behavior, but not with leisure-time physical activity, in university students college students' motivation for physical activity: differentiating men's and women's motives for sport participation and exercise role of built environments in physical activity, obesity, and cardiovascular disease eating habits and lifestyle changes during covid-19 lockdown: an italian survey a meta-analysis of college students' physical activity behaviors role of counseling to promote adherence in healthy lifestyle medicine: strategies to improve exercise adherence and enhance physical activity application of the transtheoretical model to sedentary behaviors and its association with physical activity status levels of physical activity, motivation and barriers to participation in university students funding: this research received no external funding. the authors declare no conflict of interest. key: cord-312265-48odnlal authors: chenneville, tiffany; gabbidon, kemesha; hanson, patricia; holyfield, cashea title: the impact of covid-19 on hiv treatment and research: a call to action date: 2020-06-24 journal: int j environ res public health doi: 10.3390/ijerph17124548 sha: doc_id: 312265 cord_uid: 48odnlal the impact of the covid-19 pandemic is far reaching, with devastating effects on individuals, communities, and societies across the world. people with chronic health conditions may be at greater risk of contracting or experiencing complications from covid-19. in addition to illness or death for those who contract the virus, the physical distancing required to flatten the curve of new cases is having a negative impact on the economy, the effects of which intersect with mental health and other existing health concerns, thus affecting marginalized communities. given that hiv also has a disproportionate impact on marginalized communities, covid-19 is affecting people with hiv (pwh) in unique ways and will continue to have an impact on hiv research and treatment after the covid-19 crisis passes. using the biopsychosocial framework to contextualize the impact of covid-19 on pwh, the purpose of this review article is to: (1) outline the similarities and differences between the covid-19 and hiv pandemics; (2) describe the current and future impact of covid-19 on pwh; and (3) outline a call to action for scientists and practitioners to respond to the impact of covid-19 on hiv prevention and treatment. the first cases of covid-19 appeared in wuhan, china in december 2019 [1] . similar to other severe acute respiratory viruses (e.g., sars-cov), covid-19 is a highly contagious disease but with an even higher reproduction number, which refers to the average number of people a person with the virus will infect, thus serving as a metric of how easily a virus is transmitted [2] . covid-19 has spread quickly throughout the world. covid-19 results in mild illness for most people who contract the virus [3] . however, people who are older in age or have pre-existing conditions are at risk of severe illness or death [3] . healthcare systems in many countries are taxed, particularly in areas where infection rates are high, resulting in health implications not only for patients with covid-19 but also for other people who require healthcare services. the who's [3] recommendation for physical distancing to limit the spread of covid-19, echoed by the centers for disease control and prevention [4] in the united states (us), has resulted in stay-at-home orders in many places. the economic and psychosocial toll of self-quarantining is significant as people face challenges associated with unemployment or underemployment as well as anxiety, fear, and grief, not to mention the deleterious effects of social isolation. in addition, many families are confronted with the added burden and stress of juggling the virtual educational demands of school-aged children due to school closures. people with hiv (pwh) are particularly vulnerable during the time of covid-19. although recent research suggests that pwh may not be contracting covid-19 at disproportionate rates, which is taking into account the connection between mind and body, the biopsychosocial model acknowledges the impact of interacting biological, psychological, and social factors on health and health outcomes [7, 8] . the biopsychosocial framework has been used to better understand a variety of diseases and medical conditions, such as postpartum depression [9] , multiple sclerosis [10] , and spinal cord injuries [11] as well as hiv. for example, recent research has incorporated the biopsychosocial framework into hiv research on stigma among older adults [12] , pain and substance abuse [13] , and fatigue [14] , to name just a few studies. the biopsychosocial model also recently was used by an international panel of experts to guide practice for pain management during the covid-19 pandemic [15] . thus, the biopsychosocial framework is well suited to contextualize a discussion of the similarities and differences between covid-19 and hiv and the impact of covid-19 on hiv treatment and research as well as scientists' and practitioners' potential response. hiv is a member of the genus lentivirus and is part of the family retroviridae [16] . lentiviruses are slow moving, characterized by long incubation periods and illness duration. hiv acts primarily by depleting the immune system cells, namely macrophages and cd4+ cells, which leaves one vulnerable to opportunistic infections. globally, the hiv-1 subtype is responsible for most infections, whereas the hiv-2 subtype is most prevalent in west africa [16] . hiv transmission occurs through exposure to infected bodily fluids (e.g., blood, semen, vaginal fluids, breast milk). the most common transmission routes are through condomless sexual intercourse, intravenous drug use and occupational exposures, and from mother-to-child during pregnancy, delivery, or breastfeeding. comparatively, severe acute respiratory syndrome coronavirus 2 (sars-cov-2), also known as the 2019 novel coronavirus (2019-ncov), is responsible for the covid-19 pandemic. unlike hiv, sars-cov-2 is an acute respiratory infection with a short incubation period. sars-cov-2 is a positive-sense single stranded rna virus, genetically similar to sars-cov [17] , seen in the 2003 global pandemic. the novel sars-cov-2 belongs to the genus β-covs (betacoronavirus) and the subgenus sarbecovirus [17] . most recent evidence shows respiratory droplets and contact as the primary routes of transmission [17] . preliminary research also showed the potential for oral-fecal transmission [18, 19] . concurrent research provides some evidence that the virus is viable on plastic and steel surfaces but less viable on cardboard or copper [20] . the duration of sars-cov-2 s viral shedding or period of infectivity remains unknown; however, the incubation period is believed to be similar to that of other coronaviruses, which is 2-14 days. with hiv, an undetectable viral load means the virus is un-transmissible [21] , but this is not the case with sars-cov-2, as presence of the viral rna does not indicate a current infection [22] . as briefly mentioned, the basic reproduction number (r 0 ) is defined as the expected number of secondary cases when one case interacts with a susceptible population [23] . susceptible populations are those without any acquired immunity either through previous exposure or immunization. as described by hsieh and wang [23] , r 0 has been used to determine the capacity for emerging infectious diseases to become endemic. r 0 values are highly susceptible to interventions (e.g., medication use, drug resistance, behavior modification). an example of this was demonstrated by velasco-hernandez and colleagues [24] , who assessed the r 0 value for hiv among men who have sex with men (msm) in san francisco, in which 50-90% of the cases received antiretroviral therapy (art). the authors determined an r 0 of 0.90 if risky sexual behavior was reduced and approximately 10% of the treated cases developed resistance to art. however, if no change occurred in sexual behaviors and 10% of the treated cases developed resistance to art, the r 0 was estimated to increase to 1.0 [24] . finally, if risky sexual behavior increased and 10-60% of the population developed art resistance, the r 0 then increased to 1.16 [24] . overall, hiv has a relatively low r 0 value when art is used. comparatively, the r 0 value of sars-cov-2 is quite fluid. liu and colleagues [2] reported a mean r 0 of 3.28. this is similar to the 2003 sars-cov pandemic [25] . however, it should be noted that the methodology used affects the r 0 value [2] . for example, mathematical models often show higher r 0 values than when stochastic and statistical methods are used [2] . for context, it is important to compare sars-cov-2 to other respiratory infections. in a systematic review conducted to determine r values for pandemic and seasonal influenza infections, biggerstaff and colleagues [26] identified the following mean r 0 values: 1.80 (1918 h1n1 pandemic); 1.65 (1957 h2n2 pandemic); 1.80 (1968 h3n2 pandemic); 1.46 (2009 sars-cov pandemic) and 1.28 (seasonal influenza). across these viral infections, both coronaviruses demonstrate higher rates of transmissibility than influenza and hiv. it is important to think about both who and how when considering risk factors for disease. for covid-19, failure to adhere to physical distancing or hand washing recommendations constitute behaviors that increase risk for contracting covid-19 (i.e., the how). the who include people who are older in age or who have pre-existing conditions such as chronic respiratory disease, cardiovascular disease, hypertension, cancer and diabetes when describing risk factors for the coronavirus [27, 28] . comparatively, when describing risk factors for hiv, "risky" sexual or drug use behaviors are most commonly associated with the how of transmission, although hiv can also be transmitted from mother-to-child or through other means of exposure to blood (e.g., tainted blood transfusions). in terms of the who, it is well established that hiv disproportionately affects groups already marginalized, including racial/ethnic and sexual or gender minorities, as well as those living in poverty. it is quickly being recognized that covid-19 also disproportionately affects minority groups [29] , which is not surprising given existing health disparities as described in more detail below. although the impact of the covid-19 pandemic on economies across the world [30] including developed nations such as the us [31] is not yet entirely known, there is no question that covid-19 is having an impact on the global economy [32, 33] . a summary of research in this area suggested that a recession is likely [34] . maital and barzani [34] explained that covid-19 is having its greatest impact on the supply side of the economy, yet most solutions are being offered or implemented on the demand side given that little is known about how to effectively address the economic impact on the supply side. clearly, the immediate economic impact of covid-19 is more severe and far reaching than the economic impact of hiv. however, there is an economic impact to hiv prevention and treatment. the average lifetime cost of hiv treatment has been estimated at the us equivalent of usd 441,708 (based on the value of the us dollar in 2020; [35] ). there are also costs associated with the treatment of hiv-related illnesses or mental health conditions as well as hiv prevention efforts. vaccine research is underway for covid-19 and hiv; however, a covid-19 vaccine is likely to be developed long before a vaccine is developed for hiv. thus, while the immediate impact of covid-19 on the economy is far greater, the economic impact of hiv will continue long after the covid-19 pandemic is resolved. despite differences in how the viruses are spread, hiv and covid-19 have in common fear and anxiety related to transmission. similar to the early days of the hiv epidemic, when information about treatment and prevention was lacking, there is a lot of fear about contracting covid-19 in the absence of a vaccine or scientifically proven treatments to address symptoms and prevent death. such fear and anxiety have implications for mental health and promotes disease-related stigma. hiv-related stigma is well established and, because of its impact on hiv testing and treatment, research on effective hiv-stigma reduction interventions is prevalent (see stangl and colleagues [36] for a systematic review of the literature). there is emerging evidence of the mental health burden of pandemic fear related to covid-19 [37] and its potential impact on preventive behavior [38] . there is also emerging evidence of stigma and discrimination related to covid-19 [39] . mental health issues such as anxiety, depression, and posttraumatic stress and substance use are common among pwh with mental health issues and are considered both a cause and a consequence of hiv. similarly, as ho and colleagues [40] noted, pandemic fear in general can worsen existing mental health disorders and also may result in new diagnoses. for covid-19 specifically, social isolation is likely to contribute to mental health issues, especially among the elderly [41, 42] . acknowledging the mental health impact of covid-19, who [43] published recommendations for addressing mental health and psychosocial issues during the covid-19 outbreak. as with hiv, the covid-19 pandemic reveals the systemic inadequacies that produce health disparities. what these illnesses demonstrate is a disproportionate burden on already vulnerable populations experiencing poverty and other systemic stressors. the united nations' [44] report has indicated that increases in food costs and market stockpiling has had the most harmful impact on vulnerable communities, particularly those in low income nations. although vulnerable populations vary across nations, those with stigmatized or marginalized intersecting identities often experience the highest burden, including msm, transgender women, people who inject drugs, commercial sex workers, young women, and youths (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) , who account for a third of all new hiv infections [45] . furthermore, immigrants are at increased risk of infectious diseases, including both hiv and covid-19 [6] , as are other people who are displaced. not surprisingly, the covid-19 pandemic also appears to more commonly affect those with marginalized intersecting identities, exacerbating racial/ethnic, socioeconomic, disability status, and age-related disparities. this is demonstrated in the disease risk and case fatality rates. in the american context, for example, approximately 50% of covid-19 cases and 70% of deaths in chicago occurred among african american/black males, who only account for 30% of the city's population [29] . similar disparities can be seen in new york city, louisiana, michigan, and other regions of the us [46] [47] [48] . furthermore, comparable disparities among hispanics are beginning to emerge; as of late april 2020, hispanics experienced the highest covid-19 case fatality rate in new york city [47] . on 31 march 2020, the un [44] called for a comprehensive and coordinated global response to the covid-19 pandemic. in addition to supporting short-term measures such as limiting access to critical resources and creating travel bans, the un [44] urged global political leaders to develop a sustained coordinated response. unfortunately, this has not yet happened in all countries. at the time of writing, the us was the viral epicenter, yet had struggled to enforce an organized national response, instead relying heavily on state and local measures that vary considerably [49] . the most immediate response from the majority of nations (166 countries as of march 2020) was to close schools and universities [50] . however, other actions varied by country. for example, the us food and drug administration used emergency use authorization to expedite approval of potential medical interventions and waived enforcement protocols to allow non-health care industries to develop technological advances to challenge the pandemic [50] . likewise, the centers for medicare and medicaid services in the us opted to facilitate an expansion of patient care sites [50] . globally, the health care response has focused on building the workforce capacity. this includes (a) increasing the number of health care professionals available by bringing in medical professionals from other nations or adjusting medical license requirements, (b) using technology to reduce provider burden, and (c) collaborating with non-health care partners to address shortages of personal protective equipment [50] . on the economic level, governments in wealthy nations have established emergency funds to provide economic reprieve. for example, the us expanded unemployment qualifications and provided economic stimuli to some, and other nations such as south korea and canada developed emergency funds [50] . some nations opted to subsidize wages (new zealand, australia, canada, and united kingdom; [50] . economically disadvantaged nations remain vulnerable and their health care infrastructure stands to be further weakened as they address this pandemic. the global response to hiv epitomizes the convergence of politics and public health care. early on, the response was largely characterized by robust grassroot and global political efforts. grassroots efforts among those most affected by hiv would serve as the initial global response to the pandemic. many governments were criticized for their slow, moralistic response. it was activists and non-profit/non-governmental organizations that organized to advocate for immediate government response and to provide education and support to the affected local communities [51] . however, the government response has played a complicated role in the history of hiv/aids. successes include an international agenda focused on hiv; the development of unaids; and the creation of the global fund to fight hiv, tuberculosis, and malaria, among other efforts, resulting in billions in funding [52] . however, governments-or rather, their policies-have played a significant role in prohibiting progress, including laws that criminalize the behaviors of pwh, same-sex relationships, and transgender individuals; a restriction of services for key populations; limited access to arts for low-to-middle income nations; failure to provide comprehensive sex education within school settings; and poor support for evidence-based harm reduction programs [53, 54] . additionally, global financial support for hiv has declined steadily over the past few years, with many nations now viewing hiv as a non-priority [53] . covid-19 has significantly altered everyday life for individuals worldwide. the presence of the virus has introduced physical distancing and closed schools and businesses, resulting in major disruptions to daily functioning. given the social nature of human beings, people are finding ways to adjust to covid-19 for the foreseeable future. in addition to the short-term effects of covid-19, it is also critical for health care providers (e.g., doctors, psychologists, social workers, case managers, etc.) to consider how the impacts of covid-19 may affect pwh, and the provision of health care treatment across time. for pwh, adjusting to covid-19 may have significant effects on the biological, psychological and social aspects of their lives. pwh whose disease is not well managed are placed at an increased risk for contracting and experiencing complications related to covid-19, in addition to complications related to hiv disease progression. given the lifelong prognosis of hiv, it is imperative for pwh to regularly visit their healthcare providers and adhere to treatment [55] . pwh's treatment may be interrupted or otherwise affected as a result of stay at home orders. for example, in america, many health care providers canceled in-person appointments and transitioned to telehealth appointments in order to comply with federal guidelines [56] . however, telehealth services are limited in the range of services that can be provided to clients [57] , thus, pwh may be unable to fully access the services required for their hiv treatment. additionally, some pwh may be unable to access telehealth services for various reasons (e.g., lack of access to technology, limited knowledge of telehealth, etc.), which can hinder their treatment progression. pwh are also more likely to contract opportunistic infections (e.g., pneumonia, tuberculosis, toxoplasmosis, etc.; [58] ), than those without compromised immune systems. pwh who are experiencing any additional illnesses may experience delayed treatment due to covid-19. this can occur due to hospital overcrowding in an already taxed healthcare system. pwh who seek out urgent care may face an increased risk of contracting covid-19 among other illnesses while in healthcare settings [59] . given the unprecedented nature of the covid-19 outbreak, an increase in anxiety has been prevalent worldwide. furthermore, the cdc [60] has noted that individuals with chronic health conditions, such as hiv, may develop a stronger stress response than the rest of the population. this strong stress response is due to an increased risk of contracting covid-19 due to a compromised immune system. stress during an outbreak can lead to maladaptive coping mechanisms, which may include increased alcohol intake. pwh who drink one or more alcoholic beverages a day are at greater risk of death and/or other alcohol-related health issues than individuals without hiv [61] . alcohol consumption reduces immune system strength [61] , thus alcohol consumption can weaken a pwh's ability to fight hiv and covid-19. additionally, who [62] reported that alcohol consumption can increase one's risk for health problems. alcohol consumption for pwh also increases viral load over time [63, 64] . alcohol can lead to impaired judgment, such as engaging in risky sexual behaviors [61] , 2017). risky behaviors paired with an increased viral load may result in pwh passing on the virus through condomless sex. although people are practicing physical distancing, individuals who are quarantined with a romantic partner may be engaging in sexual activities more often [65] , which may be problematic for phw whose viral load is not well managed and who do not engage in protective behaviors (e.g., condom use) or whose sexual partners are not using pre-exposure prophylaxis (prep). additionally, the use of alcohol may exacerbate symptoms of depression and anxiety [66] . pwh are two to four times more likely to develop depression than those without the virus [67] [68] [69] . depression is also the most common mental health disorder among pwh (40-42%; [70] . thus, the physical distancing required to combat covid-19 may increase loneliness, which can in turn exacerbate depressive symptoms. furthermore, because hiv has a higher prevalence in populations experiencing poverty [71] , pwh may be limited in accessing resources to cope with physical distancing (e.g., cell phones, laptops, internet service). depressive symptoms that do not necessarily meet diagnostic criteria for a depressive disorder have also historically been linked to worse health outcomes for pwh, including impaired immunological response and mortality [72, 73] . though the relationship between depression and treatment adherence among pwh may not be causal, research has found that depressive symptoms such as loss of interest, feelings of worthlessness, and thoughts of death or suicide may have negative effects on pwh's desire to take their medications, or engage in the necessary medication management activities that are conducive to a healthy lifestyle [74] [75] [76] . for this reason, health care providers who work with pwh who are depressed may have to work even harder following covid-19 to ensure treatment adherence and participation in therapy activities. given the importance of mental health and continuation of services, many mental health providers have had to provide services to patients via telehealth. thus, it is possible that in the future an increased number of providers may opt to continue providing services via telehealth in order to increase attendance rates for regularly scheduled appointments, and expand access to care by cutting patient costs associated with travel, parking, childcare, and time off work [77] . despite the potential benefits of telehealth, these services are not met without several potential limitations including concerns related to client confidentiality, difficulty with internet connections which may affect audio and visual quality during sessions, and lack of face to face contact which can affect the establishment of rapport and the therapeutic alliance between a client and psychologist or health care provider. furthermore, due to the potential impacts of psychological conditions (e.g., anxiety, depression, ptsd), covid-19, and health-related concerns among pwh, there may be an increase in the number of pwh who seek mental health services following the covid-19 pandemic. it is important to note, however, that the mental health effects of covid-19 may not be apparent for every individual immediately following the pandemic. for this reason, it is also possible that in the coming years, there will be an even greater need for health and mental health care providers to support the economic and psychological impacts of covid-19. preventing, detecting, and responding to mental health conditions should be an important component of short-and long-term global health efforts. as covid-19 continues to spread worldwide, most international health bodies have introduced guidelines about physical proximity, which often include remaining two meters (six feet) away from one another in public settings, although some governments have recommended that one meter is sufficient in fast-moving public settings, since time as well as distance appears to affect exposure. as an example of guidelines in the american context, the cdc recommended limiting one's interactions with anyone outside of their household and limiting one's trips to only those that were essential (e.g., working an essential job or going to the grocery store) early in the pandemic [60] . although many countries issued mandatory stay-at-home orders, it is important to note that guidelines have varied and are changing from country to country. although physical distancing guidelines serve to benefit one's physical health, these guidelines may be detrimental to one's social and emotional health. pwh may be even more reluctant to engage in physical interaction with others. this may be especially true for newly diagnosed pwh who do not have a full understanding of the ways in which hiv is transmitted. pwh who do not have the means to connect with their friends digitally may also struggle to maintain those social bonds. pwh, like others, may be spending more time on social media sites in order to connect with others. bekalu and colleagues [78] found that using social media for emotional connection can decrease one's social well-being, positive mental health and self-rated health. because many pwh are part of marginalized communities, other social impacts also exist. for example, increased risk exists for pwh whose domestic arrangements may be risky or violent; who have reduced access to drugs normally bought on the street, or reduced access to needle exchange schemes, which are important for secondary hiv prevention; who are unemployed or underemployed or who have been furloughed as a result of covid-19; who are homeless or have unstable housing as a pre-existing situation or as a result of covid-19; who may need to resort to food banks and other community resources in order to survive during the pandemic; who may have reduced access to medical or pharmacy services as a result of reduced public transport services; or who are imprisoned or in other institutional care. there are also social impacts on people in rural and remote areas where internet services are limited or weather-dependent, or whose resources require that they subscribe to limited data plans. furthermore, pwh who were separated from partners or family when international borders closed and who are now facing long separations from their primary social supports are negatively affected by covid-19 in unique ways. finally, there are socio-political impacts related to covid-19 for pwh. although the political response to covid-19 has been good in many countries, responses have been marked by controversy in other countries. confused or delayed responses resulting from the absence of consistent public messaging in some countries has affected access to covid-19-related services and resources for pwh. clearly, the social impact of covid-19 on hiv treatment is far-reaching and multifarious, and the long-term impact is, in many ways, unforeseeable. in response to the covid-19 pandemic, research and academic institutions have halted or modified their research activities. in the short term, this results in delays in research progress, a need to transition to remote data collection methods when applicable, and redirecting research efforts to address the covid-19 crisis [79] . essentially, researchers will lose progress in the battle against hiv and other chronic illnesses such as heart disease, cancer, and diabetes. to better understand the impact on hiv research, below are examples of disruptions to hiv-related biological, psychological, and social research. while some short-term adjustments are possible, long-term implications are far more difficult to predict. however, many researchers anticipate that future funding to non-covid-19 research will see reductions [80] . more specifically, there is an expectation of declines in philanthropic and governmental support and research/grant funding [81] . biomedical research includes the investigation of the biological process and the causes of disease. it includes basic, applied, and clinical research. hiv-related biomedical research may include investigating the molecular mechanism underlying hiv-associated neurocognitive disorder, developing cost-effective prevention technologies, or determining the interaction of hiv with non-communicable diseases. across the globe, some biomedical researchers have opted to continue long-term experiments, maintain vital equipment, cell lines, and other time-sensitive research items with the use of a skeleton crew (least number of research team members needed; [82] . other experiments have been discarded or frozen for use later as they wait for directives on next steps [82] . socio-behavioral and psychological hiv research currently remains chronically underfunded and may continue to experience additional declines in funding following the pandemic. examples of hiv-related socio-behavioral and psychological research includes hiv-stigma reduction interventions, cognitive and behavioral health interventions, intersectionality and hiv prevention, treatment, and care. depending on the study methodology, these research studies can be modified to be implemented virtually; however, careful considerations must be given to research ethics (e.g., privacy and confidentiality). other studies that require lab equipment and space will need to be delayed and implemented later. researchers may choose to modify their research studies; for example, psychological researchers may choose to investigate the acceptability and uptake of hiv home testing kits and telehealth counseling services. in addition, project deliverables will need to be modified as recruitment and enrollment may be negatively impacted by the covid-19 pandemic. much like psychological research, social science research remains underfunded and undervalued and may also experience declines in funding following the pandemic. when feasible, researchers may need to think creatively about redesigning their studies. for example, hiv researchers may be interested in assessing and implementing interventions to mitigate the impact of covid-19 on vulnerable communities, which may include assessing the impact of covid-19 on hiv prevention, treatment, and care efforts, or strengthening covid-19 diagnostic and care capacity for pwh. when considering social science research, aspects of participatory research will experience severe challenges, particularly community-engaged research. physical distancing requirements prevent the use of in-person focus groups and interviews. in addition, research that requires partnership development with gatekeepers often requires time and resource-intensive efforts and may not be effectively transitioned to virtual or other remote settings. besides the logistical difficulties to host and plan community advisory meetings, train facilitators, host focus groups, and implement interventions, the psychological toll of the pandemic would likely undermine recruitment and enrollment efforts. scientists and practitioners are in a unique position to respond to the impact that covid-19 is having on pwh and hiv prevention efforts, including research. to address hiv treatment needs now and in the future, providers working with pwh are encouraged to obtain training in telehealth. the american psychological association's (apa) joint task force for the development of telepsychology guidelines for psychologists [83] may be particularly helpful for mental health care providers (even those not residing in the us) who are transitioning to telehealth or hoping to strengthen their knowledge and skills in this area. scientists conducting hiv research are encouraged to be creative and flexible when transitioning current studies into virtual formats (when doing so is feasible) and designing future hiv studies. with regard to the latter, researchers may want to consider the ways in which hiv projects may be responsive to covid-19 or other pandemic funding opportunities. for example, it might be possible to secure funding to add a covid-19-specific aim to an existing externally funded hiv project, or to incorporate hiv-related specific aims to new covid-19 projects. to these ends, interdisciplinary collaborations may be useful. finally, scientists and practitioners are encouraged to continue to contribute to efforts to reduce health disparities. this will require expanding economic and social support, building trust and social cohesion, denouncing hate, and collecting more and better data [84] . this paper outlined similarities and differences between the covid-19 and hiv pandemics, described current and future impacts of covid-19 on hiv treatment and research using a biopsychosocial framework, and delineated a call to action for scientists and practitioners by stimulating readers to consider how this framework applies to their local situation. pandemics have the capacity to illustrate the role of social, political, and economic contexts in the emergence and management of illnesses in our globalized community. the informal slogan, "we are in this together," will continue to ring true of our responses to current and future pandemics like hiv and covid-19. health and mental health care providers are urged to advocate for systemic changes that lessen the inequity experienced by marginalized and disadvantaged communities. in addition, it is important for governments to recognize that the economic cost of infectious disease outbreak management will remain more costly than that of health promotion and disease prevention [85] . a commitment to health promotion and disease prevention would lessen the frequency and severity of emerging infectious diseases and would ensure that critical progress and advances in biomedical and social-behavioral research are not negatively impacted. it is essential to recognize that all pandemics have biological, psychological, and social implications, of which health care 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lessons to mitigate future pandemics this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord-307285-bxy0zsc7 authors: dar odeh, najla; babkair, hamzah; abu-hammad, shaden; borzangy, sary; abu-hammad, abdalla; abu-hammad, osama title: covid-19: present and future challenges for dental practice date: 2020-04-30 journal: int j environ res public health doi: 10.3390/ijerph17093151 sha: doc_id: 307285 cord_uid: bxy0zsc7 covid-19 was declared a pandemic by the world health organization, with a high fatality rate that may reach 8%. the disease is caused by sars-cov-2 which is one of the coronaviruses. realizing the severity of outcomes associated with this disease and its high rate of transmission, dentists were instructed by regulatory authorities, such as the american dental association, to stop providing treatment to dental patients except those who have emergency complaints. this was mainly for protection of dental healthcare personnel, their families, contacts, and their patients from the transmission of virus, and also to preserve the much-needed supplies of personal protective equipment (ppe). dentists at all times should competently follow cross-infection control protocols, but particularly during this critical time, they should do their best to decide on the emergency cases that are indicated for dental treatment. dentists should also be updated on how this pandemic is related to their profession in order to be well oriented and prepared. this overview will address several issues concerned with the covid-19 pandemic that directly relate to dental practice in terms of prevention, treatment, and orofacial clinical manifestations. covid-19 was declared a pandemic by the world health organization (who), with substantial numbers of infected cases and deaths reported in many countries. among these countries, italy, the united kingdom, and spain had a high fatality rate ranging 4-8% [1] . the disease is caused by one of the coronaviruses, which are a large family of viruses that may cause severe illnesses, such as severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers). these viruses are common in animals with the potential of transmission to humans. they are composed of an envelope, a lipid layer, and single-stranded large rna. the name "corona" ("crown" in latin) is attributed to the spherical shape and surface projections. four subfamilies have been identified: alpha-, beta-, gamma-, and delta-coronaviruses. beta-coronaviruses seem to originate from mammals, namely bats; it was found that the genome sequence of sars-cov-2, the virus responsible for covid-19, is >90% identical to a bat coronavirus ratg13. in fact, bats represent a natural reservoir for a wide variety of coronaviruses including sars-cov-like and mers-cov-like viruses. sars-cov-2 is closely related to the sars-cov virus, and it belongs to the b lineage of the beta-coronaviruses, which are known to cause severe disease and fatalities. the origin of sars-cov-2 is still unclear, however, initial transmission from animals to humans has probably occurred in the huanan seafood market in wuhan, china in december 2019, where a cluster of pneumonia cases, caused by a newly identified β-coronavirus, were diagnosed in this city. the main clinical manifestations are respiratory in nature, and they manifest after a mean incubation period of five days (range: 0-24 days). an increased risk of infection was found in patients with certain co-morbidities mainly including hypertension, diabetes, and ischemic heart disease. a possible explanation for this association could relate to the nature of these diseases and the types of medications used for treatment. in hypertensive and diabetic patients, circulating amounts of angiotensin converting enzyme-2 (ace2) are increased. moreover, some drugs including some types of antihypertensive drugs act as ace inhibitors which further increase ace2, and as sars-cov-2 binds to the host cell's membrane via ace2, an increased risk to infection is noticed [2] . there is a wide variation between countries in the numbers of deaths and positive asymptomatic cases, with some reports indicating that approximately 80% of infected cases are asymptomatic [3] . initial symptoms consist of fever, cough, nasal congestion, fatigue and other signs of upper respiratory tract infections. in approximately two thirds of the cases, the infection can progress to severe disease with dyspnea and severe lung congestion. multi-organ failure may eventually result in the form of respiratory failure, shock, acute respiratory distress syndrome, arrhythmia, acute myocardial injury, acute liver injury, and sepsis [4] . as of 26 april 2020, there have been more than 2.9 million cases, and more than 205,000 deaths globally. in response to this challenging pandemic, the center for disease control and prevention (cdc), american dental association (ada), the national health service (nhs), as well as other health regulatory bodies have provided advice to dentists to regulate dental services and to provide them with guidance in order to protect themselves, their co-workers, and their patients from this infection. dentists are among the highest risk categories for transmission and contraction of the coronavirus, with many routine dental procedures having the potential to transmit the virus through aerosols. asymptomatic (carrier) patients as well as patients with an acute respiratory illness may present for dental treatment at outpatient dental settings. while it is important to provide treatment for patients who present with urgent or emergency dental procedures, the primary goal should be to prevent transmission of infection to patients and dental healthcare personnel. the growing fear of cross-infection, and the possible role of dental practice in spreading the infection, have obliged dentists to step aside and to confine themselves in home quarantine similar to other non-healthcare sectors of the population. in addition, there has been an increased demand for personal protective equipment (ppe), which consists of garments to protect healthcare workers or any other persons to get infected. the standard ppe consist of gloves, mask, and gown. however, in case of airborne infections like covid-19, additional equipment should be utilized including face protection, goggles, mask, face shield, gloves, gown or coverall, head cover, and rubber boots [5] . dentists are now providing emergency dental procedures only, during which they have to follow the recommended cross-infection control protocols. therefore, the main bulk of published research directed to dentists has mainly focused on giving a background on the pandemic and what the recommended cross-infection control measures are. there are many aspects of covid-19 that are related to dental practice in addition to infection control, including prevention and treatment. there are also a number of clinical manifestations that affect the orofacial region and that dentists should be familiar with. this overview addresses the medical-dental aspects of covid-19 infection. it is directed to dental healthcare personnel to update them on the recommended guidelines for provision of dental health services during this critical period, and to explain important aspects of the covid-19 infection with relevance to the orofacial region and oral healthcare. these aspects are divided into three sections: prevention, treatment, and oral manifestations. the ada has maintained a consistent stand since the pandemic was recognized. they called upon dentists to postpone elective dental procedures for all dental patients, and to provide dental treatment only for urgent or emergency cases [6] . the main aims were to minimize potential for healthcare transmission of covid-19, and to avoid shortage of ppe for healthcare personnel caring for those with covid-19, or dental healthcare personnel providing urgent dental care in emergency cases. they further clarified the meaning of dental emergencies as "potentially life-threatening conditions that require immediate treatment to stop ongoing tissue bleeding, alleviate severe pain, or infection"; therefore, the emergency conditions indicated for treatment include cellulitis, uncontrolled bleeding, or trauma [7] . within this context, provision of urgent dental treatment is to be done in regular dental clinics, and not to direct patients to emergency rooms even afterhours unless a life-threatening emergency is encountered. types of urgent dental care was also clarified in detail to include: severe dental pain; certain infections such as pericoronitis, postoperative osteitis, dry socket, or abscess/cellulitis; trauma such as symptomatic fractured tooth or avulsion/luxation; as well as certain urgent restorative procedures [7] . the nhs, on the other hand, has initially provided advice to dentists to perform routine dental care only for patients with no symptoms of covid-19, provided that no aerosol-generating procedures are undertaken. recommendations of the nhs were updated according to the evolving situation of the pandemic so that the most recent recommendation was in concordance with that of the ada. so far no definitive treatment is adopted for covid-19. a number of antiviral drugs as well as other drug categories were used so far with variable success rates. some of these drugs have direct relevance to dental practice including analgesics, hydroxychloroquine, and azithromycin. azithromycin is a macrolide antibiotic that is particularly important in dental practice. it is a recommended antibiotic in the empiric treatment of odontogenic infections mainly in penicillin-allergic patients [8] . it is also among the top five antibiotics prescribed in the dental setting in some countries including the usa, brazil, and belgium [9] [10] [11] . the long half-life of azithromycin make it a favorable antibiotic for children who lack compliance and for whom a once daily oral dosage is recommended. further, it is effective in the management of respiratory infections in young children [12] . hospitalized patients usually receive the intravenous form of the drug for the treatment of community-acquired pneumonia. this antibiotic is considered relatively safe in adults, children, and pregnant women [13] . however, a number of side effects have been identified especially with intravenous administration, which may be associated with gastrointestinal disturbances, ototoxicity, and pain and inflammation of the injection site [14] the development of resistant bacteria, [15] and its association with proarrhythmic events [16] have also been reported. the latter risk has been attributed to qt prolongation (summation of action potential of ventricular myocytes), which can lead to a life-threatening arrhythmia; however, susceptible patients usually have other co-factors such as old age, heart disease, and exposure to other qt prolonging drugs [17] . in vitro studies have shown that azithromycin is active against zika and ebola viruses, [18] [19] [20] and is able to prevent severe respiratory tract infections when administrated to patients suffering viral infection [12] however, the efficacy of azithromycin in combination with hydroxychloroquine in the treatment of covid-19 patients has not been confirmed yet [21, 22] , and more studies are needed to further investigate its clinical effects. in light of the current shift of dental services towards the provision of emergency treatment only, and the possible increase in antibiotic prescriptions for severe orofacial infections, the use of azithromycin in dentistry should be monitored, especially that its use in dental practice as a favorable antibiotic is reported in countries with a high toll of covid-19 infections. alternative antibiotics such as amoxicillin or clindamycin (in penicillin-allergic patients) should be considered for indicated cases, provided that no contraindications are present. an important example is patients who has a history of pseudomembranous colitis or ulcerative colitis, and hence cannot use clindamycin [23] . dentists and physicians working in the treatment of emergency dental cases should be vigilant in prescribing antibiotics only for indicated cases and should consider the use of analgesic alternatives to control dental pain. avoiding the development of side effects and antibiotic resistance should be considered among the goals of treatment. chloroquine is an antiparasitic drug that is primarily used as antimalarial drug since the 1930s. it has recently attracted a lot of attention due to its use in the treatment of covid-19. however, its use in the treatment of some oral diseases has been recognized for a long time. it was noticed to possess efficacy towards autoimmune diseases and has been implemented since the 1980s in the treatment of systemic lupus erythematosus (sle), a disease that may have oral manifestations like ulcers. its use in the treatment of primary sjögren's syndrome has been suggested by some scientists [24] , and it is also recommended for the treatment of chronic ulcerative stomatitis [25] . it had been suggested for the treatment of oral squamous cell carcinoma due to its role in cell protection by eliminating excessive proteins and injured/aged organelles in the microenvironment of tumors with subsequent acceleration of tumor cell death [26] . the antiviral activity of the drug has long been recognized. in the current epidemic of covid-19 many countries announced its use in their trials to eradicate this disease. scientists stated that the drug, which has established antiviral activity over the past 40 years, inhibited sars-cov-2 viral replication in vitro and human clinical application indicated apparent efficacy [27] . hydroxychloroquine is a derivative of chloroquine with significantly higher solubility, and lower toxicity, therefore fewer side effects are anticipated [28] . pharmacological modelling based on observed drug concentrations and in vitro drug testing suggest that prophylaxis with hydroxychloroquine at approved doses could prevent sars-cov-2 infection and ameliorate viral shedding [29] . the combination of antiviral drugs, such as remdesivir and chloroquine, has been considered highly effective in the control of infection in vitro and has been suggested in the treatment of covid-19 due to its safety profile [30] . however, clinical trials conducted so far are limited in sample size and their lack of randomization cast doubt on reported outcomes. it is still unknown how this drug exerts its anti-viral activity, but some researchers believe it can inhibit the development of an acidic media in endosomes that transport it from the cell membrane to cytoplasm. alkaline media in endosomes is believed to prevent viral transfer to cytoplasm and can thus limit the replication of several viruses [31] . the activity of the drug against autoimmune diseases, such as sle, is believed to be due to its action to prevent production or release of il-6 and tnf-α, and due to its inhibitory action on autophagy [32] . this activity of hydroxychloroquine has been demonstrated in vitro against influenza and coronaviruses, however, clinically in humans and on animals the therapeutic activity was less successful. the drug is generally safe, with poisoning being associated with the dangerous side-effects of retinopathy and immunosuppression [33] . however, it is contraindicated in pregnancy. during the current pandemic of covid-19, and due to increased demand, severe shortages of the drug were reported and adversely affecting on the regular autoimmune disease patients with countries banning its export. dentists have to be aware that shortages of chloroquine may influence their patients who are dependent on this drug especially sle and sjogren's syndrome patients who have oral manifestations. they also should be aware of the possible oral complications caused by the drug, namely melanotic pigmentation of the oral mucosa [34] and lichenoid reaction [35] . since the recognition of the covid-19 pandemic, professional regulatory bodies advised against provision of dental treatment except for emergency cases. it became essential that dental patients will rely on supportive therapy such as analgesics, and non-steroidal anti-inflammatory drugs (nsaids) for the control of dental symptoms of pain. among these patients, some may be asymptomatic for covid-19. furthermore, supportive analgesic, antipyretic therapy remains the backbone for the treatment of mild to moderate cases of covid-19. this may eventually lead to the increased demand on analgesics. there was a warning against the use of ibuprofen in the treatment of covid-19 due to the increased expression of angiotensin-converting enzyme-2, which is believed to be the binding receptor of the virus to the cells. consequently, the accelerated expression of this protein would theoretically potentiate and enhance the infection. this argument may be based on mechanistic or theoretical pharmacology rather than evidencebased clinical trials [36] . covid-19 can be such a severe infection in about 20% of the cases, forcing patients to choose ibuprofen as a more effective drug compared to paracetamol. thus, the clinical manifestations potentially emanate from this fierce infection itself rather than the theoretical potentiating action of the drug. further, there is no strong epidemiological evidence to suggest a harmful effect of ibuprofen on covid-19 patients [36] . the who recommendation in this case is to use paracetamol as first line treatment, while ibuprofen comes as second line treatment [37] . recently, the national institute for health and care excellence (nice) said that there is no evidence from published scientific studies to determine whether acute use of nsaids is related to increased risk of developing covid-19 or increased risk of a more severe illness [38] . this was confirmed by the nhs england in their recent commissioning policy for acute use of nsaids for people with or at risk of covid-19 [39] . dentists should remain updated as more information emerges on the topic and should weigh any benefits against harm when prescribing analgesics for patients with dental pain. paracetamol can be used as a first line analgesic, however, if it is not effective, they can prescribe ibuprofen or other nsaids unless there is a contraindication. the genome of covid-19 virus has been detected in saliva in the majority of patients with this disease [40] , indicating the potential infection of salivary glands [41] . it is interesting to know that in some cases, covid-19 was only detected in saliva, with no evidence for its presence in the nasopharynx [42] . positive salivary tests indicate possibility of transmission through the spread of saliva as respiratory viruses usually spread via direct contact or spatter and aerosol production from mouth and nose i.e., sneezing or coughing [41] . furthermore, respiratory droplets containing influenza virus have been detected even during normal breathing [43] . although it is possible to detect the virus in saliva with viral culture, this should be interpreted with caution since saliva may contain secretions that originate from the nasopharynx or the lungs through the action of cilia [41] . however, this can be ascertained by choosing the correct method of saliva collection; to collect saliva from a particular salivary gland (the parotid gland for example) rather than obtaining the sample directly from the mouth [44] . the detection of virus in saliva is being used for monitoring saliva virus load during serial viral load monitoring instead of nasopharyngeal or oropharyngeal sources to reduce patient discomfort and health hazards to the operator during successive sampling [41] . conducting covid-19 tests on saliva is easier for the patient and operator and the process bears less risk of cross contamination. specimens can be provided by asking the patient to spit into a sterile container, and the operator stands little chance of exposure with such a non-invasive procedure [41] . saliva collection is more comfortable for patients than venipuncture as well as being more cost-effective with minimal required instruments [45] . this finding is of particular interest to dentists. the initial recommendation by the nhs was to provide treatment to all patients except those with symptoms of infection. also, all dental treatment was allowed except procedures that are associated with aerosolization. however, it is established now that there is a proportion of asymptomatic patients who may transmit infection, and the presence of the virus in saliva means that even non-aerosol producing dental procedures can be a source of infection. another important aspect of this finding is that dentists who are engaged in tobacco cessation efforts should disseminate awareness among their smoker patients of the possibility of salivary virus transmission via social sharing of tobacco smoking instruments namely the electronic cigarettes and waterpipe [46] . loss of taste and smell have been recognized lately as one of the symptoms of covid-19 [47] . an italian team reported that 20 out of 59 covid-19 patients who were interviewed (33.9%) had at least one taste or olfactory disorder and 11 (18.6%) had both [47] . most of the patients with these symptoms (91%) reported the occurrence of taste alterations before being hospitalized. taste and smell disorder in this case could be explained by the fact that sars-cov-2 has been known for its interaction with angiotensin converting enzyme 2 (ace2) receptor, to facilitate its penetration into the cell, and this receptor is widely expressed on the epithelial cells of oral mucosa and the brain [48] . in fact, expression of ace2 was found to be higher in tongue, where the taste buds are most abundant, than gingiva or buccal mucosa [48] . another possibility is that sars-cov-2 could also be detected in saliva and infection of salivary glands is also possible [40] , which increases the availability of virus in the oral cavity and its uptake by the epithelial cells. dentists should be aware of this symptom since they may encounter patients with taste abnormalities in the form of dysgeusia or burning mouth syndrome. this is particularly important because these symptoms may precede the onset of respiratory diagnostic manifestations of the disease. however, reporting of this symptom should be interpreted with caution as the affected patients are known to be of the old age group who are already susceptible to taste and smell disorders. dental practitioners have an important role in the global fight against pandemics like covid-19. they are experienced in cross-infection control procedures and barrier techniques. they are competent in suture placement, hemostatic procedures, and in many countries, they can perform parenteral drug administration. they are also constructive members in multidisciplinary professional groups and experienced in managing patients in pain. they are well adapted to management of vulnerable patients including children, pregnant women, and elderly people. on the other hand, dentists should recognize the importance of following the regulations for delivery of oral healthcare so as to protect their patients and members of the dental healthcare team. practicing dentists should ensure that all members of the oral healthcare team are well acquainted to the covid-19 transmission and preventive measures. provision of dental services should take into consideration the availability of ppe, and that only emergency cases are admitted for treatment. cross-infection control measures should be applied meticulously at all times, and social distancing should be adopted in the practice unless advised otherwise. dental procedures in general are categorized into two groups according to aerosol generation. most dental procedures generate aerosol; preparing cavities for fillings, use of rotary instruments for root canal treatment, scaling and polishing of teeth, dental implantation, and surgical removal of teeth are only some examples. asymptomatic covid-19 patients may present for emergency dental treatment. these patients are expected to have saliva contaminated with the virus and they are a confirmed source of infection. moreover, the conjunctiva mucosa and upper respiratory tract are connected by the nasolacrimal duct, and they share ace2 on the cell membrane [49] . this exposes dental healthcare personnel to the risk of infection via direct exposure of conjunctiva (eyes) to droplets from patients during dental treatment. there are now restrictions for the work of dentists in many countries, however, some countries like austria and jordan will start to ease the lock down. in jordan, for instance, dentists will be permitted to work in their practices as of 27 april 2020, even though complete eradication of the virus has not been accomplished yet. considering that neither treatment nor vaccination is available for covid-19, it would be wise for dentists to rely more on non-aerosol generating procedures for treatment of their patients. excavation of caries rather than drilling and conventional root canal treatment rather than rotary instruments, for example, should be the mainstay of treatment at this point of time. researchers should focus on developing barrier techniques and negative pressure procedures to contain and isolate the aerosol so that dental procedures are safe for dental healthcare personnel and patients alike. furthermore, dentists should be aware that covid-19 patients may present with oral symptoms that are suspected to be linked to the virus such as taste abnormalities. while home confinement is considered the mainstay for populations to prevent transmission of the virus, dentists should not be confined by the society within the borders of their specialty. they have many roles to play. following the recommended cross-infection control procedures, spreading awareness based on evidence and not misconceptions, identifying emergency cases indicated for dental treatment, and practicing effective tele-dentistry when needed can all be helpful for dental patients and community as a whole. dentists should give drug prescription particular attention. when advising patients to use medications for treatment of dental problems it is important to consider the indicated clinical conditions for analgesics, anti-inflammatory drugs, and antibiotics, and patients should be advised against using antibiotic self-medication to relieve dental pain. it is certainly the right time for dental schools to expand the learning outcomes of their courses to include additional roles of dentistry that take into consideration natural disasters and pandemics. furthermore, dentists should be prepared to be active members in healthcare teams dealing with pandemics. professional dental associations should contemplate continuing educational courses for practicing dentists that reinforce their role in the healthcare team by delivering courses on essential aspects of acute healthcare such as basic life support, phlebotomy, and drug prescribing. covid-19 in colombia endpoints. are we different, like antihypertensive drugs and risk of covid-19? covid-19: four fifths of cases are asymptomatic, china figures indicate clinical features of 85 fatal cases of covid-19 from wuhan: a retrospective observational study world health organization (who) american dental association. ada coronavirus (covid-19) center for dentists antibiotic prescribing for oro-facial infections in the paediatric outpatient: a review an evaluation of dental antibiotic prescribing practices in the united states antibiotic prescription for endodontic infections: a survey of brazilian endodontists antimicrobial prescribing by belgian dentists in ambulatory care early administration of azithromycin and prevention of severe lower respiratory tract illnesses in preschool children with a history of such illnesses: a randomized clinical trial pharmacokinetic properties of azithromycin in pregnancy intravenous azithromycin-induced ototoxicity risks of population antimicrobial resistance associated with chronic macrolide use for inflammatory airway diseases electrophysiologic studies on the risks and potential mechanism underlying the proarrhythmic nature of azithromycin risk evaluation of azithromycin-induced qt prolongation in real-world practice zika virus cell tropism in the developing human brain and inhibition by azithromycin evaluation of ebola virus inhibitors for drug repurposing azithromycin inhibits the replication of zika virus hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial no evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe covid-19 infection clostridium difficile isolated from faecal samples in patients with ulcerative colitis primary sjögren syndrome: an update on current pharmacotherapy options and future directions chronic ulcerative stomatitis: a comprehensive review and proposal for diagnostic criteria in vitro and in vivo antitumor effects of chloroquine on oral squamous cell carcinoma in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting sars-cov-2 infection in vitro bioavailability of hydroxychloroquine tablets in healthy volunteers remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-ncov) in vitro effects of chloroquine on viral infections: an old drug against today's diseases? quinoline-based antimalarial drugs: a novel class of autophagy inhibitors hydroxychloroquine in systemic lupus erythematosus (sle) chloroquine-induced oral mucosal hyperpigmentation and nail dyschromia pigmented lichenoid drug eruption secondary to chloroquine therapy: an unusual presentation in lower lip safety of ibuprofen in patients with covid-19; causal or confounded? chest 2020 says there's no evidence it can worsen covid-19 covid-19 rapid evidence summary: acute use of non-steroidal anti-inflammatory drugs (nsaids) for people with or at risk of covid-19 acute use of non-steroidal anti-inflammatory drugs (nsaids) in people with or at risk of covid-19 (rps2001) covid-19: gastrointestinal symptoms and potential sources of 2019-ncov transmission consistent detection of 2019 novel coronavirus in saliva additional molecular testing of saliva specimens improves the detection of respiratory viruses infectious virus in exhaled breath of symptomatic seasonal influenza cases from a college community variations of some salivary antimicrobial factors in different disease states: a review. saudi dent human saliva: non-invasive fluid for detecting novel coronavirus (2019-ncov) unconventional materials and substances used in water pipe (narghile) by smokers in central western region, saudi arabia self-reported olfactory and taste disorders in in patients with severe acute respiratory coronavirus 2 infection: a cross-sectional study high expression of ace2 receptor of 2019-ncov on the epithelial cells of oral mucosa conjunctiva is not a preferred gateway of entry for sars-cov-2 to infect respiratory tract this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-313887-8sabsrgy authors: quandt, sara a.; lamonto, natalie j.; mora, dana c.; talton, jennifer w.; laurienti, paul j.; arcury, thomas a. title: covid-19 pandemic among latinx farmworker and nonfarmworker families in north carolina: knowledge, risk perceptions, and preventive behaviors date: 2020-08-10 journal: int j environ res public health doi: 10.3390/ijerph17165786 sha: doc_id: 313887 cord_uid: 8sabsrgy (1) background: the covid-19 pandemic poses substantial threats to latinx farmworkers and other immigrants in food production and processing. classified as essential, such workers cannot shelter at home. therefore, knowledge and preventive behaviors are important to reduce covid-19 spread in the community. (2) methods: respondents for 67 families with at least one farmworker (fwf) and 38 comparable families with no farmworkers (nonfwf) in north carolina completed a telephone survey in may 2020. the survey queried knowledge of covid-19, perceptions of its severity, self-efficacy, and preventive behaviors. detailed data were collected to document household members’ social interaction and use of face coverings. (3) results: knowledge of covid-19 and prevention methods was high in both groups, as was its perceived severity. nonfwf had higher self-efficacy for preventing infection. both groups claimed to practice preventive behaviors, though fwf emphasized social avoidance and nonfwf emphasized personal hygiene. detailed social interactions showed high rates of inter-personal contact at home, at work, and in the community with more mask use in nonfwf than fwf. (4) conclusions: despite high levels of knowledge and perceived severity for covid-19, these immigrant families were engaged in frequent interpersonal contact that could expose community members and themselves to covid-19. the 2020 coronavirus pandemic has posed a substantial threat to immigrant farmworkers in the united states (usa) and other workers in the food production and processing system worldwide [1] [2] [3] [4] . such workers are deemed essential workers [5, 6] and are unable to practice preventive measures such as sheltering at home and working from home that may be recommended to the general population. in addition, food system workers are often of low socioeconomic status, immigrant, minority, and undocumented so that they are excluded from some of the economic legal protections of workers in other industries [7] . in regard to the pandemic, they are specifically excluded from the social safety net provided by the coronavirus aid, relief and economic security (cares) act [8] . they also may not be reached by rapidly evolving public health messaging or provision of personal protective equipment intended to provide them with the knowledge and materials needed to protect themselves [5, 9] . in the usa, many immigrant workers exist at the poverty threshold and lack health insurance and access to health care [10, 11] , further diminishing their ability to protect their health in a pandemic [3, 9] . such structural factors have been found to explain the uneven distribution of covid-19 in the usa population during the pandemic [12] . substantial concern was expressed in the usa about latinx farmworkers' risk of covid-19 early in the pandemic [4, 13, 14] . these workers often work seasonally, and the spring work season commenced within the first months of the pandemic. workers were considered to be at risk because close contact in crowded housing [15, 16] and transportation used to reach the fields could increase rates of disease transmission [17, 18] . within the fields, workers often work in close proximity picking row crops; and some equipment requires two or more workers to sit side by side, e.g., on mechanical setters as they plant seedlings. they also have limited access to water and other sanitation supplies [4] . workers could then act as a vector to their larger communities by infecting other workers and family members. such patterns were observed by april 2020, in immigrant worker populations in meat and poultry processing facilities [19] , further increasing the concern for seasonal and migrant crop workers who would begin work in may and june in areas such as north carolina [20] . public health directives about covid-19 in the usa changed rapidly over the first few months of the pandemic [9] . early findings that coronavirus was stable on surfaces for hours or even days [21] led to recommendations that focused on use of cleaning products to sanitize frequently touched surfaces such as doorknobs and countertops. these were subsequently downplayed as research and modeling of effects in other countries demonstrated the importance of droplet transmission of the virus, which could be reduced through physical distancing and use of face coverings such as masks [22, 23] . similarly, some early claims for treatment and cures for covid-19 later proved false or were subject to hurried and incomplete evaluation [24] . communication of these messages to the public, particularly to those who did not receive communications well in english, sometimes lagged behind scientific findings. taken together, the rapidly changing messages, coupled with public concern, and limited availability of up-to-date information in formats for those with limited english proficiency created a situation in the usa in which latinx workers such as farmworkers were likely to lack consistent and accurate information and, as a result, practice ineffective behaviors to protect themselves and prevent spreading disease to their social network. this study is guided by constructs from the health belief model (hbm) [25] . the hbm tries to understand how knowledge and personal factors lead to actions to protect or promote health. in the hbm, perceptions of one's susceptibility to a disease and its perceived severity influence actions taken. individuals must perceive that they are susceptible, in this case, to covid-19, and that contracting and spreading the disease would have serious consequences. in addition, self-efficacy, the belief in one's ability to take effective action in the situation of risk to health, influences whether or not one engages in health protective or promoting actions. this suggests that having a strong sense of self-efficacy in practicing protective measures to prevent contracting and spreading covid-19 will lead to engaging in such measures. in this study, we measure a number of these constructs, though we do not execute a full test of the hbm. interpretation of results is placed in the framework of structural vulnerability [26] . this argues that one's health vulnerability is the product of one's place in the social hierarchy with its diverse set of power relationships, based on ethnicity and class. when applied to immigrant workers, factors such as occupation, documentation status, and access to government benefits provide context, and in fact, limit the choices, within which health behaviors understood within the hbm can occur. we report survey data collected in a narrow time window, may 2020, from women in a sample of latinx farmworker families and a comparison group of latinx nonfarmworker families in north carolina, usa. the paper has three aims. in all cases, we will compare farmworker families and families with no worker engaged in farm work. first, we will describe the families' respondents' (1) knowledge of coronavirus contagion and prevention, (2) risk perceptions, and (3) practices used for prevention and spread of covid-19. second, we will describe household social interactions and protections taken, both outside of work and at work. third, we will use these data to identify specific risks for each group, as well as areas where policy changes can help mitigate the risk for covid-19. the study reported here is part of a larger two-group, prospective study examining the health and cognitive effects of pesticide exposure in children in farmworker families. the larger study uses a comparative design, with a sample of families of latinx farmworkers with children and a sample of similar families but without any farmworker members. additional details of the study can be found elsewhere [27] . the current study used a telephone survey to reach the mother of the children in these families in may 2020, when no face-to-face contact between study staff and study participants was permitted by the institutional review board due to covid-19-related health concerns for research participants. all procedures for both the original study and this covid-19 study were approved by the wake forest university institutional review board. the study received a certificate of confidentiality from the national institutes of health. inclusion criteria for the families were similar in both samples when recruited from march 2018, to december 2019; they reflect the purpose of the larger study. each family had to have a child aged 8 years at baseline who had completed the first grade in the usa. all children had to be from families that self-identified as latino or hispanic, and with household incomes below 200% of the usa federal poverty guideline. in the farmworker sample, the mother or her partner must have been employed in farm work on nonorganic farms during the past three years. in the nonfarmworker sample, adults could not have been employed in any industry that involves routine exposure to pesticides (e.g., farm work, landscaping, or pest control) in the previous three years. families in the nonfarmworker sample could not have lived adjacent to agricultural fields in the previous three years. exclusion criteria for both samples included children having life-threatening illnesses, prior history of neurological conditions, physical condition or development disorder that would not allow them to complete or would interfere with the results of neurobehavioral tests or mris (used in the larger main study), primary language other than spanish or english spoken in the home, or refusal of mother/guardian to complete the questionnaires. in the larger study, a total of 76 children were recruited for the farmworker sample and 65 children for the nonfarmworker sample. for the recruitment of the original sample, the community partner north carolina farmworkers project developed a list of farmworker families with an 8 year old child and the locations where they lived. in addition, other community organizations that served farmworker families in the recruitment area were contacted. study personnel contacted the mothers. similarly, for the original nonfarmworker sample, local recruiters in winston-salem, nc, and community members developed a list. for both samples, mothers were contacted by a bilingual staff member who explained the overall study procedures, answered questions, and, if the mother agreed to participate, obtained signed informed consent from the mother and assent from the child. as recruitment progressed, community partners worked with the study team to balance the two samples on socioeconomic status. prior to the telephone survey, 5 children in the farmworker sample and 17 in the nonfarmworker sample withdrew, moved away from the study area, or were lost to follow-up. the remaining children represented 67 farmworker families and 45 nonfarmworker families, because some families had more than one child enrolled. for the telephone sample, 2 families refused to participate and 5 could not be reached, all in the nonfarmworker sample. a total of 67 farmworker families and 38 nonfarmworker families could be reached and agreed to participate. this sample of 105 is used in this paper. data for this study were gathered from 1 may 2020 to 5 june 2020, using a telephone survey. only 2 interviews were conducted in june. interviewers were members of the larger study team who had usual interview contact with the mothers. each interviewer participated in an individualized televideo training after which the interviewer practiced completing the form and did an oral practice interview with the study manager. to recruit participants, interviewers called the last known telephone number for the mother in each family, explained the purpose and procedures for the study, and told the mother that she would receive a $10 incentive for completing it at the next in-person study visit. if there was no answer, the interviewers tried at different times of day until the participant was reached or until at least 3 unsuccessful calls had been made. if the mother agreed to participate, her informed consent was noted, and the interviewer proceeded to conduct a standardized interviewer-administered questionnaire in the language of the participant's choice using a tablet. data were entered in real time during the interviews using research electronic data capture (redcap). redcap is hosted at wake forest school of medicine through the clinical and translational science institute. the redcap system provides secure, web-based applications for a variety of types of research [28] . data from these interviews were later merged with selected personal, family, and household variables collected in the main study questionnaires. questionnaire items relating to the coronavirus and covid-19 were adapted from existing studies (e.g., mcfadden et al. [29] ), where available, or from questions recommended for covid-19 research by governmental and nongovernmental agencies. because of the need for rapid data collection, validation was limited to checks on face validity and interviewer reports of difficulties experienced by respondents during practice interviews. variables from the main study baseline questionnaire were used to create measures to describe the sample. these included the following measures for the mother: age, country of origin, educational attainment, and current occupation. group assignment of the family to the farm work or nonfarm work sample was also noted from the baseline questionnaire. current household size was obtained by querying the number of adults (persons 18 years and older) and children living in the respondent's dwelling. knowledge of covid-19 was measured with a series of 4 questions that asked the respondent to identify the correct answer from a series of statements for the definition of covid-19, its transmission route, the definition of "close contact" for coronavirus, and availability of treatment and vaccine. a summary variable was created by summing the number (0-4) of items answered correctly. knowledge of behaviors that can prevent exposure to the coronavirus and its transmission was measured with a set of 13 items in which the respondent was asked whether or not each could prevent exposure for self or others. the list contained 8 items for which the correct response was positive (e.g., wear a face mask when out in public) and 5 items for which the correct response was negative (e.g., take herbal supplements). the number of correct responses was summed to create a summary measure of questions answered correctly, with a range of 0 to 13. perceptions of risk was measured with 8 items containing statements about health risk to self and community from covid-19. responses used a 5-point likert-type scale with values ranging from strongly agree to strongly disagree, which was collapsed to a 3-point scale for analysis with values 2 (agree), 1 (neutral), and 0 (disagree). the two items concerning personal risk or self-efficacy were added to create a summary measure of self-efficacy with values 0 to 4. this was divided into categories of low self-efficacy (0-2) and high self-efficacy (3) (4) . the cronbach's alpha for this scale was 0.62. personal behaviors to protect health and prevent spread of the coronavirus in the past month were obtained by asking the respondent if they had never, sometimes, or always practiced each of 10 behaviors. these included the 8 positive behaviors in the knowledge items described above, as well as 2 additional items (avoiding travel to areas infected with coronavirus; avoiding eating outside the home). these were summed with a possible range for the summary being 0 to 20, with each behavior scored as 0 (never), 1 (sometimes), or 2 (always). the next section of the questionnaire included questions asking about physical distancing and mask use for protection in order to overcome any social desirability [30] that may have affected the previous self-reports of behavior. respondents were first asked how many adults had visited in the respondent's house in the past week. response options were none, 1 or 2, 3 or 4, and 5 or more. those who had had visiting adults were asked how many visitors had worn masks during their visit, with the response options of all of them, some of them, and none of them. these questions were also asked about child visitors. respondents were also asked how many different houses, apartments, or trailers of others they had visited in the last week. response options were none, 1 or 2, 3 or 4, and 5 or more. those who had visited other homes were asked how often they wore a mask during their visit, with the response options of all, some, or none of the time. similar questions were asked about the household children and the respondent's spouse/partner. respondents were asked how many people they worked with, defined as the number of persons with whom they worked closely enough to have a normal conversation for at least some of the work time. response options were none, 1 or 2, 3 or 4, and 5 or more. mask use was queried for coworkers, with response options of all of them, some of them, and none of them wore masks at work. similar questions were asked for the spouse/partner at work. respondents were asked if their children had been cared for in the past week at a day care, pre-school, school, after school program, or at a relative or friend's house. any positive responses were followed by asking whether all, some, or no childcare workers wore masks and wore gloves. to obtain information on large social gatherings in the past week, respondents were asked if any household member had attended church, the approximate number of attendees, and if all, some, or none of the attendees wore masks. the same set of questions was asked about whether any household member had attended a party or other social event such as a cookout, baptism, quinceañera, wedding, or funeral in the past week. frequencies and percentages were calculated to examine the variables of interest by farmworker status and significant differences were examined using chi-square or fisher's exact tests as appropriate. all analyses were done using sas v 9.4 (sas institute, cary, nc, usa), and p-values < 0.05 are considered statistically significant. respondents ranged in age from 25 to 47 years (table 1) . about 80% of both samples were born in mexico; spanish was the preferred language for most. years of formal education for the respondents ranged from 0 to college graduate, with the median in both samples being ninth grade. their spouse/partners had slightly lower education; the medians for the farmworker and nonfarmworker samples were sixth and eighth grade, respectively. there were no significant differences between the two samples for these categorical variables. total household size ranged from 1 to 10 (median = 5) and 3 to 13 (median = 6) in the farmworker and nonfarmworker samples, respectively. for the farmworker sample, the number of adults in the household ranged from 1 to 6, while the number of children ranged from 0 (a respondent currently separated from her family) to 7. for the nonfarmworker samples, the ranges were 1 to 4 for adults and 1 to 10 for children. at baseline, farmworker families reported that the most common industry in which women worked was agriculture; for men, it was construction, followed by agriculture. for nonfarmworker families, most women were not in the labor force and the majority of men worked in construction. knowledge of the coronavirus was high ( table 2 ). all individuals in both samples had heard of the virus, and none required an explanation of what it was. the farmworker sample had more correct answers than the nonfarmworker sample on three of the four remaining items. more in the farmworker sample knew that covid-19 was a respiratory disease caused by a viral infection (100% vs. 89.47%; p < 0.05). for the item concerning treatment or vaccine for covid-19, 28.95% of the nonfarmworker sample did not know that there is currently no cure or a vaccine for covid-19, compared to only 5.97% of the farmworker sample (p < 0.01). overall, knowledge in the farmworker sample was significantly higher than in the nonfarmworker sample (p < 0.0001), with 94.03% of farmworker sample having a perfect score, compared to only 60.53% of the nonfarmworker sample. knowledge of behaviors to prevent exposure to the coronavirus or spread of covid-19 was high in both samples (table 3 ). for seven of the 13 items, both samples had 100% correct responses. more in the farmworker sample knew that avoiding touching the face with unwashed hands was protective than in the nonfarmworker sample (98.51% vs. 84.21%; p < 0.01). the only other items for which the samples had different responses were three of the five in the list that were negative options (e.g., taking herbal supplements). for these, the nonfarmworker sample had significantly more correct responses for using herbal supplements (55.26% vs. 4.48%; p < 0.0001). the farmworker sample had more correct responses for eating a balanced diet (68.66% vs. 44.74%; p < 0.05) and getting regular exercise (71.64% vs. 39.47%; p < 0.01). overall, the farmworker sample had somewhat better knowledge of prevention than did the nonfarmworker sample, but the difference was not significant (p = 0.0562). the farmworker sample respondents perceived lower risk associated with covid-19 for themselves and their community on most items than did the nonfarmworker sample respondents (table 4) . similarly, the farmworker sample perceived that they had lower ability to protect themselves from the coronavirus, with almost all responses (97.01%) falling in the lower self-efficacy category, compared to 73.68% of the nonfarmworker sample falling in the higher self-efficacy category (p < 0.0001). for self-reported actual preventive behaviors, the farmworker sample was significantly more likely to report practicing three behaviors (avoiding travel to areas infected with coronavirus [p < 0.01], avoiding eating outside the home [p < 0.01], and avoiding close contact with people who were sick [p < 0.05]), while the nonfarmworker sample was significantly more likely to report practicing four behaviors (washing hands for 20 s [p < 0.001], using surface disinfectants [p < 0.0001], avoiding touching face with unwashed hands [p < 0.0001], and covering cough with tissue [p < 0.0001]) ( table 5 ). the overall difference between the two samples was significant (p = 0.0008). slightly fewer than half of farmworker families (n = 31; 46.27%) reported that they had had adult visitors at their home in the past week. of these, 30 reported that none of the visitors had worn a mask. similarly, 28 of these families (41.79%) reported that children had visited in their home and none had worn masks. for nonfarmworker families, more had had adult visitors (n = 21; 55.26%), but some (n = 6; 28.57%) had worn masks. a lower proportion of the nonfarmworker families had had child visitors (n = 14; 36.84%), and some (n = 5; 35.71%) had worn masks. more farmworker than nonfarmworker family respondents reported visiting the homes of others in the past week (n = 26, 38.81% vs. n = 9, 23.68%). both categories of respondents reported visiting 1 or 2 other homes, except 2 from farmworker families who reported visiting 3 or 4. none of the respondents from farmworker families reported wearing masks when visiting; 22.22% (n = 2) of the nonfarmworker respondents reported ever wearing masks while visiting. twenty-seven respondents (40.30%) from farmworker families reported that their children visited other homes in the past week, and none wore masks. they also reported that 38.98% (n = 23) of their spouse/partners visited other homes, and none ever wore masks. respondents from nonfarmworker families reported fewer children (n = 9; 23.68%) and spouse/partners (n = 10; 27.78%) visiting other houses, with one spouse/partner visiting five or more houses. about a third (n = 4; 30.00%) of spouses were reported to have worn masks, though several respondents did not know, and 66.67% (n = 6) reported their children had never worn masks while visiting other homes. among respondents in farmworker families, 31 (46.27%) reported working in the past week. most (n = 26; 83.87%) worked in places with five or more employees in close enough contact to have a normal conversation at least some of the time. these respondents reported that all (n = 26; 86.67%) or some (n = 3; 10.00%) wore masks in the workplace. almost all of their spouse/partners worked (n = 57; 96.61%); 78.95% (n = 45) worked in places with five or more employees in close contact, and some or all wore masks in 60.71% (n = 34) cases. about the same proportion of respondents in nonfarmworker families worked (n = 17; 44.74%), but fewer (n = 10; 58.82%) worked in places with five or more workers in close contact. most of these respondents reported that all (n = 8; 50%) or some (n = 5; 31.25%) of coworkers wore masks. almost all (n = 32; 88.89%) spouses worked, though less than half (n = 14; 43.75%) worked in close contact with five or more workers. in about two-thirds of these worksites (63.33%), some (10.00%) or all (53.33%) workers wore masks. during the time women were surveyed, schools were closed, and no children attended preschools or day care centers. seven (10.45%) respondents in farmworker families reported that their children were cared for at a friend or relative's house and that none of the caregivers wore masks or gloves. four (10.53%) respondents in nonfarmworker families reported similar childcare arrangements. however, half reported the caregiver wore masks and gloves. five (7.46%) of the respondents in farmworker families reported that a household resident had attended church in the past week. total church attendance was estimated by the respondent at 25 (2 cases), 30 (1 case), and 40 (2 cases). all attendees wore masks in four of these church services, and none wore masks in the other. only one respondent among nonfarmworker families reported that a household member had attended church in the past week. attendance was about 10 people and all reportedly wore masks. nine (13.43%) respondents in farmworker families reported that a household member had attended a party or social event in the past week. estimates of total attendees ranged from 10 to 35; none wore masks. by comparison, three (7.89%) respondents in nonfarmworker families reported someone had attended a party or social event. in two cases, attendance was estimated at 10; the other was estimated at 20. no one wore masks at two of these events. this study was designed to describe the knowledge, perceived risk and susceptibility, and preventive behaviors reported by latinx immigrant farmworker and nonfarmworker families in north carolina during the first months of the covid-19 pandemic. these families are of particular concern because the rates of covid-19 nationally are elevated in minority populations. specifically in north carolina, on 1 june 2020, hispanics were reported to make up 10% of the state's population but 39% of the state's covid-19 cases [31] . at the same time, several farmworker camps were listed as locations of covid-19 outbreaks by the state department of health and human services. the study found that levels of knowledge were extremely high among the latinx families surveyed, both farmworker and nonfarmworker. all respondents had heard of the pandemic and knew what covid-19 is and how it is transmitted. they had somewhat less accurate knowledge about the availability of a cure or vaccine; and women in farmworker families had, overall, slightly more accurate knowledge than did the women in nonfarmworker families. both samples had strong knowledge of the health behaviors that could protect against exposure to the coronavirus and contracting or transmitting covid-19. in particular, they knew the primary public health messages promoted early in the pandemic. they were less accurate in differentiating these effective behaviors from ineffective behaviors that might be promoted for health risks other than covid-19, such as exercising and consuming a balanced diet. although both groups perceived that covid-19 presents a serious risk to health, respondents in farmworker families were significantly less likely to affirm personal susceptibility (e.g., that they would avoid going to the hospital for another illness because of risk of contracting covid-19 there and that they were more likely than others to get . similarly, these women in farmworker families had lower self-efficacy concerning their ability to protect themselves. the two samples affirmed different patterns of health promoting behaviors. for the farmworker families, behaviors that entailed avoiding others (e.g., not traveling to areas infected with coronavirus, avoiding eating out, and avoiding close contact with sick individuals) were affirmed significantly more often than by the nonfarmworker families. the latter were more likely to affirm behaviors related to personal hygiene: hand washing, using disinfectants, avoiding touching the face, and covering coughs and sneezes. together, these findings give a sense that, while the women in farmworker families had somewhat better knowledge, they perceived less personal susceptibility to covid-19. they had low confidence that they could protect themselves. this may be underlying the protective behaviors they reported. they avoided people and places that might be contaminated but did not subscribe to practicing personal hygiene behaviors. women in nonfarmworker families had greater confidence that they could protect themselves and they claimed to practice more personal hygiene behaviors. social desirability [30] can bias the way individuals respond to lists of health behaviors. with knowledge of recommendations, they may tend to see themselves or want to portray themselves as more positive and compliant than they actually are. in order to investigate behaviors in detail and try to avoid social desirability bias, the telephone survey included a series of questions about social interactions by household members and wearing masks. complex question sequences are thought to reduce social desirability bias [32, 33] . the focus on distancing and masks was considered important in light of the developing public health messages that identified the greater importance of maintaining physical distancing and protection against spreading infected droplets with masks, rather than practices such as disinfecting surfaces that had been promoted over mask use earlier in the pandemic [22] . the responses to these questions contrasted sharply with the other reported protective behaviors. they showed a high level of social interaction beyond the immediate household for both farmworker and nonfarmworkers families, with both adults and children coming into the homes of respondents and members of the respondent's household visiting in the homes of others. there was virtually no mask wearing reported by farmworker family respondents, and only some use of masks reported by nonfarmworker respondents. household sizes reported in this study (median 5 for farmworker and 6 for nonfarmworker families) are considerably larger than the usa average of 2.6 people reported for 2018 [34] , potentially creating large social networks of contacts. many of the adult household members were reported to be working outside the home and working in situations where they had close contact with other workers. these situations, plus the sheer number of adults in the household (up to six in farmworker families and four in nonfarmworker families), allows for the spread of infection through these interconnected households [3] . mask use was reported to be common in the workplaces, though measures of the consistency or enforcement of mask use were not obtained. the respondents and their family members reported continuing to engage in social situations with large numbers in attendance. this occurred in both samples and was particularly common among the farmworker families. although masks appear to have been worn for church attendance, little mask wearing was reported for other types of social events. in total, these results indicate that, despite relatively high knowledge, strong perceptions of risk from covid-19, and claims of avoiding situations where contracting or spreading infection might be likely, many of the farmworker families included here do not practice safe physical distancing measures as recommended; and their use of masks appears to be confined to work settings. the situation for the nonfarmworker families appears to be somewhat better, with greater mask wearing reported, particularly in large social gatherings. however, the social contact is still at levels that facilitate covid-19 spread. the inconsistency between women in farmworker families seeing themselves as avoiding situations for infection and their actual practices may be due to their living situations and to cultural values. most live in rural environments and few women drive [35] , so they may perceive of themselves and their households as isolated from population centers. nonetheless, it is clear that interactions take place within and between households, which can exponentially raise the possibility of transmitting infection. this is in contrast to the nonfarmworker families who live in urban environments, many in multi-unit dwellings such as apartment buildings. they may correctly perceive less ability to socially isolate themselves and, so, give greater importance to personal hygiene measures to prevent infection. for these immigrant workers (from both farmworker and nonfarmworker families), living in close proximity to extended family members plus the cultural value of familismo [36] likely affect interpretation of public health recommendations to maintain physical distance. many immigrant workers settle in the us with extended family from their home communities-siblings, cousins, parents, aunts, and uncles. this can provide considerable social and material support while living in a new environment and working in low wage jobs; family and household boundaries are likely more fluid than they are for other ethnic groups [3, 9] . these relationships are supported and reinforced by familismo. this cultural construct includes strong identification with and loyalty to family, as well as respect for family members and placing family needs over one's own needs. time spent with one's immediate and extended family is valued. in such a context, wearing masks or refusing social interaction might be considered an affront. the result can be greater contacts and less physical distancing than public health recommendations intend, increasing the risk of coronavirus infection. while covid-19 is an emerging issue, findings from previous research with immigrant latinx populations support the findings in this study. for example, research with immigrant latinx women has produced results supporting the lower self-efficacy seen among the respondents from farmworker families. studies of hiv and cancer prevention behavior have found low self-efficacy in latinx farmworker women, which is sometimes amenable to change with intervention [37] , though not always when cultural norms constrain health-promoting behavior [38] . kilanowski [39] , in a study of farmworker child nutrition, found self-efficacy for health behavior change was inversely related to acculturation, suggesting that self-efficacy may fall with greater time in the usa. none of the families in the current study are newly arrived immigrants because of the larger study eligibility criteria. other research with farmworkers has shown that they have low levels of perceived susceptibility to other health threats, most notably pesticides [40, 41] . in these cases cultural values appear to promote these ideas of low susceptibility. the farmworker families included in this study are seasonal workers, meaning that they live in the area year round, and family members work seasonally in agriculture. they may not experience the extremely crowded barrack-style sleeping quarters, kitchens, and bathroom facilities of much of the grower-provided housing where migrant workers live [17] . however, these seasonal worker families do have crowded housing [15, 16] , and they face worksite hazards for infection in crowded transportation to the fields and while working in close quarters in some situations in the fields, as well as in greenhouses or packing facilities [4] . they also often work alongside migrant workers who live in crowded conditions. although the respondents indicate mask usage, it is difficult to know how sustained that can be, considering the high levels of heat and humidity these workers endure in the fields [37] . the contrast between what the respondents in this study know about covid-19 and their seemingly contradictory behavior can be viewed through the lens of structural vulnerability [26] . the farmworker families, as well as many of the nonfarmworker families, include those who have been deemed essential workers. these include those in farm work, in construction, in building maintenance, and in food retail. as essential workers, they need to work in order to receive income. their jobs do not provide the luxury of working from home. as immigrants, most are ineligible for government benefits provided as part of the cares safety net [8] . in the case of undocumented families, worry about the xenophobic climate [9] may affect decisions to work, to seek medical care, and to complain about the lack of personal protective equipment. in short, these workers are not putting themselves and their communities at risk because they are uninformed about covid-19. they know how dangerous it is, and, while cultural values and practices may lead to some excess exposure, they do know how to prevent covid-19. one of the strengths of this study was the concentration of data collection in a short time during which changes in national information about prevention and state regulations were relatively stable. by may, reports of emerging research had started to establish the importance of physical distancing and mask use (although publications did not appear until june [21] [22] [23] ), and the initial emphasis on hand hygiene and cleaning surfaces had been downplayed. within north carolina, all families in this study would have been subject to the same governmental orders. stay-at-home orders banning gatherings of >10 persons and closing schools, bars, gyms, playgrounds, and restaurants (except for take-out and delivery) were put in place in march. on 24 april, school closure was extended for the rest of the academic year. although restaurant closure was loosened on may 20 to 50% of capacity for indoor dining, most restaurants took longer to implement this and many still remained at take-out and delivery only well into the summer. gatherings were limited to 10 people on 27 march; although 25-person gatherings outside with social distancing were allowed on 20 may, indoor gatherings were kept at 10 with no special provisions for churches. this study did not collect data on information sources about covid-19 available to study participants. although both groups frequently get information from spanish language radio, the nonfarmworker families may have had greater access to public health signage and other local messages in an urban context than the farmworker families did in rural settings. other study limitations include the fact that behaviors were self-reported and not observed. the women interviewed also reported for others in the household. responses could not be anonymous because they were collected by interviewers that the women had known through participation in the larger study; this could have increased the social desirability in responses concerning behavior. small sample sizes prevent more detailed analyses of data. nevertheless, this study represents a unique opportunity to document the knowledge, perceptions, and behaviors of latinx immigrants in the usa during the early days of the covid-19 pandemic. in particular, farmworkers are often a hidden and difficult to reach population. this study demonstrates that even with a strong knowledge base, these farmworker families lack the self-efficacy to avoid the coronavirus and covid-19. while they appear to believe that they are following public health recommendations on physical distancing and wearing masks, detailed data on their social interactions and use of personal protective equipment show that this is not the case. a comparison group of urban-dwelling latinx immigrants had greater self-efficacy, which might have led to the greater use of masks as personal protection reported by respondents in these nonfarmworker families. the transmission of a highly infectious virus like the coronavirus is facilitated by close contact among individuals in a population. the large household sizes, particularly large numbers of adults working in industries deemed essential, and weak adherence to personal protective equipment such as masks make the immigrant latinx population at risk for high rates of infection. it is likely that simple public health messages encouraging physical distancing and mask wearing may not protect the population in the context of structural barriers such as crowded housing and work in essential industries, coupled with strong cultural values placed on support of large extended families. specific actions beyond what is currently being taken by public health authorities may help improve the health-related behavior reported here and curb the spread of infection in this population. developing and disseminating culturally sensitive education to help families understand the extent of their social contact and the dangers it poses is essential. using adult educational approaches [42, 43] that could include interactive exercises to demonstrate the potential spread of infection would likely be more effective than education based primarily on print materials in this low literacy population [44] . the covid-19 pandemic has ravaged urban populations around the world, with high population density facilitating the spread of the disease. while one might, therefore, expect urban and rural conditions in the us to be markedly different, the findings here suggest that this may not be the case for latinx workers in essential rural industries. living in large households and working in close contact with large groups of workers may negate the expected isolation of rural communities. unequally vulnerable: a food justice approach to racial disparities in covid-19 cases food system 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open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors appreciate the support and participation of their community partner, the nc farmworkers project, and of student action with farmworkers. they also appreciate the valuable contributions of our community field interviewers in carrying out participant recruitment and data collection. they especially thank the mothers who participated in this study. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. key: cord-324092-ertcvh8x authors: madani, azzeddine; boutebal, saad eddine; bryant, christopher robin title: the psychological impact of confinement linked to the coronavirus epidemic covid-19 in algeria date: 2020-05-21 journal: int j environ res public health doi: 10.3390/ijerph17103604 sha: doc_id: 324092 cord_uid: ertcvh8x the covid-19 pandemic continues to spread in countries around the world. the impact of this virus is very great on populations following the application of total and partial containment measures. our study aims to study the psychological impact of total and partial containment applied in algeria, on 23 march 2020, following the spread of the virus covid-19 and also studied the habits and behaviors of the algerian population during this new way of life and this through a cross-sectional survey launched after three days from the start of confinement to quickly assess the impacts over the period from 23 march to 12 april 2020, by an online questionnaire which allowed us to obtain 678 responses from internet users, who live in confinement in algeria. according to the gender variable, our sample includes 405 men, or 59.7%, and 273 women, representing 40.3%. the results of the statistical analysis carried out using spss version 22.0 software showed that 50.3% of the respondents were in an anxious situation during these first three weeks of confinement. in addition, 48.2% feels stressed, 46.6% of the respondents confirmed to be feeling in a bad mood, and 47.4% do not stop thinking throughout the day about this epidemic and how to protect themselves. in addition, the study shows that 87.9% of the respondents in algeria found it difficult to follow the confinement instructions. a significant change in the habits of the population was noted especially for the time of going to bed, the time of waking up, and the use of the internet as well as the hours devoted to daily reading. the coronavirus pandemic covid-19 has continued to spread to countries around the world since its first appearance in wuhan, china, on 31 december 2019 [1] and the declaration of the world health organization (who), on 26 january 2020, on the high risk of the epidemic in china and worldwide [2] . the number of people tested positive continues to increase, and for 13 april 2020, it had reached 1,773,084 in several countries, which also recorded 111,652 deaths [3] . the daily increase in deaths and confirmed cases has prompted countries to take social distancing measures and other actions related to general and partial containment that are difficult for some countries to enforce. in china, covid-19 has spread rapidly since its first appearance in wuhan and has proven to be very dangerous since some affected patients do not have fever and other symptoms which complicate the diagnosis [4] . the report of the national health commission of china indicated on 27 january 2020 that people carrying the virus can infect others by respiratory droplets as well as by direct contact [2] . the severity of the disease is summed up in the ability of the virus to spread and the difficulties in identifying those affected to care for them and preventing them from infecting other people [5] . based on these conclusions, the chinese government reacted quickly by quarantining a population estimated at question of studying the relationship between socio-demographic variables and the psychological impact of containment during the covid-19 epidemic in algeria. this study will allow algerian health authorities and possibly elsewhere in the countries of the world to better understand the situation, and this in order to take the necessary measures to assist the population during this period of containment which is likely to lengthen as well after this epidemic. it is signified by containment during coronavirus covid-19 that the containment procedures were approved by the algerian state from 23 march 2020 to deal with this epidemic. the psychological impact signifies the various psychological effects of containment in algeria on the individual, measured in the current study by the sum of the responses to the questionnaire applied in the current study to a sample of respondents. daily habits represent the totality of practices and behaviors that the individual frequently embodies in his or her daily life such as: washing hands, going to bed and waking up, watching television, and using the internet. the present study is limited by its subject which studied the psychological impact of containment during the coronavirus covid-19 in algeria, by applying for this purpose a questionnaire to measure specific psychological factors; moreover, this study is limited by the number of respondents to the questionnaire, and the short duration of the study from 23 march to 12 april 2020, imposed by the exceptional nature of this confinement and this epidemic. 29 230 0 17 27 march 42 409 1 26 30 march 73 584 4 35 3 april 185 1171 22 105 4 april 80 1251 25 130 5 april 69 1320 22 152 6 april 103 1423 21 173 7 april 45 1468 20 193 8 april 104 1572 12 205 9 april 94 1666 30 235 10 april 95 1761 21 256 11 april 64 1825 19 275 12 april 89 1914 18 293 13 april 69 1983 20 313 source: the authors based on the data [15]. in the current study, we used the design of the descriptive survey by an online questionnaire, with the snowball sample 678 due to the conditions of the home confinement accompanying the spread of the coronavirus pandemic; thus, the electronic questionnaire includes items with meanings about the psychological effects of the coronavirus, and, after data collection, these were statistically analyzed by the spss program version 22 (spss inc., chicago, il, usa). then, the stage of scientific description came, which is related to the significance of the indicators of the questionnaire items. therefore, the data were collected using an online questionnaire from different regions of algeria. knowing that it was not based on random selection and the study population did not reflect the reality of the general population, we used the statistical approach to describe the results and their analysis was linked through the qualitative indicators that came along with the meanings of the questionnaire items. we adopted a cross-sectional survey to assess the immediate psychological impact on the public during the covid-19 epidemic using an online questionnaire. with a wide dissemination of the questionnaire with the help of university students, our sampling strategy based on the snowball method is suitable in exceptional cases where it is difficult to communicate with the population to study an urgent health problem related to containment. this method allowed us to obtain 678 responses from internet users, who are living through this first confinement of the coronavirus epidemic covid-19 in algeria. according to the gender variable, our sample includes 405 men, or 59.7%, and 273 women, representing 40.3% of the total sample. for the age variable, 423 of the respondents were aged between 14 and 34 years old or 62.4%, 239 of the respondents were aged between 35 and 54 years old and 35.2%, and 16 of the respondents were aged between 55 and 74 years old or 2.4% of the total number of respondents in the sample. therefore, we see in the composition of this sample the representation of practically all the age groups of the society concerned by this research issue. the psychological impact of covid-19 was measured using a global questionnaire measuring the impact of confinement during covid-19 coronavirus. this questionnaire of 29 items is composed of three subscales: social impact, psychological impact, and impact on mobility. the impact scale of the coronavirus covid-19 in algeria was designed on the standards of the likert scale which includes five response options. this means that the average score for the questionnaire items is 3, so a total score greater than three indicates a negative impact on this variable, and when it is less than 3, this means that there is no negative impact within the meaning of this element. the questionnaire includes in its entirety questions which are concerned with the following sections: impacts on mobility q23-29 in this study, we focused on the psychological impacts as the only component (psychological impacts subscale). the questionnaire was designed online to facilitate its dissemination and to obtain respondents' answers immediately. we focused on the current study on psychological effects and daily habits only, and therefore we clarify the two concepts in that psychological effects designate the emotional changes occurring in the behavior of the individual during interaction with those around him, as measured by individual self-assessment through the items of the questionnaire according to the measurement scale, where this indicates, in quantitative terms, the total score obtained by the respondent to the questionnaire in the dimension related to psychological effects. the daily social habits are the behaviors which are linked to the process of the daily interactions of the individual in various social situations. this means in our study that the habits linked to the interaction with the coronavirus, such as sleep patterns and hand washing, were measured with direct questions. the psychological impact section contains 10 items; this means that the total score varies from 50 to 10 with a theoretical average of 30, and it also means that the score which exceeds 30 reflects a negative effect of the psychological factor, and a lower score in relation to 30 expresses the absence of a negative effect of this factor. we used the alpha-cronbach coefficient to calculate the reliability on 253 answers, and the results gave a coefficient of 0.799 for the 12 questions related to social impacts, so it is a value which indicates the reliability in the tool of this study. the statistical results also show that the alpha-cronbach coefficient, in the 10 questions on psychological impacts, is equal to 0.782, which indicates the reliability of the study tool. for the six questions concerning the impacts on the mobility of the population during this period of total and partial confinement, the statistical results show that the coefficient alpha-cronbach is equal to 0.613, a value indicating the reliability of the tool of study. for the entire questionnaire, with its 29 questions on the impacts during the first total and partial containment of the coronavirus epidemic covid-19, the statistical results show that the alpha-cronbach coefficient is equal to 0.831; this value indicates the reliability of the tool used. the signified validity of the capacity of the questionnaire to measure what was ready to be actually measured involved the social, psychological, and mobility effects of total and partial confinement on citizens in algeria. for this, we used the internal validity method of the questionnaire (for 253 individuals), which indicates the correlation between the items of the questionnaire and its overall score. the results are presented in table 2 . from this table, it is clear that all the pearson correlation coefficients between the items and the total score of the questionnaire are positive and statistically significant at the level of 0.05 and 0.01. this result means that the questionnaire has a considerable degree of internal validity. a statistical analysis was performed using spss version 22.0 software. therefore, descriptive statistics were calculated for socio-demographic variables and psychological impact factors. the pearson correlation coefficient was also used to measure the correlation between various socio-demographic variables and the psychological impact of coronavirus containment covid-19. in addition, the multiple regression analysis method was used to measure the effect of socio-demographic variables on the psychological effects of confinement, and the t-test was also used to study differences in the psychological impact of coronavirus confinement between men and women. the results obtained show the impacts of confinement during the first total and partial confinement operations of the coronavirus epidemic covid-19 in algeria on certain habits of the daily life of citizens, where we note a high rate of hand washing during the day, since 51.77% of the study sample reported washing their hands up to 10 times a day, and 36.73% of the population washed their hands between 10 and 20 times a day. on the other hand, the rest of the sample 11.5% paid special and somewhat exaggerated attention to hand washing between 20 and 40 times a day (see table 3 ). we also note that 83.63% of those questioned confirm that they sleep late between midnight and 3:00 a.m., and that 12.09% of people go to bed in the regular period between 8:00 p.m. and 11:00 p.m., while the remaining 4.28% would sleep between 4:00 a.m. and 7:00 a.m. the next day. thus, we can deduce the considerable impact of the first period of total and partial confinement following the coronavirus epidemic covid-19, on the hour of going to sleep, considered to be very late. regarding waking up time, the survey results show that 45.72% of the study sample confirmed that they woke up between 10:00 a.m. and 12:00 p.m., and that 38.5% said they woke up between 7:00 a.m. and 9:00 a.m., while 3.83% of the respondents woke up between 1:00 p.m. and 3:00 p.m. for the time spent watching tv, the survey results showed that 45.28% of respondents spend up to 5 h watching tv every day, and 33.18% of citizens confirmed that they watch tv for about 10 h every day. on the other hand, we find that 21.54% of the respondents watch television programs daily for around 15 h. knowing that television is an important means of passing time during the period of the coronavirus pandemic covid-19 through the many programs and tv channels, the survey results shown in table 2 also show that 36.72% of respondents, during this period of total and partial containment linked to the covid-19 pandemic, say that they do not read books, and 34.47% devote one hour a day to reading books, and 13.87% of the respondents read books for 2 h a day. on the other hand, 14.74% of the population prefer to read between 3 and more than 5 h. what is noticed here is poor reading, but perhaps reading books is compensated by electronic reading on smart-phones and computers, and this is shown later. the respondents confirmed that they use the internet for several hours a day, so 37.9% of them spend between 10 and 15 h a day, and 33.93% spend between 5 and 10 h maximum a day surfing the internet. as for the remaining proportion, it uses less internet, 0 to 5 h a day. indeed, there is a strong dependence on the internet and related devices that allow time to pass during the period of the pandemic. finally, we find that 51.92% of respondents are interested in the content of social networks (facebook and twitter), and that of youtube, while 29.94% prefer reading including scientific research by electronic means. in addition, 18.4% of respondents prefer to follow new local and international news related to covid-19 and other areas on the internet (see table 3 ). the table 4 above shows the correlation matrix between certain study variables; we note the presence of a statistically significant negative correlation between the variables age and waking time, which means that young people get up later by comparison with the people in the older age categories (r = −0.216 **); as shown in the table, there is a statistically significant positive correlation between the variable psychological impacts and waking time (r = 0.145 ** ), which means that the increase in sleep time and the delay in getting up are linked to the increase in the level of psychological effects during the first confinement of the coronavirus epidemic covid-19. the results in table 5 above show the relative levels and weights of the psychological impact factors of the coronavirus covid-19 in algeria during the first total and partial confinement, knowing that the value 3 signifies the theoretical average. according to the respondents, we find that the item related to the difficulty of voluntary engagement in home confinement is ranked first in the psychological factors, with a mean of 4.11, and this signifies a lack of social consciousness and previous experiences in behavior during an epidemic. the rapid spread of the epidemic may not have left the time necessary for better awareness among citizens of the seriousness of the coronavirus covid-19 and the usefulness of home confinement as the sole means of current prevention. in second position for the psychological factors, we find anxiety with a mean of 3.22 where the respondents confirmed their feelings of anxiety during the confinement period, perhaps because there are difficulties in accepting confinement itself, or difficulty organizing family life inside the house. in addition, anxiety is strongly present in the event of an epidemic among fragile personalities and contributes to the deterioration of the psychological state of the individual, which affects his or her daily interactions and even his or her physical functions. the state of psychological stress is the third psychological factor affecting individuals during the coronavirus pandemic covid-19 in algeria during this period from 23 march to 12 april 2020, and this is confirmed by the respondents with a mean of 3.18. admittedly, the spread of the epidemic and the obligation of confinement at home on the one hand, and the difficulty of coping with it, on the other hand, put the individual in a state of psychological stress, especially with the transformation of daily life into a boring daily routine. the fourth psychological factor (see table 5 ) affecting individuals during confinement is a mood fluctuation with a mean of 3.17, which reflects the entry of the individual into a state of being emotionally unstable, and which negatively affects him or her and the family environment, not only because of the feeling of limited living space, but also because of a feeling of fear of the pandemic and its various repercussions. the fifth psychological factor represents dependence on thinking throughout the day about the subject of the epidemic, and this is confirmed by the respondents with a mean of 3.11. this indicates an addiction of thinking about the coronavirus covid-19, its dangers, and its consequences in an exaggerated way, which leads to psychological, moral, and physical fatigue, and especially in relation to the monitoring of new information which is sometimes incorrect about coronavirus covid-19. regarding the rest of the items and psychological factors, the current study did not show any negative effect on the sample of our research, since its arithmetic mean is lower than the theoretical mean 3. according to table 6 , in the multiple regression analysis, it is shown that the variables of sex, age, and family situation were significantly associated (ar 2 = 0.019) with the scores of the psychological impact subscale. through this table, we find that gender was significantly associated with psychology impact scores (b = 0.112, 95% ci). in addition, age was significantly associated with lower psychology impact scores (b = −0.081, 95% ci). in addition, the family situation was significantly associated with psychology impact scores (b = 0.079, 95% ci). table 7 below presents the study of the differences in psychological impact between men and women during the first confinement of the coronavirus epidemic covid-19 in algeria; the results show the existence of statistically significant differences in favor of women (m = 31.35) compared to men (m = 29.63) in the psychological impact scale. this result means that the female population is more affected by coronavirus covid-19 than men, and, to determine the details, we return to the differences in the statistically significant items. indeed, women were more delusional than men, more eager to wash their hands too much, presenting more emotional stress, fear and an unstable mood, and they were more unreal optimists that they would never be infected by the coronavirus covid-19. the results were discussed according to the structure of presenting the data by linking them to previous studies according to what we had, especially since the problem is recent. the results obtained to see the changes in behavior and habits as well as the psychological impacts on the algerian population during the first three weeks (from 23 march to 12 april 2020) of the total and partial confinement applied by the algerian government show that the difficulty of voluntary engagement in home confinement is ranked first in terms of psychological factors, especially since 87.9% of the respondents have difficulty applying the confinement instructions. our field observations confirm that some people often leave their homes and do not follow or have difficulty applying the instructions for containment. the lack of awareness through the dissemination of specialized information affects the population, which remains worried in the absence of reliable information, while previous research has revealed the presence of a wide range of psychosocial impacts on people at the individual, community, and international levels during the spread of the epidemic [6] . it is also possible that the rapid spread of the epidemic has not left the time necessary for better awareness among citizens of the usefulness of levels of home confinement as the only means of prevention. among other things, 50.3% of respondents indicated that they are in an anxious situation for various reasons related to a new organization of daily life, in addition to the measure of confinement or quarantine that shows that the authorities consider the serious situation and its risk of worsening [8] , and this worries the population; and the rapid increase in anxiety in people is linked to the lack of information on the disease and the preventive measures that produce a blockage in daily life [14] . it is also found that 48.2% of respondents experience stress during the period of total and partial containment, and certainly people are well informed that covid-19 threatens the lives of people and that there is no treatment in this current period, which has triggered a wide variety of psychological problems [16] in the population. in addition, there is the transformation of everyday life into very limited actions which in time becomes very boring. in addition, 46.6% of the surveyed population confirmed feeling in a bad mood during this first period of confinement, which means that the individual is in an unstable emotional state which negatively affects him or her as well as the family environment. in addition, 47.4% of respondents continue to reflect throughout the day on this epidemic and on the ways to protect themselves, and this dependence in an exaggerated way leads to psychological, moral, and physical fatigue. the chinese government has improved public awareness of prevention measures, and psychologists and psychiatrists use the internet and social media to share strategies for managing psychological stress [17] . the results of this survey showed that women are the most affected compared to men by the impacts of confinement linked to covid-19. therefore, women prefer to wash their hands several times, are more stressed and manifest more fear and instability of mood while they are also more unreal optimists that they would never be infected by the coronavirus covid-19. the change in population behavior during confinement also affects psychological and physical health, so, during this 3-week period 51.77% of respondents indicated that they wash their hands up to 10 times a day, and 36.73% do it between 10 and 20 times a day. on the other hand, 11.5% of the respondents exaggerate in terms of hand washing and do it between 20 and 40 times a day; this category of people either move frequently outside, in regions of partial containment and know perfectly the hygienic rules which pushes them to react like this. either he or she lives in the region where the confinement is total which forces them, for fear, to wash his or her hands regularly even at home. note that 83.63% of those questioned sleep late between midnight and 3:00 a.m. and that only 12.09% go to bed in normal h between 8:00 p.m. and 11:00 p.m. on the other hand, 4.28% of respondents say that they will go to bed between 4:00 a.m. and 7:00 a.m., which shows that confinement has changed their habits, since schools are closed, and life is slowing down. in this same context, 45.72% of respondents woke up in the morning between 10:00 a.m. and noon and 38.5% indicated that they woke up between 7:00 a.m. and 9:00 a.m. 3.83% of respondents wake up between 1:00 p.m. and 3:00 p.m.; this category represents that of young people who stay connected to the internet for a long time. these changes in the time to go to bed and wake up are a sign of an increase in the level of psychological effects during this first confinement. in addition, there are many hours spent watching television since 21.54% of respondents say they spend 10 to 15 h watching television programs daily, and 33.18% spend between 5 to 10 h watching television daily. the population is also trying to follow the information associated with the epidemic covid-19 on the various international tv channels since the gravity of the epidemic has not been widely broadcast or recognized, which has delayed protection measures and also containment [7] , which pushes citizens to search for information themselves. we also find that 45.28% stay up to 5 h in front of the television, which becomes an essential means to follow the new information on the epidemic and the measures taken by many countries which continue to make efforts to minimize the contacts between humans and guarantee good protection for the population [18] , especially since it is always difficult to fight against covid-19 of unknown origin and mysterious biological characteristics with a long period of incubation [19] . reading books, during the period of total and partial confinement in algeria, does not interest 36.72% of respondents, while 34.47% devote one hour per day to reading and 14.74% of the surveyed population prefer to read books for between 3 h and more than 5 h a day. confined people do not pay much attention to reading since it is certainly linked to reading on digital media via the internet for many hours. thus, 37.9% of respondents say that they devote to the internet between 10 and 15 h per day, and 33.93% remain connected to the internet between 5 and 10 h per day, which constitutes a strong dependence on the internet and its services during the containment period. social networks (facebook, twitter, and youtube) attract the attention of 51.92% of respondents. on the other hand, 29.94% prefer reading and scientific research on the internet; 18.4% of the surveyed population opt to follow new local, national and international information related to covid-19 and other subjects, since it would not be surprising that one day, in the near future, broader containment measures will be required to protect against this pandemic [20] . for this purpose, it is necessary to use the different means of information and communication so that psychologists increasingly approach the confined population in need of psychological help. the dissemination of information related to covid-19 must be carried out with complete transparency and by specialized scientific journalists capable of disseminating most of the information with great precision. identifying confined people through a platform and remote assistance will make it possible to quickly get closer to people in urgent need of psychological support. the covid-19 pandemic continues to spread in countries all over the world. the number of people affected and deaths is increasing every day. the impacts of this are very big on the populations following the application of total and partial containment measures. our study evaluated the psychological impact of total and partial confinement applied in algeria, on 23 march 2020, following the spread of the virus covid-19 and we also studied the habits and behaviors of the algerian population during this new mode of life, and this through an investigation launched after three days of the start of confinement to quickly assess the impacts over the period from 23 march to 12 april 2020, by an online questionnaire. the results showed that 50.3% of respondents were in an anxious state during these first three weeks of confinement. in addition, 48.2% feel stressed, 46.6% of the respondents confirmed feeling in a bad mood, and 47.4 % do not stop thinking throughout the day about this epidemic and how to protect themselves. in addition, the study shows that 87.9% of respondents in algeria found it difficult to follow the instructions for full and partial containment. a significant change in the habits of the confined population, especially about going to bed and waking up time, is observed, which shows the increase in the level of psychological effects. note also that changes in internet use and daily reading are seen in the results of this study. among others, the limitations of this study are linked to the sampling strategy, the number of respondents, and the short duration of the study. thus, this will not make it possible to generalize these results over the entire population. however, these results can help the health authorities and other services concerned by the epidemic covid-19 in the procedures for taking charge of the population during this period of confinement, which is likely to lengthen further, knowing that the psychological aspect, which influences behavior, is very important to fight against the coronavirus. it is also necessary to regularly monitor the change in daily habits since it indicates the level of awareness of citizens about health protection. in this type of situation, psychological support must be provided remotely to families and individuals to alleviate their suffering and encourage them to stay at home during the confinement period and to respect the habits of prevention against the coronavirus. the current study can be developed to study the effect of confinement on personality characteristics, quality of life, and link them to behavioral habits to be more preventive. prediction of epidemic spread of the 2019 novel coronavirus driven by spring festival transportation in china: a population-based study clinical characteristics of coronavirus disease 2019 in china a novel coronavirus emerging in china-key questions for impact assessment immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease covid-19 epidemic among the general population in china world health organization declares global emergency: a review of the 2019 novel coronavirus covid-19 the psychological effects of quarantining a city vitesse de propagation du covid-19, l'algérie sera-t-elle comme les pays les plus touchés de l'europe? available online suivi quotidien du coronavirus covid-19 lundi 13 avril 2020 covid-19 chroniques d'un géographe de la santé covid-19-navigating the uncharted psychosocial effects of an ebola outbreak at individual, community and international levels psychological effects of the coronavirus disease-2019 pandemic a nationwide survey of psychological distress among chinese people in the covid-19 epidemic: implications and policy recommendations 2019-ncov epidemic: address mental health care to empower society covid-19: a promising cure for the global panic insight into 2019 novel coronavirus-an updated interim review and lessons from sars-cov and mers-cov what further should be done to control covid-19 outbreaks in addition to cases of isolation and contact tracing measures the authors declare no conflict of interest. key: cord-306690-s5mxes4r authors: shangguan, ziheng; wang, mark yaolin; sun, wen title: what caused the outbreak of covid-19 in china: from the perspective of crisis management date: 2020-05-08 journal: int j environ res public health doi: 10.3390/ijerph17093279 sha: doc_id: 306690 cord_uid: s5mxes4r since the first known case of a covid-19 infected patient in wuhan, china on 8 december 2019, covid-19 has spread to more than 200 countries, causing a worldwide public health crisis. the existing literature fails to examine what caused this sudden outbreak from a crisis management perspective. this article attempts to fill this research gap through analysis of big data, officially released information and other social media sources to understand the root cause of the crisis as it relates to china’s current management system and public health policy. the article draws the following conclusions: firstly, strict government control over information was the main reason for the early silencing of media announcements, which directly caused most people to be unprepared and unaware of covid-19. secondly, a choice between addressing a virus with an unknown magnitude and nature, and mitigating known public panic during a politically and culturally sensitive time, lead to falsehood and concealment. thirdly, the weak autonomous management power of local public health management departments is not conducive for providing a timely response to the crisis. finally, the privatization of many state-owned hospitals led to the unavailability of public health medical resources to serve affected patients in the wuhan and hubei province. this article suggests that china should adopt a singaporean-style public health crisis information management system to ensure information disclosure and information symmetry and should use it to monitor public health crises in real time. in addition, the central government should adopt the territorial administration model of a public health crisis and increase investment in public health in china. since the first known case of a covid-19 infected patient in wuhan, hubei province, china on 8 december 2019 [1] , covid-19 has spread to more than 200 countries and infected over three million people worldwide (as of 28 april 2020), causing a worldwide public health crisis. however, the covid-19 pandemic has not only caused an unprecedented global health crisis, but has also triggered a worldwide economic downturn-"2020 is on track to witness the deepest global recession on a scale not seen since world war ii" [2] . one of the major reasons for the current global public health crisis is the failure in virus control during its early stages in wuhan and the remaining areas of hubei province. covid-19 can result in infectious diseases of the respiratory tract which is similar to sars [3] , but is spreading much faster and wider than sars. sars broke out in guangdong province, china on november 16 2002 , and spread to 24 of a total of 34 provinces, municipalities and autonomous regions in china in six months [4] , while covid-19 spread from a single city to the entire country (all 34 provinces, municipalities and autonomous regions) in just 54 days. from the typology of crises proposed by gundel [5] , it is easy to attribute the public health crisis caused by covid-19 to an unexpected crisis, which means the crisis is hard to predict but easy to influence. however, china failed to influence the rapid spread of covid-19 even though it had gained valuable experience in dealing with a public health crisis after sars and later established a disease control and prevention system led by the center for disease control & prevention (cdcp) [6] . this is a question worthy of reflection. the existing literature on covid-19 focuses on pathological characteristics of patients [7, 8] , gene sequencing of covid-19 [9, 10] , demographic features of the patients and fatality rate [11] [12] [13] . such research is largely based on clinical diagnosis, general epidemiological research, response tactics (isolation), social distancing and community containment. what is missing is the mismanagement factors contributing to the sheer speed of spatial expansion and dramatic increase in infected people. this article attempts to fill this research gap through analysis of big data, officially released information and other social media sources to understand the root cause of the crisis from the aspects of china's current management system and public health policy. to do so, this paper draws on structuralinstitutional perspectives to examine the coordination structure and mechanisms in the covid-19 crisis management system. crisis management involves multiple disciplines [14] including psychology, sociology, political science and management science [15] . the analytical methods of systemic approaches [16] and resilience engineering [17, 18] are usually adopted in crisis management. rasmussen adopted systemic approaches to build a crisis management system of socio-technical which is divided into three levels from top to bottom, namely: government, regulators and associations and company. they also explained the structure, goals, constraints, pressures and operating limits of the system [19] . based on resilience engineering, hollnagel et al. pointed out that a system that can resist a crisis requires four capabilities: (1) its ability to anticipate the occurrence of a perturbation; (2) its ability to monitor its operating condition to maintain control of its operations (during the perturbation); (3) its ability to respond when the disturbance is there; (4) its ability to learn from the occurrence of a perturbation [20] . thus, it can be seen that crisis management involves multiple subjects and they work together to prepare for, handle and recover from the crisis. in public health crisis management, five factors are usually considered [21] [22] [23] : (1) information disclosure or control; (2) assessment of dangers and threats; (3) establishment of crisis information communication channels and health education platforms; (4) the making of and implementation of strategic crisis response plans; (5) overall mobilization of critical resources. the first factor relates to crisis information disclosure and control, which is a choice for the authority to take. such a choice is viewed as having a direct impact on people's emotional reactions towards the crisis and thus is a foundation of crisis management. when an unknown crisis suddenly breaks out, people display negative psychological characteristics such as high anxiety, tension, depression, hostility, guilt and shame [24] . if these negative emotions are not well controlled, it will greatly hinder the effective implementation of crisis management [25] . rosenthal pointed out that the government usually has two choices in the management of people's emotions: controlling information and disclosing information. controlling information requires minimizing external participation, media attention, and public initiatives. when disclosing information, the government takes the opposite position and actively encourages the mobilization of various forces. information disclosure has obvious advantages, but the reality is that some governments take an information control approach to deal with a crisis [26] . perry's work shows that when a crisis cannot be quelled in the short term, controlling information normally causes even greater panic [27] . the second factor relates to scientific and effective assessment of the crisis which is performed for the later formulation of intervention policies [28, 29] . such crisis assessment should be based on accurate information because information deviation will directly lead to the expansion of the crisis [30] . therefore, in the early stages of the crisis, investigations should be carried out quickly to collect information and carefully verify the accuracy of all information. meanwhile, real-time monitoring of the crisis should be conducted to ensure the timeliness of information [31] . for a general epidemic, after collecting a large amount of data, experts and scholars will assess its infectivity, susceptible population and mortality [1] . some scholars also use mathematical models to estimate the number of people infected by the epidemic [32] . covid-19 has also been studied in mathematical modelling [33] . with the development of science and technology, the methods of crisis assessment have thus become diversified [21] . the third factor is establishment of crisis information communication channels and health education platforms, which is an important communication component in crisis management. their functions include the release of risk information, evacuation notices, risk prevention measures and available assistance by public institutions [34] . because different types of crises present different forms of threat, the emphasis on communication and education is different [35] . in a public health crisis, relevant agencies need to provide the public with information on the source of the disease, preventative measures, symptoms of the disease, treatment methods and routes of transmission in a timely manner [36] . through communication channels and health education platforms, the public can respond to the crisis autonomously, thereby helping the government control the crisis [37] . the fourth factor is the making and implementation of strategic crisis response plans, and this factor is crucial for the government [38] . theoretically, government departments can effectively curb the crisis by formulating corresponding policies based on scientific crisis assessment [39] , but for the government, the key of crisis control in crisis management is to gain time [40] . rosenthal et al. believe that the longer it takes for government decision-making to take place, the more political criticism and rumors may be induced [41] , and these factors often cause the collapse of the response policies [32] . therefore, government departments must intervene immediately when the crisis comes to light. delaying every second will negatively impact the government; however, it must take sufficient time to formulate efficient and reasonable policies. this presents a dilemma for the government. the fifth factor is overall mobilization of critical resources. during the bird flu and sars in china, resource allocation was far beyond the capacity of local resource management, causing shortages of medical substances and food supply [42] . timely and effective allocation and transportation of emergency resources can reduce losses caused by public crises [43] . as time, quantity and quality of the resources are the key limitation factors, emergency managers do have to find an optimal schedule for assigning resources to the affected areas [44] . a reasonable public health crisis response system should guarantee a certain reserve of medical space, medical materials and medical staff, which is also a prerequisite for resource mobilization [45] . based on the five factors of crisis management highlighted through a literature review, this paper intends to explain the problems in china's handling of the public health crisis caused by covid-19 and discusses the causes of such problems. all research data for this paper comes from several sources, including chinese government official reports and news, big data statistics, official statistical data and international journals and the media. (1) chinese government official reports and news chinese government official reports and news were mainly sourced from caijing (http://www. caixin.com/2020-01-20/101506242.html) and nanfang metropolis daily (https://m.mp.oeeee.com/h5/ pages/v20/ncovtimeline/?from = groupmessage&isappinstalled = 0), which are used to obtain the latest information and reports on covid-19. (2) big data statistics the big data statistics platform uses baidu (similar to google) can provide a media index (http://index.baidu.com/v2/index.html#/) of certain keywords reported by the media and emigration index (https://qianxi.baidu.com/). the media index reflects the number of keywords related to the news reported by the media and included in the baidu news channel. the keywords searched in this paper were "wuhan pneumonia" and "novel coronavirus," because the chinese media universally reported covid-19 using these words as the key title words. the emigration index reflects the scale of emigration and is the normalized value. in this paper, we searched the emigration index of wuhan and compared this index against the 25 days pre-chinese new year in 2020 and 2019: two periods of data comparison-1 january 2020 to 25 january 2020 (chinese new year was 25 january 2020) and 12 january 2019 to 5 february 2019-when there was no covid-19 (chinese new year for 2019 was 5 february 2019). our official statistical data was collected from relevant chinese departments, international journals and the media. china's official sources come from the official website of national cdcp (http://www.nhc.gov.cn/), the national health commission (hc, http://www.nhc.gov.cn/), and the national bureau of statistics (bs, http://www.stats.gov.cn/). our international journal references mainly cite publications by the lancet, which covers the largest volume of covid-19 papers. data from these departments and journal articles were used to obtain the number of people infected with covid-19, infection characteristics, control information and public health expenditure. tracing covid-19 development in china, we can see that 25 january 2020 is a dividing line. our study concentrates our research attention to the period from 8 december 2019 (the first known case) to 25 january 2020 when the central government commenced its tough lockdown policy. this was a stage of confusion and chaos. initially it was called wuhan pneumonia ("wuhan fei yan" in chinese pinyin). on the morning of 26 december 2019, mr. jixian zhang, the director of respiratory medicine of hubei provincial hospital of integrated chinese and western medicine (wuhan) found four abnormal cases of pneumonia and he reported this to wuhan cdcp the next day. on 28 and 29 december 2019, the outpatient department of that hospital admitted another three patients from the wuhan south china seafood market. the symptoms of these seven patients were similar. on 5 january 2020, the wuhan hc confirmed that there were 59 patients with an unexplained pneumonia diagnosed in wuhan. on 9 january 2020, chinese authorities officially confirmed the novel coronavirus as the pathogen of "wuhan pneumonia." since then, chinese media has described "wuhan pneumonia" as a new coronavirus (later named covid-19 by the world health organization). on 11 january 2020, the wuhan hc advised that there were 41 people infected with covid-19 and the number of infected people increased by 4, 17, and 59 on 16, 17 and 18 january, respectively. since 19 january 2020, new covid-19 infections occurred in other provinces, municipalities and autonomous regions in china. by then, a large-scale outbreak of covid-19 occurred in china. on 23 january 2020, the wuhan municipal government suspended city buses, subways, ferries, long-distance passenger transportation, airports and train stations in the city, prohibiting citizens from leaving wuhan. with the rapid spread of the virus in china, every level of government successively initiated first-level responses to major public health emergencies (the highest level of public health incident response) on 23-25 january 2020. on 25 january 2020, china officially entered the national epidemic control stage. thus, the problems in crisis management for china mainly occurred prior to 25 january 2020. this paper reports our key findings within the following five factors. research concludes that information control can temporarily prevent the spread of rumors in the crisis and eliminate the fear of the public [25] . however, the public experience greater fear if the crisis erupts in a large scale, so this is generally not advocated in crisis management [46] . the chinese case confirms that information control deprives people of their ability to prevent and resist crises. in fact, in the early stages of covid-19, the chinese government adopted information blockades and controls to prevent public panic, which resulted in most people being unprepared for covid-19. we searched baidu for the keywords "wuhan pneumonia" and there was no single media report on "wuhan pneumonia" prior to 31 december 2019 ( figure 1 ). there were very few reports during the period 1 january 2020 to 19 january 2020. our search of the media keyword "novel coronavirus" found no single report on the novel coronavirus prior to 8 january 2020. 20 and 21 january 2020 witnessed a large search for "wuhan pneumonia," which was replaced by "novel coronavirus" after 23 january 2020. in summary, the chinese government imposed a strict media blockade on the report of covid-19 before 31 december 2019 and controlled it from 1 january 2020 to 19 january 2020. it was not until 20 january 2020 that the chinese media began to cover it extensively. research concludes that information control can temporarily prevent the spread of rumors in the crisis and eliminate the fear of the public [25] . however, the public experience greater fear if the crisis erupts in a large scale, so this is generally not advocated in crisis management [46] . the chinese case confirms that information control deprives people of their ability to prevent and resist crises. in fact, in the early stages of covid-19, the chinese government adopted information blockades and controls to prevent public panic, which resulted in most people being unprepared for covid-19. we searched baidu for the keywords "wuhan pneumonia" and there was no single media report on "wuhan pneumonia" prior to 31 december 2019 ( figure 1 ). there were very few reports during the period 1 january 2020 to 19 january 2020. our search of the media keyword "novel coronavirus" found no single report on the novel coronavirus prior to 8 january 2020. 20 and 21 january 2020 witnessed a large search for "wuhan pneumonia," which was replaced by "novel coronavirus" after 23 january 2020. in summary, the chinese government imposed a strict media blockade on the report of covid-19 before 31 december 2019 and controlled it from 1 january 2020 to 19 january 2020. it was not until 20 january 2020 that the chinese media began to cover it extensively. due to the media blockade and control of information about covid-19, the baibuting community in wuhan held a banquet with more than 40,000 families on 18 january 2020, which was approved to be the single most serious infectious event in wuhan. knowing nothing about covid-19, people in wuhan still visited population-intensive places such as shopping malls, supermarkets and entertainment places in large numbers until 20 january 2020. this accelerated the rapid spread of covid-19. a few medical workers did try to warn of the outbreak, but all were silenced, including the famous "coronavirus whistleblower" dr li wenliang, who tried to warn his medical university classmates in his wechat circle of the outbreak, but was accused of spreading fake information by local police [47] , although afterwards, the chinese government acknowledged dr li 's contribution and recognised him as a martyr. in summary, the control of information and media silence directly resulted in most people being unprepared during the covid-19 outbreak. in a public health crisis, timely and effective access to information is critical. however, the hc in each province, municipality and autonomous region had concealed the epidemic in the early due to the media blockade and control of information about covid-19, the baibuting community in wuhan held a banquet with more than 40,000 families on 18 january 2020, which was approved to be the single most serious infectious event in wuhan. knowing nothing about covid-19, people in wuhan still visited population-intensive places such as shopping malls, supermarkets and entertainment places in large numbers until 20 january 2020. this accelerated the rapid spread of covid-19. a few medical workers did try to warn of the outbreak, but all were silenced, including the famous "coronavirus whistleblower" dr li wenliang, who tried to warn his medical university classmates in his wechat circle of the outbreak, but was accused of spreading fake information by local police [47] , although afterwards, the chinese government acknowledged dr li 's contribution and recognised him as a martyr. in summary, the control of information and media silence directly resulted in most people being unprepared during the covid-19 outbreak. in a public health crisis, timely and effective access to information is critical. however, the hc in each province, municipality and autonomous region had concealed the epidemic in the early stages of covid-19, which caused the national hc to make an incorrect assessment of the reality of the situation. figure 2 shows that the period from 20 january to 25 january 2020 registered the fastest spread of covid-19, whilst the official record shows no increase in the number of infected cases in hubei province from 11 january to 15 january 2020 with no emergency response measures applied, indicating that hubei hc had concealed the epidemic. some scholars have questioned the under-reporting of infected people by china [48] . by constructing a mathematical model, imai stages of covid-19, which caused the national hc to make an incorrect assessment of the reality of the situation. figure 2 shows that the period from 20 january to 25 january 2020 registered the fastest spread of covid-19, whilst the official record shows no increase in the number of infected cases in hubei province from 11 january to 15 january 2020 with no emergency response measures applied, indicating that hubei hc had concealed the epidemic. some scholars have questioned the under-reporting of infected people by china [48] . by constructing a mathematical model, imai et al. concluded that as of 12 january 2020, there should have been 1723 covid-19-infected patients (not the officially reported 41 patients in wuhan) [49] . wu et al. calculated that as of 25 january 2020, there had been 75,815 covid-19 infected patients in wuhan using the data of patients given by national hc from 31 december 2019 to 28 january 2019 [50] . under-reporting of chinese covid-19 cases can be contrasted to the experience of china's neighboring countries. as revealed in section 3.1, before 19 january 2020, covid-19 did not spread on a large scale in china, but only spread within the hubei province. this was impossible as there was one case of a covid-19 patient in thailand reported on 13 january 2020 and another case in japan on 16 january 2020. wuhan's connection to these two countries is far less frequent than other chinese provinces. how could there be no spread within china when it had spread to thailand and japan? in addition, according to spatiotemporal distribution of people infected with covid-19 as shown in figure 2 , guangzhou, shanghai and beijing, which are further away from hubei province, had covid-19 cases earlier than other provinces and municipalities around hubei province. however, according to a baidu search of wuhan's population emigration index, before 25 january about 400,000 people left wuhan moving to guangdong province, 120,000 to shanghai, 120,000 to beijing, and 680,000 to the provinces and municipalities around hubei province. this showed that the population who moved to the neighboring provinces and municipalities is almost equal to that of guangzhou, shanghai and beijing, so it is impossible for the provinces and municipalities around hubei to have had no infectious cases to report. this suggests that the hc of each province, municipality and autonomous region outside hubei province had initially concealed the epidemic. in a public health crisis caused by infectious diseases, public health agencies should establish communication channels and health education platforms in a timely manner and communicate the source, symptoms, transmission mode of the disease and isolation measures to the public [34] . however, the national cdcp did not fare well in the early debate about whether covid-19 can be transmitted from person to person. the explanation from the national cdcp about whether covid-19 can be transmitted from person to person is shown in table 1 below. official explanations no obvious human-to-human transmission found; no medical staff found to be infected 5/01/2020 no clear sign of human-to-human transmission found; no medical staff found to be infected 10/01/2020 no medical staff found to be infected 11/01/2020 no clear evidence of human-to-human transmission found 14/01/2020 limited human-to-human transmission is not excluded 16/01/2020 no clear evidence of human-to-human transmission found, the possibility of human-to-human transmission cannot be ruled out, but the risk of sustained human-to-human transmission is low 19/01/2020 the transmission route is not yet fully understood 20/01/2020 covid-19 can transmit from person to person source: chinese authoritative media. table 1 shows that the national cdcp did not explicitly point out that covid-19 could be transmitted from person to person before 19 january 2020. it was not until 20 january 2020 that nanshan zhong, an academic of the chinese academy of engineering, confirmed that covid-19 could be passed from person to person. the official media did not report this before 20 january 2020 despite cases of medical staff being infected by person-to-person transmission. interesting enough, authors including staff working in china's national cdcp and wuhan's cdcp published a paper in an english academic journal-the new england journal of medicine-with a conclusion that interpersonal transmissions had occurred among close contacts since the middle of december 2019 [7] . another english paper published in the lancet, whose leading author chen wang is an academic of the chinese academy of sciences, also mentioned 16 cases of medical workers infected with covid-19 in december 2019 [8] . another english paper published in the lancet by chen described in detail a case of family cluster transmission and demonstrated that covid-19 can be transmitted from person to person. the patients mentioned in the article were admitted to the hospital on 10 and 11 january 2020 [51] . the fact that seven medical staff were infected between 1 january 2020 to 11 january 2020, with eight more infected between 12-22 january 2020 was released to the public by various chinese media sources after the central government officially accepted interpersonal transmission [52] . generally speaking, the government plays an important role in crisis management, and it can respond to the crisis efficiently by formulating a unified response policy [46] . if the government fails to formulate a response in time, it will cause the public to panic and lose confidence in the government [40] . in the process of the crisis management of covid-19, the wuhan municipal government could have taken preventative measures at a much earlier time. based on various media reports, table 2 summarizes the key time points of other countries in taking preventative measures compared to the wuhan government who did not take measures at such times. as early as 1 january 2020, hospital doctors in wuhan found an unknown type of pneumonia based on medical testing reports (later it was confirmed that the nucleotide had the homology of covid-19, which is 82% similar to the sars virus [53] ). however, instead of strengthening the protective measures against covid-19, the wuhan local government accused the doctors of spreading rumors. at the same time, singapore and hong kong had already introduced quarantine measures on 3 and 4 january 2020, respectively. after 13 january 2020, covid-19 infected patients appeared in countries other than china, indicating that covid-19 had spread widely. however, the wuhan government did not introduce the lockdown policy until 23 january 2020. another fundamental mistake that the wuhan government made was that it allowed five million people to leave wuhan before china quarantined the city [54] . although many left due to the chinese new year, others also left to avoid quarantine. this is supported by our data comparison. using the chinese lunar calendar time table to compare to wuhan's emigration index (the emigration index here is the normalized value) from 1-23 january 2020 and the emigration index from january 2019 to 5 february 2019, we found that the emigration index in 2020 and 2019 is basically the same before lunar 22 december 2019 and shows the opposite trend from lunar 23 december 2019 to the chinese new year (see figure 3) . normally, the closer to chinese new year, the fewer people move out of wuhan, but the trend shows that the opposite occurred in 2020, indicating that many wuhan residents had been aware of the crisis and started to take the initiative to leave. the final part of this paper investigates the availability of public health crisis resources. public health crisis causes a surge in demand, especially for medical resources in the short term, so the government needs to coordinate the mobilization of resources [44] . starting from lockdown, under the leadership of the central government the chinese governments at all levels mobilized support to wuhan including transporting a large number of medical supplies and sending nearly 29,445 medical staff (excluding military medical staff) to wuhan. this also included building a "huosheng" mountain hospital (with 1000 beds) and a "leisheng" mountain hospital (with 1600 beds) in wuhan within 10 to 11 days. however, all these achievements do not overshadow the problem of a serious shortage of infectious disease medical facilities and materials in china. china is not ready to cope with a large-scale infectious disease. for a long time, china has had insufficient reserves of medical resources for infectious diseases. take wuhan as an example: the epidemic started and 14 million people (8.5 million local residents and over 5 million migrant workers or students whose hometowns are in other parts of china) were able to access only two hospitals which treat infectious diseases. the total number of beds in these hospitals is around 900 which equates to 0.64 beds per 10,000 people. this is far lower than the standard for the number of beds in infectious disease hospitals in china of 1.2 to 1.5 beds per 10,000 people [52] . on 23 january 2020, wuhan had no hospital beds available for infected people and those who suspected they were infected, so the "huosheng" mountain hospital was built, followed by the "leisheng" mountain hospital on 25 january 2020. because of the shortage of beds, doctors could only advise that patients who suspected they had covid-19 and those with mild symptoms be isolated at home. this led to a sharp increase in the number of family cluster transmissions [55] . in addition, the shortage of masks, goggles and protective clothing also caused a large number of medical staff to be infected in the early stages. according to the "analysis of epidemiological features of new coronavirus pneumonia" issued by the national cdcp, it is known that by 17 february 2020, a total of 3019 medical staff were infected with covid-19. this section will first identify what the problems in china's public health crisis management are, and then explain the key causes. the final part of this paper investigates the availability of public health crisis resources. public health crisis causes a surge in demand, especially for medical resources in the short term, so the government needs to coordinate the mobilization of resources [44] . starting from lockdown, under the leadership of the central government the chinese governments at all levels mobilized support to wuhan including transporting a large number of medical supplies and sending nearly 29,445 medical staff (excluding military medical staff) to wuhan. this also included building a "huosheng" mountain hospital (with 1000 beds) and a "leisheng" mountain hospital (with 1600 beds) in wuhan within 10 to 11 days. however, all these achievements do not overshadow the problem of a serious shortage of infectious disease medical facilities and materials in china. china is not ready to cope with a large-scale infectious disease. for a long time, china has had insufficient reserves of medical resources for infectious diseases. take wuhan as an example: the epidemic started and 14 million people (8.5 million local residents and over 5 million migrant workers or students whose hometowns are in other parts of china) were able to access only two hospitals which treat infectious diseases. the total number of beds in these hospitals is around 900 which equates to 0.64 beds per 10,000 people. this is far lower than the standard for the number of beds in infectious disease hospitals in china of 1.2 to 1.5 beds per 10,000 people [52] . on 23 january 2020, wuhan had no hospital beds available for infected people and those who suspected they were infected, so the "huosheng" mountain hospital was built, followed by the "leisheng" mountain hospital on 25 january 2020. because of the shortage of beds, doctors could only advise that patients who suspected they had covid-19 and those with mild symptoms be isolated at home. this led to a sharp increase in the number of family cluster transmissions [55] . in addition, the shortage of masks, goggles and protective clothing also caused a large number of medical staff to be infected in the early stages. according to the "analysis of epidemiological features of new coronavirus pneumonia" issued by the national cdcp, it is known that by 17 february 2020, a total of 3019 medical staff were infected with covid-19. this section will first identify what the problems in china's public health crisis management are, and then explain the key causes. (1) the media lost its supervisory function chinese media are directly managed by the chinese government, which leads them to serve the government. after the government monopolizes and controls the information resources, it can be selective in reporting and releasing information. this results in information submission errors [56] , which directly promotes the public's failure to obtain real and effective information in a timely manner. in this case, the chinese media did not help the government observe and warn of the public crisis, nor did it monitor the government's deficiencies in handling public crises. (2) a choice between addressing a virus with an unknown magnitude and nature, and mitigating known public panic during a politically and culturally sensitive time stage 1 was both politically and culturally sensitive given that nobody wanted to create any unnecessary public panic during the period leading up to chinese new year with a virus that was still relatively unknown in terms of magnitude and nature. wuhan and the rest of the local governments were getting ready in early january for the most important local yearly political meetings-the so-called "two sessions" (the national people's congress and the chinese people's political consultative conference (cppcc)). during the "two sessions," the top priority is to maintain stability and keep this period free from problems. this is also why when experts from beijing arrived to investigate the atypical pneumonia outbreak, wuhan officials tried to avoid two things: upsetting beijing and causing a public panic in advance of these two important meetings. therefore, they took a multipronged approach to control information about the outbreak [57] local officials concealed the facts due to the nature of the political climate and timing of when this was happening. china's public health management system does not allow local departments to declare infectious disease crises even in their own jurisdiction. it is the state council which possesses the power to declare a crisis involving a statutory infectious disease and to draft and implement contingency plans. meanwhile, local departments are asked to take appropriate measures to prevent diseases according to the epidemic prevention level set by the state council for infectious diseases. thus, in wuhan's case, wuhan hc and wuhan cdcp had no power to declare an infectious disease crisis or take any initial measures before authorization. more and more scholars believe that power concentration is not conducive to timely response to crises and multi-centralization of crisis management has become a trend [26] . it is important for the local departments to successfully combat any infectious disease because it obtains the information fast and should have the discretion to manage it to prevent a large-scale outbreak [40] . (4) privatization of public hospitals leads to insufficient public health medical resources a significant healthcare trend in china is the increasing privatization of medical hospitals and clinics based on a belief that private hospitals are more efficient [58] . up to 2020, the number of private hospitals in china account for over 66% of all chinese hospitals [59] . the privatization of public hospitals has attracted a large amount of social capital, effectively reducing government expenditure on health. as can be seen from figure 4 , the share of government investment decreased from 30.66% in 2011 to 27.74% in 2018, and the share of social investment increased from 34.57% in 2011 to 43.66% in 2018. however, the privatization of public hospitals has resulted in insufficient public health and medical resources. on the one hand, due to the low frequency of public health disease outbreaks, private hospitals have invested less in public health care based on market demand. on the other hand, due to the decrease in government investment in public health, a large number of technical personnel in public health have been drained, resulting in a serious shortage of public health staff [52] . based on rasmussen's socio-technical management system [19] , we can frame china's public health management systems into a three tiered hierarchical system. the chinese government is at the top level and they are both the makers and implementers of the law. the regulators and associations, such as hc and cdcp, respectively, are at the second level. they develop crisis management norms based on the law and oversee the implementation. at the very bottom level are the public who selectively cooperate with the above two levels of management based on personal interests. during the covid-19 crisis, the chinese public was generally considered to be cooperative with the government and relevant health management departments [60] , the public has little disturbance to the public health management system. using this framework, we have summarized the information flow path of china's public health management system in figure 5 . this figure shows the many checkpoints required for an infectious disease case to reach the public. we can use this to explain what caused the delay and ignorance of releasing early covid-19 information. after receiving confirmed cases from wuhan's hospital or clinic, the covid-19 infectious disease information followed two separate paths. wuhan municipal cdcp reported its first covid-19 case to wuhan municipal hc on december 8, 2019, but it could not report the same information to hubei provincial cdcp until after wuhan hc had submitted covid-19 information to hubei provincial hc. a similar prerequisite applied to hubei provincial cdcp which reported to national cdcp after hubei provincial hc reported to national hc. the most critical requirement for smooth information transmission was that any local hc could not pass covid-19 information to another upper level hc without permission from its local government. therefore, wuhan hc could report to hubei provincial hc only if wuhan municipal government approved it to do so. similar approval was required from the hubei provincial government as hubei provincial hc reported to national hc on 31 december 2019. the final stage is that state council released the covid-19 infectious disease information to the public after it received the confirmed information from the national hc on 11 january 2020. we can see that it took a total of 34 days from the first confirmed covid-19 patient reported by the wuhan municipal cdcp to the congress to the release of covid-19 information to the public. we can also see, as the most professional of all the disease management associations, wuhan municipal cdcp basically did not have any real authority to transmit disease information. it could neither issue an early warning of infectious diseases to the public nor take any emergency measures. the only authority able to release the early warning is the state council. the lack of independent management power by the local cdcps directly led to a serious lag in the release of disease information and the implementation of emergency measures. based on rasmussen's socio-technical management system [19] , we can frame china's public health management systems into a three tiered hierarchical system. the chinese government is at the top level and they are both the makers and implementers of the law. the regulators and associations, such as hc and cdcp, respectively, are at the second level. they develop crisis management norms based on the law and oversee the implementation. at the very bottom level are the public who selectively cooperate with the above two levels of management based on personal interests. during the covid-19 crisis, the chinese public was generally considered to be cooperative with the government and relevant health management departments [60] , the public has little disturbance to the public health management system. using this framework, we have summarized the information flow path of china's public health management system in figure 5 . this figure shows the many checkpoints required for an infectious disease case to reach the public. we can use this to explain what caused the delay and ignorance of releasing early covid-19 information. after receiving confirmed cases from wuhan's hospital or clinic, the covid-19 infectious disease information followed two separate paths. wuhan municipal cdcp reported its first covid-19 case to wuhan municipal hc on december 8, 2019, but it could not report the same information to hubei provincial cdcp until after wuhan hc had submitted covid-19 information to hubei provincial hc. a similar prerequisite applied to hubei provincial cdcp which reported to national cdcp after hubei provincial hc reported to national hc. the most critical requirement for smooth information transmission was that any local hc could not pass covid-19 information to another upper level hc without permission from its local government. therefore, wuhan hc could report to hubei provincial hc only if wuhan municipal government approved it to do so. similar approval was required from the hubei provincial government as hubei provincial hc reported to national hc on 31 december 2019. the final stage is that state council released the covid-19 infectious disease information to the public after it received the confirmed information from the national hc on 11 january 2020. we can see that it took a total of 34 days from the first confirmed covid-19 patient reported by the wuhan municipal cdcp to the congress to the release of covid-19 information to the public. we can also see, as the most professional of all the disease management associations, wuhan municipal cdcp basically did not have any real authority to transmit disease information. it could neither issue an early warning of infectious diseases to the public nor take any emergency measures. the only authority able to release the early warning is the state council. the lack of independent management power by the local cdcps directly led to a serious lag in the release of disease information and the implementation of emergency measures. china's covid-19 crisis management can be roughly divided into two stages. since 25 january 2020, the chinese central government launched an unprecedented national campaign to contain the disease. now, china is winning the battle and the rest of the world is fighting. however, china has paid a huge price for its initial delays and slow response. strict government control over information was the main reason for the early media silencing, which directly caused most people to be unprepared for covid-19. in fact, the same problem occurred during the sars outbreak [52] . we can see that chinese local government officials seem to be habitually choosing to underreport bad news for fear of economic losses or criticism from upper level officials, which would impact their personal political achievements. the weak autonomous management power of local governments is not conducive to taking a timely response to the crisis. critical decisions about combating covid-19 must be made and implemented under considerable time pressure. local authorities need to take action quickly. finally, the lack of appropriate medical assistance given by private hospitals to help manage covid-19 should inform chinese and relevant authorities to rethink china's health system and reform and invest more in its public health network. ultimately, this paper covers two broad dimensions of covid-19 crisis management: technical/physical and political. our findings further confirm that crisis management involves multiple subjects and they have to work together to prepare for, handle and recover from crisis. the five commonly considered factors in public health crisis management are a useful framework to analyze the problems and major causes of the covid-19 crisis in china. this crisis management analysis framework could be used to examine why china's powerful national campaign has successfully contained covid-19 in stage two and more interestingly, how some of the lessons learned from stage one had been immediately overcome in stage two. each of the five factors has been addressed differently compared with stage one. for example, the central government's china's covid-19 crisis management can be roughly divided into two stages. since 25 january 2020, the chinese central government launched an unprecedented national campaign to contain the disease. now, china is winning the battle and the rest of the world is fighting. however, china has paid a huge price for its initial delays and slow response. strict government control over information was the main reason for the early media silencing, which directly caused most people to be unprepared for covid-19. in fact, the same problem occurred during the sars outbreak [52] . we can see that chinese local government officials seem to be habitually choosing to underreport bad news for fear of economic losses or criticism from upper level officials, which would impact their personal political achievements. the weak autonomous management power of local governments is not conducive to taking a timely response to the crisis. critical decisions about combating covid-19 must be made and implemented under considerable time pressure. local authorities need to take action quickly. finally, the lack of appropriate medical assistance given by private hospitals to help manage covid-19 should inform chinese and relevant authorities to rethink china's health system and reform and invest more in its public health network. ultimately, this paper covers two broad dimensions of covid-19 crisis management: technical/ physical and political. our findings further confirm that crisis management involves multiple subjects and they have to work together to prepare for, handle and recover from crisis. the five commonly considered factors in public health crisis management are a useful framework to analyze the problems and major causes of the covid-19 crisis in china. this crisis management analysis framework could be used to examine why china's powerful national campaign has successfully contained covid-19 in stage two and more interestingly, how some of the lessons learned from stage one had been immediately overcome in stage two. each of the five factors has been addressed differently compared with stage one. for example, the central government's top-down system was able to mobilize nearly all relevant organizations and services to support the lockdown of the whole nation (factor 5); the public has been well informed: the government and media have provided continuous and clear covid-19 information to the public (factor 1); professional infectious disease control experts assess the virus threat regularly (factor 2); covid-19 public health education platforms are free for people to access (factor 3); and the officials' top priority on their daily agenda at every level of government is to make the right decisions at the right time-officials carefully listen to health experts in managing the local response action plan (factor 4). more importantly, the world could learn more from china's response to the covid-19 outbreak. late intervention to covid-19 is not an issue unique to china. in fact, countries like the united states and many european countries have also experienced some lag in the process of handling the crisis despite observing the chinese demonstrating the serious consequences of delaying any response during stage one. assigning blame is unproductive to the conversation, rather, this paper seeks the answer how china can or should make structural and management adjustments to its process of intervention so as to help the management of the future crises. therefore, it is time to consider the following policy recommendations: first, in the current organizational management structure in china, the main reasons for media loss and politics overruling the truth are information control and information monopoly. singapore's public health management system provides an idea for china's future information management. singapore has established a case management system (cms) which collects information on hospitals, ministry of health, ministries of education and general practitioners via the internet. the system can identify suspected and confirmed patients through the information collected and provide early warning flags. it also closely monitors close contacts of suspected and confirmed patients and makes available real-time information on patients, suspected cases and potential cases. china should adopt a similar system to make the epidemic information public. secondly, introducing a local territorial management model should be explored. the local public health management departments do not have autonomy to take timely action. china should adopt a local territorial management model such that as soon as a crisis occurs, local public health management departments can immediately release information to the public and take prompt measures according to the epidemic situation. any initial delay will result in large damage down the track. finally, increasing government public health investment is key. at present, china's cdcp is severely short of public health technical personnel and hospitals are short of public health medical resources. therefore, the chinese government should increase public health investments in training professional technicians and increasing medical resource reserves. to increase training, further investment in relevant education is required. to boost medical resource reserves, a medical emergency supply network system could be constructed [61] . this system could cover all cities and be funded by local governments in major infectious disease hospitals and general hospitals. each 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behavior of the public during covid-19 epidemic and its countermeasures can china's covid-19 strategy work elsewhere? science this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-254234-8w1z3un6 authors: ahmed, shahira a.; karanis, panagiotis title: cryptosporidium and cryptosporidiosis: the perspective from the gulf countries date: 2020-09-18 journal: int j environ res public health doi: 10.3390/ijerph17186824 sha: doc_id: 254234 cord_uid: 8w1z3un6 the present review discusses the burden of cryptosporidiosis in the gulf cooperation council (gcc), which is underreported and underestimated. it emphasizes that the cryptosporidium parasite is infecting inhabitants and expatriates in the gulf countries. children under 5 years are a vulnerable group that is particularly affected by this parasitic disease and can act as carriers, who contribute to the epidemiology of the disease most probably via recreational swimming pools. various risk factors for cryptosporidiosis in the gcc countries are present, including expatriates, predisposing populations to the infection. water contamination, imported food, animal contact, and air transmission are also discussed in detail, to address their significant role as a source of infection and, thus, their impact on disease epidemiology in the gulf countries’ populations. cryptosporidiosis is a significant diarrhoeal disease for both people and animals worldwide. several species of the protozoan parasite cryptosporidium can cause this disease [1] , in which cryptosporidium oocysts have ubiquitous presence in the environment. cryptosporidium oocysts transmission can occur following direct or indirect contact with an infected host usually via the faecal-oral route. person-to-person contact, zoonosis, and the consumption of contaminated food or water are well known mechanisms for faecal-oral transmission [2, 3] , with a significant risk of infection from the ingestion of a single oocyst [4] . when the oocysts enter the gastrointestinal tract, the invasive cryptosporidium causes damage to the small intestinal epithelium. it disrupts the barrier function and absorption capability that leads to mild-to-severe diarrhoea and other abdominal symptoms. in immunocompetent adults, cryptosporidium infection is usually asymptomatic or mild, which is generally self-limiting. currently, cryptosporidium has 41 reported species with more than 60 valid genotypes [5] . amongst them, 21 species and genotypes have been identified in humans, out of which c. parvum and c. hominis are the most common pathogenic species, causing more than 90% of infections in humans. c. meleagridis, c. ubiquitum, c. cuniculus, c. muris, and c. andersoni are other pathogenic species that have sporadically emerged in human cases of zoonotic outbreaks, especially when there has been direct contact with infected animals [6] [7] [8] [9] [10] . the disease-causing species and their associated subtypes have contributed to a substantial global burden of cryptosporidiosis and play a role in the severity of the disease [11] . globally, diarrhoeal diseases have killed 1.6 million people in 2017. one third of these deaths were children under 5 years, and their highest mortality are from sub-saharan africa (ssa) and south asia. this was because int. j. environ. res. public health 2020, 17, 6824 3 of 34 challenges (water scarcity, water quality, desertification, and air and marine pollution) that require reconciliation of many conflicting priorities [34, 35] . one of the most critical problems that affects public health in the gcc countries is the lack of renewable water resources. infrequent rainfall in the arabian peninsula has led to the overutilization of ground water resources that has consequently affected the qualitative and quantitative of ground water needed for agriculture, industry, and personal consumption [36] . most of the demand for fresh water in the gcc countries relies on desalination of seawater, which is a process that requires an extensive pre-treatment and conditioning of seawater [37] . due to this rigorous treatment of seawater, researchers typically do not suspect desalinated drinking water as a source of cryptosporidium contamination; however, it can happen. during the course of the water treatment process, contaminants and beneficial nutrients could be removed and of course some might be added [38] once stored in tanks or used to fill swimming pools [39, 40] . the burden of infectious diarrhoea in the countries of the gcc has been addressed in various reviews on the middle east and north africa (mena) and eastern mediterranean region (emr). infectious diarrhoea has been reported by the united states military after it experienced a significant burden from this disease in the mena campaigns of world war ii [41, 42] . traveller's diarrhoea due to ingestion of bacteria, viruses, or protozoa has been reported to affect travellers to saudi arabia [43] . diarrhoeal infections among mena children pose a significant public health challenge [44] and has been indicated in many reports affecting children in the gcc countries [39, [45] [46] [47] [48] [49] [50] [51] . the mortality from diarrhoeal diseases in the gcc countries has also been estimated in a study from the emr. it has been estimated that over 103,692 deaths have occurred in 2015 due to diarrhoea in the emr. the majority of these deaths (63.3%) have occurred in children under 5 years and the dalys/100,000 ranged from 304 in kuwait to 38,900 in somalia [21] . cryptosporidium has been reported to be the 7th leading cause among 13 diarrhoeal aetiologies responsible for death in the emr population. approximately 4569.06 death have resulted in children under 5 years and 4796.2 death from all age groups due to fatal cryptosporidiosis in the emr area. it has been noted that mainly uae and kuwait have the lowest prevalence-weighted risk for diarrhoeal infection [21] . the wealth of the gcc countries has attracted many people to seek work opportunities that has notably increased the population in the region and subsequently increased the burden of infectious diseases, particularly gastrointestinal diseases [47, 52] . the pattern of the parasitic infection has shifted to reflect this newly mixed population (inhabitants and immigrants), whereas many of these immigrant nationals have dissimilar educational backgrounds, varied eating habits, different religious beliefs and cultural practices [47] . little is known about the true extent of intestinal parasitic infection, particularly cryptosporidiosis, among the inhabitants of the gcc countries. several studies have reported intestinal parasites infection in immigrant food handlers, labourers, and hospitalized children from this region [39, [45] [46] [47] [48] [49] [50] [51] . economic migrants seeking employment in the gcc countries (e.g., servants, food handlers, housekeepers, childcare assistant, and labourers) may arrive carrying their parasitic infections with them. therefore, the risk of parasitic infection has been estimated to be higher in some sectors of the communities, especially asymptomatic carriers who are employed in the food industry [53] . the food industry has been suspected to be the greatest threat in the spread of diarrhoeal aetiologies. the gcc countries import large amounts of food in order to bridge the gap between food production and food consumption. imported food mainly comes from high-risk countries with a known epidemiology of diarrhoeal diseases [35] . imported leafy greens and other fresh produce are highly suspected to be a vehicle for the transmission of the cryptosporidium infection [18, 54, 55] . the potential for food contamination on and off farms is high since it could be produced or washed with contaminated water. infected food handlers are another common source of cryptosporidium contamination in the food chain imported by the gcc countries [17, 18] . studies from countries with low, intermediate, and high resources have identified cryptosporidium as one of the major causes of diarrhoea and childhood malnutrition [56] . the magnitude and nature of environmental threats might be the link with the incidence of cryptosporidiosis burden and might explain the differences between the previous three categories. in this context, immigrant geographic origin, globalization of food supply to meet the demand of the increased labour force, food and water contamination, climate change, as well as poor hygiene after direct animal contact have all contributed to the annual flux in cryptosporidium transmission and infection rates within the gcc countries [54, 57] . in the present review, we aim to discuss the size of the burden of cryptosporidium infection in the gcc countries based on the existing information, and to discuss the risk factors that contribute to the cryptosporidium infection in such a wealthy region. the pubmed, science direct, and scopus databases were searched with no restriction to language or year of publication. to evaluate the burden of cryptosporidium in the gcc population, a clear description of the questions raised with regard to participants, interventions, conditions, outcomes, and study design (picos) was performed. the literature search strategy was limited to title/abstract/keyword using the following mesh terms/key words: (cryptosporidium or cryptosporidiosis or parasite) and (infection or prevalence or incidence or occurrence or burden) and (human or animal or water or food) and (bahrain or kuwait or qatar or saudi arabia or oman or united arab emirates). the screened articles were published between 1971 and 2020. some relevant articles that were published in arabic local journals have been retrieved from library genesis scientific articles and egyptian knowledge bank, google scholar, iraqi scientific academic journals, and researchgate. retrieved articles with titles that suggested the topic of cryptosporidium in humans were screened and selected as part of the eligibility for inclusion in the literature review. abstracts from the selected reference titles were reviewed to determine if the selected studies have met the inclusion criteria. review of an entire article was performed based on the selected abstracts that previously met the inclusion criteria. the exclusion criteria consisted of studies on animal cryptosporidiosis or studies that related to foodborne/waterborne cryptosporidiosis as they will later be detailed in the risk factors chapter. the articles that have been published in english or arabic were the only selected languages included in the review. articles in the form of case reports or reviews or conference proceedings were excluded. for each article, the following information was extracted: location of the study, type of residents, cryptosporidium detection method, participants classification, most affected age of participants, symptoms associated with the disease (when available), number of cases, and prevalence of the disease-as reported by the authors or calculated from data presented in the paper (when available). the combined search retrieved 1874 studies. a total of 133 studies were retained based on screening of the titles. an additional six studies were added by the screening reference lists from other sources. therefore, 139 studies were subjected to abstract screening. in total, 64 articles were retained for full text analysis and subsequently 39 articles were selected for the analysis of human cryptosporidiosis, from which only 28 of the articles were selected for final analytical inclusion ( figure 1 ). due to incompatibility with the inclusion criteria, 36 articles were excluded. specifically, the exclusion criteria were based on articles that had indistinct data, absence of full text, poor quality citation, reviews, case reports, or reports that included the same results as another paper published by the same author. out of the six gcc countries, five countries have reported human infection from cryptosporidium spp. saudi arabia leads other gcc countries in the reporting of cryptosporidium infection. bahrain has not issued any reports concerning cryptosporidium infection (table 1, figure 2 ). the allocation of cryptosporidium reports in the gcc countries is presented in figure 2 . the burden of cryptosporidium in the gcc countries is presented in table 1 . molecular genotyping and sub-typing data of cryptosporidium in gulf reports are presented in table 2 . the situation of cryptosporidium in water resources of the gcc countries is summarized in table 3 . information on out of the six gcc countries, five countries have reported human infection from cryptosporidium spp. saudi arabia leads other gcc countries in the reporting of cryptosporidium infection. bahrain has not issued any reports concerning cryptosporidium infection (table 1, figure 2 ). the cryptosporidium occurrence in animals within the gcc countries is tabulated in table 4 . the results that are indicated in the figure and tables are described below. the six gcc countries are classified as high-income developing countries that share an infection prevention and control program [58] . other public health programs have been declared successful by the world health organization (who) [47] . only 28 reports of cryptosporidiosis have been published from 5 of the 6 gcc countries. considering that many of these wealthy countries have the necessary research equipment and facilities, the number of reported articles is considerably low for their capability. this situation indicates an underestimation and underreporting of cryptosporidium infection in the gulf region. saudi arabia has the highest number of reported cryptosporidium infections in humans with a significant p-value < 0.05 in comparison to the rest of the gcc countries. saudi arabian reports of cryptosporidium infection have formed half of the total reports number (16/28) cited in the literature that reached an incidental rate of 50% ( figure 2 , table 1 ). the kingdom of sa is considered to be the largest of the gcc countries with a population of 28.5 million people [33] . it has a well-established public health system and public safety measures that are applied before mass gatherings that attempt to protect pilgrims during the hajj season. gastrointestinal infections during mass gatherings are a major health hazard. therefore, sa authorities routinely provide continuous surveillance for several protozoal, viral, and bacterial pathogens as a part of its measures to protect public health [59] . the proactive safety measures and awareness of infectious disease has placed saudi arabian authorities higher in the reporting scheme within the gcc countries. even though the saudi government has key planning considerations for emerging diseases alerts based on the who's recommendations, cryptosporidium infections has been reported within the population of makkah before and during the umrah season. it has been observed that the incidental rate of various intestinal parasites has increased by 7.5% among people around the holy masjid during umrah [60] . overcrowding has been frequently cited as a significant risk factor associated with cryptosporidium infection in other low-and middle-income countries [29] . the allocation of cryptosporidium reports in the gcc countries is presented in figure 2 . the burden of cryptosporidium in the gcc countries is presented in table 1 . molecular genotyping and sub-typing data of cryptosporidium in gulf reports are presented in table 2 . the situation of cryptosporidium in water resources of the gcc countries is summarized in table 3 . information on the cryptosporidium occurrence in animals within the gcc countries is tabulated in table 4 . the results that are indicated in the figure and tables are described below. the six gcc countries are classified as high-income developing countries that share an infection prevention and control program [58] . other public health programs have been declared successful by the world health organization (who) [47] . only 28 reports of cryptosporidiosis have been published from 5 of the 6 gcc countries. considering that many of these wealthy countries have the necessary research equipment and facilities, the number of reported articles is considerably low for their capability. this situation indicates an underestimation and underreporting of cryptosporidium infection in the gulf region. saudi arabia has the highest number of reported cryptosporidium infections in humans with a significant p-value < 0.05 in comparison to the rest of the gcc countries. saudi arabian reports of cryptosporidium infection have formed half of the total reports number (16/28) cited in the literature that reached an incidental rate of 50% ( figure 2 , table 1 ). the kingdom of sa is considered to be the largest of the gcc countries with a population of 28.5 million people [33] . it has a well-established public health system and public safety measures that are applied before mass gatherings that attempt to protect pilgrims during the hajj season. gastrointestinal infections during mass gatherings are a major health hazard. therefore, sa authorities routinely provide continuous surveillance for several protozoal, viral, and bacterial pathogens as a part of its measures to protect public health [59] . the proactive safety measures and awareness of infectious disease has placed saudi arabian authorities higher in the reporting scheme within the gcc countries. even though the saudi government has key planning considerations for emerging diseases alerts based on the who's recommendations, cryptosporidium infections has been reported within the population of makkah before and during the umrah season. it has been observed that the incidental rate of various intestinal parasites has increased by 7.5% among people around the holy masjid during umrah [60] . overcrowding has been frequently cited as a significant risk factor associated with cryptosporidium infection in other low-and middle-income countries [29] . the number of cryptosporidium reports from the other gcc countries (kuwait, uae, qatar, and oman) varied between 1 and 5 reports in the literature search ( figure 2 , table 1 ). kuwait is ranked second after sa for reporting cryptosporidium infections (5 reports). in a kuwaiti study that estimated the infectious and parasitic diseases mortality, there has been a steady decline in the number of deaths from infectious and parasitic diseases in kuwait since 1975. this decrease in deaths has dropped from 758 in 1975 to 236 in 1983. however, when the researcher compared the death rate from infectious and parasitic diseases between kuwait and selected developed countries, the study showed that, despite considerable improvement, the real rate of infectious and parasitic mortality in kuwait remains very high compared to that in developed countries [81] . in qatar and uae, the reporting system for cryptosporidium infection can be considered marginal, although they have rich economies indicated by per capita gross national income (gni) [82] . the few reports that have been published from the gcc countries, with regard to parasitic infections, appear to give a false sense of security that these diarrhoeal parasitic pathogens may not be a serious problem in the region. gcc countries that neglect to screen or report the occurrence of cryptosporidiosis cases could be misinterpreted as having an absence or low prevalence of cryptosporidium in those countries. recent published data have highlighted the importance of monitoring and investigating intestinal parasites after several worldwide cryptosporidium outbreaks. bahrain is the only country in the gcc region that does not have a published record for cryptosporidium infections. in spite of reporting helminths and other protozoa in humans since 1995 [83] , cryptosporidium has not been considered or included in routine investigations of diarrhoeal infections. bahrain has a relatively smaller economy than its oil-rich neighbours in the arab gulf. over the years, bahrain's oil production has deteriorated dramatically, resulting in a high unemployment rate and poverty (11% of citizens), which may explain in part its neglected focus and research implementation of neglected diseases [84, 85] . in about 70% of the reported studies in the gcc countries, cryptosporidium has been linked to gastrointestinal symptoms, particularly diarrhoea in children under 5 years old (table 1 ). in the middle east, 76% (4348 volunteers) of military soldiers have reported at least one diarrhoeal episode [42] . in 45% of the cases, diarrhoea resulted in a median of 3 days of lost work productivity and a median of 2 days confinement to bed. adverse effects of diarrhoea have caused 62% of the affected subjects to seek medical attention and subsequent intravenous rehydration from diarrhoeal complications [42] . in the gcc countries, other categories of adult patients (immunocompromised, umrah people, and expatriates/immigrants) have also reported diarrhoea that had been caused by cryptosporidium infection [39, 49, 50, 65, 66, 68, 70] . if this is indeed the situation with adult diarrhoeal cases, it would be expected that children under 5 years are more vulnerable to the adverse effects of diarrhoea from cryptosporidium infection. two paediatric case reports as early as 1989 have linked cryptosporidium infection to symptoms of severe diarrhoea, vomiting, and low-grade fever in children from kuwait [86] . over one third of the country's infectious and parasitic deaths were reported as diarrhoeal deaths of infants and young children [81] . in jeddah, the largest commercial city of saudi arabia, it was identified that 14.9% of school children have reported diarrhoea during the previous month in a study focusing on boys' public schools (24 schools) that serve children aged 7-12 years. the main risk factor indicated in the analysis of the study was the number of children under the age of five living in the same household. other risk factors associated with an increased risk of diarrhoea that was noted in the study are sewage spillage near the home, no drying for hands after washing, use of reusable cloths to dry dishes, and eating out after school hours [87] . in uae, a survey of 500 parents with children under 5 years of age have reported that 87% of parents sought medical care for their children for the treatment of acute gastroenteritis within a three-month period, where 10% of those children required hospitalization with an average length of stay of 2.6 days due to complications of severe diarrhoea [88] . asymptomatic children with cryptosporidiosis are considered to be carriers and act as important reservoirs for cryptosporidium oocysts in the community [22] . in the global burden of diseases (gbd), injuries, and risk factors study, cryptosporidium infection was the fifth leading cause of diarrhoeal mortality in children younger than 5 years, causing 48,300 deaths in 2016. according to the study, for every episode of cryptosporidial diarrhoea, there was an associated decrease in height-for-age, weight-for-height, and weight-for-age z scores, which translated into an additional 7.85 million dalys [11] . in north africa and the middle east, researchers have distributed the dalys source in children under 5 due to cryptosporidium infection into 40% wasting, 24% acute diarrhoea, 23% underweight, 9% stunting, and 3% protein energy malnutrition [11] . paediatric diarrhoea has significant consequences on productivity and the financial impact on the livelihood of the affected families [44] . in the gcc countries, there has been a notable economic burden due to diarrhoea in children. for example, the total cost of hospitalization in oman due to paediatric diarrhoea was estimated to be $539/child/3 days stay in hospital. for all outpatient and hospital settings in oman, the total cost reached $1.8 million per year [89] . in the uae, the average cost for medical care per paediatric diarrhoeal episode has been estimated to be $64 [88] . the lack of comprehensive studies on cryptosporidium infection in paediatric diarrhoeal cases need to be strengthened in the gcc countries to reduce the economic burden associated with diarrhoeal diseases, to provide healthy children without long lasting adverse effects, and to reduce the transmission circle between family members and between families where the child is always the focus of cryptosporidium infection. diagnosis and identification of cryptosporidium infections in the gcc countries varies among the reports. the majority of them are based on the use of staining methods; however, occasionally confirmation of staining is combined with other sensitive methods like immune tests and pcr to make diagnosis ( table 1 ). the diagnostic method of choice for the detection and identification of cryptosporidium usually varies according to the investigator's goal as well as the available facilities and resources to make the diagnosis [90] . the prevalence of cryptosporidium infection also varies among the gcc countries, with a prevalence ranging between 0.1 and 69.9%. the studies that have depended on combined stains and immune tests authors noted a wide range of prevalence between 0.1 and 69.9%, while studies that have used pcr methods to confirm cryptosporidium prevalence ranged between 1.7 and 19.4%. only one study has reported a high prevalence of 94% by the authors, who used pcr to analyse previously confirmed positive samples via staining [50] (table 1) . only eight out of 28 studies (28.6%) from gcc countries have further processed their isolates by molecular analysis to verify the geno-/subtyping of cryptosporidium spp.. the molecular methods used in these studies varied between arbitrarily primed pcr, qpcr, sequencing, and pcr-rflp, where pcr-rflp was the most commonly used technique to the identify the cryptosporidium spp. and subtype ( table 2) . pcr methods are well established techniques that are used to detect cryptosporidium dna in samples with accuracy, sensitivity, and specificity over traditional staining methods. quantitative pcr (qpcr) is known to be the most accurate amongst the pcr methods due to a decreased risk of sample contamination; early reporting of results, particularly during outbreak investigations; and with the detection and quantitation of the target nucleotide sequences down to one or a few copies per samples [90] . the majority of the gcc studies used pcr-rflp to detect cryptosporidium spp., probably due to the lower costs associated with this highly accurate technique. we have concluded that the studies that used pcr methods had the most realistic prevalence and burden numbers of cryptosporidiosis in the gcc countries (1.7-19.4%). other factors must be considered that can affect the prevalence of cryptosporidium in these studies. for example, differences in method, number and type of diagnostic method used, number of selected samples for the study, target population, aim of the study, state of the population's health, symptomatology, and expertise of investigators. c. parvum, c. hominis, c. meleagridis, and c. muris have been the identified species that infect humans in the gcc countries [45, 46, 49, 50, 67, 70, 78] . distribution of different cryptosporidium genotypes in human populations can be considered an indication of the differences in infection sources [91] . c. parvum has been reported to be the dominant species in isolates from the gcc countries. in kuwait, c. parvum has been identified as the predominant causative species of cryptosporidiosis in children [49, 50] . in qatar, it was the principal species as well in the qatari children and expatriates [45, 46] . saudi arabian children from gizan and maddina were also dominantly infected with c. parvum [67] . c. parvum is a species that infects a broad range of mammals and is considered one of the major zoonotic disease problems [92] . its dominance in the gcc countries indicates that there is an animal-to-human transmission, particularly when subtyping outcomes are considered. from subtyping data of cryptosporidium infections in the gcc countries, c. parvum iid has been shown to be the predominant subtype family in most of the gcc countries ( table 2 ). the iid subtype has been referred to as the major zoonotic subtype family in europe, asia, egypt, and australia [93] [94] [95] [96] [97] [98] . its distribution has been associated with the domestication of goats, sheep, calves, horses, donkeys, and takins [99] . according to qatari and kuwaiti paediatric diarrhoeal studies that have investigated the risk factors associated with cryptosporidium infection, there has been limited, if indeed any, contact with farm animals when investigators were considering the source of initial infection [46, 49] . on the other hand, the frequent reporting of the iid subtype family in the gcc countries suggests the potential occurrence of zoonotic transmission of c. parvum. the qatari studies have indicated that there is a predominance of the iid subtype family in its hospitalized children and immigrants, and suggested that cryptosporidium contamination from foodborne transmission or person-to-person contact, but there is no indication that the source of infection could also be from contaminated water or contact to animals [45, 46] . none of the qatari studies reported prevalence or occurrence of cryptosporidium spp. in local animals or drinking water. one study from kuwait has indicated that nine of the paediatric cryptosporidiosis cases had direct contact with animals but did not demonstrate any significant association between the risks of infection from those animals [49] . another study in kuwait has investigated 47 sheep and goat farms and found a predominance of the c. parvum iid subtype family in two-thirds of the infected animals [95] . in saudi arabia, cryptosporidium has been detected in camels, sheep, and goats, but there has been no further molecular identification of these species and subtypes [100] . more research is needed in the gulf region to confirm if animal contact is a major source of infection. the prevalence of the cryptosporidium needs to be investigated in the animal population. in addition, the authors of this review have speculated that if the elderly populations were included in the gulf research studies, there may be a significant correlation between the cryptosporidium positive cases and contact with animals, particularly in arab falconers and those who enjoy breeding and riding camels (see details in the next chapter). c. hominis is a species mainly restricted to humans (anthroponotic transmission) despite it has been recently reported in young calves [101] . it has been reported to be the predominant species in children from makkah, saudi arabia [70] . other studies have noted its occurrence in a few number of cases from qatari immigrants (1) and hospitalized children (4) [45, 46] , kuwaiti symptomatic children (15) [49, 50] , and saudi arabian children (13) [67] (table 1) . person-to-person contact is also a plausible way to contract cryptosporidiosis in the gcc countries; however, it appears to only represent a very small percentage of cases in the available literature. c. meleagridis and c. muris have been the least reported species in the gcc countries. qatar and sa are the only countries that reported these species from their isolates. c. meleagridis has been described within mixed infections of c. parvum in two qatari reports (children and immigrants) [45, 46] and as a single species infection in asymptomatic saudi children [78] , whereas its transmission has not been clarified in any of those studies. c. meleagridis primarily infects birds and mammals and is considered the third most common cause of cryptosporidiosis in humans [102] , despite it frequently being reported in particular populations of thailand, peru, and japan [9, 103] . the qatari cases with c. meleagridis infection seem to be linked to travel to endemic areas or countries, or were infected from people coming from endemic areas or contact with birds, e.g., falcons. a single c. muris case has been reported in one saudi child; however, the conclusions are marginal since the authors reported pcr technical difficulties with processing the c. muris dna. further, this particular isolate was the only species that was withheld from the gel electrophoresis during their pcr-rflp analysis [78] . zoonotic and anthroponotic transmissions of oocysts are known pathways for cryptosporidium infection in the gulf population. it is essential that gulf governments, public health authorities, and investigators consider publishing more investigations on cryptosporidiosis in animals and symptomatic individuals who have had direct contact with those animals. it would be worthy to combine human and animal investigations in one study for the detection of cryptosporidium that uses molecular analysis to verify the genotype/subtype prevalence in human and animal populations. poor water quality, animal contact, overcrowded living conditions, household diarrhoea, and open defaecation have been identified as significant risk factors for cryptosporidium infection in lowand middle-income countries [29] . countries that have been identified as "poor income countries" can suffer additional risk factors that double the predisposition for cryptosporidiosis. these risk factors include inadequate water supply, water crises, unclean water, poverty, illiteracy, social unrest, climate change, political conflict, and underdevelopment, which can create dramatic consequences in the poorest members of this population [19] [20] [21] . due to the high-income status of the gcc countries, the risk factors for cryptosporidium infection and other infectious diseases are notably lower than those in the "poor income" category. collectively, the gulf reports have only addressed one major risk factor (expatriates) but neglected to specify other epidemiological factors that may contribute to cryptosporidium infection in the region. the most putative important risk factors for cryptosporidiosis in the gcc countries will be presented in the following sections. the gcc countries are considered the poorest region in the world in its water resources. this is due to their geological location and climate. they are characterized by their arid environment (hot and dry) with irregular and infrequent rainfall, high evaporation rate, and scarcity of renewable water resources [35, 104] . arid regions have a higher correlation between available water resources and public health problems [36] , which can consequently have a negative impact on the social and economic development in the region. the gcc countries depend mainly on water desalination, which is an expensive process that removes salts and minerals from seawater and brackish water [37] . there is almost no surface water either in the gcc countries [32, 105] . due to the rapid expansion of the population, lifestyle changes have occurred with the urbanization and reclamation of agricultural areas, where valuable groundwater is extracted to satisfy the demand for water [36, 104] . fortunately, the desalinated seawater can provide an unlimited supply of drinking water, although it does come with a risk when it is inadequately produced and contaminated or if the water treatment systems fails [38] . prior to pumping desalinated water into the distribution network, the water is chemically treated. in jeddah, saudi arabia, the drinking water is only distributed to properties once or twice per week. the processed water is then stored in private underground tanks for two days. afterwards, the stored water reaches the distribution facilities, where it is pumped to roof tanks on homes and businesses to be available when needed [87] . in many areas of jeddah, the domestic wastewater system uses a cesspool, which runs next to the underground water storage tanks. the long-term use of a cesspool system has caused a rapid rise in the underground water table. this has led to contamination of potable water stored in the underground tanks [106, 107] . in the western provinces of sa, the use of conventional on-site sewage systems is the exclusive pathway to dispose sewage. under ideal conditions, the waste effluent is assimilated and treated within the topsoil that is directly adjacent to the cesspool, without regulation or implementation, to ensure there is enough separation between the bottom of the cesspool and the water table [108] . it has been confirmed that the fate and movement of the chemical constituents (nitrates) and bacterial contamination from this septic/cesspool effluent mixes into the shallow groundwater, private shallow and deep wells, and dump stations [108] [109] [110] . it is recognized that the on-site sewage disposal systems have contaminated the drinking water sources and subsequently caused health problems in the gulf region. if chemical and bacterial contamination is present in the drinking water, it is expected to have parasitic contamination as well; however, this parameter is under recognized in the gcc countries. although cryptosporidium has been frequently detected in faecal samples of local inhabitants in the gcc countries (sa [66, 76, 77] , kuwait [50] , uae [80] , qatar [46] , and oman [64] ), they have little published data regarding the occurrence of cryptosporidium in the gulf water supply. however, six studies in sa, uae, and kuwait have investigated cryptosporidium in selected water resources in the gcc (table 3) , with interesting outcomes. it is remarkable that cryptosporidium was present in almost all water resources from the gcc countries, which included desalinated water, underground water, bottled water, swimming pools, irrigation water, and chlorinated water from sewage treatment plants [40, 49, [111] [112] [113] [114] . in the sa city of al-taif, cryptosporidium has been identified in 8% of desalinated water samples [40] . in makkah, another sa city located next to al-taif, the presence of cryptosporidium infection among its inhabitants has been suspected to originate from contamination from the local desalinated water system. due to the similarity and construction of the two desalination water systems, this has led investigators to suspect the desalination water system as the most plausible source of cryptosporidium infection in makkah [40, 70] . the high prevalence of cryptosporidium in kuwait has been linked to the winter desert camping areas, where large numbers of overhead water storage tanks are used to store potable water. water tanker trucks transport this desalinated water to these camping places. it is very interesting that the cryptosporidium subtyping result from the contaminated tank water has been identified as c. parvum subtype iia, and that five members of the same family using this water source at the camp were also infected with the same subtype [49] . this has provided a direct link to contaminated desalinated water as a potential source of cryptosporidium infection. moreover, the contamination of water with oocysts has probably occurred at the end of the water treatment process during distribution [49] . it has been reported that about 7.3% of underground waters (wells) are contaminated with cryptosporidium in al-taif [40] . the protected wells were previously found to be contaminated with faecal matter [115] . it is not be surprising if unprotected wells are contaminated from a variety of sources, such as wastewater effluent, overland flow from manure piles, as well as domestic or wild animal grazing. fossil groundwater covers about two-thirds of the arabian peninsula, and it is the main source of water in the gcc countries [116] . ground water pollution in the gcc countries has been caused mainly due to over-pumping from wells. however, there are other factors that have contributed to ground water pollution, such as irrigation returns, seawater intrusions, liquid effluents from septic tanks, and agricultural chemicals. these factors have led to the abandonment of many water wells in the gcc countries [117] . water well pollution highlights the necessity of higher water-protection legislation and conservation to ensure the protection of water supply for all inhabitants [118] . bottled water in tabuk, jeddah, and mekkah in sa has been reported to be contaminated with cryptosporidium using modified ziehl neelsen (mzn) as a diagnostic method [111, 112] . in these two studies, the authors have not given clear details regarding the water samples used in their investigations and they published ambiguous results concerning the bottled water contamination. in comparison, another study from al-taif, using nested pcr and five brands of bottled water (domestic and imported), has reported all samples to be free from cryptosporidium oocysts [40] . the microbiological quality of bottled water has been the focus in uae since 1999. although authors have mentioned that the presence of bacteria in bottled water can act as an indicator for the possible presence of cryptosporidium, there has been no established method yet to screen the bottled water for this protozoan parasite in the gcc region [119] . as mentioned from some of the literature, the quality of bottled water can vary between brands. researchers have speculated that it might not be any safer than tap water, unless it is distilled or pasteurized to ensure complete disinfection. the source of the bottled water is also very important, especially if it is collected from a surface water source (e.g., a stream) and it may be more likely to contain cryptosporidium and other microorganisms than bottled water derived from a ground water source (e.g., a well). therefore, it is important for companies that sell bottled water to also list the water source on the product label [120, 121] . in one study, indoor and outdoor swimming pools from five emirati schools were found to be contaminated with an average concentration of cryptosporidium between 1 and 15 oocysts/l. the ages of the swimmers were between 3 and 14 years old, who attended 1-3 swimming classes per week [113] . due to the hot weather in the gcc countries, many swimming pools are available at schools, hotels, parks, and residential areas that are frequently used by many individuals from various age groups. formed faecal incidents (poop) pose a risk for the spread of infectious disease, including parasitic protozoa [122] . the cdc's healthy swimming program has indicated that escherichia coli, a faecal indicator, has been detected in 93 (58%) of the swimming pools samples, and further explains the necessity of regular monitoring for chlorine-resistant cryptosporidium oocysts [123] . detection can signify that swimmers have introduced contaminated faecal material into swimming pools either when it washes off a swimmer's body or by release of a formed (or diarrhoeal) faecal incident into the water. the overuse of swimming pools can significantly compromise the effectiveness of proper cleaning and decontamination efforts. the risk of contamination for cryptosporidium in swimming pools is therefore estimated to be very high in spite of use of filtration and chlorination as a cleaning and sanitization method [113] . the usage of chlorine as a water disinfectant is known to be effective against many microorganisms; however, cryptosporidium oocysts are resistant to the effects of chlorine [124] and various environmental stresses, such as extreme temperature variations [40] . the oocysts are small (5 µm) and have a low infectious dose (1-10 oocysts), and reportedly has the ability to maintain viability in water longer than 6-12 months or longer with the capability to cause epidemics, even after the consumption of purified drinking water [2, 125, 126] . in the gcc countries, bacterial and fungal indices are routinely tested in different water resources [113, 127, 128] ; however, only scientific institutions care to identify the absence or presence of cryptosporidium oocysts in water samples. the dubai municipality environmental safety inspectors, who send samples to the central laboratories, do not consider the presence of cryptosporidium oocysts in swimming pool water as an indicator of its quality, while instead mainly focusing on monitoring for bacterial indicators [113] . the national, the leading english news service of the uae, has warned against the failure to keep uae pools clean due to insufficient disinfection and expressed concerns for infectious disease in swimming pools, including parasites that are known to cause severe diarrhoea amongst children. they have reported that when humans become infected with cryptosporidium, they can act as carriers and release its chlorine-tolerant-oocysts into the swimming pools, and suggested that uv irradiation be applied instead of ineffective chlorine for the disinfection of swimming pools [129] . it remains uncertain, however, whether and in what extent uv treatment has a real impact on cryptosporidium during the water treatment process. only public and private action on such warnings in all gcc countries can help protect the most vulnerable populations (e.g., children and immunocompromised individuals) from becoming infected with cryptosporidium. cryptosporidium oocysts have been detected in 94.4% of the irrigation water used in public parks in uae [114] . cryptosporidium oocysts have also been found in chlorinated water samples, as well as effluent samples collected from sewage treatment plants [114] -an indication that the water treatment systems (wastewater disinfection) have failed to eradicate the transmissible stages of cryptosporidium in the water treatment process. in the uae, it is not routine to test for the presence of cryptosporidium oocysts in recreational water and reclaimed wastewater, while bacteriological (total and faecal coliforms) indices are the only biological parameters used to assess their water quality [114, 130] . the gcc countries produce a large amount of wastewater with an average of 2.853 bm3/year [104] . this wastewater has been reported to contain a wide range of pathogens, including parasites, viruses, and bacteria [131] [132] [133] , and represents a real challenge when designing conventional treatment plants that can meet the health guidelines of the environmental protection agency [131] . status of average renewable water resources per capita in the gcc countries has already shown a warning sign, and due to the water crisis conditions they often use improperly disinfected wastewater for irrigation [134] . water contamination with cryptosporidium is an under-recognised and under-investigated problem in the gcc countries, and probably one of the main sources of diarrhoeal diseases in the region. political and social support is required to include cryptosporidium and other protozoan parasites in the testing framework for water quality and reuse of treated water. a lack of water surveillance systems has been noted in the gcc countries. water research that includes analyses of the cryptosporidium genotypes and subtypes will help strengthen the available information about the extent of this pathogenic parasite and its main sources. it would be also effective if the gulf governments consider funding infrastructural projects to efficiently treat water using good installation facilities and proper pre-treatment of chemicals in the process design. in the gcc countries, only a small number of studies have been performed on the presence of cryptosporidium in different animals. however, nine of the published studies have emphasized the concept that animals can be a significant source of cryptosporidium infection in the gulf human population. whether they are used domestically or ridden during sporting events or leisure activities, various animals and birds (sheep, goats, calves, camels, lambs, arabian oryx, falcons, and stone curlews) have tested positive for cryptosporidium infection in the gcc region (table 4 ). on a well-managed omani farm that maintains closed herds of goats, sheep, cows, and buffalo, with regular vaccinations, a severe cryptosporidiosis outbreak has been reported in goats [137] . massive catarrhal enteritis with markedly enlarged mesenteric lymph nodes have been observed in post-mortem goats due to an invasion of large numbers of cryptosporidium oocysts. another diarrhoeal outbreak in the uae that has occurred was in juvenile stone curlews [141] . although the owner maintained a good breeding system for the stone curlews, they all became infected with cryptosporidium. numerous endogenous cryptosporidial stages were confirmed in their histopathological sections. despite intense supportive care, both outbreaks have resulted in a high mortality in animals (238 kid goats and 14 adult animals died) and birds (19 stone curlews died). c. parvum has been determined to be the main species that caused both outbreaks; however, both studies failed to recognize the main source of infection [137, 141] . domestic livestock, especially goats and sheep, are widely raised for meat production in the gcc countries [142] . in sa, 22.2% of sheep and 10.3% of goats have been reported to be infected with cryptosporidium on three farms located in riyadh [100] . in kuwait, likewise a wide range of domestic animals (goats, sheep, lambs, and newborn calves) have been screened for the presence of cryptosporidium infection [95, 135, 136] , where sheep and goats constitute the majority of its livestock. these animals have the ability to adapt to the arid climatic conditions (hot/dry season and wet/cool season). cryptosporidium has been reported to be prevalent in 11.4% and 7.2% of sheep and goats, respectively. c. parvum has been noted to be the dominant species responsible for the high frequency of caprine and ovine cryptosporidiosis, and infection is usually associated with a large-size herd (overcrowding in a closed housing system), poor hygiene, and poor management practices on the kuwaiti farms [95] . many animals were imported into kuwait, particularly cattle, to re-establish the animal industry after the end of the iraqi invasion. during the first three weeks of life, calves from eight dairy farms in sulaibyia have suffered from severe diarrhoea, being unresponsive to antibiotics, which ended with a calf mortality of 40% and morbidity of 20-60%. the authors have reported that cryptosporidium was the main attributor to the diarrhoeal aetiology in the neonate calf deaths [136] . housing pens with dirt floors, accumulated manure with no regular removal, early separation from dams, and an intensive system (large number of animals raised on limited space of land) have all been cited factors in studies that might help ease the transmission of cryptosporidium oocysts in calves [135, 136] . infected calves are known to excrete large numbers of cryptosporidium oocysts that might reach millions [143] and therefore likely able to rapidly transmit the infection among herds. it deserves mentioning that the sequence analysis of the c. parvum spp. in ruminants isolates (iida20g1 and iiaa15g2r1) from kuwait [95] have been previously documented as dominant subtypes in the infected kuwaiti children [50] , suggesting that domestic animals can be potential zoonotic reservoirs for cryptosporidiosis and a source of cross contamination in the environment. similar to the situation in kuwait above for cattle imports, cattle were flown into qatar to raise supplies of milk in the midst of a country blockade led by saudi arabia. according to the bbc news, the dairy cows (holstein) came from germany-the first of about 4000 cattle to be imported was first imported into qatar. air, sea, and land restrictions have created turmoil in qatar, which is dependent on imports to meet the basic needs of its 2.7 million inhabitants. several thousand cattle were later imported from other countries. it remains unknown what epidemiological significance such animals will have for the distribution of cryptosporidial oocysts in the country. animals, whether enjoyed during sporting events or for riding for pleasure, such as camels and captive birds (falcons and stone curlews), have become the focus of cryptosporidium research in sa and uae countries. in the sa city of riyadh, cryptosporidium has been ranked first among the microorganisms (escherichia coli, corona, and rota virus) that can cause diarrhoea in 15% of the symptomatic camel calves from that area [138] . samples of camel faeces in the same city have been noted to be highly infected with cryptosporidium oocysts (22.4%) compared to goats and sheep that were screened using mzn and elisa methods in another study [100] . camels are the principal domestic animal in sa and are used as a source of meat and milk. they are likewise used for racing sports and transportation [144] . in kuwait, camels are often utilized for pleasure rides beside families who are camping in the desert. although they are reported to be infected with cryptosporidium since 1991 [145] , they were excluded as a possible source of cryptosporidium infection in kuwaiti residents who had been infected during a camping incident [49] . in uae, researchers have tested for the presence of antibodies against many infectious diseases, including protozoa, and these have been reported in their racing camels [146] . camel racing in the gulf region has returned to the height of its cultural revival [147] due to its adaptation to life in the hot and arid regions [148] . although gulf camels have been known as carriers for many zoonotic parasites [149] , since 1994, screening for cryptosporidium and other protozoa has been probably ignored in camels and the people in close contact with them. zoonotic pathogens carried by camels are a current future risk to public health [150] . the role of camels in the transmission, distribution, and maintenance of cryptosporidium in the gcc countries should be investigated by governmental authorities and researchers alike, especially in light of the increased use as an increasing source of protein and a sporting gain. captive bred birds (e.g., falcons and stone curlews) are a popular hobby for arab falconers. in uae, two falcons have been identified with cryptosporidiosis during a routine health check. their faecal samples and lung tissues tested positive for c. parvum. in that study, the two falcons were totally asymptomatic for any intestinal or respiratory signs [140] . conversely, it was reported that c. parvum caused severe symptomatic manifestations (catarrhal enteritis) with a high mortality rate in captive stone curlews in dubai [141] . the uae has no routine testing for the presence of cryptosporidium spp. in birds, owing to the lack of regional specialized laboratories. even though both falcons were bred in the uae, unfortunately the authors of the study were unable to identify the source of the c. parvum infection and failed to check their owner, "the first suspect", for the possibility of having cryptosporidiosis [140] . a greater risk for cryptosporidium infection has been linked to a low socioeconomic status [19, 22] and travel to developing countries, where poor water treatment and lack of food sanitation are prevalent [151] . gulf researchers often use terms like expatriates, immigrants, or guests for people who come to gcc countries seeking a better financial situation. sustained economic stability and rapid socioeconomic developments have attracted expatriate workers with mass influx into the gcc countries. these multinational guest workers are mainly from developing countries with a low socioeconomic status [47] . a factor that has long been associated with the transmission of parasitic diseases and is one of the main focuses of research in the gcc countries. during the pre-employment stage (at the country of origin), expatriate workers are screened for the presence of ova and intestinal worms via stool analysis and culture. although the expatriates must be free of contagious and infectious diseases (hiv, hcv, and hbv) to be allowed entrance into the gcc countries, cryptosporidium, a known pathogenic protozoan, is generally not included on the medical examination list of investigations [152] . various studies in different gcc countries (sa, qatar, uae, kuwait, and oman) have monitored for intestinal parasites among expatriates. it has been reported that the majority of these workers, including food handlers, housemaids, domestic helpers, babysitters, drivers, and private cooks, have tested positive for parasitic infections in the arabian gulf [53, 63, 79, [153] [154] [155] [156] [157] [158] . the prevalence of cryptosporidium has been investigated among expatriates (adults and children categories) from oman, qatar, sa, and uae (table 1) , who have mainly originated from developing countries (afghanistan, bangladesh, ethiopia, india, indonesia, nepal, pakistan, philippine, sri lanka, turkey, egypt, and jordan). these countries are known to be endemic with many infectious diseases, including parasitic diseases. moreover, many risk factors have been reported to be associated with expatriate workers that predispose themselves to cryptosporidiosis [45, 47, 48, 76] . in the uae, expatriate workers mainly originate from asian, african, and arabic countries, where the majority of them are from asia. these migrant workers from asia have the highest prevalence rate of cryptosporidium infection among the guest worker population. in their home countries, they live in rural settings under crowded conditions and have poor sanitation, predisposing them to infectious diseases. migrant workers are often required to stay in similar living conditions in their cgg work destinations, where they may have to live in labour accommodations and share the same bedroom (with ≥6 persons) and toilet (with >5 persons) with many people [47, 48] . during the umrah season in makkah, sa, there is crowding of a hundred thousand muslims from different nationalities with close contact and congestions between the pilgrims and local inhabitants. the overcrowding and overcapacity of available accommodations has been noted as an important risk factors for cryptosporidium infection during the umrah season [60] . in qatar, expatriates from western and eastern asia as well as north and sub-saharan africa have been examined for risk factors and the prevalence of cryptosporidiosis. in the gcc countries, many asian individuals (indian and filipinos) who hold jobs, such as housemaids, builders, mechanics, cleaners, masons, and carpenters (blue collars), have tested positive for cryptosporidium infection. at the country of origin, expatriates who have been infected with cryptosporidium had many of the risk factors associated with parasitic infection, including a low education level (elementary school only), low home index, low monthly income, and those who were accustomed to using pit latrines [45] . children of expatriates from the middle east, asia, africa, and the local qatari population have been examined for intestinal parasites, whereas c. parvum was the most common incidental parasite affecting 14.7% of cases. surprisingly, qatari nationals had the highest number of parasitic infections from any other group tested in spite of fewer reported cases in the local qatari population when compared to the expatriate groups (168 versus 412) [46] . in oman, it has been reported that many of expatriate indian food handlers were infected with multiple intestinal parasites, including cryptosporidium. the authors have stressed in their report that it is necessary to screen food handlers for parasitic infection using different diagnostic methods, especially before these individuals are allowed to work in restaurants, hotels, factories, and private homes [63] . poor personal hygiene among expatriate food handlers has been emphasized in the literature to be a significant contributor to foodborne outbreaks [159] . in the context of good hygiene and safety in food handling, multiple risk factors linked to expatriates in the gcc region are noted to promote cryptosporidiosis, which is a threat to public health. social marginalization in the form of low socioeconomic status, low living standards, low education, overcrowding, and unhygienic practices (lack of personal hygiene and/or non-practicing of proper hand washing before eating or handling food) are high risk factors for cryptosporidium infection. symptomatic expatriates (mainly food handlers and housemaids) have a greater potential to inadvertently introduce contaminated faecal material into the food industry when working with food and food processing facilitates and equipment (indirect pathway) or by infecting another person in the household or business of their employer (direct pathway). if this happens, cryptosporidium oocysts will circulate in the community (locals and expatriates) until this outbreak cycle can be halted. cryptosporidium oocysts are well known to be environmentally stable, allowing them to be highly infective within vulnerable groups (e.g., children and immunocompromised individuals). accordingly, it is crucial to increase the health awareness among expatriates (particularly food handlers, housemaids, and babysitters) about different transmission routes of cryptosporidium and the important requirement for its prevention and control. it is interesting to note that the prevalence of cryptosporidium and other intestinal parasites in expatriates has been reported to be lower in gulf studies when compared to the population of their home countries [46, 63, 160] . there has not been a single study that compares the prevalence of cryptosporidium infection between expatriates who have recently entered a gcc country and those who spent a long period of time there. the discussion table comes with a significant point about the source of infection. either expatriates come from their home country with the infection, or they have been infected in the country of their employment. further studies on the health status of gulf natives are therefore urgently required to get a true estimate of the source of cryptosporidium prevalence and finally answer the following questions: who is infecting whom? do foreigners import cryptosporidium oocysts and other infections to the gulf, or are the gulf locals actually infecting the foreigners? more research is needed to clarify cryptosporidium transmission cycle in the gcc countries. the high economic position of the ggc countries has established itself among the more food-secure and high-income countries in the world. this situation has created significant pressure on the available natural resources and food production capability in the region. the six gcc states have limited control over their food sources and production capabilities with limited sustainability due environmental challenges [35] . additionally, the population of the gcc countries has significantly expanded due to the invitation of large numbers of expatriate guest workers who are needed to help industrialize and urbanize these affluent oil producing countries. in the gcc region, many efforts have been made to transform the arid deserts into more habitable areas by using progressive desalinization and desertification processes. moreover, many challenges must still be overcome to tackle this difficult environment (high temperature and scarce water), where its soils are sandy, fragile, and poorly enriched with organic matter [161, 162] . agricultural land in the gcc countries accounts for 19.5% of total land area available, whereas only 1-2% is actually arable (cropland regularly ploughed or tilled) [163] . therefore, the gcc countries are forced to rely on imported food to meet their high demands [35, 52] . approximately 90% of the gcc's food and drinks are imported. annually they import around 33 million tons of foods with expectations to increase in the future to satisfy their expanding economies [164] . therefore, great emphasis is placed on food safety and security for all imported foods into the gcc countries, including legislation and guidelines to safeguard the quality of the imported food [37, 165] . however, their traditional food safety systems have not properly developed to identify potential problems (e.g., infectious disease and parasites) in the food supply before they occur, but rather they are organized to respond to foodborne outbreaks [166] . contaminated food and drinks with cryptosporidium oocysts and other pathogenic microorganisms are important routes for foodborne outbreaks of cryptosporidiosis far and wide. the catering and food service industries use many high-risk food materials (vegetables, fruits, shellfish, and meat) that are potentially contaminated with cryptosporidium and have been responsible for occasional outbreaks in the past [18] . the gcc countries, along with other middle east countries, have been classified to have the third-highest estimated burden of foodborne diseases per population, directly behind the african and south-east asian regions. foodborne pathogens in these regions have caused illnesses in 100 million people per year, and 32 million of those affected are children under five years [167] . gastrointestinal infections that are frequently seen in the gulf region are primarily caused by salmonella spp., followed by shigella spp. and other pathogens like hepatitis a virus and parasites [166, 168] . consumption of unpasteurized dairy products and commercial meat products have been implicated in foodborne diseases in kuwait, oman, and sa [165, 169] . in jeddah, sa, there has been a rapid increase in the number of fast food businesses owned by immigrants from developing countries who have not had adequate training in food hygiene. fast food dishes have a great potential for food contamination due to undercooked meat that does not reach the criterial temperatures to kill microorganisms [87, 170] . there are scattered reports about the role of bacteria and viruses as causative agents of foodborne diseases throughout the gcc region. often, parasites, including cryptosporidium, are the causative agents in foodborne diarrhoea; however, the actual available reports on diarrhoeal cases in the arabian gulf are scarce or non-existent. only one study in qassim, sa, has investigated the different types of leafy vegetables (green onion, red radish, garden rocket, lettuce, and parsley) for the presence of parasites. the authors reported that all vegetables tested in the study had been contaminated with a variety of parasites, such as giardia, balantidium coli, entamoeba, cryptosporidium, trichuris, enterobius, and taenia [171] . other foodborne outbreaks have been documented in sa [172] . however, microbiological surveillance has been performed in the 31 reported foodborne outbreaks, while only salmonella spp. and staphylococcus aureus were the identified pathogens from outbreaks. moreover, the authors declared that many foodborne outbreaks occur every year in the kingdom of sa [172] ; however, cryptosporidium and other foodborne parasites have been nevertheless excluded from such investigations. the gcc ministerial committee for food safety has established joint legislation and regulations on food safety based upon the certainty that imported foods may represent human health and environmental safety challenges. the food safety guidelines represent health certificates forums, technical regulations, and standards that list food categories and their certification requirements. the technical regulations emphasize the microbiological criteria and the general safety standards for contaminants and toxins [173] . regrettably, the guidelines do not specify any regulations or laws concerning food safety from parasitic contamination, which have caused foodborne outbreaks such as cryptosporidiosis. it is important to note that imported food could be contaminated with cryptosporidium oocysts (a) from the country of origin due to contamination from animal or human faeces in the water or soil sources used to produce the food, or infected individuals that grow and store the food; (b) from infected individuals transporting the food on the way to the designated country; or (c) from within the destination country via infected food handlers or businesses that store the imported food in improper conditions or washing and preparing food with contaminated water. gcc countries must apply well-developed strategies for prevention and control of foodborne cryptosporidiosis. the food security strategies must include surveillance systems in the health care system and food industry that monitor for the presence of cryptosporidium oocysts. in addition, they must establish an epidemiological information system with local governmental authorities that also partners with applied researchers towards the advancement of technologies that can effectively detect and disinfect oocysts in food and water supply. there are needs to be a modification of current regulatory standards that specifically includes parasitic contamination in imported food and educational programs made available to food handlers in order to further reduce the risk and the incidence of foodborne illnesses, such as cryptosporidium infection. the miniscule size of cryptosporidium oocysts has the capability to disseminate across the air, where they could be inhaled and cause infection in humans and animals [174] . inhalation of oocysts from contaminated air can infect the respiratory tract and manifest respiratory symptoms [175] [176] [177] . cryptosporidium oocysts have been observed in 60% of the investigated air samples in mexico [174] . direct contamination with faecal material because of the lack of sanitary infrastructure results in a greater dispersion of soil via airborne dust during dry season, particularly in those places where people are exposed to large amounts of outdoor dust [174] . the gcc countries are characterized by arid climatic conditions (long, dry, hot summers and short, relatively warm winters) [49, 95, 113] . weather conditions, such as heat, wind, and a lack of rainfall, have significantly contributed to dust and the formation of the gcc countries' regional climate [178] . therefore, the gulf population has a higher exposure to large amounts of outdoor dust, which puts them at risk for cryptosporidium infection from contaminated air particles; more so if they have close contact with infected livestock. it has been reported in the epidemiology of cryptosporidiosis that respiratory aerosol droplets from infected individuals can be one of the crucial factors in the transmission, rapid spread, and continuous circulation of cryptosporidium oocysts. evidence has suggested that oocysts can be transmitted via respiratory secretions as well as through the more common faecal-oral route [177] . it has been documented that wind can increase the spread of viruses in the saliva and respiratory droplets when someone coughs or sneezes. studies have demonstrated that airborne particles from sneezes can travel up to 6 m in 1.6 s with an accelerated dispersion rate [179] . the same scenario also could occur with respiratory droplets from individuals infected with cryptosporidium oocysts. it has been shown that cryptosporidium oocysts are able to infect epithelial organoids derived from human lungs and are successfully able to complete their lifecycle [180] . the risk of illness for cryptosporidium oocyst air inhalation has been found to be very high and has shown to reach above the safety guidelines of its presence in water (1 × 10 −4 ) [174] . with or without symptoms, cryptosporidium oocysts are involved in the respiratory tracts of avian and some mammals, which includes a small number of human cases [177] . all of the published research studies from the gcc countries have not included or excluded questions regarding respiratory symptoms in the diagnosis. however, respiratory cryptosporidium infections have been reported to occur in immunocompetent children with enteric cryptosporidiosis, individuals with an unexplained cough, and in immunocompetent adults with tuberculosis from uganda [175, 176] . it is worthy to stress that 35% of children with intestinal cryptosporidiosis and cough had cryptosporidium dna in their respiratory secretions [175] , which validates the potential for cryptosporidium to be transmitted by cough, sneeze, and expectoration from those who have cryptosporidial infections and diarrhoea. in the uae, two asymptomatic captive falcons were identified to have cryptosporidiosis and tested positive for c. parvum in their lung tissues by molecular analysis. in addition, the main endoscopic findings from the cases indicated an infectious process in the ostia, caudal lung field, and caudal thoracic air sacs with an accumulation of inflammatory cells. acid-fast positive cryptosporidial oocysts was identified as the cause of the infections in the report [140] . although, the cryptosporidium infection in the falcon's lungs could have come from the spread of infection from its intestines, the airborne transmission should also be taken into consideration as the initial source of infection, which further illustrates the potential for airborne cryptosporidium transmission in humans. there are a limited number of respiratory cryptosporidiosis cases reported in the gulf countries; however, the extent of this type of lung infection has yet to be established in the region. more research is needed to verify the actual risk from cryptosporidial respiratory tract infections in the gulf human and animal populations. already researchers have shown that breathing has the potential to release aerosols from infective individuals into a room [181] . recently, investigators have reported the use of computational multiphase fluid dynamics and heat transfer to demonstrate the transport, dispersion, and evaporation of saliva and respiratory particles that can arise from the human cough. they have calculated the effect of wind speed on social distancing safety measures during the covid-19 pandemic. interesting to note that when they considered all the environmental conditions, they concluded that a safety measure of 2 m between people is insufficient to completely prevent the inhalation of respiratory particles and droplets [179] . it is advisable that when managing patients infected with enteric cryptosporidiosis, particularly in those who have unexplained respiratory symptoms, they should be isolated or given face masks as a precautionary measure to avoid the spread of cryptosporidium oocysts from their respiratory droplets that can be released when coughing or sneezing. therefore, patients should be advised to always protect their mouths and noses with handkerchiefs when they cough or sneeze. routine diagnostic and surveillance systems are an important part of public health and the treatment of infectious diseases. they have the power to prevent outbreaks and save lives. cryptosporidium and other parasites have not yet been included in the routine diagnostic and surveillance systems of the gulf regions. however, the apparent disease burden of parasitic infections and other infectious disease has been cited in the literature from these gcc countries. the limited number of reports that was found in this review indicate that cryptosporidium has almost infected every element of the gulf region; in addition, the burden of this parasite in humans, animals, and food and water supplies is starting to show up more in the published literature. cryptosporidium has definitely had a negative impact on the economic prosperity and public health in this region, while much of this burden has been underrecognized, underestimated, and underreported in reports. many of the risk factors for contracting cryptosporidium are an everyday reality for the inhabitants of the gcc countries. the most vulnerable groups (e.g., children under 5 years and immunocompromised individuals) are the most susceptible to the adverse effects of cryptosporidiosis and should be protected from this preventable infectious disease. molecular analysis of cryptosporidium from isolates in the gulf population have revealed the presence of zoonotic and anthroponotic transmission according to the published reports. desalinated water and other drinking water sources in the gcc countries have been found to be contaminated with cryptosporidium oocysts. defective waste management systems and water treatment plants have been found to be a source of septic pollutants in the drinking water supplies. camels and other animals often accompany owners to sporting events and leisure activities in the gcc countries, which has been noted to be a significant source of zoonotic cryptosporidiosis in the region. cryptosporidium outbreaks have been recorded in animals by incidental or accidental findings. authors have commented that many of these cryptosporidiosis outbreaks in animals from gulf region continue be undetected or underreported in the literature. expatriates workers have been found to be a source of "imported" cryptosporidium infection via food handling and poor hygiene; however, more detailed investigations are needed to compare this group of the population with the native inhabitants of the area. large quantities of food are imported to feed the expanding work force in the gulf region. food is usually imported from low socioeconomic countries that are associated with a higher risk of contracting cryptosporidiosis due to their social and economic situation. food safety and security legislation has been enacted in the gcc countries to prevent foodborne outbreaks in the region. however, their regulatory standards for imported food still lack many of the parasites known to cause outbreaks, such as cryptosporidium, in their screening protocols. this needs to urgently change so that the prosperity of the local economy and the most vulnerable populations are protected from the burden of foodborne outbreaks in the gulf region. imports of animals, such as cattle, may impact the known epidemiological importance of the release and transmission of cryptosporidium oocysts. a new animal reservoir with its related implications is generated in the gcc countries due to political tensions in the region. further research is required to quantify the influence of transmission parameters such as the infective airborne respiratory droplets of cryptosporidium on disease burden, along with those of other pathogenic microorganisms. more research is needed for the development of highly effective disinfection methods to treat cryptosporidium contamination in swimming pools and the water supplies, e.g., bottled water and ground water. the gcc countries should include cryptosporidium and other parasitic pathogens in their public health protocols for the routine screening of infectious diseases in human and animal faecal samples who have contact with the food and water supply in order to avoid outbreaks. the airborne transmission of cryptosporidium oocysts is highlighted due to the particularly windy and dry environmental conditions associated with this region. the wind has the power to circulate minuscule particles of dried infective faecal matter in the surrounding areas that can poses a threat to human and animal health. more published research is needed on the epidemiology of cryptosporidium in order to determine the true prevalence of this parasitic pathogen in the gcc 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regional climatic features of the arabian peninsula on coughing and airborne droplet transmission to humans modelling cryptosporidium infection in human small intestinal and lung organoids infectious virus in exhaled breath of symptomatic seasonal influenza cases from a college community this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we would like to acknowledge chad schou, university of nicosia medical school, 24005, cy-1700, nicosia, cyprus, for the time and effort devoted to improving the linguistic quality of this review. we write to express our appreciation for his detailed and useful comments, which have much improved the english language level of this review. key: cord-291113-iizj932l authors: cumbo, enzo; gallina, giuseppe; messina, pietro; scardina, giuseppe alessandro title: alternative methods of sterilization in dental practices against covid-19 date: 2020-08-08 journal: int j environ res public health doi: 10.3390/ijerph17165736 sha: doc_id: 291113 cord_uid: iizj932l sars-cov-2, and several other microorganisms, may be present in nasopharyngeal and salivary secretions in patients treated in dental practices, so an appropriate clinical behavior is required in order to avoid the dangerous spread of infections. covid-19 could also be spread when patients touches a contaminated surface with infected droplets and then touch their nose, mouth, or eyes. it is time to consider a dental practice quite similar to a hospital surgery room, where particular attention should be addressed to problems related to the spreading of infections due to air and surface contamination. the effectiveness of conventional cleaning and disinfection procedures may be limited by several factors; first of all, human operator dependence seems to be the weak aspect of all procedures. the improvement of these conventional methods requires the modification of human behavior, which is difficult to achieve and sustain. as alternative sterilization methods, there are some that do not depend on the operator, because they are based on devices that perform the entire procedure on their own, with minimal human intervention. in conclusion, continued efforts to improve the traditional manual disinfection of surfaces are needed, so dentists should consider combining the use of proper disinfectants and no-touch decontamination technologies to improve sterilization procedures. a dental office is an environment in which bioaerosols are regularly present, which are generated especially during the use of ultrasound or other hand pieces that produce sprays. the production of these microparticles, created mostly inside the patient's mouth, are therefore microbially contaminated and seem an inevitable phenomenon, because they are closely linked to the activity of the dentist. it is known that if patients carry microbes in the mouth and respiratory tract, they can spread them into the air by aerosolization [1, 2] . as a result, dentists can easily be exposed to infections due to the short distance between them and their patients, who could also transmit microbes by sneezing, coughing, or simply speaking. paradoxically, if a patient tries to reduce the spread of his disease by coughing on the hand, as a consequence, he produces more aerosols of small particles that are potentially more suitable for diffusion in the air. there are also other conditions to consider, such as the reduced spaces of dental operating rooms and, consequently, the sharing of a small space and the breathed air that could easily lead to the transmission of biological agents. an adult man breathes about 700 l of air per hour, and, in the event of hyperventilation (which can occur if the patient is anxious or frightened due to dental treatment), the total amount of air breathed per hour can significantly increase; the more air you breathe, the greater the risk of a microbiological transmission. life-threatening viruses, such as sars-cov-2, responsible for a severe acute respiratory syndrome that, according to who, has a mortality rate of 3.4%, could be present in the respiratory tract [3, 4] . in dental offices, any surface can be contaminated with viruses through contact with infectious body fluids or through the sedimentation of airborne viral particles [5] . on those infected surfaces, in order to represent a source of infectious risk, the virus involved must be able to survive until it encounters a new sensitive host; in fact, viruses, in general, are the so-called "obligate parasites", because they cannot multiply or propagate outside specific host cells. in order to effectively fight viral infections, it is essential to know the behavior of viruses in different environmental conditions in order to improve countermeasures, making them effective especially when the infection in question assumes particular importance because it is able to put patients' lives at risk. although, in the field of medicine, doctors are well-prepared on how to fight virus-based diseases, a new enemy like sars-cov-2, also known as covid-19, can test the entire healthcare system. this microbe belongs to a family of single-stranded rna viruses (well known as coronaviridae) that are said to be zoonotic or transmitted from animals to humans. at present, there is no effective medicine for sars-cov-2, so the only drugs used are those targeted for side effects in infected patients. in this case, the best defense weapon against the spread of the virus seems to be the attempt to limit the passage from an infected patient to a new host in order to minimize the exponential spread. cov-19. to transmit the infection to a sensitive host, it must be able to survive the aerosol process and persist in the air for a long enough time to allow transfer from one person to another. numerous factors influence the survival of viruses in the air: (1) particle size, (2) atmospheric temperature and relative humidity (rh), (3) nature and composition of the aerosol, (4) atmospheric gases, and (5) irradiation [6] . all the factors mentioned are involved differently in promoting or delaying the survival of pathogenic viruses in aerosols, which are substantially airborne particles of various sizes. particles behave differently depending on their size: the larger ones settle quickly, but smaller-sized particles can remain suspended in the air for a long period of time. in a room with calm air, particles with a diameter of only 10 nm that fall through a height of 2 m take about 12 min to stabilize; under the same conditions, particles with a diameter of 40 nm would only take 40 s. furthermore, in the presence of turbulence or a simple flow of air, particles can move very far from the point of their generation, or they can remain suspended for several minutes. the smaller particles of an aerosol have a greater transmission potential for infections, because they can better penetrate and settle in the smaller passages of human lungs. the biggest threat of airborne infection in dentistry is known to be from particles smaller than 50 µm due to their ability to stay airborne and the potential to enter the respiratory tract [7] . the largest particles, greater than 50 microns in diameter, are called "splatters" and behave in a ballistic way; in fact, these droplets are expelled like bullets in a trajectory initially quite straight that, secondly, becomes curved. finally, they contact a surface or fall to the floor. these particles are too large and heavy to remain suspended in the air and are suspended in the air only for a short time. however, if the droplet starts to evaporate, its size becomes smaller and smaller and acquires the potential to remain in flight for a longer period of time. therefore, splatter droplets can be considered a potential source of infection in a dental environment; in fact, they have been implicated in the transmission of various diseases, such as sars and herpes. several studies show that the evaporation of water from small aerosol particles depends on the atmospheric temperature and the relative humidity level (rh). the evaporation of water leaves behind a residual particle that can contain organic and inorganic materials, as well as biological agents that, if not damaged by the drying process, are potentially infectious for sensitive guests [8] . therefore, the problem related to the resuspension in the air of previously dried infectious materials that could remain on work surfaces is of fundamental importance; in fact, if the infectious agents manage to survive, the direct or indirect contact of sensitive hosts with these surfaces could lead to the spread of infections. aerosol humidification studies have shown an increase in the recovery of infectious particles from certain types of viruses, such as the flu virus, indicating that the simple rehydration of virus particles in the air leads to their reactivation [9] . in contrast, other studies have shown that humidification can reduce the recovery efficiency of some types of viruses [10] . in any case, temperature and rh are the two most important factors, which often act in combination, in determining how long viruses survive in the air state. in general, the ability of viruses to survive in the air state is inversely proportional to air temperature, but there are exceptions. numerous studies on the infectivity of viral aerosols provide clues to understand how different climates influence the onset of many viral diseases. meteorological parameters are in fact important factors influencing infectious diseases, such as severe acute respiratory syndrome (sars) and influenza. yueling et al. showed a significant negative association between covid-19 mortality and room temperature, as well as absolute humidity. indeed, the daily mortality of covid-19 appears to be positively associated with the daytime temperature range (dtr) but negatively with the absolute humidity. hence, temperature and humidity are factors influencing covid-19 mortality [11] . it is generally believed that lipid-containing viruses survive better at low rh levels, and high rh levels are more conducive to aerial survival than lipid-free viruses [12, 13] . under certain experimental conditions, some types of viruses were found capable of surviving well at high and low rh levels but were sensitive to inactivation in the medium rh range; an example of such viruses is the flu virus [9] . contrary to this, other studies of the human coronavirus have shown that they survive the air state better at 20 • c when the relative humidity is maintained at 50%. other studies conducted on the human coronavirus have shown that, when the aerosols were kept at 20 • c/80% relative humidity, its half-life was only 3 h. reducing the air temperature to 6 • c/80% relative humidity can cause an increase in the half-life of the coronavirus to almost 87 h [14] . the ability of low temperatures to overcome the effect of rh on a wrapped virus such as coronavirus suggests that a reduced fluidity of the lipid bilayer may be involved in limiting the access of inactivating factors to the virus' nucleic acid or protein components. it is known that the stability of an aerosol in the air is influenced by the composition of the fluid from which the virus is aerosolized [15] . some studies on viral aerosols have been conducted using artificial spray fluids, and other studies have used natural substances such as saliva. consequently, the decay rates of artificially generated viral aerosols, under laboratory conditions, can be different from the natural aerosols of the same virus derived from body secretions, and in general, a protective effect of the natural spray is recognized. in dentistry, bioaerosols can be considered a mix of natural secretions, such as saliva mixed with blood, microorganisms, mucous membrane cells, restoration materials, dental particles, and water from handpieces normally used in dental practices. such aerosols are very common during different treatments, such as scaling and root planning using ultrasonic scalers or air polishing procedures; washing or drying with air-water syringes; and preparing the teeth with rotating instruments such as high-speed dental turbines, handpiece micromotors, or air abrasion [16, 17] . all experimental studies in this area have attempted to discover and develop chemicals in order to prevent the transmission of viruses by air. the viruses present in aerosols can be inactivated by the action of chemical gases such as propylene glycol vapors, which, for example, are effective against flu virus aerosols [18] . other studies have been conducted on hydrogen peroxide, chloramine, and hexylresorcinol tested on various viruses present in the air. the minimum concentrations of these compounds, necessary to determine a 99.9% reduction in 30 min, varied from 5 to 20 mg/m3; however, much higher concentrations of the same disinfectants were needed to bring about a 99.9% reduction in the virus titer on a contaminated surface. in order to improve the effectiveness of these chemical gases, their use has been proposed in combination with controlled rh levels; this combination could offer prospects for the effective disinfection of recycled air. both ionizing and nonionizing electromagnetic radiation affect the biological activities of microorganisms such as viruses depending on the wavelength, and their effects on biological materials differ significantly. radiation energy is also absorbed by materials around the microorganism, and these phenomena can indirectly influence the virus; in fact, radiation could alter, first of all, this material that becomes harmful to the virus due to the absorption of radiated energy that can be secondarily transferred to the virus, damaging it. uv radiation can introduce changes in bioaerosols, but its composition can influence what happens to the virus. although various changes in proteins and nucleic acids are known to be caused by radiation, it is important to evaluate whether they are relevant to the loss of the biological activity of viruses. among the ionizing radiations, we must also mention gamma rays, widely used in the field of sterilization, which are electromagnetic radiation derived from the radioactive decay of atomic nuclei. gamma rays have electromagnetic waves of shorter wavelengths and, consequently, transmit the maximum energy of the photon, with an enormous ability to penetrate and kill living organisms; in fact, among their applications, there is the sterilization of medical equipment [19] . dentists could treat, during daily practice, asymptomatic patients unaware of having been infected with sars-cov-2, which, in these cases, could be dangerously present in their nasopharyngeal and salivary secretions; therefore, an appropriate clinical behavior is needed in order to avoid the uncontrolled spread of the infection [20, 21] . covid-19 could also spread when dental patients touch a surface contaminated with infected droplets and then touch their nose, mouth, or eyes [22] ; if proper precautions are not taken, the dental office can expose patients to cross-infections. there are two different ways to deal with the problem: the first is to identify infected patients and postpone treatments (if possible) or refer them to the appropriate hospitals; the second is to consider all patients highly dangerous because they are potentially infected. it is time to consider a dental practice quite similar to a hospital surgery room, where particular attention should be paid to problems related to the spread of infections caused by air and surface contaminations, especially a time when viruses such as sars-cov-2 have emerged as an important public health problem due to their ability to spread through close person-to-person contact. there are so many aspects to focus on in order to reduce the spread of this dangerous viral infection and include environmental treatments, air ventilation, the use of personal protection, etc. in dentistry, conventional cleaning and disinfection have been used for several years, but their effectiveness can be limited by several factors-first and foremost, the right choice of products and the procedure adopted [23] [24] [25] [26] . serious errors such as the use of incorrect chemicals, inadequate dilutions, inadequate contact times, inadequate or numerically inadequate microfiber cloths or paper towels, and incorrect application methods that can spread pathogens from one surface to another can also occur. therefore, the dependence of the human operator appears to be the weak aspect of all procedures. the improvement of these conventional methods requires the modification of human behavior, which is difficult to achieve and sustain [27] [28] [29] . as alternative sterilization methods, there are some that do not depend on the operator, because they rely on devices that perform the whole procedure on their own, with minimal human intervention. these methods, which are often called noncontact disinfection systems (ntd), can be applied in the field of dentistry, especially now that important sterilization problems have arisen due to covid-19. ozone (o 3 ), also known as trioxygen, is an inorganic gaseous molecule; under standard conditions, its color is pale blue, and its presence is characterized by a pungent odor reminiscent of chlorine; most people hear it at concentrations of just 0.1 ppm in the air. o 3 as an oxygen allotrope that is much less stable than the diatomic allotrope o 2 ; in fact, it breaks down into oxygen, with a half-life of about 20 min. ozone is produced from o 2 through ultraviolet light or atmospheric electrical discharges and is present in very low concentrations, with its maximum concentration in the so-called "ozone layer" of the stratosphere, which absorbs most of the sun's ultraviolet radiation. ozone is used commercially only at low concentrations, so any concern about its instability and the risk that both concentrated gas and liquid ozone may explosively decompose at high temperatures appears insignificant [30] . the antiviral and antimicrobial properties of o 3 have been well-documented, and several macromolecular targets may be involved; this gas has been shown to kill the sars virus, which structure is quite similar to the new sars-cov-2. more precisely, ozone destroys viruses by spreading through the protein coating in the nucleic acid nucleus, causing damage to viral rna. at higher concentrations, ozone destroys the capsid or the outer protein shell by oxidation. most research efforts on the viricidal effects of ozone have focused on the propensity of ozone to break down lipid molecules in multiple-bond configuration sites. in fact, once the lipid envelope of the virus is fragmented, its dna or rna nucleus cannot survive. wrapped viruses, such as sars-cov-2, are generally more sensitive to physicochemical challenges than naked virions. although the effects of ozone on unsaturated lipids are one of its best documented biochemical actions, ozone is known to interact with proteins and carbohydrates. unlike liquid sprays and aerosols, gaseous ozone can easily penetrate all areas within a room, including cracks, fixtures, fabrics, under furniture surfaces, and on the floor [31] . ozone, with its great oxidizing power, therefore has many applications in the field of medical sterilization, especially when it is necessary to sterilize different types of surfaces (smooth or porous) containing dry or wet films of different viruses in the presence and absence of cellular debris and biological fluids [32] . such conditions are substantially present in any dental practice; therefore, its use could be widely adopted in these environments, especially in the case of the pandemic spread of dangerous viruses such as covid19. in this regard, some studies have shown that ozone gas is able to effectively kill the viruses transmitted by aerosols, with a reduction in the presence of viruses up to 99% [31, 33] . certainly, its use requires some precautions, because its high oxidizing potential makes ozone a powerful respiratory and polluting hazard; its presence, above concentrations of about 0.1 ppm, can cause damage to mucous and respiratory tissues in humans and, also, to plant tissues [34] . if the dental office has more than one operating room, this toxicity problem can be easily solved by using these rooms alternately; when a room is without people inside, the ozonator can be switched on without any risk. furthermore, to speed up the disinfection procedure, ozone can be converted into oxygen fairly quickly by means of a catalyst, and, in the absence of the latter, as an alternative method, strong ventilation is suggested. it is also important to emphasize that, when an ozone generator is used, some other precautions should be taken, such as the use of the remote control on the device or a timer, in order to always remain outside the room during the sterilization process; the procedure must also be performed with closed windows. other significant disadvantages are its ability to corrode and ruin certain materials, such as natural rubber, especially in the event of prolonged exposure; therefore, these materials can be temporarily removed if necessary [35] . during environmental sterilization by ozone, there is a correlation between the rh and efficiency of this procedure; in fact, it is assumed that the maximum enhancement effect is obtained by first increasing the ozone to the maximum level, followed by a burst of water vapor for increased rh greater than 70%-preferably, > 90%. otherwise, at ambient rh, the degree of inactivation is lower and more variable; therefore, the concentration of ozone, rh, and the exposure time seem to be fundamental. there are other important considerations that have emerged from studies in the literature-for example, both dry and wet virus films were found to be equally sensitive to ozone treatment and, at the same time, the nature of the surface on which the viruses are located, not that it makes any difference. the latter aspect can be considered positively, because the surfaces of fabric, plastic, metal, and glass are equally sterilizable, even when cellular debris, including blood, is present [36] . comparative studies have shown results on different sterilization procedures for operating theaters, and, in conclusion, the effectiveness of ozone seems to be comparable to the use of uv radiation or 2% glutaraldehyde, but without wasting products, ozone is also easy to insulate and does not require washing [37] . an air ionizer is a device which, through high voltage, can generate negative ions, which are particles with extra electrons, which give a net negative charge to the particle; conversely, the positive ions lack the electrons for which they have a positive net charge. ionizers use metal surfaces charged with electricity to create ions from air or electrically charged gases that attach to airborne particles that are then electrostatically attracted to a charged collector plate [38] . the simpler ionizer scheme contains a row of wires and a stack of large flat metal plates; between those wires and plates, a negative voltage of several thousand volts is applied. for safety reasons, the collector plates have a very low current (<80 µa); however, a high voltage ionizer can produce several billion electrons per second. the air flow first flows through the spaces between the wires and, then, passes through the stack of plates. thanks to the high voltage, an electric corona discharge ionizes the air near the electrodes, which ionizes the particles in the air flow, which are diverted to the grounded plates due to the electrostatic force; finally, the air flow removes the particles accumulated on the plates [39] . ionizers, which have been used to eliminate or reduce both bacterial and viral infectious agents suspended in the air [40, 41] , can be divided into fanless ionizers and fan ionizers. fanless ionizers are generally smaller and quieter devices that are less efficient in air purification; fan ionizers clean and distribute air much faster. some of these devices are called generations of wind electrons (ewg), which are filtration systems capable of purifying the ambient air from bioaerosols whose presence can be dangerous, for example, in operating rooms. usually, they are small devices capable of generating continuous air circulation through a network of electrodes; then, the air flow, which is drawn into the device, is sterilized by the electric field. numerous studies have been conducted over the years to develop different air purification procedures. among the various air sterilization technologies, filtration methods have become very popular [42] . the ewg air treatment significantly changes the characteristics of the microbes present in the air and shifts the main peak of the dimensional distribution of the microorganisms present in the air in the coarser bioparticles. the use of ewg sterilization seems to considerably reduce the concentration of live microbes present in rooms; in fact, several studies have shown that sterilization using the ewg system seems to be very promising, because the microbial load inside the chamber is greatly reduced thanks to the high voltage field (from 5 kvolt to 15 kvolt), which causes irreversible damage to the cellular film and disturbances in the replication of microbes following breakages of double-stranded dna [43] . however, the effectiveness of the sterilization process depends on several factors-for example, the size of the room and the number of people inside it, the working time of the device, and, consequently, the volume of air treated per hour. the best results are reported in confined spaces (e.g., 30 m 3 ) with no more than three people. due to the high voltage, significant ozone emissions have been demonstrated during ewg air filtration; it is known that the ozone emission can further reduce the number of live microorganisms in the air; however, the increase in the concentration of ozone in the rooms adversely affects the health of people. fortunately, studies have shown that applying a carbon filter to the ewg device results in a massive reduction in ozone emissions; of course, the addition of these special carbon filters also helps to collect biological and nonbiological aerosol particles [17] . numerous studies have shown a significant reduction in the spread of viral infections also among animals, and these results represent the hope of further applications in the human medical field [44, 45] . the electronic wind generator system allows people to stay in the operating room while it is turned on, with the advantage of not interrupting the workflow. all these devices are portable, so that they can be moved from one operating room to another to optimize time; obviously, this system does not work on contaminated surfaces but only against air contamination; therefore, it must be integrated with other methods, such as those based on chemical products. photocatalytic oxidation (pco) is a technology in the heating, ventilation, and air conditioning (hvac) sector. the main function of typical hvac systems is to control the temperature and relative humidity of the ambient air; moreover, thanks to the presence of mechanical or electrostatic filters, it is also possible to remove polluting air particles. if a carbon filter is present in the system, the gaseous contaminants or vapors emitted are eliminated. however, it is well-proven that filters, used to remove particles from the air, can pollute the air instead of cleaning it, especially if the humidity is high. in the case of absorbent filters, if the temperature or humidity increases, the volatile organic compounds (vocs) can be desorbed instead of being absorbed by contaminating the air [46, 47] . instead of adsorbing vocs on the absorbent filter, the photocatalytic process is able to oxidize them in co 2 and h 2 o and control biological contaminations. it is important to specify that pco, which can use uv radiation to energize the catalyst (usually tio 2 ) and oxidize bacteria and viruses, is not a filtering technology, as it does not trap or remove particles but is sometimes simply coupled with technologies filtering for air purification; in fact, it can be mounted on an existing forced air hvac system. the effectiveness of the photocatalytic filter depends on several parameters, such as the total air change speed, the type of filter, and the relative humidity; in any case, further research is necessary to establish whether this system is valid as a control of biological contamination in the field of dentistry [48, 49] . the decontamination system based on hydrogen peroxide in aerosols is a "no-touch" method that uses hydrogen peroxide (3% to 7%), which can be combined with the addition of silver ions (<50 ppm). this method, also called "hydrogen peroxide in dry mist", is based on the injection of an aerosol with particles ranging from 2 to 12 µ in size; this first phase is followed by passive aeration. the results obtained from these procedures are controversial; some studies have shown a significant reduction in microbes, including spores, but other researchers have shown incomplete eradication. like many other infection control strategies, there are currently no randomized controlled trials on the effectiveness of these systems in preventing healthcare-associated infections [50] [51] [52] . in this system, a heat generator is involved to create, from h2o2, a high-speed air/steam flow (30-35%). these generators are remotely controlled and may be able to measure the concentration of hydrogen peroxide vapor; some systems also have an integrated ventilation unit and dehumidifier designed to reach a humidity level set before the cycle starts [53, 54] . studies of these procedures have shown some efficacy against a variety of pathogens, including viruses and prions [55, 56] . ultraviolet (uv) light is an electromagnetic radiation invisible to the human eye, since its wavelength is shorter than the visible one and is between 400 nm and 100 nm, although, in some conditions, young people may be able to see ultraviolet light up to wavelengths of approximately 310 nm [57] . the uv spectrum, as a function of frequency, is divided into five segments: uv under vacuum (40-190 nm) , uv far (190-220 nm), uvc (220-290 nm), uvb (290-320 nm), and uva (320-400 nm) [58] . although uv rays are present in nature because the sun is a primary natural source, there are also artificial sources such as curing lamps, tanning booths, germicidal lamps, black lights, halogen lamps, mercury vapor lamps, discharge lamps high intensity, fluorescent and incandescent sources, and some types of lasers. due to its ability to provoke chemical reactions and to excite fluorescence in materials, uv light has a large number of applications in various fields, including medicine. in dental diagnostics, uv lights are used for the fluorescence of teeth with radiation exposure in small areas and doses not exceeding 5 j/cm2 [59] . uv rays are also one of the oldest known methods for decontamination from viruses, bacteria, and fungi; uvc germicidal lamps (220-290 nm) are mainly used in sterilization procedures, but the optimal wavelength for the best results is about 253.7 nm, since the maximum absorption wavelength of a molecule of dna is 260 nm. after uv irradiation, the dna sequence of microorganisms can form pyrimidine dimers, which can interfere with dna duplication, as well as lead to the destruction of nucleic acids and make viruses noninfectious [60] . in addition, the viral nucleic acid type, the host cell repair mechanisms, and the capsid structure of the virus play an important role in virus inactivation. uv radiation restructures the nucleic acid of the germs and destroys its replication ability; this is the reason why the viral nucleic acid type can play a critical role in the inactivation of the virus by uv rays. more precisely, viruses with rna or dna may be less sensitive to uv rays; important seems to be the presence or absence of the cell wall and its thickness. these are the reasons why ultraviolet radiation can be used in the field of sterilization-in particular, in environmental control against air and surface contaminations. uv irradiation seems to be effective even on surgical instruments, but if they have overlapping parts that remain in the shade, these procedures are not recommended; as a result, uv-c rays are mainly used in air and water purifications with good results; therefore, research on uv disinfection continues today [61] . ultraviolet light has proven effective against corona viruses and, therefore, could be used against covid-19 both in the case of bioaerosols and in the sterilization of contaminated environmental surfaces in which this microorganism is present-in particular, on products of unstable composition that cannot be treated by conventional means [62, 63] . contrary to most chemical disinfectants, uv rays have been well-recognized as an effective method for inactivating microorganisms, but their effectiveness for inactivating germs has been related to several parameters, such as the level of irradiation, the duration of irradiation (in general, the uv dose for a 99% viral reduction is two times higher than for a 90% viral reduction), and rh; at a high rh, a higher uv dose is required to inactivate viruses on contaminated surfaces [64] . the intensity of the uv light is dissipated with the square of the distance from the source, and this unfortunately limits the ability of the individual uv-c devices to disinfect large areas. a uv lamp intensity of 40 µw/cm 2 in the center of the work area is recommended to ensure surface decontamination; however, there are several sources that provide a list of uv dosages needed to kill a wide range of microorganisms [65] . the doses of lethal uv radiation necessary for viruses in the air are lower than those of viruses on surfaces; this can be explained by the fact that viruses can form aggregations on surfaces and that viruses can be less sensitive to uv rays if associated with water [66, 67] . it is known that all pathogens are sensitive to uv radiation, but this susceptibility between them is different. to classify this vulnerability to uv light, there is an index called z; the higher the index, the more vulnerable the microorganism to uv exposure [68] . in dentistry, there are two different methods of achieving a significant reduction of microorganisms by uv; the first method is based on devices capable of being effective only on microbes present in the air. in order to improve the quality of the ambient air, the air is forced into the device where the uv source is present, and, after adequate sterilization, it is released into the environment. this procedure allows people to stay in the room when the device is turned on, because there is no exposure to dangerous radiation, so air sterilization can be done for several hours without any risk. on the other hand, these devices are not effective on surfaces, including the floor, where microbes can be widely present. the second method is completely different, because it is based on the exposure to uv rays of the entire environment through the use of fixed uv-c sources strategically positioned to expose the largest possible area. alternatively, mobile supports can be used for a better and more flexible orientation of uv light towards contaminated surfaces. when considering uv-c irradiation to inactivate viruses on surfaces, special attention must be paid; in fact, the growth of microorganisms may occur in shaded areas, such as cracks or crevices where uv radiation may not arrive. the use of a mobile uv sterilization system could be the way to overcome this problem, even if the procedure becomes operator-dependent. this method, which exposes the entire room to uv rays, has the advantage of being effective simultaneously on surfaces and in the ambient air but cannot be performed if people are in the area due to negative health effects, such as the risk of skin erythema and photokeratitis. fortunately, most dental offices have two operating rooms; while one is in use, the other can be treated with uv radiation. all uv systems have numerous advantages; first of all, they are easy to use, and, unlike chemical gases such as ozone, they do not require the sealing of doors or air intakes; another advantage is that the whole procedure is relatively short. indeed, depending on the reflective surfaces in the room, an effective cycle can last differently, becoming shorter and more efficient if reflective objects and surfaces are widely present in the irradiated area. another side effect with the use of uv rays is the damage or discoloration of surfaces, especially if they are made of plastic [69] . among the different types of active and passive air purification technologies, the latter is based on units with special air filters capable of permanently removing any pollutants. these filters allow to obtain the right degree of purification based on the sizes of the particles; in fact, the air is forced through a filter, and the impurities are physically captured inside it. among the different types of filters, the high efficiency particulate stop filters (hepa) remove a very high percentage of particles and, especially, the highest classes remove at least 99.97% of 0.3-µm particles (defined by the united states department of energy) and are usually more effective at removing larger particles. following the specifications of the european union, the filtration capacity of hepa filters is divided into several classes ranging from >85% to >99.999995%. hepa was marketed in the 1950s, and today, this term is used to indicate a highly efficient generic filter [70] . hepa filters are used in various fields when contamination control is required, such as pharmaceutical production, as well as in hospitals [71] . the composition of the hepa filters is quite particular, because it is basically a randomly arranged fiber mat made of glass fiber with diameters between 0.5 and 2.0 µm. although the air space between the fibers is generally much greater than 0.3 microns, these filtration systems are designed to trap much smaller particles and pollutants, because they remain staked thanks to different mechanisms such as diffusion, interception, inertial impaction, and electrostatic attraction. in order to improve the level of filtration, hepa systems are also equipped with prefilters (activated carbon) that remove the coarser impurities (pm10 and pollen particles/10 µm) so that the final hepa fine filter remains more efficient for several hours, reducing the need to replace or clean it frequently. in any case, to ensure that a hepa filter works efficiently, it must be checked and replaced periodically. not changing a hepa filter when necessary is a risk, because it could cause, first of all, stress on the device itself and, secondly, an insufficient removal of harmful polluting particles from the air; in addition, attention must be paid to the amount of air passing through the filter, avoiding it bypassing the hepa filter. unlike other air purification systems, hepa filters do not generate harmful products such as ozone. some studies have revealed that it is possible to highlight the growth of microorganisms in bioaerosols in operating rooms even after sterilization, disinfection, and washing due to high humidity, poor ventilation, insufficient disinfection, and floor sweeping. hence, a hepa filtration system could help reduce the bioaerosol levels in these environments, including dental environments [72] . the dental literature shows that different dental procedures produce both bioaerosols and droplets that are contaminated with microorganisms mixed with blood, saliva, dental debris, restoration materials, etc. these aerosols represent a real potential pathway for the transmission of diseases between patients and dentists, but there is also the possibility of cross-transmissions between the patients themselves if the decontamination procedures are not ideal. in particular, if we focus our attention on bioaerosols, it seems clear enough that, even if the dental instruments and all surfaces are well-sterilized, an operating room with contaminated air could spread diseases among patients, considering that they spend most of their minutes with their oral cavities open. probably the easiest way to eliminate a contaminated bioaerosol is to ventilate the room for several minutes to allow a complete exchange of air, but there is no rapid clinical verification method that certifies that the air present in the operating room is free of contaminants; it is necessary to ensure that all contaminated air has been replaced with fresh and pure air. furthermore, simply opening the window may not be sufficient to guarantee the necessary exchange of air; in this case, you should rely on a forced ventilation system. this method could also be in contrast with maintaining the room temperature at constant and predetermined values, especially in very hot or very cold seasons. at this point, given the uncertainties of the results and the technical complications that could arise in the implementation of this exchange of air, it would be more appropriate to rely on more scientifically validated systems capable of treating the contaminated air and reducing, if not even zeroing with percentages close to 99%, microbial contaminations. now that the risk of spreading covid-19 is very high, it is necessary to pay particular attention to all the sterilization procedures that should be reviewed, improved, and perhaps used in combinations to obtain a final result that aims to complete the sterilization of all structures present in the operating room, including air, which for some dangerous diseases, such as sars-cov-2, is the transmission route. the latest "no-touch" decontamination technologies could help dentists achieve this important goal. in conclusion, continuous efforts are needed to improve traditional manual surface disinfections. in addition, dentists should consider combining the use of appropriate disinfectants and noncontact decontamination technologies to improve the sterilization of dental operating rooms, especially since the latter methods are independent of the operator. aerosol transmission of experimental rotavirus infection the scope of aerobiology. in airborne transmission and airborne infection; hers available online an interactive web-based dashboard to track covid-19 in real time covid-19 and dental practice viability and infectivity of microorganisms in experimental airborne infection aerosol 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adenoviruses, poliovirus and coliphages by ultraviolet irradiation inactivation of virus-containing aerosols by ultraviolet germicidal irradiation the importance of bioaerosols in hospital infections and the potential for control using germicidal ultraviolet irradiation an investigation of the changes in poly(methyl methacrylate) specimens after exposure to ultra-violet light, heat, and humidity the vacuum cleaner: a history protective effect of hepa-filtered operating room air ventilation with or without laminar airflow on surgical site infections concentration and type of bioaerosols before and after conventional disinfection and sterilization procedures inside hospital operating rooms key: cord-308652-i6q23olv authors: cobos-sanchiz, david; del-pino-espejo, maría-josé; sánchez-tovar, ligia; matud, m. pilar title: the importance of work-related events and changes in psychological distress and life satisfaction amongst young workers in spain: a gender analysis date: 2020-06-30 journal: int j environ res public health doi: 10.3390/ijerph17134697 sha: doc_id: 308652 cord_uid: i6q23olv a relentless stream of social, technological, and economic changes have impacted the workplace, affecting young people in particular. such changes can be a major source of stress and can cause a threat to health and well-being. the aim of this paper is to understand the importance of work-related events and changes in the psychological distress and life satisfaction of young workers in spain. a transversal study was carried out on a sample comprising 509 men and 396 women aged between 26 and 35 years old. the results showed that there were no differences between the men and women in the number of work-related events and changes experienced in the last 12 months, nor in terms of job satisfaction. the results from the multiple regression analysis showed that a greater number of work-related events and changes experienced during the last 12 months were associated with increased psychological distress and reduced life satisfaction amongst men, but this was not the case for women. although job satisfaction was independent from the men and women’s psychological distress when self-esteem and social support was included in the regression equation, greater job satisfaction was associated with greater life satisfaction for both men and women. it concludes that work-related events and job satisfaction are important for the health and well-being of young people, even though a larger number of work-related events and changes is associated with increased psychological distress and reduced life satisfaction for men only. profound social change has been taking place in recent decades in technological and economic terms, having an impact on work and workers. these changes are taking place at increasingly faster speeds and affect most countries across the world. from the late 1980s and, in particular, in the 1990s, researchers supporting different theoretical perspectives have recounted the consequences of the changes in manufacturing systems; the move from an industrial to post-industrial society. these changes go beyond the methods of organizing production, having a clear impact on working conditions and employment opportunities [1] . there is discussion around an environment characterized by volatility, uncertainty, complexity, and ambiguity (vuca) where companies, in response to almost unpredictable social expectations, undergo constant and rapid change [2] . among the effects of globalization, it is worth highlighting that economic, social, and health crises are no longer confined to just one country, but rather they spread to other countries-sometimes more quickly than others. within this context, working life has experienced significant changes, caused by an ever more global and flexible system [3] ; these are changes that are contributing to a significant loss of work, with an increase in unemployment, underemployment, and precarious employment throughout the world [4] . according to the international labor organization (ilo), the main problem in the world's labor markets is poor quality employment. millions of people are compelled to accept poor working conditions. recent data show that, in 2018, the majority of the total global working population of 3.3 billion did not have an adequate level of economic security, material well-being, and equal opportunities [5] . this tends to affect young people most of all, as individuals that are extremely vulnerable to an ever-changing environment, where situations of abnormal employment, temporary employment, part-time work, outsourcing, individual contracts, and self-employment prevail. the changes in the world of work that young people are facing, whether due to the introduction of new technologies or the type of employment in itself, take place in such a way that young people often do not have the chance to adapt to the position [6] . for millions of young people in the european union, finding a job is extremely difficult. in some southern european countries, more than half of all young adults are unemployed, a situation that was made even worse by the last financial crisis. this entails problems of a psychosocial nature, but can also have devastating consequences for the countries concerned-and the european union itself [7] in a post-brexit context, due to the social tensions that can arise from unemployment. in spain, in particular, youth unemployment rates double those of the adult population and affect more than half of the population [8] . the most relevant aspect has been the change in the industrial trend of male employment: stable jobs for life have made way for constant change with periods of unemployment, instability, and precariousness throughout one's working life. in addition to the difficulty of entering the labor market for the first time, replicated across europe, the problems arising from the spanish economy based on unstable productive industries must also be considered [1] . it could be assumed that this dynamic reflects the stamina of young people, but in reality it shows an overwhelming situation that hinders them in their daily routine, characterized by an uncontrolled flow of new demands that constantly force them to search for new jobs, which consistently fail to meet their expectations due to their temporary nature. according to vendramin [9] , switching jobs is part of a "normalized" journey of employment instability for young people. these changes are involuntary for 33.7% of women and 22% of men. the reality of young workers has been put in the spotlight by different visions. according to data from the ilo [5] , women are more likely to take casual work, and just like young people, they are prone to establishing weak ties with the employment market. it is undeniable that working is fundamental for the economic and psychological well-being of an individual, and of society in general [4] . in current day society, a person's job is one of their most important sources of identity and it plays a vital economic and social role for the majority of people [10] . however, employment and working conditions can involve factors that are not people-oriented, and this affects their well-being. the links between work and health have become a central issue in organizational literature, and workers are becoming more and more aware of the importance of health in their work-life balance [11, 12] . in terms of young workers, it is particularly important to understand that their initiation into the world of work is taking place under adverse circumstances; due to the lack of jobs currently on offer on the market and also due to the lack of appreciation for their personal conditions due to inexperience [6] . although work can be a source of stress, it is a fundamental aspect of life, as working age adults spend the majority of their waking hours at work [13] . work is particularly important for a young person's personal development, and due to the restricted possibilities of entering the labor market, they can end up accepting precarious employment with unfavorable conditions that put their physical and mental integrity at risk. it is worth nothing that, despite the employment crisis and the aforementioned changes in production systems, the vision and expectations of young spanish people with regard to work and professional life continue to be largely similar to those of previous generations. for them, work is a fundamental part of their lives, whether it is more instrumental and utilitarian (young people from an industrial background or from peripheral rural and semi-rural areas), or more self-fulfilling (young urbanites) [14] . in this respect, despite the fact that, among the realistic expectations of young spanish people is just how difficult it is to gain a foothold in the labor market, this does not mitigate a major psychological and social impact, which can trigger severe and significant consequences for individuals that endure over time [15] . such circumstances may be, in fact, an important source of stress that can alter the physiology and mental well-being of individuals [16] . work-related events and changes thus pose a threat to the health and well-being of women and men alike. in recent decades ample research has been carried out on the psychosocial risks of work, such as stress in the workplace, and a link was found between psychosocial risks and their consequences on physical, mental, and social health [17] . in accordance with data from the quebec national institute for public health [18] , there are several scientific studies that have shown that the presence of one or more psychosocial risks in the workplace can impinge upon workers' mental and physical health, increasing the risk of accidents. it was also stressed that workers with a low level of education working in precarious employment have to face increased psychosocial risks at work, which affects their health and hinders the possibility of improved life conditions. likewise, it was highlighted that men and women are not exposed to the same psychosocial risks in the workplace, but that women tend to be more exposed. it is important to understand that when assessing work-related psychosocial factors, analyzing job satisfaction is also important. although there is no sole definition, it is believed that job satisfaction reflects a pleasant emotional state where people value their work or work experience positively [19] . job satisfaction is a global concept that covers several aspects and is determined by specific work elements, such as the workplace or the job's characteristics, by specific personal factors such as skill or psychological status, and by non-specific factors such as demographic, cultural, and community aspects [19, 20] . there is evidence that job satisfaction has an impact on individual performance and company results, as well as affecting the health and lifestyle quality of the worker. for example, it has been found that job satisfaction is associated with trust in the company [21] , work performance [22] , and self-efficacy [23] , whilst workers that are unsatisfied can see their mental and physical health suffer due to mood changes or psychosomatic complaints, reduced efficiency, more time off, and more requests for a change in role [24] . symptoms of depression and anxiety have been named collectively as psychological distress [25] , although other symptoms such as somatic issues or insomnia are also included within psychological distress [26] [27] [28] . both clinically and in research, psychological distress is a commonly used indicator for mental health and psychopathologies [27] , as well as being associated with physical health. there is evidence showing that psychological distress is associated with higher mortality rates for various reasons [29] , and with several inflammatory markers [30] . it has also been found to increase the risk of diseases such as arthritis, cardiovascular disease, and chronic obstructive pulmonary disorder [25] . many of these effects have been studied less in young people than they have been in adults, perhaps due to morbidity and mortality rates being comparatively lower in the former group. it should be noted, however, that various health issues onset at a young age, which may affect the individual throughout the rest of their life [31] . self-esteem and social support stand out amongst the psychosocial factors related to health and well-being [32] [33] [34] [35] . self-concept refers to describing and evaluating oneself, including one's psychological and physical characteristics, qualities, skills, and roles. self-esteem is the degree to which such qualities and characteristics are perceived as being positive [36] . there are many factors that determine a person's self-esteem, including individual values, attitudes, wishes, family issues, and social factors related to work and the type of work [37] . there is evidence that self-esteem has consequences on central aspects of life and high self-esteem leads to good mental and physical health, satisfaction with close relationships, and social support [38, 39] , as well as being associated with job performance [37] and professional prestige and income [10] . across all societies, gender is fundamental in organizing work, and work is fundamental for socially constructing gender. although there is empirical evidence that men and women are similar in the majority of their psychological features [40, 41] , most societies believe that differences remain, and that they should take on different roles; and they are treated differently depending on the gender assigned to them at birth. gender is a social construct [42] that restricts people and gives them different roles and positions. traditional gender roles consider women as carers and men as the backbone of the family [43] , assuming that working is vital for a man's mental health, but somewhat secondary for women, whilst the opposite assumption occurs within family roles [44] . these assumptions are not supported by the empirical evidence that shows that the quality of job positions is associated with less psychological distress amongst men and women [44, 45] , and that the similarities between men and women are clearer than the differences, amongst a series of factors that are important for the family-work association [46] . despite this, it is still believed that the commitment of a woman to work is lower than that of a man, and the classification of gender is an important deciding factor when it comes to professional interests [47] . although there has been a trend towards more equal gender roles in recent decades [48] , gender stereotypes that present significant differences between men and women in terms of their features, occupations, and behavior still exist [49, 50] . in spite of a woman's role in the workplace having become more widespread in recent years in many countries [51] total working equality has not yet been achieved, with salary gaps and job segregation remaining [51] [52] [53] . an example of this is that men still dominate the more prestigious and creative roles, as well as the technical positions [53] . although the importance of research in the psychological aspects of work has received more recognition in recent decades, and research has been done on the psychosocial risks inherent to the workplace and the working environment [17] , the impact on health due to stress at work understood as work-related events and changes has been studied less. furthermore, the positive aspects of work such as job satisfaction or the presence of personal resources such as self-esteem, and social resources such as social support, are rarely considered in these studies. these are all variables that can differ from men to women and can be important in determining health and well-being. the aim of this paper is therefore to understand the importance of work-related events and changes experienced in the last year in psychological distress and life satisfaction for young people in spain, including satisfaction with the job role, self-esteem, and emotional and instrumental social support in the prediction model, all of which will be assessed by analyzing men and women separately. the hypotheses are: men and women who have experienced a greater number of work-related events and changes, and who report low job satisfaction, low self-esteem, and low social support will also report greater psychological distress. men and women who have experienced a lesser number of work-related events and changes, and who report high job satisfaction, high self-esteem, and high social support will also report greater life satisfaction. the sample consisted of 509 men and 396 women aged between 26 and 35 years old. the average age of the men was 30.13 (sd = 2.69) and for women was 30.08 (sd = 2.81), the difference was not statistically significant, t(903) = 0.28, p = 0.78. their professions were different: 37% was non-manual labor, 34.9% was manual labor, and 28.1% had professions that required university studies. there were also differences in their level of education, even though it was most common for them to have studied at university (41.8%), 33.7% had secondary school education and 24.5% had only basic education. more than half of the sample (59.3%) was single, 39% was married or in a civil partnership, and 1.7% was separated or divorced. psychological distress was assessed using scales of somatic symptoms, anxiety and insomnia, and severe depression as per the ghq-28 [54] , each of which includes 7 items that gathers information on general health over recent weeks. example items are "been feeling nervous and strung-up all the time?", "felt constantly under strain?", "felt that life isn't worth living?", and "felt that life is entirely hopeless?". the likert scale was used, allocating weightings from 0 (no symptoms) to 3 (greater discomfort). the internal consistency in the sample group of this paper for the 21 items is 0.92. life satisfaction was assessed with the satisfaction with life scale (swls) [55] . it is made up of 5 items with a likert-style 7-point response scale ranging from 1 (completely disagree) to 7 (completely agree). it is a tool that has been used in many countries, spain included, and has shown suitable psychometric properties for men and women [35, 56] . the internal consistency in the sample group of this paper was 0.84. the work-related events and changes were assessed using four items where participants were asked whether in the last 12 months they had experienced the following: (1) change of employment, (2) loss of employment, (3) starting new employment; and (4) change in employment conditions. each item was scored with a 0 if the person had not experienced it in the previous 12 months and with 1 if they had. the total score for work-related events and changes was obtained by adding together the responses from the 4 items, so the score range is between 0 (for the complete absence of work-related events and changes) and 4, which is the maximum score. job satisfaction was assessed using the job satisfaction questionnaire [57] . it is an open response test where there are 5 questions about whether the person is satisfied in their job, if it is the job they chose, if they want a change, and to what extent they feel fulfilled. the responses to each of the questions were scored quantitatively by applying a code created and approved by matud [57] . the internal consistency for the sample group in this paper was 0.76. self-esteem was assessed using the spanish version of the york self-esteem inventory [58] , a questionnaire made up of 51 items that takes an overall measurement of self-esteem, reflecting the assessment of several skills including personal, interpersonal, family, achievement, physical attractiveness, and the assessment of the degree of uncertainty in themselves. the answer format is on a 4-point scale that ranges from "never" (scored with a 0) to "always", which is scored with a 3. with this sample group in this paper the internal consistency was 0.94. social support was assessed using the social support scale [59] . it is made up of 12 items, answers to which are given on a 4-point likert scale that ranges from 0 (never) to 3 (always), and they assess the social support perceived emotionally (7 items) and instrumentally (5 items). the internal consistency of the sample in this paper was 0.84 for emotional social support and 0.80 for instrumental social support. furthermore, each participant was given a sociodemographic and employment data collection sheet. participants were volunteers and were not paid for their participation in this study. the sample was chosen through various work centers of spanish companies all over spain, from all production sectors. to collect data, the social networks of psychology and sociology students at 7 spanish universities were analyzed, who were trained for the testing step and received course credits for this task. after verbal informed consent was received, the questionnaires were completed individually on paper by people that met the following criteria: (1) aged between 16 and 35 years old; (2) with work experience and either working (work experience means having, or having had, a formal employment contract) or not; and (3) able to understand and speak spanish. this study is part of broader research on the importance of personal and social factors in men and women's well-being, and it was assessed positively by the animal research and well-being ethics committee at the university of la laguna (study approval no. 2012-0040). descriptive analyses were carried out to understand the socio-demographic characteristics of the participants. the reliability of the internal consistency of the study factors was calculated using cronbach's alpha coefficient. the comparisons between men and women were calculated using the student's t-test. the bivariate associations between variables were calculated using pearson's r correlation coefficient except for the educational level where spearman's rho was used as it is an ordinal variable with 7 levels, from 0 (for no studies) to 6 (for university studies spanning 6 years). to test the hypotheses and determine the importance of the number of work-related events and changes, job satisfaction, self-esteem and social support in psychological distress, and life satisfaction amongst men and women, hierarchical multiple regression analyses were made. the age and level of studies were incorporated at the first step (model 1) to control their effect. at step 2 (model 2), the number of work-related events and changes and job satisfaction. finally, at step 3 (model 3), self-esteem and emotional and instrumental social support were incorporated. the correlations and the multiple regression analyses were made independently for the sample of women and the sample of men. the statistical analyses were performed using the ibm spss statistics for windows software, version 22.0 (ibm corp., armonk, n.y., usa). sectors. to collect data, the social networks of psychology and sociology students at 7 spanish universities were analyzed, who were trained for the testing step and received course credits for this task. after verbal informed consent was received, the questionnaires were completed individually on paper by people that met the following criteria: (1) aged between 16 and 35 years old; (2) with work experience and either working (work experience means having, or having had, a formal employment contract) or not; and (3) able to understand and speak spanish. this study is part of broader research on the importance of personal and social factors in men and women's well-being, and it was assessed positively by the animal research and well-being ethics committee at the university of la laguna (study approval no. 2012-0040). descriptive analyses were carried out to understand the socio-demographic characteristics of the participants. the reliability of the internal consistency of the study factors was calculated using cronbach's alpha coefficient. the comparisons between men and women were calculated using the student's t-test. the bivariate associations between variables were calculated using pearson's r correlation coefficient except for the educational level where spearman's rho was used as it is an ordinal variable with 7 levels, from 0 (for no studies) to 6 (for university studies spanning 6 years). to test the hypotheses and determine the importance of the number of work-related events and changes, job satisfaction, self-esteem and social support in psychological distress, and life satisfaction amongst men and women, hierarchical multiple regression analyses were made. the age and level of studies were incorporated at the first step (model 1) to control their effect. at step 2 (model 2), the number of work-related events and changes and job satisfaction. finally, at step 3 (model 3), selfesteem and emotional and instrumental social support were incorporated. the correlations and the multiple regression analyses were made independently for the sample of women and the sample of men. the statistical analyses were performed using the ibm spss statistics for windows software, version 22.0 (ibm corp., armonk, n.y., usa). in table 1 are the correlation coefficients between the age, level of studies, number of workrelated events and changes, job satisfaction, self-esteem and social support with the psychological distress, and life satisfaction amongst men and women. as it is possible to observe, age is independent from the psychological distress and life satisfaction amongst men and women, and although for men said variables are also independent from the level of studies, women with a higher level of studies have less psychological distress and greater life satisfaction. for both men and women, a higher number of work-related events and changes are associated with increased psychological distress and less life satisfaction, whilst more job satisfaction, self-esteem, and social support are associated with more life satisfaction and less psychological distress. table 1 . correlations between the dependent and independent variables amongst men and women. table 2 shows the main results from the hierarchical multiple regression analysis in which the dependent variable was psychological distress for the male sample, with table 3 showing the female sample. as it is possible to observe, model 1 was only statistically significant in the female sample, albeit with the only statistically significant predictor being the level of studies (β = −0.17, p < 0.01). including the number of work-related events and changes and job satisfaction in model 2 produced a statistically significant increase in r 2 , with the beta weights being statistically significant for both variables amongst men but only job satisfaction amongst women. including self-esteem and emotional and instrumental social support in model 3 also produced a statistically significant increase in r 2 , although for the female sample only self-esteem was statistically significant (β = −0.50, p < 0.001), whilst in the male sample self-esteem (β = −0.49, p < −001) and instrumental social support (β = −0.12, p < 0.05) was. model 3, with all the independent variables in the equation, predicted 28% in table 1 are the correlation coefficients between the age, level of studies, number of work-related events and changes, job satisfaction, self-esteem and social support with the psychological distress, and life satisfaction amongst men and women. as it is possible to observe, age is independent from the psychological distress and life satisfaction amongst men and women, and although for men said variables are also independent from the level of studies, women with a higher level of studies have less psychological distress and greater life satisfaction. for both men and women, a higher number of work-related events and changes are associated with increased psychological distress and less life satisfaction, whilst more job satisfaction, self-esteem, and social support are associated with more life satisfaction and less psychological distress. table 2 shows the main results from the hierarchical multiple regression analysis in which the dependent variable was psychological distress for the male sample, with table 3 showing the female sample. as it is possible to observe, model 1 was only statistically significant in the female sample, albeit with the only statistically significant predictor being the level of studies (β = −0.17, p < 0.01). including the number of work-related events and changes and job satisfaction in model 2 produced a statistically significant increase in r 2 , with the beta weights being statistically significant for both variables amongst men but only job satisfaction amongst women. including self-esteem and emotional and instrumental social support in model 3 also produced a statistically significant increase in r 2 , although for the female sample only self-esteem was statistically significant (β = −0.50, p < 0.001), whilst in the male sample self-esteem (β = −0.49, p < −001) and instrumental social support (β = −0.12, p < 0.05) was. model 3, with all the independent variables in the equation, predicted 28% of the variability in psychological distress amongst men and 31% of psychological distress amongst women. for the male sample, psychological distress was associated with lower self-esteem, a higher number of work-related events and changes in the past year, and less instrumental social support whilst for the females it was only associated with a lower self-esteem. 6.32 (2, 393) ** 7.01 (4, 391) *** 26.72 (7, 388) *** note: β = standardized regression coefficient. * p < 0.05; ** p < 0.01; *** p < 0.001. table 4 shows the main results from the hierarchical multiple regression analysis in which the dependent variable was life satisfaction for the male sample, with table 5 showing the female sample. as it is possible to observe, model 1 was only statistically significant in the female sample where a higher level of study was associated to greater job satisfaction. including the number of work-related events and changes that had taken place in the last year and job satisfaction in model 2 produced a statistically significant increase in r 2 for men and women, with the beta weights being statistically significant for both variables, and showing that greater life satisfaction was associated to greater job satisfaction and a lower number of work-related events and changes in the previous year. including self-esteem and emotional and instrumental social support in model 3 produced a statistically significant increase in r 2 for men and women, with the beta weights for self-esteem and emotional social support in the male sample and self-esteem and instrumental social support in the female sample being statistically significant. model 3, with all the regression variables, predicted 27% of the variance in life satisfaction for men and 31% for women. for men, increased life satisfaction was associated with increased job satisfaction, greater emotional social support, higher self-esteem, and less work-related events and changes during the last year. for women, increased life satisfaction was associated to higher self-esteem, more job satisfaction, and greater instrumental social support. the aim of this paper was to understand the importance of work-related events and changes experienced in the last year in assessing psychological distress and life satisfaction for male and female young workers in spain, including these factors in the prediction model together with the number of work-related events and changes, and job satisfaction. self-esteem and emotional and instrumental social support were also included in the regression equation, with the aim of understanding the relative weight that social, personal, and work factors have on psychological distress and life satisfaction. a hierarchical regression model was used, and men and women were analyzed separately, given the evidence that gender is an important distinction in the workplace. it highlights that, in regression analysis, work-related events and changes experienced in the previous year and job satisfaction were statistically significant for men, but for women, only job satisfaction, was statistically significant. this coincides with what has been reported in literature [44, 45] ; for both men and women, the quality of job positions is associated with less psychological distress and better health. the fact that only job satisfaction was statistically significant for women could be a reflection of women facing situations of inequality, segregation, imbalances, and gender stereotypes in the labor market [49, 50] , which is still happening regardless of the academic level reached by this group in recent years. it is well known that gender places young men and women unequally in both the education and the labor market [60] . there is extensive literature on the gender gap, in general and in the spanish labor market in particular, which looks at employment discrimination, its evolution throughout the life cycle and, specifically, pay discrimination [61] [62] [63] [64] . employers still hold stereotypes about women's productivity and, in general, tend to regard women as being less committed to paid work than men [65, 66] . this reality is reported in studies that reveal the distribution of roles in accordance with gender in workplaces [51] [52] [53] , aspects, which are often highlighted in female working environments. with regard to the predictors of psychological distress and life satisfaction, there were some significant differences between men and women. in both groups, age was independent from psychological distress and life satisfaction, as was the case with the level of studies for men. for women, a higher level of studies was associated with less psychological distress and greater life satisfaction, despite the small size of the effect and its greatly reduced statistical significance when self-esteem and social support were included in the regression equation. the first hypothesis, proposing that men and women who have experienced a greater number of work-related events or changes, and who report low job satisfaction, low self-esteem, and low social support would also report greater psychological distress, was only partially supported. although in the male sample a larger number of work-related events and changes taking place in the last year and less job satisfaction predicted psychological distress (model 2), when self-esteem and social support (model 3) were included in the regression equation, job satisfaction ceased to be statistically significant in predicting psychological distress. for women, although in model 2 less job satisfaction predicted increased psychological distress, job satisfaction ceased to be statistically significant in predicting psychological distress when self-esteem and social support (model 3) were included in the regression equation. self-esteem ended up being an important predictor of psychological distress for the male sample and the only predictor for the females. these results coincide with those of other studies [33, 38] and confirm the importance of self-esteem on psychological well-being for both men and women. these results force us to consider the value of self-esteem and psychological well-being as health contributors, as highlighted by some authors in studies on psychological distress and the workplace [32] [33] [34] [35] . the results highlight the lack of importance of social support in predicting psychological distress, as it was only statistically significant in the male group, despite literature reporting social support as a protective factor of psychological distress. the second hypothesis, which proposed that men and women who have experienced a lesser number of work-related events and changes, and who report high job satisfaction, high self-esteem, and high social support would also report greater life satisfaction, was also only partially supported. in fact, in the male group, greater life satisfaction was associated with greater job satisfaction, increased emotional social support, higher self-esteem, and less work-related events and changes. however, for women, in the final model, when self-esteem and social support were incorporated, the number of work-related events and changes ceased to be statistically significant, and the social support, which was associated in a statistically significant way with greater life satisfaction, was instrumental and not emotional. this suggests that self-esteem and social support are valuable factors when surveying disrupting situations in life satisfaction for both groups. it should be noted that the perceived social support in particular has been considered by several authors as an element that facilitates protection against situations that create psychological distress. the results found highlight that there are differences between men and women in the predictive value of work-related events and changes in psychological distress, with job events and changes being much more associated with psychological distress in young men rather than women. this could perhaps be a consequence of traditional social practices and gender stereotypes that further underscore working roles amongst men more so than women [23, 47, 49, 50] , and therefore work-related events and changes could equate to a bigger threat for men's mental health than for women's. in any case, it also highlights that there were no differences between men and women in terms of their job satisfaction, and this was important for predicting life satisfaction for both sexes. the results allow us to broaden our knowledge about the relevance of work-related events and changes on the health and well-being of women and men. in this respect, the findings of our research serve as a basis for further studies aimed at the in-depth research into distress in young workers, including looking into factors that implicate the work environment as a potential trigger of psychological distress. in particular, the difference between men and women in the predictive importance that work-related events and changes have in psychological distress and life satisfaction (a construct that refers to the feeling of well-being with oneself in one's surroundings) has been highlighted, with this being much greater amongst young men than young women. in conclusion, work-related events and changes and job satisfaction are important for the health and well-being of young workers, even though a larger number of work-related events and changes amongst only men are associated with greater psychological distress and reduced life satisfaction. it is important to highlight that, for young workers, life satisfaction, social support, and self-esteem were shown to be important factors to considered in research in relation to the psychological distress created by adverse circumstances in the working environment. the study has some limitations and it should be noted that a convenience sample was used, so there can be no guarantee that this is representative of young spanish people. moreover, the study is transversal, so we cannot speak of cause-effect relationships. in addition, the percentage of variance explained in psychological distress and in life satisfaction does not exceed 31%. certain aspects could have been studied in greater depth, and remain open to subsequent study in greater detail. in particular, it would be interesting to use the holmes-rahe life stress scale, a psychological scale used to measure susceptibility to stress-induced health problems, as well as to introduce the locus of control as a study variable. finally, there should be some mention of the recent covid-19 pandemic. this study was carried out using the data of young spanish people collected in the last year. obviously, conditions have changed since the data were used, in a dynamic and changing context. we understand that the main results are still valid in this context, however, it is reasonable to consider highly likely that the socio-economic situation may be aggravated in light of the current situation, which may have an impact on the psychosocial occupational risks to which young people are exposed. empleabilidad de l@s jóvenes: formación, género y territorio (eject): informe final de proyectos de i+d+i; cso2014-59753-p the strategic position of human resource management for creating sustainable competitive advantage in the vuca world predisposition to change is linked to job satisfaction: assessing the mediation roles of 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professionals become mothers, warmth doesn't cut the ice this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-328784-9r5td4vy authors: papagiannis, dimitrios; malli, foteini; raptis, dimitrios g.; papathanasiou, ioanna v.; fradelos, evangelos c.; daniil, zoe; rachiotis, georgios; gourgoulianis, konstantinos i. title: assessment of knowledge, attitudes, and practices towards new coronavirus (sars-cov-2) of health care professionals in greece before the outbreak period date: 2020-07-08 journal: int j environ res public health doi: 10.3390/ijerph17144925 sha: doc_id: 328784 cord_uid: 9r5td4vy introduction: the ongoing severe acute respiratory syndrome (sars)-cov-2 pandemic has expanded globally. the aim of the current study is to investigate the knowledge, attitudes, and practices (kap) of health care professionals in greece towards sars-cov-2. methods: from 10–25 february 2020, 500 health care workers were approached. knowledge, attitudes, and practices towards sars-cov-2 were assessed via a personal interview questionnaire. for knowledge, each correct answer was given 1 point; attitudes, or concerns aimed at prevention of sars-cov-2 infection, and practices, or behaviors towards performing preventive practices, were assigned 1 point each. points were summed and a score for each category was calculated. results: a total of 461 health care workers returned the questionnaire and were included in the analysis (mean age ± sd: 44.2 ± 10.78 years, 74% females). the majority were nurses (47.5%), followed by physicians (30.5%) and paramedics (19%). the majority of subjects (88.28%) had a good level of knowledge (knowledge score equal to 4, or more). the majority of participants (71%) agreed with the temporary traveling restrictions ban. the uptake of a future vaccine against sars-cov-2 was estimated at 43%. knowledge score was significantly associated with both attitudes score (p = 0.011) and practices score (p < 0.001), indicating that subjects with a high knowledge score demonstrated a more positive perception on preventive measures and would practice more preventive measures. attitudes score was significantly associated with practices score (p = 0.009) indicating that subjects with a higher attitudes score are more likely to perform practices towards the prevention of sars-cov-2 transmission. conclusion: there is a high level of knowledge concerning sars-cov-2 pandemic among greek health care workers and this is significantly associated with positive attitudes and practices towards preventive health measures. the high level of knowledge of health professionals about sars-cov-2 may have contributed considerably to the successful management of the pandemic in greece. tailored educational campaigns aiming to increase the proportion of health care workers willing to accept a potential sars-cov-2 vaccine could be of paramount importance in future proactive vaccine educational campaigns. the novel coronavirus disease 2019 has spread into four continents, and human-to-human transmission has been confirmed [1, 2] . roughly 49 countries had confirmed cases of severe acute respiratory syndrome (sars)-cov-2 infection by the 29th of february 2020, and the overall numbers are growing [3] . at the end of february, most of the cases were in tourists from china or people who had recently been to china. since then, countries have reported cases in which a person who had not traveled to china contacted the virus from someone who had. some of those cases are spreading the virus as well, and the incubation period has been reported to be 5.2 days, although studies have suggested that it may be as long as 14 days [4] . after sars and middle east respiratory syndrome (mers) outbreaks, and the 2009 influenza h1n1 pandemic, the risk of a spread of a new pandemic has reemerged by a new strain of coronavirus that has not been previously identified in humans. the world health organization (who) declared the sars-cov-2 outbreak as a public health emergency of international concern on the 30th of january 2020 and then a pandemic on the 11th of march 2020, as a result of the worldwide spread of covid-19 [5] . according to the world meter (updated: july 2, 2020), sars-cov-2 has affected 213 countries and territories around the world. to date, 10,884,519 cases have been reported worldwide followed by 520,604 deaths and 6,085,813 recovered cases. in greece, there have been 3589 confirmed cases with 193 deaths [6] . the world health organization (who) rapidly developed advice to meet the need for recommendations of safe home care for patients with suspected sars-cov-2 infection presenting with mild symptoms as well as public health measures related to management of asymptomatic contacts [7] , while the centers for disease control and prevention (cdc) also published a guide with criteria for the evaluation of patients under investigation for sars-cov-2 [8] . health care workers in particular are extremely vulnerable to sars-cov-2 infection since they are frequently in contact with covid-19 patients [9] . in some countries as much as 10% of health care workers are infected with sars-cov-2 and the who has outlined the need for training of health care workers in order to reduce the rates of infection [8] the greek cdc also developed special recommendations for health care workers (hcws) [10] . despite the fact that health care workers play a central role in the response to covid-19, to our knowledge there is very limited information on the knowledge, attitudes, and practices of health care workers towards sars-cov-2. the aim of this study is to investigate the knowledge, attitudes, and practices of health care workers towards the covid-19. from 10-25 february 2020, a structured, self-administered, anonymous questionnaire was distributed via personal interviews to a convenient sample of 500 health care workers in five public hospitals during two consecutive days at work. the anonymous questionnaire was composed after taking into consideration the knowledge and practices from the health care professionals in central greece after the international guidelines were published by who and local directions by the hellenic public health authorities (greek cdc and ministry of health). health care professionals from five public hospitals from thessaly (one tertiary and four secondary) participated in the present study. ethical approval from the scientific committee of the university hospital of larissa (protocol number 5985-7/2/2020) was obtained. all participants provided verbal and written consent. three different groups of health care workers (i.e., physicians, nurses, and paramedical staff) were selected as survey subjects. the anonymous questionnaire was distributed to a convenience sample of 500 health care workers in five public hospitals and was completed voluntarily by 461 health care workers (92.2% response rate). the questionnaire included 18 questions for the assessment of knowledge, attitudes, and practices and demographics (including age, gender, district of residence, occupation, and previous work experience duration) (see online supplementary material). questions assessing recent travel history and the personal perception of the level of knowledge concerning covid-19 were included in the questionnaire. knowledge was assessed with eight questions. information for knowledge about sars-cov-2 was evaluated from the reports and the directions published by the international and local health authorities. attitudes and risk perception towards covid-19 (concerning preventive measures, preference for information source) and practices (concerning preventive measures, personal hygiene practices) were assessed. a five-point likert-type scale was used to ascertain the level of agreement or disagreement for the questions (from 1 to 5; 1 = fully disagree, 2 = disagree, 3 = uncertain, 4 = agree, 5 = fully agree). for some questions, response options included "yes", "no" or "uncertain" (see online supplementary material). scores for the different measures assessed (i.e., knowledge, attitude, and practice) were calculated as follows: for knowledge, each correct answer was given 1 point and an incorrect answer was given 0 points. for attitude, concerns aimed at prevention of sars-cov-2 infection were assigned 1 point. for practices, behaviors towards performing preventive practices were given 1 point. points were summed and a score for each category (knowledge, attitude, and practice) was calculated. especially for the knowledge score, respondents with a score of 1 to 4 were further categorized as "poor level of knowledge" and those with a score of 4 to 8 as "good level of knowledge". the questionnaire was designed and adjusted by the authors for knowledge, attitude, and practice (kap) study. a pilot test of the first draft of the questionnaire took place in two primary health centers and assessed the ability to complete the questionnaire. the time spent on the completion of the questionnaire was approximately 10-20 min. the results of the pilot testing were used in order to further modify the questionnaire and were excluded from the final analysis. absolute (n) and relative frequencies (%) were presented for qualitative variables and mean (±sd) were used for continuous variables. normal distribution was assessed by the kolmogorov-smirnov test. comparison between groups was performed with the use of student's t-test or mann-whitney u test according to variable distribution. chi-squared test was used for categorical variables. one-way analysis of variance (anova) or kruskal-wallis were used to compare more than two groups according to variable distribution. statistical analysis was performed using the spss 16 statistical package (spss, chicago, il, usa). statistical significance was defined as p-value < 0.05. mean age of the study subjects was 44.2 ± 10.77 years (table 1) . of the 461 participants, 119 were male (26%) and 341 were female (74%). the distribution according to work status of the participants was as follows: 47.5% were nurses, 30.5% were physicians, and 19% were paramedic staff. fifteen participants did not report their work position. all of the participants were of greek origin. mean work experience of the study participants was 17.9 ± 11.89 years. of the respondents, 17.2% had traveled abroad in the previous six months and 23.4% reported recent travel of a close family member. the vast majority of participants (99%) reported that they are aware of the covid-19 outbreak. the majority (69.8%) of respondents received information from tv/radio, 63% from internet/web pages/blogs, 28.1% from a physician, and 20.6% from the web page of the greek cdc. of the respondents, 76% reported that they knew who recommendations for sars-cov-2 and 55% claimed that they had sufficient knowledge for the recommendations published by the greek health authorities. a total of 50% of participants reported that sars-cov-2 can be transmitted through infected foods, 19 .9% reported that sars-cov-2 is sexually transmitted, and 99% identified the inhalation of respiratory droplets as a mode of transmission ( table 2 ). the majority of participants (85.4%) agreed that covid-19 is a cause for serious illness and death, while 88.8% reported that the symptoms of covid-19 may resemble that of seasonal influenza. in addition, 73% answered that a specific drug therapy for covid-19 does not exist and 83.5% reported that a vaccine specifically aimed for sars-cov-2 is not currently available. of the subjects included, 23.2% had a knowledge score of 6, 22.8% of 5, 18.5% of 4, 14.5% of 7, 7.7% of 8, 7.3% of 3, 4.1% of 2, 0.9% of 1, and 0.9% of the respondents had a knowledge score of 0. the majority of subjects (88.3%) had a good level of knowledge (knowledge score ≥ 4). overall, most of the respondents (94%) thought that active personal hygiene measures can reduce the risk of sars-cov-2 transmission, and the vast majority (98%) would follow special advice from the hospital infectious committee. only 43% of the participants mentioned that they would be vaccinated against sars-cov-2. the majority (84.8%) displayed a high attitudes score (equal to 2), suggesting a positive attitude concerning the prevention of sars-cov-2 infection. of the remaining, 13.7% presented an attitudes score of 1 and 1.5% a score equal to 0. most respondents reported that they were washing their hands often or very often and only 24.9% reported that they washed their hands before and after contact with the patient/patient's environment ( table 2 ). remarkably the majority of the participants (71%) agreed with the ban of traveling to countries with a high number of covid-19 cases. the majority of respondents (73.8%) displayed a practices score equal with 1 and 24.5% had a score of 2. only 1.7% of participants had a score of 0, suggesting that only few of the health care workers did not perform preventive practices aimed at sars-cov-2. subjects that were aware of who guidelines were older than subjects that reported not knowing the guidelines or subjects answering "uncertain" (45.70 ± 10.38 vs. 37.98 ± 10.65 vs. 40.85 ± 10.85 years, respectively, p < 0.001) and, in the same context, had more years of work experience (19.05 ± 11.23 vs. 13.51 ± 10.02 vs. 14.25 ± 10.54 years, respectively, p < 0.001). paramedic staff were less often aware of who guidelines for covid-19 (63.95%) compared to nurses (79.06%) and physicians (78.01%) (p = 0.019 between groups). subjects that judged the recommendations by the greek health authorities as sufficient were older than subjects answering "not sufficient" (5.62 ± 10.55 vs. 42.12 ± 10.81 years, respectively, p = 0.005) while those who judged their level of knowledge as sufficient were older than those that judged their level of knowledge as insufficient (45.63 ± 10.72 vs. 42.22 ± 10.57, respectively, p = 0.004) and had worked for more years (18.81 ± 11.49 vs. 16.38 ± 10.65 years, respectively, p = 0.047). table 3 shows the variation of knowledge according to various parameters. specialties differed significantly in almost all questions concerning transmission. in more detail, 58.2% of nurses compared to 67.9% of physicians and 46.6% of paramedics believed that sars-cov-2 can be transmitted sexually (p = 0.013) while 31.5% of nurses, 39.6% of physicians, and 23.3% of paramedics thought that sars-cov-2 can be transmitted through food consumption (p = 0.034). in the same context, 91.2% of nurses identified covid-19 as a cause of serious illness and death vs. 79.2% of physicians and 83.7% of paramedic staff (p = 0.012). as far as symptoms of covid-19 are concerned, 90.3% of nurses, 93.7% of physicians, and 80.3% of paramedics believed that covid-19 has similar symptoms to the seasonal flu (p = 0.014). when asked if there was an available specific drug therapy for covid-19, only 68% of nurses identified correctly that there is no disease specific drug compared to 90.8% of physicians and 64% of paramedics (p < 0.001). there was a marginal difference between specialties concerning whether hand washing reduces the risk of transmission with 95% of nurses, 97.1% of physicians, and 88.4% of paramedic staff answering correctly (p = 0.045). knowledge level was significantly different between specialties (p = 0.009). finally, we observed a gender difference in the question addressing whether there is a specific drug therapy for covid-19 where 16.10% of males and 30.8% of females answered "yes" (p = 0.010) and in the question assessing whether an available vaccine for sars-cov-2 exists in which 7.5% of males vs. 19.6% of females answered correctly (p = 0.008). table 4 depicts the association of attitudes towards the prevention of sars-cov-2 transmission with several variables. there was a significant difference in gender concerning willingness to be vaccinated against sars-cov-2 with more male health care workers reporting that they would be vaccinated for covid-19 than females (58.5% vs. 39%, respectively, p = 0.001). subjects with fewer work experience were more likely to be vaccinated than participants unwilling to be vaccinated (16.27 ± 11.82 vs. 18.87 ± 10.48 years, respectively, p = 0.019). in the same context, significantly fewer nurses (34%) and paramedic staff (43.5%) would agree to vaccinate against sars-cov-2 than physicians (60.7%) (p < 0. 001). more women than men supported travel bans as a measure to prevent sars-cov-2 (74% vs. 62.2%, respectively, p = 0.011). there was a significant difference between specialties concerning support of temporary travel ban restrictions with 76.14% of nurses and 76.7% of paramedic stuff in favor of it, compared to only 58.15% of physicians (p = 0.001). additionally, there was a significant difference of attitudes in favor of temporary travel ban restrictions among subjects working in a hospital vs. those working in a primary health care center (72.7% vs. 59.6%, respectively, p = 0.036). table 5 shows the association of various parameters with practices aimed at preventive measures. variables that had a significant relationship with practice scores were gender (p < 0.001), age (p = 0.030), and specialty (p = 0.005). subjects who were willing to follow instructions for covid-19 prevention had more years of work experience (17.99 ± 11.21 years) compared to subjects that would not follow public instructions (11.0 ± 4.12 years) (p = 0.016) ( table 5) . interestingly, only 16% of male health care workers washed their hands after each patient compared to 28% of females (p = 0.027). as far as specialties are concerned, 25.80% of nurses compared to 34.2% of physicians and 8.8% of paramedics washed their hands after the care of each patient (p < 0.001). * p < 0.001 between groups (nurses vs. physicians vs. paramedics),ˆp = 0.027, # p = 0.016,~p < 0.001 between groups, @ p = 0.005 between groups, $ p = 0.030 between groups. knowledge score was significantly associated with both attitudes score (p = 0.011) and practices score (p < 0.001) ( table 6) suggesting that subjects with high knowledge score exhibited a more positive perception on preventive measures and would practice more preventive measures. attitudes score was significantly associated with practices score (p = 0.009), indicating that subjects with higher attitudes score are more likely to demonstrate practices towards the prevention of sars-cov-2 transmission (table 6 ). table 6 . association between knowledge, attitude, and practices scores. attitudes score practices score 0 the vast majority of the subjects included in the study had a high level of knowledge concerning sars-cov-2 infection and transmission suggesting that most participants had been informed of covid-19. despite the high level of knowledge, almost 1 in 4 respondents did not wash their hands before and after touching a patient, and after touching patient surroundings, suggesting that health educational campaigns need to aggressively engage health care practitioners in preventive strategies. more than 80% of subjects identified covid-19 as a potentially deadly and serious health issue but less than half of them were willing to be vaccinated against sars-cov-2, indicating that even if a vaccine is developed early, many health care workers will not choose to be immunized against sars-cov-2. kap surveys are commonly used to identify knowledge gaps and behavioral patterns in order to implement effective interventions. there is a need for deep understanding and identification of factors that may influence attitudes and practices towards covid-19. we observed that knowledge scores were high among the participants of the study with only 11.06% of the health care workers exhibiting low knowledge scores, even though our survey was conducted before the who recognized the covid-19 outbreak as a pandemic [5] and just before the first case of covid-19 was registered in greece on the 25th of february [11] . our population consisted of health care workers which may at least explain the high level of knowledge. however, previously published data from a kap survey during covid-19 in the general population in china revealed a high rate of correct answers in the knowledge questionnaire that the authors attributed to the high educational level of the participants and the severity of the public health program [12] . furthermore, previous studies revealed heterogeneous results on the knowledge, attitudes, and practices of health care workers towards ebola and zika viruses. in particular, oladimeji et al. reported satisfactory knowledge of ebola virus disease but without a corresponding level of good practices among nigerian health care workers [13] . the knowledge score was significantly associated with attitudes and practices scores. patients with a high level of knowledge exhibited more positive attitudes and perceptions towards preventive measures and were engaged in more prevention practices. others have previously reported similar associations when performing kap surveys in other infectious diseases [14] . better knowledge may result in positive perceptions and attitudes and therefore in good practices, thus aiding in the prevention and management of infectious diseases. our study was conducted early during the pandemic and may help to set international public health campaigns priorities in order to address the most misunderstood and hazardous practices. one of the most disturbing findings of our study was that only 1 in 4 health care practitioners washed their hands after touching a patient, and after touching patient surroundings, despite the fact that 94.1% of the respondents knew that sars-cov-2 transmission could be reduced with hand washing. although the modes of sars-cov-2 transmission have not been fully determined, studies have proven that the disease is primarily transmitted when in close contact of a carrier or a patient via respiratory droplets produced with coughing or sneezing [15] . hand washing is recommended for the general population in order to prevent disease transmission [16] . soap and water seem to annihilate sars-cov-2 like other viruses. for health care practitioners, hand hygiene is mandatory in order to prevent infections, both for oneself and for the patients [17] . given the low rank of practices towards hand hygiene in our population, the immediate organization of a campaign aimed at health care workers that addresses hand hygiene seems mandatory. another important aspect of our study is that very few health care workers (43.3%) would be vaccinated for sars-cov-2 if there was an available vaccine. to date, the only available measures for the prevention of transmission in the community is hand washing, respiratory hygiene, social distancing, and self-isolation. currently, more than 13 candidate vaccines in clinical trials and 129 in preclinical trials are been tested [18] . given that health care workers cannot perform self-isolation, they are at high risk of getting exposed to sars-cov-2 and possibly transmitting the virus to their patients. in italy, 20% of the health practitioners have been infected, while in china. 3300 health workers have been infected and 22 have died [19] . access to personal protective equipment for health care workers is a major concern in many countries due to shortages associated with the acceleration of the pandemic. the safety of health practitioners is of great importance and the implementation of a vaccine would aid significantly in this direction. our results highlight the need of a national strategy and health education program aimed to enhance the immunization of health care workers in order to protect themselves as well as citizens from infection. more than 3 in 4 respondents were in favor of a travel ban in countries with high number of cases of covid-19. our study was performed prior to the implementation of such measures in greece. currently many nations have imposed restrictions in traveling as an attempt to slow down the spread of sars-cov-2. however, a travel ban in wuhan delayed the progression of the epidemic in the local community by only few days but by almost 80% on an international scale [20] . mathematical models have suggested that implementation of a travel quarantine could reduce only modestly the epidemic progression, although greater effects would be expected if there is at least a 50% reduction of transmission in the community. our study has several limitations. we acknowledge that the regional sample of the participants is a limitation of the study design. additionally, the convenience sampling is another shortcoming of our survey. convenient sampling has disadvantages related to population bias that may limit the extrapolation of the results in the target population. the study employed a convenient sample since time is of essence in covid-19 research and thus the sample may not be representative of all health care workers. nevertheless, we believe that the data presented here could be considered as a satisfactory reflection of the knowledge, attitudes, and practices of greek health care workers regarding sars-cov-2 infection prevention, given that our sample included staff from both general and university hospitals. moreover, thessaly is a large region in greece, with almost 10% of the country's population. kap studies present a questionnaire-based study and thus, there is a potential for information bias to occur. another potential limitation of our survey could be that participants' gender was overwhelmingly female. however, a previous study from the same region reported a similar gender distribution of the health care workforce [21] . last, we acknowledge the lack of questions addressing the use of personal protective equipment. our study highlights a high level of knowledge concerning sars-cov-2 among greek health care workers and this was significantly associated with positive attitudes and practices towards preventive health measures. the high level of knowledge of health professionals about sars-cov-2 may be considered to have contributed considerably to the successful management of the pandemic in greece. tailored educational campaigns aimed to increase the proportion of health care workers willing to accept a potential covid-19 vaccine could be of paramount importance in future proactive sars-cov-2 vaccine educational campaigns [22] . all authors read and approved the final manuscript and agree to be personally accountable for the authors' own contributions and for ensuring that questions related to the accuracy or integrity of any part of the work, even ones in which the authors were not personally involved, were appropriately investigated. funding: this research received no external funding. a novel coronavirus from patients with pneumonia in china a novel coronavirus outbreak of global health concern covid-19-new insights on a rapidly changing epidemic early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia world health organization. coronavirus disease (covid-19) outbreak covid-19 coronavirus pandemic, coronavirus cases novel coronavirus (2019-ncov) advice for the public how to protect health workers now: who covid-19 briefing knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey ebola virus disease-gaps in knowledge and practice among healthcare workers in lagos a cross sectional assessment of knowledge, attitude and practice towards hepatitis b among healthy population of quetta covid-19) how to protect yourself covid-19) advice for the public clean hands count for safe healthcare draft landscape of covid-19 candidate vaccines covid-19: protecting health-care workers the effect of travel restrictions on the spread of the 2019 novel coronavirus (covid-19) outbreak. science low acceptance of vaccination against the 2009 pandemic influenza a(h1n1), among healthcare workers in greece planning for a covid-19 vaccination program. jama 2020. online ahead of print this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors wish to thank all health care professionals who participated in this study. the authors declare no conflict of interest. key: cord-306551-qf7h9m78 authors: han, heesup; al-ansi, amr; chua, bee-lia; tariq, beenish; radic, aleksandar; park, su-hyun title: the post-coronavirus world in the international tourism industry: application of the theory of planned behavior to safer destination choices in the case of us outbound tourism date: 2020-09-06 journal: int j environ res public health doi: 10.3390/ijerph17186485 sha: doc_id: 306551 cord_uid: qf7h9m78 the tourism industry has been seriously suffering from the coronavirus disease (covid-19) crisis ever since its outbreak. given this pandemic situation, the major aim of this study is to develop a conceptual framework that clearly explains the us international tourists’ post-pandemic travel behaviors by expanding the theory of planned behavior (tpb). by utilizing a quantitative process, the tpb was successfully broadened by incorporating the travelers’ perceived knowledge of covid-19, and it has been deepened by integrating the psychological risk. our theoretical framework sufficiently accounted for the us tourists’ post-pandemic travel intentions for safer international destinations. in addition, the perceived knowledge of covid-19 contributed to boosting the prediction power for the intentions. the associations among the subjective norm, the attitude, and the intentions are under the significant influence of the tourists’ psychological risks regarding international traveling. the comparative criticality of the subjective norm is found. overall, the findings of this study considerably enhanced our understanding of us overseas tourists’ post-pandemic travel decision-making processes and behaviors. since its earliest case was detected in december 2019, the coronavirus disease, which is formally known as covid-19, has rapidly spread around the world [1] . it is estimated that covid-19 has affected more than 213 countries/regions across the globe [2] . as of 25 may 2020, there have been more than 5,206,614 confirmed cases of covid-19 globally, which includes 337,736 deaths [3] . every country has been making tremendous efforts to limit the further spread of covid-19 and minimize the number of cases and deaths. irrefutably, covid-19 has had a considerable impact on the entire economy of the world. every country is suffering economic injuries that are derived from covid-19. almost all businesses/industries are under the devastating effects of covid-19. that being said, the tourism sector the tpb is one of the most broadly used sociopsychological theories designed to predict human decisions and behaviors [16, 21] . its applicability and anticipation power for diverse human behaviors have been demonstrated through meta-analyses [23] . undeniably, the tpb is also a commonly applied theory in the tourism domain to explicate travelers' decision-making processes and behaviors [10, 12, 24] . the important aspect of these types of decision formations and behaviors comprise the tourism destination choices [12, 14] . thus, the utilization of the tpb is often considered to be efficient in a wide range of destination selection processes and behaviors [8, 21, 24] . under the framework of the tpb, individuals' intentions/behaviors can be sturdily explained because of its scope, which comprises volitional and nonvolitional processes [7, 10, 21] . the components of the tpb are the attitude toward the behavior, the subjective norm, and the perceived behavioral control [7, 17] . the attitude toward the behavior and the subjective norm are the constituents of the volitional process, whereas the perceived behavioral control is the major factor of the nonvolitional process [13, 19] . the tpb framework posits that the behavioral intention is the most proximal determinant of the actual behavior [14, 16] and that this intention is built based on the attitude toward the behavior, the subjective norm, and the perceived behavioral control [21] . in other words, the individuals' intention develops through volitional and nonvolitional procedures in a simultaneous manner [16, 24] . the tpb is an advanced model of the theory of reasoned action (tra) [7, 13] . unlike the tpb, the tra solely considers the volitional dimension to predict human behaviors [7, 17, 21] . the attitude toward the behavior is undoubtedly a salient determinant of travelers' intentions/decisions [10, 21, 25] . this concept indicates individuals' general assessments regarding whether a particular behavior is either positively or negatively valued [7, 19] . the subjective norm is another critical predictor of travelers' behavioral intentions [12, 24] . the subjective norm refers to an individual's perception of social pressure to or not to perform a particular behavior [16, 17] . the perceived behavioral control is also a crucial determinant of the traveler intention [10] . this nonvolitional factor indicates an individual's perception of their capability to or not to be involved in a particular behavior [19] . the positive associations among the attitude, the subjective norm, the perceived behavioral control, and the behavioral intention have long been tested and demonstrated in the extant studies of tourism and consumer behavior [9, 10, 12] . these studies empirically supported the conceptual justification of the tpb by ajzen [13] , which the customer's behavioral intention for a specific action develops based on the influence of a positive attitude toward the action, the perceived social pressure, and the perceived ability to carry out the action. even though the competence of the tpb has been proven in diverse settings, the findings in previous studies indicated that its anticipation ability for decisions/behaviors still needs an enhancement through expanding its framework [10, 19, 24] . in particular, the tpb overlooked the effect of the perceived knowledge and the psychological risk that are considered to be crucial to explicate individuals' purchase decision-making processes, especially for safe/risky products. many studies in the extant literature, particularly in tourism, have shown that the perceived knowledge and the psychological risk are critical concepts to clearly understanding the customers' decision formations and behaviors for reliable/uncertain tourism products [20, [25] [26] [27] [28] . in addition, the fundamental role of these concepts with forming the intention has been demonstrated in abundant researches about consumer behaviors and social psychology [28] [29] [30] [31] . the empirical cues in these studies imply that the individual's perceived knowledge and the psychological risk could be efficiently incorporated into a rational choice theory. the integration of these essential concepts could enhance the theory's ability to predict the customers' intentions/behaviors, especially when these types of intentions/behaviors are not completely accounted for by the volitional and nonvolitional processes. based on this, our conceptual framework provided a sound rationale regarding the combined consideration of the role of the perceived knowledge, the psychological risk, and the original tpb constituents into one sturdy framework. in sum, the theoretical premise of this research in the international tourism sector is that the travelers who have strong knowledge of covid-19 are likely to form a positive attitude toward safer destination choice behaviors and to perceive the social norm to practice the action, which leads to the increased intention to engage in the behavior in conjunction with the perceived behavioral control. moreover, the chain of the subjective norm, the attitude toward the behavior, and the intention relationships are strengthened by the psychological risk related to overseas tourism. travelers' perceived knowledge and the serious concern of the safety/social/environmental issues of tourism destinations have long been important concepts to explain their behaviors [29, 30, 32] . the perceived knowledge, which is a cognitive variable, indeed plays a crucial role in tourists' product/brand/destination choices in the international tourism industry [30, 33, 34] . in the tourism sector, the perceived knowledge indicates one's ability to know and understand a variety of tourism-related issues, problems, and behaviors [33] . travelers tend to avoid a situation where their knowledge to direct their specific actions is not sufficient [30] . in other words, travelers are likely to reduce the possible uncertainty by not practicing the action when their knowledge is not enough to guide a certain type of action. individuals often think their perceived level of knowledge about an object/product/event/issue is high when they believe that they know/understand it better compared to others [33] . the existing empirical studies indicated that travelers' perceived knowledge as a critical cognitive factor is an important determinant of the attitudinal and the social variables in their decision formations and behaviors [29, 30, 33] . in-line with the evidence from these studies, tourists' perceived knowledge of covid-19 can be the essential driver of their subjective norms and attitudes to generate an approachable decision for safer international tourism destination. the essential role of the attitude toward the behavior and the subjective norm as predictors of intention has been well-documented [10, 12, 24] . yet, many studies asserted the strong need of the refinement of the existing sociopsychology theory by adding/altering the path(s) between these variables [35] [36] [37] [38] . these studies demonstrated that inserting a causal relationship between the normative factor and the attitudinal factor within the tpb makes the framework more parsimonious, which eventually fortifies the theory. indeed, han et al. [37] attempted to link the subjective norm and the attitude toward the behavior for a hospitality product. their findings showed that the individuals' perceived social pressure from critical others contributed to increasing their attitudes toward the specific behaviors. they empirically verified that the prediction power of the tpb was significantly enhanced when the linkage was added. in the hotel sector, han and kim [36] explored the guests' intention generation processes. their results revealed that the extended tpb framework, which comprises the linkage from the social dimension and the attitudinal dimension, better accounted for the total variance in the guests' behavioral intentions for a hotel product than the original tpb. for the past few decades, the concept of the perceived risk has long been the critical subject of diverse research [28, 31, 39] . particularly, the perceived risk in the tourism literature is quite extensive [26, 28, 31, 40, 41] . the psychological risk is the key facet of the perceived risk, whose nature is multidimensional [20, 39, 42] . the important aspect of the psychological risks in tourism is the travel concern [28] . the psychological risks embracing this concern include fear, unnecessary tension, anxiety, and discomfort, which are related to traveling among tourists as its constituents [20, 28, 31] . the term psychological risk in tourism refers to the risk of anxiety/stress/discomfort/fear that stems from being a tourist [39] . a considerable amount of the existing literature has unearthed the possible influence of the risk perception on individuals' decision-making processes and behaviors [20, 26, 28] . particularly, in the tourism sector, the possibility of the fatal incidents while traveling boosts tourists' psychological risk perceptions [39] . when individuals feel concerned about the possibility of the occurrence of failure while traveling, they often avoid tourism activity or postpone their tourism plans [26, 39] , which means that individuals' tourism decision formations and behaviors are largely influenced by their psychological risks [26, 28] . undoubtedly, this risk perception is also of significance in travelers' international destination choice behaviors. indeed, the psychological risk and its role have been extensively researched in many destination studies [20, 28, 31, 40, 43] . for instance, in the muslim tourism sector, al-ansi et al. [20] explored that tourists' general risk perceptions, which were comprised of psychological risks, affect the formation of international muslim travelers' behavioral intentions. law [26] unearthed overseas tourists' travel decision-making processes for international tourism destinations where there exists the probability of the occurrences of infectious diseases, terrorism, or disasters. his empirical findings revealed that tourists' international travel decision formations are under the considerable impact of their perceived levels of risk. the important moderating nature of risk perception has been also asserted by han et al. [41] . their recent research demonstrated the effect of travelers' psychological risks related to inconveniences at international tourism destinations on the relationships among the cognitive factors, the affective factors, and the motivational factors and the behavioral intentions. in all, these studies discussed above indicated that the travelers' risk perceptions as a moderator influence the relationship strength between travel decisions and their drivers. the proposed conceptual model is displayed in figure 1 . the model is comprised of six research variables and seven hypotheses. within the proposed theoretical framework, the psychological risk is included as a moderator. hypotheses 1, 2, 3, 4, 5, and 6 are related to the causal relationships among the theoretical constructs to generate the travelers' behavioral intentions for safer destinations. meanwhile, hypothesis 7a and hypothesis 7b are related to the moderating role of the psychological risk. the survey questionnaire included a description of the research, the measures for the study variables, and questions for the personal demographic information. all the measures for the research constructs are adopted from the extant social psychology and consumer behavior studies [8, 13, 19, 28, 31, 33, 44] . all the study constructs were evaluated with multiple items. in particular, three items for the attitude, three items for the subjective norm, three items for the perceived behavioral control, and three items for the behavioral intention for safer destinations were used. in addition, we utilized three items for the perceived knowledge of covid-19 and three items for the psychological risk. the survey questionnaire containing these measures was pretested with tourism academics. a slight amendment was made based on their feedback. moreover, three academic experts reviewed and improved the survey questionnaire. all the measurement items used in this research are displayed in the appendix a. the study employed an online survey method to collect the data. the developed survey questionnaire was sent to general us international tourists who have experienced overseas traveling to a country located in any different continent other than north america at least once in the past three years. the rationale of selecting the sampling from the us is due to travel restrictions enforced in many affected destinations across europe and asia, which are most visited outbound destinations by us international tourists [5, 6] . even though the us was lately affected by the pandemic outbreak, many us cities were in the early stage of infection of covid-19 compared to other places in europe (e.g., italy) and asia (e.g., china) [3, 5] . the samples were chosen through an online survey company's customers information and database in a random manner. the survey invitation email was delivered to the potential survey participants. they were requested to click the url within the invitation email, which led to the survey. when accessing the survey, all respondents were invited to thoroughly check and read the research description and the survey instructions, which involved reliable sources and updated information reported by the who. only those who were older than 18 years old were asked to fill out the survey. about 1300 survey invitations were sent out in the middle of april, 2020 in the usa. a prior screening question was asked (i.e., have you visited any destination in europe or asia within the last 3 years?) to ensure valid respondents were involved. a total of 305 usable responses for our research were eventually gathered through this collection process. this sample size was sufficient to conduct a multivariate data analysis [45] . these cases were finally utilized in the analysis process. the average time that the survey participants spent to complete the questionnaire was about 15 minutes. extensively researched in many destination studies [20, 28, 31, 40, 43] . for instance, in the muslim tourism sector, al-ansi et al. [20] explored that tourists' general risk perceptions, which were comprised of psychological risks, affect the formation of international muslim travelers' behavioral intentions. law [26] unearthed overseas tourists' travel decisionmaking processes for international tourism destinations where there exists the probability of the occurrences of infectious diseases, terrorism, or disasters. his empirical findings revealed that tourists' international travel decision formations are under the considerable impact of their perceived levels of risk. the important moderating nature of risk perception has been also asserted by han et al. [41] . their recent research demonstrated the effect of travelers' psychological risks related to inconveniences at international tourism destinations on the relationships among the cognitive factors, the affective factors, and the motivational factors and the behavioral intentions. in all, these studies discussed above indicated that the travelers' risk perceptions as a moderator influence the relationship strength between travel decisions and their drivers. the proposed conceptual model is displayed in figure 1 . the model is comprised of six research variables and seven hypotheses. within the proposed theoretical framework, the psychological risk is included as a moderator. hypotheses 1, 2, 3, 4, 5, and 6 are related to the causal relationships among the theoretical constructs to generate the travelers' behavioral intentions for safer destinations. meanwhile, hypothesis 7a and hypothesis 7b are related to the moderating role of the psychological risk. of the 305 survey participants, 51.5% (n = 157) were males and 48.5% (n = 148) were females. the average age was 38.87 years old. the participants' ages ranged from 18 years old to 77 years old. in regard to the respondents' highest education level, about 80.3% reported they were university graduates or more, which was followed by two-year college/community college graduates (11.8%), and high school graduates or less (7.9%). all the participants were us citizens. when their marital status was asked, about 66.2% indicated that they were married, which was followed by single (30.2%), and other (3.6%). in regards to their ethnic backgrounds, the majority of the respondents were caucasian/white (79.3%), which was followed by asian (9.8%), african american (6.2%), hispanic (3.6%), and other (1.0%). all the participants indicated that they had visited a country in a different continent other than north america. about 53.8% reported that their most recent visit to the country in a different continent was within the last 6 months, which was followed by within 1 to 2 years (34.1%), within a month (7.2%), and within 2 to 3 years (4.9%). due to the observational nature of the study, and in the absence of any involvement of therapeutic medication, no formal approval of the institutional review board of the local ethics committee was required. nonetheless, all subjects were informed about the study, and participation was fully on a voluntary basis. the study was conducted in accordance with the helsinki declaration. prior to the evaluation of the structural equation modeling, we conducted a confirmatory factor analysis, and a maximum likelihood estimation approach was employed. the results showed that the measurement model, which included all the measures for the study variables, contained an adequate level of the goodness-of-fit statistics (χ 2 = 189.418, df = 117, p < 0.001, χ 2 /df = 1.619, rmsea = 0.045, cfi = 0.976, ifi = 0.976, and tli = 0.968). an internal consistency of the measurement items for each latent variable was evaluated. as shown in table 1 , the composite reliability values are all greater than the minimum threshold of 0.700 [45] . this result implies that the construct measures contain an appropriate internal consistency level. the average variance extracted (ave) values were estimated. as reported in table 1 , the ave values are all greater than hair et al.'s [45] suggested cutoff of 0.500. the values fell between 0.533 and 0.839. these results imply that the construct measures have an acceptable level of convergent validity. the ave values were then compared to the correlations (squired) between our theoretical constructs. all the ave values were found to exceed the squared correlations. therefore, discriminant validity of the construct measures is evident [46] . the proposed extended tpb model was estimated to evaluate the hypothesized relationships among the research variables and to assess the anticipation ability of the hypothesized theoretical framework. to accomplish this, we utilized structural equation modeling with a maximum likelihood estimation method. our findings reported that the model satisfactorily fit the data (χ 2 = 195.101, df = 80, p < 0.001, χ 2 /df = 2.439, rmsea = 0.069, cfi = 0.956, ifi = 0.956, and tli = 0.942). the model contained a sufficient level of anticipation power for us international travelers' behavioral intentions for safer destinations (r 2 = 0.402). this model was then compared to the original tpb model. as illustrated in figure 2 , the tpb model also has an adequate model fit to the data (χ 2 = 103.333, df = 46, p < 0.001, the proposed extended tpb model was estimated to evaluate the hypothesized relationships among the research variables and to assess the anticipation ability of the hypothesized theoretical framework. to accomplish this, we utilized structural equation modeling with a maximum likelihood estimation method. our findings reported that the model satisfactorily fit the data (χ 2 = 195.101, df = 80, p < 0.001, χ 2 /df = 2.439, rmsea = 0.069, cfi = 0.956, ifi = 0.956, and tli = 0.942). the model contained a sufficient level of anticipation power for us international travelers' behavioral intentions for safer destinations (r 2 = 0.402). this model was then compared to the original tpb model. as illustrated in figure 2 , the tpb model also has an adequate model fit to the data (χ 2 = 103.333, df = 46, p < 0.001, χ 2 /df = 2.246, rmsea = 0.064, cfi = 0.974, ifi = 0.974, and tli = 0.963). however, its prediction power for behavioral intention (r 2 = 0.340) is lower than the proposed extended tpb. while our structural model explained about 40.2% of the total variance in the behavioral intention, the original tpb model accounted for about 34.0% of the variance. this result indicated the superior ability of the proposed model as compared to the tpb model. the details about the proposed model evaluation results are reported in table 2 and figure 3 . the hypothesized paths' impacts of the attitudes toward the behavior, the subjective norm, and the perceived behavioral control on the intention were assessed. our results indicated that the attitude (β = 0.267 and p < 0.01), the subjective norm (β = 0.349 and p < 0.01), and the perceived behavioral control (β = 0.297 and p < 0.01) significantly influence the behavioral intention for safer destinations. therefore, hypotheses 1, 2, and 3 are supported. the linkage between the subjective norm and the attitude toward the behavior was examined. our findings show that this link is positive and goodness-of-fit statistics for the tpb model: table 2 and figure 3 . the hypothesized paths' impacts of the attitudes toward the behavior, the subjective norm, and the perceived behavioral control on the intention were assessed. our results indicated that the attitude (β = 0.267 and p < 0.01), the subjective norm (β = 0.349 and p < 0.01), and the perceived behavioral control (β = 0.297 and p < 0.01) significantly influence the behavioral intention for safer destinations. therefore, hypotheses 1, 2, and 3 are supported. the linkage between the subjective norm and the attitude toward the behavior was examined. our findings show that this link is positive and significant (β = 0.382 and p < 0.01). thus, hypothesis 4 is supported. the proposed influence of the perceived knowledge of covid-19 was assessed. the results showed that the perceived knowledge exerted a significant impact on the attitude toward the behavior (β = 0.136 and p < 0.05) and the subjective norm (β = 0.303 and p < 0.01). therefore, hypothesis 5 and hypothesis 6 are supported. the indirect and the total effects of the study variables were estimated. our close examination revealed that the subjective norm had a significant influence on the behavioral intention for safer destinations indirectly through the attitude toward the behavior (β = 0.102 and p < 0.05). in addition, the perceived knowledge of covid-19 had a significant indirect influence on the behavioral intention (β = 0.173 and p < 0.01). this result implies that the attitude toward the behavior and the subjective norm acted as significant mediators within the proposed conceptual framework. next, the total impact of the study constructs was examined. our finding showed that the subjective norm had the greatest total influence on the behavioral intention for safer destinations (β = 0.451 and p < 0.01), which goodness-of-fit statistics for the baseline model: the indirect and the total effects of the study variables were estimated. our close examination revealed that the subjective norm had a significant influence on the behavioral intention for safer destinations indirectly through the attitude toward the behavior (β = 0.102 and p < 0.05). in addition, the perceived knowledge of covid-19 had a significant indirect influence on the behavioral intention (β = 0.173 and p < 0.01). this result implies that the attitude toward the behavior and the subjective norm acted as significant mediators within the proposed conceptual framework. next, the total impact of the study constructs was examined. our finding showed that the subjective norm had the greatest total influence on the behavioral intention for safer destinations (β = 0.451 and p < 0.01), which was followed by the perceived behavioral control (β = 0.297 and p < 0.01), the attitude toward the behavior (β = 0.267 and p < 0.01), and the perceived knowledge of covid-19 (β = 0.173 and p < 0.01). this means that the subjective norm is the strongest contributor to increase us international travelers' behavioral intentions to choose safer destinations. to test the moderating effect of the psychological risk, a test for the metric invariance was conducted. first, the survey participants' responses were split into a high group and a low group in regards to psychological risk by conducting a k-means cluster analysis. the high group included 209 cases, and the low group contained 96 cases. a baseline model that encompassed these high and low groups of psychological risk was then generated. as shown in table 3 and figure 3 , our results demonstrated that the baseline model involved a satisfactorily level of the goodness-of-fit statistics (χ 2 = 314.748, df = 170, p < 0.001, χ 2 /df = 1.851, rmsea = 0.053, cfi = 0.943, ifi = 0.944, and tli = 0.930). this model is used to generate the invariance models where a particular path of interest is equally constrained for the test of the hypothesized moderating effect. the details about the baseline model assessment and the invariance test results are exhibited in table 3 . table 3 . results of the structural invariance model-intrinsic variety seeking. 930. † while the linkage for the high psychological risk group was significant, the link for the low group was not significant. hence, although the chi-square difference across the two groups was not significant, the group differences on the attitude and the intention linkages should be meaningfully interpreted. the baseline model was compared to the nested model, where the subjective norm and the attitude linkage are restricted to be equal. our findings show that the path is significantly different across the high psychological risk group and the low psychological risk group (∆χ 2 [1] = 5.652 and p < 0.05). this result supports hypothesis 7a. the relationship strength is stronger in the high group than in the low group. however, our findings showed that the path from the attitude toward the behavior to the behavioral intention is not significantly different between the high psychological risk group and the low psychological risk group (∆χ 2 [1] = 0.408 and p > 0.05). therefore, hypothesis 7b is not supported. under the worldwide covid-19 pandemic situation, this study focused on international tourism behaviors. our theoretical framework is built on the tpb to provide a clear comprehension of us overseas travelers' post-pandemic tourism decision-making processes for safer destinations, which are comparatively less affected by covid-19. the proposed model satisfactorily expanded the existing sociopsychological theory by taking the impact of the perceived knowledge and the psychological risk into account. the proposed theoretical framework showed how the cognitive dimension, the volitional dimension, and the nonvolitional dimension drive travelers' international tourism intentions for safer destinations. the constructs within the proposed model explained about 40.2% of the total variance with the intentions. this value was greater than that of the original tpb, which accounted for about 34.0% of the variance in intentions. when taken together, the efficacy of our theoretical framework to understand us travelers' post-pandemic decision formations was evident. our findings indicated that the relationships between the perceived knowledge of covid-19 and the focal variables within the tpb were significant. this result implies that us travelers' perceived knowledge of covid-19 contributed to fortifying the power of the existing sociopsychological theory when predicting their post-pandemic travel intentions for safer international tourism destinations. even though considerable efforts were made regarding travelers' destination choice behaviors [14, 20, 26, [47] [48] [49] , the criticality of travelers' perceived knowledge of covid-19 and its effects on their safer destination choices have been rarely uncovered. this research is, hence, meaningful with both theoretical and practical manners, because our results provided critical information about the essential role of travelers' knowledge/awareness of the particular disease to elucidate their intention generation process for international destination choices. the present study satisfactorily added the vital dimension to the traveler behavioral intention formation, which was absent in the extant sociopsychological theory. our investigation of the relative importance of the research variables demonstrated that the subjective norm better contributes to induce us travelers' behavioral intentions as compared to other research constructs. in particular, this volitional factor acted as a prominent antecedent of post-pandemic behavioral intentions for safer destination choices. this result supported the previous research [16, 21, 22] , which indicated the importance of the subjective norm to explain one's safe/risk behaviors. this finding provided us valuable information that individuals' perceived social pressures from family/friends/others are of the utmost criticality when they form any decision related to making a safe behavioral choice or taking risks. from the theoretical aspect, our findings indicated the necessity of the inclusion of this social dimension into the research framework regarding the safe choices of travelers' or travelers' risk-taking behaviors. from the practical perspective, for us government/tourism officials, an effective tactic to boost their citizens' post-pandemic safer international destination choice behaviors is dealing with their subjective norms. evidence of the dissimilarity on travelers' decisions for safe destination choice behaviors across the high psychological risk group and the low psychological risk group has scarcely been provided. in this research, us international tourists' psychological risks related to overseas traveling were significantly explored to be the significant moderator in the relationship between the subjective norm and the attitude toward the behavior. the association strength was greater in the high psychological risk group (β = 0.432 and p < 0.01) than in the low group (β = 0.179 and p > 0.05). this finding implies that, at a similar level of perceived social pressure from important others, us tourists who feel a high psychological risk of traveling to any country seriously affected by covid-19 are more likely to have a positive attitude toward safer destination choices than those with a low psychological risk. this result informs researchers and the practitioners that taking psychological risk into account when building a conceptual framework for individuals' post-pandemic international destination selection process is a fundamental requisite. in the current global tourism marketplace that is highly uncertain, knowing travelers' destination choice behaviors is of importance. this research successfully enriched the extant literature further, which helps researchers and practitioners to apparently understand travelers' intricate decision-making process to engage in safer destination choices by demonstrating the effect of the psychological risks related to international tourism on this type of process. in the present research, our proposition regarding the dissimilarity of the relationship between the attitude toward the behavior and the behavioral intention for safer destinations across the high psychological risk group and the low psychological risk group was not supported. nonetheless, the linkage was interestingly only statistically significant in the high psychological risk group but not in the low group (high group: β = 0.298 and p < 0.01 vs. the low group: β = 0.173 and p > 0.05). therefore, the difference on this linkage between the two groups should be meaningfully interpreted, despite the insignificant chi-square test results. these results offer tourism researchers and practitioners crucial information that us international tourists' attitudes elicit their safer destination choice behaviors only when tourists believe that traveling to tourist destinations in countries seriously affected by covid-19 outbreak are insecure. according to the results of the present research, the attitude toward the behavior and the subjective norm were all crucial mediators. this finding demonstrated the mediation mechanism among the perceived knowledge, the volitional factors, and the behavioral intention within the proposed conceptual framework. the essential mediating effect of the attitude toward the behavior and the subjective norm must not be underestimated, since the results of this study confirmed the efficacy of utilizing these mediators when broadening an extant sociopsychology model. being aware of the critical contribution of the attitude toward the behavior and the subjective norm, us government/tourism officials should deal with these factors to maximize the role of the perceived knowledge of covid-19 to induce us travelers' decisions to choose safer international tourism destinations for their vacation trips. this study included a few limitations that offer the opportunity for future research. first, the present research used us international travelers' responses as samples. irrefutably, us travelers' destination choices can differ from those who are from other countries located in different continents, and generalizing our findings to every international tourism behavior needs some caution. future research should include survey participants from diverse countries for the enhancement of the external validity. second, like many theories in social psychology, the key aspect of this research centered on the cognitive-centered view. however, some recent studies indicated the crucial role of emotional factors in traveler behaviors [19, 24] . future research needs to further extend the proposed theoretical framework by involving the emotional dimension for a more comprehensive prediction of international traveler decisions/behaviors. in conclusion, we built a robust theoretical framework for us tourists' post-pandemic travel intentions for safer international tourism destinations, which linked the perceived knowledge of covid-19 to the focal constructs of the tpb and encompassed the moderating influence of the psychological risk through the empirical approach. by filling the essential requisites of the theory extension [7] , this study effectually involved the concepts that are crucial in the international tourism and safety behavior contexts in the proposed model. the incorporated concepts also conceptually differed from the main constructs within the sociopsychological theory employed in the present study. the theoretical framework built in this research improved the prediction ability of the tpb, and it is broadly applicable in diverse tourism sectors, especially when explicating traveler decision-making processes for safe destinations/product choices. the proposed theoretical framework added important knowledge in the extant literature regarding the aspects of disease outbreak and travel behaviors, which are barely considered in a single sociopsychological theory. overall, our theoretical framework, which is comprised of high effectiveness and applicability, is a critical tool for a better comprehension of the individual's convoluted post-pandemic decision-making process and behavior for safer destination choices. the value of the present research both theoretically and practically is accordingly notable. the effect of covid-19 and subsequent social distancing on travel behavior covid-19 coronavirus pandemic dashboard who (world health organization) coronavirus disease (covid-19) dashboard. 2020 from lockdown to locked in, here's what post-pandemic travel could look like the impact of covid-19 on tourism. opinion impact assessment of the covid-19 outbreak on international tourism nature and operation of attitudes travelers' pro-environmental behavior in a green lodging context: converging value-belief-norm theory and the theory of planned behavior understanding the eco-friendly role of drone food delivery services: deepening the theory of planned behavior merging the norm activation model and the theory of planned behavior in the context of drone food delivery services: does the level of product knowledge really matter? festival quality, theory of planned behavior and revisiting intention: evidence from local and small italian culinary festivals unraveling public support for casino gaming: the case of a casino referendum in penghu the theory of planned behavior community-based tourism (tourdure) experience program: a theoretical approach schwartz personal values, theory of planned behavior and environmental consciousness: how tourists' visiting intentions towards eco-friendly destinations are shaped? an application of a modified theory of planned behavior model to investigate adolescents' job safety knowledge, norms, attitude and intention to enact workplace safety and health skills reasoned action in the service of goal pursuit a systematic literature review of the theory of planned behavior in tourism, leisure and hospitality management research the role of desires and anticipated emotions in goal-directed behaviors: broadening and deepening the theory of planned behavior effect of general risk on trust, satisfaction, and recommendation intention for halal food the contribution of driving with friends to young drivers' 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knowledge, awareness, concern and ecological behavior travel anxiety and intentions to travel internationally: implications of travel risk perception environmental knowledge, attitudes, and willingness to pay for environmentally friendly meetings-an exploratory study fostering customers' pro-environmental behavior at museum values and ascribed responsibility to predict consumers' attitude and concern towards green hotel visit intention predicting unethical behavior: a comparison of the theory of reasoned action and theory of planned behavior an investigation of green hotel customers' decision formation: developing an extended model of the theory of planned behavior application of the theory of planned behavior to green hotel choice: testing the effect of environmental friendly activities assessing it usage: the role of prior experience antecedents of space traveler behavioral intention tourist destination risk perception: the case of israel perceived inconveniences and muslim travelers' loyalty to non-muslim destinations destination risk perception, image and satisfaction: the moderating effects of public opinion climate of risk destination image differences between prospective and actual tourists in nigeria satisfaction: a behavioral perspective on the consumer multivariate data analysis evaluating structural equation models with unobservable variables and measurement error to compare or not to compare": comparative appeals in destination advertising of ski resorts influence of scarcity on travel decisions and cognitive dissonance the resident participation in endogenous rural tourism projects: a case study of kumbalangi in kerala this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. table a1 . measurement items for research constructs. traveling to a country that is not seriously affected by the covid-19 outbreak for my next vacation trip is bad (1)-good (7) . traveling to a country that is not seriously affected by the covid-19 outbreak for my next vacation trip is foolish (1)-wise (7) . traveling to a country that is not seriously affected by the covid-19 outbreak for my next vacation trip is unpleasant (1)-pleasant (7) . most people who are important to me think i should travel to a country that is not seriously affected by the covid-19 outbreak for my next vacation trip. most people who are important to me want me to travel to a country that is not seriously affected by the covid-19 outbreak for my next vacation trip. people whose opinions i value prefer that i choose a country that is not seriously affected by the covid-19 outbreak for my next vacation trip. whether i travel to a tourist destination in a country that is not seriously affected by the covid-19 outbreak is entirely up to me. i am confident that i can travel to a tourist destination in a country that is not seriously affected by the covid-19 outbreak if i want to. i have sufficient resources, time, and opportunities to visit a tourist destination in a country that is not seriously affected by the covid-19 outbreak. compared with the average person, i know the facts about covid-19. compared with my friends, i know the facts about covid-19. compared with people who travel frequently, i know the facts about covid-19. the thought of traveling to tourist destinations in countries seriously affected by the covid-19 outbreak makes me nervous. the thought of traveling to tourist destinations in countries seriously affected by the covid-19 outbreak makes me feel psychologically uncomfortable. the thought of traveling to tourist destinations in countries seriously affected by the covid-19 outbreak causes me to experience unnecessary tension.behavioral intention for safer destinations i plan to visit a country that is not seriously affected by the covid-19 outbreak for my next vacation trip after the pandemic has ceased. i will exert effort to travel to a country that is not seriously affected by the covid-19 outbreak for my next vacation trip after the pandemic has ceased. i am willing to visit a country that is not seriously affected by the covid-19 outbreak for my next vacation trip after the pandemic has ceased.note. all measurement items, except for the items for attitude, were evaluated with a seven-point scale, from "strongly disagree" (1) to "strongly agree" (7) . key: cord-297378-quyehjr1 authors: hong, yan; cai, gangwei; mo, zhoujin; gao, weijun; xu, lei; jiang, yuanxing; jiang, jinming title: the impact of covid-19 on tourist satisfaction with b&b in zhejiang, china: an importance–performance analysis date: 2020-05-25 journal: int j environ res public health doi: 10.3390/ijerph17103747 sha: doc_id: 297378 cord_uid: quyehjr1 after the outbreak of covid-19 (especially in the stage of tourism recovery), the bed and breakfast (b&b) tourism industry faced big challenges in improving its health strategies. b&bs are very important for the tourism industry in china and many other countries. however, few studies have studied the impact of b&bs, under covid-19, on tourism in china. our paper is among one of the first studies to investigate the impact of covid-19 on tourist satisfaction with b&bs in china. the work/travel restrictions started from 20 january 2020, and work/after travel resumed from 20 february 2020 in zhejiang, china. data were collected from 588 tourists (who experienced b&bs in zhejiang, china) from a wechat online survey, from 1 march to 15 march 2020. the current study attempted to fill the gap by studying the changing tourist satisfaction levels with b&bs before/after covid-19. moreover, some suggestions are given to the b&b industry for tourism resumption after covid-19 by an importance–performance analysis (ipa). corona virus disease 2019 (covid-19) is a highly infectious disease with a long incubation period [1] . it is the latest infectious disease to rapidly develop worldwide [2] . twenty-seven cases of the unknown virus were reported on 31 december 2019 [3] . an estimated 60 million residents of wuhan and many other cities in china were subjected to community containment measures from 23 january 2020. these large-scale types of actions have never been used in the past (even for sars in china) [4] . one of the important goals is to minimize the economic impact of the virus on a global scale [5] . china, as the world's most populous nation and the world's second-largest economy, had already battled with an epidemic (sars); at the time, however, it was 4% of the global total-it is now 17% [6] . breakfast (b&b)), hotels, catering, entertainment, and other traditional living service industries have suffered the most [7] . work resumption in china was raised step by step from 20 february 2020 [8] . in 2003, a window of opportunity to modify tourism development was opened by the crisis of sars [8] . nature-based areas (e.g., b&bs in the countryside) were likely to be the target destinations [9, 10] . new motivations to travel to nature-based areas became evident with sars [11] . there was a potential marketing emphasis that nature-based tourism types (e.g., nature-based b&bs) could be invigorated and expanded after the covid-19 crisis [12] . thus, this article focuses on b&bs in zhejiang, china. there are two reasons for this: (1) the covid-19 epidemic improved in zhejiang. from 23 january to 1 april, 2020, there was only one death in zhejiang. no medical staff were infected. there were also no new confirmed cases from the residents for more than 14 consecutive days. zhejiang resumed work gradually from 20 february 2020 [13] . (2) according to a b&b market development report in 2019, the main force of the b&b was from zhejiang [14] . the covid-19 epidemic has been reported in many previous papers. some researchers have reported the impact of covid-19 on mental health in china [15, 16] . however, few studies have reported the impact of the bed and breakfast (b&b) industry, under covid-19, on tourism in china, even though it has severely affected china and the rest of the world. b&bs were very important for the tourism industry in china and many other countries and were especially welcomed by tourists in china, united states, and other countries [17, 18] . our paper is among one of the first studies to investigate the impact of covid-19 on tourist satisfaction with b&b in china. the time before/after satisfaction was before the work/travel restrictions (from 20 january 2020) until work/after travel resumption (after 20 february 2020). data were collected from 588 tourists (who have experienced b&bs in zhejiang, china) from a wechat online survey, lasting from 1 march to 15 march 2020. the adjusted importance (after covid-19)-performance (before covid-19) analysis (ipa) was used. the current study attempts to fill the research gap by investigating the changes in tourist satisfaction levels with b&bs before/after covid-19. moreover, some suggestions are given to the b&b industry to recover after the covid-19 crisis by an importance-performance analysis (ipa). figure 1 shows the logical model. first, this study was carried out to measure the intervening influence of b&bs before/after covid-19 on the correlations with tourist satisfaction levels in zhejiang, china [19, 20] . there were 588 responses that were selected (who have experienced b&b in zhejiang, china) for the analysis. second, descriptive statistics and an importance-performance analysis (ipa) were used to measure the impact of b&b before/after covid-19 on tourist satisfaction levels in zhejiang. ipa is a business research technique developed as a market tool to examine and suggest management strategies [21] . ipa prioritizes management suggestions regarding the optimal allocations that should improve tourist satisfaction. thus, it could be a valuable practical tool for management decisions [22] . third, some suggestions are given to the b&b industry to recover after the covid-19 crisis by an importance-performance analysis (ipa). moreover, suggestions of crisis preparedness and disaster-management strategies for future research are given [23] . the purpose of this article was to help the b&b industry to adapt to resumption after the covid-19 crisis. this article contains six sections. section 1 is the introduction. section 2 contains a literature review. section 3 contains data collection and research methods. section 4 contains the results. section 5 comprises the impacts and limitations. section 6 contains the conclusions. 2.1. crisis (e.g., sars and covid-19) impact on chinese tourism and b&b first, natural disasters and anthropogenic environmental problems [24, 25] , as well as their potential to affect the image of destinations, have impacts on travel and tourism on various scales [26, 27] . according to world tourism organization (wto), in 2003, tourism arrivals fell by 1.2% to 694 million (compared to the same period in 2002) in china, and hotel occupancy rates fell by 10% [28] . second, the number of tourists increased by 9.2% (the first two months of 2003) over the same period in 2002, and tourism revenue increased by 14.0%. after the outbreak of sars, the number of tourists in march 2003 decreased by 6.5%, as compared to the same period in 2002. see in figure 2 the first monthly decrease in past decades [12] . this article contains six sections. section 1 is the introduction. section 2 contains a literature review. section 3 contains data collection and research methods. section 4 contains the results. section 5 comprises the impacts and limitations. section 6 contains the conclusions. 2. literature review 2.1. crisis (e.g., sars and covid-19) impact on chinese tourism and b&b first, natural disasters and anthropogenic environmental problems [24, 25] , as well as their potential to affect the image of destinations, have impacts on travel and tourism on various scales [26, 27] . according to world tourism organization (wto), in 2003, tourism arrivals fell by 1.2% to 694 million (compared to the same period in 2002) in china, and hotel occupancy rates fell by 10% [28] . second, the number of tourists increased by 9.2% (the first two months of 2003) over the same period in 2002, and tourism revenue increased by 14.0%. after the outbreak of sars, the number of tourists in march 2003 decreased by 6.5%, as compared to the same period in 2002. see in figure 2 the first monthly decrease in past decades [12] . third, how long does it take to repair the impacts of an infectious disease on tourism? the development of the crisis' events can be divided into three periods, according to the impact on tourist flow, including the incubation period, outbreak period, and recession period. the impact time of most crisis events is within one year; the impact period of a few events was around two years. taking sars as an example, the peak period of impact was from march to june 2003, and the entire impact period was about 1 year [12] . taking the accommodation industry as an example, during 2003, singlestore revenue of in high-star hotels declined significantly. b&b grew by 15.2% in 2003 and continued to grow, resulting in a 22% growth in 2004. therefore, the impact of sars on b&bs in tourism was basically eliminated about half a year after the end of sars [28] . first, the destination image is defined as an individual's mental representation and overall perception of a particular destination [29] . destination image and tourist satisfaction are also important tools to actively research and manage the perceptions of tourists about the destination [30, 31] . the key of the before/after crisis themes that emerged included a lack of disaster-management plans, damage to destination image and reputation. it also included the changes in tourist behavior during the crisis (e.g., covid-19) [23] . to influence the destination choice decision-making process and to condition the after-decision-making behaviors, including participation [32] , satisfaction, and third, how long does it take to repair the impacts of an infectious disease on tourism? the development of the crisis' events can be divided into three periods, according to the impact on tourist flow, including the incubation period, outbreak period, and recession period. the impact time of most crisis events is within one year; the impact period of a few events was around two years. taking sars as an example, the peak period of impact was from march to june 2003, and the entire impact period was about 1 year [12] . taking the accommodation industry as an example, during 2003, single-store revenue of in high-star hotels declined significantly. b&b grew by 15.2% in 2003 and continued to grow, resulting in a 22% growth in 2004. therefore, the impact of sars on b&bs in tourism was basically eliminated about half a year after the end of sars [28] . first, the destination image is defined as an individual's mental representation and overall perception of a particular destination [29] . destination image and tourist satisfaction are also important tools to actively research and manage the perceptions of tourists about the destination [30, 31] . the key of the before/after crisis themes that emerged included a lack of disaster-management plans, damage to destination image and reputation. it also included the changes in tourist behavior during the crisis (e.g., covid-19) [23] . to influence the destination choice decision-making process and to condition the after-decision-making behaviors, including participation [32] , satisfaction, and future intention (e.g., sustainable mountain tourism [33, 34] ) to revisit [35] . the destination image is generally interpreted as impressions based on information processing from various sources over time that results in a mental representation of the attributes and benefits sought in a destination [36] . second, our focus on post-crisis recovery is required because much of the research relates to tourism crisis (e.g., covid-19) management [37] . the recovery should be taken as more than just an industry or economic approach, and should focus on pre-event levels [38] [39] [40] . the importance of the relationship between marketing with tourist satisfaction and suggestions to repair destination images was identified [23] . first of all, apart from hotels and guesthouses, the most common form of accommodation is bed and breakfasts (b&bs), which is a concept that originated in europe [41] . these refer to small hotels that provide a non-commercial, home-like environment and only serve breakfast [41] . this also means that visitors or guests pay to stay in a private residence and interact with a local family [42] . b&bs allow tourists to seek lodging for the night, especially when hotels and inns are unavailable in remote areas [43] . second, the basic standards are different from other types of hotels are. the differences include b&bs being small scale, family operated and providing special services [44] . in recent years, the b&b industry has become a unique and rapidly growing industry in the hotel industry [45] . this operation attracts tourists with different standards than hotels [46] . this study was carried out in zhejiang, china. as the most popular b&b rural tourist destination in china, the area receives more than 23.52 million tourists. from 1 january 2015, to 14 december 2019, the baidu index results showed that the top 10 b&b provinces and cities were zhejiang, guangdong, sichuan, jiangsu, beijing, shanghai, shandong, henan, chongqing, and hubei. it shows that zhejiang was the most concerned about b&bs. most of these areas are economically developed provinces and cities. according to the b&b market development report in 2019, the main force of the b&b was from zhejiang province and accounts for about 60% of tourists, which is consistent with the search results of the area where b&bs are present [47] . the highest media coverage about b&bs in china was in zhejiang from january 2015 to february 2018. the topics of media concern ranged from the rapid development of b&bs and the reference of b&b experience to the problems arising in the development of b&bs and lasted until the introduction of b&b standards, which indicates that the development of b&bs in china entered a stable development stage from the initial stage of rapid growth without supervision [47] . various definitions of satisfaction have been proposed in the literature. in the tourism sector, tourist satisfaction (ts) is an essential aspect of the tourist services sector [48] . as services directly impact people [49] , some researchers have indicated that services are linked to tourist satisfaction [41] . tourist satisfaction, as a marketing tool, plays a key role in the construction of strategies in the tourism market [50] . furthermore, satisfaction is vital for successful destination marketing [51] , as well as a service organization [52] . feelings of pleasure by tourists are a sign of satisfaction [53] , while tourists who enjoy visiting are satisfied [54, 55] . therefore, tourist contentment is a considerable factor for tourists in making up their minds to visit again or not [56] [57] [58] . enhancing tourist satisfaction is a key strategy that leads to the success of companies in the hotel [59, 60] , catering [61, 62] , and tourism industries [63] . the quantitative approach with surveys was extensively adopted by scholars to study the multiple determinants of tourist satisfaction [64] . for instance, deng et al. [65] surveyed 412 overseas tourists in taiwan and found tourist complaints and service quality were related to tourist satisfaction. kim et al. [66] gathered the opinions of 317 tourists from beijing and discovered that convenience, safety, and technological inclination were the main factors that influenced tourist satisfaction. as a unique style of accommodation, it was inappropriate to employ the factors identified in other contexts directly to b&b during our investigations [67] [68] [69] . this study was carried out to measure the intervening influence of b&bs before/after covid-19 on its relationship with tourist satisfaction in zhejiang, china. we used wechat (tencent, shenzhen, china) for this online survey in zhejiang, china. we received 1120 answers to the questionnaire. however, there were 588 responses from people who have experienced b&bs in zhejiang before the covid-19 that were selected for the analysis. the responses were collected from 1 march to 15 march 2020. the questionnaire consisted of 30 factors, from the expectation of b&bs before check-in, to the perception of facilities after check-in [70] . likert's five-point scale was used to measure tourists' expectations before check-in, with five optional levels [71] : (1) importance (after covid-19): "5 = very important", "4 = important", "3 = so-so", "2 = unimportant", and "1 = very unimportant". appendix a shows the sample questionnaire [72, 73] . (2) performance (before covid-19): "5 = very good", "4 = good", "3 = so-so", "2 = not good", and "1 = bad". in addition to people's natural awareness and sharing awareness, the development of home-stays is more about providing experiential services for tourists than those provided by basic accommodation services [74] . some researchers constructed an experiential scale to tap into tourist experiences in the accommodation industry [75, 76] . the determinants of consumer satisfaction with b&b establishments were studied and a hierarchical structure of these determinants was built. thus, with the intention of bridging this gap, we aspired to develop a multiple-item scale to measure tourist opinions about b&bs before/after covid-19. ten determinants of tourist satisfaction were identified [77] . based on previous research and b&b industry evaluation standards (bies) in china (table 1, figure 3 ), a number of factors were generated. all the factors were assessed for content and face validity by a panel of experts from two institutions affiliated with the authors [78, 79] . this study was carried out to measure the intervening influence of b&bs before/after covid-19 on its relationship with tourist satisfaction in zhejiang, china. we used wechat (tencent, shenzhen, china) for this online survey in zhejiang, china. we received 1120 answers to the questionnaire. however, there were 588 responses from people who have experienced b&bs in zhejiang before the covid-19 that were selected for the analysis. the responses were collected from 1 march to 15 march 2020. the questionnaire consisted of 30 factors, from the expectation of b&bs before check-in, to the perception of facilities after check-in [70] . likert's five-point scale was used to measure tourists' expectations before check-in, with five optional levels [71] : (1) importance (after covid-19): "5 = very important", "4 = important", "3 = so-so", "2 = unimportant", and "1 = very unimportant". appendix a shows the sample questionnaire [72, 73] . (2) performance (before covid-19): "5 = very good", "4 = good", "3 = so-so", "2 = not good", and "1 = bad". in addition to people's natural awareness and sharing awareness, the development of homestays is more about providing experiential services for tourists than those provided by basic accommodation services [74] . some researchers constructed an experiential scale to tap into tourist experiences in the accommodation industry [75, 76] . the determinants of consumer satisfaction with b&b establishments were studied and a hierarchical structure of these determinants was built. thus, with the intention of bridging this gap, we aspired to develop a multiple-item scale to measure tourist opinions about b&bs before/after covid-19. ten determinants of tourist satisfaction were identified [77] . based on previous research and b&b industry evaluation standards (bies) in china (table 1, figure 3 ), a number of factors were generated. all the factors were assessed for content and face validity by a panel of experts from two institutions affiliated with the authors [78, 79] . b&b location [18, 43, 77] location and nearby facilities are safe and good. 1 facility quality [18, 43, 77] the kitchen and dining room are clean and tidy. 2 the leisure area is clean and tidy. 3 other service rooms are clean and tidy. 4 buildings are intelligent (e.g., semi-self-service management). 5 places or items for cleaning and disinfection are provided to tourists. 6 the building is safe and reliable. 7 room quality [18, 43, 77] the emergency facilities are complete (such as: first aid kit, escape equipment). 8 the shading performance is good (e.g., opaque curtains). 9 the rooms have plenty of natural light. 10 split air conditioners are used in guest rooms. 11 rooms are naturally ventilated. 12 the rooms are spacious and clean. 13 the natural landscape outside the window is good. 14 the privacy of rooms is good. 15 service quality [80, 81] contingency plans are developed and can be exercised regularly. 16 green consumption is encouraged and environmental protection measures are implemented. 17 specialties [77, 82] the indoor and outdoor transition spaces are natural and beautiful (e.g., gallery frames, awnings, balconies). 18 the outdoor space is large and natural (e.g., courtyard, terrace, roof garden [21] . while it was originally developed for marketing purposes, its applications have expanded to various fields, including tourism [90] [91] [92] , healthcare [93, 94] , sustainable cities [95] , social and economic outcomes [96, 97] , etc. the main goal of ipa is to diagnose the performance of different product or service attributes while facilitating data interpretation and providing practical recommendations for management [98] . ipa can gain insight into which product or service area managers should be targeted by identifying the most critical attributes, strengths and weaknesses [99] . the ipa technique combines measures of tourists' perceived performance and importance into a two-dimensional plot to facilitate data interpretation [21] . thus, each quadrant in the standard ipa chart represents a different strategy that can help managers to identify areas of concern and necessary measures to increase tourist satisfaction [100] . choosing the right attributes to measure importance and performance is essential for obtaining the best management decisions because these decisions rely on the information revealed from the selected attribute set [101] . figure 4 shows the ipa model. interpretation [21] . thus, each quadrant in the standard ipa chart represents a different strategy that can help managers to identify areas of concern and necessary measures to increase tourist satisfaction [100] . choosing the right attributes to measure importance and performance is essential for obtaining the best management decisions because these decisions rely on the information revealed from the selected attribute set [101] . figure 4 shows the ipa model. the best place to divide the graph into quadrant thresholds is one of the biggest problems in ipa applications [102] . the choice of threshold is almost a matter of judgment [103, 104] . however, their subjective positions has led to inconsistencies in existing ipa research results [104] . first, the data-centric (dc) method uses the actual data average of the observed importance and performance level as the critical point. therefore, scholars have proposed another solution [105] [106] [107] . that is, they set the mean of the experience gained from the data as the intersection [108] . second, some authors suggested that the sc method is more transparent when interpreting research results and usually provides a simpler description than using actual data methods [104] . however, using the scaling method has a serious drawback, that is, in addition to the fact that it is not driven by actual data, it also tends to record the high importance level of all the attributes. the latter means that, regardless of the characteristics of the interviewees, it turns out that this is the determinant of their expectations and opinions [109] . each survey will have the same discrimination threshold. incorrect threshold settings may lead to misleading and conflicting management recommendations [22] . third, other researchers used diagonal lines (dl) or so-called isolines (irl) to divide the plot into two separate areas [103] . the point on this 45° upward line indicates an attribute with the same the best place to divide the graph into quadrant thresholds is one of the biggest problems in ipa applications [102] . the choice of threshold is almost a matter of judgment [103, 104] . however, their subjective positions has led to inconsistencies in existing ipa research results [104] . first, the data-centric (dc) method uses the actual data average of the observed importance and performance level as the critical point. therefore, scholars have proposed another solution [105] [106] [107] . that is, they set the mean of the experience gained from the data as the intersection [108] . second, some authors suggested that the sc method is more transparent when interpreting research results and usually provides a simpler description than using actual data methods [104] . however, using the scaling method has a serious drawback, that is, in addition to the fact that it is not driven by actual data, it also tends to record the high importance level of all the attributes. the latter means that, regardless of the characteristics of the interviewees, it turns out that this is the determinant of their expectations and opinions [109] . each survey will have the same discrimination threshold. incorrect threshold settings may lead to misleading and conflicting management recommendations [22] . third, other researchers used diagonal lines (dl) or so-called isolines (irl) to divide the plot into two separate areas [103] . the point on this 45 • upward line indicates an attribute with the same importance and performance level; compared to the subjective threshold selection method, the irl method can be said to be a more suitable method for identifying the area of interest because it directly focuses on satisfaction and importance grade difference [22] . rial et al. [110] simplified this method by empirical means and a diagonal line with discrepancies. the difference in attributes (distance from the diagonal) is considered to be a priority in improving the service [108] . linear relationship (or linear association) is a statistical term used to describe the linear relationship between variables and constants. mathematically speaking, the linear relationship satisfies the equation: (1) in this equation, "x" and "y" are the two variables associated with parameters "m" and "b". graphically, y = mx + b is drawn on the x-y plane with the slope "m" and y-intercept "b". when x = 0, y-intercept "b" is just the value of "y". calculate the slope "m" from any two separate points (x1, y1) and (x2, y2), as follows: however, compared to the standard ipa chart (with four quadrants), it produces less information, provides limited identification ability and therefore has limited interpretation ability. therefore, it limits the usefulness of ipa [22] . the actual means of importance and performance are likely to differ in most cases, and therefore, require study-specific adjustments to the scales in order to interpret the importance and performance ratings [111] , as well as the relative interpretation of attributes within the importance and performance ratings [22] . most researchers use dc and average values of the actual importance and performance level when determining the threshold value of tourism research [108] . irl directly focuses on differences in satisfaction (before covid-19) and importance (after covid-19) ratings. therefore, this article uses the method of dc+irl when specifying the thresholds of the impact before/after covid-19 on tourist satisfaction with b&b ( figure 5 ). int. j. environ. res. public health 2020, 17, x 8 of 20 importance and performance level; compared to the subjective threshold selection method, the irl method can be said to be a more suitable method for identifying the area of interest because it directly focuses on satisfaction and importance grade difference [22] . rial et al. [110] simplified this method by empirical means and a diagonal line with discrepancies. the difference in attributes (distance from the diagonal) is considered to be a priority in improving the service [108] . linear relationship (or linear association) is a statistical term used to describe the linear relationship between variables and constants. mathematically speaking, the linear relationship satisfies the equation: in this equation, "x" and "y" are the two variables associated with parameters "m" and "b". graphically, y = m x + b is drawn on the x-y plane with the slope "m" and y-intercept "b". when x = 0, y-intercept "b" is just the value of "y". calculate the slope "m" from any two separate points (x1, y1) and (x2, y2), as follows: however, compared to the standard ipa chart (with four quadrants), it produces less information, provides limited identification ability and therefore has limited interpretation ability. therefore, it limits the usefulness of ipa [22] . the actual means of importance and performance are likely to differ in most cases, and therefore, require study-specific adjustments to the scales in order to interpret the importance and performance ratings [111] , as well as the relative interpretation of attributes within the importance and performance ratings [22] . most researchers use dc and average values of the actual importance and performance level when determining the threshold value of tourism research [108] . irl directly focuses on differences in satisfaction (before covid-19) and importance (after covid-19) ratings. therefore, this article uses the method of dc+irl when specifying the thresholds of the impact before/after covid-19 on tourist satisfaction with b&b ( figure 5 ). [22] in identifying the ipa quadrants. table 1 describes the respondents' demographic profile [96] [97] [98] . among the 588 tourists, 55.78% were women and 44.22% were men. the majority of the participants ranged from 25 to 35, accounting for 45.92% of the samples. most of the respondents had a bachelor or graduate degree (51.02%, n = 300), followed by graduate degrees (32.31%, n = 190). with regards to monthly income, 45.92% (n = 270) reported that their annual income was between $801 and $1200. the statistical software of spss 26 (ibm, new york, ny, usa) was used in the questionnaire analysis [112, 113] . the calculation of the questionnaire's reliability was based on the cronbach's alpha coefficient [101, 102] . an α larger than 0.7 indicates "highly reliable" and larger than 0.5 "reliable" [114] [115] [116] . the α for this questionnaire was 0.978, which indicated a relatively high and acceptable reliability [71, 90] . the questionnaire also proved satisfying in terms of the content validity, criterion-related validity, and construct validity ( table 2, table 3 ). cronbach's alpha is a function of the number of test items and the average inter-correlation among the items. it showed the formula of the cronbach's alpha below [114] : here, n is equal to the number of items, − c is the average covariance between the item-pairs, and − v is equal to the average variance. it can be seen from this formula that, if you increase the number of items, you will increase cronbach's alpha. in addition, if the correlation between the average items is low, the alpha will be low. as the correlation between the average items increases, cronbach's alpha will increase (keeping the number of items unchanged). the mean responses for the importance and performance of the 30 attributes were analyzed in accordance with the ipa framework and are shown in table 4 . most of the importance and performance means (table 5 .) were found to be significantly different (sig. 2-tailed) at the <0.01 level (qn. 23/25/28/29/30 <0.05) [117] . variables in each category were ranked in order by paired differences (ia-pb) [118, 119] . figure 6 shows results of the analysis. high priority area (part of quadrant 4+3): (quadrant 4) the "concentrate here" area; (quadrant 3) the "low priority" area. the attributes in this quadrant were considered to perform poorly and therefore represent the main weakness of the product and a threat to its competitiveness. in terms of investment, these attributes have the highest priority [98] . rank by paired differences (ia-pb): (1)"the layout of the rooms is scattered", (2) "split air conditioners are used in guest rooms", (3) "places or items for cleaning and disinfection are provided to tourists", (4) "rooms of single b&b are few and exquisite", (5) "contingency plans are developed and can be exercised regularly", and (6) "buildings are intelligent (e.g., semi-self-service management)". priority area (part of quadrant 1+3): (quadrant 1) the "keep up the good work" area; (quadrant 3) the "low priority" area. it represents the main and potential competitive advantages of a product or service. attributes in this quadrant are considered to be performing well and investment needs to continue. rank by paired differences (ia-pb): (7) "rooms are naturally ventilated", (8) "the emergency facilities are complete (such as: first aid kit, escape equipment)", (9) "the rooms are spacious and clean", (10) "the outdoor space is large and natural (e.g., courtyard, terrace, roof garden)", and (11) "green consumption is encouraged and environmental protection measures are implemented". implications first, to the best of our knowledge, this study is among the first to uncover the impact of covid-19 factors influencing tourists' satisfaction with b&bs. second, from the perspective of methodology, dc and irl were combined with content analysis to sort and guide the complexity of the relationship between variables, which has certain value for future research. third, some suggestions would be given to the b&b industry to recover after covid-19 by the importance-performance analysis (ipa). our study extends this research area from the traditional b&b context and adds knowledge to the post-covid-19 b&b tourism management area. this study also has practical suggestions for b&b operators in making marketing strategies after covid-19. as our results show, psychological factors can directly affect the satisfaction of consumers after covid-19. the managers of b&bs should consider the following factors in the "high priority area" and "priority area". compared to before covid-19, tourists were more concerned with the natural and safe experience associated with b&bs after covid-19. these are some suggestions to improve consumption experience. the importance and performance of these factors (e.g., "location and nearby facilities are safe and good", "other service rooms are clean and tidy") were good. low priority area (part of quadrant 2+3): (quadrant 2) the "possible overkill" area; (quadrant 3) the "low priority" area. their performance was not particularly good, but they were considered relatively unimportant to tourists; therefore, managers should not pay too much attention to these attributes. they represent a slight weakness, and poor performance is not a big problem. these factors are not important in this article (e.g., "the indoor and outdoor transition spaces are natural and beautiful (e.g., gallery frames, awnings, balconies)", "the shading performance is good (e.g., opaque curtains))". implications first, to the best of our knowledge, this study is among the first to uncover the impact of covid-19 factors influencing tourists' satisfaction with b&bs. second, from the perspective of methodology, dc and irl were combined with content analysis to sort and guide the complexity of the relationship between variables, which has certain value for future research. third, some suggestions would be given to the b&b industry to recover after covid-19 by the importance-performance analysis (ipa). our study extends this research area from the traditional b&b context and adds knowledge to the post-covid-19 b&b tourism management area. this study also has practical suggestions for b&b operators in making marketing strategies after covid-19. as our results show, psychological factors can directly affect the satisfaction of consumers after covid-19. the managers of b&bs should consider the following factors in the "high priority area" and "priority area". compared to before covid-19, tourists were more concerned with the natural and safe experience associated with b&bs after covid-19. these are some suggestions to improve consumption experience. suggestions for the rank by paired differences (ia-pb): (1) "the layout of the rooms is scattered". this shows that, after the covid-19 epidemic, tourists prefer scattered room layouts. centralized room layouts need to be reconsidered. (2) "split air conditioners are used in guest rooms". at present, central air conditioning has been used by many b&bs. however, after covid-19, this is not an ideal choice. (3) "places or items for cleaning and disinfection are provided to tourists", and (4) "rooms of single b&b are few and exquisite". at present, there are more and more rooms in many b&bs (single) and the scale is getting larger. this is obviously inappropriate for b&b tourism after the covid-19 epidemic and it needs to be changed. (5) "contingency plans are developed and can be exercised regularly". these measures were not paid enough attention before the outbreak. it needs to be focused on after the covid-19 epidemic. (6) "buildings are intelligent (e.g., semi-self-service management)". "intelligentization" will be a trend in the future. it also needs to be focused on in b&bs. suggestions for the rank by paired differences (ia-pb): (7) "rooms are naturally ventilated", (8) "the emergency facilities are complete (such as first aid kit, escape equipment)", (9) "the rooms are spacious and clean", (10) "the outdoor space is large and natural (e.g., courtyard, terrace, roof garden)", and (11) "green consumption is encouraged and environmental protection measures are implemented". the suggestion in this part is that more attention should be paid to nature and green areas in the b&b tourism after covid-19. just like after sars in 2003, people tended to go to places with nature-based areas rather than urban vacations [7, 43] . the priority suggestions in this paper will be of great help to improve the attraction of b&bs to tourists after covid-19. enough attention was not paid to these measures before the outbreak. they need to be focused on after the covid-19 epidemic. b&bs are very important for the tourism industry in many countries, and tourists have especially welcomed them in recent years in china. to the best of our knowledge, our study was among the first to investigate the immediate impact of the covid-19 pandemic on tourist satisfaction with b&bs in china. many previous studies have reported on covid-19. some others studied the correlations between covid-19 and the quality of life in china. however, few studies have reported the impact of b&b under covid-19 on tourism in china. the adjusted importance (after covid-19)-performance (before covid-19) analysis (ipa) was a new attempt. moreover, some promotion suggestions were given to the b&b industry recovery after covid-19 by the ipa. however, there were some limitations to our study and future research areas. first, the data were collected from tourists in b&bs in zhejiang, china. thus, it was somewhat difficult to apply the suggestions of the impact of covid-19 to other areas. future researchers 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muhammad nur -a.; mamun, abdullah al; husain, taha; basak, palash; permarupan, p. yukthamarani; agho, kingsley e. title: factors associated with the perception of risk and knowledge of contracting the sars-cov-2 among adults in bangladesh: analysis of online surveys date: 2020-07-21 journal: int j environ res public health doi: 10.3390/ijerph17145252 sha: doc_id: 324856 cord_uid: hf969tav this study investigated the perception and awareness of risk among adult participants in bangladesh about coronavirus disease 2019 (covid-19). during the lockdown era in bangladesh at two different time points, from 26−31 march 2020 (early lockdown) and 11−16 may 2020 (late lockdown), two self-administered online surveys were conducted on 1005 respondents (322 and 683 participants, respectively) via social media. to examine risk perception and knowledge-related factors towards covid-19, univariate and multiple linear regression models were employed. scores of mean knowledge (8.4 vs. 8.1, p = 0.022) and perception of risk (11.2 vs. 10.6, p < 0.001) differed significantly between early and late lockdown. there was a significant decrease in perceived risk scores for contracting sars-cov-2 [β = −0.85, 95%ci: −1.31, −0.39], while knowledge about sars-cov-2 decreased insignificantly [β = −0.22, 95%ci: −0.46, 0.03] in late lockdown compared with early lockdown period. self-quarantine was a common factor linked to increased perceived risks and knowledge of sars-cov-2 during the lockdown period. any effort to increase public awareness and comprehension of sars-cov-2 in bangladesh will then offer preference to males, who did not practice self-quarantine and are less worried about the propagation of this kind of virus. this may contribute to a big economic tragedy in a country such as bangladesh, which is still attributed to everyday wages, as seen in other heavily affected regions of the world. since the sheer illness of the whole country is sufficient to destroy the health care system, this current study is to examine changes of individual perception of risk for contracting sars-cov-2, and the awareness level in bangladesh during the early and late lockdowns implemented by the government of bangladesh. the findings of this study will provide an understanding of people's knowledge level, perception of risk and awareness which can be used to implement emergency policies to counter the spread of sars-cov-2. from 26 to 31 march 2020, the first cross-sectional survey entitled "early lockdown" was performed, referring to the week of the lockdown period in bangladesh and the second cross-sectional survey entitled "late lockdown" was carried out from 11 to 16 may 2020. even though a national community-based sampling survey throughout that time was not conceivable, the data were collected electronically using a google form. a standardized synchronized questionnaire was uploaded on social networking sites, such as facebook and whatsapp, which are widely used by investigators and local people throughout the country. emails with the survey link were sent in the second step via contact lists of the researchers to broaden the scope of the survey. participants in the survey received no incentives. the first survey (early lockdown) assumed a 50% proportion with 90% confidence. because the main objective of this research was on sars-cov-2 and there are no previous studies from bangladesh that examined factors associated with this, an online sample size calculator [21] was used and we took a sample size of approximately 300, including a 10% non-response rate. the second survey (late lockdown) assumed a proportion of 31% (very worried about sars-cov-2) reported in the first study (early lockdown) with 90% confidence [21] . the calculation of the total sample size for the second survey was 710, including a 10% non-response rate. the participants responding to a "yes" or "no" question obtained voluntary on-line consent to express their willingness to attend the study via google forms. this study was approved by the ethics committee (approval number: brur/dwrti/a.n.003) of the dr wazed research and training institute, begum rokeya university, rangpur. rangpur-5404, bangladesh. table 1 presents the questionnaire used in this study. the questionnaire was divided into three sections, including demographics, knowledge, and perception. the demographic variables included age, gender, marital status, education, employment, and religion. there were 12 items on the questionnaire that assessed the respondent's knowledge of covid-19, most of which required a "yes" or "no" response. each question used a binary scale. the scores for each item ranged from 0 (no) to 1 (yes). the knowledge score ranged from 0-12 points. these items have been validated elsewhere to have an acceptable internal consistency [22] . the survey tool for the covid-19 knowledge questionnaire was developed based on the guidelines from the world health organization [5, 23] for clinical and community management of covid-19. those that have contact with someone who has covid-19 infection should be isolated in the right place immediately. the observation period is usually 14 days k10 children and young adults should not take steps to prevent the covid-19 virus from infection. k11 covid-19 individuals with no symptoms of fever cannot spread the virus to anyone k12 individuals should stop being crowded to prevent covid-19 infection. please rate your chances of personal risk of infection with covid-19 for each of the following? risk of becoming infected. risk of becoming severely infected p3 risk of dying from the infection p4 how much worried are you because of covid-19? are you currently or have you been in (domestic/home) quarantine because of covid-19? how do you feel about the quarantine? i am worried/anxious/alarmed and frightened by the quarantine. i consider the quarantine as necessary and reasonable. i am nervous about the quarantine. i am bored by the quarantine. i am frustrated by the quarantine. i am angry because of quarantine. revised and adopted from world health organization, 2019: available at https://www.who.int/bulletin/online_first/ 20-256651.pdf). we asked the respondents about risk perception towards covid-19 (p1−p4). each question used a likert scale with five levels. the scores for each item ranged from 1 (lowest) to 5 (highest). the risk perception score ranged from 5 to 20 points. the cronbach's alpha coefficients of the perception items were 0.74 and demonstrated that the internal consistency of perception items was satisfactory. respondents were also asked, "how they felt about the quarantine" (p6−p11). each question used a likert scale with five levels. the scores for each item ranged from 1 (lowest) to 5 (highest) and the cronbach's alpha coefficient of the "how they felt about the quarantine items" was 0.70, indicating acceptable internal consistency. the explanatory (independent) variable included basic characteristics and explanatory factors including gender, age in categories, level of education, marital, employment, and religious status. the question of worrying about quarantine score ranged from 6 to 30 points. the worried about quarantine score was divided into three categories. the bottom 33.3% of the score was arbitrarily referred to as "low quarantine practice", the next 33.3% as "moderate quarantine practice", and the top 33.3% as "high quarantine practice". furthermore, "high quarantine practice", which was derived by combining the moderate quarantine practice (33.3%) with the high quarantine practice (33.3%) and low quarantine practice, was "low quarantine practice scores" 33.3%. data analysis was performed using stata version 14.1 (stata corp. college station united states of america). categorical variables were presented as frequency and percentage. this study used a t-test to compare the differences between means for early and late lockdowns for knowledge and risk perception items. in the univariate linear regression analysis, all confounding variables with a p-value < 0.20 were retained and used to build a multivariable linear regression model and to determine factors associated with the knowledge and perception score towards covid-19. additionally, we performed a similar stage modelling to that employed by dibley et al. [24] , and a two-staged modelling technique was employed in the multivariable modelling. in the first stage, the demography factors were entered into the baseline multivariable model. a manual process of backward elimination was performed, and variables with p < 0.05 were retained in the first model (model 1). in the second and final stage of modelling, perceived risk of covid-19 factors was added into significant variables in model 1, and variables with p-values < 0.05 were retained in the final model. for all regression analyses performed, we checked the homogeneity of variance and multicollinearity using variance inflation factors (vif). the descriptive statistics of the explanatory and dependent variables are shown in table 2 . this summary of responses was obtained from those who participated in the survey during the early lockdown (26-31 march 2020) and late lockdown (11) (12) (13) (14) (15) (16) may 2020) periods. total responses were a combination of both. most of the respondents (53.2%, n = 532) were 18-28 years old with equal representation of males and females. most respondents (58.2%, n=585) were married, and almost all (83.1%, n = 835) completed tertiary education or its equivalent. of the respondents, 88.8% (n = 892) were muslims, about two-thirds of them (65.5%, n = 658) voluntarily quarantined themselves during the study period while about a quarter of them (19.2%, n=193) did not quarantine. regarding their concern for the spread of the sars-cov-2 virus, the majority (68.7%, n = 690) stated that they were very worried. figure 1a,b show the mean and 95% confidence intervals of perceives risk and knowledge towards covid-19, respectively. data of early and late lockdown periods are presented here, correspondingly. figure 1a indicates statistical differences between early and late lockdowns (p < 0.001), with early lockdown reporting the highest mean values. additionally, as indicated in figure 1b , knowledge towards covid-19 for early lockdown significantly reported the highest mean value compared with late lockdown (p = 0.022). the horizontal values in figure 1a ,b are the minimums and maximums of perceived risk and knowledge scores. the unadjusted and adjusted coefficients for factors associated with the perceived risk of contracting sars-cov-2 are presented in table 3 . compared with the early lockdown period, the results indicated that perceived risk scores for contracting covid-19 in late lockdown period reduced significantly (adjusted coefficients (β) −0.85, 95% ci:−1.31, −0.39). other factors associated with perceived risk scores for contracting covid-19 are females, practised high quarantine, very worried about covid-19, and quarantined at the request of public health order during the lockdown period. age stratification was significant in the univariate analysis and the final model, we removed religion and replaced it with age stratification, and the result showed that age stratification was not statistically significant (wald χ 2 = 0.46, p = 0.7137) and similarly, when gender was replaced with age stratification, age stratification was not significant (wald χ 2 = 0.49, p = 0.6908). the factors associated with perceived risk scores for contracting covid-19 in early lockdown and late lockdown period are presented in tables a1 and a2. towards covid-19, respectively. data of early and late lockdown periods are presented here, correspondingly. figure 1a indicates statistical differences between early and late lockdowns (p < 0.001), with early lockdown reporting the highest mean values. additionally, as indicated in figure 1b , knowledge towards covid-19 for early lockdown significantly reported the highest mean value compared with late lockdown (p = 0.022). the horizontal values in figure 1a ,b are the minimums and maximums of perceived risk and knowledge scores. table 4 showed the unadjusted and adjusted coefficients with 95% confidence intervals (cis) of the knowledge level of covid-19. after the adjustment of potential confounding factors, knowledge about covid-19 has decreased but it was not statistically significant [β = −0.22, 95% ci: −0.46, 0.03] in late lockdown period compared to early lockdown period. additionally, comparatively less knowledge of covid-19 was pertinent among those who performed low quarantine and those who had less education (completed secondary or primary education only). increased knowledge of covid-19 was pertinent among the participants who practised high quarantine, held a bachelor and above degree, and the non-muslim participants. age stratification and employment status were significant in the univariate analysis and our final model, we removed religion and replaced it with age stratification, and age stratification was not statistically significant (wald χ 2 = 1.44, p = 0.2293) and when education was replaced with age stratification, age stratification was not significant (wald χ 2 = 2.54, p = 0.055), but when education was replaced by employment status, employment status was associated with increased knowledge of covid-19 [β = 0.26, 95% ci: 0.03, 0.49, p = 0.027 for those employed]. factors associated with the knowledge level of covid-19 for each lockdown periods are reported in tables a3 and a4. this current study reported a higher mean of perception of risk and low knowledge of contracting the sars-cov-2 among adults in bangladesh. the study also revealed factors associated with the perception of risk and knowledge of contracting the sars-cov-2 in bangladesh and found that females and those with a bachelor's degree reported decreased perceived risk and knowledge of contracting sars-cov-2 than males, and master's/higher degree holders, respectively, practised high quarantine, were very worried, and quarantined at the request of public health order during covid-19, and reported higher perceptive risk of contracting covid-19, while non-muslims (christian/hindu) practised high quarantine and quarantined at the request of public health order during covid-19, and reported increased knowledge scores of contracting the infection. the higher mean score of risk perceptions stated in this analysis could be because the bangladesh government has taken exceptional measures to track the rapid spread of the current global covid-19 disease outbreak [25] . when the number of individuals infected and the fatalities from this epidemic escalate, residents will stick to preventive measures because they are influenced by their knowledge, perceptions and practices towards this disease outbreak [26] . in this study, we analyzed the opinions of bangladeshi people about vulnerability and awareness towards covid-19 during the drastic rise period of the disease outbreak. researchers identified that many were extremely concerned about the transmission of the infectious disease in this predominantly well-educated young muslim population and more than one-third considered themselves to be at low risk of contracting the infection. such a high perception of low risk, coupled with the fairly average covid-19 knowledge scores, is extremely important because clear knowledge predicts a positive attitude and appropriate attitude against covid-19 [22] . in this study, males who were worried about contracting sars-cov-2 were more likely to perceive themselves as being at high risk of contracting the infection, as well as those who did not quarantine themselves or only did so at the request of the public health officers. these findings were similar to those reported in the studies conducted in india, china, and jordan. adults with a higher level of knowledge about covid-19 and who were in quarantine were more concerned about the infection and became frustrated as they did not know how long the impact of the pandemic would last [27] . moreover, in india, it was found that a higher level of knowledge on covid-19 was associated with the high-risk perception of contracting the infection during the consistent lockdown period [28] . in jordan [14] , it was found that, with adequate knowledge, people can perceive the importance of lockdown and the risk of contracting the infection caused by sars-cov-2. experience from previous similar virus attacks (sars-cov-1) in china highlighted the fact that, during such a crisis, people's knowledge, attitudes, and perceptions about the situation affects their response to the crisis. to effectively manage a health emergency, citizens need to be conscious of the problem, to be alert, and acknowledge their responsibilities to preserve their steadiness, because circumstances culminating in fear in the public can escalate the situation into misery [22] . a similar survey conducted to test the knowledge, attitudes, and perceptions of people in the hubei province, china, about the covid-19 outbreak found that higher knowledge, attitude and perception scores among residents was related to the ages and socioeconomic statuses of the respondents [22] . it was surprising to find an average score of knowledge against covid-19 among bangladesh residents, considering that this epidemiological survey was performed at the very early stage of the pandemic in bangladesh. we believe this to be partially attributed to the survey being skewed by people with a bachelor's degree or higher, the largest percentage of respondents being 86%. the magnitude of this pandemic and the unprecedented media attention of this public health disaster will have an important effect on people's awareness about this epidemic. television channels, bangladesh health ministry official websites, and all corporation websites had details about this infectious disease during this time. adults with higher levels of education are more likely to seek information which enhances a sense of personal control through mastering content and acquiring stronger skills [29] . similar to previous findings [22, [30] [31] [32] which suggested that men and young adults are more inclined to engage in risk-taking behaviours, the present study found a significant association between male gender and perceived high-risk of covid-19 among respondents after adjusting for other cofounders. adults who were employed at the time of this study were 0.6 times more likely to show adequate knowledge scores compared to those who were unemployed, but this association was significant only when it interacted with other demographic variables in the model. the slightly higher chances of sufficient information among citizens who did not quarantine themselves, relative to those who did so willingly, could be due to the less severe situation of the covid-19 outbreak in bangladesh and the prevalence of younger adults in this sample, resulting in respondents feeling that they had a lower probability of contamination with the sars-cov-2 virus. it is worth noting that, in this analysis, higher covid-19 awareness scores are strongly correlated with not becoming a practising muslim. it is understood that the negative mentality shown by certain religious manipulators is one of the toughest obstacles in attempts to tackle the dissemination of covid-19 awareness. while the government has called for the public to keep social distances to stop the gathering of crowds (physical distance), certain so-called religious leaders might also be preparing to host meetings involving hundreds. resistance from religious communities to physical isolating appeals has been observed across several predominantly muslim countries, such as indonesia, and the trend exacerbates local government attempts to negotiate with covid-19 propagation. research in turkey [33] echoed the significance of religious figures throughout this disease outbreak in positively motivating populations. although some practitioners preferred to seek counsel from their municipal officials, others adopted their religious leader's instructions when it came to debatable questions, such as covid-19, suggesting that religious leaders have strong influence on the respondent's attitude towards covid-19 mitigation practices during the pandemic. the finding of this study indicates the value of strengthening public health knowledge for bangladeshi citizens towards covid-19. this, in effect, would change behaviours and activities towards covid-19. research findings of the demographic variables correlated with knowledge towards sars-cov-2 are broadly compatible with previous research on sars-cov-1 in 2003 [16, 22] , further indicating that the intervention in health education towards covid-19 in bangladesh would become more successful if it had been primarily structured for mass people and those with low educational thresholds. since sars-cov-2 is a new type of coronavirus, and no pharmacologic therapies at this time are available, increased public awareness and caution seem to be the best approaches to preventing community spread. the travel bans and lockdowns placed in many countries, including bangladesh, may have worked, but they also raised the level of panic among residents. this was evident in this study, where approximately 31% of the respondents were very worried, and others were somewhat worried about the situation. in this situation, lai and others showed that educating the public is a very helpful and effective resource [34] . for countries with fragile health care systems who have dense populations, such as the sub-saharan african countries, lack of awareness about the virus and corrupt policies can combine to create a disaster that is impossible to contain [35] . in the case of covid-19, issues with the current response, lack of transparency, travel restriction delay, quarantine delay, public misinformation, and emergency announcement delay contributed to the outbreak. the findings of this study show that many of the respondents in bangladesh were very worried about the spread of covid-19 coupled with their significant inadequacies in the knowledge of the disease. this suggests the need for more awareness to increase public knowledge and reduce the worries of the bangladeshi people regarding the sars-cov-2 virus. in addition to adhering to the government recommendations of routine hand washing and home quarantine, older males of the muslim faith could be targeted to further improve the knowledge and avoid further transmission of this novel coronavirus, even as the lockdown continues. the current study provided the first evidence of the knowledge and perception of people using an appropriately sampled population during a critical period-the early stage of the covid-19 outbreak. however, the online nature of data collection meant that respondents who had an internet connection were more likely to participate, which may lead to bias, including selection bias because of the over-representation of well-educated people in bangladesh compared to the background population [36] and, as such, the findings may not represent the opinion of the less educated population. hence, findings from this study cannot be generalizable to the entire bangladeshi population and lack causal inference because it was an online cross-sectional design. despite this limitation, this was the only feasible way of data collection at the time of this study. additionally, since the virus is novel and already widespread, there is little possibility to undertake extensive social studies in bangladesh. another limitation of this study was the cross-sectional study design, making it impossible to determine causation. further studies across randomly selected populations across the country are needed to confirm these findings. such studies should also assess the social aspects of the condition. despite these limitations, the present study provides relevant information to fill research gaps in the fight for covid-19. the datasets analyzed during this study are available from the authors on reasonable request. deadliest enemy: our war against killer germs inhibition of sars-cov-2 (previously sars-cov-2) infection by a highly potent pan-coronavirus fusion inhibitor targeting its spike protein that harbors a high capacity to mediate membrane fusion world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) modelling transmission and control of the covid-19 pandemic in australia who|world health organization. maintaining essential health services and systems covid-19 infection and rheumatoid arthritis: faraway, so close! autoimmunity rev associations between immune-suppressive and stimulating drugs and novel covid-19-a systematic review of current evidence covid-19 infection: origin, transmission, characteristics of human coronaviruses characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention the response of milan's emergency medical system to the covid-19 outbreak in italy 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cross-sectional survey world health organization. covid-19 update iron and folic acid supplements in pregnancy improve child survival in indonesia the financial express who releases guidelines to help countries maintain essential health services during the covid-19 pandemic comparison of prevalence and associated factors of anxiety and depression among people affected by versus people unaffected by quarantine during the covid-19 epidemic in southwestern china study of knowledge, attitude, anxiety & perceived mental healthcare need in indian population during covid-19 pandemic examining associations between health information seeking behavior and adult education status in the us: an analysis of the 2012 piaac data sex differences in everyday risk-taking behavior in humans sex differences in risk taking behavior among dutch cyclists age patterns in risk taking across the world politics and the covid-19 pandemic: the turkish response severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and corona virus disease-2019 (covid-19): the epidemic and the challenges key: cord-325963-d0hvukbu authors: faes, christel; abrams, steven; van beckhoven, dominique; meyfroidt, geert; vlieghe, erika; hens, niel title: time between symptom onset, hospitalisation and recovery or death: statistical analysis of belgian covid-19 patients date: 2020-10-17 journal: int j environ res public health doi: 10.3390/ijerph17207560 sha: doc_id: 325963 cord_uid: d0hvukbu there are different patterns in the covid-19 outbreak in the general population and amongst nursing home patients. we investigate the time from symptom onset to diagnosis and hospitalization or the length of stay (los) in the hospital, and whether there are differences in the population. sciensano collected information on 14,618 hospitalized patients with covid-19 admissions from 114 belgian hospitals between 14 march and 12 june 2020. the distributions of different event times for different patient groups are estimated accounting for interval censoring and right truncation of the time intervals. the time between symptom onset and hospitalization or diagnosis are similar, with median length between symptom onset and hospitalization ranging between 3 and 10.4 days, depending on the age of the patient (longest delay in age group 20–60 years) and whether or not the patient lives in a nursing home (additional 2 days for patients from nursing home). the median los in hospital varies between 3 and 10.4 days, with the los increasing with age. the hospital los for patients that recover is shorter for patients living in a nursing home, but the time to death is longer for these patients. over the course of the first wave, the los has decreased. the world is currently faced with an ongoing coronavirus disease 2019 (covid19) pandemic. the disease is caused by the severe acute respiratory syndrome coronavirus 2, a new strain of the coronavirus, which was never detected before in humans, and is a highly contagious infectious disease. the first outbreak of covid-19 occurred in wuhan, province hubei, china in december 2019. since then, several outbreaks have been observed throughout the world. as from 7 march, the first generation of infected individuals as a result of local transmission was confirmed in belgium. there is currently little detailed knowledge on the time interval between symptom onset and hospital admission, nor on the length of stay (los) in hospital in belgium. however, information about the los in hospital is important to predict the number of required hospital beds, both for beds in general hospital and beds in the intensive care unit (icu), and to track the burden on hospitals [1] . the time delay from illness onset to death is important for the estimation of the case fatality ratio [2] . individual-specific characteristics, such as the gender, age and co-morbidity of the individual, could potentially explain differences in los in the hospital. therefore, we investigate the time of symptom onset to hospitalization and the time of symptom onset to diagnosis, as well as the los in hospital. we consider and compare parametric distributions for these event times enabling to appropriately take care of truncation and interval censoring. in section 2, we introduce the epidemiological data and the statistical methodology used for the estimation of the parameters associated with the aforementioned delay distributions. the results are presented in section 3 and avenues of further research are discussed in section 4. the hospitalized patients clinical database is an ongoing multicenter registry in belgium that collects information on hospital admission related to covid-19 infection. the data are regularly updated as more information from the hospitals are sent in. the individual patients' data are collected through 2 online questionnaires: one with data on admission and one with data on discharge. data are reported for all hospitalized patients with a confirmed covid-19 infection. the reporting is strongly recommended by the belgian risk management group, therefore the reporting coverage is high (>70% of all hospitalized covid-19 cases) [3] . at the time of writing this manuscript, there is information about 14,618 patients, hospitalized between 1 march 2020 and 12 june 2020, including age and gender. table a1 (appendix b) summarizes the age and living status (living in nursing home or not) of the patients. age is categorized into 4 age groups: the young population (0-20 years), the working age population (20-60 years), the senior population (60-80 years) and the elderly (80+ years). it shows that a large proportion of the hospitalized 60+ patients live in a nursing home facility (about 12% for patients aged 60-79 and 35% for patients aged 80+). the survey contains information on 1831 patients hospitalized during the initial phase of the outbreak (between 1 march and 20 march); 4998 patients in the increasing phase of the outbreak (between 21 march and 31 march); 5094 in the descending phase (between 1 april and 18 april); and 2695 individuals at the end of the first wave of the covid-19 epidemic (between 19 april and 12 june). the time trend in the number of hospitalizations is presented in figure a2 (appendix b). the time trend in the survey matches well with the time trend of the outbreak in the whole population, though with some under-reporting in april and may. the time variables (time of symptom onset, hospitalisation, diagnosis, and recovery or death) were checked for consistency. observations identified as inconsistent were excluded for analyses. details of the inclusion and exclusion criteria are provided in appendix a. some descriptive analyses of the event times are provided in appendix c. different flexible parametric non-negative distributions can be used to describe the delay distributions, such as the exponential, weibull, lognormal and gamma distributions [4] . however, as the reported event times are expressed in days, the discrete nature of the data should be accounted for. reference [2, 5] assume a discrete probability distribution parameterized by a continuous distribution. alternatively, reference [6] estimate the serial interval using interval censoring techniques from survival analysis. reference [7, 8] use doubly interval-censoring methods for estimation of the incubation distribution. we use interval-censoring methods originating from survival analysis to deal with the discrete nature of the data, to acknowledge that the observed time is not the exact event time [9] . let x i be the recorded event time (e.g., los in hospital). instead of assuming that x i is observed exactly, it is assumed that the event time is in the interval (l i , r i ), with l i = x i − 0.5 and r i = x i + 0.5 for x i ≥ 1 and l i = = 10 −3 and r i = 0.5 for x i = 0. as a sensitivity analysis, we compare this assumption with the wider interval an additional complexity is that the delay distributions are truncated, either because there is a maximal clinical delay period or because the hospitalization is close to the end of the study. first, only patients reporting a delay between symptoms and hospitalization (or diagnosis) of at most 31 days were included in the study, because it is unclear for the other patients whether the reason for hospital admission was covid-19 infection. in literature, times from onset of symptoms to hospital admission have been reported between 4 and 15 days (e.g., reference [10] [11] [12] [13] ), with no mention of observed delay times above 31 days. second, if hospitalization is e.g., 14 days before the end of the study, the observed los cannot exceed 14 days. however, it has to be noted that only patients that have left the hospital are included in the survey, and as a result it will not include patients that are hospitalized near the end of the survey and have a long length of stay. this is a clear example of right-truncation (as opposed to right-censoring under which patients are still part of the study/data and only partial information is available on their length of stay). we therefore use a likelihood function accommodating the right-truncated and interval-censored nature of the observed data to estimate the parameters of the distributions [6] . the likelihood function is given by in which t i is the (individual-specific) truncation time and f(·) is the cumulative distribution function corresponding to the density function f (·). we truncate the time from symptom onset to diagnosis and the time from symptom onset to hospitalisation to 31 days (t i ≡ 31). the los in hospital is truncated at t i = e − t i , in which t i is the time of hospitalization and e denoted the end of the study period (6 june 2020). in addition, to account for possible under-reporting in the survey, each likelihood contribution is weighted by the post-stratification weight w i ≡ w t defined as w t = n t n t ∑ t n t , where t is the day of hospitalization for patient i, n t the number of hospitalizations in the population on day t and n t is the number of reported hospitalizations in the survey on day t. this weighted likelihood is also called pseudo-likelihood in the context of complex survey data, for which consistency and asymptotic normality has been shown [14] . we assume weibull and lognormal distributions for the delay distributions. the two parameters of each distribution are regressed on age, gender, nursing home and time period (as well as interactions of these). by assuming both parameters to be covariate-dependent, we allow that both the mean and the range of the time to event variable varies in different population groups. the bfgs optimization algorithm is used to maximize the likelihood. convergence is reached for all considered models. the bayesian information criterion (bic) is used to select the best fitting parametric distribution and the best regression model among the candidate distributions/models. only significant covariates are included in the final model. overall, the delay between symptom onset and hospitalization can be described by a truncated weibull distribution with shape parameter 0.845 and scale parameter 5.506. the overall average delay is very similar to the one obtained by [15] , based on a stochastic discrete time model relying on an erlang delay distribution. however, there are significant differences in the time between symptom onset and hospitalization amongst different gender groups, age groups, living status and time period of hospitalization. as the truncated weibull distribution has a lower bic as compared to the lognormal distribution (66,923 and 68,657 for weibull and lognormal distributions, respectively), results for the weibull distribution are presented. in table 1 , the regression coefficients of the scale (λ) and shape parameters (γ) of the weibull distribution are presented. the impact on the time between symptom onset and hospitalization is visualized in figure 1 , showing the model-based 5%, 25%, 50%, 75% and 95% quantiles of the delay times. table 1 . summary of the regression of the scale (λ) and shape (γ) parameters for reported delay time between symptom onset and hospitalization and between symptom onset and diagnosis, based on a truncated weibull distribution: parameter estimate, standard error and significance (* corresponds to p-value < 0.05; ** to p-value < 0.01 and *** to < 0.001). the reference group used are females of age > 80 living in nursing home that are hospitalized in the period 01 march to 20 march. age has a major impact on the delay between symptom onset and hospitalization, with the youngest age group having the shortest delay (median of 1 day, but with a quarter of the patients having a delay longer than 2.6 days). the time from symptom onset to hospitalization is more than doubled in the working age (20-60 years) and ageing (60-80 years) population as compared to this young population (median close to 4 days and a delay of more than 6.7 days for a quarter of the patients). in contrast the increase is 50% in the elderly (80+ years) as compared to the youngest age group (median delay of 1.6 days, with a quarter of the patients having a delay longer than 4.3 days). after correcting for age, it is observed that the time delay is somewhat higher when patients come from a nursing home facility, with an increase of approximately 2 days. note that in the descriptive statistics, we observed shorter delay times for patients coming from nursing homes. this stems from the fact that 80+ year old's have shorter delay times as compared to patients of age 20-79, but the population size in the 80+ group is much larger as compared to the 20-79 group in nursing homes. and although statistical significant differences were found for gender and period, we observe very similar time delays between males and females and in the different time periods (see figure a7 ). the differences occur in the tails of the distribution; with, e.g., the 5% longest delay times between symptoms and hospitalizations observed for males. the time between symptom onset and diagnosis is also best described by a truncated weibull distribution (shape parameter 0.900, scale parameter 5.657). as again the truncated weibull distribution has a lower bic value as compared to the lognormal distribution (68,106 and 69,652 for weibull and lognormal, respectively), results for the weibull distribution are presented. parameter estimates are very similar to the distribution for symptom onset and hospitalization ( table 1 ). the median delay between symptom onset and diagnosis is approximately one day longer as compared to the median delay between symptom onset and hospitalization. the time from symptom onset to diagnosis in males had a much wider range as compared to females. this is observed in the tails of the distribution, with the 5% longest delay times being 5 days longer for males as compared to females. especially at the increasing phase of the epidemic, the time between symptom onset and diagnosis was longer as compared to the time between symptom onset and hospitalization (see figure a7 ), but this delay has shortened over time. to test the impact of some of the model assumptions, a comparison is made with an analysis without truncating the time between symptom onset and hospitalisation or diagnosis and wider time intervals (x i − 1, x i + 1). results are presented in figures a6 and a8 , and are very similar to the once presented here. it was also investigated whether or not there a difference between neonati (with virtually no symptoms, but diagnosed at the time of birth or at the time of the mothers testing prior to labour) and other children. for all children <20 years of age, we found a median time from symptom onset to hospitalization and diagnosis to be 1 and 1.6 days, respectively. if we only consider children >0 years of age, a small increase is found (1.5 (0.5-3.4) days for time to hospitalization and 1.8 (0.7-3.7) for time to diagnosis). a summary of the estimated los in hospital and icu is presented in table 2 and figure 1 based on the lognormal distribution. the lognormal distribution has a slightly smaller bic value as compared to the weibull distribution for the los in hospital (76,928 for weibull and 76,865 for lognormal) and for the los in icu (7341 for weibull and 7312 for lognormal). table 2 . summary of the regression of the log-mean (µ) and log-standard deviation (σ) parameters for the length of stay in hospital and icu, based on the lognormal distribution: parameter estimate, standard error and significance (* corresponds to p-value< 0.05; ** to p-value < 0.01 and *** to < 0.001). the reference group used are females of age > 80 living in nursing home that are hospitalized in the period 01 march to 20 march. a '/' indicates that this variable was not included in the final model. the median los in hospital is close to 3 days in the youngest age group, but 25% of these patients stay longer than 5.5 (8.6) days in hospital for females (males), and 5% stay longer than 13 (14) days for females (males). the los increases with age, with a median los of around 5.4 (5.9) days for females (males) in the working age group. a quarter of the patients in age group 20-60 stay longer than 10 days and 5% stays longer than 24 days. this increases for patients above 60 years of age, with a median los of around 8.6 (9.4) days for female (male) patients in the senior population group and 9.4 (10.3) days for female (male) patients in the elderly group. a large proportion of the elderly patients stay much longer in hospital. a quarter of these patients stay longer than 15.7-17.4 days for patients in the ageing group and longer than 17.3-19 days for the elderly. some very long hospital stays are observed in these age groups, with 5% of the los being longer than 38 (41) days for females (males) in the ageing group, and 42 (46) days in the elderly. no significant difference is found for patients coming from nursing homes. over the course of the first wave, the los has slightly decreased, with a decrease in median los of around 2 days from the first period to later periods. note that this result is corrected for possible bias of prolonged lengths of stay being less probable for more recently admitted patients. the los in icu (based on the lognormal distribution) is on average 3.8 days for the young patients, with a quarter of the patients staying longer than 7.6 days in icu. similar to los in hospital, also the los in icu increases with age. the median los in the working age population is 6.4, in the senior population 7.6, while in elderly it is slightly shorter (5.9 days). again, it is observed that a quarter of the patients in age group 20-60 stay longer than 13 days in icu, in age group 60-80 15.6 days and in 80+ 12 days. patients living in nursing homes stay approximately 2 days longer in icu. no major difference is observed in the los in icu between males and females, though some prolonged stays are observed in males as compared to females. similar as the overall los in hospital, the los in icu has decreased over time (with a decrease of 1 day from the first period to the later periods, and an additional 2 days in the last period). table 3 summarizes the los in hospital for patients that recovered or passed away. the lognormal distribution has the smallest bic value for time from hospitalization to recovery and the weibull distribution for time from hospitalization to death. for patients that recovered, the los in hospital increased with age (the median los is 5 days for the young population, which increases to 8 days in working age population, 12 days in the senior population and 15 days in the elderly). in contrast to previous results, we observe that patients living in nursing homes leave hospital approximately 1 day faster as compared to the general population. however, in contrast, the 5% longest stays in hospital before recovery are longer for patients living in nursing homes. but, while the los in hospital for patients that recover increases with age for all age groups, the survival time of hospitalized patients that died is lower for the age groups seniors (median time of 6.7 days) and elderly (median time of 5.7 days) as compared to the working age group (median time of 12.1 days). also large differences are observed amongst patients coming from nursing homes or not, with the time between hospitalization and death being approximately 3 days longer for patients living in a nursing home. no significant differences are found between males and females. a sensitivity analysis assuming that the time delay is interval censored by (x i − 1, x i + 1) is presented in figure a6 . results are almost identical to the previously presented results. it was also investigated whether the smaller duration of hospitalization for <20 years can be due to the neonati, for which the duration of stay is often determined by duration of post-delivery recovery of the mother. and indeed, the los in hospital for the youngest age group increases slightly if we take out the children of 0 years to 4.1(2.2, 7.6) days for males and 3.7(2, 6.9) days for females. the los in hospital for recovered patients increases to 6.4(3.7, 11) days for males and 5.9(3.4, 10.2) days for females of age between 1 and 19 years of age, making it very similar to the 20-60 years old patients that recovered. no impact was observed on the los in icu. table 3 . summary of the regression of the log-mean (µ) and log-standard deviation (σ) parameters for length of stay in hospital for recovered patients and patients that died, based on lognormal distribution and weibull distribution: parameter estimate, standard error and significance (* corresponds to p-value < 0.05; ** to p-value < 0.01 and *** to < 0.001). the reference group used are females of age > 80 living in nursing home that are hospitalized in the period 1 march to 20 march. a '/' indicates that this variable was not included in the final model. previous studies in other countries reported a mean time from symptom onset to hospitalization of 2.62 days in singapore, 4.41 days in hong kong and 5.14 days in the uk [16] . other studies report mean values of time to hospitalization ranging from 5 to 9.7 days [8, 17, 18] . in belgium, the mean time from symptom onset to hospitalization overall is 5.74 days, which is slightly longer as compared to the reported delay in other countries, but depending on the patient population, estimates range between 3 and 10.4 days in belgium. the time from symptom onset to hospitalization is largest in the working age population (20-60 years), followed by the elderly (60-80) years. if we compare patients within the same age group, it is observed that the time delay is somewhat higher when patients come from a nursing home facility, with an increase of approximately 2 days. the time from symptom onset to diagnosis has a similar behaviour, with a slightly longer delay as compared to time from symptom onset to hospitalization. the diagnosis was typically made upon hospital admission to confirm covid-19 infection during the first wave, explaining why the time from symptom onset to hospitalization is very close to the time to diagnosis. to investigate the length of stay in hospital, we should make a distinction between patients that recover or that die. while the median length of stay for patients that recover varies between 5 days (in the young population) to 15.7 (in the elderly), the median length of stay for patients that die varies between 5.7 days (in the elderly) and 12.2 days (in the working age population). in general, it is observed that the length of stay in hospital for patients that recover increases with age, and males need a slightly longer time to recover as compared to females. but, patients living in nursing homes leave hospital sooner as compared to patients in the same age group from the general population. patients living in nursing homes might be more rapidly discharged from hospital to continue their convalescence in the nursing home, whereas this is probably less the case for isolated elderly patients. in contrast, the time between hospitalization and death is longest for the working age population, with shorter survival time for the seniors and the elderly. the length of stay in hospital for patients that die is longer for patients coming form nursing homes, as compared to patients from the same age group from the general population. a similar trend is observed for the length of stay in icu. over the course of the first wave, the los has slightly decreased. this result is corrected for possible bias of prolonged lengths of stay being less probable for more recently admitted patients. therefore, this might be related to improved clinical experience and improved treatments over the course of the epidemic. but note that also varying patients profiles in terms of comorbidities or severity of disease over time can explain this trend, and it would therefore be interesting to correct for the patient's profile in a future study. the length of stay in belgian hospitals is within the range of the once observed in other countries, though especially the length of stay in icu seems shorter in belgian hospitals. reference [19] report a median length of stay in hospital of 14 days in china, and of 5 days outside of china. the median length of stay in icu is 8 days in china and 7 days outside of china [20] . reference [1] report estimated length of stay in england for covid-19 patients not admitted to icu of 8.4 days and for icu length of stay of 12.4 days. it should however be noted that the criteria for hospital (and icu) admission and release might be distinct in the different countries. different sensitivity analysis indicated that the results are robust to some of the assumptions made in the modeling. however, alternative methods could still be investigated to improve the estimation of the delay distributions. first, alternative distributions can be used, having more than two parameters and thus more flexibility, e.g., generalized gamma distributions (for which the gamma, exponential and weibull distributions are special cases). second, a truncated doubly-interval censored method could be considered to account for the uncertainty in both time points determining the observed delays (and their intervals). third, there is possible reporting bias in the time of symptom onset, which can influence the results. finally, the impact of severity of illness and co-morbidity on the length of stay in hospital is very important. this was not investigated in this study as this information was not made available, but is an important factor to investigate in future analyses. funding: this work is funded by the epipose project from the european union's sc1-phe-coronavirus-2020 programme, project number 101003688. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. a flow diagram of the exclusion criteria is displayed in figure a1 . the time of symptom onset and time of hospitalization is available for 13,321 patients. the date of symptom onset is determined based on the patient anamnesis history made by the clinicians. patients that were hospitalized before the start of symptoms (i.e., 715 patients) were not included. these include patients with nosocomial infections admitted prior to covid-19 infection for other long-term pathologies, then got infected at hospital and developing covid-19-related symptoms long after admission. patients reporting a delay between symptoms and hospitalization of more than 31 days (i.e., 121 patients) were also not included, because it is unclear for these patients whether the reason for hospital admission was covid-19 infection. a sensitivity analysis including patients with event times above 31 days is conducted. patients with missing information on age (i.e., 12 patients) or gender (i.e., 109 patients) were not included in the statistical analysis. this resulted in a total of 12,364 patients which were used to estimate the distribution of the time between symptom onset and hospitalization. based on the patient anamnesis history made by the clinicians. patients that were hospitalized before 258 the start of symptoms (i.e., 715 patients) were not included. these include patients with nosocomial 259 infections admitted prior to covid-19 infection for other long-term pathologies, then got infected 260 at hospital and developing covid-19-related symptoms long after admission. patients reporting 261 a delay between symptoms and hospitalization of more than 31 days (i.e., 121 patients) were also 262 not included, because it is unclear for these patients whether the reason for hospital admission was 263 covid-19 infection. a sensitivity analysis including patients with event times above 31 days is 264 conducted. patients with missing information on age (i.e., 12 patients) or gender (i.e., 109 patients) 265 were not included in the statistical analysis. this resulted in a total of 12,364 patients which were used 266 to estimate the distribution of the time between symptom onset and hospitalization. the time between hospitalization and discharge from hospital is available for 12,013 patients, 275 either discharged alive or dead. for patients that were hospitalized before the start of symptoms (i.e., the time of symptom onset and time of diagnosis is available for 13,156 patients. some of these were diagnosed prior to having symptoms (321) or experienced symptoms more than 31 days before diagnosis (136), and are excluded as these might be errors in reporting dates. similarly, the delay between symptoms and detection time is truncated at 31 days; but a sensitivity analysis including these patients is performed. in total, 125 patients were removed because of missing information on age and/or gender, resulting in 12,574 patients used in the analysis of the time from symptom onset to diagnosis. the time between hospitalization and discharge from hospital is available for 12,013 patients, either discharged alive or dead. for patients that were hospitalized before the start of symptoms (i.e., 528 patients), we use the time between the start of symptoms and discharge. patients with negative time intervals (54 patients) are excluded for further analysis. another 134 patients were discarded because of missing covariate information with regard to their age or gender. from these patients, we know that 6054 recovered from covid-19, while 2401 died. from the hospitalized patients, there is information about the length of stay at icu for 1534 patients. note that we analyzed an anonymized subset of data from the hospital covid-19 clinical surveillance database of the belgian public health institute sciensano. data from sciensano was shared with the first author through a secured data transfer platform. the observed distribution of the delay from symptom onset to hospitalization and los in hospital are presented in figure a3 . summary information about these distributions are presented in tables a2 and a3. while the observed delay between symptom onset and hospitalization is between 0 and 31 days, 75% of the hospitalizations occur within 8 days after symptom onset. this is however shorter in the youngest age group (<20 years) and in the elderly group (>90 years). also patients coming from nursing homes seem to be hospitalized faster as compared to the general population. over the course of the first wave, the observed time between symptom onset and hospitalization was largest in the increasing phase of the epidemic (between 21 march and 30 march). the time between symptom onset and diagnosis is very similar, ranging between 0 and 31 days, with 75% of the diagnoses occurring within 8 days after symptom onset. it should be noted that these observations are based on hospitalized patients, and non-hospitalized patients might have a quite different evolution in terms of their symptoms. as non-hospitalized patients were rarely tested in the initial phase of the epidemic, no conclusions can be made for this group of patients. the observed median length of stay in hospital is 8 days, with 95% of the patients have values ranging between 1 and 40 days. 25% of the patients stay longer than 14 days in the hospital. the median length of stay seems to increase with age (from 3 days in age group <20 to 6 in age group 20-80, 9 in age group 80-90 and 10 days in age group >90). on the other hand, with time since introduction of the disease in the population, the length of stay seems to decrease, though this might be biased due to incomplete reporting of los in patients who are actually still admitted at the time of writing. therefore, these observed statistics should be interpreted with care. similar results are observed for the length of stay in icu. (figures a4 and a5 hospital length of stay for covid-19 patients: data-driven methods for forward planning epidemiological determinants of spread of causal agent of severe acute respiratory syndrom in hong kong rapid establishment of a national surveillance of covid-19 hospitalizations in belgium handbook of infectious diseases data analysis robust reconstruction and analysis of outbreak data: influenza a (h1n1)v transmission in a school-based population estimation of the serial interval of influenza estimating incubation period distributions with coarse data incubation period and other epidemiological characteristics of 2019 novel coronavirus infections with right truncation: a statistical analysis of publicly available case data statistical analysis of interval-censored failure time data clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in clinical features of patients infected with 2019 novel coronavirus in clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study interim clinical guidance for management of patients with confirmed coronavirus disease (covid-19) modeling the early phase of the belgian covid-19 epidemic using a stochastic compartmental model and studying its implied future trajectories short doubling time and long delay to effect of interventions. arxiv 2020 the effect of human mobility and control measures on the covid-19 epidemic in china impact of nonpharmaceutical interventions (npis) to reduce covid-19 mortality and healthcare demand covid-19 length of hospital stay: a systematic review and data synthesis clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study publisher's note: mdpi stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-297618-9ka3y2y1 authors: chau, pui hing; li, wei ying; yip, paul s. f. title: construction of the infection curve of local cases of covid-19 in hong kong using back-projection date: 2020-09-21 journal: int j environ res public health doi: 10.3390/ijerph17186909 sha: doc_id: 297618 cord_uid: 9ka3y2y1 this study aimed to estimate the infection curve of local cases of the coronavirus disease (covid-19) in hong kong and identify major events and preventive measures associated with the trajectory of the infection curve in the first two waves. the daily number of onset local cases was used to estimate the daily number of infections based on back-projection. the estimated infection curve was examined to identify the preventive measures or major events associated with its trajectory. until 30 april 2020, there were 422 confirmed local cases. the infection curve of the local cases in hong kong was constructed and used for evaluating the impacts of various policies and events in a narrative manner. social gatherings and some pre-implementation announcements on inbound traveler policies coincided with peaks on the infection curve. the world health organization (who) declared the coronavirus disease (covid-19) as a pandemic [1] . it has been demonstrated that social distancing, contact tracing, patient isolation, early diagnosis, city lockdown, and travel restrictions were effective measures in slowing down the spread of covid-19 [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] . for the public to be prepared for dramatic changes, both physical and mental, a pre-implementation announcement is usually made. depending on the actual time of the announcement, the time gap ranges from less than 24 h to a couple of days. to date, the impact of this window of infection and its unintended consequences have not been investigated. apart from using simulations under the susceptible-exposed-infectious-removed (seir) model, an examination of the trajectory of the epidemic curve provides some insight into the impacts of various policies and events in a narrative manner. with one exception [14] , to date, those investigations on the effectiveness of preventive measures were based on epidemic curves mainly constructed using the date of diagnosis or onset [2, 6, [8] [9] [10] [11] [12] [13] . the estimated mean incubation period of the covid-19 varies from 4.9 to 7.4 days across studies [15] . the epidemic curve based on the infection date, however, would be more accurate to assess the effectiveness of various measures and the impacts of the events. as the date of infection is unobservable, it has to be estimated. the back-projection technique was originally developed to construct the infection curve for the human immunodeficiency virus (hiv)/acquired immune deficiency syndrome (aids) epidemic [16, 17] . in 2003, the authors applied the back-projection method to the severe acute respiratory syndrome (sars) epidemic [18] . the current study constructed an epidemic curve based on the date of infection estimated by the back-projection method to minimize the effects of the incubation time and reflect the possible impacts of various measures and events better. up until 31 august 2020, hong kong had 4811 confirmed covid-19 cases with 89 deaths. from january to april 2020, most of the cases were imported and clustered with known sources, and were considered as the first two waves of the infection. the third wave started in july, still continuing at the time of this publication. most of those cases were local, and the sources of many of which were unknown. the present study focused on the first two waves of local infections in hong kong. all the government announcements were systematically recorded on the official website, thus providing reliable information on the pre-implementation announcement dates and the implementation dates of the preventive measures. this provided a trusted source to examine the possible association between the pre-implementation announcements and the infection curve in a narrative manner. our objective was to estimate the infection curve of the local cases of the first two waves of covid-19 in hong kong using the back-projection method and explore the effectiveness of the preventive measures, including the possible impacts of the pre-implementation announcements by the local government. the daily number of confirmed cases of covid-19 reported by 30 april 2020 was obtained from the website of the centre for health protection, hong kong (https://www.chp.gov.hk/). a confirmed case was defined as a person with laboratory confirmation of covid-19 infection, irrespective of clinical signs and symptoms [19] . as the date of infection of the imported cases cannot reflect the impact of the preventive measures implemented locally, all imported cases were excluded from the analysis. until 30 april 2020, there were 1038 confirmed cases in hong kong, of which 422 were local cases and included in this study. among the 422 cases, 46 were asymptomatic and the date of onset was proxied by the date of report in the primary analysis. a sensitivity analysis was performed by excluding the asymptomatic cases. an infected person goes through an incubation period before the onset of the symptoms. the time when the symptoms appear is the onset time. the term "onset cases" was used to refer to the cases with onset of the symptoms on a particular day. there was also a delay between the onset of symptom(s) and the confirmation of cases. figure 1 shows the temporal relation between infection, onset, and confirmed cases. in this study, daily onset cases were used for the back-projection method. let t = 1, 2, . . . , τ denote the days, where t = 1 denotes 12 january 2020. as the earliest onset date was 22 january 2020, it was assumed that there was no infection 10 days prior to that date. furthermore, this was consistent with the fact that the earliest arrival date of imported cases was 14 january 2020. as the last time point was 30 april 2020, τ had been set to 110. the daily mean number of onset covid-19 cases (µ t ) was expressed in terms of the daily mean number of infection (λ s , s=1, . . . , t) by the convolution equation: where f t-s,s is the probability function of the incubation period, that is, the probability that an individual infected at time s developed a symptom after a period of length t-s. in other words, infected cases on day 1 went through an incubation period of t-1 days with the probability specified by the probability function of the incubation period and had onset of symptoms on day t; then infected cases on day 2 went through an incubation period of t-2 days; infected cases on day 3 went through an incubation period of t-3 days and so on, up to infected cases on day t that went through an incubation period of 0 days. the sum of all these cases was the total number of onset cases on day t. based on a recent meta-analysis on the incubation period established from eight studies [15] , the probability function of the incubation period of covid-19 was taken as a log-normal distribution with scale and shape parameters of 1.63 and 0.5, respectively. this corresponded to a mean of 5.8 days, a median of 5.1 days, and a 95th percentile of 11.7 days. the ems (estimate-maximize-smooth) algorithm was used to estimate the daily number of infection and pointwise 95% confidence interval was constructed by the bootstrap procedure. details of the back-projection method are reported elsewhere [16, 17] . python was used for running the algorithm [20] . the estimated infection curve was closely examined in relation to the major events and policies announced and/or implemented by the local government. the major events and policies were obtained from the official websites (www.info.gov.hk/gia/ and www.news.gov.hk). table s1 shows the selected government policies and major events in the period under examination. the number of covid-19 infections over this period was estimated to be 422. figure 2 gives the estimated daily number of covid-19 infections, the pointwise 95% confidence intervals on the estimated infection number, and the observed daily number of onset cases for the period from 12 january 2020 to 30 april 2020. it was estimated that the first infection occurred around 18 january 2020, roughly four days after the arrival of the first imported case on 14 january 2020. the highest peak was estimated around mid-march 2020, which was in the middle of the second wave of infection which started in march. zero infection was estimated since 4 april 2020. in the first wave, the estimated infected cases in late january 2020 could be mainly attributable to the social and family gatherings around the chinese new year. it was reported from contact history tracing that 6 infected people attended a family dinner in north point on 26 january 2020, 11 infected people attended a family gathering at a party room in kwun tong on 26 january 2020, and 13 infected people visited a buddhist worship hall in north point between 25 january and early february 2020. in the second wave, it was reported that there were two large-scale gatherings on 14 march 2020, one involved 80 guests at a wedding party and the other involved over 100 guests at a private party. a total of 14 confirmed cases were reported from those two gatherings. this was consistent with the peak in the infection curve on 14 march 2020. furthermore, 72 staff and customers of some pubs and bar areas were infected, and 31 more confirmed cases had epidemiological link to these cases. the onset date of this infection cluster was reported to be from 10 march to 13 april 2020, implying infection from around early march to early april. on 24 march 2020, it was reported that 7 people went to a karaoke and all were infected. on 26 january 2020, an announcement was made to ban inbound travelers who had visited the hubei province in the past 14 days prior to its actual implementation at midnight on 27 january 2020. from 25 to 29 january 2020, numerous policies were announced and implemented, including activation of the emergency response level, cancellation of large-scale events, quarantine of close contacts of confirmed cases, health advice to residents returning from the hubei province and other parts of china, suspension of non-emergent government services, closure of public facilities, home office arrangement for civil servants, and substantial reduction of traffic between mainland china and hong kong. as the peak of the first wave around 24-28 january 2020 was dominated by cluster infections during social gathering, it was difficult to observe potential influence from these policies. the announcement on 28 february 2020 about mandatory quarantine for inbound travelers who had been to emilia-romagna, lombardy, or the veneto regions in italy or iran in the past 14 days coincided with a local maximum. the curve, however, slightly went down after implementation of the policy on 1 march 2020. there was also an announcement on 6 march 2020 about the health declaration requirement on all inbound travelers effective from 8 march 2020. the curve declined slightly forthwith. the peaks on 13-15 march and 18-21 march 2020 were the key features of the second wave. during 2-22 march 2020, some non-emergent government services and public facilities resumed, and civil servants returned to work in the office. various policies on inbound travelers were announced and implemented during that period. however, their associations with the infection curve might be masked by the cluster infections in the wedding party, private party and the pubs and bar areas during the same period. on 10 march 2020, the government announced mandatory quarantine on inbound travelers from the whole of italy, france (bourgogne-franche-comte and grand est), germany (north rhine-westphalia), japan (hokkaido), and spain (la rioja, madrid, and pais vasco). this announcement coincided with the rise on the infection curve. on 13 march 2020, the government further announced mandatory quarantine on inbound travelers who had visited the schengen area countries. moreover, on 15 march 2020, mandatory quarantine was announced on all inbound travelers who had traveled to ireland, the united kingdom, the united states, and egypt. then, on 17 march 2020, mandatory quarantine was announced for all inbound travelers from all overseas places, which activated the downward trend again. starting from 20 march 2020, inbound travelers with symptoms of upper respiratory symptoms were tested at designated test centers and they had to wait for the results. for the second time, non-emergent government services and public facilities were closed from 23 march 2020, and the civil servants resumed to home office arrangement again. after implementation of these policies, the infection curve declined. against the declining trend, the infection number rebounded on 30 march 2020. however, the increase appeared to be not related to the pre-implementation announcements on 27 march 2020, which involved (i) strict operational instructions on the catering business (limiting the number of seats to half of the capacity, minimum distance of one and a half meters between tables, and a maximum of four seats per table); (ii) closure of scheduled premises (including amusement game centers, bathhouses, fitness centers, places of amusement, places of public entertainment, and party rooms); and (iii) ban of groups over four people in public places. the first two policies were implemented on 28 march 2020 and the third policy was implemented on 29 march 2020. furthermore, closure of karaoke, mahjong-tin kau, and nightclub establishments was announced on 1 april 2020 and closure of bars and pubs was also announced on 2 april 2020, and implemented on 1 and 3 april 2020, respectively. after implementation of all those policies, the infection number continued to fall to zero by 4 april 2020. the sensitivity analysis that excluded the asymptomatic cases ( figure s1 ) gave a similar trajectory of the infection curve. it was noted that the local maxima from 28 february to 1 march 2020 and from 29 march to 3 april 2020 were not observed in the sensitivity analysis that excluded the asymptomatic cases. the peak on 19 march 2020 in the sensitivity analysis was lower than that which included the asymptomatic cases. it might be that those infected in those periods were mostly asymptomatic. the current study constructed the infection curve of local confirmed covid-19 cases in hong kong. from studying the estimated curve closely with the major events and preventive measures, it was observed that a strict mandatory quarantine order on inbound travelers coincided with the decline from the peak in the infection number. however, some pre-implementation announcements of such policies and social gatherings corresponded with sharp increases in the infected cases. the closure of public facilities and home office arrangement might have helped to slow down the spread. it is common practice around the globe to pre-announce government policies. in hong kong, the press conference was usually held at 4:30 pm. for policies to be implemented the following day, such an announcement would only leave several hours before the actual implementation. to stir up reactions, such a short period may not be sufficient. for transportation from overseas countries to hong kong, more time is needed for preparation. thus, the announcements of mandatory quarantine on people returning from overseas were made over 24 h prior to implementation. instead of using the time to well plan for the 14-day quarantine, those from overseas, however, rushed back to hong kong to avoid the mandatory quarantine. it was reported that 46 confirmed imported cases (the largest daily imported cases) entered hong kong on 18 march 2020, just before implementation of the mandatory quarantine policy. to make things worse, social gathering still went on during that period when cluster infections related to some bars and pub areas were reported. it is understandable though for the government to announce the policies in advance to allow the people to be better prepared. however, in hong kong, many residents rushed back before the implementation to avoid the mandatory quarantine, thus increasing the risk of transmission in the community. to minimize the opportunity of infection, pre-implementation announcements should be made as close to the implementation date as possible. meanwhile, comprehensive support plans for those being quarantined and groundwork should simultaneously be in place. quarantines on inbound travelers appeared to be effective. according to a study in singapore, rapid identification and isolation, quarantine of close contacts, and active monitoring of other contacts were effective measures in controlling covid-19 [6] . nevertheless, it should be noted that quarantine should be combined with other public health measures to achieve the best result [7] . quarantine polices are important and overall well-being should be catered for too. during the sars epidemic, people felt isolated and hopeless, which resulted in a rise in the suicide rate [21, 22] . while controlling the spread of the epidemic, the mental well-being of the residents should also be taken care of [23] . fortunately, with the many social media devices, social connectedness and emotional closeness can still be maintained when practicing physical distancing. it is important to ensure those quarantined do not feel left out or forgotten. meanwhile, it appeared that screening for covid-19 at the airport might not be effective enough in catching a significant proportion of cases [24] . however, sample testing for all inbound travelers seemed to work well in preventing the cases from entering the hong kong community. since such a policy was in force together with the mandatory quarantine policy, its effect alone could not be evaluated. the suspension of non-emergent government services, closure of public facilities, and home office arrangement for civil servants at the end of january coincided with the drop in the number of covid-19 infections at the end of january. moreover, resumption of these services and work at the office in early march seemed to correlate with an increase in the infection. subsequently, the suspension of these services and home office arrangement were implemented again at the end of march. the implementation of other policies included the suspension of education and schools. however, as these policies were implemented concurrently, an evaluation on the individual effectiveness of each policy was not possible. indeed, a review suggested that the effect of school closure was less than that of other social distancing interventions [25] . this could be true in view of an example in taiwan where schools and offices were not closed, yet the infection could still be maintained at a low level. it has also been reported that highly effective contact tracing and case isolation were sufficient to control a new outbreak of covid-19 [3] . in this regard, hong kong has been performing contact tracing exceptionally well, nonetheless, its effect also could not be assessed in the current study. the strength of this study was the estimation of the infection curve based on the back-projection method. the limitation of this study was that the date of onset was subject to recall bias, and a proxy date of onset was assumed on 46 asymptomatic patients. a sensitivity analysis was conducted by excluding the asymptomatic cases, and the trajectory of the infection curve remained roughly the same. an assumption made on the incubation period might also affect the estimated infection curve. nevertheless, this study utilized the pooled estimate from a meta-analysis based on eight studies [15] . this study was a narrative study, and causality cannot be assessed. in addition, if there were more than one policy or event occurring in parallel, it would be difficult to distinguish their impacts. at the same period, there were also social events such as healthcare on strike, protests for various reasons, and panic purchase of food and toilet paper, which involved the gathering of people and reduced social distancing, yet this study did not analyze their impact. future studies might consider using the estimated infection curve to assess the effectiveness of various preventive measures and events using the quantitative approach. to conclude, the infection curve of covid-19 could be constructed by the back-projection method. the findings of this study were consistent with previous studies on the effectiveness of some preventive measures. this study suggests that social gatherings and policy announcements and implementation sometimes coincide with changes in the infection curve; however, prospective studies designed to evaluate causality are needed to further understand this observation. rolling 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follow up description of covid-19 cases along with the measures taken on prevention and control in zhejiang covid-19 social distancing in the kingdom of saudi arabia: bold measures in the face of political, economic, social and religious challenges backcalculating the incidence of infection with covid-19 on the diamond princess incubation period of covid-19: a rapid systematic review and meta-analysis of observational research a method of non-parametric back-projection and its application to aids data reconstructing the incidence of human immunodeficiency virus (hiv) in hong kong by using data from hiv positive tests and diagnoses of acquired immune deficiency syndrome monitoring the severe acute respiratory syndrome epidemic and assessing effectiveness of interventions in hong kong special administrative region global surveillance for covid-19 caused by human infection with covid-19 virus (interim guidance) python 3 reference manual; createspace the impact of epidemic outbreak a revisit on older adults suicides and severe acute respiratory syndrome (sars) epidemic in hong kong physical distancing and emotional closeness amidst covid-19 ncov working effectiveness of airport screening at detecting travellers infected with novel coronavirus (2019-ncov) school closure and management practices during coronavirus outbreaks including covid-19: a rapid systematic review key: cord-311311-rmv5rfst authors: harper, martin title: recent advances in occupational exposure assessment of aerosols date: 2020-09-18 journal: int j environ res public health doi: 10.3390/ijerph17186820 sha: doc_id: 311311 cord_uid: rmv5rfst exposure science is underpinned by characterization (measurement) of exposures. in this article, six recent advances in exposure characterization by sampling and analysis are reviewed as tools in the occupational exposure assessment of aerosols. three advances discussed in detail are (1) recognition and inclusion of sampler wall deposits; (2) development of a new sampling and analytical procedure for respirable crystalline silica that allows non-destructive field analysis at the end of the sampling period; and (3) development of a new sampler to collect the portion of sub-300 nm aerodynamic diameter particles that would deposit in human airways. three additional developments are described briefly: (4) a size-selective aerosol sampler that allows the collection of multiple physiologically-relevant size fractions; (5) a miniaturized pump and versatile sampling head to meet multiple size-selective sampling criteria; and (6) a novel method of sampling bioaerosols including viruses while maintaining viability. these recent developments are placed in the context of the historical evolution in sampling and analytical developments from 1900 to the present day. while these are not the only advances in exposure characterization, or exposure assessment techniques, they provide an illustration of how technological advances are adding more tools to our toolkit. the review concludes with a number of recommended areas for future research, including expansion of real-time and end-of-shift on-site measurement, development of samplers that operate at higher flow-rates to ensure measurement at lowered limit values, and development of procedures that accurately distinguish aerosol and vapor phases of semi-volatile substances. exposure science is underpinned by exposure assessment [1, 2] . exposure assessment includes modeling of exposures, but most importantly characterization (measurement) of exposures. in this article, six recent advances in sampling and analysis in the occupational exposure assessment of aerosols will be addressed. three advances to be discussed in detail are (1) recognition and inclusion of sampler wall deposits; (2) development of a new sampling and analytical procedure for respirable crystalline silica that allows non-destructive field analysis at the end of the sampling period; and (3) development of a new sampler to collect the portion of sub-300 nm aerodynamic diameter particles that would deposit in human airways. three additional developments will be described briefly: (4) a multi-fraction size-selective aerosol sampler; (5) a miniaturized pump with interchangeable sampling heads to meet different size-selective sampling criteria; and (6) a novel method of sampling bioaerosols including viruses while maintaining viability. in order to understand the rationale behind these recent advances, it is first necessary to recognize the historical context of prior advancements. aerosols have been measured in the occupational environment since before 1900. dust collection for investigation probably occurred even before the invention of the aëroconiscope in 1870 [3] . mining is one of the dustiest occupations and much research has been undertaken and many developments have arisen from consideration of aerosols in mining. the procedures in use at the beginning of the twentieth century are not the same as those used today. changes have been driven by advances in our understanding of aerosol behavior and toxicity in air and in the human airways, and by technological innovations. one of the first procedures to be used in mining was to pull a measured volume of air through a tube containing granulated sugar [4] . the passage of humidified air caused the surface of the sugar to become sticky, trapping particles carried in the airstream. after sampling, the sugar could be dissolved and filtered off and the particles ignited to remove organic material. then the particles could be segregated by size, if necessary, by sedimentation and then counted under a microscope in order to obtain a particle number concentration in particles per cubic centimeter or millions of particles per cubic foot. the sugar tube was used in mines prior to 1900 until its replacement by the greenburg-smith impinger in 1922 [5] . in this device, air is accelerated by passing through a nozzle immersed in water. the particles contained in the air have enough momentum to be carried to an impaction plate where their momentum is arrested and the particles are stopped, wetted and remain in the water for subsequent analysis. the original device operated at 1 cubic foot per minute (28.3 l min −1 ), but in 1934 it was miniaturized (the "midget impinger") to operate at flow rates in the range of ml min −1 [6] . impingers had the problem that they contained liquid, which was cumbersome in the field, but also it was known that very fine aerosol (original experiments used magnesium oxide fume and tobacco smoke) was not collected efficiently-such aerosol would attach to the surface of the air bubbles and be released through the bubbles bursting at the outlet. in 1944, the us bureau of mines investigated glass fiber filters [7] , and in 1957, the us public health service (the precursor of the national institute for occupational safety and health) published on the virtues of the polymeric membrane filters they had been using for several years [8] , contained in brass holders similar to those being used by the us atomic energy commission for airborne radionuclide sampling. also, in the 1950s it was realized that it was the finer or "respirable" particles that were most toxic [9] , so that size-selection curves were developed along with size-selective sampling devices (cyclones) for fine particle sampling. for several years, different respirable fractions were measured in different jurisdictions, which eventually were reconciled under iso [10] . for larger particles than those considered for pneumoconiosis in mining, it was felt that all particles should be collected, and since the critical health issue is absorption and systemic toxicity, particle mass is considered more important than particle number (with the exception of mineral fibers). in 1956, a plastic cassette to house filters was developed for "clean-room" particle sampling, and, in 1960, it was featured in the first edition of the air sampling instruments handbook from the american conference of governmental industrial hygienists [11] . it was made by the millipore corporation and known as the "millipore monitor", but is now widely manufactured and is known more generally as the "closed-face cassette" (cfc), although it can also be used with a ring piece in place of the cap, where it is known as an "open-face cassette" (ofc). both styles are manufactured to be used with filters of 25, 37, or 47 mm diameter. the cap on the cfc includes a small (4 mm) entry orifice, an advantage in preventing accidental or deliberate tampering with the filter, which was important since by that time pumps had been developed of size and weight suitable to be carried by a person for "personal sampling" [12] . it was believed that the cassette and filter, now known as a "sampler," collected all particles in the air that would be relevant to inhaled dose onto the filter. the filter was the only part analyzed and considered to be an analysis of total particulate mass (tpm). however, only particles up to a certain size were collected efficiently [13] . further research in the 1980s showed that larger particles up to 100 micrometers aerodynamic equivalent diameter (aed) could enter the nose and mouth while breathing [14] . since mass is related to the cube of the diameter, even small numbers of large particles could have a profound impact on the inhaled mass dose. note that most studies have considered solid particles; the behavior of liquid particles needs further study the "inhalable" sampling convention developed out of this research [15] and an "inhalable" sampler was developed at the institute of occupational medicine in scotland, which became known as the iom personal inhalable sampler [16] . during the development of this sampler it was clear that a substantial portion of the collected sample either did not reach the filter or bounced off the filter and was deposited on the internal surfaces [17] . the same issue affects other samplers, and its importance has now been studied over 30 years with clear conclusions bolstered by the research. that many occupational hygienists and the laboratories that serve them are either unaware of, or slow or even unwilling to accept the consequences is a puzzle. samplers for aerosols typically consist of a filter or other collection substrate, for example an impaction plate or foam, supported in a container or holder. the entire device typically is considered an aerosol sampler. part of the aerosol entering a sampler will deposit on the internal surfaces of the sampler prior to reaching the collection substrate. there are a number of mechanisms by which this can occur, including direct inertial impaction, gravitational settling, interception resulting from eddies during transport, electrostatic attraction and bounce from the filter [18] . all of these mechanisms can occur simultaneously, with the relative importance depending on factors such as particle size, shape, and density; inertial velocity; wind speed and orientation; etc. in addition, after sample collection, if the collection substrate is transported while mounted in the sampler, it is possible that particles originally deposited on the collection substrate may dislodge during transportation. such particles can thereby contribute to deposits on the walls, as well as on the base of any cover plate or plug [19] . all particles found elsewhere than on or in the collection substrate are often loosely termed "wall deposits". deposits on internal surfaces are often invisible to the naked eye, even with transparent cassettes; they often comprise a large fraction of the aerosol that enters the sampler [20] (updated with additional information from the authors, personal communication, october 2007), [21] [22] [23] [24] and can even exceed the quantity collected on the filter. example data for cfcs are presented in table 1 . if the sample of interest entails the entire aspirated air particulate into the container or holder (sampler), it is necessary to account for these wall deposits, especially if it cannot be shown that they should be disregarded. similar data for the iom sampler are given in table 2 . table 1 . summary of findings of internal wall deposits as a percentage of total catch (filter plus walls) in field samples using the 37-mm cfc sampler. copper smelter [25] 18 cu 21% 55% lead ore mill [26] 9 pb 19% 35% solder manufacture [27] 30 pb 29% 74% battery production [20] 16 pb 28% 66% battery recycling [26] 54 pb 29% 54% welding [28] 10 cr(vi) 5% 55% plating [28] 12 cr(vi) 12% 17% paint spray [28] 29 cr(vi) 7% 12% zn foundry [20] 9 zn 53% 62% zn plating [20] 18 zn 27% 91% cast iron foundry [20] 18 fe 22% 46% grey iron foundry [20] 18 fe 24% 77% bronze foundry [29] 6 cu, pb, zn 19%, 13%, 15% 45%, 17%, 21% cuproberyllium alloying [20] 4 cu, be 31%, 12% 40%, 39% solder manufacturer [30] 50 pb 45% 77% solder manufacturer [30] 47 sn 56% 93% table 2 . summary of findings of internal wall deposits as a percentage of total catch (filter plus walls) in field samples using the iom sampler. lead ore mill [26] 8 pb 19% 30% copper smelter [25] 17 cu 16% 38% copper refinery [19] 48 cu 18% 36% battery production [31] 11 pb 8% 33% welding [31] 18 al 3% 13% cast iron foundry [20] 18 fe 8% 69% grey iron foundry [20] 18 fe 5% 16% bronze foundry [29] 6 cu, pb, sn, zn 0%, 0%, 0%, 3% 10%, 3%, 23%, 6% most research exploring the extent of the wall loss phenomenon has considered inert particles [32, 33] , and metalliferous particulates [20, 21, [26] [27] [28] [29] [30] [31] . however, the issue has also been studied for airborne organic materials, including bacterial endotoxin [34] , wood [35] , and pharmaceutical dusts [22] ; another relevant study reported results from investigations in thermosetting plastics, wood, paper, and animal breeding [36] . except in the case of very large wood dust particles, there is no evidence to suggest that wall deposited particles are sufficiently different from those found on the collection substrate to warrant their exclusion [37, 38] . wall deposits are not limited to aerosol samplers for larger airborne particles but may also be found in samplers for finer particles [39, 40] . there is a justification for excluding wall deposits where the performance of an aerosol sampler tested to european standard en 13205 [41] shows appropriate compliance with the relevant iso 7708 size-selective convention without their inclusion, but it should not be assumed. the sampling and analytical methods published in the niosh manual of analytical methods (nmam) represent state-of-the-art methods for assessing worker exposures to toxic chemicals. niosh considers that all particles entering the cfcs and the iom sampler should be included as part of the sample whether they deposit on the filter or on the inside surfaces of the sampler. this is published policy [42] and is further stated in a section on the manual web page. the us occupational safety and health administration (osha) has the same policy [43] , which has specifically been addressed by their gravimetric method [44] since inception, and which is now explicitly written into new methods for metals sampling and analysis [45] . all aerosol particles entering an air sampler should be considered potential contributors to exposure, and this extends to gravimetric and chemical analyses. appropriate sample preparation procedures are necessary to account for material on the internal surfaces. a number of techniques have been proposed, depending on the analytical finish: (1) sample extraction within the cassette; (2) rinsing of internal surfaces and adding the rinse to the filter preparation and analysis; (3) wiping the interior of the capsule and adding the wipe to the filter preparation and analysis; and (4) analysis of internal sampling capsules or cartridges (sampler inserts). very few procedures have been developed and validated for carrying out sample extraction within the cassette. a procedure for in situ (that is, within-sampler) extraction in france [46] uses a 3-piece polystyrene cassette as the container for both sampling and extraction. originally the filter used consisted of quartz fiber media, but the high background of some metals in these filters, together with the need for large quantities of hydrofluoric acid for complete dissolution of the filter, has led to replacement with a cellulose support pad and mixed cellulose ester (mce) filter [47] . after sampling, the cassette is inverted and opened from the rear and the support pad removed, leaving the mce filter in place. acids (perchloric first, followed by nitric and hydrochloric, with hydrofluoric where necessary) are pipetted into the cassette, which is then sealed and placed in an ultrasonic bath for 10 min with the cassettes being upended after 5 min. rinsing has not been shown to be a procedure with efficient recovery in most cases [43, 47] . osha methods use wiping, for example with a clean "smear tab" (or 1 × 2 inch section of "ghost wipe") that has been moistened with deionized water and placed in the same digestion beaker with any rinse of the interior and the sample filter [48] . the use of a single wipe without rinse has been validated by a niosh study [47] . however, wiping is cumbersome and potentially subject to operator variability. that leaves sampler inserts as the most practical and valid method for either gravimetric analyses or digestion with analysis for metals. as noted above, osha uses a sampling method for gravimetric analysis, which is a cfc containing an internal capsule comprising a polyvinyl chloride (pvc) filter and aluminum foil cone. the cone has an inlet hole at its apex directly under the cassette inlet and the edge of the cone is tightly fixed to the filter. all particles are thus included on the filter or otherwise within the cone, which is pre-and post-weighed without removing the filter [44] . the same system is used with a cyclone pre-selector for respirable dust and respirable crystalline silica, in which case the filter is used to wipe the interior of the foil capsule before being digested for redeposition and analysis [49] . these capsules are expensive and a proposal for a cheaper all-pvc version (capsule and filter) was first suggested in 1992 for the collection of pharmaceutical dusts [50] . these sampler inserts are now available for both the 25 mm and 37 mm cfc and are known as gravi-serts™ (zefon international, inc., ocala, fl, usa), and they can be used in niosh method 0501 [51] . the disposable inhalable sampler (dis; zefon international, inc.) is a dimensional copy of the iom sampler (patent pending) and similar pvc capsules and filters are available for the dis. since the geometric design of the dis sampler is identical to that of the iom sampler it has identical size-selective sampling performance characteristics. this was tested in bakeries with identical gravimetric results for side-by-side dis and iom samplers [52] . cellulose acetate inserts with mce filters have been extensively tested [30, [53] [54] [55] and are intended for acid digestion and subsequent analysis for metals in niosh method 7306 [56] . commercially available products include solu-serts™ (zefon international, inc.) and solu-caps™ (skc inc., eighty four, pa, usa). again, a similar product is available for the dis (zefon international, inc.). the dis has other advantages over the iom sampler-for example, it is inexpensive and intended for single use, thus avoiding the need for clean-up and the possibility of cross-contamination, an important concern for trace metal analysis. background levels of the cellulosic dis after microwave digestion in a combination of acids (nitric-hydrochloric-hydrofluoric) with hydrogen peroxide, by magnetic sector inductively coupled plasma-mass spectrometry are presented in table 3 . . the method reports a bias of 0.058 and an overall precision of 0.059, for an accuracy of ± 15.5%. weight stability over 28 days was verified for both blanks and spiked capsules. independent laboratory testing on blanks and field samples verified long-term weight stability and uncertainty estimates. the working range is given as 0.25 to 5 mg per sample, with an estimated limit of detection of 0.075 mg per sample and a precision of 0.031 at approximately 2 mg per sample. an inter-laboratory study of niosh method 7306 [56] for 33 elements, gave recoveries better than 80% for all elements at both low and high spike levels, except for silver at the higher level. accuracy of analysis, calculated from a combination of precision and bias, was 25% or less for all elements except silver. niosh methods 0501 and 7306 should be used in place of older methods and the analyzing laboratory has a duty to inform their clients in this regard; iso 17205 section 7.1.2 states "the laboratory shall inform the customer when the method requested by the customer is inappropriate or out of date" [57] . consideration of internal sampler wall deposits is included in related international voluntary consensus standards, published by iso and astm international (formerly american society for testing and materials), which describe the sampling and analysis of airborne metals and metalloids in occupational atmospheres. other large particle samplers have been shown to have internal deposits other than on the filter [25] . samplers that collect both aerosols and vapor where, for example, the sampler consists of a filter cassette and sorbent tube in series may be similarly affected. where cyclone-cassette assemblies are used for fine-particle, "respirable", internal non-filter deposits are still found [39, 40] but it is more difficult to account for them. cassettes made of conductive materials dissipate the charges induced by charged fine particles, minimizing losses to the internal surfaces and should be used in place of non-conductive cassettes [42] . exposure to respirable fraction of crystalline silica (rcs) by inhalation can cause silicosis, lung cancer, other respiratory diseases, and kidney diseases [58] . silica, especially quartz, is a common constituent of mined and quarried rocks and mineral deposits and materials used in construction including concrete, cement, bricks, aggregates, granite, slate and limestone. exposure to rcs can occur during typical mining and construction. while the number of miners is relatively small, osha estimates about two million construction workers are exposed to rcs in over 600,000 us workplaces [59] . studies of construction exposures have reported excessive exposures associated with certain tasks. for example, exposures ranging as high as 100 times the niosh recommended limit of 0.05 mg/m 3 have been reported. the new osha comprehensive standard for silica in construction in effect from 23 september 2017, alongside a similar rule for general industry which took effect 23 june 2018, lowered the permissible exposure level (pel) for rcs to 0.05 mg/m 3 rcs and added a concentration level where exceedances would drive further enforcement actions (i.e., an "action level") of 0.025 mg/m 3 [59] . osha estimates that more than 840,000 construction workers are exposed to rcs levels that exceed the new pel. osha's preliminary economic analysis and initial regulatory flexibility analysis expects a net benefit between $2.8 and 4.7 billion annually over the next 60 years by preventing between 579 and 796 annual fatalities from rcs exposure in all industries [59] . demonstrating compliance with exposure limits for rcs requires the collection of respirable dust. respirable dust is sampled from air using a cyclone or impactor to separate the respirable fraction from aerosol. evaluation of rcs in the respirable dust has, until recently, required the use of off-site sophisticated laboratory analysis, but this can involve results being returned up to several weeks following the period sampled. long lag times can lead to unacceptable conditions persisting during the interim without being recognized or addressed. while x-ray diffraction (xrd) is used extensively for the determination of silica in air samples, results from a proficiency test scheme for laboratories did not show any strong bias between xrd analysis and analysis by fourier transform infra-red (ftir) spectroscopy [60] . ftir spectrometers today are manufactured sufficiently robust and small enough to be taken to the field allowing on-site analysis. a methodology to quickly determine monitoring exposure results, even if the accuracy is outside of that required for compliance purposes, can be very useful. niosh has developed a field-ready methodology capable of an end-of-shift (eos) measurement for rcs contained in airborne dusts in the mining sector [61] , and this has been found also to provide results comparable to xrd [62] . rcs is collected on a direct-on-filter (dof) sampler (eos™ silica cassette, zefon international, inc.) attached to any one of several different cyclones to select the respirable dust fraction. following sample collection, the cassette is removed from the cyclone and placed in a holder in any one of four different models of ftir spectrometer, which have been evaluated for the purpose [63, 64] . in a complex matrix of minerals, the estimation of quartz content may be subject to interference. work is continuing to minimize these interferences by means of mine-specific correction factors [65] . however, since ftir is a non-destructive analysis, samples can still be submitted to a laboratory for further analysis. this method promises to be applicable to monitoring rcs in the construction sector. however, the construction samples contain not only silica but other components, which are typically different from those found in mines and quarries. the presence of such components also may interfere with the ftir response from rcs in a manner which might require corrections to be applied to obtain a valid result. a recent pilot study evaluated possible interferences from different types of construction dusts-including drywall, plaster, cement, and brick-in laboratory-generated mixed dust samples [66] . results from a set of prepared samples analyzed by portable ftir showed that a) plaster and drywall dusts do not interfere substantially with the quartz measurement; b) cement does not interfere with the quartz measurement, but it does change the background absorbance of the filter; and c) in addition to having a substantial quartz content that has to be carefully evaluated in any study, brick dust may also contain an additional material, probably a silicate mineral, which interferes additionally with the quartz peak. in the range of interest from 20-110 µg per filter sample (bracketing the niosh rel/osha pel for a 1 m 3 air sample), 83% of the quartz contents predicted from the averaged calibration data agreed within 50% of the adjusted nominal loadings and 91% agreed within 100%. this result is encouraging given the high levels (500 or 1000 µg) of interfering dusts. an on-site reading of 100 µg is highly likely to be above the pel, and a reading of 50 µg is highly likely to be above the action level so that appropriate action could be taken prior to receiving a definitive analysis from the laboratory. samples loaded with smaller amounts of all four dusts in combination gave even better results, with all nine results within the range of interest falling within 25% of the adjusted nominal loadings. both cement and brick could be correctable interferences once the identity of the interference is revealed, in the same way that correction is made for interfering mineral dusts in mines, and this is one of the further investigations suggested by this pilot study. exposure through inhalation of both incidental and engineered nanoparticles is a primary concern for worker health and safety, since nanoparticles are considered to have greater reactivity and thus toxicity compared to larger particles of similar composition [67] . particles in this range can be engineered, for example, the metals and metal oxides and sulfides manufactured for commercial purposes, or incidental, including welding and other fumes. although it was once thought that many sub-micrometer particles quickly agglomerate and attain particle sizes that are larger than 0.5 µm, there is growing evidence that a significant fraction of particles remains in singular or small number agglomerates in the nanoparticle (<100 nm) range. around 300 nm there is a minimum in particle deposition in human airways, so that a particle of this size is far more likely to be breathed back out into the ambient atmosphere than to be deposited internally [68] . below 300 nm the deposition efficiency begins to increase with decreasing particle size as a result of the importance of particle movement by diffusion resulting from brownian motion, and interception. this deposition mechanism, unlike impaction or gravitational settling, occurs as much in the head airways as the lower respiratory tract. based initially on work on the collection efficiency of nylon screens [69] , a lightweight (60 g), personal nanoparticle respiratory deposition sampler (nrd sampler, zefon international, inc.) was developed to selectively collect particles smaller than 300 nm [70] . most samplers are designed to sampling conventions that are based on penetration, but in this case the sampler was designed to collect nanoparticles with efficiency matching their deposition in the respiratory tract, in order to provide a physiologic relevance to sampler's performance. a new sampling criterion was devised to provide the relevant deposition efficiency for the sampler [70] . the sampler operates at 2.5 lpm and consists of a respirable cyclone fitted with an impactor and a diffusion stage. the cut-point diameter of the impactor is 300 nm with a sharpness σ = 1.53. the diffusion stage collects particles smaller than 300 nm according to the proposed convention. impactor separation performance was not affected in experiments of loading at particle levels typically encountered in workplaces. the pressure drop of the nrd sampler is sufficiently low to permit its operation with conventional, belt-mounted sampling pumps. the initial design used nylon screens as the diffusion stage, and the limit of detection of common metals in welding fume using low-level spikes was determined to be 0.3 ug ni, 0.4 ug cr, and 0.9 ug fe. both laboratory [71] and field [72] trials in welding environments produced excellent results for short term samples, although it is possible that agglomerated particles, such as those which characterize welding fume, could with loading affect the porosity of the nylon screens, altering performance. studies found that interception did become important as a collection mechanism as the collection of agglomerated nanoparticles progressed to higher loadings [73] . performance of the nylon screens for agglomerated particles was found to be affected when the accumulated nanoparticle fraction loadings exceeded 1 mg. the change in performance also was accompanied by an increase in pressure drop across the screens to 14.3 kpa, and this could cause many commercial sampling pumps to fault. at the american conference of governmental hygienists (acgih ® ) threshold limit value (tlv ® ) for welding fume of 5 mg/m 3 , a one-hour sample at 2.5 l min −1 collects 0.75 mg. the nanoparticle fraction of welding fume is typically less than half the total mass [70] , so nylon screens are effective in sampling welding fume for one-hour or less. nylon screens were also used for area samples of metal gouging and lancing side-by-side with inhalable, thoracic and respirable samplers [74] . nanoparticles averaged around 170 nm in fume during gouging and around 30 nm during lancing. nrds iron mass concentration was about 21% of inhalable for gouging and 28% for lancing. unsurprisingly nanoparticles surface area dominated the total surface area. the sampler now comes with a choice of two different diffusion stages. an alternative diffusion collection substrate, polyurethane foam, has characteristics more closely resembling human airways and may be preferable for collecting agglomerated materials, such as welding fume, in higher loading scenarios [70] . polyurethane foam is easily digested in acids [75] and, unlike nylon, does not contain titanium allowing this sampler to be used to assess nanoparticle titanium dioxide [76] . values for the median background of elements on small pieces of commercially available foam (n = 10) cleaned by a proprietary procedure, have been determined [77] after microwave digestion in a combination of acids (nitric-hydrochloric-hydrofluoric) with hydrogen peroxide, by magnetic sector inductively coupled plasma-mass spectrometry and are presented in table 4 . results have been scaled to the size of the foam used in the nrd sampler. note that tin (approximately 10 micrograms per foam piece) is a cross-linking agent and is not removed by washing. the effective deposition to the foam was tested using sodium chloride aerosol, and up to 19 mg loading of metal fume was generated from welding rods using spark discharge. field studies included testing against a device providing aerosol size distributions in three workplace situations [78] . good correlations were found in the two workplaces (a heavy vehicle machining and assembly facility and a shooting range) where the aerosol was not dominated by large particles, but the correlation was not so good at an iron foundry where 95% of the particles were >1 µm aerodynamic equivalent diameter. use of nanoparticle respiratory deposition samplers is described in the astm international (formerly american society for testing and materials) standard practice [79] . as noted, particles that penetrate to the gas-exchange region of the lungs are known as respirable. the diseases caused by inert respirable particles, including rcs, asbestos, coal dust, talc, bauxite, etc. cause, respectively, silicosis, asbestosis, "black lung", talcosis and shavers' disease, known collectively as pneumoconiosis [80] . the exposures that cause these diseases traditionally have been assessed by measuring only those particles that penetrate to the gas-exchange region by means of a size-selector that only allows the fine particles to collect on the filter for analysis [81] . these size-selectors are designed to mimic size-selection in the lungs, and the most common technology is the miniature cyclone. on the other hand, particles of any size that can enter the mouth and nose that are soluble and can be absorbed, either in the lungs or in the gastrointestinal tract following expectoration and swallowing, can contribute to the dose of a systemic poison, for example, as with lead or cadmium. these particles are assessed by measurement of all particles that can enter the nose and mouth; a fraction termed "inhalable" [14] . some metals are also thought to affect the lower reaches of the lung and so occupational exposure limit values for both inhalable and respirable fractions (e.g., for nickel compounds) are beginning to appear. there are many instances where knowledge of both inhalable and respirable particulates can be important and, traditionally, it has been necessary for the worker to wear two sets of sampling equipment (samplers and pumps) for the purpose of making the two determinations. expensive multi-fraction samplers exist but are not widely used. a cheap alternative is the dis with a foam insert as size-selector. with the correct type of foam, it is possible to match the iso respirable convention. the filter collects the respirable faction, and anything between respirable and inhalable is caught in the foam, so that adding the analysis of the foam to that of the filter gives the inhalable fraction. the size-selective performance of foams has been intensively studied and the concept of using foam has been thoroughly researched [82] [83] [84] [85] [86] [87] . in a field study in several industries [86] the iom dual-fraction sampler yielded similar results as personal cyclones with an explained variance (r 2 ) of 0.8 and an association (β) of 0.93, not different from unity. the size-selective performance of the foam used in the dis has been tested at the health and safety executive in the uk. over 96% of the aerosol size-distributions tested under en13205 were separated by the dis foam with less than 10% bias from ideal separation as shown in figure 1 . a potential issue of using foam as a size-separator is the effect of progressive particle deposition within the foam on its separation characteristics. penetration tests were carried out using iom samplers with a respirable foam separator for 10 foams previously used to sample dust (aloxite f800) in the laboratory at very high concentrations for short periods of time to produce loadings up to 50 mg, 20 foams previously used in sampling from a range of industries, selected to cover different particle types and dust loadings (on the foam) of up to 20 mg, and 3 blank foams [86] . a slight trend for the 50% cut-point to decrease with increasing loading was evident, but the effect was generally small, even with the exceptionally high loadings. the rapidly loaded laboratory samples were not more affected than the gradually loaded workplace samples. loading effects were independent of particle type and small in comparison to the inherent variability of the foams. in a european study [87] , two different foam plugs were tested with loading. the 10 mm diameter plugs with a mass load of 10 mg showed a decrease in d 50 of some 7%, while 30 mm diameter plugs had a decrease of only 1%. since the plugs in the dis are 16 mm diameter, the expected reduction for a load of 10 mg is expected to be less than 5%. this study reported a limit of detection (lod) of 0.015 mg based on 3 times standard deviation and a limit of quantitation (loq) of 0.050 mg based on 10 times standard deviation of foams similar to the dis foam weighed in a glove box with controlled temperature (peltier element with small fan) and saturated salt bath to control humidity. a different set of experiments in the same study but in a laboratory room with less control on the temperature and humidity gave an lod of 0.069 mg and an loq of 0.230 mg. a potential issue of using foam as a size-separator is the effect of progressive particle deposition within the foam on its separation characteristics. penetration tests were carried out using iom samplers with a respirable foam separator for 10 foams previously used to sample dust (aloxite f800) in the laboratory at very high concentrations for short periods of time to produce loadings up to 50 mg, 20 foams previously used in sampling from a range of industries, selected to cover different particle types and dust loadings (on the foam) of up to 20 mg, and 3 blank foams [86] . a slight trend for the 50% cut-point to decrease with increasing loading was evident, but the effect was generally small, even with the exceptionally high loadings. the rapidly loaded laboratory samples were not more affected than the gradually loaded workplace samples. loading effects were independent of particle type and small in comparison to the inherent variability of the foams. in a european study [87] , two different foam plugs were tested with loading. the 10 mm diameter plugs with a mass load of 10 mg showed a decrease in d50 of some 7%, while 30 mm diameter plugs had a decrease of only 1%. since the plugs in the dis are 16 mm diameter, the expected reduction for a load of 10 mg is expected to be less than 5%. this study reported a limit of detection (lod) of 0.015 mg based on 3 times standard deviation and a limit of quantitation (loq) of 0.050 mg based on 10 times standard deviation of foams similar to the dis foam weighed in a glove box with controlled temperature (peltier element with small fan) and saturated salt bath to control humidity. a different set of experiments in the same study but in a laboratory room with less control on the temperature and humidity gave an lod of 0.069 mg and an loq of 0.230 mg. foam is easily soluble in an oxidizing acidic digestion [75] . the background and loq (based on 10 times the standard deviation of the blank) has been established through analysis by microwave digestion in a combination of acids (nitric-hydrochloric-hydrofluoric) with hydrogen peroxide, using magnetic sector inductively coupled plasma-mass spectrometry. sodium (na) and tin (sn) are normal components of the foam and loqs are 3.8 and 2.1 µg/foam, respectively. for other elements the results are presented in table 5 . table 5 . limits of quantitation (blank corrected) of elements in dis sampler foam (mean of ten foam pieces, data from wisconsin state hygiene laboratory, madison, wi, usa). foam is easily soluble in an oxidizing acidic digestion [75] . the background and loq (based on 10 times the standard deviation of the blank) has been established through analysis by microwave digestion in a combination of acids (nitric-hydrochloric-hydrofluoric) with hydrogen peroxide, using magnetic sector inductively coupled plasma-mass spectrometry. sodium (na) and tin (sn) are normal components of the foam and loqs are 3.8 and 2.1 µg/foam, respectively. for other elements the results are presented in table 5 . pvc filters are preferred for gravimetric analysis because they are more weight stable than other filters but do not digest entirely in acids, and this has led to the use of mixed cellulose-ester (mce) filters in most published methods for metals. however, complete dissolution of the filter is not required so long as the dissolution of the sampled particles is efficient and the presence of undissolved filter does not compromise the sample entry to the instrument or interfere with the analysis. niosh has evaluated method 7304 [88] for processing pvc filters using microwave digestion and osha has a method [48] for processing pvc filters using hot-block digestion. while niosh showed that some elements such as antimony, silver, and tin do not form stable solutions in nitric acid when chloride from the pvc filters is present (and tin is also present in the background of pvc as a polymer cross-linking additive), these elements are not the most commonly evaluated in industrial hygiene investigations. while the osha method does not report any validation of the procedure, there is a back-up data report for the niosh method documenting recovery [88] . in a test on pvc filters with pvc capsules, the wisconsin state hygiene laboratory (madison, wi, usa) was able to digest samples with a nitric-hydrochloric-hydrofluoric acid mixture plus hydrogen peroxide in a microwave oven. although the background quantities of tin, sulfur and sodium are relatively high, all other elements analyzed were present below 1 µg, with many <1 ng. however, recovery studies are still to be performed. using pvc filters allows for gravimetric analysis, and on-filter xrd or ftir analysis for silica, prior to digestion for metals analysis. this leads to the possibility of a single, disposable (single use) sampler with determination of inhalable and respirable particulate, inhalable and respirable metals, and respirable crystalline silica. assessing personal exposure to air pollution is limited to a degree by the technology of samplers themselves. wearable aerosol samplers are often noisy and burdensome, especially those designed to give real-time output of concentration, i.e., monitors. the ultrasonic personal aerosol (air) sampler (upas; access sensor technologies, fort collins, co, usa) has been developed to overcome many of these limitations [89] . the upas features a novel micropump with virtually silent operation. onboard environmental sensors measure and record mass airflow (0.5-2.0 l min −1 , accurate within 5%), temperature, pressure, relative humidity, light intensity, and acceleration. there is a mobile phone application available, which can be used to program and track the upas. pump flow and pressure measurements, temperature and relative humidity, global positioning system coordinates, and semi-quantitative continuous particle mass concentrations based on filter differential pressure can be uploaded to a central server automatically whenever the mobile phone is connected to the internet, with sampled data automatically screened for quality control parameters. filters and filter cartridges that are weighed pre-and post-sampling are barcoded to minimize sample collection errors and potentially track sources of contamination. interchangeable cyclone inlets provide a close match to the epa pm2.5 (particles below 2.5 µm in aerodynamic diameter) mass criterion (within 5%) for device flows at either 1.0 or 2.0 l min −1 . battery life varies from 23 to 45 h depending on sample flow rate and selected filter media. laboratory tests of the upas prototype demonstrated excellent agreement with equivalent us federal reference method samplers for gravimetric analysis of pm2.5 across a broad range of concentrations [89] . approximately 250,000 measurements of household and personal pm2.5 exposure using the upas were made in a multi-country cohort study [90] , specifically to measure pm2.5 exposures for participants in rural communities in ten countries with high levels of indoor solid fuel use. pilot study field evaluation of cooking area measurements indicated high correlation between the upas and reference harvard impactors (r = 0.91; 95% ci: 0.84, 0.95; slope = 0.95). additional inlets with collection efficiencies that match criteria for workplace respirable or thoracic mass sampling have also been developed and tested against polydisperse compressor oil aerosol [91] . the respirable mass inlet includes both an impaction stage and a cyclone, whereas the thoracic mass inlet utilizes a circular slot impactor. both the respirable mass inlet and the thoracic mass inlet have been designed to be interchangeable with the pm2.5 inlet. both inlets tested in the laboratory resulted in sample collection within ±5% of the respective criterion specifies for aerosols with reasonably broad size distributions. for dusts with mass median diameters smaller than about 6 µm the error in using the respirable inlet is under 5%. as is typical for respirable size-selectors, the error becomes larger with monodisperse dusts at larger particle sizes, but dusts with these characteristics are not commonly encountered. bias of the thoracic inlet is generally within ±5% but increases to between 10 and 20% for dusts with median diameters between about 13 and 20 µm in diameter when the geometric standard deviation is under 2.0. further validation work should include laboratory calibration with solid particles and characterization of field performance. although the presence of viable microorganisms in air has been recognized for centuries [92] , the development of quantitative sampling methods for bioaerosols only really took off in the 1990s when it was recognized that bacteria and fungi could play a role in building-related sickness [93] . the mix of species growing in damp buildings is typically different from the mix of outdoor species, so the development of sampling techniques focused primarily on the identification of bacterial and fungal species to detect problematic situations. in the absence of limit values, lesser attention was paid to the numbers, but viability was considered important in the assessment of pathogenic species, particularly spurred by the deliberate spread of anthrax bacteria in the usa. unfortunately, many species of bacteria are fragile under the stress of normal impaction or filtration sampling [94] and specific techniques have been developed for the maximal preservation of viability [95] . recent outbreaks of viral disease (sars, h1n1, h1n5, mers, sars-cov-2) have spurred investigations of airborne viruses. the dynamics and significance of aerosol transmission of respiratory viruses are still controversial. one possible reason for this may be that collected viruses are inactivated by the collection method leading to inaccurate infection risk analyses. the viable virus aerosol sampler (biospot-vivas™ sampler; aerosol devices, inc., fort collins, co, usa) is a novel device designed to sample bioaerosols while preserving their viability to the greatest extent possible [96] . the vivas operates via a water vapor condensation process to enlarge aerosolized virus particles to facilitate their capture. it consists of eight parallel, wet-walled tubes termed growth tubes. during operation, the first half region of each tube is cooled to 6 • c, and the second half region is warmed to 45 • c. in the heated region, water vapor diffuses from the wet walls into the air stream faster than the air heats creating a supersaturation condition. particles as small as 5 nm that can be wetted serve as condensation sites for the excess vapor from the supersaturated air and thus droplets are formed between approximately 10 µm and up to 2 mm in diameter. the flow exiting the tubes is directed by nozzles to a small volume of collection material in which the particles are collected, with a collection efficiency which was shown for inert particles from 8 nm to 10 µm to be greater than 95%. for viruses, the collection medium can be the same as that used typically for dilution in the generation of virus aerosols such as phosphate-buffered saline plus 0.5% (w/v) bovine serum albumin fraction v. in an evaluation of the apparatus, fine aerosols (<500 nm) containing ms2 coliphage were generated from a collison nebulizer, conditioned by a dilution dryer and collected by a vivas and a sampler commonly recommended for bioaerosol viability preservation, the biosampler (skc, inc. eighty four, pa, usa). the vivas collected >93% of the inlet virus particles compared to about 10% for the biosampler [97] . viable counts of the vivas-collected viruses were also one order of magnitude higher than those of the biosampler (p = 0.003), so that overall efficiency of the vivas exceeded that of the biosampler for the viable collection of ms2 viruses by a factor of 10-100. another set of experiments was performed using a more representative wild-type influenza, a h1n1 pandemic 2009 strain [98] . on average, the lower limit collection efficiency of the vivas was 74 ± 12% compared to 5.6 ± 3.0% for the biosampler. the higher recovery from the vivas is attributed to the higher physical collection efficiency, slower rehydration of the infectious virus, and the gentle (non-destructive) impaction onto the collection medium. a further pilot study was performed to determine whether infectious (viable) respiratory viruses in aerosols could be collected from air in a real-world environment and to determine the efficiency of viable collection compared to the biosampler. a variety of viable human respiratory viruses, including influenza a h1n1 and h3n2 viruses and influenza b viruses, were collected by the vivas located at least 2 m from seated patients, during a late-onset 2016 influenza virus outbreak [99] . the biosampler did collect virus aerosols, butt was considered less successful. these results using the vivas indicate that respiratory virus aerosols are more prevalent and potentially pose a greater inhalation biohazard than previously thought. the vivas thus appears to be a useful apparatus for microbiology air quality tests related to the detection of viable airborne viruses. in a very recent (not yet peer-reviewed) study with the vivas in a hospital, viable virus was isolated from air samples collected 2 to 4.8 m away from patients showing that patients with respiratory manifestations of covid-19 produce aerosols that contain viable sars-cov-2, and these aerosols may serve as a source of transmission of the virus [100] . anyone wishing to assess exposures to aerosols needs to understand that the science and technology exists in a continuum of research and response resulting in a ten-to twenty-year cycle of improving methodology; for example, from sugar tube to impinger to midget impinger to glass fiber filter to polymer membrane filter to closed-face cassette housing to "inhalable" samplers has taken about 100 years. even more rapid recent advances have been made possible by new technologies. a selection of novel technologies described in more detail here includes procedures to include wall deposits, on-site analysis of silica, nanoparticles deposited in the airways, multi-fraction samplers, miniaturization of samplers and preservation of viability of microorganisms, especially viruses. this is only a sub-set of current developments, being those with which the author has had recent personal experience. it is expected that many of these and other research themes will continue in the future. perhaps the most important theme is the development of samplers operating at higher flow rates [100] , necessitated by lowered limit values and made possible by advances in pump and battery technology. it is likely that investigations will continue into real-time and end-of-shift on-site analyses, for example for silica [101] and metals [25] . another situation for research is the characterization of semi-volatile aerosols. the equilibrium that exists between aerosol and vapor for semi-volatile substances has been known for a long time and there have been efforts to design samplers appropriate to the situation. however, recognition of the numbers of chemicals and situations where semi-volatile substances can occur has grown and resulted in further research into sampling methods [102] . the difficulty of obtaining an accurate separation of aerosol and vapor phases is profound, but the rewards would be a better understanding of physiological consequence of exposure and potential measures for controlling exposure, so, hopefully there will be continued research in this area. it is important to comprehend this continuum of research because it is not appropriate to ignore scientific advances and nor is it ethical to refuse to act upon them. those who are reluctant to accept change because they mistakenly believe "things have always been done this way" need to recognize that "this is not your parent's sampler" and likely, neither will it be your children's. establishing exposure science as a distinct scientific discipline commentary on a more comprehensive vision and strategy for the discipline of exposure science on the apparatus for collecting atmospheric particles the sugar tube method of determining rock dust in air a new instrument for sampling aerial dusts bureau of mines midget impinger filter-paper method for obtaining dust-concentration results comparable to impinger results use of membrane filters in air sampling dust 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system for simultaneous sampling of vapours and droplets this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the author is an employee of a company (zefon international, inc.) and previously an employee of another company (skc, inc.), whose equipment is cited in this work. this article was written in the course of the authors' employment with zefon international, inc. no other funding received. key: cord-320208-uih4jf8w authors: li, diya; chaudhary, harshita; zhang, zhe title: modeling spatiotemporal pattern of depressive symptoms caused by covid-19 using social media data mining date: 2020-07-10 journal: int j environ res public health doi: 10.3390/ijerph17144988 sha: doc_id: 320208 cord_uid: uih4jf8w by 29 may 2020, the coronavirus disease (covid-19) caused by sars-cov-2 had spread to 188 countries, infecting more than 5.9 million people, and causing 361,249 deaths. governments issued travel restrictions, gatherings of institutions were cancelled, and citizens were ordered to socially distance themselves in an effort to limit the spread of the virus. fear of being infected by the virus and panic over job losses and missed education opportunities have increased people’s stress levels. psychological studies using traditional surveys are time-consuming and contain cognitive and sampling biases, and therefore cannot be used to build large datasets for a real-time depression analysis. in this article, we propose a corexq9 algorithm that integrates a correlation explanation (corex) learning algorithm and clinical patient health questionnaire (phq) lexicon to detect covid-19 related stress symptoms at a spatiotemporal scale in the united states. the proposed algorithm overcomes the common limitations of traditional topic detection models and minimizes the ambiguity that is caused by human interventions in social media data mining. the results show a strong correlation between stress symptoms and the number of increased covid-19 cases for major u.s. cities such as chicago, san francisco, seattle, new york, and miami. the results also show that people’s risk perception is sensitive to the release of covid-19 related public news and media messages. between january and march, fear of infection and unpredictability of the virus caused widespread panic and people began stockpiling supplies, but later in april, concerns shifted as financial worries in western and eastern coastal areas of the u.s. left people uncertain of the long-term effects of covid-19 on their lives. in december 2019, an outbreak of pneumonia caused by a novel coronavirus (covid-19) occurred in wuhan and spread rapidly throughout the globe [1] . the covid-19 outbreak has forced people to change their regular routine lives and practice social distancing. such a sudden change can drastically increase people's stress level and lead to other mental health issues. the difficulties caused by the covid-19 outbreak in different geographic regions can determine the cause and degree of stress in people, which corresponds to their risk of developing serious depression [2] . according to a poll [3] , nearly half (45%) of adults in the united states reported that their mental health has been negatively impacted due to worry and stress over the virus. as the pandemic continues, it is likely that the mental health burden will increase as people's sense of normalcy continues to be disrupted by social distancing, business and school closures, and shelter-in-place orders. the preexisting stress, constant unpredictability, and lack of resources lead to even greater isolation and financial distress. traditional mental health studies rely on information primarily collected through personal contact with a healthcare professional or through survey-based methods (e.g., via phone or online questionnaire). for instance, the patient health questionnaire (phq) is a self-administered version of the primary care evaluation of mental disorders (prime-md) diagnostic instrument for common mental disorders [4] . however, these survey-based methods are time-consuming and suffer from cognitive and sampling biases, and therefore cannot be used to build large datasets for a real-time depression analysis [5] . furthermore, understanding of spatial epidemic trends and geographic distribution patterns of covid-19 provides timely information on people's risk perception of epidemics. however, these important spatial and environmental leading factors are difficult to include in a survey-based method to model covid-19 related mental stress. geographic information system (gis) and social media data mining have become essential tools with which to examine the spatial distribution of infectious diseases [6] [7] [8] , and can be used to investigate the spatiotemporal pattern of mental stress caused by the pandemic. for instance, social media data (e.g., twitter data) provide a unique opportunity to learn about the users' moods, feelings, and behaviors that reflect their mental health as they experience daily struggles [8] [9] [10] . many articles focused on using feature-based approaches to perform sentiment and emotional analysis using twitter data [11] [12] [13] [14] . for instance, go and colleagues [11] investigated the usage of unigrams, bigrams, and their combination in training the classifiers for sentiment analysis of tweets. various supervised classifiers were trained, including maximum entropy, naïve bayes [15] , and support vector machine (svm) classifiers and their performance on the n-grams was compared. however, some methods previously used [11] have become outdated; for instance, they took emoticons into account for their sentiment index, but nowadays lots of twitter users use emojis more frequently [16] . barbosa and feng [17] showed that n-grams are not useful in classifying tweets, as unused words in tweets can cause problems during classifier training. pak and paroubek [18] proposed the usage of microblogging features like hashtags, emoticons, re-tweets, and comments to train an svm classifier and showed that it resulted in higher accuracy than training using n-grams. several articles address the effect of using part-of-search (pos) tag features in text classifiers [18, 19] . abadi and colleagues [19] investigated pos, lexicon, and microblogging features. the results showed that the most relevant features are those that combine prior polarity with the pos tags of the words. however, there have been mixed results reported on the usage of pos tags. go and colleagues [11] showed that the pos tags caused reduced performance, although pos tags can be strong indicators of emotions in text and serve as a helpful feature in opinion or sentiment analysis [18] . moreover, bootstrapping approaches, which rely on a seed list of opinion or emotion words to find other such words in a large corpus, are becoming more popular and have proven effective [20] [21] [22] [23] . mihalcea, banea, and wiebe [23] described two types of methods for bootstrapping the subjectivity lexicons into dictionary-based and corpus-based. their research began with a small seed set of hand-picked subjective words, and with the help of an online dictionary produced a larger lexicon of potential candidate words. a similar bootstrapping model was effectively used to build a sentiment analysis system for extracting user-generated health review about drugs and medication [20] . however, all the aforementioned methods only detect the general emotion of tweets and lack the ability to model depression levels in detail. latent dirichlet allocation (lda) is one of the most commonly used unsupervised topical methods, where a topic is a distribution of co-occurring words [24] . however, the topics learned by lda are not specific enough to correspond to depressive symptoms and human judgments [25] . the unsupervised method can work with unclassified text, but it often causes topics overlap [26] . later, the lda method was extended by using terms strongly related to phq-9 depression symptoms as seeds of the topical clusters and guided the model to aggregate semantically-related terms into the same cluster [27] . however, this approach only detects the presence, duration, and frequency of stress symptoms, ignoring the spatial context or environmental factors that are important in modeling the covid-19 related mental stress. to identify phq related text and unrelated text, a sentiment analysis index generated by python textblob was used [27] , which only calculates the average polarity and subjectivity over each word in a given text using a constant dictionary [28, 29] . work based on the lda probabilistic generative model was found to have limitations related to interpreting high dimensional human input factors which makes it difficult to generalize generative models without detailed and realistic assumptions for the data generation process [30] [31] [32] . in this article, we propose a corexq9 algorithm that integrates correlation explanation (corex) learning algorithm and clinical phq lexicon to detect covid-19 related stress symptoms at a spatiotemporal scale in the united states. we aim to investigate people's stress symptoms in different geographic regions caused by the development of the covid-19 spread. since twitter data are high-dimensional human input data with diverse terms used to express emotions, we used the corex algorithm, a method intended to bypass the limitations of lda implementation and minimize human intervention [33] . after that, we developed a fuzzy accuracy assessment model to visualize the uncertainty of the analytical results on the map. the rest of the article is organized as follows: section 2 introduces the material and methods used in the research work including the introduction of data collection and processing methods, basilisk and machine learning classifier, and the proposed corexq9 algorithm. the results and discussion are presented in sections 3 and 4, respectively. section 5 draws conclusions. twitter data used in this article were collected through the twitter api from january to april 2020 for the continental united states. the collected data contained 80 million tweets (~70 gb), which posed significant computationally intensive challenges for the traditional gis computing environment. to address this challenge, we used a jupyter computing environment deployed on the texas a&m high performance computer. we filtered the collected twitter data using coronavirus related entities (e.g., hashtag, trends, and news). then, we removed irrelevant information (e.g., non-english language tweets, punctuation, missing data, messy code, url, username, hashtags, numbers, and query terms) from the filtered tweets. some adjustments and normalizations (e.g., uniform lower case, nonmaize vectorized tweets, standardize time sliced tweets) were also made in order to fulfill the common requirements of machine learning models. however, the stop words were removed later when applying the proposed algorithm to match the tweet phrase with lexicon. after that, the tweets were tokenized using the natural language toolkit's (nltk) tweettokenizer [33] . we also replaced repeated character sequences by using the length value of three for any sequences of length three or greater (3+), since most users often extend words or add redundant characters to express strong feelings. tweets with an exact geospatial tag and timestamp were mapped to the corresponding county using reverse geocoding method [34, 35] . other tweets (e.g., without geotags but containing user-defined location information in the user's profile) were geocoded to their corresponding county using a fuzzy set search method and city alias dataset [36] . we excluded tweets that did not have geotags nor user-defined location information. one of the key innovations in our research was to map the covid-19 caused stress symptoms at a temporal scale. in this case, we set the temporal scale to biweekly starting from 26 january 2020, so the number of tweets collected in each county could be sufficient for accurate and reliable analysis. we used the basilisk bootstrapping algorithm to find semantic lexicons that could be used to divide the tweets into two categories: stressed and non-stressed. the bootstrapping approach to semantic lexicon induction using semantic knowledge, also known as the basilisk algorithm, was developed by thelen and riloff in 2002 [37] . this approach can extend to divide the tweets into multiple categories across different areas [22] . it employs a bootstrapping method to determine high-quality semantic lexicons of nouns. the algorithm takes a huge unannotated corpus from where it finds new related words and assigns them to the different semantic categories (e.g., stressed and non-stressed in our case). it is a form of categorization that is based on the seed words manually provided to the algorithm. these seed words are bootstrapped to identify new words that fall within the two categories. basilisk must be seeded with carefully selected terms for it to be effective. the two categories of seeds used for this task consisted of 20 words each (table 1) [38]. the first category contained words describing stress and were used to bootstrap other words semantically related to stress or carrying a similar context. the second category contains words that describe non-stressed or a relaxing behavior. these two categories can be thought of as words that fall at the opposite ends of a stress level spectrum. before the bootstrapping process, the patterns were extracted on the unannotated corpus. this is used to extract all the noun phrases that were either the subject, direct object or prepositional phrase. the noun phrases were extracted from the corpus using the stanford dependency parser [39] . it is a natural language parsing program used to find grammatical structure in sentences and can be used to find relationships or dependencies between nouns and the actions or words that form a group and go together. the dependency parser was run on all the sentences in the corpus and dependency relations were extracted for each word in the text (in the conll-u format [40]). for each tweet, the following dependency information was extracted. the conll-u format of the extracted dependency pattern consists of the index, text, lemma, xpos, feats, governor, and dependency relations ( table 2 ). these extracted dependency relations were used to extract patterns that were used by the basilisk algorithm to generate seeds. these extraction patterns were created for each dependency relation obtained in the previous step. the extraction patterns consisted of noun phrases and the dependency of them with other related words in the sentence. this acted as the input to the bootstrapping method. after the input was generated, the next step was to generate the seeds using basilisk. the seed words from the initial pattern pool enlarge with every bootstrapping step. the extraction patterns were scored using rlogf metric [41] , which is commonly used for extraction pattern learning [41] . the score for each pattern was computed as: rlogf(pattern (i) ) = f i n i * log 2 f i , where f i represents the number of category members extracted by pattern (i) and n i is the total number of nouns extracted by pattern i . this formula was used to score the patterns with a high precision or moderate precision but a high recall. the high scoring patterns were then placed in the pattern pool. after this process, all head nouns co-occurring with patterns in pattern pool were added to the candidate word pool. at the end of each bootstrapping cycle, the best candidates were added to the lexicon thus enlarging the lexicon set. the process used related to basilisk, as proposed by thelen and riloff, can be described using the algorithm shown on table 3 (for notation description see appendix a). this performs the categorization task of assigning nouns in an unannotated corpus to their corresponding semantic categories. using the words generated by the basilisk algorithm, we counted the total number of occurrences of any of the keywords in both categories. after the total count of stress and non-stress words in each tweet was obtained, we determined whether the tweet was in the category of stressed or non-stressed or neutral. this was done by finding the maximum of the stress and non-stress word counts in three conditions: (1) if there were more stress words than non-stress words, we annotated the tweet as expressing stress. (2) if the number of non-stress words is greater than the number of stress words, we annotated the tweet to express relaxed behavior. (3) if the count was zero for both stress and non-stress words, we did not annotate the data. thus, tweets and their corresponding labels generated using this process were the initial training set, which was used to train a classifier to classify the other unannotated tweets. table 3 . illustration of the basilisk algorithm [41] . procedure: lexicon = {seed words} for i := 0 1. score all extraction patterns with rlogf 2. pattern pool = top ranked 20 + i patterns 3. candidate word pool = extractions of patterns in pattern pool 4. score candidate words in candidate word pool 5. add top five candidate words to lexicon 6. i := i + 1 7. go to step 1. the universal sentence encoder [42] was used to generate word embeddings. these text embeddings convert tweets into a numerical vector, encoding tweet texts into high dimensional vectors that are required to find semantic similarity and perform the classification task. it takes a variable length english text as input and outputs a 512-dimensional vector embedding. the encoder model was trained with a deep averaging network (dan) encoder [15] . after the word embeddings were obtained for each stressed and non-stressed category tweet, a technique was used to make the two classes equalized. to do this, we selected the category with fewer samples and made the other category a similar size by removing samples. this ensured that the training process was not biased towards a particular class. before training the classifier, the data were split into training and validation sets. the data were randomly shuffled and put into the two datasets, with 80% used as the training dataset. to obtain the best performance, multiple classifiers were used, and performance was compared using accuracy metrics. the classifiers used in the training process were svm [42] , logistic regression [43] , naïve bayes classifier [44] , and a simple neural network. svm handles nonlinear input spaces and separates data points using a hyperplane using the largest amount of margin. as a discriminative classifier, svm found an optimal hyperplane for our data, which helped with classifying new unannotated data points. we used different kernels to train the svm. the hyperparameters were tuned and the optimal value of regularization and gamma were also recorded. the logistic regression classification algorithm can be used to predict the probability of a categorical dependent variable. the dependent variable is a binary variable that contains data coded as 1 (stressed) or 0 (non-stressed). the logistic regression model predicts p(y = 1) as a function of x. prior to training, it shuffles the data. it uses a logistic function to estimate probabilities to calculate the relationship between independent variable(s) and the categorical dependent variable [45] . naïve bayes is another probabilistic classifier which makes classifications using the bayes rule. this classifier is simple and effective for text classification. a simple neural network consisting of three dense layers were used to train our datasets. the loss function and optimizer used in the training is binary cross entropy and rmsprop, respectively. training was done for 40 epochs with a batch size of 512. table 4 illustrates the performance evaluation of these classifiers. after the model was trained, the model was run on the unannotated tweets to label them. to label the sentence embeddings for the tweets, the same procedure was used as for the training set. the universal sentence encoder extracts 512 features and created vectors that were used to classify the tweets based on the model. the svm classifier with linear kernel was used to predict the probabilities of the tweets because it had the best trained models (see table 4 ). here, a threshold of 0.75 was set to determine if the tweet belonged to a particular category or not. if the probability of the tweet was above 0.7 for that category, the tweet was classified with the corresponding label. the tweets and labels generated using the above process were then used to train another classifier to generate the final model for classification of the entire unannotated corpus. here, a logistic regression model was used to train tweets and their corresponding labels generated using the above process to ensure that the model was robust and was not overfitted on the initial set of tweets that were filtered out using the basilisk generated keywords. the trained model had an accuracy of 90.2% on the validation data. in this article, we propose a novel corexq9 algorithm to detect spatiotemporal patterns of covid-19 related stress. table 5 illustrates the general structure of the corexq9 algorithm. the input of the algorithm was the stressed-related tweets derived by using the trained models (see sections 2.2.3 and 2.2.4) to all the processed covid-19 related tweets. we assessed the level of stress expressed in covid-19 related tweets by integrating a lexicon-based method derived from established clinical assessment questionnaire phq-9 [46] . table 6 illustrates the phq-9 lexicon examples and their corresponding mental stress symptoms. procedure: 1. shallow parsing each tweet into tweet_pharse using spacy 2. for each word_set in phq_lexicon do 3. calculate average vector of word_set and tweet_pharse using glove 4. match word_set with tweet_pharse set using cosine similarity measure 5. append each matched tweet_pharse to word_set 6. calculate tf-idf vector for all the tweets and transform the calculated value to a sparse matrix x 7. iteratively run corex function with initial random variables v random 8. estimate marginals; calculate total correlation; update v random 9. for each word_set in phq_lexicon 10. compare v random and word_set with bottleneck function 11. until convergence the phq-9 lexicon contains about 1700 clinical words, which is difficult to understand and match with the spoken language that is often used on twitter. therefore, we used the following methods to transform phq-9 lexicon to human understandable language by appending matched tweets to their best match phq-9 categories. in the first step, each tweet was placed into a set of phrase sets using natural language processing toolkit spacy [44] (see table 4 , procedure 1). after that, the tweets and phq-9 lexicon were vectorized using global vectors for word representation (glove), wikipedia, and gigaword 5 model (with 300 dimensional word vectors and four million unique tokens) [45] . glove provides a quantitative way to distinguish the nuance difference of two words (e.g., happy or unhappy), which is useful to match phrases set with the phq-9 lexicon. those pre-trained vectors were loaded to gensim [47] to perform average vector and cosine distance calculation (see equations (1) and (2)). we appended all phrases that have the similarity rate higher than 0.8 to their corresponding phq-9 lexicon (see table 4 , procedures 3-5). given any words in a phrase, the average vector was calculated using the sum of the vectors divided by the number of words in a phrase: given any two average vectors v a and v b of two phrases, the cosine similarity, cos θ, is represented by next, a sparse matrix (e.g., a vocabulary dense matrix) for stressed corpus was calculated by transforming those tokenized and vectorized tweets using frequency inverse document frequency (tfidf). the mathematical formula of tfidf is illustrated below: where t denotes the terms; d denotes each document; and d denotes the collection of documents. the first part of the formula t f (t, d) calculates the number of times each word in covid-19 corpus appeared in each document. the second part of id f (t, d) is made up with a numerator d = d 1 , d 2 , . . . d n and a denominator | {d ∈ d : t ∈ d}|. the numerator infers the document space, which is all documents in our covid-19 stress corpus. the denominator implies the total number of times in which term t appeas in all of our documents d. the id f (t, d) can be represented by we utilized scikit-learn tfidfvectorizer to transform preprocessed tweets to a sparse matrix [48] (see table 4 , procedure 6). after that, the sparse matrix and lexicon are used by the anchored corex model to perform anchored topic modeling [32] . the total correlation tc [49] (for notation description see appendix a) of each topic is calculated by anchoring the corex model with the document sparse matrix. the total correlation in our phq-9 lexicon detection can be expressed using kullback-leibler divergence as below [50] . where p(x g ) represents the probability distribution and tc(x g ) is non-negative or zero factorizes of p(x g ) (see appendix a for more detail). in the context of phq-9 detection, x g represents the group of word types among the covid-19 corpus. note that each vector in the tfidf matrix is based on the distance between two probability distributions, which is expressed as cross-entropy entropy(x) [51, 52] . when introducing a random variable y, the tc can explain the correlation reduction in x, which is a measure of the redundant information that the word types x carry about topic y [30] . the total correlation can be represented by: where i(x : y) = entropy(x) + entropy(y) − entropy(x, y) (for notation description see appendix a). thus, the algorithm starts with randomly initialized variables α i,j and p(y i |x i ), where α i,j are indicator variables of tc that are assigned to 1 if the topic is detected and p(x i ) represents the approximate empirical distribution (see table 4 , procedure 7). then, the correlation explanation updates both variables iteratively until the result achieves convergence. in each iteration, the estimate marginals p(y j |x i ) = x p(y i |x)p(x)δ x i and mutual information tc are calculated (notation description see appendix a). next, the update for a t i,j in each t step is calculated by where λ conduct a smooth optimization of the soft-max function [53, 54] . finally, the soft labeling of any x (for notation description see appendix a) can be computed by after the soft-max function α converges to the true solution at a particular step α k in the limit λ → ∞ , the mutual information terms can be ranked by the informative order in each factor. to perform semi-supervised anchoring strategies, gallagher and reing proposed the combination with bottleneck function and total correlation [32] . the bottleneck function can be represented by: the connection with corex and anchor words can be described by comparing equation (6) with equation (9). the same term i(x : y) in two equations represents the latent factor and the variable z corresponds to x i . it is worth noting that z is typically labeled in a supervised learning task [54] and β is a constant parameter to constrain supervising strength so that α = β can imply a word type x i correlated with topic y j . in this case, z was represented by each variable generated by the enriched phq-9 lexicon. to seed lexicon to detect topics, we can simply anchor the word type x i to topic y j , by constraining the β (see table 5 , procedures 8-11). the symptoms of covid-19 related stress were visualized at the county level biweekly from 26 january. here, we used the fuzzy accuracy assessment method to evaluate the uncertainty of final phq stress level for each county [55, 56] . we summarized the implementation of fuzzy accuracy assessment for a thematic map as presented by gopal and woodcock to explain our model evaluation for the phq map [55] . let x be a finite universe of discourse, which is the set of county polygons in the study area. let ζ denote the finite set of attribute membership function (mf) topics categories to the d in x; and let m be the number of categories |ζ| = m, (e.g., nine phq categories). for each x x, we define χ(x) as the mf classes assigned to x. the set: defines the data. the subset s ⊂ x of n data is used. a fuzzy set is associated with each class c ζ where µ c (x) is the characteristic of mf of c. the fuzzy set can be represented as: to implement a decision-making system for fuzzy accuracy, the model uses a boolean function σ that returns results of 0 or 1 based on whether x belongs to the class c with respect to the matrix a. that is, σ(x, c) = 1 if x "belongs" c, and σ(x, c) = 0 if x does not "belong" to c. then σ(x, c) is 1 if the numeric scale of the mf for x in category c(µ c (x)) is maximum among all map categories µ c (x), and we set the boolean function σ as max follows: according to the fuzzy set accuracy assessment, the final phq value for each county was selected based on the max function, meaning each county was colored based on the majority tweet phq value derived from the proposed corexq9 algorithm. since the accuracy assessment was based on a comparison of the phq label assigned to each county with the evaluation given by the expert (e.g., in each county, the majority tweet phq label). the rating system can thus be expressed as linguistic variables that describe the uncertainty associated with the evaluation of the class label. here, the linguistic variables are described below: 1. score 1: understandable: the answer is understandable but may contain high levels of uncertainty; 2. score 2: reasonable: maybe not the best possible answer but acceptable; 3. score 3: good: would be happy to find this answer given on the map; 4. score 4: absolutely right: no doubt about the match. it is a perfect prediction. figure 1 illustrates the fuzzy mf created for the fuzzy accuracy assessment analysis. the x-axis represents the percentage of the tweets that belong to the assigned final phq category. the y-axis represents the value of the degree of the membership function corresponding to the linguistic score. for instance, if a county was assigned to a phq category 3, and 80% (e.g., x = 0.8 in figure 1 ) of the tweets within this county polygon were labeled as phq-3 using the corexq9 algorithm, the corresponding mf should be absolutely right with membership value equal to 1. the accuracy assessment score was further visualized on the phq stress map to show the spatial uncertainty of the analysis results. the numeric scale of the mf for in category ( ( )) is maximum among all map categories ′ ( ), and we set the boolean function as follows: according to the fuzzy set accuracy assessment, the final phq value for each county was selected based on the max function, meaning each county was colored based on the majority tweet phq value derived from the proposed corexq9 algorithm. since the accuracy assessment was based on a comparison of the phq label assigned to each county with the evaluation given by the expert (e.g., in each county, the majority tweet phq label). the rating system can thus be expressed as linguistic variables that describe the uncertainty associated with the evaluation of the class label. here, the linguistic variables are described below: 1. score 1: understandable: the answer is understandable but may contain high levels of uncertainty; 2. score 2: reasonable: maybe not the best possible answer but acceptable; 3. score 3: good: would be happy to find this answer given on the map; 4. score 4: absolutely right: no doubt about the match. it is a perfect prediction. figure 1 illustrates the fuzzy mf created for the fuzzy accuracy assessment analysis. the x-axis represents the percentage of the tweets that belong to the assigned final phq category. the y-axis represents the value of the degree of the membership function corresponding to the linguistic score. for instance, if a county was assigned to a phq category 3, and 80% (e.g., x = 0.8 in figure 1 ) of the tweets within this county polygon were labeled as phq-3 using the corexq9 algorithm, the corresponding mf should be absolutely right with membership value equal to 1. the accuracy assessment score was further visualized on the phq stress map to show the spatial uncertainty of the analysis results. since corexq9 represents topic and potential symptoms as a lexicon-based topic modeling, traditional measures such as regression correlation and log-likelihood are unnecessary for the semantic topics. therefore, to evaluate the baseline performance of the corexq9 model, we first involved the semantic topic quality coherence measure methods with other common topic models. we compared corexq9 with lda and non-negative matrix factorization (nmf) [57, 58] . in addition, we used frobenius normalized nmf (nmf-f) and generalized kullback-leibler divergence nmf (nmf-lk) for a closer comparison with traditional topic modeling. all models were trained with a since corexq9 represents topic and potential symptoms as a lexicon-based topic modeling, traditional measures such as regression correlation and log-likelihood are unnecessary for the semantic topics. therefore, to evaluate the baseline performance of the corexq9 model, we first involved the semantic topic quality coherence measure methods with other common topic models. we compared corexq9 with lda and non-negative matrix factorization (nmf) [57, 58] . in addition, we used frobenius normalized nmf (nmf-f) and generalized kullback-leibler divergence nmf (nmf-lk) for a closer comparison with traditional topic modeling. all models were trained with a randomly selected covid-19 twitter dataset. the topics generated by those models were scored by topic coherence measures to identify the degree of semantic similarity between high-scoring words in the topic. a common coherence measure is umass which calculates and scores the word co-occurrence in all documents [59] : where d(w i , w j ) represents the number of documents containing both w i and w j words and d(w i ) counts the ones containing w i , and c represents a smoothing factor. the intrinsic umass [59] coherence measure calculates these probabilities over the same training corpus. additionally, the extrinsic uci measure [58] introduced by david newman uses a pairwise score function, which is based on pointwise mutual information (pmi). it can be represented by: where p(w i ) represents the probability of seeing w i in a random document, and p(w i , w j ) is the probability of seeing both w i and w j co-occurring in a random document. those probabilities are empirically estimated from an external dataset such as wikipedia. the higher the topic coherence measure score, the higher the quality of the topics. in our baseline evaluation, we calculated the coherence scores by setting the range of topic numbers from 10 to 30. the abnormal and low-quality topics were cleared and the average coherence scores (table 7) were calculated by the sum of all coherence scores divided by the number of topics. on average, the corexq9 algorithm has a better umass score than lda and nmf. even though the uci score was slightly lower than two types of nmf algorithms, we can take the external estimation dataset as an uncertainty factor of this coherence model because the result of the comparison was still meaningfully coherent and it has the competitive functionality of the semi-supervised feature, which exceeded the usable range of nmf. in our research, the methods described above were combined to generate the final thematic map. to summarize processes for each detailed procedure, the workflow for the research is shown in figure 2 . first, starting from data collection, we prepared a twitter dataset, basilisk lexicon, and phq-9 lexicon. then, we cleaned each tweet and extracted its location information using the method mentioned in section 2.1. to engage time series analysis, the whole twitter dataset was formatted and sorted by unix timestamp before being sliced into two-week intervals. third, two lexicons were separately assigned to corexq9 and basilisk algorithm (mentioned in section 2.2) with the prepared twitter dataset. in the end, we decomposed the result generated by anchored corex model into spare matrix in order to group by all tweets in county level for visualization. note that each row of the results from the corex algorithm represents the correlations index within an individual tweet explained by nine phq levels so that we can reverse convert the result to its original tweets. the selected top symptoms and topics are present in table 8 . the fuzzy accuracy assessment results of the study are illustrated in figure 3 . on each map, the individual county is colored according to the assigned phq index using the proposed algorithm and fuzzy assessment accuracy assessment method. the numbers on the map represent the spatial uncertainty indices derived from the fuzzy accuracy assessment. each number represents the assessment score calculated from section 2.2.6. for most of the hot spots areas in figure 3 , the values are greater than two, which indicates middle to high accuracy results have been reached for those regions. higher scores for an area indicate a larger percentage of the topics being present in this area at specific time region. the fuzzy accuracy assessment results of the study are illustrated in figure 3 . on each map, the individual county is colored according to the assigned phq index using the proposed algorithm and fuzzy assessment accuracy assessment method. the numbers on the map represent the spatial uncertainty indices derived from the fuzzy accuracy assessment. each number represents the assessment score calculated from section 2.2.6. for most of the hot spots areas in figure 3 , the values are greater than two, which indicates middle to high accuracy results have been reached for those regions. higher scores for an area indicate a larger percentage of the topics being present in this area at specific time region. the results also present the spatiotemporal patterns from january to april (shown in figure 3a -g. table 8 shows the detected stress symptoms and topics generated from corexq9. each map represents the spatial distribution of stress symptoms over a biweekly period. it indicates that most of the regions have low to medium phq values (topic 0-3) during january and february, since information about the u.s. covid-19 outbreak was not publicly available in the u.s. during that time. most counties that have a low phq level contain general covid-19 related topics that are tied to the cases in asia and general symptoms of covid-19 (e.g., "wenliang li" (a chinese doctor) [60] , "south korea confirms", "coughing", "sneezing"). from the end of january, a few hotspots appear in some major u.s. cities such as san francisco, denver, los angeles, and seattle with topics related to "mistakenly released", "vaccine", "pandemic bus", and "china death" (see table 8 , figure 3b ,c). for instance, the keyword "mistakenly released" reflects news story in february about the first u.s. evacuee from china known to be infected with the coronavirus being mistakenly released from a san diego hospital and returned to quarantine [61] . people who living in california reacted strongly to this news (figure 3d) . later, on 8 march (figure 3c,d) , the phq level started to increase rapidly due to the covid-19 test stations available, increased number of covid-19 death cases, and a shelter-in-place order in many states (see table 8 , march). an interesting pattern was found that the number of counties with a high phq value kept growing until 5 april and started to decrease after the second week of april [62] . figure 4 illustrates the number of increased cases in the u.s. from january to may 2020. results show that the phq stress level in our results matches well with the number of increased cases illustrated in the johns hopkins coronavirus resource centers' statistical analysis results [61] . this means the number of new cases reduced due to the social distancing practice, and at the same time, the level of people's major concerns in many geographic regions reduced as well. the results also present the spatiotemporal patterns from january to april (shown in figure 3a g. table 8 shows the detected stress symptoms and topics generated from corexq9. each map represents the spatial distribution of stress symptoms over a biweekly period. it indicates that most of the regions have low to medium phq values (topic 0-3) during january and february, since information about the u.s. covid-19 outbreak was not publicly available in the u.s. during that time. most counties that have a low phq level contain general covid-19 related topics that are tied to the cases in asia and general symptoms of covid-19 (e.g., "wenliang li" (a chinese doctor) [60] , "south korea confirms", "coughing", "sneezing"). from the end of january, a few hotspots appear in some major u.s. cities such as san francisco, denver, los angeles, and seattle with topics related to "mistakenly released", "vaccine", "pandemic bus", and "china death" (see table 8 , figure 3b,c) . for instance, the keyword "mistakenly released" reflects news story in february about the first u.s. evacuee from china known to be infected with the coronavirus being mistakenly released from a san diego hospital and returned to quarantine [61] . people who living in california reacted strongly to this news (figure 3d) . later, on 8 march (figure 3c,d) , the phq level started to increase rapidly due to the covid-19 test stations available, increased number of covid-19 death cases, and a shelter-in-place order in many states (see table 8 , march). an interesting pattern was found that the number of counties with a high phq value kept growing until 5 april and started to decrease after the second week of april [62] . figure 4 illustrates the number of increased cases in the u.s. from january to may 2020. results show that the phq stress level in our results matches well with the number of increased cases illustrated in the johns hopkins coronavirus resource centers' statistical analysis results [61] . this means the number of new cases reduced due to the social distancing practice, and at the same time, the level of people's major concerns in many geographic regions reduced as well. our results also show a meaningful explanation of the spatial pattern caused by people's risk perception to various media messages and news during the pandemic. in march 2020, people in the united states had mild concerns about the uk prime minister boris johnson's talk of "herd immunity" [65] and social distancing (see table 8 , phq0, march). on the other hand, the major stress came from topics such as cases of deaths (e.g., in washington state), lack of food and covid-19 protection equipment (e.g., panic buy), and the increasing number of confirmed and death cases in our results also show a meaningful explanation of the spatial pattern caused by people's risk perception to various media messages and news during the pandemic. in march 2020, people in the united states had mild concerns about the uk prime minister boris johnson's talk of "herd immunity" [65] and social distancing (see table 8 , phq0, march). on the other hand, the major stress came from topics such as cases of deaths (e.g., in washington state), lack of food and covid-19 protection equipment (e.g., panic buy), and the increasing number of confirmed and death cases in the united states. figure 3d ,e shows that most of the hotspots were located in washington, california, and new york, and florida matched with to the march covid-19 increased cases map (see [61] . in april, keywords such as "death camps", "living expenses", "white house", and "economy shrinks" (see table 8 ) appeared most often in the high phq value categories, which indicated that people's major concerns shifted to financial worries due to businesses shutting down and the economic depression [66] . our study was conducted to perform a spatiotemporal stress analysis of twitter users during covid-19 pandemic by the corexq9 algorithm. according to the model evaluation results, the proposed corexq9 had the best baseline performance among other similar algorithms such as lda, nmf-lk, and nmf-f models. in addition to the corexq9 algorithm, we applied a fuzzy accuracy assessment method to the corexq9 analysis results to visualize the spatial uncertainty of the analysis results. this enables expert knowledge (e.g., phq rating of tweets) to be integrated in the social media data mining process. the result of our observed pattern reasonably matched the relevant events and epidemic trends. ideally, the analytic result of our collected twitter dataset is expected to support the research of mental health for the entire u.s. population as a sample case. in our cleaned twitter dataset, those tweets were posted by 1,410,651 users, which represent over 0.4% of the u.s. population. however, a previous investigation found that the 22% of american adults who use twitter are not uniformly distributed across age [66, 67] . another study found that twitter users are getting younger [68] , but the actual age, gender, and race of twitter users from those investigations have been controversial [55] . to generalize the psychology health analysis to the whole u.s. population, further work related to the user demographic is required to reduce the influence of the sample bias. the thematic maps we created for phq topics distribution were assessed based on fuzzy sets. the purpose of this commonly used method for categorical maps is to allow explicit accounts for the possible ambiguity regarding the appropriate map label [55, [69] [70] [71] [72] . a wide variety of statistical techniques have been proposed for the accuracy assessment of thematic maps [73] . in the future, we can use the standard deviation approach to estimate the quantity derived from the distribution of the tweets as a count on specific category if the assessment is focused on how the number of labeled phq tweets were distributed in each category. even though our datasets were preprocessed and selected with entities on covid-19 related topic, some of the tweets might be outside of the topic or are influenced by other objective factors. our future focus of uncertainty assessment of the thematic maps could be to extend to spatial uncertainty [74] , temporal uncertainty [75] semantic uncertainty [76] , etc. our assessment task can be considered a criterion referenced task that can focus on a selected phq level and can represent the majority level in any location. the fuzzy area estimation methods were extended based on previous research [72] . category assessment based on fuzzy sets can estimate the accuracy of classes as a function of levels of class membership [77] . here, we used biweekly data as a temporal scale for the analysis. our research group continues collecting twitter data for this project, so analysis could be applied to more fine-grained temporal scales in the future. since coivd-19 is a global pandemic, this project could be extended to a global scale to compare the results across different countries. in the future, the model could be applied to other cases to detect the related stress symptoms and provide real-time spatial decision support for addressing the problem. an end-to-end spatiotemporal analysis system could be built if all of the modules were integrated; this would increase the efficiency of determining the potential symptoms and causes of public mental health problems. in this article, we proposed the corexq9 algorithm to analyze the covid-19 related stress symptoms at a spatiotemporal scale. the corex algorithm combined with clinical stress measure index (phq-9) helped to minimize human interventions and human language ambiguity in social media data mining for stress detection and provided accurate stress symptom measures of twitter users related to the covid-19 pandemic. there was a strong correlation between stress symptoms and the number of increased new covid-19 cases for some major u.s. cities such as chicago, san francisco, seattle, new york, and miami. people's risk perceptions were sensitive to the release of covid-19 related public news and media messages. many frequently appearing keywords in the high phq value categories represent the popular media and news publications at that time. before march, most regions had mild stress symptoms due to the low number of reported cases caused by the unavailability of test stations, creating a false sense of security among the public in the united states. the number of cases increased suddenly in march due to governmental confirmation of the seriousness of the pandemic in the united states and shelter-in-place orders in many states. from january to march, a major concern for people was being infected by the disease and there was panic-buying behavior, but this shifted to financial distress later in april along coastal eastern and western united states. our main contributions are as follows: first, we introduced a specialized stress tweets classifier, which narrows down the theoretical algorithms to practical usage on the public health area and demonstrates more effectiveness than traditional sentiment index classifiers. second, we framed corexpq9 as a topic detection model in our research. we explored the latent connection between the social media activity and phq-9 depression symptoms and topics in united states. finally, as a supplement methodology for the existing questionnaire-driven mental health research, our integrated system was used to glean depression topics in an unobtrusive way. the proposed algorithm provides an innovative way to analyze social media data to measure stress symptoms under covid-19 pandemic at a spatiotemporal scale. by doing this, we were able to observe spatiotemporal patterns of stress symptoms and answer the questions of what the major concerns related to the pandemic in different geographic regions at different time scales were. in the future, this model could be applied to other cases to detect related stress symptoms and provide real-time spatial decision support for addressing arising issues. the authors declare no conflict of interest. table a1 . notation table. pattern pool a subset of the extraction patterns that tend to extract the seed words candidate word pool the candidate nouns extracted by pattern pool are placed in candidate word pool tc total correlation, also called multi-information, it quantifies the redundancy or dependency among a set of n random variables. kullback-leibler divergence, also called relative entropy, is a measure of how probability distribution is different from a second, reference probability distribution [50] . p(x g ) probability densities of x g i(x : y) the mutual information between two random variables p(y|x) y's dependence on x can be written in terms of a linear number of parameters which are just the estimate marginals δ the kronecker delta, a function of two variables. the function is 1 if the variables are equal, and 0 otherwise. a constant used to ensure the normalization of p(y|x) for each x. it can be calculated by summing |y| = k, 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area estimation this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-306504-0wq7rc6s authors: barakovic husic, jasmina; melero, francisco josé; barakovic, sabina; lameski, petre; zdravevski, eftim; maresova, petra; krejcar, ondrej; chorbev, ivan; garcia, nuno m.; trajkovik, vladimir title: aging at work: a review of recent trends and future directions date: 2020-10-20 journal: int j environ res public health doi: 10.3390/ijerph17207659 sha: doc_id: 306504 cord_uid: 0wq7rc6s demographic data suggest a rapid aging trend in the active workforce. the concept of aging at work comes from the urgent requirement to help the aging workforce of the contemporary industries to maintain productivity while achieving a work and private life balance. while there is plenty of research focusing on the aging population, current research activities on policies covering the concept of aging at work are limited and conceptually different. this paper aims to review publications on aging at work, which could lead to the creation of a framework that targets governmental decision-makers, the non-governmental sector, the private sector, and all of those who are responsible for the formulation of policies on aging at work. in august 2019 we searched for peer-reviewed articles in english that were indexed in pubmed, ieee xplore, and springer and published between 2008 and 2019. the keywords included the following phrases: “successful aging at work”, “active aging at work”, “healthy aging at work”, “productive aging at work”, and “older adults at work”. a total of 47,330 publications were found through database searching, and 25,187 publications were screened. afterwards, 7756 screened publications were excluded from the further analysis, and a total of 17,431 article abstracts were evaluated for inclusion. finally, further qualitative analysis included 1375 articles, of which about 24 are discussed in this article. the most prominent works suggest policies that encourage life-long learning, and a workforce that comprises both younger and older workers, as well as gradual retirement. the older population is growing rapidly. in 2019, approximately 700 million people were aged 65 years or more in the world population. it is anticipated that this number will be doubled to 1.5 billion in order to answer the research questions, we examined studies on the aging labour force that were published between january 2008 and august 2019, to recognize the trends in the literature written in english with respect to motivation issues and potential solutions. we focused on the trends starting from the recession in 2008, when, although the economic growth slowed, the employment rate of older people remained strong, thus basically changing the position of older workers [24] . an additional motivation for focusing on this time period was because in the last decade, many assistive technologies have emerged that can aid older adults in different environments. at the same time, many jobs are transforming and can be successfully performed from home, which has recently become evident with the covid-19 pandemic. considering these two observations, the goal of this research is to investigate whether there is an underlying trend that reveals opportunities for aging at work. we adopted the preferred reporting items for systematic review and meta-analysis (prisma) methodology [25] to review the literature on aging at work policies. the prisma flow distinguishes separate stages of systematic reviews. these stages are the collection of papers, scanning of papers' text, evaluation of eligibility of papers, and meta-analysis. the collected papers on aging at work policies exceeded the capacity that would allow articles to be searched manually. thus, we used natural language processing (nlp) algorithms to perform an efficient search of the identified literature. the nlp toolkit [26] was designed to automate the literature search by using different search phrases, scanning, and evaluating eligibility within the prisma framework while generating visualizations of aggregate results. the nlp toolkit provides increased efficiency of the review process by screening the title and abstract while using the predetermined properties and their synonyms to determine the literature search phrases. it should be noted that the nlp toolkit does not understand the context and, therefore, categorizes more articles as relevant than a human reader would. however, it is a valuable resource that increases the efficiency of the review process, as demonstrated in a scoping review [27] that focused on wearable technology for connected health. the adopted prisma information flow is shown in figure 1 . since the nlp toolkit automates the review process of publications that are indexed in only three digital libraries and because we have not taken into account the nonindexed publishers, some relevant publications (e.g., reference [28] ) have been omitted from the analysis. this one and a few other papers were manually identified, and those publications originated from different digital libraries. they were used to confirm the findings of this review. however, we did not use these papers from other digital libraries to identify trends because the size of the searched digital libraries is sufficient for the purpose of the analysis. the nlp search strategy was applied in order to automatically screen irrelevant articles that have a low correlation with the topics of interest in the study. additionally, it helped in consolidating the collected articles by automatically merging results from multiple digital libraries as well as removing duplicate entries. moreover, it allowed us to iteratively fine-tune and modify the search phrases in the hope of identifying more relevant articles. finally, the nlp toolkit automatically generated charts (such as that highlight the trends of publications for certain topics. for more details about the inner workings of the nlp-based toolkit, we refer interested readers to [26] , and also to [27] , which applied it to review wearable technology for connected health. by using yearly graphs, we were able to analyze and report the potential trends in data by investigating articles in each property group (i.e., theme) separately. the nlp toolkit input parameters are a collection of phrases. keywords, together with their synonyms, are applied as search terms for the digital libraries used in the literature search. the input can be further expanded by nlp toolkit properties. properties are phrases that are being searched within the title, abstract, or keywords section of the articles identified from the previous keywords search. property groups are sets of properties that can be used for a more comprehensive presentation of search results. the input parameters used in this study are shown in table 1 . these keywords, property groups and properties are the final versions after an iterative process in which all authors participated and considered different alternatives of keywords and properties, and analyzed the preliminary results. in the process of selecting articles to be included in the quantitative synthesis, four authors participated, of which at least two had to be in agreement. table 1 . the nlp toolkit input parameters: keywords, property groups and properties. "active aging at work", "older adults at work", "successful aging at work", "healthy aging at work", "productive aging at work" motivations "deficit", "discrimination", "growth" solutions "eu policy", "assistance schemes", "eligibility criteria", "legislation", "national policy" active aging at work healthy aging at work older adults at work productive aging at work successful aging at work . solutions-related properties: "eu policy", "assistance schemes", "eligibility criteria", "legislation", and "national policy". the trends apply to the period from 2008 to 2019. the titles and abstracts retrieved by the nlp-based search strategy were evaluated by two independent researchers. they compared their opinions in order to select articles that satisfied the inclusion and exclusion criteria. the inclusion criteria were as follows: 1. articles that consider the concept of aging at work, i.e., the aging labour force. (a) articles that discuss any of three motivation factors, i.e., discrimination, growth, and deficit; articles that support any of three solution pillars, i.e., assistance, policies, and legislation. 2. articles that use research methodology with any results. the exclusion criteria were as follows: 1. articles that are about aging and older people in general that do not consider the concept of aging at work; 2. articles that cover any of three motivation factors, i.e., discrimination, growth, and deficit, in a context other than the aging labour force; 3. articles that cover any of three solution pillars, i.e., assistance, policies, and legislation, in the context other than the aging labour force; 4. articles that do not provide sufficient information for classification. when researchers differed in their opinions about an article's suitability, the article was selected for further consideration. this resulted in an initial selection of 70 articles. furthermore, the full texts of the chosen articles were reviewed in order to determine their suitability for further discussion. after the data abstraction of the final selected articles, two additional researchers separately reviewed 20% of randomly chosen articles. in the case of any disagreement on the suitability of articles, a third researcher was consulted for recommendation and assessment of the given article. this researcher was a specialist who drew a final conclusion regarding the article selection process. for the selection of the final 24 articles, two of three authors needed to be in agreement, considering the completeness of the methods, relevance to the study goal, details about the population, and impact of the study. we used the inductive approach for the article review and analysis. the selected articles were systematically organized into two groups: 1. articles that focused on motivation factors (i.e., discrimination, growth, and deficit); 2. articles that focused on solution pillars (i.e., assistance, policies, and legislation). we generated a detailed summary of each article and extracted the following items: objective, methods, main findings, limitations, and keywords. the extracted items provided the input data for discussion and conclusions. after searching pubmed, ieee xplore, and springer, we identified 47,330 potentially articles. after performing the prisma steps shown in figure 1 , the number of articles was reduced. specifically, the removal of duplicates reduced the number to 25,187 studies. the first screening process eliminated an additional 7756 studies with an out-of-scope publication year, or other parsing issues (no title, abstract, etc.). then, 17,431 papers were subject to the eligibility estimate using the automated nlp toolkit, which removed articles without any of the required properties. eventually, 1375 papers remained as potentially relevant and eligible for further manual inspection. a total of 70 articles were initially selected to analyze the trends on the aging labour force, while 24 articles were used to explore the motivation issues and solutions in the given context. the selected keywords aimed to show different aspects on the literature corpus on aging at work. figure 2 presents the number of potentially relevant papers that contained the defined keywords and that were additionally filtered manually based on their relevance to the defined properties per year. a relatively similar number of identified articles can be observed in the evaluated time period. "active aging at work" is the keyword with the smallest number of occurrences. the most frequent keyword phrase in the identified publications is "older adults at work". the number of research articles did not grow in the period of interest, but articles that address the associated keywords seem to be distributed more evenly over time. findings related to property groups show that the number of papers related to "motivation" of the adult workforce is relatively constant, with a small decline in the last two years, while the papers focused on the "solutions" property group seems to be slightly more predominant in the last few years ( figure 3) . a more granular analysis was carried out on the property groups data at the properties level, and the chart reveals that "growth" is the primary topic within the motivation group of papers, followed by "discrimination". the papers related to the topic of "deficit" appeared only in recent years ( figure 4 ). the focus of papers within the "solutions" property group ( figure 5 ) seems to move from "national policy" based to "legislation", while "assistant schemes" and "eu policies" seem to be of smaller interest for the scientific community. there was only one paper that addressed "eligibility criteria", which makes this topic interesting for further research. a total of 12 articles out of 24 were selected for the further analysis of motivations that drive the research on the aging labour force. the selected articles were organized into three focus groups according to the considered terms related to motivation, i.e., "discrimination", "growth", and "deficit". a more detailed analysis of these articles is presented in table 2 . the remaining 12 articles out of 24 were used for a more detailed analysis of solutions for the aging labour force. the selected articles were organized into three focus groups according to the considered solutions, i.e., assistance, policy, and legislation. table 3 shows results of the analysis. the ageing labour force could represent a risk both for society and economy unless it is well managed. therefore, the attention that researchers, governments and other stakeholders have devoted to this issue has grown over the time. according to analysis of motivations ( table 2 ) and solutions ( table 3 ) for ageing at work, possible policy implications have been identified and split into five parts: extend the length of work ability. different organizations implement changes by creating common policies and strategies, but they are not oriented toward the older workforce. intentionally interrupting the existing age-graded logic and its replacement with age-neutral logic are proposed in [16] . the authors in [29] found that the expected decline in employment could be partially offset by public policies that encourage the employment of older people. this causes problems for public finances due to expenditures on health, long-term care, pensions, etc. [3] . in order to encourage policies to maintain work ability at an old age, it is necessary to invest in decreasing of both work stress and social inequalities in health care [30] . however, extending the length of work ability does not just pose issues, but provides social and economic opportunities. avoid the age-based discrimination. the labour market will have to adapt working positions and eliminate the attitude of age-based discrimination, since it will have to fight for a working force older than 65 because it is lacking. when facing age-based discrimination at work, the organizational help and friends and family support were found to be significant in achieving better health and adaptability [31] . on the other hand, older workers with high job satisfaction without age-based discrimination remained longer in the labour market [32] . finally, the authors in [10] found that experiences of discrimination were rare and reduced with age among men, whereas almost no age differences were noticed among women. this indicates that age-based discrimination is possibly overstated, and age-related obstacles could have been miscomprehended. therefore, the flexibility of older workers can be seen as an opportunity for the active global aging trend [33] . older workers with high job satisfaction, development possibilities, affirmative relations to management, and no age discrimination stayed longer in the work market. positive relations with colleagues did not affect older workers decisions on early pension. the measures were self-evaluated. the psychosocial factors were measured at single time point. successive changes in the psychosocial work conditions could cause early pension that would be missed by the study. early pension, work conditions, management quality, job satisfaction [31] to examine the relation between successful aging and stress sources at work among older workers in china questionnaire study. study sample-242 workers aged >40 years. method variance. harman's one-factor test. factor analysis. perception of institutional support and social help from family and friends significantly corresponds to efficient aging at work. participants were surveyed at a single time point. the study relied on participants self-reports. successful aging, work stressor, social help, institutional support [10] to improve comprehension of the discrimination at work, with a focus on age and gender challenges. survey study. study sample-3203 workers with mean age 43 years. computer-aided telephone interview. binary logistic regression. daily discrimination was unusual. it appears with age among men, and not among women. the nature of work market age obstacles is not understood correctly, and the degree of aging discrimination is overstated. there was a small number of workers who faced daily discrimination. the degree of daily discrimination has to be further investigated. ageism, employment discrimination, gender, work [33] to investigate the age-related connection between job stress, extreme tiredness, prosperity, and associated personal, institutional, and community factors. survey study. study sample-1298 participants aged 18 years or older. descriptive statistics. linear regression. one-way analysis of variance. job stress was associated with several types of extreme tiredness and prosperity. personal work style, institutional and community factors were associated with prosperity. old age was connected to a poor perception of health. the study did not compare work differences. the data were cross-sectional and the causal relation of the work conditions and style with job stress, extreme tiredness, and prosperity could not be confirmed. age difference, exhaustion, prosperity, work stress, work condition growth [30] to investigate the connection of social, demographic, economic and job related factors with disability. a decrease in job stress and sociable disproportion in healthcare is appropriate for the development of policies that support aging at work. the disability indices were not formulated based on functional testing. the evaluation of stressful work was performed by abbreviated scales. position, aging workforce, work stress, work ability, social disproportion [16] to examine organizational work disrupting age-graded policies. interview study. study sample-23 organizations with employees aged 50-69 years. qualitative content analysis. organizations implement changes by creating common policies and strategies, but not those oriented toward an aging workforce. they propose to intentionally interrupt the existing age-graded logic and replace it with age-neutral logic. creative, high-tech, or communications organizations were not studied. sample size was small, so broader claims about minnesota or u.s. workers cannot be made. organizational logic, older workers, pension, flexibility [29] to examine the influence of demographic trends on the economic growth and employment level that japan is expected to face in the next 20 years the expected decline in employment could be partially offset by public policies that encourage the employment of older people. not reported. low fertility, population decline, population aging [3] to provide a literature review on the need for the senior workforce and recognize main directions for research on this topic. there is a negative association between salary and employment outcomes for the senior workforce. the connection between efficiency and salary is defined by governmental conditions and motivation to take early pension. the variations in micro-, macro-, and meso-level factors were not captured, simultaneously. there is a need for improvements in the analysis of the impact of age-based discrimination on the employing of older workers. work market, employment protection, regulation, legislation deficit [17] to examine the influence of organizational factors on work ability. cross-sectional study (online survey). study sample-306 employees. path analysis modeling. maximum likelihood estimation. organizational culture and professional effort indirectly enabled the prediction of work ability, with job satisfaction mediating these relations. the sample included mostly younger and female workers. the cross-sectional design of the study did not provide the possibility to understand causes and effects related to work ability. work ability, organizational culture [34] to recognize professions prevailed by an older workforce and evaluate their vulnerability to hazards in these professions. survey study (interviews). study sample-6502 workers aged 55 or more. chi-squared test. work-related hazards should be decreased to inhibit professional disturbance in professions prevailed by an older workforce. self-informed data were included in the study. health issues, hazards, profession, musculoskeletal disorders [35] to investigate job discrimination related to age and disability. integrated mission system data from 1993 to 2007. descriptive statistics. job discrimination of aged or disabled workers is focused on challenges involving seating, revenge, and cancellation. data do not contain supplemental information regarding a secondary cause for each filed allegation. job/age/disability discrimination [36] to investigate the relation between psychosocial factors and pension intention of older employees, while considering healthiness and work ability. survey study. study sample-3122 workers aged 50 years or older. pearson correlation. ordinal logistic regression. ageism and the absence of acknowledgement and growth opportunities are connected to older male workers' pension intention. work ability is strongly related to the pension intention of both genders. the pension age could depend on unfamiliar alternations in the worker's environment or health status. psychosocial factors, pension intention, healthiness, work ability table 3 . detailed analysis of articles that focus on solutions. assistance [37] to critically review the literature on older farmers in canada and the usa and describe how musculoskeletal disorders influence their ability to work. literature review. twelve articles analyzed in detail. musculoskeletal disturbance can lead to trauma or loss of ability to farm. it is necessary to develop safer work practices and encourage healthiness, efficiency, and professional longevity. some related articles may have been excluded from the study due to the specificity of the search strings. older farmers, work-related musculoskeletal disorders, pension age [8] to investigate the action plans that workers use to acquire skills in software and complete assignments exploratory study (interviews, surveys). study sample-10 administrative assistants. grounded theory. non-parametric statistics. administrative assistants are regularly communicating and sharing knowledge. exclusion of workers from different organizations, lack of extensive investigation on behavior at work, and creation of software tool design instructions. workplace, generations, collaboration [38] to collect information to direct the preparation of programs for returning older adults to work survey study (questionnaires). study sample-37 jobless participants aged 51-76 years. anova. chi-square test. participants who felt discriminated indicated the preference to acquire technological skills and get classroom-based education. work obstacles could not be generalized. older workers, absence of technological skills, work conditions, work experiences policy [39] to investigate factors related to perceived work ability in a sample of brazilians sample aged 50 years and more longitudinal study (surveys). study sample-8903 workers aged 50 years and over. multivariate analysis. poisson regression. work ability in old age depends on the life course, i.e., academic level, health conditions in younger and older age, minimum working age, etc. policies aiming to extend longevity in the work market must consider these factors. the collection of self-reported data associated with past experiences might have been affected by the preference to demonstrate an acceptable image, causing information bias. establishment of temporal relations for the variable related to current conditions is limited. work ability, health, socioeconomic factors [40] to review the documentation about the influence of psychological health on staying at work after pension and discuss consequences of public health policies. systematic literature review. ten articles analyzed in detail. staying at work after pension can be positive for psychological health. pension action plans are required to provide national policies that will increase the pension age and not exacerbate any disproportion in the older population. only cross-sectional and longitudinal studies investigating the impact of unexpected variables on psychological health were involved in the review. pension, job status, psychological health, social policy [7] to analyze the literature on workplace health promotion (whp) aimed at older workers systematic literature review. eighteen articles analyzed in detail. existing documentation does not demonstrate that whp enhance work ability, retention, efficiency, lifestyle, health, or prosperity of the senior workforce. the heterogeneity and low quality of the studies makes it difficult to synthesize the literature and draw the conclusions. workplace health promotion, senior workforce, health, lifestyle [41] to investigate the results of unfulfilled expectations of staying at work after age 62 on life satisfaction. longitudinal survey. study sample-1684 workers aged 51 and over. growth mixture modeling. descriptive statistics. linear regression. multi-nominal logistic regression. majority of men and almost no women expected to stay at work after age 62. the subjective prosperity of older adults is affected by unmet expectations of staying longer at work . the significance of different job options before full pension was not assessed. work expectations, pension, life satisfaction, subjective prosperity [42] to find out whether the workers' ages determine the evaluation of their work-life balance. survey study. study sample-500 workers aged from 21 to 70 years. kruskal-wallis test. spearman's r correlation analysis. the maintenance of work-life balance will be indicated by older workers. all employees do not have the same possibilities to take advantage of solutions that provide the support of work-life balance. the diversity of the answers given by the participants according to the type and state of particpants affiliation was not analyzed. work-life balance, workers'assessment, aging workforce legislation [13] to estimate the impact on the efficiency of the reduction of assortment mechanisms among senior employees. italian national institute of statistics data from 2009 to 2013. descriptive statistics. multivariate regression analysis. the growth of pension age, as well as limitations on early pension intention, kept older workers at the work without a positive influence on efficiency. more efficient older employees are mroe likely to stay at work in comparison with those who are not as efficient. the number of employees kept at the work was underestimated. the reform's influence on the employees' structure is an additional issue. aging workforce, pension reforms, labor productivity [43] to investigate the workforce participation and absence among older adults in sweden. data from the swedish population register. study sample-workers aged 55-64 years. descriptive statistics. the alternation in regulations affected the share of workers associated with illness and disability pension programs. simultaneously, the share of workers going to early pension has grown. this study noticed no alternation related to the difference in working-life exit patterns associated with hierarchical and academic positions in the organization. workforce participation, older worker, pension, illness benefits [20] to review the expert way of thinking in relation to policies influencing the employment of older adults. survey study. study sample-89 participants aged 50 years or older. descriptive statistics. a broad range of policies recommend possibilities for innovation. there is a sampling bias related to the language and review method. there were no participants from south america, while a few participants from africa demonstrated about limited internet access. aging workforce, older workers, employment policy, mandatory pension, government answers [44] to investigate whether age and mental capabilities mitigate the connection between job stress and negative affect survey study. study sample-139 workers aged 25-69 years. descriptive statistics. correlation and regression analysis. johnson-neyman technique. cognition mitigated the connection between job stress and negative affect. crystallized cognition had a large influence on the connection between job stress and negative affect for senior workers. the mitigating influence of fluid cognition was unchanging. the study did not permit a setup of directionality among variables. better evaluation of professional features and job requirements is needed. job stress, negative affect, older workers improve the well-being of older workers. difficulties that older people experience at work indicates a need for healthcare strategies to adjust the work conditions so that they are suitable for older workforce with decreased physical ability. the authors in [34] identified professions that are dominated by older workers and suggested that work-related hazards (e.g., noise, vibrations, etc.) should be reduced to prevent health problems. older workers and workers with disabilities can be used as the sources of required skills. such unutilized workers need to be recruited and well-managed to ensure that their skills are retained [35] . in order to improve the well-being of older workers, the authors in [17] considered the influence of organizational factors, whereas those in [36] examined psychosocial factors at workplace. unfulfilled prospects for work in old age influenced the prosperity of older workers [41] . therefore, it is necessary to perform workplace health promotion activities [7] . promote the lifelong learning. the growth of the aging labour force and emerging technologies change the work environment, generating a need to train older workers to improve their skills. older workers gain benefits when well-designed training approaches are used. therefore, the authors in [38] studied the training requirements and work experience, as well as the perception of ideal job features. to encourage technology adoption in the work environment, there is a need to understand how workers study software tools and complete assignments [8] . therefore, further research should concentrate on developing safer work practices and supporting worker's productivity and professional longevity [37] . encourage the late retirement. in order to achieve more successful inclusion of older people into labour market, there is a need for more comprehensive policies and harmonized all-age legislation. this is indicated by the fact that the overall decrease in the share of individuals in pension and disability programs is caused by changes in regulations [43] . in this regard, the authors in [20] studied the factors that affect the aging labour force and the range of current policies that suggest the possible opportunities for innovation. the implications for older workers are related to lifespan earnings, job retention, retirement savings, the possibility of changing jobs, or employment assurance [13, 44] . increasing the pension age should not exacerbate social and health disproportion in the older workers [40] . this is important since many older workers report unequal options to take advantage of solutions for supporting the balance between work and private life [42] . the abovementioned policy implications may be useful from policy making perspective. they could lead to the creation of framework that targets government, the non-governmental sector, private sectors and other stakeholders. however, the creation of such policy framework should take into account many other contributing factors [28] that can be the subject for future research activities. furthermore, a future research agenda should consider the concept of ageing at work at national level and intensify collaboration at international level. nevertheless, the following recommendations for governments and other stakeholders can be drawn from this research study: 1. encourage incentives to extend the working ability in old age; 2. eliminate age-based discrimination at work along with promotion of gender equality; 3. invest in education, lifelong learning, health and well-being while increasing the productivity; 4. improve the working conditions to increase the safety at work and health of workers; 5. support late retirement along with the increase of life expectancy; 6. reduce the use of early retirement if workers' health and work ability are satisfactory. this study provides a systematic review of articles related to the aging labour force in terms of recent trends and future directions. additionally, it identifies and evaluates the motivations that drive research on the aging labour force and potential solutions that address the issues related to the aging at work. sustainable growth and age-based discrimination are recognized as the main motivations to perform the research activities in the given context. on the other hand, policies that stimulate life-long learning are identified as a potential solution for the aging labour force. the additional value of this study lies in its identification of policy implications and recommendations for governments and other stakeholders. furthermore, along with this paper, we also provide a supplementary materials of all identified relevant articles that can be filtered in terms of different fields to recognize articles for further analysis in a particular subfield. this initial search for a systematic review design may provide useful results on the relevance, practicability, and time needed to carry out a systematic review. despite the valuable insights in this study, it suffers from several limitations as well. first, this study took into consideration only three digital libraries, so some relevant articles could be unintentionally omitted from the study because of the specificity of the search strings and the fact that we have not taken into account the non-indexed publishers. however, the size of the searched digital libraries is sufficient, so the obtained results are suitable for the purpose of the study. additionally, the articles obtained for this study are the results of a search query sent to different search engines with different retrieving and formatting rules from those that are used in the considered libraries. however, we are convinced that the specificities of the publishers' search engines had no influence on the findings of this study, taking into the account the number of analyzed articles. finally, the articles are categorized to provide the quantitative results that show the recent trends and future directions of aging at work, whereas the qualitative results are manually covered to a limited extent to describe the motivation issues and solutions for the aging labour force. the aging of the population raises many issues and provides many opportunities. it intensifies the requirement for long-term care, healthcare, and a better-skilled workforce, and increases the demand for age-friendly environments. on the other hand, it enables the contributions of older people to their family, local community, or broader society. in order to review articles related to the ageing at work in terms of recent trends and future directions, we performed a scoping literature review using an nlp-based framework to automate some of the steps in the prisma methodology and quickly identify potentially relevant articles. as a result, starting from over 70 thousand potentially relevant articles, we analyzed in detail about 70 of the most relevant approaches and discussed 24 of them. we identified that the most prominent works suggest policies and practices that support life-long learning, a workforce that comprises both younger and older workers, and gradual retirement. approaches like these could be the best response to the globalization issues, reduction of workforce, maintenance of financial independence of the aging workforce, and other social benefits. future work could be focused on standardizing approaches to this problem across different countries, supported by different policymakers. the goal should not be to end up with the same approaches in different environments, as this would hardly encompass all cultural, sociological, and economic factors. instead, we believe that systematically documented and well-thought-out approaches will facilitate the measurement of the results and analysis of causality when investigating benefits and drawbacks. funding: v.t., e.z., i.c. and p.l. acknowledge the support of faculty of computer science and engineering, ss. cyril and methodius university in skopje, north macedonia. in addition, this manuscript is funded by fct/mec through portuguese national funds and when applicable co-funded by feder-pt2020 partnership agreement under the project uidb/eea/50008/2020 (este trabalho é financiado pela fct/mec através de fundos nacionais e quando aplicável cofinanciado pelo feder, no âmbito do acordo de parceria pt2020 no âmbito do projeto uidb/eea/50008/2020). this manuscript is based upon work from cost action ic1303-aapele-architectures, algorithms, and protocols for enhanced living environments and cost action ca16226-sheld-on-indoor living space improvement: smart habitat for the elderly, supported by cost (european cooperation in science and technology). cost is a funding agency for research and innovation networks. our actions help connect research initiatives across europe and enable scientists to grow their ideas by sharing them with their peers. this boosts their research, career and innovation. more information in www.cost.eu. based on ca16226 project, ltc18035 inter cost was proposed for national funding support of cost action framework by meys, czech republic. this work was also supported in part by the project (2020/2206), grant agency of excellence, university of hradec kralove, faculty of informatics and management, czech republic. the demand for older workers. in ageing, health and pensions in europe: an economic and social policy perspective healthy ageing and well-being at work ageing europe: looking at the lives of older people in the eu quality of life framework for personalised ageing: a systematic review of ict solutions workplace health promotion for older workers: a systematic literature review generations in the workplace: an exploratory study with administrative assistants joint report on towards age-friendly work in europe: a life-course perspective on work and ageing from eu agencies; publications office of the european union everyday discrimination in the australian workplace: assessing its prevalence and age and gender differences older women's responses and decisions after a fall: the work of getting "back to normal". health care women int transition from the labor market: older workers and retirement ageing workforce and productivity: the unintended effects of retirement regulation in italy understanding the psychology of diversity organizational change around an older workforce primary-and secondary-level organizational predictors of work ability population aging: opportunity for business expansion, an invitational paper presented at the asia-pacific economic cooperation (apec) international workshop on adaptation sustaining work participation across the life course supporting the labor force participation of older adults: an international survey of policy options accessibility and new technology mooc-disability and active aging: technological support one size does not fit all: uncovering older entrepreneur diversity through motivations, emotions and mentoring needs aging and work: an overview employers' use of older workers in the recession preferred reporting items for systematic reviews and meta-analyses: the prisma statement automation in systematic, scoping and rapid reviews by an nlp toolkit: a case study in enhanced living environments literature on wearable technology for connected health: scoping review of research trends, advances, and barriers the sage handbook of aging, work and society population decline, labor force stability, and the future of the japanese economy socioeconomic position, psychosocial work environment and disability in an ageing workforce: a longitudinal analysis of share data from 11 european countries an investigation of predictors of successful aging in the workplace among hong kong chinese older workers psychosocial work environment and retirement age: a prospective study of 1876 senior employees age differences in work stress, exhaustion, well-being, and related factors from an ecological perspective hazards and health problems in occupations dominated by aged workers in south korea age and disability employment discrimination: occupational rehabilitation implications the association between psychosocial work environment, attitudes towards older workers (ageism) and planned retirement work-related musculoskeletal disorders in senior farmers: safety and health considerations. workplace health saf training older workers for technology-based employment life course and work ability among older adults: elsi-brazil the impact of working beyond traditional retirement ages on mental health: implications for public health and welfare policy unexpected retirement from full time work after age 62: consequences for life satisfaction in older americans work-life balance: does age matter? work has the participation of older employees in the workforce increased? study of the total swedish population regarding exit from working life the moderating effects of aging and cognitive abilities on the association between work stress and negative affect this article is an open access article distributed under the terms and conditions of the creative commons attribution the authors declare no conflict of interest. the founders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. key: cord-271736-29oavyc4 authors: madden, rosamond h.; lukersmith, sue; zhou, qingsheng; glasgow, melita; johnston, scott title: disability-related questions for administrative datasets date: 2020-07-28 journal: int j environ res public health doi: 10.3390/ijerph17155435 sha: doc_id: 271736 cord_uid: 29oavyc4 high rates of unemployment among people with disability are long-standing and persistent problems worldwide. for public policy, estimates of prevalence and population profiles are required for designing support schemes such as australia’s national disability insurance scheme; for monitoring implementation of the united nations convention on rights of persons with disabilities; and for monitoring service access, participation, and equity for people with disability in mainstream systems including employment. in the public sector, creating a succinct identifier for disability in administrative systems is a key challenge for public policy design and monitoring. this requires concise methods of identifying people with disability within systems, producing data comparable with population data to gauge accessibility and equity. we aimed to create disability-related questions of value to the purposes of an australian state and contribute to literature on parsimonious and respectful disability identification for wider application. the research, completed in 2017, involved mapping and identification of key disability concepts for inclusion in new questions, focus groups to refine wording of new questions, and online surveys of employees evaluating two potential new question sets on the topic of disability and environment. recommendations for new disability-related questions and possible new data collection processes are being considered and used by the leading state authority. australia is among the countries recognising the rights of people with disability to participate fully in society and enjoy all the same opportunities, rights, and access to services as the rest of the community. in 2008, australia ratified the united nations convention on the rights of persons with disabilities (uncrpd) [1] , and now links major public policies and programs to uncrpd objectives (e.g., national disability strategy, national disability insurance scheme, and new south wales (nsw) disability inclusion act of 2014). any success of these initiatives should be indicated by relative improvements in participation by people with disability in many life areas. the challenge for national statistics in any country is to produce reliable data capable of telling the participation story. data are therefore required on participation by people with disability compared to other citizens of the country, as well as on access to services, both specialist and mainstream. relevant and efficient data collection requires concise methods of identifying people with disability within administrative systems, as well as the ability to compare the resulting data with population data in order to gauge accessibility and equity. creating a succinct disability "identifier" for use in administrative systems is a key challenge for public policy design and monitoring in any country [2] [3] [4] . meeting this challenge involves the design and adoption of short question sets, ideally a single question, in order to identify people with disability consistently within service data systems and monitor their access to, and experience of, generic services such as health and education, and to establish employment and other participatory experience in society [5] . a "disability flag" was designed by the australian institute of health and welfare (aihw) to identify records of people with disability within data collections in various sectors. the flag aligns with australian bureau of statistics (abs) data about the need for assistance with self-care, mobility, or communication-a specific and less common level of disability [6] . the need for data development is illustrated by trends and data difficulties in important policy areas including employment and was recognised as a key need in the world report on disability [2] . despite widespread disability policy reform in australia and other countries, employment rates remain low, with australia being the 21st of 29 oecd countries in 2010 ( [7] , pp. 49-51). recent data indicate that employment of people with disability in australia is not improving. labour force participation and employment rates have decreased in recent years (table 1) . source: table 15a .73 and 5a.74 [8] . the picture in the australian state of new south wales (nsw) public sector is no better, with the reported proportion of people with disability employed dropping from 4% in 2008 to 2.8% in 2016 (p. 32 and figure 5 .3 [9] ). a target was set to double the representation of people with disability in the nsw public sector from an estimated 2.8% in 2016 to 5.6% by 2027 (in 2019 the disability employment target of 5.6% was announced as a premier's priority for nsw and the end date to achieve the target amended to 2025) (p. 31, [9] ). the nsw public service commission (psc) and the department of family and community services (facs; now the nsw department of communities and justice) are working to improve the inclusion of people with disability in the nsw public sector. the decision of employees to report their disability status is complex; people with disability, when interviewed, cited reasons such as stigma, fear of discrimination, and irrelevance to work being performed in deciding not to share this information [10] . this issue could affect the quality of data. the nsw psc has a number of data collections designed to help it understand the needs of diverse employees, including people with disability: the workforce profile (wfp) is an annual census of the nsw government workforce that has been collected since 1999. it captures a range of de-identified demographic information from employees of the nsw public sector that is extracted by government agencies from human resource (hr) systems. it collects information related to disability and environmental modifications-whether someone has indicated they have a disability, and whether they require an adjustment. in 2018, for example, representation of people with disability in the nsw public sector workforce was 2.5% [9] . the people matter employee survey (pmes) is a perception survey that encompasses the whole of the nsw government and is led by the psc. while its focus is on understanding the engagement and experiences of its workforce, it also collects information on a range of demographic information and disability. it is an anonymous survey. each year a higher proportion of respondents declare a disability than the wfp. in 2018, for example, 3.7% of survey respondents identified as having a disability [11] . this project aimed to create disability-related questions of value to the purposes of the nsw state psc and contribute to the literature on parsimonious and respectful disability identification for wider application. research was designed around the needs of the nsw psc to inform recommendations on the wording of items in the wfp collection, to better (a) identify people with disability working in the public sector and (b) seek information on workplace modifications needed to promote full and effective participation in the workplace. specifically, the project reviewed the existing questions relevant to disability in the wfp and developed and tested new potential questions about disability (d questions) and the environment (e questions) to inform recommendations for changes to existing questions in the wfp, to improve the response rate to disability-related questions. • improve the quality of data about disability and accessibility in the nsw public sector. compare the nsw public sector workforce with the nsw population (proportion of disability according to australian bureau of statistics data). provide a better evidence base to inform policy interventions. the detailed objectives of the project were to develop and trial disability-related questions and to assess how the questions were received and interpreted by nsw public sector employees, in order to ensure their appropriateness for use and inform change to questions in the wfp collection. the intention was to improve the quality of nsw public sector data on accessibility and disability representation in the wfp, assist in monitoring equity outcomes, and inform policy interventions to build a more inclusive and accessible workplace. the project was undertaken in a partnership involving the nsw psc, university of sydney, and department of family and community services (facs). the advisory sub-group (deac asg) of the disability employment advisory committee (deac) comprises public sector employees with lived experience of disability; nominees were invited to join the project team. the deac itself consisted of disability peak body representatives, as well as experts from academia and the private sector. it advised the nsw government on improving the representation and inclusion of people with disability in the public sector. the deac was invited to comment over the course of the project. four university of sydney researchers, expert in the field, were project advisors. the project was completed in three stages in 2017: (1) mapping and identification of key disability concepts for inclusion in new disability-related questions, (2) focus groups with nsw public sector employees to refine wording of new draft questions, and (3) online surveys to trial two potential new question sets with a wider group of employees. the university of sydney gave ethical approval for the focus groups (no. 2017/132) and the online survey (no. 2017/254)-stages 2 and 3. to identify key concepts for inclusion in disability-related questions, we examined 10 instruments of potential significance and relevance to disability data collection and measurement in the nsw public sector with reference to the international classification of functioning, disability and health (icf) [12] . the method involved mapping key concepts, terms, and measures in each instrument to the icf, enabling comparisons among the instruments by referencing a single framework. this approach is a well-accepted mapping or linking method for instrument examination and comparison in the disability field [13, 14] . the icf is the world standard framework and classification for organising information and data about functioning and disability. it defines the main components of functioning as body functions and structures, and activities and participation. it includes a classification of environmental factors to describe the physical, social, and attitudinal environment in which people live and conduct their lives. environmental factors have a crucial effect (as facilitators or barriers) on people's functioning and on the creation of disability in many life areas, including the workplace. the icf represents a biopsychosocial model of disability, combining both the medical and social models of disability, thus recognising that disability may require both individual support and social, environmental change [15] . the icf enables the collection and comparison of data relating to functioning and disability in many fields and is particularly suited to the present study; it provides a framework to underpin monitoring of implementation of the uncrpd [4, 12, 16] . the world health organisation (who) has called for its wider use to increase worldwide disability data quality and consistency [2, 17, 18] . australian statistical organisations such as the abs and the aihw adhere to such international standards in order to produce data that enables national and international comparisons and to capture consistent administrative data nationally [5, 19] . ten instruments were selected for mapping to the icf, on the basis of their significance to the disability field, their relevance to disability data and measurement, and australian population data that could potentially be compared with nsw public sector data. the selected instruments were the uncrpd [1]; abs survey of disability [20] , ageing and carers (sdac) [21] ; abs short module of disability for social surveys [22] ; household, income and labour dynamics in australia survey (hilda) [23] ; washington group disability questions [24] ; the current wfp questions [9] ; and four other selected instruments, used primarily for research rather than population data collection [25] [26] [27] [28] (supplementary table s1 ): mapping instruments to the icf). two authors carried out the mapping, one doing the initial mapping and the other cross-checking the results. points of difference were discussed and resolved to reach consensus. the key concepts and terms identified in stage 1 were used in different combinations, to draft five d questions (designed to identify employees with disability) and five e questions (designed to identify environmental factors that can facilitate, or act as barriers to, full and effective workplace participation); these questions were tested in focus groups with nsw public sector employees (supplementary s1). the aim was to develop agreement within each focus group on (a) question clarity and user-friendliness, bearing in mind the project aims to improve data quality, comparability, and policy relevance, and (b) the questions and terms preferred by nsw public sector employees. the results guided the design of the questions to be tested in stage 3 online surveys. of the possible focus group approaches, we used the nominal group technique [29, 30] . this technique involved a structured approach to face-to-face discussion, with responses and ideas, as well as different iterations of the d and e questions which were discussed and clarified to develop consensus [31, 32] . a facilitator encouraged all group members to participate and contribute. the nominal group was of a manageable size to enable discussion and agreement among participants. the method and protocol for the focus groups were developed by the university of sydney authors in collaboration with the psc, and in consultation with members of both public sector departments and the deac asg. five focus groups were held over an eight-day period in march-april 2017, in three locations (sydney city, parramatta, and newcastle). an email invitation for focus group volunteers was forwarded by senior office holders and key contacts in the nsw public sector for distribution within their agency cluster (administrative arrangements that bring together different but related nsw public sector agencies), and deac asg members and others with specific responsibility for diversity, including disability. at least three of the authors were present at each focus group. a senior representative of the psc involved in the project introduced the project and facilitators; a psc note-taker was also present, with both psc representatives joining discussions. facilitators were university of sydney project members. each focus group commenced with an attendee orientation to the purpose of the discussion, and "rules" were explained (e.g., mutual respect of opinions, opportunities to speak, confidentiality of the information shared, including any voluntary disclosure of personal circumstances such as disability). facilitated discussions followed, about the draft d and e questions. participants were asked probe questions such as "do you think the question is user friendly? what changes do you think should be made?" the facilitators employed an iterative approach in group discussions using comments and opinions expressed by group participants to identify preferred concepts and those to exclude, then develop majority agreement on the terms and phrases preferred. all participants were encouraged to engage in the discussions. at the end of each focus group, a formal voting process invited participants to indicate anonymously their preference for two d and two e questions by placing an adhesive sticker on print-outs of all questions. the analysis of the feedback from the focus groups involved synthesis of notes from all sessions. links between question preferences and comments about preferred concepts, terms, and phrases were identified and discussed among all authors. two new d questions and two pairs of new e questions were then developed by using the key preferred concepts as the building blocks for questions, e.g., participation, environment, barrier. reviewing focus group suggestions about the wording of questions and excluding or including particular terms and phrases. • using notes from the focus groups to inform the connecting words and phrases for the questions, e.g., "having" or "experiencing" difficulties or disability. the d and e questions drafted after the focus groups were further refined after comment from project advisors from the university of sydney and informal comments from key abs staff. two d and two pairs of e questions to be evaluated in stage 3 online surveys were agreed after final discussion at a full team meeting (psc, facs, university of sydney). in the final stage of the project, the two d questions and two pairs of e questions produced in stage 2 were tested in two online surveys of a wider group of nsw public sector employees (supplementary s2: online survey questions). criteria for judging the suitability of the questions in light of the project aims were developed to guide survey construction and analysis of the results. the relationship between each criterion and the survey-as well as other project elements-is summarised in table 2 . if the recommended d and e questions resulting from the research met all criteria, we would meet project objectives. the survey instrument was constructed over several iterations, involving the whole project team and further consultation with deac asg members. two surveys were prepared to allow for presentation of test questions in a different order, and to avoid preferencing particular responses (supplementary s2). at this stage, the question "do you have a disability?" was added to the online surveys as q11. this addition was in response to a concern expressed by some deac asg members about the wording of the d questions (e.g., an apparent focus on impairment and health conditions, also present in wfp items). online accessibility was checked by a specialist, leading to wording changes. an email invitation to participate in the online survey was forwarded for distribution to the key disability contacts including the deac sub-group members, senior office holders for distribution to diversity employee networks (including disability) in their agency, and to employees more generally. the invitation emphasised the purpose of the project and specifically the online survey. the voluntary and anonymous nature of employee contributions was clarified in the invitation and participant information statement. people who responded that they were interested in participating were then sent one of the two surveys, according to their administrative cluster. a sample size goal of 200, for each questionnaire, was set in order to enable cross-tabulation of responses by broad demographic information. surveys 1 and 2 were sent to respondents according to their cluster; that is, to approximately equal numbers of people based on cluster sizes of public sector agencies. in practice, this approach was modified, given the low responses to survey 2 initially, and respondents after an extended deadline were provided with survey 2. table 2 . project elements to ensure project criteria met. • improved response rate to disability questions (requiring clarity, meaningfulness, and user-friendliness) based on broad categorisations preserving non-identifiability of individuals. clarity-q6 (how easy is question d1 to understand?). meaning-q7 (do words need explanation); and q9 and q10 about preference for examples of life areas and health conditions. user-friendliness-q8 (comfort answering). • improved data quality for disability in nsw public sector (validity in terms of alignment with key current disability concepts). mapping to instruments (stage 1). • ability to compare nsw public sector workforce with nsw population (abs data) (requiring use of similar concepts to those of the abs sdac). mapping to abs data concepts (stage 1), informal consultation with abs (stage 2), and question design (stage 3). • better evidence base to inform policy interventions (requires personal and policy relevance of the questions). mapping (stage 1), focus groups (stage 2), online survey (stage 3). results for the three stages of the project informed each following stage, resulting in one recommended d question and two pairs of recommended e questions for further consideration and development by the psc (box 3). the 10 instruments examined all had some concordance with the icf. accordingly, there was considerable overlap in key concepts and terms included in several instruments, indicating potential to produce comparable data. there was variation in emphasis placed on the three icf components (body functions and structures, activities and participation, and environmental factors), and in the language and terms used to describe and capture data in these areas. the abs sdac was the most comprehensive of all the instruments examined, although it, like several others, was limited in its use of the environmental factors (see supplementary table s1 for further detail of these results). key concepts and terms most often included in the instruments are listed in table 3 , in three general categories broadly corresponding with three major icf concepts. the key concepts identified were used in various combinations to create five d and five e questions for discussion in the focus groups (supplementary s1). a total of 55 nsw public sector employees participated in five focus groups (32 females and 23 males), representing input from 15 agencies. each focus group (9-16 people) ran for 2.5 h. no participant was asked to disclose whether they had lived experience of disability, although a number elected to do so; the group discussions reflected representation of the lived experience whereby participants disclosed at least 15 different disabilities and long-term health conditions amongst attendees. given the aims of the study-namely, how best to elicit information to indicate disability-asking for such information in any form would have introduced circularity into the research. participant preferences on d and e questions, as voted at the end of each session, were tallied across the five groups. the most preferred d question was d4, followed by d3, and then d2; all these questions used key concepts or terms: "participation", "impairments", "long-term health conditions", and "difficulties". the preferred e question was e1, followed by e2, then e5; all these questions used key concepts or terms: "participate", "equal", "environment", and "change". the implications about key words are difficult to interpret without the benefit of detailed comments on question structure, the format of lists used, and other expressions and terms. for example, the favourite d questions did not use the word "environment" and did use "not accommodated", while the e questions (focused on the working environment) were preferred when they included "environment" and "enable" (e1 and e2) rather than "accommodate". focus group members considered each question needed revision, with no d nor e question considered "final". on completion of all focus groups, the project team drafted revisions on the basis of comments and opinions expressed by focus group participants (box 1). the new questions thus developed included two d questions (d1 and d2) and four e questions (en1 and en2 relating to environmental barriers or changes needed now, and ep1 and ep2 relating to environmental facilitators or changes already made). box 1. sample comments made in focus groups. use "work environment" rather than "workplace" as many people move around in their work (teachers, health professionals, transport workers). use a list rather than sentence for environmental factors. refer to "your environment" not "the environments". terms such as "equality", "on an equal basis", or "equal opportunity" may be confused with diversity policies or imply comparisons with peers. mentioning "long-term health condition" is ok if used alongside "impairment". how to answer if you have an impairment but no everyday difficulty (because of management and environment)? "enable" a good word. "participate fully and effectively" discussed at length-and various alternatives offered. the focus groups also began the process of obtaining comments on the draft introduction to the disability-related questions for use in the wfp, their likely effect on people's responses, and the resulting data quality. concerns were expressed about the use of data and its confidentiality, for example, concerns about potential disincentive to complete disability-related questions unless there was re-assurance on the use of data and its confidentiality, particularly regarding potential impacts on employment conditions and outcomes. focus group participants advocated a simple explanation, which would give respondents answers to questions such as why are you asking these questions, what are the data for? • what is in it for me? • what happens to the data (including who has access to it)? these concerns were explored further in stage 3 online surveys to inform implications for the introduction wording, question order, and discussion of the appropriate mechanism for collection. survey responses were received from a total of 533 nsw public sector employees (313 for survey 1, 220 for survey 2) from 41 agencies across 10 public sector clusters (27 agencies for survey 1 and 20 for survey 2, with 6 agencies represented in both surveys). here, we summarise the results for d and e questions referring to survey questions by number (supplementary table s2 ). the percentages presented in this section are the percentages of valid cases, unless stated otherwise. all survey participants answered the questions, except for free text questions, resulting in the percentage of total cases being equal to the percentage of valid cases for most questions. analysis of survey responses to q1-q11 indicated that both d questions (d1 and d2) tested are inclusive indicators of "disability", and lead to the inclusion of more people than the question "do you have a disability?" (q11): • a higher percentage of people responded to d1 (26.2%) and d2 (30.5%) in a way that indicated disability than those who answered "yes" to q11 (16.6% for survey 1 and 26.8% for survey 2) ( tables 4 and 5, supplementary table s2 ). while disability in the nsw public sector, as reported on the basis of d1 and d2, was significantly more common than the current 3% reported in the wfp, no comparison can be made; people responding voluntarily to the online surveys are unlikely to be a random sample of nsw public sector employees.) the interpretation of disability in d1 and d2 is in line with the icf world standard and the key concepts identified in the mapping exercise ( table 3 ). the results point to greater comfort answering d questions and their applicability to people who may not identify with disability, for example people with difficulties related to long-term health conditions (see data in supplementary table s2) , and comments in box 2). • both d1 and d2 "picked up" approximately 85% of people explicitly stating that they have a disability in response to q11 (44 of 52 for d1, and 50 of 59 for d2) (tables 4 and 5 ). significantly, d1 and d2, while showing a strong relationship with q11, "captured" more people who were dealing with potential difficulties in their daily lives via technologies and other strategies. of those who were not "picked up" by d1 (i.e., answered "no difficulty"), only 3.5% (8 in 231) stated later that they have a disability (in response to q11) (for d2, only 5.9% (9 in 153)) ( tables 4 and 5 ). i would answer yes to d1 and no to d2 because i have mobility issues due to arthritis but don't consider i have a disability. but am impaired somewhat with mobility. i technically have a disability (chronic pain and fatigue, mental health conditions) but have not disclosed this in past job applications. the questions being phrased in the more open way they are above would encourage me to respond more accurately. of the two d questions, it was concluded that d1 should serve as the basis for a final recommended d question for consideration and development by the nsw psc. descriptive statistics illustrated that ( table 6, supplementary table s2 ): overall, d1 was considered slightly easier to understand than d2; 93% of respondents reported that d1 was "easy" to understand, compared to 91% for d2 (q6); 12.5% felt that d1 had words that needed explanation, compared to 15.5% for d2 (q7). • survey respondents were comparatively more "comfortable" answering d1 (in response to q8)-there was little difference in survey 1 responses; difference was more marked in survey 2, with 63% in favour of d1 and 37% in favour of d2. the examples provided in d1 were appreciated by respondents to both surveys (q9, q10). examples of everyday life areas were considered helpful by 68% of respondents to survey 1 and 69% to survey 2. examples of long-term health conditions and impairments were considered helpful by 65% of respondents to survey 1 and 60% to survey 2. the text comments offered throughout the survey help explain the statistics from the online surveys. these comments generally supported the conclusions of the statistical analysis, namely, to develop d1 into a recommended d question: • "impairment" was mentioned as a word needing explanation (21 people mentioned it in response to q7, the most mentions of key words). there were few negative comments on impairment (two negative comments in response to q7 made by people reporting disability in terms of d1 or q11); the focus group discussions and the great majority of responses to the online survey did not flag any concern. impairment is a term widely used in the disability field, including in the uncrpd and icf. use of only "long-term health condition" in its place was not supported by focus group comments, which indicated a preference for using both terms; the examples of "conditions and impairments" listed in d1 (favoured by survey respondents) do contain impairments. use of impairment categories (physical, mental, intellectual, sensory) from d2 was not recommended; a number of text comments from the survey sought explanation of the bracketed words. the use of the word "disability" in the questions appears to exclude some people from responding, e.g., those with functioning difficulties arising from long term health conditions; this is the balance of evidence from the online survey statistics, text responses, and focus group results. "disability" would perhaps better be used in the introduction to the question. the word "participation" was well received by participants in focus groups and in the online survey; it was not included in d1 in the survey but should be in further development of d1. both privacy and use of the data appeared significant concerns in text responses to the introduction and requests for "any other comments", reinforcing focus group views. people reported lacking knowledge of and confidence in how data are used. on the basis of analysis of survey responses to q13-q21, we concluded that, of the four e questions (en1 and en2 relating to environmental barriers to functioning or changes needed now, and ep1 and ep2 relating to environmental facilitators of functioning or changes already made), en1 and ep1 should serve as the basis for two final recommended e questions for consideration and further development by the psc (table 7, supplementary table s3 ): • the great majority of survey respondents (95% or more) found all four e questions "very easy", "easy", or "somewhat easy" to understand (in response to q14 and q18). a correspondingly high proportion said no further words needed explanation (e.g., 93% for en1 and 89% for en2 (q15)). a higher proportion of respondents indicated that words needed explanation in en2 (11.4%) and ep2 (10.3%) compared to en1 (7.1%) and ep1 (6.0%) (in response to q15 and q20) (supplementary table s3 ). respondents demonstrated no difficulty in responding across all five areas of the icf environmental factors, and in differentiating present needs and needs met. the questions have the capacity to yield interesting information (supplementary table s3 ). there was greater comfort answering en1 than en2 (in response to q16)-59% of people in survey 1 were more comfortable answering en1; preferences were evenly split in survey 2, with 51% preferring en1 and 49% preferring en2. the word "improvement" (in en1) appeared to be favoured over "adjustment" (in en2). similarly, ep1 was preferred to ep2 (in response to q21). a higher percentage of people indicated that "improvements" are needed in all five aspects of the environment in response to en1 compared with those who indicated that "adjustments" are needed in response to en2 (q13). correspondingly, a lower percentage of people indicated "no improvement needed" (40.6%) in response to en1 compared with those who indicated "no adjustment needed" (56.4%) in response to en2. a similar but less marked pattern was seen for ep1 and ep2 (q.18)-57% in survey 1 reported no past improvements, and 65% in survey 2 reported no past adjustments. the results could reflect a difference between the samples, or that en1 and ep1 are open to wider interpretation. the relatively small number of text comments about e questions (24 in each survey) generally supported the conclusion of the statistical analysis-namely, to develop en1 and ep1 into two recommended e questions, with attention to suggestions for improvement. free text comments from survey respondents, with feedback from focus groups, provided guidance for amending the questions, and could also be used to improve layout: • generally, people preferred simpler wording, without jargon and need for further explanation. comments (in response to q15 and q20) reinforced preferences for the term "improvement" rather than "adjustment", which was frequently mentioned as a word needing explanation. other problematic terms reported include "human-made", "enable", and "colleagues". there was a suggestion from survey 1 to simplify "what aspects of your work environment" to "at work" ... "enable you to participate fully and effectively". • from survey 2, suggestions included the need for further explanation or alternative terms such as "adjustments", "en2 asks me what help i need", "en1 feels like it is seeking a criticism about my workplace", "en2 reads like we all need adjustments, and 'what adjustments have you and your employer made' may be more positive". overall, the free text responses about both the d and e questions, briefly illustrated in this paper, provided rich material for question redevelopment. with the aim of improving the wfp questions and data, the research developed a new set of questions (box 3) related to disability and accessibility, comprising one d question to identify disability, and two e questions about environmental modifications. the e questions enable data to be captured on improvements already made, as well as improvements that need to be made in the future. the mapping stage of the project ensured that the new questions correspond conceptually with the uncrpd, the icf as the world statistical standard, and abs data. the new questions performed well against the objectives of the project: • the new questions bring into scope more people than the question "do you have a disability?"-for example, people with long-term health conditions who may not identify with disability, as well as people using technologies and other strategies to manage difficulties in their daily life. comparable to nsw population data: the new questions use key concepts used in other data collection instruments (as well as key policy instruments), thus promoting comparability with the nsw population and labour force data. • clarity and meaning: the new questions were preferred to the alternatives as they were considered easier to understand. • comfort in answering: the new questions were preferred to the alternatives as more employees were comfortable answering them. following all three stages of the research, including analysis of statistical and text results of the online survey, which informed further refinement of the questions, box 3 sets out the recommended d and e questions. the inclusion of "participation" should be tested in any further refinement of the d question; while d1 was the preferred question, it did not include this popular word. box 3 illustrates how it could be included. there was strong support for lists of examples: of health conditions and impairments that may interact with the environment to create the experience of disability, as well as for areas of the environment involved in this interaction. example lists used were based (respectively) on the list used by the abs in the sdac and the environmental factors classification of the icf; the environmental lists and examples were seen as easy to understand and to require little explanation. further analysis of text responses to the online survey and of notes taken during focus group discussions could lead to even further refinement of words and examples in d, along with further plain english editing. further discussions could be undertaken with agencies with interest in disability data, including the australian human rights commission. further testing of the questions in another english-speaking country with similar national data, or use of the process described here to develop relevant national questions, may provide useful insights and comparisons in similar work-related contexts. the strong association between the new disability questions, about difficulties participating in everyday life, and the question "do you have a disability?" (q11), is interesting and perhaps reassuring. nevertheless, some analysis suggests areas of future research. notably, d1 and d2, while showing strong relationships with q11, "captured" more people who were dealing with potential difficulties in their daily life using technologies and other strategies. this finding reflects views expressed in the focus groups that the existing d question in the wfp (similar to q11) may lead to self-exclusion. for example, as illustrated by the focus group and survey comments, people with difficulties related to long term health conditions or people whose difficulties are mitigated by technology or environmental facilitators may have varying views of disability and may not identify or declare they have a disability. the apparently greater inclusivity of the new questions resonates with results from related research in a vastly different setting. disability identification in refugee situations, for the purposes of offering services and determining and meeting needs, was found to be best done using "functionality-based questions in line with international standards" along with staff training to enable "greater sensitivity to the many different ways in which disability can manifest" ( [33] , p. 60). communication at various points will be an essential part of improving data. communication may have various purposes and messages-communication about system changes; reminders about the need for updating data, the value of the data, and of participation in providing it; explanation of the importance and purpose of the questions; and accurate assurances about privacy and confidentiality; and • use various avenues-announcements, publications, presentations, and routine communication, e.g., in forms and databases including through explanation of and introduction to the questions. a communication strategy could be devised on the basis of the findings of this project and decisions made about implementation in order to support the chosen paths forward on data collections relating to disability in the nsw public sector. further high-level consideration by the psc about the purpose and use of the disability (d) and environment (e) questions is essential in order to establish the basic "why, who, when" purposes and processes. there was strong comment in both the focus groups and online survey, revealing distrust among nsw public sector employees concerning the purpose of the d question in particular and about data confidentiality. the most appropriate data collection vehicle to gather information on disability and accessibility requires consideration. some australian government jurisdictions collect their disability data through hr systems and others through sample employee surveys (anonymous and confidential), possibly similar to other countries. there are advantages and disadvantages to both methods (supplementary table s4 ). the pmes is anonymised and online, and not linked to hr systems. the psc has control of the questions and is the sole data custodian. however, because the recommended questions are long (relative to others in that survey), so as to reflect the complexity of disability, there are advantages to using them in a context where this complexity can be explored. therefore, the wfp collection, which draws information from hr systems, may remain the better approach, as it allows the accumulation of more in-depth data over time; the wfp collection was the focus intended at the start of this research. the questions could be asked during hr processes and stored in hr systems; if so, the purpose needs to be clear and assurances about use and privacy provided and demonstrated. while the purposes may include monitoring disability employment rates, locating the data with hr creates the capacity to cross-tabulate disability data with other relevant hr data (e.g., with position/level, age, and gender) and statistically monitor change over time. trust and comfort in reporting may also be influenced by the inclusiveness of the workplace, where employees feel "safe" to share their personal information. both elements-technical and cultural-are important in developing a better picture of workplace inclusion of people with disability-having appropriate survey questions, ethical data storage and use practices, and an environment where employees feel their information is respected and acted on constructively. the links between the d and e questions also need to be decided. it has been assumed that the d question comes first and acts as a filter to direct people to the e questions. an alternative could be to use the e question as the first question, and then ask for explanation of why environmental change is needed, even perhaps using all "diversity" questions as possible reasons. this approach has not yet been tested and has policy implications. in favour of this re-ordering is the finding that the e questions did not elicit the types of free-text comments made about the d questions. it was clearer why e questions were being asked and what actions might be taken on the basis of answers. however, there remains a question about timing; for example, people may find it hard to comment soon after recruitment on what environmental improvements they need. the results of this project thus raise wider questions of data collection strategy. one option is to re-think the use of two questions, on disability and environment, as part of an overall strategy to improve understanding of disability and changes needed in the workforce environment. the questions could be used to monitor changes in the environment as well as in the representation of people with disability in the workforce. the oecd noted, in contrasting disability policy reform with the lack of improvement in employment rates, "disability system reform is a huge task, for several reasons" (p. 93 [7] ). many months after completion of this research, the discussion about next steps is still in play. the research has been used to inform enhancements to the pmes and shared with other jurisdictions. inevitably, key senior staff at the psc have moved on during this period (including johnston and glasgow) with the resultant need for handover communication. in addition, the nsw government announced the jobs for people with disability plan, which has resulted in a significant reprioritisation of work to advance disability inclusion across the nsw public sector workforce. improving the accuracy and reliability of data remains a key focus area. inclusion of a clear definition of disability was drafted using this research and is to be implemented into the wfp to provide more clarity of what is included. while it is understood that the wfp remains the most appropriate vehicle for the collection of detailed data public sector-wide, implementing change to the wfp is nevertheless a significant challenge-it affects administrations across the nsw public sector (with the nsw government being the largest public sector employer in australasia). the strategic timing of such a change is made more complex by the impact on public administration in 2019-2020 of a long-term drought, severe bushfires, and now the covid-19 virus. in the public sector, creating a succinct identifier for disability in administrative systems is a key challenge for public policy design and monitoring. this requires concise methods of identifying people with disability within systems, producing data comparable with population data to gauge accessibility and equity. this paper focussed on efforts to improve data in the service of evidence-based policy. the project described here formed part of a broader program of work to improve interventions that build inclusive work environments and enable people with disability to have positive work experiences in and contribute to the nsw public sector. we aimed to create disability-related questions of value to the purposes of an australian state and contribute to literature on parsimonious and respectful disability identification for wider application. both these aims were achieved. recommendations for new disability-related questions and possible new data collection and related communication processes are under active consideration by the leading state authority, as are the additional factors identified during the collaborative research relating to the design of and communications about administrative data collections. more broadly, this research contributes methodology and findings relevant not only in the australian public sector, but in other countries with good quality national population data with which administrative data can be compared. question d1: in your everyday life, do you experience difficulty (participating), related to a long-term health condition or impairment work, education or training (including paid or voluntary work) mobility (e.g., walking, moving around, handling or lifting objects, using public transport) home life (e.g., shopping, cooking, caring for others) daily organisation (e.g., undertaking multiple tasks, making decisions, handling stress) communication (e.g., speaking or using communication devices) learning (e.g., basic learning, or applying knowledge in solving problems or making decisions) please select one of the following: • yes, i sometimes or always experience difficulty in at least one area, even when i use equipment, technology, assistance, or other techniques. • no, but i use equipment, technology, assistance note: long-term health condition or impairment may refer to the following: loss of sight or hearing shortness of breath or difficulty breathing ongoing or repeated pain or discomfort blackouts, seizures, or loss of consciousness head injury, stroke, or other acquired brain injury or any other long-term conditions. question en1: do aspects of your work environment need to be improved to enable you to participate fully and effectively at work? attitudes (e.g., attitudes or behaviour of colleagues, supervisors, or clients) flexible work options, transport, employment policy, training, or workplace and hiring policies) natural environment and human-made changes to environment (e.g., noise, light, air, or water) no improvements needed. ep1 similar to en1 but referring to the past i.e., what has been done: have aspects of your work environment been improved to enable you to participate fully and effectively at work? references 1. united nations (un) measuring disability with parsimony monitoring the united nations convention on the rights of persons with disabilities: data and the international classification of functioning, disability and health the icf as a framework for national data: the introduction of icf into australian data dictionaries australian institute of health and welfare (aihw) sickness, disability and work: breaking the barriers: a synthesis of findings across oecd countries steering committee for the review of government service provision (scrgsp) public service commission (psc) disabling the barriers-key findings public service commission (psc) international classification of functioning, disability and health (icf) icf linking rules: an update based on lessons learned refinements of the icf linking rules to strengthen their potential for establishing comparability of health information the international classification of functioning, disability and health: a new tool for understanding disability and health the icf has made a difference to functioning and disability measurement and statistics how to use the icf: a practical manual executive board (2014) who global disability action plan 2014-2021: better health for all people with disability design and quality of icf-compatible data items for national disability support services information paper: abs sources of disability information australia survey of disability, ageing and carers (sdac) 2015, household survey questionnaire and prompt cards short set of disability questions the prevalence of person-perceived participation restriction in community-dwelling older development and validation of impact-s, an icf-based questionnaire to measure activities and participation the participation scale: measuring a key concept in public health development and initial psychometric evaluation of the participation measure for post-acute care (pm-pac) the focus group as a tool for health research: issues in design and analysis the methodology of focus groups: the importance of interaction between research participants. sociol. health illn nominal group technique. a method of decision-making by committee consensus methods for medical and health services research to promote, protect and ensure: overcoming obstacles to the identification of disability in forced migration the research reported here resulted from a collaborative project involving a "project team" from the university of sydney: rosamond madden am, qingsheng zhou, sue lukersmith; the "full team" comprising the project team and also members of the nsw public service commission (psc), department of family and community services, and the disability employment advisory committee advisory subgroup. university of sydney advisers to the project team were gwynnyth llewellyn, richard madden, nick glozier, and xingyan wen. we thank all the nsw public sector employees who voluntarily participated in and greatly contributed to the research, and gratefully acknowledge the contributions of psc members adam bove, paige neave, helen evans, nicola rossini, and jane spring. this paper does not necessarily reflect the views of the nsw public service commission, the nsw department of family and community services, or the university of sydney. the authors declare no conflict of interest. this project was a collaboration as outlined in the materials and methods section. as such, the research design and context required involvement of psc representatives, other public sector departments and employees, and people with lived experience. involvement and various contributions of the collaborators is detailed in the materials and methods section. two representatives and employees of the psc (m.g. and s.j.) were involved in the conduct of the research, the writing of the manuscript, and in the decision to publish the results. key: cord-299521-igo40dbs authors: sweida, gloria; sherman, cynthia l. title: does happiness launch more businesses? affect, gender, and entrepreneurial intention date: 2020-09-21 journal: int j environ res public health doi: 10.3390/ijerph17186908 sha: doc_id: 299521 cord_uid: igo40dbs in one of the first studies to examine how positive affect, negative affect, gender, and gender roles interact with entrepreneurial intention, we conducted an online survey of 849 adults from the western, midwestern, and southern regions of the united states. a higher positive affect was associated with greater intention to start a business, however, lower levels of negative affect were not. as in previous studies, women showed less entrepreneurial intention than men, however, the presence of positive affect had a larger positive impact on women’s entrepreneurial intention than men’s. contrary to expectations, acceptance of traditional gender roles interacted with entrepreneurial intention such that women’s entrepreneurial intention increased as their support of traditional gender roles increased, and for men, entrepreneurial intention decreased slightly as acceptance of traditional gender roles increased. as we explore the myriad of ways that affect, emotion, and mood drive human behavior, particularly in the workplace [1, 2] , we also find ways by which they drive entrepreneurial behavior. many research teams have investigated the role played by the broad construct of affect in entrepreneurship. while many studies conflate the states of emotion and mood with trait-level affect, some researchers have argued that an individual's frequent experience of positive emotions and positive moods is not meaningfully distinguishable from dispositional or trait-level affect [2] [3] [4] . in their study, watson et al. [4] asked respondents to estimate their mood states across both short and long time frames, and because of the strong relationship between trait-level affect and emotional experiences based on shorter time frames, we feel confident in drawing upon the literature that includes measures of emotion, mood and affect, which we will include under the general term "affect". baron [5] considered the role of affect in decision-making, opportunity identification, and coping with adversity, all of which are important aspects of the entrepreneurial process. cardon et al. [6] considered positive affect a key component of entrepreneurial passion, which is connected to persistence and creative problem solving, and therefore positive outcomes for nascent ventures. further, other research teams have found that entrepreneurs report high work and life satisfaction [7] [8] [9] . affect may also play a role in successive entrepreneurial endeavors because of the connection to entrepreneurial passion and persistence [6, 10] . stenholm and nielsen's [10] study looked at how entrepreneurial passion was created from emotional support. they found that emotional support helped to create positive emotions that helped entrepreneurs to engage with their environment, changing their perceptions of the environment, ideas, and persons more favorably, as described by fredrickson's broaden and build theory [11] . human behavior is guided by emotion, mood, and more broadly by affect [1, 2] . affect, emotion, and mood are often conflated; however, affect refers to a more general state of consciously accessible feelings [2, 17] . in contrast, emotions are defined as a response to a stimulus, unfolding over a relatively short time [2, 11] . moods are defined as somewhat stable background sensations that are not associated with a particular stimulus [2, 17] . affect, more generally, can be considered the accumulation of the experience of positive or negative moods and emotions. the creators of the widely used positive and negative affect scale (panas), watson and colleagues [4] , created the panas as a two-factor construct, therefore, one can have positive and negative emotions at the same time. they also determined that emotions and moods are indeed generally reflective of one's dispositional-level affect. as such, even though both positive and negative affect can be conceived as both a state and trait, in this study, we study trait/dispositional-level affect. [2, 3] . affect is a form of information that influences cognitive processes such as perception, judgment, decision, memory, creativity, and coping with stress [5] . schwarz and clore's [18] affect as information theory suggests that positive or negative affect act as categories for organizing experiences and making similar material easier to retrieve. several researchers have utilized this theory [5, 19, 20] to posit that affect impacts cognition by priming memories and associations, and by serving as a heuristic for classifying and responding to objects, ideas, and people. positive affect includes emotions such as joy, hope, and inspiration [21] . positive affect facilitates approach behavior and prompts people to engage with their environment. engaging with one's environment tends to facilitate the acquisition of resources in the external world [11] . the resources accrued during states of positive emotions outlast the transient emotional states that led to their acquisition. the positive emotions can lead to the urge to explore the environment, take in new information, and expand the self [22, 23] . from an entrepreneurial perspective, for instance, this could lead to creative ideation or a playful investigation that might lead to a new product or business. therefore, the often-incidental effect of experiencing a positive emotion has the impact of leading to an increase in one's resources [11] which can positively impact one's overall personal, psychological, professional, and physical well-being. positive affect also helps build social capital and psychological well-being, which leads to personal growth, meaningful goals, and self-acceptance [24] . additionally, those with more positive affect experience more positive outcomes in work, health, and relationships [11, 25, 26] . this may be because positive affect serves as a conduit for the integration of new ideas into current knowledge. the new knowledge can inspire innovative and creative thinking about goal attainment. positive affect broadens thinking and enhances resilience and the ability to cope with challenging situations [11, 27] . positive emotions, over time, may loosen the hold that negative emotion has on one's reactions to events, such as the flee response to something fearful. positive affect can broaden a person's momentary thought-action repertoire to include ideas of play or exploration. positive affect also yields better health outcomes, as the frequent experience of positive emotions yields a faster recovery time from cardiovascular stress, lessening damage to the body over time [11] . positive affect influences several key entrepreneurial processes. trope and colleagues [28] found that positive affect positively impacted general decision making. george and zhou [29] revealed a relationship between positive affect and entrepreneurial creativity and ideation. positive affect also positively predicts opportunity recognition [30, 31] . positive affect influences outcomes for business, as well. baron and tang [32] found that higher degrees of positive affect predicted sales growth and innovation. they also found that the benefits of positive affect influenced smaller entrepreneurial ventures more than larger ventures. cardon and colleagues' model of entrepreneurial passion emphasizes the role of high-activation positive affective states such as joy, energy, excitement, and enthusiasm. these states lead to key performance outcomes for the health of the nascent organization. furthermore, an entrepreneur's energy leads to persistence in the face of adversity [6] . the entrepreneur's absorption in the activities of venture creation results in higher quality products and services. the entrepreneur's ability to solve problems also creatively helps the organization carve its niche in the marketplace. the mechanism behind these outcomes can be explained through broaden and build theory [11] . building on affect-as-resource theory and affect-as-information theory [18, 33] broaden and build theory suggests that positive affect broadens thought-action repertoires and acts as a resource that helps one persist and learn from negative information [19] . entrepreneurship entails risk and reward and is fraught with dangers and uncertainty. however, positive affect is not the only source of information for entrepreneurs; negative affect may also play a role. brundin and gustafsson [34] found that entrepreneurs' likelihood to persist in a failing project increased with increased positive emotion (hope, self-confidence, and challenge in their study) and decreased with stronger feelings of embarrassment, frustration, and strain. negative affect includes emotions such as anger, fear, shame, and nervousness [4] . negative emotions exist independently of positive emotions and can, therefore, be experienced at the same time as positive emotions [35] . affect-as-information theory suggests that negative affect informs a person that things are not going well [19] . negative information represents a potential threat to survival, as it is attended to and processed more thoroughly than positive emotions [36] . even though entrepreneurs experience fewer negative emotions than those who work for wages [9] , successful management of negative emotions is a key factor in successful entrepreneurship [37] . because entrepreneurs have more decisional autonomy than people who are employed by others, they can use more problem-focused coping mechanisms to overcome adversity [7] . overall, a mix of positive and negative emotions may be optimal for entrepreneurship. mixed and conflicting emotions are an important predictor of risk perception, which helps people avoid the common trap of overconfidence [38] . baron [5] found that an excess of positive affect yielded diminishing returns, with a medium amount of positivity being optimal. while positive affect enhanced leaders' abilities to recognize entrepreneurial opportunities, too much positive and negative affect both lowered their likelihood of acting on those opportunities [13] . birthed by bird's [39] conception, eints shape the form, direction, and development of an organization. it links the entrepreneurs' ideas and attitudes to their entrepreneurial behavior. thompson [40] added that while conviction and planning are essential to eint, actual venture creation is not. this is because entrepreneurial activities are rare and difficult to measure. for example, what constitutes "planning"? is it the spark that ignites the thought or feeling that starting a business would be desirable or does a formal business plan need to be in place? even though business start-up may not be the inevitable outcome, eint is a strong predictor of behaviors [41] and is measured as a continuous versus dichotomous variable. this explains its use not only as a proxy for entrepreneurial behavior but also, as thompson [40] suggests, as a construct that can stand on its own and be used as an independent and control variable. the theory of planned behavior (tpb) [41] is one of the most cited unidirectional models of intention. according to tpb, three factors, social norms, attitudes and perceived control, work in concert to influence the intention to act. social norms refer to the perceived acceptance or aversion toward a specific behavior of those the target deems important in their immediate social environment. attitudes are the target's judgments and evaluations of the behavior. lastly, perceived control is consistent with self-efficacy, the belief in one's capability to perform specific tasks. using the tpb framework to describe conscious intent, we define eint as the desire and plan to start a business. affect-as-information theory [18] suggests that affect attunes people to the safety of conditions in their environment. positive affect tells people all is well and they can relax, while negative affect leads people to search their environment for threats. therefore, positive affect may tend to make people approach new situations more confidently, making them more likely to move forward with starting a business. this leads us to the hypothesis: hypothesis 1a (h1a): higher positive affect is correlated with higher eint. further, negative affect may heighten people's estimation of threats to successful entrepreneurship, making would-be entrepreneurs less willing to trust their vision, and therefore less likely to create new ventures. therefore, we propose that: hypothesis 1b (h1b): higher negative affect is correlated with lower eint. an extant amount of research highlights interest in investigating the role of gender in entrepreneurial processes [42] [43] [44] [45] [46] . even though research has resulted in some mixed findings [45, 47] when comparing women and men's eint, copious research indicates that women report lower eint compared to men [15, 16, 43, 47] . the main reasons cited for differences between men and women's eint are (1) perceptions that the characteristics necessary for successful entrepreneurship are stereotypically male, (2) lack of training for women, (3) unfavorable economic and social environments for women, (4) lack of education for women, and (5) a lack of entrepreneurial self-efficacy among women [48, 49] . regardless of why this occurs, we have no reason to expect this study to be inconsistent with the abundance of past studies supporting a lower reported eint of women compared to men. however, a better understanding of influential factors on eint is an important step to closing the gap. hypothesis 2a (h2a): women will report lower eint than men. social constructivist theories suggest that social norms and roles regulate emotions by signaling appropriate and valued responses [50] . social roles held by men and women heighten sex differences in emotions and social behavior between men and women [51] . as suggested by eagly and wood [52] , men and women are likely to possess sex-differentiated skills, beliefs, and subjective experiences that enhance the enactment of sex-typed social roles [52] . for example, women are socialized at an early age to be nurturing and develop verbal skills whereas men are encouraged to be aggressive and develop math skills. these socialization norms are reinforced through parents, media, and peers [53] [54] [55] [56] [57] [58] . consistent with social role predictions, women experience and display emotions congruent with expectations of their gender. women report experiencing pleasant stimuli such as happiness more intensely than do men [59] [60] [61] . additionally, women also suppress negative emotions and display positive emotions more than men [62] . alexander and wood's [59] review of research highlights that women report more intense positive emotions than men, they more frequently express such emotions to others, and they respond more extremely to certain psychophysiological measures. thus, if women experience positive emotions more intensely, suppress negative emotions, and display positive emotions more than men, we suggest that they will confer the benefits of an approach mindset and process opportunities more readily than men. the benefits of positive affect, such as broadening one's mind to possibilities, may open them to the idea of starting a business more easily than men. therefore, we expect positive affect to enhance eint. however, we expect this relationship to be greater for women than men because women's socialization and past gender-role-related experiences are likely to instill subjective positive emotions and ways to respond to emotions that are congruent with their gender. hypothesis 2b (h2b): positive affect will moderate the relationship between gender and eint, such that it will be more influential on women's eint than men's. role congruity theory suggests that entrepreneurship would be challenging for women because the role of the entrepreneur is male-typed [43, 63] and contrary to that of the stereotypical female gender role, whereas the male stereotype of entrepreneurship would confer a benefit for men. numerous gender stereotypes surround women and are based on perceptions of what women's roles are: from women's views on education [64] to having nurturing personalities [65] , which construct the way women approach career-related decisions. examples of traditional gender roles would be that males are breadwinners and leaders of the family, whereas women are the homemakers and caretakers of the family. consequently, acceptance of traditional gender roles may provide a boost for entrepreneurial men but a hindrance for women. therefore, we hypothesize the following: hypothesis 3 (h3): acceptance of traditional gender roles moderates the relationship between gender and eint such that stronger acceptance of traditional gender roles increases men's eint and decreases women's eint. the data used for this paper were part of a larger study that utilized an internet-based survey and examined multiple constructs including eint, acceptance of traditional gender roles, career choice, entrepreneurial industry interest, positive and negative affect, marketing strategies, and kidpreneur activities. the present study explored positive and negative affect, eint, gender, and acceptance of traditional gender roles. the following is the full set of procedures used to administer the survey in the original study. a convenience sampling method was used to recruit participants for the original study in 2019. recruitment efforts included posts on social media such as facebook and linkedin, referrals from friends, family, associates, as well as undergraduate and graduate students from four colleges in the midwest, south, and western parts of the united states. all students (n = 504) were offered a maximum of 2% extra-credit to take the survey. upon completion of data collection, the sample consisted of n = 928 subjects. cases were examined for missing data and 76 cases were removed because of missing responses. the sample was narrowed to those responding as male or female, as only three participants identified as bigender. this left a usable sample size of n = 849 cases. the ethnic diversity of the sample was homogeneous in that most participants (69.2%) identified as caucasian. the ages of the participants ranged from 18 to 79 years with a mean of 26.2 years (sd = 10.86). only about a quarter of the participants had earned an undergraduate or graduate degree (22.6%), 39% had completed some college, and about 21% had earned an associate's degree. lastly, 446 participants had attempted to start at least one business or made at least one attempt to earn money in a self-employed way as an adult (m = 2.34, sd = 1.74, ra = 1-10 or greater). dispositional affect was measured using the 10-item international positive and negative affect scale (i-panas-sf; thompson, 2007) , an international shortened version of the panas [3] . the stem question, "thinking about yourself and how you normally feel, to what extent do you generally feel:" was followed by five items for the positive affect scale and five items for the negative affect scale. eint was measured using thompson's 10-item eint measure [40] , which has three items reverse-coded and four filler items and was assessed on a five-point likert scale (1 = does not describe me; 5 = describes me extremely well). two sample items include: i intend to set up a company in the future, and i never search for business startup opportunities. the cronbach alpha was 0.82 for this measure. brown and gladstone's [66] short version of the gender role beliefs scale was used to assess the strength of participants' acceptance of traditional gender role ideology. this measure has ten items. one of the ten items is reverse-coded. the measure used a one (strongly disagree) to 7 (strongly agree) likert scale. examples of items from this measure include: (1) women should be concerned with their duties of childbearing and house tending, rather than with the desires for professional and business careers, and (2) swearing and obscenity are more repulsive in the speech of a woman than a man. cronbach alpha for this measure reached 0.75. the analysis (see table 1 ) showed several significant correlations among the independent, dependent, and two demographic variables. positive and negative affect were negatively correlated with each other, r = −0.19, p < 0.01. eint had a significant and positive correlation with positive affect r = 0.28, p < 0.01. and a significant negative correlation with negative affect r = −0.10, p < 0.01. this suggests that both higher levels of positive affect and lower levels of negative affect are associated with greater intention to start a business. of note in the demographic variables, the number of business started was significantly and positively correlated with age (r = 0.11, p < 0.01), education (r = 0.09, p < 0.05), and eint (r = 0.22, p < 0.01). in all the following analyses, the number of businesses started as an adult was the only control variable. this was done because age, education, the number of businesses started were correlated and because research shows prior business ownership to be predictive of eint [67, 68] . as shown in [69] , centering variables to mitigate potential threats of multicollinearity in unnecessary. however, we have done this to alleviate concerns. furthermore, as can be seen in table 1 , the correlations between variables are fairly small. therefore, the threat of multicollinearity is mild at best. hypothesis 1a stated that positive affect would lead to higher levels of eint and hypothesis 1b stated that negative affect would lead to lower levels of eint. hierarchical linear regression was conducted to test these hypotheses. eint was entered as the dependent variable, positive and negative affect were entered as the independent variables, and the number of businesses was the control variable. the overall model was significant f(3824) = 36.69, p < 0.001. as can be seen in table 2 , the model explained twelve percent of the variance in eint, r 2 = 0.12, p < 0.001. positive affect was a significant predictor of eint, unstandardized b = 0.34, se b = 0.05, t(827) = 7.54, p < 0.001. however, negative affect did not predict eint (p > 0.05). therefore, we found support for hypothesis 1a but not for hypothesis 1b. hypothesis 2a stated that women will report lower eint than men and hypothesis 2b argued that positive affect will moderate the relationship between gender and eint, such that it will be more influential on women's eint than men's. ordinary least squares regression was used to test these hypotheses by employing hayes process macro-regression analysis (model 1). a 5000-bootstrap sample was conducted to test this hypothesis [70] . gender was coded zero for male and one for female. controlling for the number of businesses, eint was entered as the dependent variable and gender as the independent variable and positive affect as the moderator. the overall model was significant f(5, 822) = 32.31, p < 0.001, and explained sixteen percent of the variance r2 = 0.16 (see table 3 ). examination of the unstandardized coefficients revealed a significant main effect for the number of businesses started, b = 0.10, se b = 0.02, t(827) = 5.51, p < 0.001. this result suggests that for each additional attempt at business ownership, eint is predicted to rise 0.10 (one-tenth) of a unit. there was also a significant main effect for gender, b = −0.42, se b = 0.07, t(827) = −6.48, p < 0.001. lastly, the interaction was also significant b = 0.17, se b = 0.09, t(827) = 1.94, p < 0.001. based on the negative coefficients, the mean scores for eint by gender (male mean = 2.79, sd = 0.95; female mean = 2.35, sd = 1.01) and the regression slopes which show a steeper slope for women than men, shown in figure 2 , show that women report lower levels eint and that positive affect positively influences this relationship. therefore, hypothesis 2a and hypothesis 2b were supported. hypothesis 3 stated that stronger acceptance of traditional gender norms would moderate the relationship between gender and eint, such that, as acceptance of traditional gender roles increases, men's eint also increases, and women's eint decreases. ordinary least squares regression was used to test these hypotheses by employing hayes process macro-regression analysis (model 1). a 5000-bootstrap sample was conducted to test this hypothesis [70] . gender was coded zero for male and one for female. controlling for the number of businesses participants started as adults, eint was entered as the dependent variable, gender as the independent variable, and acceptance of gender roles as the moderator. as can be seen in table 4 , the overall model was significant f(4826) = 21.96, p < 0.001 and explained 10 percent of the variance in eint, r 2 = 0.10, p < 0.001. examination of the unstandardized coefficients revealed that there was a significant main effect for gender b = −0.40, se b = 0.07, t(830) = −5.70, p < 0.001 and acceptance of gender roles b = 0.07, se b = 0.03, t(830) = 1.99, p < 0.05. this result suggests that for each additional step in acceptance of traditional gender roles eint is predicted to rise 0.07 (one-seventh) of a unit. a significant interaction was found between acceptance of traditional gender roles and gender, b = 0.15, se b = 0.07, t(830) = 2.21, p = 0.017. the interaction explained an additional five percent of variance (p = 0.03). however, the interaction was in the opposite direction (see figure 3 ) than hypothesized. for men, eint decreased slightly as acceptance of traditional gender roles increased. the slope was steeper for women and was also in the opposite direction, as predicted. women's eint increased as their support for traditional gender roles increased. therefore, hypothesis 3 was not supported. 0.10 *** note: business started as adult response range 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 +; stgr = support for traditional gender roles. * p < 0.05, ** p < 0.01, *** p < 0.001. this study adds to the research about entrepreneurial affect by relating positive and negative affect to eint. this approach considers positive and negative affect to be relatively independent dimensions [35] . our results extend the few other studies examining affect and eint, by demonstrating that higher positive affect is associated with higher eint and that positive affect influences women's eint more than men's. positive affect fuels resilience, which helps entrepreneurs to persevere in deciding if a problem is worth solving, and then solving it [71] . the ability to persevere and decide where to spend your personal and financial resources is a critical factor in entrepreneurial success. using the broaden and build theory, the development of emotional and interpersonal relationships is consistent with long-term success in entrepreneurship. congruent with affect-as-information theory, positive affect can act as a resource for perseverance through adversity, which is critical to entrepreneurial success. however, our results did not show that higher levels of negative affect were related to lower eint. the relationship of negative affect to eint has not been well studied in previous work. when positing on the relationship, we thought that a higher negative affect may deter potential entrepreneurial motivation. however, in this study, higher negative affect was not related to lower eint. the correlational analysis revealed a statistically small and negative relationship between the two constructs, however, enough variance was consumed by prior business experience during the regression analysis, for it to become not significant. opportunities to engage in entrepreneurship may counteract the effects of negative affect, by providing mastery experiences. mastery experiences allow people to learn and improve and thereby increase confidence [72] and motivation. in this way, negative affect may support systematic thinking that enables more focused attention on problem solving and opportunity recognition [73] [74] [75] . as negative affect is an inevitable part of the journey of entrepreneurship, successfully coping with negative emotions is an important part of the successful entrepreneurship trajectory [7] . our result showing that women's eint is lower than men's eint is consistent with previous work [15, 16, 43, 47] . however, our novel finding that positive affect has more impact on the eint of women than of men suggests that women can confer a benefit from stereotyping. women are socialized to display more positive affect, therefore experiencing positive affect allows them more congruency with their gender role, making the road to entrepreneurship smoother. as for the surprising result regarding the non-relationship between acceptance of gender roles and eint, we recognize three possible explanations. first, women may report the belief that traditional gender roles should exist [76] yet consider entrepreneurship from a feminized perspective. for example, entrepreneurship can be used to supplement the household income. based on the larger dataset from which these data were drawn [77] , it was found that women tended to report the desire to start businesses in more feminized industries that are amenable to income replacement versus wealth generation. second, a shift in entrepreneurship may allow for easier entry and the ability for women to start a business and maintain a more traditional female gender-role. technology has democratized internet access, which enables entrepreneurs to tap into a larger audience of potential buyers than ever before and has made the location of the business almost irrelevant. both factors allow women more flexibility to work around family duties. perhaps this shift is changing entrepreneurship from a rarefied pursuit, only for the well-financed and well-connected, to one enabling women to connect with entrepreneurship in a way that is more congruent with stereotypical female gender roles. third, meta-analysis shows that gender roles and stereotypes are changing around perceptions of women's roles [78] . as such, staying at home to take care of the family and home as women's only responsibility may be fading from the female stereotype. additionally, it may be that stereotypes about women in entrepreneurship are changing [43] , or at least being cognitively neutralized [79] . the women in gupta and colleagues' study [79] showed that women, unlike their male counterparts, perceive entrepreneurs to have male and female characteristics. imbuing the idea of entrepreneurship with female characteristics may allow women to reconcile cognitive dissonance between their gender-role and the entrepreneurial role. these results are relevant for leadership and entrepreneurial training programs, especially those aimed at women. building positive emotions over time can lead to more positive affect [2, 3] . focusing on providing positive experiences and producing higher positive affect within programs can help women increase their self-efficacy and increase the chances for successful entrepreneurship, thereby, increasing benefits to society such as job creation, new markets, and innovation. for example, an examination of emotion in leadership training sessions for entrepreneurs [80] revealed that when entrepreneur participants spoke of their companies, they used language that was more emotive than rational, particularly if they were speaking about their fear of failure. part of the emotional salience sprang from the fact that the entrepreneurs' identity was entwined with their business. in the second day of training, the entrepreneurs engaged in difficult and potentially frustrating activities. during the debrief, the participants realized that they were being manipulated in order to understand their emotions and that, framed appropriately, the experienced emotions became an impactful and remembered part of the training [80] . early entrepreneurial training which teaches the core tenets of business ownership (e.g., market research, strategy, or finance) can include stories of and learning from other successful women who are small business owners, entrepreneurs, or serial entrepreneurs. some research shows that the development of women's entrepreneurial self-efficacy can be contextual to size of business, industry of the business, and the level of female representation within an industry [81] . understanding the lessons learned from successful launches by other women entrepreneurs will encourage positive affect through hope and inspiration. the increase in positive affect will increase self-efficacy via vicarious learning and social persuasion [11, 72] . furthermore, positive affect can lead to more openness to new ideas, in turn building resources to use in future problem-solving. women entrepreneurs can use those resources in new and creative ways to implement feasible solutions and in opportunity recognition or venture creation [11, 73] . building positive affect during training is the start of what can flourish into positive outcomes for the would-be business, such as sales growth and innovation. this is an important factor because many women tend to migrate to industries with little growth that are not attractive candidates for financing [82] . negative affect is not a barrier to future action, but rather information about challenges that need solving. focusing attention on negative affect in training can include role-playing of difficult emotional conversations and discussions of venture failure [7] . in this way, would-be entrepreneurs are not blind-sided by the intensity of feelings that they may experience in creating their business. in sum, opportunities to broaden thought repertoire can lead women to consider new ideas and ways of doing business and help dispel the myths about women entrepreneurs [83] , such as not having the financial savvy or resources to start high-growth businesses, or that women do not have the right kinds of experiences. the main strength of this research is that we add to the literature examining positive and negative affect, eint, and gender which, to our knowledge, have never been studied simultaneously. another strength can also be considered a limitation: the utilization of a homogeneous sample. our sample was predominately students from state universities and professional adults across the united states. according to a study from the ewing marion kauffman foundation, most entrepreneurs find that a college education is important [84] and most entrepreneurs have studied in college, even if they have not received a degree. therefore, our sample may be representative of would-be entrepreneurs. when researchers are limited to convenience samples, homogeneous samples convenience samples are a positive alternative because they can generalize to a subpopulation [69] . however, this strength is, of course, also a limitation, as we discuss. a convenience sampling procedure was used to recruit participants and a large portion of the sample were students from state universities and professional adults across the united states. as with all samples of convenience, the benefits of ease of access to participants and relatively low cost for researchers on a shoe-string budget must be weighed against the disadvantages of lack of generalizability to the population as a whole, under-or over-representation of the population, and biased results based on participants' willingness to take part in the research. as stated earlier, entrepreneurs consider education important and have engaged in some higher education [84] . therefore, the sample for this study is reasonably generalizable to an american college-educated population and would-be entrepreneurs but not to the population as a whole. another limitation of the study, as with survey studies, is the potential for common methods bias. common methods bias has been defined as "response tendencies that raters apply across measures, similarities in item structure or wording that induce similar response, the proximity of items in an instrument and similarities in the medium, timing, or location" ( [85] , p. 476). since positive and negative affect and eint data were collected at the same time in this study, temporal separation was not available between the measurement of positive and negative affect and eint variables. future research can provide more granularity on why women are less likely than men to engage in entrepreneurial activities. a longitudinal study to better assess eint and positive and negative affect over time could help disambiguate how affect, emotion, and mood impact eint. the current economic environment in response to covid-19 shows women's unemployment to be 10.5%, while men are at 9.4% [67] . although many men are stepping up to increased responsibilities in the 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trade and economic aspects of food security: evidence from 45 developing countries date: 2020-08-10 journal: int j environ res public health doi: 10.3390/ijerph17165775 sha: doc_id: 268716 cord_uid: lbxmteyn the stability of food supply chains is crucial to the food security of people around the world. since the beginning of 2020, this stability has been undergoing one of the most vigorous pressure tests ever due to the covid-19 outbreak. from a mere health issue, the pandemic has turned into an economic threat to food security globally in the forms of lockdowns, economic decline, food trade restrictions, and rising food inflation. it is safe to assume that the novel health crisis has badly struck the least developed and developing economies, where people are particularly vulnerable to hunger and malnutrition. however, due to the recency of the covid-19 problem, the impacts of macroeconomic fluctuations on food insecurity have remained scantily explored. in this study, the authors attempted to bridge this gap by revealing interactions between the food security status of people and the dynamics of covid-19 cases, food trade, food inflation, and currency volatilities. the study was performed in the cases of 45 developing economies distributed to three groups by the level of income. the consecutive application of the autoregressive distributed lag method, yamamoto’s causality test, and variance decomposition analysis allowed the authors to find the food insecurity effects of covid-19 to be more perceptible in upper-middle-income economies than in the least developed countries. in the latter, food security risks attributed to the emergence of the health crisis were mainly related to economic access to adequate food supply (food inflation), whereas in higher-income developing economies, availability-sided food security risks (food trade restrictions and currency depreciation) were more prevalent. the approach presented in this paper contributes to the establishment of a methodology framework that may equip decision-makers with up-to-date estimations of health crisis effects on economic parameters of food availability and access to staples in food-insecure communities. over the decades, food insecurity concerns have been emerging, along with the growth of the world population. among the united nations sustainable development goals [1] to be achieved by 2030, ending hunger and establishing food security hold an important place. however, despite the best efforts of the international community to combat food insecurity across the globe, the number of undernourished people has resumed growth in 2015, after a steady decline during the 1990-2000s. the food and agriculture organization (fao) reports that over 820 million people in the world suffer from hunger, while about two billion people experience moderate or severe food insecurity [2] . in view of the fact that an additional 60 million people have become affected by hunger since 2014, the number of undernourished people is projected to exceed 840 million by 2030 [3] . in the past, the main reasons for food shortages used to be droughts and other natural disasters. with the emergence of globalization, food security has become an economic rather than an agricultural issue. being a combination of the physical availability of food and economic access to adequate supply [4] , food security at the national these countries are net importers of food and agricultural products. according to the fao [2] , out of 65 developing economies and ldcs where recent adverse impacts of the economic downturn due to the covid-19 pandemic on food security have been strongest, 52 countries rely heavily on agricultural imports. in a situation of disrupting food supply, dependence on imports tremendously threatens the food security of those nations, especially when export restrictions are imposed by the world's leading suppliers like russia, vietnam, and ukraine. as the spread of covid-19 and strict quarantine measures trigger economic decline, even developed economies experience food price rises unless the governments take preventive actions or retailers absorb some of the costs. since february 2020, the global average price for rice has increased by 7.1%, for meat of cattle-by 7.0%, for meat of chicken-by 5.5%, for potatoes-by 8.3% [23] . due to a limited capacity to produce staple crops domestically, developing economies are more vulnerable to food inflation and supply shortages. in just the first three months of 2020 at the very onset of the covid-19 outbreak, over fifteen developing countries already experienced an increase in the cost of a basket of food staples (over 10%) [24] . at many markets, food prices have been increasing because of local logistical problems [16] . there is also a dependence of developing countries with their limited resources on a small range of food products exported to a few markets [25] , many of which have been affected by the covid-19 outbreak [15] . in one of the trade scenarios simulated by vos et al. [5] , a 1% global economic slowdown due to the pandemic could cause a decline in developing-country agri-food exports by almost 25%. there is an array of studies that address trade aspects of food supply [26] [27] [28] [29] [30] , but the majority of them focus on food self-sufficiency rather than food security. according to the fao [31] , a self-sufficient country satisfies its needs in food by means of domestic production. although some developing countries of africa (mali and senegal) and latin america (bolivia, ecuador, and venezuela) have embraced the idea of food self-sufficiency in their national policies [32] , progressing liberalization of food trade over the past few decades has refocused attention from self-sufficiency, a concept that is often related to protectionism and even autarky [33] , to food security. the latter incorporates a wider range of parameters of food availability, economic access to adequate nutrition, utilization of nutrients, and stability of food supply [4] . while wegren and elvestad [34] , meskhia [35] , clapp [36] , and saidi and diouri [37] , among others, argue that food security is about establishing a balance between domestic production and imports, many studies categorize food security as agricultural [38, 39] , economic [40, 41] , or health [42] [43] [44] issues rather than as a trade one. however, at the height of the covid-19 crisis, both larger demand gaps and higher food price surges suggest that international trade policies play a more pervasive role in ensuring food security at the national level than previously thought. against the backdrop of the health crisis, an increase in the number of undernourished people is coupled with a global economic slowdown [2] -a trilemma that has not been adequately explored in previous studies. lockdowns, export restrictions, and quarantine measures exacerbate these problems and call for the investigation of trade and economic impacts on food security in a new reality of food chain disruptions. so far, empirical assessments of the pandemic's effects on food and agriculture sectors have been grouped around international organizations, such as fao (food and agriculture organization of the united nations), who (world health organization), wfp (world food programme), unctad (united nations commission on trade and development), and ifpri (international food policy research institute). in a collective study compiled by the unctad's committee for the coordination of statistical activities [45] , three dozen organizations and institutions identified the pandemic's primary channels of transmission to food and agriculture sectors, and quantified the potential impacts of covid-19 outbreak on agricultural input markets, food trade, and food consumption. since the report covered a wide range of topics, it thus was not particularly focused on the analysis of trade-related aspects of food security. in the regional section of the report, the economic and trade impacts of covid-19 on food security were not detailed for developing economies and ldcs. in the ifpri study that particularly focused on developing countries, vos et al. [5] applied a general equilibrium model to assess possible impacts of the pandemic on prices, income, and poverty. the impacts of productivity declines on prices of some food products were forecasted, as well as on income of households, but the parameters of food availability and access to food and agricultural products were not addressed. similarly, trade impacts on food supply chains have remained scantily explored across the array of studies on covid-19 that have emerged in 2020. most of these recent papers have particularly emphasized the aspects of food safety [46] , agriculture productivity [47, 48] , and healthy nutrition [49] , rather than of food imports and trade balance as dimensions of food availability. the impacts of both international exchange fluctuations and food inflation on the access pillar of food security have also remained under investigated. the link between price increase and access to food has been primarily considered in terms of supply disruptions and shortages along the retail food supply chain [50, 51] , not currency exchange rates. to the best of the authors' knowledge, there are no comprehensive studies that link the incidence rates of covid-19 with either the number of undernourished people or the degree of dependency on food imports. in this study, the authors attempt to bridge the said gaps in the "covid-19-trade-food security" agenda by (1) identifying interactions between the number of covid-19 cases on one side and availability and access pillars of food security on the other; (2) assessing the cointegration between the pandemic-induced trade parameters of food availability and the number of undernourished people; (3) revealing the impacts of food inflation and currency exchange volatilities amid the global health crisis on economic access to food in domestic markets; and (4) detailing the analysis of above-mentioned health, food security, trade, and economic parameters across an array of developing economies and ldcs. the approach employed in this study is to assess the relationships between the food security parameter, on one side, and health and macroeconomic variables that affect availability and access pillars of food security, on the other. the number of people with insufficient food consumption (y) was used as a dependent variable (table 1) . it is defined by the world food programme (wfp) [52] as a total number of individuals with a poor or borderline level of food consumption. poor food consumption refers to households that are "not consuming staples and vegetables every day and never or very seldom consume protein-rich food such as meat and dairy" [52] . households in borderline food consumption status are those "consuming staples and vegetables every day, accompanied by oil and pulses a few times a week" [52] . the value of exports of food and agricultural products less imports of food and agricultural production. month-on-month percentage change in the price of a standard basket of food as calculated from the national consumer price index. the number of confirmed covid-19 cases (x 1 ) was utilized to show the overall effect of the pandemic on food security. the selection of x (2) (3) (4) variables is based on the wfp's hunger map patterns. balance of food trade (x 2 ) reflected the dependency of a country on food imports and thus demonstrated the changes in the food supply. food inflation (x 3 ) and currency exchange (x 4 ) were used to reveal the influence of changes in access to food and agricultural products on food security. the choice well correlates with the recommendations of huseynov [53] , who used exchange rate, inflation rate, and food trade as variables to identify short-term and long-term effects on food security. the period of analysis included six months from january 2020 (when first covid-19 cases were confirmed outside china) till the end of june 2020 (when many countries gradually lowered health alert levels). the data were obtained from the wfp's hunger map portal [52] , trading economics [54] , and the united nations conference on trade and development (unctad) [45, 55] . among developing economies, the wfp [52] reports 93 countries that experience the prevalence of undernourishment (pou), a percentage of people in the total population that are in the condition in which an individual's habitual food consumption is insufficient to provide the amount of dietary energy required to maintain a normal, active, healthy life. the study proceeded with 45 economies where the pou was the highest as of 30 june 2020 (table 2) . to reveal diverse effects on food security across a variety of macroeconomic environments, the selected countries were distributed into three groups. group 1 included low-income economies defined by the world bank [56] as those with a gross national income (gni) per capita of $1025 or less. group 2 comprised lower-middle-income economies with a gni per capita between $1026 and $3995. in group 3, we included countries with the upper-middle level of gni per capita between $3996 and $12,375. note: * portion in the total population of countries included in the group; ** change in percentage points; "+" parameter increment; "-" parameter decrement. source: authors' development based on wfp's hunger map portal [52] . to capture potential divergences in both economic and geographical specificities of food security, we selected the countries from six regions of africa, asia, latin america, and the middle east ( figure 1 ). the classification by income group is based on the world bank atlas method [57] , while that by geographic region-on the world bank country classification [56] . to capture potential divergences in both economic and geographical specificities of food security, we selected the countries from six regions of africa, asia, latin america, and the middle east ( figure 1 ). the classification by income group is based on the world bank atlas method [57] , while that by geographic region-on the world bank country classification [56] . the following hypotheses were established to reflect supposed variations in y-x(1-4) interactions depending on the level of income: the covid-19 pandemic has hurt the entire international community ranging from the least developed countries of africa to the wealthiest economies of europe and america [16, 58] . therefore, we hypothesize that: in low-income economies, food shortages and other disruptions of food availability are commonly considered to be the major factors of food insecurity [59] [60] [61] [62] [63] . additionally, due to the world's highest portion of disposable income spent on food in low-income countries [64] [65] [66] [67] , even a slight deterioration in the economic access to staple foods harms the food security status of the households. as the spread of the covid-19 and lockdown measures trigger economic decline, we suggest that: hypothesis 2. in group 1 countries, the strongest influence over y is exerted by food availability and food access parameters, x2 and x3, respectively. the following hypotheses were established to reflect supposed variations in y-x (1-4) interactions depending on the level of income: the covid-19 pandemic has hurt the entire international community ranging from the least developed countries of africa to the wealthiest economies of europe and america [16, 58] . therefore, we hypothesize that: hypothesis 1. x 1 exert a direct strong effect on y across groups 1-3 countries without regard to income level. in low-income economies, food shortages and other disruptions of food availability are commonly considered to be the major factors of food insecurity [59] [60] [61] [62] [63] . additionally, due to the world's highest portion of disposable income spent on food in low-income countries [64] [65] [66] [67] , even a slight deterioration in the economic access to staple foods harms the food security status of the households. as the spread of the covid-19 and lockdown measures trigger economic decline, we suggest that: hypothesis 2. in group 1 countries, the strongest influence over y is exerted by food availability and food access parameters, x 2 and x 3 , respectively. with a rise in income level, a portion of imported food in consumption increases due to importing higher-quality and pricier products [68] [69] [70] , whereas the fluctuations in world prices and import volumes exert stronger effects on the food security status of the households compared to those of domestic supply. in a situation when global food supply chains are disrupted by currency exchange volatilities and trade restrictions amid the covid-19 pandemic, we assume that: hypothesis 3. in group 3 countries, the effects of x 4 and x 2 on y are the highest among the economies included in the study, while that of x 3 is the lowest. across the array of six variables, the four-stage analysis was conducted individually for each of the forty-five countries ( table 3) . at stage 1, a stationary test was conducted to check whether a co-integration existed between the selected variables. to illustrate short and long-run interactions between the variables, the autoregressive distributed lag (ardl) method was employed at stage 2. then, we applied yamamoto's causality test to reveal the causality directions of the variables. finally, by utilizing the variance decomposition approach, we attempted to predict the future relative strengths of causalities between the variables. table 3 . study flow algorithm. stationary test by augmented dickey-fuller (adf) and phillips-perron (pp) methods. as certainty of cointegration between y and x (1-4) . autoregressive distributed lag (ardl), fully modified ordinary least squares (fmols) and dynamic ordinary least squares (dols). identification of short and long-run interactions between the variables individually in forty-five countries, generalization of the results across three groups of economies by income and seven groups by region. prior to the identification of the relationships between the variables, it is important to understand if the data is stationary [71, 72] . the system behaves correctly in the case where static and dynamic properties of the variables remain unchanged and values of the system state belong to an acceptable interval [73] . a variety of approaches have been developed to check the stationarity and to investigate further the cointegrating interactions between stationary variables. concerning macroeconomic parameters, the most commonly used techniques are the adf test by dickey and fuller [74] and the pp test by phillips and perron [75] . they were used by herwartz and reimer [76] to reveal the relationship between interest rates and inflation across developing economies, by chang et al. [71, 77] to investigate stationarity of gdp per capita in the oecd countries, by ranjbar et al. [78] and su et al. [79] to study income convergences in developing and least developed countries of africa, and by hoarau [80] to test the purchasing power parities for real exchange rates in central america. in combination with the adf and the pp tests, aliyev et al. [81] , humbatova et al. [82] , and naseem et al. [83] , among others, used the kpss (kwiatkowski-phillips-schmidt-shin) unit root method to enhance the robustness of the stationary test results. the kpss test has been widely used in macroeconomics and international finance (for instance, by kuo and mikkola [84] , gunduz [85] , and tsen [86] ) to check long-run and functional time series for stationarity [87, 88] . in short-run time series similar to those used in our study, the employment of the kpss test might be misleading due to the invariance of the technique to seasonal dummies [89] and the duality of the level stationary and time trend stationary models used in the test [90] . to ensure the correct interpretation of data in the short-run, we abandoned the kpss method and utilized the adf and the pp techniques to check the cointegration between y and x (1-4) . after the stationarity of the variables is confirmed, the interactions between the variables may be verified. to identify the relationships between the variables within the two established multitudes, we employed the autoregressive distributed lag (ardl) method elaborated by pesaran et al. [91] (equation (1)). although the use of this technique in food security studies has been very rare, many scholars have employed the method to identify both short-and long-run relationships between various macroeconomic parameters in developing countries. for instance, öztürk and özdil [92] used ardl to investigate the interplays between economic growth and unemployment in the oecd countries, elian et al. [93] tested the relationship between foreign direct investment inflows and economic growth across the brics countries, and appiah et al. [94] studied growth determinants in emerging economies. to the best of the authors' knowledge, we have not been able to track previous applications of the ardl method in studying availability or access-related parameters of food security. however, there are abundant examples of an effective utilization of the ardl in revealing the interplays between domestic supply and imports [53, 95] , trade balances [53, 96, 97] , inflation [98, 99] , international currency exchange [100, 101] , and health [102] . where ∆ = first difference operator; δ 0 = constant term; δ 1 , δ 2 , δ 3 , δ 4 , and δ 5 = short-run elasticities of the variables; i = ardl model lag order; ect t−1 = error correction term; ε t = error disturbance; t = time. if f-statistics is larger than the upper critical bounds value [i(1)], the series are cointegrated. if it is below the lower critical bounds [i(0)], the variables are not cointegrated. as robustness tests for the ardl, we utilized fully-modified ordinary least squares (fmols) and dynamic ordinary least squares (dols). according to phillips and hansen [103] , testing the ardl results by fmols allows one to correct the system for endogeneity and serial correlation effects. it is a non-parametric method to identify a correlation between the components of model error terms [104] . the approach was used by narayan and narayan [105] , abu [106] , and adebayo [97] to test the interactions between various macroeconomic variables, including trade volume, inflation, and currency depreciation. the rationale of using fmols in our study is that it allows receiving consistent parameters even in the small samples in the short-run. additionally, it helps to overcome the problems of endogeneity and serial correlation and thus allows for the heterogeneity in the parameters [107, 108] . dols has been commonly utilized in combination with fmols as a computationally convenient alternative to fmols estimators. according to stock and watson [109] , dols is employed to estimate the equilibria that is corrected for potential simultaneity bias among explanatory variables. similar to fmols, dols is applicable to small samples in the short term [110] . its estimators obtained from least-squares estimates are unbiased and asymptotically efficient even in the presence of the endogenous problem [111] . echoing the successful application of both fmols and dols in testing the robustness of the ardl results by yuzbashkandi and sadi [104] , pasha and ramzan [112] , priyankara [107] , and adebayo [97] we consider these two methods as efficient estimators to study serial interactions and examine potential correlations between y and x (1-4) . some scholars, for instance, aliyev et al. [81] , guan et al. [113] , yue et al. [114] , and rahman et al. [115] , further checked fmols and dols results by employing the canonical cointegration regression (ccr). the method is commonly implemented to remove the long-run dependencies between the cointegrating equation and stochastic regressors, which does not apply to small samples in the short-run used in our study. the utilization of the ardl method allows us to identify the interaction between the variables, but not the direction of causalities. to capture these directions, we employed a causality test elaborated by toda and yamamoto [116] . this technique has been extensively used by many scholars, including pantamee et al. [117] , adebayo [97] , and bilgehan [118] , to estimate causal relationships between domestic market parameters and exogenous factors across developing countries worldwide. among the drawbacks of the ty causality test is the inability to predict the relative strength of causalities between the variables beyond the period under study. sankaran et al. [119] , rana and sharma [120, 121] , and wang and ngene [122] suggested to overcome this problem by using the wald or modified wald (mwald) tests, but hayashi et al. [123] and lemonte [124] demonstrated that, in small samples when used empirically to search for unimportant parameters, the wald test procedure could be misleading. in furtherance of zhang et al. [125] , mao et al. [126] , adebayo [97] , and chan et al. [127] , we used variance decomposition instead of the wald test to explore the strengths of inter-variables causal interactions and to reveal potential causality impacts. the method was applied for nine consecutive periods from july 2020 till march 2021. the results of the adf and the pp tests across three groups of countries (see supplementary materials to this paper, tables s1-s3) demonstrate that all five variables are stationary at a level of either i(0) or i(1). in all cases, the calculated f-statistics values exceed the upper bound (table 4 ). it means that the precondition for co-integration between y and x (1-4) is established in all countries included in the study. the stationarity of the data series along with the revealed co-integration between the variables both confirm the appropriateness of the established data set for the ardl analysis. since the study includes six periods (months), it is mainly centered on explaining the short-run relationship between the number of people with insufficient food consumption and independent variables. the ardl short-run estimates for the three groups of countries are summarized in table 5 , the detailed per-country calculations are provided in supplementary materials (tables s4-s6 ). in group 1 countries, the strongest effect on the growth of y is caused by an increase in food inflation x 3 . this effect is statistically significant across the group. some variables also exert strong direct influence on y, for instance, x 2 in sierra leone and yemen and x 4 in haiti and niger. when other factors remain constant, an increase in the number of registered covid-19 cases by 1% results in the growth of y by 0.14% in tajikistan and by 0.05% in mozambique and sierra leone. in niger, a 0.18% increase in the number of people with insufficient food consumption is caused by a 5% rise in x 1 (0.16% in guinea, 0.14% in tanzania, and 0.03% in afghanistan). in group 2 countries, we see kaleidoscopic linkages between y and x 1 . in pakistan and india, the countries of south asia which have been severely hit by the pandemic, an increase in covid-19 cases by 1% results in the growth of the number of people with insufficient food consumption by 0.56% and 0.53%, respectively. in east asia, on the contrary, we see that the food security status of the households improves when the number of registered covid-19 cases goes up (when other variables remain constant). in cambodia and vietnam, where the growth of ∆x 1 in january-june 2020 was more moderate compared to some of their neighbors in south asia, we see a negative x 1 -to-y relationship. the lower portion of imports in the balance of food trade has a positive and statistically significant impact on the number of people with insufficient food consumption in cameroon, kenya, tunisia, and india, whereas, in cambodia, the relationship between x 2 and y is negative. the effects of x 3 and x 4 on y are positive in all countries, except cambodia, but not that significant compared to x 1 and x 2 . while the increase in the number of confirmed covid-19 cases is found to have a significant positive effect on y in the countries of latin america and the caribbean, in the case of many other group 3 countries, there is a negative relationship between these variables (botswana, namibia, libya, jordan, and iran). the strongest impact of x 1 on y is revealed for peru and ecuador, where an increase in covid-19 cases by 1% is associated with the growth of the number of people with insufficient food consumption by 0.54% and 0.40%, respectively. statistically strong interplays are reveled between y and x 2 in algeria, botswana, and colombia, between y and x 3 in sri lanka and turkey, and between y and x 4 in ecuador and namibia. the negative influence of x 2 on y is identified to be statistically significant in sri lanka and iran, of x 3 on y-in algeria, dominican republic, iran, and iraq, of x 4 on y-in sri lanka. error correction measure is statistically significant in the case of all three groups of countries. the results of the fully-modified ordinary least squares (fmols) and dynamic ordinary least squares (dols) tests are employed to check the robustness of the ardl estimates (table 6 for a group-based summary, tables s7-s9 for country-specific data). the number of registered covid-19 cases is confirmed to result in higher food insecurity across three types of economies included in the study, except some countries of sub-saharan africa (burkina faso, chad, ethiopia, zambia, botswana, and namibia), middle east and north africa (yemen, iran, jordan, and libya), and east asia and pacific (cambodia and vietnam). among these twelve countries, for which we see a reverse relationship between covid-19 cases and the number of people with insufficient food consumption, there are representatives of various income groups. reasoning from this fact, we can assume that in a particular country, the direction of the y-x 1 link does not depend on gni per capita. however, when the relationship between these two parameters is positive, there is evidence of a stronger y-x 1 correlation in group 3 countries compared to that in group 1 low-income economies. the toda-yamamoto test demonstrates the most significant causality flowing from the number of covid-19 cases to the number of people with insufficient food consumption in group 3 countries of latin america (colombia, ecuador, and peru) and europe (turkey), whereas, in low-income economies, the x 1 →y causality is weaker (table 7 , tables s10-s12). similarly to bidirectional interactions between covid-19 cases and food insecurity across all groups of countries, both the fmols and dols tests confirm divergent relationships between the number of people with insufficient food consumption and the balance of food trade. in group 2 and group 3, y-x 2 relations are positive (except for cambodia, iran, and sri lanka), while in group 1, they are negative for almost half of the countries. in sub-saharan africa (burkina faso, chad, mali, niger, and tanzania), an increase in the balance of food trade is identified to be effective at reducing the number of people with insufficient food consumption. from the estimation of the toda-yamamoto causality test (table 7) , we see the unidirectional x 2 →y causality in group 1 countries, but the significance of the link is low. the strongest influence of food access on food security is revealed in low-income economies of sub-saharan africa (burkina faso, ethiopia, guinea, mali, mozambique, and sierra leone), as well as some countries of central asia (tajikistan) and middle east (yemen). in some group 3 countries, robustness tests show a negative relationship between x 3 and y when the number of people with insufficient food consumption goes up amid food deflation. we also see examples of such reversal links in upper-middle-income countries of the middle east (iran and iraq), where food prices are to a large extent under government control. confronting hypothesis 3, in lower-middle-income economies of southeast asia (cambodia, india, indonesia, pakistan), seasonal retreat in food prices does not immediately result in higher food security expectations among people. in these countries, the x 3 →y causality link is weak due to the high portion of locally produced seasonal food in consumption. among group 2 economies, more significant causality flowing from food inflation to food insecurity is revealed for the countries of sub-saharan africa (cote d'ivoire, nigeria, zambia, kenya), where diversity of locally-produced staples is narrower compared to asia. when a portion of marketed food in supply is higher, a deterioration in economic access to marketed products imposes a more significant impact on the aggravation of food insecurity. it is assumed that in the countries where a large portion of the food supply is ensured by imports, food inflation might correlate with currency exchange. however, we see that in low-income economies, where food access strongly correlates with food inflation, the number of people with insufficient food consumption is marginally affected by currency exchange fluctuations. the weaker link between y and x 4 across group 1 stems from the fact that low-income economies import a considerably lower amount of high-quality and expensive food products compared to lower-middle and upper-middle-income countries. as contrasted with low-income countries, group 3 economies are deeper integrated into global supply chains of value-added food products. from this perspective, amid the covid-19 pandemic, the most significant causal relationships between volatilities in currency exchange and food supply are found in the countries with the highest gni per capita among those included in the study-turkey, colombia, and peru. with the current dynamics of registered covid-19 cases across three groups of countries, the extrapolation of the short-run ardl estimates to the future forecasts a gradual increase in the proportion of food insecurity variance explained by the effects of the pandemic. variance decomposition of y-x (1-4) interactions (table 8 , tables s13-s15) indicates a diversity of potential causality impacts of covid-19 cases, balance of food trade, food inflation, and currency exchange on the number of people with insufficient food consumption. for group 1 countries, the decomposition analysis suggests a rather stable and weak y-x 1 linkage over a three-quarters horizon (table s13) . only in nepal, yemen, and mali, the food security situation could be significantly predicted by the variations of x 1 . but even in these countries, we see that the expected proportions of x 4 and x 3 in y nearly equal that of x 1 in size. for most of the low-income economies, variance decomposition projects an increase in the proportion of y explained by food inflation (14.84% in ethiopia, 13.70% in chad, 11.12% in the democratic republic of the congo) and currency exchange (9.01% in burkina faso, 7.72% in mali, 6.65% in niger). in lower-middle-income economies, the number of people with insufficient food consumption seems to be increasingly affected by food availability. by march 2021, in import-dependent kenya and kyrgyzstan, the proportion of y explained by the balance in food trade is forecasted to exceed 10% (table s14 ). the weight of food access in establishing food security will grow in the countries of east asia (15.98% and 15.27% of y explained by x 3 in vietnam and cambodia, respectively) and sub-saharan africa (12.44% in cote d'ivoire and 11.60% in zambia). the projected causality between y and x 1 is the strongest in the countries of south asia. in india, at the current rate of registered covid-19 cases, almost 14.50% of the proportion of insufficient food consumption will be impacted by the pandemic. it is the highest expected impact of the pandemic on food security among forty-five countries included in the study. in bangladesh, the strength of the y-x 1 linkage will exceed 12.00% by the second quarter of 2021. across sub-saharan africa and east asia, a relatively low number of registered covid-19 cases allows one to predict the moderate role of x 1 in the explanation of y variations over a nine-month horizon. among upper-middle-income countries, the impact of the pandemic on the number of people with insufficient food consumption is not expected to vary significantly from region to region. the proportion of y explained by x 1 is expected to peak in the countries, where the number of covid-19 cases per capita in january-june 2020 was the highest among group 3 economies. over the entire time horizon considered in this study, the growth in x 1 will most likely and consistently be converted into a higher percentage of the population in food insecurity status in peru, iran, and turkey (table s15) . variance decomposition also projects significant contributions of x 1 to y in colombia (8.93%), algeria (8.35%), and ecuador (6.91%). the revealed interplays between the variables across three groups of countries allowed us to test the hypotheses: hypothesis 1: not confirmed. the x 1 -y relationship is uneven across group 1-3 countries, where the strength of causal interaction between the two variables increases with the growth of income level. the effect of the covid-19 outbreak on the number of people with insufficient food consumption is observed across the three groups of countries. this finding supports the expectations of the fao [3, 16] , the wfp [14] , and the wto [15] , as well as the projections of many scholars [5, 10, 50] , who say that the spread of covid-19 may bring damage to global food security, particularly painful in the least developed and developing economies. according to our results, the number of registered covid-19 cases is indeed associated with higher food insecurity in many countries included in the study. the y-x 1 linkage is statistically significant in the countries (primarily, middle-income economies) where the number of registered covid-19 cases per capita is high (pakistan, india, peru, ecuador, turkey). across low-income economies; however, the impact of covid-19 on food insecurity is much weaker compared to that in upper-middle-income countries. this result well agrees with the fao's estimation that higher-income countries are more likely to face food supply disruptions during the novel health crisis, given their deeper integration in global supply chains and capital-intensive agricultural systems [45] . in 2019, the wfp [14] reported yemen, the democratic republic of congo, afghanistan, venezuela, ethiopia, south sudan, syria, sudan, nigeria, and haiti to constitute the worst food crises. confronting the established hypothesis 1, we see that in most of these countries, the relationship between the number of people with insufficient food consumption and the number of covid-19 cases is not strong but moderate. for example, in afghanistan, where at least 35% of the population is in a state of food crisis [14] , the increase in the number of covid-19 cases by 5% results in the growth in food insecurity by only 0.03%. moreover, we see that in several low-income countries, the dynamics of covid-19 cases is related to y in a negative way. in some countries, where the number of covid-19 cases remained low during january-june 2020, there is a reversal y-x 1 relationship. in haiti, an increase in the number of covid-19 cases by 1% is associated with the improvement in the food security status of the population by 0.11% (by 0.03% in nepal and by 0.02% in chad). such a relationship can be explained by a statistically insignificant correlation between x 1 and y due to the low number of confirmed covid-19 cases per capita. still, the effects of the pandemic on food security in low-income countries should not be underestimated. even without considering the direct health-related influences of the spreading covid-19 virus, the fao projects low-income economies of africa to overtake both lower-middle-income and upper-middle-income countries of asia and latin america to become the region with the highest number of undernourished people in 2030 [3] . covid-19 could exacerbate this trend, while the effects of the current health crisis on food security may be amplified by local outbreaks of other diseases that have been endemic in africa and asia. many scholars, including mouloudj et al. [128] , bakalis et al. [12] , poudel et al. [129] , and siche [130] , witnessed significant adverse effects of sars, mers, avian and swine flu, ebola, and other outbreaks on both agricultural production and food consumption behavior. on a smaller scale and in a more localized context, endemic diseases cause disruptions across local food supply chains similar to those the covid-19 pandemic does to the global food supply. according to ceylan and ozkan [131] , both sars and mers had a downsizing effect on the production and supply of food, as well as on labor demand in agriculture. kodish et al. [132] and wernery and woo [133] found movement restriction policies and quarantines introduced during mers, ebola, and other more local outbreaks to have substantial effects on agricultural production, food industry, as well as on distribution and retailing of many staples. dounamou et al. [134] revealed a significant shift in consumption patterns during ebola outbreaks in west africa. in an attempt to avoid the consumption of wild meat potentially associated with the ebola virus disease, many people tend to switch to domestic meat and fish. in a situation when affordability and availability of alternative protein sources are deteriorated by trade and economic factors (as we see it amid the covid-19 pandemic), local outbreaks of other diseases may substantially aggravate both health and food security status of broad segments of the population. transmissibility of covid-19 is estimated to be 2.5 compared with 2.4 for sars. other recent pandemics had lower basic reproductive rates-1.5 for the 2009 influenza pandemic and only 0.9 for mers [135] . despite comparable transmissibility rates, the trajectories of covid-19 and sars are different. while sars 2003 outbreak was contained within eight months with a global total of 8098 reported cases across 26 countries [136] and mers caused 2494 reported cases in 27 countries [137] , covid-19 is spreading rapidly with over 10 million known cases as the end of june 2020. but the unprecedented spread of covid-19 throughout the world compared with other pandemics of the past is caused by greater ease of global transportation [138] and higher population density [12] the world has achieved by 2020, not exclusively by higher contagiousness or better transmissibility of the novel coronavirus. with the growing globalization, any local outbreak has its chance to emerge to the global pandemic, while climate change and environmental degradation may increase the appearance of zoonotic diseases in humans [139, 140] . in ldcs and developing countries of africa, asia, and the middle east, the impact of outbreaks on the food security status of people is particularly severe in transitional food value chains, such as wet markets [141] . they bring together large numbers of people in crowded spaces at considerable risk of contagion [142] . according to hasöksüz et al. [143] and silva-jaimes [144] , in such traditional food markets where human-wildlife interactions and cross-species infections are frequent, novel coronaviruses are likely to emerge periodically. petersen et al. [135] also expect a post-covid-19 pandemic of another coronavirus, an influenza virus, a paramyxovirus, or a completely new disease to be highly likely in the nearest future. due to rather high economic and social costs of bringing local outbreaks under a successful level of control at early stages [145] , ldcs and developing countries of africa and south asia are particularly vulnerable to the frequency and intensity of disease cycles that may realize their "pandemic potential". on top of the health and economic effects of covid-19, there are climatic pressures that often aggravate supply-side food shocks in africa and asia (droughts, heatwaves, locust swarms, etc.) [7] . in 2020, production declines due to dry weather conditions are expected in morocco and tunisia [146] . in east africa and south asia, significant rainfall amounts resulted in floods and caused damages to farmland and livestock deaths. zurayk [50] has recognized locust invasion in the countries of the middle east and east africa as a further destabilizer of the stability of food supply in the times of the pandemic. shilomboleni [147] prognoses the covid-19 pandemic to put a further strain on africa's agricultural sector amid the recent desert locust outbreak in the horn of africa. in west africa, covid-19 lockdowns are limiting population movement and causing local labor supply shortages [146] . according to fao's crop prospects [146] , adverse weather resulted in a below-average output in north africa and central asia and near-average cereal harvests in central america and the caribbean. amid such climate-change driven disruptions of food systems, the pressure of both covid-19 and local outbreaks on food consumption may be intensified by lower harvests and higher food prices in group 1 countries, as well as across a wider community of developing economies. mouloudj et al. [128] and janssens et al. [148] expect developing countries of africa and asia in which agriculture contributes significantly to gdp (sierra leone, chad, niger, mali, cambodia, and vietnam) to be affected by both climate and economic effects of the pandemic (suspension of agricultural activities, agricultural labor lockdowns, etc.). according to the fao estimates [146] , over 14 million people in africa in 2020 need urgent food assistance, including 7 million in nigeria, 2.1 million in burkina faso, 2 million in niger, 1.3 million in mali and sierra leone, and 1 million in chad. with respect to food availability, domestic agricultural production in ldcs and developing countries of africa may be severely affected by the disruption of the supply of various inputs [13] , including animal feed and ingredients for food product preparation, especially if they need to be imported [145] . hypothesis 2: partly confirmed. in group 1 economies, the influence of food inflation over access to food and agricultural products is stronger than that of food trade over food availability. in low-income economies, the food security status of people is significantly influenced by both the physical availability of and economic access to food products. according to fao's most recent food security report, a key reason of growing food insecurity in developing countries is that many people cannot afford the increasing cost of healthy diets, while the nutritional status of vulnerable population groups has been deteriorated due to the economic impacts of covid-19 [3] . martin and anderson [20] and freund and özden [149] assumed that protectionist trade policy could bring a risk of additional economic losses for developing countries by insulating domestic markets from global food price fluctuations. the fao's monitoring of food price changes [23] since february 2020 demonstrates that amid the covid-19 crisis, trade restrictions are imposed against the backdrop of growing food prices. the fao food price index averaged 93.2 points in june 2020 (by 2.4% higher than in may 2020) [150]. zurayk [50] reports a global price increase in the food basket of 20% to 50% with the prices of dairy products, vegetable oils, sugar, and other food and agricultural products rebounded to multi-month highs [150] . our results indicate that rising food inflation deteriorates food access across group 1 countries as it is tightly linked with the increasing number of people with insufficient food consumption. this correlates with fao's estimation that the cost of a healthy diet in 2020 has exceeded the international poverty line, making it unaffordable for the poor and thus fueling food insecurity in most developing countries, particularly in sub-saharan africa and southern asia [3] . healthy diets have become 60% less affordable compared to the nutrient adequate diets and five times more expensive than diets that meet only dietary energy needs through a starchy staple [3] . many scholars, including bakalis et al. [12] , berkowitz et al. [151] , gundersen and ziliak [152] , and garcia et al. [153] , associate undernourishment with adverse health outcomes, including chronic conditions, mental health challenges, and increased risk of mortality. niles et al. [154] found that lower economic access to food forced many food-insecure households to disrupt eating, cut meals, eat less to stretch their food, or even go hungry. this link between the cost of a diet and food security status has an important impact on individual health. an increase in food inflation is confirmed to have a significant effect on food insecurity in group 1 countries, thereby supporting hypothesis 2 and confirming previous findings of smith et al. [59] , power [66] , sonnino et al. [67] , esturk and ören [155] , and many other authors who linked food insecurity with the level of income rather than with food imports. in our study, the strongest influence of food inflation on the number of people with insufficient food consumption is revealed in low-income economies of sub-saharan africa (burkina faso, ethiopia, guinea, among others), as well as some countries of asia and the middle east. the unctad [45] also acknowledged the countries of sub-saharan africa to be particularly exposed to demand-side risks of food access during the covid-19 crisis, including contracting incomes, downturns in economic growth, undernutrition, and micronutrient deficiencies in response to income shocks. food inflation affects demand, but inflation itself is often a product of changing demand patterns. during the economic crisis of 2008-2009, reduced income made people spend less and resulted in shrinking demand for food [16] . the novel health crisis is quite a different story. on the back of rising lockdown fears in february-march 2020, food inflation was fueled by higher demand due to panic buying [145, 156] . although yuen et al. [157] , zurayk [50] , and fawzi et al. [156] did not account for the level of income as a factor that affected such consumer behavior, we may assume the contribution of panic buying to food inflation to be more significant in group 3 countries. in low and lower-middle-income economies, people have less free money to stock up food, while most cases of panic buying have been evidenced in developed countries [158, 159] . in ldcs and developing economies, no significant spikes in food demand have been registered in the first quarter of 2020. on the contrary, the fao [16] expects the crisis-induced economic downturn to alter dietary patterns in the developing world due to a disproportionately larger decline in consumption of higher-value products like meat, fish, fruits, and vegetables. many scholars [160] [161] [162] have found the likelihood of food insecurity to increase with income inequality. according to the fao [2] , the inequality-insecurity link is 20% stronger for low-income economies compared with middle-income ones. this well agrees with our finding of the disproportional effects of food inflation on food insecurity across the three groups of countries. for instance, in mozambique (group 1), keeping other variables constant, a 1% increase in food inflation leads to a growth in the number of people in food insecurity status by 0.80% (by 0.71% in tajikistan, by 0.53% in burkina faso, 0.41% in guinea, and so on down the list of group 1 economies). in group 2, the x 3 -y link is weaker while that in group 3 is the weakest among the countries included in the study. there are even negative relationships between x 3 and y in some group 3 countries of the middle east and southeast asia. with that said, our study demonstrates that in lower-middle and upper-middle-income developing countries, the causality link between food inflation and food security is weaker compared with that in ldcs. generally, in low-income countries, food supply is for the most part ensured by local staple foods, whereas extensive import is prohibitively expensive. according to the fao [3] , low-income countries rely more on staple foods and less on fruits and vegetables and animal source foods than high-income countries. as previously found by thome et al. [65] , ritchie et al. [62] , and elbushra and ahmed [163] , weak cointegration between food inflation and food security in low-income economies could be explained by the high portion of locally produced staples in consumption. amid the covid-19 outbreak, some countries have decreased food purchases from abroad, thus automatically increasing their foreign trade balances due to the lower portion of imports. as more households switched to locally produced staples, their food security status improved. however, as noticed by devereux et al. [11] and farrell et al. [13] , a closure of open-air markets and a ban on street vendors (the two most common food outlets in poorer countries) may disrupt food access even in a situation when consumption is reoriented on local products. prior to the current health crisis, many food-insecure households have reported such food coping strategies as, for example, seeking resources from the charitable food sector or relying on social networks for support [164, 165] . amidst covid-19 lockdowns and restrictions, most of the nutrition assistance programs have been frozen. therefore, it is revealed that food availability seems to be strongly related to the food security status of households, but through local supply, not import. following deuss [166] , martin and anderson [20] , and hendrix [19] , we assume that food trade restrictions were more pronounced in the countries with a higher import dependency. according to wood et al. [167] , for import-dependent economies, both global food chain disruptions and protectionist trade policies on the part of key suppliers could have serious negative consequences for food security. this agrees with puma et al. [21] , who found that ldcs suffer greater import losses due to disruption of food supply chains through their increased dependence on imports of staple foods. there is a unidirectional x 2 →y causality across group 1, but the significance of the link is low even in the countries where food availability largely depends on imports (haiti, guinea, tajikistan). these findings do not support hypothesis 2. with an increase in the level of income, the link between food trade balance and food availability becomes tighter. the strongest effect of x 2 on y is revealed for import-dependent upper-middle-income economies (jordan, lebanon, botswana, algeria, colombia). in most low-income countries, we see how a lower proportion of food imports in trade amid the covid-19 outbreak is associated with a reduction in the number of people with insufficient food consumption. hypothesis 3: confirmed. different from the low-income economies, in group 3 countries, the food security status of people is affected by food trade and currency exchange rather than by food inflation. as recognized by wood et al. [167] and hendrix [19] , food import is particularly essential to ldcs for meeting the dietary needs of their population during the covid-19 outbreak. our results; however, suggest that group 1 and group 2 economies rely on less diversified imports compared to group 3 countries which are deeper integrated into global supply chains. for the latter, higher dependence on imports results in a stronger influence of food trade balance and currency exchange on food supply and, consequently, on the food security status of people. while devereux et al. [11] stated that covid-19 had not compromised food supply globally, mouloudj et al. [128] and toffolutti et al. [8] found food security status of developing countries that depended on imports of staples to be particularly threatened by disruptions of the food supply in the first half of 2020. in import-dependent developing countries, currency depreciation drives up the cost of food imports [49] . thus amid market uncertainties induced by the covid-19 crisis, currency exchange becomes a factor of both food availability (more expensive imports due to currency depreciation) and access to food (the higher price of imported food on the domestic market when expressed in national currency). the unctad [45] revealed heightened risks to food security in those countries of north africa and the middle east that rely on food imports and thus are dependent on currency volatilities triggered by the pandemic. in support of this unctad's estimation, the strongest effects of x 2 and x 4 on y are found for algeria and turkey. in furtherance of hypothesis 3, we expect an increase in the proportion of y explained by both food trade and currency exchange, particularly, in upper-middle-income countries. in libya, where the dependency on food imports exceeds 90%, the impact of x 2 on y is projected to be the highest among the three groups of countries (18.03%). in namibia, another group 3 country largely dependent on imports, the proportion of x 2 in y will almost reach 12.20% by march 2021. the importance of currency exchange in securing food supply will go up in the countries deeply integrated into global food supply chains. for instance, in turkey, 15.21% of y will be explained by x 4 . the effect of food inflation on the number of people with insufficient food consumption is found to be weaker across upper-middle-income economies compared to that in low-income countries. this finding both supports hypothesis 3 and agrees with frankenberg and thomas [168] and smith and glauber [69] , who revealed that higher prices for staple foods aggravated poverty traps for low-income households, but might not have much effect on the food security status of relatively well-off households. on the other hand, domestic price volatility may be exacerbated by trade restrictions that have been implemented by some group 2 and group 3 countries on the backdrop of the covid-19 outbreak. in the studies on the effects of export restrictions during the global crisis of 2007-2008, deuss [166] and djuric et al. [169] demonstrated that protectionist policies did not achieve their objective of reducing price volatility in the country imposing the restriction. there are also studies that show how trade restrictions resulted in food price spikes during the food crises in 1973-1974 [170] , 1986-1988 [171] , 2006-2008 [21,172-174] , and 2010-2011 [20] . dawe and timmer [175] and abbott [176] found that, in the short-run, an export ban could be a successful decision to ensure the food security of a country by both establishing a reserve of staples and isolating domestic market from the global price volatility. for instance, in cambodia, that limited exports of certain agricultural products in march-april 2020, we see how both negative balances of food trade and low food inflation resulted in the reduction in the number of people with insufficient food consumption. for vietnam and turkey, on the contrary, their decisions to restrict food export have not brought much success. the ardl analysis demonstrates that in vietnam, a 1% change in the food trade balance is associated with an increase in food insecurity by 0.02%. in turkey, the x 2 -y relationship is weaker but still positive. in both countries, we revealed substantial causal interaction between x 3 and y (5%→0.35% in turkey and 5%→0.31% in vietnam). this result supports the estimations of anderson and nelgen [177] , giordani et al. [178] , and rude and an [179] , who found that trade protectionism might trigger food inflation and thus aggravate food insecurity. irrespectively of any particular economic or food crisis, developing countries with their limited resources are more vulnerable to the deterioration of the macroeconomic environment. food price volatility, no less food trade bans, is particularly detrimental to low-income countries where either a disruption of a supply chain or a contraction of economic access to staples may raise food conflicts. before the covid-19 outbreak, over two billion of the most impoverished people in the world spent up to 70% of their disposable income on food. the economic downturn stemmed from the pandemic may result in substantial growth of this figure, since in poorer countries, food demand is particularly linked to income [16] . in the past, both global (sars and mers) and local (ebola, avian and swine flu) outbreaks had significant adverse effects on not only the health of people but also agricultural production and food consumption patterns across the developing world. the fao expects hunger to increase in developing countries where the economy has slowed down or contracted due to the covid-19 crisis [2] . there are threats to the access of the poor to food as a consequence of lost income from lockdowns, trade restrictions, food inflation, and currency depreciation. most ldcs as well as many developing countries also suffer from underinvestment in public health, which may amplify the pandemic's impacts [16] . this study is the very first try to assess the preliminary effects of the covid-19 pandemic on the food security status of people across the developing world. in the cases of 45 ldcs and developing countries most vulnerable to food insecurity, the authors attempted to contribute to the nascent array of studies on trade and economic influences of the global health crisis over food availability and access to food and agricultural products. as distinguished from those few studies on covid-19 effects on food supply chains that have been published so far, we revealed interactions between the number of covid-19 cases and food security status of people across three groups of ldcs and developing economies. the consecutive application of the ardl method, yamamoto's causality test, and variance decomposition allowed us to assess the impacts of foreign trade, inflation, and currency exchange on the number of people with insufficient food consumption during the global health crisis. three key findings have emerged from testing of the hypotheses in this study. first, the covid-19 pandemic affects both the food security status of people and the stability of food supply chains in developing countries across the world. the effects are more perceptible in upper-middle-income economies than in ldcs given the deeper integration of the former in global supply chains and capital-intensive agricultural systems. second, in lower-income developing countries, food security risks attributed to the emergence of the covid-19 health crisis are mainly related to economic access to adequate food supply (represented by food inflation parameter). third, in higher-income developing countries, availability-sided food security risks are more prevalent (represented by the parameters of food trade and currency exchange) (figure 2 ). obviously, the estimations provided in this paper are rather rough. the study is built on a short array of data covering only six months that have passed from the start of the covid-19 spread. over time, seeding of new data on the number of new covid-19 cases, dynamics of food trade balances, food inflation rates, and currency exchange volatilities will allow one to use the established methodology framework to obtain more well-grounded quantitative assessments of the pandemic's impacts on food security. as more comprehensive data become available from the reports by wfp, fao, wto, and other organizations, the set of variables should be expanded to capture a multidimensional character of food security, including stability of food supply and utilization of food and agricultural products. we do not know whether the pandemic will decelerate by the fall of 2020 or whether the second wave will strike the world in 2021. it is yet hard to predict how effective the containment measures will be in slowing the spread of the virus. that is why the three-quarter variance decomposition projections presented in this study must be tested and adjusted continually to monitor the strengths of inter-variables causal interactions in the long-run. this will equip decision-makers with reliable estimations that may help to design coherent and effective policies to mitigate the impact of covid-19 on food security across developing countries in various parts of the world. supplementary materials: the following are available online at www.mdpi.com/xxx/s1. table s1 : adf and pp tests results, group 1, table s2 : adf and pp tests results, group 2, table s3 : adf and pp tests results, group 3, table s4 : ardl short-run estimates, group 1, table s5 : ardl short-run estimates, group 2, table s6 : ardl short-run estimates, group 3, table s7 : fmols and dols tests results and ardl long-run estimates, group 1, obviously, the estimations provided in this paper are rather rough. the study is built on a short array of data covering only six months that have passed from the start of the covid-19 spread. over time, seeding of new data on the number of new covid-19 cases, dynamics of food trade balances, food inflation rates, and currency exchange volatilities will allow one to use the established methodology framework to obtain more well-grounded quantitative assessments of the pandemic's impacts on food security. as more comprehensive data become available from the reports by wfp, fao, wto, and other organizations, the set of variables should be expanded to capture a multidimensional character of food security, including stability of food supply and utilization of food and agricultural products. we do not know whether the pandemic will decelerate by the fall of 2020 or whether the second wave will strike the world in 2021. it is yet hard to predict how effective the containment measures will be in slowing the spread of the virus. that is why the three-quarter variance decomposition projections presented in this study must be tested and adjusted continually to monitor the strengths of inter-variables causal interactions in the long-run. this will equip decision-makers with reliable estimations that may help to design coherent and effective policies to mitigate the impact of covid-19 on food security across developing countries in various parts of the world. table s3: adf and pp tests results, group 3, table s4 : ardl short-run estimates, group 1, table s5 : ardl short-run estimates, group 2, table s6 : ardl short-run estimates, group 3, table s7 : fmols and dols 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and oilseed price volatility: the role of export restrictions this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflicts of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-315037-lmur80te authors: lin, chien-yu; hwang, david; chiu, nan-chang; weng, li-chuan; liu, hsin-fu; mu, jung-jung; liu, chang-pan; chi, hsin title: increased detection of viruses in children with respiratory tract infection using pcr date: 2020-01-15 journal: int j environ res public health doi: 10.3390/ijerph17020564 sha: doc_id: 315037 cord_uid: lmur80te respiratory viruses are a common cause of respiratory tract infection (rti), particularly in neonates and children. rapid and accurate diagnosis of viral infections could improve clinical outcomes and reduce the use of antibiotics and treatment sessions. advances in diagnostic technology contribute to the accurate detection of viruses. we performed a multiplex real-time polymerase chain reaction (pcr) to investigate the viral etiology in pediatric patients and compared the detection rates with those determined using traditional antigen tests and virus cultures. fifteen respiratory viruses were included in our investigation: respiratory syncytial virus a/b (rsv), influenza virus a (flua) and influenza virus b (flub), human metapneumovirus (mpv), enterovirus (ev), human parainfluenza virus (piv) types 1–4, human rhinovirus (rv), human coronavirus oc43, nl63, and 229e, human adenovirus (adv), and human bocavirus (boca). in total, 474 specimens were collected and tested. respiratory viruses were detected more frequently by pcr (357, 75.3%) than they were by traditional tests (229, 49.3%). the leading pathogens were rsv (113, 23.8%), rv (72, 15.2%), piv3 (53, 11.2%), flua (51, 10.8%), and adv (48, 10.1%). for children younger than 5 years, rsv and rv were most prevalent; for children older than 5 years, flua and adv were the most frequently detected. of the specimens, 25.8% (92/357) were coinfected with two or more viruses. rv, boca, piv2, flub, and piv4 had higher rates of coinfection; mpv and piv1 had the lowest rates of coinfection (9.1% and 5.3%). to conclude, the detection power of pcr was better than that of traditional antigen tests and virus cultures when considering the detection of respiratory viruses. rsv and rv were the leading viral pathogens identified in the respiratory specimens. one-quarter of the positive specimens were coinfected with two or more viruses. in the future, further application of pcr may contribute to the rapid and accurate diagnosis of respiratory viruses and could improve patient outcomes. respiratory viruses are ubiquitous and cause a large variety of clinical symptoms. respiratory tract infection (rti) is undoubtedly common, and the recognition of a causative pathogen contributes to the appropriate management [1] . in addition to the well-known respiratory viruses, such as respiratory syncytial virus (rsv) and influenza virus, human metapneumovirus (mpv) was identified in 2001, followed by the discovery of other respiratory viruses [2, 3] . currently, the disease burden of respiratory viruses is beyond our knowledge. respiratory viruses have been detected in more than two-thirds of children with radiographically confirmed community-acquired pneumonia (cap) [4] . similarly, in the united states, molecular diagnostics revealed viral infection in 43%-67% of pediatric cap cases [5] . respiratory viruses also play an important role in adult pneumonia and are detected in 15%-56% of adult cap cases [5, 6] . viruses are responsible for the majority of respiratory infectious diseases in both children and adults, causing a massive disease burden [7, 8] . furthermore, the identification of causative viruses enables the accurate diagnosis of respiratory infections and prescription of specific antiviral agents against certain viruses, such as oseltamivir for influenza viruses, and improves evaluation of the prognosis [9] [10] [11] . recognizing causative viruses can also provide information on the appropriate infection control measures, which can potentially reduce unnecessary hospital stays and allow discontinuation of unnecessary antibiotics [12] [13] [14] . in summary, respiratory virus infection is common, and testing for respiratory pathogens can improve understanding of the roles of pathogens in respiratory diseases and contribute to their better clinical management [15] . a timely and accurate diagnosis of viral infection can be challenging. rapid antigen tests are used to detect influenza virus infection worldwide, but there are some concerns regarding the sensitivity of currently available viral antigen tests [6, 15] . technological advances have improved the sensitivity, accessibility, and utility of viral diagnostic tools [16] . molecular assays have been developed and progressively multiplexed to diagnose a large number of respiratory viruses in a single assay with excellent sensitivity and specificity [10, [17] [18] [19] [20] . the importance of molecular-based diagnostic modalities is currently on the rise, and polymerase chain reaction (pcr) technology is being increasingly used in the clinic to rapidly diagnose respiratory infections [19] . this study aims to detect respiratory viruses in children using pcr and to compare the detection power of this technique against that when using traditional antigen tests and virus cultures. the clinical conditions were also investigated. this study was approved by the institutional review board of the mackay memorial hospital, taipei, taiwan (approval no. 14mmhis030). for children with respiratory symptoms and with a clinical suspicion of virus infection, a test for rsv antigen test, human parainfluenza virus (piv) type 3 antigen test, viral pcr for enterovirus, or viral cultures was prescribed by the judgment of pediatricians. a nasopharyngeal swab or aspiration was performed by pediatricians using a small swab that was inserted into the nostril. the cotton swab was then inserted and mixed in a 2.5 ml viral transport medium. after testing original tests, the residual specimens were stored at −20 • the viral nucleic acids were extracted from 200-µl of each sample using the high pure viral nucleic acid kit (roche applied science, castle hill, germany) following the manufacturer's instructions. extracted nucleic acids were eluted in 100 µl elution buffer and stored at −70 • c. reverse transcription (rt) was carried out using high-capacity complementary dna (cdna) reverse transcription kit (applied biosystems part number: 4375575 rev.c). the total volume of rt mix was 40 µl per reaction, containing 4 µl rt buffer (10×), 1.6 µl dntp mixture (25 mm of each dntp), 4 µl random primers (10×), 2 µl rnase inhibitor (20 u/µl), 2 µl multiscribe reverse transcriptase (50 u/µl), and 26.4 µl template, whereby the rt reagent mix was prepared on ice. the thermal profile of the rt program consisted of 10 min incubation at 25 • c, 120 min rt at 37 • c, 5 min rt inactivation at 85 • c, and cooling down to 4 • c and was performed in a 96-well geneamp pcr system 9700. the resulting cdna was stored at −20 • c. the following multiplex pcr assays were performed for each sample to detect rna/dna of 15 respiratory viruses, including rsv a or b, flua, flub, human enterovirus (ev), mpv, human parainfluenza virus types 1-4, human rhinovirus (rv), coronavirus oc43/nl63/229e, human adenovirus (adv), and human bocavirus (boca). in the present study, previously published primers and pcr assays were used for multiplex rt-pcr and the details of primers are summarized in table s1 [21] [22] [23] [24] [25] [26] . briefly, the pcr reaction was performed by adding 3 µl rt product to 22 µl pcr mix. the conditions of amplification were as follows: initial denaturation at 95 • c for 10 min; followed by 40 cycles of 95 • c for 1 min, 60 • c for 1 min, and 72 • c for 1 min; a final extension at 72 • c for 10 min. amplification products were visualized by 1% agarose gel electrophoresis with ethidium bromide staining and observed under ultraviolet light. for each pcr assay, a positive and negative control for each parameter was performed. internal control was also performed to detect sample inhibition and avoid false-negative results. external and internal amplification controls were designed for quality control and validation. the detection limits of the multiplex pcr assays were 10 to 100 copies of the individual virus. student's t-test and chi-square test were used to analyze and compare the categorical demographic characteristics including clinical manifestations and laboratory tests. kappa statistic was used to evaluate the consistency between pcr and original tests (categorical variables) and cohen's kappa coefficient (κ) was regarded as poor to fair consistency if κ ≤ 0.4; moderate consistency if 0.41 ≤ κ ≤ 0.60; and good consistency if 0.61 < κ. a two-sided p < 0.05 was considered statistically significant. statistical analyses were performed using the spss software version 23.0 (spss inc., chicago, il, usa). in total, 474 residual specimens for detecting respiratory viruses were obtained, including 156 specimens for rsv antigen tests, 58 for parainfluenza virus antigen tests, and 260 for viral cultures. table 1 summarizes the detection rates of viruses. the overall positive rate for traditional tests was 48.3% (229/474), and the individual positive rate was 28.8% for rsv antigen tests, 5.2% for parainfluenza virus antigen tests, and 69.6% for viral cultures. all specimens underwent present multiplex pcr for the 15 abovementioned viruses, and higher detection rates were observed; 357 (75.3%) specimens were positive for at least one virus. the leading pathogens were rsv (113, 23.8%), rv (72, 15.2%), piv3 (53, 11.2%), flua (51, 10.8%), and adv (48, 10.1%) ( figure 1 ). among these positive specimens, 25.8% (92/357) were coinfected with two or more viruses. the coinfection rates of individual virus were demonstrated in table 1 . we observed that rv, boca, piv2, flub, and piv4 were associated with higher rates of coinfection. however, mpv and piv1 had the lowest rates of coinfection (9.1% and 5.3%). the consistency of the results between virus culture and pcr was also investigated. with the exception of flub, a high consistency was observed between virus culture and pcr (coefficient k: 0.72~0.961, p < 0.01, table 1 ). were associated with higher rates of coinfection. however, mpv and piv1 had the lowest rates of coinfection (9.1% and 5.3%). the consistency of the results between virus culture and pcr was also investigated. with the exception of flub, a high consistency was observed between virus culture and pcr (coefficient k: 0.72~0.961, p < 0.01, table 1 ). the seasonality of virus detection is shown in figure 2 ; virus detection was more common in summer and autumn. the seasonal distribution of the five most commonly detected viruses (rsv, rv, piv3, flua, and adv) was also plotted. we also compared the detection rate in different age groups ( figure 3 ). for children younger than 5 years, rsv and rv were the leading pathogens; for older children, flua and adv were prevalent. the clinical manifestations and laboratory tests are summarized in table 2 (complete data available in table s2 ). except for age, no obvious differences were found between individual viruses. more than one-quarter of the specimens were coinfected with more than one virus. we further compared the clinical manifestations of patients in which either no viruses, a single infection, or coinfections were detected. the age, body weight, duration of hospitalization, intensive care unit (icu) stay, white blood cell counts (wbc), and c-reactive protein (crp) levels were not significantly different, with higher platelet counts being the only difference noted in patients with coinfections (table 3) . were found between individual viruses. more than one-quarter of the specimens were coinfected with more than one virus. we further compared the clinical manifestations of patients in which either no viruses, a single infection, or coinfections were detected. the age, body weight, duration of hospitalization, intensive care unit (icu) stay, white blood cell counts (wbc), and c-reactive protein (crp) levels were not significantly different, with higher platelet counts being the only difference noted in patients with coinfections (table 3 ). were found between individual viruses. more than one-quarter of the specimens were coinfected with more than one virus. we further compared the clinical manifestations of patients in which either no viruses, a single infection, or coinfections were detected. the age, body weight, duration of hospitalization, intensive care unit (icu) stay, white blood cell counts (wbc), and c-reactive protein (crp) levels were not significantly different, with higher platelet counts being the only difference noted in patients with coinfections (table 3 ). in this study, we found that pcr had higher detection rates compared with traditional antigen tests and viral cultures (75.3% vs. 48.3%). rsv, rv, and piv3 were the leading pathogens detected in pediatric rti patients. however, flua, adv, and ev were more prevalent in children older than 5 years. knowledge of epidemiology contributes to the awareness of pathogen, accurate diagnosis, and prompt management. we also found that approximately one-quarter of specimens were coinfected with two or more viruses. however, no obvious differences in clinical manifestations and laboratory tests were found in individual virus infection or between single infection and coinfection; the clinical significance of coinfection was not fully elucidated. a rapid and accurate diagnosis of respiratory viruses is increasingly important in clinical settings. the availability of rapid diagnostic assays is essential for optimizing the efforts of infection control teams to reduce the transmission of virulent or resistant pathogens in hospitals [27] . nucleic acid amplification tests are the new gold standard for the diagnosis of respiratory viruses. our study has shown high detectability of pcr for respiratory viruses, suggesting that pcr-based diagnostic tools may be practical for detecting a wide range of respiratory viruses. viral infection can be fatal, especially in premature infants and infants with congenital heart disease [28] . in a previous study, symptomatic and asymptomatic premature infants were prospectively screened in a neonatal icu using multiplex pcr twice weekly; respiratory viruses were identified in 52% of prematurely born infants during their birth hospitalization. their length of hospital stay was significantly longer (70 days vs. 35 days), and bronchopulmonary diseases were more frequent in infected infants [8] . in adult and pediatric patients, the major impact of respiratory viral infections with hematologic malignancies, hematopoietic stem cell transplantation, and solid organ transplantation has been recognized over the past decade [7, 28] . in the most immunocompromised populations, respiratory viruses have a high rate of progression to pneumonia (20%-40%). the mortality among those patients ranged from 30% to 50%. the application of multiplex pcr for respiratory virus detection in high-risk groups has been proved to be valuable [17] . our study showed a high detectability of pcr for respiratory viruses, suggesting that pcr-based diagnostic tools may be helpful for detecting a wider range of respiratory viruses. we also showed a high consistency of pcr with virus cultures, except for flub, suggesting the accuracy of the pcr method. virus culture is time-consuming and not feasible for clinical practice. it was even impossible to detect some viruses by virus cultures, e.g., coronaviruses (229e, oc43, nl63, and hku-1), piv4, rv, and boca. approximately just over half of the viruses could be detected after the wide application of pcr. these results re-enforce the importance of pcr-based diagnosis. viral infections are ubiquitous and may present with fever and respiratory symptoms. it is sometimes difficult to differentiate between bacterial infections and viral infections, and thus the use of unnecessary antibiotics is common. antimicrobial resistance (amr) has been increasing worldwide, resulting in poor treatment responses and deplorable clinical outcomes [29] . the problem of amr is an urgent and critical health threat and is directly associated with the overuse of antibiotics [30] . antibiotic treatment does not improve the clinical outcomes of viral infections [31] . decreasing the use of unnecessary antibiotics is the key to combating amr, and accurate and rapid diagnosis is crucial to decrease antibiotic prescriptions with a minimized risk [9, 10, 32] . the present study demonstrates that pcr has higher detectability for respiratory viruses compared to traditional antigen tests and viral cultures. pcr-based viral detection may help physicians to make appropriate decisions and decrease unnecessary antibiotic use. furthermore, the precise diagnosis of certain viruses may contribute to timely antiviral agent treatment, e.g., oseltamivir against influenza infections. we discovered that influenza is common among pediatric patients (11.6% of respiratory specimens) and is the most commonly detected pathogen in older children (27% in children aged 5-9 years and 16.7% in children older than 10 years). rapid diagnosis of influenza viruses and early treatment with oseltamivir or peramivir is crucial. in addition, prompt diagnosis of respiratory viruses also contributes to appropriate infection control measures and isolation care [8, 27] . in recent years, the cost of pcr testing has decreased, and the availability and feasibility has been largely improved. some commercialized pcr machines are increasingly available and may serve in point-of-care testing [18] . hence, the widespread use of pcr-based detection of respiratory viruses is increasing and may become more practical. the incidence of etiologic pathogens differs between adults and children. it has been reported by jain et al. that, among the hospitalized adults with cap, pathogens were detected in 38% of patients, and the leading pathogens were rv (9%) and influenza viruses (6%) [6] . by contrast, pathogens were detected in 81% of the hospitalized cap children, and the leading pathogens were rsv (28%), rv (27%), and mpv (13%) [4] . generally speaking, viral infections are more prevalent in children than in adults. the leading pathogens may also differ according to geographical region, climate, season, and year. the leading pathogens detected in our study were rsv (23.8%), rv (15.2%), and piv3 (11.2%). a previous study conducted in taiwan found that rsv was the most common pathogen (41.7%), followed by mpv (27.1%), boca (6.3%), and ev (6.3%) [33] . some important studies investigating the epidemiology of respiratory tract infection are summarized in table 4 [4, 6, 13, 15, 23, 34, 35] . rsv is always the most common pathogen in young children worldwide, but the accompanying pathogens are not always the same [4, 5, 7, 13, 36, 37] . virus detection was more common in summer and autumn in our study. taiwan is located in a subtropical zone, where there are no swift changes in temperature amplitudes. although rsv infections occur biennially, with peaks reported in the spring and autumn in taiwan, variations in rsv infections are not particularly large [38] [39] [40] . detection of respiratory viruses could enable estimation of the local epidemiology of respiratory viral infection and help pediatricians to improve their clinical judgments. one-quarter of the positive specimens were coinfected with other respiratory viruses in our study. a similar prevalence was found in previous studies [4, 41, 42] . the rates of coinfection were between 18.8% to 36.2% in previous studies (table 4 ). with the advances in diagnostic testing, the number of detectable viruses will increase. however, the clinical significance of coinfection remains unclear [43] [44] [45] [46] . some studies reported increased severity of coinfection [45, 46] , but the impact of coinfection was not particularly obvious in other studies [47, 48] . diversities in the study design, population, and detection methods may be the reason for this inconclusiveness. when we compared the clinical manifestations and laboratory tests for patients with negative detection, single infection, and coinfections, we found no statistically significant differences in age, body weight, hospitalization duration, icu stay, crp level, and complete blood cell counts; although higher platelet counts were observed in patients with coinfection. further studies are required to clarify the clinical significance of our findings. the strength of our study lies in the comprehensive detection of respiratory viruses and further comparison of the clinical manifestations and laboratory tests in single and coinfection. our study is subject to some limitations that warrant discussion. firstly, although our findings were consistent with those of previous studies, respiratory specimens were not collected in all patients with respiratory symptoms. the prevalence of ev was underestimated because the clinical diagnosis of ev infection relies mainly on the presence of oral vesicles. further virus culture might not be performed when vesicles over oropharynx were found. secondly, we did not include bacteria in our detection spectra. some bacteria such as mycoplasma pneumoniae and streptococcus pneumoniae also play an important role in respiratory infections and commonly cause coinfections with other pathogens [49] . furthermore, some respiratory viruses were not included in our testing, such as the middle east respiratory syndrome coronavirus and human polyomaviruses ki and wu [50] . the use of pcr resulted in greater detection of respiratory viruses than the use of traditional rapid antigen tests or viral cultures. more than half of the respiratory specimens that showed negative detection in the original tests were positive for the pcr-based detection method. further application of pcr has great potential for rapid and accurate diagnosis and will be beneficial for primary pediatricians. furthermore, rsv and rv were the leading pathogens identified in our pediatric respiratory specimens; in children older than 5 years, flua, adv, and ev were more prevalent. approximately one-quarter of the positive respiratory specimens were coinfected with two or more viruses, but no obvious differences in clinical manifestations and laboratory tests were observed between single infection and coinfection. further studies are warranted to investigate the accuracy, feasibility, accessibility, and cost of pcr in detecting respiratory viruses, and to clarify the clinical significance of coinfection. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/2/564/s1. table s1 : primers and pcr assays for multiplex pcr. table s2 a newly discovered human pneumovirus isolated from young children with respiratory tract disease identification of a new human coronavirus community-acquired pneumonia requiring hospitalization among us children viral pneumonia community-acquired pneumonia requiring hospitalization among us respiratory viral infections during the first 28 days after transplantation in pediatric hematopoietic stem cell transplant recipients unrecognized viral respiratory tract infections in premature infants during their birth hospitalization: a prospective surveillance study in two neonatal intensive care units implementation of rapid diagnostics with antimicrobial stewardship the role of multiplex pcr in respiratory tract infections in children early diagnosis of lower respiratory tract infections (point-of-care tests) etiological diagnosis reduces the use of antibiotics in infants with bronchiolitis casas, i. spectrum of respiratory viruses in children with community-acquired pneumonia resisting the use of antibiotics for viral infections diagnostic value of respiratory virus detection in symptomatic children using real-time pcr are we ready for novel detection methods to treat respiratory pathogens in hospital-acquired pneumonia? multiplex pcr system for the rapid diagnosis of respiratory virus infection: systematic review and meta-analysis the clinical significance of filmarray respiratory panel in diagnosing community-acquired pneumonia comparison of real-time pcr assays with fluorescent-antibody assays for diagnosis of respiratory virus infections in children rapid and sensitive method using multiplex real-time pcr for diagnosis of infections by influenza a and influenza b viruses, respiratory syncytial virus, and parainfluenza viruses 1, 2, 3, and 4 public health responses to reemergence of animal rabies frequent detection of viral coinfection in children hospitalized with acute respiratory tract infection using a real-time polymerase chain reaction an economical tandem multiplex real-time pcr technique for the detection of a comprehensive range of respiratory pathogens real-time reverse transcriptase pcr assay for detection of human metapneumoviruses from all known genetic lineages design and performance testing of quantitative real time pcr assays for influenza a and b viral load measurement simultaneous detection of influenza a, influenza b, and respiratory syncytial viruses and subtyping of influenza a h3n2 virus and h1n1 (2009) virus by multiplex real-time pcr rapid testing for respiratory syncytial virus in a paediatric emergency department: benefits for infection control and bed management 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of hospitalization among single virus infections causing influenza like illnesses epidemiological study of hospitalization associated with respiratory syncytial virus infection in taiwanese children between prolonged seasonality of respiratory syncytial virus infection among preterm infants in a subtropical climate global respiratory syncytial virus-associated mortality in young children (rsv gold): a retrospective case series epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children etiology and impact of coinfections in children hospitalized with community-acquired pneumonia the role of infections and coinfections with newly identified and emerging respiratory viruses in children co-infections with influenza and other respiratory viruses respiratory syncytial virus: co-infection and paediatric lower respiratory tract infections dual infection of infants by human metapneumovirus and human respiratory syncytial virus is strongly associated with severe bronchiolitis human metapneumovirus as a causative agent of acute bronchiolitis in infants clinical features and complete genome characterization of a distinct human rhinovirus (hrv) genetic cluster, probably representing a previously undetected hrv species, hrv-c, associated with acute respiratory illness in children clinical and epidemiological characteristics in children with community-acquired mycoplasma pneumonia in taiwan: a nationwide surveillance the human polyomaviruses ki and wu: virological background and clinical implications acknowledgments: this study is supported by mackay memorial hospital, taipei, taiwan (project number: mmh-103-65). this study was approved by the institutional review board of the mackay memorial hospital, taipei, taiwan (approval no. 14mmhis030). the authors declare no conflict of interest. key: cord-314211-tv1nhojk authors: eltoukhy, abdelrahman e. e.; shaban, ibrahim abdelfadeel; chan, felix t. s.; abdel-aal, mohammad a. m. title: data analytics for predicting covid-19 cases in top affected countries: observations and recommendations date: 2020-09-27 journal: int j environ res public health doi: 10.3390/ijerph17197080 sha: doc_id: 314211 cord_uid: tv1nhojk the outbreak of the 2019 novel coronavirus disease (covid-19) has adversely affected many countries in the world. the unexpected large number of covid-19 cases has disrupted the healthcare system in many countries and resulted in a shortage of bed spaces in the hospitals. consequently, predicting the number of covid-19 cases is imperative for governments to take appropriate actions. the number of covid-19 cases can be accurately predicted by considering historical data of reported cases alongside some external factors that affect the spread of the virus. in the literature, most of the existing prediction methods focus only on the historical data and overlook most of the external factors. hence, the number of covid-19 cases is inaccurately predicted. therefore, the main objective of this study is to simultaneously consider historical data and the external factors. this can be accomplished by adopting data analytics, which include developing a nonlinear autoregressive exogenous input (narx) neural network-based algorithm. the viability and superiority of the developed algorithm are demonstrated by conducting experiments using data collected for top five affected countries in each continent. the results show an improved accuracy when compared with existing methods. moreover, the experiments are extended to make future prediction for the number of patients afflicted with covid-19 during the period from august 2020 until september 2020. by using such predictions, both the government and people in the affected countries can take appropriate measures to resume pre-epidemic activities. by january 2020, the covid-19 outbreak that originated in china has spread globally, with the number of infected persons rising to 6,479,495 and a fatality of about 383,015 persons (https://www.worldometers.info/ coronavirus. last accessed 3 june 2020). with the global spread of this infectious disease, the world health organization (who) designated it as a pandemic. besides the personal tragedies and casualties brought by this pandemic, the economic implications of this pandemic are significant. most of the affected countries locked their borders and ordered closure of factories, restaurants, big malls, and clubs. consequently, the world is suffering from an economic recession as the global economic losses are estimated to approach usd 23 trillion (the economist, "covid carnage," 21 march 2020). this dire situation motivates researchers to conduct research on covid-19 focusing on two main areas: medicine and engineering. of the narx neural network-based algorithm is described in section 4. sections 5 and 6 present the results of the experiments and conclusions of the study, respectively. before investigating the literature on covid-19, we conducted a brief bibliographic search about covid-19 for two purposes. firstly, to find out the number of research works published on covid-19 and secondly, to identify the different research areas focusing on covid-19. for those purposes, we used some keywords like covid-19, novel coronavirus, and hubei pneumonia. it was found that more than 8000 research documents have been published on this topic. figure 1 shows the different types of research documents published on covid-19. by looking at figure 1 , it can be observed that the vast majority of published works are in the form of journal articles, whereas a small number of research works have appeared as conference papers. this is because most conferences have been canceled due to the outbreak of the covid-19 pandemic [22] . before investigating the literature on covid-19, we conducted a brief bibliographic search about covid-19 for two purposes. firstly, to find out the number of research works published on covid-19 and secondly, to identify the different research areas focusing on covid-19. for those purposes, we used some keywords like covid-19, novel coronavirus, and hubei pneumonia. it was found that more than 8000 research documents have been published on this topic. figure 1 shows the different types of research documents published on covid-19. by looking at figure 1 , it can be observed that the vast majority of published works are in the form of journal articles, whereas a small number of research works have appeared as conference papers. this is because most conferences have been canceled due to the outbreak of the covid-19 pandemic [22] . bibliographic search is then continued to identify the different research areas focusing on covid-19. the findings are presented as a pie chart in figure 2 . as covid-19 is a novel disease, it is noticed that the majority of these research works (around 61%) has focused on medicine, whereas the rest are distributed in different areas, like biochemistry, social sciences, and engineering. these research areas are discussed in the next section. bibliographic search is then continued to identify the different research areas focusing on covid-19. the findings are presented as a pie chart in figure 2 . as covid-19 is a novel disease, it is noticed that the majority of these research works (around 61%) has focused on medicine, whereas the rest are distributed in different areas, like biochemistry, social sciences, and engineering. these research areas are discussed in the next section. in this section, we discuss the different research areas that have considered covid-19, including medicine and engineering. in the field of medicine, most of the early research on covid-19 is focused on understanding the symptoms of the disease [1] , characterizing it [2] , and finally estimating its incubation periods [3] . in addition, wang et al. [23] have reported that the elderly are more likely to die from covid-19, because of their underlying comorbidities [24] . however, the virus attacks not only the elder people but also children [25] . this means that everybody can be infected by covid-19. moreover, zhuang et al. [8] have showed that people infected with covid-19 are asymptomatic in many cases. in this section, we discuss the different research areas that have considered covid-19, including medicine and engineering. in the field of medicine, most of the early research on covid-19 is focused on understanding the symptoms of the disease [1] , characterizing it [2] , and finally estimating its incubation periods [3] . in addition, wang et al. [23] have reported that the elderly are more likely to die from covid-19, because of their underlying comorbidities [24] . however, the virus attacks not only the elder people but also children [25] . this means that everybody can be infected by covid-19. moreover, zhuang et al. [8] have showed that people infected with covid-19 are asymptomatic in many cases. covid-19 has a long incubation period of 4 to 14 days, and in many cases, patients are asymptomatic [4] ; thus, it has a high infection rate. therefore, it is of great importance to predict and estimate the number of people affected by covid-19. this motivates researchers to focus on the engineering aspect of this disease, that is, the prediction of covid-19 cases. usually, prediction can be conducted using traditional statistical methods. for example, remuzzi and remuzzi [5] and tuite et al. [6] have utilized the statistical methods to predict the number of covid-19 cases in italy. similarly, the number of covid-19 cases has been predicted in different countries/territories such as, iran [7, 8] , spain, and france [9] . beside the statistical methods as mentioned above, the mathematical modeling and simulation including logistic growth and susceptible-infected-recovered (sir-model) have been utilized to predict the new covid-19 cases in china [10] and saudi arabia [11] . moreover, papastefanopoulos et al. [12] have investigated and compared the accuracy of six time-series forecasting approaches, namely, arima, holt-winters additive model (hwaas), tbat, facebook's prophet, deepar, and n-beats, in predicting the progression of covid-19. in a similar work, hernandez-matamoros et al. [13] have developed an arima model to predict the spread of the virus. the developed model consists of arima parameters, including the population of the country, the number of infected cases, and polynomial functions. ivorra et al. [26] have proposed a new mathematical model for predicting the spread covid-19 outbreak in china. the proposed model, θ-seihrd model, considers a fraction θ of detected cases over the realized total infected cases. there are other studies that focus on collecting and analyzing posts related to covid-19 from social media sites. this is because keyword search trends related to covid-19 on search engines proved tremendously helpful in predicting and monitoring the spread of the virus outbreak. qin et covid-19 has a long incubation period of 4 to 14 days, and in many cases, patients are asymptomatic [4] ; thus, it has a high infection rate. therefore, it is of great importance to predict and estimate the number of people affected by covid-19. this motivates researchers to focus on the engineering aspect of this disease, that is, the prediction of covid-19 cases. usually, prediction can be conducted using traditional statistical methods. for example, remuzzi and remuzzi [5] and tuite et al. [6] have utilized the statistical methods to predict the number of covid-19 cases in italy. similarly, the number of covid-19 cases has been predicted in different countries/territories such as, iran [7, 8] , spain, and france [9] . beside the statistical methods as mentioned above, the mathematical modeling and simulation including logistic growth and susceptible-infected-recovered (sir-model) have been utilized to predict the new covid-19 cases in china [10] and saudi arabia [11] . moreover, papastefanopoulos et al. [12] have investigated and compared the accuracy of six time-series forecasting approaches, namely, arima, holt-winters additive model (hwaas), tbat, facebook's prophet, deepar, and n-beats, in predicting the progression of covid-19. in a similar work, hernandez-matamoros et al. [13] have developed an arima model to predict the spread of the virus. the developed model consists of arima parameters, including the population of the country, the number of infected cases, and polynomial functions. ivorra et al. [26] have proposed a new mathematical model for predicting the spread covid-19 outbreak in china. the proposed model, θ-seihrd model, considers a fraction θ of detected cases over the realized total infected cases. there are other studies that focus on collecting and analyzing posts related to covid-19 from social media sites. this is because keyword search trends related to covid-19 on search engines proved tremendously helpful in predicting and monitoring the spread of the virus outbreak. qin et al. [14] developed a prediction technique based on the lagged series of social media search indexes to forecast the number of new suspected covid-19 cases. the considered social media search indexes include common covid-19 symptoms such as dry cough, fever, pneumonia, etc. in another study by li et al. [15] , the daily trend data related to specific keyword search such as "coronavirus" and "pneumonia", has been acquired from google trends, baidu index, and sina weibo index search engines to investigate and monitor new covid-19 cases. li et al. [16] have collected data on the posts related to covid-19 that are posted by chinese users on weibo using an automated python programming script. the collected data have been analyzed quantitatively and qualitatively in order to recognize trends and characterize key themes. other applications using social media to predict covid-19 cases have been reported by shen et al. [27] and ayyoubzadeh et al. [28] the major drawback of statistical methods and mathematical modeling is their inability to consider massive amounts of data. this leads to poor prediction of the number of covid-19 cases. this drawback can be avoided by using data analytics, which is explained in the next section. data analytics is one of the efficient tools in discovering the relationships, trends, and other useful information existing in a body of data. the number of data analytics tools is large. among these tools, the neural network is one of the most efficient tools in uncovering the relationship between an output (i.e., response) and multiple inputs (i.e., indicators) [29, 30] . this efficiency has been applied in handling different applications, including stock price forecasting in the financial industry [31] , flight delay prediction in aviation industry [32] [33] [34] , organ prediction in healthcare sector [35] , and demand forecasting in the railway industry [36] . these previous studies reveal the importance of data analytics for prediction purposes. this motivates researchers to adopt data analytics in the domain of covid-19. for example, chen et al. [17] utilized data analytics to predict the number of covid-19 cases to avoid overwhelming hospital capacity in taiwan. the pitfall of this research work is that it has only focused on historical data of the number of covid-19 cases while considering a limited number of factors, like travel and occupation. another research work by zhou et al. [18] coupled geographic information system (gis) and data analytics together to identify the infection network of covid-19. additionally, machine learning and artificial intelligence tools have been utilized by many studies to develop covid-19 prediction approaches. wieczorek et al. [19] have developed a forecasting model for covid-19 new cases based on the deep architecture of neural network using nadam training model. however, the pitfall of this study is the focus on one dataset, called total number of confirmed covid-19 cases, while overlooking many other factors. magesh et al. [37] have proposed an ai-based algorithm for predicting covid-19 cases using a hybrid recurrent neural network (rnn) with a long short-term memory (lstm) model. the authors have conducted their experiments while considering some demographic factors like sex, age, and temperature. indeed, many other social factors were not considered in their model. pinter et al. [20] have developed a hybrid machine learning approach to forecast covid-19 cases in hungary. the proposed hybrid approach encompasses the adaptive network-based fuzzy inference system and multi-layered perceptron-imperialist competitive algorithm. a machine learning-based approach for predicting covid-19 new cases has been proposed in the study by tuli et al. [38] , who have used an iterative weighting for fitting generalized inverse weibull distribution. for extensive study and more details about the forecasting approaches for covid-19, the interested readers are referred to the work by bragazzi et al. [21] who have reviewed the potentials of applying artificial intelligent and big data based approaches in predicting and managing the covid-19 pandemic outbreak. these previous studies show successful application of data analytics in multiple areas. therefore, it is reasonable to use data analytics in this study. from the above, it is clear that most of the data analytics studies have focused on historical data of confirmed covid-19 cases, while some studies have considered some factors like temperature and patient sex. indeed, many other important external factors that affect the spread of the disease have been completely ignored. these important factors include population, median age index, public and private healthcare expenditure, air quality as a co 2 trend, seasonality as month of data collection, number of arrivals in the country/territory, and education index. this results in a poor prediction of the number of covid-19 cases. a thorough examination of the literature reveals some observations, which can be outlined as follows. first, there is no previous study that simultaneously considers the historical data of the number of covid-19 cases and most of the external factors that affect the spread of the virus. secondly, there is no research work that provides future prediction of the number of covid-19 cases using data analytics techniques. therefore, efforts of the government to improve the healthcare system in the affected countries are greatly hampered. consequently, in this research work, we have tried to fill this gap by proposing a data analytics algorithm, in which all the aforementioned features can be simultaneously considered. this paper has the following contributions. firstly, in contrast to the existing approach [17, 18] , which only focuses on the historical data of persons infected with covid-19, we propose a more robust approach. our approach simultaneously considers the historical data of covid-19 cases alongside most of the external factors that affect the spread of the disease. these external factors include population, median age index, public and private healthcare expenditure, air quality as a co 2 trend, seasonality as month of data collection, number of arrivals in the country/territory, and education index. to consider all those massive number of factors, we develop a nonlinear autoregressive exogenous input (narx) neural network-based algorithm. this algorithm is developed because it is the most appropriate one to handle time-based factors, like the number of covid-19 cases. moreover, narx algorithms have been successfully applied in different research areas, as shown in section 2.3. second, instead of predicting the number of covid-19 cases in one or two countries [7] [8] [9] , we use our algorithm to predict the number of covid-19 in multiple countries, including top five affected countries in each continent. this is fruitful as it gives wide information about the spread of covid-19 in different parts of the world. lastly, it has been observed in the literature that most research papers have not provided future prediction of the number of covid-19 cases. as opposed to these previous research papers, we use the trained data produced from our algorithm to make future prediction of the number of covid-19 cases. by using such predictions, both the government and people in the affected countries can take appropriate measures to resume pre-epidemic activities. in this section, we present how data analytics can be used in predicting the new daily cases of covid-19. instead of using the traditional approaches, which either focus on historical data or assume a normal distribution for the number of daily cases, we use a data analytics approach. in particular, this approach has the ability to consider a massive amount of data, including historical data of daily cases besides other external factors. the proposed methodology includes a nonlinear autoregressive exogenous input (narx) neural network-based algorithm. the main steps of this algorithm are presented as follows: step 1: collecting the data. the data have been collected from online websites, including "worldometers" [39] , "our world in data" [40] , "world bank open data" [41] , and the official website of the world health organization (who). besides, human development reports have been used to pick other kind of information, like median age and education index [42] . the scope of this study includes collecting data for about 189 countries/territories by focusing on two types of data: main data and other external factors. the main data include considering the number of confirmed coronavirus disease cases/day, the number of deaths due to coronavirus disease/day, and the total number of confirmed cases [39, 40] . the external factors, on the other hand, include considering the factors that affect the spread of coronavirus disease. note that the data have been collected for about 224 days, from 31 december 2019 until 10 august 2020. this leads naturally to set the size of data at 224. step 2: preprocessing the data. while collecting the data, it was observed that data were not always available for the whole 189 countries/territories. to alleviate this situation, a refinement was performed by ruling out any countries/territories that suffer from data unavailability. this results in cancelling around 39 countries/territories, so that only 150 countries/territories have been considered. our preliminary goal is to predict the new cases for all 150 countries/territories. however, this is not reasonable for two reasons. firstly, it is not possible to present all the results in a single study due to page limitation. secondly, it is computationally expensive to run this algorithm for 150 countries/territories. for the above reasons, we have limited our scope to considering the most affected countries in each continent. by doing so, the top five affected countries/territories have been considered from each continent. more details are presented in section 5. step 3: identifying the input sets. these sets contain historical data of some information alongside the external factors. these sets can be outlined as follows: i. main set, which includes two main information: the number of deaths due to coronavirus disease/day and the total number of confirmed cases; ii. external factor set that comprises the factors that affect the spread of coronavirus including population [42] , median age index [41] , public and private healthcare expenditure [41] , air quality as a co 2 trend [42] , number of arrivals in the countries/territories [41] , and education index [42] . there is another factor that should be considered, called seasonality. before incorporating this factor in the model, it should be clarified here that, in most countries, we can find cities with different seasons. for example, iran has four seasons in its different cities [43] . other examples include usa, china, saudi arabia, and egypt. this observation indicates that, to consider the seasonality using seasons as a factor, the cities should be the scope of the study. since the scope of this study is not cities but the countries, seasonality factor using seasons themselves cannot be considered in our algorithm. to find a compromise for this situation, the month of collecting data is selected to capture the seasonality in the proposed algorithm. it should be noted that the main data for the daily covid-19 cases have been collected from the website "our world in data", corrected through the website "worldometers". next, the data have been doublechecked and refined by the data from the official website of who. in addition, because the considerable predictors are diverted, and they are not available on one database, their data have been collected from several websites. in further details, the data that have been collected from the website "world bank open data" are the median age, number of arrivals, and health expenditure as a percentage of gdp [41] , while the education index has been collected from united nations development programme [42] . step 4: test of hypothesis using regression analysis. since our study goal is to accurately predict the number of covid-19 cases, we should focus on the most influential external factors. to do so, test of hypotheses using regression analysis should be conducted for each external factor. these hypotheses can be outlined as follows: after outlining the test of hypothesis, the regression analysis has been conducted, in which the p-value is calculated. if the p-value < 0.05, which is the significance level in this study, we reject the null hypothesis h 0 and go in favor of the alternative hypothesis h 1 . if p-value ≥ 0.05, we cannot reject the null hypothesis h 0 . by doing so, the significant factors have been picked, including all the previous external factors except public health expenditure and air quality as a co 2 trend. more details about test of hypothesis using regression analysis are shown in section 5.1. step 5: designing the neural network structure. we have utilized the feedforward time-delay neural network as this structure has been commonly used in the literature due to its efficiency [44] . this network is composed of three main layers: input, hidden, and output. regarding the activation function, the sigmoid function has been selected because it is efficient in reflecting the non-linear relationship among multiple factors. step 6: training the neural network. to achieve this goal, the supervised learning method has been adopted. in this method, 70% of the data have been used for training purposes, whereas the rest have been reserved for validation and testing purposes. step 7: predicting new cases of covid-19. the trained data, known as the output of the network, have been used to predict the new cases of covid-19 in the period from august 2020 until september 2020. figure 3 represents diagrammatically the structure of the neural network. it should be noted that neural network is a common artificial intelligence technique. indeed, this technique uses the idea of information flow between brain neurons, which is represented as a network via arrows and nodes. arrows represent the input details and the output information, whereas nodes stand for the neurons. usually, the nodes or neurons receive the input data, then analyze it to give suitable outputs. this straightforward movement of data from several input points is the simplest way to obtain an output. such network structure is called feedforward neural network (ff), which has been used in our algorithm. usually, feedforward neural network is either single layer feedforward neural network, as shown in the left-hand side of figure 3 , or multiple layers feedforward neural network, as shown in the right-hand side of figure 3 . in multiple layers feedforward neural network, the input layer is indirectly connected with the output layer by means of hidden layers (i.e., each layer in the network is in connection with the next layer). in particular, the input is connected to the first hidden layer, and this layer is connected to the next hidden layer. these connections move forward in this sequence until reaching to the output layer. as mentioned earlier, the neural network structure adopted in this research is feedforward neural network with multiple layers. the type of the neural network is narx neural network. the analysis of this network is based on the time-series modeling [45] . this means that it uses data obtained at successive times in the past in order to predict data in the future. therefore, it is commonly used as a predicting tool in different fields, such as predicting the solar radiations per day [46] , predicting electricity price of day-ahead [47] , and the prediction of bearing life [48] . as any neural network, input data are processed in the narx neural network through the nodes using the following function: where a(t) is the output of the narx neural network at time t. on the other hand, the values a(t − 1), a(t − 2), . . . ., a(t − n) are the outputs of the narx neural network in the past, whereas n a is the number of delays in the output. the values b(t − 1). b(t − 2), . . . , b(t − n b ) are the inputs of narx neural network, and n b is the delay in the inputs. from this equation, it is clear that, in order to get an output a(t) at time t, not only the input data is used but also the output data of the past should be used as well. for example, in order to predict the number of covid-19 tomorrow a(t), the input data besides, the predicted data of today and the past few days a(t − 1), a(t − 2), . . . ., a(t − n a ) will be used as well. as mentioned earlier, the neural network structure adopted in this research is feedforward neural network with multiple layers. the type of the neural network is narx neural network. the analysis of this network is based on the time-series modeling [45] . this means that it uses data obtained at successive times in the past in order to predict data in the future. therefore, it is commonly used as a predicting tool in different fields, such as predicting the solar radiations per day [46] , predicting electricity price of day-ahead [47] , and the prediction of bearing life [48] . as any neural network, input data are processed in the narx neural network through the nodes using the following function: after presenting the algorithm, some questions might be asked. one of these questions is "is seasonality a factor that might have an impact on the results?". before answering this question, it should be clarified here that, in most countries, we can find cities with different seasons. for example, iran has four seasons in its different cities [43] . other examples include usa, china, saudi arabia, and egypt. this observation indicates that, to consider the seasonality as a factor, the cities should be the scope of the study. since the scope of this study is not cities but countries, we have considered the month of data collection as a measure of seasonality to overcome the above situation. the proposed algorithm deals with variable population size, meaning that countries with higher population size impact more on the algorithm than lower population size countries, which can induce a high uncertainty in the predictions. the question here is "how this fluctuation was accounted for in the algorithm?" indeed, to avoid the high fluctuation in the predictions, the best parameter setting input layer output layer output layer hidden layers single layer multiple layers after presenting the algorithm, some questions might be asked. one of these questions is "is seasonality a factor that might have an impact on the results?". before answering this question, it should be clarified here that, in most countries, we can find cities with different seasons. for example, iran has four seasons in its different cities [43] . other examples include usa, china, saudi arabia, and egypt. this observation indicates that, to consider the seasonality as a factor, the cities should be the scope of the study. since the scope of this study is not cities but countries, we have considered the month of data collection as a measure of seasonality to overcome the above situation. the proposed algorithm deals with variable population size, meaning that countries with higher population size impact more on the algorithm than lower population size countries, which can induce a high uncertainty in the predictions. the question here is "how this fluctuation was accounted for in the algorithm?" indeed, to avoid the high fluctuation in the predictions, the best parameter setting for the algorithm should be used, while adopting the proposed algorithm in prediction [49] . for this purpose, the taguchi method has been adopted, as shown in section 5.2. after presenting the narx neural network-based algorithm that helps in predicting the new cases of covid-19, it is necessary to present the effectiveness of the algorithm. for this purpose, some experiments are conducted while considering the top five affected countries from each continent, as shown in table 1 . note that the experiments of this case study have been performed using an intel i5 cpu and 2.52 ghz clock speed laptop. the memory is 8 gb ram and runs the windows 10 software. in addition, the algorithm is coded in matlab2019a. the results of experiments are presented in the following subsections. before conducting the experiments of this study, we have collected the external factors that seems to affect the spread of coronavirus. these factors include population, median age index, public and private healthcare expenditure, air quality as a co 2 trend, seasonality as month of data collection, number of arrivals in the countries/territories, education index, and the month of collecting data. since our study goal is to accurately predict the number of covid-19 cases, only the most influential external factors should be considered. towards this goal, the test of hypothesis using regression analysis has been adopted using minitab software [32, 50] , in which the number of covid-19 cases and their related external factors have been collected for about 160 countries/territories. note that the regression analysis has been conducted with a significance level of 5% [32] . the results of hypothesis test are summarized in table 2 . by looking at the results presented in table 2 , it is noticed null hypothesis h 0 related to hypotheses # 1, 2, 4, 6, 7, and 8 is rejected, and the alternative hypothesis h 1 is picked. this means that the external factors like population, median age index, private healthcare expenditure, number of arrivals, education index, and month of collecting data have a significant effect on the number of covid-19 cases. this is because p-values of these factors, which appear in boldface, are lower than the significance level, which is 5% in this study. in contrast, the null hypothesis h 0 related to hypotheses # 3 and 5 cannot be rejected, meaning that alternative hypothesis h 1 is rejected. this indicates that external factors like public healthcare expenditure and co 2 trend do not have significant effect on the number of covid-19 cases. based on the above test of hypothesis, our experiments are further conducted while considering only the significant external factors, meaning considering all the factors except public healthcare expenditure and co 2 trend. after selecting the most influential factors, it is the time for conducting the prediction experiments. however, before doing so, the best parameter setting of narx neural network-based algorithm should be determined. towards this end, the most influential parameters are selected, and their corresponding levels are determined [33, 51, 52] , as shown in table 3 . to select the best parameter settings, taguchi method has been utilized as it is one of the effective tools in determining the best parameter settings by applying an orthogonal array and signal-to-noise (s/n) ratios [49, [51] [52] [53] . the orthogonal array approach can be defined as an economic approach that is commonly adopted with an objective of minimizing the number of conducted experiments. the s/n ratio can be described as a performance indicator that indicates the quality of each conducted experiment. since our taguchi experiment includes four parameters with three levels, the orthogonal array l 9 should be selected in our experiments, which have been conducted using minitab software. figure 4 illustrates the average s/n ratio of the selected parameter at each level, while using our proposed algorithm. since our algorithm aims at predicting the covid-19 cases, the objective in this study is to minimize the error between the predicted and real values. based on this observation, the parameter level should be selected based on the smaller is better criterion. this means that the level with small average s/n ratio is better than the level with higher average s/n ratio. by applying this criterion in figure 4 , the best level for the parameters 1, 2, 3, and 4 should be set at are levels 2, 3, 3, 2, respectively. these levels appear in a boldface in table 3 . in this section, we report the performance of the narx neural network-based algorithm. it should be noted that the performance of the algorithm has been evaluated using a commonly used performance indicator, called root mean square error (rmse) [44] . the rmse is used to reflect the error between real and predicted values of covid-19 cases. besides, the correlation has been calculated to indicate the closeness of the predicted data to observed data. to select the suitable correlation test, the normality of the observed and predicted covid-19 cases should be checked. by doing so, it has been noticed that both the observed and predicted covid-19 cases are not normally distributed. this observation naturally leads to using spearman correlation test [54] [55] [56] . to measure the model uncertainty, the error standard deviation has been calculated [57] . details of the results are presented in table 4 . by looking at table 4 , it is noticed that the value of the rmse is low in most african and asian countries. this is because the values of predicted and real cases are a bit low if compared with other countries. it is also observed that that the value of the rmse is a bit large in some countries like usa, spain, and china. for instance, rmse = 420 while considering usa. at a first glance, an rmse value of 420 can give the impression of a large difference between predicted and real values, implying a poor performance of the proposed algorithm. indeed, 420 is not that big at all, because predicted or real values reach up to 48,529. thus, 420 is not a big figure if compared with 48,529, meaning that the performance of the algorithm is still reasonable, while handling a large number of covid-19 cases. to summarize, we can say that the proposed algorithm produces large rmse when the real and predicted values are large, and vice versa. this indicates the consistency and robustness of the proposed algorithm. in this section, we report the performance of the narx neural network-based algorithm. it should be noted that the performance of the algorithm has been evaluated using a commonly used performance indicator, called root mean square error ( ) [44] . the is used to reflect the error between real and predicted values of covid-19 cases. besides, the correlation has been calculated to indicate the closeness of the predicted data to observed data. to select the suitable correlation test, the normality of the observed and predicted covid-19 cases should be checked. by doing so, it has been noticed that both the observed and predicted covid-19 cases are not normally distributed. this observation naturally leads to using spearman correlation test [54] [55] [56] . to measure the model uncertainty, the error standard deviation has been calculated [57] . details of the results are presented in table 4 . regarding the correlation, it is observed that the correlation factor is larger than 0.9 in all countries with p-value of zero. this means a strong positive significant correlation between the observed and predicted data, which indicates a closeness of the predicted data to the observed data. this reflects the high accuracy of the proposed algorithm. by looking at the error standard deviation, it indicates low error variability in countries characterized with low number of covid-19 cases and vice versa. this confirms the stability and reliability of the proposed algorithm. after presenting the performance of the proposed algorithm, there is a question that might be asked here, "what is the advantage of the proposed algorithm over the existing traditional method in the literature?". to answer this question, our experiments have been further extended to make a comparison between our proposed algorithm and the traditional method that can be represented in the study by chen et al. [17] . note, both studies have the same objective, which is predicting the number of covid-19 cases. however, both studies are different in their considered factors. the study by chen et al. [17] has only focused on historical data of the number of covid-19 cases while considering a limited number of factors, like travel and occupation. in contrast, our study has the same focus as the study chen et al. [17] , besides, it has considered many external factors that overlooked in their study. these factors include population, median age index, public healthcare expenditure, private healthcare expenditure, air quality as a co 2 trend, education index, and seasonality as month of collecting data. the experiment results obtained from both approaches are summarized in table 5 . by looking at table 5 , the results show that the narx neural network-based algorithm is more accurate than the traditional method. this outperformance is due to considering more factors that affect the spread of covid-19, such as the external factors like the population, the health expenditures, and others. this results in an accurate prediction for the proposed algorithm. in contrast to the proposed algorithm, the traditional method only focusses on the historical data and neglect many external factors. hence, some important factors that affect the spread of the virus are neglected, leading finally to a poor prediction of the number of covid-19 cases. this section establishes that the proposed algorithm gives improved results when compared with the traditional method. thus, the significance of utilizing this algorithm in real practice is further affirmed. so far, we have presented the performance of the proposed algorithm and its advantage over the existing methods. it is fine, but still, there are some questions that have not been answered like "what next in the future?", "how can we benefit from the algorithm in predicting future cases of covid-19?", "when will coivd-19 end?". answering these questions necessitates extending our experiments, in which we use the trained data to predict the number of future cases of covid-19. in the experiments of the previous sections, we observe that in the countries that control the spread of covid-19, the peak in the number of daily cases appeared after 3-4 months. this observation has been taken as a reference to predict future covid-19 cases in the countries where the disease is yet to peak. it is interesting to recall that the future prediction has been done for about two months, in the period from august 2020 until september 2020. the results of these experiments are presented in figures 5-8 , which represent the future predictions in europe, north and south america, asia, and africa, respectively. after presenting the future prediction of covid-19 cases in european countries, we have some observations, which are outlined as follows: • in most european countries, like italy, uk, and russia, the number of cases has already reached its peak before our future prediction. based on this observation, we predict that the number of future coivd-19 cases will decrease gradually during the period from august 2020 until september 2020. it is worth to mention that our predicted reduction in the number of covid-19 cases appear during august 2020. the abovementioned reduction is because of strict compliance with the precaution guidelines established by who. in contrast to most of european countries, the situation in spain and france is quite similar, as the number of cases has raised recently and formed another peak. in spain, the second peak has been already formed, therefore, our algorithm predicts a gradual decrease during the period from august 2020 until september 2020. in france, the algorithm predicts a slight increase followed by a gradual decrease in the number of cases during the same period. by looking at figure 6 , some observations can be summarized as follows: • in the case of usa, the number of covid-19 cases has already formed its second peak by mid of july 2020. therefore, we have predicted a slow reduction in the number of future covid-19 cases. this prediction, in terms of reduction, appears in the usa during the first half of august 2020. it should be noted that this slow reduction is because of the dysfunction experienced in the healthcare system of the usa [59] . in the case of brazil, we observe that the peak has been reached. then, we predict that the number of future covid-19 cases will experience a wavy reduction during the period from august 2020 until september 2020. it is important to mention that the predicted slow reduction in future covid-19 cases agrees with the actual reduction realized during august 2020. this wavy reduction is due to overlooking the social distancing instructions by most of brazilian residents [60] . in case of canada, the number of covid-19 cases has reached its peak since beginning of may 2020. therefore, it is reasonable to predict a gradual decrease in the number of cases during the period from august 2020 until september 2020. in the case of peru, we observe an increase in the number of covid-19 cases by july 2020. then, we predict that, during the period from august 2020 until september 2020, this increase will continue a bit before a decline in the number of future covid-19 cases. this increase is due to the bad behavior of the people, so that the situation becomes even worse during those days [61] . • in the case of ecuador, we predict the number of future covid-19 cases will keep its wavy motion, meaning that the number will tend to zero and increase again. this wave appears because there is no transparency in the reported number of covid-19 cases, meaning that the government has not disclosed the real number of covid-19 cases [62] . reached the peak. our algorithm predicts a gradual reduction in the number of future covid-19 cases, which has been realized during august 2020. the situation in india is completely different compared to the rest of asian countries. this is because india is yet to reach its peak. based on this observation, we predict that the increase in the number of covid-19 cases will continue during the period from august 2020 until september 2020. after presenting the future prediction of covid-19 cases in european countries, we have some observations, which are outlined as follows: • in most european countries, like italy, uk, and russia, the number of cases has already reached its peak before our future prediction. based on this observation, we predict that the number of future coivd-19 cases will decrease gradually during the period from august 2020 until september 2020. it is worth to mention that our predicted reduction in the number of covid-19 cases appear during august 2020. the abovementioned reduction is because of strict compliance with the precaution guidelines established by who. in contrast to most of european countries, the situation in spain and france is quite similar, as the number of cases has raised recently and formed another peak. in spain, the second peak has been already formed, therefore, our algorithm predicts a gradual decrease during the period from august 2020 until september 2020. in france, the algorithm predicts a slight increase followed by a gradual decrease in the number of cases during the same period. by looking at figure 6 , some observations can be summarized as follows: • in the case of usa, the number of covid-19 cases has already formed its second peak by mid of july 2020. therefore, we have predicted a slow reduction in the number of future covid-19 cases. this prediction, in terms of reduction, appears in the usa during the first half of august 2020. it should be noted that this slow reduction is because of the dysfunction experienced in the healthcare system of the usa [59] . in the case of brazil, we observe that the peak has been reached. then, we predict that the number of future covid-19 cases will experience a wavy reduction during the period from august 2020 until september 2020. it is important to mention that the predicted slow reduction in future covid-19 cases agrees with the actual reduction realized during august 2020. this wavy reduction is due to overlooking the social distancing instructions by most of brazilian residents [60] . in case of canada, the number of covid-19 cases has reached its peak since beginning of may 2020. therefore, it is reasonable to predict a gradual decrease in the number of cases during the period from august 2020 until september 2020. in the case of peru, we observe an increase in the number of covid-19 cases by july 2020. then, we predict that, during the period from august 2020 until september 2020, this increase will continue a bit before a decline in the number of future covid-19 cases. this increase is due to the bad behavior of the people, so that the situation becomes even worse during those days [61] . in the case of ecuador, we predict the number of future covid-19 cases will keep its wavy motion, meaning that the number will tend to zero and increase again. this wave appears because there is no transparency in the reported number of covid-19 cases, meaning that the government has not disclosed the real number of covid-19 cases [62] . after presenting the results of asian countries, we have the following observations: • china is one of the few cases that has fully controlled the situation. this is apparent as the number of future covid-19 cases is almost zero. thanks to the chinese government and medical system, strict typical quarantining measures have been implemented, thus, leading finally to overcoming this hard time. the situation in turkey, iran, and saudi arabia is like other european countries that have reached the peak. our algorithm predicts a gradual reduction in the number of future covid-19 cases, which has been realized during august 2020. the situation in india is completely different compared to the rest of asian countries. this is because india is yet to reach its peak. based on this observation, we predict that the increase in the number of covid-19 cases will continue during the period from august 2020 until september 2020. by looking at figure 8 , we can draw the following observations: • most of african countries are quite similar, except morocco, as the peak of covid-19 cases has already appeared. it is predicted that the future number of covid-19 cases will decrease gradually, during august and september 2020. so far, the trend of our predicted graph has been realized in the aforementioned african countries. in contrast to the above-mentioned african counties, in morocco, the peak of covid-19 cases has not yet appeared. therefore, the future number of covid-19 cases will continue its increase during august and september 2020. it is important to mention that this increase has been realized during the first half of august 2020. based on the above observations, we outline some recommendations, which are as follows: • it is recommended for the people living in the usa, brazil, ecuador, peru, and india to strictly follow the precautions instruction recommended by who. this includes quarantining infected people, whereas healthy people should stay home to avoid covid-19 infection, and when they go out, they should follow the rules of social distancing. it is recommended for the government and healthcare system of countries like the usa and brazil to raise their private and public health expenditures to control the number of future coivd-19 cases. in addition, penalties may be applied to the people who violate the instructions recommended by who. it is recommended for the government of ecuador to release the correct number of covid-19 cases so that the people can understand the severity of the situation and obey the health guidelines released by who. in the countries that fully or partially control the covid-19 like china, it is recommended for the people to keep following the medical instructions. otherwise, covid-19 may come back in a mutated form causing another global pandemic. this study investigates how new covid-19 cases can be predicted while considering the historical data of covid-19 cases alongside the external factors that affect the spread of the virus. to do so, data analytics was adopted by developing a nonlinear autoregressive exogenous input (narx) neural network-based algorithm. the effectiveness and superiority of the developed algorithm are demonstrated by conducting experiments using data collected for top five affected countries in each continent. the results show an improved accuracy if compared with the existing methods. moreover, the experiments are extended to make future prediction of the affected covid-19 cases during the period from august 2020 until september 2020. the predicted covid-19 cases help in providing some recommendations for both the government and people of the affected countries. this study provides a novel way for predicting the number of covid-19 cases. however, there are some venues that might be suitable for future directions. for example, predicting the number of deaths could be one direction. another direction might be predicting the number of recovered people. one of the fruitful ideas is predicting the number of covid-19 cases in the top affected cities, while considering the 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environ. res. public health 2020, 17, 7080 key: cord-317667-8ya8tvv2 authors: garcía-fernández, jerónimo; gálvez-ruiz, pablo; grimaldi-puyana, moisés; angosto, salvador; fernández-gavira, jesús; bohórquez, m. rocío title: the promotion of physical activity from digital services: influence of e-lifestyles on intention to use fitness apps date: 2020-09-18 journal: int j environ res public health doi: 10.3390/ijerph17186839 sha: doc_id: 317667 cord_uid: 8ya8tvv2 e-lifestyles are individual forms of behavior in the digital environment that reflect the values, activities, interests, and opinions of consumers. likewise, fitness apps are considered technological tools for promoting physical activity online. although there are studies related to sports lifestyles, it has not been analyzed yet how e-lifestyles are related to the use of fitness apps. based on this, this study represents a step to clarify how e-lifestyles influence different relationships with perceived ease of use, perceived usefulness, attitude, and intentions to use fitness apps. therefore, the objective of the study was to analyze the relationship between the e-lifestyles of consumers of boutique fitness centers and their relationship with the perceived ease of use, the perceived usefulness, the attitude, and the intention to use fitness apps. the sample was 591 customers (378 women and 213 men) of 25 boutique fitness centers. an online questionnaire was used for data collection. data was analyzed with confirmatory factor analysis and structural equation model. findings provide an insight into the importance of e-lifestyles in the intention of using fitness apps and therefore in promoting physical activity through online fitness services. the results showed positive relationships between e-lifestyles, perceived ease of use, perceived usefulness and attitude toward fitness apps. finally, the attitude toward fitness apps offered a very high predictive value on use intention. this study provides a better understanding of consumer´s intention to use fitness apps. the conclusions and recommendations for sports managers of fitness centers highlight the importance of e-lifestyles as a predecessor for the use of fitness apps. the sports sector has become a highly competitive and sometimes saturated market in some of its areas, like physical education teachers or public administration [1] . this influences the development of strategies that allow organizations to generate a differential advantage over their competitors, positioning them in a specific offer within the market [2] . specifically, the fitness sector, framed in the sports sector, is constantly being updated, and new models of specialized gyms are emerging. these new fitness facilities are adapting to new business proposals that tend toward professionalism, cost control, and the ability to increase income from various sources, called boutique fitness centers [3, 4] . lifestyles are distinctive patterns of behavior; understanding these patterns in a broad and global sense [13] involves people's physical and psychological environments [14] . thus, they are based on a large number of individual demographic, domestic, leisure, and professional variables [15] . these behavior patterns are specified in the way in which people invest their time and money, in their interests, and in their vital priorities, among other aspects [16, 17] having an impact on consumer health [18] . specifically, regarding consumer behavior, the decisions made are determined by cultural patterns [19] , purchasing power, personality, motivation, or family history [20] . the segmentation of lifestyles is considered an extension of psychographic segmentation based on the study of consumer interests, opinions, and daily activities [21] . according to the literature, some authors used sociodemographic variables such as age, gender, education, or income level to classify mobile device users [22, 23] . however, gonzález and bello [24] and yang [10] state that the sociodemographic variables are limited for the study of users' consumption patterns. thus, the segmentation of consumers according to their lifestyles helps to know and predict their consumption behaviors [25, 26] . zaheer and kline [14] highlight the importance of lifestyle segmentation due to its limited literature [14, 20, 21, 27, 28] . for this reason, it is possible to find works that have used the segmentation of the population according to their lifestyles in sectors as diverse as tourism, organic products, shopping centers, cinema, the financial sector [29] , world fashion [30] , the pharmaceutical industry [31] , and even the sports sector [32] . specifically, suresh et al. [32] claim to be able to determine the loyalty of external clients of wellness centers through marketing strategies based on segmentation according to lifestyles. in the context of technology consumption, hoon et al. [33] postulated that electronic lifestyles could differ from traditional lifestyles and therefore should be studied specifically and independently of the former. technological innovations and the evolution of smartphones have generated a new dimension of electronic lifestyle associated with products and services based on information and communication technologies [34] . for hoon et al. [33] and yu [2] , e-lifestyles are individual forms of behavior in the digital environment that reflect the values, activities, interests, and opinions of consumers. in line with this recommendation, lee et al. [27] identified four e-lifestyle factors: fashion consciousness, leisure orientation, internet involvement, and e-shopping preferences. fashion consciousness is defined as the level of involvement of a person with fashion and prevailing trends [35] . this implication has been shown to affect decision making regarding the consumption of technological products [36, 37] . leisure orientation reflects patterns of the active pursuit of intrinsically motivating activities to spend free time on. for its part, internet involvement reflects behavior patterns focused on what is digital, so that the person makes extensive use of the internet both for their work (for example, searching for information or sending a large number of emails) and for the rest of personal facets (for example, using online entertainment systems) [27, 34] . finally, e-shopping preference is related to the tendency of certain consumers to purchase products and services digitally rather than through traditional systems [38] . although these e-lifestyles are changing consumption patterns, it is necessary to understand what theories are related to understanding the associated variables. in fact, these relationships between e-lifestyles and digital consumption have been strongly linked to different technological theories, helping to understand people's behavior toward information and communication technologies and their use. the theory of reasoned action (tra) [39] explains the relationship between people's attitudes, their behavioral intention, and their actual behavior, the latter influenced by the subjective social norm. based on this theory, davis [40] developed the technology acceptance model (tam) with the aim of explaining how consumers use and accept new information technologies. the tam relates two concrete base factors, the perceived ease of use (peu), and the perceived usefulness (pu), with the consequent intention of behavior and the subsequent real behavior of the individual. peu can be defined as the cognitive and deliberative level that is required of the individual to learn to use technology [41] . that is, the effort that the user must make-or not-to use the technology [42] . pu is defined as the degree to which people believe that a certain system will help perform a certain task [43] , usually the degree to which it will simplify their work [42] . the importance of this model is the positive relationship between its variables and its influence on attitudes toward technology and the intention to use it [44, 45] . for this reason, the tam has been one of the most traditionally used models in professional settings thanks to its great robustness and applicability [9, 46] , paying special attention to the utilitarian aspect of the technology [47] and with the intention of understanding the consumer's intention to use it [48] . the model has shown its utility by explaining the use of mobile technology in different contexts such as finance, instant messaging, healthcare, gambling, and tourism [9] . in the sports sector, there are some studies that have analyzed these variables, finding relationships between peu and pu [49, 50] , peu and pu on the intention of use [25, 49, 51] , or the intention of use and the actual use of the app [12] . likewise, they have been analyzed in different sport contexts, such as sports websites [52] , fitness apps [49] , sports products [53] , sport teams apps [51] , or smartphone use for sports consumption [50] . finally, the model has been influenced by other external variables, such as social norms [49] , health awareness [54] , commitment to or participation in sport [50] , and entertainment [55] , and sociodemographic variables, such as gender, age, or frequency of use [53] . in this way, research with tam has determined that peu and pu are influenced by different external variables. however, it is not known whether lifestyles or e-lifestyles could also affect these relationships in the fitness context. coursaris and van osch [15] state that the relationship between e-lifestyles and the intention to use technologies has not been widely studied. still, there are some works that have linked e-lifestyles with the use and acceptance of new technologies, using tam as a theoretical basis (i.e., [27, 42, 56] ). thus, it has been suggested that e-lifestyles determine attitudes that can affect the intention to use information and communication technologies [15, 27, 37, 57] . kim and lee [42] relate e-lifestyles with motivation and the intention to use in apps advertising, finding four different profiles of consumers according to their e-lifestyle, where motivation significantly influenced peu and pu as well as the future intention of use. for their part, pan et al. [56] indicated that lifestyles can also influence consumer adoption intention and behavior through factors such as aesthetics, compatibility, or work. specifically, e-lifestyle characterized as fashion consciousness has been shown to have a positive impact on the peu and pu of consumers of technological products [27, 56] . furthermore, it has been shown to have a positive impact on the intention to purchase high-end technology products [27] as well as digital services [37] . regarding the leisure orientation lifestyle, consumers with this e-lifestyle perceived technological products as more useful for creating intrinsically motivating moments than consumers with low leisure orientation, correlating with the intention of adopting high-end technological products [27] . thus, an e-lifestyle highly involved with the use of the internet positively correlates with the peu and the pu of online banking consumers [58] . along these lines, consumers with a high technological knowledge better understand the product and are more likely to be involved in the purchase of these devices [59] . finally, e-lifestyles and the trend toward online shopping have changed consumer behaviors [60] . hence, lee et al. [27] point out that an e-lifestyle tending to online shopping positively correlates with the pu of technological devices. based on the literature review, we developed the following five hypotheses ( figure 1 ): there is a direct and positive relationship between e-lifestyle and peu in boutique fitness centers customers. there is a direct and positive relationship between e-lifestyle and pu in boutique fitness centers customers. there is a direct and positive relationship between peu and pu in boutique fitness centers customers. there is a direct and positive relationship between peu and attitude toward fitness apps in boutique fitness centers customers. there is a direct and positive relationship between pu and attitude toward fitness apps in boutique fitness centers customers. there is a direct and positive relationship between attitude toward fitness apps and intention to use in boutique fitness centers customers. according to different studies and international organizations, the fitness sector is a growing market [8]. among the different fitness business models that exist in the industry, in recent years low-cost fitness centers have been those that have had the greatest increase in the volume of fitness facilities and consumers. however, europe active [61] has reported that there has been a notable increase in boutique fitness center chains that have created a new situation in the fitness sector. these chains of boutique fitness centers are characterized by the personalization of the service, they are social, they are trendy, and they help members achieve fast results [3] . spain is one of the countries with the highest market penetration in the fitness sector [8], having created chains of boutique fitness centers. among them, sano center was created in 2014 and currently has more than 50 centers located in spain and mexico. its positioning is due to the high personalization of its services, a highly individualized study of the client's objectives, and a team of professionals specialized in physical activity, who design programs based on the physical characteristics of the client and help users find their objectives in a personalized way. to track and prescribe training in a digital format, the chain of boutique fitness centers uses an app from a university spin-off called fitbe. this app allows the visualization of the exercises, the realization of directed classes in streaming and the interaction with clients through video calls. the sample is made up of 591 customers (378 women and 213 men) from the boutique fitness center chain, sano center. the inclusion criteria to participate in the study was that the customers had downloaded the specific fitness app from sano center. of the sample, 4.6% (n = 27) were under 20 years old, 25.7% (n = 152) between 21 and 30 years old, 34.2% (n = 202) between 31 and 40 years old, 28.0% (n = 168) between 41 and 50 years old, and 7.1% (n = 42) were over 50 years old. with respect to length of membership, 26.4% (n = 156) had been less than three months as a customer, 18.8% (n = 111) between three and six months, 27.9% (n = 165) between six and twelve months, and 26.9% (n = 159) over one year. in turn, it is worth noting that 56% (n = 331) attend twice a week and 36.7% (n = 217) three times a week. a questionnaire instrument was developed using prior research [9, 38, 51, 62] . the questionnaire included demographic questions and a total of 34 items grouped into two sections. the first section consisted of scales to measure customer e-lifestyles [27] . three items measured fashion consciousness (e.g., "design is the most important factor in choosing electronic products"), four measured leisure orientation (e.g., "i thoroughly enjoy my leisure time"), internet involvement was measured by four items (e.g., "i spend less time watching tv because of the internet"), and seven items measured e-shopping preference (e.g., "i enjoy buying things on the internet"). the customers had to evaluate the perception of the specific fitness app from sano center. thus, the second section consisted of 12 items proposed by kim and chiu [63] to evaluate perceived ease of use (4 items; e.g., "fitness apps are easy to use"), perceived usefulness (4 items; e.g., "using fitness apps improves my exercise experience"), and intention to use (4 items; e.g., "i will use fitness apps on a regular basis in the future"). to evaluate attitude toward fitness app, we used the scale proposed by rivera et al. [9] with 4 items (e.g., "using fitness apps is a good idea"). a five-point likert scale with a range from "completely disagree" (1) to "completely agree" (5) was used for possible responses. the boutique fitness center chain, sano center, was contacted to inform them of the study and the intended objectives. after two meetings with the general management and the sports and marketing managers, it was decided to ask the managers of each fitness facility if they wanted to participate in the study. after the approval of 25 centers belonging to the boutique fitness centers chain, the online questionnaire was sent to each of the facilities. finally, each director sent the questionnaire to his/her customers. google forms was used to collect information. all the participants were guaranteed personal confidentiality and informed of the importance of their honesty in answering the questions and the voluntary nature of participating in the research. once all the information was collected, it was combined into a single database to be able to use it for data analysis. the information collection period lasted three months. we calculated descriptive statistics (means and standard deviation). the normality of the data (univariate skewness and kurtosis), with values smaller than the criterion 3 and 7, respectively [64] , supported the normality for structural equation model (sem) analysis. we performed a maximum likelihood method of estimation for structural equation modeling using the amos 21.0 (21.0, ibm spss, chicago, il, usa), procedure recommended by joreskog and sorbom [65] for conducting path analysis. first, we conducted confirmatory factor analysis (cfa) to test the psychometric properties for the measurement model. second, we conducted a sem that analyzed the predicted hypothesized relationships between the variables for the present study. in the above sem (figure 1 ), four reflective variables and corresponding observing variables constitute the intention of using the evaluation model in the context of the present study. for both analyses, we used the following goodness-of-fit indexes: the ratio of the chi-square to its degrees of freedom (χ 2 /df), the root mean square error of approximation (rmsea) and the respective confidence interval (90% ci), the comparative fit index (cfi), the tucker-lewis index (tli), and the parsimony comparative fit index (pcfi). for these indexes, the following cut-off values were adopted: χ 2 /df ≤ 3 [66] , rmsea ≤ 0.08 [67, 68] , cfi and tli ≥ 0.90 [69, 70] , and pcfi ≥ 0.80 [71] . internal consistency was calculated via composite reliability, adopting 0.70 as the cut-off value [69, 72] . convergent validity was examined through an average variance extracted calculation (ave ≥ 0.50; [72, 73] ), while discriminant validity was established when the ave for each construct exceeded the squared correlations between that construct and any other [72, 74] . there were no missing values in the data and an item-level descriptive statistics showed no deviations from univariate normality in any of the items (all the skewness and kurtosis values were lower than 3 and 7, respectively). confirmatory factor analysis was performed on the measurement model and found to have excellent goodness-of-fit statistics: χ 2 (499) = 1083.90 (p = 0.000); χ 2 /df = 2.17; rmsea = 0.060 (ci = 0.055, 0.065); cfi = 0.93; tli = 0.92; pcfi = 0.82. the χ 2 /df value was situated below the minimum acceptable value of 3.0. the rmsea index offered a good adjustment obtaining an index of 0.08. the cfi and tli values were greater than the minimum recommended threshold of 0.90, and the pcfi index was above the good adjustment threshold 0.80. this is satisfactory evidence of proportional adjustment. the size of the factor loading is a criterion used to evaluate the reliability of the indicator with the constructs it intends to measure [75] . for this reason, the items were maintained with a factorial loading (λ) greater than the conservative threshold of 0.50 [76] , and items not loading properly were eliminated. all the values, except three items (leisure orientation 4: λ = 0.12; internet involvement 10: λ = 0.24; e-shopping preference 17: λ = 0.34), were greater than 0.50, so when eliminating them, the overall fit indices indicated the robustness of the resulting measurement model: χ 2 (406) = 878.79 (p = 0.000); χ 2 /df = 2.16; rmsea = 0.059 (ci = 0.054, 0.065); cfi = 0.94; tli = 0.93; pcfi = 0.83. all the factor loadings were statistically significant (p < 0.01), and also the z-values ranged from 10.80 to 34.47, indicating that the items accurately captured their respective factors [77] . in this sense, evidence of the measures' validity is provided by the fact that all factor loadings are significant and above 0.5, suggesting high levels of internal consistency and adequate item reliability [76] as seen in table 1 . the composite reliability (cr) for all the constructs ranged from 0.75 to 0.97 (values above the recommended 0.70), and average variance extracted (ave) ranged from 0.50 to 0.89 (greater than the prescribed 0.50). as shown in table 2 , fashion consciousness has lower mean scores, while leisure orientation presents the highest average of the four e-lifestyle factors. the discriminant validity of the measures was accepted given that the square correlations between each construct and any others were lower than de ave values for each construct [72] . we estimated the hypothesized model and the standardized regression weights for the causal paths as presented in table 3 . the results indicate support for all the causal relationships except h2 and h4, along with excellent goodness-of-fit for the causal model: χ 2 (424) = 942.59 (p = 0.000); χ 2 /df = 2.23; rmsea = 0.061 (ci = 0.056, 0.066); cfi = 0.93; tli = 0.93; pcfi = 0.85. the hypothetical model established that e-lifestyles were positive and significant predictors of the perceived ease of use but were not significant concerning the perceived usefulness. however, the perceived usefulness was shown to be a strong predictor on the attitude toward mobile apps, which does not occur with perceived ease of use. finally, the attitude toward mobile apps offered a very high predictive value on intention to use. regarding the invariance of the measurement model across genders, the results showed that it is invariant. furthermore, as demonstrated in table 4 , ∆cfi, ∆rmsea, and ∆nnfi were acceptable according to [78] recommendations for measurement invariance. despite measurement invariance in our results, it is possible to observe that the residual invariance score calculated by ∆cfi in all the models was >0.01 [78, 79] . note. χ 2 = chi-squared: df = degrees of freedom; ∆χ 2 = differences in the value of chi-squared; cfi = comparative fit index; srmr = standardized root mean square residual; rmsea = root mean square error of approximation; ci = configural invariance; mi = measurement invariance; si = structural invariance; ri = residual invariance. the sports industry, and in particular the fitness sector, has always been linked to the promotion of healthy habits and the promotion of physical activity. specifically, the fitness sector aims to provide fitness services that foster people's quality of life. these fitness services have been offered from business models that back low-cost [80] to highly personalized business models that are conceptualized as boutique fitness centers [3, 4] . likewise, until now, fitness services have been eminently face-to-face, but the new situation caused by the covid-19 pandemic has meant that fitness services can also be online, and therefore, technology can become a great ally for the promotion of physical activity. in fact, people's consumption has been transformed by a more technological lifestyle that could therefore change the perspectives and the promotion of physical activity [81] . that is why e-lifestyles and the promotion of physical activity could be closely linked. thus, the promotion of physical activity is being offered from online fitness services through mobile apps [82] . with this premise, the objective of this work was to analyze the relationship between the e-lifestyles of consumers of boutique fitness centers and the perceived ease of use, the perceived usefulness, the attitude, and the intention to use fitness apps. some authors have indicated that lifestyles can be summarized in behavioral patterns linked to the investment of time, money, or interests, which could in turn have an impact on consumer health [17, 18] . specifically, e-lifestyles refer to people's behaviors in which interests, activities and opinions are observed in the digital environment [28, 33] . thus, the findings of this study have helped to understand how e-lifestyles are linked to technological behaviors in relation to fitness apps and could therefore favor the prediction of fitness consumption behaviors [26] . similarly, these results have highlighted the importance of the analysis of e-lifestyles, which are currently changing fast and are therefore necessary to analyze [83] . thus, among the theories with the greatest recognition in relation to the understanding of the intention to use technologies, this study opted for the tam [40] . the importance of the model lies in the acceptance by the literature of the positive relationship between ease of use and the perceived usefulness regarding attitudes toward technology and the intention to use them. in fact, it is a model that presents great robustness and applicability in numerous sectors [9] . in particular, the findings found in this study have shown a positive relationship between e-lifestyles and the perceived ease of use fitness apps. hence, these results have coincided with works carried out in other sectors [27, 56, 58] , which makes this study the first to corroborate such findings in the sports sector and, more specifically, in the fitness sector. in fact, lee et al. [27] stated that there was a positive relationship between e-lifestyles and the intention to use apps in high-technology products, as pan et al. [56] and boateng et al. [58] showed for online banking. for this reason, this study reduces the research gap in the sports management literature, as it stated that e-lifestyles have a positive effect on the intentions to use fitness apps. that is why this research, firstly, gives an important role to e-lifestyles as predecessors of the mobile applications´use, and secondly, it provides knowledge of this relationship in the fitness sector, in particular in relation to the use intention of fitness apps. thus, so far, there are no studies that have shown these relationships in the fitness sector, even though it is considered as a sector in global growth [8] . however, the results did not coincide with previous studies in relation to their influence on the perceived usefulness [27, 58] , which suggests that the usefulness of fitness apps is not conditioned by e-lifestyles. in fact, these findings show that e-lifestyles linked to online shopping preferences, the use of technology as an extensive aspect of daily life or work, or the level of involvement by a technological trend, would directly influence the perceived ease of use fitness apps but not the final perceived usefulness offered by these virtual tools. likewise, this study has shown that if e-lifestyles are directly related to the perceived ease of use fitness apps, they would later also be related to the perceived usefulness of the apps. these relationships therefore confirm previous studies in the sports sector in which perceived ease of use has a positive and direct relationship with the perceived usefulness of fitness apps [49] . that is why the perceived ease of use would mediate between e-lifestyles and the perceived usefulness of fitness apps. in fact, the findings found after the analyses are interesting, since no positive relationships were found between perceived ease of use and attitudes toward fitness apps. for this reason, the results do not corroborate what was previously studied [49, 51] , so it is suggested that e-lifestyles could have an indirect impact on these relationships. thus, previous studies that affirmed positive relationships between perceived usefulness and attitudes toward fitness apps were corroborated by this work, also resulting in a positive relationship with the intentions of use [49, 51] . these results have contributed to a gap that existed in the academic literature on the history of the use of fitness apps. in fact, authors such as ha et al. [50] showed that there were no research works that had investigated the factors or behaviors that conducted sports consumers to use sports apps. thus, as with previous authors [27, 37, 57] , this study's findings have shown that the use intentions of fitness apps could be conditioned initially by e-lifestyles and that perceived ease of use and the perceived usefulness would mediate the attitudes and intentions of using fitness apps. as practical applications, this study confirms the prominent role of e-lifestyles as predictors of fitness app adoption. therefore, it is the first related study that highlights the importance of values and behaviors in the digital environment for people to use fitness apps. understanding the effects of e-lifestyles on the adoption of fitness apps could allow fitness centers to emphasize the benefits' characteristics of practicing online fitness services. in fact, this aspect is very important due to the long periods of confinement that have occurred due to the covid-19 pandemic. the results of the study have provided knowledge that the use of fitness apps, and therefore the consequences of practicing physical activity through these technological tools, is influenced by technological preferences and consumers' knowledge of them. for this reason, if the fitness centers' managers use fitness apps in order to prescribe and control the fitness services, they should train and adapt consumers to technological habits. for example, advertising campaigns for fitness centers could highlight the importance and benefits of using technology in fitness centers. this fact would provoke changes in e-lifestyles, favoring their involvement in the ease of use of fitness apps. thus, it is logical to think that consumers with more developed e-lifestyles also have a greater perception of ease of use and therefore lead to a greater intention to use fitness apps. therefore, the promotion of online fitness services ought to be associated with strategies that increase perceived ease of use and perceived usefulness, since this would lead to a greater use of these sports technologies and therefore a greater promotion of online fitness services. like all research work, this study has a number of limitations. firstly, the sample used belongs to a business model in the fitness sector where the ages included were under 50 years old. this situation could result in different behaviors and e-lifestyles to other older population groups, and therefore, the relationships between the variables could also be different. the results have also been tested from a participants´sample from a specific country and business model (boutique). this fact could interfere with the generalization of the findings due not only to the digital culture of the participants themselves but also to the use of the fitness app in the fitness chain where the study hypotheses have been studied. similarly, the model tested has used e-lifestyles as a second order variable, which could reduce the resulting information. that is why although it is one of the first investigations to study these relationships in fitness apps, the results could be basic in terms of the relationships between the variables analyzed. likewise, the relationships between e-lifestyles and the variables proposed in the tam model have been tested. although the tam model has been the most referenced and used in the fitness sector [84] , it could be improved by the inclusion of other variables. these limitations help to understand what the future lines of research could be. in particular, the model tested could be applied to other business models in the fitness sector and therefore characterized by different population groups. possibly, the e-lifestyles of the youngest would be different from those of the oldest, and therefore, the relationships obtained could differ. likewise, it would be interesting to investigate separately the relationships of the different e-lifestyles (fashion consciousness, leisure orientation, internet involvement, and e-shopping preference) and perceived ease of use and perceived usefulness, since it has been seen that such relationships could be modified separately. furthermore, the separate analysis of e-lifestyles could help to understand consumer segmentations and their intention to use fitness apps. finally, an analysis with other models that predict the use of technologies in the fitness industry could help to comprehend the relationship of e-lifestyles with other variables that predict the intention of using fitness apps and would therefore promote physical activity. this study analyzed the relationships between e-lifestyles and the final intention to use fitness apps. to do so, the model tested included mediating variables such as perceived ease of use, perceived usefulness, and attitudes toward fitness apps. having carried out analyses, and in light of the findings, it can be concluded that e-lifestyles influence perceived ease 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research: a content analysis and recommendations for best practices introduction to structural equation modeling using spss and amos evaluating structural equation models with unobservable variables and measurement error on the evaluation of structural equation models distinguishing coupon proneness from value consciousness: an acquisition-transaction utility theory perspective success factor validation for global erp programmes multivariate data analyses structural equation modeling in practice: a review and recommended two-step approach sensitivity of goodness of fit indexes to lack of measurement invariance evaluating goodness-of-fit indexes for testing measurement invariance exploring fitness centre consumer loyalty: differences of non-profit and low-cost business models in spain information management research and practice in the post-covid-19 world europeactive releases its new information paper on innovation and digitalisation in europe exploring lifestyle habits, physical activity, anxiety and basic psychological needs in a sample of portuguese adults during covid-19 the intention to use fitness and physical activity apps: a systematic review this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord-329536-3xsncmyi authors: passos, lígia; prazeres, filipe; teixeira, andreia; martins, carlos title: impact on mental health due to covid-19 pandemic: cross-sectional study in portugal and brazil date: 2020-09-17 journal: int j environ res public health doi: 10.3390/ijerph17186794 sha: doc_id: 329536 cord_uid: 3xsncmyi mental health effects secondary to the covid-19 pandemic were till recently considered less important or were neglected. portugal and brazil are facing the pandemic in quite different ways. this study aimed to describe the mental health status of the general adult population in portugal and brazil during the covid-19 pandemic and analyze the differences between the two countries. a cross-sectional quantitative study was based on an online questionnaire. socio-demographic data were collected in addition to four validated scales: cage (acronym cut-annoyed-guilty-eye) questionnaire, satisfaction with life scale, generalized anxiety disorder-7 and patient health questionnaire-2. for each outcome, a multiple linear regression was performed. five hundred and fifty people answered the questionnaire (435 women). the median age was 38 (q1, q3: 30, 47) years, 52.5% resided in brazil and 47.5% in portugal. the prevalence of anxiety was 71.3% (mild anxiety was present in 43.1%), the prevalence of depression was 24.7% and 23.8% of the sample had both depression and anxiety. isolation was a significant factor for depression but not for anxiety. well-being was below average. mental illness was considerably higher than pre-covid-19 levels. portugal and brazil will have to be prepared for future consequences of poor mental health and contribute immediate psychological support to their adult populations. during the current global health crisis, caused by the declaration of the coronavirus disease 2019 (covid-19) outbreak as a pandemic on 11 march 2020 by the world health organization (who) [1] , countries' main efforts are concentrated on implementing measures to prevent, control and treat the illness caused by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), along with research to develop a vaccine. the first positive case was registered in brazil on 26 february 2020 [2] and in portugal on 2 march 2020 [3] . in brazil, the first death from covid-19 occurred on march 12 [4] and 4 days later the same happened in portugal [5] . portugal and brazil are facing the pandemic in quite different ways. the government of portugal acted quickly with health precautionary measures, contingency plans and political union. on 18 march 2020, a national state of emergency was declared, suspending some citizens' rights so that public health protection measures could be implemented. some of the measures adopted throughout the countries of the impact on the emotional well-being of the decrease in interpersonal contact due to covid-19. this is a cross-sectional quantitative study based on an online questionnaire conducted from 27 may to 8 july 2020, among adults from the general population living in portugal or brazil. for inclusion in the study, participants should be residents in portugal or brazil, be over 18 years old, give their informed consent and agree to participate in the study. the questionnaire was built in the google forms platform and the questionnaire web link was sent by e-mail to the researchers' contact network, and through community groups in social networks, thus generating a snowball sample, where invited respondents shared the online questionnaire with their contacts. socio-demographic and other factors: variables assessed included age, gender, country of residence (portugal or brazil), marital status, educational level, employment status, social isolation self-label, duration of social isolation, living arrangements during social isolation, diagnosis of covid-19, alcohol consumption and alcohol addiction measured by the presence of two or more positive answers to the four-item cage (acronym cut-annoyed-guilty-eye) questionnaire [33, 34] translated and validated for the portuguese language [35] . satisfaction with life scale (swls): a global cognitive measure of satisfaction with one's life [36, 37] . it consists of five items rated on a five-point likert scale, ranging from 1: "strongly disagree" to 5: "strongly agree". this scale was translated and validated for the portuguese language [38] . a total score is obtained by the sum of the five items (range from 5 to 25 points). cronbach's alpha for this scale was 0.87 as reported by diener et al. (1985) [37] and 0.88 for the current sample. generalized anxiety disorder-7 (gad-7): a brief self-report scale to identify probable cases of generalized anxiety disorder and assess its severity in both the primary care setting and the general population [39] [40] [41] . the seven items of this instrument are scored on a four-point likert scale where 0: "not at all"; 1: "several days"; 2: "more than half the days"; and 3: "nearly every day". a total score is obtained by the sum of the seven items (range from 0 to 21 points). the cut-off points for classifying the severity of anxiety are: 0-4 = none/normal, 5-9 = mild, 10-14 = moderate and 15-21 = severe. gad-7 was validated for the portuguese language by sousa et al. (2015) [42] . in the present study, gad-7 was found to have excellent internal consistency (cronbach's alpha of 0.90). for the purpose of the current study, a total score of five points or above was used to indicate the possible presence of anxiety [42] . patient health questionnaire-2 (phq-2): a two-item depression screener. it includes the first two items of the phq-9 [43, 44] and evaluates the frequency of depressed mood and anhedonia. some authors consider phq-2 more explanatory than using all the phq-9 questions [45] . the two items of this instrument are scored on a four-point likert scale where 0: "not at all"; 1: "several days"; 2: "more than half the days"; and 3: "nearly every day". the sum score ranges from 0 to 6 points. a total score of 3 or above indicates that major depressive disorder is likely [46, 47] . in the present study, phq-2 was found to have good internal consistency (cronbach's alpha of 0.83). data analysis was performed using spss 26.0 version statistical software (ibm, armonk, ny, usa) and jamovi (version 1.2) (computer software, sydney, australia). categorical variables were described using absolute and relative frequencies, n(%) or (n; %). the prevalences are presented with the respective 95% confidence intervals. continuous variables not normally distributed were described by the median and the interquartile interval, mdn (q 1 , q 3 ). the normality of continuous variables was assessed by observation of q-q plots. the comparison of continuous variables between portugal and brazil was made by the mann-whitney test since the variables were not normally distributed. the comparison of categorical variables was made by the chi-squared test. for each outcome-satisfaction with life (swls), anxiety (gad-7) and depression (phq-2)-a separated multiple linear regression was performed. to decide which independent variables to include in each multiple regression, simple linear regressions were performed with each variable in the dataset, including socio-demographics, variables related to covid-19 and emotional variables, were obtained from questionnaires: satisfaction with life (slws), anxiety (gad-7) and depression (phq-2). all variables that correlated with the outcomes at p ≤ 0.20 in a simple regression were included in the multiple linear regressions [48] . only the significant variables were maintained in the final multiple models. the results of linear regressions were presented by the coefficient values (β) and the respective p-value. to evaluate the model, the determination coefficient (r 2 ) was presented. assumptions of the linear regression models were verified as follows: (1) visual analysis of histograms to assess the normality of residuals and (2) plotting residuals versus the fitted predictive values for checking homoscedasticity. values of p ≤ 0.05 were considered significant. the sum of the portuguese and brazilian populations over 18 years of age are approximately 164,058,140 [49, 50] . the minimum sample size (n = 385) was calculated for proportions and considering the most conservative scenario (a proportion of 50%), a population of 164,058,140 individuals, a level of confidence of 95% and an error margin of 5%. the present study followed the declaration of helsinki ethical standards and was approved by the ethics committee of the university of beira interior (ce-ubi-pj-2020-041). electronic consent was obtained from all participants. responses were anonymous. the questionnaire was answered by 550 participants, 289 (52.5%) residing in brazil and 261 (47.5%) in portugal. this sample size corresponds to a margin of error of 4.18% (in the same conditions of the sample size calculator). all participants fully completed swls, gad-7 and phq-2 instruments. no participants were excluded from the analysis. the characteristics of the participants are summarized in table 1 . most of them were female (435; 79.5%). the median age was 38 (q1, q3: 30, 47) years. regarding marital status, 290 (52.8%) were married or cohabiting. the level of education was high, with 51.3% (n = 282) being postgraduates, masters or phds and 61.6% (n = 335) declared being employed. notice that 88.2% of participants (n = 485) were in social isolation, with a median duration of 70 (q1, q3: 60, 90) days, and of these 485 participants, 81.4% (n = 395) had experienced more than 51 days in social isolation. most participants (383; 69.6%) lived with their families during this period. only 12.2% of participants (n = 67) were tested for covid-19 and only 1.3% (n = 7) tested positive. more than half (310; 56.4%) reported consuming alcoholic beverages. alcohol addiction (two or more points on cage) was present in 10.3% (n = 31) of the respondents, without a statistical difference between the residents of the two countries (chi-squared test; p = 0.995). a chi-squared test of independence was performed to examine the relation between the country of residence and isolation. residents in brazil were more likely than residents in portugal to isolate (p = 0.003); and the length of the isolation period was more likely to be longer than 51 days in brazil (p < 0.001). respondents scored slightly below average in life satisfaction (swls), with a median score of 18 (q1, q3: 14, 21) points and there were no significant differences between residents of portugal and brazil (p = 0.292; table 2 ). considering gad-7, the median score was 6 (q1, q3: 4, 11) points, also without significant differences between residents of portugal and brazil (p = 0.113; table 2 ). the prevalence rate of anxiety was 71.3% (95% ci, 67.5-75.1) (mild anxiety was present in 43.1% (95% ci, 39.0-47.2), moderate anxiety in 17.6% (95% ci, 14.5-21.1) and severe anxiety in 10.5% (95% ci, 8.0-13.1) of the sample). the median phq-2 score was 2 (q1, q3: 0, 2) points and residents of brazil had a slight but significantly higher median score than portuguese ones (2 vs. 1, p = 0.040; table 2 ). the prevalence rate of depression was 24.7% (95% ci, 21.1-28.3) and 23.8% (95% ci, 20.3-27.4) had both depression and anxiety. no differences were found in the prevalence of having both anxiety and depression between the portuguese and brazilian subgroups (p = 0.059 and p = 0.273, respectively; table 2 ). gender, educational level, professional status, co-living status and depression (phq-2 score) were found to be significant factors for life satisfaction (swls) in multiple linear regression (r 2 = 0.211; table 3 ). women's life satisfaction scores were higher by an average of 1.08 in comparison to men (p = 0.027). higher levels of education were significantly associated with increased levels of life satisfaction scores (β = 1.81, p = 0.006). students' life satisfaction scores were higher by an average of 1.56 in comparison to employees (p = 0.002). those who lived with family members or with a partner in the period of social isolation were significantly associated with increased levels of life satisfaction (β = 1.59, p = 0.023 and β = 2.53, p = 0.001, respectively). higher levels of depression (phq-2) were significantly associated with a reduction of life satisfaction levels (β = −1.26, p < 0.001). gender and depression (phq-2 score) were found to be significant factors for anxiety (gad-7) in multiple linear regression (r 2 = 0.462; table 4 ). women's anxiety levels were higher by an average of 0.88 in comparison to men (p = 0.020). higher levels of depression (phq-2) were significantly associated with an increase in anxiety levels (β = 2.03, p < 0.001). table 4 . regression coefficients for generalized anxiety disorder-7 (gad-7) as an outcome with socio-demographic and emotional variables as predictors, from univariate multiple linear regressions. social isolation, life satisfaction (swls) and anxiety (gad-7) were found to be significant factors for depression (phq-2) in multiple linear regression (r 2 = 0.519; table 5 ). being in social isolation was significantly associated with an increase in depression levels (β = 0.33, p = 0.026). higher levels of life satisfaction (swls) were significantly associated with a reduction of depression levels (β = −0.07, p < 0.001). higher levels of anxiety (gad-7) were significantly associated with an increase in depression levels (β = 0.20, p < 0.001). all levels of anxiety had a significant association with the phq-2 scale, in comparison with the group without/normal anxiety levels. those with severe anxiety had a depression level that was on average higher by 3.14 (p < 0.001). to the extent of the authors' knowledge, the present study is the first to analyze the mental health status of the general adult population in portugal and brazil during the covid-19 pandemic. it has been previously expressed that mental health conditions are going to be the great pandemic of this century [51] and, to some extent, the results of the current study corroborate this statement. in the present study, the prevalence of anxiety was 71.3% (mild anxiety was present in 43.1%), the prevalence of depression was 24.7% and 23.8% of the sample had both depression and anxiety. the observed frequency of mental illness was considerably higher than pre-covid-19 levels, as expected from the results of previous studies that suggested a connection between a public health crisis and mental health conditions [52, 53] . even before the covid-19 outbreak, brazil had the highest prevalence of anxiety among all countries in the world, with 9.3% of the population having some type of anxiety disorder. at the same time, the prevalence of anxiety in portugal was 4.9%. regarding depressive disorders, the prevalence was similar in both countries (5.7% vs. 5.8% for portugal and brazil, respectively) [54] . even though the studies were done during the initial stage of the covid-19 outbreak [16] and used different scales or populations so no direct comparison between studies is possible, the present study showed a similarly high prevalence of mental health conditions (e.g., the prevalence rate of depression was 50.7% and that of generalized anxiety was 44.7% in a multicenter study involving around one and a half thousand chinese medical workers [55] ). it can thus be suggested that the covid-19 pandemic has significantly affected the mental health of the general adult population in portugal and brazil, with an increased risk of future challenges of impairment, alcohol or drug coping, negative religious coping, hopelessness and suicidal ideation, as was the case in other samples with high levels of anxiety related to covid-19 [56] . female gender was associated with higher levels of psychological distress in the time of covid-19 [16] . in the present study, women were associated with higher rates of anxiety but not depression. this finding is contrary to previous studies which have suggested that women are at higher risk of anxiety and depression [57, 58] . this inconsistency may be due to the effect of the current public health crisis on the use of coping strategies, like positive reframing [59] . although females showed higher anxiety in comparison to males, this did not affect their self-rated life satisfaction. this could be an important issue for future research. in portugal, the social confinement lasted about 51 days for many people [21] (and much more in brazil, although with state dissimilarities), despite that, the individuals that were isolated had higher depression levels. this result suggests that social isolation may be a risk factor for depression, in agreement with the results obtained by previously published research [60, 61] , and this may be even more evident when a quarantine is imposed [20] or if loneliness is present [62] . one interesting finding of this study was that during the ongoing covid-19 pandemic, anxiety and depressive disorders continue to be particularly comorbid [63] , with higher levels of depression being significantly associated with increasing levels of anxiety and vice versa. prior studies have noted that almost half of depressive individuals (45.7%) have had an anxiety disorder during their life [64] and that 42% of individuals with anxiety have had at least one episode of depression in their life [65] . an implication of the current study's results is the possibility that individuals experiencing the covid-19 pandemic are at higher risk of developing more severe symptoms and poor treatment response for depression/anxiety [66] . regarding the impact of the covid-19 pandemic on well-being, respondents scored slightly below average on the life satisfaction scale (swls), without significant differences between residents of portugal and brazil; these scale results may be due to the presence of a meaningful problem in only one area of their lives, or more likely, in the current pandemic crisis, to the presence of problems in several areas of the respondents' lives [67] , from multiple potential stressors, such as respondents' worries for their finances, health or those close to them, social isolation and loneliness, loss of pre-covid routines and contact with former sources of positive reinforcement [68] , which in turn may increase the risk of depression. some of these areas were confirmed by the significant factors for life satisfaction found in multiple linear regression: professional status, educational level, co-living status and depression. in the present sample, a considerable effect on the well-being of working individuals (that students would not experience) may be due to the presence of feelings of anxiousness regarding future work and finances and this may be even more prominent in individuals with lower educational levels whose jobs are not suitable for teleworking (or remote working) during social distancing measures [69] . an implication of this is the possibility that workers with low educational levels may benefit from being well informed about their sick pay and benefits rights during the current pandemic. some limitations must be considered when interpreting the results of the present study. one limitation concerns convenience sampling and, although it was carried out in two countries, it still does not allow for the generalization of results since respondents shared similar demographic characteristics. the lack of a diverse sample limits the ability to explore how some demographic characteristics (e.g., socioeconomic status) may affect mental health during the pandemic. portugal and brazil faced the pandemic in different ways (e.g., social distancing measures), and distinct societal and economic characteristics between the two can still have an impact on the mental health of each population and may increase poverty and inequalities between the two countries. some risk factors of poor mental health (or its protective factors) were not collected and therefore their role in determining the results of the present study cannot be calculated. further work is needed to evaluate the social, environmental and economic determinants of mental health in the covid-19 pandemic. the role of uncertainty stress on the development of mental ill-health should also be studied. another limitation is the fact that no information regarding the previous mental health of the participants was collected. thus, it is not possible to analyze the extent to which the covid-19 pandemic contributed to an expected worsening of depressive and anxiety symptoms. future longitudinal studies could contribute to a better understanding of the late effects of social isolation on the mental health of adults. evidence suggests that the presence of mental illness was considerably higher than pre-covid-19 levels, both in portugal and brazil. the prevalence of anxiety was 71.3% (mild anxiety was present in 43.1%), the prevalence of depression was 24.7% and 23.8% of the sample had both depression and anxiety. consequently, well-being was below average. portugal and brazil will have to be prepared for future consequences of poor mental health and contribute immediate psychological support to their adult population. the development and improvement of mental health public policies must be an essential part of governments' response to the covid-19 pandemic, with a commitment to support and care for affected individuals. the first step should be to campaign to raise public awareness about mental illnesses so not only those with issues seek early help but also those who are at increased risk (e.g., females and those in social isolation). mental health services must be expanded and widely funded, as part of the universal health coverage, and health professionals should be knowledgeable regarding the risk factors and protective factors of mental disorders and be able to provide in-person or virtual counseling or therapy. to improve well-being during a crisis like the covid-19 pandemic, there is the need to maintain social connections, decrease isolation and care for the mental health of individuals by the use of, for 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social isolation, loneliness and their relationships with depressive symptoms: a population-based study the critical relationship between anxiety and depression anxious and non-anxious major depressive disorder in the world health organization world mental health surveys psychiatric comorbidity in patients with generalized anxiety disorder clinical characteristics and treatment outcomes of patients with major depressive disorder and comorbid anxiety disorders -results from a european multicenter study understanding scores on the satisfaction with life scale covid-19: psychological flexibility, coping, mental health, and wellbeing in the uk during the pandemic ability to work from home: evidence from two surveys and implications for the labor market in the covid-19 pandemic this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-289451-yjrh5l4u authors: xiao, huidi; shu, wen; li, menglong; li, ziang; tao, fangbiao; wu, xiaoyan; yu, yizhen; meng, heng; vermund, sten h.; hu, yifei title: social distancing among medical students during the 2019 coronavirus disease pandemic in china: disease awareness, anxiety disorder, depression, and behavioral activities date: 2020-07-14 journal: int j environ res public health doi: 10.3390/ijerph17145047 sha: doc_id: 289451 cord_uid: yjrh5l4u background: during the coronavirus disease (covid-19) pandemic, harsh social distancing measures were taken in china to contain viral spread. we examined their impact on the lives of medical students. methods: a nation-wide cross-sectional survey of college students was conducted from 4–12 february 2020. we enrolled medical students studying public health in beijing and wuhan to assess their covid-19 awareness and to evaluate their mental health status/behaviors using a self-administered questionnaire. we used the patient generalized anxiety disorder-7 and health questionnaire-9 to measure anxiety disorders and depression. we used multivariable logistic regression and path analysis to assess the associations between covariates and anxiety disorder/depression. results: of 933 students, 898 (96.2%) reported wearing masks frequently when going out, 723 (77.5%) reported daily handwashing with soap, 676 (72.5%) washed hands immediately after arriving home, and 914 (98.0%) reported staying home as much as possible. prevalence of anxiety disorder was 17.1% and depression was 25.3%. multivariable logistic regression showed anxiety to be associated with graduate student status (odds ratio (aor) = 2.0; 95% confidence interval (ci): 1.2–3.5), negative thoughts or actions (aor = 1.6; 95% ci: 1.4–1.7), and feeling depressed (aor = 6.8; 95% ci: 4.0–11.7). beijing students were significantly less likely to have anxiety than those in the wuhan epicenter (aor = 0.9; 95% ci: 0.8–1.0), but depression did not differ. depression was associated with female students (aor = 2.0; 95% ci: 1.2–3.3), negative thoughts or actions (aor = 1.7; 95% ci: 1.5–1.9), and anxiety disorder (aor = 5.8; 95% ci: 3.4–9.9). path analysis validated these same predictors. conclusions: despite medical students’ knowledge of disease control and prevention, their lives were greatly affected by social distancing, especially in the wuhan epicenter. even well-informed students needed psychological support during these extraordinarily stressful times. coronavirus disease (covid-19) is a public health emergency of worldwide concern [1] . up through june 2020, covid-19 had affected 213 countries, territories or areas, and two international conveyances (cruise ships) [2] since its initial december 2019 report as an "unknown pneumonia" in wuhan, hubei province, china [3] . infections and deaths increased rapidly with global travel fueling transmission spread worldwide, first to other parts of china, south korea, and iran, and soon thereafter to europe and the united states. other nations such as russia and brazil then experienced expanding case numbers while infections in africa have also been mounting. to interrupt further transmission, many chinese provinces and cities suspended public transportation [4] and even locked down cities altogether. these were unprecedented and harsh social distancing measures and they affected every aspect of daily life in china, as elsewhere. "social distancing" is done to reduce close physical interactions (<2 m) between people to avoid viral transmission. chinese measures included closure of schools, office buildings, and public markets; events were cancelled, and gatherings discouraged [5] . the united nations educational, scientific and cultural organization (unesco) estimates that nationwide closures in more than 160 countries have affected over 87% of students in the world, with wider closures affecting even more [6] . a 2009 influenza a (h1n1) pandemic survey in hong kong demonstrated marked anxiety associated with distancing [7] . a 2020 covid-19 survey in china found that many respondents (including students) reported symptoms of moderate to severe anxiety and depression [8] . medical students are a reservoir for the future health labor force. in the early response in the epicenter in china, as well as other countries, the sudden outbreak overwhelmed health professional's preparedness in terms of personal protective equipment (ppe) shortages and psychological readiness [9, 10] . it is critical to understand how much the pandemic affects this future health labor force. we sought to understand the psychological effects of distancing measures and possible effects on medical student wellness. even without pandemic stresses, medical students may have some anxiety and depression due to their high study-related or job-seeking burdens [11] [12] [13] . we studied the associations between covid-19 distancing and the lives of public health students on anxiety [14] , depression, and other behaviors. we also examined the differences among public health students in two universities, capital medical university (ccmu) in beijing, and huazhong university of science and technology (hust) in wuhan, the early epicenter of the covid-19 outbreak in china. we conducted a cross-sectional survey among the medical students in two schools of public health at two universities: ccmu in beijing and hust in wuhan. the present study is part of a nation-wide cross-sectional survey of college students conducted from 4-12 february 2020. we developed a self-administrated, 84-item questionnaire focused on: (1) covid-19 awareness; (2) personal protective measures; (3) mental health status; and (4) behavioral changes in the past 14 days. our instrument was based on social-cognitive theory and the theory of planned behavior and we measured knowledge, attitude, belief, and practice (kabp) [15] , enhanced with psychological assessments. we used the validated generalized anxiety disorder-7 (gad-7) and patient health questionnaire-9 (phq-9) to assess anxiety disorder and depression, respectively [16, 17] . most questions were one-choice, brief, and easy to answer, such that it took only 10 min on average to complete the survey. we used wenjuanxing ® (changsha haoxing information technology co., ltd., changsha, china) software for the informed consent process and the online survey questionnaire. participants obtained and completed the self-administrated questionnaire on the mobile phone by scanning the qr code using wechat ® software. after consent was obtained, we detailed the workflow of the survey with one page of text. the investigators received the completed questionnaires via the software platform. facilitated by their teachers, we approached all medical students with public health majors in the ccmu and hust schools of public health. the study was approved by ethics review board of capital medical university (2020sy004) and anhui medical university (20200319). informed consent and a response to the questionnaire were obtained from 933 of 1061 (87.9%) students who were approached. hence, we could infer the different preventive knowledge, behaviors, and psychological status modified by distance to the epicenter amid social distancing in the pandemic. covariates included socio-demographic characteristics, knowledge of covid-19, personal protective measure, behaviors, and degree of worry about the virus. variables included sex, age, year of study, university, living quarters, knowledge about the covid-19 incubation period, mortality, susceptibility (e.g., chronic illness), drugs taken, mask wearing, face and hand hygiene, times and reasons for going out, room cleanliness and ventilation via windows, and concerns about the covid-19 epidemic and contracting the virus. we also asked about negative thoughts or actions ("always feel dirty", "feel uneasy in a crowded place", "often suspect being infected", "worse appetite than before", "feel less energic than before", "hold unhappy intentions in my heart" and "angry with others when in a bad mood"), positive thoughts or actions ("accept the truth when facing an obstacle" and "relieve pain in a positive way"), healthy lifestyles ("work and rest regularly", "arise regularly", "sleep regularly" and "have meals regularly"), video screen time per day, and the number of anger episodes or quarrels in the past week. principal outcomes were anxiety disorder and depression measured by scale scores of gad-7 and phq-9, respectively. the gad-7 scale score was divided into four categories: normal (0-4), mild (5-9), moderate (10) (11) (12) (13) (14) , and severe (15) (16) (17) (18) (19) (20) (21) . the phq-9 scale score was divided into five categories: normal (0-4), mild (5-9), moderate (10) (11) (12) (13) (14) , moderate to severe (15) (16) (17) (18) (19) , and severe (20) (21) (22) (23) (24) (25) (26) (27) . if a participant's score was ≥5 points (i.e., mild or above), we considered the student to have evidence of anxiety disorder. we used descriptive statistics including the chi-squared test for the associations of covid-19 knowledge with sociodemographic characteristics and use of personal protective measures. we used multivariable logistic regression to examine the association between independent variables and covariates with anxiety disorder and/or depression. we deployed the hosmer-lemeshow test to determine the goodness-of-fit of the logistic regression model. only variables with two-sided p ≤ 0.05 were deemed significant in the final model. we used path analysis to determine the interplay of covariates with anxiety disorder and depression via a structural equation model. we used maximum likelihood estimation and assessed the goodness-of-fit by absolute fit indices that determine how well the a priori model predicts the actual data, including the root mean square error of approximation (rmsea), goodness of fit index (gfi), and adjusted goodness of fit index (agfi). we also used incremental or relative fit indices, specifically the incremental fit indices (ifi), comparative fit indices (cfi), normed fit index (nfi), and the non-normed fit tucker-lewis index (tli). rmsea < 0.10 and gfi and agfi > 0.90 indicate the model fits well. the incremental fit measures-cfi, nfi, ifi, and tli-are >0.90 when the model fits well. we used spss statistic ® 21.0 and spss amos ® 26.0 graphics software (ibm spss statistics, new york, ny, usa). of 933 participated students, 558 students attended ccmu (94.4% agreed to participate) in beijing, and 375 students attended hust (79.6% agreed) in wuhan. graduate students doing masters of public health degrees did better than undergraduates in the knowledge questions that were answered correctly (p = 0.037). it is important to note that the chinese system has undergraduate medical students and before graduation, medical students can pursue specialties such as public health, pediatrics, etc.; then at the graduate level they may choose to major in epidemiology and statistics, environmental health, etc., if they chose the public health specialty. the prevalence of anxiety disorder (p = 0.015) and depression (p < 0.001) in women was significantly higher than in men. anxiety disorder was higher in wuhan students than ccmu students (p = 0.001; table 1 ). the correct answers to the four knowledge questions were given by 97.2%, 67.1%, 69.3%, and 89.4% of respondents (table s1 ). the awareness of mortality risk was higher in hust students than ccmu students (p = 0.04). as to preventive measures and behaviors during social distancing, 898 (96.2%) reported wearing masks frequently when going out, 869 (93.1%) washed their hands with water regularly, 723 (77.5%) washed their hands with soap every day, 676 (72.5%) washed their hands immediately after arriving home, 239 (25.6%) considered it difficult to wash their hands for at least 20 s, 295 (31.6%) washed their hands for more than 20 s frequently, 914 (98.0%) avoided unnecessary outings (i.e., they tried to stay at home as much as possible), and 878 (94.1%) kept clean, well-ventilated rooms. beijing-based ccmu students were significantly more likely to report wearing masks (p = 0.037), avoiding touching their mouths, noses, and eyes with their hands (p < 0.001), washing their hands immediately after arriving home (p < 0.001), and handwashing for at least 20 s (p < 0.001). wuhan-based students at hust were more likely to report washing their hands with soap (p < 0.001), staying at home (p = 0.028), and keeping their rooms clean and well-ventilated (p = 0.044; table 2 ). assessing anxiety disorder, 773 (82.9%) were classified as normal, 117 (12.5%) had mild anxiety, 30 (3.2%) had moderate anxiety, and 13 (1.4%) had severe anxiety disorder. assessing depression, 697 (74.7%) students were classified as normal, 165 (17.7%) had mild depression, 43 (4.6%) had moderate depression, 18 (1.9%) had moderate to severe depression, and 10 (1.1%) had severe depression. the prevalence of anxiety disorder differed between the two universities, and was significantly higher in wuhan (p = 0.001) which was far more severely affected by covid-19. the prevalence of depression between the two universities was also higher in wuhan, but this may have been due to chance (p = 0.12; table 1 and figure 1 ). bar charts present the distribution of different degrees of anxiety disorder and depression, comparing students at capital medical university (ccmu) in beijing with students at huazhong university of science and technology (hust) in wuhan. the x-axis represents the different degrees of anxiety disorder and depression, and the y-axis represents the proportion of students. bar charts present the distribution of different degrees of anxiety disorder and depression, comparing students at capital medical university (ccmu) in beijing with students at huazhong university of science and technology (hust) in wuhan. the x-axis represents the different degrees of anxiety disorder and depression, and the y-axis represents the proportion of students. multivariable logistic regression shows that being a graduate student (adjusted odds ratio (aor) = 2.03; 95% confidence interval (ci): 1.18-3.49; p = 0.011), having negative thoughts or actions (aor = 1.55; 95% ci: 1.38-1.73; p < 0.001), and feeling depressed (aor = 6.84; 95% ci: 4.00-11.71; p < 0.001) were associated with a higher likelihood of anxiety. students at ccmu, far from the wuhan epicenter, were less likely to experience anxiety (aor = 0.90; 95% ci: 0.82-1.00; p = 0.049; table 3 ). women students (aor = 1.98; 95% ci: 1.19-3.29; p = 0.009), persons having negative thoughts or actions (aor 1.68; 95% ci: 1.50-1.88; p < 0.001), and persons with anxiety (aor = 5.81; 95% ci: 3.43-9.86; p < 0.001) had higher odds of having some depression. having a healthy lifestyle was associated with less depression (aor = 0.88; 95% ci: 0.79-0.97; p = 0.013). a includes: "always feel dirty", "feel uneasy in a crowded place", "often suspect being infected", "worse appetite than before", "feel less energic than before", "hold unhappy intentions in my heart", and "angry with others when in a bad mood". b includes: "accept the truth when facing obstacles", and "relieve pain in a positive way". c includes: "work and rest regularly", "arise regularly", "sleep regularly", and "have meals regularly". across the two sites, 426 (48.7%) students reported using computers or other electronic devices over 4 h daily, 484 (51.9%) used their cellphones over 4 h daily, 635 (68.1%) woke up later than usual, 234 (24.0%) went to bed later than usual, 234 (35.1%) worked and rested irregularly, 157 (16.8%) had meals irregularly, and 221 (23.7%) ate different volumes of food from usual (either more or less). within one week before the survey, 306 (32.8%) reported having gotten angry at others, 201 (21.5%) reported one or more quarrels, 585 (62.7%) felt terrible because of the epidemic, and 112 (12.0%) quarreled with others online. figure 2 shows the factors relevant to anxiety disorder and depression, and table s2 presents standardized estimation of coefficient values. students in their senior grade year (β = 0.074) suffered more from anxiety disorders. negative thoughts or actions were associated with depression (β = 0.86) while healthy lifestyles (β = −0.077) were negatively associated with depression. longer video screen time (β = −0.24) negatively affected a healthy lifestyle. concerns about the covid-19 epidemic were associated with more negative thoughts or actions (β = 0.23) and anger and quarreling behaviors (β = 0.20); negativity and anger/quarrels were correlated (β = 0.34). overall, negative thoughts or actions predicted a higher impact of both anxiety disorders (β = 0.87) and depression (β = 0.86). goodness-of-fit indices for the model were good and key parameters were rmsea = 0.051, gfi = 0.93, agfi = 0.91, cfi = 0.93, nfi = 0.91, ifi = 0.93, and tli = 0.92. standardized estimation of coefficient values. students in their senior grade year (β = 0.074) suffered more from anxiety disorders. negative thoughts or actions were associated with depression (β = 0.86) while healthy lifestyles (β = −0.077) were negatively associated with depression. longer video screen time (β = −0.24) negatively affected a healthy lifestyle. concerns about the covid-19 epidemic were associated with more negative thoughts or actions (β = 0.23) and anger and quarreling behaviors (β = 0.20); negativity and anger/quarrels were correlated (β = 0.34). overall, negative thoughts or actions predicted a higher impact of both anxiety disorders (β = 0.87) and depression (β = 0.86). goodnessof-fit indices for the model were good and key parameters were rmsea = 0.051, gfi = 0.93, agfi = 0.91, cfi = 0.93, nfi = 0.91, ifi = 0.93, and tli = 0.92. our survey findings suggest that the awareness of medical students of covid-19 fundamentals was very high, as might be expected given the profile in chinese society by february 2020. anxiety and depression were common among medical students in whom social distancing was reported with longer video screen time and less healthy lifestyles. concern about the epidemic was associated with negative actions and thoughts, which were, in turn, associated with an increased likelihood of anxiety disorders. the hust medical students in wuhan, the epicenter, presented with higher anxiety than our survey findings suggest that the awareness of medical students of covid-19 fundamentals was very high, as might be expected given the profile in chinese society by february 2020. anxiety and depression were common among medical students in whom social distancing was reported with longer video screen time and less healthy lifestyles. concern about the epidemic was associated with negative actions and thoughts, which were, in turn, associated with an increased likelihood of anxiety disorders. the hust medical students in wuhan, the epicenter, presented with higher anxiety than did ccmu medical students in beijing. the findings underscore our study's significance that the health reservoir suffer from psychological stress and need attention. less than half (43.7%) of the medical students had fully correct (four out of four questions) knowledge of the covid-19 epidemic situation. students, all of whom were studying public health, were less knowledgeable about mortality and susceptible groups, compared to incubation period and available drugs (table s1 ). over 90% of students complied with social distancing and effective preventive measures, like wearing masks frequently when going out, washing hands with water regularly, avoiding unnecessary outings (i.e., staying at home), and keeping their rooms clean and ventilated [18] . according to our findings, students preferred washing their hands with only water to also using soap; about half (54%) of students tried to avoid touching their mouth, nose, and eyes with their hands, though both behaviors can reduce the risk of exposure [19] . a quarter (25.6%) of the students considered it hard to wash their hands for at least 20 s and less than a third (31.6%) washed their hands over 20 s frequently. given that good hand hygiene can effectively prevent virus transmission [20] and washing hands for at least 20 s is a basic component of hand hygiene as per the world health organization (who, geneva, switzerland), it was disappointing to learn from medical students that they found this challenging [21] . it is likely that, comparing the two participating universities, notable differences were fueled by the differing epidemiologic context of the two urban venues. among the 44.0% of students from hust who lived in the epicenter of hubei province or adjacent provinces, they were more likely to obey harsher social distancing rules, like staying at home and deploying hand hygiene. while most students (88.2%) from ccmu lived far away from hubei province, they reported being more fastidious in wearing masks. during social distancing, our study showed 17.1% of students had anxiety disorder symptoms (mainly mild), and 25.3% of students had depression symptoms (mainly mild). an interesting survey in 190 chinese cities surveyed the general population twice: during the initial outbreak and during the epidemic's peak four weeks later [22] . they surveyed demographics, symptoms, knowledge, concerns, and precautionary measures against covid-19. among the 333 persons who took both surveys, post-traumatic stress disorder (ptsd by the mean impact of event scale-revised (ies-r) scale scores) declined with time, but at both surveys, the mean ies-r scores of the first-and second-survey respondents were above the cut-off scores (>24) for ptsd symptoms, suggesting that the reduction in scores was not of clinical significance [22] . previous studies report that student populations can be more vulnerable towards stress-related anxiety and depression [22, 23] . our findings underscore the importance of providing essential psychological support to students, even when they are as well-informed as are medical students in a public health track. both multivariable logistic regression and path analysis reinforced the findings of principal factors related to anxiety disorder and depression. compared to undergraduates, graduate students had a higher risk of anxiety [13, 24] . we think that this may be due to increased pressure for job-seeking or completion of thesis required for graduation. females were more likely to be depressed compared to men, consistent with prior studies [24, 25] . healthy lifestyles were negatively associated with depression, compatible with other findings that healthy lifestyles can improve mental health [26] . some students adopted an unhealthy lifestyle during social distancing, reflecting difficulties in adjusting to domestic life for a prolonged time; as expected, many students reported bad moods and/or behaviors [27] . nearly a quarter of students (23.7%) changed their diets by eating more or less than usual. either excessive or poor appetites can be symptoms of depression [28] . longer video screen time had an indirect impact on depression, as other studies reported [29, 30] . half of our participants spent over four hours on electronic devices; aside from increasing risk for depression, this can negatively affect vision, or spawn weight gain and cardiovascular risk from adoption of a sedentary life [31] . we found that the prevalence of anxiety disorder was higher in wuhan than in beijing (p = 0.001), while depression was also somewhat higher (p = 0.12). research on college students from changzhi medical college (shanxi province, about midway between wuhan and beijing) in the same time period reported that 24.9% of students had anxiety disorder using screening criteria similar to ours [32] . it is unclear whether differences in reported prevalence are related to school location, though it is plausible that proximity to the pandemic's epicenter would be more anxiety-provoking [33] . that negative thoughts or actions, anger and quarreling behaviors, and concerns about covid-19 were all positively related to either depression or anxiety disorder has been seen in other studies [32, 34, 35] . many of our participants reported that they had been angry and quarreling within one week before the survey; 46.7% of them felt terrible because of covid-19. it is plausible that irritable behaviors suggest that mental status or moods may have been affected by social distancing due to lack of normal social activities during the pandemic [36] . as expected, we found a strong positive interaction effect between anxiety disorder and depression. reduced physical activity may increase anxiety or depression, but we did not find a clear association in our survey. strengths of the study include its uniqueness, a survey in two sites (including wuhan) conducted just two months after the report of the pulmonary syndrome and one month after recognition of sars-cov-2 circulation in china. limitations include the cross-sectional survey design. while we could compare sites and assess predictors of anxiety and depression, we could not assess mental health circumstances before the emergence of the virus and therefore cannot infer temporality, the vital element to assess causality. the participants are medical students studying public health from two universities; therefore, results and conclusions cannot be generalized to other populations. moreover, because we used self-rating scales, the frequency of anxiety disorder and depression symptoms self-reported by the students is less reliable than thorough clinical diagnoses. as an emerging disease, our understanding of covid-19 keeps evolving and we selected "knowledge questions" based on what was known in late january 2020, based on several rounds of expert consultations and consistent with who and us centers for disease control and prevention updates. the covid-19 pandemic has posed an unprecedented impact on the lives of medical students. necessary psychological support was not available to them during the time of social distancing beyond an awareness campaign regarding preventive measures. it is likely that more economically vulnerable persons would have stress levels exceeding that of medical students, but we learned that this well-informed population was nonetheless in substantial distress in the context of epidemic concerns. mental health pressures in medical students are likely compounded among practicing clinicians; these professionals need psychosocial assistance at the time of pandemic mental stress. we recommend incorporating pandemic preparedness education within health education, including mental health elements, especially within the healthcare labor force. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/14/5047/s1, table s1 : preventive knowledge of covid-19, comparing correct answer frequencies between the two universities (n = 933), table s2 the sponsors had no role in the study design; in the collection, analyses, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication. china coronavirus: who declares international emergency as death toll exceeds 200 who. coronavirus disease (covid-19) situation report the continuing 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general population during the covid-19 epidemic in china covid-19 and mental health: a review of the existing literature study on the public psychological states and its related factors during the outbreak of coronavirus disease 2019 (covid-19) in some regions of china a nationwide survey of psychological distress among chinese people in the covid-19 epidemic: implications and policy recommendations lifestyle choices and mental health: a longitudinal survey with german and chinese students nutrition and lifestyle intervention on mood and neurological disorders appetite changes in depression is screen time associated with anxiety or depression in young people? results from a uk birth cohort mental health problems and social media exposure during covid-19 outbreak sedentary behaviour and risk of all-cause, cardiovascular and cancer mortality, and incident type 2 diabetes: a systematic review and dose response meta-analysis the psychological impact of the covid-19 epidemic on college students in china factors associated to depression and anxiety in medical students: a multicenter study associations between negative life events and anxiety, depressive, and stress symptoms: a cross-sectional study among chinese male senior college students relationship between intrinsic motivation and undergraduate students' depression and stress: the moderating effect of interpersonal conflict social integration, perceived stress, locus of control, and psychological wellbeing among chinese emerging adult migrants: a conditional process analysis acknowledgments: we thank qi fu and niu piye and dean rui chen for survey facilitation and all the students participating in the survey for their time. the authors declare no conflicts of interest. key: cord-302847-d5serpz5 authors: fischer, tatjana; jobst, markus title: capturing the spatial relatedness of long-distance caregiving: a mixed-methods approach date: 2020-09-02 journal: int j environ res public health doi: 10.3390/ijerph17176406 sha: doc_id: 302847 cord_uid: d5serpz5 long-distance caregiving (ldc) is an issue of growing importance in the context of assessing the future of elder care and the maintenance of health and well-being of both the cared-for persons and the long-distance caregivers. uncertainty in the international discussion relates to the relevance of spatially related aspects referring to the burdens of the long-distance caregiver and their (longer-term) willingness and ability to provide care for their elderly relatives. this paper is the result of a first attempt to operationalize and comprehensively analyze the spatial relatedness of long-distance caregiving against the background of the international literature by combining a longitudinal single case study of long-distance caregiving person and semantic hierarchies. in the cooperation of spatial sciences and geoinformatics an analysis grid based on a graph-theoretical model was developed. the elaborated conceptual framework should stimulate a more detailed and precise interdisciplinary discussion on the spatial relatedness of long-distance caregiving and, thus, is open for further refinement in order to become a decision-support tool for policy-makers responsible for social and elder care and health promotion. moreover, it may serve as a starting point for the development of a method for the numerical determination of the long-distance caregivers on different spatial reference scales. in many regions of the world demographic dynamics and thus unbalanced care support rates lead to new challenges in caregiving for the elderly in rural as well as in urban areas [1] . particularly, the quality of intergenerational caregiving on the basis of adult children and ageing parents depends on geographical proximity and shifts to the center of the debate on the maintenance of informal domestic caregiving and the appropriateness and necessity for adaption of current (elder) care and health (support) infrastructures, both for the cared-for persons themselves and their caregiving relatives [2, 3] . with regard to the latter target group, the so-called long-distance caregivers already receive special attention in the context of the protection of well-being and health promotion by the social and health sciences. from this perspective, the discussion of the quality of life of this target group is considered relevant because from today's perspective it can be assumed that the trend towards an increasing spatial dislocation of residential locations between the caring adult children and their parent(s) in need of care will continue [3, 4] ; thus, the number of long-distance caregivers will continue to increase [5] [6] [7] . framework for ldc including the role of contextual factors [6] and, so to speak, a spatial turn in the debate of ldc. based on the roughness of internationally reported cross-sectional empirical findings, this paper aims to conceptualize the spatial relatedness of ldc from an interdisciplinary spatial research perspective, namely spatial planning and geo-informatics, applying a mixed-methods approach combining single-case evidence with graph theory. with graph-based structures and semantic ontologies in terms of fundamental spatial data and caregiving information structures, the authors attempt to introduce flexible information modeling, an extensive spatial information structure, and semantic understanding for the creation of a domain open and spatial and infrastructure planning environment. whereas spatial data standards for data sharing have been implemented within the last decade, the sharing of common spatial semantics for domain specific issues are investigated for standardization within the topics of machine learning and artificial intelligence (ai). bensmann et al. [15] highlight prerequisites and propose an architecture for geospatial linking, but cannot rely on standardized structures and procedures. the purpose of the paper is to develop and sharpen the understanding of the spatial relatedness of ldc from a (spatial) planning and geoinformatics perspective, taking into account: how space and spatial aspects impact the engagement in caregiving, well-being, and quality of life of the long-distance caregivers themselves; 2. the significance of objective and subjective aspects of spatial relatedness; 3. in order to model the space-care nexus, considerations on the availability and appropriateness of already existing geospatial data and further requirements; 4. the limits of the conceptual grasp of ldc applying an interdisciplinary mixed-methods approach. finally, this paper should be the impetus for starting the discussion on (cross-cutting) methodologies for the quantification of the ldc phenomenon [1] . a spatial-oriented discussion of ldc requires a detailed factual analysis with the most detailed data that are available. but data availability is only one specific aspect. available data need to be interoperable across different thematic domains and qualities. most spatial analyses intend an automated processing of all information sources and with this support objective planning decisions. some open information sources already exist under the acquis of europe's digital transformation and future-oriented data strategy [16] . but many information sources in the area of health and caregiving are still closed down for the purpose of the general data protection regulation. enormous effort is needed to complete the required records and create consistent information, like it is done by the european statistical office [17] . completeness and consistency are just a first dimension that has to be reached. a cross-domain data integration, as it is needed for a comprehensive planning, presupposes semantic interoperability and flexibility for qualitative and quantitative information inputs. there is an emotional, thematic, and spatial impact on the analysis of the topic of ldc. the spatial dimension relates to the activity centers of the caregivers with focus on connectivity, time consumption, and diversity. are there more than two activity centers, like work-living and caring, that have to be served? the thematic dimension concerns the "focus of question", which may have an impact on the analysis of the ldc topic. in other words, the "focus of question" could highlight the overall situation of the single use evaluation. the emotional dimension embeds spatial sequences of barriers or encouragement, which can be identified in the evaluation of the specific use case. zhang et al. [18] show that the ldc observation, which is done as interview and therefore in form of storytelling, could be distorted by emotional immersion, which is significantly more immersive than spatial immersion. this significance affects perception of time, realism, sense of engagement, sensory cues, emotional aspects, and many more. in terms of attention and image motion, spatial immersion seems to be as immersive as emotional immersion. a central challenge is the issue of data integration of different sources and especially the mixture of qualitative and quantitative data structures. according to the recommendations of the united nations expert group (un-ggim) [19] , the main challenges for the integration of structured data sources are missing keys. in addition, misleading semantics and hardly considered standards make it hard to combine data usefully. therefore, the united nations expert group (un-ggim) recommends following a five-principle model, which starts with the creation of fundamental national geospatial infrastructures, establishment of geocoding mechanisms, and ends with the full interoperability of statistical topics with geospatial reference data. the main challenge for qualitative data is the creation of structures and semantics that consider space and spatially related emotions. in addition, spatially related emotions are influenced by occurring situations [20] , which need to be considered in the data structures, semantics, and even integration mechanisms. for the example of health situations, long-distance caregivers could play their specific role in epidemiological spreading as it was observed in the covid-19 pandemic crisis. at least ldc needs to be considered in the actions of pandemic control in order to keep up caring mechanisms. from the data-driven point of view, the integration of occurring data varieties enhances their importance for the single-use analysis. an evaluation of possible methodologies for describing the common understanding of space, the relation to qualitative information (interview), and the actual state of standardization seems to be appropriate for creating a higher reliance of the results. an ontological research approach was chosen for the analytical conceptualization and modeling of the spatial relatedness of ldc. for this purpose, conceptual considerations on the spatial relevance of ldc were made from a spatial sciences' perspective and a suitable approach was sought for the operationalization of spatial relevance through the application of spatial semantics of ldc. based on this, an analysis grid was developed into which empirical data were fed. it was decided to test the suitability of the analysis grid using existing primary material from an already existing single case study of a female long-distance caregiver in austria, who according to bledsoe et al. [6] represents "the´typical´long distance caregiver" [ibid, 305]: middle aged, highly educated, and with high income. subsequently, the space-care nexus was modeled using graph theory (see figure 1 ). engagement, sensory cues, emotional aspects, and many more. in terms of attention and image motion, spatial immersion seems to be as immersive as emotional immersion. a central challenge is the issue of data integration of different sources and especially the mixture of qualitative and quantitative data structures. according to the recommendations of the united nations expert group (un-ggim) [19] , the main challenges for the integration of structured data sources are missing keys. in addition, misleading semantics and hardly considered standards make it hard to combine data usefully. therefore, the united nations expert group (un-ggim) recommends following a five-principle model, which starts with the creation of fundamental national geospatial infrastructures, establishment of geocoding mechanisms, and ends with the full interoperability of statistical topics with geospatial reference data. the main challenge for qualitative data is the creation of structures and semantics that consider space and spatially related emotions. in addition, spatially related emotions are influenced by occurring situations [20] , which need to be considered in the data structures, semantics, and even integration mechanisms. for the example of health situations, long-distance caregivers could play their specific role in epidemiological spreading as it was observed in the covid-19 pandemic crisis. at least ldc needs to be considered in the actions of pandemic control in order to keep up caring mechanisms. from the data-driven point of view, the integration of occurring data varieties enhances their importance for the single-use analysis. an evaluation of possible methodologies for describing the common understanding of space, the relation to qualitative information (interview), and the actual state of standardization seems to be appropriate for creating a higher reliance of the results. an ontological research approach was chosen for the analytical conceptualization and modeling of the spatial relatedness of ldc. for this purpose, conceptual considerations on the spatial relevance of ldc were made from a spatial sciences' perspective and a suitable approach was sought for the operationalization of spatial relevance through the application of spatial semantics of ldc. based on this, an analysis grid was developed into which empirical data were fed. it was decided to test the suitability of the analysis grid using existing primary material from an already existing single case study of a female long-distance caregiver in austria, who according to bledsoe et al. [6] represents "the ´typical´ long distance caregiver" [ibid, 305]: middle aged, highly educated, and with high income. subsequently, the space-care nexus was modeled using graph theory (see figure 1 ). the conceptualization of the spatial relatedness of ldc requires comprehensive considerations and taking into account not only objective facts but also subjective perceptions and feelings of the people involved in the ldc setting. the latter is done on the basis of the available empirical material from a single case, focusing on the perspective of the long-distance caregiver. in a first step the term "spatial relatedness" was operationalized, which means that according to the spatial semantic hierarchy of kuipers [21] , the geospatially related structure has been classified. this spatial semantic hierarchy (ibid.) aims at artificial intelligence with a fully automated spatial decision methodology. from his point of view, spatial metaphors are unique for the communication of spatial relationships and processes because space delivers a preexisting knowledge base [22] . according to kuipers [21] the information in a spatial semantic hierarchy is split into five layers, which span from a sensory-, control-, causal-, topological-to a metrical-tier. for our approach of applying spatial semantics the causal-, topological-, and metrical tiers are of specific interest. the metrical tier represents a global 2d geometry in a euclidian space. in the case of spatial semantics for ldc the metrical tier specifies coordinates, a georeference, and geodetic distances. the topological tier represents places, paths, connections, and order. it also inherits one dimensional distance. in the case of the ldc spatial semantic the topological tier becomes expressed by the graph model with its nodes and relationships. the properties of the nodes define places and order. the relationships of the nodes define connections. the causal tier includes actions, causal schemas, and individual views. the causal tier bridges the qualitative interview with topology. within the spatial semantic model of ldc, the causal tier can be embedded by labels for the nodes and relations. it may even express causal properties if strong positions characterize common valid entities. in the following the information from the single case was merged with spatial semantics in order to capture the space-care nexus taking into account the considerations of van broese groenou and de boer [23]: (a) the (assumed) correlation between the physical distance between the places of residence and the commuting rhythm or the length of stay of the long-distance commuting family member with the parent(s); (b) the perceived need on the part of the long-distance caregivers for intensive engagement in the care of the parent(s) depends on the social environment and the infrastructural quality of the direct living environment of the cared-for old(er) persons; the idea now was to describe "places" identified as relevant in the context of ldc as well as the relationships between places using spatial semantics in order to be able to provide answers to the following key questions: • "how far do you have to drive?"/"how far is one willing to travel as a caring relative?"; • "how difficult is it to overcome geographical distances and how often is a caring relative willing to overcome this distance?"; • "what are the local living conditions of the person in need of support or rather care that requires (more) engagement on the part of the adult child(ren) living far away from the parent(s) in need of support and care?" for this reason, building on the relationships between space, concern, and factual engagement in taking over caregiving tasks described in international literature (see table 1 ), the spatial-related aspects in the context of ldc considered as relevant were assigned to the semantic categories as follows: • geographic distances in euclidean space (= distances in miles or rather kilometers) (= metric semantics); • spatial-related aspects addressing all aspects of overcoming geographic distances and explain (partly) the efforts in the contexts of ldc such as topography, reachability, transport modes (= topological semantics); • spatial-related aspects related to the availability of infrastructure supply structures, above all professional and informal care and social support structures in the immediate vicinity of the place of residence of the cared-for persons, which are decisive for a person becoming an ldc (= causal semantics). geographical distances between the places of residence of the caregiver and the cared-for person (national as well as international) [9] ambivalence of feelings [24] and "unique difficulties that are less frequently experienced by local family and friends providing care" [25] feeling of being excluded and under-informed [4] being expected to keep in contact with the old(er) parent(s) in need of support or rather care [26] having the feeling of not doing enough for their elder parent(s) [2, 10] topological (traverses between places/influence on reachability) topography connection of places of residence to high ranking modes of transport (i.e., motorways) efforts for overcoming geographic distances [7] maintaining work/life/care balance [2] influence on kind of provided support for and visiting the cared-for person [3, 6] "watching the deterioration of their loved one" [7, 27] use of telecommunication to keep in contact with the cared-for person or rather to stay informed [28] [29] [30] cost expenditure and choice of means of transport emotional stress [7] and opportunity to take advantage of health promotion offers [1] causal (attributes/qualities) availability and quality of public transport [31] availability of informal and formal elder care support and infrastructure in the residential municipality of the domestic cared-for person ((potential) co-resident caregivers, local caregivers, neighbors, friends) quality of the built environment of the cared-for person (construction-related barriers, maintenance of the garden) reasons for being worried determination of amount of engagement [31] reason for engagement in on-site domestic care and support for the cared-for person [7] the lack of a comprehensive understanding of the spatial relatedness of ldc and the lack of sound and validated empirical evidence justifies the application of a single case study approach [32, 33] . the primary data on the single case which in the following builds the empirical basis for the analytical framework for the spatial relatedness of ldc originates from a finding on an austrian female long-distance caregiving daughter. in order to understand the complexity of the space-care nexus and the relevance of spatial scatteredness of life in the context of ldc over time, the long-distance caregiver was consulted twice: in 2015 and in 2018. the first consultation took place in may 2015 and was part of a series of face-to-face interviews with five austrian long-distance caregivers. the survey aimed to draw attention to the spatially related challenges of long-distance caregivers and the relevance of the topic of ldc in connection with social and health planning in austria for the very first time. the motivation for carrying out this survey was exclusively based on the interest in knowledge and, thus, investigative [34] . in this context, the term "multilocal caregivers" was introduced, which aptly describes the "spatial scatteredness of life" [35] . the explorative face-to-face interviews took place at various meeting points (café, at the interviewees' workplace), and were based on guiding questions and addressed the following topics: the description of the spatial constellation of the places of residence both of the interviewee and the cared-for older parent(s) and the engagement in domestic care (residential locations of the caregiver and the cared-for person(s), degree of kinship); • the need for support or rather care of the person being cared for and the care mix (professional and informal care, support by the respondents themselves); • challenges related to overcoming geographical distance and the consequences for the nature or rather periodicity of support and the quality of life of the (long-distance) caregivers; • the impacts of ldc on health and well-being of the interviewees and their coping strategies. due to the fact that this research did not count as investigative medical research, no approval from an ethics committee was required. the interviewees were informed about the purpose of the survey and gave their verbal consent to publish the findings in anonymized form. access to the interviewees on the one hand was provided by the heads of the viennese nursing care discussion forums (4 out of the 5 interviewees), on the other hand through snowballing among family and colleagues. at the time of the survey, the interviewees were aged between 40 and 70 years and looked after at least one of their parents. it turned out that three out of the five interviewees met the criteria for being a long-distance caregiver. the interviews lasted between one and two hours, and were recorded on tape and then transcribed mutatis mutandis by the interviewer, including direct quotations. one of the interviews was particularly intensive because the interviewee was-also due to her educational background-very interested in the topic and the relevance of the spatial dimension of ldc. therefore, and due to her ability to accurately express herself verbally, from the very first moment she tried her best to reflect her personal caregiving situation comprehensively and critically, pointing out the cause and effect of extensive geographical distances on her well-being and the amount of on-site support for the parents as well as the challenges and limitations of overcoming distances for caregiving purposes. furthermore, she did not shy away from looking into the future and also openly addressed the issue of repression of what may yet come. the ease of the conversation flow as well as the sympathy between the interview partners encouraged the interviewer to go into depth in terms of content, taking into account all the rules of good conversation and respecting the dignity and intimacy of the interviewees according to the guidelines for good scientific practice of the austrian agency for research integrity [36] . finally, the conversation developed into a mixture of biographical-narrative interview following the research questions and problem-centered interview approaching the space-care nexus. at the end of the interview, the interview partners agreed to keep in contact and to continue to exchange on the topic on occasion. two and a half years later, in december 2017-in the meantime, the interviewee had changed her job and moved to another province of austria-the interviewer again contacted the interviewee by telephone with the request to talk again about the caregiving situation. knowing details of the new place of residence and the workplace (name of the respective municipality), the researcher was interested in finding out to what extent these changes had an effect on the caregiving situation and the organization of daily life. therefore, the focus of the second consultation was on an in-depth investigation of the space-care nexus, with particular attention to and taking into account of eventual changes in the health status of the looked after or rather cared-for parent(s), the care-life balance, and the emotions associated with being on the move. this time she wished to deal with the questions in writing. in addition, she wanted to take enough time for a sufficiently intensive answering of the questions. for this reason, the respondent was asked to describe her living situation in text form and, if possible, to depict her emotions graphically by using symbols. a theme-centered questionnaire comprising ten open-ended questions was developed, preceded by an introductory text based on the findings from the face-to-face interview in 2015 (see table 2 ). table 2 . questionnaire for the second consultation in december 2017. current state of health of the parents and requirements for the respondent as caregiving family member "in our first interview on 19 may 2015, you described yourself as a caring daughter who acts as she does, of her own free will and without pressure from her parents." question 1 "please describe the course of your parents' illness since may 2015 and the associated time and-if you wish to do so-the psychological requirements for you as a caring daughter." "over a period of xy years (please add) you had three spatial centers of life: x-y-z." question 2 "in retrospect, what do you associate with x?" question 3 "if you had to depict x graphically, which places and emotions would you depict graphically, and which symbols would you use for this?" question 4 "what do you associate with y?" question 5 "if you had to draw a picture of y, which places and emotions would you draw, and which symbols would you use?" question 6 "when you think of z, then you think of . . . " the questionnaire was sent out at the end of december 2017 via e-mail and the respondent was informed about the purpose of the second survey and the intention to publish the findings sometime and in an anonymized manner according to the general data protection regulation of the european union. the respondent provided her answers at the end of february 2018 and gave consent. from a technological viewpoint all given information has to get connected. a connection can be established when the understanding of the connected nodes is correct. a description of the nodes' and relations' semantics is accomplished in an ontology. the standardization for connecting data on the web is driven by the world wide web consortium (w3c) [37] . these standards are a good meeting point for exploring the ldc data diversity and its modeling, because it shows a similar characteristic to the diversity of data on the web. in the following we describe the importance to link location, thematic information, and narratives. we will introduce the main existing ontologies on the web and give an insight into technologies for a prototypical evaluation. nowadays data science is driven by the integration of different sources of information. key issues are the relation to space, because most of information originates anywhere, and time, because information always has time relevance. moreover, the structures of different sources of information are not consistent or even unstructured, which opens up new research fields in data and geoinformation science. for example, bhatt and wallgrün (2014) [38] highlight new perspectives for gis and its methodologies, which effect, on the one hand, knowledge engineering, semantics, and modeling, and on the other hand, analytical processing. both aspects are driven by a narrative-centered representational and computational apparatus for next-generation gis. from a high-level point of view, a knowledge network that incorporates location, structured information, and narratives seems to deliver the most appropriate fundament to govern essential decisions. this form of data integration is important because location is the main link between society, the economy, and the environment [15, 19] . the main application field for ontologies is the web, where information needs to be found and different junks of information are linked together. this initial characteristic of the web has been further discussed for the definition of notions like web 2.0 or web 3.0 [39] , which mainly relate to the semantic web. automation of information retrieval leads to application fields in machine learning and artificial intelligence, which make use of the semantic annotation of features. because of this main application field, one of the most impressive ontologies, besides the web ontology by w3c [40] , is schema.org [41] . its defined vocabulary structures the knowledge of the web and is used in search engines and applications beyond. the vocabulary covers features, actions, as well as relations between features and actions. it can be used with different encodings like rdfa, microdata, or json-ld, and is easily extensible with a well-documented extension model (ibid.). other extensive ontologies have been created for the knowledge structuring of wikidata [42] , dbpedia [43] , or geonames [44] . all of these examples embed a spatial component, a specific description of the spatial thing, and its relations. standardization procedures exist for the formats and syntax that describes an ontology and its vocabulary. the semantic content, the definitions of features, and relations are almost not controlled and standardized. many knowledge networks that are built for specific analysis with linked data use their own internal definitions. this results in the situation that those results can hardly be combined with other results and therefore do not follow fair (findable, accessible, interoperable, reusable) principles [45] . storing semantic content may challenge data storing and accessing mechanisms. whereas many applications make use of relational database management systems (rdbms), newer developments enhance performance with nosql and graph databases. exchange interfaces incorporate standards for rdfa or json-ld. the storage and accessing structures differ for the mentioned db models. the authors of this paper assume that the analysis and evaluation of the different information sources for ldc will improve by the technology of labelled property graphs [46] , which allow for attributing features, entities, actions, and relations. the spatial aspect is very much often underestimated and needs to be improved. several initiatives try to enhance and interpret graph structures for spatial data on the web [47] . several initiatives regarding the modeling of spatial relatedness of ldc based on the perspective of the long-distance caregiving person and graph theory must be preceded by an appropriate preparation of the available relevant spatial information and its assignment to the various semantic categories. for this purpose, an analysis grid was developed, in which all spatially relevant information extracted from the single case was filled in. in terms of ldc, spatially relevant information includes information on environment, arrangements, interfaces, development, perceived challenges and benefits, and place-associated feelings, and was broken down in categories [48] . the categorization was as following: • relevant places on different spatial scales (residential community, neighborhood, the flat/house) and their relevance and function for the life, well-being, and health of the both the long-distance caregiving person and the cared-for person(s); in order to maintain anonymity to the respondent, subsequently the place names were anonymized; instead of this, a distance matrix (see table a3 ) was created in order to portray the relationships between the different places (= paths) and the causal semantics of the places were supplemented by information from other data sources. although the authors know that a map will present the physical context of ldc and topographical influence on mobility issues best, this visualization has not been created in view of rural situations, where a village consists of a few households, and therefore ethical research codes could not be assured. maps are planned for follow-up research documentations beyond the single case study. in order to vividly illustrate the space-care nexus, direct quotes from the interview as well as the written survey were inserted at appropriate places in the analysis grid. as shown with thematic clusters, the analysis of an ldc situation incorporates various domains, which exceed the geospatial methodology. those different domains characterize the data that can be extracted from observations, measurements, and interviews. in general, these data, whenever translated into relational tables, lead to rigid relational models, which hardly express and adapt to the real situation. in contrast, a graph-based model is flexible enough to be extended with individual observations of an ldc analysis. as a result, the ldc ontology that describes the space-care nexus may shape a common applicable knowledge structure for a better interpretation and planning basis. a graph-based analysis structure makes use of a graph database, which consists of the underlying storage and the processing engine. the storage component is responsible for storing and managing the graphs in a native manner. the processing engine provides a native graph processing, which results in significant performance advantages of an index-free adjacency [49] . in our approach we use the graph modeling and therefore focus on the storage component of a native graph database. whereas in traditional relational databases the data are connected with foreign keys and stored in table collections, in a graph database the relationship is the "first-class" object. this leads to the assembling of simple abstractions with nodes and relationships and enables the creation of sophisticated models that are close to the real-world problem [50, 51] . furthermore, graphs are additive by nature. this means that the adding of new relationships, nodes, labels, or even subgraphs does not influence existing queries and analysis. in case of the ldc exploration, a stepwise extension of the model with new insights is easily done. beside the relations and nodes in a graph model, labels are used to categorize nodes in the model. some of the nodes are persons, others are places, or transit modes. a more detailed description is accomplished with properties, which are arbitrary key-value pairs in the form of simple data types, like strings or numbers. for some graph algorithms it is useful to add properties to the relations as well in order to describe the connections with additional metadata, like the quality, time, or weight. the result then is a labeled property graph [52] . the categorization of nodes and relationships leads to a specific ontology, which is a common valid structure of semantics-in our case for the ldc situation. this semantic structure with its embedded "naming" of nodes, relations, properties, and attributes is domain specific. a comprehensive standardization is missing. kuhn [53] tries to collect a common understanding for geospatial semantics and differs between the semantics of expressions, semantics of services, semantics of interfaces, and geospatial semantics [47] . from a pragmatic implementation-oriented view, geospatial semantics is different with some important properties [54] that influence the modeling of ldc: human perception and social agreements directly influence geospatial information, when objective measurements are mixed with subjective judgements. a mapping between both [55] is a main challenge which helps to make geospatial information more meaningful; 2. the identification of geographic entities is used to enable georeferencing and better translation capabilities. these identifiers are used to link entities and, in the case of knowledge graphs, to establish relations; 3. the situation of ldc and its geographical reference is not a static view, but a process in time and space [56] . distances, directions, and relations move and therefore the overall situation changes. a formal description of the ldc theme needs to consider processes in time and space; 4. the modeling with geographical information incorporates vagueness, uncertainty, and different levels of granularity. the relation of these granularity levels of geographic information [57] with the semantic granularity of ontologies [58] and a qualitative information coming from an interview is an essential part of a valid knowledge graph model for ldc. these key characteristics of geospatial semantics give reasons for the theory of semantic translation, which is capable to join geospatial information with thematic information across the boundaries of their different communities [59] and data characteristics. the ability of semantic translation to link up different knowledge communities even leads to new formal methods in qualitative spatio-temporal reasoning, actions in spatio-temporal dynamics, and new perspectives for the development of the foundational spatial informatics. in geospatial narrative semantics we seek to define formal models of spatial and temporal relations that consider aspects of space, topology, direction, distance, size, traversal distance, and so on. the resulting field of qualitative spatio-temporal representation and reasoning (qstr) has been evolved as specialized discipline within artificial intelligence [38, 60] and could assist a formal evaluation of ldc. the intention of an ldc ontology and a spatial knowledge model is to create a common formal understanding, which is stable enough that it can be used to support strategic planning decisions on elder care. from the authors' point of view this robustness depends on the identification of evaluation nodes and consistent relations. in the following, necessary (spatial related) information on the single case-comprising the long-distance caregiver and the cared-for parents-is provided in order to give a comprehensive insight into the specific caregiving situation. female, in her 40s, university degree in spatial science; • employed: at the time of the first interview working as a teacher, currently employed in career guidance; • living alone and childless: "structural deficiencies of regional labor markets create personal destinies." . . . "i unwillingly have no children. i've changed jobs often. . . . i often wonder what it will be like when i'm older." that is why she feels like "the last link in a chain"; • being a long-distance caregiving daughter since 2013, but does not consider herself a caregiver: "i am an intercessory, supportive, hopefully mentally uplifting daughter who is worried about her parents"; • she has a sister and a good relationship with her and exchanges information with her about their parents. "yes, the parents are a subject of our talks. the sister is burdened by the job. there are no grandparents. she has tried to return to [ . . . ]. but there is no suitable job opportunity. she holds a university degree." • her heart beats for the countryside and she is closely emotionally tied to her parents and her municipality of origin. for this reason, she can imagine returning to z, the municipality where her parents are still living. "it's the roots, the identity. both compensate for the deficits that i face in the city." . . . "we [her sister and herself] are attached to the parents' house." additionally, in her opinion, family cohesion can compensate for the infrastructural deficits in the countryside. at the same time, she mentions that she has no friends in her municipality of origin, because they moved away, too; • her central concern: staying with her parents as often as possible-not only for caregiving reasons, but also because she likes to come home. "for me distance is not a relief, it is a burden, because i have a close, positive, friendly relationship with my parents." she does not feel like a victim; she likes what she does. "on the part of the parents there is no pressure at all." • she was born in austria and grew up in the countryside "in a political district with high unemployment"; • since university days she has been living and working in urban areas, having several centers of life; • in 2013, she moved to x "for the love of her profession", as she could not find an adequate job in financial respects. "this is a problem for people who are living alone: they earn too much to die, too little to live." if she had stayed in [ . . . ] with a badly paid job, "it would have all gone up in the car fuel"; • she has always maintained regular contact with parents via information and communication technologies: "the virtual connection helps to make things a little easier. you have the feeling that you are there. but it doesn't take away the guilty conscience that you still have, because you can't give immediate support when it counts"; • she has found commuting a burden, especially in the past: "the quality of life goes down the drain. . . . doing the housework, seeing that food is there and the laundry is done . . . but the household activities remain the same"; • in 2018 she changed her job and returned to her former place of work and education. since she has been living here again, the time and effort required for ldc has significantly reduced. now it takes her about an hour by car getting from y to z, three hours getting from x to z: "that is what makes the difference." returning to y was accompanied by an increase of the frequency of visits and a shortening of the visit interval: "yes, the frequency has increased significantly, because the journey is now only one hour in one direction. this means a maximum of two hours of concentrated car driving on the motorway on weekends." • medical history started at the beginning of 2013: one parent suffered from brain cancer (four surgeries between 2013 and 2017); she moved to z before the diagnosis; • one parent suffers from heart disease since 2014 (a surgical procedure was undertaken in the same year); • both of the parents are physically impaired, one parent takes medication regularly; both parents are not allowed to perform heavy lifting and should avoid exposure to direct sunlight; • especially the time immediately after the first surgical intervention on the mother was difficult for all of them: "leaving [ . . . ] was not easy, leaving the parents behind, who were overstrained. the mother was always a central figure (note: in the household, there was classic division of tasks between the two), the father was in shock . . . but it was good luck that the sister was on maternity leave at this time." (note: her sister now (as of 2015) lives in x, the same municipality of residence and work of the interviewees). during this time, the respondent took over work in the parents' household and in the garden, whenever possible; • the situation has calmed again: car driving, climbing stairs is again possible for both of them. the living environment itself is no longer a problem (the house is a bungalow): "that was good luck." but gardening is still a problem. living independently in their own four walls is still possible to a large extent, there is no need for accompanying co-resident professional caring support; • one parent has to go to hospital regularly for check-ups. the father's brothers take over the transport service to the therapies in the hospital. "taking the bus would have been conceivable, but there is no public transport"; • "the parents' social network is the family. the father has four brothers, one of whom is a direct neighbor. . . . the parents' friends weren't any help to them, but the father's family was . . . there is no additional support from neighbors, associations, or the church." 6.6. outlook on the future as a long-distance caregiving daughter • on the part of the parents there is a tendency to want to live closer to the children, but "it is difficult to resettle someone of this age from a rural region to another place. they are not urban people." moreover, "the housing situation also ought to be clarified"; • when observing the ageing of her parents, the interviewee thinks about what basic infrastructural infrastructure should be available in the parents' municipality of residence. "i critically observe the development: ongoing concentration in the metropolitan areas, the rural regions are lagging behind. . . . grocery stores, small retail shops, public transport and buses are rare. not imaginable, if you live in x." with this, the interviewee expresses her concern about the changing structures, above all the thinning out of the infrastructure, which is important to maintain the quality life at a very old age; • regarding whether she would talk to the mayor about domestic or stationary care facilities and opportunities, the interviewee replied: "when i am here, i don't have time for that." furthermore, she is not in z during the mayor's office hours; • although she is anxious about the father's physical fitness [61] , she currently has no concrete reason to worry about the distant future. nevertheless, she has already talked about nursing and care such as the choice for a certain nursing home: " . . . unimaginable, because up to now all of the family members have been cared for by relatives and not in a nursing home." this section discusses the meaning of places and the memories and emotions associated with them. in her life, she has already had three (2013-2017) or rather two focal centers of life (since 2017) with which she associates certain memories and emotions in the context of ldc (see table a1 , appendix a): on the one hand, these are the municipalities in which she lives, works, and maintains friendships and social contacts. x = place of work and residence at time of survey 1 (interview in 2015) y = place of work and residence at time of survey 2 (written survey in 2018) z = municipality of origin and residential municipality of the cared-for older parents referring to these centers of life, the interviewee identifies specific relevant places that were or still are of particular importance to her due to the activities carried out there. moreover, the interviewee points out the importance of communities as well as other persons and aspects. at the time of the first consultation in 2015, it seemed to her that her whole life was thoroughly organized: "i feel like i am living by the clock. no matter where i am, i think about the fact that i will have to leave soon. . . . the return trips from the parents to x must be well planned. i want to be back in x by 5 p.m. at the latest, otherwise i will not get a parking space. otherwise i will be forced to make a detour, park the car somewhere else, and continue by public transport. it is a tension and physical challenge." in order to better understand the emotional burdens of commuting for caregiving reasons and emotionally being torn due to the spatial scatteredness of life, the long-distance caregiver was asked to describe her emotions associated with being on the move (see table 3 ) table 3 . feelings of being on the move. on the way to the parents (y → z) on the way back from the parents (z → y) "joy to see the parents" "focusing on the social environment" "inner well-being, coziness, inner brightness" "friends, colleagues, social network" "reliability, cordiality, communication" "roots, security" "job" "responsibility" "focus on important things" when she passes the z's place-name sign, she feels . . . on departure from the parents (z → y) "inner well-being, happiness and joy" "simply a good feeling to be always welcome" "looking forward to the next visit, hoping that the parents are well and that they enjoy life in the meantime" "i am glad that the distance to y is only an hour's car drive and that i can go to z anytime i need to" the single case study gives a very detailed, but also individual relevant image of ldc. it is nearly impossible to relate the individual relevant information to spatial infrastructures, which will allow for a prospective spatial analysis of ldc. from the interview, we can observe spatial centers of life, their related associations, spatially related characteristics of long-distance caregiving and the dependency on supporting infrastructures and the influence of emotion. all mentioned elements are somehow related and embedded in a story. according to [62, 63] a graph-based semantical structure helps for reasoning and efficiently answering technical questions. in addition the works on "spatialization of narratives" [64] and the "finding of answers with knowledge graphs" [65] indicate that graphs are a promising approach to relate our single case study of ldc to a common spatial understanding. this first step of modeling ldc information has the aim to bridge individual views to common spatial infrastructures and spatial knowledge graphs [66] [67] [68] . for the modeling of ldc information (see figure 2 ), the authors of this contribution made use of a basic ldc ontology, which collects information elements and their connections [69, 70] . this ldc ontology is an information structure on the basis of the interviews of the single case study and observations of ldc literature. the main findings have been listed earlier in this chapter with the case vignette and spatial centers. table a2 (see appendix b) and table a3 (see appendix c) show relevant places and their spatial-related attributes from the perspective of the long-distance caregiver as well as a distance matrix. all these elements have been categorized in a way that the connection to "external" existing knowledge graphs becomes enabled and data integration with spatial data infrastructures is supported [71, 72] . in table a2 (see appendix b). transport roughly consists of the transportnetwork with its properties of modality, distance, and time, and topography with a first rough topographic classification to mountainous, rural, and urban. health facilities cover the properties' hospital, doctors' office, or medical supply. the authors would like to express that the classifications are a first step towards a comprehensive ldc ontology on the basis of international literature and the single case study. it needs to be expanded for meaningful applications. the ldc ontology is a first model which is a topic for further research. we observed that different kinds of places are relevant for ldc. all those places have an impact on the possibilities, willingness, and burden for the ldc. although place is defined only once in several existing knowledge graphs [41] [42] [43] , it has different additional meanings for the ldc´s perspective. to a large extent, those meanings can be described and enriched with common points-of-interest (poi) collections, which become increasingly on the basis of the single case evidence, infrastructure is mainly built up by the variety of places, transport, and health facilities. the variety of places has been expressed by the table of relevant places in table a2 (see appendix b ). transport roughly consists of the transportnetwork with its properties of modality, distance, and time, and topography with a first rough topographic classification to mountainous, rural, and urban. health facilities cover the properties' hospital, doctors' office, or medical supply. the authors would like to express that the classifications are a first step towards a comprehensive ldc ontology on the basis of international literature and the single case study. it needs to be expanded for meaningful applications. the ldc ontology is a first model which is a topic for further research. we observed that different kinds of places are relevant for ldc. all those places have an impact on the possibilities, willingness, and burden for the ldc. although place is defined only once in several existing knowledge graphs [41] [42] [43] , it has different additional meanings for the ldc's perspective. to a large extent, those meanings can be described and enriched with common points-of-interest (poi) collections, which become increasingly available from authoritative sources. other poi are of individual character that is expressed by a person's social environment, interest, and emotions [20] . one element that is often used for the definition and categorization of ldc is the "transportnetwork", especially its properties of modality, distance, and time. modality describes the kind of transport, such as train, car, or airplane. although the transportnetwork on one hand is an important element for ldc and a central part of the infrastructure, it is, on the other hand, only a secondary element from the ldc point of view. this means that the simple travel distance and time to the caring person is not a sufficient dimension to categorize an ldc environment. instead, the variety of places, their persistence, topography, and topological structures need to be considered as it is indicated in the ldc ontology. health facilities cover hospitals, doctors' office, and medical supply. these properties are elements of specific places (with the property "care") and use the transport network as many health facilities may cause additional traveling. health facilities from the knowledge network point of view are required for the cared-for person(s) and also cause visits for the caregiving person. this paper is the result of a first attempt to comprehensively analyze and operationalize the spatial relatedness of long-distance caregiving by combining spatial sciences' and geoinformatics' considerations and developing an interdisciplinary mixed-method approach combining primary data from a single case with graph theory. from the spatial data science point of view, we can conclude that the ldc ontology is a first step towards integrating information of a single case study into spatial knowledge infrastructures. the matching of individual expressions to common semantic definitions and even to external knowledge graphs opens additional accessible data sources and densifies information, e.g., points of interest, that is needed for a more objective ldc spatial analysis. we were able to prove the linking to external knowledge graphs works in principle. we observed that neither the specific topic of ldc is covered in currently available knowledge graphs [41] [42] [43] nor authoritative data sources with appropriate information interfaces, like geosparql, exist. the last is already a topic of european legislation for 2021 as european open data directive [73] . the extension of knowledge graphs for ldc and the creation of use cases for spatial analysis as well as planning will be further steps for research and a feasibility study. the openly extensible knowledge graph of wikidata [42] offers an interface and guidance for enhancing the knowledge structure. in the case of local proof of concepts [74, 75] the connection to external knowledge graphs and semantic definition registries is an obligation. it enables data integration and a more objective spatial analysis for the topic of long-distance caregiving, which is a focus for future research. the elaborated conceptual framework could serve as a starting point for a more detailed and precise interdisciplinary discussion on the spatial relatedness of long-distance caregiving and, thus, is open for further refinement in order to become a decision-support tool for policy-makers responsible for social and elder care and health promotion. being aware of the methodological and content-related limitations of this approach, we hope that the model will be applied in different countries and on different spatial reference scales and receives validation and extension by as many (longitudinal) empirical findings as possible, in order to: grasp the principles of the space-care nexus in the context of long-distance caregiving quickly and comprehensively and thus make visible the heterogeneity of the long-distance caregivers in terms of their burdens and needs; 2. stimulate a critical discussion about geographical proximity, which goes beyond a categorization according to distance classes [11] , and the limits of the separability of objective and subjective components in terms of content; 3. take greater account of the importance of the time dimension of long-distance caregiving careers and the variability of relevant aspects in order to better be able to explore the relevance of the time scale as well as the limits of interpolation between different points in time; 4. initiate a spatial turn within the debate on the various issues of long-distance caregiving with regard to the discussion about the ability to influence spatial-related aspects in order to maintain well-being and quality of life of all persons involved in long-distance caregiving and, thus, to critically reflect on the suitability or accuracy of strategic demand planning in the context of elder care and health promotion, which, up to now, exclusively is based on demographic indicators and to raise the awareness of the issue of long-distance caregiving among key players in social and health care [fischer and jobst 2019]; 5. further develop methodologies for the numerical determination of long-distance caregivers at (pre-defined) spatial scales and in spatial settings (urban, rural, suburban, remote). for this purpose, it would be valuable to: 1. on the one hand, apply the analysis grid and the graph model to other people involved in long-distance caregiving (e.g., the cared-for persons themselves, co-resident (family) caregivers, local caregiving (family) members, as well as health and social care professionals); 2. on the other hand, evaluate the model by multi-professional teams of researchers-involving representatives of the spatial sciences' and geoinformatics-and therefore critically examine the suitability of the model as being a part of a decision-support tool in social and health care planning. acknowledgments: the open access publishing was supported by boku vienna open access publishing fund. the authors declare no conflict of interest. table a1 breaks down the gathered information related to the spatial scatteredness of life as well as place-related associations. table a1 . spatial scatteredness of life and place related associations. "working" "ict-supported communication with parents" "making new friends with both room colleagues" "little space" the flat of the sister "family, nephew, being godmother, babysitting, talking" no additional information provided at work "colleagues, interactive working with the pupils, new friendships and leisure activities with colleagues" no additional information provided y (urban center) "friends and social network" "job, education" "sports, nature, culture" "my home" "socializing and cordiality" "education, maturing, development" "satisfaction and happiness" the flat no additional information provided "the view, nature, living space" no additional information provided university no additional information provided no additional information provided z (rural municipality) "parents, grandparents and family" "social contacts" no additional information provided "love, childhood, coziness, roots, being earthed, trust and openness, security, reliability, home" "honesty, down-to-earth" "wideness, nature, and silence" "responsibility" the parents' house and garden no additional information provided appendix b table a2 gives an overview over relevant places and their spatially related attributes from the perspective of the long-distance caregiver. table a2 . relevant places and their spatially related attributes from the perspective of the long-distance caregiver ("spatial-related scatteredness of life and ambivalence of feelings"). places of residence of the long-distance caregiver two places of residence: place of residence 1 (x) = municipality of work = secondary residence = place of residence of the sister place of residence 2 (y) = place of education = primary residence = place of residence of friends third place of relevance (z) = municipality of origin = place of residence of the parents dream job; purpose-oriented stay; staying as long as necessary rare staying; visits as often as possible every weekend (friday afternoon to sunday afternoon), if possible, and during school holidays emotional ties (sister and nephew) city greater emotional bonding in comparison to place of residence 1 (x) here is where the heart beats. city, very good job opportunities as well as infrastructure and cultural offers city rural municipality, an hour's car drive from the next urban core zone [76] spatial staying as long as possible as well as often as necessary; usually on weekends (friday afternoon to sunday afternoon) and during school holidays here the interviewee feels at home and secure mentioned available infrastructure (as of survey 1): one practitioner, pharmacy, motorway exit, the latter is considered to be "an advantage for the municipality" the proximity to nature family support observation of infrastructural changes (thinning out) and worries about care needs of the parents in later life (they want to stay there, in their own built house; informal domestic care is a long-standing tradition in the interviewee's family she is thinking of returning to z after retirement the parents' house = place of support = place of cordiality = accomodation during the visits whenever she visits her parents or looks after them place of childhood both the interviewee and her sister are emotionally attached to the parents' house; the interviewee would like to take it over one day the house and the garden; not barrier-free she lives there when he's with her parents. therefore, no additional distance is to be overcome as well as no additional expenditure for commuting apply stress and bad conscience: "can't support the parents in gardening" prospects for a probably long-lasting caregiving career: the parents want to stay in their own four walls ("you don't plant an old tree") the motorway the direct and fastest connection between the two places of residence (caregiving daughter & parents) as long as necessary, as quick as possible the fastest connection; nevertheless, the motorway is experienced as a burden: "it is necessary to concentrate fully for three hours" distance and topology justify the choice of transport mode (own car) = explanation of physical and psychological strains in the context of overcoming distances (x → z) "the weekend trips to my parents' house in z meant all things considered more than six hours of concentrated driving on the motorway" health care facilities for medical and nursing care (hospitals, medical practices) place of medical treatment for the parents no relationship identified she would like to support her parents by taking them to their medical treatments; but due to the extensive distances to overcome she can't appendix c table a3 shows the functional relationships between the relevant places; distances, time efforts, and emotions in the context of overcoming distances (always on the move) from the perspective of the long-distance caregiver. table a3 . always on the move: functional relationships between the relevant places; distances, time efforts, and emotions in the context of overcoming distances from the perspective of the long-distance caregiver. explanation of why she can only support the parents selectively and cannot visit them regularly she can hardly maintain her social contacts in y distance and travel time as reasons for being always in a hurry: "on fridays getting from x to z as early as possible", but "this often doesn't work because there is always something to be organized in x" "departing from z as late as possible" since 2017, x no longer plays a role in her life note: distances and efforts for overcoming distances. road distances and travel times are calculated using googlemaps. on the suitability and potential of nursing care discussion forums as a health promotion measure for long-distance caregiving relatives: evidence from upper austria long-distance caregiving: a systematic review of the literature over the hill and far away: distance as a barrier to the provision of assistance to elderly relatives information quality, uncertainty, and quality of care in long-distance caregiving communication in the context of long-distance family caregiving: an integrated review and practical applications long distance caregiving: an evaluative review of the literature living arrangements of older persons: a report on an expanded international dataset pflegen auf distanz? eine qualitative interviewstudie mit "distance caregivers long distance parental caregivers' experiences with siblings geographical proximity and depressive symptoms among adult child caregivers: social support as a moderator retirement effects on parent-adult child contacts parent care and geographically distant children long distance caregiving for older adults an infrastructure for spatial linking of survey data a european strategy for data healthcare services in europe general description contribution attributes attribute datatype description spatial immersion versus emotional immersion, which is more immersive? united nations committee of experts on global geospatial information management. the global statistical geospatial framework crowdsourcing affective responses to space the spatial semantic hierarchy 23. van broese groenou, m.i.; de boer, a. providing informal care in a changing society interpersonal conflict and health perceptions in long-distance caregiving relationships long-distance caregiving: personal realities and practice implications long-distance caregiving: a case study of an african-american family elderly parents and the geographic availability of their adult children reducing the distance in distance-caregiving by technology innovation out of mind": parent contact and worry among senior ranking male officers in the military who live long distances from parents technology and web-based support caregiving at a distance case study research: design and methods better stories, not better constructs, to generate better theory: a rejoinder to eisenhardt multilokalität-eine zentrale herausforderung für sorgende angehörige multilokale lebensführungen und räumliche entwicklungen-ein kompendium arl-akademie für raumentwicklung in der leibniz-gemeinschaft guidelines for good scientific practice owl-semantic web standards geospatial narratives and their spatio-temporal dynamics: commonsense reasoning for high-level analyses in geographic information systems handbook of research on web 2.0 and second language learning owl 2 web ontology language structural specification and functional-style syntax wikidata: introduction-wikidata geonames ontology-geo semantic web the fair guiding principles for scientific data management and stewardship graph algorithms: practical examples in apache spark and neo4j-neo4j graph database platform comprehensive geographic information systems application of a case study methodology graph databases graph theory graph algorithms in the language of linear algebra geospatial semantics: why, of what, and how? a method for the formalization and integration of geographical categorizations from objects to events: gem, the geospatial event model granularity in change over time semantic granularity in ontology-driven geographic information systems conceptual spaces. the geometry of thought qualitative spatial reasoning. in handbook of knowledge representation distance caregiving a family member with cancer: a review of the literature on distance caregiving and recommendations for future research semantic technologies for intelligent data access efficiently answering technical questions-a knowledge graph approach narrating space/spatializing narrative: where narrative theory and geography meet by learning to answer ambiguous questions with knowledge graph relaxing unanswerable geographic questions using a spatially explicit knowledge graph embedding model generating quiz questions from knowledge graphs narrative geospatial knowledge in ethnographies: representation and reasoning semantic web 0 (2016) 1-0 geoai: spatially explicit artificial intelligence techniques for geographic knowledge discovery and beyond spatial exploration of economic data and methods of interdisciplinary analytics manual of digital earth european open data directive semantic systems. the power of ai and knowledge graphs native parallel graphs; the next generation of graph database for real-time deep link analytics urban-rural typology by statistics austria this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-307038-c58mzcu9 authors: shukla, nagesh; pradhan, biswajeet; dikshit, abhirup; chakraborty, subrata; alamri, abdullah m. title: a review of models used for investigating barriers to healthcare access in australia date: 2020-06-08 journal: int j environ res public health doi: 10.3390/ijerph17114087 sha: doc_id: 307038 cord_uid: c58mzcu9 understanding barriers to healthcare access is a multifaceted challenge, which is often highly diverse depending on location and the prevalent surroundings. the barriers can range from transport accessibility to socio-economic conditions, ethnicity and various patient characteristics. australia has one of the best healthcare systems in the world; however, there are several concerns surrounding its accessibility, primarily due to the vast geographical area it encompasses. this review study is an attempt to understand the various modeling approaches used by researchers to analyze diverse barriers related to specific disease types and the various areal distributions in the country. in terms of barriers, the most affected people are those living in rural and remote parts, and the situation is even worse for indigenous people. these models have mostly focused on the use of statistical models and spatial modeling. the review reveals that most of the focus has been on cancer-related studies and understanding accessibility among the rural and urban population. future work should focus on further categorizing the population based on indigeneity, migration status and the use of advanced computational models. this article should not be considered an exhaustive review of every aspect as each section deserves a separate review of its own. however, it highlights all the key points, covered under several facets which can be used by researchers and policymakers to understand the current limitations and the steps that need to be taken to improve health accessibility. appropriate and timely access to healthcare is of the utmost importance; if not provided, it can lead to several concerns like missed scheduled appointments, delayed medication, and potential fatality. the barriers to accessibility are varied and are dependent on location, affected disease and patient characteristics. australia is a vast country with a very diverse population where settlement is spread thinly over vast areas [1] . the country also has an aging population which will require healthcare support in the future. therefore, understanding the models used to analyze barriers to healthcare access across various diseases is crucial. in terms of geographic patterns, 31% of the population live in rural and remote areas; they have lower usage rates due to the distance-decay relationship. the distance-decay association suggests that people who live farther from healthcare facilities have lower rates of usage, after the adjustment of other factors for need, than those who we also analyzed the states where the studies were conducted. the results reveal that 20% of the studies were conducted on a national level. the studies conducted in specific states are illustrated in figure 2 . the analysis was performed based on the state where the study was conducted irrespective of covering a small part of the state. we also analyzed the states where the studies were conducted. the results reveal that 20% of the studies were conducted on a national level. the studies conducted in specific states are illustrated in figure 2 . the analysis was performed based on the state where the study was conducted irrespective of covering a small part of the state. we also analyzed the states where the studies were conducted. the results reveal that 20% of the studies were conducted on a national level. the studies conducted in specific states are illustrated in figure 2 . the analysis was performed based on the state where the study was conducted irrespective of covering a small part of the state. healthcare access was classified into 5 categories in [8] , which are: (a) availability, (b) accessibility/proximity, (c) affordability, (d) acceptability and (e) accommodation. the first two (availability, accessibility) can be considered spatial whereas the remaining factors are non-spatial [9] . geographic information systems (gis) is considered a powerful tool to integrate both spatial and non-spatial factors [10] . however, most studies analyzed hindrance to access in the spatial context irrespective of disease type. the studies focusing on spatial accessibility were analyzed using three different techniques: (i) distance/time to nearby services, (ii) gravity models and (iii) population versus provider services: doctor-population ratio (dpr) or bed-population ratio (bpr) [11, 12] . the first approach is a simple technique wherein the distance between population residence and service provider (proximity) is determined without considering the availability aspect of spatial accessibility. the determination of accessibility was usually carried out by determining travel time. however, some studies used the line-of-sight measure, in which distances were used as a measure of access [13] [14] [15] [16] . this concept can be used in some scenarios as access to cars is one of the highest in the world for people residing in urban areas of australia, due to a highly developed road network [13] . the second approach considers both aspects (availability and proximity); however, the limitation of using gravity models is a challenge for the determination of the distance-decay function [9, 17] . the population versus provider services approach uses a classification of the population and health services within a defined region instead of the spatial movement as used in the other two approaches. the determination of the ratios is easy to compute, as the data for both the population and the health centers are usually available. the use of such an approach involves two assumptions: (a) that the population is expected to use health services within the defined region, and (b) that the proximity aspect is negligible within the region [11] . the significant difference lies in the selection of defined regions. as the name suggests, the floating catchment area (fca) method uses floating areas or "windows" instead of defined regions, the size of which is determined by the availability of the required services within a region. the use of fca leads to the major challenge of not considering the demand aspect with respect to supply-demand concerns. this challenge was addressed by [18] , which introduced the spatial decomposition method, and this approach was then used by [17] , which introduced the two-step fca or 2sfca method. the 2sfca method is performed in two steps, first calculating the size of the population within the catchment area, and then determining the available services in the catchment area. evaluation of the accessibility of healthcare is usually conducted using gis techniques, which measure the travel distance and time required for using public or private transportation systems. the studies can be categorized as revealed accessibility or potential accessibility [3] . revealed accessibility is the actual time taken to reach health centers, whereas potential accessibility analyses the potential to access healthcare determined using either gravity models or specialized gravity models like the 2sfca method. after collecting and determining the relevant health barriers, statistical models were applied to analyze the association of the factors with survivability along with the interrelationship of the barriers. the present review looks at the models used to understand the barriers to healthcare access for various diseases in australia. the aim is also to analyze survivability or outcomes in relation to the barriers. the review was conducted based on several categories including disease, study area, models used, number of patients, rural vs. urban, consideration for indigenous people, and the dataset (source and time period) used. the australian healthcare system is considered a hybrid model where people can purchase private insurance coverage along with the public insurance they already receive, making both public and private hospitals available [19] . the vast geographical area of the country, varied residential locations and their uneven distribution of population, network of roads and traffic conditions and the allocation of hospital resources lead to an imbalance of health service access for the people [12] . in terms of practicing physicians, australia has 3.39 per 1000 people, which is one of the highest in the world [19] . it also spends the most on healthcare among the organization of economic cooperation and development (oecd) countries, which are a consortium of 34 countries dedicated towards developing policies for various social and economic challenges [19] . a detailed understanding of the australian healthcare system can be found in [20] . it has been well established that following illness, health outcomes can get worse upon traveling a greater distance to health centers. similar bias is often visible among residents living in rural areas as compared to urban areas. the variation between survivability among rural and urban residents for various health cases has been analyzed by several studies [21] [22] [23] . the rural population suffers from higher fertility and perinatal mortality rates compared to the urban population. the chance of health cases (e.g., diabetes, high cholesterol, cancer, heart disease) is higher than in the urban population, which lowers their life expectancy by 4 years. the national rural health alliance found that the barriers dividing remote areas from major cities are enormous: for example, in the case of remote/very remote areas, over 58% of people reported not having a specialist nearby as compared to only 6% in the case of major cities. such startling differences are also present across different disease types and health visits. the geographical classification of the country is based on the australian statistical geography classification (asgc) framework provided by the australian bureau of statistics (abs) (figure 3 ). this classification was initiated in 2011; prior to it the australian statistical geography standard (asgs) classification was used. the studies conducted determined the geographical location of their respective study region based on census classification, which has been modified over the years. the population can be based on either place of enumeration (based on the location on census night) or place of usual residence (based on the location where they usually live). the studies relating to healthcare access were conducted based on place of usual residence. before 2001, the census was based on statistical local area (sla), which was changed to collection district (cd) level in the next census. for the 2011 census, the australian statistical geography standard (asgs) was used, in which the data were available at statistical area 1 (sa1) level, which could be aggregated to higher spatial scales of geography. the remoteness of a place can be categorized into one of five classifications: major cities, inner regional, outer regional, remote and very remote [4] . remoteness has been defined based on the asgc-ra (remoteness area) classification ( figure 4 ). this classification determines the physical distance of a location and allows the quantitative comparison between metropolitan and rural regions. to compute asgc-ra, the accessibility/remoteness index of australia (aria+) score is determined. this is an index of remoteness with values ranging from zero (high accessibility) to 15 (high remoteness) based upon the physical distance of a location from the nearest urban center according to census data on population size [24] . the remoteness of a place can be categorized into one of five classifications: major cities, inner regional, outer regional, remote and very remote [4] . remoteness has been defined based on the asgc-ra (remoteness area) classification ( figure 4 ). this classification determines the physical distance of a location and allows the quantitative comparison between metropolitan and rural regions. to compute asgc-ra, the accessibility/remoteness index of australia (aria+) score is determined. this is an index of remoteness with values ranging from zero (high accessibility) to 15 (high remoteness) based upon the physical distance of a location from the nearest urban center according to census data on population size [24] . . the other critical factor while determining accessibility is socio-economic status (ses), which is based on the socio-economic index for areas (seifa) developed by the australian bureau of statistics (abs) and is a set of four indexes: the index of relative socio-economic disadvantage (irsd); the index of relative socio-economic advantage and disadvantage (irsad); the index of education and occupation (ieo); and the index of economic resources (ier). the seifa comprises five categories, which are: most disadvantage; above average disadvantage; average disadvantage; below average disadvantage; and least disadvantage [13] . generally, a socio-economic index is assigned using area-based measurement, which tends to be biased and often inaccurate. this was highlighted by [25] which used individual-based demographic data and compared survival disparity when considering local government area (lga) and cd classification in the new south wales region. the results highlight the underestimation of survival disparity with little variation when relative excess risk (rer) is calculated. factors like patient characteristics including smoking, employment, ethnicity, disability, indigeneity, stigma and discrimination have also been explored by researchers under various circumstances [26, 27] . the covid19 pandemic has revealed new barriers and challenges for healthcare workers and patients affected by it. this has caused patients with several necessary and critical health conditions to prematurely die in several oecd countries. among the oecd countries, australia has conducted a commendable job in addressing the barriers for healthcare professionals. although the situation is still unfolding, a few research articles and news reports are attempting to understand the gravity of the situation. some have reflected on the emotional state of healthcare professionals [28] , while others have suggested the importance of linguistic and communication barriers. in the australian context, lakhani [29] a conducted spatial analysis to understand the most vulnerable populations in the melbourne region depending on their characteristics. finally, the survivability of patients is determined by utilizing either the overall survival or relative survival measures. overall survival is defined as an estimate of survival from the initiation of either the diagnosis or medication, whereas relative survival is defined as an estimate of net survival which measures the deaths specifically associated with cancer diagnoses [22] . such risks are also dependent on ses. therefore, relative excess risk (rer) has been defined; this is the ratio of excess risk of death in a particular ses quintile compared to that of the reference (least disadvantaged) ses group, controlling the other factors. the other critical factor while determining accessibility is socio-economic status (ses), which is based on the socio-economic index for areas (seifa) developed by the australian bureau of statistics (abs) and is a set of four indexes: the index of relative socio-economic disadvantage (irsd); the index of relative socio-economic advantage and disadvantage (irsad); the index of education and occupation (ieo); and the index of economic resources (ier). the seifa comprises five categories, which are: most disadvantage; above average disadvantage; average disadvantage; below average disadvantage; and least disadvantage [13] . generally, a socio-economic index is assigned using area-based measurement, which tends to be biased and often inaccurate. this was highlighted by [25] which used individual-based demographic data and compared survival disparity when considering local government area (lga) and cd classification in the new south wales region. the results highlight the underestimation of survival disparity with little variation when relative excess risk (rer) is calculated. factors like patient characteristics including smoking, employment, ethnicity, disability, indigeneity, stigma and discrimination have also been explored by researchers under various circumstances [26, 27] . the covid19 pandemic has revealed new barriers and challenges for healthcare workers and patients affected by it. this has caused patients with several necessary and critical health conditions to prematurely die in several oecd countries. among the oecd countries, australia has conducted a commendable job in addressing the barriers for healthcare professionals. although the situation is still unfolding, a few research articles and news reports are attempting to understand the gravity of the situation. some have reflected on the emotional state of healthcare professionals [28] , while others have suggested the importance of linguistic and communication barriers. in the australian context, lakhani [29] a conducted spatial analysis to understand the most vulnerable populations in the melbourne region depending on their characteristics. finally, the survivability of patients is determined by utilizing either the overall survival or relative survival measures. overall survival is defined as an estimate of survival from the initiation of either the diagnosis or medication, whereas relative survival is defined as an estimate of net survival which measures the deaths specifically associated with cancer diagnoses [22] . such risks are also dependent on ses. therefore, relative excess risk (rer) has been defined; this is the ratio of excess risk of death in a particular ses quintile compared to that of the reference (least disadvantaged) ses group, controlling the other factors. in terms of diseases, numerous studies have been conducted for various types, of which the greatest number have been performed for cancer (35%), followed by primary health care (14%), dental care (11) and cardiovascular conditions (10%). figure 5 depicts the studies conducted for various diseases. in terms of diseases, numerous studies have been conducted for various types, of which the greatest number have been performed for cancer (35%), followed by primary health care (14%), dental care (11) and cardiovascular conditions (10%). figure 5 depicts the studies conducted for various diseases. studies focused on understanding the inequalities in healthcare access based on various traits like location (rural, urban), origin (indigenous, nonindigenous), and access to health services. among the various regions, most studies were performed in queensland (38%), followed by new south wales (34%), victoria (14%) and the entire country (14%). cancer is the most significant global public health problem and a leading cause of death and illness in the world in the 21st century, including australia [30] . breast cancer is estimated to have been the most commonly diagnosed cancer in 2019, followed by prostate cancer. the distribution of the studies related to cancer types has also been varied with most studies being conducted on colorectal cancer followed by breast, prostate and lung cancer. generally, the studies conducted form a framework in which barriers were analyzed independently as well as in terms of their interrelationship and their relationship with health outcomes. general accessibility factors like age, sex, patient characteristics and disease stage (incidence, various cancer stages) were collected from the respective state's cancer registry. the distance to the health facility was determined by geocoding the distance of all the facilities to the centroid of each sla or to the address of the patient if available. there seems to be a set framework when studying barriers to cancer care that considers various geographic and demographic parameters, thereby determining the survival rate. studies focused on understanding the inequalities in healthcare access based on various traits like location (rural, urban), origin (indigenous, nonindigenous), and access to health services. among the various regions, most studies were performed in queensland (38%), followed by new south wales (34%), victoria (14%) and the entire country (14%). cancer is the most significant global public health problem and a leading cause of death and illness in the world in the 21st century, including australia [30] . breast cancer is estimated to have been the most commonly diagnosed cancer in 2019, followed by prostate cancer. the distribution of the studies related to cancer types has also been varied with most studies being conducted on colorectal cancer followed by breast, prostate and lung cancer. generally, the studies conducted form a framework in which barriers were analyzed independently as well as in terms of their interrelationship and their relationship with health outcomes. general accessibility factors like age, sex, patient characteristics and disease stage (incidence, various cancer stages) were collected from the respective state's cancer registry. the distance to the health facility was determined by geocoding the distance of all the facilities to the centroid of each sla or to the address of the patient if available. there seems to be a set framework when studying barriers to cancer care that considers various geographic and demographic parameters, thereby determining the survival rate. the remoteness index (aria+) and socio-economic index are considered when determining the effects on patient survival. the models used to determine survivability included the poisson regression model [31] and the cox proportional hazards model [32] . survivability can be expressed in either a spatial [33] or a temporal context [34] . yu et al. [31] used the poisson regression model to determine survivability by analyzing residential location in diagnoses of colorectal cancer. however, frowen et al. [35] investigated the impact of pre-treatment factors including demographic parameters. baade et al. [36] determined the survival rate among colorectal cancer patients residing in queensland. the study introduced a multilevel approach to assess area-level variation in colorectal cancer survival due to causative factors (disease stage, comorbidity, patient characteristics and healthcare access) and analyze their individual contribution to survival. baade et al. [32] analyzed the relation between distances to radiotherapy facilities and survival outcomes for rectal cancer patients in queensland using the cox proportional hazards regression model. the results revealed that survival rate is low in areas of socio-economic disadvantage, remoteness and greater distance to radiotherapy facilities. hsieh et al. [37] quantified the additional barriers that impacted treatment among women in queensland diagnosed with breast cancer. a bayesian spatial modeling approach was used to analyze the spatial inequalities of utilizing adjuvant therapy and found that socio-economic aspects did not play a significant role. however, the choice of therapy (radiotherapy, chemotherapy, hormonal therapy) was dependent on the age of the patient. coory et al. [38] studied the disparity in cancer-related deaths among people residing in regional and remote areas for a period of 10 years (2001-2010). they used an arithmetic methodology wherein the number of deaths precluded in australia and excess cancer deaths in regional areas were computed. the results revealed a slight improvement in curtailing the disadvantage of such areas, with a death rate lower than metropolitan areas. an interesting study was conducted in [39] , which introduced a new parameter, "country of birth", along with socio-economic status, remoteness and ethnicity among patients diagnosed with cancer in the new south wales region. a logistic regression model was used to analyze the relation between variables and the distant summary stage. the results revealed that people born outside of australia were more likely to be diagnosed, with socio-economic status also playing a significant role. mahmud et al. [30] used multivariate analysis to analyze the trends associated with cancer incidence, hospitalization, and fatality for several barriers. the study was conducted for the period 1982-2014 and the results revealed that socio-economic and geographical access play a significant role in patient outcome. even though there was improvement over the time period, significant improvements need to be made to improve the lifespan of people residing in regional areas. access to primary health care (phc) via general practitioners (gp) is critical as a key to improving health outcomes, with more than 80% of people visiting at least once every year [40, 41] . access is quite varied among people residing in rural and urban areas and therefore the focus has been more on understanding access to phc in rural areas. it has been proven and accepted that with an increase in distance to health centers the utilization of such centers becomes less [42, 43] . studies have primarily focused more on the spatial context. the 2sfca method has been heavily used to analyze barriers to primary health care services in australia for both small and large catchment areas. there have been several improvements in the use of the 2sfca approach studied in [44] . these improvements include the addition of the distance-decay function and the variable distance-decay function. the distance-decay function included the consideration of distance/time when calculating barriers within a catchment area, whereas the inclusion of the variable distance-decay function considers situations in which travel distance is greater according to the health service required. such a situation is quite evident in rural areas where a patient may need to travel farther for a specific health service requirement as the services are sparsely distributed. this variation was explored in [45] for the victoria region where the number of health services was limited to 100 with a travel time of up to 60 min. mcgrail et al. [40] developed a national index of access which contributed towards an improved understanding of spatial accessibility, which helped locate areas with access disadvantages and could be used for proper health planning. similar studies were conducted [43, 46] for five communities in the victoria and new south wales regions and the metropolitan adelaide region, respectively. the results revealed that travel behavior needs to be considered when analyzing accessibility. however, the variation was understood only by categorizing the population into rural and urban, which may not provide accurate results when analyzing a large study area. this was overcome by the same authors [47] when they defined rules for selection of the catchment area with respect to travel time and the number of health services and performed the study for the entire country. the fundamental challenge of using the 2sfca method is the definition of catchment areas, and researchers have attempted to define new ways with the ability to accurately assess the disparity in access to gps in rural and urban regions [48] . however, these studies failed to consider the socio-economic status of the population studied. this aspect was explored in [49] , which was performed in the inner regional area of new south wales. the study applied a bivariate analysis to understand the relationship between remoteness and socio-economic status, leading to the construction of a composite score of deprivation. thereafter, a pairwise correlation matrix between the number of physicians, remoteness and socio-economic status was performed and validated with the health outcomes. the results revealed that socio-economic status plays a significant role compared to remoteness and physician numbers for determining risk per 1000 persons. schofield et al. [50] utilized six different variables (sex, age, income, remoteness, health status, employment status) to understand gp access, focusing on people with low socio-economic status residing in rural areas. the results indicated that gp services do not depend on the per capita utilization of the services, irrespective of whether they are based in rural or non-rural areas. however, this relation may not be accurate when considering indigenous people. the inclusion of indigenous people in understanding barriers to accessing phc services was studied in [41] , which highlighted the need for also considering indigenous staff as social and cultural biases may exist. gibson et al. [51] conducted an in-depth study by reviewing articles related to the barriers faced by indigenous people when assessing phc. it is evident that primary health care is probably the most basic and frequently visited health service by the population regardless of region, ethnicity, and socio-economic status. therefore, it is imperative to understand the various barriers faced by every section of society. the focus has primarily been on understanding the association between remoteness and health outcomes. several other regions are yet to be explored with the focus shifting towards local areas and considering the social and cultural aspects of the population, which would provide an accurate understanding of these access barriers. the studies involving dental care were more focused on the spatial understanding of access barriers [13] [14] [15] [16] 52] . the focus also seemed to be on analyzing the difference between public and private dental clinics, where roughly 80% of the population visit private clinics [52] . most of the studies used the line-of-sight method to measure distances to dental care instead of determining travel time as they focused on metropolitan regions with a focus on using geospatial tools to identify accessibility [13, 16] . the study in [52] focused on private dental clinics in the western australia region and found that rural areas were more disadvantaged compared to the metropolitan areas. mcguire et al. [13] conducted a study in victoria and found that almost three-quarters of the population resided within 10km of a dental clinic. almado et al. [16] analyzed dental clinic accessibility for eight metropolitan cities of australia. the analysis revealed that only 33-50% of people were able to avail of dental services depending on various capital city locations. however, an interesting study was conducted in [26] analyzing the barriers faced by people with disabilities residing in adelaide. the study was analyzed using bivariate and multivariate models and the results revealed that access was poor for people with disabilities living in rural areas compared to people in community settings. the study also found that a significant barrier to accessing dental care is the unwillingness of dentists to treat disabled people. a similar study was conducted in [27, 53] for homeless people in brisbane and identified fear as a barrier among the homeless population. mental health is essential but can be considered as the poorest service in terms of access, especially in rural and remote areas of the country [54] . taylor et al. [55] studied the state of patients experiencing mental health issues who needed to be transferred to metropolitan health centers. qualitative analysis was performed through interviews conducted among six patients and 21 medical staff in the southern australia region to understand the barriers faced while transferring patients. fennell et al. [56] conducted a similar study for adults living in rural parts of south australia and suggested that health professionals needed to be educated about these barriers. they also used evidence-based approaches to understand the concerns faced by patients. saurman et al. [54] analyzed the mental health emergency care (mhec) rural access project implemented in new south wales ensuring 24 h access to specialists over video conferencing using a concurrent mixed-methods approach. wohler and dantas [57] conducted a review of the barriers faced by immigrant and refugee women when accessing mental health services in australia. the study highlighted that the barriers include factors like religion, self-reliance and resilience, suggesting that measures need to be undertaken to address these concerns. maas et al. [58] conducted a spatial analysis using autocorrelation indexes and spatial regression to determine patterns of referral for a mental health program in the western sydney region. the results revealed that the distribution formed a pattern covering the areas with low socio-economic status. the factors affecting easy access to mental healthcare programs are varied and efforts need to be made to analyze the barriers at a local scale and implement steps to overcome them. however, the work surveyed clearly shows that indigenous people, remote areas and low-income people are the most affected. cardiovascular disease (cvd) contributes to almost 35% of deaths in the country and is the second most prevalent disease after cancer [59] . this section discusses studies related to cardiovascular diseases and cardiac rehabilitation services. studies relied on gis to determine remoteness and accessibility. bamford et al. [60] developed cardiac aria to quantify the accessibility of cardiac services via the available road networks. the significant difference between aria and cardiac aria lies in the selection of a location for accessibility modeling: aria uses population location whereas cardiac aria uses the location of the health service. cardiac aria measures travel time to relevant health centers in two categories: (a) acute cardiac aria, which determines the travel time by ambulance in the event of an acute cardiac arrest, and (b) aftercare cardia aria, which evaluates the travel time by private transport after hospital discharge. coffee et al. [59] calculated the cardiac aria index for the entire country based on both categories and concluded that the current system provides timely access for the majority of the population. cardiac rehabilitation serves as a primary step for preventing cvd and access to it has been a major concern, especially in remote areas [61] . higgins et al. [62] reported that the percentage of people attending rehabilitation programs after coronary artery bypass graft surgery varied from 37-66% and identified the lack of effective referral protocols as a major factor. they based their study on patients admitted to the royal melbourne hospital, victoria, and used a logistic regression model to determine patient characteristics as well as visiting the rehabilitation programs. the uneven distribution of cardiovascular services in the country was highlighted in [63] , which argued that barriers are not only confined to distance and transport reliability but are multidimensional, involving other socio-economic parameters. van gaans et al. [64] developed the spatial model of accessibility, involving both the geographic and the socio-economic factors. the model determined ratings based on the patients who enrolled in the program versus completion rate of the program. the other diseases where the relation between barriers and the health outcome was studied included obesity, kidney transplants, diabetes, strokes, and services such as clinical trials and maternity. the number of people who are obese has increased drastically over the last three decades [65] . remoteness and socio-economic disadvantage have been found to be the most critical factors affecting obesity [66, 67] . the relationship between these factors and body mass index among australian immigrants was studied using statistical analysis in [65] . in terms of wait listing for kidney transplantation, [21] studied the various barriers faced by patients. the study was conducted using univariate and multivariate models and found that access to the waitlist is based on numerous factors like sex, ethnicity and remoteness. the disparity between indigenous people and nonindigenous people in kidney transplant accessibility was studied by [68] . statistical analysis including the cox proportional hazards model was used to understand this disparity. scott et al. [69] used regression models to analyze the demographic relationship with healthcare service coverage for the hepatitis c virus. the results revealed that despite the cost of the drug being low, more than 50% of the geographical area treated less than 10% of people suffering with the virus. gilbert et al. [70] conducted a qualitative study to understand the barriers faced by patients when accessing cataract surgery. they found five significant parameters, i.e., travel time, reputation of the health center, surgeon experience, cost and the wait time for surgery. sabesan et al. [71] analyzed the willingness for clinical trials among rural and regional patients in north queensland. using data from 178 patients and statistical analysis, they found that rural patients are more willing compared to the urban patients. zdenkowski et al. [72] analyzed the barriers faced by patients when enrolling in a clinical trial for cancer medication. the study was performed by conducting interviews among 188 people under various scenarios ranging from variation in travel time, change in oncologist, trial type and increase in cost. logistic regression was used, and the results revealed that if the cost and the oncologist remained same, the willingness of participants were greater. however, an increase in travel time led to a decrease in participation, whereas there was no difference concerning trial type. the outcome of this review could be useful for researchers for understanding the various modeling approaches used for understanding barriers to healthcare access in australia and could also be used in other countries with similar diversity. it provides a broad understanding of the techniques being used, which could serve as a starting point for researchers looking to work in this domain for the first time. the analysis can be useful for identifying some existing shortcomings and the important research questions to be addressed in the future. the findings from the study are illustrated in figure 6 , which depicts three different domains on which the present article has focused, with the various barrier types, the models used to understand the barriers and the diseases for which the study has been conducted. after analyzing all the components of the different domains, we conclude by summarizing the current focus of the research study and providing future directions on which research should focus. the first gap is the need to focus on other diseases than cancer. primarily, more research has been conducted towards cancer, which is understandable due to the high number of patients suffering and the rate of fatality. however, more efforts need to be put towards focusing on other major health issues. the second issue is the lack of studies on a finer scale, as most of the studies conducted were either of an entire state or of the whole country. certain barriers for a specific disease type are pertinent at a local level and their effect on accessibility is also critical. therefore, emphasis should be on moving towards understanding barriers at a local scale. the covid19 pandemic has shown the gaps present in the healthcare system in dealing with infectious diseases and our lack of research towards handling barriers for both patients and healthcare workers. although the australian health system has considerably performed well compared to other economically developed countries, our understanding of the relevant barriers needs to be comprehensively studied ahead of future infectious disease outbreaks. in general, the main barriers are providing sufficient testing capacities, emotional and physical stress among the health workers and the dispersion of accurate information among the general public. in understanding various healthcare barriers, accessibility, specifically spatial accessibility, is one specific area where a lot of improvements can be made. the spatial mobility aspect can be considered as the most significant barrier to healthcare access. while the topic has been very well studied in the fields of traffic monitoring and congestion, its application to healthcare studies in australia has been limited. in terms of the spatial accessibility of health facilities, it can be broadly categorized into two sections: (i) navigation to health centers, which could be proximity to the health center as well as distance or travel time between a certain location and the health center, which would be critical in cases of medical emergencies, (ii) setup of new health facilities, which can be achieved by considering the population demand according to the diseases being suffered from along with the first gap is the need to focus on other diseases than cancer. primarily, more research has been conducted towards cancer, which is understandable due to the high number of patients suffering and the rate of fatality. however, more efforts need to be put towards focusing on other major health issues. the second issue is the lack of studies on a finer scale, as most of the studies conducted were either of an entire state or of the whole country. certain barriers for a specific disease type are pertinent at a local level and their effect on accessibility is also critical. therefore, emphasis should be on moving towards understanding barriers at a local scale. the covid19 pandemic has shown the gaps present in the healthcare system in dealing with infectious diseases and our lack of research towards handling barriers for both patients and healthcare workers. although the australian health system has considerably performed well compared to other economically developed countries, our understanding of the relevant barriers needs to be comprehensively studied ahead of future infectious disease outbreaks. in general, the main barriers are providing sufficient testing capacities, emotional and physical stress among the health workers and the dispersion of accurate information among the general public. in understanding various healthcare barriers, accessibility, specifically spatial accessibility, is one specific area where a lot of improvements can be made. the spatial mobility aspect can be considered as the most significant barrier to healthcare access. while the topic has been very well studied in the fields of traffic monitoring and congestion, its application to healthcare studies in australia has been limited. in terms of the spatial accessibility of health facilities, it can be broadly categorized into two sections: (i) navigation to health centers, which could be proximity to the health center as well as distance or travel time between a certain location and the health center, which would be critical in cases of medical emergencies, (ii) setup of new health facilities, which can be achieved by considering the population demand according to the diseases being suffered from along with considering other factors like affordability, and indigenous status. for both these aspects, the use of gis integrating with the transport model and the concept of spatio-temporal paths should be encouraged [73] . the effects of spatial accessibility during the pandemic outbreak have revealed some serious gaping holes in the system and its decisionmakers. while the studies in the australian context focused more on the use of the 2sfca and other statistical models to calculate distance to health centers, focus should shift towards considering different techniques, e.g., the three-step floating catchment area (3sfca), which uses distance, proximity and population demand. it could also help in identifying disparities in healthcare access in a regional-level study. apparicio et al. [74] analyzed the accessibility of health services using various distance and aggregation methods. such analysis needs to be performed at various spatial scales (national, regional and local) to standardize the basic methodology to be used, which can then be improved in the future. in addition, the input data used for conducting similar studies rely heavily on google earth/maps or openstreetmap. efforts need to be made to use a high spatial dataset [75] which would improve the spatial mobility significant in health scenarios. such use of a high spatio-temporal dataset would help in identifying the nearest health center along with the shortest route to reach it considering population density [76] . this would immensely support decisionmakers and stakeholders in gaining better access to health centers. the recent work in [77] on determining distance and travel time for helsinki, finland using several transportation modes provides a model for deciding the travel mode to be used in cases of medical emergency, clinical check-up and rehabilitation. such development of a disease-specific travel time dataset, e.g., check-ups for breast and prostate cancer, dental care and gps, could better aid people in deciding which health facility to go to. it has been well acknowledged that remote areas suffer from an inadequate number of health centers, but the type of health centers for a specific disease type is also quite erratic even in urban areas. although the specialized field of analyzing the setup of new health centers is a separate entity, we attempted to look at it solely from the different barrier point of view. the lack of facilities can be overcome by setting up new facilities, but the challenges could range from accessibility to cultural difficulties and affordability. the accessibility component can be solved by utilizing the measures mentioned above; however, the other challenges would be detrimental which could be understood by conducting interviews and understanding specific requirements at a community level. the challenge lies in setting up new health centers specific to community-based barriers with the consideration of socio-economic status as well as cultural and regional biases. the steps to set up a new health center could begin with the understanding of broader aspects like accessibility and affordability, and thereafter fill in the gaps of cultural differences with the capacity to upgrade in the future. another important aspect found while conducting this review was the comparison between rural and urban healthcare accessibility, with a few studies comparing different metropolitan regions. however, comparison between accessibility and health outcomes among the rural regions in a state or across several states was not heavily researched. such analysis would be interesting to understand which states struggle to provide rural healthcare services and thereafter necessary steps can be taken by the respective state health departments to improve these services. care must be taken when analyzing the rural regions as patient characteristics like indigeneity, cultural and linguistic barriers would be critical when addressing rural health issues. this review paper is an attempt to analyze the models used in understanding barriers to healthcare access and the survivability of the patient across various disease types. current research practice is lacking in various domains ranging from spatial accessibility techniques to the consideration of patient characteristics and the analysis of different disease types as well as studies concerning only rural/remote areas. additionally, our understanding of the barriers for infectious disease outbreak is still in infancy and the covid19 situation would help in determining the various concerns among patients and health workers that should be considered in the future. the study highlighted the key areas on which research has focused: cancer and primary health care-related studies, the 2sfca method and rural vs. urban health outcomes. the conclusions from the study are as follows: â�¢ it is important to note that the barriers are multifaceted, of which the major ones are geography, ethnicity and socio-economic status. the most deprived section for healthcare access is indigenous people, and this could be even worse if their economic status is poor. the focus needs to shift towards addressing cultural and linguistic barriers, especially for indigenous people. there are also several other barriers which are specific to the disease the patient is suffering from. as most studies have focused on a large geographical area, the distance/time determination using the smallest administrative boundary for better accuracy has been missed. the emphasis should be on analyzing at the smallest administrative boundary. the focus has also primarily been on a few diseases only, such as cancer and primary health care, and the location of the study has focused primarily on a few states only. both aspects need to be improved, the type of disease and the study area. the distance/time calculation to health centers is determined spatially using gis and various geospatial tools. it is encouraging that the available models, such as the 2sfca method, have been tested very extensively for different regions and have been proved to be performing well. however, new models and techniques like 3sfca and machine learning need to be attempted for better accuracy. the increase in the availability of data would help in developing machine learning-based tools aimed at identifying key shortcomings and the steps needed to be taken for better healthcare access at both local and regional scales. geographical access to health care. in access health care are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? a systematic review understanding shortages of sufficient health care in rural areas the distribution of 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distances by different travel modes in helsinki region this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-288409-idq780jb authors: alsahafi, abdullah j.; cheng, allen c. title: knowledge, attitudes and behaviours of healthcare workers in the kingdom of saudi arabia to mers coronavirus and other emerging infectious diseases date: 2016-12-06 journal: int j environ res public health doi: 10.3390/ijerph13121214 sha: doc_id: 288409 cord_uid: idq780jb background: the kingdom of saudi arabia has experienced a prolonged outbreak of middle east respiratory syndrome (mers) coronavirus since 2012. healthcare workers (hcws) form a significant risk group for infection. objectives: the aim of this survey was to assess the knowledge, attitudes, infection control practices and educational needs of hcws in the kingdom of saudi arabia to mers coronavirus and other emerging infectious diseases. methods: 1500 of hcws from saudi ministry of health were invited to fill a questionnaire developed to cover the survey objectives from 9 september 2015 to 8 november 2015. the response rate was about 81%. descriptive statistics was used to summarise the responses. results: 1216 hcws were included in this survey. a total of 56.5% were nurses and 22% were physicians. the most common sources of mers-coronavirus (mers-cov) information were the ministry of health (moh) memo (74.3%). only (47.6%) of the physicians, (30.4%) of the nurses and (29.9%) of the other hcws were aware that asymptomatic mers-cov was described. around half of respondents who having been investigated for mers-cov reported that their work performance decreased while they have suspicion of having mers-cov and almost two thirds reported having psychological problems during this period. almost two thirds of the hcws (61.2%) reported anxiety about contracting mers-cov from patients. conclusions: the knowledge about emerging infectious diseases was poor and there is need for further education and training programs particularly in the use of personal protective equipment, isolation and infection control measures. the self-reported infection control practices were sub-optimal and seem to be overestimated. the kingdom of saudi arabia has experienced a prolonged outbreak of middle east respiratory syndrome (mers) coronavirus since 2012 [1, 2] . healthcare workers (hcws) form a significant risk group for infection [3] [4] [5] . most of the cases in health care workers occurred in the early period of the outbreak [6] . the risk of importation of other emerging infectious diseases, particularly with large population movements during the hajj and umrah is also significant. we aimed to explore the knowledge, attitudes and behaviours of healthcare workers in the kingdom, particularly focusing on the recent disease of international significance mers-coronavirus (mers-cov). a survey was performed of healthcare workers in mecca, medina and jeddah in the kingdom of saudi arabia in 2015. the questionnaire was developed by the primary author and pilot tested on a small number of healthcare workers. participants were recruited from 9 september 2015 to 8 november 2015. the survey was administered on paper in either arabic or english according to respondent preference. the responses entered into an electronic database for analysis. the content areas included mers coronavirus knowledge and sources of information; personal experiences with mers-cov; opinions about the location of management of patients with emerging infectious diseases; attitudes of the hcws to infection control practices; the educational needs of the hcws about emerging infectious diseases; and self-reported infection control practices of the hcws. all responses were anonymous. a chi square test was used to compare differences in the proportions of categorical variables. significance was determined at the 0.05 threshold. ethical permission to conduct the survey was obtained from the department of medical research and studies, jeddah, kingdom of saudi arabia (approval number a00298). this department is registered in saudi national committee for biomedical ethics (registration number h-02-j-002). of the 1500 invited to participate in the survey, responses were received from 1216 health care workers (hcw) included in this survey. this included 267 (22%), medical practitioners, 685 (56.5%) nurses, and 264 other healthcare workers, including health inspectors, pharmacists, lab technicians and radiology technicians. of the participants, 472 (68.9%) of the nurses and 207 (77.5%) of the physicians working in primary health care centres. the majority of survey participants were saudi (87.9%), and had diploma qualifications (64.5%) ( table 1) . almost all participants had heard about mers-cov (98.8%) and understood it to be a problem for the community (86.1%). a significant minority (28.9%) of participants had worked at facilities where mers-cov had been diagnosed and many respondents had personally been tested for mers-cov mostly due to contact with cases within or outside the workplace (table 1) . healthcare workers generally had a good understanding of the requirement to test patients admitted to icu and those who were contacts, but a significant minority felt there was no indication for mers-cov investigation for the patient with acute respiratory illness requiring hospitalisation but not icu. the majority of respondents correctly identified the need for infection prevention measures, patient risk factors and the mode of transmission by close contact. unexpectedly, a significant proportion of respondents thought that mers-cov could be spread through mosquito bites. only (47.6%) of the physicians, (30.4%) of the nurses and (29.9%) of the other hcws were aware that asymptomatic mers-cov was described (table 2) . a significant minority of respondents reporting having been investigated for mers-cov. only about two thirds of the hcws (60.4%) received the result of their investigations in the first two days, it also, shows that, there are 351 (28.9%) of hcws in this study work in places where mers-cov cases had been diagnosed in the last 2 years or less. (62%) of them are nurses, (21%) are physicians and (17%) are other hcws. 145 (11.9) from the hcws in this study were care sharing providers to mers-cov infected patients (table 1) . of these respondents, around half reported that their work performance decreased while they have suspicion of having mers-cov, a similar proportion had disturbances in their social lives, and almost two thirds reported having psychological problems during this period. almost two thirds of the hcws (61.2%) reported anxiety about contracting mers-cov from patients patient and more than half (56.8%) reported avoiding contact with others in public areas (table 1 ). a high proportion of all respondent groups felt that their workplaces were not well prepared to care for patients with emerging infectious diseases, although many respondents indicated that they were personally well prepared. a significant minority of respondents reporting having been investigated for mers-cov. only about two thirds of the hcws (60.4%) received the result of their investigations in the first two days. it also, shows that, there are 351 (28.9%) of hcws in this study work in places where mers-cov cases had been diagnosed in the last 2 years or less. (62%) of them are nurses, (21%) are physicians and (17%) are other hcws. 145 (11.9) from the hcws in this study were care sharing providers to mers-cov infected patients (table 1) . of these respondents, around half reported that their work performance decreased while they have suspicion of having mers-cov, a similar proportion had disturbances in their social lives, and almost two thirds reported having psychological problems during this period. almost two thirds of the hcws (61.2%) reported anxiety about contracting mers-cov from patients patient and more than half (56.8%) reported avoiding contact with others in public areas (table 1) . a high proportion of all respondent groups felt that their workplaces were not well prepared to care for patients with emerging infectious diseases, although many respondents indicated that they were personally well prepared. the majority of respondents believed that patients with mers-cov and other emerging infectious diseases should be managed in specialised centres, but a significant proportion also agreed that general hospitals also had a role in managing such patients. a minority indicated that patients with emerging infectious diseases could be managed in primary healthcare clinics (figure 2) . agreed that general hospitals also had a role in managing such patients. a minority indicated that patients with emerging infectious diseases could be managed in primary healthcare clinics (figure 2 ). it was noted that 45% of physicians, 53% of nurses and 61% of other hcws in the study perceive their knowledge about mers-cov, ebola and others emerging infectious diseases to be low, while 40% of them indicated that it was moderate and ≤7% indicated it was high ( figure 3 ). as expected, the majority of the hcws in the study (≥72.3%) indicated that that they are in need for educational courses and training about the mers-cov, ebola and other emerging infectious diseases (figure 3) . it was noted that 45% of physicians, 53% of nurses and 61% of other hcws in the study perceive their knowledge about mers-cov, ebola and others emerging infectious diseases to be low, while 40% of them indicated that it was moderate and ≤7% indicated it was high ( figure 3 ). agreed that general hospitals also had a role in managing such patients. a minority indicated that patients with emerging infectious diseases could be managed in primary healthcare clinics (figure 2 ). it was noted that 45% of physicians, 53% of nurses and 61% of other hcws in the study perceive their knowledge about mers-cov, ebola and others emerging infectious diseases to be low, while 40% of them indicated that it was moderate and ≤7% indicated it was high ( figure 3 ). as expected, the majority of the hcws in the study (≥72.3%) indicated that that they are in need for educational courses and training about the mers-cov, ebola and other emerging infectious diseases (figure 3) . as expected, the majority of the hcws in the study (≥72.3%) indicated that that they are in need for educational courses and training about the mers-cov, ebola and other emerging infectious diseases (figure 3 ). a large majority of participants reported that they were more eager to apply infection control measures since the onset of mers-cov in ksa. unexpectedly, almost two thirds of respondents were unaware of guidelines or protocols for the care of patients with mers-cov infection. only 22.8% reported having received training about dealing with infectious disease outbreaks, 37.1% reported training in infection control policies and procedures, 54.4% reported training in hand hygiene and 45.6% reported training in n95 mask wearing techniques (table 3) . a high proportion of respondents agreed that emergency department overcrowding, poor hand hygiene and mask use contributed to the risk of hcw being infected with mers-cov. similarly, a high proportion agreed that a lack of knowledge about the mode of transmission, a lack of policies and procedures, and insufficient training in infection control procedures also contributed to the risk (table 3) . self-reported compliance with hand hygiene was moderate, with only about two thirds of the hcws (60.3%) of the physicians, (64.8%) of the nurses and (60.6%) of the other hcws practicing regular hand washing after patient contact. less than half of respondents reported full compliance with use of surgical masks when required, and a similar proportion reported compliance with n95 respirators when required (table 3) . compliance with immunisation recommendations was poor, with only 59.5% self-reporting receipt of annual influenza vaccine within the last 12 months, 74.4% reporting receipt of meningococcal vaccine in the last 3-5 years, and 50.4% reporting have received hepatitis b immunisation or testing for immunity during their work career (table 3) . table 3 . hcws attitudes and barriers to infection control practices following mers-cov outbreak. the control of emerging infectious diseases in the hospitals can be limited by case detection and management using transmission-based precautions to all confirmed and probable cases. for mers-cov in health care settings, this requires early recognition, testing and airborne precautions [7] . in this survey we found that despite a high basic level of awareness about mers coronavirus and the importance of infection control, there remained significant misconceptions. we have previously described more than 171 secondary cases in healthcare workers in the 939 cases reported to july 2015 with another 174 cases acquired by other patients while in hospital [8] . another study suggested that, infected health care workers were an important group involved in disease spread [9] . this survey revealed that, about two third of the hcws whose contact to mers-cov cases were investigated for possible infection, which may reflect a high index of suspicion , the anxiety about infection and accessibility to health services. this study also showed significant proportion with personal experience of mers-cov either as hcw at institutions caring for cases or being investigated for possible infection following contact with cases [10] . a survey of healthcare workers in south korea found a poor level of knowledge of the modes of transmission, which was implicated in the rapid spread of the infection in hospitals. worryingly, more than half of respondents in this survey thought that mers-cov could be spread through mosquito bites [10] . the infection control measures are very crucial for respiratory infectious cases in the healthcare institutes [11] . a high proportion of respondents identified hospital overcrowding, poor hand hygiene and mask use, lack of knowledge about the mode of transmission, a lack of policies and procedures, and insufficient training in infection control procedures also contributed to the risk of spread. self-reported adherence with infection control measures was surprisingly poor, particularly in light of previous studies suggesting that self-reported adherence generally overestimates observed behaviour. the results of this survey suggest that there was poor knowledge about emerging infectious diseases, and self-reported infection control practices were sub-optimal. however, there was recognition in respondents of the need for further education and training, particularly in the use of personal protective equipment despite the high level of trust in official sources of information. system level improvements, such as incorporation of emerging infectious diseases into medical schools and continuous medical education programs, the implementation of isolation and infection control measures, and appropriate nursing-to-patient ratios would also improve preparedness [12] . isolation of a novel coronavirus from a man with pneumonia in saudi arabia first cases of middle east respiratory syndrome coronavirus (mers-cov) infections in france, investigations and implications for the prevention of human-to-human transmission contact investigation for imported case of middle east respiratory syndrome hospital outbreak of middle east respiratory syndrome coronavirus middle east respiratory syndrome coronavirus infections in health care workers first confirmed cases of middle east respiratory syndrome coronavirus (mers-cov) infection in the united states, updated information on the epidemiology of mers-cov infection, and guidance for the public, clinicians, and public health authorities the epidemiology of middle east respiratory syndrome coronavirus in the kingdom of saudi arabia institutional preparedness for infectious diseases and improving care healthcare workers infected with middle east respiratory syndrome coronavirus and infection control emerging problems in infectious diseases lessons to learn from mers-cov outbreak in south korea healthcare policy and healthcare utilization behavior to improve hospital infection control after the middle east respiratory syndrome outbreak we thank the department of medical research and studies, jeddah, kingdom of saudi arabia for the ethical approval of this study and general directorate departments of health in makkah, medina and jeddah ministry of health, saudi arabia for facilitating the data collection of this survey. we also appreciate the efforts of ibrahim asiri from jeddah directorate departments of health and tariq al maghamsi from general directorate departments of health in medina for helping us in data collection.author contributions: abdullah j. alsahafi designed the study, obtained ethical approval, collected, entered and analyzed the data and wrote the manuscript; allen c. cheng reviewed and supervised all parts of the work. all authors have read, reviewed and approved the final manuscript before submission. the authors declare no conflict of interest. this work is self-funded and there is no competing financial interest of the authors. key: cord-298156-d0pb1kik authors: cheval, sorin; mihai adamescu, cristian; georgiadis, teodoro; herrnegger, mathew; piticar, adrian; legates, david r. title: observed and potential impacts of the covid-19 pandemic on the environment date: 2020-06-10 journal: int j environ res public health doi: 10.3390/ijerph17114140 sha: doc_id: 298156 cord_uid: d0pb1kik various environmental factors influence the outbreak and spread of epidemic or even pandemic events which, in turn, may cause feedbacks on the environment. the novel coronavirus disease (covid-19) was declared a pandemic on 13 march 2020 and its rapid onset, spatial extent and complex consequences make it a once-in-a-century global disaster. most countries responded by social distancing measures and severely diminished economic and other activities. consequently, by the end of april 2020, the covid-19 pandemic has led to numerous environmental impacts, both positive such as enhanced air and water quality in urban areas, and negative, such as shoreline pollution due to the disposal of sanitary consumables. this study presents an early overview of the observed and potential impacts of the covid-19 on the environment. we argue that the effects of covid-19 are determined mainly by anthropogenic factors which are becoming obvious as human activity diminishes across the planet, and the impacts on cities and public health will be continued in the coming years. the earth is a dynamically changing planet, permanently shaped by socio-ecological interactions. variations and changes are common in a nonlinear and dynamic system such as our planet but passing certain thresholds may push the stability of the systems into a new regime which can have significant consequences at different spatial and temporal scales. understanding and early prediction of the impacts of such dramatic changes is a challenge for all sciences (including economics, social or medical sciences) but also for our society as a whole [1, 2] . extreme variations in natural processes and phenomena, in many cases enhanced or even caused by human actions, generate hazards that lead to risks for both communities and the environment, and as a result, sometimes disasters occur. the concept of disaster has evolved over time, and here we use an adapted intergovernmental panel on climate change (ipcc) definition: a disaster is an event, which severely alters the functioning of a community due to hazardous physical, biological or human related impacts leading to widespread adverse effects on multiple scales and systems (environment, economic, social). immediate emergency the main cause of pandemic events and epidemic diseases is the close interaction between human populations with both domesticated and wildlife pathogens [27] . most pathogens pass from wildlife reservoirs and enter into human populations through hunting and consumption of wild species, wild animal trade and other contact with wildlife. urban areas are especially vulnerable through the high population density and mobility. the covid-19 dwarfs the six previous large scale epidemics of the 21st century in terms of spatial extent and societal consequences [24] , and it is the only pandemic with widespread and complex environmental impacts. we briefly present a few characteristics of the other large-scale epidemic events of the 21st century. a. the severe acute respiratory syndrome (sars) occurred in 2003, leading to more than 8000 infections with a mortality rate of approximately 10% and an impact limited only to local and regional economies [28] . the epidemic ended abruptly in july 2003 and no human cases of the sars coronavirus have been detected since. b. the 2009 h1n1 influenza virus (swine flu) was a pandemic which first appeared in mexico and the united states in march and april of 2009. it became a global pandemic as a result of global mobility and airline travel and led to an estimated 0.4% case fatality [29] . c. middle east respiratory syndrome (mers) was first identified in humans in saudi arabia and jordan in 2012 [30] . mers is considered a zoonotic pathogen, with infected dromedary camels being the animal source of infection to humans [31, 32] . by contrast to sars, which was contained within a year of emerging, mers continues to have a limited circulation and causes human disease with intermittent sporadic cases, community clusters and nosocomial outbreaks in the middle east region with a high risk of spreading globally [33] . d. the ebola virus was first detected in 1976 in zaire (presently the democratic republic of congo). since the virus was first detected, over 20 known outbreaks of ebola have been identified in sub-saharan africa, mostly in sudan, uganda, democratic republic of congo and gabon [34] . at present, no vaccine or efficient antiviral management strategy exists for ebola [35] . although the ebola virus has substantial epidemic and pandemic potential (due to the ease of international travel), as shown by the 2013-2016 west-african ebola virus epidemic with approximately 28,000 confirmed cases and 11,000 deaths [36, 37] , ebola outbreaks have been geographically limited [34] . e. the zika fever (2015-2016) was first isolated in 1947 from a febrile rhesus macaque monkey in the zika forest of uganda. since 1954, when the first cases in humans were reported, the zika virus had only limited sporadic infections in africa and asia. however, a large outbreak with approximately 440,000 to 1,300,000 cases spread from brazil to 29 countries in the americas in 2015 [38] . in november 2016, who announced the end of the zika outbreak. f. avian flu (bird flu) was first reported in 1997 in hong kong with only 18 infections and 6 human deaths. more than 700 cases of the avian flu have been reported from over 60 countries [39] of the reported outbreaks occurred in 2016 in china [40] . in the absence of any effective treatments, sars-cov, mers-cov and sars coronaviruses are of very high societal concern since they could unexpectedly become a global pandemic at any time [30] . as a result, coronaviruses in general have been studied to anticipate their societal and environmental impact. this has immediate application to the covid-19 virus. furthermore, [25] summarizes relevant knowledge on the causative agent, pathogenesis and immune responses, epidemiology, diagnosis, treatment and management of the disease, control and prevention strategies of the covid-19. a calendar of the covid-19 events potentially related to the environmental impacts is presented as list s1. the development and spread of covid-19 under the control of environmental factors justify the scientific interest for the combined studies of coronaviruses on one side and socio-ecological systems (including the interplay between climate, water, soil) on the other side. the number of scientific publications examining such topics has constantly increased in recent decades, and the covid-19 pandemic strongly motivates the 2020 record ( figure 1 ). saharan africa, mostly in sudan, uganda, democratic republic of congo and gabon [34] . at present, no vaccine or efficient antiviral management strategy exists for ebola [35] . although the ebola virus has substantial epidemic and pandemic potential (due to the ease of international travel), as shown by the 2013-2016 west-african ebola virus epidemic with approximately 28,000 confirmed cases and 11,000 deaths [36, 37] , ebola outbreaks have been geographically limited [34] . e. the zika fever (2015-2016) was first isolated in 1947 from a febrile rhesus macaque monkey in the zika forest of uganda. since 1954, when the first cases in humans were reported, the zika virus had only limited sporadic infections in africa and asia. however, a large outbreak with approximately 440,000 to 1,300,000 cases spread from brazil to 29 countries in the americas in 2015 [38] . in november 2016, who announced the end of the zika outbreak. f. avian flu (bird flu) was first reported in 1997 in hong kong with only 18 infections and 6 human deaths. more than 700 cases of the avian flu have been reported from over 60 countries [39] of the reported outbreaks occurred in 2016 in china [40] . in the absence of any effective treatments, sars-cov, mers-cov and sars coronaviruses are of very high societal concern since they could unexpectedly become a global pandemic at any time [30] . as a result, coronaviruses in general have been studied to anticipate their societal and environmental impact. this has immediate application to the covid-19 virus. furthermore, [25] summarizes relevant knowledge on the causative agent, pathogenesis and immune responses, epidemiology, diagnosis, treatment and management of the disease, control and prevention strategies of the covid-19. a calendar of the covid-19 events potentially related to the environmental impacts is presented as list s1. the development and spread of covid-19 under the control of environmental factors justify the scientific interest for the combined studies of coronaviruses on one side and socio-ecological systems (including the interplay between climate, water, soil) on the other side. the number of scientific publications examining such topics has constantly increased in recent decades, and the covid-19 pandemic strongly motivates the 2020 record ( figure 1 ). in general, temperature, humidity, wind and precipitation may favour either the spread or the inhibition of epidemic episodes. however, while some research found that local weather conditions of lowered temperature, mild diurnal temperature range and low humidity may favour the transmission [41] , other studies claim there is no evidence that warmer weather can determine the decline of the case counts of covid-19 [42] . increased ultraviolet light, as occurs particularly during the summer months, leads to inactivation of the coronaviruses and [43, 44] analyse the subject comprehensively and find that warming weather is unlikely to stop the spread of the pandemic. to understand the relative importance between physical and social parameters that favour the spread of the virus, an area in which different health and social policies have been equally in general, temperature, humidity, wind and precipitation may favour either the spread or the inhibition of epidemic episodes. however, while some research found that local weather conditions of lowered temperature, mild diurnal temperature range and low humidity may favour the transmission [41] , other studies claim there is no evidence that warmer weather can determine the decline of the case counts of covid-19 [42] . increased ultraviolet light, as occurs particularly during the summer months, leads to inactivation of the coronaviruses and [43, 44] analyse the subject comprehensively and find that warming weather is unlikely to stop the spread of the pandemic. to understand the relative importance between physical and social parameters that favour the spread of the virus, an area in which different health and social policies have been equally implemented on a variety of environmental and climatic conditions must be examined. italy is a viable experimental model to examine the impact of different health policies, as stated by the government authorities themselves [45, 46] . in italy, the regionalization of public health has addressed the pandemic following completely different schemes from one region to another and represents an important test to verify the scientific hypotheses on the behaviour of sars-cov-2. given that coronaviruses tend to spread in lowered temperatures and drier conditions during the winter months (i.e., during a period of reduced solar radiation), it is surprising that italy was the first european country severely affected by the pandemic and its hospitals were suddenly overrun. northern italy experienced a very dry and mild winter caused by the presence of a strong polar vortex. the winter of 2019-2020 was one of the driest winters in 60 years (https://www.arpae.it/dettaglio_n otizia.asp?idlivello=32&id=11052). the impact on the social and economic structure of the country immediately gave rise to concerns about the potential transmission pathways of the virus and the spread at european scale. the impact of the covid-19 pandemic on the environment raised attention from the very beginning of the crisis, consisting of (a) observations and analysis of the immediate effects and (b) estimations related to long-term changes. qualitative assumptions prevail, while consistent quantitative research must wait for relevant data sets and additional knowledge. most facets of the environmental impact of the covid-19 pandemic have not directly resulted from the virus itself. the consequence of abruptly limiting or closing economic sectors, such as heavy industry, transport, or hospitality businesses, has affected the environment directly. moreover, the impact of the covid-19 pandemic on socio-ecological systems may be highly variable, from radical changes in individual lifestyle, society and international affairs [47] , to simply facilitating a faster change than would normally have emerged [48] . from an anthropocentric perspective, the pandemic may lead to a more sustainable future, including increased resilience of the socio-ecological systems or shorter supply chains, which is a positive development. however, it is still possible that some nations will opt for less sustainability by pursuing rapid economic growth and focusing less concern on the environment. while negative impacts on the economy and society in general are probably huge, it is very likely that the global-scale reduction of economic activities due to the covid-19 crisis triggers a lot of sensible improvements in environmental quality and climatic systems. however, not all the environmental consequences of the crisis have been or will be positive. this includes an increased volume of nonrecyclable waste, the generation of large quantities of organic waste due to diminish agricultural and fishery export levels and difficulties in maintenance and monitoring of natural ecosystems [49] . the temporal resolution of the coronavirus impact ranges from immediate (days to weeks), short-term (months) and long-term (years), and different examples are provided in a matrix ( figure 2 ). while the first impacts are divided between rapid environmental improvements, such as urban air and water quality, and pollution episodes, such as the ones caused by the sanitary disposals, the estimated short-and long-term impacts are mainly positive. impacts are rarely limited to a single physical system. however, for the sake of better inventory and understanding, the impact of the covid-19 on the physical systems focuses on the air, water and soil individually, with an emphasis on urban areas. large cities or megacities are often very centralized structures providing a certain degree of comfort and protection for the citizen, but they increase the exposure to specific threats. for example, the higher population densities favour higher exposure to hazards. in contrast to rural areas, where the population tends to have gardens, the effects of the lockdown conditions in cities showed more severe effects on the mental health of individuals living in close quarters. the covid-19 crisis is driving towards a new paradigm that brings urban policies closer to present and strengthens the future needs of urban population and public health. one of the key characteristics of the pandemic event in focus in this study is the spatial extent but also versatility of the scale of the impact. no other disaster has covered the whole planet with comparable intensities over so many urban areas with multifaceted threats that are challenging our cities during the crisis. air quality is highly sensitive to anthropogenic emissions. in the european economic area countries (eu, norway, liechtenstein and iceland), the energy used by industrial processes and the road transportation sector is responsible for about 54% of the nonmethane volatile organic compounds (nmvoc), 51% of the nox, 30% of pm2.5 and 25% of sox emissions [50] . the covid-19 crisis has caused severe impacts to the energy and resources, high-tech and communications, retail, manufacturing and transportation sectors, in terms of personnel, operations, supply chain and revenue [51] . by mid-april, a 40% to 50% decline in economic activity was estimated as a result of the draconian disease-suppression policies, and severe multiquarter economic impacts in multiple markets became imminent [52] . consequently, the impact on air quality was rapidly visible at various spatial scales. even as early as the end of march 2020, reductions in air pollution were reported in china, italy and new york city, and sharp declines in global greenhouse-gas emissions have been predicted for the rest of the year [53] . moreover, an overview focused on several european countries impacts are rarely limited to a single physical system. however, for the sake of better inventory and understanding, the impact of the covid-19 on the physical systems focuses on the air, water and soil individually, with an emphasis on urban areas. large cities or megacities are often very centralized structures providing a certain degree of comfort and protection for the citizen, but they increase the exposure to specific threats. for example, the higher population densities favour higher exposure to hazards. in contrast to rural areas, where the population tends to have gardens, the effects of the lockdown conditions in cities showed more severe effects on the mental health of individuals living in close quarters. the covid-19 crisis is driving towards a new paradigm that brings urban policies closer to present and strengthens the future needs of urban population and public health. one of the key characteristics of the pandemic event in focus in this study is the spatial extent but also versatility of the scale of the impact. no other disaster has covered the whole planet with comparable intensities over so many urban areas with multifaceted threats that are challenging our cities during the crisis. air quality is highly sensitive to anthropogenic emissions. in the european economic area countries (eu, norway, liechtenstein and iceland), the energy used by industrial processes and the road transportation sector is responsible for about 54% of the nonmethane volatile organic compounds (nmvoc), 51% of the no x , 30% of pm 2.5 and 25% of so x emissions [50] . the covid-19 crisis has caused severe impacts to the energy and resources, high-tech and communications, retail, manufacturing and transportation sectors, in terms of personnel, operations, supply chain and revenue [51] . by mid-april, a 40% to 50% decline in economic activity was estimated as a result of the draconian disease-suppression policies, and severe multiquarter economic impacts in multiple markets became imminent [52] . consequently, the impact on air quality was rapidly visible at various spatial scales. even as early as the end of march 2020, reductions in air pollution were reported in china, italy and new york city, and sharp declines in global greenhouse-gas emissions have been predicted for the rest of the year [53] . moreover, an overview focused on several european countries reveals that the reduction of the weekly no 2 , pm 10 and pm 2.5 concentrations during march and april 2020 is quasigeneral ( figure s1 ). one possible cause of the impact of the pandemic in northern italy is that a high concentration of particulate matter (pm, including pm 10 and pm 2.5 ) makes the respiratory system more susceptible to infection and complications of the coronavirus disease. higher and consistent exposure to pm (particularly for the elderly) leads to a higher probability that the respiratory system is compromised before the onset of the virus. this was a serious concern right after the publication of a position paper by sima (italian environmental medical society), where correlations were found between pollution levels and the spread of the virus [54] . strong evidence exists on the greater predisposition of the respiratory system to serious diseases [55] , but the hypothesis that pollutants can be a carrier for the virus in the free atmosphere seems very unlikely. the spread of droplets produced by sneezing or coughing is necessary so that high viral concentration and a lack of air circulation and exchange can be potentially very dangerous [56] [57] [58] [59] . the analysis of the demographic and economic characteristics of the two italian regions most affected by the pandemic help to understand that the spread of the virus is dependent on parameters other than simply air transport [60] . the most affected regions are quite similar demographically; lombardy has a population density of 420 per km 2 while veneto has a density of 270 per km 2 and the average age of the populations is practically identical. economic indicators also reveal a gross domestic product of lombardy of 34,000 â�¬/capita and veneto of 29,500 â�¬/capita. the number of beds in the healthcare facilities for intensive care are nearly identical in the two regions, while there is a public health laboratory for every 3,000,000 inhabitants in lombardy and for every 500,000 people in veneto. the healthcare structure is a very important aspect that explains the notable difference between the two regions, as the home care service for the elderly and disabled is more than double in veneto than in lombardy [61] . for neighbouring regions with similar pollution levels, the infection rate is extremely uneven. thus, it appears unlikely that pm is a viable vector for the virus, but it does illustrate the concern over disparate regional healthcare systems. this also has an important impact on future exit strategies from the pandemic and on the use of personal protective equipment (ppe) as the virus may vector using healthcare workers [62] . it is very likely that the italian case provides lessons for other european countries and validates the measures taken to limit the effects of the pandemic. as for the environmental impacts, physical and ecological systems have been affected in many places, as addressed and detailed in the next sections. the massive lockdowns of entire cities, economies, schools and social life for weeks led to unknown large-scale and extensive restrictions in mobility as a response to social distancing guidance related to covid-19 ( figure 3 ). globally, largest reductions in mobility are visible for western and southern europe (e.g., spain-59%, italy-55%, france-51%) and south america (e.g., bolivia-60% or columbia-54%). in south america, mobility in the period april 1 to april 17 showed a mean decrease of 47% compared to the 5-week period 3 january-5 february 2020. other continents showed a mean decrease of around 30%. south korea was the only country that showed a slight positive trend of +1.8% for the analysed period. the reason here is that the mobility trends for places like national parks, public beaches, marinas, dog parks, plazas, and public gardens increased significantly, although other mobility categories (e.g., workplaces, transit stations) showed a decrease. even if general mobility characteristics may vary by country and the period of strongest reductions in mobility may not be evident in april, figure 3 shows the global picture of the effects of the covid-19 pandemic. in particular, one of the most hit sectors was the aviation that contributes about 1-2% of global greenhouse gas emissions [63] and about 3-5% of global co2 emissions [64] . between 23 january 2020 and 21 april 2020, travel restrictions caused air traffic to decline by around 63% in the total number of flights and about 75% in the number of commercial flights ( figure 4 ). the latest scenario of the international air transport association (iata) suggests that air traffic will fall by 48% for 2020 [65] . even if the aviation sector returns to its pre-pandemic levels, 40% of the passengers indicate they will wait at least six months before returning to air travel. specifically, 70% indicate they will wait for their financial situation to stabilize [65] . the strong decrease in both short-term and mid-term aviation travel will lead to a reduction in greenhouse gas emissions, particularly co2. additionally, the reduction in contrails may increase the daily temperature range [66] . the reduction of contrails will probably lead to a decrease in air temperature due to the decreasing greenhouse effect [67] . in particular, one of the most hit sectors was the aviation that contributes about 1-2% of global greenhouse gas emissions [63] and about 3-5% of global co 2 emissions [64] . between 23 january 2020 and 21 april 2020, travel restrictions caused air traffic to decline by around 63% in the total number of flights and about 75% in the number of commercial flights ( figure 4 ). the latest scenario of the international air transport association (iata) suggests that air traffic will fall by 48% for 2020 [65] . even if the aviation sector returns to its pre-pandemic levels, 40% of the passengers indicate they will wait at least six months before returning to air travel. specifically, 70% indicate they will wait for their financial situation to stabilize [65] . the strong decrease in both short-term and mid-term aviation travel will lead to a reduction in greenhouse gas emissions, particularly co 2 . additionally, the reduction in contrails may increase the daily temperature range [66] . the reduction of contrails will probably lead to a decrease in air temperature due to the decreasing greenhouse effect [67] . in particular, one of the most hit sectors was the aviation that contributes about 1-2% of global greenhouse gas emissions [63] and about 3-5% of global co2 emissions [64] . between 23 january 2020 and 21 april 2020, travel restrictions caused air traffic to decline by around 63% in the total number of flights and about 75% in the number of commercial flights ( figure 4 ). the latest scenario of the international air transport association (iata) suggests that air traffic will fall by 48% for 2020 [65] . even if the aviation sector returns to its pre-pandemic levels, 40% of the passengers indicate they will wait at least six months before returning to air travel. specifically, 70% indicate they will wait for their financial situation to stabilize [65] . the strong decrease in both short-term and mid-term aviation travel will lead to a reduction in greenhouse gas emissions, particularly co2. additionally, the reduction in contrails may increase the daily temperature range [66] . the reduction of contrails will probably lead to a decrease in air temperature due to the decreasing greenhouse effect [67] . regarding the transport sector, motor vehicles were responsible for 30% of the 2018 greenhouse gases emissions in austria, for example. this was the second largest source of greenhouse gas emissions in austria, behind the energy and industry sectors, which together contributed 36% [68] . regarding the transport sector, motor vehicles were responsible for 30% of the 2018 greenhouse gases emissions in austria, for example. this was the second largest source of greenhouse gas emissions in austria, behind the energy and industry sectors, which together contributed 36% [68] . regarding the transport sector, motor vehicles were responsible for 30% of the 2018 greenhouse gases emissions in austria, for example. this was the second largest source of greenhouse gas emissions in austria, behind the energy and industry sectors, which together contributed 36% [68] . the covid-19 crisis has led to a substantial reduction in motor vehicle traffic with not only a reduction in greenhouse gas emissions and particulate pollution but also a major reduction in traffic noise and tire wear on road surfaces. in vienna, with a population of 1.9 million, car and truck traffic were reduced by 52% and 50%, respectively, between 1 march and the first week of april [69] . these reductions, extrapolated to similar urban areas in europe, have led to significantly improved air quality. in milan, average concentrations of no 2 for the 16-22 march period was 21% lower than for the same week in 2019. in bergamo, average concentrations of no 2 in 2020 were 47% lower than in 2019 for the same week, and similar reduction of average no 2 concentrations have been observed in other major cities (e.g., barcelona, 55%; madrid, 41%; lisbon, 51%) [70] . data also show a reduction in the urban pm concentration. reduced concentrations of pm 2.5 in seoul (south korea) were 54% lower from 26 february to 18 march 2020 when compared to the same period in 2019. los angeles (united states) observed its longest continuous period of clean air on record, lasting over 18 days from march 7 to 28. pm 2.5 concentration levels were lower by 31% from the same time last year and down 51% from the average of the previous four years (https://www.iqair. com/blog/air-quality/report-impact-of-covid-19-on-global-air-quality-earth-day). for barcelona, [71] reported approximately 50% reduction of no 2 and black carbon, 30% decrease of pm 10 and 33-57% increase of o 3 concentrations, very likely due to the lockdown of the city. however, the favourable role of meteorological conditions was also granted. well-known for its high level of pollution, milan is considering a shift from car traffic to pedestrian and bicycle over 35 km of streets, as a result of the coronavirus crisis (https://www.theguardian.com/ world/2020/apr/21/milan-seeks-to-prevent-post-crisis-return-of-traffic-pollution). milan launched on 24 april 2020 a new strategy for adaptation asking for an open contribution from the population [72] where it is clearly stated that the mission is to elaborate a new strategy to exit from pandemic, called phase 2. the objectives are to remake the city by accounting for problems faced during the pandemic. public transportation is one of the main foci along with the protections of elderly people. the immediate impact of the covid-19 pandemic on aquatic systems and water resources is very limited, but water quality and resources may be affected on monthly and annual perspectives. due to less boat traffic and tourist activities, venice waters cleared during the coronavirus lockdown of the city in march and april 2020 (figure 7) . reference [73] first detected the presence of the sars-cov-2 in sewage and indicated it as a sensitive tool to monitor the circulation of the virus. although the viral rna has been detected in wastewater, this does not necessarily imply a risk [74], either to the public or to the environment. reference [75] showed that coronaviruses die off rapidly in wastewater and are inactivated faster in warmer water (i.e., 10 days in water at 23 â�¢ c and >100 days in water at 4 â�¢ c). disposal of sanitary consumables, such as ppe, is already creating concern about the impact of the pandemic event on water bodies. by may 2020, many reports have claimed significant harm on the aquatic environment especially along the shorelines (e.g., in hong kong and canada) due to sanitary disposal resulting from medical activities or personal protection. the covid-19 crisis has and probably will exhibit longer-term impacts on water resources usage and management. the economic effects of the covid-19 pandemic, changes in national budgets and changes in funding priorities may lead to lack of funding for water related infrastructure and water utilities. the impacts of underfunding (e.g., increased forthcoming losses or lack of investments to improve efficiency) may only manifest after a few years. reference [73] first detected the presence of the sars-cov-2 in sewage and indicated it as a sensitive tool to monitor the circulation of the virus. although the viral rna has been detected in wastewater, this does not necessarily imply a risk [74], either to the public or to the environment. reference [75] showed that coronaviruses die off rapidly in wastewater and are inactivated faster in warmer water (i.e., 10 days in water at 23 â°c and >100 days in water at 4 â°c). disposal of sanitary consumables, such as ppe, is already creating concern about the impact of the pandemic event on water bodies. by may 2020, many reports have claimed significant harm on the aquatic environment especially along the shorelines (e.g., in hong kong and canada) due to sanitary disposal resulting from medical activities or personal protection. the covid-19 crisis has and probably will exhibit longer-term impacts on water resources usage and management. the economic effects of the covid-19 pandemic, changes in national budgets and changes in funding priorities may lead to lack of funding for water related infrastructure and water utilities. the impacts of underfunding (e.g., increased forthcoming losses or lack of investments to improve efficiency) may only manifest after a few years. during lockdown conditions, water utilities from germany and austria report that the daily peak in water consumption in the morning is shifted by around 1.5 to 2 h. generally, a dampening effect and a more even distribution in water consumption during the day is observed. regarding the amount of water consumed, increases as well as decreases of around 5% are reported. increases are explained by higher demands due to watering of gardens-surprisingly, not due to increased hand washing-and decreases by fewer commuters, students and pupils in supply areas [76] [77] [78] [79] [80] . by contrast, municipalities with high touristic activity-a leading cause of water demand [81,82]-will exhibit important reduction in water consumption. reports from the strong tourism heritage of tirol, austria, suggest reductions in water consumption of up to 50% in municipalities where tourism plays an important role [79] . depending on the return of tourism following the end of the pandemic, a noteworthy reduction of water demand and pressures on water resources can be expected. during lockdown conditions, water utilities from germany and austria report that the daily peak in water consumption in the morning is shifted by around 1.5 to 2 h. generally, a dampening effect and a more even distribution in water consumption during the day is observed. regarding the amount of water consumed, increases as well as decreases of around 5% are reported. increases are explained by higher demands due to watering of gardens-surprisingly, not due to increased hand washing-and decreases by fewer commuters, students and pupils in supply areas [76] [77] [78] [79] [80] . by contrast, municipalities with high touristic activity-a leading cause of water demand [81, 82] -will exhibit important reduction in water consumption. reports from the strong tourism heritage of tirol, austria, suggest reductions in water consumption of up to 50% in municipalities where tourism plays an important role [79] . depending on the return of tourism following the end of the pandemic, a noteworthy reduction of water demand and pressures on water resources can be expected. industrial water consumption, a generally poorly measured quantity, has certainly decreased. the longer-term impacts on water resources will depend on economic developments following the crisis. in comparison to domestic and industrial water demand, the highest pressures on water resources come from the agricultural sector. here, long-term forecasts will depend on the return of agriculture following the crisis, although short-term effects are probably visible in reduced irrigation demand. soil provides essential ecosystem services for human society, ranging from agricultural production to carbon sequestration, which are fundamental for several sustainable development goals (sdgs), such as "zero hunger" or "life on land" [83] . the immediate impact of the pandemic or other similar disasters on the soil environment is linked with the increasing risks of food insecurity and disruption of the food supply chain. the persistence of sars-cov-2 on different surfaces is a key issue for successfully controlling its spread. reference [84] found the viruses can remain viable on surfaces for several days. other studies investigated the survival of different viruses in soils and sediments [85] . at present, there is no clear evidence about the role of the soil environment in hosting and transmission of the sars-cov-2 nor about the impact of this coronavirus on the soil surface, and calls for collecting eventual results have been issued [86] . from an ecological perspective, the covid-19 crisis is fundamentally related to the relationships between society and ecosphere. while the origin in a wuhan wet market or industrial livestock or other source is not yet fully clarified [87] , it is well known that mers-cov, sars-cov and sars-cov-2 are all animal coronaviruses which infected people and then succeeded to spread in different communities at large scale. around the globe more than 2.7 million people are dying from zoonosis in a year [88] , but the impact is even greater as the zoonosis are also affecting human health, livestock sector and agriculture and usually the poorer human populations are more affected. the coronavirus crisis is most probably one of the many challenges our society will have to face in the forthcoming decades as an indirect consequence of the impact of climate change on the ecosphere through many mechanisms, including diminishing species habitats [89] , changing species distributions [90] and an increasing influx of alien invasive species [91] . currently, economic development focuses on continuous growth without considering the conservation of natural systems. in a letter sent to the who (world health organisation) in april 2020, more than 300 animal welfare and conservation organisations stressed the need to recognise the link between wildlife markets and pandemics (https://lioncoalition.org/2020/04/04/open-letter-to-world-health-organisation/). however, this is related with the need to act on existing international conventions, such as cites (the convention on international trade in endangered species of wild fauna and flora, also known as the washington convention) to protect endangered plants and animals from trafficking. as this is not the first time such outbreaks have occurred (see the sars event between 2002 and 2003), conventions like cites should be reinforced. forest landscape fragmentation also may facilitate more often human contact with wild animals, increasing the likelihood of transmission risk of animal-to-human viruses [92, 93] . the pandemic has also had an impact on ecological research, field work and experiments. in many cases, this research activity has been diminished or halted, with important consequences on conservation of species and habitats. there is also a possible economic impact on conservation programs around the globe as a result of pandemic and different programs are assessing their long-term viability (such as the global environmental fund) [89] . even after the pandemic ends, a danger exists that both research and conservation programs will be diminished mainly due to miscommunication between decision makers and scientists. however, perhaps the most important impact of the pandemic on the ecological transition focuses on sustainability and the still possible choices that the society could make to ensure its long-term survivability. as explained in figure 8 , the coupled natural-human system is on a path of transitioning from an unsustainable development towards sustainability being under pressure from different drivers. the instability caused by the pandemic is characterized by variables that have sudden and multiple impacts on both the natural environment and on society and could push the system into three different potential states. the fast variables are characterizing the instability phase and the slow variables act as controlling variables [94] [95] [96] . only one of these potential states is the desirable one, moving away from unwanted events and ensuring that the pandemic was a painful but still a "learning event" that drove towards a "better future". the main characteristic of the pandemic is that it is acting like a shock that pushes the system towards a regime shift with difficult to predict consequences. system into three different potential states. the fast variables are characterizing the instability phase and the slow variables act as controlling variables [94] [95] [96] . only one of these potential states is the desirable one, moving away from unwanted events and ensuring that the pandemic was a painful but still a "learning event" that drove towards a "better future". the main characteristic of the pandemic is that it is acting like a shock that pushes the system towards a regime shift with difficult to predict consequences. reference [93] advocates that nature is part of the solution for recovery and sustainable reconstruction. nevertheless, the effect of the covid-19 pandemic on ecological systems has not yet been fully realized, and further monitoring will bring new findings and perspectives. it is very likely that the covid-19 pandemic will reshape the economic and environmental policies at an international scale. the strength of some bilateral agreements and international partnerships has been tested by this pandemic. whereas china persistently invested in africa's natural resources and infrastructure projects, the treatment of african citizens living in china and the frustration at beijing's opposition on granting debt relief could deteriorate the chinese economic and political supremacy in africa [97] . reference [98] also discusses the impact of the crisis on african economies with unpredictable environmental consequences. the roles that china and the usa currently play for mitigating risk include an ecological emphasis to the pandemic strategy preparedness in order to better protect the global community from zoonotic disease [99] . the coronavirus epidemic could significantly impact the italians' relationship with the eu, as indicated by the widely spread perception that the eu was not efficient in supporting the fight against coronavirus [100] , at least in february-march (i.e., 88% of italians believed so in march 2020). such changes are expected to generate indirect long-term environmental impacts. climate changes are often perceived as a risk driver at the global scale and covid-19 has offered an excellent example of how a single underestimated threat can challenge the foundations of global security, economic stability and democratic governance [101] . according to analyses before the reference [93] advocates that nature is part of the solution for recovery and sustainable reconstruction. nevertheless, the effect of the covid-19 pandemic on ecological systems has not yet been fully realized, and further monitoring will bring new findings and perspectives. it is very likely that the covid-19 pandemic will reshape the economic and environmental policies at an international scale. the strength of some bilateral agreements and international partnerships has been tested by this pandemic. whereas china persistently invested in africa's natural resources and infrastructure projects, the treatment of african citizens living in china and the frustration at beijing's opposition on granting debt relief could deteriorate the chinese economic and political supremacy in africa [97] . reference [98] also discusses the impact of the crisis on african economies with unpredictable environmental consequences. the roles that china and the usa currently play for mitigating risk include an ecological emphasis to the pandemic strategy preparedness in order to better protect the global community from zoonotic disease [99] . the coronavirus epidemic could significantly impact the italians' relationship with the eu, as indicated by the widely spread perception that the eu was not efficient in supporting the fight against coronavirus [100] , at least in february-march (i.e., 88% of italians believed so in march 2020). such changes are expected to generate indirect long-term environmental impacts. climate changes are often perceived as a risk driver at the global scale and covid-19 has offered an excellent example of how a single underestimated threat can challenge the foundations of global security, economic stability and democratic governance [101] . according to analyses before the covid-19 pandemic, if countries are unable to implement the nationally determined contributions as ratified through the paris agreement, the emissions reduction efforts would cost the whole world about 149.8-792.0 trillion dollars until 2100 [102] . plans prepared for reinforcing the emission reduction goals established under the 2015 paris agreement are not only postponed until 2021, but they will probably suffer consistent adjustments in the new economic circumstances. in the short term, it is hard to assume that climate change and environmental sustainability will be priorities for the world governments or local authorities, while the long-term cost for emission reduction could be raised. the coronavirus crisis also threatens local commitments to implement climate change adaptation and mitigation measures that have been initiated in the recent period [103] . both national and international governance will be affected. the impact of coronavirus on the eu climate plan was already the subject of discussions in several meetings in brussels and there are concerns that the targets set for 2050 now will be difficult to reach especially due to the necessity for a rapid economic recovery. poland, in particular, expressed doubts on reaching the targets set for 2050 (http://www.caneurope.org/publications/press-releases/1864-eu-aims-f or-net-zero-emissions-by-2050-now-it-needs-to-work-on-raising-the-2030-target). big industries such as car manufacturers also have expressed concerns of not being able to meet the targets set (https://ww w.carbonbrief.org/daily-brief/eu-leaders-agree-to-consider-climate-in-coronavirus-recovery-plan). during the 2010s, environmental efforts have intensively addressed the generous framework of the "transforming our world: the 2030 agenda for sustainable development" [104] . this agenda includes 17 sustainable development goals (sdgs) designed to eradicate poverty and achieve sustainable development by 2030. we argue that most of these goals were immediately impacted by the covid-19 pandemic, while longer-term effects are also expected ( table 1) , most of them directly connected to urban areas and population health. it is very likely that the concept and implementation of the agenda must be reconsidered according to the new findings related to our exposure, vulnerabilities and resilience to global disaster risks. the discovery of the permanence of the virus on surfaces and in aquifers requires a revision of the purification and sanitation systems. days to years [109] 7: affordable and clean energy alternative energy sources and backup storage and transport systems should be developed to secure societal needs during crises. years to decades [110] 8: decent work and economic growth the pandemic has shown that there are groups of workers most exposed to risk to health and life by requiring a revision of the working methods in industry, commerce and health. months to decades [105, 111] 9: industry, innovation and infrastructure technological innovation and a close link with the research invention, also to the advantage of a change in production methods, has proved to be an unavoidable condition for the solution of global problems months to decades [112, 113] 10: reduced inequality improvements in access to information technologies to reduce inequalities in poor and large families who have to use remote school systems and access to other resources. days to months [24, 114] 11: sustainable cities and communities revisions of adaptation plans are foreseen for major cities to increase health resilience in citizens and to better protect elderly population. months to decades [72, 115, 116] revision of production systems from the global to the local scale to ensure access and distribution of strategic resources with consequent enhancement of territorial activities. months to decades [117] months to decades [92, 93] 16: peace and justice strong institutions the importance of strong coordination between institutions has been markedly indicated for national ones but, above all, for international ones where the exchange of exact and punctual information can indicate safe ways for solving problems on a global level. months to decades [99, 120] 17: partnerships to achieve the goal the efficiency of international agreements have been dramatically challenged, and the need for rethinking regional and global partnerships emerged. days to decades [103] the covid-19 crisis has challenged environmental monitoring and climate services, creating both adversities in observations as well as challenges to create better preparedness. lack of reliable data on the spread of covid-19 could lead to not only a once-in-a-century pandemic but also a once-in-a-century decision fiasco [110] . the crisis has revealed the crucial need to access long-term, real-time data for supporting policy makers and reaction at different scales, and it has motivated environmental scientists to reinforce our monitoring capacity to address sustainability issues the pandemic has raised [121] . challenges like the dearth of airborne meteorological measurements or the maintenance of environmental monitoring in protected areas will gradually be resolved once previous levels of social and economic activity resume [49] . however, actions are needed now to build reliable responses to future threats. the covid-19 crisis has strongly biased the production and delivery of both weather forecasting (https://news.un.org/en/story/2020/04/1060772) and climate services (i.e., climate-based information and products tailored for various end-users related to the present climate and adaptation to different scenarios) as well as the observation of oceans and remote locations (https://www.theguardian.com/sc ience/2020/apr/03/climate-monitoring-research-coronavirus-scientists#maincontent). the pandemic has dramatically lowered the quantity and quality of aircraft weather observations, thereby adversely impacting weather forecasts and modelling efforts. the european centre for medium-range weather forecasts (ecmwf) has noted a reduction of 65% in aircraft reports received between 3 march and 23 march (figure 9 ). on 9 april, the world meteorological organization (wmo) issued its concern about the impact of the crisis on the global observing system [122] . however, the exceptional slowdown of societal activities that began in march of 2020 has generated opportunities to capture environmental information of a novel event. for example, the "noise" associated with human activities that adversely affect seismographic records dropped sharply around the world, improving the ability to detect seismic waves and the locations of number of daily aircraft reports over europe received and used at ecmwf. source: https://www.ecmwf.int/en/about/media-centre/news/2020/drop-aircraft-observations-could-h ave-impact-weather-forecasts. however, the exceptional slowdown of societal activities that began in march of 2020 has generated opportunities to capture environmental information of a novel event. for example, the "noise" associated with human activities that adversely affect seismographic records dropped sharply around the world, improving the ability to detect seismic waves and the locations of earthquake aftershocks [123] . transmission of diseases by population mobility within the context of climate change received scientists' attention before the current pandemic [124, 125] . the examination of the relationship between climate and coronavirus focuses on two queries: (a) how the climate can modulate the spread and persistence of the virus, and (b) the extent of the impact of the virus on economic policies taken to offset climate impacts. the first aspect is inherently scientific and mainly involves the atmospheric and epidemiological disciplines. the second is much more complex as the economic, political and social dynamics will affect processes that will alter our worldview. climatic effects on the coronavirus are currently difficult to estimate given that this pandemic is still under development. these effects, therefore, can only be speculated by comparing them to the characteristics of other coronaviruses. reference [118] investigated the observed growth rate of coronavirus worldwide and related it to the climate, making a prediction for forthcoming seasons. they argue a specific climate exists in which the coronavirus spreads optimally. outbreak dynamics also were investigated in terms of climate and environmental conditions [126] to link directly daily growth rates to the local climate. the correlation found was significant leading them to conclude that such a link was valid, but their study also highlighted the fact that population density could be a confounding variable. these results, although very speculative, have led to initial hypotheses on the transmission conditions of sars-cov-2 under different combinations of atmospheric parameters [127] and to forecast conditions for the summer of 2020 [128, 129] . an analogy with the other coronaviruses becomes fundamental to validate such hypotheses but it is not currently possible to establish whether the virologic characteristics of the new pathogen can be assumed to be like other coronaviruses. analysing the direct and indirect effects of the pandemic on the climate is more complicated as forecasts must resolve not just the contagion dynamics but also incorporate economic, social, and political aspects of the virus propagation. direct effects on climate change could result mainly from the global slowdown of production activities and transportation. at this stage, the overall effects are not easily determined but, for example, emissions in china-the country with the longest period of closure-have decreased by 25% [130] , corresponding to a decrease of about 200 million tons of co 2 in february alone [131] . nevertheless, the possible decrease in global co 2 emissions is likely to be around 5% worldwide [132] (reuters, 2020). for the representative concentration pathway (rcp)6 climate change scenario, scripps research institute [20] suggests a possible trend in emissions ( figure 10 ) which shows an immediate drop followed by a recovery when activities resume. this projection leads to fundamental speculations as to what indirect effects coronavirus will have on the earth's climate. we note that following the 2008-2009 economic crisis, co 2 emissions exhibited rapid growth [133] and we suggest that a similar response will follow this pandemic. experts suggest one of two sharply divergent paths will arise from the demise of the pandemic [134] . on the one hand, a feeling exists that the coronavirus will support the government, science, and business infrastructure in addressing environmental issues, including climate change [135] . although the coronavirus and climate change operate on different time scales, they represent similar phenomena in terms of the evolution and impacts of the problem. thus, lessons from the pandemic provide lessons to be learned in environmental protection. recovery from the pandemic, therefore, may lead the focus away from environmental concerns [53] . surely something has already changed. covid-19 has undermined the basic tenets of global manufacturing. companies must now reconsider the multistep, multi-country supply chains that dominated production and derivative production [132] . individuals too must reconsider life choices as profound changes also await us [131, 136] . scripps research institute [20] suggests a possible trend in emissions ( figure 10 ) which shows an immediate drop followed by a recovery when activities resume. this projection leads to fundamental speculations as to what indirect effects coronavirus will have on the earth's climate. we note that following the 2008-2009 economic crisis, co2 emissions exhibited rapid growth [133] and we suggest that a similar response will follow this pandemic. experts suggest one of two sharply divergent paths will arise from the demise of the pandemic [134] . on the one hand, a feeling exists that the coronavirus will support the government, science, and business infrastructure in addressing environmental issues, including climate change [135] . although the coronavirus and climate change operate on different time scales, they represent similar phenomena in terms of the evolution and impacts of the problem. thus, lessons from the pandemic provide lessons to be learned in environmental protection. recovery from the pandemic, therefore, may lead the focus away from environmental concerns [53] . surely something has already changed. covid-19 has undermined the basic tenets of global manufacturing. companies must now reconsider the multistep, multi-country supply chains that dominated production and derivative production [132] . individuals too must reconsider life choices as profound changes also await us [131, 136] . the covid-19 pandemic has triggered unprecedented environmental impacts in terms of spatial extent, complexity and even uniqueness. it is the first time in history that the metabolism of all the urban agglomerations with more than 1 million inhabitants from europe was virtually stopped regarding movement, traffic and economic exchanges. the societal and economic measures adopted to contain the pandemic led to local, regional and global impacts, both negative and positive, spanning from immediate to long-term consequences. the full evaluation of the impacts is far from being possible with an ongoing disaster of epic proportion and tremendous complexity, and this paper pledges for several directions to be pursued by further research. the covid-19 pandemic provides a clear demonstration that human and planetary health are intimately interconnected [137] , and the role of interdisciplinary approaches in finding solutions has been clearly highlighted [138] . the disaster reached the planetary scale within only two months (i.e., february through march 2020). despite six other pandemic outbreaks having occurred during the 21st century, humankind was still not prepared to deal with a global event. most countries adopted a strict lockdown of economies and societal activities, triggering immediate impacts on many physical and ecological systems. longer-term consequences are also assumed, and a systemic approach is required to support the prevention, early warning, and similar impacts of environmental degradation. the covid-19 pandemic has triggered unprecedented environmental impacts in terms of spatial extent, complexity and even uniqueness. it is the first time in history that the metabolism of all the urban agglomerations with more than 1 million inhabitants from europe was virtually stopped regarding movement, traffic and economic exchanges. the societal and economic measures adopted to contain the pandemic led to local, regional and global impacts, both negative and positive, spanning from immediate to long-term consequences. the full evaluation of the impacts is far from being possible with an ongoing disaster of epic proportion and tremendous complexity, and this paper pledges for several directions to be pursued by further research. the covid-19 pandemic provides a clear demonstration that human and planetary health are intimately interconnected [137] , and the role of interdisciplinary approaches in finding solutions has been clearly highlighted [138] . the disaster reached the planetary scale within only two months (i.e., february through march 2020). despite six other pandemic outbreaks having occurred during the 21st century, humankind was still not prepared to deal with a global event. most countries adopted a strict lockdown of economies and societal activities, triggering immediate impacts on many physical and ecological systems. longer-term consequences are also assumed, and a systemic approach is required to support the prevention, early warning, and similar impacts of environmental degradation. the coronavirus pandemic has generated an active involvement of the research community and has garnered an early response from international, national, and local authorities. since the events are ongoing and the end is still difficult to predict, we shall refer only to preliminary results and possible lessons to be learned. the reaction of the scientific community to the crisis was prompt and led to rapid accumulation of knowledge and operational decisions. faced with an unprecedented interruption of data from aeronautical meteorological service providers (amsps) and other observational platforms, the wmo has enumerated preliminary guidelines to assist the amsps [122] at the beginning of april 2020. eventually, problems associated with environmental monitoring have reinforced the need to secure backup systems to collect information, as such data are crucial for operational forecasting of ecological, weather and hydrological conditions. of note, relationships between weather conditions and the spread of the virus are still unclear and more research is needed to derive relevant conclusions. the advancements of new specific techniques would be of great interest for controlling the environmental dissemination of coronaviruses [126] , and more precise and extended monitoring would favour the collection of more relevant information. early developments with this crisis have revealed that monitoring of socio-ecological conditions is crucial for an early intervention to limit the scale of the epidemic and the pandemic hazard. reference [139] argues that better monitoring of immigrant tracks and travel volumes could have helped countries be better prepared to contain the spread of the novel coronavirus. data, tools and lessons learned may provide significant improvements in preparation to fight potential pandemics in the future [140] . this global crisis has convincingly demonstrated that the disaster research, climate change diplomacy and ecosystem services must reconsider their strategic and integrated development considering even the most unlikely events. eventually, the covid-19 pandemic will determine profound changes of the social and economic behaviour at the planetary scale, and this study highlights the environmental dimension of the 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trigger biggest fall in carbon emissions since world war two 456 correspondence: rapid growth in co2 emissions after the 2008-2009 global financial 457 crisis. nat after the coronavirus, two sharply divergent paths on climate how the world will look after the coronavirus pandemic. foreign policy the real impact on the climate-geographical magazine covid-19 and air pollution: a deadly connection. available online covid-19: epidemiology, evolution, and cross-disciplinary perspectives coronavirus and migration: analysis of human mobility and the spread of covid-19 a data ecosystem to defeat covid-19 this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we thank very much the four reviewers for their valuable comments and suggestions. the authors declare no conflict of interest. key: cord-307362-1bxx4db2 authors: salmerón-manzano, esther; manzano-agugliaro, francisco title: bibliometric studies and worldwide research trends on global health date: 2020-08-09 journal: int j environ res public health doi: 10.3390/ijerph17165748 sha: doc_id: 307362 cord_uid: 1bxx4db2 global health, conceived as a discipline, aims to train, research and respond to problems of a transboundary nature in order to improve health and health equity at the global level. the current worldwide situation is ruled by globalization, and therefore the concept of global health involves not only health-related issues but also those related to the environment and climate change. therefore, in this special issue, the problems related to global health have been addressed from a bibliometric approach in four main areas: environmental issues, diseases, health, education and society. science aims to answer questions, and from a pragmatic approach, science can be understood as a resolution of problems in our society. science cannot be considered an independent activity, and therefore, it must be remembered that prior studies have been carried out in any given scientific field. combining scientific aspects with documental aspects gives rise to a certain type of scientific work: scientometric, bibliometric, and informetric studies. these take different titles according to the final approach of the work, such as the following: examining the scholarly literature, evolution, and new trends; worldwide research trends; mapping of the knowledge base; visualizing the knowledge structure; analysis of global research; publication trends; knowledge domain visualization. scientific literature is losing its relevance more and more quickly, but the aging of literature is not uniform for all scientific subjects. this means that being up to date in a scientific field requires bibliometric studies through which new trends are revealed when undertaking scientific studies of interest to the community. two topics of special interest to society today are environmental research and public health, and within these larger topics are sub-topics related to global health. global health, in a broad context, refers to improving health worldwide, reducing disparities, and protecting against global threats that do not consider national borders. this special issue aims to provide a global view of all of these global health issues, and through bibliometric studies, we believe that this objective can be achieved. therefore, articles reviewing the state of the art in any of these fields, bibliometric or scientometric studies, and research articles dealing with a global perspective are welcome. the summary of the call for papers for this special issue on the 28 manuscripts submitted: rejected (12; 43%) and published (16; 67%). the submitted manuscripts come from many countries and are summarized in table 1 . for this statistic only the first affiliation of the authors has been considered, in which it gives the opportunity to observe 66 authors from nine countries. note that it is common for a manuscript to be signed by more than one author and for authors to belong to different affiliations. the average number of authors per published manuscript in this special issue was seven authors. there are 23 different affiliations of the authors. note that only the first affiliation per author has been considered. table 2 summarizes the authors and their first affiliations. table 3 summarizes the research conducted by the authors in this special issue, by identifying the areas to which they report. it was noted that they have been grouped into four main lines of research: environmental issues, diseases, health and society. they have mainly explored the issue of disease research, these have been: covid-19, asthma, pulmonary disease, hiv/aids, and diabetes. related to health, they were: medicinal plants, musculoskeletal risks, and obesity. the environmental issues were related to: microplastics, climate change, and wastewater treatment. finally, research related to education and society: academic performance, patents, bibliometric analysis, and social networks and young people. table 3 . topics for worldwide research trends on global health. current state and future trends: a citation network analysis of the academic performance field global research output and theme trends on climate change and infectious diseases: a restrospective bibliometric and co-word biclustering investigation of papers indexed in pubmed (1999-2018) studies of novel coronavirus disease 19 (covid-19) pandemic: a global analysis of literature the contribution of spanish science to patents: medicine as case of study global mapping of research trends on interventions to improve health-related quality of life in asthma patients interventions to improve the quality of life of patients with chronic obstructive pulmonary disease: a global mapping during a scientometric analysis of global health research global research on quality of life of patients with hiv/aids: is it socio-culturally addressed modeling the research landscapes of artificial intelligence applications in diabetes (gapresearch) global mapping of interventions to improve quality of life of people with diabetes in 1990-2018 wastewater treatment by advanced oxidation process and their worldwide research trends characterizing obesity interventions and treatment for children and youths during 1991-2018 a bibliometric analysis of the health field regarding social networks and young people musculoskeletal risks: rula bibliometric review bibliometric profile of global microplastics research from 2004 to 2019 author contributions: the authors all made equal contributions to this article. all authors have read and agreed to the published version of the manuscript.funding: this research received no external funding. the authors state that there are no conflict of interest. key: cord-331718-rjggiklf authors: kubota, takeo; mochizuki, kazuki title: epigenetic effect of environmental factors on autism spectrum disorders date: 2016-05-14 journal: int j environ res public health doi: 10.3390/ijerph13050504 sha: doc_id: 331718 cord_uid: rjggiklf both environmental factors and genetic factors are involved in the pathogenesis of autism spectrum disorders (asds). epigenetics, an essential mechanism for gene regulation based on chemical modifications of dna and histone proteins, is also involved in congenital asds. it was recently demonstrated that environmental factors, such as endocrine disrupting chemicals and mental stress in early life, can change epigenetic status and gene expression, and can cause asds. moreover, environmentally induced epigenetic changes are not erased during gametogenesis and are transmitted to subsequent generations, leading to changes in behavior phenotypes. however, epigenetics has a reversible nature since it is based on the addition or removal of chemical residues, and thus the original epigenetic status may be restored. indeed, several antidepressants and anticonvulsants used for mental disorders including asds restore the epigenetic state and gene expression. therefore, further epigenetic understanding of asds is important for the development of new drugs that take advantages of epigenetic reversibility. autism spectrum disorders (asds) are complex, pervasive neurodevelopmental disorders that are characterized by dysfunctions in social interactions and communications and restricted/fixated interests or repetitive behavior that manifest in early childhood [1] . asds include classical autism, asperger syndrome, and pervasive developmental disorder-not otherwise specified [2, 3] . a number of environmental factors are known to be involved in the pathogenesis of asds, including nutritional factors and hormones [4] . furthermore, inappropriate child rearing, such as child abuse and malnutrition by parents with psychiatric problems, can be associated with asds [5] [6] [7] [8] . viral infections with rubella and cytomegalovirus and associated immunological reactions via activation of microglia are also thought to be involved in asds, which has been demonstrated by pathological studies of post-mortem brains and neuroimaging studies of asd patients [9] [10] [11] [12] [13] [14] , although some epidemiological studies conducted in denmark and taiwan did not support the hypothesis that pre-and postnatal infection and immunological reaction are involved in asd cases with regard to herpes and influenza viral infection and kawasaki disease (a disorder potentially associated with corona virus) [15] [16] [17] . in addition, endocrine-disrupting chemicals (edcs) are thought to be involved in the development of asds, including tobacco, air pollutants, solvents, metals, pesticides, and organic edcs such as flame retardants, non-stick chemicals, phthalates, and bisphenol a (bpa) [18] . conversely, a number of genetic factors have been identified as causes of asds. mutations in genes encoding neurotransmitters such as synapsin, dopamine transporter, and neuroligin, and synapse-associated proteins such as scaffold proteins including shank and lin7b, have been identified in asd patients [19] [20] [21] [22] [23] [24] . unexpectedly, mutations have also been identified in chromatin-remodeling factors such as histone modifying enzymes and chromodomain helicases in congenital asds (e.g., kleefstra syndrome) [25] [26] [27] . these findings suggest that asds can be recognized as a "synaptic and chromatin-remodeling disorders" [25, 28] . chromatin is a genetic unit that consists of dna and histone proteins, which are modified by enzymes for dna methylation, histone acetylation and methylation and by chromatin-binding polycomb proteins. a recent three-dimensional resolution imaging technology provided a precise chromatin organization with epigenetic modifications [29] . furthermore, autism susceptibility candidate 2, a nuclear protein involved in cortical neuronal migration and neuritogenesis in the developing brain [30] and whose mutations cause asds [31, 32] , forms a complex with polycomb repressive complex 1 to purge its repressive function and activates expression of neurodevelopmental genes involved in axon guidance in the developing forebrain, such as neruocan [33, 34] . these results suggest that close interaction between neuronal molecules and epigenetic molecules is important for normal brain development and failure of this interaction is potentially associated with asds. in this review, we introduce congenital epigenetic disorders with asd-like phenotypes and environmental factors that affect epigenetic regulation of neuronal genes, and discuss transgenerational epigenetic inheritance and therapeutic strategies for asds taking advantage of use of the epigenetic reversibility. rett syndrome (rtt) is a representative asd characterized by repetitive and stereotypic hand movements, seizures, gait ataxia and autism [35] and is caused by mutations in the gene that encode methyl-cpg-binding protein 2 (mecp2), which is associated with chromatin remodeling [36] . since rtt is an x-linked dominant disorder, male patients are embryonic lethal and thus all patients are female. mecp2 interacts with the sin3a/hdac complex [37] [38] [39] [40] , and binds to methylated cpg in dna to suppress a number of genes associated with synaptic function (e.g., bdnf, dlx5, id, crh, igfbp3, cdkl1, pcdhb1 and pcdh7, lin7a) in neurons and other types of brain cells [41] [42] [43] [44] [45] [46] [47] , thereby controlling excitatory synaptic strength by regulating the number of glutamatergic synapses [48] . induced pluripotent stem cells (ipscs) can be used to determine how a disease develops in patients, especially inaccessible brain cells. using ipsc technology, it is possible to generate neural cells from patients' peripheral tissue such as skin fibroblasts. several studies have shown that rtt ipsc-derived neurons exhibit maturation and electro-physiological defects reminiscent of those seen in rtt patients and mouse models [49] [50] [51] , and we have shown that astrocyte-specific genes (e.g., gfap) are aberrantly expressed in neural cells generated from ipsc lines that lack mecp2 expression, which leads to the de-suppression of astrocyte-specific genes ( figure 1a ) [52] . interestingly, not only functional deficiency of mecp2 protein (i.e., due to mutations of mecp2) but also increased dosage of mecp2 protein (i.e., due to duplication of mecp2) results in severe mental retardation in males [53] and cognitive impairment with learning difficulties and speech delay in females [54] . the increased dosage effect of mecp2 on neurological function has been confirmed in a model mouse that exhibits motor coordination deficits, heightened anxiety, and impairments of learning and memory [55] , and in a monkey model that exhibits a higher frequency of repetitive circular locomotion, increased stress responses, less interaction with wild-type monkeys, reduced interaction time with other transgenic monkeys, and stereotypic cognitive behaviors [56, 57] . these findings indicate that the expression of mecp2 within a normal range is essential for normal brain development. interestingly, not only functional deficiency of mecp2 protein (i.e., due to mutations of mecp2) but also increased dosage of mecp2 protein (i.e., due to duplication of mecp2) results in severe mental retardation in males [53] and cognitive impairment with learning difficulties and speech delay in females [54] . the increased dosage effect of mecp2 on neurological function has been confirmed in a model mouse that exhibits motor coordination deficits, heightened anxiety, and impairments of learning and memory [55] , and in a monkey model that exhibits a higher frequency of repetitive circular locomotion, increased stress responses, less interaction with wild-type monkeys, reduced interaction time with other transgenic monkeys, and stereotypic cognitive behaviors [56, 57] . these findings indicate that the expression of mecp2 within a normal range is essential for normal brain development. icf syndrome is a congenital disorder named after three major features, such as immunodeficiency, centromere instability, and facial anomalies [58] . although the cause is different between rtt and icf syndromes, the consequence is similar; both lead to the de-suppression of target genes by the failure of dna methylation-dependent gene regulation ( figure 1a ). icf syndrome is diagnosed by specific chromosome findings with breakage of the pericentric heterochromatic regions of chromosomes 1, 9 and 16, which are normally hypermethylated but are hypomethylated due to deficiency of dnmt3b in icf [59] . the patients show distinct low levels of immunoglobulins (e.g., igg and iga) and they required intravenous immunoglobulin supplementation every 2 weeks. although a recent study has demonstrated an icf-specific dna hypomethylation pattern in mesenchymal stem cells differentiated from the ipscs of icf patients [60] and another study has shown a subset of hypomethylated genes in icf patients [61] , the precise molecular mechanism for the immune dysregulation, which is the main clinical feature in icf, is still largely unknown. it may be necessary to analyze purified b lymphocytes from icf patients in order to identify hypomethylated dnmt3b-driven immunological genes. interestingly, mutations in a gene encoding another dna methyltransferase, dnmt3a, cause intellectual disability with overgrowth [62] , suggesting that dna methyltransferases are essential for normal brain and immunological development. icf syndrome is a congenital disorder named after three major features, such as immunodeficiency, centromere instability, and facial anomalies [58] . although the cause is different between rtt and icf syndromes, the consequence is similar; both lead to the de-suppression of target genes by the failure of dna methylation-dependent gene regulation ( figure 1a ). icf syndrome is diagnosed by specific chromosome findings with breakage of the pericentric heterochromatic regions of chromosomes 1, 9 and 16, which are normally hypermethylated but are hypomethylated due to deficiency of dnmt3b in icf [59] . the patients show distinct low levels of immunoglobulins (e.g., igg and iga) and they required intravenous immunoglobulin supplementation every 2 weeks. although a recent study has demonstrated an icf-specific dna hypomethylation pattern in mesenchymal stem cells differentiated from the ipscs of icf patients [60] and another study has shown a subset of hypomethylated genes in icf patients [61] , the precise molecular mechanism for the immune dysregulation, which is the main clinical feature in icf, is still largely unknown. it may be necessary to analyze purified b lymphocytes from icf patients in order to identify hypomethylated dnmt3b-driven immunological genes. interestingly, mutations in a gene encoding another dna methyltransferase, dnmt3a, cause intellectual disability with overgrowth [62] , suggesting that dna methyltransferases are essential for normal brain and immunological development. prader-willi syndrome (pws) is a hallmark epigenetic disease; the causative epigenetic abnormality was identified more than 20 years ago. approximately 70% patients have a chromosomal deletion at 15q11-q13, and the remaining patients have genomic imprinting errors. in pws patients with maternal uniparental disomy, both paternal and maternal alleles of genes within the 15q11-q13 region are hypermethylated and thus expression from both alleles is suppressed ( figure 1a ) [63] [64] [65] . the clinical features of pws includes neurocognitive deficits, excessive daytime sleepiness, muscle hypotonia, short stature, small hands and feet, hypergonadism, hyperphagia starting from infancy, and subsequent obesity and type 2 diabetes [66] . angelman syndrome is characterized by severe intellectual disability, intractable epilepsy, puppet-like ataxic movement, and paroxysms of laughter. the critical region is the same as pws (i.e., 15q11-q13), but parental-of-origin is different; either maternal deletion or paternal uniparental disomy causes angelman syndrome, because the causative gene, ubiquitin protein ligase e3a (ube3a), is maternally expressed [67] . interestingly, the increased copy number (i.e., duplication or triplication) of the maternal 15q11-q13 region that leads to ube3a overexpression causes an asd [68] . these findings indicate that the expression of ube3a within a normal range is essential for normal brain development. epigenomic studies were conducted within the regions of various neuronal genes and asd-specific differential dna methylation was revealed. for example, increased dna methylation at the promoter regions subsequent reduced expression were observed within the genes of oxytocin receptor (octr), engrailed-2 (en2) and reelin (reln) in the postmortem brain tissues from asd patients [69] [70] [71] . increased hydroxymethylation and subsequent increased binding of mecp2 associated with gene silencing were identified within the promoter region of glutamate decarboxylase 1 (gad1) in the postmortem brain tissues from asd patients [71] . recent genome-wide dna methylation studies using array-based infinium beadchip identified asd-associated differential dna methylation at zfp57 associated with folate metabolism, which is a potential contributor to asd risk, in the postmortem brain tissues [72] [73] [74] , and at brain-derived neurotrophic factor (bdnf) in the peripheral blood tissues from asd patients [75] . findings through these studies potentially generate robust epigenetic biomarkers for risk, diagnosis and prognosis of asd, which may also be used to monitor response to early interventions [76, 77] . as mentioned above, not only genetic factors (i.e., dna mutations) but also environmental factors are involved in asds, and a combination of heritability (g: genetic factor such as single nucleotide polymorphism) and experience (e: environmental factor)-that is, "g, x, e"-has been the main concept for understanding common diseases, including asds. recently, new g x e model has been proposed in which e dynamically changes g and causes dna and histone chemical modifications (i.e., epigenetics), but not dna sequence changes [78] . edcs are compounds released from chemical, agricultural, pharmaceutical, and consumer product industries that have estrogenic activity or interfere with endogenous sex hormones. of the many edcs, bpa is associated with reproductive toxicity, altered growth, and immune dysregulation, and alters dna methylation in fetal mouse brains [79] . moreover, perinatal bpa exposure via maternal diet decreases global dna methylation in bone marrow-derived mast cells of the offspring during adulthood [80] , and it alters dna methylation of stat3 dose in a dose dependent manner in mouse liver [81] . high dose exposure of polybrominated diphenyl ethers (flame retardants) decreases dna methylation at the promoter of tnfα, a proinflammatory gene, and increase tnfα protein expression in human cord blood [82] . furthermore, the altered dna methylation patterns in ahrr, myo1g, cyp1a1, and cntnap2 caused by maternal tobacco smoking detected in cord blood was confirmed in the peripheral blood of their children at 17 years of age [83] , suggesting that altered dna methylation in the early development period can persist for a long period and it may be useful as a long-lasting signature of maternal stress or history of the offspring. nutrition also influences programming of an offspring's epigenome, which includes folic acid and vitamins b2, b6 and b12 that are essential for one-carbon metabolism and are involved in dna methylation ( figure 1b) . moreover, a calorie-or protein-restricted maternal diet decreases dna methylation and induces the over-expression of energy storage-associated genes (e.g., pparγ) in fetal liver to generate a "thrifty phenotype," which promotes survival under conditions of poor nutrition before and after birth [84, 85] . once an individual is born with a thrifty phenotype in modern society with an abundance of food, the nutritional mismatch between prenatal and postnatal conditions induces metabolic and mental disorders [86] [87] [88] [89] , the concept of which is referred to as "developmental origins of heath and disease (dohad)" [90] . several lines of evidence suggest that not only materials (e.g., chemicals and nutrients) but also mental stresses can alter an offspring's epigenome ( figure 1b) . for example, exposure of short-term postnatal stress by separating offspring from the mother induced hypermethylation within the promoter region of the glucocorticoid receptor (nr3c1) gene, which encodes a hormone associated with resilience, in the hippocampal region of the offspring, leading to abnormal behavior in rats [91] . furthermore, exposure to prenatal maternal stress also predicts a wide variety of behavioral and physical outcomes in the offspring. a recent study of women who were pregnant during a disaster (the ice storm in quebec in 1998) revealed that dna methylation profiles were altered in genes related to immune function in the peripheral blood of their offspring [92] . similarly, it has been demonstrated that maternal stress during pregnancy alters dna methylation of the imprinted genes igf2 and gnasxl in cord blood [93] , and that maternal stress also alters dna methylation in nr3c1 and bdnf in buccal mucosa dna samples obtained from 2 month-old infants born to mothers with depressive symptoms during pregnancy [94, 95] . environmental factors that alter a phenotype not only affect the exposed individual but also subsequent progeny for successive generations. in other words, ancestral experiences could influence subsequent generations, the concept of which is termed "transgenerational inheritance." furthermore, environmental factors such as edcs and nutrition do not promote genetic mutations but instead promote epigenetic changes; the permanent programming of an altered epigenome in the germline can allow for the transmission of transgenerational epigenetic phenotypes [96] . the evidence supports the theory of lamarckian inheritance in which an organism can pass on phenotypes that it acquired during its lifetime to its offspring. more precisely, a hypothesis has emerged that environmental stress results in epigenetic changes at some loci in the genome and these can escape the epigenetic reprogramming that normally occurs between generations [97, 98] . short-term postnatal mental stress by separating offspring from their mother alters dna methylation not only in the brain but also in the sperm of male offspring, and then the environmentally induced epigenetic and expression alterations of crfr2 are transmitted up to the third generation (f1 sperm and f2 brain) along with behavioral abnormalities [99] . since this initial observation, similar findings have accumulated. for example, prenatal stress exposure induces changes in dna methylation and mirna expression in the placenta and brain, which leads to an increase in risk for schizophrenia, attention deficit hyperactivity disorder, asds, and anxiety-or depression-related disorders later in life [100] . besides mental stress, exposure to an edc (e.g., vinclozolin) during embryonic gonadal sex determination can alter male germ-line epigenetics, and the alteration of dna methylation in the germ line appears to result in the transmission of transgenerational adult-onset diseases, including spermatogenic defects, prostate disease, kidney disease and cancer [101] . a recent study demonstrated that exposure to bpa in early life induces glucose intolerance and β-cell dysfunction, with hypermethylation and associated decreased expression of igf2 in the islets of male f2 offspring; this finding suggests that bpa exposure during early life can result in generational transmission of glucose intolerance and β-cell dysfunction through the male germ line by an epigenetic mechanism [102] . however, evidence that such effects persist in the subsequent generations has been inconclusive [97, 103, 104] . the effects must be observed in the f3 generation to be considered transgenerational, because the in utero nature of the ancestral perturbation affects not only the somatic and germ cells of the developing f1 fetus, but also the germ cells of the f2 generation. in this context, a recent study demonstrated that treatment of pregnant mice with the edc methoxychlor altered the methylation of all imprinted genes examined (i.e., h19, meg3 (gtl2), mest (peg1), snrpn, and peg3) in the f1 offspring, but these effects disappeared gradually from f1 to f3 [105] . these finding suggests that transgenerational epigenetic inheritance is not "solid" inheritance, such as genetic (dna sequence-based) inheritance, but "soft" inheritance [106, 107] . in this article, we have introduced asds with epigenetic abnormalities caused by genetic mutations in enzymes and proteins involved or chromosomal abnormalities such as rett and prader-willi syndromes (i.e., congenital and syndromic asds) and asds with epigenetic abnormalities caused by environmental factors such as chemicals, nutrition, and mental stress (i.e., acquired and non-syndromic asds). furthermore, we introduced the concept of transgenerational epigenetic inheritance in which environmental stress-induced epigenetic changes can be transmitted to the subsequent generations by escaping from erasure during epigenetic reprogramming. however, transgenerational epigenetic inheritance is not "solid" inheritance but "soft" inheritance because epigenetics is a reversible mechanism based on the addition and removal of chemical residues on dna and histone proteins. taking advantage of this epigenetic reversibility, some psychotropic drugs, such as valproic acid for epilepsy and mental disorders and imipramine for depressive disorders, can restore altered histone modifications and gene expression [108] [109] [110] . a recent epidemiological study demonstrated that supplementation of folic acid during pregnancy, which is an important nutrient and substrate for dna methylation, reduced the risk of asds in the offspring [111] . furthermore, studies using rtt or mecp2-duplication mouse models demonstrated that genetic supplementation of mecp2, bone marrow transplantation, or antisense oligonucleotides after birth successfully attenuated neurological symptoms [112] [113] [114] . these findings support the idea that the phenotypes of asds caused by epigenetic dysregulation are reversible and thus treatable. further epigenetic understanding of asds will offer new concepts for therapeutic strategies. american psychiatric association. diagnostic and statistical manual of mental disorders, text revision diagnostic and statistical manual of mental disorders proposed revision: a 05 autism spectrum disorder. dsm-5 development website environmental factors 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sustained hippocampal chromatin regulation in a mouse model of depression and antidepressant action long-term imipramine treatment increases n-methyl-d-aspartate receptor activity and expression via epigenetic mechanisms association between maternal use of folic acid supplements and risk of autism spectrum disorders in children reversal of neurological defects in a mouse model of rett syndrome wild-type microglia arrest pathology in a mouse model of rett syndrome reversal of phenotypes in mecp2 duplication mice using genetic rescue or antisense oligonucleotides the author declares no conflict of interest. key: cord-291535-91j1lleq authors: jose, thulasee; hays, j taylor; warner, david o. title: improved documentation of electronic cigarette use in an electronic health record date: 2020-08-14 journal: int j environ res public health doi: 10.3390/ijerph17165908 sha: doc_id: 291535 cord_uid: 91j1lleq the use of electronic cigarettes (e-cigarettes) can affect patient health and clinical care. however, the current documentation of e-cigarette use in the electronic health records (ehr) is inconsistent. this report outlines how the ambulatory clinical practices of a large u.s. hospital system optimized its electronic health records (ehr) framework to better record e-cigarettes used by patients. the new ehr section for e-cigarette information was implemented for outpatient appointments. during a 30-week evaluation period post-implementation, 638,804 patients (12 yrs and older) completed ambulatory appointments within the health system; of these, the new section contained e-cigarette use information for 37,906 (6%) patients. among these patients, 1005 (2.7%) were identified as current e-cigarette users (current every day or current some day e-cigarette use), 941 (2.5%) were reported as former e-cigarette users, and 35,960 (94%) had never used e-cigarettes. a separate ehr section to document e-cigarette use is feasible within existing clinical practice models. utilization of the new section was modest in routine clinical practice, indicating the need for more intensive implementation strategies that emphasize the health effects of e-cigarette use, and how consistent ascertainment could improve clinical practice. cigarette smoking is the leading cause of preventable disease and death in the united states [1] . despite the overall progress made to curb combustible cigarette smoking in the u.s. (the prevalence of smoking was 13.7% in 2018), between 2014 and 2018, the prevalence of electronic cigarette (e-cigarette) use increased from 5.1% to 7.6% in u.s. adults aged 19-24 years [2] . e-cigarettes are battery-powered devices that deliver an aerosol by heating solutions that usually contain nicotine, propylene glycol, and a variety of other solvents and flavoring agents [3] . the devices (also known as "vapes"), can be used to deliver other substances, including tetrahydrocannabinol (thc) [4] . according to the world health organization (who), many countries lack tobacco surveillance and monitoring systems to effectively assess the prevalence of current e-cigarette use [5] . a recent report suggested that in mid-2018, at least 40 million adults across the globe used e-cigarettes [6] . although these devices may function as nicotine delivery systems to help adult cigarette smokers quit, they may also serve as a means to initiate or perpetuate nicotine addiction in adults and the youth. in addition, the potential dangers and health consequences of e-cigarette use were illustrated by the outbreak of e-cigarette, or vaping, associated lung injury (evali) [7, 8] . although many patients who developed evali used products containing tetrahydrocannabinol, some used devices containing only nicotine [9] . for these reasons, it is important for clinicians to accurately ascertain and record e-cigarette use in their patients. however, the current documentation of e-cigarette use in the electronic health records (ehr) is inconsistent [10] . the evidence suggests that many clinicians record e-cigarette information within the "tobacco use" section of the ehr, along with multiple combustible tobacco products (cigarettes, cigars, pipes, etc.), or as free-text entries as a part of their clinical notes [11, 12] . these documentation efforts are not consistent across clinical practices, nor systematically tracked by the health system. reliable population health data could bolster research efforts to generate evidence addressing gaps in our understanding of trends in e-cigarette use by patients and their overall impact on health [10, 13, 14] . these data are also important for clinicians to deliver optimal care, as many may not even be aware of their patients' e-cigarette use [15] . the current version of the ehr system used by the health system does not utilize a separate section to document e-cigarette use, but rather employs a single tab called "e-cigarettes" within the "tobacco use" section of the social history, that clinicians can use to indicate every use of e-cigarettes. however, it is not possible with this tab to separately describe cigarette and e-cigarette use for dual users. the anecdotal experience suggested that clinicians were not consistently capturing e-cigarette use (perhaps because many clinicians do not perceive e-cigarettes to be a tobacco product). therefore, our objective was to design and institute a separate documentation framework within the ehr system to capture e-cigarette use information from patients, and to record this information separately from other tobacco product use information. this report describes the design and pilot implementation of this documentation system within a large u.s. hospital system. clinical setting: mayo clinic is a large academic u.s. hospital system, with over 4000 physicians serving approximately 1.5 million patients annually, with primary campuses in minnesota, florida, and arizona. the clinical practice is supported by an ehr vendor, epic© systems corporations. the design and implementation work described in this report was performed at the mayo clinic in rochester, mn and applicable to all ambulatory practices within the health system. prior ehr documentation of e-cigarette use: prior ehr documentation of e-cigarette use was limited to single tab within a "tobacco use" section of the "substance and sexual activity" history. note that for users of more than one tobacco product, it is not possible to ascertain status (i.e., current user, former user, etc.) for each product. for example, for dual users of cigarettes and e-cigarettes, it is not possible to determine whether they are currently using both, or have discontinued the use of one. indeed, clinicians and patients may not consider that e-cigarette use falls under "smoking status", as their use may not be considered to be "smoking". in addition, tobacco use information within the substance and sexual activity history can be updated by a clinician at any time, and need not be within the context of an appointment with the patient. typically, this section is updated as part of a clinical encounter with the patient. however, in the event that patients are not asked about their tobacco use history during a clinical appointment, information that is currently on file would remain as is. the current institutional policy for ambulatory clinical practices mandates that tobacco use history must be ascertained and updated, at least once a year for all patients age 12 and over, although individual practices may update more frequently. our preliminary request to epic© was let us optimize the "tobacco use" history, and include a separate section for e-cigarette information. this request was initially declined, citing that the tobacco-related documentations entered in this section were being used for regulatory requirement reporting purposes. as a result, we proposed to design and pilot the new e-cigarette documentation framework for the ambulatory clinical practices and utilize this as a template for epic©'s future optimization efforts. new e-cigarette documentation framework design: the new ehr documentation framework was designed for the outpatient clinical practices of the health system. the design considerations for the new framework included the following: provide a distinct section within the social determinants of the health section for e-cigarette use documentation, separate from the "tobacco use" information within the substance and sexual history section; 3. provide the ability to record the frequency of e-cigarette use, types of devices, the types of substances used, the start date, the end date, counseling status; and 4. provide the option for free entry of information by clinicians, given the wide range of available devices and substances that could be used. the new e-cigarette section is designed to be available only during ambulatory appointments and must be completed by a clinical provider (not the patient) as part of the routine patient health history. unlike the previous documentation system where information on the patient file could be updated by a clinician at any time, the new section to record e-cigarette information is made available only within the context of a "clinical encounter with the patient" and cannot be filled outside the "ambulatory appointment". this feature was designed to encourage providers to complete this section as part of the patient visit. per current institutional policy, information collected in this section is not a "required" component of the ehr and, therefore, clinicians are allowed to skip the new section. examples of "required" components of an ehr include patient name, age, ethnicity, gender, address, insurance information, etc. only a highly selective group of information is considered as a "mandatory" requirement for all patient ehrs. the remaining sections, including the patient medical history sections, are filled out based on institutional, departmental, and clinical practice guidelines. this is done intentionally to ensure patient ehrs can be created to provide medical services during urgent situations without delay. the development, testing, and implementation of the new documentation framework were conducted at the rochester campus, with additional oversight from epic©. the content, layout, and the location of the new section were finalized after consulting with tobacco treatment specialists at the mayo clinic nicotine dependence center and the evidence based guidelines in this domain [16, 17] . it was approved for use by institutional clinical practice and ehr oversight committees. implementation: prior to the implementation of the new framework, an online newsletter communication was delivered to all clinicians, announcing the importance of using the new section as part of ambulatory clinical practice. on the week of implementation, the new upgrade was announced on the ehr update webpage run by the hospital system. no other specific implementation activities were conducted. analysis: the utilization rate of the new section in ehr was assessed by a report of the total number of responses recorded for the selected variables (i.e., e-cigarette use, types of devices, and counseling status) during the evaluation period. the 30 weeks between 26 february 2019-21 september 2019, was considered as the pre-implementation period. the new section was implemented in the ehr system on 27 september 2019. a one-week period between 27 september and 6 october 2019, was considered as a "run-in" period and was not used for evaluation. the evaluation period for the new e-cigarette section was 30 weeks, from 7 october 2019, to 30 april 2020. the new section on e-cigarettes is the first tab under the social determinants of the health section of the ehr and is labeled as "electronic nicotine delivery devices" (figure 1 ). this descriptor was selected to distinguish from the traditional combustible nicotine delivery devices (i.e., cigarettes, cigars, cigarillos, hookah, etc.) and chewing tobacco types that are recorded under the tobacco use section. in the newly designed section, discrete choices are provided to document the frequency of e-cigarette use, the type of device used, the number of disposable or refill units used per day, the date when e-cigarette use began, the date when the patient quit using e-cigarettes (for former users), if the provider performed counseling for the patient about e-cigarette use, and an open text box to write additional information provided by patients (i.e., brand names of e-cigarettes, user behaviors associated with vaping, etc.). the new e-cigarette section was implemented across the ambulatory clinical practices of the health system on september 27, 2019. during the 30-week evaluation period subsequent to implementation, a total of 1914,353 outpatient visits were completed by 638,804 patients (age ≥ 12 years old) across the health system. of these, the records of 37,906 (6%) patients had information in the new e-cigarette section completed by a clinician. a summary of total responses recorded in the sections is presented in table 1 . of the 37,906 patients with a completed "frequency of use" section, 23,221 (61%) were female. regarding age, 1782 (5%) were less than 18 years old, 3293 (9%) were between 18-25 years old, 10,293 (27%) were between 26-45 years old, 12,151 (32%) were between 46-65 years old, and 10,387 (27%) were more than 65 years old. a total of 666 (1.8%) patients reported current every day use, 339 (0.9%) patients reported current some day use and 941 (2.5%) reported former use of e-cigarettes. the most commonly used type of ethe new e-cigarette section was implemented across the ambulatory clinical practices of the health system on 27 september 2019. during the 30-week evaluation period subsequent to implementation, a total of 1914,353 outpatient visits were completed by 638,804 patients (age ≥ 12 years old) across the health system. of these, the records of 37,906 (6%) patients had information in the new e-cigarette section completed by a clinician. a summary of total responses recorded in the sections is presented in table 1 . of the 37,906 patients with a completed "frequency of use" section, 23,221 (61%) were female. regarding age, 1782 (5%) were less than 18 years old, 3293 (9%) were between 18-25 years old, 10,293 (27%) were between 26-45 years old, 12,151 (32%) were between 46-65 years old, and 10,387 (27%) were more than 65 years old. a total of 666 (1.8%) patients reported current every day use, 339 (0.9%) patients reported current some day use and 941 (2.5%) reported former use of e-cigarettes. the most commonly used type of e-cigarette device was refillable, followed by rechargeable devices and disposable types of devices. the counseling status section was completed for 4391 patient records; 776 (17.6%) patient records indicated counseling on e-cigarette use by clinicians. counseling was provided by clinicians to 355 of 1005 (35.3%) current or some day e-cigarette users, 91 of 941 (9.6%) former e-cigarette users, and 321 of 35,777 (0.9%) never users. there is a growing need for more training, research, and support for clinicians regarding e-cigarette use among patients, given their significant impacts on health [15, 18, 19] . the overall prevalence of reported current e-cigarette use among u.s. adults was reported as 3.2% in 2018, including 7.6% of those 18 to 24 years-old [20] . this overall rate of use is consistent with the rates observed in those patients with information entered in the new section, with 2.6% of patients reporting every day or some day use, and 2.5% reporting former use. prior reports suggest that e-cigarette use information appears to be under-reported in the ehr [11, 12, 14] . studies examining e-cigarette use information in the ehr suggest several deficiencies, including misclassification and inconsistent documentation practices [10, 11, 14] , with the general lack of structured fields in ehrs to document e-cigarette use serving as one potential barrier [21] . on the other hand, by increasing the already considerable provider, the ehr burden could become counterproductive if systems are not carefully designed. the ehr systems undergo frequent upgrades, and clinicians need to quickly adapt to such changes [22] . designing systems to record e-cigarette use is particularly challenging because clinicians may not routinely screen patients for e-cigarette use [23] . the new e-cigarette section is distinct from the documentation of other tobacco products. reasons for this separation include (1) some e-cigarette products do not contain nicotine; (2) clinicians may not realize that e-cigarettes are tobacco products, and (3) a separate section may also serve as a cue for clinicians to systematically record e-cigarette use. previously, clinicians had to record any additional information about e-cigarettes within clinical notes. the new framework still allows limited free text entry by clinicians to enter information as reported by patients. for example, a free text entry from a clinician read "quit when she found out she was pregnant and when coronavirus concerns occurred", suggesting that clinicians can find this feature useful. however, the use of structured data fields facilitates the conduct of digital health surveillance of patients that use these devices, and provides the opportunity to generate clinical and analytical reports that can support research investigations examining the epidemiology, potential risks, and impact of e-cigarette use. the utilization of the new section by the clinical staff was modest (with information entered for only 6% of patients). several factors could have contributed. our implementation effort in terms of educating clinicians was minimal (i.e., a one-time online communication newsletter sent to providers), so many clinicians may not be aware of the new section. the added documentation also increases the clinician burden. although we intended to improve the capture of e-cigarette use information, we transitioned from a single checkbox documentation system to a separate section with six new questions and space for free text entry. adding more documentation fields could impact the clinical workflow and increase the overall ehr documentation burden [24] . possible solutions would be to allow self-entry of medical history by the patients (e.g., allow patients to complete own medical history via online patient portal prior to outpatient appointments), assigning other members of the care team (i.e., patient scheduling team, medical assistants, or rooming staff) to record medical history, and engaging the clinical practice leadership to advocate for systematic ascertainment of e-cigarette use. finally, clinicians may be less likely to complete this section if patients do have a history of e-cigarette use, although the finding that the use rates noted among patients with this section completed are consistent with national data argues against this possibility. clearly additional implementation efforts are indicated to increase the utilization of this new section, and planning for these efforts is underway. one limitation of our work is that we were not able to compare clinician utilization of the new section with the section used in prior documentation (i.e., the single tab in the "tobacco use" section), due to the different procedures used to update each section. future evaluation studies would be necessary to compare different methods of recording e-cigarette use. a separate ehr section to document e-cigarette use is feasible and provides a consistent approach to assess e-cigarette use in both youth and adult populations. this implementation was the first of its kind for epic©, one of the largest ehr vendors in the u.s. this work ultimately contributed to the 2020 epic© foundation build upgrade that optimized the tobacco use history, including a similar separate section to record e-cigarette use information. utilization of the new section was modest in routine clinical practice, indicating the need for more intensive implementation strategies that emphasize the health effects of e-cigarette use, and how consistent ascertainment could improve clinical practice. national center for chronic disease prevention and health promotion (us) office on smoking and health. the health consequences of smoking-50 years of progress: a report of the surgeon general update: interim guidance for health care providers evaluating and caring for patients with suspected e-cigarette, or vaping, product use associated lung injury-united states overview of electronic nicotine delivery systems: a systematic review characteristics of a multistate outbreak of lung injury associated with e-cigarette use, or vaping-united states nicotine without smoke: fighting the tobacco epidemic with harm reduction hospitalizations and deaths associated with evali review of health consequences of electronic cigarettes and the outbreak of electronic cigarette, or vaping, product use-associated lung injury characteristics of persons who report using only nicotine-containing products among interviewed patients with e-cigarette, or vaping, product use-associated lung injury-illinois documentation of e-cigarette use and associations with smoking from 2012 to 2015 in an integrated healthcare delivery system documentation of ends use in the veterans affairs electronic health record investigating the documentation of electronic cigarette use in the veteran affairs electronic health record: a pilot study towards the standardized documentation of e-cigarette use in the electronic health record for population health surveillance and research do you vape? leveraging electronic health records to assess clinician documentation of electronic nicotine delivery system use among adolescents and adults beliefs and self-reported practices of health care professionals regarding electronic nicotine delivery systems: a mixed-methods systematic review and synthesis establishing consensus on survey measures for electronic nicotine and non-nicotine delivery system use: current challenges and considerations for researchers recommended core items to assess e-cigarette use in population-based surveys the knowledge, concerns and healthcare practices among physicians regarding electronic cigarettes e-cigarettes and the clinical encounter: physician perspectives on e-cigarette safety, effectiveness, and patient educational needs tobacco product use and cessation indicators among adults-united states exploring physician attitudes regarding electronic documentation of e-cigarette use: a qualitative study a qualitative study of physician perspectives on adaptation to electronic health records discussions between health professionals and smokers about nicotine vaping products: results from the 2016 itc four country smoking and vaping survey physician stress and burnout the authors declare no conflict of interest. key: cord-303203-1kpw4ru0 authors: guo, jing; feng, xing lin; wang, xiao hua; van ijzendoorn, marinus h. title: coping with covid-19: exposure to covid-19 and negative impact on livelihood predict elevated mental health problems in chinese adults date: 2020-05-29 journal: int j environ res public health doi: 10.3390/ijerph17113857 sha: doc_id: 303203 cord_uid: 1kpw4ru0 the covid-19 pandemic might lead to more mental health problems. however, few studies have examined sleep problems, depression, and posttraumatic symptoms among the general adult population during the covid-19 outbreak, and little is known about coping behaviors. this survey was conducted online in china from february 1st to february 10th, 2020. quota sampling was used to recruit 2993 chinese citizens aged ≥18 years old. mental health problems were assessed with the post-traumatic stress disorders (ptsd) checklist for the diagnostic and statistical manual of mental disorders, fifth edition (dsm-5), the center for epidemiological studies depression inventory, and the pittsburgh sleep quality index. exposure to covid-19 was measured with questions about residence at outbreak, personal exposure, media exposure, and impact on livelihood. general coping style was measured by the brief coping style questionnaire (scsq). respondents were also asked 12 additional questions about covid-19 specific coping behaviors. direct exposure to covid-19 instead of the specific location of (temporary) residence within or outside the epicenter (wuhan) of the pandemic seems important (standardized beta: 0.05, 95% confidence interval (ci): 0.02–0.09). less mental health problems were also associated with less intense exposure through the media (standardized beta: −0.07, 95% ci: −0.10–−0.03). perceived negative impact of the pandemic on livelihood showed a large effect size in predicting mental health problems (standardized beta: 0.15, 95% ci: 0.10–0.19). more use of cognitive and prosocial coping behaviors were associated with less mental health problems (standardized beta: −0.30, 95% ci: −0.34–−0.27). our study suggests that the mental health consequences of the lockdown impact on livelihood should not be underestimated. building on cognitive coping behaviors reappraisal or cognitive behavioral treatments may be most promising. the covid-19 pandemic not only affects physical health, it might also lead to elevated levels of mental health problems such as sleep problems, depressive issues, and posttraumatic stress symptoms [1, 2] . the pandemic is, however, a multifaceted and complex type of exposure. living in the epicenter of the outbreak or having travelled to that center might make a difference in the way the the survey was conducted online from 1-10 february 2020, and the questionnaires were distributed and retrieved through a web-based platform (https://www.wjx.cn/app/survey.aspx). quota sampling was used to recruit participants. chinese citizens aged ≥ 18 years old were invited to participate. in total, 2993 participants from 31 provinces in china responded to the survey; 552 students were excluded because of their special status, which resulted in a final n = 2441 adults. to reach more subjects with high exposure to covid-19 and from somewhat lower social economic strata, we targeted recruitment to six groups that might otherwise have remained underrepresented, namely medical workers, service staff, social service workers, (school and college) teachers, blue-collar workers and farmers, and unemployed individuals and others. the convenience sampling was conducted as followed. first, several key contact persons in these specific groups were selected, for example a chief nurse, class tutor, or company manager. second, the key contact persons helped us distribute the questionnaires to the subjects through their wechat group (a very popular chinese online communication tool). third, the subjects in each wechat group were asked to send our questionnaire web link to their friends. this way data were collected from medical workers (n = 421, 14.7%), service staff (n = 259, 9.1%), social service workers (n = 230, 8.0%), (school and college) teachers (n = 648, 22.7%), blue-collar workers and farmers (n = 388, 13.6%), unemployed individuals and others (n = 488, 17.1%). almost 48% of the respondents were male, and 90.3% of the subjects were between 18-50 years old. more than half of the sample completed at least undergraduate studies, and more than 70% were married. the large majority had a middle to high income and 39% worked in the formal labor market. there were some differences between the participants within wuhan, in sub-wuhan, and outside wuhan (for details, see table 1 ). all participants gave consent after being informed about the aim of the survey and joined the study voluntarily. the study was approved by the ethics committee of peking university medical center. depressive symptoms were assessed with the 20-item center for epidemiological studies depression scale (cesd), which has been widely used to measure depression in the general population [11] . previous studies demonstrated that this scale has adequate reliability and validity among chinese respondents [12, 13] . respondents reported the frequency of each type of symptom on a 4-point scale: 0 (rarely or never; less than 1 day), 1 (some of the time; 1-2 days), 2 (a moderate amount of the time; 3-4 days), or 3 (most or all of the time; 5-7 days). the total score ranges from 0 to 60, with a higher score indicating a higher level of depressive symptoms. in this study the cronbach's alpha was 0.93. with a cut-off point at 21 [14] , respondents were divided into two categories, "depressed" or "not depressed". post-traumatic stress symptoms (ptss) ptss were assessed with the self-report post-traumatic stress symptoms disorders (ptsd ) checklist for the diagnostic and statistical manual of mental disorders, fifth edition (dsm-5), estimating the degree to which individuals had been struggling with dsm-5-related ptss symptoms in the past month [15] . respondents answered the 20 items on a 4-point rating scale from 0 (not at all) to 4 (extremely). items were summed for a total score ranging from 0 to 80, with higher scores indicating higher level of ptss. cronbach's alpha was 0.97. the 20 items were clustered in the following areas: intrusions, avoidance, negative alterations in mood and cognitions, and alterations in reactivity and arousal. the diagnostic criteria of dsm-5 require at least one "intrusion" symptom, one "avoidance" symptom, two "negative alterations in mood and cognitions" symptoms and two "alterations in reactivity and arousal" symptoms, all rated 2 or higher. sleep problems were assessed using the pittsburgh sleep quality index (psqi) [16] . the psqi consists of 19 items rated from 0 to 3 including estimation of sleep latency, duration, disturbances, and the severity and frequency of other sleep problems. the total psqi score ranges from 0 to 21 with higher scores indicating worse sleep quality. cronbach's alpha was 0.86. with a cut-off point at 7 [17] , respondents were divided into two categories, struggling with "insomnia" or "no insomnia". because of the high correlations between the scales for depression, ptss, and insomnia, ranging from r = 0.39-0.75, we decided to compute a principal component analysis. a strong first component emerged, with loadings >0.69. the aggregated scale for mental health problems was the sum of scales for ptss, depressive symptoms, and sleep problems. the question about wuhan exposure concerned living in or having travelled to wuhan, with "1" referring to living in or having had a wuhan travel history, or "0" referring to no wuhan residence or travel history. also, two questions were asked about living near wuhan city, and not living in the vicinity of wuhan city, with yes or no as possible answers. exposure to the covid-19 pandemic through watching or using the media was answered on a 4-point rating scale for frequency: very frequent, often, some, no exposure). direct exposure to covid-19 was assessed with a question about possibly having suffered or suffering from covid-19, or someone in the family, or neighborhood or among friends, with "1" for covid-19 of self, a member of the family, a friend, someone in the neighborhood, and "0" referring to no exposure). the respondents were asked to estimate the impact of the pandemic on their livelihood, with four response alternatives (none, some, relatively large, very large impact). it was measured by the simplified coping style questionnaire (scsq), developed in china [18] . the scsq is a self-report scale which comprises of 20 items with a 5-point rating scale, ranging from 1 (not used) to 5 (used a great deal). the scsq consists of two subscales: problem-focused coping and emotion-focused coping. the problem-focused coping category includes twelve items that describe positive cognitive and behavioral strategies to manage distress. the emotion-focused coping category includes eight items that describe negative cognitions and avoiding behavioral activities to manage the problem. this inventory has good internal and test-retest reliability. in the present study, cronbach's alpha of the total scale was 0.89 and that for problem-focused coping and emotion-focused coping were 0.85 and 0.93, respectively. respondents were asked how they were coping with covid-19. the questions concerned 12 specific coping behaviors, including "tell myself that everything will be better soon", "reading and watching tv", "getting more knowledge about covid-19", "wearing a mask when going outside", "staying home and following the social distancing rule", "disinfecting and deep cleaning", "crying, being angry, and yelling", "drinking", "smoking", "praying", "taking more medicine", and "taking one's temperature". the respondents were asked to rate the behaviors from 1 (not used) to 5 (used a great deal). the following covariates were measured. demographic variables included ethnicity (han, else), marriage (having no spouse, having a spouse), education (junior high school and below, high school/technical school, junior college, undergraduate, postgraduate and above), and income (low, middle, or high income). job descriptions included the seven categories mentioned above and categorized into jobs in the formal versus informal sector. following previous studies [19, 20] , health-related variables included questions pertaining to prior mental health problems (yes, no), and occurrence of two-week illnesses (yes, no), and prior exposure to potential trauma (experience of a traumatic event in the last year (yes, no)). the main analyses consisted of multiple regressions on the aggregate outcome of mental health problems in four steps, and in each step the same covariates were used: age, gender, educational level, formal or informal job, married, income, past illness, prior exposure, prior mental health problems. in model 0 each of the predictors were included separately to estimate their 'raw' contribution to the prediction of mental health problems, controlling for the covariates. in model 1 the three predictors of (potential) exposure (location, media, direct exposure) were included to examine which component would be the most powerful predictor. in model 2 the perceived impact on livelihood was added, and finally, in model 3 emotion-focused and problem-focused coping behaviors were included to explore how much variance coping would predict in mental health problems. the standardized beta's can be compared across models and predictors, lower and upper 95% confidence intervals (cis) were computed as well as the p-values. in the next series of logistic regression analyses, the odds and their 95% ci and p-values for the predictors of the three components of mental health problems were computed, again with the same four models. the components ptss, depression, and insomnia were dichotomized to differentiate between clinical and nonclinical cases. in a final set of analyses regressions with the 12 coping behaviors as predictors of mental health problems were conducted, controlling for the same set of covariates used in the previous regressions. the software for statistics and data science (stata) version 14.0 (statacorp., college station, tx, usa) was used to carry out all analyses. in table 2 the results of the multiple regressions on the aggregate outcome of mental health problems are presented. the largest variance in mental health problems was explained by coping behaviors, with more use of problem-focused coping behaviors predicting less problems (effect size beta = −0.31), and more use of emotion-focused coping behaviors predicting more problems (effect size beta = 0.50). furthermore, an important predictor was the perceived impact on livelihood. larger impacts were associated with more mental health problems and the standardized beta for the respondents feeling the largest impact amounted to a standardized beta of 0.21. finally, direct or indirect exposure to covid-19 through location, media, or infected cases predicted statistically significant variance in mental health problems, with wuhan location, very frequent media exposure, and actual direct exposure to the virus predicting elevated levels of mental health problems. standardized beta's ranged from 0.03 to 0.09 (positive or negative), thus considerably smaller effect sizes compared to those found for impact on livelihood or coping. a sensitivity analysis was conducted including formal versus informal job as a predictor of mental health problems instead of its role as a covariate but the beta in model 3 was a negligible 0.00 (95% ci: −0.04-0.03). for predicting ptss the models showed that exposure through location, media, or direct contact was less important than the impact on livelihood and coping behaviors. more impact on livelihood and more emotion-focused coping were associated with higher risk of clinical ptss levels, whereas problem-focused coping reduced this risk (see table 3 ). this was similar for the prediction of risk for depression, but living in the neighborhood of wuhan instead of within the city of wuhan lowered the risk for depression (odds = 0.50), whereas direct exposure added predictive value by elevating the risk of becoming clinically depressed (odds = 1.39, see table 4 ). direct exposure also was associated with elevated risk of insomnia (odds = 1.70, see table 5 ). the models with more predictors included in the same regressions did not make much of a difference compared to model 0 with only one predictor at a time included (and the covariates of course). only in model 3 in which coping was included in the last step the negative beta for living in the neighborhood of wuhan but not in wuhan itself was not statistically significant anymore (beta = −0.04). very frequent media exposure and direct exposure to covid-19 kept predicting elevated levels of mental health problems. the large effect sizes for impact on livelihood and coping attenuated only slightly from model 0 to model 3, and they were still substantial, in particular problem-focused and emotion-focused coping style. in figure 1 the practical coping behaviors are presented. more emotion-focused coping behaviors such as "crying, being angry, and yelling", "drinking", or "smoking" seemed to be associated with largest risk for mental health problems but more frequently "praying", "taking more medicine", or "taking one's temperature" also elevated this risk albeit to a somewhat lesser extent. most helpful in decreasing the risk for mental health problems were coping behaviors such as "telling myself that everything will be better soon", "getting more knowledge about covid-19", and "staying home and following the social distancing rule". to a somewhat lesser extent it seemed also to help when coping with "reading and watching tv", "wearing a mask when going outside", and "disinfecting and deep cleaning" were used (see figure 1a) . a similar picture emerged or the association between coping behaviors and ptss, depression, and insomnia separately (see figure 1bfigure 1 . the relationship between coping behavior and post-traumatic stress symptoms (ptss), depression, insomnia, mental health problems. (a) coping and ptss, (b) coping and depression, (c) coping and insomnia, and (d) coping and mental health score. notes: v1 refers to "tell myself that everything will be better soon", v2 refers to "reading and watching tv", v3 refers to "getting more knowledge about covid-19", v4 refers to "wearing a mask when going outside", v5 refers to "staying home and following the social distancing rule", v6 refers to "disinfecting and deep cleaning", v7 refers to "crying, being angry, and yelling", v8 refers to "drinking", v9 refers to "smoking", v10 refers to "praying", v11 refers to "taking more medicine", and v12 refers to "taking one's temperature". these 12 items were asked in a random order in the questionnaire. all confounding variables were controlled in above models. or, odds ratio. ci confidence interval. coping and depression, (c) coping and insomnia, and (d) coping and mental health score. notes: v1 refers to "tell myself that everything will be better soon", v2 refers to "reading and watching tv", v3 refers to "getting more knowledge about covid-19", v4 refers to "wearing a mask when going outside", v5 refers to "staying home and following the social distancing rule", v6 refers to "disinfecting and deep cleaning", v7 refers to "crying, being angry, and yelling", v8 refers to "drinking", v9 refers to "smoking", v10 refers to "praying", v11 refers to "taking more medicine", and v12 refers to "taking one's temperature". these 12 items were asked in a random order in the questionnaire. all confounding variables were controlled in above models. or, odds ratio. ci confidence interval. our main findings point at the significant role of direct exposure to covid-19 instead of the specific location of (temporary) residence within or outside the epicenter of the pandemic. increased mental health problems were also associated with more intense exposure through the media. most importantly, in our relatively highly educated and predominantly lower to upper 'middle-class' participants the perceived negative impact on livelihood showed the largest effect size in predicting the level of mental health problems. we also examined the effect of coping style and coping behaviors against covid-19 and found that a problem-focused coping style and positive cognitions and prosocial coping behaviors predicted reduced mental health problems. compared to wuhan, we found a lower mental health level among sub-wuhan participants. however, this difference disappeared after adjusting for coping. previous studies on earthquake survivors and on 9/11 world trade center survivors showed that participants who were living closer to the epicenter showed increased mental health issues [21, 22] . our study provides somewhat contrasting evidence for the covid-19 affected population. direct exposure, perceived impact on livelihood, and how one was coping with the pandemic seemed more important than the specific location of (temporary) residence within or outside the epicenter (wuhan) of the pandemic. for specific mental health problems some different associations were found. direct exposure to covid-19 elevated the risk for depression and insomnia but not for clinical ptss, for which the perceived impact on livelihood seemed more important. impact on livelihood was also associated with depression but not with insomnia. direct exposure to covid-19 involves higher risks for infection and severe respiratory illness, leading to more mental disorders [23] , but it is unclear why only the risks of clinical depression and insomnia but not ptss appeared to be elevated. for ptss the threat of poverty and the deterioration of economic conditions due to the outbreak seem more important. this threat to livelihood reduces social resources such as access to medical care, education, employment, and well-being for the individual and his or her family, which may cause even greater harm to mental health than the epidemic itself [24] . our findings demonstrate that coping styles are associated with mental health problems due to covid-19. a problem-focused coping style seems to relieve individuals' post-traumatic stress, depression, and insomnia symptoms, and the emotion-focused coping style seems to exacerbate mental health symptoms [25] . problem-focused coping is a positive strategy that entails some active methods such as finding out several different ways to solve the problem or seeking advices from relatives or friends. emotion-focused coping tends to emphasize passivity and powerlessness, which enhances anxious and depressed feelings. in line with positive effects of problem-focused coping, we found that practical behaviors such as emphasizing positive cognitions [26] and getting more information about the virus indeed were associated with less mental health problems. in a previous study, positive cognitions about the severe acute respiratory syndrome (sars) outbreak were shown to result in less psychological disorders [27] . it also seemed to help when participants tried to cope by following the (pro-)social distancing and hygienic rules. a recent study indicated that personal psychoneuroimmunity prevention measures such as the frequent practice of hand hygiene and wearing face masks could decrease the likelihood that individuals would experience psychiatric symptoms [28] . through knowledge acquisition and hygienic behaviors individuals actively try to alleviate their fear of uncertainty about the future. some implications may follow from these findings. first and foremost, the mental health consequences of the expectation of a large negative impact on livelihood should not be underestimated. regardless of location or exposure the economic threats of the pandemic seem to leave a rather strong imprint on mental health. as a worldwide recession has been predicted to follow the current pandemic [29] , our findings foreshadow indeed 'a crashing wave' not only of immune-system related neuropsychiatric disorders [30] , but also of a wide array of stress-related depressive symptomatology without a direct link to deficits of the immune system. the most effective coping behaviors are pointing at cognition and might suggest the potentially promising role of reappraisal interventions [31] or cognitive behavioral treatments [32] in fighting the negative mental health consequences of the pandemic. also, the positive role of following the rules of social distancing and hygiene may suggest the importance of active, prosocial involvement in the containment or slowing down of the virus infection also for coping with the mental burden of the pandemic. it may induce a collective feeling of empowerment and some control over an otherwise overwhelmingly stressful experience [33] . some limitations of this study should be mentioned. first, although it is tempting to interpret our findings causally it should be noted that the cross-sectional design without experimental manipulation does not allow for causal conclusions. it is difficult, however, to see how exposure to covid-19 might be the effect instead of the cause of elevated mental health problems, controlling for pre-existing problems. nevertheless, the associations with perceived impact on livelihood and with coping behaviors might be (partly) caused by elevated mental health problems, and longitudinal or quasi-experimental studies may throw some light on the causal direction [34] . second, because we used an internet survey in a large sample it was not possible to include a long series of scales, questions, and items. we relied for example on a simple but clear-cut question about the respondents' feelings about the impact of the pandemic on their livelihood and we want to emphasize the need for further research on this issue with more elaborated measures. our findings certainly demonstrate that this is a fruitful path to follow in the near future. third, generalizability of the results might be restricted in time, geography and sociocultural context. our data were collected at the beginning of february 2020, a moment in time where the true nature of the pandemic seemed not yet clear to the general public worldwide or even to the experts. furthermore, the study was conducted in various parts of china but surely did not have worldwide coverage and thus its findings might be (partly) specific to this geographic environment. lastly, we recruited a chinese convenience sample for which the nonresponse rate could not be established because of anonymity requirements and in which poor participants from rural areas without internet connections were underrepresented. this underrepresentation of poor participants might have led to an underestimate of the mental health consequences of worries about livelihood issues during and after the lockdown. the covid-19 outbreak in wuhan was followed by a worldwide pandemic and unprecedented lockdown of many large cities and entire countries. here we reported on the early mental health sequelae (in the first few weeks of february 2020) of the outbreak in the city wuhan, the province of hubei and other provinces in china. we found that direct exposure to covid-19 and the impact on livelihood are important predictors of mental health problems, and that people found cognitive and prosocial ways to cope with the strains and stresses of the lockdown. we hope that our findings will contribute to the lessons to be learnt about the mental health correlates and consequences of such a pandemic and radical lockdown. mental health and the covid-19 pandemic multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science mental health problems and social media exposure during covid-19 outbreak coping as a mediator of emotion pandemic influenza and community preparedness immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china covid-19 and 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the pittsburgh sleep quality index reliablility and validity of the chinese version of coping style scale. chin the sars (severe acute respiratory syndrome) pandemic in hong kong: effects on the subjective wellbeing of elderly and younger people risk factors for chronic post-traumatic stress disorder (ptsd) in sars survivors association between prenatal exposure to the haiti 2010 earthquake, consequent maternal ptsd and autistic symptoms in offspring substance use in adolescents 10 years after the world trade center attacks in new york city causal inference using different phenotypic traits related to trauma exposure, trauma response, and posttraumatic stress disorder social relationships and the sense of self: the consequences of an improved financial situation for persons suffering from serious mental illness. community ment dementia caregivers' coping strategies and their relationship to health and well-being: the cache county study an emotion and a vital coping resource against despair zhang, z. behavioural, cognitive and emotional responses to sars: differences between college students in beijing and suzhou is returning to work during the covid-19 pandemic stressful? a study on immediate mental health status and psychoneuroimmunity prevention measures of chinese workforce how the covid-19 recession is like world war ii? bloomberg opinion are we facing a crashing wave of neuropsychiatric sequelae of covid-19? neuropsychiatric symptoms and potential immunologic mechanisms the efficacy of stress reappraisal interventions on stress responsivity: a metaanalysis and systematic review of existing evidence the efficacy of cognitive behavioral therapy: a review of metaanalyses acute stressors and cortisol responses: a theoretical integration and synthesis of laboratory research longitudinal study on the mental health of general population during the covid-19 epidemic in china acknowledgments: we thank all the participants for their collaboration. the authors declare no conflict of interest. int. j. environ. res. public health 2020, 17, 3857 key: cord-327300-dvlb61tw authors: abu, thelma zulfawu; elliott, susan j. title: when it is not measured, how then will it be planned for? wash a critical indicator for universal health coverage in kenya date: 2020-08-08 journal: int j environ res public health doi: 10.3390/ijerph17165746 sha: doc_id: 327300 cord_uid: dvlb61tw the quality and safety of healthcare facility (hcf) services are critical to achieving universal health coverage (uhc) and yet the who/unicef joint monitoring program for water supply, sanitation and hygiene report indicates that only 51% and 23% of hcf in sub-saharan africa have basic access to water and sanitation, respectively. global commitments on improving access to water, sanitation, hygiene, waste management and environmental cleaning (wash) in hcf as part of implementing uhc have surged since 2015. guided by political ecology of health theory, we explored the country level commitment to ensuring access to wash in hcfs as part of piloting uhc in kisumu, kenya. through content analysis, 17 relevant policy documents were systematically reviewed using nvivo. none of the national documents mentioned all the component of wash in healthcare facilities. furthermore, these wash components are not measured as part of the universal health coverage pilot. comprehensively incorporating wash measurement and monitoring in hcfs in the context of uhc policies creates a foundation for achieving sdg 6. accessing quality health services is a challenge, especially in the global south. lack of access to water, sanitation, hygiene, waste management and environment cleaning (wash) undermine the quality of services provided in healthcare facilities [1, 2] . the absence or inadequacy of safe wash in healthcare facilities compromises infection prevention and control, patient safety and child and maternal health [3] . meanwhile, the who/unicef joint monitoring program for water supply, sanitation and hygiene reported that in sub-saharan africa (ssa), only 51 percent of healthcare facilities have access to basic water services and 23 percent have access to basic sanitation services. forty-one percent of healthcare facilities have basic waste management services. data on hygiene and environmental cleaning in healthcare facilities were inconclusive due to inadequate monitoring [1] . similarly, cronk and bartram [2] evaluated the environmental conditions of healthcare facilities in 78 low-and middle-income countries (lmics) and found that only two percent of the healthcare facilities provided water, sanitation, hygiene and waste management services. also, ensuring access to wash in healthcare facilities extends beyond disease control to issues of dignity and respect. for example, women after childbirth in healthcare facilities require a clean bathroom with running water to maintain their personal hygiene. kohler, renggli, & lüthi [4] in a comparative study in india and uganda sought to address the gender gap in access to wash in healthcare facilities. they undertook a needs assessment in hygiene and sanitation issues during menstruation and childbirth among women in selected maternal ward and inpatient facilities which were run by government. wash in healthcare facilities were assessed based on hygiene and health, security and safety, privacy, accessibility, comfort and menstrual hygiene management. from their study, lack of safe wash infrastructure and menstrual hygiene facilities were a burden for women in both countries. in addition, gon et al. in 2016 engaged in a study to investigate the status of water and sanitation in relation to childbirth in healthcare facilities and homes. from their study, less than 50 percent of all delivery facilities and homes had access to wash in all countries [5] . for example, in kenya, 18 percent of women delivered with improved access to water and sanitation. furthermore, climate change and variability and conflicts burden the functioning of wash in healthcare facilities. first, 90 percent of disasters in ssa, especially the horn of africa, are water-related [6] . prolonged drought and floods have affected the quantity and quality of water available [7, 8] . second, displaced people face wash related challenges and these events increase health risks and disease outbreaks such as cholera [9, 10] . prior global commitments on ensuring access to wash were concentrated at the household level to the neglect of institutions. the widespread effects of ebola in 2014 even in healthcare facilities leading to the loss of several healthcare workers [11] [12] [13] and the subsequent world health organization assessment on wash in healthcare facilities in 2015 initiated discussions and led to several global commitments to address this challenge of infection prevention and control in healthcare facilities. at the global stage currently, significant efforts towards ensuring access to wash have included and prioritized public spaces such as healthcare facilities. this is included in the sustainable development goals (sdg). goal 6 seeks to ensure access to water and sanitation. targets 6.1 and 6.2 of the sdgs highlight the need to expand wash monitoring by relevant stakeholders in non-household settings, such as healthcare facilities. similarly, goal 3 seeks to ensure healthy lives and promote wellbeing for all at all ages. target 3.8 highlights achieving universal health coverage which does not just incorporate reducing the financial burden of people, but further ensuring quality essential healthcare services for all. similarly, in 2015, world leaders adopted the sendai framework for disaster risk reduction (drr) and one of its targets is to substantially reduce disaster damage to critical infrastructure and disruption of basic services, among them health facilities through developing their resilience by 2030 [14] . this framework was a paradigm shift from managing disasters to disaster risk reduction. achieving this target means ensuring the effectiveness and efficiency of all the components of a health system, including wash. in march 2018, as part of the launch of international decade for action "water for sustainable development 2018-2028", the un secretary general also made a global call to action for wash in all healthcare facilities [15] . in response, various ministers of state signed the world health assembly resolution on wash in healthcare facilities as part of the implementation of universal health coverage scheme. in addition, various assessment tools, healthcare facility guidelines and frameworks on wash were published by the global community especially world health organization. however, it is evident from research that socially and institutionally driven challenges such as lack of data and knowledge are major hindrances to improved service provision such as healthcare in ssa [10, 16, 17] . for instance, adjei, sambu & smiley [18] explored historical and emerging policies and institutional arrangements surrounding urban water supply in sub-saharan africa. the persistent lack of water in urban areas was attributed to weak institutional arrangements and poor enforcement of legislations. the authors recommended the need for institutional rectification to achieve the sustainable development goals by 2030. similarly, maina et al. [3] in their study on the role of wash on antimicrobial resistance in healthcare facilities in kenya highlighted the need for government institutional support for healthcare managers to enable them achieve access to basic wash in healthcare facilities. it is evident from research that the availability and enforcement of regulations such as policies and legislations on an agenda enhance their achievement [19] . guo & bartram [20] in their investigation on the predictors for water quality in rural healthcare facilities concluded that the presence of a protocol for operation and management in a facility was associated with safe water use. following this, there is little research to understand the implementation process or the institutional arrangements of wash in healthcare facilities and the influence of global commitments on country level policy environment on ensuring access to wash in health facilities in ssa. therefore, this paper reviews the framing of wash in healthcare facilities in relevant global and country-level institutional documents (policies, legislations, guides, plans and monitoring tools) using kenya as a case study. following the introduction, the second section explores the theoretical framing of this paper, the political ecology of health theory. the third section explores the study context, kenya. the fourth section indicates the methods of data collection and analyses. the presentation of the results and discussion make up the fifth and sixth sections, respectively. the seventh section concludes the paper with a summary of the key points and emphasizing the relevance of wash in healthcare facilities to sdg 3 and sdg 6. social theories provide a more comprehensive connection between determinants and processes of health and wellbeing [21] [22] [23] . the paper is guided by political ecology of health theory, which explores how power, politics, structures, agendas and/or agents shape the environment and health risks of populations [24, 25] . this theory further explores how growing discourse on health at the global scale influence and shape local contexts such as policies development and implementation. the prioritization, implementation and management of wash interventions are political and power-laden at the global, national and local levels [26] . this theory has been useful in the study of prioritization and implementation of development projects and health and wellbeing of local populations [27] [28] [29] . it has also guided studies in healthcare services in lmics [24] and privatization of water and its impacts on health and wellbeing [30] . kenya is an east african country with an estimated population of about 48 million [31] . the country has 47 counties. according to the kenyan health policy 2012-2030, kenya has an agenda to implement universal health coverage and achieve countrywide coverage by 2022. in 2018, the universal health coverage scheme was launched and currently piloted in four counties, kisumu, isiolo, machakos and nyeri. a policy brief written by wangia & kandie [32] and published by the ministry of health with a focus on quality of care and essential elements in attaining universal health coverage in kenya indicated the need for appropriate water and sanitation infrastructure in healthcare facilities. according to the who/unicef joint monitoring program for water supply, sanitation and hygiene report based on 2016 data, only 65% of healthcare facilities in kenya had access to basic water services. this served a population of 31, 784, 828 people. healthcare facilities with limited and no water services were 17.6 percent and 16.8 percent, respectively. concerning sanitation in healthcare facilities, monitoring and data collection was inadequate. eighty-six percent of healthcare facilities had insufficient data and 14 percent of healthcare facilities recorded no sanitation services. regarding hygiene, insufficient data for 99.6 percent of healthcare facilities was recorded. in addition, 0.4 percent of the healthcare facilities recorded no hygiene services. only 33.1 percent of healthcare facilities recorded basic waste management services, 62.1 percent recorded limited services and 4.8 percent reported no waste management services. for environmental cleaning in healthcare facilities data were insufficient for comprehensive and conclusive analysis. from these data it is evident that access, regular monitoring and evaluation of wash in healthcare facilities are major challenges. other researchers such as bennett, otieno, ayers, & odhiambo [33] , essendi et al. [34] and maina et al. [3] have reported lack of wash in healthcare facilities in kenya in their studies. in addition, at the community level, residents questioned the quality of healthcare delivery in hospitals without the appropriate wash infrastructure [35, 36] . according to wangia & kandie [32] , quality care is not yet a legal requirement and issues such as poor enforcement of legislation and minimal information on quality of care especially in private facilities will negatively impact achieving universal health coverage. other key challenge to accessing wash in healthcare facilities are climate variability and civil disruptions. the amount of rainfall affects the quantity and quality of water available for use in most marginalized communities. the struggle to access safe water is worsened in the face of climate variability. floods from torrential rains and effects of drought from prolonged dry seasons have displaced many citizens, especially in rural and marginalized areas. as of september 2017, about 5.6 million kenyan citizens were in need due to several episodes of drought [9] . kenya has also recorded an increasing influx of migrants from neighboring countries greatly affected by drought. these people are further exposed to health hazards subsequently increase attendance at healthcare facilities. kenya has a partial plan to support ensuring access to wash in health care facilities [10] . despite progress and new initiatives, more needs to be done to understand and solve the challenge of lack of wash in healthcare facilities. qualitative content analysis was used to analyze the framing of wash in healthcare facilities in relevant documents for this paper. relevant wash in healthcare facility documents such as policies, legislations, guidelines, plans and monitoring tools were gathered for this research from may 2019 to june 2020. documents included in this research were accessed using two methods. first, desktop searches were conducted to identify and access current and operational wash in healthcare facility documents. desktop searches on key phrases like "wash in healthcare facilities", "quality care" and "universal health coverage" were done using google and google scholar. the websites of the ministry of health, kenya, world health organization, who/unicef joint monitoring program for water supply, sanitation and hygiene as well as the official website for wash in healthcare facilities were searched for relevant documents. second, the ministry of health, kisumu county office, kenya was contacted in person by researchers from june 2019-september 2019 for relevant documents on wash in healthcare facilities. current operational documents guiding the implementation and monitoring of wash in healthcare facilities, quality healthcare and the piloted universal health coverage as of september 2019 were sought at the ministry. documents included in this study were based on three criteria after been carefully screened. first documents comprehensively indicated wash in healthcare facilities or/and health care (quality care and universal health coverage) as their focus. second, current and operational national documents with an agenda on wash in healthcare facilities, quality care in healthcare facilities and universal health coverage were also considered. third, document was listed by relevant key stakeholders identified and interviewed at the ministry of health, kisumu county office. the documents included in this study were published from 2007 to 2019. documents prior to 2015 when the upsurge in campaigns for wash in hcfs and uhc were included because they set the foundation for drafting current wash in hcf guidelines and policies. table 1 shows a list of relevant documents included in this research. first, the documents were categorized based on scale-global and national. second, based on the purpose of the document-legislation, policy, guidelines, monitoring tool and plans. in total, 17 documents were included, five (5) global level documents and eight (12) national level documents regulating issues of wash in healthcare facilities. two of the twelve national documents are county level documents. kenya has a decentralized government system and the counties have the power to contextualize national policies or develop policies that meet their needs. a coding frame (table 2 ) was developed to guide the coding process. the frame was guided by the logic framework (input, activities, output and impact), heuristic framework (agenda setting, formulation, implementation and evaluation) [37] and policy triangle (grounded in a political economy perspective and considers actors, context, process and content shape policymaking) [38] . the authors adapted the washfit conceptual framework [39, 40] . it is a framework designed to help implementers identify risks in healthcare facilities and it provides practical tools and templates for managing wash and facilities. themes developed for coding were first guided by the water-health nexus. cook & bakker [41] define water security as "sustainable access on a watershed basis to adequate quantities of water, of acceptable quality, to ensure human and ecosystem health". this definition embodies two sdgs, sdg 3-good health and wellbeing, of particular interest to this research is target 3.8 (achieve universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all) and sdg 6, clean water and sanitation for all. in addition, the key components of wash-water, sanitation, hygiene, waste management and environmental cleaning were adapted from the who/unicef joint monitoring program for water supply, sanitation and hygiene. key indicators for monitoring wash in healthcare facilities and categorized as improved, basic, limited and no service [1] . guided by this coding frame, a coding schedule (tables 3-5) was developed for coding. content analysis was done deductively using nvivo 12. key phrases like wash in healthcare facilities, universal health coverage, wash in healthcare facility stakeholders and quality care were coded. this research explored the framing of wash in healthcare facilities in relevant global and national policies, guidelines, monitoring tools and legislations. from the content analysis, five (5) global documents comprehensively mentioned wash in healthcare facilities. two national level documents mentioned water, sanitation and hygiene in phrases or sentences while environmental cleaning and waste management were excluded. "the core indicators define "basic" service levels for water, sanitation, hygiene, health care waste management and environmental cleaning in health care facilities" (core questions and indicators for monitoring wash in health care facilities in the sustainable development goals) the need to ensuring access to water, sanitation and hygiene in health care facilities was mentioned: "ensure that all new health facilities are appropriately designed and constructed with reliable water supply and environmental sanitation and hygiene facilities, including toilet and hand-washing facilities, taking into account gender, age and disability considerations" (kenya environmental sanitation and hygiene policy 2016-2030). "facility design and planning should ensure the following: adequate supply of safe water, adequate floor space for beds, adequate space between beds, adequate hand-washing facilities, adequate sanitary facilities" (national infection prevention and control guidelines for health care services in kenya, 2010). the global documents serve as a guide for national wash in healthcare facility implementation. they also specify the core areas of wash in healthcare facilities that need facility managers and implementers attention: "to develop and implement a road map according to national context so that every healthcare facility in every setting has, commensurate with its needs: safely managed and reliable water supplies; sufficient, safely managed and accessible toilets or latrines for patients, caregivers and staff of all sexes, ages and abilities; appropriate core components of infection prevention and control programmes, including good hand hygiene infrastructure and practices; routine, effective cleaning; safe waste management systems, including those for excreta and medical waste disposal; and, whenever possible, sustainable and clean energy" (a72_r7 wash in healthcare facilities resolutions). the global wash in healthcare facilities documents also set a monitoring standard for countries given in-country monitoring indicators on wash in healthcare facilities are often not comprehensive: "in support of sdg monitoring and to allow for comparable data to be generated within and between countries, a core set of harmonized indicators and questions that address basic wash services in health care facilities that will be applicable in all contexts is needed" (core questions for monitoring wash in healthcare facilities in the sustainable development goals). the individual components of wash were highlighted in the documents assessed. the various components are outlined below. recommended water sources for healthcare facilities include piped water, boreholes or tube wells, protected dug wells, protected springs, rainwater and packaged or delivered water. the theme water in healthcare facilities was mentioned in nine (9) documents of which four were national documents. some documents highlighted the need for water in healthcare facilities: "sufficient water-collection points and water-use facilities are available in the health center to allow convenient access to, and use of, water for drinking, food preparation, personal hygiene, medical activities, laundry and cleaning" (essential environmental health standards in healthcare). the types of water systems in healthcare facilities were also mentioned in some documents: "improved water sources in healthcare settings include piped water, boreholes/tube wells, protected wells, protected springs, rainwater and packaged or delivered water" (washfit, a practical guide for improving quality of care through wash in hcfs). at the national level, the water act mentions the provision of water in healthcare facilities: "nothing in this section prohibits-(a) the provision of water services by a person to his employees; or (b) the provision of water services on the premises of any hospital, factory, school, hotel, brewery, research station or institution to the occupants thereof, in cases where the source of supply of the water is lawfully under its control or where the water is supplied to it in bulk by a licensee" (water act cap 372). recommended sanitation infrastructure includes flush/pour flush to piped sewer system, septic tanks or pit latrines; ventilated improved pit latrines, composting toilets or pit latrines with slabs. sanitation in healthcare facilities was highlighted in five (5) global documents and three (3) national documents. basic sanitation service was defined as follows: "basic sanitation services definition: proportion of health care facilities with improved and usable sanitation facilities, with at least one toilet dedicated for staff, at least one sex-separated toilet with menstrual hygiene facilities, and at least one toilet accessible for users with limited mobility" (core questions in monitoring wash in healthcare facilities in the sustainable development goals). the maintenance of sanitary infrastructure was highlighted. "ensuring houses, institutions, hospitals and other public places maintain environment to the highest level of sanitation attainable to prevent, reduce or eliminate environmental health risks" (kenya health act no.21 of 2017). hygiene infrastructure include sink with tap, water tank with tap, bucket with tap or similar device, alcohol based hand rub dispensers. hygiene in healthcare facilities was highlighted in eight documents analyzed. three (3) national level documents and five (5) global documents. hygiene was defined as: "basic hygiene services definition: proportion of health care facilities with functional hand hygiene facilities available at one or more points of care and within 5 meters of toilets" (core questions for monitoring wash in healthcare facilities in the sustainable development goals). the importance of hygiene facilities was also highlighted in some documents, for example: "hand hygiene is the single most important ipc precaution and one of the most effective means to prevent transmission of pathogens associated with health care services. appropriate hand hygiene must be carried out upon arriving at and before leaving the health care facility, as well as in the following circumstances" (national infection prevention and control guidelines for health care services in kenya) waste management in healthcare facilities was highlighted in nine (9) documents. different types of waste are generated from various sectors of the healthcare facility as a result waste segregation was highly illustrated in the documents: "the four major categories of health-care waste recommended for organizing segregation and separate storage, collection and disposal are: • sharps (needles, scalpels, etc.), which may be infectious or not • non-sharps infectious waste (anatomical waste, pathological waste, dressings, used syringes, used single-use gloves) • non-sharps non-infectious waste (paper, packaging, etc.) • hazardous waste (expired drugs, laboratory reagents, radioactive waste, insecticides, etc.)" (essential environmental health standards in healthcare). it is recommended colors and images be used to identify waste containers and waste should be appropriately disposed by incineration, autoclaving and burial in a lined, protected pit. the repercussions of improper healthcare waste management were mention. "review medical waste management guidelines for health care facilities to protect public health and safety, provide a safer working environment, minimize waste generation and environmental impacts of medical waste disposal and ensure compliance with legislative and regulatory requirements" (kenya environmental sanitation and hygiene policy 2016-2030). basic environmental cleaning in a healthcare facility was defined as: "definition: proportion of health care facilities which have protocols for cleaning, and staff with cleaning responsibilities have all received training on cleaning procedures" (core questions for monitoring wash in healthcare facilities in the sdg). "housekeeping refers to the general cleaning of hospitals and clinics, including the floors, walls, certain types of equipment, furniture, and other surfaces. cleaning entails removing dust, soil, and contaminants on environmental surfaces. cleaning helps eliminate microorganisms that could come in contact with patients, visitors, staff, and the community; and it ensures a clean and healthy hospital environment for patients and staff." (national infection and prevention and control guidelines for health care services, 2010) environmental cleaning is a major challenge due to financial constraints: "as a result, health facilities often lack funds for capital infrastructure investments and ongoing operation and maintenance as well as for overlooked functions such as cleaning and waste management" (wash in hcf, practical steps to achieving quality care). the constitution of kenya indicted the right to a clean environment by all citizens but does not specifically address healthcare facilities. "every person has the right to a clean and healthy environment, which includes the right-f(a) to have the environment protected for the benefit of present and future generations through legislative and other measures, particularly those contemplated in article 69" (kenya constitution). the importance of wash in connection to achieving sdg3 was highlighted in some of the documents: "noting that without sufficient and safe water, sanitation and hygiene services in health care facilities, countries will not achieve the targets set out in sustainable development goal 3" (a72_r7 wash in healthcare facilities resolutions). specifically, the role of wash in healthcare facilities in achieving quality care as part of the implementing and achieving universal health coverage was mentioned. "in addition, wash in hcf is important for meeting several targets under sdg 3 (health for all) and in particular target 3.8 on universal health coverage" (core questions for monitoring wash in healthcare facilities in the sustainable development goals). universal health coverage was framed to include both financial and quality care. "universal health coverage (uhc) means that all individuals and communities receive the health services they need without suffering financial hardship. it includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care" (wash in hcf, practical steps to achieving quality care). however, the national level documents did not mention universal health coverage in line with wash in healthcare facilities, but did associate uhc with quality care: "other projects include digitization of records and health information system; accelerating the process of equipping of health facilities including infrastructure development; human resources for health development; and initiating mechanisms towards universal health coverage" (kenya health policy 2014-2030). "the goal of devolution in health is to enhance equity in resource allocation and enhance access to essential services by accelerating universal health coverage (uhc) and improving quality service delivery for all kenyans, especially those who need it most" (planning, budgeting performing, review process guide for health sector). the national monitoring tool focused on the registration process of citizens for the uhc and the frequency of visits by patients to a healthcare facility: "what mechanisms are in place to identify those registered for uhc" (final uhc level 2 and 3 final supervision tool). access and functionality of wash in healthcare facilities were associated with infection control in healthcare facilities and beyond: "recalling wha68.7 (2015) on the global action plan on antimicrobial resistance, which underscores the critical importance of safe water, sanitation and hygiene services in community and health care settings for better hygiene and infection prevention measures to limit the development and spread of antimicrobial-resistant infections and to limit the inappropriate use of antimicrobial medicines, ensuring good stewardship" (a72_r7 wash in healthcare facilities resolutions). infection prevention and control in healthcare facilities was defined as: "infection prevention and control (ipc) is broadly defined as the scientific approaches and practical solutions designed to prevent harm caused by infection to patients and health workers associated with delivery of health care" (wash in hcf, practical steps to achieving quality care). kenya has a guide on healthcare infection prevention and prevention: "these guidelines are intended to provide administrators and hcws with the necessary information and procedures to implement ipc core activities effectively within their work environment in order to protect themselves and others from the transmission of infections" (national infection prevention and control guidelines for health care services in kenya, 2010). infection control in healthcare facilities was also associated with waste management: "strengthening infection prevention and control systems including health care waste management in all health facilities" (kenya health act.21 of 2017). wash, infection control and prevention were also associated with the safety of the public, patients, caregivers and healthcare workers: "every patient and every family member and facility staff who cares for them deserves a clean and safe health care environment with high quality water, sanitation, and hygiene services" (wash in hcf, practical steps to achieving quality care). aside focusing on the safety of all who visit health care facilities, some of the documents also highlighted the safety of healthcare workers: "strategies to protect health workers include the following: implementing standard precautions, immunizing all health workers against hbv, especially those working in health care settings, providing ppe, managing exposures in a timely manner, eliminating unnecessary sharps and injections successful implementation of these strategies requires an effective quality improvement or infection prevention and control committee (ipcc) with support from the hospital management team" (national infection prevention and control guidelines for health care services in kenya). some national documents highlight the provision of safe healthcare facilities, but did not link safety to wash nor explain what a safe working environment entail: "the right to a safe working environment that minimizes the risk of disease transmission and injury or damage to the health care personnel or to their clients, families or property" (kenya health act no.21 of 2017). the functionality of wash in healthcare facilities is impacted by climate change or weather patterns or civil disruptions. in the context of the national documents, the increased burden on healthcare facilities was highlighted: "political instability in the eastern africa region and the subsequent in-migration of refugees into kenya has the result of increasing the demand for health services in the country and raising the risk of spreading communicable diseases" (kenya health policy 2014-2030). the need to appropriately site infrastructure was mentioned: "the site should have proper drainage, be located downhill from any wells, free of standing water, and not be in a flood-prone area. the site should not be located on land that will be used for agriculture or development" (national infection prevention and control guidelines for health care services in kenya). the impact of climate change was highlighted, but framed as a question in the washfit tool: "do seasonality and/or climate change affect wash services and are there plans in place to cope with this?" (washfit, a practical guide for improving quality of care through wash in hcfs). measures to reduce or eliminate the impact of climate change, civil disruptions and anthropogenic activities at the healthcare facility were mentioned: "buildings are designed and activities are organized so as to minimize the spread of contamination by the movement of patients, staff and careers, equipment, supplies and contaminated items, including healthcare waste, and to facilitate hygiene" (essential environmental health standards in healthcare). "care must be taken, when siting latrines, to avoid contaminating groundwater and risk of flooding" (essential environmental health standards in healthcare). the national documents mention ddr in light of the general public not specific to the healthcare and wash facilities. healthcare services are needed in times of disasters or disease outbreaks. the importance of wash in healthcare facilities as part of emergency preparedness was highlighted: "wash services strengthen the resilience of health care systems to prevent disease outbreaks, allow effective responses to emergencies (including natural disasters and outbreaks) and bring emergencies under control when they occur" (washfit, a practical guide for improving quality of care through wash in hcfs). the national monitoring tool mentioned emergency preparedness in terms of referral systems, functional emergency teams and the presence of ambulances for patient transportation to referral hospitals: "emergency preparedness and timely response in facility and referral. has there been any referral in the last one month? do you have a functional emergency response team?" (uhc level 2 and 3 final supervision tool). at the county level, the hospital preparedness did not include wash: hospital preparedness. infrastructure-numbers of hospitals with casualty departments, icu, bed capacity, morgue facilities. human resource-well trained cadres (basic life support, advanced cardiac life support.) contingency/response plan updated. disaster emergency kits, medicine stockpiles. community support-alternative treatment centers (health and nutrition sector contingency plan, 2019) wash in healthcare facilities stakeholders emerged in six (6) documents. the implementation of wash in healthcare facilities is a multi-stakeholder activity. at the national level: "however, wash is not the responsibility of the ministry of health alone. ministries of water and sanitation are critical for improving municipal wash supplies and providing technical expertise to health care facilities. ministries of finance can provide important budget allocations and financing mechanisms. moreover, local governments have a responsibility to manage and fund wash at the local level. overall, coordination requires a high level of leadership beyond any one ministry to ensure a common, cohesive approach" (wash in hcf, practical steps to achieving quality care). specifically, quality health care services should be monitored: "the district health management team (dhmt) is responsible for monitoring the facilities within the district for using and complying with ipc practices. the dhmt is also responsible for ensuring that adequate and appropriate resources are available to support ipc practices within these facilities" (national infection prevention and control guidelines for health care services in kenya). other aspects of stakeholder engagement are training, monitoring and evaluation were mentioned. "prepare a budget that reflects aims and available resources, with potential to scale-up. the training budget should realistically consider all the costs, which include the actual training, but also the followup support that is required to assist facilities in ongoing challenges and improvements. in addition, it is useful to consider the funds for physical supplies as even providing some minor, immediate improvements (such as hand hygiene stations, low-cost water filtration or on-site chlorine generation) can help realize major improvements in reducing health risks and set the foundation for longer term improvements such as piped water" (washfit, a practical guide for improving quality of care through wash in hcfs). guided by the political ecology of health theory this paper explored the framing of wash in healthcare facilities in relevant policies, guidelines, legislation, plans, monitoring and evaluation documents at the global and national context using kenya as a case study. in these documents, wash in healthcare facilities was framed in relation to the importance of wash in a healthcare facility such as infection prevention and control, quality care and achieving universal health coverage. it was also framed in terms of infrastructure in healthcare facilities. from a political ecology of health perspective, the global agenda on wash in healthcare facilities influenced the growing concerns of wash in healthcare facilities at the national level in kenya. from this study, the global agenda on achieving the sustainable development goal 3 and goal 6 influenced political, social, economic and cultural factors in the implementation and use of wash in healthcare facilities in kenya. the global resolutions, guidelines and monitoring documents are guides for national level adaption. similarly, with respect to the influence of global campaigns on national agenda, asiki et al. [19] established that the kenya national guidelines on cardiovascular diseases were guided by existing global initiatives and guidelines such as the tobacco control act. specifically, the global campaign on achieving universal health coverage led by the world health organization accelerated movements to implementing universal health coverage in kenya as stated in the kenya health policy (2013-2030). kenya is currently piloting universal health coverage in four counties. the acronym wash means water, sanitation, hygiene, waste management and environmental cleaning [1] . from this research comprehensive mention of wash in healthcare facilities was dominant in global documents than national documents. two national documents mentioned water, sanitation and hygiene in sentences excluding environmental cleaning and waste management. other national documents mentioned one of these components. first, this could be associated with the fact that the global documents addressed wash in health care facilities specifically. none of the national documents were published specifically for wash in healthcare facilities. second, most of the national documents were published before the agenda for wash in healthcare facilities was initiated. in addition, the final monitoring tool for universal health coverage does not comprehensively measure access and functionality of water, sanitation, hygiene, waste management and environmental cleaning. it monitored aspects of water and hygiene. waste management, sanitation and hygiene are in the same category. for instance, the presence of a functional incinerator, a well-protected ash pit, a well-protected placenta pit and having a set of three color-coded bins in all wards and clinical departments and used for segregating waste at the point of generation are in the same category. at the time of data collection, a universal health coverage policy or agenda was not instituted. however, it was evident from the final universal health coverage monitoring tool for the kisumu county that efforts towards the implementation of universal health coverage were directed towards finance and registration of citizens than quality care. indicators for wash in healthcare facilities were not adequately presented and this could have impacts on the planning and financing of quality care when the universal health coverage program is fully rolled out in the country. similarly, maccord et al. [42] highlighted the need for quality data collection on relevant wash in healthcare indicators to achieve environmental health policies in healthcare facilities in their research in malawi. in addition, inadequate or inconsistent data will complicate the assessment of interventions towards implementing universal health coverage [43] . it was also evident that the previous healthcare facility monitoring tool, titled the integrated management supportive supervision tool measured more wash in healthcare indicators than the final universal healthcare monitoring tool measured. although this tool did not comprehensively cover all the aspects of wash, it touched on all five components of wash. for instance, the tool monitored separated toilets for staff and patients. wash in healthcare facilities cannot be achieved without the relevant key stakeholders at both the national and global levels. ensuring access to wash in healthcare facilities is complex and requires the efforts of different institutions. forming partnerships are very critical to achieving complex and connected challenges [44] . the global documents such as the wash resolutions document listed some key institutions, ministry of health, water, finance and energy in achieving wash in healthcare. other relevant key stakeholders include communities where healthcare facilities are situated and nongovernmental organizations. wash in healthcare facilities was also framed in terms of stakeholder engagements such as trainings. training on wash management or infection control, budgeting of funds for implementing wash in healthcare services and monitoring and evaluations are some of the key roles of government and nongovernmental organizations mentioned in both the global and national documents. for instance, inadequate data collection has been associated with lack of technical knowledge on policy documents or monitoring tools by government officials [42] . this barrier hinders advocating for the appropriate resources required for effectively implementing environmental health policies and plans by civil society groups and non-governmental organizations. maina et al. [3] in their research on the role of wash in healthcare facilities in averting anti-microbial resistance in 14 county level hospitals reported inadequate resource allocation by the government as a key challenge to accessing wash in healthcare facilities. similarly, guo & bartram [20] reported that about a fifth of facilities overall 14 countries they investigated as part of a study to explore predictors of water quality in rural healthcare facilities reported having an insufficient budget for supplies for water, sanitation and hygiene or infection control. resources or funding is a major requirement to implementing wash in healthcare facilities [45] . anderson et al. [46] in their paper expressed the need for wash in healthcare facility stakeholders to adequately monitor the quality, quantity, input and output of wash services in healthcare facilities to ensure effective costing when planning for water, sanitation, hygiene, waste management and environmental cleaning in a healthcare facility. it is also recommended that wash national documents in ssa should include relevant stakeholders such as the cleaners and maintenance officers since they directly deal with issues of wash in a healthcare facility [46] . the importance of wash in healthcare facilities cannot be underestimated in terms of infection control and prevention and safety of facility users and workers. cleaning and disinfection of healthcare facilities prevent disease transfer and if not adequately handled weakens the healthcare system. similar to the ebola outbreak, the current covid-19 outbreak has compromised the quality of care in many healthcare facilities and a growing number of healthcare workers have died even in global north countries. however, wash is not listed as a requirement for hospital preparedness in the 2019 county level health and nutrition contingency plan. the issue of wash and safety of patients, caregivers and workers were dominant in global documents than the national documents. the national infection prevention and control guidelines for health care services in kenya clearly lays out the procedures, roles and responsibilities in infection prevention and control at the health care facility. other documents mentioned the need for ensuring a safe working environment for healthcare workers, but do not clearly define what a safe environment means. however, the previous monitoring tool for healthcare facilities monitored the presence of personal protective equipment such as the single use of aprons, goggles, gloves, fire extinguishers and fire exit. the safety and functionality of wash services in healthcare facilities were also framed in the context of natural disasters such as drought and floods. only the health act mentioned issues of wash in healthcare facilities in association with impacts of climate change. wash infrastructure and climate change is also framed as a caution to ensure wash infrastructure are efficient and can withstand and recover from the shocks of climate variability impacts. for instance, engaging in waste burial or burning in a flood prone area facilitates surface and ground water contamination. civil disruptions such as political instability burdens the functionality of healthcare facilities and wash infrastructure in two ways. the structures are often destroyed or the healthcare facilities are burdened with people seeking healthcare. however, these civil disruptions are not mentioned in the global documents in the context of wash in healthcare facilities. kenya has recorded several civil disruptions. of most significance is the post-election violence in 2017. civil disruptions need to be considered in wash in healthcare facility planning, implementation and maintenance. this brings to question the framing of wash and disaster risk reduction in healthcare facilities. disaster risk reduction was framed as a recommendation to healthcare managers. the universal health coverage policy was not available at the time of this study, the authors only had access to the final universal health monitoring tool for level 2 and level 3 facilities. this is a limitation of this study since the authors could not comprehensively analyze the framing of quality care as part of the universal health coverage campaign in the country. however, access to the uhc final monitoring tool highlights the indicators of uhc being prioritized during the piloting phase. this phase is critical to the finalization of the uhc policy in the country. from a policy perspective, there is a need for the development of a national level wash in healthcare facility guideline which addresses contextual factors of kenya across all levels of the healthcare system. all relevant stakeholders should be engaged in the development of a comprehensive binding document on wash in healthcare facilities. this is necessary because research has closely associated the prevalence of disease and poor health management to the lapses in government policies in ghana than other countries [47] . second, the final monitoring tool for universal health coverage needs to be revised to comprehensively measure water, sanitation, hygiene, environmental cleaning and waste management indicators in healthcare facilities using the global tools as guides. it will ensure effective data collection, planning and implementation of wash in hcf. for example, it is evident that integrating washfit training and supervision enhance quality service provision in healthcare facilities [48] . similarly, researchers have contextualized some monitoring tools in wash in hcf research. maina et al. [40] adapted and contextualized the washfit tool and developed washfast for the assessment of wash indicator performance in facilities beyond primary healthcare level. the authors developed a total of 65 wash in healthcare indicators relevant to monitoring wash in hospitals in limited resource areas. in addition, there are existing monitoring tools which can be useful in monitoring wash in hcf indicators. patel et al. [49] review on wash in healthcare monitoring tool developed from 1991 to july 2018 recommended the need for more comprehensive and concrete wash in health care monitoring tools. a recent assessment by the usaid and maternal child survival program on the kenyan health management information systems (hmis) indicated that half of hospitals surveyed used an electronic medical record that was not linked to the district health information software (dhis2) in 2016 [50] . the hmis and the dhis2 could be instrumental in monitoring required wash indicators and quality services should relevant wash indicators be included. from this review, the district health management team (dhmt) is responsible for monitoring all activities in healthcare facilities. access, functionality, safety and availability of water, sanitation, hygiene, environmental cleaning and waste management indicators should be reviewed by the dhmt. effectively monitoring the indicators of wash in hcf will efficiently prepare facilities for disease outbreaks and disasters. in addition, it is evident that kenya has policies, plans and guidelines which when enforced can address the issues of quality healthcare facilities. for instance, the need to include wash infrastructure in healthcare facilities was published in the national infection prevention and control guidelines for healthcare services in kenya in 2010. this is again emphasized in the kenya environmental and sanitation policy, published in 2016. it is evident more needs to be done to ensure policies are fully implemented (42) . commitment by all state officials, nongovernmental organizations and civil society groups are needed to achieve quality care in healthcare facilities. a review of reports on global meeting on wash in healthcare facilities: from resolution to revolution and the wash in health care facilities stakeholder commitments indicated varied levels of commitments. several partners such as non-governmental organizations and private institutions have made commitments to support kenya through global/national/local advocacy, technical support, implementation, research and learning [51] . however, kenya government or country was not listed in the country level commitment section of the report published in 2019 [52] . commitment and prioritization of wash in healthcare facilities by the country's institutions and leaders will accelerate achieving quality healthcare. issues of wash in healthcare facilities should gain equal prominence as issues of financing curative measures in healthcare facilities in the yet to be implemented uhc policy across the country by 2022. in summary, accessing quality healthcare services is a challenge especially in marginalized areas. the lack of access to water, sanitation, hygiene, environmental cleaning and waste management in healthcare facilities affect the quality of care provided. from this research, relevant documents addressing issues of wash in healthcare facilities, quality health services and universal health coverage at the global and national levels framed wash in healthcare facilities in terms of its importance, like infection prevention and control and enhancing universal health coverage and types of infrastructure. factors such as climate change and civil disruptions that affect the access and use of wash in healthcare facilities were also highlighted and framed as precautions to healthcare managers. however, the national document did comprehensively covered issues of water, sanitation, hygiene, waste management and environmental cleaning. in addition, the global guidelines at the national level are not comprehensively implemented which will lead to recurrent insufficient data on wash in healthcare planning. the influence from the global level on universal health coverage implementation at the local level is positive, but efforts at the national level were directed at the number of citizens registering and medication supply. efforts should also be directed towards ensuring healthcare facilities have the appropriate infrastructure for infection control and safety of healthcare facility users. ensuring good health through providing care as stated in sdg 3 cannot be achieved without efforts to achieve wash, sdg 6 at a healthcare facility. environmental conditions in health care facilities in low-and middle-income countries: coverage and inequalities evaluating the foundations that help avert antimicrobial resistance: performance of essential water sanitation and hygiene functions in hospitals and requirements for action in kenya wash and gender in health care facilities: the uncharted territory. health care women int who delivers without water? 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management information systems (hmis) review: survey on data availability in electronic systems for maternal and newborn health indicators in 24 usaid priority countries wash in health care facilities; from resolution to revolution sanitation, and hygiene in healthcare facilities we are grateful to festus ogada, medical officer of health, kisumu east sub county, department of water and sanitation, ministry of health, kisumu county and cohesu, kenya for their contribution to this research during data collection. the authors declare no conflicts of interest. key: cord-315197-4wnes04g authors: zhao, yu; li, mingtao; yuan, sanling title: analysis of transmission and control of tuberculosis in mainland china, 2005–2016, based on the age-structure mathematical model date: 2017-10-07 journal: int j environ res public health doi: 10.3390/ijerph14101192 sha: doc_id: 315197 cord_uid: 4wnes04g tuberculosis (tb), an air-borne infectious disease, is a major public-health problem in china. the reported number of the active tuberculosis cases is about one million each year. the morbidity data for 2005–2012 reflect that the difference in morbidity based on age group is significant, thus the role of age-structure on the transmission of tb needs to be further developed. in this work, based on the reported data and the observed morbidity characteristics, we propose a susceptible-exposed-infectious-recovered (seir) epidemic model with age groupings, involving three categories: children, the middle-aged, and senior to investigate the role of age on the transmission of tuberculosis in mainland china from 2005 to 2016. then, we evaluated the parameters by the least square method and simulated the model and it had good alignment with the reported infected tb data in mainland china. furthermore, we estimated the basic reproduction number [formula: see text] of [formula: see text] , with an obtained 95% confidence interval for [formula: see text] of [formula: see text] by latin hypercube sampling, and we completed a sensitivity analysis of [formula: see text] in terms of some parameters. our study demonstrates that diverse age groups have different effects on tb. two effective measures were found that would help reach the goals of the world health organization (who) end tb strategy: an increase in the recovery rate and the reduction in the infectious rate of the senior age group. tuberculosis (tb) is an air-borne infective disease caused by the slowly-replicating bacterium mycobacterium tuberculosis (mtb). person-to-person transmission of mtb occurs via the respiratory system, which can happen through both close contact between people and through infectious bacilli being carried throughout buildings by air currents [1] . according to the world health organization's (who) global tuberculosis report 2013 [2] , an estimated 8.6 million new cases of tb and 1.3 million deaths, including 320,000 deaths among hiv-positive people, were recorded in 2012. approximately 80% of all new tb cases in the world occur in 22 high burden countries that have incidence rates from 59 to 1003 per 100,000 people. india and china have the largest number of cases at 26% and 12% of the global total, respectively. despite widespread implementation of control measures, including the bacillus calmette guerin (bcg) vaccination, antiretroviral therapy, antimicrobial chemotherapy, mathematical modeling has become a powerful tool for analyzing epidemiological characteristics [5] [6] [7] [8] [9] . different models have been developed for defining target sub-populations for treating latent tb infections and incorporating certain factors, such as drug-resistant strains, co-infection with hiv, relapse, re-infection, and vaccination, to study the transmission dynamics of tb [7, [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] . in particular, blower et al. [10] proposed a simple tb transmission model and presented a theoretical framework for assessing the intrinsic tb transmission dynamics. bhunuet et al. [14] considered a tb model incorporated the treatment of infectives and chemoprophylaxis. liu et al. [19] studied a tb model incorporating seasonality. huynh et al. [24] developed an individual-based computational model to explore the trajectory of the tb burden if the dots strategy is maintained or if new interventions are introduced. a more detailed discussion on different tb models was completed by white and garnett [25] . however, few works have used mathematical models with age groupings to study the transmission of tb in china. in this paper, based on the reported data and the observed morbidity characteristics, we created a susceptible-exposed-infectious-recovered (seir) model with age groups of childhood, middle-aged, and senior, to investigate the role of age on the transmission process and evaluate feasible control strategies to reach the goals outlined in the who end tb strategy. we estimated the basic reproduction number r 0 , analyzed the globally dynamic behavior of the model, and used the model to simulate the annual data of infected tb cases reported by the center for disease control (cdc) from 2005 to 2016. finally, we completed uncertainty and sensitivity analysis of r 0 , and explored some effective and targeted control measures for the transmission of tb in china. the rest of this paper is organized as follows. in section 2, we present the data collection; formulate the tb model; obtain the theoretical results, such as existence and uniqueness of the solution; and define the basic reproduction ratio r 0 and global stability of disease-free equilibrium. in section 3, data fitting and sensitivity analysis of r 0 are shown, and the feasibility of the who end tb strategy is assessed. a brief discussion ensues in section 4. the reported annual and cumulative tuberculosis cases in mainland china from 2005 to 2016 were obtained from the national notifiable disease surveillance system (nndss) ( in this section, we introduce a deterministic tb model incorporating age grouping with control measures. the entire population is classified into four classes: susceptible (s), latency (e), infectious (i) and recovered (r). based on the observation that the morbidity among diverse age groups is significantly different (figure 1 ), to explore the role of age on the infection pattern between susceptible and infectious classes, the susceptible class was further divided into three age groups: childhood (s 1 ), middle-aged (s 2 ), and senior (s 3 ). we also assumed that the latent, infectious, and recovered classes are the same for different age groups. since the latent tb cases, which are individuals who have been infected by tb bacteria but are asymptomatic, and cured tb cases may not directly cause death [26], we assumed that the death rate of the latent and recovered classes were related to the natural death rate d. additionally, for infectious class, we added the term µ, based on natural death rate d, to describe the deaths caused by tb infection. our assumptions for the dynamic transmission of tb in china with age groupings are demonstrated in figure 2 . the model we created has the compartmental structure of the classical seir epidemic model, and is described by the following differential equations: where all the parameters are positive. a is the annual birth rate of the population; m 1 and m 2 are the conversion rates from the susceptible children to the susceptible middle-aged group, and from the susceptible middle-aged group to the susceptible senior group, respectively; λ 1 , λ 2 and λ 3 are the morbidities of children, middle-aged, and senior susceptible age groups, respectively; p is the fraction of fast-developing infectious cases; v is the re-activation rate of the latent tb patients; d 1 , d 2 and d 3 are, respectively, the mortalities of the adolescent, the middle-aged and the elderly susceptible age groups; d is the natural death rate; µ is the disease-induced death rate; γ is the recovery rate; and η is the recurrence rate of successfully treated tb cases. due to the severity of the transmission situation, china developed and implemented two five-year national plans in the 1980s and one 10-year national plan in the 1990s to control tb. after implementing these national tb control programs, the modern tb control strategy was implemented. subsequently, china increased high-quality directly observed treatment, short course chemotherapy (dots) [24] , and a compulsory bacillus calmette guerin (bcg) immunization program for newborns [27] . these actions helped to effectively control the increase of tb in china. given this, and based on model (1), we considered two kinds of control strategies for tb in china: the incremental recovery rate per year due to dots, ξ (0 < ξ < 1), and the immunity rate of the bcg vaccine, ϕ (0 < ϕ < 1). by assuming the newborns that received the bcg vaccine remain in the susceptible compartment, model (1) becomes the following: (2) in epidemiology, the basic reproduction number (denoted r 0 ) of an infection can be viewed as the number of cases one case generates on average over the course of its infectious period [28] . this is one of the most important indexes in evaluating the risk of an infectious disease. the asymptotical dynamic behavior of infectious diseases can be reflected by the steady state, which implies the disease will die out or persist in the future. therefore, we first provided some mathematical analysis results of model (2), whose proofs are shown in appendix a. • model (2) has the following positively invariant set: • making use of the next generation matrix (see [29] ), we obtained the basic reproduction number of model (2) as follows: (4) • this model has a disease-free equilibrium and the endemic equilibrium p * = (s * 1 , s * 2 , s * 3 , e * , i * , r * ), which is determined by the following equations • if r 0 < 1, the disease-free equilibrium p 0 is globally asymptotically stable. despite the central government completing two 10-year control plans, many difficulties still exist elsewhere in the country's tb control programs. the spread of severe acute respiratory syndrome (sars) in 2003 revealed substantial weaknesses in the country's public health system. after the sars epidemic was controlled, the government made better efforts to tackle public health problems, and increased public health funding, revised laws that concerned the control of infectious diseases, implemented the world's largest internet-based disease reporting system, and started a program to rebuild local public health facilities. these measures contributed to an acceleration in the efforts to control tuberculosis [30, 31] . because the data quality for tb is higher after 2004, we decided to fit the data for the infected tb cases for 2005-2016 in china using model (2) . the data from, 2005-2015 were used to fit and those of 2016 were used to check the predictive power by residual and r 2 statistic. to perform the numerical simulations, we first needed to estimate the model parameters. according to the existing literature and related results of the chinese population statistic yearbook, we estimated the parameters. the values of the parameters are listed in table 2 , and the detailed estimation process of the parameter values are as follows. (a) from the results in the china population statistic yearbook from 2005 to 2015 [32] , we obtained the natural death rate of the entire population and those of the three age groups. hence, the mean and the 95% confidence interval are d ≈ 0.0067, 95% ci (0.0065, 0.0069), d 1 ≈ 0.0017, 95% ci (0.0013, 0.0021), d 2 ≈ 0.0023, 95% ci (0.0023, 0.0024), d 3 ≈ 0.0367, 95% ci (0.0352, 0.0382) and a ≈ 1.623 × 10 7 , 95% ci (1.606 × 10 7 , 1.643 × 10 7 ). (b) based on the proportions of age groups in 2005, we calculated the initial value s 1 (0) = 26,504 × 10 4 , s 2 (0) = 94,197 × 10 4 , s 3 (0) = 10,055 × 10 4 . the initial number of people infected with tb is i(0) = 1,259,308, which is the number of people infected with tb in 2005. moreover, the percent ages of people with a tb bacteria infection but asymptomatic and those successfully treated for tb are 12.1% and 80%, respectively [3] . in 2004, the number of people infected with tb was 970,279, so we assumed the initial value of e(0) ≈ 970,279 × 12.1% = 117,403 and r(0) ≈ 970,279 × 80% = 776,223. (c) using the following system and the census data of total population in china from 2005 to 2015, we estimated the parameters m 1 and m 2 by nonlinear least-square method (see figure 3 ). the total pupulation fitting curve (d) the latent period of tb is about two months [33] , thus we calculated the re-activation rate of latent tb patients v = 12 2 = 6 annually. from the 2013 who global tuberculosis report [2] , we obtained the disease-induced death rate µ = 0.0025, and from blower et al. [10] , we knew the fraction of fast-developing infectious cases p is 0.05 and the recovery rate is γ = 0.496. according to the fifth national tb epidemiological survey [3] , we knew that the incremental recovery rate of tb ξ is 0.51 and ϕ is 0.9. (2), we simulated the cumulative number of people infected with tb from 2005 to 2016. the infection rate values λ 1 , λ 2 , λ 3 were obtained by the nonlinear least-square method. first, we let x(t) denote the cumulative number of people infected with tb at time t. according to the flow chart of tb transmission by age grouping (figure 2 ), we knew that three parts contributed to the number of infectious compartments: the number of infected people from the three susceptible age group , the latency, and the tb recurrence from recovery: where x(t) represents the cumulative number of people infected with tb at time t, and i(t) denotes the number in compartment i at time t, which includes the newly-infected tb cases and recovery tb cases at time t. thus, to estimate the newly-infected tb cases, we had z(t) = x(t) − x(t − 1) represent the newly-infected tb cases. in the following, we used z(t) to simulate the reported tb infected cases per year. the decrease in infected tb cases may be due to the current control strategies not being fully effective [31] , which aligns with the dynamic behaviors of model (2) . china developed and implemented two five-year national plans in the 1980s and one 10-year national plan in the 1990s to control tb. after implementing these national tb control programs, the full modern tb control strategy was implemented. the increase of tb in china has since been effectively controlled. with help from the matlab (the mathworks, inc., natick, ma, usa) tool fminsearch, which is part of the optimization toolbox, we estimated the optimal parameters for model (2) . then, using the fourth-order and five-order runge-kutta algorithm (ode45 function), which is a powerful tool for solving ordinary differential equations, according to the corresponding parameters of model (2) listed in table 2 , we simulated the data of the cumulative number and reported cases of tb infection from 2005 to 2016. meanwhile, by random sampling of the 95% confidence interval (ci) of the parameters, we further plotted the 95% ci of the trajectories of the tb infection data, both cumulative and newly-infected tb cases, based on 2000 independent repeated simulations of model (2) (see figure 4 ). figure 4 shows both the time evolution of infection cases and a comparison with the empirical records of tb infection cases, and also shows the 95% percent interval for all 3000 passing simulation trajectories. moreover, we calculated the residual of 2016 as 235 and r-square (r 2 ) statistic to show goodness of fit [34] , where the r-square value is 0.9812. we also observed that the actual reported tb infection data almost fell into the 95% ci of our simulation trajectories. thus, our simulation results are in good accordance with the reported tb infection data, both cumulative and newly-infected tb cases, from the cdc in china from 2005 to 2016. model (2) had a better predictive performance. in addition, to evaluate the tb burden of china based on our model, according to the definition of incidence that the number of new and relapse cases of tb arising in a given time period, usually one year, we can further translate the reported infected tb cases into the incidence rate of tb. for comparison, we also plot the global tb incidence and the estimated tb incidence of who from 2005 to 2015. figure 5 shows that after 2008, the tb incidence is lower than that of estimated value by who, which may implies that china substantial accelerate the control effects of tb. moreover, we can observed that the tb incidence of china is far below the global level. due to the uncertainty in the initial parameter estimates, we performed a latin hypercube sampling (lhs) on the estimated parameters (see, e.g., [8, 35, 36] ). since the lhs requires assigning a probability density function (pdf) to each of the parameters, we stratified the pdfs into 3000 equiprobability areas and then independently randomly sampled 3000 times without replacement, forming 3000 input parameter vectors [21] .these input parameter vectors were then used to calculate the numerical distribution of the basic reproduction number r 0 . with the simulated parameter values, we obtained the numerical distribution of the basic reproduction number r 0 (see figure 6 ), and estimated the basic reproduction number from 2005 to 2016 is r 0 = 1.7858 and the 95% confidence interval of r 0 is (1.7752, 1.7963 ). for the sensitivity analysis of r 0 , we can calculate partial rank correlation coefficient (prcc), which reflects the correlation between parameters a, λ 1 , λ 2 , λ 3 , m 1 , m 2 , γ, η and r 0 . the prcc of the estimated parameters with respect to r 0 are listed in table 3 . it follows from table 3 that there exist a positive correlation between a, λ 1 , λ 2 , λ 3 , m 1 , η and r 0 , and a negative correlation between m 2 , γ and r 0 . furthermore, we can obtain that prcc(a) > prcc(γ) > prcc(λ 3 ) > prcc(m 2 , λ 1 , λ 2 , η, m 1 ) , namely, a, γ, λ 3 play the most important role to determine r 0 . significant progress in controlling tb has been made during the last two decades, however, the who proposed a post-2015 global end tb strategy in 2014 [37] . this strategy aims to end the global tb epidemic, with targets to cut new cases by 90% by 2035 and a milestones of 50% reduction in tb incidence rate in 2025. in the above analysis, γ and λ 3 are the most important risk factors for tb control. to examine the tb controlling effects with respect to γ and λ 3 , we examined if reaching the who end tb strategy would be feasible based on the current different control strategies. we used the parameter values listed in table 2 as a baseline to compare the control effects. first, we only considered the single intervention scenario including λ 3 , and, as shown in figure 7a , we would not be able to reach the goal of who end tb strategy under the current plan, even with decreasing λ 3 by 50%. then, we considered the single intervention scenario of γ, and as shown in figure 7b , 15% increasing of the baseline γ would allow us to reach the who target. finally, we considered an integrated control strategy including both γ and λ 3 simultaneously. figure 7c shows that if we can reduce the morbidity in the senior group λ 3 by 15%, and increase the recovery rate γ by 10%, then we will meet the tb end target. therefore, we concluded that, by using the current tb control interventions, china may not reach the who end tb strategy in 2025. to achieve the who end tb strategy goal, china will need to pay more attention to enhance their combination tb interventions and further explore the feasibility of additional control strategies. the millennium development goal's target in china was achieved with the decrease in the reported number of tb cases, however, the aging demographic represents an increasing challenge to tb control as china considers its post-2015 end tb strategy [24] . importantly, significant differences exist among different age groups in terms of the morbidity of tb. taking this into account, and using the reported tb data in china from 2005 to 2016, we proposed a seir epidemic model with three age groups, children, middle-aged, and senior, to study the transmission of tuberculosis in china. by means of the least square method, we evaluated the parameters and simulated the model, and the model agrees well with the annual reported tb data in china. furthermore, we calculated the basic reproduction number r 0 ≈ 1.7858, and obtain the 95% confidence interval for r 0 is about (1.7752, 1.7963) by latin hypercube sampling. we also assessed the feasibility of reaching the who end tb strategy goal under current china tb control initiatives by using a sensitivity analysis of r 0 in terms of the parameters. (i) our results demonstrate that taking the age grouping into consideration is reasonable to characterize the transmission and to improve the control strategies of targeting therapy for tb in china. based on the age-structuring model, more risk factors for different age groups can be identified. interventions could be targeted toward specific groups, which would be particularly effective as an epidemic control measure [38] . thus, the age grouping pattern provides a meaningful scheme, based upon the treatment of active cases and the chemoprophylaxis of latently infected individuals, to define targeted sub-populations for treating tb infections. for instance, the bcg vaccine is useful only for younger people but is less effective for the middle-or the senior-aged groups, having an average efficacy of only about 50% for those groups [2, 39] . however, with the aging of the chinese population and high morbidity rate of tb in seniors, perhaps an analogue of the bcg vaccine control strategy should be implemented for the potentially high-risk senior sub-population, which may result in the decreasing the morbidity in that group. in addition, the nationwide dots program should be more focused on the senior-aged group, such as providing more financial assistance for this group, who may experience catastrophic costs due to tb [26] , and should place more emphasis on the people with latent tb in middle-aged group, who may increase the proportion of the actively infected people in the senior group. (ii) from the analysis of prcc of r 0 in table 3 , it is shown that γ, λ 3 , m 2 and λ 1 are the most effective methods for controlling tb in china. although the who's target treatment levels may not lead to eradication, these non-eradication treatment levels could significantly reduce morbidity and mortality [11] . thus, two important indexes must be improved: first, the tb treatment success rate and treatment coverage (increasing γ), for example, by providing high-quality tb care to prevent suffering and death from tb. second, monitoring and detecting the latent tb in the senior population (reducing λ 3 ) may help prevent the development of active tb in those already infected with mycobacterium tuberculosis, including further strengthening the public health facilities and providing an isolation policy for those with detected latent tb. for tb infection in children, contact tracing is one of the key components of tb prevention, so educational programming and campaigning can be aimed the youngest age group. (iii) our feasibility assessment of reaching who end tb strategy goal for 2015-2025, showed that even with any single intervention or combination of interventions, china may not reach the goal at the country level, as shown by the multi-models result in houben et al. [5] . due to the influence of drug-resistant strains, co-infection with other diseases including hiv, diabetes mellitus, etc., and increasing infection opportunities that accompanies world travel, tb will be weakly persistent and should show an overall decreasing trend in the future (see figure 7) . shows that if we can reduce the morbidity of the senior group by 15%, and increase the recovery rate by 10% , then we could potentially achieve the who tb end target. similar to wang et al. [31] pointed out, china is not on track, nor does it appear to be currently possible, to reach the required reduction in prevalence. therefore, there is still a need for sustained improvements in tb control to keep reducing the burden of tb in china. from a practical viewpoint, clarifying the role of age in the transmission of tb may aid in forecasting the long-term health risks, in proposing a targeted tb control strategy, and in setting objectives and using limited resources more effectively [19] . , substituting (a2) into the fifth equation in (6) yields we can see from the expressions of s 1 , s 2 and s 3 in (a2) that it follows from (a3) that f (i) is monotonously decreasing with respect to i in [0, â d ]. if r 0 > 1, we can compute that f (0) = (1 − ϕ)λ 1 s 0 1 + λ 2 s 0 2 + λ 3 s 0 3 − (1−ϕ)λ 1 s 0 1 +λ 2 s 0 2 +λ 3 s 0 3 r 0 > 0 and f ( â d ) < 0. thus equation (a3) has a unique positive solution i * ∈ (0, â d ). submitting i = i * into (7) we obtain the unique endemic equilibrium p * = (s * 1 , s * 2 , s * 3 , e * , i * , r * ) of model (2) . when r 0 < 1, we know that dl dt = 0 if and only if s 1 = s 0 1 , s 2 = s 0 2 , s 3 = s 0 3 , otherwise dl dt < 0. thus, by lasalle's invariant set principle [40] , it follows that the disease-free equilibrium p 0 is globally asymptotically stable in the set ω when r 0 < 1. ◻ problems and solutions for the stop tb partnership the fifth national tuberculosis epidemiological survey in 2010 healthy aging in china feasibility of achieving the 2025 who global tuberculosis target in south africa, china, and india: a combined analysis of 11 mathematical models transmission dynamics of a multi-group brucellosis model with mixed cross infection in public farm the use of mathematical models in the study of the epidemiology of tuberculosis transmission dynamics and control for a brucellosis model in hinggan league of inner mongolia modeling direct and indirect disease transmission using multi-group model the intrinsic 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transmission: an hiv model as an example uncertainty and sensitivity analysis of the basic reproductive rate: tuberculosis as an example world health organization. who end tb strategy early therapy for latent tuberculosis infection potential public health impact of new tuberculosis vaccines the stability of dynamical systems key: cord-288392-khjo6j8u authors: davern, melanie; winterton, rachel; brasher, kathleen; woolcock, geoff title: how can the lived environment support healthy ageing? a spatial indicators framework for the assessment of age-friendly communities date: 2020-10-21 journal: int j environ res public health doi: 10.3390/ijerph17207685 sha: doc_id: 288392 cord_uid: khjo6j8u the age-friendly cities and communities guide was released by the world health organization over a decade ago with the aim of creating environments that support healthy ageing. the comprehensive framework includes the domains of outdoor spaces and buildings, transportation, housing, social participation, respect and inclusion, civic participation and employment, communication and information, and community and health services. a major critique of the age-friendly community movement has argued for a more clearly defined scope of actions, the need to measure or quantify results and increase the connections to policy and funding levers. this paper provides a quantifiable spatial indicators framework to assess local lived environments according to each age-friendly cities and communities (afc) domain. the selection of these afc spatial indicators can be applied within local neighbourhoods, census tracts, suburbs, municipalities, or cities with minimal resource requirements other than applied spatial analysis, which addresses past critiques of the age-friendly community movement. the framework has great potential for applications within local, national, and international policy and planning contexts in the future. research has long recognized that environmental factors play a significant role in determining health and wellbeing in older age [1] , and there are rising proportions of older people in the populations across the world. consequently, the recently released united nations decade of healthy ageing 2020-2030 calls for sustained global action to generate transformative change in four priority areas: addressing ageism; creating age-friendly communities; delivering integrated and person centered care; and providing long-term care [2, 3] . increased urbanization and policy discourses supporting ageing in place add to the urgency to create and plan for age-friendly environments. on a global scale, life expectancy has increased from 47 years in the mid-20th century to an expected 78 years by the mid-21st century [4] and 21% of the world's population is predicted to be aged over 60 years by 2050 [5] . the world health organization (who) world report on ageing and health [6] documented how age-friendly environments play a which often includes transportation systems, land development patterns, and microscale urban design (e.g., footpaths) [27, 28] . a lived environment reflects the importance of locality and access to good urban design, as well as human-made and natural environments to support health and wellbeing in the local neighbourhoods where people live. this is consistent with the argument regarding the narrow application of the term "built environment" where both human made and natural worlds are conceived as though there is no separation between them [29] . spatial indicators provide a quantitative measurement of local lived environments using geocoded data (defined by x and y co-ordinates) developed using geographic information systems (gis). data linked to a street address can be mapped using gis and calculated as spatial indicators, providing aggregated measures across a range of geographic areas, including neighbourhoods or census tracts, suburbs, municipalities, regions, or states. aggregated geocoded data can be drawn from a range of existing administrative data sources that assess the lived environment and a range of social, economic, and environmental issues. spatial afc indicators consequently provide objective and cost-effective assessments of age-friendliness that are easily replicated across large geographic areas using desktop spatial analysis. these indicators can also be made readily accessible to local governments using online digital planning portals and liveability indicator systems for cities, like the australian urban observatory (auo.org.au) [30] . the development of quantifiable spatial indicators of afc addresses the major critiques of the afc initiative-that it is too descriptive in approach [31] , not measured or monitored by indicators [31] , and without a clear understanding of an indicator framework [32] . this paper proposes spatial indicator tools that can be applied for the assessment of afc in local lived environments using a gis methodology. these afc spatial indicators can also be applied in a variety of international contexts with direct relevance to the healthy cities movement [33] , the new urban agenda, and the 2030 agenda for sustainable development [34] . the 2030 agenda provides a global framework for sustainable urban development up until 2030 signed by all 193 members states with 169 specific targets. these include sustainable development goals (sdgs) with specific mention of older people in targets for goal 10 reduced inequalities, goal 11 sustainable cities and communities, and goal 17 partnerships for the goals. in addition, the decade of healthy ageing [3] calls for disaggregated data in twenty-eight indicators across eleven goals. spatial indicators measuring afc in lived environments are noted by the united nations as being necessary for the measurement and monitoring of any actions contributing to sustainable development (goal 17) and multi-stakeholder partnership development and policy and institutional coherence. they have been developed to address segregation or siloed approaches in the current planning approaches and to encourage discussion and action that can promote integrated policy, planning, and practice across urban planning and public health. often the outcome of afc remains the sole responsibility of health or social planning with little integration across important portfolios, such as transport or statutory or strategic planning. the implementation of afc principles must extend beyond practitioners with interest in ageing and should ideally be integrated across policy portfolios with budget and legislative support. this paper aims to introduce a new set of afc spatial indicators that can be used to quantify and assess the age-friendliness of local lived environments and monitor changes in age-friendliness over time consistent with the sdgs and 2030 agenda. these indicators seek to support the decade of healthy ageing, which includes a commitment to action in the development of age-friendly environments and improved measurement, monitoring, and research [8] as well as tools to support planners and practitioners working within government settings. these spatial indicators of afc also identify the importance of older people and their lived environments in sustainable urban development and the 2030 agenda. eight interconnected domains are included in afc ( figure 1 ). the selection of specific spatial indicators to assess the lived environment of each afc domain was made following a workshop held with all five authors to identify the most relevant measures for each of these domains. the multidisciplinary experience of the research team spans gerontology, public health, urban planning, psychology, epidemiology, sociology, health geography, health policy, governance, and community development. with all five authors to identify the most relevant measures for each of these domains. the multidisciplinary experience of the research team spans gerontology, public health, urban planning, psychology, epidemiology, sociology, health geography, health policy, governance, and community development. potential indicators were then judged against the key criteria recommended by the who (box 1) as well as other best practice principles for indicator application [36] including: direct links to policy; connection to theory and existing research; available time series data; connection to budgeting and planning; relevance to most people; and connection to lived reality. these latter criteria being understood and relevant to most people, particularly older people, are particularly important and informed by previous research in the development of a specific indicator of access to services for older people [37] , which included focus groups of older people to determine the local needs and services of highest importance. the selected measures also needed to be relevant to the majority of older people living in a wide range of lived environments, and to measure the most critical requirements for places that support afc principles. box 1. the criteria suggested for defining local afc indicators [15] . will variations in the indicator be observable over time due to specific actions? disaggregation possible: can the indicator be disaggregated by gender, age group, or across neighbourhoods? there are also other strategies that could be important in the local context, including ethnicity, socioeconomic status, etc. aligns with local goals and targets: does the indicator link to a broader local agenda? can be linked to action: does the indicator provide an understanding of the various actions that might need to be undertaken? within local influence: does the local government or community have the mandate or authority to act on this indicator? for example, a federal insurance scheme is mostly beyond the influence of the municipal government. easy to collect: are the data required to produce the indicator easy to collect in a timely manner? socially acceptable: is the collection of this information acceptable to the communities and individuals concerned? the following section describes each of the selected afc spatial indicators with research evidence provided to support each indicator (table 1 ). potential indicators were then judged against the key criteria recommended by the who (box 1) as well as other best practice principles for indicator application [36] including: direct links to policy; connection to theory and existing research; available time series data; connection to budgeting and planning; relevance to most people; and connection to lived reality. these latter criteria being understood and relevant to most people, particularly older people, are particularly important and informed by previous research in the development of a specific indicator of access to services for older people [37] , which included focus groups of older people to determine the local needs and services of highest importance. the selected measures also needed to be relevant to the majority of older people living in a wide range of lived environments, and to measure the most critical requirements for places that support afc principles. box 1. the criteria suggested for defining local afc indicators [15] . will variations in the indicator be observable over time due to specific actions? disaggregation possible: can the indicator be disaggregated by gender, age group, or across neighbourhoods? there are also other strategies that could be important in the local context, including ethnicity, socioeconomic status, etc. aligns with local goals and targets: does the indicator link to a broader local agenda? can be linked to action: does the indicator provide an understanding of the various actions that might need to be undertaken? within local influence: does the local government or community have the mandate or authority to act on this indicator? for example, a federal insurance scheme is mostly beyond the influence of the municipal government. easy to collect: are the data required to produce the indicator easy to collect in a timely manner? socially acceptable: is the collection of this information acceptable to the communities and individuals concerned? the following section describes each of the selected afc spatial indicators with research evidence provided to support each indicator (table 1) . additional contextual factors for consideration include: the estimated resident population; proportion of population aged more than 60 years; population age distribution including proportions of older and younger populations in area; ethnicity; education; homeownership; residential density; remoteness e.g., accessibility/remoteness indices or the distance between towns in rural settings; the risk of natural disasters; climatic conditions; and the impact of climate change. * recommended as priority indicators for inclusion. the suggested spatial indicators for each afc domain are presented in table 1 with the priority indicators notated with asterisks. this provides flexibility for practitioners in identifying the key spatial indicators of importance to afc or additional optional indicators where resources are available. additional information is provided below explaining why these indicators are recommended for each afc domain with detailed explanations of the supporting research evidence. the indicators recommended in the following section were identified in accordance with indicators acting as icebergs and highlighting issues of major importance [37] . only after the major factors have been quantitively assessed should further qualitative assessment be completed, similar to a hierarchy of need. for example, if there are no public open spaces available there is little point in assessing the maintenance, shelter, or facilities available in public open spaces within an area. additional qualitative assessment could also include local consultation with older residents and relevant stakeholders. the priority indicators identified for this domain are walkability for transport [38, 39] and access to public open space within 400 m [22] . these indicators are directly related to walking [40] [41] [42] , specifically in older people [43] , and associated with physical health benefits [44] and mental health benefits [45] . walkable neighbourhoods are important for older people because, along with the fact that they enable people to reach destinations with commercial and social opportunities [43, 46] , walking is also associated with maintaining functional independence [47] and better cognitive function [48] . similarly, public open spaces that are easy to visit with walkable access are important for older people and important in reducing social isolation and increasing physical activity [49] . data required to create indicators of walkability are commonly available within municipal and planning contexts. road network analysis (a way to walk), land use mix (destinations to walk to), and housing density (people to service the destinations) are common key components of walkability assessments. similarly, public open space location data are also regularly held by most municipal governments. footpaths are an important infrastructure supporting walking in older people [50, 51] , and walkability can also be refined by superimposing footpath access where spatial data are available. an example of a walkability for transport assessment for the regional city of launceston in tasmania, australia was calculated and is provided in figure 2 to demonstrate the value of neighbourhood level walkability assessments. the results clearly suggest that the inner neighbourhoods of the city of launceston have good walkability while the outer neighbourhoods are less supportive of walking for transport, particularly those on the eastern side of town. additional spatial indicators for consideration include intersections with visual and auditory signalled pedestrian crossings that allow time for older people to cross over roads, and particularly busy intersections [53, 54] . in australia, many regional towns avoid the use of signalized pedestrian crossings and opt for roundabout intersections, which encourage continual traffic flow and can be frightening for people with reduced mobility. access to public seating is also recommended to be available within local public open spaces to encourage rest stops while walking (overlapping with the suggested measure of accessibility to public open space). clean and safe public toilets are also recommended, including those with accessibility features [51] and should also be included within high quality public open spaces. accessible buildings are italicised in table 1 due to the difficulty in sourcing data that measure buildings developed according to universal design principles. if possible, these are recommended, as older people experience difficulties associated with access to public buildings and the lack of handrails, narrow corridors, and steps [51] . post occupancy evaluations are generally more common in sustainability assessments [55] and are time and staff resource intensive but could be considered as an alternative measure if no other data are available to assess buildings. additional spatial indicators for consideration include intersections with visual and auditory signalled pedestrian crossings that allow time for older people to cross over roads, and particularly busy intersections [53, 54] . in australia, many regional towns avoid the use of signalized pedestrian crossings and opt for roundabout intersections, which encourage continual traffic flow and can be frightening for people with reduced mobility. access to public seating is also recommended to be available within local public open spaces to encourage rest stops while walking (overlapping with the suggested measure of accessibility to public open space). clean and safe public toilets are also recommended, including those with accessibility features [51] and should also be included within high quality public open spaces. accessible buildings are italicised in table 1 due to the difficulty in sourcing data that measure buildings developed according to universal design principles. if possible, these are recommended, as older people experience difficulties associated with access to public buildings and the lack of handrails, narrow corridors, and steps [51] . post occupancy evaluations are generally more common in sustainability assessments [55] and are time and staff resource intensive but could be considered as an alternative measure if no other data are available to assess buildings. there is a growing body of evidence showing a positive association between healthy ageing and blue space [56] . this is worthy of future consideration but is not accessible within all lived environments and, hence, has not been included as a recommended measure within the outdoor space and building domain but could be considered as second tier measures. blue space is defined as outdoor environments (natural or manmade) that prominently feature water and are accessible proximally (being located in, on, or near water) or distally/virtually (being able to see, hear, or sense water) [57] . therapeutic design of a built environment using urban green and blue infrastructure was shown to be protective for healthy ageing while supporting those with cognitive decline, or illness [58] . similarly, a study of largely older people in hong kong found that general health was significantly higher in people with a sea view from their home [59] , while, in ireland, older people had a lower risk of depression in those with more sea views [60] . in addition, nature-based solutions, there is a growing body of evidence showing a positive association between healthy ageing and blue space [56] . this is worthy of future consideration but is not accessible within all lived environments and, hence, has not been included as a recommended measure within the outdoor space and building domain but could be considered as second tier measures. blue space is defined as outdoor environments (natural or manmade) that prominently feature water and are accessible proximally (being located in, on, or near water) or distally/virtually (being able to see, hear, or sense water) [57] . therapeutic design of a built environment using urban green and blue infrastructure was shown to be protective for healthy ageing while supporting those with cognitive decline, or illness [58] . similarly, a study of largely older people in hong kong found that general health was significantly higher in people with a sea view from their home [59] , while, in ireland, older people had a lower risk of depression in those with more sea views [60] . in addition, nature-based solutions, through green and blue space urban management planning, can mitigate the health impacts of climate change while addressing the need for climate resilience in local communities [61] . future revisions of the afc principles could consider the inclusion of more detailed measures of green and blue spaces in the domain of outdoor spaces and buildings to address changing climates around the globe. these could include access to local blue spaces, public and private tree canopy coverage, public street tree canopy coverage and the associated shade capability, in combination with the currently recommended measures of walkability and accessibility to public open space. these measures are very worthy of consideration but bring their own challenges in terms of data access and spatial capability making them harder to produce. consequently, they are suggested as potential expanded, not essential, measures of the afc lived environment assessment. transport is an important determinant of health [62, 63] influencing access to local services, engagement in paid and non-paid productive activities (such as employment or volunteering), maintaining and developing social networks and supports, and engaging in social and recreational activities. public transport has also been identified as a critical influence of liveability in a community [19] and active transport important to older people [64] . policy-relevant spatial public transport indicators are typically based on 400 m access or a 5-min walk [20, 65] . another important factor that influences the use of public transport is service frequency. consequently, access to any public transport stop provides a high-level assessment while access to frequent public transport provides a more refined assessment. similar measures are also included in the australian government's national cities performance framework (https://www.bitre.gov.au/national-cities-performance-framework). for older people, mobility is essential for social participation and wellbeing [66] . public transport is particularly important for older people who might have a reduced ability to drive. older people tend to use public transport more frequently if there is easy access to public transport in neighbourhoods at a distance less than 5 min away [67] . this is also consistent with existing research that found that the frequency of public transport and wait time affected older people's willingness to travel [68] and that a high proportion of older people are no longer driving [69] . data for these indicators can most often be sourced from public access data portals, open street map or general transit feed specification (gtfs) where public transport data are provided by transport agencies into a computer readable format for web developers [70] . gaining access to more detailed data describing public transport that meets disability standards is another very valid indicator and has been associated with increased satisfaction and perceived useability in older people [71] . similarly, access to a bus stop with an accompanying shelter and seat is also important for older people's mobility, as well as dropped curves, footpaths, and pedestrian signals [54] . housing is central to living a productive, meaningful, and healthy life, and housing quality is an important influence on self-reported health [72] . unaffordable housing is detrimental to mental health in low to moderate income households [73] . unaffordable housing has also been associated with an increased risk of poor self-rated health, hypertension, and arthritis, and renting, rather than owing a home, increases associations between unaffordable housing and self-rated health [74] . consequently, housing costs and gentrification [75] are particularly important to consider, with housing stress in lower income households being a particularly important indicator for the assessment of age-friendly cities. housing needs, sizes, and types can change as people age. older people might consider downsizing to smaller homes with reduced maintenance needs or to be closer to extended family for support to age in place [76] . in rural and regional areas, older people might need to move from larger farms and back into towns where services are more readily available. alternatively, frail older residents might require the support of aged care providers to support high care needs. addressing these issues means that communities need to understand the available housing diversity options (e.g., larger houses, smaller houses, units, and apartments to serve broad community needs) as well as access to services for residents. afc supports multiple housing options that are beneficial to all residents with many municipalities thinking primarily about formal aged-care accommodation when addressing housing needs for older people. even more concerning in australia, it is common for aged care facilities to be built on the outskirts of cities and towns where there is an abundance of inexpensive and undeveloped land. this isolates older people from the rest of the community, makes it harder for people to access and visit, decreases access to other community services, and decreases intergenerational contact within communities. the 30/40 housing affordability indicator is recommended and describes the proportion of households in the bottom 40% of household incomes spending more than 30% of their income on housing costs [77] . this measure is also referred to as the ontario measure where the interest in housing affordability first identified the disproportionate impact of housing costs on lower income households [78, 79] . understanding community demographic profiles, particularly age, in combination with the high incidence of 30/40 housing affordability issues should raise concerns for any community wanting to support age-friendliness. specifically, older adults on an aged pension within the private rental market will face significant challenges in housing affordability [80] . the indicator of access to services for older people was developed with older people themselves [37] and includes hospitals, general practitioners, aged care facilities, public transport stops, supermarkets, community centres, libraries, and universities of the 3rd age, and could also include places of worship and parks. this indicator also provides a useful assessment for the afc domain of community support and health services but is included in the housing domain to reinforce the importance of urban planning that supports the co-locations of services and housing options. the proportion of government owned dwellings could also be investigated as an additional support measure of afc, particularly in lower income areas. meaningful social relationships and participation are essential for good health, with health defined as a social phenomenon in the social determinants of health [81] . social participation has been associated with physical activity [82] , mental health [83] , reduced psychological distress [84] , reduced risk of myocardial infarction [85] , and up to a 50% increased likelihood of survival in people with strong social relationships compared to lifestyle risk factors [86] . for older people, social participation provides greater life satisfaction [87] , is protective against cognitive decline [88] , and contributes to resilience in older people [89] , especially in rural communities [90] . social participation is also being taken seriously internationally, and the united kingdom appointed a new minister for loneliness and a national government action plan on loneliness [91] . the recommended spatial indicators supporting social participation connect to the access to services for older people [92] that are included in the housing domain. two indicators are recommended: access to community centres and neighbourhood houses; and access to recreational services that cater to the needs of older people. shared or 'third spaces' such as these are critical social infrastructure [25] and essential in supporting social participation for older adults [93] . recreational services also support physical and mental health through opportunities for physical activity designed for older people and supporting community connections. another indicator recommended for inclusion is access to a local library, which also supports the afc domains of respect and social isolation, communications and information, and community support and health services. libraries provide multiple community benefits beyond simply lending books [94, 95] , including multimedia borrowing, technology training, community classes, lectures, and opportunities for intergenerational and community connections. libraries also support the need for learning opportunities across the course of life with universities of the third age (u3as) providing social and learning benefits to older people [96, 97] . this is associated with better physical health and activity levels [98] . places of worship are also considered an important facilitator of social connections and social capital [99] , particularly in humanitarian arrivals [100] and different cultures [101, 102] . respect and social inclusion are essential to ensure social participation for older people. there is much debate on the definition of social inclusion, though most studies refer to an objective participation in society and a more subjective assessment of whether the actual participation meets an individual's preferences [103] . most definitions of social exclusion emphasise the importance of social activities as a core component [104] . however, the effects of cumulative disadvantage, decreasing social networks, and age discrimination magnify the negative health and wellbeing impacts of social exclusion in later life [105] . a local or lived environment must provide accessible buildings, housing and transport, along with opportunities for social activities to occur if social inclusion and social participation are supported and encouraged. previous research on the services deemed important for older people has emphasised the importance of local services, such as shops [37, 69] , and this is supported by the use of new spatial indicators that can access formal and informal places to meet. these include recommended indicators of access to social clubs/senior citizens clubs or participation in international clubs, like rotary or probus, that are more formally organised by older people themselves. alternatively, informal opportunities for social inclusion include an indicator of distance-based access to local cafes that support broader intergenerational social opportunities. older people need a range of venues to create opportunities for social activities as a foundation for community respect and social inclusion. empowerment, autonomy and control [63, 106] , and employment conditions [107] were all found to be important influences of actual and self-reported health. control over one's own destiny has also been proposed [106] , consistent with an understanding of health being simultaneously influenced at the individual (micro/personal), place and community context (meso/community) as well as the larger societal context (macro/societal level) [108] . civic participation and employment are important influences of agency and autonomy in a society. consequently, it is important to understand how many older people are engaged in paid and unpaid productive activity in the community. this is best measured through the proportion of people who remain employed past the official retirement age (66 years in australia noting there is no official retirement age and eligibility for the aged pension is currently 66 years increasing to 67 years by 2023) or people aged 60 years or more who are engaged in regular volunteering. these indicators of paid and unpaid productive activity are also important measures of social engagement and civic participation and could be separated into additional age brackets or deciles (e.g., 60-75 years) for more detailed information. it is important to note that employment is also not defined according to hours worked, acknowledging both the civic connections and benefits that come from any level of paid employment and that retirement is not a single event and includes a diverse range of retirement patterns [109] . there has been criticism regarding the dominance of volunteering in measures of collective civic social participation in older people [110] with voting participation argued as a better measure of civic participation [111] . however, voting participation is less relevant in countries like australia where electoral voting is compulsory and volunteering activities are measured every 4 years. volunteering is also particularly important in regional areas of australia where third sector or non-profit organisations rely on older people volunteering [112] with increasing proportions of older people residing in rural locations [113] . in countries where voting is not compulsory (e.g., the usa), then voting participation could be considered as an additional measure of civic engagement. in 2016, approximately 86% of australian households had access to the internet [114] . this proportion decreased to 77% in remote areas where it is common to have a high proportion of older people within populations, with entertainment, social networking, and banking the most commonly supported activities supported by internet connection. internet access is also becoming more necessary to access information about the government, health, banking, and community services as well as to maintain contact with friends and family. finding information on services like these is also critical for older people to age in place and is necessary to support independent living and the connection to communities [115] . th information provision also extends beyond essential services and includes services provided by local libraries, which includes online books, audio, audio-visual, and educational resources that can be made available online for people with physical or geographical mobility restrictions. online streaming (e.g., netflix) is another more recent example of recreational activities supporting social connection and information provision. however, all these online resources require household internet access. access to a national radio service is another important source of information and becomes particularly important in emergency management, including preparation and recovery from natural disasters, such as floods, droughts, and bushfires, which are becoming increasingly more commonplace in australia. emergency sms messaging systems are also deployed during emergency situations to inform residents of impending safety risks but are worthless without adequate mobile phone reception. climate change is predicted to increase the likelihood of these emergency situations making telecommunications assessment essential in the support of afc. it is also necessary for developing technologies, including passive surveillance of movement monitoring within the home, personal alarm devices, and telehealth [116] , which have become increasingly accessible and necessary during the 2020 coronaviruses 2019 (covid-19) pandemic. communication is an important influence on the wellbeing of older people [117] , and both household internet and mobile phone reception provide essential telecommunication systems that support both intergenerational communication with family and friends, the communication of essential information [118] , and the ongoing adoption of new technologies [119] , as well as influence the quality of life [120] . currently, there is a paucity of references or inclusion of technological solutions offered to support afc and healthy ageing and technology, and icts have recently been suggested as a new smart age-friendly ecosystem framework [118] . suggestions included in this new framework to assist afc include: the development of smart housing; the inclusion of ageing in smart cities and engagement with the internet of things (iot); the better use of digital assistants (e.g., alexa) in the home; the use of digital robots for deliveries; electronic camera enabled doorbells; and motion sensors to detect mobility. technological features like these require inclusion during new housing development and have benefits across multiple afc domains beyond communication. they also require a rethink and interdisciplinary collaboration between planners, architects, developers, computer science, industry, and the government. while the opportunities are waiting for action, they also require engagement with older people themselves and their families using qualitative and ethnographic research methods [121] . this is an important area of growth and future development in afc and requires further research. access to primary health support services is essential and necessary for people to age in place. it is also the preferred option for most older people to maximise their health and wellbeing [122] . within the local community, access to general practitioners has been identified by older people themselves as essential community support services [36, 69, 123] and the key access point for primary health care. consequently, access to general practitioners was identified as an indicator of primary importance within community support and health services. these practitioners also provide gateway services and referrals to any other medical specialists, including geriatricians, who specialise in treating conditions that affect older people, including dementia. additional indicators that should be included relate to housing support either as in-home support packages or residential aged-care accommodation. all of these services are also included within a complete definition of social infrastructure, which has an important influence on subjective wellbeing [25] and are important components of liveability [19] . the approaches and spatial measures described above were applied in a case study in a regional context and rural centre in north-eastern victoria, australia. the regional town is located over 200 km north-east of the capital city of melbourne in the centre of the state of victoria, south-eastern australia. the major industries are agriculture and manufacturing, with a population of over 9000 people. both the state government department of health and the local municipality/council were interested in analysing and understanding afc and broader liveability given an increasingly ageing rural population. the spatial measures used to assess this included: walkability (with and without footpaths); access to public open space; access to public transport; housing affordability; housing diversity; government owned dwellings (social housing); access to services for older people; libraries; universities of the 3rd age; places of worship; volunteering; households with internet access; aged care facilities; and access to general practitioners. the results were presented to the local health department officials, the local municipality, and as a community presentation to residents at the local library. many of the challenges and barriers to afc planning were identified in the spatial measures and were confirmed by the lived experiences of residents from the local community. these included: poor walkability on the outer areas of town; difficulty getting to doctors and medical services located at the regional hospital located on the outer town boundary with limited public transport and poor walkability; disconnection between the older people, families, and younger people in the town due to the location of residential aged care on the town boundary next to the hospital; the importance of cafes and social spaces in the centre of town to support community and social connections; the value of the town's library, art facilities, and public open spaces; and inequity in the disadvantaged areas of the town that had reduced access to public transport and lower levels of household internet connections. the use of mapped spatial measures of afc was hugely beneficial for inter-agency conversations and planning initiatives as well as community conversations, engagement, and validation of the spatial analyses. the results also highlight the future negative impact of the age-friendliness of the town if future residential aged care development is supported in the outer areas of the town. the original who global age-friendly cities guide was developed in response to the rapid population ageing and urbanisation across the world and was informed by interviews conducted with older people themselves in over 33 different countries [7, 15] . the ultimate aim of afc is to create environments that support healthy ageing. this paper provided detailed, objective, and functional spatial measures of age-friendliness across lived environments that can be used to assess, monitor, evaluate, and communicate age-friendliness refined to the neighbourhood level. objective spatial measures of the lived environment are critical for the following reasons: to simplify assessments of afc; to provide a foundation level of knowledge about the age-friendliness of an environment; to assist local and state government planning by informing and monitoring future actions and interventions needed to promote healthy ageing in communities; and to include older people into targets of the 2030 sustainable development goals and the new urban agenda. the movement has previously been criticised for a lack of objective measurements and the need to connect these ideals into functional measures connected to policy, planning, and financial levers [10] . previous attempts at developing indicators of age-friendliness have been non-specific, non-coordinated, and reliant on survey-based responses (e.g., world health organization [15] ). such assessments are also beyond the budget, resources, capabilities, and motivation of local planning agencies and municipalities. the proposed spatial measures of age-friendliness across lived environments is relevant to planners, policymakers, advocacy organisations, governments, architects, industry, citizens and research audiences. the suggested indicators are provided to guide and inform discussions and interventions to promote healthy ageing. the measures can also be adopted and customised to local environments ranging in geographic and population sizes, rurality, climate conditions, and resource limitations. the proposed spatial indicators of afc address these issues through the application of gis technology to produce an objective assessment of the age-friendliness of local lived environments, drawing on indicators from the liveability literature that are specifically relevant to the values, preferences, and needs of older adults. these indicators provide measurement and quantification of afc domains consistent with the idea that value comes with measurement and leads to knowledge production as argued by lord kelvin over 200 hundred years ago [124] . the more simplistic interpretation of this, is that what is measured, is valued, and consequently is done. one of the critical issues raised in the recommended afc spatial indicators is the connection of all indicators within existing policy and planning contexts [13] . all the recommended indicators can be linked to existing policy and planning environments regardless of whether these have a local/municipal, state, or national focus. the connection of indicators to policy has been long identified within social indicator research [125, 126] . these indicators can assist governments in meeting their commitments to the sustainable development goals in a way that is meaningful for a growing segment of their populations. there is also an increasing interest and development in public health digital observatories. for example, relevant liveability indicators for the 21 largest cities of australia are available in the australian urban observatory (auo.org.au) launched in 2020. there is an opportunity to make spatial indicators available through novel data visualisation and ease of communication providing an influence on the policies required for healthy ageing across communities. the spatial indicators recommended for assessing afc domains can all be influenced and improved through policy levers. this includes the indicators suggested for outdoor spaces, transport, housing, social participation, respect and social inclusion, civic participation and employment, communications and information, community support, and health services. the indicator results can be influenced though local and immediate strategies or applied in advocacy with the responsible higher government agencies. this can include reviewing afc assessments within the context of current policy contexts, existing public health planning, liveability planning, transport planning, strategic planning, land use, and statutory planning it is also important to acknowledge the limitations of afc spatial indicators and understanding that these aggregated area-based results effectively act as icebergs of knowledge [35] providing a tip of the iceberg assessment of what is occurring, with additional information required to understand why the result is happening and how it can be addressed. consequently, the objective afc spatial indicators should also be combined with additional sources of knowledge. these include consultation and engagement with local older people themselves to expand understanding, prioritise actions, and support the greatest social and economic benefits and returns on investments that support improved health and quality of life for older people. given the diversity of cities, communities, and places, it is recognised that the achievement of all suggested indicators might not be feasible across all geographic settings. this is particularly relevant to rural and regional locales, which often have a lower population density and reduced levels of physical or social infrastructure. consultations with older people and combining subjective understandings with more objective afc spatial indicators will also help to inform the understanding of unique community contexts, including regional and remote areas. for example, high levels of walkability might not be possible across an entire town in a rural area with a small population. alternatively, signaled pedestrian crossings might not be necessary. however, a walkability assessment using the recommended walkability indicator could identify walking and transport barriers (e.g., a major road or bridge across a rail line) or identify the best location for new community services. alternatively, the distances and measures of accessibility listed within indicators may vary across diverse rural and regional settings, but as noted above, these definitions of access within indicators must be determined through consultation with the older adults and communities to a reach consensus on what can be reasonably expected within this locale. consequently, in certain settings, these proposed indicators should act as a tool to prompt place-specific discussions around what is important in terms of measurement indicators, and what is achievable (particularly in relation to what should constitute reasonable access). a notable challenge of afc planning is the absence of the relevant climate change implications in the current afc principles and domains and inclusion of ict and new technology. we recommend that future revision of afc should expand and account for the challenges associated with climate change given the implications on the health and wellbeing of older people [127] and the ultimate afc goal of healthy ageing. the relationship between older people's physical health and mental health with the environment, urban design, architecture, and afc could also be considered in the development of future indicators [128] . understanding and expanding afc spatial indicators for unique contexts and environments is needed in the future and this current foundation of recommended indicators can be applied and tested across a range of different locations. this could include localities with climatic extremes (e.g., heat, cold, and snow), regional and rural locations, international comparisons, and cultural differences to explore how communities differ and what additional indicators should be included. the major aim of this research was to propose a foundational set of objective afc spatial indicators that can be applied in any location with minimal resources and are directly aligned for policy intervention. this is particularly relevant to planning and policymakers working in government and was neither previously available nor consistently applied within afc locations. further research should investigate how this proposed suite of afc spatial indicators can be added to, refined, or customized to address the needs of many different locations, including the relevant subjective indicators to enhance knowledge. the inclusion of new technology and ict and 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and development: a report from the eklipse project the authors declare no conflict of interest. key: cord-323898-054gv684 authors: khan, anas a.; alruthia, yazed; balkhi, bander; alghadeer, sultan m.; temsah, mohamad-hani; althunayyan, saqer m.; alsofayan, yousef m. title: survival and estimation of direct medical costs of hospitalized covid-19 patients in the kingdom of saudi arabia (short title: covid-19 survival and cost in saudi arabia) date: 2020-10-13 journal: int j environ res public health doi: 10.3390/ijerph17207458 sha: doc_id: 323898 cord_uid: 054gv684 objectives: assess the survival of hospitalized coronavirus disease 2019 (covid-19) patients across age groups, sex, use of mechanical ventilators (mvs), nationality, and intensive care unit (icu) admission in the kingdom of saudi arabia. methods: data were retrieved from the saudi ministry of health (moh) between 1 march and 29 may 2020. kaplan–meier (km) analyses and multiple cox proportional-hazards regression were conducted to assess the survival of hospitalized covid-19 patients from hospital admission to discharge (censored) or death. micro-costing was used to estimate the direct medical costs associated with hospitalization per patient. results: the number of included patients with complete status (discharge or death) was 1422. the overall 14-day survival was 0.699 (95%ci: 0.652–0.741). older adults (>70 years) (hr = 5.00, 95%ci = 2.83–8.91), patients on mvs (5.39, 3.83–7.64), non-saudi patients (1.37, 1.01–1.89), and icu admission (2.09, 1.49–2.93) were associated with a high risk of mortality. the mean cost per patient (in sar) for those admitted to the general medical ward (gmw) and icu was 42,704.49 ± 29,811.25 and 79,418.30 ± 55,647.69, respectively. conclusion: the high hospitalization costs for covid-19 patients represents is a significant public health challenge. efficient allocation of healthcare resources cannot be emphasized enough. coronavirus disease 2019 (covid19) has affected every continent on earth, and the number of confirmed cases has exceeded 9 million worldwide [1] . as more details about covid-19 and its associated risk factors have surfaced, the diagnostic and clinical features, treatment, typical clinical course, and monitoring which distinguish the virus that causes covid-19, severe acute respiratory syndrome coronavirus 2 (sars-cov-2), have become clear. however, there remain inconsistencies in disease severity among patients and mortality among different countries that hamper the assessment and triage of patients [2] [3] [4] [5] [6] . the overall case fatality rate (cfr) of covid-19 has been estimated be~0.7% (95% confidence interval (ci): 0.4-1.0) and to range from 0.001% to 10.1% among those under 20 and over 80 years of age, respectively [7] . moreover, it has been reported that the cfr can reach as high as 17% in the northern regions of italy [8] . in china, yan-ni and colleagues estimated the cfr to be 6.1 ± 2.9% [9] . however, the cfr can be as high as 28% among hospitalized patients [10] . although the rate of hospitalization among patients confirmed to have covid-19 is <5%,~19% of hospitalized patients in france are transferred to the intensive care unit (icu) [7] . the median length of l stay (los) for covid-19 patients has been reported to be ≤8 days based on a chinese study; however, larger studies may be needed to better understand the course of covid-19 after icu admission [6, 11] . in addition, the los varied significantly between countries even before the pandemic [11] . in saudi arabia, the rate of hospitalization among all confirmed covid-19 cases during march 2020 was 71.6% according to alsofayan and colleagues, but the mortality rate was as low as 0.65% [12] . this high reported rate of hospitalization among covid-19 cases may exacerbate the cost burden of viral respiratory infections in a country that was deeply affected by the middle east respiratory syndrome (mers) in 2012, and resulted in a huge financial burden with an estimated direct medical cost per patient of sar 48,551.36 (united states dollars (usd) 12,947.03) [13] . in light of the high rate of hospitalization among covid-19 patients in saudi arabia, there is a need to identify different sociodemographic (e.g., age, sex) and medical (e.g., mechanical ventilator (mmv) use, icu admission) status that might increase mortality risk. moreover, the cost of hospitalization should be estimated. providing government officials and clinicians with clear guidance on the risk factors, mortality rate, and how to prioritize screening, testing, isolation or quarantining of covid-19 cases is imperative to manage this pandemic effectively and efficiently. here, we investigated the survival of hospitalized covid-19 patients in saudi arabia across age groups, sex, nationality, mv use, and icu admission. furthermore, the average cost of hospitalization due to covid-19 per patient was estimated. this study protocol was approved by the ethics review board committee of the central ministry of health (20-75m) in riyadh, saudi arabia. the data of this study were retrieved from the health electronic surveillance network (hesn) database of the saudi ministry of health (moh) for covid-19 patients. all symptomatic patients with confirmed covid-19 after being tested in outpatient settings and confirmed in inpatient settings upon admission in saudi hospitals from 1 march to 29 may 2020 were included. the retrieved variables were age, sex, nationality (saudi vs. non-saudi), city, hospital, date of hospital admission, date of discharge from hospital, mv use, inpatient environment (icu vs. general medical ward (gmw)), and final status (discharge vs. death). data on comorbidities were missing for most cases. no re-admissions for the covid-19 patients were encountered in the retrieved data. all consecutive patients were assumed to receive standardized treatment protocols for covid-19 as posted on the moh website, and these protocols were (and are still being) updated on a regular basis. the cost of hospitalization was estimated using the micro-costing method as stated in the protocols for covid-19 management set by the moh. the cost of hospitalization was based on the cost of: all medications (e.g., antivirals, antibiotics, anticoagulants, hydroxychloroquine); personal protective equipment (e.g., n95 masks, gowns, protective eyewear); oxygen; mvs; isolation-room fees (icu vs. gmw); fees of physicians and other medical staff; laboratory and diagnostic tests (e.g., polymerase chain reaction, complete blood count, liver/cardiac enzymes, swabs, cultures, radiographs and computed tomography of the chest). data on inpatient costs were retrieved from the moh cost center. the cost is presented in saudi riyals (sar). this was a retrospective cohort study upon which covid-19 patients were followed up retrospectively between 1 march and 29 may 2020 from the date of hospital admission to discharge from hospital with final status which was either death or discharged alive (censored). those without any update on their status were excluded. kaplan-meier (km) survival analyses were created to examine the survival probability overall as well as across age groups. moreover, the survival probability was estimated across mv use and sex, nationality (saudi vs. non-saudi), and inpatient environment (icu vs. gmw). comparisons of different strata were adjusted using tukey's method. the hazard ratio (hr) for death was generated using multiple cox proportional-hazards regression that included the variables of: mv use (no vs. yes), age, sex (female vs. male), and inpatient environment (icu vs. gmw). significance was considered at α < 0.05, and the 95%ci is shown for different strata in all km survival curves and reported for all hrs. statistical analyses were conducted using sas ® v9.4 (sas, cary, nc, usa). the number of patients hospitalized due to covid-19 between 1 march 2020 and 29 may 2020 was 6575. however, 5153 patients were not listed as having a final status (discharged alive or death) in the hesn database as of 29 may 2020. therefore, only 1422 patients with final status (discharged alive or death) were eligible to be included in our analyses ( figure 1 ). the majority of the patients were male (77.71%), and between 25 and 54 years of age (67.65%). most patients were non-saudi (68.78%), and from medina (57.95%). only 15% of patients were admitted to the icu, and mv use was indicated in 13% (table 1) . about 16% of patients (263 patients) died in hospital. the median los was 7.93 days, with a maximum los of 43 days. the overall mean survival time from admission to final status (discharged alive or death) for the study cohort was 21 days with differences across different variables (table 2 ). older covid-19 patients had a significantly shorter mean duration of survival compared with their younger counterparts (p < 0.0001). patients on mvs had a significantly shorter mean duration of survival compared with those not on mvs (8.87 vs. 18.93 days, p < 0.0001). likewise, those admitted in icus had a significantly shorter mean duration of survival compared with those admitted to other inpatient environments (11.13 vs. 18.89 days, p < 0.0001). the survival probability (which was estimated using km curves in all cases) of the overall study cohort from hospital admission up to the second day of hospitalization was estimated to be 0. figure 6 ). for each 1-year increase in age, the death risk increased by an estimated 2.3% (hr = 1.023, p < 0.0001). the risk of death among patients on mvs was five-times higher compared with their counterparts who were not on mvs (hr = 5.15, p < 0.0001). the death risk for non-saudi patients was 36% higher than that of their saudi counterparts (hr = 1.36, p = 0.049). furthermore, the death risk for patients admitted to the icu was more than twice that of their counterparts admitted to the gmw (hr = 2.08, p < 0.0001). being female was not associated with a lower risk of death (hr = 0.944, p = 0.725). the adjusted hrs with their 95%cis are shown in table 3 and figure 7 . the covid-19 pandemic has had a detrimental effect on global healthcare systems, and affected every aspect of human and economic life [14] . as of 22 june 2020, the number of covid-19 cases in saudi arabia has exceeded 161,000, with an estimated case fatality rate (cfr) of 0.81% [15] . the reported cfr is far below that of france, belgium, spain, italy, and the uk, which have reported a cfr between 11.5% (spain) to 16% (belgium) [1, 5, 16] . however, the cfr among hospitalized covid-19 patients is far higher than the population-level cfr. our study (which is the first to report the survival probability across age groups, sex, nationality, mv use, and icu admission among a sample of hospitalized covid-19 patients in saudi arabia) revealed the cfr to be 16.6%. this cfr is far below the reported cfr among hospitalized patients in the uk (33%) [17] (docherty et al., 2020), italy (27%) [18] , and the usa (21%) [19] . in addition, the percentage of hospitalized patients treated in the icu or who received invasive ventilation was similar to the one reported in the usa [19] . the overall 30-day mortality among our cohort was 16.6%, but the 14-day mortality (15.81%) represented >91% of deaths. this finding suggests that the first 14 days of hospitalization are critical for covid-19 patients, which has also been reported among a sample of hospitalized italian patients with covid-19 [18] . the overall 14-day and 30-day survival probability (using km curves) was 0.699 and 0.459, respectively. this observation is consistent with a study conducted in sichuan province in china, which found that the los was associated with higher risk of death [20] . older adults were at a significantly higher risk of death compared with those in other age groups, a finding that is in accordance with the work of other scholars [21, 22] . this higher risk of mortality among icu patients aligns with the findings of research studies among hospitalized covid-19 patients [23] . although most hospitalized patients were male, the risk of mortality was not higher among male patients in comparison with their female counterparts. this finding contradicts the observations of other scholars who showed a higher risk of mortality among hospitalized male patients with covid-19 [24, 25] . patients on mvs had a more than five-times higher risk of death compared with their counterparts not on mvs, a finding that is similar to data from auld and colleagues [26] . pareek and collaborators reported that ethnicity may have a role in the survival of covid-19 patients [27] . we found that hospitalized non-saudi patients were at a slightly higher risk of mortality. this could be attributable to the fact that many non-saudi patients who were hospitalized for covid-19 did not have legal residence status, and lack health insurance coverage prior to the covid-19 pandemic. however, this could change if other diseases (e.g., diabetes mellitus, asthma, hypertension, cardiovascular diseases, or chronic renal failure) were controlled for in the analysis. a major concern about the covid-19 pandemic is the high cost burden to healthcare systems. we calculated the direct medical cost associated with treatment of covid-19 patients in saudi arabia. the cost of covid-19 treatment was calculated based on moh treatment protocols and accounted for all health resources used to deliver care to covid-19 patients. our cost data highlighted differences in resource utilization between patients presenting with moderate-to-severe symptoms versus critical cases who required icu admission. our cost analyses illustrated that the mean direct medical cost of patients with moderate-to-severe covid-19 symptoms admitted to the gmw was sar 5303.21per patient per day, which was much lower compared with the mean cost per patient per day for patients admitted to the icu (e.g., sar 9727.41). however, the difference in the mean cost per patient per day between patients who needed mvs and those who did not need them was sar 2244.42 and sar 3405.42 among patients admitted in gmw and icu, respectively. the total direct medical cost per patient was calculated based on the level of care and los. the total direct medical cost per patient for those with moderate-to-severe symptoms admitted to the gmw was sar 42,704.49. however, there was an approximate twofold increase in the cost for icu patients (e.g., sar 79,418.30). interestingly, the total cost for patients on mvs was slightly lower in comparison with their counterparts admitted to the gmw but who were not on mvs. this finding was largely attributable to a significantly shorter duration of survival and higher rate of mortality among patients on mvs, which translated to a shorter los and, eventually, lower total cost per patient. however, this finding is not consistent with data from a study by rae and colleagues, who reported that patients on mvs often required a longer hospital stay with a higher cost of healthcare-resource utilization [28] . there is a dearth of data about the direct medical cost of covid-19 in the middle east. very few scholars have assessed the financial impact on healthcare systems worldwide. the mean direct medical cost per patient (in usd) has been reported to be 2395 in china [29] , 10,000 in canada [30] and 4633.43 in india [31] . a study published recently in the usa reported the mean cost of treatment of patients with mild covid-19 who were not hospitalized ranged from usd 32 for consultation over the telephone to usd 96 for a clinic visit [32] . those data are in accordance with our observations because mild cases are often not hospitalized and used medications mainly for relief from fever or pain only. moreover, that usa study estimated the median direct medical cost of caring for patients with moderate covid-19 symptoms who did not require hospitalization but had to be seen at emergency department was usd 3045, and was usd 14,366 for those with more severe symptoms that necessitated hospitalization. based on those estimates, the total direct medical cost in the usa has been projected to range from usd 163.4 billion to usd 654.0 billion [32] . in sweden, the total direct medical cost has been projected to reach usd 2 billion [33] . the mean direct medical cost per patient we estimated was sar 48,436.18 (usd 12,916.31), which was not significantly different from the one reported for the management of a mers-cov patient in saudi arabia (usd 12,947.03) [13] . however, the total direct medical cost of covid-19 far exceeds the one reported for mers-cov due to the high number of covid-19 infections that are being reported on a daily basis. these variations in cost estimates across countries highlight the challenges in estimating and comparing the direct medical costs globally given the vast differences in the cost of treatment protocols, personnel cost, and utilization rates of healthcare resources and their prices between countries. our study had four main limitations. first, we did not include all hospitalized patients in saudi arabia, which limits the generalizability of our findings. second, variables such as comorbidities (e.g., diabetes mellitus, asthma, cancer, hypertension, chronic kidney disease), smoking status, and occupation were not investigated, which may have changed our findings if they had been controlled for in our analyses. additionally, the study did not control for the changes in the treatment protocols and their potential impact on mortality rates. third, this study was conducted from the perspective of healthcare payers, and did not take into consideration other important costs, such as productivity losses and "lockdown" costs. therefore, the economic impact of covid-19 would have been much greater. fourth, the outcomes for patients who were discharged alive (censored) cannot be ascertained as some discharged patients may have died or readmitted afterwards. future research should examine the: (i) survival probability for hospitalized covid-19 patients controlling for comorbidities and other potential confounders; (ii) cost of covid-19 on other important sectors of the economy; (iii) total direct medical costs of covid-19 to the saudi arabia healthcare system. an interactive web-based dashboard to track covid-19 in real time clinical features of patients infected with 2019 novel coronavirus in systematic review of covid-19 in children shows milder cases and a better prognosis than adults the novel coronavirus pneumonia emergency response epidemiology team the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19)-china, 2020 case-fatality rate and characteristics of patients dying in relation to covid-19 in italy clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a 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tracker website china spends $2395 on average for each covid-19 patient effectiveness and cost-effectiveness of public health measures to control covid-19: a modelling study rs 3.5 lakh spent on each covid-19 patient in victoria hospital: karnataka minister the potential health care costs and resource use associated with covid-19 in the united states. health aff covid-19 health care demand and mortality in sweden in response to non-pharmaceutical (npis) mitigation and suppression scenarios this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-302553-d0hk4ipg authors: shan, siqing; yan, qi; wei, yigang title: infectious or recovered? optimizing the infectious disease detection process for epidemic control and prevention based on social media date: 2020-09-19 journal: int j environ res public health doi: 10.3390/ijerph17186853 sha: doc_id: 302553 cord_uid: d0hk4ipg detecting the period of a disease is of great importance to building information management capacity in disease control and prevention. this paper aims to optimize the disease surveillance process by further identifying the infectious or recovered period of flu cases through social media. specifically, this paper explores the potential of using public sentiment to detect flu periods at word level. at text level, we constructed a deep learning method to classify the flu period and improve the classification result with sentiment polarity. three important findings are revealed. firstly, bloggers in different periods express significantly different sentiments. blogger sentiments in the recovered period are more positive than in the infectious period when measured by the interclass distance. secondly, the optimized disease detection process can substantially improve the classification accuracy of flu periods from 0.876 to 0.926. thirdly, our experimental results confirm that sentiment classification plays a crucial role in accuracy improvement. precise identification of disease periods enhances the channels for the disease surveillance processes. therefore, a disease outbreak can be predicted credibly when a larger population is monitored. the research method proposed in our work also provides decision making reference for proactive and effective epidemic control and prevention in real time. the traditional infectious disease detection process is being challenged by potential social media applications [1, 2] . the latest estimates released by the united states centers for disease control and prevention (us-cdc) revealed the worldwide severity of the illness. according to this authoritative report, the us-cdc estimates that in the period between 1 october 2018 and 4 may 2019, there were approximately 37.4 million to 42.9 million flu infectious in the population population, among which there were from 17.3 to 20.1 million flu-related medical visits [3] . furthermore, 531,000 to 647,000 people require flu-related hospitalizations, and unfortunately, influenza caused 36,400-61,200 estimated deaths. this estimate is based on more recent data from a larger and more diverse group of countries, including lower middle-income countries, and this estimate excludes deaths from non-respiratory diseases. the statistics indicate a severe reality and a pressing challenge because influenza causes significant losses of human life and damage to property worldwide. as evidenced by the current flu season, influenza viruses can rapidly mutate, evading the most current vaccine formulations [4] . infectious diseases continue to be the leading cause of death worldwide, and they cause serious loss of life and property when they cannot be quickly and accurately assessed [5] . the world health the fundamental cause of these serious outbreaks is summarized as follows. first, traditional disease prevention and control institutions mainly rely on a single channel for information monitoring and access. specifically, data are exclusively sourced from clinical statistics. however, relying exclusively on clinical statistics has obvious disadvantages, such as being time consuming and creating high labor costs [8, 9] . the traditional detection methods cannot integrate multichannel infectious disease information, such as social media and search engine data. second, social media data are a powerful and promising tool that have been applied to many research subjects, such as healthcare informatics [10, 11] , sentiment analytics [12] , and disaster management [13] [14] [15] . the remarkable value of social media has been widely recognized [16] . particularly in this paper, we refer to microblogs posted on social media platforms especially from sina weibo as weibos. although disease prevention and control institutions have exerted a significant role in disease detection, they might come up against substantial difficulties in using social media data in disease detection and control due to the lack of analytic methods or accurate monitoring of outbreaks and periods of infectious diseases. there is still a long journey to go to fully utilize social media data in disease prevention and control. third, the flu is characterized by strong contagiousness and rapid spread, which makes it difficult to monitor in real-time or precisely estimate the spread of the flu. for the fundamental cause of these serious outbreaks is summarized as follows. first, traditional disease prevention and control institutions mainly rely on a single channel for information monitoring and access. specifically, data are exclusively sourced from clinical statistics. however, relying exclusively on clinical statistics has obvious disadvantages, such as being time consuming and creating high labor costs [8, 9] . the traditional detection methods cannot integrate multichannel infectious disease information, such as social media and search engine data. second, social media data are a powerful and promising tool that have been applied to many research subjects, such as healthcare informatics [10, 11] , sentiment analytics [12] , and disaster management [13] [14] [15] . the remarkable value of social media has been widely recognized [16] . particularly in this paper, we refer to microblogs posted on social media platforms especially from sina weibo as weibos. although disease prevention and control institutions have exerted a significant role in disease detection, they might come up against substantial difficulties in using social media data in disease detection and control due to the lack of analytic methods or accurate monitoring of outbreaks and periods of infectious diseases. there is still a long journey to go to fully utilize social media data in disease prevention and control. third, the flu is characterized by strong contagiousness and rapid spread, which makes it difficult to monitor in real-time or precisely estimate the spread of the flu. for example, the flu can be easily spread by droplets or contaminated items in the air and contact among people. the centers for disease control and prevention (cdc) publishes data on influenza-like illness ili based on statistics and evaluation after a patient's visit. it would be extremely difficult to obtain information and perform an analysis before the visit. however, apparently, time lags could lead to delayed treatment. fourth, google flu trends (gft) provided an estimate of more than double the proportion of clinical data for influenza-like illness (ili) published by the centers for disease control and prevention (cdc) [17] . the ili was calculated based on surveillance reports from laboratories across the united states [18] . google used web search data to propose a gft model for real-time monitoring. when patients are aware of their active flu period and search for flu-related keywords through search engines such as google, the patients' behavior is recorded by the search engine. social media sensors, in contrast, show unique advantages for quick flu monitoring and reliable estimation and prediction. there has been a growing consensus that social media sensors can also perform real-time monitoring that is more accurate than gft [8] . fifth, part of the ili data cannot be collected and thus are not available if the patient does not go to the hospital, which makes disease monitoring information inaccurate and incomplete. therefore, the severity and urgency of the disease as reflected by traditional statistics are often underestimated. however, social media can capture this part of the data because when bloggers catch a cold, they can post their own flu symptoms through social media. if bloggers do not realize that they catch flu, they can also post some flu-related microblogs on social media. this part of the data can also be seen in advance of cdc released reports [19] . sixth, the previous literature mainly focused on whether the bloggers are infected based on the social media platform [20] and cannot accurately distinguish the various periods of the disease, which largely reduces the effectiveness and pertinence of the information for disease control measures. this section provides an extensive review of the relevant literature in three parts: optimization of the infectious disease detecting process, social media utilization for disease detection and semantic analysis techniques based on social media data. much of the current research focuses on social media to analyze short texts [21] [22] [23] , in which several papers predict flu trends by classifying flu-related social media data [19] . however, these studies do not divide the flu periods any further. speedily evolving infectious diseases, including sars, ebola and influenza, pose significant health threats throughout the world because of their rapidly changing status and complicated detection process [24, 25] . a considerable amount of work is devoted to forecasting disease outbreaks. a two-period model optimized the process of when and where to assign ebola treatment units across geographic regions during the outbreak's early phases [26] . chen et al. (2018) developed a mixed-integer programming (mip)-based framework to systematically analyze a rich set of policies and to determine the optimal hepatocellular carcinoma surveillance policies that maximize the societal net benefit [27] . it is observed that the surveillance policies should be adapted to different disease progression rates and states. several studies in this area focused on finding optimal surveillance solutions for flu vaccine production and allocation [28, 29] . another study considered the conditions of limited reporting and spatial aggregation on the optimization of influenza surveillance system design [30] . research in this area is mainly concerned with epidemiological inference and prediction based on clinical data collection, but few of the studies provide improved detecting measures using social media data, which represent an alternative source of passive traditional surveillance data that have a larger volume and fewer reporting delays. data from social networks show apparent advantages in several aspects, such as being real time and time-sharing, along with a broad scope of data coverage [31] [32] [33] [34] . disease surveillance has been investigated based on the recent rise in the popularity and scale of social media data. aiello et al. (2011) reviewed and addressed the use, promise, perils, and ethics of social media-and internet-based data collection for public health surveillance [35] . additionally, the infectious disease detection process is being challenged by the potential applications of social media [1, 2, 36] . multiple types of social media have become emerging and promising data sources of disease surveillance and shown advanced achievements in tracking health informatics in different areas all over the world. raamkumar et al. (2020) examined the differences of covid-19-related public responses on facebook in the united states, england and singapore and showed that social media analysis was capable of providing insights about the communication strategies during disease outbreaks [37] . lwin et al. (2018) and vijaykumar et al. (2017) investigates how facebook can be utilized to implement and adapt in responding to the zika epidemic in singapore [38, 39] . moreover, dubey et al. (2014) identified and evaluated youtube as significant resource for providing and disseminating information on public health issues like west nile virus infection [40] . davidson et al. (2015) constructed an empirical network to substantially improve performance in predicting infections one week into the future using cdc data and combining this with internet-based data in the u.s. [41] . chen et al. (2016) proposed two temporal topic models to capture hidden states of a flu-related user and get better flu-peak predictions by using twitter data. in addition, they validated their approaches by modeling the flu using twitter in multiple countries of south america [42] . lamb et al. (2013) demonstrated that the use of twitter data leads to significant improvements in flu surveillance by discriminating those categories of flu tweets that reported infection from those that expressed concerned awareness of the flu as well as tweets about the authors versus those about others [43] . sentiment classification [44, 45] , feature extraction [46] and public opinion monitoring [47, 48] are performed based on a social network dataset for sentiment analysis. chen et al. (2020) introduced a novel approach of adding semantics as additional features into the training set for sentiment analysis, and they applied this approach to predict sentiment for three different twitter datasets [49] . the authors also investigated the real-time flu detection problems and proposed a flu detection model with emotional factors and semantic information [50] . adamopoulos et al. (2018) examined the effect of latent personality traits on consumers' behavior and preferences, which originated from social media users' levels of emotional range [51] . the effect of social media advertising content on customer engagement was also studied via facebook users' humor and emotion [52] . although sentiment analysis has been widely applied to many fields, few researchers consider it to be a powerful tool to be used in determining a patient's status when detecting infectious diseases. furthermore, word embedding techniques, such as bag of words [53] and word2vec [54] , have become effective means of text processing. high-quality word vector representations provide distributional information about words [55] , especially for word2vector, which appears to be outstanding at improving a model's performance on a limited amount of data. the development of word2vector significantly improves the effectiveness of word representations by transforming sparse, discrete and high-dimensional vectors into dense, continuous and low-dimensional vectors [56] . it is a foundation to transform word segments into fixed dimensional vectors, namely, word embedding, when studying user-generated content [57, 58] . in this paper, the use of high dimensional numeral vectors to represent words serve as semantic feature extractors or the input variables of a neural network. artificial neural network (ann) techniques have been used widely in text classification. hughes et al. (2017) have used convolutional neural networks (cnns) for text processing and classification in online news, reviews and medical text [59] . a large number of modified ann techniques have emerged with technical advancements. recurrent neural networks (rnns) have also been an effective method for speech recognition and text sequence tagging [60] , and long short term memory (lstm) networks [61] perform well for sequence-based learning tasks. in addition, a large amount of text processing research has emerged, including the use of part-of-speech tagging [62] , lexicon approaches [63] , and other deep learning techniques [64] . the extant literature has several key limitations. firstly, the abovementioned studies have mainly focused on a single aspect of text processing, sentiment classification or flu tracking [43, 62] . more importantly, these papers do not adequately consider the influence of sentiment polarity on the classification of flu-related weibos or on dividing the different periods of flu-related weibos [50] . therefore, this paper incorporates sentiment factors into flu surveillance research, and the period classifications of flu-related weibos are probed. second, neural network techniques are used to process the weibos at the text level [61, 65] . lstm networks can be used for sentiment analysis of film reviews, part-of-speech tagging, and other fields [60] . previous studies show that lstm performs relatively well in text processing but has been rarely used for disease weibo analysis. to fill in this gap, this paper aims to investigate the relationship between sentiment polarity and the flu period at the word level and text level based on a weibo dataset. the main research rationale of this study is straightforward, i.e., first, to investigate the relationship between the sentiment polarity and the flu period from social networks, and second, to optimize the disease detecting process by predicting the different periods of flu. the model proposed in this paper can detect infectious diseases through multiple channels; they can be perceived earlier and the model larger populations and more efficiency than traditional processes (see figure 2) . as the "to-be" process optimized by social media, the mc-iddp process can improve the reliability of detecting infectious disease and discover more infectious people. it recognizes the disease periods earlier and works in an efficient way. next, we propose 4 propositions and corresponding demonstrations. figure 3 . figure 3a shows the logical structure model of a solitary channel, and figure 3b shows the logical structure model for multiple channels. the upper part of figure 2 is a schematic diagram of a traditional solitary infectious disease detecting process. patients usually go to the hospital when they have already suffered influenza. only afterwards it is possible for the cdc to detect the flu trends of the whole society. in the "as-is" process, there is only one channel to detect infectious diseases, which is through hospital institutions. the "as-is" process is abbreviated as sc-iddp. the "to-be" process is the multiple channel infectious disease detection process (mc-iddp). the bottom part of figure 2 illustrates the mc-iddp process based on social media platforms. mc-iddp has three infectious disease detecting channels. channel 1 is the traditional infectious disease detecting channel, mentioned above. channel 2 monitors the infectious diseases by using search engines [17, 18] . this paper constructs channel 3 to detect infectious diseases using social media data. compared with channel 1 and 2, channel 3 enables more effective disease detection for the following three reasons. first, the traditional channel 1 is not able to use social media data to detect diseases, such as flu, whereas channel 2 and channel 3 can use these data. second, search engines can detect the keywords of the corresponding flu symptoms and treatments in channel 2 when people realize that they have the flu. it neglects some of the patients who have caught the flu but do not search for flu keywords and simultaneously adds fake patients who run the search engine for flu keywords without flu. third, although people do not realize that they have caught the flu, they usually post tweets via social media to reflect their feelings, opinions and behaviors, which can be detected by channel 3. it helps the cdc to analyze social media data to discover early flu trends. additionally, channel 3 can not only monitor infectious disease outbreaks in early stages but also identify the flu period. the content inside the dotted line (shown in figure 2 ) is the main research content of this paper, which aims to find the flu-related weibos and further determine the flu period to improve the accuracy of infectious disease detection. as the "to-be" process optimized by social media, the mc-iddp process can improve the reliability of detecting infectious disease and discover more infectious people. it recognizes the disease periods earlier and works in an efficient way. next, we propose 4 propositions and corresponding demonstrations. figure 3 . figure 3a shows the logical structure model of a solitary channel, and figure 3b shows the logical structure model for multiple channels. as the "to-be" process optimized by social media, the mc-iddp process can improve the reliability of detecting infectious disease and discover more infectious people. it recognizes the disease periods earlier and works in an efficient way. next, we propose 4 propositions and corresponding demonstrations. figure 3 . figure 3a shows the logical structure model of a solitary channel, and figure 3b shows the logical structure model for multiple channels. the main parameters are described as follows. represents the number of possible infectious people; represents the number of possibly infectious people recorded by hospitals using a solitary channel; represents the number of possibly infectious people but do not go to the hospital in a solitary channel; represents the number of infectious people who are diagnosed and reported to the cdc in a solitary channel; represents the number of possibly infectious obviously, in a solitary channel, in multiple channels, without the loss of generality, it is assumed that the number of infectious people who are admitted to the hospital remains the same regardless of whether it is a solitary channel or multiple channels, which is, (3) the following relationship exists, according to formula (4), in multiple channels, more infectious people can be detected. proposition 1 is validated. the mc-iddp process recognizes the patients early and detects the infectious disease in time. the google flu trends model provides a promising measure in that the search engine records the users' relevant search data on disease symptoms and treatments, to detect infectious diseases. additionally, some of the patients do not realize that they might be infected but post weibos with disease symptoms. therefore, people's sentiment and physical conditions can be reflected in social media, which is an important infectious disease sensor. we added time information in figure 3b to generate figure 4 . the horizontal axis t indicates the earliest time at which each channel can detect infectious disease information. no go to the hospital, and do not use search engines and social media in multiple channels; represents the number of infectious people who are diagnosed and reported to the cdc in a solitary channel; represents the number of infectious people who are detected by the three channels and reported to the cdc. obviously, in a solitary channel, in multiple channels, without the loss of generality, it is assumed that the number of infectious people who are admitted to the hospital remains the same regardless of whether it is a solitary channel or multiple channels, which is, the following relationship exists, according to formula (4), in multiple channels, more infectious people can be detected. proposition 1 is validated. the google flu trends model provides a promising measure in that the search engine records the users' relevant search data on disease symptoms and treatments, to detect infectious diseases. additionally, some of the patients do not realize that they might be infected but post weibos with disease symptoms. therefore, people's sentiment and physical conditions can be reflected in social media, which is an important infectious disease sensor. we added time information in figure 3b to generate figure 4 . the horizontal axis t indicates the earliest time at which each channel can detect infectious disease information. in figure 4 , ept represents the earliest possible time, and represents the earliest possible time to detect the disease by channel . obviously, we conclude that in figure 4 , ept represents the earliest possible time, and t ept ci represents the earliest possible time to detect the disease by channel i. obviously, we conclude that according to formula (5), the ept for channel 3 is the smallest, and the ept for channel 1 is the largest. therefore, the mc-iddp process based on social media data can achieve more timely monitoring. proposition 3. the mc-iddp process can conduct infectious disease detection more efficiently. demonstration 3. in the mc-iddp process, channel 1 requires a large number of doctors and staff with high operating costs, but channel 2 and channel 3 rely only on big data and analytical tools to conduct the surveillance. compared with channel 1, the operation costs of channel 2 and channel 3 can be negligible. therefore, the total cost of the mc-iddp process is almost the same as the total cost of the sc-iddp process. however, the mc-iddp process can achieve a wider range of detection (according to proposition 1), and thus, the mc-iddp process has higher monitoring efficiency. proposition 3 is validated. the detection accuracy is defined as the percentage of the correct number of patients out of the total number of possible patients who have been monitored through the infectious disease detection channels. in this paper, the detection accuracy (acc d ) can be calculated by the following equation, where tp is an abbreviation of true positive, which indicates that an infectious patient is diagnosed as a patient; tn is an abbreviation of true negative, which means that a nonpatient is diagnosed as a nonpatient; fp is an abbreviation of false positive, which indicates that a nonpatient is misdiagnosed as a patient (type i error); fn is an abbreviation for false negative, which means that a real patient is misdiagnosed as a nonpatient (type ii error). the detection accuracy in any channel of the mc-iddp process helps to improve the entire accuracy of the disease detection. the mc-iddp process has three disease detection channels. each channel has independent methods and techniques. the detection accuracy of channel 1 depends on the hospital's medical plan and medical technology. the detection accuracy of channel 2 depends on the statistical analysis and technical means used by the search engine. the detection accuracy of channel 3 depends on the semantic analysis and machine learning application to social media data. the detection results of the three channels do not affect one another, and thus, the detection accuracy of each channel is related to only the method and supporting technology of that channel. increasing the detection accuracy in any channel can improve the entire accuracy of the disease detection. the proposition is validated. this paper focuses on detection channel 3. to improve the detection accuracy of channel 3 using social media data, this paper proposes an effective dual analytical activity model to determine the status and period of the infected population. the next section discusses the infectious disease detection channel 3 and the main activities. the infectious diseases detection channel 3 is a crucial channel for the mc-iddp process that makes direct use of social media data. it has two main activities: flu-related semantic examination activity and flu-period sentiment measure activity, and thus, channel 3 is also named the dual analytical activity model, as shown in figure 5 . the contents and features of the model are described in detail in the following section. the purpose of the flu-related semantic examination activity is to enable semantic recognition and analysis of social media data based on infectious diseases (taking the flu as an example). the main content of the activity includes at least 12 steps, such as determining keywords for searching infectious disease data and obtaining relevant social media data, as shown in figure 5 . next, we provide some crucial steps. six keywords were crawled from sina weibo; these six keywords include "flu (gan mao)", "influenza (liu gan)", "cough (ke sou)", "fever (fa shao)", "sneeze (pen ti)" and "nasal congestion (bi sai)". we used python for this task, and these flu-related weibos constitute an elementary corpus. considering the existence of advertisements and forwarding, this study used support vector machine (svm) to screen the invalid data and retain the flu-related weibos. the final flu-related weibo corpus is generated after word segmentation and the removal of stop words. the entire process the purpose of the flu-related semantic examination activity is to enable semantic recognition and analysis of social media data based on infectious diseases (taking the flu as an example). the main content of the activity includes at least 12 steps, such as determining keywords for searching infectious disease data and obtaining relevant social media data, as shown in figure 5 . next, we provide some crucial steps. 1. obtaining flu data based on social media six keywords were crawled from sina weibo; these six keywords include "flu (gan mao)", "influenza (liu gan)", "cough (ke sou)", "fever (fa shao)", "sneeze (pen ti)" and "nasal congestion (bi sai)". we used python for this task, and these flu-related weibos constitute an elementary corpus. 2. cleaning the flu data considering the existence of advertisements and forwarding, this study used support vector machine (svm) to screen the invalid data and retain the flu-related weibos. the final flu-related weibo corpus is generated after word segmentation and the removal of stop words. the entire process is shown in figure 6 . this activity is mainly to accurately identify the patient's disease period to improve the detection accuracy of infectious diseases. the whole process includes six steps. activity 2 in figure 5 shows that the word level detection consists of 3 steps and the text level includes 3 steps, which is introduced as follows. word2vector is an efficient training method to transform a symbol into a structure and digital representation. word embedding is represented differently in different vocabularies or by different training methods. the principles of word2vector are mainly separated into three parts to transform the words from the vocabulary of a flu-related weibo into high-dimensional space vectors, as follows in figure 7 . building the vocabulary of the flu-related weibo texts: the processing of the text, which means that a specific vocabulary is required; â�¢ initializing the network structure of the weibo text: the initialization of parameters in the cbow model, with huffman coding generation; â�¢ saving the word embedding: saving the result in a specific form. this activity is mainly to accurately identify the patient's disease period to improve the detection accuracy of infectious diseases. the whole process includes six steps. activity 2 in figure 5 shows that the word level detection consists of 3 steps and the text level includes 3 steps, which is introduced as follows. 1. relationships between sentiment polarity and flu period at the word level word2vector is an efficient training method to transform a symbol into a structure and digital representation. word embedding is represented differently in different vocabularies or by different training methods. the principles of word2vector are mainly separated into three parts to transform the words from the vocabulary of a flu-related weibo into high-dimensional space vectors, as follows in figure 7 . building the vocabulary of the flu-related weibo texts: the processing of the text, which means that a specific vocabulary is required; â�¢ initializing the network structure of the weibo text: the initialization of parameters in the cbow model, with huffman coding generation; â�¢ saving the word embedding: saving the result in a specific form. (cbow model) the cbow model contains three layers, including the input layer, projection layer and output layer. the window size used in this paper is 5. the vectors that correspond to each word are first found to be summarized from the input layer to the projection layer. after all of the word vectors in the window are gathered, they are stored in the projection layer, and the mean value is calculated. (hierarchical softmax) hierarchical softmax is a key technology that is used in word2vec to improve the performance. in the huffman tree, the softmax mapping of the hidden layer to the output layer is proceeded step by step along the hoffman tree and, thus, this softmax is named "hierarchical softmax". (cbow model) the cbow model contains three layers, including the input layer, projection layer and output layer. the window size used in this paper is 5. the vectors that correspond to each word are first found to be summarized from the input layer to the projection layer. after all of the word vectors in the window are gathered, they are stored in the projection layer, and the mean value is calculated. (hierarchical softmax) hierarchical softmax is a key technology that is used in word2vec to improve the performance. in the huffman tree, the softmax mapping of the hidden layer to the output layer is proceeded step by step along the hoffman tree and, thus, this softmax is named "hierarchical softmax". recurrent neural networks (rnns) perform well in text classification. however, long-term dependence occurs if the interval of two words is overly large. this paper adopts a novel type of rnn called long short-term memory that works better than traditional rnns on tasks that involve long time lags. its architecture permits lstm to bridge massive time lags between relevant input events (1000 steps and more) [65] . figure 8 shows the structure of the network with 8 main layers, and we describe each layer below. 2. detecting the flu period based on sentiment polarity at the text level recurrent neural networks (rnns) perform well in text classification. however, long-term dependence occurs if the interval of two words is overly large. this paper adopts a novel type of rnn called long short-term memory that works better than traditional rnns on tasks that involve long time lags. its architecture permits lstm to bridge massive time lags between relevant input events (1000 steps and more) [65] . figure 8 shows the structure of the network with 8 main layers, and we describe each layer below. two lstm neural networks in parallel are built to perform binary classification for sentiment classification and flu-period classification in this section. the input is the word embedding trained by the word2vector based on the corpus of flu-related weibos. the entire process is shown in figure 9 . two lstm neural networks in parallel are built to perform binary classification for sentiment classification and flu-period classification in this section. the input is the word embedding trained by the word2vector based on the corpus of flu-related weibos. the entire process is shown in figure 9 . two lstm neural networks in parallel are built to perform binary classification for sentiment classification and flu-period classification in this section. the input is the word embedding trained by the word2vector based on the corpus of flu-related weibos. the entire process is shown in figure 9 . the lstm network is used to construct two neural networks to classify flu-related weibos. the first is to classify the sentiment polarity. the other intends to classify the period of the flu bloggers. each neural network consists of 8 main layers, as follows. (input layer and masking layer) the first layer is the input layer, which uses 128-dimension vectors by means of the word2vector algorithm. the mask value is set to 0 in the masking layer. the lstm network is used to construct two neural networks to classify flu-related weibos. the first is to classify the sentiment polarity. the other intends to classify the period of the flu bloggers. each neural network consists of 8 main layers, as follows. (input layer and masking layer) the first layer is the input layer, which uses 128-dimension vectors by means of the word2vector algorithm. the mask value is set to 0 in the masking layer. (lstm layer) each lstm unit is a storage unit that controls the passage or filtering of information through the three gates, to alter the cell state. "implementation" is set to 2 to combine the input gate, forget gate, and output gate into a single matrix for more efficient operations. (fully connected layer) the core operation of the full connection is the matrix vector product. the essence is a linear transformation from one feature space to another feature space. a dense layer is used. (dropout layer) the settings of this layer are mainly to prevent overfitting in neural network training. the parameters of this layer are set to 0.3, which implies that the unit that was transferred from the lstm layer will be randomly discarded by 30% during training, leaving 70% of the units used. (activation layer) the activation function in this layer is "relu" (rectified linear units), and as a result, the convergence rate of the model is maintained at a steady state. (loss layer and output layer) since the classification of the sentiment polarity and the period are all binary classifications, binary cross entropy is agreeable as a loss function, with the accuracy rate as a metric of the model. the classification result and test score are received through the output layer. according to the 41st china statistical report on internet development published by the china internet network information center (cnnic), weibo has 316.01 million users and a user usage rate of 40.9% on social media by december 2017 [66] . sina weibo has maintained the top rank in china's weibo. according to the second quarter earnings released by sina, monthly active users from sina weibo reached 431 million by 30 june 2018, outstripping twitter as the world's largest independent social media company in terms of user scale [67] . sina weibo has always been the data source of various types of major events and emergencies in china and has a far-reaching scope of dissemination and important social influence. this study uses web-based social media data in sina weibo. the details are clearly shown in table 1 . we collected the texts that contained the keywords, namely, "flu (gan mao)", "influenza (liu gan)", "cough (ke sou)", "fever (fa shao)", "sneeze (pen ti)" and "nasal congestion (bi sai)" in 2016 and 2017 through a sina application programming interface (api). we purchased the official data collection service from gooseeker. gooseeker is an authorized api of sina weibo. the data do not include private information such as personal name, gender, age, etc., and do not endanger privacy and other related issues. all data can be used legally. however, the data include a large amount of advertising and unrelated material. thus, the support vector machine (svm) is used to filter out unrelated flu weibos. ultimately, 100,000 flu-related weibos were chosen randomly as a word2vector training corpus in which 10,000 weibos in 2016 and 10,000 weibos in 2017 were randomly selected as a neural network classification dataset of sentiment polarity and period. in what follows, the 20,000 weibos are labeled according to the following rules. in terms of sentiment polarity, "0" represents positive sentiment, whereas "1"indicates negative sentiment. in terms of the period, "0" indicates the infectious period, while "1" represents the recovered period. the dataset was divided into 4 labeled groups with a total of 12 people involved. every three members were in one group. each group was assigned 5000 weibos. each member in one group was required to label all 5000 weibos without communication to intentionally make the marked category accurate since artificial annotation has a certain subjectivity. the blog was thought to be invalid if the results were inconsistent among the 3 members. after the process of cleaning and arrangement, 15,301 weibos were valid, with the remaining 4699 weibos invalid. we randomly chose 70% of the 15,301 valid weibos as the neural network training set and 30% as the test set. first, a word2vector corpus was built from the 100,000 flu-related weibos, including 50,000 weibos from 2016 and 50,000 weibos from 2017, by removing irrelevant stop words and symbols. the word frequency of the remaining words was calculated to generate word embedding by similarity and distance between words. each word consists of a 128-dimensional vector. one-hundred ninety-five words ranked first and associated with the flu were screened out from the vocabulary and divided into four classes, which represent the two types of flu period (infectious and recovered) and two types of sentiment polarity (positive and negative). the words in the infectious period mainly describe flu confrontation and symptoms. the recovered period describes the status of improvement or remission of the flu. one-hundred ninety-five words in four classes can be found in table 2 . to display the distribution of the 195 words in two-dimensional space, we used t-distributed stochastic neighbor embedding (t-sne) to reduce the dimension of the word embedding. the scatter plot was drawn by the two-dimensional coordinates of each word in figure 10 . each point is a word, with a total of 195 points. it is clear that the words that denote positive sentiment and the recovered period are clustered together, and the words in the negative sentiment and infectious period are clustered together closely. in addition, between these 195 words, this paper calculates the similarity between every two words of the flu period and the sentiment polarity based on word2vector. additionally, a similarity greater than 0.6 was reserved, which is represented by the connections in figure 10 . therefore, as seen from figure 10 , there are four types of connections, which are divided between the infectious period and negative sentiment, infectious period and positive sentiment, recovered period and negative sentiment, and recovered period and positive sentiment. this paper also performed statistical analysis on these four types of lines in the scatter plot. when the similarity is greater than 0.6, it is found that there are 53 links between the infectious period and negative sentiment and more than 16 links between the infectious period and positive sentiment. additionally, there are 81 links between the recovered period and positive sentiment and more than 7 links between the recovered period and negative sentiment. obviously, the infectious period is much more similar and closer to negative sentiment than to positive sentiment. in contrast, the recovered period is much more similar and closer to positive sentiment than to negative sentiment. period are clustered together, and the words in the negative sentiment and infectious period are clustered together closely. in addition, between these 195 words, this paper calculates the similarity between every two words of the flu period and the sentiment polarity based on word2vector. additionally, a similarity greater than 0.6 was reserved, which is represented by the connections in figure 10 . therefore, as seen from figure 10 , there are four types of connections, which are divided between the infectious period and negative sentiment, infectious period and positive sentiment, recovered period and negative sentiment, and recovered period and positive sentiment. this paper also performed statistical analysis on these four types of lines in the scatter plot. when the similarity is greater than 0.6, it is found that there are 53 links between the infectious period and negative sentiment and more than 16 links between the infectious period and positive sentiment. additionally, there are 81 links between the recovered period and positive sentiment and more than 7 links between the recovered period and negative sentiment. obviously, the infectious period is much more similar and closer to negative sentiment than to positive sentiment. in contrast, the recovered period is much more similar and closer to positive sentiment than to negative sentiment. to demonstrate the relationship between these 195 words and their similarity, a force directed graph of words' similarity is shown in figure 11 , where a total of 195 nodes represent the 195 words. the nodes are divided into four categories, and the edges between the nodes are also divided into four categories, the same as in the legend in figure 10 . the force of the nodes is the similarity between the two words. it can be clearly seen from figure 11 that most of the edges around recovered nodes, such as health and fitness, are all positive nodes, such as cheerful and happy. additionally, positive nodes, such as active, alive and kicking, are connected with recovered nodes, such as get well and heal. in addition, as can be seen from the similarity forces, these three recovered nodes-in good health, healthy, and fitness-which indicate a healthy status, are connected to more positives nodes than these words are, which indicates that the blogger is recovering but not yet healthy. this finding shows that the healthier the bloggers are, the more positive sentiments they have. additionally, infectious nodes, such as feel bad and uncomfortable, are mutually connected to negative nodes, such to demonstrate the relationship between these 195 words and their similarity, a force directed graph of words' similarity is shown in figure 11 , where a total of 195 nodes represent the 195 words. the nodes are divided into four categories, and the edges between the nodes are also divided into four categories, the same as in the legend in figure 10 . the force of the nodes is the similarity between the two words. it can be clearly seen from figure 11 that most of the edges around recovered nodes, such as health and fitness, are all positive nodes, such as cheerful and happy. additionally, positive nodes, such as active, alive and kicking, are connected with recovered nodes, such as get well and heal. in addition, as can be seen from the similarity forces, these three recovered nodes-in good health, healthy, and fitness-which indicate a healthy status, are connected to more positives nodes than these words are, which indicates that the blogger is recovering but not yet healthy. this finding shows that the healthier the bloggers are, the more positive sentiments they have. additionally, infectious nodes, such as feel bad and uncomfortable, are mutually connected to negative nodes, such as bad mood and anxious. among the infectious nodes, from uncomfortable to not good to feel bad, the more serious the disease is, the more the negative nodes are connected. as bad mood and anxious. among the infectious nodes, from uncomfortable to not good to feel bad, the more serious the disease is, the more the negative nodes are connected. to locate the word of each point clearly, the scatter of the points for the positive sentiment and recovered period is plotted in figure 12 . the scatter of the points for the negative sentiment and infectious period is shown in figure 13 . it can be seen from figure 12 and figure 13 that semantically related words and words with similar meanings are close to each other. since the number of words that describe the recovered period is significantly lower than the number that describe the infectious period and the meanings of the words that describe the recovered period are mostly similar, it can be determined that the words of the recovered period and positive sentiment are clustered in the second and third quadrants, as shown in figure 12 . the distribution of the words that represent the infectious period and negative sentiment appear to be more scattered in figure 13 , which denotes that these two classes are more relevant. to locate the word of each point clearly, the scatter of the points for the positive sentiment and recovered period is plotted in figure 12 . the scatter of the points for the negative sentiment and infectious period is shown in figure 13 . it can be seen from figures 12 and 13 that semantically related words and words with similar meanings are close to each other. since the number of words that describe the recovered period is significantly lower than the number that describe the infectious period and the meanings of the words that describe the recovered period are mostly similar, it can be determined that the words of the recovered period and positive sentiment are clustered in the second and third quadrants, as shown in figure 12 . the distribution of the words that represent the infectious period and negative sentiment appear to be more scattered in figure 13 , which denotes that these two classes are more relevant. to measure the interclass distance of these four categories in the scatter, this paper adopts two sample class distances to compare the relationship between the sentiment polarity and the flu period. the first distance is a centroid cluster, which measures the interclass distance by the distance between the two variables' mean value. the coordinates of each class's center gravity are presented in table 3 . the scatter of the class center gravity is plotted through the two-dimensional coordinates of the four categories shown in figure 14 . figure 14 clearly determines the distribution of four types of class center gravity. to measure the interclass distance of these four categories in the scatter, this paper adopts two sample class distances to compare the relationship between the sentiment polarity and the flu period. the first distance is a centroid cluster, which measures the interclass distance by the distance between the two variables' mean value. the coordinates of each class's center gravity are presented in table 3 . the scatter of the class center gravity is plotted through the two-dimensional coordinates of the four categories shown in figure 14 . figure 14 clearly determines the distribution of four types of class center gravity. to measure the interclass distance of these four categories in the scatter, this paper adopts two sample class distances to compare the relationship between the sentiment polarity and the flu period. the first distance is a centroid cluster, which measures the interclass distance by the distance between the two variables' mean value. the coordinates of each class's center gravity are presented in table 3 . the scatter of the class center gravity is plotted through the two-dimensional coordinates of the four categories shown in figure 14 . figure 14 clearly determines the distribution of four types of class center gravity. afterwards, we calculated the euclidean distance matrix of the center gravity in the following section. from the matrix, the distance between the recovered period and positive sentiment is 4.297, while the distance between the recovered period and negative sentiment is 7.632, which significantly shows that the recovered period is closer to positive sentiment. in terms of the infectious period, the distance to the positive sentiment is 9.521, and the distance to the negative sentiment is 7.867, which indicates that the infectious period is closer to the negative sentiment. in addition, another interclass distance measurement method was selected to further verify the correctness of the conclusion, which is known as the between-group linkage and which measures the interclass distance by the average distance between the two categories of individuals. the euclidean distance matrix is shown in the following section. this finding implies that the conclusion is consistent with the above. the recovered period is closer to the positive sentiment, and the infectious period is closer to the negative sentiment. the flu-related information perceived by social media can detect trend changes and peak points earlier than traditional methods [8, 9, 19, 43] . we also compare the trend of the flu-related weibos ratio afterwards, we calculated the euclidean distance matrix of the center gravity in the following section. from the matrix, the distance between the recovered period and positive sentiment is 4.297, while the distance between the recovered period and negative sentiment is 7.632, which significantly shows that the recovered period is closer to positive sentiment. in terms of the infectious period, the distance to the positive sentiment is 9.521, and the distance to the negative sentiment is 7.867, which indicates that the infectious period is closer to the negative sentiment. in addition, another interclass distance measurement method was selected to further verify the correctness of the conclusion, which is known as the between-group linkage and which measures the interclass distance by the average distance between the two categories of individuals. the euclidean distance matrix is shown in the following section. this finding implies that the conclusion is consistent with the above. the recovered period is closer to the positive sentiment, and the infectious period is closer to the negative sentiment. the flu-related information perceived by social media can detect trend changes and peak points earlier than traditional methods [8, 9, 19, 43] . we also compare the trend of the flu-related weibos ratio and ili% from the cdc. it can be seen in figure 15 ; the flu data perceived on social media can reflect the trend of official ili data and report changes and peaks earlier in certain weeks. and ili% from the cdc. it can be seen in figure 15 ; the flu data perceived on social media can reflect the trend of official ili data and report changes and peaks earlier in certain weeks. two lstm neural networks were built to classify the sentiment polarity and flu-period in this paper. the input is the word embedding trained by the word2vector based on the corpus of flurelated weibos. it is worthwhile to note that the dimension of the word embedding for the lstm input is the original word embedding training, which resulted in 128 dimensions. the output of the network is 0 or 1. for the sentiment classification, the output "0" represents negative sentiment, while the output "1" denotes positive sentiment. for the flu-period classification, the output "0" implies that the blogger is infected, while the output "1" implies that the blogger is recovered. in the lstm for sentiment classification, the accuracy of the test set reached 0.844 after 30 steps of training. in the lstm for flu-period classification, the accuracy of the test set reached 0.876 after 30 steps of training. the statistical result of the test set of 4590 weibos was counted to compare the relationship between the flu-period and the sentiment polarity. the prediction result was 876, in which the weibos simultaneously show positive sentiment and the recovered period, shown in table 3 ; the other types of prediction results are also shown in table 3 . apart from these findings, we also counted the number of correct weibos to predict the flu-period in the four types of prediction results. the statistics are shown in table 4 . two lstm neural networks were built to classify the sentiment polarity and flu-period in this paper. the input is the word embedding trained by the word2vector based on the corpus of flu-related weibos. it is worthwhile to note that the dimension of the word embedding for the lstm input is the original word embedding training, which resulted in 128 dimensions. the output of the network is 0 or 1. for the sentiment classification, the output "0" represents negative sentiment, while the output "1" denotes positive sentiment. for the flu-period classification, the output "0" implies that the blogger is infected, while the output "1" implies that the blogger is recovered. in the lstm for sentiment classification, the accuracy of the test set reached 0.844 after 30 steps of training. in the lstm for flu-period classification, the accuracy of the test set reached 0.876 after 30 steps of training. the statistical result of the test set of 4590 weibos was counted to compare the relationship between the flu-period and the sentiment polarity. the prediction result was 876, in which the weibos simultaneously show positive sentiment and the recovered period, shown in table 3 ; the other types of prediction results are also shown in table 3 . apart from these findings, we also counted the number of correct weibos to predict the flu-period in the four types of prediction results. the statistics are shown in table 4 . the overall accuracy rate is shown as follows, weibos for both positive sentiment and the recovered period and weibos for both negative sentiment and the infectious period were predicted by the lstm neural network for a total of 3832 pieces. the accuracy rate is calculated as follows, compared to the two results, it can be determined that the accuracy rate increases to 0.926 when the result of the sentiment classification is added, which indicates that the flu period has a certain correlation with sentiment polarity and the classification accuracy of the flu period improves. the shortcomings of traditional data are evident since they are manually collected and time-consuming, which leads to high labor costs [8, 9] . in addition, traditional methods based on clinical data make it challenging to shed light on the current situation and predict future developing trends [41] . along with the widespread use of the internet, social networking data, including web-based epidemiological data, have had explosive growth. data from social networks show apparent advantages in several respects, such as being real-time and having time-sharing, along with a broad scope of data coverage [31] [32] [33] [34] . in terms of the scale of users, sina weibo's monthly active users reached 431 million on 30 june 2018, overtaking twitter, which makes sina weibo the world's largest independent social media platform [67] . sina weibo is the most popular social media platform in china for the public to share opinions and disseminate information about emergencies and major social events. therefore, weibo has a far-reaching scope of dissemination and is an important social influence. therefore, the use of web-based social media data growth is an imperative trend to use for effective disease control and prevention. weibo messages carry rich and meaningful implications. previous approaches in flu state detection through social media have yielded outstanding achievements but have some limitations at the same time. most obviously, the semantic information was seldom considered; this information might be important for flu detection [50] . however, to our knowledge, this area of study has serious limitations. for example, bloggers experience different flu periods of the latent, infectious, or recovered kind, and their sentiments correspond to the different periods. in reality, most bloggers who are ill are usually negative, while bloggers in recovered periods are active and optimistic. therefore, omitting the key flu period and non-differentiating weibo messages data could lead to data contamination and misleading conclusions. it is important to investigate the relationship between the flu period and the sentiment polarity, to make it possible to be conducive to accuracy for classifying the flu period, which directly results in accurately estimating the number of patients in different flu periods. this approach would also help the cdc to take early action for disease control and prevention. this paper aims to detect the flu period with sentiment polarity at the word and text level based on sina weibo data (web-based social media platform), and it proposes optimization suggestions for optimizing the disease detecting process. several important findings are produced. (1) social media is a promising and powerful data platform to detect flu patients by earlier discovery rather than traditional medical data. their periods can be further sorted into infectious and recovered, as mined from social media. (2) the semantic information varies from the weibo texts posted by patients in different flu periods. the interclass distance between the recovered period and positive sentiment is closer than between the recovered period and negative sentiment, and the interclass distance between the infectious and the negative is closer than that of the positive. additionally, it was noted that the healthier the bloggers are, the more positive sentiments they have. the more serious the flu is, the more that bloggers are connected with negative emotions. (3) a multichannel disease detection model is developed in this study to evaluate and classify the flu period with an accuracy of up to 0.926 based on the lstm network. our optimized model effectively improves the classification accuracy of the flu period after adding the sentiment classification results. the research findings have important theoretical implications. (1) the previous literature investigates the sentiment and disease predictions separately. this paper examines the relationship between sentiment and disease detection. we found that by adding sentiment factors, the classification accuracy is improved remarkably, from 0.876 to 0.926. (2) this paper explores the relationship between the sentiment polarity and the flu-period at two levels of words and text, combining the methods of word2vector and lstm, which have been used rarely for disease surveillance studies. (3) this research proposes a complete theoretical framework based on web-based social media data. the use of this model can be extended to many aspects, such as monitoring chronic and mental diseases. this study also has important practical implications. (1) this paper optimizes the disease detecting process and establishes multichannel surveillance measures for cdc decision making. (2) this paper will monitor a larger range of infected population. furthermore, it can identify patients in advance who are not aware of disease. (3) the previous weibo text processing classifies only flu-related weibos and unrelated weibos. this paper further divides flu-related weibos into two periods: recovered and infectious. research outcomes improve the reliability and accuracy for the prediction of flu trends. both point (2) and point (3) not only help the cdc to detect disease information in real time but also provide a novel method for disease information management. (4) the conclusion supports the expansion of the number of neural network training sets, eliminating some of the high cost of manual labeling. the classification results of the flu-period can be replaced in the model to increase the amount of training set data, which enables the lstm neural network to fully learn to better characterize the model. timely and reliable flu monitoring is an important basis for successful control of the spread of disease and mitigation of the associated damage. however, due to its high contagiousness and rapid spread, the flu epidemic has caused great difficulties in prevention and surveillance. with the rapid development and popularity of web-based social media platform data, sina weibo, one of the world's largest social media companies, has become an ideal data source to make real-time, low-cost surveillance possible as an early warning of outbreaks and an adjunct to traditional methods of investigation. according to the latest estimate by the united states centers for disease control and prevention (us-cdc), as many as 650,000 people worldwide die from seasonal flu-related respiratory diseases each year. it is evident that the flu imposes a heavy burden on the international community, and the flu's global, social and economic costs are considerable. it is worth noting that improving the ability to monitor infectious disease is the key to further strengthening management capacity of the health system and organizing a massive flu outbreak response. however, most traditional epidemiological surveillance methods adopt clinical data through manual information collection, showing the shortcomings of high labor costs but also causing a lag in data timeliness. the data limitation makes it difficult to understand the current situation, which is critical for flu trend forecasting. social media data increase at a rapid pace, including epidemiological data, which offer benefits in terms of timeliness and magnitude. sina's 2018 quarter earnings report that the number of monthly active users of sina weibo is larger than that of twitter, which makes it the world's largest independent social media company in terms of user scale. sina weibo has always been the starting data source of various types of major emergencies in china, and its commercial value has been continuously promoted and has great potential. this paper explores the relationship between the flu-period and sentiment polarity from two levels based on sina weibo data. to be specific, at the word level, we used word2vector to create the flu-related weibos corpus and the t-sne method to reduce the dimension. the centroid cluster and between-group linkage were jointly used to measure the distance between the four classes, thus visually showing the relationship between the sentiment polarity and flu-period. at the text level, the sentiment polarity and flu-period of flu-related weibos were classified by the lstm networks, respectively. we counted the classification results as both belonging to the infectious and negative sentiment as well as to the recovered and positive sentiment, and we calculated the accuracy rate. we then compared the rate with the overall flu-period classification accuracy to observe the differences. this paper proposes an integrated conceptual framework and practical methods for optimizing the disease detection process with fast information, early discovery, added infected cases and high accuracy. these contributions are described in detail as follows: first, in theory, this paper integrates various channels for detecting infectious diseases in real time with fast information. in addition to the clinical data and search engine data, the detecting data obtained through social media can also provide prompt and time-sharing disease information to the centers for disease control and prevention (cdc). the monitoring mechanisms operate in real time, which can help the cdc fully prepare for the next round of prevention and control. second, in practice, social media enables the early discovery of disease infection. the sooner the disease is diagnosed, the easier it is to properly treat and controlled. the cdc is committed to pursuing early detection of diseases. through social media platforms, we can detect the spread and severity of a disease earlier than search engines and the cdc. when diseases break out, the patient might not be aware of them but could post on twitter or weibo. the behavior would be recorded by social media sensors. based on human behavioral theory, the data possess unique value for detecting disease trends. third, social media is adept at tracking more patients than traditional clinic data. larger infectious populations can be monitored by social media than with clinic data. influenza-like illnesses (ili) published by the cdc are measured according to outpatient statistics when fevers are higher than 38 degrees and are accompanied by a cough or sore throat. however, a considerable number of people often choose not to go to the hospital for treatment when they have the flu or might buy medicine from a pharmacy by themselves, which cannot be counted in ili measurements. social media can detect these patients, which could result in a larger amount of meaningful data being collected, and thus, these data could lead to more reliable prediction of disease outbreaks. fourth, this paper detects disease periods with observably high accuracy, which could directly result in significant differences in treatment and disease control measures. targeting the disease period precisely helps clinical managers to improve the treatment effect and reduces the prevention cost by rationally allocating resources, such as medical personnel and medicine as well. this paper can not only detect whether the patient has the flu but also classify the flu period, infectious or recovered period, which lays the foundation for predicting future flu trends. it also provides another data source to assist the cdc in managing disease information. fifth, in terms of theoretical contributions, this paper investigates the relationship between sentiment polarity and the flu period at different word and text levels by combining the word2vector and lstm methods, thereby carrying out interdisciplinary research in the fields of sentiment analytics and health informatics. in addition, this paper provides an effective solution for artificially labeling a training set. high-accuracy weibo texts can be used to boost the size of the training set, thus saving time and labor costs. in future work, we need to study a wider range of data since the current data only cover two years, 2016 and 2017. moreover, this paper compares the trend of official ili data from the cdc and flu-related data from social media in 2016. we will examine more valuable disease information from social media-based data on a larger scale. health monitoring on social media over time twitter as a potential data 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of twitter data lexicon-based methods for sentiment analysis analysis on block chain financial transaction under artificial neural network of deep learning learning precise timing with lstm recurrent networks the 41th china statistical report on internet development weibo posts unaudited earnings for the second quarter this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. the authors declare that we have no financial and personal relationships with other people or organizations that can inappropriately influence our work, there is no professional or other personal interest of any nature or kind in any product, service or company that could be construed as influencing the position presented in, or the review of, the manuscript entitled. key: cord-319899-nso0ob27 authors: wilke, jan; mohr, lisa; tenforde, adam s.; edouard, pascal; fossati, chiara; gonzález-gross, marcela; ramirez, celso sanchez; laiño, fernando; tan, benedict; pillay, julian david; pigozzi, fabio; jimenez-pavon, david; novak, bernhard; url, david; zhang, mandy; van poppel, mireille; heidt, christoph; willwacher, steffen; vogt, lutz; verhagen, evert; hollander, karsten; hespanhol, luiz; yuki, gustavo title: restrictercise! preferences regarding digital home training programs during confinements associated with the covid-19 pandemic date: 2020-09-07 journal: int j environ res public health doi: 10.3390/ijerph17186515 sha: doc_id: 319899 cord_uid: nso0ob27 confinement measures during the covid-19 pandemic have caused substantial reductions in global physical activity (pa) levels. in view of the manifold health benefits of pa, the development of interventions counteracting this trend is paramount. our survey with 15,261 participants (38 ± 15 years, 58.5% females) examined preferences towards digital home exercise programs in 14 countries affected by covid-19. more than two-thirds of the sample (68.4%, n = 10,433) indicated being interested in home exercise, and most participants were willing to work out at least three times per week (89.3%, n = 9328). binary logistic regression revealed that female sex, working part-time, younger age, and being registered in a gym were associated with willingness to exercise. flexibility (71.1%, n = 7377), resistance (68.6%, n = 7116), and endurance training (62.4%, n = 6478) were the most preferred types of exercise. our results may guide health providers in developing individually tailored pa interventions during the current and future pandemics. the spread of the novel coronavirus, also referred to as covid-19, has prompted countries worldwide to restrict public life over weeks to months. investigations into the effectiveness of related measures demonstrate that confinement strategies effectively curbed the pandemic [1, 2] . however, controlling the contagion by means of lockdowns could have negative implications for health. a recent population-based survey recruiting 13,503 participants from five continents revealed a 41% decline in physical activity (pa) compared to pre-restrictions [3] . on the basis of data collected in china, it was estimated that the portion of insufficiently active individuals in china tripled during the early phase of the pandemic [4] . according to the literature, inactivity causes 9% of premature mortality, and reducing it by only 10% could avert more than 500,000 deaths per year [5] . the impact of the current pa decreases may, therefore, have detrimental consequences. with gyms, sports clubs, and other public activity spaces rendered inaccessible, the development of alternative movement opportunities is paramount. tele-exercise represents a cost-effective and easy-to-distribute option for individuals mandated to stay at home [6] . previous research demonstrated that meeting the individual preferences of the target population represents a key aspect to consider in the design of new pa offers. for instance, older adults' adherence to fall prevention programs is related to the inclusion of specific components (e.g., balance exercise) rather than to the general effectiveness of the interventions [7] . in a similar way, back and neck pain patients are more compliant with home exercise when positively evaluating the program characteristics [8] . against this background, the present study examined the preferences towards digital home exercise programs in individuals affected by the covid-19 pandemic. the cross-sectional asap (activity and health during the sars-cov-2 pandemic) survey [9] was performed in 14 countries (argentina, australia, austria, brazil, chile, france, germany, italy, the netherlands, singapore, south africa, spain, switzerland, and the united states of america (usa)). approval was obtained from the study center's ethics committee (local ethics committee of the faculty of sports sciences and psychology, ref. 2020-13) and the ethics committees of the other collaborating partners. all participants provided informed consent. individuals aged 18 and older from countries with (1) official cases of covid-19 and (2) governmental restrictions limiting movement in public spaces were eligible. recruitment included social media promotions (e.g., facebook), mailing lists, and health-related multipliers (e.g., national "exercise is medicine" chapters). the herein reported part of the asap survey measured the participants' preferences regarding digital home exercise programs delivered via internet. in addition to ascertaining the general willingness to participate in related programs (yes/no), the optimal duration (free entry, min/week), training frequency (workouts per week; 1-2, 3-4, 4-6 or daily), and exercise types (flexibility, resistance, endurance, balance/stability, cognition, relaxation) were assessed. additional information obtained from other sections of the asap survey included age, sex, work mode (home office/office/both), and volume (part-time/full-time), as well as physical activity guideline compliance (yes/no; ≥150 min moderate, ≥75 min vigorous pa or an adequate combination of both as per the world health organization (who), assessed using the nordic physical activity questionnaire, short version [10] ). data are presented as mean and standard deviation (sd), median and interquartile range (iqr), or absolute and relative frequency, as appropriate. factors influencing (a) the willingness to exercise and (b) the preference of specific components (e.g., resistance or endurance exercise) were investigated using multiple binary logistic regression. the results were presented as adjusted odds ratios (or) and 95% confidence intervals (ci). calculations were made with spss 22 (spss inc., chicago, il, usa). over two-thirds of the participants (68.4%, n = 10,433) indicated readiness to engage in digital home exercise. among these, the chosen duration (median) was 40 (iqr: 30-60) minutes per session. the majority of the participants preferred working out at least three times weekly (89.3%, n = 9328). the most popular contents were flexibility (71.1%, n = 7377), resistance (68.6%, n = 7116), and endurance exercise (62.4%, n = 6478), while relaxation (42.6%, n = 4416) and cognitive training (24.2%, n = 2514) were selected less frequently. logistic regression revealed four factors associated with interest in digital home exercise: female sex, working part-time, younger age, and having exercised in a gym pre-restrictions (table 1) . with regard to exercise types (table 2) , older participants (≥40 years) were more likely to select flexibility and less likely to choose resistance, endurance, and cognitive training. marked differences also occurred between men and women. female sex was associated with a more frequent choice of flexibility and relaxation exercises and a less frequent selection of resistance, cognitive, and endurance exercise. participants with high physical activity levels (meeting who pa recommendations) more often preferred resistance, endurance, and balance/stability training, but not other forms of exercise. type of employment (full-time/part-time) was weakly/not associated with exercise preference. in most cases, individuals working remotely (home office) had comparable odds to participants working outside the home (in the office). however, individuals who combined working at home and in the office had a higher preference of most exercise types than persons working outside the home only. not having a formal employment was associated with a less frequent choice of resistance and endurance training but more frequent choice of balance/stability, cognitive, flexibility, and relaxation exercise. a wealth of evidence supports the manifold health benefits of sufficient and regular engagement in physical activity [11] . not only because of these general effects, but also because exercise can have a positive impact on immune function and reduce upper respiratory tract infections [12] , researchers have underlined the need to maintain or improve pa habits during mandated lockdowns [13, 14] . to the best of our knowledge, the present study is the first to describe the exercise preferences of individuals affected by the covid-19 pandemic. more than two in three participants indicated willingness to engage in digital home exercise programs. this particularly applied to women whose odds of being interested were 1.7 times higher than those of men. on the whole, our data suggest that tele-health interventions could be well received, thereby helping to stem any reduced pa during confinements [3] . reports from china indicate that public life restrictions caused considerable increases in anxiety and depression [15] . as exercise is effective in addressing both, supporting the maintenance of regular pa may be crucial not only for physical health, but also for mental well-being. although abundant evidence underlines the relevance of matching program design and participant preferences in special populations such as patients, the elderly, or postmenopausal women [8, 9] , there is a paucity of studies investigating the preferences of asymptomatic individuals. this report provides significant information toward supporting tailored programs on the basis of specific needs of different target groups during the covid-19 pandemic. for example, new programs should have a minimum frequency of three sessions per week. this is in line with statements of the american college of sports medicine [16] recommending resistance, flexibility, and neuromotor training 2-3 times weekly and cardiorespiratory training 3-5 times weekly. flexibility training was the most preferred exercise type, followed by resistance and endurance training. benefits of flexibility exercise include the promotion of well-being and relaxation [17] . therefore, its choice could be an attempt to minimize the psychological impact caused by public life restrictions. furthermore, flexibility exercise does not require extensive space or equipment, making it easy to perform at home and potentially more attractive than other forms of training. however, exercise preference varied considerably as a function of sex and age. whereas women presented a stronger orientation to flexibility and relaxation, men were more interested in endurance, resistance, and cognition. the latter three were also more popular among younger vs. older participants who rather seemed to require flexibility. the observed patterns might be explained by the belief that resistance and endurance exercise could be more "vigorous" than flexibility and/or relaxation exercises. the perceived "safety" (e.g., in terms of injuries during training) might, hence, influence exercise preference. this particularly applies to women/older participants who display a higher health perception and are more conservative with regard to healthy behaviors than men and younger individuals [18, 19] . while future studies should test this hypothesis, we suggest calibrating the exercise modality and intensity to the risk appetite of each group, in order to encourage compliance. finally, another remarkable finding was that active participants had more than twice the odds of preferring resistance exercises and about 1.5 the odds of preferring endurance training. seeking to improve performance, they may prefer vigorous exercises, while less active individuals may select less vigorous exercises aiming to acquire health benefits with the lowest possible risk of adverse events. some limitations have to be discussed. firstly, this was an internet survey, and promotion was mainly based on social media promotion. persons with limited or no internet access and individuals with small affinity for digital content may, therefore, have had a lower chance to participate. another issue relates to the items included. although the questions were mostly self-explanatory, a few contents could be interpreted differently. for instance, some participants may have assigned yoga and light stretching/mobility training to "relaxation exercise". while others may have understood the term as only describing specific techniques such as progressive muscle relaxation. finally, while we examined important program characteristics such as the exercise type, training frequency, and session duration, we did not include preferred intensity, which would have been interesting as it may moderate the protective effect of exercise against viral infections. in summary, a large portion of individuals affected by confinements related to the covid-19 pandemic are interested in digital home exercise. interventions meeting their needs should consider factors such as the frequency (minimum: three times a week), duration (40 min), and type (flexibility, resistance, endurance) of program. additionally, carefully balancing the different needs of individuals, such as old versus young, male versus female, and active versus inactive, is recommended. the authors received no financial support for the research, authorship, and/or publication of this article. the positive impact of lockdown in wuhan on containing the covid-19 outbreak in china evaluation of the lockdowns for the sars-cov-2 epidemic in italy and spain after one month follow up a pandemic within the pandemic? physical activity levels substantially decreased in countries affected by covid-19 physical activity, screen time, and emotional well-being during the 2019 novel coronavirus outbreak in china effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy physical activity and coronavirus disease 2019 (covid-19): specific recommendations for home-based physical training. manag adherence to and efficacy of home exercise programs to prevent falls: a systematic review and meta-analysis of the impact of exercise program characteristics how do care-provider and home exercise program characteristics affect patient adherence in chronic neck and back pain: a qualitative study activity and health during the sars-cov2 pandemic (asap): study protocol for a multi-national network trial validation of the npaq-short-a brief questionnaire to monitor physical activity and compliance with the who recommendations health benefits of physical activity a systematic review of current systematic reviews physical activity for immunity protection: inoculating populations with healthy living medicine in preparation for the next pandemic the immunological case for staying active during the covid-19 pandemic physical activity during the coronavirus (covid-19) pandemic: prevention of a decline in metabolic and immunological functions immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise viscoelastic stress relaxation in the hamstrings before and after a 10-week stretching program gender differences in health perceptions and meaning in persons living with heart failure gender differences in food choice: the contribution of health beliefs and dieting the authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. key: cord-325722-ixozph19 authors: yip, paul; chen, mengni; so, bing kwan; lam, kwok fai; wat, kam pui title: optimal strategies for reducing number of people in the social security system date: 2020-02-18 journal: int j environ res public health doi: 10.3390/ijerph17041305 sha: doc_id: 325722 cord_uid: ixozph19 providing social security to the population in need has become a major expenditure for many governments. reducing the number of dependents in the social security system and maintaining a dynamic economically active population is a high priority concern for policymakers. a good understanding of the dynamics of the social security system—specifically, who enters and who exits the system—would be helpful for formulating effective interventions. here, we made use of the data of hong kong’s comprehensive social security assistance (cssa), which is currently a basic welfare scheme in hong kong that provides supplementary payments to households that cannot support themselves financially. we proposed a stochastic model to examine the inand outmovement in the cssa scheme and conducted elasticity analyses. the elasticity analyses allowed us to identify the potential target groups of people that would lead to the largest reduction in the number of the cssa recipients in the system. this analytical method can also reveal whether policies would be more effective in preventing people from entering the cssa system or helping them leave the cssa scheme. our analyses suggest that targeting those aged 30–49 with children would have the largest impact. additionally, we found that policies that aim to prevent this group from entering the cssa system would be more effective in reducing the number of cssa recipients compared with policies that aim to help them exit. in contrast, for the younger age group of 10–29, policies that help them leave cssa would be more effective than policies that prevent them from entering cssa. providing employment for those unemployed in this younger group would be more effective. the results indicate that by tailoring measures to specific subgroups, the overall number of cssa recipients would be reduced, thereby improving the efficiency of hong kong’s social security system, which has accounted for more than 16.5% of hong kong government expenditure in 2018, amounting to more than hkd 92 billion. "leave no one behind" is the overarching principle of the united nations' 2030 sustainable development goals [1] . ending poverty everywhere, in all its forms, is the first of the sustainable development goals (sdg). in signing the sdg agenda 2030, governments around the world have committed to achieving this goal over the coming years. hong kong is one of the richest cities in the world with an impressive gdp of usd 46,000, but with a large gini coefficient of 0.537, and thus the issue of poverty deserves special attention. the poverty line in hong kong is set at 50% of the median until 1997, hong kong was a british colony for more than 150 years (since 1842). the social security system in hong kong was shaped by the laissez-faire philosophy under the previous colonial regime. the concept of self-reliance via employment is deeply rooted in the psyche of the hong kong population, and the so-called hong kong "lion rock spirit" captures an ethic of hard working and mutually helping one another in the community. only the very needy and vulnerable families would receive support by the government. thus, hong kong's welfare system was perceived as a typical example of the residual model of welfare, which views the government welfare provision only as a last resort. the laissez-faire philosophy and residual welfare model were also compatible with chinese confucian values, which emphasize filial piety, respect for older people, love for one's family, self-restraint, shouldering collective responsibility, mutual help, and so on. chiu and wong (2005) [11] have argued that confucian ideology has been used by the hong kong government as "a means to contain social welfare costs", as well as to justify the residual welfare model. on july 1st of 1997, the sovereignty over hong kong was returned back to mainland china and the city has become a special administrative region of the people's republic of china (hksar). under the principle of "one country, two systems", hong kong has enjoyed a high degree of autonomy and is responsible for its domestic affairs including tax system. the hksar government does not have to contribute any revenue towards the central government. since 1997, the social policies in hong kong have been not only shaped by the laissez-faire philosophy that were "inherited" from the colonial regime, but also constrained by the basic law that was issued after the handover to china [10] . according to the basic law, the hong kong government can only increase its public expenditure on social welfare within the limits of the budget surplus [12] . thus, social policies have become sensitive to the government budget. since 1997, the government experienced 6 years of budget deficit, from 1998-1999 to [2004] [2005] , which was related to the 1997 asian financial crisis and the 2003 severe acute respiratory syndrome (sars) epidemic. during this period, the low-income group suffered most from the two economic shocks. the rising social welfare needs of low-income families greatly increased government spending, and consequently new social policies to expand and diversify the social welfare system had to be suspended [10] . the comprehensive social security assistance (cssa) is the most important welfare program in hong kong. previously, this social security was called "public assistance", which was introduced in 1971 and modified from the british national assistance act. public assistance aimed to help the aged and the sick to maintain a basic living standard with a minimal allowance. it was in 1993 that public assistance was renamed cssa. the applications of cssa have to go through income and assets means tests. in the first year (i.e., 1993), the number of cssa cases was 91,362 and the number of cssa recipients was 121,060. there can be more than one recipient in one case, as the household is treated as a case unit and all the members within the household can be recipients. figure 1 shows the trends of cssa cases and recipients over the period of 1993-2017. the number of cases rapidly increased and reached a peak in the year 2005 (of 298,011); since then, it has steadily declined to 232,134 in 2017. the number of recipients had a similar trend, with a dramatic increase in the years of 1997 of , 1998 of , 2002 of , and 2003 of . in 1997 of and 1998 on july 1st of 1997, the sovereignty over hong kong was returned back to mainland china and the city has become a special administrative region of the people's republic of china (hksar). under the principle of "one country, two systems", hong kong has enjoyed a high degree of autonomy and is responsible for its domestic affairs including tax system. the hksar government does not have to contribute any revenue towards the central government. since 1997, the social policies in hong kong have been not only shaped by the laissez-faire philosophy that were "inherited" from the colonial regime, but also constrained by the basic law that was issued after the handover to china [10] . according to the basic law, the hong kong government can only increase its public expenditure on social welfare within the limits of the budget surplus [12] . thus, social policies have become sensitive to the government budget. since 1997, the government experienced 6 years of budget deficit, from 1998-1999 to 2004-2005, which was related to the 1997 asian financial crisis and the 2003 severe acute respiratory syndrome (sars) epidemic. during this period, the low-income group suffered most from the two economic shocks. the rising social welfare needs of low-income families greatly increased government spending, and consequently new social policies to expand and diversify the social welfare system had to be suspended [10] . the comprehensive social security assistance (cssa) is the most important welfare program in hong kong. previously, this social security was called "public assistance", which was introduced in 1971 and modified from the british national assistance act. public assistance aimed to help the aged and the sick to maintain a basic living standard with a minimal allowance. it was in 1993 that public assistance was renamed cssa. the applications of cssa have to go through income and assets means tests. in the first year (i.e., 1993), the number of cssa cases was 91,362 and the number of cssa recipients was 121,060. there can be more than one recipient in one case, as the household is treated as a case unit and all the members within the household can be recipients. figure 1 shows the trends of cssa cases and recipients over the period of 1993-2017. the number of cases rapidly increased and reached a peak in the year 2005 (of 298,011); since then, it has steadily declined to 232,134 in 2017. the number of recipients had a similar trend, with a dramatic increase in the years of 1997 of , 1998 of , 2002 of , and 2003 of . in 1997 of and 1998 , when the asian financial crisis struck hong kong, the number of recipients had increased by 59,239 and 86,000, respectively. 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 number of cssa cases and recipients year case recipients figure 2 shows the age composition of the recipients. as shown, in 1993, those aged 60 and above accounted for almost 60% of recipients, whereas those aged 15-59 and under 15 occupied about 25% and 15%, respectively. the proportion of recipients aged 0-59 initially rose continuously, reaching about 66% in 2004; since then, it has started to decline and the proportion was about 50% in 2017. as the population continues to age rapidly due to low fertility and long life expectancy, the proportion of recipients aged 60 and above is expected to increase. int. j. environ. res. public health 2020, 17, 1305 4 of 15 figure 2 shows the age composition of the recipients. as shown, in 1993, those aged 60 and above accounted for almost 60% of recipients, whereas those aged 15-59 and under 15 occupied about 25% and 15%, respectively. the proportion of recipients aged 0-59 initially rose continuously, reaching about 66% in 2004; since then, it has started to decline and the proportion was about 50% in 2017. as the population continues to age rapidly due to low fertility and long life expectancy, the proportion of recipients aged 60 and above is expected to increase. such a large share of spending on cssa and its rate of increase have become a concern for the hong kong government, especially in the years of the asian financial crisis and sars epidemic, such a large share of spending on cssa and its rate of increase have become a concern for the hong kong government, especially in the years of the asian financial crisis and sars epidemic, such a large share of spending on cssa and its rate of increase have become a concern for the hong kong government, especially in the years of the asian financial crisis and sars epidemic, when the budget turned to a deficit. the government did take steps to control the expenditure on cssa and balance their budget by reducing the value of cssa payments and the number of recipients. theoretically, reducing the number of recipients can be achieved either by preventing people from entering the cssa system or helping them leave the system. the "entering approach" often influences a relatively larger number of the population at risk of poverty, preventing "potential candidates" from falling into cssa with more universal measures. the universal measures often include minimum wage, universal health insurance, subsidized education, public housing, and so on, from which both cssa recipients and non-cssa people can benefit [13] . in particular, the universal cash handout scheme in hong kong is a very typical example. the hong kong government introduced scheme hkd 6000 and scheme hkd 4000 in 2011 and 2019, respectively. under these schemes, any hong kong permanent resident aged 18 and above was eligible to get a lump-sum payment of hkd 6000 and hkd 4000 in 2011 and 2019, respectively. in contrast, the "leaving approach" is more likely to affect a relative smaller group of people that are unemployed, in low-paid work, or single parents, helping them get out of the system with more focused measures. the focused measures include single parent allowance, transportation subsidy for low-income families, job training programs for the unemployed, and so on [13] . the hong kong government seemed to have adopted an "entering approach" in the 2000s, but the specific means of preventing people from entering was controversial. before 2004, hong kong residents could apply for cssa if they had lived in hong kong for at least 1 year. in 2004, the requirement for residence was then raised up to 7 years, effective from 2004 until 2013. this revision was mainly driven by concerns about the budget shortfall [14] . scholars also think that the government pursued the "entering approach" by blaming the poor for their laziness using the media, so that they were discouraged to apply for cssa [8, 9] . this created a psychological hurdle for those physically able adults and made them turn away from cssa voluntarily. wong (2000) [9] argued that the image of "laziness" and "dependency" constructed (whether intentionally or unintentionally) for the cssa recipients actually reflected "a failure rather than a success in fighting against poverty". the cssa is meant to provide timely help for those needy families such that they still can receive the necessary financial support while looking for employment. it does not mean to create some dependence on the system, and those seeking help should not be stigmatized. furthermore, it is always the children from cssa families who would need more support to break up intergenerational poverty. meanwhile, it should be emphasized that "welfare dependency" is a very common problem that many social security systems would face or try to avoid [15] [16] [17] . when the incentives to take and sustain jobs are not strong enough, people would continue claiming benefits from the social security system as they are often more secure and attractive than employment; thus, it would create a culture of "dependency", "laziness", or "worklessness", leading to "excessive and ineffective public expenditure", as well as "persistent and prevalent poverty" [17] . to reduce such "welfare dependency", an effective "leaving approach" may help to incentivize cssa recipients to return to and survive in the labor market. the poverty commission in hong kong has advocated social enterprises to play a role in poverty alleviation, particularly helping welfare dependents become self-sufficient, as social enterprises would provide more opportunities to the disadvantaged, as well as improve their skills and employability [18] . it is important to consider whether the "entering approach" is indeed more effective than the "leaving approach" in reducing the number of cssa recipients in hong kong. very few studies have provided evidence for the "entering approach". furthermore, without reducing the cssa payment and restricting the eligibility, is there any better way to control the expenditure on cssa? which group of people and in what approach should the government intervene so that the number of recipients can be effectively reduced? this paper tries to answer these mostly unexplored questions. specifically, by modelling the dynamics of the cssa system in a markov chain process and performing an elasticity analysis, we aimed to identify the potential target group and the group-specific approaches. the findings can shed some light on how to enhance and optimize the social security system in hong kong. the data required for the analysis included (1) the age-specific number of people who entered the cssa system during 2014-2015, (2) the age-specific number of people who left the system during 2014-2015, (3) the age-specific population in 2014, and (4) the number of births by mothers in terms of age group in 2014. on the basis of these data, we estimated the age-specific transition probabilities; that is, the probabilities of leaving cssa and the probability of entering cssa. all of the data are from the hong kong census and statistics department (hkc&sd). we modelled the dynamic of people moving in and out of the cssa system using a stochastic process (markov chain process). this method has been increasingly used in labor economics and demographic research, especially in evaluating social policies [19] [20] [21] [22] [23] . we first present a simplified model. suppose in a certain year, the probability of entering the system is p t and the probability of leaving the system is q t . let x t be the proportion of cssa recipients in the total population at time t. therefore, we can simply formulate the inflow and outflow of cssa recipients in equation (1). where a is a 2 × 2 matrix, the proportion of cssa recipients in the total population, x t+1 , can be reduced either through reducing the probability of entering cssa, p t , or through increasing the probability of leaving cssa, q t . to investigate whether the former or the latter approach is more effective in reducing the number of cssa recipients is of great importance to policymakers. in order to answer this question, we introduced the concept of elasticity. elasticity is originally a concept in economics. in economics, price elasticity, for instance, measures the impact on the demand of a product when its price changes, that is, percentage change in the quantity demanded of one product in response to percentage change in the price. very often, it is precisely interpreted as the percentage change of demand per 1% change in the price [24] . the concept of elasticity has recently been adopted by some scholars to evaluate the targeting of policies, for example the targeting of family polices in singapore, taiwan, and australia [21] [22] [23] . analogously, here we define the elasticity as the ratio of percentage change of x t+1 to the percentage change of any of the parameters (p t or q t ). the larger the elasticity, the more influential the parameter to x t+1 . the elasticity with respect to p t and q t can be formulated as follows: (2) by comparing the absolute values of δ p t and δ q t , we will know whether the "entering" or "leaving" approach is more effective in reducing the number of cssa recipients in a certain year. in reality, the probability of leaving or entering the cssa system often varies across different age and socioeconomic groups. as the data of cssa recipients by socioeconomic status is not available, we cannot include the socioeconomic groups in our analysis. thus, we further elaborated our model by considering age to better reflect the real dynamics of the cssa system in hong kong. let x in this study, we restricted our attention to those aged below 60, because those cssa recipients aged 60 and above have a high chance of leaving the cssa system due to death. the financial situation of older adults, and particularly those over the retirement age of 65, would also typically show little change due to the relatively low employability of older adults. on the basis of the data from hkc&sd, we estimated the transition parameters p (i) t and q (i) t for 10 year age-specific groups (covering the ages of 0-59). within the age group, those aged 0 deserve special attention. according to the rules under the cssa system, the newborns of a cssa recipient will become cssa recipients directly. on the basis of the assumptions that the birth rates of the cssa recipients and non-cssa people are the same, and that the births are from women aged 15-49, x (0) t and y (0) t can be formulated by equation (5). are the corresponding age-specific birth rates at time t. certainly, b (1) . the goal of our analysis was to investigate which group should be targeted and in which approach of "leaving" or "entering", so that the overall proportion of cssa recipients can have the largest reduction. let x denote the overall proportion of the cssa recipients in the population aged under 60, which can be calculated from the following formula: where w (i) t refers to the proportion of the age group i in the total population aged under 60 at time t, and 59 i=0 w t was estimated on the basis of the age-specific population in 2014 from hkc&sd. to achieve the goal, we estimated the elasticity with respect to p (i) t and q (i) t from the following formulae, which were modified from equations (2) and (3): moreover, to better understand the moving-in and -out of the cssa system, we calculated the probability of a cssa recipient aged i to first exit the system at or before the age of 60, as well as his/her mean time of staying in the system before the first exit. equations (9) and (10) were used to estimate the probability and the mean time. i) = 1 − 1 − q (i) t 1 − q (i+1) t · · · 1 − q (59) t (9) mean time = 1 × q (i) t + 2 × q (i+1) t × 1 − q (i) t + · · · +(60 − i) × q (59) t × 1 − q (58) t · · · 1 − q (i) t(10) the estimated age-specific probabilities of entering and leaving the cssa system are shown in table 1 . the probability of leaving was found to be much higher than the probability of entering across all the ages. the 20-29 age group has the highest probability of leaving and the lowest probability of entering the cssa system. except for the two youngest age groups, the probability of leaving cssa declines with the increase of age, indicating the increasing difficulty of raising their income above the level of the threshold. on one hand, this declining trend may be due to the fact that the family size will increase with people's age, and thus it would become more difficult to move all the family members out of the cssa system. on the other hand, previous research shows that in hong kong, as men and women get older, particularly after age 30, upward mobility of earnings declines while downward mobility of earnings increases [25] . workers in the lowest income quintile are more likely to be trapped at the bottom, experiencing no earning mobility [25, 26] . moreover, the declining probability of leaving for the two youngest age groups (i.e., ages of 0-9 and 10-19) is very much related to the parents' probability of leaving. parents of children aged 10-19 are more likely to be older, in the 40s and 50s, and that is probably why the leaving probability of the 10-19 age group is lower and very close to that of the 40-49 and 50-59 age groups. regarding the probability of entering cssa, the 0-9 and 10-19 age groups were found to be at the highest level-much higher than the other age groups. this was because these two groups are too young to participate in the labor market and their economic situation often depends on their parents. once their parents' incomes fall below the threshold level of cssa, they become cssa recipients directly. hence, these young people are indirectly entering the cssa system. thus, reducing their probability of entering should not directly aim at these young dependents but at improving incomes of their parents who are often in the age range of 30-49. maintaining the economic environment by keeping the unemployment rate low is important for middle-aged workers. table 2 shows the probability of a cssa recipient first exiting the system before age 60 and the mean duration of staying in the system. it is encouraging to see that the probabilities of first exit among those aged under 30 are higher than 0.99, implying that almost all of them will leave the cssa system before age 60. there was a significant decline in the probability of first exit after age 30. this is very consistent with the age pattern shown in table 1 . the probability dropped to 0.73 for those aged 50 and 0.48 for those aged 55. this is because there is much less time for them to leave the cssa before the cutoff age of 60. regarding the mean time of staying in the system, children under age 15 were found to have the longest duration. the mean time was found to decrease to about 4.8 years for those in their 20s and then starts to rise again in the age range of 30-40. those in their 50s have a much shorter duration of staying before they first leave the system. on the basis of the age-specific probability of entering and leaving cssa, we performed the elasticity analysis. the results (in absolute values) are shown in table 3 increased by 0.1, the overall proportion of cssa recipients would decrease by 0.0012 (= 0.012 × 0.1). from these results, it seems that preventing people aged 20-29 from entering the cssa system has a larger impact; that is, the "entering" approach would be more effective in reducing the number of cssa recipients in 2014. however, it should be noted that it is impossible and unrealistic to achieve a decrease of 0.1 in p is only 0.0015 and a decrease of 0.1 will make it negative. in reducing the number of cssa recipients; for the 10-19 and 20-29 age group, helping the cssa recipients leave the system will have a larger impact (see the last column in table 3 ). in sum, these results suggest that targeting the age group of 30-49 through the "entering approach" would lead to the greatest reduction in the number of cssa recipients, as aiming at this group would also effectively prevent those aged 0-9 from entering the cssa system. this study investigated the targeting of the social security system in hong kong by evaluating the cssa scheme, which is the fundamental welfare program. we have made use of the markov chain process to model the dynamics-the inflow and outflow-of the cssa system. we conducted elasticity analyses to identify the potential target group and the appropriate approaches for different subgroups classified by age. the results have revealed that the largest elasticity was in the 0-9 age group, meaning that targeting children at this age will lead to a largest decrease in the number of cssa recipients. currently, child poverty is a serious issue in hong kong. in 2017, before government intervention, the poverty rate among children aged below 18 was about 23.1%, much higher than many other developed societies [2,27]. as child poverty often results from parents' low income and unemployment, policies that support households with children would be desirable. more precisely speaking, the results suggest that targeting those aged 30-49 with children by decreasing the risk of entering cssa would have the largest impact on the number of cssa recipients. studies on child poverty in hong kong have found that family structure is a strong predictor. it was found that children from immigrant families are more likely to live below the poverty line in hong kong due to low education of parents, high unemployment rate of mothers, and low payment of parents' jobs [28] . moreover, children living with single parents have high risk of poverty; the poverty gap between children with single parents and children with two parents has been widening in recent decades [29] . the ethnic minority families such as pakistani, nepalese, and other south asian countries also have higher child poverty rates, as a result of discrimination in the education system and labor market due to the language barriers faced by their parents [30] . poverty is found to have a significant impact on children's psychological well-being-in hong kong, children in poverty have reported lower levels of self-esteem and more depressive symptoms, and they are more likely to live in public housing which is often more crowded, having poor hygiene and lack of facilities [31] . food insecurity, as well as limited educational opportunities and learning resources would have a therefore, compared to the rates of change, the elasticity that takes into account the feasibility of changing the parameter is preferable. as shown in table 3 , the elasticity to the probability of leaving in the 20-29 age group δ q (20−29) t was 0.109, meaning that given 1% increase in the probability of leaving (i.e., an increase of 1% × 0.2103), the proportion of cssa recipients would reduce by 0.109%. the elasticity to the probability of entering the group δ p (20−29) t × was 0.04, meaning that given a 1% decrease in the probability of entering (i.e., a decrease of 1% × 0.0015), the proportion of cssa recipients would reduce by 0.04%. thus, according to the elasticities, increasing the probability of leaving would have a greater impact, indicating that the "leaving approach" rather than the "entering approach" is more effective for the age group 20-29. as shown in figure 5 , the elasticities of the leaving probabilities decline with age, implying that the "leaving approach" is more effective in younger age groups than in older groups, as the employability of young people is much higher than their older counterparts and earning a salary through employment is the most effective way to leave the cssa system. the elasticities of entering probabilities also showed a decreasing trend over ages, although the 20-29 and 50-59 age groups had the lowest elasticities. this means that the "entering approach" for these two groups is relatively less effective than in other age groups. the age pattern of the elasticities showed that targeting younger age groups would make a larger difference than targeting older groups. therefore, intuitively, it may seem most effective to target the 0-9 age group. however, instead of focusing on these young dependents, attention should be paid to their parents who are often in the age group of 30-39 and 40-49. furthermore, elasticities of entering probabilities were larger than leaving probabilities in the 0-9, 30-39, and 40-49 age groups, whereas the opposite pattern was shown in the 10-19 and 20-29 age group. these findings inform us that for the 0-9, 30-39, and 40-49 age group, preventing them from entering the cssa system would be more effective in reducing the number of cssa recipients; for the 10-19 and 20-29 age group, helping the cssa recipients leave the system will have a larger impact (see the last column in table 3 ). in sum, these results suggest that targeting the age group of 30-49 through the "entering approach" would lead to the greatest reduction in the number of cssa recipients, as aiming at this group would also effectively prevent those aged 0-9 from entering the cssa system. this study investigated the targeting of the social security system in hong kong by evaluating the cssa scheme, which is the fundamental welfare program. we have made use of the markov chain process to model the dynamics-the inflow and outflow-of the cssa system. we conducted elasticity analyses to identify the potential target group and the appropriate approaches for different subgroups classified by age. the results have revealed that the largest elasticity was in the 0-9 age group, meaning that targeting children at this age will lead to a largest decrease in the number of cssa recipients. currently, child poverty is a serious issue in hong kong. in 2017, before government intervention, the poverty rate among children aged below 18 was about 23.1%, much higher than many other developed societies [2, 27] . as child poverty often results from parents' low income and unemployment, policies that support households with children would be desirable. more precisely speaking, the results suggest that targeting those aged 30-49 with children by decreasing the risk of entering cssa would have the largest impact on the number of cssa recipients. studies on child poverty in hong kong have found that family structure is a strong predictor. it was found that children from immigrant families are more likely to live below the poverty line in hong kong due to low education of parents, high unemployment rate of mothers, and low payment of parents' jobs [28] . moreover, children living with single parents have high risk of poverty; the poverty gap between children with single parents and children with two parents has been widening in recent decades [29] . the ethnic minority families such as pakistani, nepalese, and other south asian countries also have higher child poverty rates, as a result of discrimination in the education system and labor market due to the language barriers faced by their parents [30] . poverty is found to have a significant impact on children's psychological well-being-in hong kong, children in poverty have reported lower levels of self-esteem and more depressive symptoms, and they are more likely to live in public housing which is often more crowded, having poor hygiene and lack of facilities [31] . food insecurity, as well as limited educational opportunities and learning resources would have a negative impact on the development of children from poor families, creating intergenerational poverty in hong kong [32] . therefore, it is very important to identify the reasons of falling into the cssa system and barriers to exit among households with children. single parenthood, unemployment, and low-earnings are the major reasons for physically-able adults becoming cssa recipients. the latest poverty study in 2017 shows that poverty among those who are working was only 4.9% in comparison to 14.7% in the general community [2]. providing jobs and enhancing job earnings for the age group of 30-49 would effectively reduce the number of cssa recipients. the hong kong government has initiated the public transport fare subsidy scheme to enhance people's ability to look for employment across districts [33] . the government also provides additional support for families-especially single-parent families-to work part-time and look after their children after work. of course, the employment remuneration conditions should be improved so that working parents can earn enough to support the family without the need of cssa. the introduction of a minimum wage by the hong kong sar government in 2011 has helped to narrow the income gap, despite the fact that the minimum wage is still at a very low level of about hkd 37.5 (about usd 4.8) per hour. in many western countries, the minimum wage is substantially higher (e.g., usd 13.3 in australia, usd 10.3 in the united kingdom), despite the fact that hong kong's gdp per capita of usd 49,000 actually ranks higher. thus, it is important to examine the minimum wage structure, especially for those in low-skilled jobs, to improve their quality of life. meanwhile, different subgroups call for different approaches. the "entering approach" is not always most desirable for all the subgroups. it is found that for the 10-29 age groups, policies that aim to help people leave cssa will be more effective than policies that aim to prevent people from entering cssa. according to the hong kong poverty situation report 2017, the unemployment rate among the young people 15-29 is relatively higher than the general population. on the other hand, for those who are employed, young households have the highest proportion of high-skilled workers and the lowest poverty rate [2]. by upgrading working skills of young cssa recipients, young adults can enhance their employability and secure jobs with better earnings, so that they can support themselves without cssa. diversifying the economic and working opportunities is also of great importance in improving the employability of our young people. most of the economic activities in hong kong are in the professional, financial, and service sectors, and limited opportunities are available in other sectors, such as creative industries and local startups. the excessive rental cost in hong kong has been found to be a barrier for young people to start their own business. it is important for the government to provide initial support for these young entrepreneurs at the early stage of their career development. meanwhile, for the 30-59 age groups, policies that aim to prevent people from entering cssa will be more effective than policies that aim to help people leave cssa. people of these ages often have other family members to care for, either young children or old parents, and sometimes both. more often, they have jobs but the earnings are not adequate to cover the living expense of the whole family, and thus all members in the household become cssa recipients. in this case, policies that can increase the family income can prevent them from entering cssa. we should try to maintain or enhance the employability of these groups of people as a matter of importance. keeping them in the job is important for poverty alleviation. it will be difficult for the unemployed individuals to reenter to the workforce, especially for those who are not professionals. the bargaining power to aim for better working conditions would also be limited for the low-skilled workers as there are plenty in supply due to the current migration policy, with there being an influx of migrants of 150 per day from mainland china entering into hong kong. the wage of the low-skilled worker has been lagging behind the economic growth. hong kong still has one of the largest poverty gaps among the high income societies with a gini coefficient of 0.54 [2] . it is important to improve the wage level, especially for the low-skilled workers in hong kong. the minimum hourly wage is hkd 37.5 (usd 4.8), which is one of the lowest in comparison to other oecd (i.e., the organization for economic co-operation and development) countries. currently, the individual-based work incentive transport subsidy (i-wits), to some extent, can help middle-aged adults broaden their horizons for better job opportunities across the whole territory [33] . in addition, the working family allowance can provide extra income to households with children. the results have provided insights into the improvement of the cssa system in terms of accurate targeting. it should be emphasized that the probability of entering and leaving cssa, as well the elasticities with respect to these probabilities, should be monitored frequently and closely so that a more timely response can be in place to improve the efficiency of cssa. in spite of the positives, there are some limitations in this study. first, due to data limitations, we were only able to investigate the targeting groups by age, and did not include the subpopulations by socioeconomic status (e.g., education, employment, occupation). future research can assess the role of different socioeconomic subgroups in reducing the number of cssa recipients, with better data access. apparently, the young graduates from universities have less financial responsibility towards their parents and they can afford to have some gap years before graduation and employment. for the young professionals, once they work, it would be easier for them to leave poverty. second, we did not take into account gender difference. the number of female cssa recipients was found to often be larger than male recipients, which is mainly the contribution of women's overrepresentation in the "single-parent" case under cssa [34] . for example, in 2017, 87.6% of single-parent recipients were female, most of whom were divorced or separated, in the age of 30-49 [35] . however, due to a lack of gender-specific data, we were unable to examine whether the elasticities were different between men and women, and how big the difference was. third, we only restricted our analysis to those under age 60 and did not consider the elderly population due to limited information of the elderly people leaving cssa because of death. fourth, the markov chain and elasticity analyses were based on several assumptions (e.g., assumption of the same birth rates between cssa recipients and non-cssa people), and consequently they did not fully model the exact dynamics of the cssa system. fifth, we did not take into consideration the differential cost in achieving the same unit of the entering and exiting approach. however, this method is still a very useful tool to assess the targeting of the social security system and it can be further elaborated if more information about the cssa recipients and employment data is available. the propose model provides empirical evidence to identify the potential target groups of people that would lead to the largest reduction in the number of the cssa recipients in the hong kong social security system. this analytical method has also revealed whether policies would be more effective in preventing people from entering the cssa system or helping them leave the cssa scheme. despite the limitations of the stochastic model, it helps to improve the effectiveness of the social security system in hong kong. poverty and income inequality have become one of the major causes of the recent months of social unrest in hong kong in 2019-2020. the government has been increasing its expenditure on welfare spending. sometimes, the improvement is still quite limited. our model can be used as a tool to examine its effectiveness of any poverty program with the aim to reduce the number of cssa recipients. author contributions: manuscript preparation and data analysis-m.c., b.k.s., k.f.l. and k.p.w.; leading the investigation as the pi for the project, critical review and final approval of the paper-p.y. all authors have read and agreed to the published version of the manuscript. funding: this research was funded by the hong kong government: sppr-12. the common welfare: hong kong's social services social security inequality and the third world the 2018-2019 budget the basic law of the hong kong special administrative region of the people's republic of china; the constitutional and mainland affairs bureau speech by the chief executive in delivering "the chief executive's 2017 policy address" to the legislative council the social security system in hong kong: establishment and readjustment of the liberal welfare model the failure of social security in alleviating poverty in hong kong changes in 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this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors are grateful for data supplied by the social work department and the census and statistics department of the hong kong sar government and the many useful comments from the reviewers. the research is supported by the chief executive community project for poverty alleviation and the hong kong charities trust. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. key: cord-293861-n6733nfd authors: juhász, attila; nagy, csilla; varga, orsolya; boruzs, klára; csernoch, mária; szabó, zoltán; ádány, róza title: antithrombotic preventive medication prescription redemption and socioeconomic status in hungary in 2016: a cross-sectional study date: 2020-09-19 journal: int j environ res public health doi: 10.3390/ijerph17186855 sha: doc_id: 293861 cord_uid: n6733nfd this work was designed to investigate antithrombotic drug utilization and its link with the socioeconomic characteristics of specific population groups in hungary by a comparative analysis of data for prescriptions by general practitioners and the redeemed prescriptions for antithrombotic drugs. risk analysis capabilities were applied to estimate the relationships between socioeconomic status, which was characterized by quintiles of a multidimensional composite indicator (deprivation index), and mortality due to thromboembolic diseases as well as antithrombotic medications for the year 2016 at the district level in hungary. according to our findings, although deprivation is a significant determinant of mortality due to thromboembolic diseases, clusters can be identified that represent exemptions to this rule: an eastern part of hungary, consisting of two highly deprived counties, had significantly lower mortality than the country average; by contrast, the least-deprived northwestern part of the country, consisting of five counties, had significantly higher mortality than the country average. the fact that low socioeconomic status in general and poor adherence to antithrombotic drugs irrespective of socioeconomic status were associated with increased mortality indicates the importance of more efficient control of preventive medication and access to healthcare in all districts of the country to reduce mortality due to thromboembolic diseases. the latest joint publication of the organisation for economic co-operation and development (oecd) and the european commission [1] on health and access to health services illustrates the existing notable health inequalities between and within european union (eu) member states. there are persisting inequalities in life expectancy between sexes and among groups with different socioeconomic 2 of 16 statuses (sess), defined mainly by education, income levels, or occupations. as shown in a europe-wide analysis [2] , "in central and eastern european countries inequalities in mortality have disastrously exploded since the early 1990s". the most significant cause of mortality differences is cardiovascular disease (cvd) [3] , and studies have shown that in almost all european countries, as well as in countries from other regions [4] , those with a lower ses have higher rates of cvd mortality and morbidity [5] . the relative risk of premature mortality caused by cvds is especially unfavorable in post-communist member states of the eu [6] . according to the latest available data, the years of life lost (ylls) due to cvds are greater than or almost equal to 10,000 ylls per 100,000 among males in five eu member states, including hungary, romania, latvia, lithuania, and bulgaria [7] . although it has been shown that a remarkable decline in cvd mortality over the last 25 years was experienced in lower socioeconomic groups, "further reducing inequalities, especially in the nordic, central-european and baltic countries, remains an important challenge for european health systems and policies" [8] . a recent descriptive study [9] on inequalities and premature mortality underlined that although cvd mortality in harmony with a longer-term trend in the united kingdom (uk), which is classified as highly developed, has been decreased radically during the study period (2003) (2004) (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) (2016) (2017) (2018) , there are groups, e.g., women living in deprived areas, requiring further attention. although cvds cover a broad range of diseases, including thromboembolic diseases, such an inverse relationship between ses and morbidity/mortality seems to present for thromboembolic diseases. for example, a nationwide study found that higher neighborhood ses was associated with a lower incidence of venous thromboembolism in the netherlands [10] . another nationwide study carried out in sweden reported that high educational level and certain occupations requiring high levels of education were negatively associated with venous thromboembolism [11] . it is generally accepted that a substantial benefit can be derived from preventive medication in both primary and secondary prevention in addition to lifestyle-modifying interventions. in primary prevention, aspirin and lipid-lowering and antihypertensive drugs, as indicated by the existing symptoms, are widely used [12] [13] [14] [15] . for secondary prevention of certain cvds-in addition to medicines also used in primary prevention-antiplatelet drugs and anticoagulants, which exhibit their effect by blocking the pathways for the activation of platelet aggregation and the coagulation cascade, are strongly recommended. clinical trials have demonstrated the safety and efficacy of antiplatelet medication for non-cardioembolic stroke prevention, while anticoagulants are recognized for preventing cardioembolic stroke, atrial fibrillation, and thrombotic complications related to different heart diseases [16] . the persistent long-term use of these preventive drugs has become widespread [17] , and guidelines state at what levels of risk preventive drugs are recommended [1, 18] . the prospective urban rural epidemiology (pure) study illustrated that within groups of countries categorized by income (low, lower-middle, upper-middle, and high), the average use of treatment drug-among them, antiplatelet medication-for secondary prevention of cvd is low, particularly in low-income countries. later, a study based on the results acquired in the pure study revealed marked cross-country differences [19] . although data on the level and availability of secondary prevention at the country level would be essential for planning and targeting national health system policies that can decrease premature cvd mortality and morbidity, only a few studies have been published on the link between the utilization of antiplatelet drugs and anticoagulants (hereafter antithrombotic agents) for preventive purposes and socioeconomic status. a study from china demonstrated a more than 70% lower use of antiplatelet agents among patients with lower ses, while another study from sweden showed that the odds of prescribing warfarin (common vitamin k antagonist oral anticoagulant agent) were more prominent among men and women living in high-ses neighborhoods than among their counterparts residing in low ses neighborhoods-men: odds ratio (or) = 1.44 (95% confidence interval (ci) 1.27-1.63); women: or = 1.19 (95% ci 1.05-1.36). individuals in low-ses neighborhoods more often undergo inadequate treatments and less warfarin according to treatment recommendations for atrial fibrillation and likely for other cardiovascular diseases as well [20] . contrary to a recent study based on an electronic cohort of individuals aged over 20 in wales (uk) and using linked data from primary and secondary care followed for six years (2004) (2005) (2006) (2007) (2008) (2009) (2010) , no significant evidence of socioeconomic inequality was demonstrated across quintiles of the welsh index of multiple deprivation, an area-based measure of socioeconomic inequality, in the adherence to recommended medication for primary and secondary prevention of coronary heart disease [21, 22] . since physicians in general practice play a major role in initiating, coordinating, and providing long-term follow-up for the prevention of non-communicable diseases [23] , our study examined the prescription and redemption rates of the most common oral antiplatelet drugs and anticoagulants prescribed for thrombosis prevention from all general practices and defined their relationships with socioeconomic status in hungary. our cross-sectional ecological study aimed to examine whether inequalities exist in preventive antiplatelet and anticoagulant treatments in association with socioeconomic conditions. in the analysis, the relationships between the following were investigated: deprivation and mortality caused by thrombotic diseases; 2. deprivation and the prescription/redemption of selected oral antiplatelet and anticoagulant drugs, with special focus on the comparison between areas with high mortality, although socioeconomically well developed and areas with relatively favorable mortality although socioeconomically deprived, and 3. the level of deprivation and the prescribing pattern of antithrombotic drugs. in line with our previous studies on preventive medication, the methodology developed by our group [24] [25] [26] was used in this study. for 2016, mortality caused by stroke (icd-10 i63, i64), arterial embolism and thrombosis (icd-10 i74), phlebitis and thrombophlebitis (icd-10 i80), portal vein thrombosis (icd-10 i81), and other venous embolism and thrombosis (icd-10 i82) data were acquired from the hungarian central statistical office (hcso), while population data were obtained from the central office for administrative and electronic public services. both mortality and population data for the 40+ age group used were stratified by the districts and 5-year age bands and sex. data on prescriptions by general practitioners (gps) and redeemed prescriptions for the four most commonly used oral antithrombotic drugs were comparatively analyzed in hungary during the last year of data availability (2016) for validated databases allowing district-level analysis. the number of prescriptions and the number of redeemed prescriptions for specified oral antithrombotic drugs as prime examples of commonly used classes of antithrombotic agents for secondary cardiovascular prevention [16] , such as vitamin k antagonists (a coumarin derivate, acenocoumarol-syncumar;-all warfarin products available in hungary), a factor xa inhibitor (rivaroxaban-xarelto), and a platelet aggregation inhibitor (clopidogrel-all originator and generic products available in hungary), were collected from the national health insurance fund administration of hungary for each primary-healthcare practice for the entire year of 2016. according to the hungarian regulations, general practitioners can prescribe only one type of drug as a 1-month dose of one prescription for patients with long-term medication use. a deprivation index (di) to characterize the socioeconomic deprivation at the municipality level in comparison with the national average could be calculated by using the last census data originally obtained from hcso (census 2011) and the hungarian tax and financial control administration (2011), and presently available from the regional informational system of the ministry of local government and regional development. the method to calculate di values and their efficacies to identify ses-related inequalities in cvd mortality have been explained previously [26] and has been used to conduct former studies to describe the association between deprivation and mortality amenable to healthcare [27] , premature mortality attribute to alcoholic liver disease [28] , statin utilization [24] , between deprivation and the incidence and survival of childhood leukemia [29] , as well as between deprivation and antihypertensive medication use in hungary [25] . briefly, the di is based on seven municipality-level basic socioeconomic indicators, including income, level of education, rate of unemployment, proportion of one-parent families, proportion of large families, density of housing, and car ownership [26] . after natural log transformation and standardization of these variables, the area-specific indices as weighted sums of the z-scores were defined by applying a principal component analysis. positive index values indicate districts/municipalities with a lower socioeconomic status compared with the national average, and the converse is true for districts with negative index values. hungary is divided administratively into 19 counties, in addition to the capital budapest. thus, it has 20 european regions at the third level of the nomenclature of territorial units for statistics (nuts). the counties are further subdivided into 198 districts constituting local administrative unit 1 (lau1), formerly known as nuts level 4 of hungary [30] . the number of gp practices in hungary serving 2809 municipalities of the country was 6199 in 2016. the number of clients registered by the gps varied extensively (800-3000 persons/practice), and the average size was 1581 persons/practice. generally, more family practices are available in urban areas, whereas one family practitioner provides services for more than one municipality in rural areas. free choice of a physician at the primary care level is a norm in hungary, and di is not used at the practice level. thus, to reduce the risk of misclassification, all data were aggregated to the district level. to define the frequency of prescription and that of redemption, the denominator was the size of the 40±-year-old population adjusted by sex and age. all districts included in the analysis were classified into 5 groups (quintiles), ranging from the least deprived (quintile i) to the most deprived (quintile v), with each containing one-fifth of the districts analyzed. applying the "disease mapping" option within the rapid inquiry facility (rif) [31] , the spatial pattern of hierarchical bayesian indirectly smoothed standardized mortality caused by stroke (icd-10 i63, i64), arterial embolism and thrombosis (icd-10 i74), phlebitis and thrombophlebitis (icd-10 i80), portal vein thrombosis (icd-10 i81), and other venous embolism and thrombosis (icd-10 i82) for the 40+ age group for 2016. it was examined and visualized with posterior probabilities at the district level [32, 33] . the frequency of prescriptions for the selected oral antithrombotic agents, redeemed prescriptions, and the ratios for compliance in relation to the national average was also mapped using the rif, and their association with deprivation was defined using quintiles of di as a district-based categorical covariate. the ratios between the number of redeemed prescriptions and that of the prescriptions for antithrombotic drugs were utilized to define the characteristics of the level of primary non-compliance. the results were analyzed by types of drugs and deprivation quintiles. as was described in our previous publications [24, 25] and also demonstrated in the present paper, deprivation index values defined by districts varied from −3.76 to +5.83, as shown in figure 1a the least-deprived districts of the country were localized at the northwestern part of hungary, in the capital city of budapest, and its neighboring areas. the spatial distribution of mortality due to thromboembolic diseases could be characterized by significant inequalities, and the areas of highest standardized mortality ratios (smrs) were detected in the northwestern, western, northeastern, and southeastern regions of the country. however, a cluster consisting of five counties with high mortality caused by thromboembolic diseases was detected in the northwestern and western parts of the country (circle drawn by the dashed red line), where the majority of the least-deprived districts were localized, while a cluster consisting of two counties (circle drawn by the dashed green line) that were highly deprived with low mortality figures was localized in the northeastern region ( figure 1a,b) . the least-deprived districts of the country were localized at the northwestern part of hungary, in the capital city of budapest, and its neighboring areas. the spatial distribution of mortality due to thromboembolic diseases could be characterized by significant inequalities, and the areas of highest standardized mortality ratios (smrs) were detected in the northwestern, western, northeastern, and southeastern regions of the country. however, a cluster consisting of five counties with high mortality caused by thromboembolic diseases was detected in the northwestern and western parts of the country (circle drawn by the dashed red line), where the majority of the least-deprived districts were localized, while a cluster consisting of two counties (circle drawn by the dashed green line) that were highly deprived with low mortality figures was localized in the northeastern region ( figure 1a ,b). the results of the regression analysis presented that deprivation was a significant but non-linear determinant of mortality due to thromboembolic diseases in deprivation quintiles iii-iv, and it was found to be higher by approximately 30-40%, while in quintile v, it was approximately 30% higher than that in the least-deprived region (quintile i) ( table 1) . the results of the regression analysis presented that deprivation was a significant but non-linear determinant of mortality due to thromboembolic diseases in deprivation quintiles iii-iv, and it was found to be higher by approximately 30-40%, while in quintile v, it was approximately 30% higher than that in the least-deprived region (quintile i) ( table 1) . in hungary, 1,729,058 clopidogrel, 1,024,233 syncumar, 447,050 warfarin, and 165,816 xarelto prescriptions for 28 days/one month were issued by general practitioners in 2016. the highest frequencies of both prescription and redemption per person aged 40+ years old were noticed for clopidogrel, and the lowest frequencies were shown for xarelto. the redemption rate of the four types of antithrombotic drugs differed significantly. the redemption rate of syncumar prescriptions was the highest, 76.24%, while the redemption rate of clopidogrel was the lowest, only with 54.4% (table 2 ). the frequency of clopidogrel prescriptions in relation to the national average was higher in districts in the southwestern and northeastern parts of hungary. the frequency of syncumar prescriptions also had a similar spatial pattern with a higher relative prescription rate in the middle of the country (figure 2a,b) . the districts with a higher relative frequency of warfarin prescriptions were located in the northeastern, southern, and western parts of hungary ( figure 2c ). districts with a higher relative prescription ratio for xarelto were located along the axis in the southwestern and southeastern parts of the country ( figure 2d ). the spatial patterns of relative redemption ratio were very similar to prescription ratio for each anticoagulant drug, respectively ( figure 3a-d.) districts in the southwestern and northeastern parts of hungary. the frequency of syncumar prescriptions also had a similar spatial pattern with a higher relative prescription rate in the middle of the country (figure 2a,b) . the districts with a higher relative frequency of warfarin prescriptions were located in the northeastern, southern, and western parts of hungary ( figure 2c ). districts with a higher relative prescription ratio for xarelto were located along the axis in the southwestern and southeastern parts of the country ( figure 2d ). concerning the total number of drugs utilized, clopidogrel prescription and redemption were the highest (approximately half of the total prescriptions and 40.7% of the total redemptions), followed by the prescription and redemption of syncumar, warfarin, and xarelto. the proportions of clopidogrel and syncumar prescriptions and redemptions were increased by deprivation level, while the proportion of warfarin and xarelto prescriptions and redemptions showed an opposite trend, i.e., in the most-deprived quintile, the proportions were much lower than in the least-deprived quintile. the most remarkable differences between the least-deprived and the most-deprived quintiles were observed for xarelto prescription and redemption (6.22% vs. 3.53% and 6.14% vs. 3.87%, respectively) ( figure 4) . concerning the total number of drugs utilized, clopidogrel prescription and redemption were the highest (approximately half of the total prescriptions and 40.7% of the total redemptions), followed by the prescription and redemption of syncumar, warfarin, and xarelto. the proportions of clopidogrel and syncumar prescriptions and redemptions were increased by deprivation level, while the proportion of warfarin and xarelto prescriptions and redemptions showed an opposite trend, i.e., in the most-deprived quintile, the proportions were much lower than in the least-deprived quintile. the most remarkable differences between the least-deprived and the most-deprived quintiles were observed for xarelto prescription and redemption (6.22% vs. 3.53% and 6.14% vs. 3.87%, respectively) ( figure 4) . of clopidogrel and syncumar prescriptions and redemptions were increased by deprivation level, while the proportion of warfarin and xarelto prescriptions and redemptions showed an opposite trend, i.e., in the most-deprived quintile, the proportions were much lower than in the least-deprived quintile. the most remarkable differences between the least-deprived and the most-deprived quintiles were observed for xarelto prescription and redemption (6.22% vs. 3.53% and 6.14% vs. 3.87%, respectively) ( figure 4) . a significant association was discovered between the frequency of clopidogrel prescriptions per 100 persons aged 40+ years and deprivation. the incidence rate ratios in the highest deprivation quintile (quintile v) were 60.7% higher than those in the lowest quintile area (quintile i). a similar association was found in the case of syncumar prescriptions, with 25.342 prescriptions/100 persons a significant association was discovered between the frequency of clopidogrel prescriptions per 100 persons aged 40+ years and deprivation. the incidence rate ratios in the highest deprivation quintile (quintile v) were 60.7% higher than those in the lowest quintile area (quintile i). a similar association was found in the case of syncumar prescriptions, with 25.342 prescriptions/100 persons in the most-deprived quintile ( table 3 ). the results show that deprivation is a significant but non-linear determinant of the frequency of warfarin prescriptions, and no association was found between xarelto prescription frequency and deprivation. similar but stronger, positive associations were detected between deprivation and redemption regarding clopidogrel, syncumar, and warfarin, but no association was found for xarelto. when the number of redeemed prescriptions and that of the prescriptions for antithrombotic drugs were compared, the frequency of redemption and the redemption rate were shown to be increased as the deprivation became more pronounced, i.e., better primary compliance was observed in quintile v than in quintile i, and the highest rates (independent of the types of drugs) were always associated with the districts with the highest deprivation (table 3) . the cluster with high mortality (standardized mortality ratio: 1.393) caused by thromboembolic diseases in the northwestern part of the country, consisting mainly of counties with the highest socioeconomic performance, was further analyzed, and it was shown that both prescription and redemption rates for each drug were less favorable than the country average (table 4 ). to better demonstrate the extent of the discrepancy between socioeconomic development and thromboembolic disease mortality, as well as preventive medication, further analysis was performed. prescription and redemption rates, as well as the relative redemption rate, were defined for each drug for an eastern hungarian region consisting of two highly deprived counties with significantly lower mortality than the country average (standardized mortality ratio: 0.747, and all the rates were found to be significantly higher than that in the northwestern cluster, close to or even better than the national average values). table 4 . mortality rate of the population aged 40+ years to thromboembolic diseases and frequency of the prescription and redemption, as well as redemption rate of oral antithrombotic drugs in the less deprived counties with high mortality (bordered by a red line on figure 1 ) of the northwestern part of hungary and in highly deprived counties with a low mortality rate (bordered by a green line on figure 1 ) of the eastern part of hungary in comparison with the national average data, 2016. highly in our previous studies, a notable positive association between the relative risk of premature cardiovascular mortality and deprivation was shown in hungary [24] [25] [26] . regarding preventive medication at the primary-care level, high inequalities linked with socioeconomic deprivation were shown both in the case of lipid-lowering treatment (statin medication) and of antihypertensive medication [24, 25] . in the country-wide analyses of statin and antihypertensive medication, mapping the frequency of prescriptions, redeemed prescriptions, and ratios for primary compliance in comparison to the national average was done, and were defined by their associations with deprivation (with tertiles of the deprivation index as a district-based categorical covariate) [24] . in the case of statin utilization, a low relative frequency of statin prescriptions was noticed in districts with the highest deprivation; however, significantly higher primary compliance (redemption) was noted in these districts. data from this study suggested that lack of statin utilization may illustrate a significant barrier to reducing cvd mortality, particularly among people living in highly deprived areas of the country. similarly, risk analysis of antihypertensive medication [25] showed a significant association between premature cardiovascular and cerebrovascular mortality risk and deprivation. the patterns of antihypertensive drug prescription and redemption significantly differed by di tertile. in areas with the highest deprivation, higher relative frequencies of angiotensin-converting enzyme inhibitors, beta-blockers, and calcium channel blocker prescriptions and lower relative frequency of angiotensin ii receptor blocker prescriptions were found. the proportion of angiotensin ii receptor blockers among the antihypertensive medications used elevated with the improvement in socioeconomic status. our current study was designed to examine antithrombotic drug utilization and its relationship with the socioeconomic characteristics of different population groups in hungary with a focus on the comparative analysis of data for prescriptions by general practitioners and the redeemed prescriptions for antithrombotic drugs. among the four preventive drugs, the redemption rate of syncumar prescriptions was the highest, 76.24%, while the redemption rate of clopidogrel was the lowest, only 54.4%. the frequency of prescription for these drugs (except for xarelto) was positively associated with deprivation. in fact, as the deprivation became more pronounced, the redemption rate was noticed to increase, irrespective of the types of drugs. however, the interactions between prescription/redemption measures and mortality due to thromboembolic diseases among districts were not consequent in hungary. in a cluster of high mortality caused by thromboembolic diseases in the northwestern part of the country, consisting mainly of counties with the highest socioeconomic performance, prescription and redemption rates for each drug were found to be less favorable than the country average. in contrast, an eastern hungarian region consisting of two highly deprived counties with significantly lower mortality than the country average had a significantly higher prescription and redemption rates than this northwestern cluster. the reason why these discrepancies exist cannot be squarely defined. it is reasonable to suppose that a study on healthcare access and performance would be able to-at least partly-clarify the background of these unexpected inequalities. there are 36 stroke units in hungary, of which performance is assessed by the thrombolysis rate (national thrombolysis rate is 13%). only a single stroke unit (veszprém) in the northwestern cluster slightly overperformed (14%) compared to the average, lagging behind the performance of centers in budapest and debrecen responsible for the healthcare of the population of the eastern cluster with significantly better mortality rates of thromboembolic diseases and better coverage in preventive medication. such deficiency in healthcare performance might be explained by human resource deficits in the northwestern cluster caused by increased out-migration and, consequently, the attrition of physicians after the eu accession of hungary [34] . in addition, a significant portion of physicians living in the northwestern part of the country are cross-border commuters working in austrian healthcare institutions [35] , especially in the bordering province of burgenland, where, in certain hospitals, the proportion of commuting hungarian doctors reaches 23%. this fact became known due to the connection with the covid-19 pandemic [36] . in line with our findings, insufficient anticoagulant treatment and its link with ses have been reported by several studies [37] . prescribing was less frequent with older age and in patients born in other nordic countries or countries outside of europe than in those born in sweden. university education and higher income were associated with higher levels of oral anticoagulant prescription [38] . in an italian study based on the italian geographical macro-regions (north, central, south), data on medication adherence of nonvalvular atrial fibrillation patients were analyzed to assess whether socioeconomic conditions might also influence medication adherence. regional disparities exist in drug prescriptions. in high-risk patients, oral anticoagulants were more likely to be prescribed in northern and central patients than in high-risk southern patients. additionally, medication adherence was noticed as a progressive decrease from north to south [39] . a review presented 47 articles concerning anticoagulant therapy on patients' perspectives and patients' adherence. the findings through five interacting dimensions of adherence were synthesized: patient-related factors, therapy-related factors, condition-related factors, health system factors, and social, economic factors [40] . overall, one-fifth of the studies in the review examined the impact of patients' background in social and economic aspects on their perception of and adherence to warfarin therapy [41] [42] [43] [44] . the financial burden of warfarin to patients is dependent on healthcare service costs to individuals and the extent to which these medicines are subsidized by the governments or insurance companies in those countries where they are available. in regard to warfarin, only two studies stated that a small number of patients were financially burdened by further expenses associated with managing the therapy [41, 44] . in hungary, the higher redemption rate of the antithrombotics-including the high-cost xarelto-in deprived districts might be explained by the broad access to prescription exemption certificates. in contrast, the vitamin k antagonist warfarin applied in acute thromboembolic diseases as anticoagulant therapy could cause similar redemption patterns across quintiles. the effectiveness of oral anticoagulants is critically dependent on patients' adherence to intake regimens. lee et al. underlined the significant role of promoting medication adherence for risk reduction, especially in low-income patients with cvds [45] . contrary to the approach of "the lower social, economic status associated with lower adherence" [46] , our study indicates that a more complex relationship exists between socioeconomic factors and medication adherence. there is a need to address medication nonadherence, which is an important cost driver in healthcare expenditures and inequalities [47] , as an interconnected network. beyond policies targeting health behavior (new taxes on "unhealthy" food, such as sweetened, salty, and fatty products, anti-smoking legislation) that were introduced by the hungarian government, actions to facilitate favorable changes in inequalities in health services are necessary. for example, financial incentives are effective tools to achieve a major contribution to the reduction in inequalities in the delivery of clinical care related to area deprivation [48] . additionally, it can be supposed that underlying problems exist at the level of service provision and/or access to health services in certain clusters given the fact that low prescription and redemption rates occur together with high ses. in general, an analysis of the spatial distribution pattern of mortality in connection with that of the relevant preventive medication can result in the identification of regions/populations with no adequate treatment, including preventative medication, which may help to identify gaps in service provision and to diminish preventable and amenable mortality. only limited literature is available on the relationship between antithrombotic drug utilization and ses. additionally, the majority is focused on warfarin. to the best of our knowledge, this is the first comprehensive study that analyzed the relationship of ses to mortality caused by thromboembolic diseases and the utilization of antithrombotic drugs in a post-communist member state of the eu, which is characterized by an extremely high relative risk of premature cvd mortality by applying a multidimensional composite indicator to properly characterize the ses and using risk analysis capabilities to estimate the relationships between deprivation and thromboembolic disease burden as well as antithrombotic medication. an additional strength of this study is the complete coverage of the entire population. however, some limitations need to be considered in the interpretation of our findings. in our observational study with the methodology of cross-sectional and ecological studies, the statistical associations detected do not indicate a causal relationship, and the relationships observed between deprivation and mortality, as well as deprivation and preventive medication at the population level, may not be linked with mortality and preventive medication in individuals [49] . there are factors (e.g., related to patients, physicians, and health system) with an actual impact on antithrombotic drug utilization not included in the study [50] . in hungary, the high prevalence of health behavior risk factors (such as smoking, uncontrolled alcohol consumption, physical inactivity, unhealthy nutrition) is a severe problem regarding the prevention of chronic diseases [51] , and these factors were unmeasured confounders in our study. the combined effect of deprivation and adherence to preventive medication on cardiovascular mortality was addressed by this work. although deprivation is a significant determinant of mortality due to thromboembolic diseases, the identified clusters underlined that a complex relationship exists between socioeconomic factors and medication adherence. a linear association was noticed between the relative frequency of prescriptions/redemptions and deprivation for most antithrombotic drugs, except xarelto, and the incidence rate ratio of redemption and redemption rate was found to be higher as deprivation became more pronounced. however, prescription and redemption rates of the severely deprived eastern hungarian counties were at the level of the country average, while in the least-deprived northwestern cluster, these rates were significantly lower. our analysis of the spatial distribution pattern of mortality in connection with that of the relevant preventive medication can result in the identification of regions/populations with no adequate treatment, thus in more effective service provision to diminish preventable and amenable mortality. health at a glance: europe 2018: state of 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childhood leukaemia and their relations to socioeconomic status in hungary european regional and urban statistics reference guide evaluation of spatial relationships between health and the environment: the rapid inquiry facility bayesian image restoration, with two applications in spatial statistics interpreting posterior relative risk estimates in disease-mapping studies out-migration and attrition of physicians and dentists before and after eu accession cross-border mobilities in the austrian-hungarian and austrian-slovak border regions. available online: www.reminder-project ungarisches spitalspersonal im burgenland umworben factors associated to adequate time in therapeutic range with oral vitamin k antagonists in tunisia socioeconomic inequalities in the prescription of oral anticoagulants in stroke patients with atrial fibrillation medication prescription and adherence disparities in non valvular atrial fibrillation patients: an italian portrait from the arapacis study factors affecting patients' perception on, and adherence to, anticoagulant therapy: anticipating the role of direct oral anticoagulants patients' perspectives on taking warfarin: qualitative study in family practice risk factors for nonadherence to warfarin: results from the in-range study predictors of noncompliance with warfarin therapy in an outpatient anticoagulation clinic survey of the use of warfarin and the newer anticoagulant dabigatran in patients with atrial fibrillation combined effect of income and medication adherence on mortality in newly treated hypertension: nationwide study of 16 million person-years improving medication adherence in cardiometabolic disease: practical and regulatory implications a meta-analysis of the association between adherence to drug therapy and mortality effect of financial incentives on inequalities in the delivery of primary clinical care in england: analysis of clinical activity indicators for the quality and outcomes framework ecologic studies in epidemiology: concepts, principles, and methods self-assessed health and socioeconomic inequalities in serbia: data from 2013 national health survey delivery of cardio-metabolic preventive services to hungarian roma of different socio-economic strata author contributions: a.j. contributed to the conception, design, analysis, interpretation of findings, and drafted manuscript. o.v. and c.n. contributed to design, acquisition, analysis, interpretation, and drafted manuscript. k.b. contributed to conception, interpretation, and critically revised the manuscript. m.c. contributed to the aggregation of data by districts. z.s. contributed to the selection of drugs for analysis and interpretation of data. r.á. contributed to conception, design, acquisition, analysis, interpretation, and critically revised the manuscript. all authors have read and agreed to the published version of the manuscript. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-320914-zf54jfol authors: parrish, rebecca; colbourn, tim; lauriola, paolo; leonardi, giovanni; hajat, shakoor; zeka, ariana title: a critical analysis of the drivers of human migration patterns in the presence of climate change: a new conceptual model date: 2020-08-19 journal: int j environ res public health doi: 10.3390/ijerph17176036 sha: doc_id: 320914 cord_uid: zf54jfol both climate change and migration present key concerns for global health progress. despite this, a transparent method for identifying and understanding the relationship between climate change, migration and other contextual factors remains a knowledge gap. existing conceptual models are useful in understanding the complexities of climate migration, but provide varying degrees of applicability to quantitative studies, resulting in non-homogenous transferability of knowledge in this important area. this paper attempts to provide a critical review of climate migration literature, as well as presenting a new conceptual model for the identification of the drivers of migration in the context of climate change. it focuses on the interactions and the dynamics of drivers over time, space and society. through systematic, pan-disciplinary and homogenous application of theory to different geographical contexts, we aim to improve understanding of the impacts of climate change on migration. a brief case study of malawi is provided to demonstrate how this global conceptual model can be applied into local contextual scenarios. in doing so, we hope to provide insights that help in the more homogenous applications of conceptual frameworks for this area and more generally. the climate change-migration nexus has been the subject of research debate for decades. indeed climate change has been instigated in human migration since early humans first moved out of africa and migration has long been an adaptive strategy to climate shocks, long-term changes or cyclic climate conditions [1] . the field of climate migration has been gaining global scientific and popular attention since roughly the 1970s [2] , and very much so in recent years, since the emergence of the concept of 'environmental refugees' [3] . since the 2015 european migration 'crisis', the topic has received increasing controversy and non-evidence-based rhetoric in the media. as climate change int. j. environ. res. public health 2020, 17 , 6036 2 of 20 continues throughout the 21st century, it will likely serve as a threat magnifier of other migration drivers [4] . whilst terms such as 'climate refugee' are not recognised legally, migration and conflict are considered key mechanisms by which climate change has become a priority global health concern [5] [6] [7] . indirect health impacts of climate change, such as those mediated via migration and displacement, are often under-recognised and under-researched. the ongoing covid-19 pandemic is a poignant example of how the special circumstances of migrant communities creates unique and extreme health vulnerabilities: whilst some migrants living in displacement camps are unable to practise good hygiene and social distancing, other migrants are finding themselves denied their right to asylum, neglected or turned away at borders due to travel restrictions and fear of new waves of infection. the lancet countdown on climate change and health created a 'climate migration' indicator [4] whilst the newly launched lancet migration collaboration aims to explore and provide evidence for policy on the impacts of climate change on migrant health [8] . despite these advances, conceptual frameworks for robustly exploring and understanding the impacts of climate change upon migration are lacking in some key areas, and the body of empirical studies remains thin. these gaps undermine the ability of policy makers to design effective evidence-based policy, public health interventions, and strategies to support safe and positive migration experiences. the aims of this paper are to provide a critical review of existing climate migration literature; from this, we also suggest modifications to existing conceptualisation of climate migration by providing a new conceptual model of the system of migration determinants. the model is designed to be pan-disciplinary and transferable to any geographic or social context. we advocate the systematic application of theory in climate migration studies which may help better geographic representation [9] and improve our understanding of how climate change is impacting migration with contextual relevance to policy makers and public health interventions. finally, we apply this model to a case study of malawi to demonstrate how doing so can improve understanding of the local context and result in well-grounded and policy-relevant insights into the true impacts of climate change on migration. in order to improve conceptual modelling, several critical issues related to climate change and migration have been identified and discussed here. a key characteristic of migration is the multicausal nature of its drivers. climate change may act as a direct driver of displacement but in many cases is also inextricably linked to other, dynamic and interacting social, political, demographic and economic drivers [10] [11] [12] . a popular constructed narrative is that climate change acts as a threat magnifier of existing migration drivers. this can result in many empirical studies identifying that economic factors rather than climate factors dominate the decision to migrate [13] [14] [15] . however, it is possible that such studies overlook the mediated effect of climate change through other factors such as agriculture [16] . it is now largely acknowledged that the relationship between climate change and migration is complex, dynamic and non-directional. another critical issue relates to the multifaceted nature of climate change itself. scholars typically outline several classes of climate change: a change in climate variability; changes in frequency and magnitude of fast-onset climatic events (including extreme weather events, droughts, floods, and heatwaves); and slow-onset climate change, including long term changes in average temperature, rainfall and chronic drought or flooding [17] . this wide temporality as well as severity of climate change must be accounted for when discussing the implications of climate change on future population movements. migration itself may occur over a range of spatial scales-from movements between rural and urban areas, to international migration-as well as a range of temporal scales such as short-term migration, circular migration, to permanent moves. the decision of each individual to migrate may also carry different levels of human agency. the decision to migrate is due to an aggregation of micro-level (typically household or individual) and macro-level (societal) drivers. as such, each potential migrant has their own unique profile of factors and drivers. such individualistic situations are often described in terms of the individual's or community's vulnerability [18] [19] [20] . this presents a key challenge in many existing studies, which struggle to reconcile drivers at the macro-and micro-demographic scales. a key challenge remains the paucity and compatibility of datasets regarding both migration and potential drivers thereof, and the scarcity of such data at appropriate spatial and temporal levels, particularly in low-income and in indigenous communities. the necessity for localised quantitative studies can result in fragmented analyses of specific timescales, geographies, types of migration and drivers thereof. furthermore, this can make it difficult to summarise and build a global narrative of the risks of climate change to human security [21] . the resultant synthesis is that the impacts of climate change on migration are complex, multifaceted and dynamic. as such, increased attention on the upstream drivers of migration is called for. some authors argue that there is also some limitation in theoretical development and so in recent years there has been a push to promote a more sophisticated theoretical understanding of how climate change may interact with other drivers of migration [11, 16, 22] . this has allowed the narrative to evolve through time: the conventional narrative suggests a more simplistic view of climate change as a blanket push driver resulting in large-scale waves of migration [18] . however, newer frameworks appreciate the multi-driver nature of migration as well as the resilience and adaptive strategies of affected individuals and communities. nevertheless, such frameworks still struggle to capture the dynamic nature of such drivers including feedback and lag times, as well as the interactions between drivers themselves through time. the rising concept of ecological public health goes some way to attempt to address this, yet many policy-facing groups remain slow on the uptake [23] . understanding of climate-induced migration is further skewed by the discipline of researchers: each scientific discipline-be it epidemiology, economics, political sciences or anthropology-carries with it its own intrinsic assumptions and methodologies [22, 24, 25] which can perpetuate the fractured nature of the literature. therefore, to advance the understanding of the impacts of climate change on migration requires a truly interdisciplinary response. the collective result of these challenges is that current understanding of climate-induced migration is geographically uneven and studies are often non-transferable to other settings which presents an obstacle for policy makers and health intervention design. to aid design of interventions, scientists and decision makers (such as governments and humanitarian agencies) should engage with each other at all points of the intervention design and implementation. this can help ensure that interventions are contextually relevant and evidence based and that their impacts can be measured and evaluated. from the challenges identified in the above critical analysis, a new conceptual framework of climate migration is provided. migration, as a subjective concept, cannot carry one single definition and is highly contextualised. however, this is often neglected within most quantitative studies. in particular, the terms 'environmental migration' and 'climate migration' lack unanimous definitions across academic, ngo and political actors. migration exists as a normative behaviour in most communities globally but may also manifest as forced displacement and other involuntary or voluntary movements. furthermore, often overlooked in climate migration literature is the possible inhibiting effect of climate change on migration, resulting in reduced mobility rather than driving migration events [26, 27] . many scholars advocate the need for appropriate migration typologies and several have been presented. for instance, stojanov et al. [2] argue the need for contextualisation of climate drivers on a community in order to appropriately discern climate driven migration from normative or otherwise induced movement. renaud et al. [28] also comment on the difficulty of identifying the environmental signal within migration drivers and present a decision-making framework and accompanying typology of environmentally induced migration. carling [29] created the first iteration of the aspiration-capability framework, which describes voluntary or involuntary, mobility or immobility, based on both desire and ability to migrate. based on a review of a large variety of both qualitative and quantitative literature, we identify four dimensions which quantify migration: societal, temporal, spatial, and agency levels. "societal level" refers to the level of society affected, from micro scale (individual and household level) to macro scale (community, regional or population level). "temporal level" refers to the time duration of the migration, and the short term may consist of a matter of months, the long term is typically considered to be a year or more, though there is much range within empirical studies, and permanent migration represents the longest form of migration. "spatial level" refers to the physical distance covered by the migration. short distance may consider anywhere from intracommunity, intra-regional movements, to movements within the country and includes movements to between rural and urban hubs. long distance constitutes international movements across large geographical areas. whilst some cross-border movements may only require a few miles of travel and as such may be considered short distance, a large amount of international movements cover multiple countries and sometimes continents. such movements are of international political interest, though do not represent a large quantity of migrants or types of mobility [30, 31] . the spatial scale, like the societal scale may also be summarised in terms of macro (generally medium or large distance) and micro (small, community level distances) and may align to climate and economic macro-or micro-level determinants. "agency level" refers to the level of choice afforded to each migrant, existing as a continuous scale between the extremes of totally involuntary (in other words, forced) to totally voluntary. it should be noted that all four dimensions are continuous variables and hence demarcations used should be contextually modulated. by applying generalised demarcations, however, we classify five key categories of environmentally induced migration. the first category is forced displacement, also referred to as distress migrants [20] or temporary displaced migrants [2] . the second category is adaptive migration at the decision of the migrant(s) [11] . whilst this is a voluntary movement, a crucial caveat is applied here to note that such migration may not be truly voluntary; whilst many scholars and decision makers consider it as such, there is an emergent narrative arguing that migration due to longer-term environmental or economic degradation, or erosion of human security constitutes a type of forced migration, rather than a voluntary or adaptive movement [32] . the third category is proactive migration at the decision of wider authority such as local or national government referred to as 'planned resettlement' [5] . the fourth category is for trapped populations, which refers to a lack of mobility due to at-risk populations becoming trapped by environmental and socioeconomic barriers such as poverty [32] . the final category is immobility, which represents a lack of mobility at the decision of the person(s) at environmental risk [32, 33] . table 1 summarises these classifications according to the four dimensions outlined. throughout the remainder of this paper, we shall use the term 'climate migration' for simplicity. a newly proposed conceptual framework for identifying the determinants of any given migration is presented in figure 1 below. this framework is an updated iteration of prior models, which, over time, have converged to agree that migration is generally the result of a combination of upstream drivers, split into five categories: social, economic, political, demographic and environmental. however, consideration of interactions and evolution of these drivers through time, societal and spatial scales remains low. climate change is presented as an external driver which is expected in many contexts to act as a threat magnifier by exaggerating negative, push factors for vulnerable populations [34] [35] [36] . attributes of climate change are split into three categories: physical, biological/ecological, and anthropogenic impacts [37, 38] . the physical effects of climate change may be fast onset or slow onset. fast onset includes sudden events such as extreme weather or disaster events. slow onset consists of more gradual changes of mean values such as annual rainfall, rainfall variability and chronic droughting and flooding. secondary, or ecological climate aspects may include changes in land cover, flora and fauna habitats, including disease vectors and pollinators. tertiary or anthropogenic aspects include subsequent changes to anthropogenic systems such as crop yield and fish or game catch. a newly proposed conceptual framework for identifying the determinants of any given migration is presented in figure 1 below. this framework is an updated iteration of prior models, which, over time, have converged to agree that migration is generally the result of a combination of upstream drivers, split into five categories: social, economic, political, demographic and environmental. however, consideration of interactions and evolution of these drivers through time, societal and spatial scales remains low. climate change is presented as an external driver which is expected in many contexts to act as a threat magnifier by exaggerating negative, push factors for vulnerable populations [34] [35] [36] . attributes of climate change are split into three categories: physical, biological/ecological, and anthropogenic impacts [37, 38] . the physical effects of climate change may be fast onset or slow onset. fast onset includes sudden events such as extreme weather or disaster events. slow onset consists of more gradual changes of mean values such as annual rainfall, rainfall variability and chronic droughting and flooding. secondary, or ecological climate aspects may include changes in land cover, flora and fauna habitats, including disease vectors and pollinators. tertiary or anthropogenic aspects include subsequent changes to anthropogenic systems such as crop yield and fish or game catch. the model aims to build upon this a priori understanding by providing deeper discussion of the complexity of driver interactions, driver dynamicity and the evolution of both drivers, and their linkages over time and spatial scales. importantly, the range of possible migration outcomes receives greater attention in this conceptual model, with recognition that different combinations of causal and contextual determinants may result in different migratory responses, including differences in the level of agency of a migrant. the model is designed with the purpose of being pan-disciplinary and, as such, relevant in any academic or non-academic context. the model presents not only a theoretical exercise, but a frame of thinking to support quantitative studies, with a view to informing future research, data collection or intervention design. drivers within each of the five classes may act as push agents-encouraging movement away from the origin, or pull agents-attracting movement to a host area. bowles et al. [38] also identify glue and fend factors. glue factors act to cement a potential migrant in his/her home location such as cultural and family ties, whilst fend factors deter migration into an area such as hostile immigration policies. recent studies highlight that climate change may act as a glue factor in many situations, the model aims to build upon this a priori understanding by providing deeper discussion of the complexity of driver interactions, driver dynamicity and the evolution of both drivers, and their linkages over time and spatial scales. importantly, the range of possible migration outcomes receives greater attention in this conceptual model, with recognition that different combinations of causal and contextual determinants may result in different migratory responses, including differences in the level of agency of a migrant. the model is designed with the purpose of being pan-disciplinary and, as such, relevant in any academic or non-academic context. the model presents not only a theoretical exercise, but a frame of thinking to support quantitative studies, with a view to informing future research, data collection or intervention design. drivers within each of the five classes may act as push agents-encouraging movement away from the origin, or pull agents-attracting movement to a host area. bowles et al. [38] also identify glue and fend factors. glue factors act to cement a potential migrant in his/her home location such as cultural and family ties, whilst fend factors deter migration into an area such as hostile immigration policies. recent studies highlight that climate change may act as a glue factor in many situations, rather than as a push factor as is often popularised [26] . climate change is a sub-category of environmental drivers which may be further categorised into three classes [10, 37, 39] . these are perhaps best described as primary physical effects, secondary biological and ecological effects, and tertiary anthropogenic effects [37, 38] . climate change is segregated here from other environmental factors and framed as an externality to the determinant system. this facilitates investigation of the impacts of climate change as an upstream pressure to all five classes of drivers. each of the five categories is described in further detail below. to demonstrate the temporal nature of the system, the model is presented on a set of axes with time on the horizontal dimension with arbitrary timepoints t 0 and t 1 . this encourages consideration of the dynamicity of all determinants, as well as the changing nature of their interactions through time. as such, feedback implication on both host and source environments and communities of a migration decision may be decoded. externalities, such as future climate shocks or political interventions, such as climate mitigation, which may alter the system and resultant migration can also be presented and their impacts conjectured. the y axis depicting scale of impact refers simultaneously to the societal and spatial level of impact thereby encouraging the disparate nature of drivers on these scales to be considered. micro refers to small-scale, individual-or household-level factors whilst macro may be factors affecting large distances and large numbers of people. within the next section, we take a more granular view of each of the key families of drivers, and consider how each may directly or indirectly impact migration. this analysis is not exhaustive but attempts to provide a detailed summary of drivers over time and space, thereby encouraging a more nuanced and detailed exploration of the complexity of climate change. all climate factors are considered to occur at the macro spatial scale (figure 1 ), which correlates to the macro societal impact level as described in table 1 above. temporality of climate factors varies, and depends on the climate determinant (as shown in table 2 ). the true speed of climate change varies geographically and so there can be no definitive definition for fast or slow onset. furthermore, some aspects may manifest across multiple timeframes. it is well established that climate change is increasing the frequency and magnitude of extreme weather events and climate shocks, which can be a direct cause of forced displacement. nevertheless, in such natural hazard events, socially constructed vulnerabilities often govern the extent and type of migration responses which occur. myers et al. [40] , in a study of displacement due to hurricane katrina in 2005, identified a range of social vulnerability factors which had a significant impact upon outmigration from affected places. similarly, gray and bilsborrow [14] identified within an ecuadorian household migration survey, that household vulnerability factors such as home ownership, connectedness of household (to roads and schools), and poverty level, all confounded the environmental signal in the causes of observed migrations. less clear is the extent to which long-term or chronic climate change affects migration. chronic changes may include changes in average temperature, average rainfall, rainfall variability or extent of periodic drought and flooding. such changes often impact migration via mediating biological and anthropogenic factors such as impeded agricultural outputs [13, 41] , adverse health outcomes [42, 43] , or labour productivity [44] . in such examples, the extent of climate factor as a driver of migration compared to other sociodemographic and economic factors is seen to vary greatly across studies. to better understand such relationships, we classify these indirect impacts as biological or anthropogenic (secondary or tertiary). biological or secondary impacts are as a result of physical climate change, which may lead to changes in regional geochemistry, and flora and fauna. such biological changes may alter the vulnerability of human populations. for instance, climate change may drive changes in the distribution of disease vectors [37, 45] . anthropogenic or tertiary aspects of climate change comprise the resultant alterations to human systems. examples may include changes in anthropogenic land use and land availability due to sea level rise. alterations, for example, in crop yield and fish catch, may have direct implications to socioeconomic factors, for example, due to reduced agricultural output [41] , food security [1] , and therefore upon urbanisation rates due to rural to urban migration [38] . such anthropogenic pathways generally act over a longer temporal scale and can lead to the climate signal being masked by more proximal factors. as such, understanding of their impact on migration remains inconclusive [46] and less studied than direct physical impacts [39] . furthermore, additional consideration is needed to assist the recognition of dynamic interactions between the physical, ecological and anthropogenic aspects of climate change. there are of course a range of other drivers of migration which are important to understand as well as how they may be affected by climate change. it is usually a combination of drivers that culminates in an individual's decision to migrate and in what manner. within the context of climate change, we refer to this aggregation of drivers (climatic and other) as the 'vulnerability profile' which will be unique to each individual. we now present a more detailed view of some key drivers within each of the five main classes identified. these are outlined in table 3 below. as well as existing as intermediary drivers, each of these drivers may have direct impacts on migration decisions. for example, henry et al. [13] using regression modelling and gray and bilsborrow [14] using discrete time event history modelling both found that high literacy rates and economic status can act as significant push factors for migration. ezra and kiros [15] also found marital status and poverty level acted as push factors. warner et al. [1] clearly identified the role of government relocation policy on driving planned resettlement of communities away from flood plains in mozambique. such epidemiological methods are well utilised for analysing such direct causes. however, each analysis is limited to a specific type of migration and set of pre-assumed key drivers. it is not possible within this paper to examine in depth the nature and relationships of each driver, rather the authors focus on presenting a broad overview, elucidating the multilevel and multitemporal nature of migration drivers, as well the dynamicity of the drivers and their linkages. some key examples are used to demonstrate such complexities. table 3 . non-climatic drivers of migration. drivers are split into five classes: social, economic, political, demographic and environmental. societal level refers to the societal scale at which drivers typically impact. some drivers may exist both as micro and macro factors. temporal scale refers to the typical timescale of change in each driver. whilst there is no set demarcations, slow change refers to a change typically over years or decades and change fast refers to changes which may occur immediately or over a short timeframe of months. static implies that factor is not usually time varying. many studies examine the importance of social factors such as migration networks [47] [48] [49] [50] . education and literacy rates have also commonly been identified as determinants of vulnerability [35, [51] [52] [53] [54] . social drivers such as education and poverty may also alter other drivers. for example, other studies have identified that in poor areas of malawi where rain-fed agricultural practices reigned, the predominant climate change adaptation approach was not seasonal migration but the introduction of irrigation techniques to increase crop yields [54, 55] . however, joshua et al. [55] concluded that increased irrigation triggered increased water insecurity and hence water conflict. this interaction between poverty and adaptation approach has significant implications for future vulnerability levels and on future social and political factors. of course, such impacts are not isolated to only impoverished communities. developed countries with lower poverty levels can also suffer compound impacts of climate change on other social determinants [56] . however, developed countries generally have a higher capacity to mitigate or adapt to such changes resulting in different outcomes (migration and other), with different distributions across communities [57] . closely linked to social factors are economic considerations such as employment opportunity and household wages [58] at the micro societal level. poverty is also a key determinant of an individual's vulnerability and hence ability to migrate [1, 14, 15] . macro-level factors such as average employment rates and average income of a community may also act as push or pull factors which have often been identified as the dominant drivers of migration [11, 41] . there also exists a debate on the role of failed politicised economic models such as 'trickle down' and 'rent seeking 'as being largely responsible for the increase in wealth gaps and rising relative poverty [22] . these economic models may contribute to future migration behaviour due to relations between poverty and mobility [1] and the effect of inequality gradients acting as sinks for migration [59] . for instance in the malawian example given above, findlay [54] also comments on the additional causes of food insecurity beyond water scarcity, including soil erosion, socioeconomic factors including vulnerability to poverty, ability to financially withstand crop failures, low food utilisation and infrastructural factors such as high transport costs. political drivers are largely absent from environmental migration quantitative studies and yet present a significant category of migration drivers. possibly the most influential and most studied of this category is the role of political insecurity on migration. whilst the role of political insecurity and conflict is a well-acknowledged driver of migration, the role of climate change in driving political instability remains contested [20] . burrows and kinney [6] present an overview of multiple pathways through which climate change may lead to or exacerbate conflict such as through increasing rural to urban migration, resource competition or dispute between migrant and host communities. sokolowski et al. [60, 61] also discuss the role of political interventions such as efforts for conflict resolution, international relief, and immigration policy such as the closing of borders, and their impact upon migration outcomes. though largely overlooked in general climate migration literature, some models do focus on political drivers of migration with relatively accurate predictions [59, 62] . sokolowski and banks [60] modelled population displacements that occurred in syria in 2013 using unhcr guidelines for factors prompting departure. indeed, the syrian conflict can be argued to contain both political and climate determinants in the mass displacement that has resulted [63] . other political drivers include level of governance and trust in government and the level of institutionalisation and infrastructure within a community. infrastructure and governmental and non-governmental organisations are critical intervention nodes and as such their connection to environmental migration form an important area of potential study. other policies such as water, food and agricultural policy also co-interact and may result in a range of normative and adaptive migration approaches. for example, loevinsohn [64] studied the 2002 malawian food crisis and identified primary causal factors to be both environmental drought and the underinvestment by the national government in agricultural stock. loevinsohn further identified that 39% of households interviewed during 2002 had migrant family members working seeking alternative income [64] . crackdown on immigration policies in western countries such as britain, the usa and across the eu will also have significant impact upon future migration trends. with climate change expected to impact the numbers of both internal and international migrants in the future, existing dichotomies between the evidence on migration drivers and the political response to it will undoubtedly renew pressure on migration issues [65] . demographic factors at the micro level (such as age, gender, ethnicity) as well as at the macro level (such as average living conditions, affluency, diaspora presence) can act as push or pull factors as well as interact with other factors. the combined effect of climatic drivers and demographic drivers have resulted in many developing countries being the most vulnerable nations to climate change and has helped to drive research and narratives around climate justice [66] and climate refugees [67] . rapid urbanisation is often a trend in such locations, leading to slum development, poor infrastructure and high vulnerability to future climate change, not to mention other shocks such as the covid-19 pandemic. in developed countries, different demographic challenges such as population ageing may also impact upon population mobility and health. for example, an older population may result in a reduced willingness to move and increased mental health burden of doing so [68] . conversely, countries with aging populations can benefit from the 'healthy-migrant' effect [69] . as such, appreciating the demographic factors, their dynamics and interactions is essential to understanding climate risk on future sustainable development and population changes. when modelling future environmental migration, it is therefore essential to take into account the demographic situation of the study area. climate change is a key driver of environmental change. environmental degradation, such as desertification, permafrost melt and coastal erosion, undermines livelihoods and therefore acts as a push driver for migration away from these regions. in the short term, there may be positive environmental changes such as increased precipitation and improved agricultural production in many parts of the globe which may act as a migration pull factor [58] . environmental determinants such as rainfall and vegetation cover are commonly used in quantitative studies of climate change though other ecosystem attributes and ecosystem degradation appears somewhat overlooked in migration studies, such as food availability from natural sources and pollution of water. many environmental factors occur independently of climate change and may be influenced by other socio-political factors, often overlooked in environmental migration studies. for example, changes in land use, urbanisation, overexploitation of natural resources, environmental pollution and geophysical natural hazards may each be key determinants of migration. such environmental changes often have strong feedback loops-for example, rural to urban migration has significant repercussions on environmental degradation, air and water pollution, energy consumption and greenhouse gas emissions [70] . environmental drivers have been found to be critical in many development studies. the environmental kuznets curve ("ekc") hypothesis purports that the early stages of economic development are coupled to environmental degradation and has been found to be true in many contexts [71] . in the context of urbanisation led by adaptive migration, this hypothesis suggests that urbanisation will result in further environmental degradation, with significant implications for future development [33, 72] , health [73] , political security [74] , and internal migration [75] . we now provide a brief example of applying the conceptual model to a case study. we select rural malawi as a pertinent example of a climate-vulnerable society. malawi is a land-locked country in southern africa whose main economy is small-scale, rainfed agriculture, employing approximately 85% of malawians [76] . as such, many people's livelihoods as well as key source of food is highly climate sensitive. already malawi has witnessed an annual mean temperature increase of 0.9 â�¢ c since the 1960s, and whilst local rainfall patterns are difficult to accurately model, there has been an observed increase in frequency and magnitude of drought and flood events [77] . by conducting an in-depth literature review of malawi's political, demographic, environmental, social and economic makeup and then applying the conceptual approach described above by considering the impacts of climate change (primary, secondary and tertiary) to each key factor, we arrive at the case-specific model shown in figure 2 below. we now provide a brief example of applying the conceptual model to a case study. we select rural malawi as a pertinent example of a climate-vulnerable society. malawi is a land-locked country in southern africa whose main economy is small-scale, rainfed agriculture, employing approximately 85% of malawians [76] . as such, many people's livelihoods as well as key source of food is highly climate sensitive. already malawi has witnessed an annual mean temperature increase of 0.9 â°c since the 1960s, and whilst local rainfall patterns are difficult to accurately model, there has been an observed increase in frequency and magnitude of drought and flood events [77] . by conducting an in-depth literature review of malawi's political, demographic, environmental, social and economic makeup and then applying the conceptual approach described above by considering the impacts of climate change (primary, secondary and tertiary) to each key factor, we arrive at the case-specific model shown in figure 2 below. a key advancement of this malawi-specific model is that each variable is quantifiable using observational datasets. as such, it demonstrates how the application of the generalised conceptual model in figure 1 , to a local context, allows the creation of an astute, practical and measurable model, from which well grounded, policy-relevant research questions may be formulated and tested. by applying this methodological process, the malawi-specific model that is generated is based on wellgrounded assumptions and it holistically captures key variables that may be of relevance for future testing. additional information about each variable can be found in supplementary information table s1 . based on this conceptual model, the next step in the method would be to identify appropriate study and modelling techniques such as epidemiologic, mathematical, or integrated models to quantify the extent of each relationship depicted by the arrows in figure 2 . the insights from such models may therefore make possible evidence provision which can be particularly relevant for national adaptation, economic development and public health plans. a key advancement of this malawi-specific model is that each variable is quantifiable using observational datasets. as such, it demonstrates how the application of the generalised conceptual model in figure 1 , to a local context, allows the creation of an astute, practical and measurable model, from which well grounded, policy-relevant research questions may be formulated and tested. by applying this methodological process, the malawi-specific model that is generated is based on well-grounded assumptions and it holistically captures key variables that may be of relevance for future testing. additional information about each variable can be found in supplementary information table s1 . based on this conceptual model, the next step in the method would be to identify appropriate study and modelling techniques such as epidemiologic, mathematical, or integrated models to quantify the extent of each relationship depicted by the arrows in figure 2 . the insights from such models may therefore make possible evidence provision which can be particularly relevant for national adaptation, economic development and public health plans. complexities naturally arise when taking an upstream, systems-thinking approach to migration determinants. there are two key complexities identified. firstly, the acknowledgement of multilevel and interactions and feedbacks between drivers. secondly the dynamicity of drivers and their connections over time and space. despite these complexities, models must be transparent and provide results from which simplicity may be derived in order to be useful for decision makers and intervention planning. to aid reflection upon such interactions, figure 3 depicts a simple representation of the interactions between individual and classes of drivers. each class of driver is represented by a funnel, from which a combination of both macro and micro drivers is filtered from an interconnected reservoir where drivers from different classes interact on a range of temporal, spatial and social scales. the combination of drivers at the individual migrant level results in a unique vulnerability profile and context which determines the migration decision made by each potential migrant. climate change is again presented as an externality, cross-cutting all other driver classes and acting across the temporal and societal levels. as in figure 1 , each driver may vary over both time and spatial dimensions. however, modelling such dynamicity requires simultaneous understanding of drivers, their interactions, and their evolution through time and space. the insight that such dynamic modelling would allow may enable the effective identification of suitable intervention nodes for public health, land use and immigration policy to name but a few. connections over time and space. despite these complexities, models must be transparent and provide results from which simplicity may be derived in order to be useful for decision makers and intervention planning. to aid reflection upon such interactions, figure 3 depicts a simple representation of the interactions between individual and classes of drivers. each class of driver is represented by a funnel, from which a combination of both macro and micro drivers is filtered from an interconnected reservoir where drivers from different classes interact on a range of temporal, spatial and social scales. the combination of drivers at the individual migrant level results in a unique vulnerability profile and context which determines the migration decision made by each potential migrant. climate change is again presented as an externality, cross-cutting all other driver classes and acting across the temporal and societal levels. as in figure 1 , each driver may vary over both time and spatial dimensions. however, modelling such dynamicity requires simultaneous understanding of drivers, their interactions, and their evolution through time and space. the insight that such dynamic modelling would allow may enable the effective identification of suitable intervention nodes for public health, land use and immigration policy to name but a few. the concept of a vulnerability profile allows for the acknowledgement that each migrant has a unique set of drivers due to the multilevel and multitemporal combination of factors he or she is subjected to. in this way vulnerability may be conceived as a meta-driver of migration. the concept of vulnerability describes the ability of an individual or community to withstand and recover from a risk such as a disaster event [20] . other meta-drivers include resilience and adaptive capacity [78] [79] [80] . whilst vulnerability is a commonly used meta-driver in much climate migration literature, resilience is often the currency of choice in the fields of disaster management and climate change adaptation [81] . however, these terms are broad and often overlap and are even used interchangeably, rendering their distinction and usefulness within scientific analysis questionable. despite this, such meta-drivers are the dialogue of choice for policy makers and must be utilised for research to have political relevance. however, care should be taken when referring to such metathe concept of a vulnerability profile allows for the acknowledgement that each migrant has a unique set of drivers due to the multilevel and multitemporal combination of factors he or she is subjected to. in this way vulnerability may be conceived as a meta-driver of migration. the concept of vulnerability describes the ability of an individual or community to withstand and recover from a risk such as a disaster event [20] . other meta-drivers include resilience and adaptive capacity [78] [79] [80] . whilst vulnerability is a commonly used meta-driver in much climate migration literature, resilience is often the currency of choice in the fields of disaster management and climate change adaptation [81] . however, these terms are broad and often overlap and are even used interchangeably, rendering their distinction and usefulness within scientific analysis questionable. despite this, such meta-drivers are the dialogue of choice for policy makers and must be utilised for research to have political relevance. however, care should be taken when referring to such meta-drivers and the contributing drivers as explored above must be contextually relevant and carefully selected. previous conceptual models explore the linkages between climate change and migration with different assumptions and perspectives. the 2011 foresight report identifies five key families of drivers and concludes that migration may be an adaptive strategy in the face of climate change and represents possibly the best to-date, globally accepted conceptual model for climate migration [10] . the report disputes the long-time argument that migration represents a failure to adapt in situ. this conclusion, however, fails to consider several key aspects of migration: firstly, the agency and social well-being of migrants involved at each stage of the migration process (prior to movement, in transit, and at host destination). secondly, the level of agency afforded to would-be migrants during the migration decision-even as a supposedly proactive adaptation measure. finally, the delicate line between forced and voluntary movement, based upon a composition of drivers and the bias of the person(s) awarding the classification. the ongoing lancet commission on climate change and health also presents an interesting framework where migration as a result of climate change is appropriately framed as a health challenge, and a public health opportunity [7] . this framework, however, does not give a large amount of consideration to intermediate drivers and various pathways by which climate change may drive migration or produce trapped communities. helping to close this gap, and drawing on a range of political and economic, as well as health literature, the model presented by sellers, ebi and hess considers a puzzle of immediate and longer-term drivers of social instability, with both climate shocks and migration as contributing factors and possible outcomes [82] . mcmichael et al. [5] also present a foundational model whereby the basic links between climate change and migration are presented though driver interactions and dynamics are not discussed in depth. whilst this and other conceptual models encourage an upstream approach to environmentally induced migration, putting such thinking into practise presents further challenges. the paucity of empirical studies limits our understanding of how global climate change may threaten development and public health, particularly regarding the indirect impacts of climate change. lack of suitable data and quantitative metrics needed to conduct such studies remains a perennial challenge. it is essential that these challenges be overcome through future data collection and empirical modelling. migration datasets are largely based on cross-sectional survey and census data whilst information about health and well-being, disaggregated by migration status, is largely lacking. furthermore, collecting and disseminating such data present significant ethical and privacy concerns. for many drivers, proxies may be used. for instance, the normalised difference vegetation index (ndvi) may act as a proxy for natural resource availability [67] . henderson et al. use a simple count of manufacturing industries as a proxy for urban industrial capacity when analysing the relationship between climate change and urbanisation in an african context [83] . lu et al. [84] suggest the possibility of using out-migration rates as a proxy for changes in habitability. neumann and hilderink [17] present a range of possible datasets such as glasod for soil degradation and lada for biomass production of earth observation land degradation data. however, each of these datasets has its own challenges concerning spatial and temporal resolution, uncertainty and effectiveness as a proxy. furthermore, misalignment of datasets at the spatial, temporal and social levels creates further challenges in appropriately modelling migration determinants. other, more squidgy drivers such as perceived political stability and social networks remain elusive to measurement and under-represented in quantitative studies. the availability and quality of data in turn create methodological challenges for empiricists. some studies utilise a range of statistical and epidemiological methods. however, traditional epidemiological methods each have their short-comings. cross-sectional analyses do not allow for the temporal nature of drivers. timeseries analyses are often impeded due to lack of sufficient data and the ability to control interactions between drivers across a range of temporal and spatial resolutions. gravity models can capture linear push and pull factors at the macro level, though may struggle with ecological fallacy and in modelling of the more nuanced relationship between driver and migration outcome. recent developments in mathematical models offer useful insight. such models include improved agent-based modelling (abms) and multiagent systems approaches [21, 52, 85, 86] . study approaches must be chosen appropriately based on the assumed relevant determinants and their interactions, as choice of methods may have significant impact on the study results. the advantage of such systems approaches is that driver dynamics and interactions may be inbuilt and allowed to alter in timesteps. the individual nature of human decisions may also be captured through abms. however, abms require high-resolution data and are generally only applicable for small geographical scales. economic approaches such as economic bargaining theory can also be used to explain some micro-level migration decisions such as the 'healthy-migrant' effect, whereby young and fit-for-work individuals may be more likely to move in search of work and remittance opportunities [87] . however, since climate change exists only as a macro factor, such micro-level considerations within current models of climate migration are often lacking. other approaches have been proposed to deal with complexity and dynamicity. barbieri et al. [88] use a combined economic-demographic-climate model to understand the interactions between different classes of drivers over time (using appropriate proxies) in the northeast region of brazil. another emerging method is the use of shared socioeconomic pathways (ssps) to provide a combined set of scenarios for future population, urbanisation and wealth factors [89] . the ssps are designed to be used in conjunction with climate change representative concentration pathways (rcps) for future radiative forcing emission scenarios. application of this approach can be seen within the 2018 groundswell report who combine the rcps and ssps into three scenarios and use gravity modelling to provide a view of internal migration for three global regions [75] . finally, we make a crucial note regarding the overall approach by scientists towards climate migration. care must be taken when treading the literature of various typologies and terminologies which are necessarily subjective and vary by author and by discipline. furthermore, climate migration may be studied through a variety of academic lenses. as such, the impact of different epistemologies on conclusions is complex and often overlooked [24] . politically impactful research should attempt to transcend traditional research boundaries and avoid tribalism in science [90, 91] . indeed, in the pursuit of improved global health, research of climate migration should be contextually relevant, and politically pertinent and timely. one way to help achieve this is to adopt a pan-disciplinary approach such as the one demonstrated within this paper. table 4 elucidates this point by demonstrating a selection of fields which contribute to the study of climate migration as an aspect of global health. table 4 . an overview of the range of scientific disciplines which contribute to the study of climate migration, its drivers and impacts. human geography offers a range of frameworks and tools for studying human migration and its drivers. through the study of human behaviour, anthropological methods offer a deeper insight into the decision-making process behind migration, as well as the impacts of migration upon individual and societal well-being. ethnography offers a unique and rich insight into people's opinions and decision making. political sciences political sciences may be used to explore the effects of policy on immigration, as well as the geographic, economic and social drivers of migration policy and sentiment. both macro and micro economics can be used to quantify migration as well as study the economic drivers and impacts of migration. for example, in the case study of malawi, econometric modelling could be applied in the study of the impact of failed crops on household wealth and as such on migration. mathematics a range of mathematical models are used in the study of migration such as system dynamic models, agent-based models, gravity models, and diffusion models. environmental epidemiology can be used in the study of migration and its drivers. for example, the field of ecological public health supports the exploration of the relationships between the biological and material realms [92] . disaster risk reduction sciences disaster risk reduction relates mainly to sudden-onset events and short-term, forced displacement and as such provides cross-over to the field of migration science. computer sciences computer science is used in migration studies to model and simulate migration and its quantifiable drivers and impact. sociology can be used to study migration and its impacts at the societal level, with special interest in demographic makeup and the social structure of migrant (and non-migrant) communities. the study of population dynamics and structure places migration as a core component. ultimately, climate change may have critical impacts upon future migration across the globe and has significant implications for public health, human security and sustainable development. climate change is already and will continue over the coming decades to contribute to large numbers of displaced persons [93] , refugees [94] , internal migrants [75] , international migrants [26] and immobile and trapped persons [27] . as such, better understanding of the relationship between climate change and migration is essential for effective future policy planning in all sectors. this can be achieved through the systematic and homogenous application of robust conceptual frameworks to local contexts. a lack of data, particularly for low-income and indigenous settings, is a key set back which obstructs furthering our understanding. it also hinders the ongoing desire of academia, national and international policy makers to identify who are the climate migrants of today and of the future and count how many there are. this paper has attempted to demonstrate the need for a flexible and pan-disciplinary approach to environmentally induced migration. research which cross-cuts traditional discipline boundaries, in accordance with the planetary health viewpoint, is encouraged when using such a conceptual framework in the study of climate migration [95] . in this way, traditional pitfalls may be avoided, better reconciliation of macro and micro determinants may be achieved and more visibility of the dynamics of drivers and hence a more accurate understanding of their role in driving migration may be elucidated. however, the review within this paper is non-exhaustive and draws lightly on a wide range of literature and academic standpoints. as such, it is designed to demonstrate a nuanced approach to climate migration theory and application, rather than present a comprehensive "how-to" guide. finally, it was beyond the scope of this paper to fully apply our conceptual model to mathematical and epidemiological quantitative models, providing instead a simple overview, though this is the natural progression of the research. table s1 : a descriptive table providing an overview 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res public health doi: 10.3390/ijerph13030253 sha: doc_id: 307133 cord_uid: bm9z8gss mathematical models have been used to understand the transmission dynamics of infectious diseases and to assess the impact of intervention strategies. traditional mathematical models usually assume a homogeneous mixing in the population, which is rarely the case in reality. here, we construct a new transmission function by using as the probability density function a negative binomial distribution, and we develop a compartmental model using it to model the heterogeneity of contact rates in the population. we explore the transmission dynamics of the developed model using numerical simulations with different parameter settings, which characterize different levels of heterogeneity. the results show that when the reproductive number, [formula: see text] , is larger than one, a low level of heterogeneity results in dynamics similar to those predicted by the homogeneous mixing model. as the level of heterogeneity increases, the dynamics become more different. as a test case, we calibrated the model with the case incidence data for severe acute respiratory syndrome (sars) in beijing in 2003, and the estimated parameters demonstrated the effectiveness of the control measures taken during that period. mathematical models play an important role in understanding epidemic spread patterns and designing public health intervention measures [1] [2] [3] [4] . the traditional deterministic compartmental models usually assume homogeneous mixing, which means that each individual has the same probability of contact with all of the others in the population [4] . however, there is a growing awareness that this assumption is not the case in reality, because heterogeneity can arise due to many sources [5] , including age, sex, susceptibility to disease, position in space and the activities and behaviors of individuals, among others [6] . here, we will focus on the heterogeneity in host contact rates at the population level. in recent years, scientists have developed different approaches to model heterogeneity in host contact rates. first, traditional compartmental models were extended: the infection term of the homogeneous mixing compartmental models was modified [7] [8] [9] . the compartments were further divided into multiple subgroups with similar behavioral characteristics (e.g., risk [10] ) or demography (e.g., age [11, 12] ). second, along with the rapid development in research on complex networks, a large body of literature has examined the effects of the heterogeneous contact structure on disease spread in networks [13, 14] . the third type of modeling approach considering heterogeneity is agent-based modeling [15] [16] [17] , which characterizes the heterogeneity in individual attributes and behaviors. additionally, several researchers have attempted to bridge the gap between traditional compartmental models and individual-based models [18] [19] [20] . in this paper, we develop a new compartmental model to incorporate heterogeneous contact rates in disease transmission. first, by combining a poisson distribution and a gamma distribution, we derived a negative binomial distribution (nbd) transmission function, with which we developed a compartmental model. then, we explored the influence of different levels of heterogeneity on the transmission dynamics of infectious diseases using numerical simulations. finally, we calibrated the model with the number of daily cases of severe acute respiratory syndrome (sars) in beijing in 2003, and the estimated parameters show that the control measures taken at that time were effective. the heterogeneity in transmission can be modeled by assuming that the number of contacts among individuals varies from person to person. let x i represent the number of effective contacts (the number of contacts that would be sufficient for transmitting the disease successfully, were it to occur between a susceptible individual and an infectious individual [21, 22] ) with infectious individuals of the i-th susceptible person per unit time. assume that x i has a poisson distribution π(θ i ), where θ i is the mean of the number of effective contacts that the i-th susceptible individual makes with infectious individuals per unit time. that θ i are identical means that each individual has an equal chance of effective contact with infectious individuals and an equal chance of being infected, thereby resulting in a traditional homogeneous-mixing model. in reality, however, individuals typically come into contact with only a small, clustered, subpopulation [20] . therefore, it is reasonable to assume that different individuals have different average effective numbers of contacts in a certain period of time; that is, θ i is itself a random variable. the gamma distribution is a good choice for describing θ i for a variety of reasons: it is bounded on the left at zero (the numbers of contact must be non-negative), is positively skewed (it has non-zero probability of an extremely high number of contacts) and can represent a variety of distribution shapes [23] . it has been used to describe the expected number of secondary cases caused by a particular infected individual [24] . therefore, we assume a gamma distribution for θ i , with shape parameter k, rate parameter m (or scale parameter 1 m ) and the following probability distribution function: the conditional distribution of x i given θ i = θ is: we obtain the marginal distribution of x i : this is the probability density function of an nbd with mean k m and variance k(1+m) m 2 . then, the probability of a susceptible individual escaping from being infected can be represented by the zero term of the nbd: let the mean of the nbd be equal to the mean of the number of effective contacts of all susceptible individuals with infectious individuals, that is k m = βi n , where β denotes the transmission rate, defined as the per capita rate at which two specific individuals come into effective contact per unit time [22] ; i denotes the number of infectious individuals; and n denotes the size of the total population. it follows that 1 m = βi kn , and: consider a closed population (without births, deaths and migration into or out of the population). let s t and i t denote the numbers of the susceptible and infectious individuals at time t, respectively. then, the difference equation relating s t and i t at successive time steps t and t + 1 is: here, λ t = 1 − (1 + βi t kn ) −k is the risk of a susceptible individual becoming infected between time t and t + 1. using the relationship between the risk and rate derived in [22] , risk = 1 − e rate , we obtain the rate at which susceptible individuals become infected at time t: therefore, the rate of change in the number of susceptible individuals can be represented by the differential equation representing: we call k ln(1 + βi kn ) in the right side of this equation the nbd transmission function. a similar function, k ln(1 + ap t k ), and its discrete form, (1 + ap t k ) −k , were first used in host-parasitoid models, where a denotes the per capita searching efficiency of the parasitoid and p t denotes the number of parasitoids [25, 26] . then, they were used in insect-pathogen models [27] . in [28] , the author used the transmission function, k ln(1 + βi k ), to model a possum-tuberculosis (tb) system. the influence of different transmission functions on a simulated pathogen spread was studied in [29] . because: when k → ∞, the nbd transmission function we derived here approximates the frequency-dependent transmission function of the homogeneous-mixing model. therefore, it can be regarded as a generalized frequency-dependent transmission function [1, 4] . similarly, the nbd transmission function used in [28] can be regarded as a generalized density-dependent transmission function [1, 4] . comparing the nbd transmission function with the density-dependent transmission function, βsi, and the frequency-dependent transmission function, βsi n , of the homogeneous-mixing model [4, 22] , we obtain one more parameter, k, which is the shape parameter of the gamma distribution (equation (1)). denote the mean of the gamma distribution as µ θ ; then, the variance is µ 2 θ k . setting the mean to be a constant and letting k → ∞, the variance goes to zero, resulting in homogeneous-mixing, just as shown in equation (2) . in contrast, the variance increases as the value of k decreases, which indicates greater heterogeneity of the contact rates between the susceptible and infectious populations. therefore, the parameter k characterizes the level of heterogeneity. the standard susceptible-exposed-infectious-recovered (seir) model divides the total population into four compartments: susceptible (s, previously unexposed to the pathogen), exposed (e, infected, but not yet infectious), infected (i, infected and infectious) and recovered (r, recovered from infection and acquired lifelong immunity) [1, 4, 22] . the infection process is represented in figure 1 . children are born susceptible to the disease and enter the compartment s. a susceptible individual in compartment s is infected after effective contact with an infectious individual in compartment i and then enters the exposed compartment e. after the latent period ends, the individual enters the compartment i and becomes capable of transmitting the infection. when the infectious period ends, the individual enters the recovered class r and will never be infected again [4, 22] . in each compartment, individual death occurs at a constant rate, µ, which is equal to the birth rate. death induced by the disease is not considered here. therefore, the total population size in the model, n, remains unchanged. the seir model and its extension have been used to model many infectious diseases, for example, measles [30] [31] [32] , rubella [33, 34] , influenza [35, 36] and sars [37, 38] , among others. using the nbd transmission function, we set up a new seir model in a closed population, represented by a set of ordinary differential equations: where the parameter α is the rate at which individuals in the exposed category become infectious per unit time, and its reciprocal is the average latent period [4, 22] ; the parameter γ is the rate at which infectious individuals recover (become immune) per unit time, and its reciprocal is the average infectious period [4, 22] ; and the parameter µ refers to the birth and death rates. based on the next-generation matrix approach [39] , we derive the basic reproductive number (see appendix a for further details), which is identical to that of the homogeneous-mixing model with a frequency-dependent transmission function [4] . it is worth noting that it is irrelevant to k, which means that it does not depend on the level of heterogeneity. this can be explained by r 0 being an average quantity, which means that it does not consider the individual variance in infectiousness [24] . this result is in agreement with the conclusion made using a meta population version of the standard stochastic sir model incorporating spatial heterogeneity [40] . we now determine the equilibrium states. without much work, we can obtain the disease-free equilibrium (n, 0, 0, 0). we also derive the approximate size of the infectious compartment at the endemic equilibrium, . this is identical to that of the homogeneous-mixing model with a frequency-dependent transmission function [4] . similar to r 0 , it does not depend on k. in other words, the contact heterogeneity does not influence the endemic equilibrium, although it does change the dynamics, which we demonstrate using numerical simulations in the next section. using numerical simulations, we explore the influence of the heterogeneity level on the transmission dynamics, characterized by the parameter k. the results show that the infectious curves with fixed β, but different values of k achieve a peak after a period that is almost the same in duration (figure 2a) . however, the transmission speed and, therefore, the peak size, as well as the dynamics after the peak are very different. a low level of heterogeneity results in dynamics similar to those predicted by the homogeneous-mixing model with a frequency-dependent transmission term, βsi n . this is consistent with the conclusion inferred in equation (2). as the value of k decreases, that is the level of heterogeneity increases, the dynamics differ increasingly from those predicted by the homogeneous-mixing model. the greatest difference is that at the overall level, the heterogeneity slows the transmission speed and decreases the peak sizes, which means milder disease outbreaks, because in the scenario with a high level of heterogeneity, only a small proportion of susceptible individuals have chances of coming into contact with infectious individuals and becoming infected, which results in a slower increase of the infected population. second, after the peak is attained, the infectious curves do not decline as rapidly as those predicted by the homogeneous-mixing model and the nbd models (equation (4)) with larger values of k (figure 2a) , and the disease persists over a long term in the population ( figure 2b ). compared to the homogeneous-mixing model or the nbd models with larger values of k, up to the peak time (almost the same), there are many more individuals who are still susceptible to the disease. a proportion of them come into contact with infectious individuals and become infected, and this process persists for a long period of time. moreover, figure 2b shows that the endemic sizes of the two scenarios are approximately equal, just as noted in the previous section. in addition, when k drops to a very small value, there will be no disease outbreak, because almost none of the susceptible individuals have any chance of coming into contact with infectious individuals and becoming infected. it is shown that the contact patterns exhibit more heterogeneity than that assumed by homogeneous-mixing models, but they do not appear extremely heterogeneous [6] . we also simulate the dynamics with a fixed value of k and different values of β. because the dynamics obtained with a large value of k are similar to those of the homogeneous-mixing model with a frequency-dependent transmission term, we only show the results for a relatively small value of k = 10 −4 (figure 3 ). for larger values of β, the infectious curves reach their peaks earlier, and the peaks are higher than those obtained for smaller values of β. after the peak of the disease outbreak is achieved, the infectious curves decrease slowly and reach endemic equilibrium gradually ( figure 3b ). additionally, for much smaller values of β, such that r 0 < 1, there will be no disease outbreak (here, for example, β = 0.1). the sars disease broke out in the beginning of march 2003 in beijing, spread rapidly over the next six weeks and peaked during the third and fourth weeks of april [41] . in total, 2048 confirmed cases were reported during the entire outbreak period (the circle markers shown in figure 4 ; the data were provided by the chinese center for disease control and prevention). prompted by the rapid expansion of the epidemic, on 17 april, the beijing municipal government established a joint sars leading group and deployed 10 task forces to oversee crisis management [41, 42] . on 20 april, a larger number of cases was reported, and the chinese government canceled the may day holiday in an effort to reduce the mass movement of people [43] . multiple measures were taken to control the spread of the disease, including the provision of personal protective equipment and training for healthcare workers [41] ; introduction of community-based prevention and control through case detection, isolation, quarantine and community mobilization [41] ; closure of the sites of public entertainment and schools [42] ; and stopping the entry of all visitors or screening them for fever upon entry to universities and other places [42] . additionally, a general increase in sars awareness played an important role in controlling the outbreak [42] . the multiple measures implemented in beijing likely led to the rapid resolution of the sars outbreak [42] . to evaluate the effectiveness of the control measures taken in beijing at that time, we calibrated the nbd model to the data of the sars daily cases using the globalsearch algorithm in the matlab global optimization toolbox [44, 45] and estimated the parameters. we used two different values, k 1 and k 2 , to characterize the different levels of heterogeneity in contact in the population before and after 20 april [38] . we assumed a fixed value for β for simplicity (in reality, the value of β decreased along with the control strategies [38] ; we mainly discuss the influence of the other parameter, k). we chose the normalized root mean square error (nrmse) [46] as the goodness of fit between the model output and the daily case data, as well as the objective function of the calibration procedure. in order to compute the nrmse, we solved the set of differential equations (equation (4)) with unknown parameters α, β, γ and k = k 1 from 7 march to 20 april. the initial conditions were set as follows: s(0) = 1.4564 × 10 7 , which was the size of the permanent population in beijing in 2003 [47] ; t = 0 corresponds to 7 march 2003; e(0) = 0; i(0) = 2, which was the number of daily cases on 7 march 2003; and r(0) = 0. then, the output of the model on 20 april was taken as the initial value to solve equation (4) with parameters α, β, γ and k = k 2 from 20 april to 4 june. finally, the two outputs were combined and used to calculate the goodness of fit to the sars daily case data. the birth and death rate, µ, was assumed to be 1/70 year −1 . in total, there were five unknown parameters to be estimated: k 1 , k 2 , α, β and γ. the starting points of the parameters for the calibration procedure were selected randomly between the bounds of the parameters shown in table 1 . because of the stochasticity of the globalsearchalgorithm [44, 45] , the results varied slightly every time. we ran the procedure 100 times. table 2 presents the minimum, maximum, mean and standard variance of the results. the average latent and infectious periods are 1 α = 6.8661 days and 1 γ = 4.8439 days, respectively. the much smaller k 2 value indicates that the control measures are extremely effective in controlling the sars transmission in beijing in 2003. this is in agreement with the result in [38] . figure 4 shows the 100 fitted infectious curves and the daily cases. in this paper, we aimed to study the influence of heterogeneity in the contact rates in disease transmission at the population level. the developed nbd model can be regarded as a generalized homogeneous-mixing model with a frequency-dependent transmission function. our results show that, keeping other conditions identical, the higher is the level of heterogeneity in contact rates, the greater is the difference in the disease dynamics observed from those predicted using the homogeneous-mixing models. it is worthwhile to compare our approach and results to previous approaches and results. to address heterogeneous-mixing within populations, the populations were further divided into multiple subgroups [10] [11] [12] , and used the waifw matrix ("who acquires infection from whom" [1] ), in which any individual is more likely to come into contact with other individuals from within the same subgroup than those outside. however, in this framework, contact rates within the subgroups are still homogeneous. a different class of approaches for extending the traditional compartmental models to incorporate heterogeneity involves modifying the transmission term; our approach belongs to this class. the work in [7, 8, 19] replaced the bilinear transmission term (si) in the homogeneous compartmental model with a nonlinear term ks p i q , where k, p, q are the "heterogeneity parameters". their results showed that the modified model was capable of predicting the disease transmission patterns in a clustered network [19] . stroud et al. used a power-law scaling of the new infection rate i(s/n) v , with scaling power v greater than one, to relax the homogeneous-mixing assumption [9] , and it was demonstrated that this power-law formulation leads to significantly lower predictions of the final epidemic size than the traditional linear formulation. compared to these empirical or semi-empirical modifications [7] [8] [9] 19] , the nbd transmission function seems to agree more with the real transmission mechanics, in that it assumes that the mean of the number of effective contacts of the susceptible individuals with infectious individuals per unit time is different from individual to individual, and the choice of the gamma distribution offers multiple advantages (see section 2.1). in recent years, several network-based models have been developed to study the influence of contact heterogeneity on disease transmission. keeling et al. reviewed multiple types of networks and the statistical and analytical approaches for the spread of infectious diseases [13, 14] . in particular, bansal et al. demonstrated that the high-level heterogeneous degree distributions generate an almost immediate expansion phase compared to homogeneous degree distributions, such as the poisson distribution [6, 49, 50] . the nbd-seir model does not exhibit this feature. we suspect that this is because our approach belongs to the mean-field class of approaches and considers a large population at the overall level. in addition, it is possible to approximate the main features of disease spread in networks with compartmental models using an appropriate construction. the work in [20] used r 0 as a fundamental parameter to formulate a mean-field type model, which can implicitly capture some important effects of heterogeneous-mixing in contact networks. the work in [51, 52] applied "edge-based compartmental modeling" (ebcm), which focuses on the status of a random partner rather than a random individual, to capture the heterogeneous contact rates in disease transmission. although it incorporates the heterogeneous contact rates in disease transmission in a tractable manner, the nbd model has some weaknesses. first, the parameter k characterizes the level of heterogeneity, which is difficult to measure directly, and this can be overcome by using contact tracing data. second, some features cannot be recovered by the nbd model. in future research, it will be interesting to incorporate other factors that influence transmission dynamics, such as the migration of populations, seasonality and vaccinations, among others. using the probability density function for the negative binomial distribution, we constructed a nbd transmission function and further developed a compartmental model for direct infectious disease. the developed model considers the heterogeneity of contact rates in the population. the simulation results show that, at the population level, the dynamics vary widely according to the level of heterogeneity in contact rates. once r 0 > 1, a low level of heterogeneity results in dynamics similar to those predicted by the homogeneous mixing models. keeping other conditions identical, as the level of heterogeneity increases, the transmission speed becomes more and more slowly, the peak size becomes smaller and smaller. these results have implications for developing interventions, such as isolation, targeted vaccination, among others. individuals: x = (e, i, s, r). here, the infected compartments are e and i, yielding m = 2. then, we decompose the components of the differential equations into f , in which f i is the rate of appearance of new infections in compartment i, and v , in which v i is the rate of transfer of individuals into and out of compartment i by all other means: the disease-free equilibrium (dfe) for this model is x 0 = (0, 0, n, 0). then, giving: this is called the next-generation matrix for the model [39] . finally, the basic reproductive number, r 0 , is calculated using the spectral ratio: because the total population size n is a constant and r = n − s − e − i, the last equation in equation (4) is redundant. to find the endemic equilibrium, we set the right side of the other three equations to zero. then, s and e can be represented by i: s = µn µ + k ln(1 + βi kn ) , e = γ + µ α substituting them into k ln(1 + βi kn )s − (α + µ)e = 0 and after some algebraic manipulation, we obtain: obviously, it is difficult and even impossible to find an explicit solution. we find an approximate solution using the first-degree taylor polynomial of ln(1 + x) near x = 0, that is ln(1 + x) ≈ x. it follows that, we obtain the approximate solution for i: where r 0 is given in equation (5). infectious diseases of humans: 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test and reference data frequently asked questions about sars dynamical patterns of epidemic outbreaks in complex heterogeneous networks sir dynamics in random networks with heterogeneous connectivity edge-based compartmental modelling for infectious disease spread incorporating disease and population structure into models of sir disease in contact networks the author for correspondence, jinfeng wang, designed the whole study, and lingcai kong implemented the method and drafted the manuscript. weiguo han and zhidong cao revised the manuscript critically and made constructive suggestions for the interpretation of the results. there was no conflict of interest regarding the submission of this manuscript, and it was approved by all authors for publication. using the next-generation operator approach [39] , we compute the basic reproductive number r 0 . first, we sort the compartments so that the first m compartments correspond to infected key: cord-291916-5yqc3zcx authors: hozhabri, hossein; piceci sparascio, francesca; sohrabi, hamidreza; mousavifar, leila; roy, rené; scribano, daniela; de luca, alessandro; ambrosi, cecilia; sarshar, meysam title: the global emergency of novel coronavirus (sars-cov-2): an update of the current status and forecasting date: 2020-08-05 journal: int j environ res public health doi: 10.3390/ijerph17165648 sha: doc_id: 291916 cord_uid: 5yqc3zcx over the past two decades, there have been two major outbreaks where the crossover of animal betacoronaviruses to humans has resulted in severe acute respiratory syndrome coronavirus (sars-cov) and middle east respiratory syndrome coronavirus (mers-cov). in december 2019, a global public health concern started with the emergence of a new strain of coronavirus (sars-cov-2 or 2019 novel coronavirus, 2019-ncov) which has rapidly spread all over the world from its origin in wuhan, china. sars-cov-2 belongs to the betacoronavirus genus, which includes human sars-cov, mers and two other human coronaviruses (hcovs), hcov-oc43 and hcov-hku1. the fatality rate of sars-cov-2 is lower than the two previous coronavirus epidemics, but it is faster spreading and the large number of infected people with severe viral pneumonia and respiratory illness, showed sars-cov-2 to be highly contagious. based on the current published evidence, herein we summarize the origin, genetics, epidemiology, clinical manifestations, preventions, diagnosis and up to date treatments of sars-cov-2 infections in comparison with those caused by sars-cov and mers-cov. moreover, the possible impact of weather conditions on the transmission of sars-cov-2 is also discussed. therefore, the aim of the present review is to reconsider the two previous pandemics and provide a reference for future studies as well as therapeutic approaches. coronaviruses (covs) are a group of highly enveloped viruses that are diversely found in humans and wildlife. with their high mutation rate and infectivity, covs are important zoonotic pathogens that can infect animals [1, 2] and humans, leading to 5-10% of acute respiratory syndromes [3] . apart from infecting a variety of economically important vertebrates (such as pigs and chickens), six species have been identified to cause disease in humans [4] . they are known to infect respiratory, gastrointestinal, hepatic and neurologic systems with a wide range of clinical features from asymptomatic course to severe disease that require hospitalization in the intensive care unit [4, 5] . the first human coronaviruses (hcovs), hcov-229e and oc43, shown to be significant respiratory pathogens, were identified in the 1960s [6, 7] . however, it is assumed that the first recorded coronavirus-related disease was feline infectious peritonitis (fip) in 1912 [8] . the "corona"-like or crown-like morphology of these viruses leads to choose the name "coronavirus," in 1968 [6] . coronaviruses were not considered as highly pathogenic for humans before the beginning of the 21st century. afterward, two highly pathogenic hcovs, including severe acute respiratory syndrome coronavirus (sars-cov) and middle east respiratory syndrome coronavirus (mers-cov), emerging from animal reservoirs, have led to global epidemics of deadly pneumonia in humans with high morbidity and mortality [9, 10] . in december 2019, seven years after mers outbreak, the third pathogenic hcov emerged in wuhan, the capital city of hubei province in china, causing severe pneumonia [11, 12] . considered as agents that are a great public health threat, an epidemiological alert was placed by the world health organization (who) and this new coronavirus was named sars-cov-2 and the related respiratory disease covid-19 (https://www.who.int). compared with sars-cov, sars-cov-2 appears to be more readily transmitted from human-to-human, spreading to multiple continents and the outbreak of sars-cov-2 was declared on january 30, 2020 [13] (https://www.who.int). in this review, we will introduce the current knowledge on the origin and evolution of sars-cov-2, emphasizing its characteristics and its genetic diversity from previous coronaviruses, with a brief comment on its epidemiology and pathogenesis. we also highlight the environmental factors involved in virus transmission. knowledge about this novel coronavirus is rapidly evolving, and efforts must be implemented in order to protect the populations by reducing transmission and controlling the spread of this fatal disease. according to the international committee on taxonomy of viruses, covs are classified under the order of nidovirales, a family of coronaviridae and subfamily of coronavirinae [14] . based on previous serologic and recent genomic evidences, the family of coronaviridae encompasses two subfamilies: subfamily orthocoronavirinae and subfamily torovirinae ( figure 1) [7, 15] . the subfamily of orthocoronavirinae consists of four genera: alphacoronavirus, betacoronavirus, gammacoronavirus and deltacoronavirus [7, 16, 17] . covs can be isolated from different animal species, including birds, livestock and mammals such as camels, bats, masked palm civets, mice, dogs and cats [18, 19] . animal covs are known to cause acute diseases in several animals and could be responsible for economic losses in domestic animals or birds [20, 21] . domestic animals may play an important role as intermediate hosts that enable virus transmission from one species to humans [17] . the genera gamma-and deltacoronavirus infect birds, but some of them can also infect mammals [16] . these animal covs include transmissible gastroenteritis virus (tgev), porcine epidemic diarrhea virus (pedv), avian infectious bronchitis virus (ibv)-and more recently-swine acute diarrhea syndrome coronavirus (sads-cov). however, animal covs can also infect humans that can spread the infection through human-tohuman transmission [17, 22] . on the other hand, alpha-and betacoronavirus infect only mammals and usually cause respiratory illness in humans; among these, strains 229e, oc43, hku1 and nl63 are the most widespread infecting young children, infants as well as elderly individuals [23] [24] [25] . the high rates of mutation characterizing all rna viruses [23, 26] , the evolving nature of covs and the simplicity of transmission from one species to another are the most relevant features learned from sars-cov and mers-cov previous outbreaks [15, 23, 25] . importantly, most of alpha-and betacoronavirus were found only in bats, and many genetically diverse coronaviruses phylogenetically related to sars-cov and mers-cov have been discovered in diverse bat species worldwide [17] . therefore, hcovs such as sars-and mers-covs seem to have originated in bats by sequential mutations and recombination, including those occurring in the intermediate hosts, civets and raccoon dogs for sars-cov and camels in the case of mers-cov, finally acquiring the ability to infect humans [15, 17] . comparative genome studies published in recent papers strongly support the hypothesis that sars-cov-2 originated in bats and that pangolins (manis javanica) acted as intermediate mammalian hosts [11, 27] (figure 2) . indeed, the genetic sequence of the sars-cov-2 showed more than 79% nucleotide identity with the sequence of sars-cov and 50% with mers-cov [17, 19] . the high degree of homology of the angiotensin-converting enzyme 2 (ace2) receptor in several animal species can be considered as an additional evidence to support that sars-cov-2 originated from bats [28] . based on findings from molecular studies, the ace2 proteins of non-human primates, pigs, cats and ferrets closely resemble the human ace2 receptor. therefore, these species covs can be isolated from different animal species, including birds, livestock and mammals such as camels, bats, masked palm civets, mice, dogs and cats [18, 19] . animal covs are known to cause acute diseases in several animals and could be responsible for economic losses in domestic animals or birds [20, 21] . domestic animals may play an important role as intermediate hosts that enable virus transmission from one species to humans [17] . the genera gammaand deltacoronavirus infect birds, but some of them can also infect mammals [16] . these animal covs include transmissible gastroenteritis virus (tgev), porcine epidemic diarrhea virus (pedv), avian infectious bronchitis virus (ibv)-and more recently-swine acute diarrhea syndrome coronavirus (sads-cov). however, animal covs can also infect humans that can spread the infection through human-to-human transmission [17, 22] . on the other hand, alphaand betacoronavirus infect only mammals and usually cause respiratory illness in humans; among these, strains 229e, oc43, hku1 and nl63 are the most widespread infecting young children, infants as well as elderly individuals [23] [24] [25] . the high rates of mutation characterizing all rna viruses [23, 26] , the evolving nature of covs and the simplicity of transmission from one species to another are the most relevant features learned from sars-cov and mers-cov previous outbreaks [15, 23, 25] . importantly, most of alphaand betacoronavirus were found only in bats, and many genetically diverse coronaviruses phylogenetically related to sars-cov and mers-cov have been discovered in diverse bat species worldwide [17] . therefore, hcovs such as sars-and mers-covs seem to have originated in bats by sequential mutations and recombination, including those occurring in the intermediate hosts, civets and raccoon dogs for sars-cov and camels in the case of mers-cov, finally acquiring the ability to infect humans [15, 17] . comparative genome studies published in recent papers strongly support the hypothesis that sars-cov-2 originated in bats and that pangolins (manis javanica) acted as intermediate mammalian hosts [11, 27] (figure 2) . indeed, the genetic sequence of the sars-cov-2 showed more than 79% nucleotide identity with the sequence of sars-cov and 50% with mers-cov [17, 19] . the high degree of homology of the angiotensin-converting enzyme 2 (ace2) receptor in several animal species can be considered as an additional evidence to support that sars-cov-2 originated from bats [28] . based on findings from molecular studies, the ace2 proteins of non-human primates, pigs, cats and ferrets closely resemble the human ace2 receptor. therefore, these species may be susceptible to sars-cov-2 infection, as has been shown for sars-cov. although a recent study showed that neither pigs nor chickens are susceptible to sars-cov-2 by intranasal or oculo-oronasal infections, more evidences are needed to exclude pigs as intermediate host of sars-cov-2 [29] . [15] . based on the genetic sequence identity and the phylogenetic reports, sars-cov-2 is sufficiently different from sars-cov; thus, who has classified it as a new betacoronavirus that infects humans [30] . the genome of hcovs is a single-stranded positive-sense rna (+ssrna) (~26-32 kb) with 5′cap structure and 3′-poly a tail, which is among the largest known rna genomes [31] [32] [33] . the typical hcovs gene order is 5′-replicase-s-e-m-n-3′, with numerous (6 to 11) open reading frames (orfs) encoding accessory proteins scattered among the structural genes [34, 35] . the first orfs (orf1a and 1b) comprise two-thirds (approximately 67%) of the genome length and encode 16 nonstructural polyproteins (nsps [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] and are directly translated from the genomic rna [17] . there is a −1 ribosomal frameshift between orf1a and orf1b, leading to the production of two large replicase polypeptides (pp): pp1a and pp1ab. these polypeptides are further processed by two virally encoded cysteine proteases, the papain-like protease (plpro) and a 3-chymotrypsin-like protease (3clpro) into 16 nsps [3, 33, 36] . there are at least four structural proteins encoded by the coronaviral genome: a spike glycoprotein (s), an envelope protein (e), a membrane protein (m) and nucleocapsid protein (n) with short untranslated regions at both termini, required to produce a structurally complete viral particle [37] . the typical coronavirus virion structure and proteins are shown in figure 3 . the m protein is in higher quantities in comparison to any other proteins in the virus particle; with its three transmembrane domains, it shapes virions, promotes membrane curvature and binds to the nucleocapsid [38, 39] . the n protein contains two domains, both of which can bind to nsp3 protein to help tether the genome to replication-transcription complex (rtc) and package viral rna into the viral particle during viral assembly [39, 40] . the e protein is involved in virus assembly and virion release from host cells, while the s protein plays a vital role in attachment to host receptors, viral entry and determines host tropism [41, 42] . additionally, some coronaviruses, such as hcov-oc43 and hcov-hku1, have a hemagglutinin-esterase (he) gene between orf1b and s [43] [44] [45] [46] . this based on the genetic sequence identity and the phylogenetic reports, sars-cov-2 is sufficiently different from sars-cov; thus, who has classified it as a new betacoronavirus that infects humans [30] . the genome of hcovs is a single-stranded positive-sense rna (+ssrna) (~26-32 kb) with 5 -cap structure and 3 -poly a tail, which is among the largest known rna genomes [31] [32] [33] . the typical hcovs gene order is 5 -replicase-s-e-m-n-3 , with numerous (6 to 11) open reading frames (orfs) encoding accessory proteins scattered among the structural genes [34, 35] . the first orfs (orf1a and 1b) comprise two-thirds (approximately 67%) of the genome length and encode 16 nonstructural polyproteins (nsps 1-16) and are directly translated from the genomic rna [17] . there is a −1 ribosomal frameshift between orf1a and orf1b, leading to the production of two large replicase polypeptides (pp): pp1a and pp1ab. these polypeptides are further processed by two virally encoded cysteine proteases, the papain-like protease (plpro) and a 3-chymotrypsin-like protease (3clpro) into 16 nsps [3, 33, 36] . there are at least four structural proteins encoded by the coronaviral genome: a spike glycoprotein (s), an envelope protein (e), a membrane protein (m) and nucleocapsid protein (n) with short untranslated regions at both termini, required to produce a structurally complete viral particle [37] . the typical coronavirus virion structure and proteins are shown in figure 3 . the m protein is in higher quantities in comparison to any other proteins in the virus particle; with its three transmembrane domains, it shapes virions, promotes membrane curvature and binds to the nucleocapsid [38, 39] . the n protein contains two domains, both of which can bind to nsp3 protein to help tether the genome to replication-transcription complex (rtc) and package viral rna into the viral particle during viral assembly [39, 40] . the e protein is involved in virus assembly and virion release from host cells, while the s protein plays a vital role in attachment to host receptors, viral entry and determines host tropism [41, 42] . additionally, some coronaviruses, such as hcov-oc43 and hcov-hku1, have a hemagglutinin-esterase (he) gene between orf1b and s [43] [44] [45] [46] . this hemagglutinin, like the influenza homolog enzyme, binds to sialic acid on host cell-surface glycoproteins and possesses acetyl-esterase activity [47] . besides coronavirus-conserved genes, the sars-cov, sars-cov-2 and mers-cov genomes contain several specific accessory genes including orf3a/b, 4a/b, orf5, orf6, orf7a/b, orf8a/b and 9b ( figure 4) [4, 48, 49] . all the structural and accessory proteins are translated from subgenomic rnas (sgrnas) generated during genome transcription/replication of covs [4] . hemagglutinin, like the influenza homolog enzyme, binds to sialic acid on host cell-surface glycoproteins and possesses acetyl-esterase activity [47] . besides coronavirus-conserved genes, the sars-cov, sars-cov-2 and mers-cov genomes contain several specific accessory genes including orf3a/b, 4a/b, orf5, orf6, orf7a/b, orf8a/b and 9b ( figure 4) [4, 48, 49] . all the structural and accessory proteins are translated from subgenomic rnas (sgrnas) generated during genome transcription/replication of covs [4] . attachment, cell entry, translation of viral replicase, genome replication, translation of structural proteins and virion assembly and release are the phases of coronavirus replication cycle [4, 50] . sars-cov, mers-cov and sars-cov-2 bind to different host receptors to gain entry into host cells [4, 51, 52] . viral entry is mediated by the transmembrane s glycoprotein that comprises two functional subunits (s1 and s2 subunits) responsible for receptor recognition and viral-host cell membranes fusion, respectively [53, 54] . s1 receptor-binding domain (rbd) mediates binding to the cognate host cell receptor; however, the s2 domain mediates the fusion events, between viral envelope and host cell membrane [52, 55, 56] . as recently found, sars-cov-2 uses the same ace2 receptor [57] , as sars-cov, whereas mers-cov uses dipeptidyl peptidase 4 (dpp4, also known as cd26) receptor (table 1 ) [58] . the fusion of the s protein to the plasma membrane of host cell generates a double membrane vesicle in the host cell, thereby allowing release of the nucleocapsid into the cytoplasm, followed by genome transcription [53, 54] . upon entry into the cell, virus-specific rna and proteins are synthesized, probably entirely in the cytoplasm. translation starts with the expression of two polyproteins, pp1a and pp1ab, which undergo co-translational proteolytic processing into the proteins that form the replicase complex. this complex is used to transcribe a 3′-coterminal set of nested subgenomic mrnas, as well as genomic rna that have a common 5′ "leader" sequence derived from the 5′ end of the genome. new virions are assembled by budding into intracellular membranes of the pre-golgi compartment and released through the cell secretory mechanisms [4, 42, 48, 50] . attachment, cell entry, translation of viral replicase, genome replication, translation of structural proteins and virion assembly and release are the phases of coronavirus replication cycle [4, 50] . sars-cov, mers-cov and sars-cov-2 bind to different host receptors to gain entry into host cells [4, 51, 52] . viral entry is mediated by the transmembrane s glycoprotein that comprises two functional subunits (s1 and s2 subunits) responsible for receptor recognition and viral-host cell membranes fusion, respectively [53, 54] . s1 receptor-binding domain (rbd) mediates binding to the cognate host cell receptor; however, the s2 domain mediates the fusion events, between viral envelope and host cell membrane [52, 55, 56] . as recently found, sars-cov-2 uses the same ace2 receptor [57] , as sars-cov, whereas mers-cov uses dipeptidyl peptidase 4 (dpp4, also known as cd26) receptor (table 1 ) [58] . the fusion of the s protein to the plasma membrane of host cell generates a double membrane vesicle in the host cell, thereby allowing release of the nucleocapsid into the cytoplasm, followed by genome transcription [53, 54] . upon entry into the cell, virus-specific rna and proteins are synthesized, probably entirely in the cytoplasm. translation starts with the expression of two polyproteins, pp1a and pp1ab, which undergo co-translational proteolytic processing into the proteins that form the replicase complex. this complex is used to transcribe a 3 -coterminal set of nested subgenomic mrnas, as well as genomic rna that have a common 5 "leader" sequence derived from the 5 end of the genome. new virions are assembled by budding into intracellular membranes of the pre-golgi compartment and released through the cell secretory mechanisms [4, 42, 48, 50] . , the 3′-terminus of the sars-cov-2 and sars-cov genomes contain eight accessory proteins (3a, 3b, p6, 7a, 7b, 8b, 9b and orf14 and 3a, 3b, p6, 7a, 7b, 8a, 8b and 9b, respectively) while mers-cov genome contains only five (3, 4a, 4b, 5 and 8b). the genes encoding accessory proteins are unique in different coronaviruses in terms of number, genomic organization, sequence and functions (data extracted from [35, 49, 57] the coronavirus genomes encode two replicase polypeptides pp1a and pp1ab translated from orf1a and orf1b; four structural genes encoding for four structural proteins including (s) spike, (m) membrane, (e) envelope and (n) nucleocapsid proteins. the single-stranded rna genomes of sars-cov-2 (~29.8 kb), sars-cov (~29.7 kb) and mers-cov (~30.1 kb) harbor two large genes, the orf1a (red) and 1b (blue) genes encoding accessory genes (nsps 1-16, shades of red and blue). encoded nonstructural proteins: 16 nsps (nsp1-nsp16) in sars-cov-2, sars-cov and mers-cov. along with structural proteins (s, e, m and n), the 3 -terminus of the sars-cov-2 and sars-cov genomes contain eight accessory proteins (3a, 3b, p6, 7a, 7b, 8b, 9b and orf14 and 3a, 3b, p6, 7a, 7b, 8a, 8b and 9b, respectively) while mers-cov genome contains only five (3, 4a, 4b, 5 and 8b). the genes encoding accessory proteins are unique in different coronaviruses in terms of number, genomic organization, sequence and functions (data extracted from [35, 49, 57] virologic as well as genetic studies have demonstrated that bats are reservoir hosts of both sars-cov and mers-cov, but also that they can use other species as intermediate hosts before spreading to humans [59, 60] . the detection of two genomes distinct from known swine in ill piglets were reported by two independent groups [61, 62] . the phylogenetic analyses showed that these novel swine enteric alphacoronaviruses (seacovs) were strongly related to the rhinolophus bat coronavirus hku2 isolated in guangdong province, in southern china [61, 62] . this suggests that coronaviruses of bat origin may have 'jumped' the barrier of the species to infect pigs as intermediate hosts. the cd26 receptor sequence alignment between humans and pigs demonstrates a 94.5% overlap, which is sufficient for the possible cross-species transmission [63] . it has also been documented that pigs are susceptible to human sars-cov [64] and mers-cov infections [65] . the large number of mutations within the rbd enabled viruses to infect new hosts, representing a potential threat for both animal and human health. in southern china, the unique climate, the high density of domestic as well as wild pigs, along with the extensive bat distribution and carriage of tremendous quantities of recombinant novel coronaviruses may result in the appearance of more novel coronaviruses in the future [66] . it is generally acknowledged that numerous viruses have existed and were restricted to their natural reservoirs for lengthy times [17] . the consistent spillover of viruses from natural hosts to humans and other species is essentially related to human activities, including urbanization and modern agricultural practices, leading to the constant human exposure to the ever-changing mutant covs from their reservoirs [15, 17] . the close contact between humans and animals and the practice of eating raw meat are both risk factors for causing a new human cov outbreak [15] . hence, covid-19 should be considered as a zoonotic disease that spread from animals to humans. following the first sars-cov-2 outbreak in seafood and wildlife market in wuhan, secondary cases started to be identified after ten days. although these new patients did not have any contact with the market, they had a history of contact with people who attended the market [60] . therefore, similarly to sars-cov and unlikely to mers-cov, human-to-human transmission for sars-cov-2 has been reported and is currently considered as the main type of transmission worldwide [5, 19] . on january 13, 2020, thailand announced the first non-chinese case of infection that spread from the chinese provinces, to the asian continent [60] . this case was a chinese tourist who has traveled to thailand and did not have any epidemiological link to the market [30] . more recently, forster et al., by using phylogenetic analysis based on nucleotide mutations of 160 complete human sars-cov-2 genomes found that three variants of sars-cov-2 (a as the ancestral type, plus b and c) represent the bat outgroup coronaviruses. in particular, the a and c types were found mostly in european-american patients, whereas the b type was common in east asia suggesting that this kind of analysis could help in following the evolution of sars-cov-2 [67] . it was demonstrated that sars-covs have adapted themselves to bind to human ace2 receptor and infect human cells effectively [68] . this form of adaptation required a series of amino acid changes in the rbd within the s protein of sars viruses that circulated in bats [56, 68] . therefore, the human-to-human transmission that was seen in the course of the sars-cov outbreaks is directly attributable to the ability of sars-covs to adapt their s protein to efficiently bind to human ace2, thus infecting ciliated bronchial epithelial cells and type ii pneumocytes [15, 69] . similar to sars-cov, ace2 is also used by sars-cov-2 as the entry receptor in the ace2-expressing cells, suggesting that sars-cov-2 has a life cycle similar to sars-cov [56, 68] . as outlined before, sars-cov s protein regulates the receptor binding and membrane fusion activities determining host tropism and transmission capacity. several evidences highlighted a higher binding affinity of sars-cov-2 rbd to the ace2 receptor. in particular, molecular and in silico analyses demonstrated that sars-cov-2 rbd conformation and amino acid composition enhance the bonding between the s protein and ace2 receptor [51, 70, 71] . a recent biophysical and structural analysis of the sars-cov-2 s protein showed that it binds to ace2 receptor with about 10-to 20-fold higher affinity than the s protein of sars-cov [52, 72] . this high affinity could account for its extreme infectivity among human populations. another feature of the powerful infectivity of sars-cov-2 is that the shedding pattern of viral particles in sars-cov-2 diagnosed patients is similar to that of influenza patients in which viral loads at the time of symptom onset are higher and gradually decrease within days; interestingly, this pattern seems to be different from that reported for sars-cov patients where the highest shedding is reported 10 days after the onset of symptoms [20, 73, 74] . these results indicate that sars-cov-2 can spread more easily than sars-cov in the community even in the absence of symptoms or when only initial mild symptoms are present [75] . the human-to-human transmission of sars-cov-2 mainly occurs by inhalation of respiratory droplets spread by coughing or sneezing from an infected individual, but also by direct contact of contaminated surfaces and then touching the nose, mouth and eyes [24, [76] [77] [78] . the virus was shown to remain stable in favorable atmospheric conditions on different surfaces for days [79] . additionally, transmission in an unventilated environment or closed spaces due to high aerosol concentrations has been suggested [76, 77] . in agreement, the presence of sars-cov-2 in the surfaces of the houses of confirmed patients was reported, further strengthening this mode of contact transmission. moreover, live viruses were also found in the stool of covid-19 patients, as previously found for both sars-cov and mers-cov [77] . given its capacity for survival in feces and the expression of ace2 within intestine, it was demonstrated that sars-cov-2 can infect these tissues and can be released in feces; therefore, water supply contamination and fecal-oral route transmission is also hypothesized [24, 80] . however, at present, there have not been reported cases of fecal-oral transmission of the virus. studies have also indicated that sars-cov-2 transmission via ocular surfaces should not be overlooked, as contaminated droplets and body fluids could easily infect the human conjunctival epithelium [81] . sars-cov-2 is also responsible for cluster transmission, in particular within family clusters [77] . in some cities, 50% to 80% of all reported cases of covid-19 accounted for cluster transmission [82] . based on the current information, there is no evidence for transplacental transmission from infected pregnant women to their fetus, who underwent caesarean section [24, 78] . therefore, whether transmission during vaginal birth can occur remains to be established, neonatal covid-19 disease as postnatal transmission was documented [83] . although, sars-cov-2 may definitely infect infants, it has been reported that neonates, infants and children develop significantly milder forms of the disease than their adult counterparts [24, 84] . coronaviruses are responsible for 5-10% of acute respiratory illness while it has been estimated that 2% of the population is deemed as an asymptomatic carrier of these viruses. the first discovered hcov was ibv that causes respiratory disease in human whereas, hcov-229e and hcov-oc43, which cause the common cold in humans [15, 26, 85] . they were not considered to be highly pathogenic for humans until the outbreak of sars in guangdong state of china in 2002 and 2003. sars-cov infected more than 8000 people worldwide and caused 916 deaths (table 2) , representing a mortality rate by around 10% [86] . ten years later in 2012, mers-cov emerged in saudi arabia and infected over 2494 people with 858 deaths, accounting for a mortality rate approximately of 35% [9, 24, 87] . starting in china in december 2019, there were reports of patients presenting severe viral pneumonia [15, 88, 89] . this public health concern resulted in many unknown pneumonia cases who were admitted to local hospitals [22, 78] (https://www.who.int). primary etiologic investigations performed in those patients showed that they were epidemiologically linked to a huanan wholesale seafood market that also traded live animals and wildlife [17, 24, 90] . by january 7th, 2020 chinese authorities announced that a new type of coronavirus was isolated [60, 91] . the epicenter of infection was probably linked to a zoonotic pathogen being present in the seafood and exotic animal wholesale market [60, 91] . the rapid increasing numbers and rate of fatalities indicated a second mode of transmission, from human-to-human, that allowed viral spreading primarily in other asian countries such as south korea and iran followed by many countries such as italy, spain, germany, france, brazil and usa [24, 60] . it is very intriguing to note that the sars epidemic in southern china in 2002 and the current outbreak of covid-19 had peaked in mid-february due to exposure to live animals sold in markets. furthermore, similar to the sars outbreak, this epidemic has occurred during the spring festival in china, as the most famous traditional countrywide festival in china, gathering nearly three billion people from different areas. these favorable conditions caused the wide transmission of this fatal pneumonia and severe difficulties for disease control and prevention of the epidemic [92] . based on clinical data of diagnosed patients during the sars-cov-2 outbreak, the basic reproduction number (r0) is estimated to range between 2 and 6.47 in various modeling studies [76, 93] . the sars-cov-2 r0 is in line with the one estimated for sars-covs and mers-covs (from 2 to 5) [94, 95] . currently, increasing countries are experiencing clusters of cases and community transmission following sars-cov-2 pandemic. since its emergence, the covid-19 has drawn well-deserved attention from authorities in order to protect their community and stop or slow down transmission of this disease. at the time of this review, according to the daily report of the world health organization, sars-cov-2 has affected over 17,889,134 people with around 228,611 daily new cases and killed more than 686,145 people all over the world, by august 3rd, 2020 (the up to date fatality rate is reported from https://covid19.who.int). we must take into consideration that these data are relative to laboratories and clinically confirmed cases while the actual number including asymptomatic cases, infected undiagnosed and death patients would be much higher than reported cases. the transmission of seasonal respiratory coronaviruses can be affected by several climate parameters such as temperature and humidity [96] . therefore, understanding the relationship between weather and transmission of covid-19 is the key to forecast the intensity and end time of this pandemic. to this regard, emerging evidence suggests that whether climate conditions may influence the transmission of the sars-cov-2 by boosting the spread (much of the data have not been peer-reviewed yet). to date, covid-19 has had a significant expansion in the northern hemisphere (nh) belt, given that it covers cities and populated areas; conversely, in the belt of the southern hemisphere (sh), which covers very low population and landless areas, covid-19 has not been reported yet. based on climate and era-interim reanalysis dataset in nh belt from november 2019 to march 2020, we compared the average rate of humidity and temperature between five cities in european countries with significant community transmission of covid-19 versus five cities of north africa which are expected to be less exposed to covid-19. the information recorded by the meteorological stations has been used, since these are more accurate than satellite data [97] . as shown in table 3 , the average amount of humidity is very close between european and african selected sites. the main reason is the proximity of these cities to the mediterranean sea coastline. in addition, the north wind, which blows from northern europe to european cities (ecs), increases the humidity of these cities. conversely, there are temperature differences between considered ecs and north african cities (table 3) . thus, temperature and humidity should be considered parameters involved in the transmission of covid-19. up to know, few studies have investigated the association of temperature and humidity with covid-19 incidence and death rates. the first meteorological study was done in 100 different chinese cities each having more than 40 cases of covid-19 in a 3-day period during the end of january [98] . this group showed that high temperature and humidity significantly reduces the transmission of covid-19. their results indicate that the increases of 1 • c in temperature and 1% in relative humidity lower r by 0.0225 and 0.0158, respectively [98] . a preprint study on confirmed covid-19 cases collected from 429 cities showed that every 1 • c increase in the minimum temperature of higher-temperature cities reduced the disease incidence and death rates by 0.86 [99] . another preprint study suggested that the average increase of 1 • c in temperature correlates negatively with the predicted number of cases worldwide [100] . these results are in accordance with wu y et al. who showed that among all confirmed covid-19 new cases and new deaths from 166 countries (excluding china), a 1 • c increase in temperature is associated with a 3.08% reduction in daily new cases and a 1.19% reduction in daily new deaths, whereas a 1% increase in relative humidity was associated with a 0.85% reduction in daily new cases and a 0.51% reduction in daily new deaths [101] . a recent study conducted in italy showed a positive correlation of sars-cov-2 spreading and weather conditions including temperatures ranging 4-12 • c and relative humidity of 60-80% [102] . in a geographic and population modeling study conducted in five largest cities in colombia, the transmission of sars-cov-2 seems to be comodulated by temperature and humidity. their observation revealed a strong reduction of transmission in climates with temperatures above 30 • c and relative humidity below 78% which may comodulate the infectivity of sars-cov-2 within respiratory droplets [103] . table 3 . average humidity and temperature in 10 different cities in europe and north africa between november 2019 to march 2020. the first five cities represent significant communities where transmission of covid-19 was reported, whereas the second 5 cities are expected to be less exposed to covid-19 due to different weather conditions. average humidity (%) temperature ( • c) rome 71 65 66 63 63 15 1 11 13 14 paris 78 76 79 74 66 9 8 8 9 9 madrid 70 67 68 63 61 10 10 9 13 12 milan 77 74 69 58 62 11 8 7 11 11 lisbon 75 74 77 76 71 15 14 12 15 15 rabat 72 71 69 72 74 16 17 14 17 16 algiers 64 62 61 61 66 16 17 15 18 16 tunis 61 66 72 65 70 17 16 14 15 15 tripoli 80 83 73 75 71 15 10 8 9 11 cairo 45 52 55 53 46 25 18 16 18 22 overall, these meteorological analyses support that the combination of temperature and humidity could represent a direct influence on the transmission of the covid-19. it can be assumed that the arrival of summer and rainy season in the nh can effectively reduce the transmission of the covid-19. the distribution of covid-19 across different longitudes and latitudes with a range of temperatures and humidity may help to predict the prevalence of this disease in terms of environmental characteristics. this could lead to a better understanding of how the virus spreads around the world ( figure 5 ). it should be noted that apart from the capability of sars-cov-2 to persist on environmental surfaces under favorable atmospheric conditions, the duration of its persistence may be affected by temperature and humidity. however, caution is needed when considering the implications of these findings, which may be subject to confounding. although warmer climates may slow the spread of sars-cov-2, relying on weather changes alone to slow the transmission of covid-19 are unlikely to be enough. however, using this type of dataset and climate analysis modeling is possible to identify areas that are most likely to be at risk of significant covid-19 cases in the future and serve as an alarm signal to various government departments and agencies to adopt the necessary measures to prevent virus spread [104] . moreover, more data are gathering around the world due to the change of the season and all authors agree that the association between temperature/humidity and sars-cov-2 is an appreciable hypothesis, but not a certainty yet. 19 cases in the future and serve as an alarm signal to various government departments and agencies to adopt the necessary measures to prevent virus spread [104] . moreover, more data are gathering around the world due to the change of the season and all authors agree that the association between temperature/humidity and sars-cov-2 is an appreciable hypothesis, but not a certainty yet. the most common symptoms of patients at onset of covid-19 disease are defined as fever, dry cough, fatigue and less often, symptoms of sputum production, headache, sore throat, myalgia; hemoptysis, dyspnea, diarrhea and lymphopenia were also observed [15, 24, 28] (figure 6 ). the spectrum of clinical features of covid-19 has been found ranging from an asymptomatic state to severe respiratory failure and multiorgan dysfunction [24, 76] . symptomatic people are considered to be more contagious, similar to most viral-related respiratory diseases. however, individuals who remain asymptomatic may also transmit the virus and cases infected by an asymptomatic individual in the prodrome period of covid-19 have also been reported [76] . asymptomatic infections can occur because of weakened immune responses and subclinical manifestations or also because the the most common symptoms of patients at onset of covid-19 disease are defined as fever, dry cough, fatigue and less often, symptoms of sputum production, headache, sore throat, myalgia; hemoptysis, dyspnea, diarrhea and lymphopenia were also observed [15, 24, 28] (figure 6 ). the spectrum of clinical features of covid-19 has been found ranging from an asymptomatic state to severe respiratory failure and multiorgan dysfunction [24, 76] . symptomatic people are considered to be more contagious, similar to most viral-related respiratory diseases. however, individuals who remain asymptomatic may also transmit the virus and cases infected by an asymptomatic individual in the prodrome period of covid-19 have also been reported [76] . asymptomatic infections can occur because of weakened immune responses and subclinical manifestations or also because the virus is waiting for opportunities to invade and reproduce. a recent study has shown that a viral load detected in an asymptomatic patient was just like to the one observed in symptomatic patients, indicating the capability of transmission in asymptomatic patients [74] . according to disease presentation, covid-19 can be classified as mild, moderate, severe and critical ( virus is waiting for opportunities to invade and reproduce. a recent study has shown that a viral load detected in an asymptomatic patient was just like to the one observed in symptomatic patients, indicating the capability of transmission in asymptomatic patients [74] . according to disease presentation, covid-19 can be classified as mild, moderate, severe and critical (table 4 ) [57, 76, 105] . in 81% of all confirmed covid-19 cases. dry cough, mild fever, sore throat, nasal congestion, muscle pain, headache and malaise. absence of serious symptoms like dyspnea, also the absence of radiograph features. it may rapidly deteriorate into severe or critical cases, non-pneumonia or mild pneumonia. dry cough, tachypnea and shortness of breath. acute respiratory distress syndrome (ards), severe pneumonia, severe dyspnea, sepsis or septic shock, tachypnea (respiratory frequency) ≥ 30/min, blood oxygen saturation (spo2) ≤ 93%, partial pressure of arterial oxygen to fraction of inspired oxygen ratio (pao2/fio2) < 300, and/or lung infiltrates > 50% within 24 to 48 h. fever can be absent or moderate. in 5% of all confirmed covid-19 cases. respiratory failure, septic shock, rnaemia, cardiac injury and/or multiple organ dysfunction or failure. case fatality rate is 49% (higher case fatality rate for patients with preexisting co-morbidities and lower-case fatality rate (0.9%) for patients without co-morbidities). cardiovascular disease (10.5%), diabetes (7.3%), respiratory disease (6.5%), hypertension (6%) and oncological complications (5.6%). in 81% of all confirmed covid-19 cases. dry cough, mild fever, sore throat, nasal congestion, muscle pain, headache and malaise. absence of serious symptoms like dyspnea, also the absence of radiograph features. it may rapidly deteriorate into severe or critical cases, non-pneumonia or mild pneumonia. dry cough, tachypnea and shortness of breath. acute respiratory distress syndrome (ards), severe pneumonia, severe dyspnea, sepsis or septic shock, tachypnea (respiratory frequency) ≥ 30/min, blood oxygen saturation (spo 2 ) ≤ 93%, partial pressure of arterial oxygen to fraction of inspired oxygen ratio (pao 2 /fio 2 ) < 300, and/or lung infiltrates > 50% within 24 to 48 h. fever can be absent or moderate. in 5% of all confirmed covid-19 cases. respiratory failure, septic shock, rnaemia, cardiac injury and/or multiple organ dysfunction or failure. case fatality rate is 49% (higher case fatality rate for patients with preexisting co-morbidities and lower-case fatality rate (0.9%) for patients without co-morbidities). cardiovascular disease (10.5%), diabetes (7.3%), respiratory disease (6.5%), hypertension (6%) and oncological complications (5.6%). and 95% of patients are likely to experience symptoms within 12.5 days from contact [24, [106] [107] [108] . however, in an asymptomatic carrier the incubation period was 19 days, complicating the challenge to contain the outbreak [109] . the median time between onset of symptoms and dyspnea is 5 days, 7 days for hospitalization and 8 days for acute respiratory distress syndrome (ards) (figure 7 ) [24] (https://www.epicentro.iss.it/coronavirus/sars-cov-2). patients at this stage in intensive care unit (icu) with quarantine facilities may require mechanical ventilation. moreover, bacterial infections can cause a secondary pneumonia [108] . in addition, the period from the beginning of covid-19 symptoms to death varied between 6 and 41 days with an average of 14 days [110] . this period depends on immune system status and the patient's age, being shorter in 70-year-old subjects compared with those younger [78, 110] . in people with compromised immune systems and in elderly patients with underlying health problems, sars-cov-2 is able to infect the lower respiratory tract leading to severe pneumonia [111] . in 25-30% of patients presenting acute lung injury, shock, ards and acute kidney injury, icu admission was absolutely required [24] . recovery started within the 2nd or 3rd weeks with the median duration of hospitalization of 10 days. the virus appears to be more fatal in individuals with underlying co-morbidities (50-75% of fatal cases) [24, 111] . available dataset was obtained from italian istituto superiore di sanità (iss) on 34,026 patients dying in-hospitals ( figure 7) . the mean number of diseases was 3.3 (median 3, sd 1.9). overall, 4.0% of the reported cases has no co-morbidities, 14.0% with a single comorbidity, 20.6% with 2 and 61.4% with 3 or more (https://www.epicentro.iss.it/coronavirus/sars-cov-2). sars-cov-2 infections revealed some unique clinical characteristics that include targeting the lower airway which is evident by symptoms of upper respiratory tract including rhinorrhoea, sneezing and sore throat [78] . chest computed tomography (ct) scans revealed pneumonia in most sars-cov-2 infected patients and several cases showed an infiltrate in the upper lung lobe, which is related to increasing dyspnea with hypoxemia [28, 78, 112] . table 4 describes the full picture of covid-19 clinical manifestation. atypical symptoms include rnaemia, acute cardiac injury, ards and grand-glass opacities that lead to death [113] . it should be noted that covid-19 manifestations such as fever, dyspnea, dry cough and bilateral ground-glass opacities in chest ct scans are similar to the previous betacoronavirus-related diseases [113, 114] . although gastrointestinal symptoms such as diarrhea were reported in sars-cov-2 infected patients, the similar gastrointestinal distress occurred in only a small percentage of mers-cov or sars-cov patients ( figure 6 ) [78] . it was shown that severe cases were characterized by an increased inflammation due to both systemic and localized immune response activation [78, 115] . higher leukocyte numbers, significantly high blood concentrations of cytokines and chemokines were noted in these cases [28, 78] . hence, it is now accepted that high levels of proinflammatory cytokines could worsen the prognosis [28, 113] . the symptoms of sars-cov-2 infection appear after an incubation period of 1 to 14 days, similar to those of sars-and mers-cov infections (median approximately 5.2 days in different studies) and 95% of patients are likely to experience symptoms within 12.5 days from contact [24, [106] [107] [108] . however, in an asymptomatic carrier the incubation period was 19 days, complicating the challenge to contain the outbreak [109] . the median time between onset of symptoms and dyspnea is 5 days, 7 days for hospitalization and 8 days for acute respiratory distress syndrome (ards) (figure 7 ) [24] (https://www.epicentro.iss.it/coronavirus/sars-cov-2). patients at this stage in intensive care unit (icu) with quarantine facilities may require mechanical ventilation. moreover, bacterial infections can cause a secondary pneumonia [108] . in addition, the period from the beginning of covid-19 symptoms to death varied between 6 and 41 days with an average of 14 days [110] . this period depends on immune system status and the patient's age, being shorter in 70-year-old subjects compared with those younger [78, 110] . in people with compromised immune systems and in elderly patients with underlying health problems, sars-cov-2 is able to infect the lower respiratory tract leading to severe pneumonia [111] . in 25%-30% of patients presenting acute lung injury, shock, ards and acute kidney injury, icu admission was absolutely required [24] . recovery started within the 2nd or 3rd weeks with the median duration of hospitalization of 10 days. the virus appears to be more fatal in individuals with underlying co-morbidities (50%-75% of fatal cases) [24, 111] . available dataset was obtained from italian istituto superiore di sanità (iss) on 34,026 patients dying inhospitals ( figure 7) . the mean number of diseases was 3.3 (median 3, sd 1.9). overall, 4.0% of the reported cases has no co-morbidities, 14.0% with a single comorbidity, 20.6% with 2 and 61.4% with 3 or more (https://www.epicentro.iss.it/coronavirus/sars-cov-2). figure 7 . median times, in days, from the onset of symptoms to death, to hospitalization, from hospitalization to death with and without intensive care unit (icu)-admittance (report based on available data on july 9th, 2020 collected from istituto superiore di sanità, iss). sars-cov-2 infections revealed some unique clinical characteristics that include targeting the lower airway which is evident by symptoms of upper respiratory tract including rhinorrhoea, sneezing and sore throat [78] . chest computed tomography (ct) scans revealed pneumonia in most sars-cov-2 infected patients and several cases showed an infiltrate in the upper lung lobe, which is related to increasing dyspnea with hypoxemia [28, 78, 112] . table 4 describes the full picture of covid-19 clinical manifestation. atypical symptoms include rnaemia, acute cardiac injury, ards and grand-glass opacities that lead to death [113] . it should be noted that covid-19 manifestations figure 7 . median times, in days, from the onset of symptoms to death, to hospitalization, from hospitalization to death with and without intensive care unit (icu)-admittance (report based on available data on july 9th, 2020 collected from istituto superiore di sanità, iss). covid-19 clinical evaluation is focused mainly on epidemiological data, clinical symptoms and clinical and laboratory tests. although the scenario is continually changing, several approaches were selected as standard laboratory methods for covid-19 diagnosis. lab tests, differently from clinical-based analyses, immediately reveal sars-cov-2 infected patients. this was particularly important for diagnosis due to the difficulties in detecting specific clinical signs and symptoms in covid-19 patients. moreover, atypical manifestations revealed by pulmonary imaging [116] and the huge number of different clinical signs and symptoms forced the development of molecular-based laboratory tests [117, 118] . lastly, the analysis of personal history of each patient played a fundamental role in covid-19 diagnosis and up to now is considered one of the key information for detecting infected patients also in the early phases of infection. therefore, the epidemiological history together with clinical and laboratory tests are all required for the diagnosis of covid-19. a detailed description focused on clinical diagnostic methods was reviewed by taisheng li [119] . herein, we present an updated overview of the principal techniques used for covid-19 diagnosis. high-throughput sequencing and real time quantitative polymerase chain reaction (rt-qpcr) are the best nucleic acid detection techniques for sars-cov-2. however, in clinical diagnosis, the application of high-throughput sequencing technology is limited due to high cost and its equipment dependency [114, 120, 121] . moreover, to speed up the development of standardized analytic kits for diagnostic application, the quantification of viral load was not considered. therefore, the rt-pcr method was chosen as the gold standard for the detection of sars-cov-2 infections from the commonly used samples such as naso-and oropharyngeal swabs [106, 107, 121, 122] . this molecular method relies on the amplification of up to three sars-cov-2 specific targets including the rna-dependent rna polymerase (rdrp), e and n genes [121] . the who has released numerous rt-pcr protocols for the detection of sars-cov-2 rna at https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/laboratory-guidance (accessed march 15, 2020). three of those protocols are mentioned below. the us centers for disease control and prevention (cdc) developed an rt-pcr that includes three sets of oligonucleotide primers and probes recognizing three regions of the virus n gene (named n1, n2 and n3) and an additional primer/probe set to detect the human rnase p gene (rp) representing an internal control for rna extraction and retro-transcription. moreover, the positive control consisting in retro-transcribed viral rna is also available at cdc. to report the positivity for sars-cov-2 two out of three n regions must be positive. the chinese center for disease control and prevention (china cdc) recommends the use of specific primers and probes targeting the orf1ab and n gene regions for sars-cov-2 detection by rt-pcr [123] . the positivity is confirmed when both targets are detected. available online: http://ivdc.chinacdc.cn/kyjz/202001/t20200121_211337.html (accessed on 21 january 2020). overall, the who summarized all the primer pairs and probes that can be used to detect sars-cov-2 in clinical specimens with the description of rt-pcr settings and the specificity. apart from the possibility to perform the rt-pcr in house using the selected primer pairs and probes, several ready to use kits were developed for rt-pcr performing. one of the most used is the allplex 2019-ncov (seegene, seoul, south korea) which includes three different viral targets and a positive control [124] . another example is represented by the bgi's real-time fluorescent rt-pcr kit for detecting sars-cov-2 that includes one sars-cov-2 specific target and an internal control of the reaction (bgi, cambridge, ma, usa). both companies declared a sensibility of 100-150 viral copies per ml and a high specificity that excludes most respiratory tract viral and bacterial pathogens. the recommended samples for both in-house and ready-to-use rt-pcr kits include upper and lower respiratory specimens such as throat, nasal nasopharyngeal (np) and/or oropharyngeal (op) swabs, lower respiratory tract aspirates, sputum, bronchoalveolar lavage (bal) fluid and nasopharyngeal wash/aspirate or nasal aspirate. it was observed that samples of the lower respiratory tract provide the higher viral loads [74] . on the other hand, it was shown that in the early stage of infection, the positive rate of rt-pcr was reported to be about 60% for throat swab samples [125] . indeed, although being the gold standard, the rt-pcr presents some drawbacks. one of the most important is related to the sensibility because it was extensively reported that in the presence of low viral load this technique fails in detecting viral genome leading to false negative results [126] . due to this problem, clinical governance as well as kit troubleshooting indicate to retest all the samples showing only single positive target along with patient resampling. to this respect, it should be underlined that operator skills or sampling sources can profoundly affect rt-pcr testing results [22] . finally, during this pandemic several microbiologic labs worldwide are experiencing scarce availability of rna extraction as well as ready-to-use rt-pcr kits increasing the timing of diagnosis confirmation through molecular approaches. very recently, it was reported that the allplex 2019-ncov and the realstar sars-cov-2 rt-pcr kits can amplify the target genes bypassing the rna extraction step for a faster diagnosis [127] . although rt-pcr is specific for the diagnosis of covid-19, its false-negative rate cannot be overlooked due to the severe consequences of missed diagnosis. clinicians have demonstrated the usefulness of ct and chest radiography for the diagnosis of covid-19 associated pneumonia [128] . moreover, the ability of radiologists to diagnose covid-19 pneumonia from chest ct evaluations has been reported to be very high [129] . then a combination between rt-pcr and ct imaging represents the best approach for the correct covid-19 diagnosis. in particular, for early detection and assessment of disease severity, the high-resolution ct (hrct) of the chest is considered necessary [130, 131] . one study analyzed the consistency and diagnostic value of rt-pcr test compared with chest ct in 1014 patients with suspected sars-cov-2 infection. findings indicated that the chest ct sensitivity in suspected patients was 75% based on negative rt-pcr results and 97% based on positive rt-pcr results [132] . moreover, salehi et al. confirmed the higher sensibility of pulmonary imaging with respect to rt-pcr for covid-19 diagnosis and showed a positive correlation between specific ct findings with the different stages of the disease and its severity [116] . the collection of numerous ct images has opened the possibility to build a database of pulmonary images from covid-19 patients. interestingly, the recent progress in integrating artificial intelligence (ai) with computer-aided design (cad) software for diagnostic imaging revealed that ai could be used to support disease diagnosis [133, 134] . ito et al. reviewed the literature on the use of ai for lung diagnostic imaging of covid-19 patients. among the 15 selected studies, 11 used ai for ct and 4 used ai for chest radiography. the number of datasets ranged from 106 to 5941, with sensitivities ranging from 67-100% and specificities ranging from 81-100% for prediction of covid-19 pneumonia. this study revealed the usefulness of ai approach to support the diagnosis of covid-19, but also for future emerging diseases [134] . all the collected knowledge on lung lesions revealed some characteristic ct findings of covid-19 pneumonia: the pulmonary ground-glass opacities in a peripheral distribution and the consolidation referring to an increase in pulmonary parenchymal density [135] [136] [137] . however, chest ct manifestations can vary in different patients and stages of infection, highlighting certain shortcomings of this approach. apart from atypical manifestation that cannot be recognized by radiologists, several lung images are common in viral pneumonia leading to misdiagnosis [138] . soon after the beginning of sars-cov-2 spreading, infected patients underwent antibody research for both basic research and clinical applications. one of the first studies reported the seroconversion of 100% of infected patients (n = 285) within 19 days after symptom onset. seroconversion for igm and igg occurred simultaneously or sequentially and both immunoglobulins titers plateaued within 6 days after seroconversion. importantly, the application of serology testing in surveillance in a cluster of 164 close contacts of covid-19 patients identified 4.6% of positive patients showing negative rt-pcr results [139] . hence, several studies underlined the recommended usage of serology to promote the detection of sars-cov-2 infections where np swab specimens were improperly collected, molecular assays were unsatisfactorily carried out and for determining asymptomatic infections [122] . based on these data, several companies developed kits for igm/igg testing showing a high detection rate of infected patients. basically, there are two different testing methods: the rapid igg-igm test and the classical enzyme-linked immunosorbent assay (elisa)-based test. the rapid test consists in a lateral flow qualitative immunoassay on a strip to detect the presence of both anti-sars-cov-2-igm and anti-sars-cov-2-igg in human specimens such as whole blood, serum and plasma. this igg-and igm-combined antibody test kit has a sensitivity of 88.66% and specificity of 90.63%. results are obtained in 15 min leading to its useful application as point-of-care testing and in supporting rt-pcr-based diagnostic [140] . on the other hand, several elisa-based kits are now commercially available, and their sensitivity and specificity were compared showing an overall high specificity, but a variable sensibility [141] . differently from the rapid tests, the elisa-based test should be performed on serum or plasma samples collected from venous sampling. interestingly, the authors showed the neutralizing capacity of sars-cov-2 specific antibodies on caco-2 cells directly incubating the sera from patients with the cell monolayers [141] . this assay is extremely important for the plasma-based therapies that are successfully used to treat seriously ill patients (see below). finally, recently published papers described the seroconversion of covid-19 patients including the evaluation of iga that seems high in the early stages of infection (about 4 days' post symptom development) [142, 143] . another interesting application of antibody detection is represented by the fluorescence immuno-chromatographic assay for the detection of sars-cov-2 nucleocapsid protein in human specimens such as np swab [144] . it shows the fastness of rapid tests (results in 10 min), the possibility to use the same type of sample that is commonly used for rt-pcr-based diagnosis and high sensibility (detection of the nucleoprotein in all positive samples tested). although these methods were suggested for covid-19 diagnosis, the extent of antibodies production by infected patients is greatly variable. moreover, the delay of antibodies production with respect to the onset of symptoms affects the use of this approach for diagnosis. vice versa, it is reported that several governments, included italy, are using serologic test for population screening to assess the proportion of people that have developed an immunological response against sars-cov-2 (http://www.salute.gov.it/portale/nuovocoronavirus). this screening will help also to detect asymptomatic and/or paucisymptomatic subjects. the rapid spread of sars-cov-2 raises an urgent requirement for effective therapeutic strategies against covid-19. although many efforts have been intended to develop vaccines against hcovs infections in recent years, there is no official and effective treatment against sars-cov-2. however, different considerable options have been applied for possible vaccine validity, efficacy and safety along with speeding up other ongoing searches to discover valuable modalities for dealing with the emerging covid-19 [12, [145] [146] [147] [148] . most of the drugs that are being used to cope with covid-19 epidemic are directed towards specific viral molecular targets and biologic processes through which the virus spreads damaging the host. in line, all available experimental therapies for covid-19 management are based on previous experiences in treating sars-cov and mers-cov infections, such as inhibitors of sars-cov-2 fusion/entry/replication, anti-viral agents against main viral proteases, regulators of sars-cov-2 induced host inflammatory response and direct administration of human monoclonal antibodies (mabs) (figure 8 ) [149] . apart from all these possible therapeutic approaches, it has been reported that the chinese medicine products, as lianhuaqingwen and shufeng jiedu capsules may be helpful for sars-cov-2 treatment [12, 150] . indeed, this product is mainly used to treat upper respiratory tract infections such as the flu, swelling and pain in the throat, mumps and strep throat [151, 152] . moreover, four covid-19 cases have been described to gain improvement after taking combined chinese and western medicine [153] . notably, encouraging progress in deciphering sars-cov-2 genome will lead to new potential therapeutic targets. likewise, more prospective, rigorous population studies are urgently required to confirm the therapeutic effect as well as the safety of new potential therapeutic strategies in order to further implement robust preventive and control measures against sars-cov-2 spread. as outlined above, multiple strategies are aimed at developing covs vaccines, most of which are headed for the surface-exposed spike (s protein) glycoprotein as the major virus-host cell membrane interactor. to this aim, vaccines under study are based on full-length s protein, s1-rbd, expression of virus-like particles (vlp), dna or viral vectors [42, [154] [155] [156] [157] [158] . as outlined above, the s1 includes the rbd that interacts with its host cell receptor, ace2, whereas the s2 mediates fusion between the virus and host cell membranes promoting the entry and subsequent replication of the viral rna into the cytoplasm [158] . the ace2 receptor, as a specific biologic target for vaccine development, is under study in a controlled pilot clinical trial to investigate the effect of recombinant human ace2 (rhace2; gsk2586881) in patients with severe covid-19 (nct04287686) ( figure 8i ) [159, 160] . vice versa, both recombinant proteins containing rbd and the recombinant vectors encoding rbd can be used to generate the effective sars-cov vaccines given the capability of this domain to induce neutralizing antibody [156] . indeed, the first available sars-cov-specific human monoclonal antibody with neutralizing activity against sars-cov, named cr3022, was found to bind potently to sars-cov-2 rbd, in agreement with the high homology shared by this domain with sars-cov homolog [161] . however, it must be taken into account that more than 85% of the rbd antibody epitopes in sars-cov-2 show implicit noticeable changes, indicating the necessity to develop more specific monoclonal antibodies for sars-cov-2 [162] . angiotensin receptor blockers (arbs), such as losartan, valsartan, telmisartan, usually assumed for treating high blood pressure, heart and kidney failure in people with diabetes, have been recently proposed as a novel therapeutic approach to block sars-cov-2 rbd binding to ace2-expressing cells binding, similarly to ace inhibitors [163] . additional targetable epitopes that should be considered are the heptad repeat 1 (hr1) and heptad repeat 2 (hr2) in sars-cov-2 s protein. in fact, the hr2-derived peptides (hr2p) and ek1 (a modified oc43-hr2p peptide), exhibit effective fusion inhibitory activity towards sars-cov-2, suggesting a promising strategy in treating sars-cov-2 infection, although further studies are required to strengthen these hypotheses ( figure 8i ) [164, 165] . lately, immuno-informatics have been employed to identify significant cytotoxic t lymphocyte (ctl) and b-cell epitopes in sars-cov-2 s protein, such as the nucleocapsid (n) protein as well as the potential b cell epitopes of the e protein of mers-cov as likely immunoprotective targets [166, 167] . reverse genetic strategies have been successfully used in live-attenuated vaccines to inactivate the exonuclease effects of non-structural protein 14 (nsp14) or to wipe out the envelope protein in sars [154] . a recent study also revealed that the invasion process requires the priming of the s protein which is facilitated by the host cell produced serine protease tmprss211. the clinically demonstrated serine protease tmprss2 inhibitor camostat mesylate, which partially blocks sars-cov-2 entry into host cells, was shown to be a good target to significantly reduce pulmonary infection in covid-19 affected individuals ( figure 8i ) [168] moreover, it has been suggested that coronavirus entry also involves ph and receptor-dependent endocytosis [169, 170] ; thus, targeting endocytosis may be another assessable option for fighting sars-cov-2 ( figure 8i ). in this view, throughout ai technology, a group of approved drugs, such as the janus kinase (jak) inhibitor baricitinib [171] targeting the ap-2-associated protein kinase 1 (aak1) regulating clathrin-mediated endocytosis, has been developed ( figure 8i ) [172] . furthermore, other drugs such as arbidol (chictr2000029621), a haemagglutinin inhibitor and chloroquine phosphate, a traditional antimalarial drug, have been added to the national health commission of the people's republic of china (nhc) guidelines for covid-19 treatment ( figure 8i ) (http://www.nhc.gov.cn). in particular, in vitro studies have demonstrated that chloroquine as well as hydroxychloroquine could impair the endosome-mediated viral entry or later stages of viral replication [173] . combination of hydroxychloroquine and azithromycin has also been suggested as a valid approach since it showed more rapid resolution of infection than hydroxychloroquine alone [174] ; however, the combined use of azithromycin and hydroxychloroquine seems to be associated with at increased risk of arrhythmias. available online: https://www.acc.org/latest-in-cardiology/articles/2020/03/27/14/00/ventricular-arrhythmia-riskdue-to-hydroxychloroquine-azithromycin-treatment-for-covid-19 (accessed on 29 march 2020). to date, several attempts have also been made in targeting viral main enzymes; in fact, many inhibitory drugs targeting the coronavirus main proteinase 3c-like protease (3clpro) have been validated in clinical trials (e.g., lopinavir/ritonavir; chictr2000029387, chictr2000029468, chictr2000029539) ( figure 8ii ) [175] . moreover, four additional molecules including prulifloxacin, tegobuvir, bictegravir and nelfinavir, detected by high-throughput screening, showed reasonable binding conformations with the viral main protease [176] . moreover, a recent study by performing a virtual screening using a three-dimensional model of the sars-cov-2 3c-like protease (3cl), identified 16 biologic candidates that deserve further consideration. among these, the antivirals ledipasvir or velpatasvir proved to be particularly attracting as therapeutics to combat the new coronavirus showing optimal anti-viral activity and minimal side effects, such as fatigue and headache; also, epclusa (velpatasvir/sofosbuvir) and harvoni (ledipasvir/sofosbuvir) are promising antivirals, not only for their effective and synergic inhibitory activities against two viral enzymes, but also for their minimized possibilities to develop resistance [177] . a certain number of clinical trials on antiviral drugs aimed to arrest sars-cov-2 replication are currently in progress, such as remdesivir (nct04252664, nct04257656) favipiravir (chictr2000029600, chictr2000029544) and asc09 (chictr2000029603) ( figure 8iii ). among these, remdesivir was recently approved for medical use in america and european union and seems to be the most promising antiviral for fighting sars-cov-2 [178] (http://www.who.int), as in vitro studies demonstrated that this molecule, a mono-phosphoramidate prodrug of an adenosine, effectively inhibited sars-cov-2 rna synthesis [179] . targeting the sars-cov-2 rna genome could, therefore, be another potential strategy. in fact, a crispr/cas13d technology, which is an rna-guided rna-targeting crispr system, has been employed to specifically chew up sars-cov-2 rna genome. in this system, a cas13d protein and guide rnas-containing spacer sequences are used to specifically complement the virus rna genome ( figure 8iv ). furthermore, rna genome can be packaged into one adeno-associated virus (aav) vector, making the crispr/cas13d system more efficient for virus elimination and resistance prevention, taking into account that aav has serotypes highly specific to the lung, the main organ infected by sars-cov-2 [180] . in addition to antiviral therapy, a new treatment strategy having a significant impact on clinical outcomes is utmost required. immunomodulatory therapy to downregulate the cytokine storm may provide great benefit to the treatment of covid-19. recently, researchers focused on targeting specific molecular markers involved in inflammatory cytokines-receptors interactions, their correlation in health and disease and drugs in use that can activate or block their actions. a higher concentration of cytokines has been found in the plasma from covid-19 patients in icu compared with the ones from non-icu covid-19 patients, suggesting that the cytokine storm could be linked to the severity of the disease [113] . corticosteroids are among the most commonly used drugs for immunomodulatory therapy of infectious diseases. however, the use of corticosteroids in the treatment of covid-19 can cause host immune suppression and delay of viral clearance. a recent study on 201 patients with ards showed that treatment with methylprednisolone decreased the risk of death (hazard ratio 0.38, 95% confidence interval 0.20-0.72). these findings indicate that using corticosteroids does not influence viral clearance time, length of hospital stays or duration of symptoms in patients with mild covid-19 [181] . thus, the use of corticosteroids is considered beneficial in severe cases of covid-19 (especially in patients with ards), but not in mild cases. accordingly, a recent retrospective study showed the potential benefits from low-dose corticosteroids treatment in a subset of critically sars-cov-2 patients [182] ; these data are in contrast with nhc guidelines that highlight that systematic use of corticosteroids is not recommended for these cases, due to their immunosuppressive effects. however, administration of corticosteroids has been indicated for specific reasons such as exacerbation of asthma or chronic obstructive pulmonary disease (copd), septic shock or severe acute respiratory distress syndrome (ards). further studies are required to find out how and when it is appropriate the use of corticosteroids for covid-19, as there are no available data on the benefits of corticosteroid treatment in sars-cov or mers infection [183] . apart from corticosteroids, il-6 pathway inhibitors such as sarilumab, siltuximab and tocilizumab have been proposed as experimental approach considering the increased il-6 levels that have been observed in patients with severe covid-19 [184] . tocilizumab is a recombinant, humanized monoclonal antibody commonly used for treating patients with rheumatoid arthritis, lupus and psoriasis that binds to il-6 receptors blocking fcr activation; in covid-19 patients, tocilizumab could reduce sars-cov-2-induced inflammatory responses [185] . accordingly, several case reports have referred positive outcomes regarding tocilizumab [113, [186] [187] [188] [189] [190] , but clinical impact of tocilizumab on covid-19 patients as an approved clinical approach has not been evaluated yet. in line, to further investigate the efficacy and safety of tocilizumab in patients with covid-19, a controlled clinical trial is now under way (chictr2000029765) ( figure 8v ). overall, the combination of an immunomodulatory agent to reduce the cytokine storm with an antiviral agent may give physicians more time to provide supportive treatment for patients with covid-19. at the time of writing this review, due to the lack of a specific available therapy, plasma from convalescent patients containing specific antibodies has been proposed as a principal treatment [190, 191] , for patients in rapid disease progression, severe or critical conditions ( figure 8vi ). in a recent retrospective study, one dose (200 ml) of convalescent plasma (cp) collected from 10 severe adult cases has been reported to be tolerated; thus, increasing or maintaining high level of neutralizing antibodies broke down the viral load in seven days, improve clinical symptoms and paraclinical criteria within three days and lung lesions were found to be differently absorbed on radiological examination within seven days [192] . therefore, being cp a promising rescue option for severe covid-19, several clinical trials (chictr2000030010, chictr2000030179, and chictr2000030381) are in progress to investigate the efficacy and safeness of cp direct infusion in covid-19 patients [191] . in addition, combined therapy with mabs and remdesivir seems to be an ideal therapeutic option for covid-19 [193] . pharmaceuticals companies are now focused on searching for specific and effective mabs against covid-19. taking into account that technologies capable of making fully human antibodies such as human single-chain antibody variable fragments (hu-scfvs) or humanized-nanobodies (single-domain antibodies, sdab) able to overpass virus-infected cell membranes (trans bodies) and to interact or interpose with biologic processes required for virus replication are already available [194] . a large number of clinical trials regarding cell-based therapies have been started in china during covid-19 outbreak. among these, mesenchymal stromal cells (mscs)-based therapy displayed strong safety profile and possible efficacy in patients with ards, according to covid-19-related clinical studies listed on the who's international clinical trials registry platform (who ictrp) and national institutes of health's clinical trials.gov databases [195] . nevertheless, further investigations are required to better understand if these therapies could be effective in treating respiratory virus-induced complications. mscs have been largely employed in basic research and clinical trials [196] [197] [198] , and their safeness and effectiveness have been extensively documented especially in immune-mediated inflammatory disorders, such as graft-versus-host disease (gvhd) [199] and systemic lupus erythematosus (sle) [200] . mscs immunomodulatory and differentiation abilities [201] as well as their competency to produce several cytokine types or to directly interact with immune cells have been already described [202] . indeed, they are activated by pathogen-associated molecules (pamps) such as single or double-stranded rnas [203, 204] , priming the immune response during infections. two clinical investigations of systemic msc administration in patients with either covid-19 or avian influenza a (h7n9) have been recently published [205, 206] . the first one, a single-center msc transplantation pilot study, was aimed at exploring mscs therapeutic potentiality in patients with covid-19 pneumonia and conducted at the you'an hospital in beijing, china, from 23 jan 2020 to 16 feb 2020 (chictr2000029990). seven patients with covid-19 pneumonia, sars-cov-2 rna positive, with different degrees of severity, including one critically ill requiring icu care were enrolled and monitored for 14 days after msc injection. a significant improvement of pulmonary function and symptoms were observed two days after msc transplantation characterized by an increase of peripheral lymphocytes and of the anti-inflammatory il-10 levels and a decrease of the c-reactive protein and tnf-α amounts [205] . moreover, an increment of the cd14 + cd11c + cd11b mid regulatory dendritic cell (dc) population and a decrease of cytokine-secreting immune cells such as cxcr3 + cd4 + t cells, cxcr3 + cd8 + t cells, and cxcr3 + nk were detected within 3-6 days in the treated patients compared to the placebo control group [205] . mscs play a role in attenuating cytokine storm, most importantly, because these cells do not express ace2 and tmprss2 viral receptors are insusceptible of sars-cov-2 infection. these observations are in agreement with the knowledge that mscs induce the maturation of dendritic cells into a novel jagged-2-dependent regulatory dendritic cell population [207] , shifting the th1/th2 balance towards th2. thus, from these preliminary results, it seems evident that mscs intravenous transplantation could represent a secure and effective treatment in patients with covid-19 pneumonia, especially those critical. indeed, it inhibits the over activation of the immune system and promotes endogenous repair by preventing pulmonary fibrosis and improving both pulmonary microenvironment and lung function [205] . more than 15 potential vaccine candidates for covid-19 are under development around the world, including inactivated, recombinant subunits, nucleic-acid-based, adenoviral vector, and recombinant influenza viral vector vaccines [208] . moreover, taking into consideration the strong homologies existing among the various coronavirus strains, it was thought that vaccines acting on other coronaviruses, such the avian live ibv vaccine (strain h) directed towards the chicken cov ibv, could be a valuable alternative therapeutic strategy [209] . the coalition for epidemic preparedness innovations (cepi) recently announced that three programs aimed to develop covid-19 vaccines, by utilizing established vaccine platforms, have started [210] . in addition, cepi already financed the company moderna, inc. to compare mrna therapeutics and vaccines, allowing the release of the first batch of mrna-1273 in february 2020, which is an mrna vaccine against sars-cov-2 ready for phase i study in the united states. available online: https://investors.modernatx.com/news-releases/news-release-details/moderna-ships-mrnavaccine-against-novel-coronavirus-mrna-1273 (accessed on 24 february 2020). more recently, scientists from the university of pittsburgh have announced a potential vaccine against sars-cov-2, delivered throughout a fingertip-sized patch, capable of producing sars-cov-2 specific igg antibodies, sufficient for virus neutralization in mice. this vaccine, called pittcovacc (acronym of pittsburgh coronavirus vaccine), is a trimeric recombinant sars-cov-2-s1 subunit vaccine delivered intracutaneously by microneedle arrays (mnas) [211] . delivering vaccine components to a defined skin microenvironment improves safety by reducing systemic exposure, allowing to reach high vaccine concentrations with a relatively low dose of antigen [212, 213] . furthermore, the skin delivery strategy promotes strong and long-lasting antigen-specific antibody responses due to both the high immunogenicity [214] [215] [216] [217] [218] and the redundant immunoregulatory circuits of the skin [217, 219, 220] . given the urgent need for covid-19 vaccines, mnas strategy seems to be a promising immunization approach against coronavirus infection including sars, mers and other emerging infectious diseases. on april 24, the oxford chadox1 ncov-19 vaccine was the first in europe to start human trial stage, with 1110 healthy volunteers enrolled for the tests. oxford scientists have already employed chadox1 in the past to dispense vaccines against ebola, chikungunya, rift valley fever and, above all, mers. chadox1, a chimpanzee-derived adenovirus vector, has been employed to deliver the full-length mers spike gene and shown to induce large amounts of neutralizing antibodies against mers in a mouse model [221, 222] . therefore, the modified chadox1 vaccine, carrying the sars-cov-2 spike gene is under human trial stage. on april 30, the university of oxford has announced a collaboration with the uk-based global biopharmaceutical company astrazeneca for further development, large-scale production and potential delivery of the covid-19 vaccine candidate. available online: https://www. ovg.ox.ac.uk/news/landmark-partnership-announced-for-development-of-covid-19-vaccine (accessed on 30 april 2020). since chadox technology is already available and formerly tested in humans for other vaccines, phase iii will consist in administering vaccine to volunteers following them into their regular environments to ensure that these subjects actually become immune to the disease up to three years. if trials succeed, oxford researchers have proposed to complete testing throughout ring vaccination, namely delivering vaccine to members of the first circle of contacts of covid-19 positive people and then to evaluate if the virus spreads to the second circle, as was previously done during the 2018 ebola epidemic in the democratic republic of the congo. to be a promising immunization approach against coronavirus infection including sars, mers and other emerging infectious diseases. on april 24, the oxford chadox1 ncov-19 vaccine was the first in europe to start human trial stage, with 1110 healthy volunteers enrolled for the tests. oxford scientists have already employed chadox1 in the past to dispense vaccines against ebola, chikungunya, rift valley fever and, above all, mers. chadox1, a chimpanzee-derived adenovirus vector, has been employed to deliver the full-length mers spike gene and shown to induce large amounts of neutralizing antibodies against mers in a mouse model [221, 222] . therefore, the modified chadox1 vaccine, carrying the sars-cov-2 spike gene is under human trial stage. on april 30, the university of oxford has announced a collaboration with the uk-based global biopharmaceutical company astrazeneca for further development, large-scale production and potential delivery of the covid-19 vaccine candidate. available online: https://www.ovg.ox.ac.uk/news/landmark-partnership-announced-fordevelopment-of-covid-19-vaccine (accessed on 30 april 2020). since chadox technology is already available and formerly tested in humans for other vaccines, phase iii will consist in administering vaccine to volunteers following them into their regular environments to ensure that these subjects actually become immune to the disease up to three years. if trials succeed, oxford researchers have proposed to complete testing throughout ring vaccination, namely delivering vaccine to members of the first circle of contacts of covid-19 positive people and then to evaluate if the virus spreads to the second circle, as was previously done during the 2018 ebola epidemic in the democratic republic of the congo. figure 8 . schematic representation of sars-cov-2 infection and virus-induced human immune system response. proposed drugs directed both towards specific sars-cov-2 molecular targets and biologic processes are highlighted: inhibitors of sars-cov-2 fusion/entry targeting ace2 receptor, spike protein, tmprss2 or hr1 and hr2 epitopes and clathrin-mediated endocytosis (i); molecules against sars-cov-2 main protease (ii); molecules against viral genome replication (iii); crispr figure 8 . schematic representation of sars-cov-2 infection and virus-induced human immune system response. proposed drugs directed both towards specific sars-cov-2 molecular targets and biologic processes are highlighted: inhibitors of sars-cov-2 fusion/entry targeting ace2 receptor, spike protein, tmprss2 or hr1 and hr2 epitopes and clathrin-mediated endocytosis (i); molecules against sars-cov-2 main protease (ii); molecules against viral genome replication (iii); crispr technologies targeting sars-cov-2 rna genome (iv); modulators of sars-cov-2 induced inflammatory response (v) and human neutralizing antibodies (vi). ace2, angiotensin-converting enzyme 2; tmprss2, type 2 transmembrane serine proteases; rdrp, rna-dependent rna polymerase; hr1, heptad repeat 1; hr2, heptad repeat 2; hr2p, heptad repeat 2-derived peptides; ek1, a modified oc43-hr2p peptide. adapted from [223] . overall, a joint effort headed to apply both already consolidate and innovative approaches, such as ai to facilitate drug discovery, will be required to develop a broad-spectrum antiviral drugs and vaccines towards existing and potential future coronavirus infections to prevent another highly pathogenic virus epidemic. moreover, continuous collaboration in basic and clinical studies will improve the discovery of new antiviral drugs with therapeutic potentials, decrease the time for drug release on the market and make them affordable for all countries. furthermore, vaccine delivery strategies and cell-based therapies benefit from the significant progresses made by recombinant dna technologies combined with emerging biotechnology and bioengineering methodologies. thus, these approaches can speed up the development and set up of new vaccines and clinical therapies to fight against novel pathogens to protect public health all over the world. this study represents a holistic picture of the current investigations in response to the outbreak of covid-19. the current pandemic is obviously an international public health problem and it remains a challenging task to fight the sars-cov-2 of unknown origin and mysterious biologic features. lesson from the previous two pandemics, mers and sars outbreaks, provide valuable insights about how to manage the current pandemic and provide a reference for future studies to combat disease progression. despite sars-cov-2 rapid transmission, the scale up country readiness, speedy response teams and the capacity of all laboratories are reducing the spread of the virus as well as its mortality rate. as the pandemic is still ongoing and expanding, further studies on all aspects of the disease are needed to better understand the infection, beneficial treatments and development of vaccines. nevertheless, this pandemic, together with the previous ones, have taught us in the harshest possible way that the entire scientific community must be vigilant and ready to advice appropriate containment and screening measures to avoid the spread of any future emerging pathogen. we would like to acknowledge majidi nezhad for providing the meteorological data and climate analyses and gaia scoarughi and adeleh salehi for drawing figures. the authors declare no conflict of interest. the following abbreviations are used in this manuscript: 16 nonstructural polyproteins (nsps 1-16); 2019 novel coronavirus (2019-ncov); 3-chymotrypsin-like protease (3clpro); 3c-like protease (3cl); acute respiratory distress syndrome (ards); adeno-associated virus (aav); angiotensin receptor blockers (arbs); angiotensin-converting enzyme 2 (ace2); ap-2-associated protein kinase 1 (aak1); artificial intelligence (ai); avian infectious bronchitis virus (ibv); basic reproduction number (r0); blood oxygen saturation (spo2); bronchoalveolar lavage (bal); centers for disease control and prevention (cdc); chinese center for disease control and prevention (china cdc); chronic obstructive pulmonary disease (copd); coalition for epidemic preparedness innovations (cepi); computed tomography (ct); computer-aided design (cad); convalescent plasma (cp); coronavirus (cov); cytotoxic t lymphocyte (ctl); dendritic cell (dc); dipeptidyl peptidase 4 (dpp4, also known as cd26); envelope glycoprotein (e); enzyme-linked immunosorbent assay (elisa); european center for medium-range weather forecasts (ecmwf); european cities (ecs); feline infectious peritonitis (fip); graft versus-host disease (gvhd); hemagglutinin-esterase glycoprotein (he); heptad repeat 1 (hr1) and heptad repeat 2 (hr2); high-resolution ct (hrct); hr2-derived peptides (hr2p); ek1 (a modified oc43-hr2p peptide); human coronaviruses (hcovs); human covs (hcovs); human single-chain antibody variable fragments (hu-scfvs); humanized-nanobodies (single-domain antibodies, sdab); intensive care unit (icu); istituto superiore di sanità (iss); janus kinase (jak); membrane glycoprotein (m); mesenchymal stromal cells (mscs); microneedle arrays (mnas); middle east respiratory syndrome coronavirus (mers-cov); monoclonal antibodies (mabs); naso-pharyngeal (np); national health commission of the people's republic of china (nhc); nonstructural protein 14 (nsp14); northern hemisphere (nh); nucleocapsid phosphoprotein (n); open reading frames (orfs); oro-pharyngeal (op); papain-like protease (plpro); partial pressure of arterial oxygen to fraction of inspired oxygen ratio (pao2/fio2); pathogen-associated molecules (pamps); pittsburgh coronavirus vaccine (pittcovacc); polypeptides (pps); porcine epidemic diarrhea virus (pedv); real time quantitative polymerase chain reaction (rt-qpcr); receptor-binding domain (rbd); recombinant human ace2 (rhace2); replication-transcription complex (rtc); rna-dependent rna polymerase (rdrp); rnase p gene (rp); severe acute respiratory syndrome coronavirus (sars-cov); single-stranded positive-sense rna (+ssrna); southern hemisphere (sh); spike glycoprotein (s); subgenomic rnas (sgrnas); swine acute diarrhea syndrome coronavirus (sads-cov); swine enteric alphacoronaviruses (seacovs); systemic lupus erythematosus (sle); transmissible gastroenteritis virus (tgev); virus-like particles (vlp); who's international clinical trials registry platform (who ictrp); world health organization (who). the emerging novel middle east 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cells and mast cells microneedle patches for vaccination in developing countries organization of the skin immune system and compartmentalized immune responses in infectious diseases neuronal regulation of cutaneous immunity a novel chimpanzee adenovirus vector with low human seroprevalence: improved systems for vector derivation and comparative immunogenicity chadox1 and mva based vaccine candidates against mers-cov elicit neutralising antibodies and cellular immune responses in mice pharmacologic treatments for coronavirus disease 2019 (covid-19): a review key: cord-296312-nh4poc71 authors: kowitt, sarah d.; cornacchione ross, jennifer; jarman, kristen l.; kistler, christine e.; lazard, allison j.; ranney, leah m.; sheeran, paschal; thrasher, james f.; goldstein, adam o. title: tobacco quit intentions and behaviors among cigar smokers in the united states in response to covid-19 date: 2020-07-25 journal: int j environ res public health doi: 10.3390/ijerph17155368 sha: doc_id: 296312 cord_uid: nh4poc71 combustible tobacco users appear to be at greater risk for serious complications from covid-19. this study examined cigar smokers’ perceived risk of covid-19, quit intentions, and behaviors during the current pandemic. we conducted an online study between 23 april 2020 to 7 may 2020, as part of an ongoing study examining perceptions of different health effects of cigars. all participants used cigars in the past 30 days (n = 777). three-quarters of the sample (76.0%) perceived they had a higher risk of complications from covid-19 compared to non-smokers. the majority of participants (70.8%) intended to quit in the next six months due to covid-19, and almost half of the sample (46.5%) reported making a quit attempt since the start of the covid-19 pandemic. far more participants reported increasing their tobacco use since covid-19 started (40.9%) vs. decreasing their tobacco use (17.8%). black or african american participants, participants who reported using a quitline, and participants with higher covid-19 risk perceptions had higher intentions to quit using tobacco due to covid-19, and higher odds of making a quit attempt since covid-19 started. more research is needed to understand how tobacco users are perceiving covid-19 risks and changing their tobacco use behaviors. cigarette, cigar, and other combustible tobacco users appear to be at greater risk for developing serious complications from covid-19 [1] [2] [3] [4] . at least four systematic reviews/meta-analyses have concluded that smoking is associated with adverse outcomes associated with covid-19 and worse disease progression [1] [2] [3] [4] , which aligns with research showing that smokers are at greater risk for contracting and experiencing severe respiratory infections [5, 6] . however, some research has suggested that there are no associations between tobacco use and severity of covid-19 complications, or that using tobacco use may confer protective benefits, such as smokers being at lower risk for contracting covid-19 [7] [8] [9] [10] . while there appear to be substantial limitations to this latter work [11] , more research is needed on how covid-19 is affecting tobacco users, including how they perceive covid-19 risks and how they are altering their intentions and behaviors in response to this new threat. due to the potential negative health outcomes associated with covid-19, it is possible that many tobacco users feel more vulnerable to its health effects and are trying to quit using tobacco-which aligns with both previous research and theory on risk perception [12, 13] . however, it is also possible that some tobacco users are increasing their tobacco use due to stress or anxiety associated with covid-19, which has also been documented in previous research on stress and smoking behavior [14] [15] [16] [17] . one study recently examined smoking behaviors due to covid-19, reporting descriptive changes in smoking in a small, convenience sample [18] . more research is needed examining how tobacco users are perceiving and reacting to covid19 . the goals of this study were to examine cigar smokers' perceived risk of covid-19, quit intentions, and behaviors during the current pandemic. in the united states (us), cigars are one of the most commonly used tobacco products with 7.2% of adults reporting smoking cigars in the past 30 days [19] . while cigars are used less frequently than cigarettes [19] , dual use of cigarettes and cigars is high. research shows that between 30-60% of cigar smokers also smoke cigarettes [20] , and over 30% of cigarette smokers smoke cigars [21] . compared to cigarette smokers, cigar smokers tend to be younger [22] , include more african americans [22] , and use cigars on fewer days per month [23, 24] . we also examined how other correlates were associated with covid-19 quit intentions and behaviors, including demographics, such as age and race, and tobacco use variables, such as other tobacco use and nicotine dependence. we did so because research has found several factors in the us to be associated with risk of acquiring covid-19 and experiencing complications, including race/ethnicity, age, and other comorbidities. specifically, african americans in the us are dying of covid-19 at greater rates than white people, and are experiencing more complications [25] . increasing age and other co-morbid conditions, like types 2 diabetes, also elevate the risk of complications, including death [26, 27] . we recruited participants as part of an ongoing study examining perceptions of different health effects of cigars. specifically, this study presented different text statements about the health effects of cigars (e.g., cigar smoking can cause lung cancer) to participants, and asked them to answer if they were aware of this health effect and how effective it was at discouraging their cigar use. this study will be used to develop effective warnings for little cigar and cigarillo packages. we expanded eligibility to include all cigar users to be more representative of the cigar smoking population. participants were recruited and compensated through qualtrics services-a leader in the field of survey software, deployment, methodology, and consumer research. qualtrics has existing panels that can be used for social science research [28] [29] [30] , and has a survey platform for designing and analyzing online surveys. qualtrics recruited participants for our study, administered the survey that we created, compensated them, and performed an initial cleaning of the data. to be eligible for study participation, adults had to be 18 years or older, speak english, and currently use traditional large cigars, little cigars, or cigarillos (defined as using one of those products in the past 30 days). all participants were located in the us. qualtrics recruited a final sample of 777 participants for our study from 23 april 2020 to 7 may 2020. each survey took participants 12 min on average to complete. the university of north carolina at chapel hill institutional review board approved the study (study number 20-0871). we had two primary outcomes: (1) quit intentions in the next 6 months due to covid-19 (average of three items, adapted from reference [31] ), and (2) whether or not participants made a quit attempt since covid-19 started (adapted from reference [32] ). to assess quit intentions, we asked participants: "how interested are you in quitting smoking in the next 6 months because of covid-19?"; "how much do you plan to quit smoking in the next 6 months because of covid-19?"; and "how likely are you to quit smoking in the next 6 months because of covid-19?". for each of these three items, response options ranged from 1 (e.g., not at all interested) to 4 (e.g., very interested). to assess quit attempts, we asked participants: "since covid-19 started, how many times have you stopped smoking for 1 day or longer because you were trying to quit smoking?". for this item, participants could respond with any number between 0 and 30. we dichotomized responses as no quit attempts (for responses of 0) or at least one quit attempt (responses of 1-30). we adapted the quit intentions and quit attempts items from previously validated measures by adding "covid-19" to the item stems. we also examined change in tobacco use since covid-19 started (newly developed item) in bivariate models but not a multivariable model for reasons described below. for this measure, we asked participants: "since covid-19 started infecting people in the us, would you say that your tobacco use has . . . " with five response options ranging from 1 (increased a lot) to 5 (decreased a lot). we examined several correlates of interest, including participant characteristics, tobacco use variables, and other covid-19 variables. participant characteristics included age, gender, sexual orientation, race, hispanic or latino ethnicity, education, income, and perceived physical and mental health status [33, 34] . to assess perceived physical and mental health, we asked participants: "would you say that in general your physical health is . . . " and "in general, would you say your mental health is . . . " with response options ranging from 1 (poor) to 5 (excellent) [33, 34] . tobacco use variables included other tobacco use [35] and nicotine dependence (using items that assess nicotine dependence for users of multiple tobacco products) [36] . to assess other tobacco use, we asked participants: "in the past 30 days, which of the following products have you used at least once?" [35] . response options included: cigarettes, smokeless tobacco (e.g., chewing tobacco, snuff, dip, or snus), e-cigarettes, and waterpipe tobacco. participants were allowed to select more than one response option. we included e-cigarettes in this measure since e-cigarettes are regulated as a tobacco product in the us. to assess nicotine dependence, we asked participants five questions about potential symptoms of dependence on tobacco products (e.g., "during the past 30 days, have you had a strong craving to use tobacco products of any kind?") [36] . for all five items, participants could respond "yes" (coded as 1) or "no" (coded as 0). finally, the survey assessed covid-19 variables including quitline use since covid-19 started (newly developed item), perceived risk of complications due to covid-19 compared to non-smokers (newly developed item), covid-19 risk perceptions (average of three items, adapted from reference [37] ), and frequency of social distancing efforts (newly developed item). to assess quitline use since covid-19 started, we asked participants: "since covid-19 started, have you called the quitline (national phone number for help to quit smoking)?" participants could respond "yes" (coded as 1) or "no" (coded as 0). to assess perceived risk of complications due to covid-19 compared to non-smokers, we asked participants: "please think about if you were to become infected with the coronavirus. compared to a non-smoker, what impact do you think that your smoking has on your risk of serious health complications, hospitalization, and death from covid-19?". response options ranged from 1 (my smoking gives me a much higher risk of complications from covid-19) to 5 (my smoking gives me a much lower risk of complications from covid-19). to assess covid-19 risk perceptions, we asked participants three items adapted from a validated scale (e.g., how likely is it that you will become infected with covid-19 at some point in the future?) with four response options ranging from 1 (e.g., very unlikely) to 4 (e.g., very likely) [37] . finally, to assess frequency of social distancing efforts, we asked participants: "physical distancing, or social distancing, is the practice of deliberately increasing the physical space between people to avoid spreading illness. how often do you currently practice daily social distancing as a result of covid-19?". response options ranged from 1 (never) to 5 (always). all covid-19 measures are presented in supplementary table s1. we conducted analyses in sas v.9.3 (sas institute, 2011, cary, nc, usa). we first examined bivariate associations with our two outcomes (quit intentions and quit attempts) and all correlates of interest-participant characteristics, tobacco use variables, and other covid-19 variables. we then examined bivariate associations among our two primary outcomes and changes in tobacco use since covid-19 started (i.e., increased use, decreased use, or unchanged use). finally, we examined associations among all correlates and our two primary outcomes in separate multivariable models. as our first outcome-quit intentions-was continuous, we entered all participant characteristic, tobacco use, and covid-19 correlates in a multivariable linear regression model. as our second outcome-quit attempts-was dichotomous, we entered all correlates in a multivariable logistic regression model. we included all correlates in the adjusted multivariate regression models, because we did not have any a-priori hypotheses for which correlates would be associated with our outcomes. while we planned to examine changes in tobacco use as a third outcome in a multivariable, multinomial regression model, we did not run this model due to small cell counts in some of the tobacco use response options. results from the first model include beta coefficients (b) and standard errors (se). if the b is positive, the interpretation is that for every 1-unit increase in the correlate, the outcome variable will increase by the b value. results from the second model include adjusted odds ratios (aor) and 95% confidence intervals (ci). an aor of more than 1 means that there is a higher odds of the outcome happening with exposure to the correlate. an aor of less than 1 means that there is a lower odds of the outcome happening. for all analyses, we set α = 0.05 and used 2-tailed statistical tests. participant characteristics and tobacco use variables are presented in table 1 . the mean age of participants was 39.9 (sd: 13.4), and the majority of the sample was white (66.2%), non-hispanic or latino (84.9%), and straight or heterosexual (87.4%). everyone in the sample was a cigar user and most used other tobacco products, including cigarettes (83.8%), e-cigarettes (37.7%), smokeless tobacco (21.9%), and waterpipe tobacco (13.3%). covid-19 variables are presented in table 2 . three-quarters of the sample perceived that they had a higher risk of complications from covid-19, compared to non-smokers (76.0%). the great majority of respondents (70.8%) reported intentions to quit smoking in the next six months due to covid-19. almost half reported making a quit attempt (46.5%), and 22.9% reported calling a quitline due to covid-19. despite these positive steps, many more participants reported increasing their tobacco use a lot or a little since covid-19 started (40.9%), compared to those that reported decreasing their tobacco use a lot or a little (17.8%). bivariate associations among our two outcomes with changes in tobacco use are presented in table 3 . interestingly, reported quit intention scores (which ranged from 1-4, with higher values indicated more interest in quitting) were higher among people who reported decreasing their tobacco use (2.9, sd: 1.0) and people who reported increasing their tobacco use (2.9, sd: 1.0), compared to people who reported keeping their tobacco use the same (2.2, sd: 1.0) (p < 0.001 for both comparisons). similarly, participants who reported decreasing their tobacco use were more likely to report making a quit attempt (63.0%), and participants who reported increasing their tobacco use were also more likely to report making a quit attempt (57.6%), compared to participants who reported keeping their tobacco use the same (28.4%) (p < 0.001). finally, participants who reported making a quit attempt had higher quit intentions (3.2, sd: 0.8) than participants who did not report making a quit attempt (2.1, sd: 1.0) (p < 0.001). all bivariate associations among correlates of interest and our two outcomes (quit intentions because of covid-19 and quit attempts since covid-19 started) are presented in supplementary tables s2 and s3. black or african american participants had higher quit intentions due to covid-19 (b = 0.25, p = 0.002) and had higher odds of making a quit attempt since covid-19 started (aor: 1.94, 95% ci: 1.26, 2.97), compared to white participants (table 4 ). better mental health status was associated with higher quit intentions due to covid-19 (b = 0.10, p = 0.005). participants who smoked cigars and cigarettes had lower odds of making a quit attempt since covid-19 started (aor: 0.56, 95% ci: 0.34, 0.94), compared to participants who smoked cigars and did not smoke cigarettes. in addition, participants who smoked cigars and used smokeless tobacco had higher odds of making a quit attempt since covid-19 started (aor: 2.42, 95% ci: 1.47, 3.98), compared to participants who smoked cigars and did not use smokeless tobacco. participants who reported calling a quitline had higher quit intentions due to covid-19 (b = 0.47, p < 0.001), and had higher odds of making a quit attempt since covid-19 started (aor: 8.66, 95% ci: 4.89, 15.34), compared to participants who did not report calling a quitline. participants who believed they had a higher risk of complications due to covid-19, compared to non-smokers had higher quit intentions due to covid-19 (b = 0.47, p < 0.001) than participants who believed they had the same risk of complications. in addition, having higher risk perceptions of covid-19 was associated with higher quit intentions due to covid-19 (b = 0.38, p < 0.001) and higher odds of making a quit attempt since covid-19 started (aor: 1.31, 95% ci: 1.04, 1.64). finally, greater social distancing efforts were associated with higher quit intentions due to covid-19 (b = 0.11, p = 0.01). the covid-19 epidemic has negatively impacted millions of people around the globe, particularly those with co-morbid conditions that elevate risk of complications, including death [26] . combustible tobacco use appears to be a major risk factor for worse outcomes if a tobacco user contracts covid-19 [1, 2] . results from our study suggest that most tobacco users correctly perceive themselves to be at higher risk of covid-19 complications, and this risk appears to relate to intentions to quit using tobacco and attempting to quit. this relationship appears even stronger for african americans, who are at an even higher risk of complications and death due to covid-19 [25] . yet, despite this knowledge and these intentions / behaviors, over twice as many tobacco users reported increasing rather than decreasing their tobacco use in our study. these results have implications for practitioners, policy-makers, and public health agencies. for practitioners, out results suggest that their patients who use tobacco have a heightened interest in quitting because of covid-19. each year around two thirds of tobacco users want to quit and make a quit attempt [38, 39] . that the majority of tobacco users in our study, most of whom used multiple tobacco products and displayed multiple symptoms of nicotine dependence, intended to quit and made a quit attempt is important. to translate quit attempts into successful cessation, support for tobacco users should be made available during this time, including increased access to nicotine replacement therapy, virtual support with tobacco treatment counselors, and mental health assistance, particularly since better perceived mental health was associated with increased intentions to quit in our study. tailoring support to sub-groups of tobacco users may also be important. for instance, tobacco users who have increased their tobacco use in response to covid-19 may need additional help with higher dependency, as well as with coping strategies for stress and anxiety. those who have decreased their tobacco use have an even greater chance of successfully quitting with clinician support. tobacco users with higher covid-19 risk perceptions appear to have higher quit intentions and higher odds of making a quit attempt since covid-19 started. however, not all smokers believed that they had a higher or similar risk of covid-19 complications, compared to non-smokers. these findings indicate that clear and consistent messages about risks of covid-19 to tobacco users are needed. importantly, these messages may need to evolve as more data on tobacco use and covid-19 become available. interestingly, we found that more people reported increasing their tobacco use (41%) than decreasing their tobacco use (18%). only one previous study, to our knowledge, has examined how tobacco users have changed their behaviors in response to covid-19 and reported similar results. in this study of 345 dual cigarette and e-cigarette users, 30.3% of participants reported increasing their cigarette use and 29.1% reported increasing their e-cigarette use since learning of covid-19 [18] . extending these findings, we found interesting relationships between changes in tobacco use, quit intentions, and quit attempts since covid-19 started. specifically, quit intentions and odds of making a quit attempt were higher in people who reported decreasing their tobacco use and people with higher covid-19 risk perceptions, which is in line with what is often called the "vulnerability hypothesis". indeed, both theory and research support the idea that as individuals feel more vulnerable to the health effects of smoking, they are more likely to intend to quit smoking, make quit attempts, and successfully quit [12, 13] . however, we also found that people who reported increasing their tobacco use also reported higher quit intentions and had higher odds of making a quit attempt-in line with research on the "stress hypothesis". it is possible that these people want to quit, but are stressed or anxious, and are increasing their tobacco use despite their 'good' intentions. to this point, we did find that better mental health status was associated with higher intentions to quit. in addition, people may be bored or have stockpiled tobacco products before sheltering in place orders, which could have increased their tobacco use. finally, it is also possible that people may want to quit but are not able to easily access evidence-based cessation resources like pharmacotherapy or behavioral support [40] . we also found that over a fifth of participants in our sample reported calling a quitline because of covid-19, and that those who reported calling a quitline had higher quit intentions and attempts. although the majority of us smokers are aware of quitlines [41, 42] , they only reach 1-2% of smokers nationally [43, 44] . however, states have been able to increase quitline reach through targeted efforts. for instance, by adding hours of operation and implementing a cigarette tax, maine was able to reach over 6% of smokers [45] . in addition, the national tobacco education campaign "tips from former smokers (tips)," which tagged many of its ads with 1-800-quit-now, led to 170,000 additional quitline calls over a three-month period [46] . it is possible that characteristics of our study sample-which was comprised of many heavy tobacco users-meant that participants were more likely to want to quit and use available resources to do so. it is also possible that many people answered this question favorably because of a social desirability bias. regardless, our study findings indicate that many tobacco users reported wanting to quit because of covid-19 and reported using a quitline for help. that many participants did not quit, suggests that tobacco quitlines may need more resources and covid-19 specific information to help smokers quit. finally, we identified several characteristics that were associated with covid-19 quit intentions and attempts. for instance, black or african american participants had higher quit intentions and attempts due to covid-19. african americans in the us are dying of covid-19 at greater rates than white people and experiencing higher rates of complications [25] . this may explain why we observed an increased desire to quit smoking among these participants. we also found that people who smoked cigarettes (in addition to cigars) had lower odds of making a quit attempt, compared to people who did not smoke cigarettes, and that people who used smokeless tobacco (in addition to smoking cigars) had higher odds of making a quit attempt, compared to people who did not use smokeless tobacco. it is possible that smokeless tobacco users had higher odds of making a quit attempt, because they do not want to put their fingers in their mouth to use these products. it is also possible that people are substituting some tobacco products with others. for instance, people could be switching to using smokeless tobacco because they are not combustible. further research, especially longitudinal data, are needed to understand how people are changing their patterns of tobacco use in response to covid-19. to our knowledge, we are the first to use and modify previously available measures to apply to covid-19. as tobacco control researchers continue to collect data on tobacco use and covid-19, the items we developed-especially those related to covid-19 specific quit intentions, quit attempts, and perceived risk-can be used. there are several limitations to this study. first, all data were self-reported, which introduces threats of social desirability bias. second, this was a one-time cross-sectional study, which means that we were unable to assess temporality of associations or trends over time. future longitudinal research is needed to understand how covid-19 is changing participants' smoking and quitting behaviors. third, all participants were recruited online and are not representative of the us population or of tobacco users, which means that study findings may not apply to other countries or groups of tobacco users. fourth, since this was a cross-sectional study and there was no possibility of randomizing participants to different exposures, we cannot make any claims of causality. we are careful throughout this article to use language like "correlates" rather than "predictors" and "associated with" rather than "causes." fifth, we created several measures in this study that have not been previously used (e.g., changes in tobacco use since covid-19 started) given the novelty of covid-19 and the rapid research needed to understand it. many tobacco users included in our study perceived that they were at risk higher risk of covid-19 complications, reported intending to quit due to covid-19, and reported making a quit attempt since covid-19 started, however, more tobacco users reported increasing their tobacco use due to covid-19 than decreasing it. more research is needed to understand how tobacco users are perceiving risks of covid-19 and changing their tobacco use behaviors. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/15/5368/s1, table s1 : measures, table s2 : bivariate associations between variables and quit intentions due to covid-19 (higher values indicate higher intentions to quit), table s3 : bivariate associations between variables and whether participants made a quit attempt or not since covid-19 started. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. the impact of copd and smoking history on the severity of covid-19: a systemic review and meta-analysis covid-19 and smoking: a systematic review of the evidence impact of smoking status on disease severity and mortality of hospitalized patients with covid-19 infection: a systematic review and meta-analysis smoking is associated with covid-19 progression: a meta-analysis cigarette smoking and the occurrence 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chih-cheng title: spread of infectious disease modeling and analysis of different factors on spread of infectious disease based on cellular automata date: 2019-11-25 journal: int j environ res public health doi: 10.3390/ijerph16234683 sha: doc_id: 313869 cord_uid: 3x2qf3yu infectious diseases are an important cause of human death. the study of the pathogenesis, spread regularity, and development trend of infectious diseases not only provides a theoretical basis for future research on infectious diseases, but also has practical guiding significance for the prevention and control of their spread. in this paper, a controlled differential equation and an objective function of infectious diseases were established by mathematical modeling. based on cellular automata theory and a compartmental model, the slirds (susceptible-latent-infected-recovered-dead-susceptible) model was constructed, a model which can better reflect the actual infectious process of infectious diseases. considering the spread of disease in different populations, the model combines population density, sex ratio, and age structure to set the evolution rules of the model. finally, on the basis of the slirds model, the complex spread process of pandemic influenza a (h1n1) was simulated. the simulation results are similar to the macroscopic characteristics of pandemic influenza a (h1n1) in real life, thus the accuracy and rationality of the slirds model are confirmed. infectious diseases are diseases that can be transmitted from person to person, from person to animal, or from animal to animal after proto-microorganisms and parasites infect human beings or animals [1] [2] [3] . infectivity, epidemic, and uncertainty are the three main characteristics of infectious diseases. a thorough study of the spread causes, spread routes, spread processes, and epidemic laws of infectious diseases is the main method for effective prevention, control, and elimination of infectious diseases. at present, the mathematical study of infectious diseases is mainly based on the theory and method of infectious disease dynamics [4] [5] [6] . the essence of infectious disease dynamics is to establish a mathematical model that can reflect the spread process, spread law, and spread trend of infectious diseases. its advantage is that, according to the characteristics of infectious diseases, the model of infectious diseases is reasonably assumed, the appropriate parameters are set, and the appropriate variables are selected. then, the dynamic characteristics of infectious diseases can be clearly revealed. it has laid a solid foundation for further analysis of the causes and key factors of the spread of infectious diseases, and for seeking the optimal strategies for the prevention and control of such diseases. the main method to study and forecast the spread mechanism of infectious diseases is to establish mathematical models. some of these are used to study the general laws of infectious diseases, while others are used to study specific infectious diseases, such as hfmd (hand foot and mouth disease), tuberculosis, aids, and so on. in 1760, bernoulli [7] began using mathematical models to study the spread of smallpox by vaccination. in 1906, hamer [8] constructed and analyzed a discrete time model for the study of recurrent measles epidemics. in 1927, kermack and mckendrick [9] proposed the sir (susceptible-infected-recovered) compartmental model for the first time in order to study the epidemic law of the black death prevailing in europe at that time. on the basis of the sir model's analysis, the "threshold theory" was proposed to distinguish the spread or regression of the disease. the validity of the sir model has been proven by the data regarding large-scale infectious diseases in history, thus the deterministic model [10] based on a differential equation has been widely accepted. with the deepening of research, the factors involved in establishing the mathematical model are increasing, and the dimension of the model is also increasing. based on the classical sir model, aron and schwartz [11] proposed the seir(susceptible-exposed-infective-recovered) model in 1984. that model considers that the latency of infectious diseases also has an impact on infectious diseases, so the model is more realistic. focusing on severe acute respiratory syndrome (sars) infectious disease spread in recent years, safi and gumel [12] constructed the seqijr(susceptible-exposed-quarantine-infective-isolation-recovered) model according to the characteristics of sars. small and chi [13] studied the effects of vaccination and isolation on the sars epidemic and constructed the seirp (susceptible-exposed-infective-recovered-persevered) model. in addition, some researchers start with the population structure of infectious disease spread and study the spread model of infectious disease. according to the influence of age on the spread of infectious diseases, boklund et al. [14] proposed a model to better characterize the effect of age heterogeneity on the spread of infectious diseases. according to the difference in population, meng et al. [15] divided the population into different groups, and they proved the global stability of disease-free equilibrium and endemic equilibrium. with the development of artificial intelligence, the network dynamics model has gradually become a new research method of infectious disease model. the most common network dynamics models include the ordinary differential equation model, the discrete differential equation model, the impulsive differential equation model, and the differential equation model with time delay. the main methods are finite equation theory, matrix theory, bifurcation theory, k-order monotone system theory, central manifold theory, lasalle invariant principle, etc. however, these research methods are all theoretical studies on infectious diseases, but it is difficult to apply them to practical problems. the concept of cellular automata was proposed in the 1940s. cellular automata can be described as a dynamic system consisting of a transformation function in cellular space, which is discrete in time and space. the cellular automata model can be formally expressed as ca = (l c , s, m, f ), where ca represents the cellular automaton system, l c represents the mesh space which is divided according to given rules, a mesh corresponding to a cell of cellular automata, s represents the set of cell states, m = (c 1 , c 2 , . . . , c n ) represents the set of current cell adjacent to cells, and f represents the transformation function which can transform c n to c, the function that can calculate the state of cell c at t + 1 time according to the state of adjacent cells of cell c at t time. adjacent cells are moore neighbors with radius = 1. as shown in figure 1 , cells can move in eight directions. misra et al. [16] gave a comprehensive introduction to the theory and application of cellular automata. since the 1990s, epidemic spread models based on cellular automata [17] [18] [19] [20] have been extensively studied. according to the characteristics and mechanism of aids, pan et al. [21] proposed a spread model of aids based on cellular automata. lópez et al. [22] proposed an epidemic spread misra et al. [16] gave a comprehensive introduction to the theory and application of cellular automata. since the 1990s, epidemic spread models based on cellular automata [17] [18] [19] [20] have been extensively studied. according to the characteristics and mechanism of aids, pan et al. [21] proposed a spread model of aids based on cellular automata. lópez et al. [22] proposed an epidemic spread model based on cellular automata that considers individual heterogeneity, population mobility ratio, and individual maximum moving distance. because cellular automata can perform some experiments that cannot be done in real life by modeling, we can analyze the actual situation and obtain the results, in order to solve the complex problems that cannot be dealt with in the deterministic model. it is thus becoming a typical representative of the network dynamics model. based on the ability of cellular automata to model complex problems, this paper considered that, in real society, population mobility is caused by economic development, living environment, education level, and other factors, and that population density, sex ratio, and age structure of area also have some influence on the spread of infectious diseases. an epidemic spread model susceptible-latent-infected-recovered-dead-susceptible (slirds) based on cellular automata was therefore established. the contributions of our research are as follows: • a more realistic epidemic spread model based on cellular automata was established and achieved good results in simulation experiments. the effects of population density, sex ratio, and age structure on the spread of infectious diseases were discussed, and the simulation results were analyzed to observe the effects of the above three factors on the spread process of infectious diseases. the suggestions given in this paper based on the three influencing factors provided strong support for researchers to study the spread process of infectious diseases in different environments. the rest of this paper is organized as follows. the methodology of our research is introduced in section 2. simulation results and analysis are given in section 3. discussions are presented in section 4. finally, conclusions are given in section 5. on the basis of the sir and sis (susceptible-infected-susceptible) models, the state of the population was divided into susceptible, latent, infected, recovered, and dead. the total number of members of the population is denoted as n(t). s(t) represents susceptible population, meaning the number of members of the population who are not infected but are susceptible to infection at time t. latent population is denoted as l(t), meaning the number of members of the population infected at time t but not yet affected, and at this time the individual is not infectious. infected population is denoted as i(t), meaning the number of members of the population who are infected and have infectivity at time t. recovered population is denoted as r(t), meaning the number of members of the population who are immune at t time and will not be infected for a certain period of time. dead population is denoted as d(t), meaning the number of members of the population who died of infectious diseases at time t, and individuals are not infectious at the moment. the slirds model can be described through the following differential equation models: where δ represents the proportion of the population who lost immunity to the infectious disease, β is the ratio coefficient of the infection rate, ω is the latency ratio coefficient of the infectious disease, γ is the ratio coefficient of the recovered infected population, and i o and s o represent the ratio of infected and susceptible individuals in the initial population, respectively. the transition relationships of states in the slirds model are shown in figure 2 . where represents the proportion of the population who lost immunity to the infectious disease, is the ratio coefficient of the infection rate, ω is the latency ratio coefficient of the infectious disease, is the ratio coefficient of the recovered infected population, and and represent the ratio of infected and susceptible individuals in the initial population, respectively. the transition relationships of states in the slirds model are shown in figure 2 . in order to simulate the phenomenon of crowd movement in the real world, this paper introduced the idea of random walk cellular automata to simulate individual movement in the crowd. considering the limitation of individual movement, the maximum step length l is set for individual movement. at the same time, considering the individual activity m, all individuals are scanned randomly in each time step, and the individuals whose proportion is m are selected. and ( | |, ≤ ) are chosen randomly for each selected individual ( , ) , and then ( , ) and ( , ) are exchanged to complete the individual movement. in this paper, the slirds epidemic model based on cellular automata is proposed. assuming that the environment of the crowd is a regular = × mesh space, a sparse matrix whose density is = ⁄ ( is the set of individuals) is generated randomly. each non-zero element of the matrix represents an effective individual. represents the neighbor set of cellular nodes, and it uses a moore neighbor with radius = 1. ( , ) ( ) = 0,1,2,3,4 is used to represent the cell state in the i-th row and the j-th column at time t. different values represent different states as follows: in order to simulate the phenomenon of crowd movement in the real world, this paper introduced the idea of random walk cellular automata to simulate individual movement in the crowd. considering the limitation of individual movement, the maximum step length l is set for individual movement. at the same time, considering the individual activity m, all individuals are scanned randomly in each time step, and the individuals whose proportion is m are selected. d i and d j (|d i |, d j ≤ l) are chosen randomly for each selected individual c (i,j) , and then c (i,j) and c (i+d i ,j+d j ) are exchanged to complete the individual movement. in this paper, the slirds epidemic model based on cellular automata is proposed. assuming that the environment of the crowd is a regular n = n × n mesh space, a sparse matrix whose density is ρ = c n /n (c n is the set of individuals) is generated randomly. each non-zero element of the matrix represents an effective individual. m represents the neighbor set of cellular nodes, and it uses a moore neighbor with radius = 1. s (i,j) (t) = {0, 1, 2, 3, 4} is used to represent the cell state in the i-th row and the j-th column at time t. different values represent different states as follows: s (i,j) (t) = 1 represents susceptible state, meaning that individuals are not infected and they are immune to this infectious disease; s (i,j) (t) = 2 represents latent state, meaning that individuals have been infected, but they do not have infectivity; s (i,j) (t) = 3 represents infected state, meaning that individuals are infected and infectious; s (i,j) (t) = 4 represents recovered state, meaning that individuals have recovered and acquired immunity within a certain period of time; s (i,j) (t) = 0 represents dead state, meaning that individuals are dead and they do not have infectivity. because cellular automata cannot reflect every individual's and their neighbors' randomness, unified parameters t 1 , t 2 , and t 3 are introduced, t 1 representing the maximum peak of latency time for each individual, t 2 representing the maximum peak of illness time for each individual, and t 3 representing the maximum peak of immunization time for each individual. t 1 s (i,j) (t) represents latency time of the individual, t 2 s (i,j) (t) represents illness time of the individual, and t 3 s (i,j) (t) represents immunization time of the individual. because of heterogeneity among individuals, each individual shows different resistance, infectivity, and infectious range to disease. this paper considers the effects of population density, sex ratio, and age structure on infectious disease spread in the population, and discusses the influence of different factors on infectious disease spread. in real life, because there are differences in climate, economy, education, and medical treatment, the population is not divided by rules like cellular automata. for example, in china, the population density in the southeast coastal areas is greater than that in the northwest. in addition, because of the different distribution of business districts, schools, and hospitals, the distribution of population in the same city is not uniform. in areas with a large population density, the distance between individuals is shorter and the spread range of individuals is wider. individuals in the population have higher contact frequency and more neighbors around them, so their infectivity and the probability of being infected also increase. in order to study and analyze the influence of population density on infectious disease spread, each individual is mapped into a cell in the cellular automata model. when there is no individual and the individual is in dead state in a cell, they are not infectious. in order to simulate the difference in population density, the population density can be simulated by setting the value of d(t) in the initial state. at this time, d(t) does not represent the number of dead individuals, but represents that there is no individual in the cell. in this paper, a sparse matrix was used to simulate the random distribution of population and the infectious disease spread, and then the trend of infectious disease spread under different population densities as well as the influence of different population densities on infectious disease spread were analyzed. due to the influence of economic development and other factors, the population ratio and age structure in different regions are also different. for example, young and middle-aged people in remote mountainous areas go to work in big cities, resulting in a large number of old and young people in the original area. in areas where labor is scarce, such as coal mines and crude oil mining areas, there is an imbalance in the proportion of men to women. therefore, it is of great practical significance to study the influence of sex ratio and age structure on infectious disease spread. in real life, because of different living environments, living habits, resistance levels to viruses, infectious abilities to diseases, levels of drug resistance, and spread ranges, and in order to simulate the spread mechanism of infectious diseases more accurately, it is particularly important to consider individual heterogeneity, establish an infectious disease spread model, and further analyze and predict the spread mechanism of the epidemic situation. in this paper, the probability of infection p (i,j) (t) was used to describe individual heterogeneity. individual heterogeneity is determined by the individual's resistance to disease and the infectivity of neighbor cells. the state of neighbor cells of cell c (i,j) at (i, j) can be expressed by an adjacency matrix as follows: after three times spread, its adjacency matrix is defined as follows: the infection rate of cell c (i,j) at time t is defined as follows: because the probability of infection is inversely proportional to one's own resistance, it is proportional to the infectivity of one's neighbors. thus, it can be expressed as follows: where f c (i,j) ,c(k,l) represents the infectivity of cell c (k,l) to cell c (i,j) (because of the difference in the constitution of different individuals, they have different infectivity and resistance) and f c (i,j) ,c(k,l) obeys (0,1) uniform distribution [23] . r c (i,j) represents the infectious disease resistance of cell c (i,j) . some diseases have different influences on different sex and age groups, that is, individual sex and age differences are also important factors affecting an individual's resistance to disease. thus, it can be expressed as follows: where g m and g f represent the proportion of males and females in the population, f m and f f represent the influence coefficient of infectious diseases on males and females, y 1 , . . . , y n are the proportion of various age groups in the population, f 1 , . . . , f n are the influence coefficient of infectious diseases on n groups of populations, and t c (i,j) obeys (0,1) uniform distribution [23] . the infection probability of each individual is determined by its own resistance to infectious diseases and the infectivity of its neighbors. at each time step, the individual state is updated synchronously. according to a given population density, the sparse matrix is generated to simulate the distribution of population, and then through the age structure and sex ratio, each individual sets their attribute values. the initial state of all individuals is set to s = 1, the state of the infected individuals is set to s = 2. individuals in cells are updated according to the following rules: (1) when s (i,j) (t) = 1, individual infection probability p (i,j) (t) is calculated, and then whether the individual will be transformed into s (i,j) (t) = 2 is determined. otherwise, s (i,j) (t) = 1. meanwhile, individual latency time t 1 s (i,j) (t) = t 1 s (i,j) (t) + 1. (2) when s (i,j) (t) = 2, when t 1 s (i,j) (t) < t 1 , s (i,j) (t + 1) = 2. otherwise, s (i,j) (t + 1) = 3. meanwhile, individual illness time t 2 s (i,j) (t) = t 2 s (i,j) (t) + 1. (3) when s (i,j) (t) = 3, when t 2 s (i,j) (t) < t 2 , s (i,j) (t + 1) = 3. otherwise, the individual enters into dead state with probability λ, and s (i,j) (t + 1) = 0; the rest of individuals have recovered and acquired immunity, and s (i,j) (t + 1) = 4. meanwhile, individual immunization time t 3 s (i,j) (t) = t 3 s (i,j) (t) + 1. (4) when s (i,j) (t) = 4, when t 3 s (i,j) (t) ≥ t 3 , individual immunity to the infectious disease disappears with probability δ. the individual then turns into susceptible state, s (i,j) (t) = 1. (5) at each time step, all individuals move. without considering other factors, this paper focused on the influence of three factors, namely, population density, individual heterogeneity, and mobility on infectious disease spread, and the slirds model based on cellular automata was constructed. in order to verify the validity of the model, this paper took pandemic influenza a (h1n1) as an example to simulate the spread process of pandemic influenza a (h1n1). in this paper, we used matlab simulation software (r2013b, mathworks, natick, ma, usa) to carry out 200 simulation experiments; the simulated curves are realizations of the average from all simulations. according to the latent and infectious characteristics of pandemic influenza a (h1n1), the time step of simulation is in days, and the total time is set to t = 40. the simulated initial number of members of the infected population was consistent with the actual number of members of the infected population, and we assumed that the proportion of the initial latent population was 0.15%. first, the number of members of the infected population in the slirds model simulation experiments was compared with the actual data of pandemic influenza a (h1n1) in beijing in mainland china (june-july 2009) [24] . the comparison results are shown in figure 3 . (2) when ( , ) ( ) = 2 , when ( ( , ) ( )) < , ( , ) ( + 1) = 2. otherwise, ( , ) ( + 1) = 3. meanwhile, individual illness time ( ( , ) ( )) = ( ( , ) ( )) + 1. (3) when ( , ) ( ) = 3, when ( ( , ) ( )) < , ( , ) ( + 1) = 3. otherwise, the individual enters into dead state with probability , and ( , ) ( + 1) = 0; the rest of individuals have recovered and acquired immunity, and ( , ) ( + 1) = 4. meanwhile, individual immunization time ( ( , ) ( )) = ( ( , ) ( )) + 1. (4) when ( , ) ( ) = 4, when ( ( , ) ( )) ≥ , individual immunity to the infectious disease disappears with probability . the individual then turns into susceptible state, ( , ) ( ) = 1. (5) at each time step, all individuals move. without considering other factors, this paper focused on the influence of three factors, namely, population density, individual heterogeneity, and mobility on infectious disease spread, and the slirds model based on cellular automata was constructed. in order to verify the validity of the model, this paper took pandemic influenza a (h1n1) as an example to simulate the spread process of pandemic influenza a (h1n1). in this paper, we used matlab simulation software (r2013b, mathworks, natick, ma, usa) to carry out 200 simulation experiments; the simulated curves are realizations of the average from all simulations. according to the latent and infectious characteristics of pandemic influenza a (h1n1), the time step of simulation is in days, and the total time is set to t = 40. the simulated initial number of members of the infected population was consistent with the actual number of members of the infected population, and we assumed that the proportion of the initial latent population was 0.15%. first, the number of members of the infected population in the slirds model simulation experiments was compared with the actual data of pandemic influenza a (h1n1) in beijing in mainland china (june-july 2009) [24] . the comparison results are shown in figure 3 . in figure 3 , the abscissa is the time step of simulation and the ordinate is the number of infected individuals. the correlation coefficient of the two sets of data is 0.97215 by t-test. it shows that the simulation results are close to the actual data and that the model is reasonable and effective. in figure 3 , the abscissa is the time step of simulation and the ordinate is the number of infected individuals. the correlation coefficient of the two sets of data is 0.97215 by t-test. it shows that the simulation results are close to the actual data and that the model is reasonable and effective. all things being equal, the parameters of two simulations for the slirds model were set as follows: in figure 4 , considering the difference in population base, the number of members of the population that died, were susceptible, were infected, and were immunized was replaced by death, susceptibility, infection and immunization rates to describe the changes in population in different states. from the death rate curve in figure 4a , it can be seen that the death rate increases with the increase in figure 4 , considering the difference in population base, the number of members of the population that died, were susceptible, were infected, and were immunized was replaced by death, susceptibility, infection and immunization rates to describe the changes in population in different states. from the death rate curve in figure 4a , it can be seen that the death rate increases with the increase of population density, but the overall trend is rising and tending to be stable. from the susceptibility rate curve in figure 4b , it can be seen that the change in population density has little influence on the susceptible population, and the susceptibility will first decrease and then reach a stable value when the population density is large. from the infection rate curve in figure 4c , it can be seen that the change in population density has little influence on the infected population. when the population density is large, the number of members of the infected population is greater, but the general trend is rising first, then falling, and finally tends to be stable. from the immunization rate curve in figure 4d , it can be seen that the change in population density has little influence on the immune population. when the population density is large, the immunity first rises and then reaches a stable value. according to the above analysis, it is known that when the population density is large, the spread rate of infectious diseases is faster. all things being equal, the ratio of males to females was 4:1. the parameters of two simulations for the slirds model were set as follows: (1) the influence coefficients of infectious disease on males and females were 0.1 and 0.9, respectively. (2) the influence coefficients of infectious disease on males and females were 0.9 and 0.1, respectively. two simulation results are shown in figure 5 . as shown in figure 5a , we can see that when infectious diseases have a greater influence on males, the number of deaths is higher, but the overall trend is rising and gradually stable. as shown in figure 5b , we can see that infectious diseases have less influence on susceptible population under different influence coefficients; when infectious diseases have a greater influence on females, the number of members of the susceptible population first decreases and then reaches a stable value. as shown in figure 5c , we can see that infectious diseases have less influence on infected population under different influence coefficients; when infectious diseases have a greater influence on males, the number of members of the susceptible population first decreases and then reaches a stable value. however, the overall trend is first rising and then falling, and finally tends to be stable. as shown in figure 5d , we can see that infectious diseases have less influence on recovered population under different influence coefficients; when infectious diseases have greater influence on males, the number of members of the susceptible population increases first, and then reaches a stable value. according to the above analysis, it is known that in cities with more males than females, when the infectious disease has a great influence on males, infectious diseases have a greater influence on the population because of the large population base of males. similarly, there are corresponding phenomena in cities with more females than males. (1) the influence coefficients of infectious disease on males and females were 0.1 and 0.9, respectively. (2) the influence coefficients of infectious disease on males and females were 0.9 and 0.1, respectively. two simulation results are shown in figure 5 . as shown in figure 5a , we can see that when infectious diseases have a greater influence on males, the number of deaths is higher, but the overall trend is rising and gradually stable. as shown in figure 5b , we can see that infectious diseases have less influence on susceptible population under different influence coefficients; when infectious diseases have a greater influence on females, the number of members of the susceptible population first decreases and then reaches a stable according to related materials [24] , the influence coefficient of pandemic influenza a (h1n1) on males and females is very different. in simulation experiments, the influence coefficients of pandemic influenza a (h1n1) on males and females were set to g m = 0.55, g f = 0.35, respectively. the parameters of two simulations for the slirds model were set as follows: (1) the ratio of males to females is 4:1. (2) the ratio of males to females is 1:4. two simulation results are shown in figure 6 . from the death curve in figure 6a , we can see that when the number of males is large, the number of deaths is higher, but the overall trend is rising and gradually stable. from the susceptibility curve in figure 6b , we can see that under different sex ratios, infectious diseases have little influence on susceptible population. when the number of females is large, the number of members of the susceptible population first decreases and then reaches a stable value. from the infection curve in figure 6c , we can see that under different sex ratios, infectious diseases have little influence on the infected population. when the number of males is large, the number of members of the infected population decreases first and then reaches a stable value. from the immunization curve in figure 6d , we can see that under different sex ratios, infectious diseases have little influence on the immunization population. when the number of males is large, the number of members of the immunization population increases first, and then reaches a stable value. according to related materials [24] , the influence coefficient of pandemic influenza a (h1n1) on males and females is very different. in simulation experiments, the influence coefficients of pandemic influenza a (h1n1) on males and females were set to = 0.55, = 0.35 , respectively. the parameters of two simulations for the slirds model were set as follows: (1) the ratio of males to females is 4:1. (2) the ratio of males to females is 1:4. two simulation results are shown in figure 6 . from the death curve in figure 6a , we can see that when the number of males is large, the number of deaths is higher, but the overall trend is rising and gradually stable. from the susceptibility curve in figure 6b , we can see that under different sex ratios, infectious diseases have little influence on susceptible population. when the number of females is large, the number of members of the susceptible population first decreases and then reaches a stable value. from the infection curve in figure 6c , we can see that under different sex ratios, infectious diseases have little influence on the infected population. when the number of males is large, the number of members of the infected population decreases first and then reaches a stable value. from the immunization curve in figure 6d , we can see that under different sex ratios, infectious diseases have little influence on the immunization population. when the number of males is large, the number of members of the immunization population increases first, and then reaches a stable value. according to the above analysis, it is known that when the number of males is larger in the cities where infectious diseases affect men more, infectious diseases have a greater influence on the population. due to factors such as mobility and spatial environment, age structure of the population presents different distributions. the age structure of a city can be divided into three types: young, adult, and aged according to the proportion of children, adolescents, youth, middle-aged people, and elderly people. according to the above analysis, it is known that when the number of males is larger in the cities where infectious diseases affect men more, infectious diseases have a greater influence on the population. due to factors such as mobility and spatial environment, age structure of the population presents different distributions. the age structure of a city can be divided into three types: young, adult, and aged according to the proportion of children, adolescents, youth, middle-aged people, and elderly people. according to related materials [24] , the influence coefficient of pandemic influenza a (h1n1) on children, adolescents, youth, middle-aged people, and elderly people is very different. in simulation experiments, the influence coefficients of pandemic influenza a (h1n1) on children, adolescents, youth, middle-aged people, and elderly people were set to f 1 = 0.65, f 2 = 0.58, f 3 = 0.46, f 4 = 0.37, f 5 = 0.68, respectively. all things being equal, the parameters of three simulations for the slirds model were set as follows: figure 7 . the death, susceptibility, infection, and immunization curves are shown in figure 7a -d, respectively. it can be seen that the number of deaths in the aged cities is the largest. the number of young urban deaths is only inferior to that of the aged cities, whereas the number of deaths in the adult cities is the least. however, the overall trend of change is gradually stable after rising for all types of cities. the difference in age structure of the population has little influence on the susceptible population, and the number of members of the susceptible population in adult cities decreases first and then reaches a stable value. the difference in age structure of the population has little influence on the infected population. the number of members of the infected population in the aged cities is the highest, but the general trend is rising first and then decreasing for all types of cities. the difference in age structure of the population has little influence on the immunization population, and the number of immune individuals in the adult city rises first to then reach a stable level. according to the above analysis, it is known that infectious diseases spread more slowly in adult cities than in aged and young cities, but the resistance of young cities to infectious diseases is slightly greater than that of aged cities. according to related materials [24] , the influence coefficient of pandemic influenza a (h1n1) on children, adolescents, youth, middle-aged people, and elderly people is very different. in simulation experiments, the influence coefficients of pandemic influenza a (h1n1) on children, adolescents, youth, middle-aged people, and elderly people were set to = 0.65, = 0.58, = 0.46, = 0.37, = 0.68, respectively. all things being equal, the parameters of three simulations for the slirds model were set as follows: (1 figure 7 . the death, susceptibility, infection, and immunization curves are shown in figure 7a -d, respectively. it can be seen that the number of deaths in the aged cities is the largest. the number of young urban deaths is only inferior to that of the aged cities, whereas the number of deaths in the adult cities is the least. however, the overall trend of change is gradually stable after rising for all types of cities. the difference in age structure of the population has little influence on the susceptible population, and the number of members of the susceptible population in adult cities decreases first and then reaches a stable value. the difference in age structure of the population has little influence on the infected population. the number of members of the infected population in the aged cities is the highest, but the general trend is rising first and then decreasing for all types of cities. the difference in age structure of the population has little influence on the immunization population, and the number of immune individuals in the adult city rises first to then reach a stable level. according to the above analysis, it is known that infectious diseases spread more slowly in adult cities than in aged and young cities, but the resistance of young cities to infectious diseases is slightly greater than that of aged cities. in this paper, we used the idea of a sparse matrix to add population density, sex ratio, and age structure factors into the slirds model. population density was set to 1 and 0.8, respectively. all things being equal, with the increase of population density, infectious diseases spread faster, and infectious diseases have a greater influence on the population. when analyzing the influence of sex ratio on the spread of infectious diseases, we considered two factors, namely, different influence coefficient and different sex ratio. first, the ratio of males to females was set to 4:1. because of the large population base of males, infectious diseases have a greater influence on the population when the infection coefficient is greater. second, the influence coefficients of infectious diseases on males and females were 0.9 and 0.2, respectively. because infectious diseases have a greater influence on males, when the number of males is larger, the influence of infectious diseases on the population is greater. when analyzing the influence of age structure on the spread of infectious diseases, we simulated three types of population distribution structure, namely, young, adult, and aged, according to the age structure distribution ratio. the number of members of the infected population and deaths in the aged cities were the largest, and the susceptibility of adult cities to infectious diseases was stronger. that is, the uniform distribution of age plays a more active role in the spread of infectious diseases. in order to effectively prevent the spread of infectious diseases in the population, we offer three suggestions according to the three influencing factors. (1) population density: the regional economy should be balanced, the large-scale turnover of personnel should be reduced, the density of urban population should be controlled, the population in densely populated areas such as schools should be evacuated during the epidemic period of infectious diseases. (2) sex ratio: when infectious disease has a greater influence on a certain sex, or if the sex ratio is larger in the population, attention should be paid to prevention and treatment with respect to that sex. (3) age structure: the age structure should be optimized and the age structure of the city should be stabilized. on this basis, we should pay attention to prevention and treatment with respect to disadvantaged groups (such as the elderly and children) in the spread of infectious diseases. many factors affect the spread of infectious diseases. this paper only studied the influence of the above three factors on the spread of infectious diseases. the many factors that must be further explored in the future include the following: first, the influence of population activity on the spread of infectious diseases; second, the influence of population size on the spread of infectious diseases; and third, in view of the analysis of the influence factors, how to implement effective prevention and control measures against the spread of infectious diseases in specific cities. in order to study the main factors that affect the spread process of infectious diseases, the slirds model was proposed in this paper. combined with cellular automata, an epidemic model based on cellular automata was established. in the simulation experiment, the influence of population density, sex ratio, and age structure on infectious disease spread was analyzed by comparing the results with those from the actual spread process of pandemic influenza a (h1n1), and the accuracy of the slirds model was confirmed. with research on the spread of infectious diseases, the advantage of using cellular automata to model complex problems can be used to optimize epidemic models. the system can better analyze the factors affecting the spread of infectious diseases, and provide better theoretical support for the prevention and control of infectious diseases. because cellular automata cannot reflect every individual's and their neighbors' randomness, there was a lack of individual randomness in the slirds model for the maximum peak of each state for the different durations. this will be the direction that we take in 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authors contributed to the work in this paper. s.b., g.s., and c.-c.c. designed the research and wrote the paper. g.s. participated in the creation of the graphics.funding: this research was funded by the shandong provincial natural science foundation, china, grant number zr2017mg011. the authors declare no conflict of interest. key: cord-300338-duhyb754 authors: urashima, mitsuyoshi; otani, katharina; hasegawa, yasutaka; akutsu, taisuke title: bcg vaccination and mortality of covid-19 across 173 countries: an ecological study date: 2020-08-03 journal: int j environ res public health doi: 10.3390/ijerph17155589 sha: doc_id: 300338 cord_uid: duhyb754 ecological studies have suggested fewer covid-19 morbidities and mortalities in bacillus calmette–guérin (bcg)-vaccinated countries than bcg-non-vaccinated countries. however, these studies obtained data during the early phase of the pandemic and did not adjust for potential confounders, including pcr-test numbers per population (pcr-tests). currently—more than four months after declaration of the pandemic—the bcg-hypothesis needs reexamining. an ecological study was conducted by obtaining data of 61 factors in 173 countries, including bcg vaccine coverage (%), using morbidity and mortality as outcomes, obtained from open resources. ‘urban population (%)’ and ‘insufficient physical activity (%)’ in each country was positively associated with morbidity, but not mortality, after adjustment for pcr-tests. on the other hand, recent bcg vaccine coverage (%) was negatively associated with mortality, but not morbidity, even with adjustment for percentage of the population ≥ 60 years of age, morbidity, pcr-tests and other factors. the results of this study generated a hypothesis that a national bcg vaccination program seems to be associated with reduced mortality of covid-19, although this needs to be further examined and proved by randomized clinical trials. currently, more than four months since declaration of the coronavirus disease 2019 (covid19) as a pandemic by the world health organization (who) on march 11th, 2020, more than 14 million people have been infected with the virus and more than half a million have died worldwide. marked differences in covid-19 mortalities have been observed in different countries. for example, the mortality per million population is till now several tens of times or even higher in western countries, e.g., belgium (845), the united kingdom (uk, 664), the united states of america (usa, 426) and germany (109), than in asian countries, e.g., india (19) , japan (8) and china (3), as of 17 july 2020. this is quite the opposite of what was reported during the 1918-20 influenza pandemic, the so called spanish flu, in which the population mortality was over 30-fold higher, with excess death rates observed in low-income countries, such as india, than in high-income countries, such as those in the west [1] . higher morbidities and mortalities may be explained by easy access to diagnostic polymerase chain reaction tests (pcr-tests) for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) in these western countries. in contrast, they may be underestimated in middle-and low-income countries due to low capacities of pcr-testing and poor access to health care. alternatively, there is growing concern that racial and ethnic minority, as well as socioeconomic and biological factors may influence the high morbidity and mortality. a retrospective study of integrated health care systems suggested that black race compared with white race, increasing age, male sex, having a greater burden of comorbidities, type of public insurance, residence in a low-income area and obesity were associated with increased odds of hospital admission [2] . on the other hand risk of in-hospital mortality increased only in aged patients and was not associated with the black race, sex, comorbidities, obesity and other factors after multivariate adjustment [2] ; this phenomenon was also confirmed in other races, i.e., asians and hispanics, compared with the white race [3, 4] . moreover, since covid-19 is an infectious disease that spreads mainly through the droplet route by close contact in dense human societies, metropolitan areas, such as new york city in the usa [5] and lombardy in italy [6] , paris in france [7] , sao paulo in brazil [8] , and so on, have tended to be regional epicenters. however, associations between population dynamics, e.g., population size, density, migrants and urbanization and the morbidity/mortality of covid19 have not yet been well examined. in addition to the factors listed above, several scientists proposed a hypothesis [9] [10] [11] [12] that bacillus calmette-guérin (bcg) vaccination has preventive effects not only against tuberculosis, i.e., the target disease of the vaccine, but also other non-specific infectious diseases, i.e., off-target diseases such as covid-19, through epigenetic mechanisms [13] [14] [15] . in fact, ecological studies have suggested that both covid-19 morbidities and mortalities were less in bcg-vaccinated countries than in bcg-non-vaccinated countries [16] [17] [18] . however, because these studies only obtained data during the early phase of the pandemic, by which time the disease load had escalated in western countries, but not yet escalated in low-and middle-income countries where bcg is given at birth and did not adjust for any potential confounders, including pcr-test number per million population, the bcg-hypothesis needs to be reexamined now, more than four months after declaration of the pandemic, since the number of pcr-confirmed covid-19 cases are still growing in many countries. we therefore aimed to explore whether recent bcg vaccine coverage is associated with covid-19 morbidity and/or mortality rates, using linear regression models to explore associations between the two continuous random variables adjusted for a variety of potential confounders, such as median age and body mass index (bmi) in individual countries through this ecological study. institutional review board approval for this work was not sought due to the use of publicly available data obtained from open resources. this ecological study compared population data of each country. all data were obtained from open resources: information on total number of cases, total number of deaths and number of pcr-tests performed per million population were obtained from 'coronavirus update' [19] , data regarding population dynamics were obtained from 'world population clock' [20] , socioeconomic covariates were obtained from 'the united nations database' [21] , bcg vaccine coverage data were obtained from 'the bcg world atlas' [22] and 'the global health observatory' on the who homepage [18] and other health related data were from the same who site [23] . definitions of each of the covariates are described in the supplement. only countries that had data of both total deaths and bcg vaccine coverage were included for analyses in this study. the outcomes evaluated in this study were covid-19 morbidity, i.e., total covid-19 cases per million population and covid-19 mortality, i.e., total covid-19-related deaths per million population, in each country, obtained from 'worldometer covid-19 data' on july 17th, 2020 [19] . data on the total number of pcr-tests performed per million population were simultaneously obtained from the same 'worldometer covid-19 data' website. pcr-test positivity was simply calculated as the total covid-19 case number divided by the total number of pcr-tests performed in each country. recent bcg vaccine coverage was defined as the percentage of the vaccinated population among one-year-olds in each country (world health data platform, the world health observatory, bcg-immunization coverage estimates) [23] . for countries that have already stopped a national bcg vaccine immunization program [22] , which includes a significant number of countries, their bcg vaccine coverage rate was counted as zero percent in this study. the covariates evaluated in this study, the definitions of which are described in the supplement (table s1) , included: (1) population (n); (2) yearly change in population (%); (3) net change in population (n); (4) population density (n/km 2 ); (5) land area (km 2 ); (6) net number of migrants (n); (7) fertility rate (n); (8) median age (years); (9) urban population percentage (%); (10) world share (%); (11) population between age 0 to 14 years (%); (12) population ≥ 60 years of age (%); (13) population ≥ 70 years of age (%); (14) gross domestic product (gdp) (million us dollars); (15) gdp per capita (us dollars); (16) total unemployment rate (%); (17) male unemployment rate (%); (18) female unemployment rate (%); (19) total labor force participation rate (%); (20) male labor force participation rate (%); (21) female labor force participation rate (%); (22) annual incidence of tuberculosis per 100,000 population (n); (23) international health regulation (ihr) score (%); (24) universal health coverage (uhc) index; (25) hospital beds (n) per 10,000 population; (26) medical doctors (n) per 10,000 population; (27) nursing midwifery (n) per 10,000 population; (28) licensed qualified anesthesiologists who usually cover management of intensive care units actively working (n) per 10,000 population; (29) total expenditure on health as a percentage of gdp (%); (30) population with household expenditures on health greater than 10% of total household expenditure or income (%); (31) prevalence of high blood pressure (systolic ≥ 140 or diastolic ≥ 90 mmhg) (%); (32) prevalence of elevated fasting blood glucose levels (≥7.0 mmol/l or on anti-diabetic medication); (33) prevalence of elevated total cholesterol levels (≥5.0 mmol/l) (%); (34) mean bmi (body weight [kg]/height 2 [m 2 ]); (35) prevalence of obesity among adults, bmi ≥ 30 kg/m 2 (%); (36) prevalence of 'overweight' people among adults, bmi ≥ 25 kg/m 2 (%); (37) alcohol drinking, total per capita (≥15 years of age) consumption (in liters of pure alcohol over a calendar year); (38) prevalence of smoking any tobacco product among males aged ≥ 15 years (%); (39) prevalence of smoking any tobacco product among females aged ≥ 15 years (%); (40) prevalence of insufficient physical activity among adults aged ≥ 18 years (%); (41) estimated population-based prevalence of depression (%); (42) neonatal mortality rate (n per 1000 live births); (43) infantile mortality rate (n per 1000 live births); (44) under-five mortality rate (probability of dying by the age of 5 years per 1000 live births); (45) mortality rate for 5-14-year-olds (probability of dying per 1000 children aged 5-14 years); (46) adult mortality rate (probability of dying between 15 and 60 years of age per 1000 population); (47) probability of dying between age 30 and exact age 70 years from any of the following causes: cardiovascular disease, cancer, diabetes or chronic respiratory disease; (48) life expectancy at birth (years); (49) life expectancy at age 60 years (years); (50) healthy life expectancy (hale) at birth (years); (51) hale at age 60 years (years); (52) death due to chronic obstructive pulmonary disease (%); (53) death due to ischemic heart disease (%); (54) death due to lower respiratory infections (%); (55) death due to stroke (%); (56) death due to tracheal, bronchial and lung cancers (%); (57) total of (52) to (56) as ambient and household air pollution-attributable death rate (n per 100,000 population); and (58) annual mean concentration of particulate matter less than 2.5 microns in diameter (pm 2.5 ) [µg/m 3 ] in urban areas; and (59) coverage rate with the first dose of a measles-containing-vaccine (mcv1) among one-year-olds (%) as well as (60) recent bcg coverage and (61) pcr-tests number. for preprocessed data, outcomes, i.e., morbidity and mortality per million population were transformed to the common logarithm (log10) to adjust for normality of the distribution, which was verified by means of kurtosis tests. when the number of total deaths was zero, these were changed to 0.01 per million population, because zero cannot be transformed to the common logarithm. variance inflation factor (vif) was used to detect the presence of multicollinearity. only one variable among biologically similar variables, e.g., 'median age (years)', '≥ 60 years of age (%)' and '≥ 70 years of age', was selected to maximize adjusted r 2 in the multi-linear regression models to avoid the influence of collinearity. if the variance inflation factor (vif) of certain covariates was more than 10, then the covariates were avoided in multivariate analyses because of a collinearity issue. multiple linear regression models were used to screen potential risk or preventive factors associated with morbidity by adjusting for pcr-test numbers transformed to the common logarithm (log10) and those associated with mortality were screened by adjusting for pcr-test numbers and morbidity per million population. considering type i error due to a multiple testing, the significance level of alfa was set as p < 0.001. then, all the screened factors were assessed in a multi-linear regression model to determine significant factors with p < 0.05 as the cutoff point. each model was evaluated by adjusted r 2 as a coefficient of determination. pearson's correlation coefficient for variables with normal distributions or spearman's rank correlation for variables with non-normal distributions, represented as rho, was used to quantify the strengths of associations between morbidity, mortality and significant factors determined by the final models, as: absolute value of rho ≥ 0.5: very strong; rho ≥ 0.4: strong; 0.4 > rho ≥ 0.2: moderate; and rho < 0.2: weak associations. data were analyzed using stata version 14.0 software (statacorp lp, college station, tx, usa). a total of 173 countries that had data of both total covid-19 deaths and bcg vaccine coverage were included for analyses in this study. the 20 countries with highest and lowest covid-19 morbidities (table 1 ) and mortalities (table 2) , as well as their pcr-test rate per million population are shown below. marked differences in morbidities and mortalities were observed among these countries, ranging from 1 (papua new guinea) to 37,566 (qatar) and from 0 (vietnam, etc.) to 845 (belgium), respectively. six and thirteen countries that do not have a bcg national vaccine program at present (indicated with bold and mark " ") were included in the 20 countries with the highest covid-19 morbidity and mortality, respectively. histograms of morbidities and mortalities were drawn as normal density plots ( figure 1 ). although the histograms of morbidity and mortality were skewed to the right, they followed a normal distribution by transformation with the common logarithm (log10). first, associations represented by rho and vif between morbidity (n = 173), mortality (n = 173) and pcr-tests (n = 155) are shown ( figure 2a ). these three variables were predicted to have very strong and positive associations with each other. however, vifs were less than 2 among these three factors. multicollinearity is considered to be present when the vif is higher than 5 to 10 [24] . thus, any variable with a vif < 5.0 was considered for inclusion in multiple linear regression analyses. considering the number of pcr-tests per million population may exhibit associations with morbidity, adjustment was performed for the pcr-test number in every analysis when screening for the risk factors of covid-19 morbidity per million population ( figure 2b ). considering morbidities and the number of pcr-tests per million population may exhibit associations with mortality, adjustment was performed for the morbidity and pcr-test number in every analysis when screening for the risk factors of covid-19 mortality per million population ( figure 2c ). first, associations represented by rho and vif between morbidity (n = 173), mortality (n = 173) and pcr-tests (n = 155) are shown (figure 2a ). these three variables were predicted to have very strong and positive associations with each other. however, vifs were less than 2 among these three factors. multicollinearity is considered to be present when the vif is higher than 5 to 10 [24] . thus, any variable with a vif < 5.0 was considered for inclusion in multiple linear regression analyses. considering the number of pcr-tests per million population may exhibit associations with morbidity, adjustment was performed for the pcr-test number in every analysis when screening for the risk factors of covid-19 morbidity per million population ( figure 2b ). considering morbidities and the number of pcr-tests per million population may exhibit associations with mortality, adjustment was performed for the morbidity and pcr-test number in every analysis when screening for the risk factors of covid-19 mortality per million population ( figure 2c ). associations between morbidity, mortality and pcr-tests. either pearson's correlation coefficient or spearman's rank correlation was applied to calculate rho; (b) associations between morbidity and risk factors were adjusted for pcr-tests per million population (log10); (c) associations between mortality and risk factors were adjusted for morbidity (log10) and pcr-tests (log10) per million population. since fewer pcr-tests may underestimate morbidity and mortality, the association between mortality as the outcome and morbidity as the exposure was adjusted for number of pcr-tests performed (table 3 ). in this multiple regression analysis, higher morbidity was associated with higher mortality, whereas more pcr-tests were associated with lower mortality. evaluation of the association between pcr-test positivity and mortality, shown as a scatter plot, indicated a very strong association between them (rho = 0.54) (figure 3 ). countries with higher pcrassociations between morbidity, mortality and pcr-tests. either pearson's correlation coefficient or spearman's rank correlation was applied to calculate rho; (b) associations between morbidity and risk factors were adjusted for pcr-tests per million population (log10); (c) associations between mortality and risk factors were adjusted for morbidity (log10) and pcr-tests (log10) per million population. since fewer pcr-tests may underestimate morbidity and mortality, the association between mortality as the outcome and morbidity as the exposure was adjusted for number of pcr-tests performed (table 3 ). in this multiple regression analysis, higher morbidity was associated with higher mortality, whereas more pcr-tests were associated with lower mortality. evaluation of the association between pcr-test positivity and mortality, shown as a scatter plot, indicated a very strong association between them (rho = 0.54) (figure 3 ). countries with higher pcr-positivity rates tended to have higher mortality rates. pcr-test positivity rates of countries where no deaths due to covid-19 were observed were less than 3.5%. minimum positivity and no deaths were observed in vietnam. among the 59 covariates, plus bcg vaccine coverage and pcr-testing rate, i.e., a total of 61 factors, 'urban population' and 'insufficient physical activity' were significantly (p < 0.001) associated with morbidity after adjustment for pcr-test rate (table 4 ). next, these two significant factors were used in a multi-linear regression model to eliminate confounding ( table 5) . as a result, 'urban population' (p = 0.02) and 'insufficient physical activity' (p = 0.01) remained significant factors associated with covid-19 morbidity, even after adjustment for pcr-tests. the adjusted r 2 was 0.5037. among the 59 covariates, plus bcg vaccine coverage and pcr-testing rate, i.e., a total of 61 factors, 'urban population' and 'insufficient physical activity' were significantly (p < 0.001) associated with morbidity after adjustment for pcr-test rate (table 4 ). next, these two significant factors were used in a multi-linear regression model to eliminate confounding ( table 5) . as a result, 'urban population' (p = 0.02) and 'insufficient physical activity' (p = 0.01) remained significant factors associated with covid-19 morbidity, even after adjustment for pcr-tests. the adjusted r 2 was 0.5037. the association between 'urban population' and morbidity, demonstrated below as a scatter plot, showed a very strong association (rho = 0.55) (figure 4) . the association between 'urban population' and morbidity, demonstrated below as a scatter plot, showed a very strong association (rho = 0.55) (figure 4 ). rates. covid-19-related morbidity rates per million population on july 17, 2020 were transformed to the common logarithm (log10) in the graph. since the variable of 'urban population' showed a nonnormal distribution, spearman's rank correlation was applied to calculate rho, to quantify the strength of the association. countries that had never had or that had stopped a national program of bcg vaccination are indicated in red, while countries that currently follow a national bcg vaccine program are indicated in black. selected country names are shown using three-letter country codes. the association between 'insufficient physical activity' and morbidity, demonstrated below as a scatter plot, also showed a very strong association (rho = 0.52) ( figure 5 ). rates. covid-19-related morbidity rates per million population on 17 july 2020 were transformed to the common logarithm (log10) in the graph. since the variable of 'urban population' showed a non-normal distribution, spearman's rank correlation was applied to calculate rho, to quantify the strength of the association. countries that had never had or that had stopped a national program of bcg vaccination are indicated in red, while countries that currently follow a national bcg vaccine program are indicated in black. selected country names are shown using three-letter country codes. the association between 'insufficient physical activity' and morbidity, demonstrated below as a scatter plot, also showed a very strong association (rho = 0.52) ( figure 5 ). covid-19-related morbidity rates per million population on july 17th were transformed to the common logarithm (log10) in the graph. countries that had never had or that had stopped a national program of bcg vaccination are indicated in red, while countries that currently follow a national bcg vaccine program are indicated in black. selected country's name was shown using three-letter country codes. covid-19-related morbidity rates per million population on july 17th were transformed to the common logarithm (log10) in the graph. countries that had never had or that had stopped a national program of bcg vaccination are indicated in red, while countries that currently follow a national bcg vaccine program are indicated in black. selected country's name was shown using three-letter country codes. among the 58 covariates evaluated, plus bcg vaccine coverage, adjusted for morbidity and pcr-tests, age-related factors, i.e., median age, ≥60 years of age (%) and ≥70 years of age (%), were significantly (p < 0.001) associated with mortality (table 4 ). since these three age-related factors had collinearity for mortality, '≥ 60 years of age' was selected to maximize adjusted r 2 of the multi-linear regression models. moreover, 'bcg vaccine coverage', 'elevated total cholesterol levels' and 'life expectancy at 60 years of age', were also significant (p < 0.001) factors associated with mortality. next, these significant factors were used in a multi-linear regression model to eliminate confounding ( table 6) . as a result, '≥60 years of age' (p < 0.001) and 'bcg vaccine coverage' (p = 0.002) remained significant factors associated with covid-19 mortality, even after adjustment for morbidity and pcr-tests. the adjusted r 2 was 0.8254. among the 58 covariates evaluated, plus bcg vaccine coverage, adjusted for morbidity and pcr-tests, age-related factors, i.e., median age, ≥60 years of age (%) and ≥70 years of age (%), were significantly (p < 0.001) associated with mortality (table 4 ). since these three age-related factors had collinearity for mortality, '≥ 60 years of age' was selected to maximize adjusted r 2 of the multi-linear regression models. moreover, 'bcg vaccine coverage', 'elevated total cholesterol levels' and 'life expectancy at 60 years of age', were also significant (p < 0.001) factors associated with mortality. next, these significant factors were used in a multi-linear regression model to eliminate confounding ( table 6) . as a result, '≥60 years of age' (p < 0.001) and 'bcg vaccine coverage' (p = 0.002) remained significant factors associated with covid-19 mortality, even after adjustment for morbidity and pcr-tests. the adjusted r 2 was 0.8254. evaluation of the association between 'median age' and mortality, demonstrated as a scatter plot, showed a very strong association between these two variables (rho = 0.54) ( figure 6 ). countries with a larger population ≥ 60 years of age (%) showed a tendency toward a higher mortality rate. finally, evaluation of the association between 'bcg vaccine coverage' and mortality, demonstrated as a scatter plot, indicated a moderately negative association (rho = −0.29) (figure 7) . countries with higher bcg vaccine coverage showed a tendency toward lower mortality. additionally, covid-19 mortality rates did not have significant associations with bcg strain, e.g., tokyo 172. moreover, there were no significant associations between mortality and either the year of stopping or introducing a national bcg vaccine program (data not shown). evaluation of the association between 'median age' and mortality, demonstrated as a scatter figure 6 . scatter plot showing the association between ≥60 years of age (%) of the population and mortality rate. mortalities per million population on july 17, 2020 transformed to the common logarithm (log10) are presented in the graph. since the variable of 'percentage of population ≥ 60 years of age (%)' showed a non-normal distribution, spearman's rank correlation was applied to calculate rho, to quantify the strength of the association. countries that had never had or that had stopped their national bcg vaccine program are indicated in red, while countries that currently follow a national bcg vaccine program are indicated in black. selected country names are shown using three-letter country codes. finally, evaluation of the association between 'bcg vaccine coverage' and mortality, demonstrated as a scatter plot, indicated a moderately negative association (rho = -0.29) (figure 7) . countries with higher bcg vaccine coverage showed a tendency toward lower mortality. additionally, covid-19 mortality rates did not have significant associations with bcg strain, e.g., tokyo 172. moreover, there were no significant associations between mortality and either the year of stopping or introducing a national bcg vaccine program (data not shown). figure 6 . scatter plot showing the association between ≥60 years of age (%) of the population and mortality rate. mortalities per million population on 17 july 2020 transformed to the common logarithm (log10) are presented in the graph. since the variable of 'percentage of population ≥ 60 years of age (%)' showed a non-normal distribution, spearman's rank correlation was applied to calculate rho, to quantify the strength of the association. countries that had never had or that had stopped their national bcg vaccine program are indicated in red, while countries that currently follow a national bcg vaccine program are indicated in black. selected country names are shown using three-letter country codes. among the variety of parameters abstracted from open resources, 'bcg vaccine coverage' had a significant association with covid-19 mortality, even after adjusting for morbidity, pcr-tests, age, universal health coverage, numbers of medical doctors, elevated total cholesterol and healthy life expectancy. on the other hand, bcg vaccination was not associated with covid-19 morbidity. the mortalities per million population on 17 july 2020 are transformed to the common logarithm (log10) in the graph. since the variable of 'bcg vaccine coverage' showed a non-normal distribution, spearman's rank correlation was applied to calculate rho, to quantify the strength of the association. selected country names are shown using three-letter country codes. among the variety of parameters abstracted from open resources, 'bcg vaccine coverage' had a significant association with covid-19 mortality, even after adjusting for morbidity, pcr-tests, age, universal health coverage, numbers of medical doctors, elevated total cholesterol and healthy life expectancy. on the other hand, bcg vaccination was not associated with covid-19 morbidity. the main results of this study are consistent with a very recent article demonstrating that every 10% increase in the bcg index was associated with a 10% reduction in covid-19 mortality [25] . moreover, a retrospective cohort study suggested that bcg-vaccinated individuals were less likely to require hospital admission during the disease course [26] . in contrast to bcg, coverage of the measles vaccine, which is also considered to induce heterologous protection against infections through long-term boosting of innate immune responses [9] , showed no association with the morbidity and mortality of covid-19, which was also consistent with a very recent article showing a significant low risk of covid-19 mortality in countries with higher bcg vaccine coverage, but not with measles vaccine coverage [27] . moreover, sars-cov-2 is a single-stranded positive-sense rna virus and the bcg vaccine has been shown in controlled trials to reduce the severity of infections by other viruses with such a structure [9] . for example, the bcg vaccine reduced yellow fever vaccine viremia by 71% in volunteers in the netherlands [28] . however, some countries with a current national bcg vaccination policy have high mortality rates. plausible reasons for this discrepancy may be: (1) low coverage of bcg vaccination in these countries (% coverage-mortality per million population), e.g., ireland (18%-354); portugal (32%-165); and greece (50%-19): (2) late introduction of bcg vaccine program (year of introduction-mortality per million population), e.g., iran, (1984-162): (3) oral delivery of the bcg vaccine, e.g., brazil retained oral delivery of the vaccine until 1977: (4) uk administered the vaccine to older children (12 to 13 years of age) and (5) connection with endemic country by land, e.g., mexico, panama, peru and chile. higher morbidity, but fewer pcr-tests, were associated with higher mortality. moreover, higher pcr-test positivity was associated with higher mortality, which was consistent with the report by hisaka et al. [29] . expanding application of pcr-tests not only to typical symptomatic cases, but also to mild or asymptomatic cases and to those who had close contact with patients, may decrease the pcr-test positivity rate. thus, enhancing the capacity of pcr-testing may enable identification of cases, so that appropriate measures can be taken to prevent them spreading sars-cov-2 to others at home, at their work place or at events of mass gatherings. in this study, the covariate of 'urban population' and 'insufficient physical inactivity' had a strong and positive association with morbidity, but not with mortality. people living in urban areas tend to have close contact with a greater number of people per day than those in rural areas, independent of age. a report on 4103 patients with covid-19 in new york city found that obesity, which may strongly depend on the balance between physical activity and diet, was one of the clinical features leading to hospital admission [30] . on the other hand, older age was associated with higher mortality, which is consistent with previous articles [2] [3] [4] . from this study, the risk factors for morbidity seem to be different from those associated with mortality, suggesting that factors related to susceptibility may be different from those related to disease severity. there are several limitations to this study. first, although we selected 61 covariates in this study, we did not evaluate range and timing of non-pharmaceutical interventions, e.g., school closures, workplace closures, cancellation of public events, restrictions on public gatherings, stay-at-home restrictions, restrictions on internal movement, international travel controls, etc., all of which would also have had significant effects on covid-19-related morbidity and mortality. therefore, the present study results are burdened with an extreme error. second, the study design was ecological. therefore, the outcome of this work should be considered highly limited, with a potential risk of high bias. consequently, only the hypothesis that bcg vaccination mitigates covid-19 mortality can be proposed here; cohort or case-control studies and randomized clinical trials, similar to the bcg-corona study [31] , are required to test this hypothesis. third, the covid-19 pandemic is still ongoing, although we have confirmed the results using the latest data. however, the results may be different a few months from now. fourth, it is clear that an extremely large number of covariates, i.e., 61, were selected for the limited number of 173 countries. this sample size could allow use of a maximum of 10 covariates in multiple regression analysis. therefore, significant (p < 0.001) variables were at first screened after adjustment for pcr-tests and morbidity (table 4) . then, multivariable linear regression using the screened variables were performed after adjustment for pcr-tests and morbidity (table 5 for morbidity and table 6 for mortality). fifth, mortality in each country should be compared with excess deaths whether these two do not make a big difference. sixth, the definition of covid-19 cases may differ by country, e.g., including pcr confirmed, but asymptomatic cases and pneumonia cases with negative pcr-tests. seventh, there were still residual confounders even after adjustment for pcr-tests. our results suggest the hypothesis that greater bcg vaccine coverage may reduce the risk of deaths due to covid-19, which needs to be further studied by observational studies and confirmed by randomized clinical trials. estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918-20 pandemic: a quantitative analysis hospitalization and mortality among black patients and white patients with covid-19 socioeconomic deprivation, and hospitalization for covid-19 in english participants of a national biobank covid-19 by race and ethnicity: a national cohort study of 6 million united states veterans and the 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bcg-induced trained immunity: can it offer protection against covid-19? is bcg vaccination affecting the spread and severity of covid-19? allergy 2020 is global bcg vaccination-induced trained immunity relevant to the progression of sars-cov-2 pandemic? is bcg vaccination causally related to reduced covid-19 mortality? coronavirus update world population clock a world of information the global health observatory multicollinearity and misleading statistical results barillas-mury, c. bcg vaccine protection from severe coronavirus disease 2019 (covid-19) bacillus calmette-guérin vaccination and clinical characteristics and outcomes of covid-19 in rhode island, united states: a cohort study significantly improved covid-19 outcomes in countries with higher bcg vaccination coverage: a multivariable analysis bcg vaccination protects against experimental viral infection in humans through the induction of cytokines associated with trained immunity global comparison of changes in the number of test-positive cases and deaths by coronavirus infection (covid-19) in the world obesity and risk of covid-19: analysis of uk biobank bcg-corona study team: two randomized controlled trials of bacillus calmette-guérin vaccination to reduce absenteeism among health care workers and hospital admission by elderly persons during the covid-19 pandemic: a structured summary of the study protocols for two randomised controlled trials the authors thank the personnel who created the excellent open resources. we also thank haruka wada for data management at the division of molecular epidemiology, jikei university school of medicine. the authors declare no conflict of interest. key: cord-314733-fyximykl authors: butu, alina; brumă, ioan sebastian; tanasă, lucian; rodino, steliana; dinu vasiliu, codrin; doboș, sebastian; butu, marian title: the impact of covid-19 crisis upon the consumer buying behavior of fresh vegetables directly from local producers. case study: the quarantined area of suceava county, romania date: 2020-07-29 journal: int j environ res public health doi: 10.3390/ijerph17155485 sha: doc_id: 314733 cord_uid: fyximykl the present paper intends to address the impact of covid-19 crisis upon the consumer buying behavior of fresh vegetables directly from local producers as observed 30 days later, after enforcing the state of emergency in romania within a well-defined area, namely, the quarantined area of suceava. the study relies on the interpretation of answers received from the quarantined area (n = 257) to a questionnaire applied online nationwide. the starting point of this paper is the analysis of the sociodemographic factors on the purchasing decision of fresh vegetables directly from local producers before declaring the state of emergency in romania (16 march 2020). further research has been conducted by interpreting the changes triggered by the covid-19 crisis on the purchasing intention of such products before and after the end of the respective crisis. the aim of this scientific investigation relies on identifying the methods by which these behavioral changes can influence the digital transformation of short food supply chains. pandemics are not exactly a novel phenomenon strictly related to the current modern societies as they were recorded since ancient times. each pandemic triggered major changes in economics, regional and global policies, social behavior, and citizens' mentalities as well. the most significant changes (which have been preserved over the medium term and long term) have been those institutionalized [1] . by contrast, the changes which were least preserved are related to mentalities and social behavior as the institutionalized modifications [2] , through public policies, were not sufficiently coupled and consolidated with the psychosocial changes [3] . like any other pandemics, covid-19 has caused significant changes on all levels of contemporary society [4] [5] [6] [7] [8] [9] . all states; continents; regions; urban and rural communities; families; and ultimately, thinking and lifestyle of each individual have been impacted by the pandemic [10] [11] [12] [13] [14] , and we may never return to the normality previously experienced before covid-19 [15, 16] . images processed by authors and reproduced with permission from geo-spatial.org [36] . suceava county covers an area of 8553.5 km 2 , while the quarantined area is 409.4 km 2 . the quarantined area is bordered by suceava municipality (52.1 km 2 ), salcea town (55.6 km 2 ), and the communes of adâncata (38.6 km 2 ), bosanci (49.6 km 2 ), ipotești (22.8 km 2 ), moara (41.9 km 2 ), șcheia (58.3 km 2 ), pătrăuți (37.7 km 2 ), and mitocu dragomirnei (52.9 km 2 ) [37]. the population of suceava county was 764,123 inhabitants (3% of romania's population) on 1 january 2020. approximately 25% of suceava's population live in the quarantined area, having an irregular territorial distribution (table 1) . data adapted from nis database : [38] . almost 73% of the quarantined population from suceava county lives in urban area (67% in suceava municipality and 6% in salcea town). the population distribution of age groups, in the quarantined area is as follows: 23% of the population is under 20 years old, 21% is between 20 and 34 years old, 24% ranges between 35 and 49 years old, 19% is between 50 and 64 years old, and 13% is figure 1 . the quarantined area of suceava. images processed by authors and reproduced with permission from geo-spatial.org [36] . suceava county covers an area of 8553.5 km 2 , while the quarantined area is 409.4 km 2 . the quarantined area is bordered by suceava municipality (52.1 km 2 ), salcea town (55.6 km 2 ), and the communes of adâncata (38.6 km 2 ), bosanci (49.6 km 2 ), ipotes , ti (22.8 km 2 ), moara (41.9 km 2 ), s , cheia (58.3 km 2 ), pătrăut , i (37.7 km 2 ), and mitocu dragomirnei (52.9 km 2 ) [37]. the population of suceava county was 764,123 inhabitants (3% of romania's population) on 1 january 2020. approximately 25% of suceava's population live in the quarantined area, having an irregular territorial distribution (table 1) . data adapted from nis database: [38] . almost 73% of the quarantined population from suceava county lives in urban area (67% in suceava municipality and 6% in salcea town). the population distribution of age groups, in the quarantined area is as follows: 23% of the population is under 20 years old, 21% is between 20 and 34 years old, 24% ranges between 35 and 49 years old, 19% is between 50 and 64 years old, and 13% is over 65. therefore, nearly 64% of the population is included in the category of active population (20-64 years old) . based on the sociocultural characteristics mentioned above, we have worked on the assumption that there are direct correlations among the state of exception induced by quarantine, behavioral changes in the direct purchase of fresh vegetables from producers, and digital transformation of short food supply chains (sfsc). therefore, the main objective of this research was to identify the possible behavioral changes of the consumers during the covid-19 crisis, particularly of those customers who bought fresh vegetables with direct delivery. the second objective lies in identifying the possible effects of these behavioral changes on the digital transformation of sfsc. a cross-sectional study was carried out based on a survey run between the 10 and 25 april 2020 within the population located in the quarantined area of suceava (romania). the basic hypothesis of this paper relies on the assumption that the state of exception that arose from the total quarantine produced significant changes in the consumer buying behavior regarding fresh products directly from local producers. at the same time, these changes can trigger substantial alterations towards the digital transformation of the short food supply chains within the consumer community of romania. to test this hypothesis, our research identified sociocultural factors impacting consumer purchasing decisions before the covid-19 crisis. further, the analysis has focused on how the quarantine influenced consumer buying behavior and its possible effects in the post-crisis period. the narrative-argumentative sketch of this analysis is outlined in figure 2 . based on the sociocultural characteristics mentioned above, we have worked on the assumption that there are direct correlations among the state of exception induced by quarantine, behavioral changes in the direct purchase of fresh vegetables from producers, and digital transformation of short food supply chains (sfsc). therefore, the main objective of this research was to identify the possible behavioral changes of the consumers during the covid-19 crisis, particularly of those customers who bought fresh vegetables with direct delivery. the second objective lies in identifying the possible effects of these behavioral changes on the digital transformation of sfsc. a cross-sectional study was carried out based on a survey run between the 10 and 25 april 2020 within the population located in the quarantined area of suceava (romania). the basic hypothesis of this paper relies on the assumption that the state of exception that arose from the total quarantine produced significant changes in the consumer buying behavior regarding fresh products directly from local producers. at the same time, these changes can trigger substantial alterations towards the digital transformation of the short food supply chains within the consumer community of romania. to test this hypothesis, our research identified sociocultural factors impacting consumer purchasing decisions before the covid-19 crisis. further, the analysis has focused on how the quarantine influenced consumer buying behavior and its possible effects in the post-crisis period. the narrative-argumentative sketch of this analysis is outlined in figure 2 . the survey was based on a questionnaire designed as follows: eight questions meant to identify the sociological profile of the respondents (age, marital status, gender, education, number of people in household, and location); three questions meant to identify the people who bought this type of products before and after 16 march 2020, and those who declared that they would buy after the end of the crisis; one question related to the favorite type of fresh vegetables preferred by respondents; five questions related to the preferred buying method, the frequency of placing orders, the minimum value of order, and payment method. the survey was based on a questionnaire designed as follows: eight questions meant to identify the sociological profile of the respondents (age, marital status, gender, education, number of people in household, and location); three questions meant to identify the people who bought this type of products before and after 16 march 2020, and those who declared that they would buy after the end of the crisis; one question related to the favorite type of fresh vegetables preferred by respondents; five questions related to the preferred buying method, the frequency of placing orders, the minimum value of order, and payment method. the questionnaire was pretested between the 8 and 10 april, and all the necessary adjustments revealed during this process were operated by rephrasing several questions and introducing new answer choices. the questionnaire was disseminated through the social media channels and by email. the scope of the survey and objectives of the research were made available to all participants. the participants gave consent and voluntarily joined the study. the survey was applied one month after the restrictions imposed on free movement of the population were enforced in accordance with the military ordinance no. 3. out of 916 answers received, 257 (28%) are from the quarantined area and represents 0.14% of the total population quarantined, meeting the requirements of the representative sample criterion. the data were compiled, tabulated, and analyzed in accordance with the hypothesis of the study and argumentative-narrative sketch. to better visualize and process the data collected, we have used excel software ( [39] [40] [41] [42] [43] [44] [45] . based on this graphic projection, we have run a descriptive analysis which led to anthropological conclusions on the consumer buying behavior and its modifications and impact upon the digital transformation of the short food supply chains as well. the main concepts employed here are related to short food supply chains (sfscs), local producers, food safety and security, and sustainable rural development. to have a deeper understanding of the conceptual frame, it is necessary to bring into question the matter of sustainable development, short food supply chains, global and local effects of the crisis upon the sfscs. the sustainable rural development in the emerging countries, romania included, is a necessary condition for these society's sustainable growth since the population from rural areas still holds a significant percentage in comparison with the more developed economies. the modern development of rural economy involves transition from scale economies to a sustainable local economy, and it is mirrored by the reconfiguration of food supply chain logistics [46] [47] [48] [49] [50] . the re-spatialization and reconfiguration of the conventional agricultural systems requires developing new forms of agricultural organization opposed to mass production, namely sfscs, food hubs, local agri-food systems, and rural networks [51] [52] [53] . short food chain supply (sfsc) systems provide multiple benefits (of economic, social, environmental, cultural, and health nature) for people and society as a whole: new job opportunities in the agri-food sector at local level [54] , encouraging knowledge transfer, counter-balancing the effects of population migration [55] or gentrification, supporting the local services and suppliers by sustaining the stores of small producers and farmers' markets, preserving cultural heritage, including promotion of tourism [56] and local gastronomy, and improving the quality of life by securing access to healthier food [57] . at the same time, sfsc systems play a key role in ensuring the quality of the products supplied by direct contact with the producer [58] or by traceability guarantees, although the quality of products is often related to their origin, specifically sustainable agriculture, and particular practices of the post-production process [59] . the fact that sfscs can facilitate a better interaction between various local agri-food sector producers and potential buyers has been already pointed out by some researchers interested in the development of local food systems. several authors have highlighted that sfscs should be considered when discussing how agriculture can be oriented towards more environmentally friendly practices and economic processes while still delivering quality food products [60] . in this context, it should be noted that sometimes short circuits make use of instruments mostly employed by long logistics chains, such as e-commerce, that facilitate the contact between potential buyers and local producer(s) in a certain region. in addition to the effects of demand-side shocks and potential supply-side disruptions, it is worth considering whether the covid-19 pandemic will have longer-lasting effects on the nature of food supply chains. two aspects come to mind: (1) the growth of the online grocery delivery sector and (2) the extent to which consumers prioritize "local" food supply chains. an element of food distribution that is undergoing significant change during the covid-19 pandemic is the expansion of online grocery deliveries [61] . changing consumption patterns and holding excess inventory in the commercial chains and by customers as well changing the percentage of basic food products/fresh food, collapses in the agro-industrial sector, and exponential increase of online deliveries are impacts from the pandemic in agriculture for most european states, romania included. potential challenges include imposing restrictions on the movement of goods, lack of labor force due to the enforced quarantine, closing down important economic agents such as horeca (hotels/restaurants/café) network, as well as the temporary closure of schools and cafeterias [62] . regarding goods and services consumed at home, there will be both substitution (positive) and income (negative) effects on demand. the positive substitution effect reflects a switch from out-of-home to in-home consumption (such as the switch from restaurants to home cooking, home delivery, and in-home entertainment) [63] . another observation is that long food supply chains can be affected by the imposed restrictions through the special measures enforced within the european union as response to the covid-19 pandemic. consequently, the short food supply chains are a complementary solution to the public alimentation, and it can even become a durable and sustainable alternative post crisis. given the effects of covid-19, it is of the utmost importance that countries succeed in keeping the food supply chains running to prevent major food shortages. accordingly, the food and agriculture organization strongly supports the implementation of concrete measures, mainly specific strategies such as extending emergency food assistance services and offering urgent assistance to smallholders' agricultural production by improving their involvement in e-commerce [64] . the primary interest of our narrative sketch was focused on the possible determinations of the sociocultural context on the consumer buying behavior before enforcing the state of emergency. table 2 summarizes the frequencies of the demographic data of the respondents within this survey. the majority of survey respondents (85%) live in the urban space of the quarantined area, suceava-215 (84%) and salcea-4 (2%). from the rural space of the quarantined area, we received 38 (15%) answers, with the following distribution by locality: adâncata (3-1.2%), bosanci (1-0.4%), ipotes , ti (14-5.4%), moara (3-1.2%), s , cheia (13-5.1%), pătrăut , i (1-0.4%), and mitocu dragomirnei (3-1.2%). most answers (87%) from all survey respondents (n = 257) come from women. other prevalent characteristics of respondents were being married, between 20 to 49 years old, having a master's degree and/or bachelor's degree, and living with two to four people in their household ( table 2) . based on the frequencies observed above, we shall further analyze the key factors for consumer buying behavior. as shown in figure 3 , we generated a biplot based on gender for the multivariate correspondence analysis of the sociodemographic data and purchase of fresh vegetables directly delivered from local producers before the enforcement of the state of emergency (16 march 2020) . the validation of the definite data under analysis has been done by using working packages which are typical of r programming, ggplot2, namely factoextra [39] [40] [41] [42] [43] [44] [45] . in these types of graphs, the four quadrants represent different combinations of sociocultural characteristics we surveyed. by analyzing the influence of the sociodemographic factors upon the consumer buying behavior of fresh vegetables directly delivered from producers before march 16 ( figure 3 ), several relevant features can be highlighted and used for outlining the profile of the consumer from the quarantined area. the highest concentration of male gender variables appears in q1, where there is particular presence of those respondents who did not buy fresh vegetables directly from producers before march 16, and who are included in the age category of 35-49, belong to households of four or five people, and are phd fellows. the distribution of female respondents is much more uniform and falls nearly equal in all categories of age, education, purchase preference, or persons in the household. the majority of respondents who did not buy fresh vegetables directly from producers before 16 march are located in q1 and q4, and are both women and men, especially from the age category of 35-49 years old, of various education levels, and living with four to six people in the same household. women from the 20-34 and 50-64 age categories, master's degree holders, and coming from families of two or three people living in the same household appear more inclined to purchasing fresh vegetables directly from producers before march 16. buying behavior. as shown in figure 3 , we generated a biplot based on gender for the multivariate correspondence analysis of the sociodemographic data and purchase of fresh vegetables directly delivered from local producers before the enforcement of the state of emergency (16 march 2020) . the validation of the definite data under analysis has been done by using working packages which are typical of r programming, ggplot2, namely factoextra [39] [40] [41] [42] [43] [44] [45] . in these types of graphs, the four quadrants represent different combinations of sociocultural characteristics we surveyed. after observing the correlations between the main values in the dataset, we aim to further observe the evolution of consumer buying behavior before, during, and post crisis. in table 3 the frequencies regarding the purchase of fresh vegetables directly from producers before and after march 16 are presented as well as what is expected to happen after the end of covid-19 crisis. the health crisis triggered by covid-19 has brought major change in purchase behavior towards direct delivery of fresh vegetables from local producers within the quarantined area of suceava ( figure 4 ). although 88% of the respondents have stated that they did not buy vegetables with direct delivery from producers before the state of emergency was declared, after that date the percentage of consumers who placed direct delivery orders has increased to 60%. even more, approximately 81% of the respondents have chosen this option post crisis, and only one respondent does not prefer this system of delivery (table 3 and figure 4 ). after march 16, the number of buyers increased to 67. in the 35-49 age category (123 respondents), 16 (6%) persons bought before march 16, while 107 (42%) favored another type of purchase. after march 16, the number of buyers increased to 72 (29%). regarding the manner of product selection, the questionnaire data and our research revealed the overwhelming inclination of fresh vegetable consumers to choose specific products and quantities, according to their own needs rather than buying a pre-defined basket. the clusters of those who have declared that they bought or did not buy fresh vegetables from local producers with direct delivery, before march 16, distributed according to age categories and statement that they bought or did not buy directly from producers after march 16. we are dealing with a localization of vegetable consumption, but in this context, the question arises as to whether it is a psychosocial reaction of the moment in response to the state of emergency, or it is a long-term modification that emerged in the representation system of the consumers from the quarantined area. to have a better understanding of this situation, we shall analyze the distribution of replies depending on the consumers' statements on what they bought or did not buy before and it is visible that there is a reversal in the balance of power between those who buy and those who do not buy directly delivered vegetables from producers. it should be noted that in the green-marked columns, there are 31 persons (12%) out of the total of n = 257 respondents who declared that they had bought fresh vegetables directly from producers before march 16, and after this date, their number increased to 154 (60%). the most significant data are to be found in the age groups ranging between 20-34 and 35-49 ( figure 5 ). within the age group of 20-34 years old (98 respondents), 13 (5%) people bought before march 16, while 87 (34%) preferred another type of purchase method. after march 16, the number of buyers increased to 67. in the 35-49 age category (123 respondents), 16 (6%) persons bought before march 16, while 107 (42%) favored another type of purchase. after march 16, the number of buyers increased to 72 (29%). regarding the manner of product selection, the questionnaire data and our research revealed the overwhelming inclination of fresh vegetable consumers to choose specific products and quantities, according to their own needs rather than buying a pre-defined basket. . regarding the manner of product selection, the questionnaire data and our research revealed the overwhelming inclination of fresh vegetable consumers to choose specific products and quantities, according to their own needs rather than buying a pre-defined basket. the clusters of those who have declared that they bought or did not buy fresh vegetables from local producers with direct delivery, before march 16, distributed according to age categories and statement that they bought or did not buy directly from producers after march 16. we are dealing with a localization of vegetable consumption, but in this context, the question arises as to whether it is a psychosocial reaction of the moment in response to the state of emergency, or it is a long-term modification that emerged in the representation system of the consumers from the quarantined area. to have a better understanding of this situation, we shall analyze the distribution of replies depending on the consumers' statements on what they bought or did not buy before and figure 5 . the clusters of those who have declared that they bought or did not buy fresh vegetables from local producers with direct delivery, before march 16, distributed according to age categories and statement that they bought or did not buy directly from producers after march 16. we are dealing with a localization of vegetable consumption, but in this context, the question arises as to whether it is a psychosocial reaction of the moment in response to the state of emergency, or it is a long-term modification that emerged in the representation system of the consumers from the quarantined area. to have a better understanding of this situation, we shall analyze the distribution of replies depending on the consumers' statements on what they bought or did not buy before and after march 16 and whether they will keep buying or stop buying after the end of covid-19 crisis (figures 6 and 7) . the respondents who stated that they bought fresh vegetables from local producers with direct delivery before state of emergency can be regarded as loyal and experienced consumers who prefer this type of purchase, a feature which is still supported, at least in their statements, after overcoming the covid-19 crisis. out of 31 respondents who bought fresh vegetables directly from producers before march 16, 29 have stated they will keep buying after the end of covid-19 crisis ( figure 6 ). interestingly, only one respondent of the 31 total respondents expressed no interest in purchasing directly delivered fresh vegetables from local producers after the end of covid-19 crisis. this person also belongs to the category that did not buy before 16 march 2020. after march 16 and whether they will keep buying or stop buying after the end of covid-19 crisis (figures 6 and 7) . the respondents who stated that they bought fresh vegetables from local producers with direct delivery before state of emergency can be regarded as loyal and experienced consumers who prefer this type of purchase, a feature which is still supported, at least in their statements, after overcoming the covid-19 crisis. out of 31 respondents who bought fresh vegetables directly from producers before march 16, 29 have stated they will keep buying after the end of covid-19 crisis ( figure 6 ). interestingly, only one respondent of the 31 total respondents expressed no interest in purchasing directly delivered fresh vegetables from local producers after the end of covid-19 crisis. this person also belongs to the category that did not buy before 16 march 2020. the imposition of restrictions on free movement, followed by quarantining suceava municipality and its adjacent localities has caused a fundamental shift among consumers of fresh vegetables who steered towards alternative ways of purchasing produce. after march 16, the number of those who chose to buy fresh vegetables straight from local producers has grown exponentially and reached 154 out of 257 respondents (60%). among these, 131 (51% of the total percentage) have declared that they will keep ordering vegetables directly from producers post covid-19 crisis. among the respondents who did not order vegetables after march 16 (103), 76 (30% of the total percentage) have stated that they will keep buying post covid-19 crisis (figure 7 ). figure 6 . the clusters of those who stated that they bought or did not buy fresh vegetables from local producers with direct delivery before the 16 of march, distributed according to age categories and statement that they will buy or not directly from local producers after the covid-19 crisis. figure 6 . the clusters of those who stated that they bought or did not buy fresh vegetables from local producers with direct delivery before the 16 of march, distributed according to age categories and statement that they will buy or not directly from local producers after the covid-19 crisis. the imposition of restrictions on free movement, followed by quarantining suceava municipality and its adjacent localities has caused a fundamental shift among consumers of fresh vegetables who steered towards alternative ways of purchasing produce. after march 16, the number of those who chose to buy fresh vegetables straight from local producers has grown exponentially and reached 154 out of 257 respondents (60%). among these, 131 (51% of the total percentage) have declared that they will keep ordering vegetables directly from producers post covid-19 crisis. among the respondents who did not order vegetables after march 16 (103), 76 (30% of the total percentage) have stated that they will keep buying post covid-19 crisis (figure 7) . the emotional state of people living in quarantined areas [65] [66] [67] leads us to the conclusion that this type of data does not provide enough evidence to consider that after emerging from the covid-19 crisis, the behavior of direct purchase will increase or have a high inertia. as shown in figure 8 , the abruptly ascending dynamics of the respondents' number (grouped on clusters related to the purchase intent from before, during, and after the state of emergency) conveys an emotional charge in those who replied to this questionnaire. figure 7 . the clusters of those who declared that they bought or did not buy directly delivered fresh vegetables from local producers after march 16, distributed according to age categories and statements that they will keep buying or not from local producers after the covid-19 crisis. the emotional state of people living in quarantined areas [65] [66] [67] leads us to the conclusion that this type of data does not provide enough evidence to consider that after emerging from the covid-19 crisis, the behavior of direct purchase will increase or have a high inertia. as shown in figure 8 , the abruptly ascending dynamics of the respondents' number (grouped on clusters related to the purchase intent from before, during, and after the state of emergency) conveys an emotional charge in those who replied to this questionnaire. figure 8 . the number of those who declared that they bought directly delivered fresh vegetables straight from local producers before and after march 16 and who will keep buying after the covid-19 crisis, grouped by age categories. however, exposing the customers to this type of experience provides new opportunities for producers and local authorities to support this type of behavior through tailor-made strategies and figure 7 . the clusters of those who declared that they bought or did not buy directly delivered fresh vegetables from local producers after march 16, distributed according to age categories and statements that they will keep buying or not from local producers after the covid-19 crisis. the clusters of those who declared that they bought or did not buy directly delivered fresh vegetables from local producers after march 16, distributed according to age categories and statements that they will keep buying or not from local producers after the covid-19 crisis. the emotional state of people living in quarantined areas [65] [66] [67] leads us to the conclusion that this type of data does not provide enough evidence to consider that after emerging from the covid-19 crisis, the behavior of direct purchase will increase or have a high inertia. as shown in figure 8 , the abruptly ascending dynamics of the respondents' number (grouped on clusters related to the purchase intent from before, during, and after the state of emergency) conveys an emotional charge in those who replied to this questionnaire. figure 8 . the number of those who declared that they bought directly delivered fresh vegetables straight from local producers before and after march 16 and who will keep buying after the covid-19 crisis, grouped by age categories. however, exposing the customers to this type of experience provides new opportunities for producers and local authorities to support this type of behavior through tailor-made strategies and figure 8 . the number of those who declared that they bought directly delivered fresh vegetables straight from local producers before and after march 16 and who will keep buying after the covid-19 crisis, grouped by age categories. however, exposing the customers to this type of experience provides new opportunities for producers and local authorities to support this type of behavior through tailor-made strategies and policies. the purchase frequency can provide additional insight to further analyze this situation. the weekly version of delivery was preferred by respondents (149 answers out of 257) both before and after march 16 (figure 9 ). this weekly purchase system has the highest percentage for each age group (57% from the 20-34 age group, 59% from the 35-49 age group, 61% from the 50-64 age group, and 37% from the age group over 65 years old). policies. the purchase frequency can provide additional insight to further analyze this situation. the weekly version of delivery was preferred by respondents (149 answers out of 257) both before and after march 16 ( figure 9 ). this weekly purchase system has the highest percentage for each age group (57% from the 20-34 age group, 59% from the 35-49 age group, 61% from the 50-64 age group, and 37% from the age group over 65 years old). at the same time, the weekly purchase is also the logical recommended version, considering the high perishability of the fresh vegetables. therefore, it is highly likely that buyers will generally adhere to this pattern and choose a weekly purchase. weekly purchase of produce is the most dynamic and a key vector for enhancing and increasing the trust degree between consumer and producer. the consumer-producer communication has a higher frequency, and the consumer can notice the producers' compliance with the safety and quality standards over a shorter period. another interesting aspect is provided by the similar consumer buying behavior for all age categories considered. the relatively similar distribution of replies presented in figure 9 shows that all age categories are determined by the same representation system (symbolic systems) related to the preference for the purchase frequency. this situation can be explained by the mainly traditional nature of the quarantined community, the wide access to the same information sources, and the dominantly family nature when purchasing this type of products. given the significant number of respondents who have chosen the "weekly" version, it is obvious that there are solid arguments indicating that post covid-19 crisis more and more consumers will prefer ordering directly from local producers by weekly home delivery. cash will remain the favorite payment method. survey respondents who purchased or plan on purchasing locally before, during, and after the covid-19 crisis have similar percentage values for frequency of these purchases (figure 10 ). at the same time, the weekly purchase is also the logical recommended version, considering the high perishability of the fresh vegetables. therefore, it is highly likely that buyers will generally adhere to this pattern and choose a weekly purchase. weekly purchase of produce is the most dynamic and a key vector for enhancing and increasing the trust degree between consumer and producer. the consumer-producer communication has a higher frequency, and the consumer can notice the producers' compliance with the safety and quality standards over a shorter period. another interesting aspect is provided by the similar consumer buying behavior for all age categories considered. the relatively similar distribution of replies presented in figure 9 shows that all age categories are determined by the same representation system (symbolic systems) related to the preference for the purchase frequency. this situation can be explained by the mainly traditional nature of the quarantined community, the wide access to the same information sources, and the dominantly family nature when purchasing this type of products. given the significant number of respondents who have chosen the "weekly" version, it is obvious that there are solid arguments indicating that post covid-19 crisis more and more consumers will prefer ordering directly from local producers by weekly home delivery. cash will remain the favorite payment method. survey respondents who purchased or plan on purchasing locally before, during, and after the covid-19 crisis have similar percentage values for frequency of these purchases ( figure 10 ). for survey respondents purchasing locally before (31 replies), during (154 replies), and who plan on purchasing after (207 replies) the crisis, preference for weekly orders dropped while preference for ordering every two weeks increased. the structure diagrams previously shown clearly indicate that the percentage of respondents who ordered "when needed" is on the rise, from 10% before the crisis, 17% during the crisis, and 15% post crisis. this shift of behavior, purchasing only when necessary, suggests consumers may be more sensitive to food waste and are aware of the high perishability of fresh vegetables. accordingly, consumer interest increased for local, fresh, and highly nutritious food, which could impact quality of life for consumers. at the same time, the data obtained reveal a phenomenon of growing confidence in the consumer-local producer relation, and this feature is a key element for mapping and improving the efficiency of the short food supply chains [68] . for survey respondents purchasing locally before (31 replies), during (154 replies), and who plan on purchasing after (207 replies) the crisis, preference for weekly orders dropped while preference for ordering every two weeks increased. the structure diagrams previously shown clearly indicate that the percentage of respondents who ordered "when needed" is on the rise, from 10% before the crisis, 17% during the crisis, and 15% post crisis. this shift of behavior, purchasing only when necessary, suggests consumers may be more sensitive to food waste and are aware of the high perishability of fresh vegetables. accordingly, consumer interest increased for local, fresh, and highly nutritious food, which could impact quality of life for consumers. at the same time, the data obtained reveal a phenomenon of growing confidence in the consumer-local producer relation, and this feature is a key element for mapping and improving the efficiency of the short food supply chains [68] . the key factors of the consumer buying behavior for the digital transformation of sfsc consist of channels of information and order, frequency of purchasing fresh vegetables, manner of choosing the products, and preferred methods of payment. these factors should be considered by the producers for the digital transformation of their businesses. table 4 presents frequencies of online or face-to-face channels preferred by consumers purchasing local produce. as expected, if we take into consideration the social media culture of romania, facebook is by far the preferred choice of the respondents regarding the favorite method of information on fresh vegetables distributed through short chains ( figure 11 ). after facebook, another top preference is represented by specialized platforms or websites. these three categories of answers can prove useful for both local producers and processors, as well as policymakers with respect to elaborating the digital development strategy of the business or local communities. the romanian producers who run small-or medium-sized farms are already active on facebook. however, most of them stopped here since it seemed sufficient for their businesses. they did not develop their own websites nor invested in affiliation with marketing platforms. this type of behavior shows that producers have largely focused on the production activity and ignored diversifying online marketing platforms. figure 10 . the order frequency on the clusters of the respondents who have stated that they bought fresh vegetables directly from producers before and after march 16 and that they will keep buying post covid-19 crisis. the key factors of the consumer buying behavior for the digital transformation of sfsc consist of channels of information and order, frequency of purchasing fresh vegetables, manner of choosing the products, and preferred methods of payment. these factors should be considered by the producers for the digital transformation of their businesses. table 4 presents frequencies of online or face-to-face channels preferred by consumers purchasing local produce. as expected, if we take into consideration the social media culture of romania, facebook is by far the preferred choice of the respondents regarding the favorite method of information on fresh vegetables distributed through short chains ( figure 11 ). after facebook, another top preference is represented by specialized platforms or websites. these three categories of answers can prove useful for both local producers and processors, as well as policymakers with respect to elaborating the digital development strategy of the business or local communities. the romanian producers who run smallor medium-sized farms are already active on facebook. however, most of them stopped here since it seemed sufficient for their businesses. they did not develop their own websites nor invested in affiliation with marketing platforms. this type of behavior shows that producers have largely focused on the production activity and ignored diversifying online marketing platforms. concurrently, from previous research, we have noticed that the eagerness for growth of small local producers is rather limited. generally, it is about family or inter-community businesses since expanding the business was regarded as unsustainable. therefore, before the enforcement of the state of emergency, small producers had mostly focused their businesses on dedicated customer groups. every producer of the sort developed a network of dedicated clients, a hard-core type of buyers. in this case, two phenomena are likely to emerge. due to the imposition of the state of emergency and reduced interaction between producers and loyal customers, the dedicated consumers can migrate from one producer to another or to a producer who intends to expand his/her business. under the circumstances, digital development will become a survival requirement, not just a mere expansion of the business. in table 5 , the frequencies of the channels preferred by consumers (n = 257) to order fresh vegetables directly from producers can be seen. similar to the information on channels regarding the fresh vegetables directly delivered from producers, the preferred channels for placing orders are those which proved successful in the case of short food supply chains ( figure 12 ). concurrently, from previous research, we have noticed that the eagerness for growth of small local producers is rather limited. generally, it is about family or inter-community businesses since expanding the business was regarded as unsustainable. therefore, before the enforcement of the state of emergency, small producers had mostly focused their businesses on dedicated customer groups. every producer of the sort developed a network of dedicated clients, a hard-core type of buyers. in this case, two phenomena are likely to emerge. due to the imposition of the state of emergency and reduced interaction between producers and loyal customers, the dedicated consumers can migrate from one producer to another or to a producer who intends to expand his/her business. under the circumstances, digital development will become a survival requirement, not just a mere expansion of the business. in table 5 , the frequencies of the channels preferred by consumers (n = 257) to order fresh vegetables directly from producers can be seen. similar to the information on channels regarding the fresh vegetables directly delivered from producers, the preferred channels for placing orders are those which proved successful in the case of short food supply chains ( figure 12 ). however, based on the data obtained, there are several intriguing behavioral features worth mentioning. firstly, although phone and email are the tools registering the highest scores of social interaction, they also register the lowest values in the answers received (email: 37 replies out of the total of 257 (14%); phone: 81 answers out of the total number of 257 (31%). this may be explained by the synesthetic nature of the visual consumer's behavior (here it can be rather related to the desire of seeing the products on a platform, specialized website, or facebook account). the synesthetic nature is also supported by romanian consumers symbolically associating agri-food products with childhood memories or idyllic life in the countryside [69] . distinguished here. again, there is a possible explanation here too. in the case of short food supply chains, in particular fresh vegetables from producers, there are relatively few specialized websites and platforms in romania. among existing online platforms, there are even fewer e-commerce apps. this suggests a high degree of wishful thinking by survey respondents. most answer options are included in the category of online order form (69%, 178 out of 257), online platforms (42%, 107 out of 257), and facebook (36%, 93 out of 257) ( table 5 ). table 6 presents the frequencies of the preferences (n = 257) for the selection method of fresh vegetables directly from producers. even under restrictive circumstances, in what concerns the method for selecting products, most respondents (95%) prefer to make their own choices when it comes to products and quantities, while the version based on basket order is favored by merely 5% (table 6 ). secondly, although the online platform and order form are tools which nearly overlap in terms of order technology, the high number of answers received in the category of order form is clearly distinguished here. again, there is a possible explanation here too. in the case of short food supply chains, in particular fresh vegetables from producers, there are relatively few specialized websites and platforms in romania. among existing online platforms, there are even fewer e-commerce apps. this suggests a high degree of wishful thinking by survey respondents. most answer options are included in the category of online order form (69%, 178 out of 257), online platforms (42%, 107 out of 257), and facebook (36%, 93 out of 257) ( table 5) . table 6 presents the frequencies of the preferences (n = 257) for the selection method of fresh vegetables directly from producers. even under restrictive circumstances, in what concerns the method for selecting products, most respondents (95%) prefer to make their own choices when it comes to products and quantities, while the version based on basket order is favored by merely 5% (table 6 ). this way, the inertia of some specific features is exposed to view by following an empirical line in the case of the purchase decision. the romanian consumer chooses to control directly and contextually the products and quantities he/she wishes to buy. this piece of information should be noted down and integrated in the distribution strategies on long and medium-term, to achieve an efficient functioning of the short food supply chains. under the circumstances, the producers should integrate and adjust their offer of products so the consumers could be able to select themselves the ordered products and quantities. the covid-19 crisis has not changed the buying behavior related to the selection method of fresh vegetables directly delivered by producers. the personal choice of products and quantities is still in the top of most consumers' preferences over the pre-arranged basket of products as it has been observed throughout all the periods under analysis. table 7 introduces the frequencies of the favorite methods of payment for ordering fresh vegetables directly from producers (n = 257). as shown in table 7 , almost half of the respondents (47%) have chosen cash payment, while bank transfer is the least preferred payment method. if we analyze only the answers received from persons choosing home delivery (before, during, and post crisis) the percentage of respondents who use cash payment was lower than for card payments or bank transfers ( figure 13 ). this demonstrates that during the covid-19 crisis, the population became aware that card payments or bank transfers can be safe preventive measures against the covid-19 epidemic. at the same time, this type of behavior is supported by the fact that over this period of crisis, buyers lack cash, since the regulations enforced by the state of emergency have greatly decreased atm cash withdrawals. to be able to commercialize fresh vegetables with home delivery, local producers need to adjust and facilitate their customers' payments using square point of sale (pos) or facilitating electronic bank transfers. we again use multivariate correspondence to analyze the correlations between the sociodemographic data and the consumer buying behavior before march 16, after this date, and post the crisis triggered by the new coronavirus ( figure 14 ). in the quadrant 1 (q1) of figure 14 , the strongest correlations are visible among those who ordered fresh vegetables from producers before march 16, those who will order post-crisis, those who order weekly, those who order twice a week, those who prefer to pay cash, and the age category of 35-49. regarding the order frequency, the highest percentage of respondents who choose direct delivery prefer weekly purchases. since "after the covid-19 crisis yes" is located near the intersection of the two axes from figure 14 (q1), this confirms that most respondents will order vegetables with direct delivery after the crisis (207 respondents, 81%). among these, the highest percentage considers the "weekly" delivery version as the most convenient one (q1 in figure 14) . accordingly, there are relevant arguments indicating that the post covid-19 period will redirect more and more consumers to weekly home delivery ordering from local producers, while cash remains at the top of preferred payment methods. in q1, the strongest correlations are between the motivations and purchasing behaviors of high inertia, which favor the purchasing of fresh vegetables directly from producers. the buyer's profile (accordingly figure 14 ) is the following: aged 35-49, purchasing on a weekly basis (once or twice a week), who bought directly from producers before march 16, prefer to pay cash, and will keep buying post-crisis. we again use multivariate correspondence to analyze the correlations between the sociodemographic data and the consumer buying behavior before march 16, after this date, and post the crisis triggered by the new coronavirus ( figure 14 ). in the quadrant 1 (q1) of figure 14 , the strongest correlations are visible among those who ordered fresh vegetables from producers before march 16, those who will order post-crisis, those who order weekly, those who order twice a week, those who prefer to pay cash, and the age category of 35-49. regarding the order frequency, the highest percentage of respondents who choose direct delivery prefer weekly purchases. since "after the covid-19 crisis yes" is located near the intersection of the two axes from figure 14 (q1), this confirms that most respondents will order vegetables with direct delivery after the crisis (207 respondents, 81%). among these, the highest percentage considers the "weekly" delivery version as the most convenient one (q1 in figure 14) . accordingly, there are relevant arguments indicating that the post covid-19 period will redirect more and more consumers to weekly home delivery ordering from local producers, while cash remains at the top of preferred payment methods. in q1, the strongest correlations are between the motivations and purchasing behaviors of high inertia, which favor the purchasing of fresh vegetables directly from producers. the buyer's profile (accordingly figure 14) is the following: aged 35-49, purchasing on a weekly basis (once or twice a week), who bought directly from producers before march 16, prefer to pay cash, and will keep buying post-crisis. quadrant 2 (q2) corresponds to those who order fresh vegetables directly from producers monthly, who have not ordered since march 16, are in the 50-64 age category, and prefer to pay by bank transfer. quadrant 3 (q3) is associated with people who did not order fresh vegetables directly from producers before march 16, those who will not order or are not certain whether they will order post crisis, and those who prefer ordering every two weeks or whenever it is necessary. they are generally over 65 years old and prefer to pay by debit card. it is highly likely that this profile corresponds to retired people. for them, shopping is a form of socializing, especially in public places. these elderly people normally go shopping for fresh vegetables at farmers' markets located near their homes. it can be also asserted that this category of consumers does not go shopping to the farmers' market to support the small local producers (since the go-between traders are present everywhere in these markets, at the expense of small local producers), but they most likely do it by force of habit. quadrant 4 is associated with consumers who ordered fresh vegetables directly from producers after march 16 and are in the age category of 20-34. at the same time, the values from q4 show strong correlations and certain categories from q1, namely, preference for weekly ordering, payment made by card, and willingness to buy post crisis. several aspects of age cluster data distribution warrant further consideration. the clusters of those ranging between 20-34 and 35-49 years old are approximately equally distributed on the horizontal and vertical lines, exhibiting a higher presence in q1 and q2. in this area, it is about the high purchasing frequencies and partiality for cash payment. the cluster of those ranging between 50 and 65 years old is mainly distributed to the right side (q2 and q3). however, the difference from the distribution visible in q1 and q2 is not significant. this suggests the inertia of traditional buying behavior in short food supply chains (sfscs) is rather higher for older consumers. the cluster of the persons over 65 is mainly distributed in q3 and shows a high resilience of the purchase of fresh vegetables directly from producers on sfscs. as we have previously mentioned, such elderly people's motivations could reside in culture or could be related to socializing needs of this age group. the most representative age categories in the case of the analyzed batch prefers to pay cash and by quadrant 2 (q2) corresponds to those who order fresh vegetables directly from producers monthly, who have not ordered since march 16, are in the 50-64 age category, and prefer to pay by bank transfer. quadrant 3 (q3) is associated with people who did not order fresh vegetables directly from producers before march 16, those who will not order or are not certain whether they will order post crisis, and those who prefer ordering every two weeks or whenever it is necessary. they are generally over 65 years old and prefer to pay by debit card. it is highly likely that this profile corresponds to retired people. for them, shopping is a form of socializing, especially in public places. these elderly people normally go shopping for fresh vegetables at farmers' markets located near their homes. it can be also asserted that this category of consumers does not go shopping to the farmers' market to support the small local producers (since the go-between traders are present everywhere in these markets, at the expense of small local producers), but they most likely do it by force of habit. quadrant 4 is associated with consumers who ordered fresh vegetables directly from producers after march 16 and are in the age category of 20-34. at the same time, the values from q4 show strong correlations and certain categories from q1, namely, preference for weekly ordering, payment made by card, and willingness to buy post crisis. several aspects of age cluster data distribution warrant further consideration. the clusters of those ranging between 20-34 and 35-49 years old are approximately equally distributed on the horizontal and vertical lines, exhibiting a higher presence in q1 and q2. in this area, it is about the high purchasing frequencies and partiality for cash payment. the cluster of those ranging between 50 and 65 years old is mainly distributed to the right side (q2 and q3). however, the difference from the distribution visible in q1 and q2 is not significant. this suggests the inertia of traditional buying behavior in short food supply chains (sfscs) is rather higher for older consumers. the cluster of the persons over 65 is mainly distributed in q3 and shows a high resilience of the purchase of fresh vegetables directly from producers on sfscs. as we have previously mentioned, such elderly people's motivations could reside in culture or could be related to socializing needs of this age group. the most representative age categories in the case of the analyzed batch prefers to pay cash and by debit card. furthermore, those ranging 20-34 years old choose to pay by debit card and cash, while those of 35-49 years old prefer to pay cash and by debit card. the density of values is represented most closely to the junction of both axes in our multivariate correspondence graphs. cash or debit card payments show high densities, which are close in terms of percentage. in a western society, this feature might look slightly concerning, given the strong digital transformation undergone by these cultures. in the case of romania, the values recorded are still positive and show an increase related to the degree of acceptance of digital transformation in short food supply chains that are currently in an emergent phase in romania. there are numerous researchers who have already insisted on the consequences brought by pandemics on the economy, especially on the product distribution systems [70] [71] [72] [73] [74] [75] . some of these support the idea that such sanitary crises were followed by economic growth as a direct consequence of the increases in consumption [76, 77] , while others say that on the contrary, the effects are negative for the human activities [78] [79] [80] , especially for agriculture [81] . when it comes to the current pandemic, carlsson-szlezak [82, 83] argue there are three types of effects covid-19 has had on consumption, the market, and distribution chains. this the main reason why we think that the food distribution systems should be redesigned to strengthen resilience in the future to address the complexity of contemporary society [84] [85] [86] [87] . in this context, purchasing fresh vegetables from local producers based on order and direct delivery comes up with a series of advantages, including the fight to reduce the spread of contamination with the new coronavirus. however, consumers avoid shopping at grocery stores, farmers' markets and/or supermarkets which were often crowded during the pandemic. social distancing is respected and contact with unknown, possibly infected people is avoided. to increase local food production and sales in romania, small local producers need to adhere to shifting customer preferences and innovate their marketing strategies. cultivation of native varieties, connecting with the local features and measures for environmental protection can constitute advantages for promoting local products in the national agri-food sector. if we take into account the high degree of internet infrastructure development, the e-commerce development of vegetable farmers and virtual farmers' markets or platforms can also represent solutions for developing businesses in the short food supply chains in times of crises and beyond. based on the analyses run in this study, a series of general recommendations stand out for local producers. first, it is advisable for agricultural producers to adjust payment methods to consumers' demands by purchasing mobile pos systems as well as to develop their own brands and products with an integrated promotion (in analog and digital system). at the same time, and of equal importance, it is imperative for producers to implement up-to-date technologies for placing online orders by developing their own specialized websites and social media. additionally, innovative marketing and planning of the distribution should be made in accordance with the customers' demands and short food supply chains. last but not least, local producers could associate in cooperative organizations for a better access to the market. for business development, certain limitations need to be taken into consideration. first, supply of fresh vegetables directly from local producers cannot be achieved in romania throughout the calendar year due to the seasonal nature of crops and reduced areas designated for greenhouses or poly tunnels [88, 89] . the quantities and vegetable varieties locally produced and available on the market are reduced due to their zonal and seasonal nature, and consequently, the demand cannot be exclusively covered by local production [88] . another key factor is the final price of the product, as the price of the local vegetables sold through sfscs is regularly higher than the prices of similar products in the hypermarket networks [90, 91] . to address these issues and come up with viable solutions, the producers could follow the successful associative models from western europe thus gaining more visibility and authority in the marketplace. however, the reticence of romanian small producers is a common denominator when it comes to associating and cooperating locally, including making a common brand, which cannot but become a hindrance for penetrating the local market [92] [93] [94] . in romania, the digital transformation of small producers can have a positive effect for the entire economy. however, the digital transformation is also influenced by certain local factors. for instance, to develop distribution channels, small producers need to invest in infrastructure. nevertheless, their financial possibilities are rather limited, and they choose to invest in means of production at the expense of infrastructure for commercialization and marketing [95] . furthermore, many small enterprises are in dire need of time, another impediment for digital transformation as they allot most of their activities to production and bringing products to market. additionally, the scarce digital literacy of agricultural producers is a barrier preventing and limiting the development of the these innovative marketing instruments [96] . concurrently, we strongly encourage the consumption of fresh vegetables directly purchased from producers and the development of short food supply chains (sfscs), which bring a series of benefits to the consumers. typically, local products distributed by sfscs have superior nutritional value and favorable impacts on people's general condition and health. using spscs now and into the future can result in indirect economic benefits to consumers by retaining capital locally, which, in turn, has a multiplying effect within the regional economy (maintaining and creating jobs, reinvested profit in productive activities, duties and taxes for the local revenue, etc.) additionally, the acquisitions made within the sfscs contribute to environmental protection and hence improve the life quality, especially in urban areas, not to mention the fact that the purchase of fresh vegetables directly from local producers on a regular basis tackles the issue of food waste. moreover, by consuming local fresh vegetables, the consumer brings his/her own contribution to the preservation of local tradition and identity (local gastronomy, local varieties of vegetables, rural culture, circular rural economy). finally, the direct delivery of fresh vegetables saves time for consumers by reducing the time spend on purchasing food. our results confirm the hypothesis that the covid-19 pandemic induced significant changes in consumer purchasing behavior of fresh vegetables. consequently, consumers are more determined to place online orders of fresh vegetables directly delivered by producers. prior to enforcing the state of emergency, 12% of the respondents from the quarantined area of suceava chose the online purchase of fresh vegetables directly delivered by producers. an increased percentage of the respondents (60%) have stated that they intend to adopt this system of buying from short food supply chains (sfscs) following the covid-19 crisis. the preference of consumers for digital instruments of gathering information, ordering, and payment proves that the changes in consumer buying behavior are not merely visible in the purchase intention within this distribution system, but also in their wish for digital transformation of sfcss. the fact that 95% of the respondents have declared that they prefer a personal selection of the products shows that they choose to involve directly and emotionally in the process of selection and purchase. this is a feature that has not undergone any changes in the timeline determined by the period before march 16, after this date, and after emerging from the covid-19 crisis. on the other hand, this study reaches the conclusion that producers should develop their own distribution instruments in a novel manner and by taking into account the preferences shown by the romanian buyers for high-frequency purchases (weekly or once every two weeks). thus, sfscs represent a viable solution to the pandemic, since in romania's current context, the reliability and safety of the conventional pattern of agricultural production has been brought into question. last but not least, to be able to run their businesses under 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like to thank our reviewers for the suggestions that led to improving this manuscript. the authors declare no conflicts of interest. key: cord-304996-st1nn3pc authors: baggiani, angelo; briani, silvia; luchini, grazia; giraldi, mauro; milli, carlo; cristaudo, alfonso; trillini, lucia; rossi, lorenzo; gaffi, stefano; ceccanti, giovanni; martino, maria carola; marchetti, federica; pardi, marinella; escati, fabio; scateni, monica; frangioni, simona; ciucci, antonella; arzilli, guglielmo; sironi, daniele; mariottini, francesco; papini, francesca; casigliani, virginia; scardina, giuditta; visi, giacomo; bisordi, costanza; mariotti, tommaso; gemignani, giulia; casini, beatrice; porretta, andrea; tavoschi, lara; totaro, michele; privitera, gaetano pierpaolo title: preparedness and response to the covid-19 emergency: experience from the teaching hospital of pisa, italy date: 2020-10-09 journal: int j environ res public health doi: 10.3390/ijerph17207376 sha: doc_id: 304996 cord_uid: st1nn3pc in italy, the coronavirus disease 2019 (covid-19) emergency took hold in lombardy and veneto at the end of february 2020 and spread unevenly among the other regions in the following weeks. in tuscany, the progressive increase of hospitalized covid-19 patients required the set-up of a regional task force to prepare for and effectively respond to the emergency. in this case report, we aim to describe the key elements that have been identified and implemented in our center, a 1082-bed hospital located in the pisa district, to rapidly respond to the covid-19 outbreak in order to guarantee safety of patients and healthcare workers. italy has been heavily affected by coronavirus 2019 disease , along with other countries such as spain [1] . during the pandemic, healthcare facilities had to quickly adapt to address the clinical complexity of covid-19 cases, the high influx of cases in hospitals and the rise of transmission of the pathogen among hospitalized patients and health care workers (hcw), modifying health service pathways greatly. in italy, the first locally acquired covid-19 cases were detected in the regions of lombardy and veneto on 21 february 2020 [2] . the country reached more than 100,000 cases and over 10,000 deaths by the end of march [3] . the severity of the outbreak convinced the italian government to adopt unprecedented measures, with the imposition of a national lockdown on 9 march 2020 [4] and the closure of all activities not providing essential services on 22 march 2020 [5] . in tuscany, an italian region of 3.7 million inhabitants, the first confirmed case of covid-19 was detected in florence on 25 february 2020 [6] . since then, the epidemic has grown rapidly, though at a lower rate than has been observed in the most affected italian regions (i.e., lombardy), and the epidemic has also grown unevenly among different provinces, with massa and lucca recording the highest impact. the number of cumulative cases increased significantly during march and april 2020, with an exponential growth at the start that later turned out to be better approximated by the gombertz function, with the exponential growth slowing down and becoming linear until a plateau was reached. in tuscany, the number of new daily cases was highest at the beginning of april (maximum n = 406 on 2 april) and then decreased gradually (<100 new cases on 21 april). the number of individuals simultaneously requiring hospital care reached its peak in the first week of april (n = 1149 on 3 april) and remained steady for a few weeks before slowly decreasing at the end of the month. during the plateau, individuals requiring intensive care represented almost 25% of inpatients (maximum hospitalized patients = 297 on 1 april). since 24 april, 742 deaths have been reported in tuscany among covid-19 cases, with a case-fatality rate of 8.2%, lower than the national average of 13.4% [7] . figure 1 reports the covid-19 infection trend in tuscany during the emergency. convinced the italian government to adopt unprecedented measures, with the imposition of a national lockdown on 9 march 2020 [4] and the closure of all activities not providing essential services on 22 march 2020 [5] . in tuscany, an italian region of 3.7 million inhabitants, the first confirmed case of covid-19 was detected in florence on 25 february 2020 [6] . since then, the epidemic has grown rapidly, though at a lower rate than has been observed in the most affected italian regions (i.e., lombardy), and the epidemic has also grown unevenly among different provinces, with massa and lucca recording the highest impact. the number of cumulative cases increased significantly during march and april 2020, with an exponential growth at the start that later turned out to be better approximated by the gombertz function, with the exponential growth slowing down and becoming linear until a plateau was reached. in tuscany, the number of new daily cases was highest at the beginning of april (maximum n = 406 on 2 april) and then decreased gradually (<100 new cases on 21 april). the number of individuals simultaneously requiring hospital care reached its peak in the first week of april (n = 1149 on 3 april) and remained steady for a few weeks before slowly decreasing at the end of the month. during the plateau, individuals requiring intensive care represented almost 25% of inpatients (maximum hospitalized patients = 297 on 1 april). since 24 april, 742 deaths have been reported in tuscany among covid-19 cases, with a case-fatality rate of 8.2%, lower than the national average of 13.4% [7] . figure 1 reports the covid-19 infection trend in tuscany during the emergency. on the same date, the north-west (nw) area was the most affected, followed by the central and the south-east (se) areas. additionally, hospitalization rates (hr) among cases and proportions of inpatients requiring intensive care varied greatly among different sub-regional areas, with the nw area presenting an hr of 10.2% (c: 15.4% and se: 9.8%) and a proportion of patients admitted to intensive care units (icus) of 21.3% (c: 17.0% and se: 16.4%). health services in tuscany are organized by the regional department of health (rdh) in three sub-regional areas: central, with a population of 1,500,000 and 3000 hospital beds; nw, with a population of 1,200,000 and 3000 hospital beds; and se, with a population of 800,000 and 1600 hospital beds. in each area there is one teaching hospital (th), a number of district hospitals (dh) and smaller hospitals. on 4 march, the rdh established a regional task force (tf) with the aim of on the same date, the north-west (nw) area was the most affected, followed by the central and the south-east (se) areas. additionally, hospitalization rates (hr) among cases and proportions of inpatients requiring intensive care varied greatly among different sub-regional areas, with the nw area presenting an hr of 10.2% (c: 15.4% and se: 9.8%) and a proportion of patients admitted to intensive care units (icus) of 21.3% (c: 17.0% and se: 16.4%). health services in tuscany are organized by the regional department of health (rdh) in three sub-regional areas: central, with a population of 1,500,000 and 3000 hospital beds; nw, with a population of 1,200,000 and 3000 hospital beds; and se, with a population of 800,000 and 1600 hospital beds. in each area there is one teaching hospital (th), a number of district hospitals (dh) and smaller hospitals. on 4 march, the rdh established a regional task force (tf) with the aim of coordinating the preparedness plan of the regional health services and providing technical guidance [8] . the assessment of the demand for icu beds in tuscany was carried out by the remote center for medical relief operations (rcmro), founded in pistoia (tuscany, italy). the rcmro coordinated the availability and use of beds in hospitals outside of tuscany. ths were designated as the referral hospitals for patients affected by covid-19 in their respective area (core hospital type a). dhs were divided into two groups: hospitals type b (secondary hospitals) and type c (primary hospitals). type b hospitals provide care for time-dependent diseases like stroke, and a sufficient number of icu beds are reserved for covid-19 patients if needed. type c hospitals, such as some public hospitals and all nursing homes, lack adequate icu and are reserved for patients who tested negative for sars-cov-2. in anticipation of a high influx of icu covid-19 cases, planned activities were scaled down, resulting in an icu occupation rate of 68% on march 19 [9] . in the nw area, more than half of icus (46 of 79) and ordinary beds (184 of 326) available for covid-19 patients were housed in our tertiary hospital. other measures the territorial health care services took to respond to the additional needs included the creation of special units composed of a doctor and a nurse that provided dedicated home care to patients with suspected or confirmed covid-19 infection; assessing the need of nasopharyngeal swab or hospitalization [10] ; the set-up of health hotels for covid-19 patients discharged from hospital but still positive; increasing the number of beds for intermediate care hospitals [11] ; and reinforcing the epidemiological monitoring of nursing homes and long-term care facilities for elderly [12] . the nw area registered its first case on 27 february. a few days earlier, territorial healthcare services and the nw referral hospital, azienda ospedaliero-universitaria pisana (aoup), began their reorganization. the aoup is a highly specialized teaching, tertiary, 1082-bed hospital, and it is organized into two main facilities: cisanello and santa chiara. shortly after the first tuscany covid-19 case, aoup organized a multidisciplinary tf, composed of experts in infection prevention and control (ipc), occupational medicine and hospital management. based on scientific data published since the start of the outbreak and previous experience from former outbreaks (sars and mers-cov), the tf developed a technical procedure to face the pandemic, structured in five key domains: reorganization of hospital services, management of suspected or confirmed covid-19 patients, management of corpses, guidelines for cleaning and disinfection, implementation of cleaning and disinfection procedures, and personal protective equipment. after drafting the procedure, the tf divided the emergency medicine hospital into covid-19 and not-covid-19 areas, which were organized into accident and emergency (a&e), clinical wards, icus and operating rooms. healthcare workers were assigned to one area or another with no interchangeability. the a&e in covid area was organized into four settings: pre-triage area, triage area, one negative pressure room and one room to perform the nasopharyngeal swab (swabbing room). a&e in not-covid-19 area consisted of one triage area. clinical wards of covid area were divided into infectious disease units and pulmonology units. from 19 march, several clinical wards and operating rooms, located in different hospital units, have been repurposed to realize 160 additional beds in covid-19 clinical wards (covid-19 area 1-2-3-4). in icus of covid-19 area, a total of 83 beds were divided into five icus (icus 1-5). out of 83 beds, 53 (65%) were placed in a positive-pressure environment and may be considered as "conventional icu beds". the remaining 30 beds were installed in negative-pressure rooms. negative-pressure isolation room system (−9 pa) and hepa15 filters were installed to contain airborne microorganisms within the room. negative pressure isolation rooms were used for covid-19-positive patients with respiratory failure, usually treated with aerosol-generating c-pap therapy (c-pap beds) [13] . icus of not-covid-19 areas were reduced to 38 beds. covid-19 and not-covid-19 areas included 3 and 23 operating rooms, respectively. subdivision of covid-19 and not-covid-19 areas is shown in figures 2-4. in aoup, a pre-triage tent was set up in front of the a&e entrance and a pre-triage nurse performed a symptoms-based screening of incoming patients, including those arriving by ambulance). individuals with fever or respiratory symptoms, or those fulfilling any epidemiological criteria, were considered suspected cases [14] . testing of suspected covid cases was conducted by a dedicated triage nurse in one of the a&e covid-19 area rooms; all other patients were directed to a&e not-covid area triage. dedicated hcws went to the isolation room and made an evaluation of the clinical conditions. on the basis of anamnestic and clinical examination, the suspected case of covid-19 could be excluded or confirmed. if confirmed, the patient underwent the nasopharyngeal swab for sars-cov-2. patients who had emergency clinical signs and needed surgery or interventional procedures were subjected to swab in a&e or directly in the operating/interventional room. since 9 march (the day national lockdown started), the procedure of admission changed and every patient who needed to be hospitalized was tested for covid. if the patient's clinical condition suggested the need for a radiological examination, a reserved path was defined. suspected covid cases who needed an immediate cpap cycle were treated in the a&e negative pressure box or were immediately hospitalized in a surgery room turned into a negative-pressure cpap room. until the swab result was available, the patient remained in a dedicated area. upon arrival of the swab outcome, if the swab was positive, the patient was directed to the covid area (icu or medical ward). otherwise, if the swab was negative, the patient was directed to the not-covid area (icu or medical ward). despite a negative swab, patients with strong clinical/radiological suspicion were directed to the covid area (for these cases it was recommended to repeat the swab after 24 h). for covid wards, a monitoring and management system called "visual covid" was established, allowing the real-time display of the beds available in areas of various care intensity. a preparedness plan for the safe handling of dead bodies of suspected or confirmed covid-19 cases at the site of death and during transport and storage in the hospital morgue was established in accordance with national institutional reports [15, 16] . to secure safety for healthcare staff at the site of death, a face mask was placed over the mouth of the deceased in order to prevent the release of droplets. staff responsible for transport of bodies from the site of death to the morgue had to wear appropriate ppe, and the corpses had to be wrapped in a sheet and a body bag (two if significant leakage of bodily fluids was present) in order to avoid contamination of environmental surfaces and minimize risk of transmission to staff related to direct contact with human remains. once arrived at the morgue, if the body had to be placed in the cold room, it was preferable to choose the lower cells, and it had to be written on the appropriate blackboard that the body was a covid-19 dead body. forensic examination of covid corpses was discouraged if not strictly necessary. before the closure of the coffin, one family member at a time was authorized to see the body from a distance of at least two meters. cleaning and disinfection procedures were drawn up in accordance with the available scientific indications issued by the main international health organizations [17] [18] [19] . disinfection methods used for sars-cov-1 and mers-cov did not differ from those used routinely in the hospital [20] and were assumed to be reasonably valid also for sars-cov-2. as recommended by the italian national institute of health, the following biocides were applied: in aoup, appropriately trained cleaning staff sanitized covid-19 patients' rooms four times per day. moreover, after the discharge or transfer of a covid-19 patient, the nursing coordinator initiated the cleaning service by filling a dedicated form. in addition, reusable medical devices were cleaned and properly sanitized. laboratory equipment was sanitized in accordance with the manufacturer's instructions or in accordance with the internal laboratory protocols. disposable cloth with disinfect solution was used to reduce risk of aerosol spreading. floors and high touch surfaces (bed sides, bedside tables, tabletops, handles, push buttons and all bathroom surfaces) were cleaned with water and common detergents followed by disinfection with sodium hypochlorite (0.5% free chlorine). sodium hypochlorite was used for biological liquid decontamination (15 min before removing and sanitizing it, using disposable wipes). following all activities involving aerosol production (e.g., bed preparation) and before proceeding with any other activities, rooms had to be adequately ventilated (at least 30 min in case of natural ventilation and if an adequate ventilation system was not available). in accordance with the above, used bed linen was placed in a hermetically sealed bag that was sent directly to an industrial washing chain (washing cycle of 60 • c for at least 30 min). according to currently available data [22] , wastes generated during patient care had to be managed according to current hospital protocols, without specific additional measures. for laboratory wastes, dedicated procedures have been applied. cleaning personnel wore appropriate personal protective equipment (ppe) described for service personnel (table 1) , including an additional pair of rubber gloves. all staff received appropriate training in dressing/undressing procedure. in not-covid-19 areas, patients and workers used surgical masks, gloves and gowns as ppe as described by who and national institute of health [23, 24] . in covid-19 areas, ffp2 or ffp3 masks, eye protection, a double pair of gloves and a second gown were recommended, mostly during the aerosol-generating procedures. all masks needed to be certified as described by british standard (bs) en 149:2001 standard [25] . all staff in covid-19 and not-covid-19 areas were trained on how to dress and undress. the dressing and undressing procedures for healthcare workers in covid-19 areas followed the national guidelines [26]. this case report gives an overview of the strategies adopted in our teaching hospital to respond to the first phase of the emergency. the hospital response had to be integrated with a territorial response, where the creation of multidisciplinary teams composed of different professional figures secured the presence of medical assistance for suspected or confirmed covid-19 patients outside the hospital. in our opinion, among all possible measures that could be adopted by the hospital, the differentiation of covid/not covid pathways associated with the delay of all surgical interventions that were not urgent and the decision to limit hospital admission only to people needing immediate care were the most appropriate interventions to reduce transmission of the disease among other patients and healthcare staff. as described elsewhere [27] , when an outbreak of an emerging infectious disease occurs, it is important to use revised triage and hospital protocols to reorganize the provision of healthcare services. the experience of the aoup can be useful for other similar tertiary hospitals facing this and future emergencies. furthermore, the possibility of a second wave in our nation is not to be excluded, and many countries around the world are still struggling to control the emergency. novel coronavirus (covid-19) situation covid-19 deaths in lombardy, italy: data in context. lancet public health 2020, 5, e315 covid-19, situation report updated at decreto del presidente del consiglio dei ministri 09 marzo 2020 decreto del presidente del consiglio dei ministri 22 marzo 2020 due casi sospetti ancora in attesa di conferma dall'iss ricostruzione di scenari dell'epidemia covid-19 in toscana ordinanza del presidente della giunta regionale n • 7 del 04 marzo 2020 covid-19 ricostruzione di scenari dell'epidemia in toscana-rapporto 24 luglio 2020 ordinanza del presidente della giunta regionale n • 20 del 29 marzo 2020 ordinanza del presidente della giunta regionale n • 18 del 25 marzo 2020 management of healthcare areas for the prevention of covid-19 emergency in an italian teaching hospital infezione respiratoria da covid-19-documento su autopsia e riscontro diagnostic-comlas e siapec-iap rapporto iss covid-19-n. 1/2020 "indicazioni ad interim per l'effettuazione dell'isolamento e della assistenza sanitaria domiciliare nell'attuale contesto covid-19 rapporto iss covid-19 n. 4/2020 rev.-indicazioni ad interim per la prevenzione e il controllo dell'infezione da sars-cov-2 in strutture residenziali sociosanitarie persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents environmental contamination of sars-cov-2 during the covid-19 outbreak in south korea aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 chemical disinfectants and antiseptics-quantitative suspension test for the evaluation of virucidal activity in the medical area-test method and requirements (phase 2/step 1) pilsen rapporto iss covid-19 n. 3/2020 rev. 2-indicazioni ad interim per la gestione dei rifiuti urbani in relazione alla trasmissione dell'infezione da virus sars-cov-2 world health organization. rational use of personal protective equipment for coronavirus disease (covid-19) and considerations during severe shortages rapporto iss covid-19 n. 2/2020 rev. 2-indicazioni ad interim per un utilizzo razionale delle protezioni per infezione da sars-cov-2 nelle attività sanitarie e sociosanitarie (assistenza a soggetti affetti da covid-19) nell'attuale scenario emergenziale sars-cov-2 respiratory protective devices. filtering half masks to protect against particles. requirements, testing, marking revised triage and surveillance protocols for temporary emergency department closures in tertiary hospitals as a response to covid-19 crisis in daegu metropolitan city this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-334889-mn8ctg6x authors: song, yang; sun, dong; istván, bíró; thirupathi, anand; liang, minjun; teo, ee-chon; gu, yaodong title: current evidence on traditional chinese exercise for cancers: a systematic review of randomized controlled trials date: 2020-07-12 journal: int j environ res public health doi: 10.3390/ijerph17145011 sha: doc_id: 334889 cord_uid: mn8ctg6x traditional chinese exercise (tce) has gradually become one of the widespread complementary therapies for treatment and recovery of cancers. however, evidence based on the systematic evaluation of its efficacy is lacking, and there appears to be no conclusion regarding the setting of tce interventions. the purpose of this systematic review is to summarize the current randomized controlled trials (rcts) that outline the effects of tce on cancer patients. relevant studies were searched by google scholar, sciencedirect, and web of science using “traditional chinese exercise” and “cancer.” only rcts published in peer-reviewed english journals were included. a total of 27 studies covering 1616 cancer patients satisfied the eligibility criteria for this review. despite the methodological limitation and relatively high risk of bias possessed by some included studies, positive evidence was still detected on the effects of tce on these cancer-related health outcomes in physical, psychological, and physiological parameters. the 60-min or 90-min course of tce intervention for two to three times per week for 10 to 12 weeks was found to be the most common setting in these studies and has effectively benefited cancer patients. these findings add scientific support to encourage cancer patients to practice tce during or after conventional medical treatment. nevertheless, future well-designed rcts with improved methodology and larger sample size on this field are much warranted for further verification. corona virus disease 2019 has recently swept the globe, causing escalating health costs and economic loss to all countries in the world [1] . according to the latest report released by world health organization (who), coronavirus pneumonia has infected 3,917,366 people and caused 274,361 deaths worldwide by the time of 10:00 cest, 10 may 2020 [2] . the situation now is the most severe in the united states, where the number of infection and death caused by covid-19 is still rising rapidly [2] . up to now, 1,300,696 cases of covid-19 infection and 78,771 deaths have been confirmed in the united states based on the latest update from centers for disease control and prevention (cdc), accounting for almost a third of number worldwide [3] . while the covid-19 has caused tremendous damage to human beings, cancer, as the second leading cause of death worldwide, has become one of the biggest threats to increase human life a thorough computer-aided literature search of google scholar (all years), sciencedirect (all years), and web of science (1960-present) was performed until 15 april 2020, to identify all relevant studies. the following search terms were used for this review "traditional chinese exercise" and "cancer." the search procedure is outlined in figure 1 , while the search strategy varies slightly with the above databases. in google scholar database, the "advanced search" was applied, "traditional chinese exercise" and "cancer" were put into "with all of the words" option and "anywhere in the article" was chosen. in sciencedirect and web of science databases, the "keyword search" was chosen, and key words were entered in order: "traditional chinese exercise" and "cancer." to ensure the study searching process is thorough and rigorous, two authors independently checked and assessed all the retrieved records, and disagreements regarding inclusion (if happened) were resolved by discussing or consulting a third author. furthermore, the citation snowballing method was used to manually locate all the potential relative papers in the bibliographies of the eligible articles or retrieved reviews [16, 17] . the studies were eligible for inclusion if they met the following eligibility criteria: (1) types of studies: only randomized controlled trials (rcts) published in peer-reviewed english journals were covered. observational studies, cross-sectional studies, reviews, case reports, conference papers were considered for exclusion. (2) types of participants: patients who have been diagnosed with cancers were considered, but there is no restriction on age, gender, cancer type, tumor grade, and treatment state (pre-/mid-/post-treatment). (3) types of interventions: studies where tce (e.g., qigong, tai chi chuan, and baduanjin) was applied in the intervention group were included, but there is no restriction on the control group where usual care, low-intensity exercises, health education, or psychological therapy can be used. (4) types of outcomes: studies used physical, and/or psychological, and/or biochemical parameters to assess the effects of tce on cancer patients were included. for each study, the following data were extracted and summarized independently by an author and verified by another author, study characteristics (e.g., authors, nationality of the first author, and the studies were eligible for inclusion if they met the following eligibility criteria: (1) types of studies: only randomized controlled trials (rcts) published in peer-reviewed english journals were covered. observational studies, cross-sectional studies, reviews, case reports, conference papers were considered for exclusion. (2) types of participants: patients who have been diagnosed with cancers were considered, but there is no restriction on age, gender, cancer type, tumor grade, and treatment state (pre-/mid-/post-treatment). (3) types of interventions: studies where tce (e.g., qigong, tai chi chuan, and baduanjin) was applied in the intervention group were included, but there is no restriction on the control group where usual care, low-intensity exercises, health education, or psychological therapy can be used. (4) types of outcomes: studies used physical, and/or psychological, and/or biochemical parameters to assess the effects of tce on cancer patients were included. for each study, the following data were extracted and summarized independently by an author and verified by another author, study characteristics (e.g., authors, nationality of the first author, and published year), participant characteristics (e.g., ethnicity, number of participants, age, gender, cancer types, and treatment state), description of interventions (e.g., exercise types, frequency, and duration), outcome parameters, and primary results. disagreements (if any) were resolved by discussing or consulting a third author. mendeley reference management software (elsevier ltd., amsterdam, the netherlands) was applied for organizing papers and generating citations. the quality of each included study was assessed independently by two authors based on the cochrane risk of bias assessment tool [18] . a third author was consulted if any disagreements happened. the following seven domains were evaluated: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other biases. each domain has three grades: low risk of bias, unclear risk of bias, and high risk of bias. as shown in figure 1 , the literature search yielded 275 records from the above three databases, and they were reduced to 157 after excluding all the irrelevant or duplicate studies. then, according to the eligibility criteria, 108 papers from google scholar, 23 papers from web of science, and 5 papers from sciencedirect were further excluded for several reasons (e.g., studies were not randomized; animal studies or studies were not related to cancer patients; studies were not related to tce; study protocols without any outcomes). thirteen additional articles were identified after manually checking the reference lists of the eligible articles or retrieved reviews, while 7 studies were further excluded because of duplicates between databases. a total of 27 trials satisfied the eligibility criteria were finally included in this review. all included studies were assessed in terms of the risk of bias ( figure 2 and table 1 ). because of the nature of intervention, it may be not possible to blind the participants and/or personnel to group allocation and outcome. therefore, the corresponding two domains, blinding of participants and personnel and blinding of outcome assessment, were the major sources of risk of bias from these studies (n = 27, 100.00%). in addition, of the 27 studies, only 16 trials (59.26%) described the method of group randomization in detail and 8 trials (29.63%) used the allocation concealment, which also increases the risk of bias. however, a low risk of incomplete outcome data bias (n = 26, 96.30%) and selective reporting bias (n = 27, 100.00%) was reported in most studies. allocation and outcome. therefore, the corresponding two domains, blinding of participants and personnel and blinding of outcome assessment, were the major sources of risk of bias from these studies (n = 27, 100.00%). in addition, of the 27 studies, only 16 trials (59.26%) described the method of group randomization in detail and 8 trials (29.63%) used the allocation concealment, which also increases the risk of bias. however, a low risk of incomplete outcome data bias (n = 26, 96.30%) and selective reporting bias (n = 27, 100.00%) was reported in most studies. the basic characteristics of all included studies are summarized in table 2 . the countries or regions of these publications are mainly the united states (n = 15, 55.56%), the people's republic of china (n = 8, 29.63%), australia (n = 3, 11.11%), and malaysia (n = 1, 3.70%). twenty-seven studies covered 1616 cancer patients (14 studies covered patients with breast cancer; 5 studies covered patients with heterogeneous cancer; 4 studies covered patients with lung cancer; 2 studies covered patients with prostate cancer; 1 study covered patients with non-hodgkin's lymphoma; 1 study covered patients with colorectal cancer), and most of patients are caucasian, non-latino, or white race. the modes of tce intervention used in these studies were mostly tai chi and qigong, and there are also two studies that combined the above two tce. of all the tai chi chuan interventions applied in these studies, yang-style tai chi chuan was the most common one. on the other side, various types of qigong were used, such as guolin new qigong, chan-chuang qigong, zhi neng qigong, and baduanjin qigong. the total duration of tce interventions varied from 3 to 24 weeks, with 10 to 12 weeks being the most common one. in addition, the intervention frequency ranged from 1 to 7 times per week, in which each time persisted for 20 to 120 min. the primary findings that reported in these included studies are showed in table 3 . summary of these results are presented in the following three parts: (1) effects of tce on physical outcomes; (2) effects of tce on physiological outcomes; (3) effects of tce on psychological outcomes. five studies that evaluated the effects of tce on physical outcomes were included in this review. galantino et al. [19] first started rct on breast cancer patients. subjects were required to take part in a 60-min course of yang-style tai chi chuan or walking interventions three times per week for 6 weeks in total. they found that both interventions have no appreciable effects on patients' body mass index, and they indicated that it is due to the small sample size. two subsequent articles also based on breast cancer patients reported some positive results [20, 21] . both trials employed a 12-week yang-style tai chi chuan or psychosocial interventions (60 min × 3 times/week) on subjects, and the results demonstrated that tai chi chuan can improve the overall function capacity, including aerobic capacity, muscular strength, and flexibility, when compared to psychosocial therapy or pre-intervention. finally, two recent studies have investigated the effects of qigong on cancer patients. ying et al. [22] compared the effects of a continuous baduanjin qigong intervention (60 min per day for 6 months) with original physical activity on breast cancer patients and found that the former have a significantly better effect on physical rehabilitation, such as body mass index and shoulder range of motion, which put a conflicting result with galantino et al. study [19] . lu et al. [23] conducted a relatively similar study on colorectal cancer patients. subjects were asked to perform baduanjin qigong exercise (20-40 min) five times per week for 24 weeks. they reported that this type of tce can help improve physical activity level. twelve studies were included in this category. oh et al. conducted three trials in 2008, 2010, and 2012, respectively [24] [25] [26] , with the aim to investigate the effects of qigong on inflammatory markers in cancer patients (mainly breast cancer patients). a 90-min course of modified qigong program was applied in their studies two times per week for 8 to 10 weeks, and all three studies demonstrated that qigong exercise can significantly decrease the level of inflammatory markers compared to control group where subjects only received standard medical care. it is interesting to note that, peppone et al. [14] in 2010 compared the influences of tce with standard support therapy on bone loss biomarkers in breast cancer patients. they reported that a 12-week yang-style tai chi chuan intervention for three times per week with 60 min per time can exert more positive effects on bone health of breast cancer patients. in 2011 and 2014, similar to what oh et al. found, two studies examined the influences of tai chi chuan exercise on inflammatory markers in breast cancer patients and also reported positive effects [27, 28] . twelve-week yang-style tai chi chuan intervention (60 min × 3 times/week) and 3-month tai chi chuan intervention (120 min per week) were applied in the two studies, respectively. besides the effects of tce on inflammatory markers, the expression of genes encoding pro-inflammatory mediators was found lower after tce by irwin et al. [27] , while janelsins et al. [28] also reported that the level of insulin remained stable after tce but increased after control intervention when compared to pre-intervention. however, conflicting results also emerged in recent years. although there are some differences in the tce intervention settings (three times per week at 60 min per time for 12 weeks by campo et al. [29] , while 90 min per week for 10 weeks by sprod et al. [30] ), these two studies reported that tai chi chuan intervention exhibited no superior effects on inflammatory markers than control group. nevertheless, campo et al. [29] found some positive effects on blood pressure and salivary cortisol after tce intervention. also, in terms of blood parameters, in a larger rct in 2017, chuang et al. [13] investigated the effects of 21-day chan-chuang qigong intervention (25 min per time for 2 to 3 times per day) on 100 non-hodgkin lymphoma patients, and they reported that the white blood cell counts and hemoglobin levels were significantly improved after tce when compared to control intervention. there are three more studies included in this category, which evaluated the effects of 16-week tai chi chuan intervention (60 min per time for three times per week), respectively on the proliferation and cytolytic/tumoricidal activities of peripheral blood mononuclear cell [31] , the balance between cellular and humoral immunity [32] , and the cellular immune responses [33] in non-small cell lung cancer patients. all of them found positive, statistically significant effects after tce intervention. the majority of rcts included in this review (19 out of 27 trials) investigated the effects of tce on psychological outcomes in cancer patients. to be more specific, quality of life was assessed in 11 studies, fatigue in 10 studies, mood status (e.g., distress, anxiety, and depression) in 8 studies, sleep quality in 6 studies, and cognitive function in 1 study. the functional assessment of cancer therapy-general (fact-g) was generally used to measure the score of quality of life. of all these 11 studies, most (n = 9) reported significantly positive effects after tce interventions on quality of life, and the 60 or 90 min per time at 2-3 times per week for 10-12 weeks was the commonly used setting of tce intervention [13, 21, [24] [25] [26] 30, [34] [35] [36] . nevertheless, the remaining two studies conducted in 2013 proposed some different results. campo et al. [37] employed a 12-week tai chi chuan intervention (60 min per time for three times per week) on solid tumor cancer patients (83% breast cancer patients), and they reported that there is no difference on quality of life between tce and control intervention. robins et al. [38] also found no difference between groups and even compared to pre-intervention after 10-week tai chi chuan intervention (90 min per week) on breast cancer patients. assessed using brief fatigue inventory (bfi) or functional assessment of chronic illness therapy (facit), more than half studies (seven of ten trials) found that tce can significantly reduce the cancer-related fatigue [13, 23, 25, 34, [39] [40] [41] . however, the setting of tce intervention varied greatly between studies, which make it inconclusive. besides, contrary findings also existed. two studies based on breast cancer patients and one study on prostate cancer patients reported no positive effects after 6-week yang-style tai chi chuan intervention (60 min per time for three times per week) [19] , 8-week zhi neng qigong intervention (30 min per time for three times per week) [35] , and 6-to 8-week yang-style tai chi chuan and qigong intervention (40 min per time for three times per week) [42] , respectively. in terms of mood status and sleep quality, conflicting and equivocal results continued to emerge in recent years. five of eight studies that examined the effects of tce on mood status using corresponding self-administered questionnaire (e.g., profile of mood state (pms)) reported significantly positive effects compared to control intervention [22, 25, 34, 36, 39] , while the remaining three studies found no difference [35, 38, 40] . similarly, only two of six studies that investigated the effects of tce on sleep quality using corresponding self-rated questionnaire (e.g., pittsburgh sleep quality index (psqi)) reported significantly positive effects compared to control intervention [13, 23] , while the remaining four studies found no difference [34, 40, 42, 43] . the diversified settings of tce intervention may be the potential reason for these contraries. finally, a study by oh et al. [26] explored the effects of a 90-min modified qigong program (two times per week for 10 weeks) on cognitive function in patients with heterogeneous cancers, and the results showed that tce was more effective in improving cognitive function than the control intervention. this systematic review comprehensively summarized evidence from a large number of rcts investigating the effects of tce on health outcomes in cancer patients during or after the standard medical treatment, with the aim to determine the appropriate setting of tce intervention that can contribute to beneficial outcomes for the treatment and recovery of cancer. there is a great variability in outcome parameters reported in these included studies. to be more specific, physical, physiological, and psychological parameters are all examined in the 27 trials covered in this review. regarding physical and physiological outcomes, most of the related studies reported significantly positive effects after tce interventions. nevertheless, one study investigated the effect of tce on body mass index and two on inflammatory markers have not come out with better results when compared to pre-intervention or control group. galantino et al. [19] demonstrated that the small sample size may be the main reason for this controversy. findings became more conflicting and equivocal when it comes to psychological parameters, which may be due to the limited number of studies after they have been divided into several secondary outcomes, such as quality of life, fatigue, mood status, sleep quality, and cognitive function. in terms of the tce intervention, tai chi and qigong have been widely used in these studies, and a thorough examination of the included trials indicated that the 60 or 90 min per time at two to three times per week for 10 to 12 weeks is the most common and frequent used setting. overall, the findings of this review added support to the previous studies suggested that cancer patients may benefit more from tce both during and after the standard medical treatment. however, more rcts investigating the effects of tce intervention on the psychological outcomes in cancer patients are much warranted for further verification. the potential mechanisms by which tce can help in the treatment and recovery of cancer patients have been extensively speculated, while data compiled in this review showed only restricted evidence to support these. tce is a complex mind-body exercise that is based on the essential theories of chinese medicine [12] . most forms focus on the inter-coordination of posture, breathing patterns, and meditation, by which the natural health recovery-mechanisms could be evoked, while the release level of endogenous neurohormones could be balanced [44] , thus, the physical and emotional tension and immune function may be improved [25] . it is interesting to note that a study by janelsins et al. [28] developed a model to compare the micro-molecular changes that occurred during tce or non-physical activity interventions in breast cancer patients. they hypothesized that cytokines interleukin (il-6) may be associated with the inflammation-medicated cellular proliferation and tumor growth, while with the processing of tce intervention (e.g., tai chi chuan), the derived il-6 would contribute to the anti-inflammatory effects and the lipolysis then is induced, which ultimately help in maintaining weight and reducing the recurrence risk. also, studies have demonstrated that overweight cancer patients (e.g., breast, prostrate, and colorectal cancer patients) may be associated with higher risk of cancer recurrence and even death [45] [46] [47] . thus, the above internal mechanism could be plausible to some specific cancer patients. nevertheless, the underlying mechanisms may vary with many aspects (e.g., population, the type, and stage of cancer) and remain to be further clarified. some notable flaws of study design that existed in these included studies need further addressing. for example, small sample size is problematic as it may increase the risk of type π error for results [48] . of the 27 included studies, more than one-third of the studies (n = 12) had a sample size of less than 50, with the smallest number being 11 participants. thirteen studies were based on a sample size of more than 50 but less than 100. only 2 studies covered a sample of more than 100. in addition, the relatively high risk of bias possessed by these included studies is another problem. as stated in the result part, blinding of participants and personnel and blinding of outcome assessment were the major sources of risk of bias from these studies. besides, of the 27 included studies, only 16 studies described the method of group randomization in detail and 8 used the allocation concealment. thus, the result reliability of these studies would be weakened, which may also put certain influence on the synthesis of these results. this review also brings some implications for future studies on this field. above all, future research needs to investigate the long-term impacts of tce intervention in a large sample. the motivation and exercise history of the recruited patients should be assessed before group randomization in order to maximize their adherence to the tce programs. in addition, most included studies explored the effect of tai chi or qigong on cancer patients. however, other tce modalities, such as yijinjing and liuzijue, are also worth studying. in conclusion, this review further confirmed that tce could be more beneficial than the standard medical care or even other exercises with the similar intensity for improving physical, physiological, and psychological outcomes in cancer patients. the 60-min or 90-min course of tce intervention for two to three times per week for 10 to 12 weeks was found to be the most common setting in these studies that may effectively benefit cancer patients. however, limited number of rcts in certain field (e.g., psychology), methodological flaws, and relatively high risk of bias in these included studies remain to be further addressed and clarified. the authors declare no conflict of interest. crossref] 2. world health organization. coronavirus disease (covid-19) situation report-111 covidview: a weekly surveillance summary of u.s. covid-19 activity global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the global burden of disease study global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study the epidemiologic 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(2013) [37] 1. quality of life. 1.although mental score after tce is higher than pre-intervention, there is no difference in quality of life between the two groups. campo insulin. improvement in the level of cytokine/myokine il-6 after tce compared to con; 2.the levels of insulin remained stable after tce but increased after con compared to pre-intervention. key: cord-334282-8fni03cj authors: arvelo, enrique; de armas, jesica; guillen, monserrat title: assessing the distribution of elderly requiring care: a case study on the residents in barcelona and the impact of covid-19 date: 2020-10-15 journal: int j environ res public health doi: 10.3390/ijerph17207486 sha: doc_id: 334282 cord_uid: 8fni03cj in this work, we establish a methodological framework to analyze the care demand for elderly citizens in any area with a large proportion of elderly population, and to find connections to the cumulative incidence of covid-19. thanks to this analysis, it is possible to detect deficiencies in the public elderly care system, identify the most disadvantaged areas in this sense, and reveal convenient information to improve the system. the methods used in each step of the framework belong to data analytics: choropleth maps, clustering analysis, principal component analysis, or linear regression. we applied this methodology to barcelona to analyze the distribution of the demand for elderly care services. thus, we obtained a deeper understanding of how the demand for elderly care is dispersed throughout the city. considering the characteristics that were likely to impact the demand for homecare in the neighborhoods, we clearly identified five groups of neighborhoods with different profiles and needs. additionally, we found that the number of cases in each neighborhood was more correlated to the number of elderly people in the neighborhood than it was to the number of beds in assisted living or day care facilities in the neighborhood, despite the negative impact of covid-19 cases on the reputation of this kind of center. caring for the elderly is a profoundly human experience. throughout human history, every generation has been tasked with caring for their elderly when they reach their later years. despite the universal nature of elderly care, it can be carried out in different ways. apart from familial care, there are three main types of elderly care services: assisted living facilities (al), day care facilities (dc), and homecare services (hc). all three services can be privately operated as a private for-profit business or publicly operated government programs. for example, in barcelona, the local government is obliged to provide elder care services to all residents who cannot afford basic support. however, there are also higher-end alternatives for individuals who are willing and able to pay for them. from the point of view of companies or institutions offering any of these care services, it is important to balance the quality of service and the operating efficiency, although it is not easy to measure and quantify it [1] . all of these services are designed to fulfill the special needs of senior citizens, who can be defined as those above the age of 65. the eldercare market is an enormous global market, which is estimated to exceed 417 billion usd by the year 2026 [2] . al, colloquially known as nursing homes, are a popular form of elderly care where the elderly live in dormitory-like facilities among some of their peers. in these institutions, the elderly citizens have accordingly, this work is structured as follows. section 2 is devoted to describing the data required and the methodology proposed to develop the analysis; in section 3, we outline our tests and results; section 4 provides a discussion on pros and cons of each kind of care service in barcelona and demand trends in the future; and finally, conclusions and implications are described in section 5. to develop this study, we gathered some data about barcelona from different sources, and we applied several analysis techniques to extract patterns and knowledge. in the following, we detail the data sources and variables and the methodology applied. a comprehensive database of barcelona's demographics was compiled primarily through combining several tables from open data bcn [8] . open data bcn is a public resource offered by the barcelona government, where they host hundreds of high-quality open-source data tables. barcelona's al and dc are also available in this data source. in addition to the data tables from barcelona open data, there were some relevant data manually extracted from official government reports and papers published on barcelona's government website [9] . these data have been complemented with covid-19 information. on july 16th 2020, the first wave of covid-19 was virtually finished, with no cases in hospitals and almost no new cases per day. we compiled two indicators, the cumulated number of confirmed covid-19 cases and the rate of confirmed cases per 100,000 residents by zone. the data were provided directly by the municipal data office. table 1 shows a summary of the data sources. a few publicly available variables that would be interesting to analyze to gauge the demand for elderly care in barcelona are the total population, rfid (spanish acronym of disposable household income index), elderly population, elderly population living alone, and disabled elderly population. the total population is a global variable for understanding the scale of the city. the rfid is a centered index that measures the disposable income per household, where neighborhoods with mean values are given an rfid index of 100. given the current understanding, regions with higher disposable income will demand less public elderly care since they can afford more premium private services. the elderly population is a significant variable because they are the target audience, representing the total possible consumer population. elderly population living alone is a critical demographic for care services because this demographic does not have immediate familial support accordingly, this work is structured as follows. section 2 is devoted to describing the data required and the methodology proposed to develop the analysis; in section 3, we outline our tests and results; section 4 provides a discussion on pros and cons of each kind of care service in barcelona and demand trends in the future; and finally, conclusions and implications are described in section 5. to develop this study, we gathered some data about barcelona from different sources, and we applied several analysis techniques to extract patterns and knowledge. in the following, we detail the data sources and variables and the methodology applied. a comprehensive database of barcelona's demographics was compiled primarily through combining several tables from open data bcn [8] . open data bcn is a public resource offered by the barcelona government, where they host hundreds of high-quality open-source data tables. barcelona's al and dc are also available in this data source. in addition to the data tables from barcelona open data, there were some relevant data manually extracted from official government reports and papers published on barcelona's government website [9] . these data have been complemented with covid-19 information. on july 16th 2020, the first wave of covid-19 was virtually finished, with no cases in hospitals and almost no new cases per day. we compiled two indicators, the cumulated number of confirmed covid-19 cases and the rate of confirmed cases per 100,000 residents by zone. the data were provided directly by the municipal data office. table 1 shows a summary of the data sources. a few publicly available variables that would be interesting to analyze to gauge the demand for elderly care in barcelona are the total population, rfid (spanish acronym of disposable household income index), elderly population, elderly population living alone, and disabled elderly population. the total population is a global variable for understanding the scale of the city. the rfid is a centered index that measures the disposable income per household, where neighborhoods with mean values are given an rfid index of 100. given the current understanding, regions with higher disposable income will demand less public elderly care since they can afford more premium private services. the elderly population is a significant variable because they are the target audience, representing the total possible consumer population. elderly population living alone is a critical demographic for care services because this demographic does not have immediate familial support to help them complete daily activities. finally, the disabled elderly population is another critical demographic. these individuals are elderly people suffering from some degree of disability that may impair them in completing everyday activities. we propose a methodological framework composed of a sequence of steps to analyze the demand for elderly care services in a predefined area and to find connections to the cumulative incidence of covid-19. as mentioned before, we chose barcelona due to the elderly population percentage and number of cases of covid-19, although the same methodology can be applied to any other similar area. for the subsequent analysis, some analytic techniques were employed to reveal patterns and structure hidden within the data. choropleth maps (cm) are used to understand the distribution of the elderly demanding care services across different neighborhoods by analyzing the distribution of variables linked to this demand. cluster analysis (ca) serves to elucidate the elderly demographics across neighborhoods. these clusters then provide a framework for developing a plan for addressing the different demands of the neighborhood groups. principal component analysis (pca) summarizes complex data with several variables into a lower dimension or a single figure, allowing one to understand the patterns in the data and how the variables relate to one another. in this study, pca was used to understand where each neighborhood is positioned concerning select demographic variables. linear regression (lr) is a classical statistical technique to model the expected outcome as a function of covariates. here, we modelled the number of covid-19 cases per zone and the number of confirmed cases per 100,000 residents as a function of some demographic characteristics. the aim of this analysis was to detect the most important factors in the scope of this work that impacted the number of covid-19 cases. our case study analyzed the area of barcelona to understand the needs of care for barcelona's elderly population and to find connections between covid-19 cases and some variables related to the elderly population. in the following sections, we detail the four framework steps applied to this case study. through this analysis, we took a deeper dive into the distribution of the previously discussed demographic variables across barcelona's different neighborhoods. this allows us to begin to understand how the demand for elderly care is distributed across neighborhoods and how resources should be efficiently allocated. in the following, we analyze the distribution of the population in detail, considering the whole population, elderly population, rfid, elderly population living alone, and disabled elderly population. population: the population of neighborhoods (see figure s1a ) has a positively skewed distribution, with a mean of 22,203 and a median of 20,487. the population has a wide range, ranging from 610 in el clot (42) to 58,180 in la nova esquerra de l'eixample (09). looking at the map, it is clear that the distribution is not randomly distributed geographically. the bulk of the population is centered in the center of the city, in the eixample neighborhoods and the neighborhoods immediately to the north of it. apart from this central cluster, sant andreu, in the top right, has the second-highest population of any of the neighborhoods. the neighborhoods in the top of the map near the mountains and bottom of the map near the coast are less populated on average. • elderly population: the total elderly population, intuitively, very closely resembles the distribution of the population (see figure s1b ,c). the mean elderly population is 4782.63 per neighborhood, ranging from 90 people in el clot (42) to 13,413 in la nova esquerra de l'eixample (09). to account for the difference in demand between the neighborhoods, the darker shaded neighborhoods should typically be allocated more resources than lighter shaded neighborhoods to allow them to service their larger elderly population. however, the number of resources must be adjusted to account for the rfid, elderly living alone, and disabled elderly population. the map of the relative percentage of elderly per neighborhood sheds some light on how the distribution of the elderly differs across different neighborhoods. the general geographic trend is that the neighborhoods tend to have a higher percentage of elderly as one moves up from the coast to the mountains. • rfid: the rfid index (see figure s1 .d) has a wide range, where the most impoverished neighborhood is la trinitat nova (53), with an rfid index of 34.70, indicating that the average household in that neighborhood has 34.70% of the average disposable income. the wealthiest neighborhood is pedralbes (21), with an rfid index of 251.7, indicating that the average household in that neighborhood has 2.5 times more disposable income than the mean. like many income variables, it is very positively skewed, with the high-income area pulling the average up; 72.6% of the neighborhoods lie below the average, with only 27.3% lying above the average. this variable can be used as a scaling factor, where neighborhoods that have above the mean rfid receive fewer relative resources for their population. the map shows that the city's income seems to be correlated with geographic location. the neighborhoods in the eixample, sarrià, gràcia, and les corts tend to have rfid scores above 100. the five neighborhoods in the top of the map, trinitat nova, torre baró, ciutat meridiana, vallbona, and la trinitat vella, and the neighborhood at the bottom, la marina del prat vermell, have the lowest rfid scores, all below 50. then, the majority of the neighborhoods on the right half of the map and the bottom left of the map have rfid indexes between 50 and 100. elderly population living alone: the elderly living alone map (see figure s1e ) correlates with the elderly population map; as the number of elderly increases, those that live alone will also increase. therefore, to extract new information, it would be interesting to analyze the relative distribution of elderly people living alone ( figure s1f ). the percentage of elderly living alone has a reasonably normal distribution with a mean of 25.07%. the variable ranges from 13.56% in vallbona (56) to 34.34% in sant pere, santa caterina i la ribera (04). there is not a clear geographic concentration or correlation like in the previous charts; however, we can still see some minor patterns. ciutadella district neighborhoods have a large percentage of elderly people living alone. like the rfid, this variable can be used to adjust the base demand. neighborhoods with more significant percentages of elderly people living alone should receive a greater share of resources than a neighborhood of a similar population with a lower percentage of elderly people living alone, all other things held equal. • disabled elderly population: the base elderly disabled population stat is highly correlated with the elderly population ( figure s1g ,h); therefore, we look at the percentage of elderly that are disabled in the neighborhood. the percentage of disabled, again, has a relatively normal distribution, with a mean of 20.41%. the variable ranges from 12.94% in les tres torres (24) to 33.80% in la marina del prat vermell (12). the geographical pattern resembles the rfid pattern, but high income is negatively correlated with high disability rates. once again, this variable can be used to scale the base demand for homecare, where neighborhoods with larger percentages of disabled elderly people should receive a greater share of resources than a neighborhood with a similar population and a lower percentage of disabled elderly people, all other things held equal. this section builds on the analysis of barcelona's demographics, describes a brief market study, and segments barcelona's neighborhoods based on the characteristics that are likely to impact the demand for homecare in the neighborhoods. this analysis will provide us with a deeper understanding of how the demand for elderly care is dispersed throughout the city and how it can be used to create a generalized action plan to target each of the segments before specializing in the individual neighborhoods. this segmentation was created using a non-hierarchal k-means euclidean clustering method to group the neighborhoods into different clusters. the variables used in our clustering were the scaled values for the absolute values of the elderly population, rfid, percentage of the elderly with a disability, and percentage of elderly living alone. these variables were chosen because these variables directly impact the resources needed to serve the elderly of the community. the variables where then scaled (normalized) using a min-max scaling algorithm to account for the difference in the scale and variance of each variable. the scaling made it so that no variable dominated the other variables. the incremental improvement in the between-cluster variance for the barcelona neighborhood data is shown in figure 2 . given that we wanted to maximize the improvement while keeping the number of clusters relatively small, five clusters seemed to be the optimal number. five clusters are a manageable number that allows for more straightforward interpretation and the development of unique strategies for each cluster of neighborhoods. • disabled elderly population: the base elderly disabled population stat is highly correlated with the elderly population ( figure s1g ,h); therefore, we look at the percentage of elderly that are disabled in the neighborhood. the percentage of disabled, again, has a relatively normal distribution, with a mean of 20.41%. the variable ranges from 12.94% in les tres torres (24) to 33.80% in la marina del prat vermell (12) . the geographical pattern resembles the rfid pattern, but high income is negatively correlated with high disability rates. once again, this variable can be used to scale the base demand for homecare, where neighborhoods with larger percentages of disabled elderly people should receive a greater share of resources than a neighborhood with a similar population and a lower percentage of disabled elderly people, all other things held equal. this section builds on the analysis of barcelona's demographics, describes a brief market study, and segments barcelona's neighborhoods based on the characteristics that are likely to impact the demand for homecare in the neighborhoods. this analysis will provide us with a deeper understanding of how the demand for elderly care is dispersed throughout the city and how it can be used to create a generalized action plan to target each of the segments before specializing in the individual neighborhoods. this segmentation was created using a non-hierarchal k-means euclidean clustering method to group the neighborhoods into different clusters. the variables used in our clustering were the scaled values for the absolute values of the elderly population, rfid, percentage of the elderly with a disability, and percentage of elderly living alone. these variables were chosen because these variables directly impact the resources needed to serve the elderly of the community. the variables where then scaled (normalized) using a min-max scaling algorithm to account for the difference in the scale and variance of each variable. the scaling made it so that no variable dominated the other variables. the incremental improvement in the between-cluster variance for the barcelona neighborhood data is shown in figure 2 . given that we wanted to maximize the improvement while keeping the number of clusters relatively small, five clusters seemed to be the optimal number. five clusters are a manageable number that allows for more straightforward interpretation and the development of unique strategies for each cluster of neighborhoods. the between-cluster variance was equal to 0.687. this indicates that the clustering explained approximately 68.7% of the total variance in the data set. the neighborhoods were not evenly distributed among the clusters, with cluster 1 with 13, cluster 2 with 14, cluster 3 with 7, cluster 4 with 29, and cluster 5 with 10 (see the outcome of ca in table s1 ). these clusters were then mapped as shown in figure 3 , to better understand the make-up of the different neighborhood groups. analyzing this figure, it is interesting to see how geographically similar the neighborhoods in each cluster were to one another. cluster 1 is composed of outskirt neighborhoods on the borders of the city, primarily on the top right. cluster 2 is composed of the neighborhoods in the center of the city. cluster 3 is primarily composed of neighborhoods in the top left in the sarria-sant gervasi district. cluster 4 is the largest group with the largest spread, with the bulk of the neighborhoods spanning from the bottom right to the central top. finally, cluster 5 is the between-cluster variance was equal to 0.687. this indicates that the clustering explained approximately 68.7% of the total variance in the data set. the neighborhoods were not evenly distributed among the clusters, with cluster 1 with 13, cluster 2 with 14, cluster 3 with 7, cluster 4 with 29, and cluster 5 with 10 (see the outcome of ca in table s1 ). these clusters were then mapped as shown in figure 3 , to better understand the make-up of the different neighborhood groups. analyzing this figure, it is interesting to see how geographically similar the neighborhoods in each cluster were to one another. cluster 1 is composed of outskirt neighborhoods on the borders of the city, primarily on the top right. cluster 2 is composed of the neighborhoods in the center of the city. cluster 3 is primarily composed of neighborhoods in the top left in the sarria-sant gervasi district. cluster 4 is the largest group with the largest spread, with the bulk of the neighborhoods spanning from the bottom right to the central top. finally, cluster 5 is composed of neighborhoods primarily in the ciutat vella district, with a few neighborhoods scattered in the top right. this map is useful for understanding the cluster's general distribution and how the population in the city is distributed using one simple figure. composed of neighborhoods primarily in the ciutat vella district, with a few neighborhoods scattered in the top right. this map is useful for understanding the cluster's general distribution and how the population in the city is distributed using one simple figure. the next step was to validate the robustness of the k-means clustering. the ward clustering for the barcelona data is presented in figure 4 . composed of neighborhoods primarily in the ciutat vella district, with a few neighborhoods scattered in the top right. this map is useful for understanding the cluster's general distribution and how the population in the city is distributed using one simple figure. the next step was to validate the robustness of the k-means clustering. the ward clustering for the barcelona data is presented in figure 4 . as we can see from the dendrogram and table 2andtable 3, the models were similar but not identical, with an overall hit rate of 82.3%. in other words, 82.3% of the observations from the initial k-means cluster were placed in the same cluster under the ward clustering. breaking it down by clusters, cluster 1 had a hit rate of 92.3%, cluster 2 had a hit rate of 100%, cluster 3 had a hit rate of 100%, cluster 4 had a hit rate 58.7%, and cluster 5 had a hit rate of 100%. the majority of the misclassifications occurred between clusters 1 and 4, where ten neighborhoods that were classified in cluster 4 using k-means were classified in cluster 1 when using the ward distance. these results were mixed. clusters 2, 4, and 5 were fairly consistent across the two models, suggesting that these clusters are discrete structures in the data. however, the models had a difficult time distinguishing between clusters 1 and 4. these two clusters had very similar distributions for the rfid and percentages of elderly people living alone, which caused some smaller neighborhoods in cluster 4 to be classified as cluster 1 using the ward method. looking forward, the pca shows that although clusters were distinguishable, they bordered one another, with some neighborhoods in both clusters having similar characteristics. the largest distinguishable difference between these "borderline" neighborhoods is that those in cluster 1 had a higher percentage of disabled elderly citizens. the goal of the segmentation was to serve as an exploratory exercise to understand the clusters better and develop a general action plan for implementing care services in the different neighborhoods of barcelona. this segmentation would need to be taken along with other analysis such as the maps or pca. therefore, although the segmentation was not entirely robust, its hit rate was tolerable for the scope of this work. the distribution of the clusters for critical variables was analyzed ( figure s2 corresponds to four boxplots, which are the basis for the profiles of the different clusters). cluster 1: forgotten neighborhoods. this cluster represents barcelona "forgotten" neighborhoods. cluster 1, along with cluster 4, is home to barcelona's most vulnerable elderly population. these small neighborhoods on the outskirts of the city have a low population, the lowest levels of disposable income, and high levels of disabled elderly. however, they, fortunately, have a lower percentage of elderly people living alone. it is imperative that despite the peripheral location and low population, these neighborhoods receive adequate resources. the low income and high disability indicate that neighborhoods in this cluster require a more substantial amount of resources per capita than clusters 2, 3, and 4. • cluster 2: densely populated city districts. this cluster represents the more stereotypical, highly populated neighborhoods. these neighborhoods have large populations with the overall largest number of elderly people. these districts have a high percentage of elderly living alone. however, this is offset by an above-average disposable income and low percentages of elderly people. these districts need a large number of resources to serve a large number of people in the neighborhoods. however, they likely need fewer resources per person due to their above-average wealth and low disability rate among the elderly. • cluster 3: wealthy and healthy. this cluster represents barcelona's most privileged communities. cluster 3 has, by far, the highest disposable income, giving them much greater access to resources than others. this district has the lowest disability rate among the elderly and the lowest percentage of elderly living alone. this district would likely need fewer resources per elderly citizen than the rest of the districts. the high wealth will allow a possible user to afford more premium elder care services. the low percentage of elderly living alone indicates that they, on average, have support, which decreases the demand for homecare in minor cases. all this compounded with the fact that the district has the lowest elderly disability rate indicates that resources could be better used in other districts. • cluster 4: middle class. this cluster is the largest in terms of neighborhoods, and it represents barcelona's middle-income neighborhoods. this cluster of neighborhoods is the second most populous behind the cluster. they have a middle level of income, with an rfid around 76, which is around the midpoint when accounting for the right skew of the variable. when compared to the other neighborhoods, it has mid-level percentages of disabled, elderly, and disabled elderly. these neighborhoods act as the baseline for barcelona in terms of demand for care services. they should receive more resources per capita than clusters 2 and 3 but less than clusters 1 and 5. cluster 5: vulnerable. this cluster represents barcelona's most vulnerable neighborhoods. these neighborhoods, along with those in cluster 1, have the lowest disposable income in barcelona. in addition, these neighborhoods have, by far, the highest percentages of elderly living alone and of elderly with disabilities. putting it all together, it paints a grim picture for the quality of life for the elderly citizens in this cluster. these neighborhoods should be a priority when implementing an elderly care system in barcelona and be allocated the highest amount of resources per capita compared to the rest of the clusters. pca is an additional tool that, along with the segmentation and cm, can help to characterize the different neighborhoods in terms of some key variables. the directions of the arrows represent the directions in the plot that the particular variables increase, and the color of the text represents the cluster of the neighborhood. overall, the pca was able to capture 78% of the data's variation, indicating that the chart is useful but should not be taken as an exact representation. in a pca analysis, it is possible to form a characterization of a neighborhood or group of neighborhoods by looking at where they are positioned in the plane and the direction of the arrows (see figure s3 ). at an initial glance, the chart seems to support the previous ca and their characterizations. except for a few outliers, the clusters lie in clear groups. these characterizations created with the pca corroborate those developed with the initial ca. cluster 1 is spread out into the top right region of the map; we can see that neighborhoods in this cluster tend to have a smaller cumulative population of elderly citizens, a lower percentage of people living alone, a higher percentage of disabled, and a lower rfid index. • cluster 2 is located at the bottom left of the chart; this positioning indicates that these neighborhoods have a higher cumulative number of elderly citizens, a higher than average rfid, a large percentage of elderly citizens living alone, and a low percentage of disabled elderly people. • cluster 3 is located on the top left of the map, indicating that it has the highest rfid, a somewhat higher number of elderly than average, low percentages of elderly people living alone, and the lowest percentage of disabled elderly. • cluster 4, as mentioned in the previous section, represents the median neighborhoods, as it lies in the midpoint of the chart, indicating it represents the mean value for the four variables. • cluster 5 is located on the bottom right of the map. like cluster 1, it has lower values for the rfid and a high percentage of disabled elderly. however, unlike cluster 1, it is located towards the bottom of the map, indicating a large elderly population and a large percentage of elderly people living alone. table 4 presents the results of regression models for the number of covid-19 cases in each neighborhood as a function of some characteristics. the results show that the most important factor is the number of elderly residents in the neighborhood. what we can obtain from such a model is an association; we cannot really prove causality, but we can conclude that there is a positive relationship between those zones with a higher number of elderly people and those zones with a higher number of covid-19 cases. once this demographic variable is in the model, the number of al or dc does not seem to be related to the outbreak. we may also add that younger people have had a tendency to be carrying the virus while experiencing no symptoms themselves, whereas elderly people showed more severe signs and so they were tested and confirmed. at the current stage, we cannot see a causal relationship, but we certainly see that the covid-19 outbreak was not exclusive to community services where elderly people live together, even if contagion between elderly patients was easier in those institutions than at home. in order to see the influence of service capacity and the percentage of disabled elderly citizens on the response variable, which is the number of cases in the neighborhood after the first wave, we created eight different models. table 4 displays, in the first four columns, the models that do not include the percentage of disabled elderly residents and, in the last four columns, the models that contain this covariate. in models (1) to (4) and (5) to (8), we introduce the dc capacity, al capacity, total elderly service capacity, and former two. the model results show adjusted r 2 above 75%, and all the models indicate that the larger the number of elderly residents, the higher the expected number of total cases in the neighborhood, while the higher the income index (rfid), the lower the expected number of cases in the neighborhood; i.e., wealthier areas are expected to have fewer cases. in order to provide a comparison that is not influenced by the population size in each neighborhood, we analyzed covid-19 cases per 100,000 residents. in this new set of models, we included the percentage of elderly population instead of the total elderly population. table 5 presents the model results. the results in table 5 lead to the same conclusions as those in table 4 ; the expected number of covid-19 cases per 100,000 residents increases in neighborhoods with a larger percentage of elderly population and lower income index, while there is no evidence of an association with the number of elderly services (al, dc, or both) in the neighborhood. table 5 . regression analysis for the cases per 100,000 residents in barcelona by neighborhood until 20 july 2020 (standard errors are displayed in parenthesis under the coefficient estimates, n = 73 neighborhoods). (1) figures 5 and 6 show that the density of covid-19 cases is not concentrated in the areas with more facility services, but it could be argued that the centers in the central areas are smaller than those located in the outskirts. the regression models control for the size of the al and dc services, and they show that, when controlling for the influence of the elderly residents, al and dc size are not associated with a larger number of expected positive covid-19 cases. neighborhood, we analyzed covid-19 cases per 100,000 residents. in this new set of models, we included the percentage of elderly population instead of the total elderly population. table 5 presents the model results. the results in table 5 lead to the same conclusions as those in table 4 ; the expected number of covid-19 cases per 100,000 residents increases in neighborhoods with a larger percentage of elderly population and lower income index, while there is no evidence of an association with the number of elderly services (al, dc, or both) in the neighborhood. table 5 . regression analysis for the cases per 100,000 residents in barcelona by neighborhood until july 20th 2020 (standard errors are displayed in parenthesis under the coefficient estimates, n = 73 neighborhoods). (1) figures 5 and 6 show that the density of covid-19 cases is not concentrated in the areas with more facility services, but it could be argued that the centers in the central areas are smaller than those located in the outskirts. the regression models control for the size of the al and dc services, and they show that, when controlling for the influence of the elderly residents, al and dc size are not associated with a larger number of expected positive covid-19 cases. as mentioned before, there are three main kinds of care services for elderly people, al, dc, and hc. additionally, teleassistance and similar options seem to have gained popularity during the first coronavirus wave [11] . these are offered to fragile citizens who live alone or are alone most of the day. citizens can obtain urgent assistance by simply pushing a button in a necklace, or they can be contacted by phone. within this global vision of elderly care services, the advantages of hc can be summarized in the following main ideas: lower cost and more scalable than other options without decreasing care quality, increased independence of the elderly person, better quality of life, and limited contact between elderly individuals, which implies limited spread of viral diseases in the case of an outbreak. a study by nordic researchers stated that "on average, a place in a retirement home costs 49,500 euros annually, whereas homecare costs 20,300 euros" [12] . these savings show that expanding the homecare system is generally more cost-effective than systematically moving individuals into assisted living facilities. breaking it down, to implement an assisted living center or a day center, it is necessary to build a physical facility with room to house patients, common areas, dining areas, bathrooms, and kitchens. these facilities would cost a significant amount of money to set up and have significant maintenance costs associated with cleaning and rent. additionally, as the number of patients admitted to the facilities increases, the quality of service each client receives decreases as the relative space per user drops [13, 14] . each facility has a maximum capacity, and once that capacity is met, they cannot accept any more people. this leads to scenarios of underserved communities, where people needing care are denied state-run al and put on long waitlists with no guarantee of ever getting off [15] . by nature of their design, hc avoid many of these problems, because elderly people stay in their own homes and if demand increases, providers may recruit additional specialized carers [16] . indirect savings from homecare come from a decreased number of doctor visits and hospital admissions for people enrolled in homecare systems. a 2014 study found that elderly residents enrolled in hc who had experienced some mental decline had a significantly lower inpatient hospital admission rate than those without hc [17] . they also went to the doctor 25% less than those who were not enrolled [18] . these studies show that adopting hc can lead to significant savings later on. another critical reason to adopt hc is that, in general, elderly people prefer them to the other options. hc provide the user with a level of autonomy, comfort, and privacy that is not available from the other options. a 2016 survey conducted by the american association of retired persons (aarp) found that 90% of elderly citizens in the united states want to remain living in their homes for as long as possible [19] . as mentioned before, there are three main kinds of care services for elderly people, al, dc, and hc. additionally, teleassistance and similar options seem to have gained popularity during the first coronavirus wave [11] . these are offered to fragile citizens who live alone or are alone most of the day. citizens can obtain urgent assistance by simply pushing a button in a necklace, or they can be contacted by phone. within this global vision of elderly care services, the advantages of hc can be summarized in the following main ideas: lower cost and more scalable than other options without decreasing care quality, increased independence of the elderly person, better quality of life, and limited contact between elderly individuals, which implies limited spread of viral diseases in the case of an outbreak. a study by nordic researchers stated that "on average, a place in a retirement home costs 49,500 euros annually, whereas homecare costs 20,300 euros" [12] . these savings show that expanding the homecare system is generally more cost-effective than systematically moving individuals into assisted living facilities. breaking it down, to implement an assisted living center or a day center, it is necessary to build a physical facility with room to house patients, common areas, dining areas, bathrooms, and kitchens. these facilities would cost a significant amount of money to set up and have significant maintenance costs associated with cleaning and rent. additionally, as the number of patients admitted to the facilities increases, the quality of service each client receives decreases as the relative space per user drops [13, 14] . each facility has a maximum capacity, and once that capacity is met, they cannot accept any more people. this leads to scenarios of underserved communities, where people needing care are denied state-run al and put on long waitlists with no guarantee of ever getting off [15] . by nature of their design, hc avoid many of these problems, because elderly people stay in their own homes and if demand increases, providers may recruit additional specialized carers [16] . indirect savings from homecare come from a decreased number of doctor visits and hospital admissions for people enrolled in homecare systems. a 2014 study found that elderly residents enrolled in hc who had experienced some mental decline had a significantly lower inpatient hospital admission rate than those without hc [17] . they also went to the doctor 25% less than those who were not enrolled [18] . these studies show that adopting hc can lead to significant savings later on. another critical reason to adopt hc is that, in general, elderly people prefer them to the other options. hc provide the user with a level of autonomy, comfort, and privacy that is not available from the other options. a 2016 survey conducted by the american association of retired persons (aarp) found that 90% of elderly citizens in the united states want to remain living in their homes for as long as possible [19] . the most topical reason for the adoption of hc is the reduction of disease spread. the layouts of al and dc are conducive to the spread of viruses. in these facilities, the residents spend the vast majority of time under the same roof as dozens of other residents. they all share bathrooms, eat in dining halls, and occupy the same common spaces. if a visitor, worker, or doctor gets sick and passes the infection on to a resident, everyone else in the facility is at risk, and due to the design plan, it is difficult to maintain social distance and avoid contaminated surfaces when many people are living under the same roof [20] . this is increasingly worrisome when considering that elderly citizens who need assistance are the population group most vulnerable to some diseases such as the flu or viruses. this problem was highlighted during the coronavirus crisis. the world health organization stated in mid-april 2020 that up to half of the covid-19 deaths in europe occurred in long-term-care facilities [21] . these centers facilitate the spread of disease and are not equipped to handle an outbreak once it occurs, although some policies have been considered after this first coronavirus wave [22] . the workers are often not medical professionals and do not feel the same obligation to treat their residents as a nurse or doctor would. around the globe, family visits were banned to attempt to mitigate the spread of disease into nursing homes; however, this decision may have come with the unintended effect of many residents being forcefully detached from any support system and abandoned. a particularly gruesome example of this happened when the spanish military was sent to disinfect al around madrid; they found dozens of residents either dead in their beds or left completely abandoned. this is not an isolated incident, as a large number of al in italy, spain, and the united states are under investigation for malpractice. unfortunately, this was a problem long before covid-19, since studies have shown that al are hotbeds for respiratory and gastrointestinal infections, although these devastating consequences often go unrecognized and unappreciated [23] . this grave problem could be mitigated by increasing the use of hc as the preferred method of elderly care. in a homecare environment, there are substantially fewer opportunities for contagion from co-residents. users live in their own private homes and only come in contact with their homecare worker. for a disease to spread from one user to another, it would need to go from the infected person to the homecare worker and to the other, which is unlikely if proper safety precautions are taken such as washing hands, covering coughs, and using appropriate ppe when working with a sick patient. additionally, homecare users will not lose access to their support systems during times of crises, as they have the autonomy to reach out for help from family, friends, or neighbors. we anticipate that citizens would possibly prefer hc in the future due to the large number of covid-19 cases observed during the first wave in al. this has had an enormous negative impact on the reputation of al. in this regard, we show that the number of cases in each neighborhood is more correlated to the number of elderly people in the neighborhood than it is to the number of beds in al or to the number of dc in the area we have used as a case study. considering that the elderly population is on the rise in many countries of the world, there is a clear need for an adequate system to deal with the care of the elderly in the near future, especially in the face of pandemics such as covid-19. thanks to the methodological framework proposed in this work, it is possible to analyze the care demand for elderly citizens and to find connections to the number of cases of covid-19 in any area with a large proportion of elderly population. as a case study, we applied it to barcelona, a city with a large elderly population and a high incidence of covid-19. thus, we have evidenced that data on elderly care services and demographic information help to understand the geographical dispersion and singularities of a large metropolitan area, showing that there may be zones more deprived than others and areas that need to improve the number of care services in the next decades. it is possible to detect deficiencies in the elderly care system and provide interesting insights to improve it. this analysis can be considered as a system to alert one to the need for better resources. additionally, our case study for the city of barcelona, at the end of the first coronavirus wave of the 2020 outbreak, shows that the cumulative incidence of covid-19 was higher in those geographical zones that had a large number of elderly citizens. this leads us to conclude that not only should al and dc be under lockdown primarily in the early stages of an outbreak, but also that extended hc should be specially designed to isolate the fragile population at home, thus preventing contagion. improving hc is especially important for active residents who do not need round-the-clock surveillance. we propose that teleassistance, which has a virtually 100% coverage of the target population at risk, elderly and fragile individuals living alone, can be used to provide these citizens with basic needs and support to avoid their contact with the community outside their dwellings. as future work, we plan to monitor new waves of the coronavirus crises and their impact on the elderly population living in metropolitan areas. since hc seem to be the preferred form of long-term care for the majority of citizens and they could be more demanded after this pandemic, we will work to propose a framework to assess the state of this kind of care system in a certain area. this is a challenge, since we will need data on elderly under this kind of care, their satisfaction, and the resources and cost of hc in that area. depending on the particular area or country, hc can be provided by different institutions (health or social), increasing the difficulties in accessing and evaluating data about these services. the following are available online at http://www.mdpi.com/1660-4601/17/20/7486/s1. figure s1 : choropleth maps, figure s2 : boxplots of critical variables by clusters, figure s3 : pca of the neighborhoods, figure s4 : correlation matrix for data on 73 neighborhoods in barcelona, table s1 : cluster with k-means (k = 5). the database created and used in this work is available online at www.upf.edu/web/ephocas/ repository. the project leading to these results received funding from "la caixa" banking foundation under the project code sr0225. study of the relevance of the quality of care, operating efficiency and inefficient quality competition of senior care facilities elder care services market size 2020 industry share, trends evaluation, global growth, recent developments, latest technology, cagr of 2.4%, and 2026 future forecast research report living arrangements of older adults and covid-19 risk: it is not just nursing homes a deluged system leaves some elderly to die, rocking spain's self-image a multi-criteria decision-making model for evaluating senior daycare center locations estimating the value of social care population register ajuntament de barcelona's open data service territorial distribution of family income per capita in barcelona telemedicine in the era of covid-19 operations research improves quality and efficiency in home care a systematic literature review of efficiency measurement in nursing homes efficiency and quality of care in nursing homes: an italian case study senior care in spain home-based primary care led-outbreak mitigation in assisted living facilities in the first 100 days of coronavirus disease home instead senior care and global coalition on aging. relationship-based care and positive outcomes for people with alzheimer's and their families home instead senior care. paid in-home care: more care & better care for seniors aging in place: a state survey of livability policies and practices the unique challenges faced by assisted living communities to meet federal guidelines for covid-19 nursing homes linked to up to half of coronavirus deaths in europe, who says policy brief: covid-19 and assisted living facilities infectious disease outbreaks in nursing homes: an unappreciated hazard for frail elderly persons acknowledgments: m.g. thanks icrea academia and the spanish ministry of science pid2019-105986gb-c21. j.da. thanks the ministry of science, innovation and universities of the government of spain (ministerio de ciencia, innovación y universidades (mciu), agencia estatal de investigación (aei), fondo europeo de desarrollo regional (feder)) rti2018-095197-b-i00. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. key: cord-310165-xj025ruz authors: jones, rodney p title: would the united states have had too few beds for universal emergency care in the event of a more widespread covid-19 epidemic? date: 2020-07-19 journal: int j environ res public health doi: 10.3390/ijerph17145210 sha: doc_id: 310165 cord_uid: xj025ruz (1) background: to evaluate the level of hospital bed numbers in u.s. states relative to other countries using a new method for evaluating bed numbers, and to determine if this is sufficient for universal health care during a major covid-19 epidemic in all states (2) methods: hospital bed numbers in each state were compared using a new international comparison methodology. covid-19 deaths per 100 hospital beds were used as a proxy for bed capacity pressures. (3) results: hospital bed numbers show large variation between u.s. states and half of the states have equivalent beds to those in developing countries. relatively low population density in over half of us states appeared to have limited the spread of covid-19 thus averting a potential major hospital capacity crisis. (4) conclusions: many u.s. states had too few beds to cope with a major covid-19 epidemic, but this was averted by low population density in many states, which seemed to limit the spread of the virus. the covid-19 pandemic has caught health systems around the world by surprise. covid-19 places a special burden on acute medical and intensive care beds [1] [2] [3] . the world's largest economy, the usa, was also struggling to find the necessary resources to battle the virus. as with many countries, supplies of protective equipment and ventilators were initially in short supply [4] . new york experienced an exceptionally large number of covid-19 deaths [5] . are there any lessons to be learned from the outbreak so far within the context of a healthcare system in which both primary and secondary care are mainly resourced to deal with just insured patients [6] ? this study will seek to evaluate if u.s. states had enough hospital beds to cope with a large epidemic across all parts of the country and will use a new method for comparing inter-and intra-national bed numbers to do so. for more than four decades economists have known that health care costs and resource usage escalate toward the end of life, more so than from age per se [7] [8] [9] . this is especially so for hospital inpatient care with numerous studies demonstrating increased admissions and bed occupancy toward the end of life, which is moderately independent of the age at death [10] [11] [12] [13] . this has collectively been called the nearness to death (ntd) effect or the time to death (ttd) effect. one study indicated that while 45% of lifetime admissions occurred in the last year of life some 55% of bed occupancy occurred in this period [14] . unfortunately, these relationships have never been incorporated into methods for forecasting healthcare demand and capacity planning. such methods almost exclusively rely on time series analysis or variants of demographic or age-based forecasting [14] [15] [16] [17] [18] [19] . the limitations of these methods are discussed elsewhere [15, [18] [19] [20] [21] [22] [23] . research into better methods for comparing hospital bed numbers between countries and regions has culminated in a new method which relies on the operation of the ntd effect [24, 25] . based on this observation, bed numbers in different countries can be plotted on a graph showing beds per 1000 deaths (y-axis) versus the log of deaths per 1000 population (x-axis), also called the crude death rate. the deaths per 1000 population serve as a measure of age structure while beds per 1000 deaths reflects the role of nearness to death. this method avoids the limitations of simplistic international comparisons based on beds per 1000 population [20] , which contains no adjustment for age structure or nearness to death. regarding the use of deaths per thousand population it should be noted that as far back as 1981 a relationship between bronchitis and emphysema (men aged [65] [66] [67] [68] [69] [70] [71] [72] [73] [74] admissions per 1000 population and deaths per 1000 population had been demonstrated [19] . in this new method a set of parallel lines (by changing the intercept) can be drawn which intersect the bed provision in different countries. the average for developed countries has the equation [25] : beds per 1000 deaths = 1057 − 230.3 × ln(deaths per 1000 population), the country with the highest intercept is japan; however, this arises from ambiguity in the definition of a hospital bed where japan counts the equivalent to nursing home care in its definition of a hospital bed [25] . the lowest bed availability in the developed world, where comprehensive health care is provided for the entire population, can be found in singapore and new zealand. this has been achieved by over 20 years of government policy and policy implementation in integrated care [24, 25] . for these two countries the intercept in the above equation is 790 rather than 1057 for the international average. the method was validated at sub-national level using beds in the states of australia where a long-standing deficit in bed numbers in the state of tasmania was correctly quantified [25] . the method has subsequently been confirmed to apply at local level using data for the populations covered by clinical commissioning groups in england (submitted). total hospital bed numbers have been used in this study because they are routinely available [26] . the number of medical beds is not generally available except for several european countries and only up to the year 2009 [27] . the health insurance system and population distribution in the u.s. places a set of constraints on physician and bed availability as resources follow a mix of population density and wealth, and not necessarily need [28] [29] [30] . these issues are addressed further in the discussion section. in this analysis confirmed covid-19 deaths were from bing.com [5] , total hospital bed numbers include adult and pediatric acute care, plus maternity and mental health. international total hospital beds were from the world bank [26] , total hospital beds by us state was from the kaiser family foundation [31] , while the number of acute beds by us state was from the american hospital directory [32] . available beds are beds staffed to receive patients. state population and median household income was from united states census bureau [33, 34] . proportion rural population and rural poverty were from the us department of agriculture [35] . land use was from the national park service [36] . deaths in u.s. states was from the centers for diseases control and prevention (cdc) wonder database [37] . weighted population density was from decision science news [38] . all data is publicly available but can be obtained on request from the author. all data was manipulated, and charts prepared using microsoft excel. covid-19 deaths per bed was calculated by dividing deaths (at the 9th of june) by total hospital bed number as in the data sources. adjusted bed number by state was calculated as the higher of two methods as follows. total hospital bed numbers [31] were compared to acute bed numbers [32] . the former is from a non-mandatory survey while the latter are mandatory for medicare. the ratio of one to the other was calculated for each state. the median value of this ratio was 12% higher for total hospital beds. in 28 states, total hospital beds were lower than acute beds and in those states the higher of total hospital beds or acute beds times 1.12 was used in this study. beds in some mental health hospitals or smaller community hospitals may have been missing from the count of total beds. all other numbers are derived by simple division of one parameter by the other, i.e., covid-19 deaths per 100 total hospital beds. international data in figure 1 was from previous studies on this topic [24, 25] while the parameter adjusted beds per 1000 deaths is detailed in previous studies [24, 25] . all data was manipulated, and charts prepared using microsoft excel. covid-19 deaths per bed was calculated by dividing deaths (at the 9th of june) by total hospital bed number as in the data sources. adjusted bed number by state was calculated as the higher of two methods as follows. total hospital bed numbers [31] were compared to acute bed numbers [32] . the former is from a nonmandatory survey while the latter are mandatory for medicare. the ratio of one to the other was calculated for each state. the median value of this ratio was 12% higher for total hospital beds. in 28 states, total hospital beds were lower than acute beds and in those states the higher of total hospital beds or acute beds times 1.12 was used in this study. beds in some mental health hospitals or smaller community hospitals may have been missing from the count of total beds. all other numbers are derived by simple division of one parameter by the other, i.e., covid-19 deaths per 100 total hospital beds. international data in figure 1 was from previous studies on this topic [24, 25] while the parameter adjusted beds per 1000 deaths is detailed in previous studies [24, 25] . beds per 1000 population has been used to compare international bed numbers for many years and hence it is useful to see how this compares with beds per 1000 deaths. such a comparison is given for us states in figure 1 where it can be seen that, as expected, there is a degree of relationship between the two, such that, beds per 1000 deaths is approximately equal to 109 × beds per 1000 population. typically, younger populations lie above the trend line while older ones lie below. applying the same approach to international data [24] gives a trend line with a slope of 121 as the international average (data not shown). however, a series of lines describe the international data with a slope ranging from 63 (mainly russia and former soviet countries and also west virginia in figure 1 ) to 172 (encompassing most countries), through to 600 (kuwait, bahrain which have the youngest populations and the least deaths per 1000 population). beds per 1000 population has been used to compare international bed numbers for many years and hence it is useful to see how this compares with beds per 1000 deaths. such a comparison is given for us states in figure 1 where it can be seen that, as expected, there is a degree of relationship between the two, such that, beds per 1000 deaths is approximately equal to 109 × beds per 1000 population. typically, younger populations lie above the trend line while older ones lie below. applying the same approach to international data [24] gives a trend line with a slope of 121 as the international average (data not shown). however, a series of lines describe the international data with a slope ranging from 63 (mainly russia and former soviet countries and also west virginia in figure 1) to 172 (encompassing most countries), through to 600 (kuwait, bahrain which have the youngest populations and the least deaths per 1000 population). while beds per 1000 deaths is a useful comparator the new method has the advantage that it uses both deaths and population to compare bed provision (next section). figure 2 shows a plot using data for u.s. states in 2018 using the new method which also includes lines for the international average for developed countries, and for new zealand and singapore. data for canada (red diamond) and the uk (purple triangle) are also shown for comparison as examples of low bed number countries offering universal health care. canada and the uk lie on a line parallel to but above that for new zealand and singapore. the data point for the entire usa is the red square. all us states, except for the federal district of washington d.c. (district of columbia) and to a less extent south and north dakota, have far fewer hospital beds that the average for developed countries, while several states (washington, oregon) have less beds than the average for the less developed countries. around half of u.s. states are below the most bed efficient line for universal care in singapore and new zealand. while beds per 1000 deaths is a useful comparator the new method has the advantage that it uses both deaths and population to compare bed provision (next section). figure 2 shows a plot using data for u.s. states in 2018 using the new method which also includes lines for the international average for developed countries, and for new zealand and singapore. data for canada (red diamond) and the uk (purple triangle) are also shown for comparison as examples of low bed number countries offering universal health care. canada and the uk lie on a line parallel to but above that for new zealand and singapore. the data point for the entire usa is the red square. all us states, except for the federal district of washington d.c. (district of columbia) and to a less extent south and north dakota, have far fewer hospital beds that the average for developed countries, while several states (washington, oregon) have less beds than the average for the less developed countries. around half of u.s. states are below the most bed efficient line for universal care in singapore and new zealand. for comparison, the international range in deaths per 1000 population is from around 1.0 in the oil rich gulf countries through to 17 in sierra leone. the uk has a ratio of 9.0 [18] . countries near to the less developed countries average are colombia, ecuador, and algeria. around 20% of us states lie close to this line. despite the lower slope for the line describing the less developed countries (equation (2) for comparison, the international range in deaths per 1000 population is from around 1.0 in the oil rich gulf countries through to 17 in sierra leone. the uk has a ratio of 9.0 [18] . countries near to the less developed countries average are colombia, ecuador, and algeria. around 20% of us states lie close to this line. despite the lower slope for the line describing the less developed countries (equation (2) above), over the limited range in deaths per 1000 population seen in us states (5.9 in utah to 13.1 in west virginia), the two equations are almost parallel and the equation for developed countries can be applied to adjust all countries to the us average of deaths per 1000 population (next section). the average line for the least developed countries has the equation (analysis not shown): beds per 1000 deaths = 318 − 111 × ln(deaths per 1000 population), the line for the least developed countries lies below the scale in figure 2 and includes countries such as sierra leone, madagascar, senegal, niger, etc. by adjusting all u.s. states to the average deaths per 1000 population for the u.s., namely 8.69, and adjusting world countries to the same number allows direct comparison between u.s. states and their nearest international equivalent. this comparison is given in table 1 for the states with the least number of beds which are at or below the u.s. average. as can be seen oregon has equivalent beds to burundi, washington (not to be confused with washington d.c.) to costa rica, california has equivalent to albania, and colorado has equivalent to algeria. the average for the usa is equivalent to vanuatu. such low levels of bed provision clearly indicate that large parts of the u.s. may be susceptible to a major epidemic and specific issues relating to covid-19 will now be investigated. the possibility that covid-19 transmission may have been reduced in those states with lower population density is investigated in figure 3 . the possibility that covid-19 transmission may have been reduced in those states with lower population density is investigated in figure 3 . [38] to adjust for the fact that the surface area of most states is largely devoted to agriculture, forestry, or national parks. for example, there are 345,000 km 2 of national parks [36] which represent 1.4 times the size of the united kingdom. most of the population therefore experience a far higher (weighted) population density than the simple division of population by land area. in figure 3 , covid-19 confirmed cumulative deaths were up to the 9th june 2020 [5] , while deaths in 2018 [37] (the most recent data available for the u.s.) were taken as the baseline per annum deaths in the absence of covid-19. hence excess covid-19 deaths as a percentage of total deaths. as can be seen in figure 3 low population density is generally associated with lower excess covid-19 confirmed mortality. mortality generally rises for state weighted population density above 1000 persons per mile 2 (390 persons per km 2 ). virus transmission in an epidemic always leads to a granular spatial distribution of cases [39] . the major focus of the covid-19 epidemic in the u.s. was the heavily populated north east corner, with new york receiving the fifth highest number of international visitors in the u.s. [40] . in the absence of international hospital admissions due to covid-19 the cumulative deaths per hospital bed can be used as a measure of potential capacity pressure upon available beds. figure 4 shows the relationship between cumulative deaths per bed and cumulative excess mortality for us states. as can be seen 36 states had less than 10 covid-19 deaths per 100 beds (10%) over the 70-day period 1 march to 9 june which reflects the lower covid-19 cases and deaths in those states with lower populations density. while new york received international attention due to the high number of deaths figure 4 shows that new jersey, massachusetts, and connecticut all 0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 10 100 1,000 10,000 100,000 state weighted population density per square mile [38] to adjust for the fact that the surface area of most states is largely devoted to agriculture, forestry, or national parks. for example, there are 345,000 km 2 of national parks [36] which represent 1.4 times the size of the united kingdom. most of the population therefore experience a far higher (weighted) population density than the simple division of population by land area. in figure 3 , covid-19 confirmed cumulative deaths were up to the 9th june 2020 [5] , while deaths in 2018 [37] (the most recent data available for the u.s.) were taken as the baseline per annum deaths in the absence of covid-19. hence excess covid-19 deaths as a percentage of total deaths. as can be seen in figure 3 low population density is generally associated with lower excess covid-19 confirmed mortality. mortality generally rises for state weighted population density above 1000 persons per mile 2 (390 persons per km 2 ). virus transmission in an epidemic always leads to a granular spatial distribution of cases [39] . the major focus of the covid-19 epidemic in the u.s. was the heavily populated north east corner, with new york receiving the fifth highest number of international visitors in the u.s. [40] . in the absence of international hospital admissions due to covid-19 the cumulative deaths per hospital bed can be used as a measure of potential capacity pressure upon available beds. figure 4 shows the relationship between cumulative deaths per bed and cumulative excess mortality for us states. as can be seen 36 states had less than 10 covid-19 deaths per 100 beds (10%) over the 70-day period 1 march to 9 june which reflects the lower covid-19 cases and deaths in those states with lower populations density. while new york received international attention due to the high number of deaths figure 4 shows that new jersey, massachusetts, and connecticut all experienced higher potential bed demand while rhode island experienced intermediate potential demand. washington d.c. experienced relatively lower bed demand due to the high number of hospital beds in this federal district. experienced higher potential bed demand while rhode island experienced intermediate potential demand. washington d.c. experienced relatively lower bed demand due to the high number of hospital beds in this federal district. the relatively low population density in most us states seemingly averted a catastrophic covid-19 bed capacity overload. while many countries seek to develop a coordinated universal healthcare system, healthcare in the us is largely left to market forces [41] . medicaid and medicare provide some basic care to the poor and elderly, government workers and the military are covered by state and federal government schemes while the rest of the population is covered by private insurance via their employer or themselves, or to remain uninsured. medicaid and medicare recipients can take out additional insurance to complement the basic government scheme. [41, 42] . there are over 900 medical insurers offering a complex variety of schemes with different terms and conditions [42] . hospitals can be either for-profit or not-for-profit and are either independent, state owned or part of larger chains, and are free to make their own planning decisions regarding bed numbers. some 14% of the us population lives in a rural area (range 0% washington d.c., new jersey, delaware to 69% in wyoming), 16.1% of the rural population lives below the poverty threshold (range 6.9% in connecticut to 26.9% in arizona) [35] . rural populations in the us are known to access hospital services less than their urban counterparts due to distance and poverty [43] . however, even in the densely-populated uk with free access to healthcare, rural populations have 20% lower hospital bed occupancy than their urban counterparts [44] . the rural population is served by a multitude of small community hospitals, such that half of us hospitals have fewer than 100 beds [30] . in 2019 that us average was 191 acute beds per hospital (range 90 in wyoming to 259 in new jersey and connecticut and 306 in new york) [32] the relatively low population density in most us states seemingly averted a catastrophic covid-19 bed capacity overload. while many countries seek to develop a coordinated universal healthcare system, healthcare in the us is largely left to market forces [41] . medicaid and medicare provide some basic care to the poor and elderly, government workers and the military are covered by state and federal government schemes while the rest of the population is covered by private insurance via their employer or themselves, or to remain uninsured. medicaid and medicare recipients can take out additional insurance to complement the basic government scheme. [41, 42] . there are over 900 medical insurers offering a complex variety of schemes with different terms and conditions [42] . hospitals can be either for-profit or not-for-profit and are either independent, state owned or part of larger chains, and are free to make their own planning decisions regarding bed numbers. some 14% of the us population lives in a rural area (range 0% washington d.c., new jersey, delaware to 69% in wyoming), 16.1% of the rural population lives below the poverty threshold (range 6.9% in connecticut to 26.9% in arizona) [35] . rural populations in the us are known to access hospital services less than their urban counterparts due to distance and poverty [43] . however, even in the densely-populated uk with free access to healthcare, rural populations have 20% lower hospital bed occupancy than their urban counterparts [44] . the rural population is served by a multitude of small community hospitals, such that half of us hospitals have fewer than 100 beds [30] . in 2019 that us average was 191 acute beds per hospital (range 90 in wyoming to 259 in new jersey and connecticut and 306 in new york) [32] . the us average occupancy rate for acute hospital beds is 55% (range 25% in wyoming with 69% rural population to 76% in washington d.c. with 0% rural population) [32] . the smallest hospitals tend to occur in the states with the lowest average income [30] . the small size of u.s. hospitals imposes low average occupancy [45] , and higher unit costs [46] , leading to hidden barriers to access acute care. hence healthcare in the u.s. is what many may regard as overly complex and with little government intervention to ensure universal health care. generally poorer rural populations seek less acute care, which is then compounded by low population density leading to small hospital size with resulting marginal commercial viability. hence the generally low bed numbers in figures 1 and 2 and table 1 and the difficulty in explaining exactly which factors contribute to low bed numbers in some states. as demonstrated in figure 2 around 40% of u.s. states fall below the line for new zealand and singapore. states lying below the line for new zealand and singapore has bed availability levels equivalent to the "less developed" countries where universal health care is also not available [24, 25] . lowest bed availability occurs in oregon. the netherlands and australia have total beds near the international average. australia has a higher proportion of rural population than the u.s. [47] , and rurality per se cannot be an explanatory factor for the low number of u.s. hospital beds. washington d.c. which has some of the most prominent hospitals and research institutes, has the highest number of physicians per capita, the highest median household income, and only 3.7% of persons are uninsured [34, 48] . washington d.c. is probably the closest approximation to universal healthcare in the u.s. countries like germany and austria which have 3-times the u.s. average number of beds [24] can manage a surge event such as covid-19 with far greater ease [49] . it is well recognized that the u.s. healthcare industry only represents a proportion of the population and hence comparative international health outcomes are poor [3, 50] . this is confirmed by the low levels of hospital bed provision in figures 1 and 2 while data on the number of medical beds in the us and elsewhere is not available it is obvious that the number of these beds must be lower than the total beds. for example, in england available mental health beds account for 15% of total hospital beds while maternity accounts for a further 6% [51] , the medical group of specialties accounts for 55% of total occupied beds [52] . research suggests that the demand for medical beds is directly proportional to the number of total deaths and has a far flatter slope than figure 1 [53] . the average number of available (staffed) medical beds per 1000 deaths across europe was 205 [27] , with a 20-year average of 165 ± 5 (±standard deviation) occupied medical beds per 1000 deaths in england [53] . in england medical beds operate at over 95% average occupancy [51] . some us states have barely enough total beds to accommodate just the medical group of patients under universal health care. as in other countries, the us did shut down routine surgery to create space for covid-19 patients [54] ; however, the basic position of too few beds remains an overriding problem. the major impact of covid-19 has been the high use of critical care beds [1, 3] . as with medical beds, research shows that critical care bed requirements are likewise directly proportional to the number of deaths [55] . the u.s. has the highest number of critical care beds per population in the world [56] but did need additional critical care beds to service covid-19 hot spots. under normal circumstances the poorer communities (not covered by medicaid) affected by covid-19 would not have been able to access hospital care [57, 58] , and many with health insurance, especially the elderly, would not seek medical care due to the risk of bankruptcy due to co-payments [57] [58] [59] [60] . this would have acted to further spread the disease. on the 3 april president trump announced a covid-19 support package in which the inpatient care of uninsured persons suffering from covid-19 would be covered by the federal government [61] . some insurers have also announced that co-payments would be waived. however, it is unclear how effectively this has been communicated and if hidden barriers to access remained such as access to covid-19 testing and fear of a high bill for attending the emergency department should the illness not be due to covid-19. indeed, those recently unemployed appear to fall into a policy gap [58] . a recent study has used age-specific mortality patterns along with population demographic data to map projected burden of covid-19 and the associated cumulative burden on the healthcare system (total hospital beds and intensive care beds) at county level in the us for a scenario in which 20% of the population of each county acquired infection. it was suggested that per capita disease burden and relative healthcare system demand may be highest away from major population centers where there are the fewest hospital and critical care beds [62] . the states identified in this study roughly align with those identified by miller et al. [62] simply because too few beds, mainly located in large cities, are an inescapable limitation to treating covid-19 patients requiring hospitalization. figures 2 and 3 shows the resulting granular distribution of covid-19 confirmed deaths. states with extremely low bed provision such as oregon were spared from a potential medical disaster by virtue of low incidence of cases relative to available beds. the u.s. has a somewhat unique population distribution. only five cities (including new york at 33,000 per square mile) have a weighted population density above 10,000 persons per square mile [29, 38, 63, 64] . by comparison london has a weighted density of 22,000 per square mile and some 40% of the population in england live at greater than 10,000 persons per square mile [29] . much of the remainder of u.s. has low population density. population density is a critical factor in disease and covid-19 transmission [65, 66] . this association for covid-19 has been observed in english local authorities [67] , and in england and wales the age-standardized covid-19 mortality rate in urban major conurbations was 6-times higher than in rural hamlets [68] . figure 3 showed the relationship between the ratio of confirmed covid-19 deaths (at 19 april 2020) per 1000 population versus the weighted population density for each state. weighted population density is the effective population density experienced by the average person in the state [38, 64] . weighted population density considers that most people live in cities and towns hence the population density that they experience is much higher than the simple division of population by total land area. hence this is between 12 to 60 times higher than the raw density [38, 64] . population density is not the only factor responsible for spread of covid-19 and factors such as international exposure, household crowding and mass gatherings will also play a role [65, 66] . while the extent of covid-19 testing varies between us states, figure 3 nevertheless establishes an important precedent. as demonstrated the states with lowest weighted population density all experience low death rates. these states tend to have fewer hospitals simply because a hospital needs a high population within a reasonable travel distance to be financially viable. hence low weighted population density in over half the states has acted to avert a medical disaster in the usa. given the complexities of healthcare in the u.s. discussed in section 4.1 the issue of exactly why some states have such low bed numbers has no easy answer. one study has demonstrated that the average number of beds per hospital was related to average state income [30] . average length of stay in each state was related to average number of beds per hospital, being generally lowest in those states with the smallest hospitals, and lowest average income [30] . another study demonstrated that the number of bed days per death (or occupied beds per 1000 deaths) rose with population density [29] . population density and proportion rural population are interrelated, and it would therefore seem that urban populations seem to make greater use of hospital care at the end of life. in past decades the u.s. was able to claim that lower length of stay (los) was an explanation for fewer beds; however, in recent years los in many countries is now reasonably close to or lower than that in the u.s. [69, 70] and this can be dismissed as an explanatory factor. hence the reason why oregon, a mainly agricultural state focusing on horticulture (16% rural, 15% rural poverty) has so few beds is a complex mix of numerous factors which seem not to have been adequately investigated, and which are largely irrelevant in the context of the u.s. health care industry. the proportion of persons who are insured is probably an overly simplistic indicator since insurance policies issued by 900 insurers can have widely different terms and conditions. a simple overview is that in the u.s. healthcare resources follow "money" rather than "need" and this is then distorted by population density, or more correctly population distribution. due to the absence of numbers of persons admitted to hospital for covid-19 the total confirmed covid-19 deaths has been used as a proxy measure. clearly persons die of covid-19 in nursing homes [71] and at home; however, this is probably a reasonable proxy for hospital capacity pressure since death is most likely to occur in older people who are most represented in covid-19 admissions [72, 73] . in new york it was recognized that elderly covid-19 patients were overly rapidly discharged into nursing homes, which led to cross-infection and further compounded the number of deaths [74] . the same hasty discharge into nursing homes occurred around the world [71] . covid-19 deaths are themselves an underestimate due to variable testing capacity between states and the real excess mortality may be 28% higher [75] ; however, the available data must be used to make comparisons despite its limitations. the second limitation is the use of total hospital beds to compare between states and countries. once again given the lack of detailed international data covering just acute beds this is a reasonable proxy. the issue of international hospital bed number comparisons is highly topical and the new method for bed comparison is an improvement on the former simplistic beds per 1000 population. the new method should be used to delve further into the reasons why different healthcare systems operate with such widely varying bed numbers. factors such as population density, average hospital size, and rurality need to be given greater prominence. a new method for comparing international bed numbers has been used to give greater insight into the variation in bed numbers between u.s. states. decades of focus on providing medical resources to the insured, along with high levels of co-payment imposed by insurers to discourage use of those resources [57] [58] [59] [60] has left the us with very a very wide range in bed provision between states and generally low levels of hospital beds in relation to other developed countries. some states have numbers of beds equivalent to those in less developed countries. despite extremely low bed numbers in many states the u.s. was spared from a full-scale disaster due to concentration of cases in a few states with relatively high bed numbers. the healthcare "system" in the us is in a seemingly intractable dilemma from which it is difficult to extract itself and which leaves it open to the impact of future pandemics should they occur with a different spatial distribution or mode of transmission to covid-19. indeed, statistics indicate that spread of covid-19 has increased in recent days [76] . the demand for inpatient and icu beds for covid-19 in the us: lessons from chinese cities. harvard university. 2020. available online characterization and clinical course of 1000 patients with coronavirus disease 2019 in new york: retrospective case series forecasting critical care bed requirements for covid-19 patients in england, cmmid repository covid-19: the crisis of personal protective equipment in the us com coronavirus (covid-19) statistics. 2020 higher spending, worse outcomes? the commonwealth fund the high cost of dying medical care at the end of life: diseases, treatment patterns, and costs counting backward to health care's future: using time-to-death modelling to identify changes in end-of-life morbidity and the impact of aging on health care expenditures hospital care for the elderly in the final year of life: a populationbased study use of acute hospital beds does not increase as the population ages: results from a seven-year cohort study in germany hospital admissions, age, and death: retrospective cohort study use of health services in the last year of life and cause of death in people with intellectual disability: a retrospective matched cohort study hospital use by an ageing cohort: an investigation into the association between biological, behavioural and social risk markers and subsequent hospital utilization models for forecasting hospital bed requirements in the acute sector a methodology for estimating hospital bed need in manitoba in 2020 comparison of different methods to forecast hospital bed needs how many beds? capacity implications of hospital care demand projections in the irish hospital system forecasting hospital bed needs the demography myth-how demographic forecasting underestimates hospital admissions and creates the illusion that fewer hospital beds or community-based bed equivalents will be required in the future growth in nhs admissions and length of stay: a policy-based evidence fiasco condition specific growth in occupied beds in england following a sudden and unexpected increase in deaths have doctors and the public been misled regarding hospital bed requirements? hospital beds per death how does the uk compare globally a pragmatic method to compare hospital bed provision between countries and regions: beds in the states of australia hospital beds (per thousand people) acute care hospital beds, medical group of specialties, world health organisation unequal distribution of the u.s. primary care workforce population density and healthcare costs average length of stay in hospitals in the usa hospital beds per 1000 population by ownership type, kaiser family foundation the american hospital directory. hospital statistics by state. ahd. 2020. available online median household income by us state, us census bureau united states department of agriculture. state fact sheets deaths in us states weighted population density, decision science news on the predictability of infectious disease outbreaks the most visited states in the u.s.; world atlas overview of the united states healthcare system largest health insurance companies of 2020 understanding shortages of sufficient health care in rural areas demand for hospital beds in english primary care organisations hospital bed occupancy demystified and why hospitals of different size and complexity must operate at different average occupancy a guide to maternity costs-why smaller units have higher costs demography and population us states with the most hospital beds, world atlas too little or too much? missing the goldilocks zone of hospital capacity during covid-19 us: address impact of covid-19 on the poor, human rights watch bed availability and occupancy data-overnight how many medical beds does a country need? an international perspective elective surgeries set to resume, with complications and concerns. nbc news trends in critical care bed numbers in england variation in critical care services across north america and western europe medical bankruptcy and the economy, the balance the health of private insurance in the us during covid-19 understanding a health insurance copayment. ehealth increased ambulatory care co-payments and hospitalizations among the elderly government will pay for uninsured americans' coronavirus treatment: trump, the new york post mapping the burden of covid-19 in the united states density calculations for u.s. urbanized areas, weighted by census tract, austin contrarian on population-weighted density mapping risk factors for the spread of covid-19 in africa, africa centre for strategic studies the disconcerting association between overpopulation and the covid-19 crisis, the times of israel how many extra deaths have really occurred in the uk due to the covid-19 outbreak? vii. infectious granularity, research gate deaths involving covid-19 by local area and socioeconomic deprivation: deaths occurring between 1 length of stay in hospital: how countries compare length of hospital stay mortality associated with covid19 outbreaks in care homes: early international evidence. article in ltccovid.org, international long-term care policy network existing conditions of covid-19 cases and deaths factors associated with hospital admission and critical illness among 5279 people with coronavirus disease health officials ordered coronavirus patients to nursing homes despite empty beds estimation of excess deaths associated with the covid-19 pandemic in the united states funding: there are no sources of funding. the author declares no conflict of interest. key: cord-299797-s1zdmf2u authors: dettori, marco; pittaluga, paola; busonera, giulia; gugliotta, carmelo; azara, antonio; piana, andrea; arghittu, antonella; castiglia, paolo title: environmental risks perception among citizens living near industrial plants: a cross-sectional study date: 2020-07-06 journal: int j environ res public health doi: 10.3390/ijerph17134870 sha: doc_id: 299797 cord_uid: s1zdmf2u the present work is a cross-sectional study aimed at assessing the risk perception and evaluating the community outrage linked to environmental factors among a self-selected sample of citizens living in an area characterized by the presence of industrial structures of high emotional impact. an anonymous questionnaire was administered to the population by publishing a google form url code in local and regional newspapers and via social media. the resulting data were entered on excel and analyzed. qualitative variables were summarized with absolute and relative (percentage) frequencies. the results showed that the event that causes the greatest worry was air pollution, with 92.6% of the respondents stating that they perceived the problem as “very” or “quite” worrying. furthermore, all the health problems investigated in relation to environmental quality aroused concern among the interviewees, with 93.1% believing there was a cause-effect relationship between environmental quality and health. overall, as other studies had previously underlined, the survey shows that the perceived risks are not always in line with the real ones, thus, it is imperative to articulate interventions aimed at offering the population objective tools to enable them to interpret the risks themselves. in this regard, a fundamental role is played by adequate communication between the competent bodies and political decision-makers and the population. the relationship between environment and health is of extreme relevance in public health. according to the world health organization (who) [1] , 23% of all deaths globally are attributable to environmental factors, and several diseases could be avoided if we lived in healthier environments. in particular, according to the european environmental agency [2] , poor air quality causes 6.5 million premature deaths worldwide, 620,000 of which are in the who european region. indeed, the european environment agency [3] also certifies that noise and air pollution continue to have a serious impact on the health of the population, and human activities (mainly the key sectors of industry, energy, transport, agriculture) are a source of strong environmental pressure [4] [5] [6] [7] . the growing awareness of the health impacts caused by the alteration of environmental conditions by anthropic activities, such as industrial expansion near urban areas, atmospheric pollution, and climate change, plays a key role in the judgment and acceptability of the risks related to environmental owing to its insularity, the region lends itself very well to observational investigations and represents an excellent test case in relation to the reported social dynamics. in fact, the island has already proven to be well suited to epidemiological studies as it preserves the region from interferences caused by territorial contiguity. as such, it can act as an excellent exercise for the reported social and epidemiological dynamics. in particular, the present study was conducted in the marghine area, a historical region in central sardinia which covers an area of 475.42 km 2 and includes 10 municipalities: birori, bolotana, borore, bortigali, dualchi, lei, macomer, noragugume, silanus, and sindia [31] [32] [33] [34] . figure 1 shows the study area's territorial framework and the population of each municipality in 2018, the year in which observation was carried out, whereas table 2 as shown in figure 2 , several industrial plants (mostly dedicated to the management of solid waste from the entire region) are situated in marghine, located near urban areas, in particular in the municipality of macomer, the main town in the area, with a population of 10,019 in 2018. as shown in figure 2 , several industrial plants (mostly dedicated to the management of solid waste from the entire region) are situated in marghine, located near urban areas, in particular in the municipality of macomer, the main town in the area, with a population of 10,019 in 2018. [35, 36] . in the same industrial zone there is also a purifier that treats the waste water from the waste-toenergy process [36] [37] [38] . finally, the production cycle also includes the management of the controlled landfill, again serving the tossilo plant, located in monte-muradu, in the area north of macomer. although the area is heavily industrialized, the official data published by the health authority and the environmental protection agency have always highlighted parameter values that comply with the regulatory limits, the absence of pollution from the environmental matrices, and excluded an excesses of pathologies in the area of study [39-41]. [35, 36] . in the same industrial zone there is also a purifier that treats the waste water from the waste-to-energy process [36] [37] [38] . finally, the production cycle also includes the management of the controlled landfill, again serving the tossilo plant, located in monte-muradu, in the area north of macomer. although the area is heavily industrialized, the official data published by the health authority and the environmental protection agency have always highlighted parameter values that comply with the regulatory limits, the absence of pollution from the environmental matrices, and excluded an excesses of pathologies in the area of study [39-41]. an anonymous questionnaire was built, tested, adjusted, and validated through a pilot study, carried out on a convenience sample of 20 experts in public health (data not published). the internal consistency was assessed with cronbach's alpha test. the questionnaire consisted of 14 close-ended questions divided into two areas of investigation: 6 personal data questions; 8 questions related to health concerns and risk perception. to complete the questionnaire it was required to answer each question. only one question (item no. 13) allowed for more than one answer. the questionnaire was administered by publishing a google form url code in the local and regional newspapers (i.e., "il marghine" and "la nuova sardegna"), and via social media (i.e., facebook public profiles of the same newspapers). the questionnaire was to be completed in the period between 1st september 2018 and 31st december 2018. the full questionnaire is shown in tables 2 and 3 (results section): table 2 reports 6 questions related to the respondents' general information; table 3 shows 8 questions (numbers 7 to 14) related to health concerns and risk perceptions, together with their close-ended answers. questions and answers are reported in the first and second columns of the tables, respectively. data were entered on excel (microsoft office, microsoft corporation, redmond, wa, usa) and analyzed using the stata software 16 (statcorp., austin, tx, usa). qualitative variables were summarized with absolute and relative (percentage) frequencies. the differences between mean values for quantitative variables were tested applying the student t-test, whereas for proportions, z test was applied. the independence for qualitative variables was tested applying the x 2 test. in order to evaluate the equality of distributions, kolgomorov smirnov test for two samples was performed. a p-value less than 0.05 was considered statistically significant. with regard to the internal consistency, the questionnaire showed a cronbach's alpha reliability test global value of 0.9044, which highlights a very good internal consistency. no missing data were managed. during the observation period, 651 residents in the study area voluntarily answered the questionnaire. the respondents' general information related to the first six questions is shown in table 3 . of the 651 respondents, 500 were from macomer, whereas 151 lived in the other municipalities in marghine. as regards the age and gender of the respondents, the average age was 38.7 years (±13.8), without statistically significant differences between gender, and more than half of the self-selected sample were between 18 and 39 years old. as regards the equality of the distribution by age groups, no differences were observed between genders (combined kolmogorov-smirnoff k-s = 0.05; p = 0.82). moreover, 64.4% were female. as regards marital status, most of the respondents were unmarried, and this percentage was in line with that of the general population (45.3% and 45.0%, respectively). all age groups had at least one respondent. over 80% of the sample interviewed had a high school diploma or a university degree, while more than half said they were in employment. finally, 89.9% of the respondents had resided in the study area for over 10 years. the results of the descriptive analysis are shown in table 4 (questions 7 to 14). as regards the respondents' perception in relation to the environmental problems reported in question 7, the results are shown graphically in figure 3 . in particular, the interviewees showed quite a high level of concern regarding all the environmental problems investigated. as the graphic shows, the events that cause the greatest worry are air pollution, with 95.3%, and hazardous waste, with 92.7% of the respondents stating that they perceived the problem as "very" or "quite" worrying, respectively. these latter two figures (air pollution and hazardous waste) seem to significantly differ between genders, with a concern proportion, from quite to very high, of 91.8% vs. 97.1% and 88.8% vs. 95.0%, for males and females, respectively. statistically significant differences for the same two figures were also observed among age groups (p < 0.001). in particular, the concern seems to grow according to age, ranging from 75.0% in <18 years old to 98.4% in 60-69 years old. in particular, the interviewees showed quite a high level of concern regarding all the environmental problems investigated. as the graphic shows, the events that cause the greatest worry are air pollution, with 95.3%, and hazardous waste, with 92.7% of the respondents stating that they perceived the problem as "very" or "quite" worrying, respectively. these latter two figures (air pollution and hazardous waste) seem to significantly differ between genders, with a concern proportion, from quite to very high, of 91.8% vs. 97.1% and 88.8% vs. 95.0%, for males and females, respectively. statistically significant differences for the same two figures were also observed among age groups (p < 0.001). in particular, the concern seems to grow according to age, ranging from 75.0% in <18 years old to 98.4% in 60-69 years old. the answers to question 8 are shown in figure 4 . in particular, the interviewees showed quite a high level of concern regarding all the environmental problems investigated. as the graphic shows, the events that cause the greatest worry are air pollution, with 95.3%, and hazardous waste, with 92.7% of the respondents stating that they perceived the problem as "very" or "quite" worrying, respectively. these latter two figures (air pollution and hazardous waste) seem to significantly differ between genders, with a concern proportion, from quite to very high, of 91.8% vs. 97.1% and 88.8% vs. 95.0%, for males and females, respectively. statistically significant differences for the same two figures were also observed among age groups (p < 0.001). in particular, the concern seems to grow according to age, ranging from 75.0% in <18 years old to 98.4% in 60-69 years old. the answers to question 8 are shown in figure 4 . the events that respondents found less likely are war, terrorism, nuclear risk, and addiction, while diseases were considered to be the most likely event. figure 5 shows the results of the answers given to question no. 9, concerning worries about one's own health regarding environmental determinants. as the figures show, all the health problems investigated in relation to environmental quality aroused concern among the interviewees, in particular tumors and (temporary or permanent) damage to the respiratory tract, without statistically significant differences between gender and age groups. finally, the results of the questionnaire show that 93.1% believed there was a cause-effect relationship between environmental quality and health (question no. 10), 60.3% believed that the environmental situation in the area was serious (question no. 11) and 63% believed that citizens do not have an influential role in decisions made by the municipal administration (question no. 12). question number 13 revealed the respondents' main sources of information (more than one answer was allowed) and the answers are shown in figure 6 . as can be seen from the graph, the internet was found to be the most widely used source of information, as opposed to consulting political decision-makers, municipalities, and the regional agency for environmental protection agency (arpas). finally, question number 14 highlighted the willingness of over 40% of the interviewees to relocate away from their place of residence. the events that respondents found less likely are war, terrorism, nuclear risk, and addiction, while diseases were considered to be the most likely event. figure 5 shows the results of the answers given to question no. 9, concerning worries about one's own health regarding environmental determinants. as the figures show, all the health problems investigated in relation to environmental quality aroused concern among the interviewees, in particular tumors and (temporary or permanent) damage to the respiratory tract, without statistically significant differences between gender and age groups. finally, the results of the questionnaire show that 93.1% believed there was a cause-effect relationship between environmental quality and health (question no. 10), 60.3% believed that the environmental situation in the area was serious (question no. 11) and 63% believed that citizens do not have an influential role in decisions made by the municipal administration (question no. 12). question number 13 revealed the respondents' main sources of information (more than one answer was allowed) and the answers are shown in figure 6 . as can be seen from the graph, the internet was found to be the most widely used source of information, as opposed to consulting political decision-makers, municipalities, and the regional agency for environmental protection agency (arpas). finally, question number 14 highlighted the willingness of over 40% of the interviewees to relocate away from their place of residence. the survey enabled an evaluation of environmental risk perception in a self-selected sample of a population living near industrial plants with a high emotional impact. the strengths and weaknesses presented in the study are discussed in this section. during the observation period, 651 people responded to the survey, with female respondents more numerous. this figure is attributable to the fact that in the region, and in the area subject to observation, the female population outnumbers the male. furthermore, as is known, the female population is more sensitive than the male to environmental issues. for this reason, the greater frequency of female respondents is in line with what has been reported in other similar surveys [42] . of the 651 respondents, 500 claimed to reside in macomer. this, on the one hand, is attributable to the fact that the municipality counted almost a half of the population of the entire area observed at the time of the investigation; on the other, the fact that the main industrial plants in the area (i.e., the survey enabled an evaluation of environmental risk perception in a self-selected sample of a population living near industrial plants with a high emotional impact. the strengths and weaknesses presented in the study are discussed in this section. during the observation period, 651 people responded to the survey, with female respondents more numerous. this figure is attributable to the fact that in the region, and in the area subject to observation, the female population outnumbers the male. furthermore, as is known, the female population is more sensitive than the male to environmental issues. for this reason, the greater frequency of female respondents is in line with what has been reported in other similar surveys [42] . of the 651 respondents, 500 claimed to reside in macomer. this, on the one hand, is attributable to the fact that the municipality counted almost a half of the population of the entire area observed at the time of the investigation; on the other, the fact that the main industrial plants in the area (i.e., waste-to-energy plants, landfills, and purifiers) were in close proximity to the town center could explain the citizens' greater sensitivity toward this investigation. as far as the self-selected sample's general information is concerned, over half of the respondents were aged between 18 and 39 years, with an average age of 38.7 years. in particular, with regard to the population of sardinia (average age of 45.9 years), and of marghine (average age of 47.9 years), the respondents were younger. nevertheless, approximately 90% of those surveyed said they had lived in the area for more than 10 years. although, on the one hand, the way the questionnaire was administered may have favored a response by people more inclined toward the use of it tools, on the other hand, all age groups are represented in the survey. another interesting result, in line with what has been described on the international scene, was the link between educational qualifications and perception of environmental risks. looking at the sample of respondents to the survey, over 80% of them had a high school diploma or university degree. as previously stated by carducci et al. and by ozdemir et al. [43, 44] , subjects with a higher level of education perceive environmental risks to be higher. in general, there was a clear concern among respondents toward environmental determinants, both in relation to the perception of risks and possible effects on health, with 93.1% of respondents claiming the existence of a clear cause-effect relationship between the state of the environment and health status. consequently, all of the environmental problems investigated worried the majority of respondents. in particular, percentages equal to or even greater than 90% were observed in relation to the presence of hazardous industries, particularly landfills and incinerators/waste-to-energy plants. as recently observed by other authors [11, 45] , these structures play an important role in environmental risk perception in populations exposed to them, and could explain the consequent high level of concern regarding food and aquatic environment pollution, hazardous material transportation, noise, and air pollution, and hazardous waste. as can be expected, these latter are closely related to the presence of industrial plants and may explain the citizens' apprehension about possible industrial catastrophes and long-term damage to health that emerged from this survey. in particular, a very high concern was observed among females and older age groups. these figures confirm the aforementioned statement that females are more sensitive than males to environmental issues. moreover, it seems interesting to point out the higher concern among older individuals. considering the younger mean age of our respondents compared to the general population, this aspect could imply that the real concern could be even greater. moreover, the self-selected respondents were concerned by severe weather phenomena (44.1%) and fires (45.0%). on the one hand, the catastrophes caused by extreme weather events that have hit italy [46] and sardinia [47] in recent years have certainly influenced the current fear of such an event. on the other hand, the concern about fires is not surprising, given that these events are frequent in the region [48] . it is also interesting to note two peculiar conditions declared by the interviewees. first, although sardinia is a region with moderate seismic hazard [49] , more than half of the respondents (54.6%) said they were worried by earthquakes. this particular fact could be traced back to the seismic events occurring in central italy starting from 2016 [50] which were most likely, according to the dynamics of availability bias, responsible for people's tendency to base their judgments on recent information, forming opinions conditioned by the latest news acquired [51, 52] . second, a factor that caused little concern was terrorism. in this case, contrary to what was described above, a terrorist cell had been uncovered in macomer shortly before the present investigation [53] , proving the gap that can be found in a population between the perception of a risk (outrage) compared to the real danger (hazard) [16, 54] . with regard to road or work accidents, however, a mixed feeling of exposure emerged from the investigation. on the one hand, in fact, respondents showed a high perception of the risk inherent in road accidents. in this case, as found in accordance with the investigations proposed by the italian national statistics institute and by congiu et al. [55, 56] , this phenomenon not only represents a known public health problem, but is also increasing if we take fragile categories into consideration. on the other hand, however, the scant perception of the danger inherent in accidents at work could be attributed to the fact that almost 50% of the volunteer participants were unemployed, students, housewives, or occasional workers. as for the perception of the environmental quality of the area of residence, although the official analyses carried out by the regional environmental protection agency of sardinia excluded the presence of pollutants in the environmental matrices at the time of investigation [39], and excessive numbers of disease cases have not been reported by health authorities [41], the concern of respondents is tangible. nevertheless, a possible determinant of the outrage could be identified in a controversy that arose in the territory understudy at the end of 2015. in fact, at that time the conversion of the incinerator into a waste-to-energy plant had started and an environmentalist association was in opposition to this transformation. this association claimed that there was an excess of pathologies and specific mortality caused by tumors in that territory. the data on which this position were based derived in part from some incorrect health statistics that had been published in that period [57] , in part from an incorrect reading and interpretation of available epidemiological data. not even the subsequent correction and publication of correct data [41, 58] was able to quell the controversy and judicial investigations were also initiated which had no effect and the waste-to-energy plant was set up. even some time later, the sense of bewilderment so clearly raised by the numerous newspaper articles that appeared in the local media for several months still remains strong. this fact could explain why the concern for an excess of tumors was high in both sexes, without significant differences. as jonathan swift said, "falsehood flies and truth comes limping after; so that when men come to be undeceived it is too late; the jest is over and the tale has had its effect" [59] . this situation is aggravated by the fact that most respondents (over 60%) believed that citizens do not play an influential role in the decisions made by the municipal administration. in fact, as highlighted by peter sandman himself [27] with the aforementioned outrage theory, the perception of a risk increases when the situation that generates it is independent of one's will and is attributable to third parties. furthermore, over 40% of respondents declared the will to relocate. this figure appears to be in contrast with the sardinian people's well-known sense of belonging and attachment to their land, as well as antithetical to the fact that almost 90% of the replies had been residing in the area for more than 10 years. nevertheless, since the question referring to the will to relocate in relation only to the perceived environmental risks is not explicitly asked, there could be social, economic, and cultural dynamics behind this desire to move away. the present study has evaluated the role of environmental risk perception among a self-selected sample of citizens living in an area where industrial plants with high perceptual and emotional impact are situated. in particular, as other studies had previously underlined, the study shows that the perceived risks are not always in line with the real ones, if we think of how, for example, the respondents answered regarding fear of earthquakes, highly unlikely events in the territory under observation. thus, it is imperative to articulate interventions that are aimed at offering the population objective tools to enable them to interpret the risks themselves. in this regard, a fundamental role is played by adequate communication between the competent bodies and political decision-makers and the population. moreover, the study also revealed how the process of participation in decision-making is one of the determining aspects that influences a person's environmental risk perception, and promoting citizens' involvement in decisions can strengthen their sense of belonging, attachment to the territory, and empowerment. in fact, any action on the territory and even more so its protection (and consequently the perception of the risk linked to the action) that does not stem from an involvement of the local community, is in vain, as it is not legitimized by the context [60] . starting from the results of the survey, although the study is descriptive in nature and, therefore, requires further investigation in order to better understand the dynamics underlying the high outrage found, some practical actions could be implemented. these should not only concern informing and educating citizens, but should also be addressed to health authorities and institutions (municipalities). in particular, the results of this survey could be very useful for the launch of projects in the area that see the active participation of citizens in decision-making. for this reason, it will be necessary to bring into play multiple professional skills, not only public health professionals and sociologists, but also designers, planners, and urban planners. in addition, an important role is played by journalists, who are responsible for informing citizens. as known, the mass media are often responsible for riding the wave of news stories that attract the attention of readers as they are fueled by an emotional component [15] . for this reason, it would be appropriate to implement a training project that also involves this category of professionals. finally, a reflection in light of the pandemic that the world is currently experiencing opens up interesting prospects for this study. indeed, it is worth questioning whether the desire to leave the territory studied in this paper is not quenched precisely because low population density is 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popolazione per età, sesso e stato civile sardegna in cifre 14 • rapporto arpas gestiti dalla società tossilo spa promoting a rules-based approach to public participation environment and health: risk perception and its determinants among italian university students the impact of higher education on environmental risk perceptions a calculation model for improving outdoor air quality in urban contexts and evaluating the benefits to the population's health status le città e i territori alla sfida del clima alluvione sardegna: 5 anni fa 19 morti publications office of the european union: luxembourg primi elementi in materia di criteri generali per la classificazione sismica del territorio nazionale e di normative tecniche per le costruzioni in zona sismica rischio sismico-terremoto centro italia illusory correlation in observational report arrestato in sardegna presunto terrorista: preparava attentato con sostanze tossiche social deprivation indexes and anti-influenza vaccination coverage in the elderly in sardinia, italy, with a focus on the sassari municipality incidenti stradali in sardegna built environment features and pedestrian accidents: an italian retrospective study nuovi dati aggiornati sulla mortalità per tumore aree industriali the examiner no. 14 tutela ambientale e progetto del territorio: integrare, incrementare, interagire why italy first? health, geographical and planning aspects of the covid-19 outbreak deaths in sars-cov-2 positive patients in italy: the influence of underlying health conditions on lethality this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors would like to thank emma dempsey for the english language revision. the authors declare no conflict of interest. key: cord-319226-yvgvyif0 authors: french, jeff; deshpande, sameer; evans, william; obregon, rafael title: key guidelines in developing a pre-emptive covid-19 vaccination uptake promotion strategy date: 2020-08-13 journal: int j environ res public health doi: 10.3390/ijerph17165893 sha: doc_id: 319226 cord_uid: yvgvyif0 this paper makes the case for immediate planning for a covid-19 vaccination uptake strategy in advance of vaccine availability for two reasons: first, the need to build a consensus about the order in which groups of the population will get access to the vaccine; second, to reduce any fear and concerns that exist in relation to vaccination and to create demand for vaccines. a key part of this strategy is to counter the anti-vaccination movement that is already promoting hesitancy and resistance. since the beginning of the covid-19 pandemic there has been a tsunami of misinformation and conspiracy theories that have the potential to reduce vaccine uptake. to make matters worse, sections of populations in many countries display low trust in governments and official information about the pandemic and how the officials are tackling it. this paper aims to set out in short form critical guidelines that governments and regional bodies should take to enhance the impact of a covid-19 vaccination strategy. we base our recommendations on a review of existing best practice guidance. this paper aims to assist those responsible for promoting covid-19 vaccine uptake to digest the mass of guidance that exists and formulate an effective locally relevant strategy. a summary of key guidelines is presented based on best practice guidance. as we work to develop a range of safe and effective covid-19 vaccinations, the anti-vaccination movement has already fired the first shots in what will be a global public health battle. research shows that general vaccine hesitancy (i.e., 'the delay in acceptance or refusal of vaccines despite the availability of vaccination services') is rising for several diseases, resulting in serious disease outbreaks. for example, 11 european countries experienced more than 1000 cases of measles in 2008 [1] . vaccine hesitancy has also steadily increased in more than 90% of countries since 2014 [2] . given the potential to undermine vaccination coverage, all states must take steps to understand the extent and nature of hesitancy and to start promoting covid-19 vaccine uptake. as the who recommends, 'each country should develop a strategy to increase acceptance and demand for vaccination' [1] . each country must consider the appropriate time to start promoting the uptake of covid-19 vaccines based on its specific trajectory of covid-19 infection and its ability to provide access to vaccination. as covid-19 vaccination uptake develops, governments should continue to promote other protective behaviors such as handwashing and physical distancing. this paper aims to set guidelines that governments and regional bodies across the world should take to enhance the impact of their pro-vaccination strategy. we base our summary on recommended best practice with the aim of assisting professionals to digest the mass of guidance that exists in the hope that the summary contained will inform the guidelines needed to maximize uptake of covid-19 vaccines. it is imperative that planning for a covid-19 vaccination uptake strategy begins in advance of vaccine availability for two reasons. first, countries will need to determine population sub-groups and build a consensus about the order in which these will get access to the vaccine. second, we should reduce fear and concern and create demand for vaccines. a key part of this strategy is to counter the anti-vaccination movement that is already promoting hesitancy and resistance. since the beginning of the covid-19 pandemic, we have witnessed a tsunami of misinformation and conspiracy theories that have the potential to reduce vaccine uptake. to make matters worse, sections of populations in many countries display low trust in governments, official information about the pandemic, and the official approach in tackling the epidemic. the who advocates a pre-emptive pro-vaccination strategy that psychologically inoculates the population and maximizes uptake of vaccines as they become available [1] . this paper sets out the core elements of such a strategy. the paper explores key issues that relevant organizations must address and summarizes best practices that should be addressed when developing behavioral influence strategies to promote the uptake of covid-19 vaccines effectively, efficiently, and ethically as they become available. this paper does not set out a full review or commentary on the thousands of scientific papers and national and international guidance documents that already exist with respect to promoting vaccine uptake and reducing vaccine hesitancy. the volume and dispersed nature of this literature is, in some ways, an impediment to action as few people will have a full grasp of the multiple fields of research that inform it. the paper also does not attempt to set out a full planning model or a 'how-to' guide, as numerous well-tested examples already exist [3] [4] [5] [6] . the paper does not provide a comprehensive set of references; instead, it cites select evidence summaries and guidance documents to aid further reading. finally, we have not included a separate evaluation strategy, as each of the key guidelines will need an integrated monitoring and evaluation strategy to enable continuous improvement. context matters. each government and public health service face its own set of unique challenges. different countries also have differing resources, capacities, capabilities, assets, and constraints. regardless of such settings and challenges, governments and relevant bodies can action a number of key processes identified in the literature that will enhance vaccine uptake. we set out these key action areas in the guidelines below. see table 1 . it is highly likely that in the coming months the who and other public health institutions will issue guidance about how to optimize the uptake of covid-19 vaccines. we present the guidelines set out in this paper as an ideal model based on the lessons learned from successful intervention programs to inform such guidance. organizations, however, should approach each action area in a locally relevant way. it is also clearly a big ask to address all the recommended guidelines identified, but the more of these actions that can be applied, the more likely it is that a successful uptake strategy will be delivered. it is important that a systematic approach to planning is adopted. there are numerous planning models from the fields of health promotion and social marketing that authorities can use to define objectives, design processes, and conduct monitoring and evaluation of efforts to promote vaccine uptake [5] . the most crucial action is to set out a transparent (open access) and a logical plan that covers all the essential components contained in the guidelines included in this paper. however, a coordinated and a systematic approach will require strong leadership. behaviour change plans should also be informed by lessons from the fields of management, logistics, and emergency and disaster planning such as the highlight, audience, behaviour, intervention, test (habit) behaviour disaster change planning framework [4, 7] . authorities should also consider lessons and tips set out in several detailed planning models and guides developed specifically for vaccine promotion efforts such as: who. guide to tailoring immunization programs (tip) for infant and child vaccination [1] . the tip principles apply to communicable, non-communicable, and emergency planning where behavioral decisions influence outcomes [8] https://www.who.int/immunization/programmes_ systems/global_tip_overview_july2018.pdf?ua=1 european centre for disease control (ecdc). technical guide to social marketing https://www.ecdc.europa.eu/en/publications-data/social-marketing-guide-public-healthprogramme-managers-and-practitioners who. improving vaccination demand and addressing hesitancy. https://www.who.int/ immunization/programmes_systems/vaccine_hesitancy/en/ ecom: effective communication in outbreak management (ecom) [9] . the e.u. funded ecom project brings together multiple disciplines to develop an evidence-based behavioral and communication package for health professionals and agencies throughout europe in case of significant outbreaks of infectious diseases. http://ecomeu.info/ tell me. review of population behavior and communication during pandemics: https://www. tellmeproject.eu/ human center design for health. a comprehensive set of tools developed by unicef to apply the human-centered design approach to challenges facing health services, with a particular emphasis on demand for immunization and health services. https://www.hcd4health.org/resources social science research for vaccine deployment in epidemic outbreaks. a practical guide to using social science research and insights to better understand social, behavioral, cultural, community and political dynamics as part of efforts to introduce vaccines in epidemic outbreak settings. https://opendocs.ids.ac.uk/opendocs/bitstream/handle/20.500.12413/15431/ pracapproach%206.pdf?sequence=2&isallowed=y further generic planning guidance can be found at: building better health: a handbook for behavioral change. "the handbook blends proven disease prevention practices and behavioral science principles into a one-of-a-kind, hands-on manual." [10] (p. xiii). cdcynergy planning tool for social marketing. centers for disease control and prevention planning tool for social marketing, atlanta, ga. also available is cdcynergy "lite", intended for those who have previous social marketing experience and those who are familiar with the full cdcynergy edition. https://www.thecommunityguide.org/resources/cdcynergy applying behavioral insights-simple ways to improve health outcomes. a tool for the application of behavioral insights to improving health outcomes from the world innovation summit for health. https://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innovation/ behavioral_insights_report-(1).pdf if governments develop vaccine uptake programs based only on expert opinion, they are likely to be suboptimal [11, 12] . what is required is an approach that seeks to gather as much understanding as possible about what people say will prevent, encourage, and assist them in taking up vaccines. authorities must understand what people value and what they fear when developing an effective promotional program. a targeted approach that uses a different intervention mix for different subsets of the population will be more effective. people do not respond uniformly to preventive interventions. for example, being older, female, and more educated is associated with a higher likelihood of adopting protective behaviors [13, 14] . 'insight' data about citizens' attitudes, beliefs, wants, and behaviors should inform interventions. insights are 'deep truths' and understanding about why people act as they do. such insights can be developed from formative qualitative and quantitative survey research, observational data, demographic data, service use data, problem or issue tracking data, and epidemiological data. the development of deep insights into people's lives, with a focus on what will or will not motivate or enable people to take up vaccination, is a crucial investment that must be made to inform all aspects of vaccination promotion uptake strategy. a key component of behavioral planning is the setting of measurable behavioral objectives that are relevant and timely in relation to maximizing vaccine uptake. setting measurable goals related to uptake, attitudes, intention, understanding and beliefs will help focus behavioral planning and enable meaningful ongoing tracking and evaluation of impact [15] . segmentation is key to success. segmentation is the identification of groups who share similar beliefs, attitudes and behavioral patterns. segmentation goes beyond demographic, epidemiological, and service uptake-based targeting. segmentation includes data about people's attitudes, values, understanding and observed behaviors. population segmentation models enable public heath planners to tailor interventions to specific audiences [16] . fournet et al. have identified four unprotected and under-protected population groups that could form the basis for the development of a locally developed strategy [17] : • 'the hesitant'-those who have concerns about perceived safety issues and are unsure about needs, procedures and timings for immunizing. • 'the unconcerned'-those who consider immunization a low priority and see no real perceived risk of vaccine-preventable diseases. • 'the poorly reached'-those who have limited or difficult access to services, related to social exclusion, poverty and, in the case of more integrated and affluent populations, factors related to convenience. • 'the active resisters'-those for whom personal, cultural, or religious beliefs discourage them from vaccinating. other segments that need dedicated foci are health and social care workers. studies have revealed that certain healthcare workers hesitate to vaccinate themselves or their family members [9, 18] . the ecdc provides guides and toolkits for healthcare workers, immunization program managers, and public health experts, to support their efforts in addressing vaccine hesitancy [19] . frontline workers can be a significant source of trusted advice and information but are often not optimally used in such roles. these workers lack training and support in advocacy roles and may also lack a full awareness of risks and safety issues associated with the disease and vaccination. governments and responsible agencies should facilitate support structures that increase worker awareness and willingness to act as public health advocates. to effectively promote and maintain demand for a covid-19 vaccine, governments and regional bodies must develop an insight-informed pro-vaccination strategy that includes action to reduce the impact of four kinds of competition: • active competition from the ani-vaccination movement • passive competition in the form of inaccurate media coverage • competition from negative social norms • competition in the form of structural and economic factors effective campaigning against vaccine misinformation should focus on the dangers of the disease as well as on the benefits of the vaccines, which can include highlighting protection. such approaches draw on the powerful motivator of fear of loss along with the possibility of gain of positive health [20] . intervention designers should involve the target populations in building campaigns, and use data-supported insights about what will and what will not motivate them to take up vaccine programs and about how to frame the promotion of vaccination. a competition strategy that seeks to reduce the impact of those promoting hesitancy that emphasizes fact-checking and myth-busting may do more harm than good. such approaches often repeat misinformation as part of rebuttal strategies. engaging directly with conspiracies often spreads rather than closes down such views. people often exhibit what lord calls confirmation bias; they look and accept information that fits with their existing views and reject information that runs counter to their existing views [21] . so, when repeating misinformation in order to debunk it, people may just hear the misinformation. a more effective approach is a combination of positive messaging that emphasizes the protective (individual, family, and community) benefits of the vaccine and the loss associated with not being vaccinated (death, poor health, loss of freedom and social solidarity, inability to travel, etc.) [22, 23] . anti-vaccination advocates should not be left free to spread misinformation. public health authorities and their coalition partners, including both the traditional and digital media sectors, should proactively work together to reduce and remove at speed false content and misleading information. traditional media providers should be supported and briefed so that they are aware of anti-vaccination propaganda identified by public health authorities and do not repeat it. traditional media and social media sectors should also provide authorities with the information they have detected that anti-vaccination advocates are propagating so that information can be rebutted. public health agencies should seek protocols with media providers about the issue of how journalistic balance will be addressed. agreements should be put in place about how the media will identify and flag false and misleading anti-vaccination information and advocates. in this regard authorities and media channel providers should be alert to 'astroturfing' (anti-vaccination advocates disguising their views as coming from grass roots movements) and act swiftly to expose such tactics. finally, agreements should be developed about how and when misleading information and advocates of such information should be removed and flagged as being problematic on social media. distrust in elites and experts and political populism can also fuel antivaccination sentiment [24] . social norms and cultural influences can have a significant effect on people's willingness at the population level to take up vaccine programs [25] . as an initial step, authorities need to understand what informs social norms and beliefs. persuasive efforts should appeal to the values and beliefs that people already hold, such as a desire to protect family members, rather than a focus on factual or probabilistic messaging. validating people's existing motivations and using them to encourage behaviour is more effective than trying to shift people's world view. if, however, people hold incorrect opinions about the social norms prevailing in their community, for example, the erroneous belief that most people oppose vaccination, it can be helpful to inform them that a high percentage of people do in fact, support vaccination. subjective social norms, i.e., those that are informed by what we think key others in our social circles believe, are also crucial in promoting vaccine uptake [18, 26, 27] . opinion leaders in the anti-vaccination community may hold negative attitudes and beliefs, so intervention organizers should also develop interventions with such key informants to address these concerns and seek to turn such informants into advocates for vaccination. previous reviews of vaccine demand campaigns using a systematic process, such as in the area of human papilloma virus (hpv) vaccine, have found that myths and misinformation, often prevalent in communities, can also pose significant barriers to vaccine adoption. evans et al. studied several hpv and cervical cancer awareness studies in low-and middle-income countries (lmics) [28] . these studies confirm many widely reported barriers to hpv vaccination; these include myths (e.g., the vaccine causes infertility), beliefs that it will increase promiscuity, negative social norms within social groups, and concerns about safety and efficacy. solutions to these barriers include: • increasing knowledge about the risks prevented by the vaccine. promoting understanding that the community of interest is at risk; improving beliefs in vaccine safety, effectiveness, and community benefit. • dispelling unfounded myths. building a social norm that vaccination uptake is widespread and accepted in society (descriptive and injunctive normative beliefs). vaccine uptake strategy must address difficulties in accessing vaccines due to cost, lack of transportation to vaccination sites or clinics, and/ or a lack of a cold-chain network. authorities need to work with partners across government, ngos, communities, and the for-profit sector to reduce these barriers. poor access can reduce confidence in and demand for the vaccine. vaccine uptake promotion should thus facilitate availability and convenience. it is vital that countries review their public health finances early on to allocate funds to vaccinate their populations, as many countries already carry large debts. to inoculate the entire global community will require significant resources. countries with lower incomes will need to develop plans to access support from the international aid programs provided by governments, u.n. bodies and foundations, and other sources to secure adequate supplies of vaccines. promoters of the covid-19 vaccine should also consider that their efforts do not negatively impact on the availability and the uptake of other vaccine programs, predominantly for children. public health organizations rarely have sufficient resource capacity to develop, deliver, and maintain population-level change-focused programs. building and sustaining coalitions of organizations and individuals who can assist through the provision of resources, expertise, credibility and access is a crucial early action that needs to be addressed. critical asset identification and management falls into three main categories: government capacity coordination, private sector and ngo sector mobilization, and the mobilization of civil society. building alliances within government and across departments is a crucial aspect of asset identification and mobilization [29] . there is a need to develop plans and structures to coordinate action between government agencies and departments and organizations such as hospitals, clinics and schools [30] . an alliance or coalition team should also coordinate mechanisms and resources and set out chains of command and responsibilities. the ngo and private sectors can play a pivotal role in promoting the uptake of vaccines. partnerships with the pharmaceutical industry to develop, manufacture, promote, and distribute vaccines are underway across the world. many other for-profit organizations can also be harnessed to provide logistical and promotional support. the ngo sector is also well placed in terms of its reach, high level of understanding about local communities, and high levels of trust to act as a critical advocate and network for vaccine uptake. the third leg of the asset and capability resource base is civil society, represented by community groups and associations such as religious groups, community associations, recreational groups and community charities and volunteers. these groups and communities can play a crucial role in encouraging vaccine uptake and assisting with distribution and access. however, the part that civic society can play in promoting and helping with vaccine uptake is highly country-specific; therefore, local plans will need to reflect the role that such groups can play [30] [31] [32] . developing and maintaining a vaccine promotion coalition of government, the private sector, the ngo sector, and civic society requires resources and staff with expertise in creating and managing stakeholder relationships. authorities need to identify the resources needed to undertake these essential tasks, set objectives, monitor progress, and provide feedback. well planned, evidence-based, and theory-informed health communication and health marketing can significantly impact behavior and vaccine uptake [9, 33, 34] . well-designed campaigns, together with the application of behavioral science techniques, need to be supported by ease of access to vaccines, distribution networks and logistics, and taking notice of broader socio-economic and cultural factors [35, 36] . those responsible for creating demand for the vaccine need to work with vaccine suppliers, administrators, and those delivering vaccination to bring together a full mix of demand-side and supply-side interventions. the intervention mix needs to include coordinated action in the fields of prioritization and access policy, supply systems, and promotions strategy. prioritization is especially critical, given insufficient availability, especially after the initial months of vaccine launch. more important than building general demand are building awareness and support for covid-19 vaccination prioritization plans and fostering high acceptance among people in priority groups. the key to promoting demand is a deep understanding of what will enable and encourage uptake. campaign managers should conduct formative research including secondary research based on published literature and case studies and primary research with interviews and surveys in each population to gain audience-specific insights. governments will need to deliver and communicate what mix of incentives and penalty interventions will be used to promote demand [37] . demand strategy will also need to be supported by the development of a compelling, insight informed and segmented promotion that speaks to people's needs, values, and wants. health communicators must develop narratives that emphasize the positive personal, family, and community benefits associated with vaccine uptake. the demand strategy will need to include guidelines that reduce the influence of anti-vaccination advocates (see sections below for critical steps to consider when developing a competitor strategy). the demand strategy must also utilize positive narratives in both traditional and social media and apply behavioral influence tactics informed by behavioral sciences [10, 38] . the who recommends that every country should include ongoing community engagement and trust-building programs. programs should be focused on confidence-building and active hesitancy prevention, together with regular national assessments of population concern and trust [1, [39] [40] [41] . trust is built and maintained through transparency, constancy, active listening programs, and encouraging dialogue. agencies and governments need to share knowledge about certainty and uncertainty. governments and public health agencies also need to pre-empt and address any safety issues that are expressed or felt by the public or media [41] . governments should also be transparent about vaccine licensing, manufacture, and prioritization planning. consistency of both messaging and policy directives is also crucial. the absence of these conditions will trigger confusion and reduce trust [42] . anti-vaccination attitudes do not always relate to factors like level of education [43] . instead, they are often related to anger and suspicion towards elites and experts and increasing support for anti-establishment political concerns. governments should listen actively and build dialogue, encouraging continuous feedback from citizens, key commentators, and influencers. regular proactive public media and influencer briefings should also form a central plank of trust-building strategy. the application of citizen-focused and human-centered design principles can also enhance program development and implementation [44] . relevant agencies should realize the need for a coordinated mix of interventions to promote vaccine access, led by a strong leadership team [45] . promoting uptake through the media and community advocates is a critical element of any pro-vaccination strategy, but it is not a panacea for convincing everyone reluctant to vaccinate. research shows that behavioral change is a complex process that entails more than having adequate knowledge about an issue. uptake and hesitancy are also related to cultural factors, attitudes, motivations and experiences, social norms, and structural barriers. understanding the multiple factors involved in people's decisions is, therefore, key to success. governments and public health authorities can enhance the effectiveness of their efforts by combining multiple strategies [46] . for example, they could integrate financial and non-financial incentives, call and reminder interventions, along with penalties for non-compliance by imposing restrictions on travel, education, or employment [37] . vaccine access information, requirements and support will need to reflect each country's vaccination implementation strategy. will it be mandatory? will there be penalties for non-compliance? communicators should deliver implementation and access strategies through a segmented approach that provides specific and relatable information to identified subgroups of the population about how and when they can have access to vaccination. call mechanisms will need to be established and monitored as part of this element of the strategy. with regard to vaccine selection, assuming that the medical fraternity has developed several safe and effective vaccines by 2021, governments and public health authorities will need to explain to the population why they selected a particular vaccine in terms of its efficacy, safety, cost, etc. authorities will also need to explain their reasoning for the prioritization model for the vaccination that they adopt. for example, if a risk-based approach is adopted in which older people and care workers are prioritized over younger people and non-essential workers, this needs to be explained. governments and regional bodies need to explain and justify these decisions in terms of health protection, social and economic imperatives, safety and cost imperatives. schedules and timetables for total population vaccination should also be developed and shared before vaccination roll out begins so that everyone understands when they will get access. ideally authorities should share their plans for vaccine roll out prior to availability so that there is time for ethical and procedural issues to be publicly debated and a consensus reached. a coordinated national approach to communication will be successful among many groups, but not all [37] . success depends on the nature and degree of immunization hesitancy and the degree of segmentation. tailored messages focusing on known motivators for specific groups are more likely to produce a desired behavioral response than a 'one size fits all' approach [47] [48] [49] . to produce tailored messages, we recommend quantitative and qualitative formative research and ascertaining the efficacy of strategies with pre-test research before launch. as stated previously, there is a need to set out a compelling narrative that avoids 'backfire effects' [50] , validates people's concerns, and addresses both fear of loss and the positive gain that will accrue from vaccine uptake. as tversky and kahneman have demonstrated, when confronted with choices we are averse to any that might result in perceived loss [51] . we also do not like being confronted with complex choices. it follows that, if governments want to influence people to take up vaccination, they are more likely to be successful if the strategy emphasizes the positive gains accrued from vaccination, the loss that will occur if vaccination is refused, and that access to vaccines is easy. we know that the perceived attractiveness of options varies when communicators frame the same choice differently. therefore, the language used, the imagery, the messengers, and audio-visual effects are all important considerations that communicators should pilot test. as stated previously, authorities should tailor their promotional strategies by subgroups of the population, as each segment will respond differently to varied messaging and narratives. familiarity and trust in the messenger, as well as the message, is also a crucial success feature in tackling vaccine hesitancy [1, 52] . authorities should determine which campaign face and voice should be used based on formative research with the target audience. messages that come from a variety of trusted sources are likely to make a vaccine promotion programs more successful. spokespeople recruited from trusted groups, including healthcare professionals and relatable members of the public, can enhance the effectiveness of campaigns. high-profile personalities can also be effective in communicating messages, as they lend their prestige and trust to the health communication activity. the use of religious leaders (like the cooperation offered by muslim religious leaders in india to communicate the importance of polio vaccination), community influencers and third-party advocates, such as teachers, can also improve support for vaccination uptake [53] . as part of long-term public health strategy, governments and public health agencies should enhance media and digital literacy in schools and community settings, specifically related to health and vaccine topics [54] . newly acquired literacy will equip the public to identify reliable sources of information and encourage reporting of misinformation to social media providers and regulating authorities. the news and general media can contribute significantly to address fears and risk perceptions, which can hurt vaccine uptake [55] . it is, therefore, necessary to develop a proactive strategy for working with traditional media. any media management and engagement strategy that is developed will need to include proactive, rolling media briefings, story generation, editorial feeds, facilitating access to medical and other clinical and public health experts, advisers, and data. the media management and engagement strategy will also need to include 24/7 media monitoring and rebuttal/correction systems. communicators should mediate ongoing relationships between media contacts and experts who can provide accurate opinions on all aspects of vaccine promotion and safety. authorities should additionally monitor the strength of this relationship and address rapidly any conflicts that may arise. the responsibility of government agencies and others advocating for covid-19 vaccination is to communicate better, more visible, and more highly credible messages than the sceptics. successful media engagement is more likely when the public health system has developed a strong collaborative and open relationship with key editors, sub-editors and journalists. public health authorities and governments should continuously nurture trust and positive working relationships with media organizations so that the audience views the former as accessible and trustworthy. this will, however, require government authorities to be transparent, honest, and open regarding vaccine safety and effectiveness data that could be, or is, worrisome. anti-vaccination advocates abound on facebook, twitter, whatsapp, and youtube. social media platforms are already buzzing with misinformation about covid-19 vaccine safety, development, and planned rollout, months before vaccines are ready to be used at population level. it is encouraging to see such media platform owners starting to act against the anti-vaccination movement. for example, instagram avoids health misinformation in its explore page; youtube has demonetized anti-vaccination videos and gofundme has recently taken down anti-vaccination fundraising appeals. governments and their public health agencies need to develop a dialogue and joint strategy with social media platform providers to review and action against anti-vaccination misinformation and vaccine hesitancy promotion. governments and regional bodies should convince or regulate platform providers to remove misinformation. public health authorities need to build a proactive covid-19 vaccine trust capacity for active engagement in the social media space as part of their overall promotional strategy [56] . social media platforms are now the primary information source and communication channel for a large and growing number of citizens. public health agencies need to invest in building teams of specialist staff trained and capable of understanding how to build and maintain social media presence. the key responsibilities of public health staff focused on social media are the development of and support for continuous positive story streams, nurturing multiple supportive voices, and amplification of pro-vaccination grassroots advocates. these dedicated staff need to support pro-vaccine influencers, advocates and social networks. public health staff can also assist in the identification of and responses to false social media posts. the team should address such negative posts instantly to prevent the decline of trust in public health authorities. we know, for example, that parents who are resistant to getting their children vaccinated are more likely to have based their decision on information obtained on the internet [57] . the strategic and tactical guidance set out above provides a framework for promoting the uptake of covid-19 vaccines as they become available. this paper also acknowledges the importance of evidence and theory-driven behaviour change tools in addressing vaccine hesitancy. this is consistent with who's recent establishment of the technical advisory group on behavioral insights and sciences for health [58] . key to the success of promoting vaccine uptake will be a significant and sustained strategic program, including strengthening of local capacities, to build and maintain confidence and trust [59] . a crucial factor in the delivery of such a trust-building and demand building approach is the need for investment in communication, behavioral influence, and community engagement capacity and capability. communication and behavioral influence are often underfunded or under-resourced in public health organizations and within government ministries. building communication and behavioral influence capacity and expertise should be a priority. it is now often said that everything will be different in the post covid world; hopefully one difference will be a commitment to investment in developing and delivering the key action elements set out in this paper. this investment will need to be sustained over time in line with best practice requirements regarding risk communication and community engagement so that we are better prepared for inevitable future events [39] . the authors acknowledge that countries, high-, low-and middle-income, have been using many of the guidelines described in this manuscript to foster high vaccination coverage. the challenges are not that they are unaware of the actions described here but rather: (1) they have very limited resources (e.g., money, people) to implement all the actions at the scale the authors are recommending; and (2) they are responsible for promoting and achieving compliance with vaccination schedules, not just a single vaccine. governments and relevant bodies should bear these limitations in mind as they consider our guidelines. world health organization. the guide to tailoring immunization programs; world health organisation vaccine hesitancy around the globe: analysis of three years of who/unicef joint reporting form data-2015-2017 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for disease control and prevention. gateway to health communication and social marketing practice government communication network and the central office of information. communications and behaviour change when corrections fail: the persistence of political misperceptions rational choice and the framing of decisions methods to overcome vaccine hesitancy social marketing in india health literacy and vaccination: a systematic review making a drama out of a crisis. a multidisciplinary study of news media coverage of a public health crisis and the role of emotion using social media to create engagement: a social marketing review a postmodern pandora's box: anti-vaccination misinformation on the internet technical advisory group on behavioural insights and sciences for health by failing to prepare, you are preparing to fail: lessons from the 2009 h1n1 'swine flu' pandemic this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license acknowledgments: not applicable. the authors declare no conflict of interest. key: cord-326851-0jxdnm1l authors: lee, sang m.; lee, donhee title: lessons learned from battling covid-19: the korean experience date: 2020-10-16 journal: int j environ res public health doi: 10.3390/ijerph17207548 sha: doc_id: 326851 cord_uid: 0jxdnm1l background: the covid-19 pandemic has swept the world like a gigantic tsunami, turning social and economic activities upside down. methods: this paper presents some of the innovative response strategies implemented by the public health system, healthcare facilities, and government in south korea, which has been hailed as the model country for its success in containing covid-19. korea reinvented its public health infrastructure with a sense of urgency. results: korea’s success rests on its readiness, with the capacity for massive testing and obtaining prompt test results, effective contact tracing based on its world-leading mobile technologies, timely provision of personal protective equipment (ppe) to first responders, effective treatment of infected patients, and invoking citizens’ community and civic conscience for the shared goal of defeating the pandemic. the lessons learned from korea’s response in countering the onslaught of covid-19 provide unique implications for public healthcare administrators and operations management practitioners. conclusion: since many epidemic experts warn of a second wave of covid-19, the lessons learned from the first wave will be a valuable resource for responding to the resurgence of the virus. the recent spread of the coronavirus (covid-19) has thrown the world into total chaos. covid-19 has caused not only a health and social crisis of immense proportions forcing people to deal with the fear of infection and the physical, emotional, and financial damage from government recommended physical distancing, but it has also caused a global economic turmoil [1, 2] . the virus started spreading in wuhan, china in late december 2019, and became a shocking pandemic by mid-march 2020; by this time, it had already caused several hundred deaths, disrupted the global economy, and forced countries to close their doors to visitors [3] [4] [5] . the world health organization (who) defined covid-19 as "an infectious disease caused by a newly discovered coronavirus" [6] . who declared the novel coronavirus outbreak a global pandemic, the highest category for infectious diseases, on 11 march 2020, officially notifying the global community that a health crisis is upon us [3, 7] . major infectious diseases that have occurred during the past 20 years include severe acute respiratory syndrome (sars: 2003), novel influenza virus (h1n1: 2009), middle eastern respiratory syndrome (mers: 2012), avian influenza (2014 and 2017), and covid-19 (2019), most of which were originally reported in china. particularly, covid-19 has potent infectivity, implying that it spreads quicker and its mutations are more complex than other infectious diseases. as the numbers of confirmed cases and deaths began to rise exponentially, halting the coronavirus became a global issue. in addition to the immediate health concerns, the covid-19 pandemic disrupts and destroys global supply chains along the associated systems of purchasing, manufacturing, logistics, and sales [8] . this study attempts to present directions for potential changes in the crisis response systems of public healthcare worldwide, by analyzing covid-19 pandemic response cases, both successes and failures, in korea. more specifically, this study has the following objectives: (1) to analyze korean experiences with cases where healthcare facilities failed to prevent previous infectious diseases from spreading, and how these failures served the government in devising effective approaches to encounter the covid-19 pandemic, (2) to dissect cases that showed innovative and successful response measures to deal with the covid-19 pandemic, and (3) to elaborate on suggestions for crisis management based on the lessons learned from these covid-19 response cases in korea. the rest of this paper is structured as follows. in section 2, we present a review of relevant literature on global infectious diseases and covid-19 as well as several real cases of korean healthcare providers in managing the covid-19 pandemic. section 3 presents the innovative response strategies deployed in korea (k-response model) to fight the pandemic. in section 4, we summarize the important lessons learned from the korean experience. we conclude the study in section 5 by discussing implications of the study results, limitations of the study, and future research needs. infectious diseases refer to those "caused by pathogenic microorganisms, such as bacteria, viruses, parasites, or fungi; the diseases can spread, directly or indirectly, from one person to another" [20] . these diseases can infect people by contact with other humans, animals, or other reservoirs infected by a pathogen or toxic substance. additionally, communicable diseases refer to those that directly or indirectly spread between humans or between humans and animals. thus, an infectious disease pandemic is an epidemic that has the potential to be easily transmitted and to affect the global population due to its highly infectious nature [21] . since the second world war, the world has seen many innovative developments in vaccines and antibiotics; such advances have ensured that communicable and infectious diseases are reasonably controlled [11] . an important study by the institute of medicine, "emerging infections: microbial threats to health in the united states," shed some light on the issues involved with novel infectious diseases [22] . soon thereafter, the who passed the resolution "global health security: epidemic alert and response" in 2001 [23] , which enabled the collection of information and enforcement of actions through cooperative work by inter-governmental agencies, non-governmental institutions, private organizations, and governments around the world. in 2003, the sars outbreak in china quickly spread fear of a pandemic that could cross borders and affect countries worldwide. particularly, china failed to promptly and transparently disclose epidemic information. the chinese government reported the outbreak to the who several months after the first confirmed case of sars, thus delaying effective response measures by world organizations. immediately, the who raised the alert that the sars outbreak was of high risk, subsequently issuing a travel advisory notice (e.g., advising a travel ban to places where the epidemic had occurred) aimed at suppressing the spread of the disease. as a result of this experience with sars, many countries worldwide recognized the importance of a global infectious disease governance system, which should stretch beyond the governance of each country [24] . in 2005, the international health regulations were revised and expanded to include not only communicable diseases but also other possible threats (i.e., biological terrorism and events that induce international public health crises). nevertheless, other highly contagious diseases have continued to emerge throughout the last two decades. in the presence of healthcare emergencies, such as the infectious and coronavirus outbreaks discussed above, public healthcare should be available throughout the country not only with rapid response but also based on an equitable basis [5, 19, 25] . the sense of equity involves a person's perception of the input and output relationship which should not create tension or displeasure as a result of cognitive dissonance [26] . rousseau [27] defined equity as a function of customer's perception in a service encounter experience. equity is realized when a person believes his/her outcome concerning resources invested is in harmony with that of others [28] . equity theory has become the theoretical foundation for service recovery as it helps create possible recovery approaches for service failures through recognition, procedures, and mutual interaction involving customer complaints [29, 30] . it is important that people perceive that a service is being provided equitably. especially in a crisis such as the covid-19 pandemic, it is imperative for people to perceive that urgent public healthcare is being provided equitably [5] . such perceived equity inspires people to be transparent about their activities (e.g., infection status, contacts, self-quarantine, etc.) that are the first line defense against the disease. this study examines the successes and failures of the korean healthcare organizations in their efforts to contain covid-19, from an equity perspective relating to healthcare services. korea has a history of responding poorly to infectious diseases (e.g., sars, h1n1, and mers). in 2012, saudi arabia was the first country to experience the mers outbreak. korea was the most detrimentally affected country by the virus as many korean global firms have operations in saudi arabia. in korea, the first mers case was confirmed in 2015 and its rapid spread resulted in a significant number of casualties which heightened anxiety that swept throughout the country. furthermore, the serious blow caused to the national economy clearly revealed the weakness of korea's infection crisis management system [10, 31] . the korean government's limited response capacity regarding mers and its poor communication to its citizens weakened people's trust in the government's infection crisis management policies to the point where many started believing that the national epidemic prevention system could easily collapse [31] . there were 185 confirmed cases of mers among those who traveled to the middle east, 38 of whom died in 2015. the causes of the high mortality rate could be attributed to the limited capacity of the healthcare delivery system for handling the new virus, shortage of epidemic prevention equipment for medical first responders, and the moral hazard among patients [10, 31] . after painful experiences in dealing with past diseases, the korean government was determined to establish an effective infrastructure to deal with future epidemic emergencies, with kcdc as the control tower. the new infrastructure includes an increased number of negative-pressure isolation wards, real-time systems for data and transparent information collection and analysis, and modernization of the healthcare system. since the mers crisis, the korean government has reinvented a national healthcare delivery system equipped with advanced digital technologies and expanded the facilities specifically designed to deal with infectious diseases (e.g., the creation of negative pressure wards) [10, 31] . thus, kcdc was well prepared to respond effectively to epidemic emergencies when the covid-19 crisis occurred. when covid-19 began to spread, the korean government raised the response level to serious (the highest) on 23 february 2020 and promptly established the central disaster and safety countermeasure headquarters, headed by the prime minister to bolster government-wide responses to the virus with kcdc as the command center [32] . according to the korea economic daily [33] , the rapid spread of covid-19 around the world, especially in china, italy, and in the united states, and the subsequent spike in the number of deaths, has brought global attention to the prevention model and early response operational strategy implemented by daegu city, the epicenter in korea. daegu took aggressive actions with speed to prevent the collapse of its healthcare system without placing the city in a lockdown [34] . the city government performed aggressive screening, testing, and quarantining of patients in the communities that were confirmed to have, or suspected of having, infected citizens. according to kcdc [32] , daegu city did not implement this approach at the onset of the covid-19 outbreak in korea (18 february 2020). daegu and the north gyeongsang province (where daegu is located) were heavily criticized for the exponential growth rate of infected patients as ground zero. this region accounted for 70% of the confirmed cases in korea, caused primarily by the shincheonji church gatherings (worship services where people sat on the floor shoulder-to-shoulder) and the mass infections that occurred among the first medical responders while providing care services. the city government performed screening tests of the entire congregation of the shincheonji church, isolated severely ill patients, and secured enough quarantine beds for those in need of treatment and isolation. to achieve this, daegu operated a public-private partnership (ppp) network (composed of the emergency response advisory group, the daegu medical association, and three infectious disease management support groups), which served as the control team for the covid-19 epidemic [35] . the ppp collaboration network deployed several response strategies against covid-19. first, private hospitals were converted into isolation hospitals. a group chatroom for the control team was created, through which experts held discussions about the situation throughout the night. through these discussions, the daegu dongsan hospital and the ministry of defense were contacted and asked to secure as many beds as possible at the daegu armed forces hospital and daejeon hospital. at that time (18) (19) (20) (21) (22) (23) (24) (25) , there were only about 30 available negative pressure wards in daegu, and some confirmed patients died while waiting to be admitted into a hospital. second, the entire congregation of the shincheonji church was tested, and those who had symptoms were identified. on the night of 18 february 2020, 70% of confirmed cases of covid-19 were members of the shincheonji church. the daegu secured information on the 3000 members of the church, identified them, and ordered 544 symptomatic patients to remain in self-quarantine for two weeks. a leading physician at the kyungbook national university stated that "the rate of confirmed cases reached 80% among patients who showed symptoms; so, if we had not prompted early isolation of those shincheonji church members who showed symptoms, daegu might have been in the same situation as europe or the united states" [33] . third, members of the daegu medical association provided care to those patients in self-quarantine via video calls using 100 outgoing-call-only smartphones provided by daegu city, hence eliminating the previously existing void in the response system. these response activities represent innovative strategies implemented in the initial stage of the covid-19 invasion (e.g., aggressive testing, almost immediate test results, contact tracing of infected persons, and prompt treatment of severely ill patients). the mortality rates in new york, usa (6.44%) and in madrid, spain (12.62%) are much higher than that in daegu, korea (2.76%) as of 1 june 2020 (see table 1 ). these high mortality rates indicate that their patient monitoring and healthcare facilities operations were not systematic. it is evident that "the most potent operational strategy amid the lack of a cure is not search and destroy, but identification and isolation of symptomatic citizens" [33] . fourth, drive-through screening centers were developed for the first time in the world, supported by a world-leading ict infrastructure [36] . the yeungnam university medical center, in the vicinity of daegu, had admitted a covid-19 patient on 19 february 2020, which resulted in the closing of the emergency room (er) and prompted self-isolation of its medical staff. based on this experience, the medical center decided to establish a drive-through screening center, which eliminated the risk of shutting down er and self-quarantining first responder medical staff. moreover, the existing screening center was inefficient in handling the large crowd of people needing testing in a small space. thus, this was another innovation in need that led to the strategy of developing drive-through testing centers. laura bicker, a bbc correspondent in seoul, referred to the drive-through testing centers as "such a clever idea and so quickly set up". sam kim, an economics reporter at bloomberg, mentioned that korea "once again proved to be among the world's innovative nations," and ian bremmer, president of the eurasia group, a think tank in the us, stated that "innovation drives resilience" [37] . innovative operation strategies are critical in fighting such a formidable global pandemic as covid-19. finally, creative applications of the national ict infrastructure and rapid development of mobile apps by young entrepreneurs have helped analyze the details about confirmed patients and their contacts (e.g., locations, people contacted, and travel patterns before their infection confirmation). kcdc [32] collected and released relevant information (e.g., regions, pockets of high infection density, and places visited) on covid-19 patients in real-time. such transparency regarding the handling of covid-19 patients encouraged citizens to voluntarily participate in physical distancing and personal hygiene. this is another strategy that has helped korea effectively manage the crisis when compared to other nations such as italy and the us. in korea, after kcdc disclosed the movements of the first covid-19 patient in daegu on 18 february, all the places the patient had visited were immediately shut down and disinfected; moreover, the government analyzed security footage (e.g., cctv from the entrance of the church) to help identify and isolate anyone who might have come into contact with the patient. local governments sent out emergency alert text messages to provide real-time updated information so that the population of other provinces and cities could be advised not to visit the infected locations. table 1 summarizes the current (as of 1 june 2020) state of the cities with the greatest number of confirmed cases among countries most affected by covid-19, and the innovative operational strategies implemented by daegu to respond to the covid-19 pandemic. daegu, the epicenter of covid-19 cases, is currently in the process of being transformed into a smart city. it is noteworthy that the city/area where an explosive outbreak of covid-19 cases occurred had higher mortality rates than that of the country as a whole. table 2 summarizes statistics of the number of confirmed covid-19 infection cases, deaths, and mortality rates among the top 10% of 169 countries, including italy, china, and south korea, as of 7 september 2020. the table also indicates average statistics for the entire 169 countries. figure 1 shows the mortality rates of the top 10 countries for covid-19 infection, including south korea, as of 7 september 2020 (including the average for the entire 169 countries as a group). the bars in the figure show the number of deaths per 100,000 population. in the early phase of the coronavirus spread, south korea recorded the second highest number of infected persons after china. however, as shown in tables 1 and 2 and figure 1 , korea initiated aggressive strategies for testing and contact tracing based on its well-established public health infrastructure. thus, the country has been able to flatten the curve of infected cases which resulted in relatively low rates of deaths/infected cases and mortality (deaths/100,000 population) [44] . source [45] . the crisis caused by a pandemic can lead to issues of equity in the public healthcare service [46] . particularly, failures in providing equitable public healthcare and in community participation in the decision making process should not be repeated. thus, it is necessary to analyze the successes and failures experienced in the current situation (i.e., the first wave) as a preparation for the possible mortality: deaths/100k population (7 september 2020) the crisis caused by a pandemic can lead to issues of equity in the public healthcare service [46] . particularly, failures in providing equitable public healthcare and in community participation in the decision making process should not be repeated. thus, it is necessary to analyze the successes and failures experienced in the current situation (i.e., the first wave) as a preparation for the possible onslaught of the second wave of the pandemic. to conduct an in-depth analysis of the causes and consequences of the covid-19 virus spread in korea, we examine the operational procedures and strategies implemented by several healthcare facilities. many seriously ill patients with the virus were diagnosed or infected in er. even in a normal day, er operates at the disaster level [47] . the covid-19 pandemic severely tested the agility, flexibility, and resilience of er operations at every hospital. the following five cases are investigated based on the information released by kcdc [32] . hospital a is an 808-bed tertiary general hospital located in seoul with 2000 employees. the hospital provides care to an average of 600 inpatients and 2000 outpatients daily. the first covid-19 case in this hospital was confirmed on 21 february 2020, and was consequently quarantined for two weeks until 5 march. a careful contact tracing of the patient resulted in 14 additional confirmed cases within the hospital. the first confirmed case in the hospital was a patient aide who helped patients move from the ward to the lab. prior to the diagnosis, it was found that this aide had helped 207 patients. after the diagnosis of the first confirmed case, the hospital's er and outpatient clinics were closed and quarantined. hospital b is a 251-bed general hospital with 644 employees located in seoul. it was closed for two weeks, from 8 to 22 march, due to a patient's dishonesty. the patient was a resident of daegu city but falsified his home address when hospitalized. after being diagnosed with covid-19, the patient was isolated. the hospital shut down its outpatient center, some wards, and er. the particular concern which this patient caused was the fact that the person had visited the artificial kidney unit, contacting many high-risk patients. although there was no additional positive case found, the hospital was quarantined for two weeks. hospital c is a psychiatric hospital (housed on floors 8-11 in a high-rise building) in daegu with 286 inpatients and 72 employees. the first positive diagnosis of covid-19 was made on 26 march, after which the number of confirmed cases increased at an alarming rate. this case happened because the first patient was originally at a convalescent hospital (located on floors 3-7 in the same building) where the first positive case was tested on 20 march and spread quickly to133 patients. when the first case was confirmed at the convalescent hospital, the building management firm failed to disinfect the entire building and consequently the virus spread to hospital c. hospital c conducted virus tests on its own employees but did not screen all patients because all the employees were tested negative. there were 196 infected patients as of 20 april and the hospital was closed. kcdc conducted a thorough investigation of hospital c and found that the mass infection occurred because of the failure to screen all patients [32] . further, due to the nature of the psychiatric hospital (i.e., closed wards in confined spaces), the infection spread rapidly, and subsequently the number of infected cases increased at an accelerated rate. hospital d is a 700-bed general hospital located in seongnam city, in the vicinity of seoul, with 1400 employees, including 140 specialists in 26 specialty areas. the hospital serves an average of 5000 patients daily. one patient was discharged after treatment in the hospital and returned to receive outpatient care. the same patient became very ill and was brought to er and diagnosed with covid-19 infection on 5 march. consequently, a mass infection of the virus occurred among healthcare providers within the hospital (43 confirmed cases). hence, the hospital was closed from 6 march to 12 april (38 days). hospital d provided incomplete information to kcdc, as a person in need of isolation was omitted from the list [32] . hospital e implemented proactive measures to suppress the spread of covid-19. all patients and their respective caregivers were required to fill out a paper-based health questionnaire upon admission. however, there were concerns about having the patients complete the questionnaire, which might take too much time while they were crowded in a limited space. in order to reduce crowding and minimize hospital-acquired virus infections, a mobile health questionnaire was delivered by the hospital. the questionnaire asked patients to precisely list all travel to foreign countries, visits to regions or facilities with confirmed cases, and any symptoms of fever or respiratory difficulties. hospital e reported that (https://www.yuhs.or.kr/en/), between 12 and 19 march, an average of 6136 people submitted the mobile health questionnaire each day. on average, the questionnaire took 1 min 29 s to complete (8.9 s for each of 10 items). further, hospital e sent the mobile health questionnaire to visitors scheduled for outpatient services or testing at 6 am on the day of the appointment via kakaotalk (korean sns) or text message. once the patient had completed the questionnaire, a quick response (qr) code was generated. if the patient had self-reported covid-19-related flagging, a red qr code was assigned, and no flagging was noted with a black qr code. only visitors who had the red qr code were issued with proper stickers and allowed to enter the hospital. the patients with the red qr code were required to undergo an additional evaluation at the hospital entrance. based on this evaluation, they were either directed to a designated safe care facility or were not allowed to enter the hospital for treatment. moreover, visitors who were not able to use a mobile questionnaire or were not aware of this requirement were provided with the paper-based questionnaire at the entrance. the implementation of this mobile questionnaire was an effective measure to reduce hospital-acquired infections, among the patients and between employees and patients (hospital press release; https://www.yuhs.or.kr/en/). table 3 presents a summary of problem causes and response strategies employed by the sample hospitals. during a pandemic crisis, the government should encourage people to take preventive measures for their own safety, and share information transparently, including that on the risk involved. after failing to effectively manage the mers outbreak in the past, korea improved its public health infrastructure and expanded its relevant medical facilities. this experience enabled the korean government and healthcare providers to develop innovative response strategies to covid-19. drive-through and walk-through testing centers were implemented for the first time in the world. these systems have been heralded as a creative response model to the pandemic, and they have been benchmarked and copied by countries worldwide [14, 36, 48] . the compelling motivation for these systems was rooted in the challenging problems experienced by some screening centers. these centers were overwhelmed by an onslaught of patients with suspected covid-19 symptoms. the average waiting time for a screening was as high as six hours or even longer in some cases, consequently raising serious cross-infection concerns [32] . a drive-through screening center can process suspected patients through several steps (e.g., completion of the patient questionnaire, physician's examination, sample collection, and education) without them getting out of their automobiles, hence shortening the testing duration to less than 10 min per patient [32] . these testing systems lower the risk of infection, minimize contact between test recipients and healthcare providers, and save time. in a regular screening center, the room must be disinfected and ventilated after treating each patient. drive-through centers, on the other hand, do not require such procedures, thus not only diminishing the risk of contamination but also greatly increasing the number of daily cases handled. for example, a regular screening center could process two cases per hour (20 daily cases), whereas a drive-through center can process up to six cases per hour (60 daily screenings) [32] . furthermore, the people being tested preferred the drive-through system because the waiting time for the test is far less and the queue time is spent in the comfort and safety of their own cars [48] . the most challenging task in controlling the spread of covid-19 is making sure incoming international travelers are not carriers of the virus. thus, kcdc set up 16 walk-through outdoor screening booths (eight for each of the two international terminals). all incoming passengers are tested as they walk through the station at the rate of 5 min per person, screening more than 2000 passengers per day. one of the most important aspects of suppressing the spread of the pandemic is the battle against time. performing aggressive testing in a short period of time to identify and isolate confirmed patients is the most critical operational strategy for flattening the curve of infection cases [49] . the screening systems discussed here represent innovations developed due to the desperate need to contain covid-19 at the most critical point of time, the beginning of the rapid spread stage [32] . on 10 march 2020, the korean government established residential treatment centers to treat confirmed covid-19 patients while maintaining their quarantine. in this residential system, each room is occupied by one person as a rule, and all residents must conduct self-monitoring twice daily and are on constant monitoring and treatment by health professionals residing in these centers. such centers' primary aim is to triage and categorize patients into four levels (mild, moderate, severe, critical), and the secondary aim is to manage patients with mild conditions. this system helps ensure that hospital beds are provided for covid-19 patients needing critical inpatient care. the resident treatment centers are managed independently by each local government. the primary goal of these centers is to prevent the spread of the virus by treating, isolating, and medically monitoring infected patients. while it is not necessary to send patients with mild symptoms to hospitals, it is still necessary to isolate them as they have the potential to widen the spread of the disease. thus, these patients are the major targets of residential centers. to achieve their strategic objectives, these residential centers need to make their operations flexible and dichotomous, encompassing both hospitals and centers. hence, their provision requires accurate triage of confirmed patients, active participation by residents, and strict compliance with the care policies and regulations within the center. these residential treatment centers represent an innovative model of care that has helped prevent the spread of the infection to the community while addressing the shortage of hospital beds. "untact" means no human-to-human contact in service encounters [17] . during the covid-19 pandemic, korea has been able to provide untact services to its population based on innovative applications of digital technologies. this operational strategy has contributed a great deal to suppressing the spread of covid-19 through an advanced healthcare system (e.g., drive-through screening centers). one of the best examples of such untact services is the self-diagnosis app and the self-quarantine protection app [32] . on 10 february 2020, the central disaster management headquarters of korea announced that it was going to use a self-diagnosis app to monitor the virus infection status of all incoming travelers through a special entry procedure in order to strengthen infection management. this app monitors the symptoms once a day and provides a quick consultation by medical staff for everyone who enters the country. after this app became mandatory, permission to enter korea has been granted to only those (citizens and foreigners alike) who provided their personal information (e.g., name, passport information, nationality, and actual address) in the app. anyone entering korea must consent to use the app and download it themselves as a special entry procedure. the results of the self-diagnosis feature (i.e., fever, cough, and/or sore throat) are submitted to the corresponding public health center and kcdc. moreover, this app provides important information to the user about screening centers (i.e., the closest available area/location for inspection and contact information), the sns channel of kcdc, and 1339 consultation call centers. untact technology-based approaches are currently making a substantial contribution to address the challenges regarding patient management, shortage of healthcare staff, and lack of resources needed to provide a diagnosis. additionally, aimed at healthcare providers, a dashboard was developed by the korea university medical center and softnet to automatically send information about patients' (self-assessed) body temperature, symptoms recorded on the app, pulse and blood pressure (taken with a bluetooth blood pressure cuff) to healthcare providers [50] . the application of such innovative apps involves a trade-off between the concern of staying safe from the virus and personal privacy [50] . nonetheless, these measures have proven to be essential for preventing the spread of the pandemic through prompt and convenient reporting of symptoms among all travelers to korea. the crisis caused by a pandemic requires a robust response system to prevent global health, economic, and social disasters. the key lesson learned from the korean experience in managing the covid-19 crisis is the importance of innovative response strategies at the onset of the pandemic. based on the review of some of the experiences of sample hospitals and the practices that have been proven effective, an innovative pandemic management system should include the following strategies. the pandemic response cannot be made by one independent organization. there should be a collaborative public-private partnership that can utilize the synergistic capabilities of governments, private enterprises, healthcare institutions, university research centers, and volunteer organizations (e.g., daegu's collaborative network: emergency response advisory group + daegu medical association + daegu center for infectious disease control and prevention). such a collaborative innovation partnership is imperative to generate creative strategies, operational plans, and detailed work procedures. when a collaborative system is established, especially with many volunteer entities, it is difficult to seamlessly execute strategies and actions in a timely fashion in the face of the rapidly spreading pandemic. thus, an explicitly designed governance system with clearly defined roles, responsibilities, and authorities is as important as the strategic plans. in the exponential increase stage of the pandemic infection, healthcare facilities in the ground zero area could be overwhelmed by severely ill patients, causing the collapse of the system. for effective response management, healthcare facilities in the affected area (cities and surrounding counties) should be integrated as an emergency response system. then, the various healthcare facilities can be dichotomized based on their scale and core competencies so as to designate some as intensive care facilities where severely ill patients are quickly assigned for treatment and others as safe facilities where patients with non-virus related illnesses are treated [4] . fighting a pandemic requires much more than simply testing and treating infected patients. it is essential to secure a sufficient quantity and quality of medical supplies, protection of frontline health professionals, and secure supply chains. it is imperative to develop an effective logistics system for timely delivery of medical supplies (e.g., testing kits, medications, ventilators, additional er facilities, ambulances, helicopters, etc.). the healthcare delivery system is bound to collapse if frontline healthcare providers are infected because of insufficient or ineffective personal protective equipment (ppe) such as face shields, masks, and body covers (for head, hands, shoes, and body). in addition, stable and emergency supply chains are necessary to ensure timely supply of all medical and other supplies in order to provide urgent care to the patients on an on-demand basis in the face of the pandemic crisis [8] . the spread of a pandemic is not even throughout a country or region. while a national pandemic management center is necessary (e.g., kcdc) to develop nation-wide guidelines and strategies, each region of the country has its own unique patterns of virus infection. thus, each local area government or virus control center should be allowed to establish its own strategies to control the spread of the pandemic. as the virus spreads throughout the community at a rapid pace, the need for mature civic consciousness usually grows proportionately. the current physical distancing campaign is a good example. many countries incurred enormous damage due to citizens not abiding to recommended guidelines to prevent the spread of the pandemic (e.g., social distancing, shelter-in-place, personal hygiene, etc.), awakening the need for social co-consciousness and citizen engagement [51] . therefore, policymakers of the central government should develop definite policies regarding the devolution of control and direction, which are required of all citizens during the critical phase of a pandemic. the covid-19 pandemic has brought a total upheaval to the way people live, businesses operate, and governments function. the pandemic has infected more than 27 million people, brought profound sadness to people who lost their loved ones (881,464 deaths as of 7 september 2020), and hundreds of millions lost their jobs around the world in a matter of several months. we must learn from our experience of failure, and some successes, so that we can be better prepared to prevent and manage future pandemics. there are several lessons that have now been learned and identified as important elements for managing a pandemic from the covid-19 experience in korea. at the time of the mers outbreak, the ministry of public safety and security of korea sent out tips to the entire population on how to prevent the virus via an emergency text message. however, this only occurred during the early days of the outbreak, and the government's crisis management system-which should have directed efforts to manage the epidemic-failed to function properly [10] . consequently, despite having a response system for infectious diseases, the government failed to effectively execute early responses and was criticized for aggravating the damage caused by mers. this inefficacy of early responses resulted in human casualties, public anxiety, and substantial economic damage, all of which revealed the weakness of the government's infection crisis management system [52] . this failure not only made the korean government recognize the vulnerability of the national epidemic prevention system but also provided an opportunity to learn from the failure [31] . leadership was recognized as a key contributor to the successful containment of the sars outbreak in korea in 2003. previous studies show that leadership has played a significant role in the effective implementation of proactive measures and facilitation of inter-agency communication in the face of an epidemic [53] . more specifically, during the current pandemic outbreak, the national crisis management capacity which was strengthened due to the lessons learned from mers helped execute necessary response steps at the critical early stage of the pandemic spread. an emergency leadership team should be established with experts in the relevant fields to develop specific strategies for prevention, response measures, and medical treatment procedures to contain the pandemic. the international media have been reporting korean strategies and practices for controlling covid-19 as a model [44, 54] . most korean provincial governments have been effectively containing the spread of the pandemic without shutting down business operations such as restaurants, coffee shops, retail stores, and even golf courses [48, 54] . particularly, the international media praised korea's testing capacity with its innovative drive-through and walk-through stations, rapid processing for results (less than 4 min), and the korean government's information management that did not require a lockdown enforcement like wuhan, china. the new york times [55] reported that, if south korea succeeds in containing the infection as it has, it will set an example for the world to follow. johnson et al. [56] also noted that korea's advanced diagnostic capability was proven to be the enabler of its massive testing of more than 35,000 a day, while the u.s. was testing a mere 426 persons (reported on 25 february 2020). moreover, health korea news [57] reported that the mortality rate of covid-19 patients was only 0.7% among 10,000 infected patients during the early stage of covid-19 spread. it is evident that the korean government's quick response capacity, information disclosure transparency, and implementation of innovative models to protect patients and healthcare providers were the key factors for early success in containing the pandemic. korea had a bitter experience with mers which helped the government to learn from failures and then establish a proven infrastructure to handle the spread of pandemics. a set of best practices, what is now known as "the k-response model," is based on standardized proven systems that can be applied by all healthcare providers, including testing procedures, contact tracing, isolation by self-quarantine, hospitalization, treatment procedures of severely ill patients, and release after being cured. the control tower in central government and in each local government should proclaim a standardized preventive system (e.g., closing all large audience events such as sports, theaters, shopping centers or educational institutions; limiting the number of people in any group gathering to 10 or less, with social distancing of 6 feet or more; the stay-at-home policy; closing all business operations for 2-4 weeks, including all personal services such as hair salons, massage parlors, physical therapy centers, dental offices, etc.) [32] . the operating systems and strategies that the korean government implemented to contain covid-19 have proven to be effective. the ebola outbreak in west africa in 2014 caused more than 10,000 deaths with a 40% mortality rate. the affected governments' approaches to combatting the virus failed to foster trust among the citizens, causing fear, and inaccurate information led to a considerable amount of time spent on tracing the actual movements of those infected [58] . a previous study analyzed the outbreak of novel infectious diseases since 1990, focusing on global pandemic management systems [11] . this study stressed the importance of transnational monitoring and information sharing about the spread of diseases (e.g., disease symptoms and infected areas). another study investigated the outbreak of sars and pinpointed the chinese government's failure to provide effective early response to the pandemic, either concealing or underreporting, as the reason for the global spread of the disease [59] . the korean government, in response to the current covid-19 pandemic, has been reporting the number of confirmed cases, the number of deaths, and the actual movements of confirmed patients in real-time. such government efforts for transparency and urgency regarding the pandemic have gained the public's attention regarding the risk involved. such government efforts also gained the trust of citizens and helped people comply with issued guidelines. the government also announced disinfection measures and schedules for locations where confirmed patients made contact with others on a daily basis. this information indirectly advised the general public not to visit those hot spots. in addition, local governments sent out text messages to all citizens upon confirmation of a new infection case in their region and other helpful safety tips about the virus. such real-time information sharing about the pandemic has been possible because of the advanced mobile technology infrastructure and the public's high mobile device usage in korea. as covid-19 began to spread throughout the country in february 2020, various apps were developed rapidly by young entrepreneurs (e.g., apps showing confirmed patients' locations, the closest place where masks and gloves can be purchased, assistance tips for self-quarantine, etc.). currently, several european countries (e.g., uk and italy) are also attempting to utilize a gps tracking system to locate confirmed patients and to inform disinfection and prevention activity areas using smartphone apps. a team of medical researchers at oxford university in england published a report suggesting that communicable diseases can be controlled effectively if many utilize digital contact tracing [60] . based on the current covid-19 situation in korea, while the government's response capacity is crucial to prevent the disease from spreading, mature civic consciousness is essential to ensure social compliance with the imposed measures. in korea, people did not engage in panic buying during the early days of the pandemic outbreak. for example, when there was a shortage of masks, instead of the profiteering behavior of some hoarders, many people began to donate some of their daily allotted masks to the community for those in need. mass media also encouraged beneficence through public emotions showing a strong spirit of community and unity. people recorded their daily lives in sns, including health status and places visited, to help prevent the infection from spreading to others around them. some people even traveled only on foot to prevent spreading the disease in the community. furthermore, people complied with the five-day rotating purchase system for masks, which was instituted by the government to ensure a fair distribution to everyone in the face of mask shortages. the global media has praised koreans for their voluntary civic engagement and compliance with government guidelines to contain covid-19. the washington post [61] reported that korean citizens canceled major events and most religious services were held online at the outset of the pandemic breakout. daegu, the epicenter of a massive spread of the virus, was able to manage the situation without a lockdown, as people in other parts of the country voluntarily refrained from visiting the city. moreover, the bbc news [62] stated that south korea was able to manage the spread of covid-19 without implementing a complete lockdown or strict measures against people's movement. koreans voluntarily wore masks everywhere outside of their homes and were tested for covid-19, demonstrating mature community and civic consciousness. responding together and responsibly to the threat of covid-19 have now become a battle cry for koreans [63] . contrastingly, there were cases where civic duty was not practiced. there were incidents where people lied about their addresses, pretending to be from an area of mass infection, to receive priority care. there were also cases where people under the required self-quarantine violated the isolation guidelines and roamed around the community restaurants and coffee shops, thus spreading the infection [32] . there was a major relapse of the virus infection after two weeks of almost no daily infection had been reported in korea. during 24 april-6 may 2020, over 5500 young party goes visited several night clubs in seoul during the social distancing enforcement period. these clubs are known for their loud music, dancing, and drinking in a rather confined space. these clubs often restrict entry only to young people, enforced by a reverse carding system (usually only under 40 years of age). among those who visited the clubs, more than 270 infected people were identified by june 1. however, there was a social stigma issue (regarding the sexual orientation of many regular customers of the clubs) involved which made contact tracing difficult for those who visited the clubs. it was reported that many club goers falsified their names or addresses (e.g., cell phone numbers). to suppress the spread of a dangerous pandemic, a spirit of unity and shared purpose is required. korean people realized the potentially devastating chain of infection that could sweep through their communities and the country as a result of the misguided actions of a single person. in addition to the government's control measures, the public's strict adherence to government guidelines and voluntary participation in implementing certain rules (e.g., mask rationing) based on a sense of community have played a major role in suppressing the spread of covid-19 [32, [62] [63] [64] . in response to the covid-19 pandemic, physical distancing has been encouraged based on the recommendation of the who [2, 32, 64] . as people refrain from engaging in outside activities, many businesses (e.g., restaurants) start to experience financial difficulties. the drive-through covid-19 screening model has been applied to other businesses, and a new drive-through shopping model emerged. for example, south korea's large seafood markets are utilizing their parking lots to provide drive-through services, where customers can order sushi meals from their cars as they approach the market and vendors fulfill the order immediately. department stores are delivering pre-ordered products to customers at the valet parking service lot. in addition, services such as drive-through book-lending and agricultural product sales have flourished [65] . most of package and food delivery services have transitioned from personal service to the "untact" method that minimizes direct human-to-human contacts. classes and lectures in elementary, middle, and high schools and colleges have transitioned to online platforms. video conferences and home-offices have also become the common method of running operations. automobile repair services now provide a "special pick-up and delivery" option to ensure that their services are untact, helping those customers who have hesitated to visit a service center due to covid-19. diebner et al. [66] pp. 3-4 stated that digital delivery has become a necessity for "most customers who are confined at home" and "that app downloads and new sign-ups have grown between 80-250%" during the covid-19 pandemic. as covid-19 has been reported to infect people via contact with infected people's droplets [32, 60] , untact services utilizing innovative technology applications have flourished and are expected to expand continuously. when a pandemic outbreak occurs, identifying the source of infection and suppressing its spread are the most important steps. amidst the covid-19 crisis, healthcare institutions are like battlefield military units that are fighting an enemy with necessary weapons, albeit in the form of much-needed medical supplies. in response to the pandemic emergency, many organizations have shifted to remote-working to ensure operational continuity and employee safety. however, many business firms that cannot operate remotely (e.g., manufacturing plants, construction sites, sports events, etc.) had to completely shut down business. enterprises are scrambling to make fast adjustments to their disrupted supply chains [8] . educational institutions were ordered to shift the teaching mode from the classroom to the online educational environment. these are "new normal" in the covid-19 crisis [2] . this study reviewed the cases of innovative responses, as well as failures, to the explosive spread of covid-19 in korea since the first confirmed case on 18 february 2020. based on the review of these cases, we summarized the lessons learned from korea's covid-19 experiences. the knowledge gained from the struggle against the virus provides new insights about required strategies for managing the pandemic. our study suggests that the healthcare policy makers and related organizations must be transparent in demonstrating to the citizens that emergency healthcare services are being provided on an equitable basis throughout the country. based on these experiences, policy makers should develop strategies that include the government's response capacity, information sharing, mature sense of unity and community, and application of advanced technologies in the time of urgency. the results of this study provide several theoretical and practical implications. first, the covid-19 outbreak taught the world that massive and rapid testing is essential to identify infected patients and infection clusters to prevent the pandemic from spreading. the identified patients can be either treated promptly (severely ill cases) or quarantined. second, we showed that the spread of an epidemic can be effectively suppressed only through well prepared public health infrastructure; coordinated and exhaustive efforts of the central/local governments, disinfection and prevention authorities and healthcare providers; and the spirit of unity and community of citizens (e.g., adhering to the government guidelines regarding social distancing, stay-at-home, avoiding large gatherings of people, etc.). third, innovative operational strategies should be established based on past experiences (e.g., the mers failures) in order to ensure success in managing the pandemic. in korea, the primary cause of the early spread of covid-19 was related to a mass gathering within a confined indoor space (e.g., worship services of religious organizations). the koreans learned quickly about the perils of such undisciplined activities and their consequences in terms of the uncontrollable spread of the pandemic [32] . moreover, the korean government enforced an aggressive covid-19 screening program to promptly identify and trace contacts made by infected people and treat seriously ill patients while strictly isolating them from the general population. furthermore, these measures cannot be implemented successfully without active cooperation of the citizens. from the outset, the government asked all citizens to refrain from participating in group gatherings or events, both indoors and outdoors, that could pose a threat to others, and strongly encouraged the practice of physical distancing. moreover, the government also placed a legal liability on agents who proceeded with non-recommended events. a mature civic consciousness is needed to voluntarily comply with government guidelines. a crisis is said to be a combination of danger and opportunity. president john f. kennedy analyzed the word "crisis" in chinese and pointed out that the word consists of two characters, one representing danger and the other representing opportunity [67] . winston churchill's famous quote was also in the same vein, "a pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty" [68] . these quotes serve as reminders that every crisis encompasses opportunities for creating a better future. the koreans have learned this lesson from their experience with the covid-19 pandemic. therefore, we might view the crisis from the perspective of "crisis = danger + opportunity" based on response efforts. the covid-19 crisis shows how each country organizes the delicate balance between achieving efficient results (avoiding high rate of mortality) and intrusion on personal privacy and economic security. this means that there is a trade-off relationship between two important factors in life: health and economy. for example, much of the offline education system will most likely transition to the online environment, causing a trade-off relationship between students' face-to-face education needs and a safer/cheaper mode of delivery. the measures undertaken by the korean government to avoid repeating the same mistakes incurred during the mers outbreak (i.e., re-organization of the kcdc, the healthcare delivery system, and disinfection and prevention systems, as well as the expansion of healthcare facilities) were shown to have a significant impact on the effectiveness of the implemented response strategies in the face of the covid-19 pandemic. therefore, developing an effective public healthcare infrastructure and new operational strategies based on past experiences could turn a crisis into an opportunity for preventing such virus infections [5] . we are confident that the fear of covid-19 that is currently sweeping the globe will soon be overcome and hope that this costly experience will serve the world well in preparing for the next pandemic. this study has reviewed the response strategies of korea in dealing with the covid-19 pandemic outbreak. korea's pandemic management approach, known as the k-response strategy, has been effective in containing covid-19 as the country learned a bitter lesson from the pains of mers and reinvented its public health infrastructure as a preparation for the next pandemic. we do hope that the operational strategies of korea discussed in this study would help prepare effective crisis management systems in other nations. this study, however, has some limitations. first, the scope and experience of the covid-19 cases discussed in this study are specific to korea. thus, the results of the study have limited generalizability to other situations or countries with different cultures and social systems. future research that includes various cases from around the world would further reinforce the findings of our study. second, the covid-19 pandemic is still causing havoc around the world and its end is difficult to predict. furthermore, the world will surely encounter new coronavirus pandemics in the future. the results of our study are limited to the discussion of covid-19 that we are battling today. thus, new pandemics will require different research approaches, although the lessons learned from the current pandemic will certainly be of much value. covid-19 and commercial pharma: navigating an uneven recovery the path to the next normal who declares covid-19 a pandemic sustainable covid-19 mitigation: wuhan lockdowns, health inequities, and patient evacuation covid-19 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economic daily. daegu, the initial response was fast. it was different from south korea's health minister on how his country is beating coronavirus without a lockdown daegu operated a public-private partnership network drive-through screening center for covid-19: a safe and efficient screening system against massive community outbreak corona 19 'drive through' topic covid-19 pandemic data sources covid-19 pandemic in mainland china covid-19 pandemic in italy. available online covid-19 pandemic in spain. available online covid-19 pandemic in south korea covid-19 pandemic in the united states special report: how korea trounced u.s. in race to test people for coronavirus. reuter covid-19 pandemic data sources healthcare service justice and community engagement in crisis situation: focusing on failure cases in response to covid-19 emergency department resilience to disaster-level overcrowding: a component resilience framework for analysis and predictive modeling south korea's drive-through testing for coronavirus is fast-and free. national public radio needs to do today to follow south korea's model for fighting coronavirus time community treatment center. weekly dong-a 2020 civic capital and social distancing: evidence from italians' response to covid-19. vox cepr policy portal uncertainties of international standards in the mers cov outbreak in korea: multiplicity of uncertainties factors influencing the response to infectious diseases: focusing on the case of sars and mers in south korea south korea controlled its coronavirus outbreak in just 20 days. here are the highlights from its 90-page playbook for flattening the curve worldwide confirmed coronavirus cases top 2 million a faulty cdc coronavirus test delays monitoring of disease's spread. the philadelphia inquirer korean government's response to corona 19 addressing contact tracing challenges-critical to halting ebola virus disease transmission implications of sars epidemic for china's public health 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angelillo, italo francesco title: knowledge, attitudes, and practices towards infectious diseases related to travel of community pharmacists in italy date: 2020-03-24 journal: int j environ res public health doi: 10.3390/ijerph17062147 sha: doc_id: 333015 cord_uid: xgudk2h0 pharmacists should be educated about travel medicine, since they could influence their own choices and those of the individuals they encounter. this study aims to investigate the knowledge, attitudes, and behaviors towards infectious diseases related to travel among community pharmacists in italy. the data was collected from september 2018 to september 2019 using semi-structured telephone interviews. only 1.8% answered correctly to all seven questions regarding the infectious diseases related to travel. community pharmacists who had heard about travel medicine and those who had received information were more likely to have good knowledge. more than two-thirds of the respondents believed that it is important to provide information to the public about travel medicine. pharmacists who worked a higher number of hours per week, were more knowledgeable about the more frequent infectious diseases related to travel, believed that travel medicine was a pharmacist competency, believed that they could give advice to the public, and had received information from scientific journals and educational activities were more likely to have this positive attitude. more than two-thirds often/always informed the public about the importance of having travel health center counseling. pharmacists who had heard about travel medicine and those who believed that they could give advice to the public were more likely to inform. interventions are needed to improve knowledge in order that community pharmacists can play an active role in counseling the public. during the past decade, the number of international travelers to many destinations in various geographic regions has steadily risen leading to an increased risk in travel-related health problems with a subsequent impact on international public health and an increased potential demand for health services [1, 2] . although the destination can be one important risk factor for certain health problems, many travelers are unaware and often fail to seek appropriate preventative pre-travel care. healthcare professionals have a central role in providing recommendations on travel diseases. in particular, primary care providers should be familiar with destination-specific disease risks, be knowledgeable in pre-travel health advice in order to reduce the risks for travelers, be prepared to prescribe and recommend medications for treatment that can be taken during the trip, and be able to identify those who might need additional follow-up after the trip [3] . among healthcare professionals, pharmacists potentially have an important role in travel medicine within the community, and they are able to provide useful insights. in italy, community pharmacists have a primary role also in providing recommendations to patients on the use of the healthcare services, and they can sell over-the-counter drugs to the public without medical counseling. indeed, pharmacists can be one of the most common sources of healthcare information as they are closer to home and individuals often seek their services directly without consulting traveler medical centers. therefore, pharmacists should be highly educated about travel medicine, since they could influence their own choices and those of the individuals they encounter. several investigations on the knowledge, attitudes, and behavior of the general population and physicians regarding travel medicine have been conducted in different countries [4] [5] [6] , and, to date, there is also research on the involvement of community pharmacists in this field [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] . this is of utmost importance in order to provide important information for planning training interventions targeted towards these professionals to positively affect travelers' health. therefore, to enhance the existing information, the current study investigated the level of knowledge, attitudes, and behaviors towards infectious diseases related to travel and their influencing factors among community pharmacists in italy. the study was one of the key components of a larger national survey and a detailed description of the procedure has been published previously [17] and is described in brief below. this cross-sectional survey was conducted from september 2018 to september 2019, enrolling a random sample of 550 community pharmacists derived from the national list of those practicing in italy. for the sample size calculation, the prevalence of respondents who believe that it is important to provide information to the public about infectious diseases related to travel was assumed to be 70%, with a significance level of 5%, a margin of error of 5%, and to account for a response rate of 70%. a sample size of 461 participants was calculated. five trained and experienced interviewers initially contacted every selected community pharmacy by phone, and the pharmacist-in-charge or pharmacist manager were invited to participate in the survey. data were collected from the individuals who responded. at the beginning of each telephone call, participants were informed about the purposes and confidentiality of the survey and data protection, that participation was voluntary, that they could not skip questions and whole sections, but they were free to terminate the call whenever they wished without any consequences. the selected person was able to indicate whether he/she wished to participate in the survey. all participants expressed their verbal informed consent to their inclusion before initiating the interview. to improve the response rate, additional telephone reminder calls with each of the pharmacists that were not able to complete the survey the first time were made every week. at least three additional calls were made at different times and days to reach a pharmacist before he/she was considered as a non-responder. survey participation was not compensated. structured telephone interviews were designed to collect information divided into five sections. the first part consisted of the participants' socio-demographic and professional characteristics and included questions regarding their age, gender, marital status, year of graduation, number of years in practice, and practice size. the second part consisted of questions related to the pharmacists' knowledge about infectious diseases related to travel. fourteen main infectious diseases selected according to the most frequently visited countries by the italian population [5, [18] [19] [20] [21] were listed and pharmacists had to self-evaluate their knowledge giving their answers by choosing one of the three options: "yes", "no", or "don't know". the scale was then dichotomized ("yes" = 1 and "no"/"don't know" = 0) and the total knowledge score for each participant was computed by adding up the scores (maximum score of 14). the total score was then categorized as poor knowledge (score of ≤2), moderate knowledge (score of 3-4), and good knowledge (score ≥5). the third part assessed participants' attitudes with three statements on the importance of travel medicine for their work activity, asking whether they agreed that travel medicine is a pharmacist competency and whether they should give advice regarding travel medicine as part of their work activity, with response options on a 5-level likert scale ranging from "strongly disagree" to "strongly agree", and whether they believed that it is important to provide information to the public about travel medicine, with the response on a numerical 10-point likert scale with higher values corresponding to a stronger attitude. the fourth part collected information about their practice and communication with the public regarding travel medicine. three responses were collected on a 5-level likert scale ranging from "never" to "always" and the others through multiple-choice alternatives. the fifth part included two questions on whether respondents had received information about travel medicine and whether they had educational needs. a pilot study for clarity, length, and simplicity was conducted on a total of 20 interviews and some minor wording changes were made in the revised version. these 20 pilot study interviews were not included in the main study. then, the final protocol, including the informed consent form, and the questionnaire were approved by the ethics committee of the teaching hospital of the university of campania "luigi vanvitelli". the statistical analysis was conducted using stata statistical software, version 15 (statacorp., college station, tx, usa) [22] . first, descriptive analyses were performed to assess all characteristics of the participants. second, chi-square and student's t-test were conducted to examine the relationship between the independent variables and the outcomes of interest. third, multivariate ordered, linear, and logistic regression analysis was conducted by including in the models the variables with a p-value ≤ 0.25 at the bivariate analysis in order to estimate the independent association between potential predictors and the outcomes of interest. the following three models were developed: (1) pharmacists' level of knowledge about the more frequent infectious diseases related to travel (poor = 1; moderate = 2; good = 3) (model 1); (2) pharmacists who believed that it is important to provide information to the public about travel medicine (continuous) (model 2); (3) pharmacists who often or always inform the public about the importance of having travel health center counseling (no = 0; yes = 1) (model 3). initial candidate variables included in all models were age (continuous), gender (male = 0; female = 1), marital status (unmarried/separated/divorced/widowed = 0; married = 1), number of years since degree (continuous), number of years in practice (continuous), number of hours worked per week (continuous), employment type (owner = 1; employee = 2; director = 3), having heard about travel medicine (no = 0; yes = 1), sources of information on travel medicine (none = 1; scientific journals and educational activities = 2; internet and mass media = 3), and need of additional information on travel medicine (no = 0; yes = 1). moreover, the following variables were also included: pharmacists' level of knowledge about the more frequent infectious diseases related to travel (poor = 1; moderate = 2; good = 3), pharmacists who believed that travel medicine is a pharmacist competency (strongly disagree/disagree/uncertain = 0; agree/strongly agree = 1), pharmacists who believed that they could give advice to the public about travel medicine (strongly disagree/disagree/uncertain = 0; agree/strongly agree = 1) in models 2 and 3, and pharmacists who believed that it is important to provide information to the public about travel medicine (continuous) in model 3. a stepwise backward procedure was used to select which variables to include in the final models and in order to find the most parsimonious models. p-values of 0.2 and 0.4 were considered as a threshold to include and to eliminate variables. odds ratios (ors) and their respective 95% confidence intervals (cis) were calculated using ordered and logistic regression. standardized regression coefficients (β) were presented for the linear regression models. all tests were two-sided with p-values less than or equal to 0.05 considered statistically significant. among the 550 community pharmacists who were approached for the study, a total of 390 agreed to participate, resulting in a response rate of 70.9%. the socio-demographic and professional characteristics of the community pharmacists who participated in the survey are presented in table 1 . the majority of pharmacists were female (59.9%), the average age was 47.9 years, half of the sample were pharmacy owners (50.5%), the average number of years in practice was 18.1, and the mean number of hours worked per week was 41.2. number for each item may not add up to total number of study population due to missing values; * mean ± standard deviation (range). regarding the level of knowledge, an overwhelming majority of respondents were aware of travel medicine (85.4%). notably, the highest achieved score on the knowledge of infectious diseases related to travel was 7 out of a maximum score of 14, and only 1.8% provided correct answers to seven questions and were aware of none of these diseases. travel diarrhea (91.9%), hepatitis a (44.5%), malaria (44.3%), and cholera (36.5%) were the more recurrent diseases known by pharmacists. for all participants, the total score for knowledge of infectious diseases related to travel ranged between 0 and 7, with a mean of 2.9. associations between the different outcomes of interest and potential predictor variables using multivariable linear and logistic regression analyses are shown in table 2 . from the initial model and after the stepwise backward procedure, the final ordered logistic regression model with the outcome the score of the knowledge about the infectious diseases related to travel comprised two variables: level of knowledge and sources of information about travel medicine. pharmacists who had heard about travel medicine (or = 2.28; 95% ci = 1.26-4.11), having received information from scientific journals and educational activities (or = 5.57; 95% ci = 3.42-9.1) and from the internet and mass media (or = 3.96; 95% ci = 2.37-6.6), compared with those who did not receive information, were more likely to have a good knowledge about the more frequent infectious diseases related to travel (model 1). with regard to attitudes, 44.3% and 56.2% of the respondents agreed respectively with the statements that travel medicine is part of their professional responsibilities as healthcare workers and that they could properly give advice to the public on this topic. moreover, more than two-thirds of respondents (77.6%) believed that it is important to provide information to the public about travel medicine, with a mean value of 6.9, on a scale of 1 to 10. the results of the multivariate linear regression model, built to test the variables associated with this outcome of interest, showed that pharmacists who worked a higher number of hours for week, those who had a higher level of knowledge about the more frequent infectious diseases related to travel, those who believed that travel medicine is a pharmacists' competence, those who believed that they could give advice to the public about travel medicine, and those who had received information from scientific journals and educational activities compared with those who did not receive any information were more likely to believe that it is important to provide information to the public about travel medicine (model 2 in table 2 ). regarding the behaviors, more than one-third of the sample (37.2%) indicated that they sometimes receive requests for advice on travel medicine from the public, mainly regarding travel diarrhea (83.4%), safeness of food and water (77.6%), insect punctures (65.9%), and vaccinations (31.2%). moreover, more than half (52.1%) reported that the public often ask for medications for travel purposes without a prescription. the reasons for these requests included the inability to get a prescription in time (76.5%), advised information from the internet (47%), and unavailability of the physician (19.1%). more than two-thirds (69.5%) often or always informed the public about the importance of having travel health center counseling. multivariate logistic regression analysis showed that pharmacists who had heard about travel medicine (or = 6.44; 95% ci 3.2-12.97) and those who believed that they could appropriately give advice to the public about travel medicine (or = 3.61; 95% ci 1.9-6.84) were more likely to inform the public about the importance of having travel health center counseling (model 3 in table 2 ). among the survey participants, only two-thirds (65.6%) reported searching for information about travel medicine. when asked about the source of information, a higher number of respondents stated that the internet was the most frequently reported trusted source (52.9%), followed by scientific journals (27.9%), and educational activities (20.7%). the vast majority of responders (84.6%) felt they did not have sufficient information on travel medicine and expressed willingness to acquire more knowledge. the present study is to our knowledge the first and largest published national survey that has attempted to provide an overall picture about the knowledge, attitudes, and practices of community pharmacists in italy regarding infectious diseases related to travel and of the factors associated with these main outcomes of interest, adding to the existing literature by providing key findings. the study findings suggest that the participants had a knowledge gap in travel medicine and this situation is alarming as a basic level of knowledge about common infectious diseases is expected from healthcare staff. indeed, a striking finding depicted that less than a quarter of participants seemed knowledgeable about the seven more frequent infectious diseases related to travel, with a total mean score of knowledge of 2.9. the finding that respondents had a lack of knowledge is in accordance with previous reports, which have shown that community pharmacists have a knowledge gap and low confidence in providing this type of care [15, 23] . this fact emphasizes the importance that pharmacists should be informed since their level of awareness should primarily be improved. moreover, pharmacists who had a higher level of knowledge were far more likely to believe that it is important to provide information to the public about travel medicine and to inform them about the potential risks of travel diseases and the importance of having travel health center counseling before their departure. therefore, it is necessary that all pharmacists choose to improve their knowledge in order to offer travelers accurate and expert counselling. with respect to the attitudes towards travel medicine, this study indicated that 44.3% and 56.2% of the respondents agreed that travel medicine is part of their professional responsibilities as healthcare workers and that they could properly give advice to the public. a similar result was observed among malaysian community pharmacists who agreed that they are in a position to provide health information and recommendations regarding travel health [7] . this is a relevant finding because pharmacists should give advice to patients in order to guarantee the appropriate behaviors before and during their travels and they may be a key and trusted source of information. multivariate linear regression analysis showed that pharmacists who believed that knowledge about travel medicine is a part of their role were more likely to believe that it is important that they provide information to the public. this result can be explained by the fact that pharmacists who had this attitude were more likely to acquire information because they thought travel medicine was a key professional skill. therefore, policy makers and healthcare managers should implement programs that actively involve the pharmacists because pharmaceutical services are available throughout the territory and can easily be accessed, and this could lead to a greater adherence of the public to preventive measures and may contribute to patient safety and appropriate use of medications. concerning the practices for travelers, community pharmacists play a key role in the public's awareness of travel diseases and their recommendations may be an important determinant of travel health. in this study, 69.5% of the participants often or always informed the public about the importance of having a travel health center counselling session. this underlined the availability of the community pharmacists in providing information to the public regarding travel diseases. however, it is important to highlight that in italy pharmacists cannot dispense some medicines without a physician's prescription, and it should be considered that more than half reported that the public often asked for medications for imminent travel because their general practitioners were unavailable. this result is in line with those of a similar study conducted in australia that showed that pharmacists had a role in advising travelers, who would not normally visit a physician before travelling, on travel-related health issues before visiting certain destinations [24] . furthermore, the result of the logistic regression analysis showed that the positive attitude of the study participants about different health seeking behaviors predicted their real practices since those who believed that they could give advice to the public regarding travel medicine were more likely to often or always inform the public about the importance of having travel health center counselling than those who did not. the findings from this survey are consistent with several previous results from similar studies among different groups of individuals that have demonstrated the importance of scientific information for their knowledge and attitudes. indeed, as described in prior studies [5, 17, [25] [26] [27] [28] [29] , it is evident from the multivariate analysis that receiving information from scientific journals and educational activities facilitates the emergence of pharmacists who have better knowledge and have more positive attitudes. this is important because the pharmacists themselves, in order to effectively influence others, must be well equipped with an appropriate level of knowledge, and interventions should be aimed at including such sources as an important conduit of travel medicine-related information, which can support the pharmacists' confidence. however, an unsurprising finding was that a large majority of pharmacists identified the internet as being their main source of information, rather than the medical establishment. it should be underlined that several studies have expressed concern about the quality and accuracy of health information on the web [30] [31] [32] , and, therefore, it may not provide all of the details necessary to allow the pharmacists to make well-informed suggestions. consequently, it is possible that there are missed opportunities for pharmacists to provide high quality information. health information via the internet should not replace other healthcare professional experts in travel medicine who can give advice for specific situations. furthermore, the vast majority of responders felt they did not have sufficient information to adequately answer questions on this field. clear communication and knowledge about travel medicine would help to instill confidence in pharmacists and keep them adequately informed in order to meet the needs of their community, as well as enable them to discuss any concerns with their customers that may arise from what their customers have read. therefore, pharmacists must have the capacity needed to effectively educate and address public questions and concerns since the delivery of information from a trusted or known source with which the individual has already developed a relationship may be beneficial. this is crucial also in light of the measures taken for the coronavirus disease (covid-19) by the italian authorities [33] , as pharmacists represent an important element in order to provide appropriate recommendations to the public about preventive measures. when considering the study findings, it is important to take into account some potential methodological limitations such as those normally observed in similar survey-based studies. first, the cross-sectional design of this study can only demonstrate associations between the different outcomes of interest and the observed determinants, and it is not possible to say anything about causality. second, data collection through the telephone survey was based on self-reported information, and so may be subject to reporting bias. third, there is also the risk for social desirability bias, by which participants do not report attitudes and behaviors fully or accurately and may provide the responses they believe the researcher wants to know instead of the truth, as opposed to answering honestly, and it is possible that they may over-report socially desirable attitudes and behaviors or under-report socially undesirable attitudes and behaviors. efforts were made to minimize the risk of these biases by ensuring participants that the study was anonymous and confidential and that their data would be de-identified. fourth, it is possible that pharmacists with specific positive or negative opinions or interest in the topic were more or less likely to respond to the survey. if such bias exists, it may lead to an over-or underrepresentation of the rate of positive responses. however, the high response rate could offset this bias. moreover, no difference has been observed between respondents and non-respondents regarding the geographic area of activity. in conclusion, this survey provides some insights into the knowledge, attitudes, and behaviors regarding infectious diseases related to travel among community pharmacists in italy and identifies their associated characteristics. the findings will prove useful when designing and implementing targeted interventions to improve the level of knowledge of pharmacists so that they can play an active role in counseling the public and also in working more closely with the health services in travel medicine. crossref] 2. world health organization (who). international travel and health travel medicine: what's involved? when to refer? destination specific risks of acquisition of notifiable food-and waterborne infections or sexually transmitted infections among finnish international travellers travelers' knowledge, attitudes, and behavior related to infectious diseases in italy knowledge, attitude and practice of travel medicine among primary care physicians in oman: the need for intervention travel health-related activities and services provided by community pharmacies in selangor, malaysia: a cross-sectional analysis pharmacy-based travel health services in the united states the role of community pharmacists in travel health and vaccination in switzerland is travel health a new destination for pharmacy practice and business? an examination of revenue opportunities from pre-travel consultations australian pharmacists' in travel health perceptions and practices the role of pharmacists in travel medicine in south training pharmacists in travel health pharmacy travel health services: current perspectives and future prospects provision of travel medicine advice through community pharmacies: assessment of knowledge, attitudes and practices of pharmacists in malaysia needs assessment study for community pharmacy travel medicine services the knowledge, attitudes, and practices of community pharmacists in their approach to antibiotic use: a nationwide survey in italy principali malattie dei viaggiatori infectious diseases of potential risk for travellers international travelers' sociodemographic, health and travel characteristics: an italian study statacorp. stata statistical software: release 15; statacorp llc: college station are pharmacists ready for a greater role in travel health? an evaluation of the knowledge and confidence in providing travel health advice of pharmacists practicing in a community pharmacy chain in alberta australian pharmacists' perceptions and practices in travel health investigating knowledge, attitudes, and practices regarding vaccinations of community pharmacists in italy knowledge, attitudes, and behaviors of parents towards recommended adult vaccinations: an explanatory survey in the geographic area of rotavirus infection and vaccination: knowledge, beliefs, and behaviors among parents in italy seasonal influenza: knowledge, attitude and vaccine uptake among adults with chronic conditions in italy vaccinations among italian adolescents: knowledge, attitude and behavior parent resources for early childhood vaccination: an online environmental scan the growing vaccine hesitancy: exploring the influence of the internet internet exposure associated with canadian parents' perception of risk on childhood immunization: cross-sectional study decreto del presidente del consiglio dei ministri 11 marzo 2020 this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors gratefully acknowledge all community pharmacists participating in this survey. the costs of the open access publication were supported by the "programma valere 2020" of the university of campania "luigi vanvitelli" (naples, italy). the authors declare no conflict of interest. key: cord-308319-1l6xooyz authors: wiseman, kara p.; hauser, lindsay; clark, connie; odumosu, onyiyoza; dahl, neely; peregoy, jennifer; sheffield, christina w.; klesges, robert c.; anderson, roger t. title: an evaluation of the process and quality improvement measures of the university of virginia cancer center tobacco treatment program date: 2020-06-30 journal: int j environ res public health doi: 10.3390/ijerph17134707 sha: doc_id: 308319 cord_uid: 1l6xooyz tobacco use after a cancer diagnosis can increase risk of disease recurrence, increase the likelihood of a second primary cancer, and negatively impact treatment efficacy. the implementation of system-wide comprehensive tobacco cessation in the oncology setting has historically been low, with over half of cancer clinicians reporting that they do not treat or provide a referral to cessation resources. this quality improvement study evaluated the procedures for assessing and documenting tobacco use among cancer survivors and referring current smokers to cessation resources at the university of virginia cancer center. process mapping revealed 20 gaps across two major domains: electronic health record (ehr), and personnel barriers. the top identified priority was inconsistent documentation of tobacco use status as it impacted several downstream gaps. eleven of the 20 gaps were deemed a high priority, and all were addressed during the implementation of the resulting tobacco treatment program. prioritized gaps were addressed using a combination of provider training, modifications to clinical workflow, and ehr modifications. since implementation of solutions, the number of unique survivors receiving cessation treatment has increased from 284 survivors receiving cessation support during year 1 of the initiative to 487 in year 3. the resulting tobacco treatment program provides a systematic, personalized, and sustainable comprehensive cessation program that optimizes the multifaceted workflow of the cancer center and has the potential to reduce tobacco use in a population most in need of cessation support. tobacco use is associated with at least 15 types of cancer and accounts for 30% of all cancer deaths. yet, 15% of adults in virginia are current smokers, with regional variation ranging from 10-24% [1] . the university of virginia (uva) cancer center, a national cancer institute (nci)-designated cancer center for over 30 years, provides care to a diverse patient population from 87 counties in virginia and eastern west virginia. many of the counties are non-metropolitan and rural, which report some of the highest rates of tobacco use in virginia. smokers in rural areas also smoke more cigarettes per day, are more likely to be dual and poly tobacco users, and initiate tobacco use at an earlier age than those in non-rural areas [2] [3] [4] [5] . as a result, cancer patients (hereafter referred to as cancer survivors) living in these regions may be highly addicted to nicotine and yet have limited access to cessation services in their local communities [5] . in response, cancer centers are often looked at to provide cessation services to support survivors. in 2018, uva was involved in the care of roughly 4,000 cancer survivors; in 2019, among all patient encounters, about 11% of survivors self-reported current tobacco use. providing consistent and effective cessation in the cancer setting is critical [6] . continued tobacco use after a cancer diagnosis can increase disease recurrence, increase the likelihood of a second primary cancer, and negatively impact treatment efficacy [7] . importantly, quitting tobacco use can have significant benefits including improved quality of life and increased survival [8] . a cancer diagnosis can increase a person's motivation and interest in tobacco cessation and creates a potential opportunity for oncology clinicians to engage and offer cessation services [9] . to that end, the american society for clinical oncology recommends assessing tobacco use status at every clinic visit given the likelihood in changes motivation and relapse [10] . even with the known benefits of cessation and national recommendations supporting cessation in oncology care, consistent cessation is not always provided [11] . specifically, less than half of oncology clinicians actively treat or refer their patients to cessation services [12] . barriers at multiple levels, including providers' lack of knowledge of existing intervention resources, a lack of easy referral systems, and trouble identifying smokers, may explain some of the low utilization of cessation services in oncology settings [11] . more thorough integration of tobacco control activities in oncology settings provides an opportunity to better identify current tobacco users and provide consistent, tailored treatment based on personal factors and cancer treatment plan, which would result in higher cessation rates and reduced negative implications from continued tobacco use during and after oncology care [13] . as a part of the nci cancer "moonshot program", the uva cancer center was one of 42 cancer centers funded as part of the cancer center cessation initiative (c3i) to build and implement a sustainable tobacco cessation treatment program for cancer survivors at any treatment stage [6] . herein, we describe a quality improvement study conducted using lean methodology, implemented as part of the c3i at the uva cancer center and describe the resulting tobacco treatment program (ttp). the current quality improvement study assessed existing procedures for determining and documenting tobacco use, referring tobacco users to cessation resources, and implementation of cessation services at the emily couric clinical cancer center (ecccc) through a six-month comprehensive process. uva's participation in the c3i and subsequent initiation of the quality improvement began in october 2017. the uva health system does not require institutional review board (irb) approval for assessments of quality improvement processes and implementation of new clinical practice. therefore, irb approval was not required as part of the uva c3i. lean methodology aims to improve a process by maximizing value for patients through the elimination of non-value adding activities while involving all employees in the process of identifying and eliminating those non-value adding activities [14, 15] . the five principles of lean methodology are: identify value, map the process, create flow, establish pull, and seek perfection. it is an ongoing process with no specific end point, and no requirement to "complete" the five principles. the first principle, "identify value" involves identifying the customer and the value of the service. in health-care settings, value is defined from the perspective of the patient [16] . within the uva c3i, the "customers" were current tobacco users and the service was the ttp or cessation. the value is the health of the survivor through cessation. the second principle, "map the process" defines the existing process, which assists in identifying gaps that need to be addressed. the third principle, "create flow" focuses on developing solutions to maximize efficiency and service, reduce waste, and achieve program goals. the fourth principle, "establish pull", is focused on creating demand and sustained interest in the program. the fifth principle, "seek perfection" stresses the importance of iteration and growth of program implementation, capturing the need to continue to develop and grow. the uva c3i encompasses all five principles. however, the quality improvement study was primarily guided by "identify value", "map the process", and "create flow", which are describe in more detail below. lead by a quality improvement manager and guided by the c3i team, the process phase separated the ttp into phases starting with a cancer survivor arriving to the cancer clinic through their follow up visits for the ttp. specifically, the tobacco treatment specialist (tts) for the ttp as the subject matter expert and the manager for cancer support services (leadership), provided the quality improvement manager a detailed description of the ttp, including all steps, stakeholders, decisions, and potential endpoints. the quality improvement manager took this detailed description of the process and created a value stream map using lucid chart software ( figure 1 ). the goal of the value stream map was to separate the process into discrete segments. the value stream map used unique identifiers for actions that occurred during the process, movement between processes, question/decision points, end points, and identification of potential or known gaps in the process. the process review also included the quality improvement manager performing a gemba walk, which is observing the actual process, engaging with employees, gaining knowledge about the work process, and exploring opportunities to improve [17] . during the gemba walk the quality improvement manager observed the process and validated the value stream map by shadowing and asking questions with the tts, rooming staff and patient schedulers. throughout this stage, the value stream map was reviewed with the c3i team for correction and fine-tuning. the process review concluded by categorizing the identified gaps (examples of where gaps are located in the value-stream are depicted below in call-out boxes). within the uva c3i, two categories were identified: electronic health record (ehr) system and clinical personnel. following process mapping and identification of gaps, each one was reviewed and prioritized, and potential solutions began to be developed. gap prioritization focused on those that most reduced the value of the ttp, were significantly limiting efficiency, or had important downstream effects to other identified gaps. for some gaps, solutions were readily available. for gaps where additional information was needed, an "a3" was conducted. an a3 is a concise method used to define a problem, with the name being derived from the goal of being able to summarize the problem on a a3 piece of paper (11.7 × 16.5 inches) [18] . the a3 defines one problem at a time in the most structured way possible to facilitate the development of solutions. it can include verbal or visual aids and provide easily digested information. an a3 was created for many gaps, however, it was primarily used for solution development for the highest priority gap, tobacco use documentation in the ehr. specifically, departmental reports were run to examine tobacco encounters at the survivor level for each clinic visit at the ecccc. the total number of encounters (e.g., visits) was compared to the total number of updated tobacco histories. additionally, the quality improvement manager performed additional gemba walks by shadowing of the tts and licensed practical nurses (lpns, n = 3), as well as rounding in clinics, engaging, and surveying front line staff. these observations revealed additional gaps and allowed for discussion of potential solutions between the c3i team and others who would be directly impacted by process changes. the a3 concluded by providing a structured, operationalized definition of the problem, potential solutions, and definitions to document impact of potential solutions. potential solutions were discussed by the c3i team. during this process, the tts presented and discussed potential solutions with multiple stakeholder groups (patient schedulers, care coordinators, tumor board and core staff meetings). the tts also participated in training (if applicable) during implementation of final solutions. following process mapping and identification of gaps, each one was reviewed and prioritized, and potential solutions began to be developed. gap prioritization focused on those that most reduced the value of the ttp, were significantly limiting efficiency, or had important downstream effects to other identified gaps. for some gaps, solutions were readily available. for gaps where additional information was needed, an "a3" was conducted. an a3 is a concise method used to define a problem, with the name being derived from the goal of being able to summarize the problem on a a3 piece of paper (11.7 × 16.5 inches) [18] . the a3 defines one problem at a time in the most structured way possible to facilitate the development of solutions. it can include verbal or visual aids and provide easily digested information. an a3 was created for many gaps, however, it was primarily used for solution development for the highest priority gap, tobacco use documentation in the ehr. specifically, departmental reports were run to examine tobacco encounters at the survivor level for each clinic visit at the ecccc. the total number of encounters (e.g., visits) was compared to the total number of updated tobacco histories. additionally, the quality improvement manager performed additional gemba walks by shadowing of the tts and licensed practical nurses (lpns, n = 3), as well as rounding in clinics, engaging, and surveying front line staff. these observations revealed additional gaps and allowed for discussion of potential solutions between the c3i team and others who would be directly impacted by process changes. the a3 concluded by providing a structured, data to quantitatively assess ttp implementation and outcomes was provided using ehr reports. reports were pulled quarterly starting in 2017 and included the number of adult survivor visits at the ecccc, the number of survivors with documented tobacco use status, the number of current cigarette smokers, and the number of survivors who enrolled in the ttp. among survivors who enroll in the ttp, a second ehr report provides information on self-reported quit rates and number of cigarettes smoked per day using the most recently reported data. assessment rates were defined as the number of survivors who had tobacco use status documented/number of survivors seen in the eccc over the same reporting period. quitting smoking was defined as the number of survivors who reported quitting smoking completely/number of survivors enrolled in the ttp over the same reporting period. reduction in smoking is associated with subsequent cessation; thus, this metric is an important prognostic indicator of future smoking cessation [19] and was defined as the number of survivors who reported reducing their number of cigarettes smoked per day by at least 50%/number of survivors enrolled in the ttp over the same reporting period. the gap analysis identified 20 gaps across the two major domains (ehr/personnel, table 1 ). personnel gaps were further divided between clinician and center-level. specifically, of the 20 identified gaps, 45% (n = 9) were ehr gaps, 45% (n = 9) were center gaps, and 10% (n = 2) were clinician or clinician/center gaps. an ehr-related gap was the absence of an automatic referral process for tobacco treatment within the ehr, making it more time consuming to manually create each referral. under the domain of clinician gaps, lpn staff responsible for assessing tobacco use had not received an orientation or training on how to assess this behavior. a center-level gap included a lack of orientation for nurses and residents/fellows about the ttp and existing workflow. among the 20 identified gaps, 11 were identified as high priority. among those identified as a high priority, 36% (n = 4) were ehr gaps, 46% (n = 5) were center/workflow level gaps, and 18% (n = 2) were clinician or clinician/center gaps. as a result of the gap analysis, the top identified priority was inconsistent documentation of tobacco use status in the social history section of the ehr. this lack of consistent documentation was a top priority because it had significant downstream effects on the program. for example, addressing priority 1 could also indirectly begin to address and correct priorities 2, 4, 6, and 7. it was hypothesized that the inefficiency in documentation could be either a system routing and/or flow error or a lack of training for staff around properly documenting social history, leading to several potential solutions. the a3 identified specific barriers including inconsistent documentation of cancer survivor tobacco use history between departments in the ehr, a lack of education around tobacco use and terms, and discomfort addressing tobacco use at every visit. with direction from the front-line staff, an updated standard of work and staff education tools were developed. this included a one-page quick reference guide highlighting what needed to be completed in the tobacco use history section of the ehr and definitions of the terms included in the tobacco use history section. in addition to the quick reference, the tts joined monthly staff meetings to review the new standard work and engage in conversation around how to assess tobacco use at every clinic visit. through the gap analysis the efficiency of the current tiered triaging system was identified as not being optimally utilized by the referring providers. providers would incorrectly refer survivors to a treatment tier because guidelines were not clear, and it was hard to differentiate between each tier. to simplify the tiered system, the model was adjusted to two tiers for survivors ready to quit and one tier for survivors not yet ready to quit ( table 2 ). in addition, tier 1, the most robust tier had clear clinical criteria that had to be met for a survivor to receive that level of care. additionally, the number of sessions were modified to increase efficiency of the program based on the needs and interests of the survivor. the tts spent two to three hours each week training physicians and care coordinators on the new system and criteria. specifically, the tts educated providers by attending tumor board, grand rounds, and staff meeting for all level of care providers. this training was important initially and as a continued process due to the nature of the uva cancer center as an academic hospital with a continual rotation of medical students, residents and fellows as well as normal staff turnover. prior to the implementation of the triaging improvements, 43% of survivors were referred as "urgent". by the end of the year one of the c3i, urgent referrals were reduced to 19%. the original ttp operated using paper tobacco use questionnaires and manual entry for survivor tracking. to improve tracking of survivor progression longitudinally and to standardize documentation the entire process, a "flowsheet" was developed within the ehr. the original paper questionnaire, which includes the fagerström test for nicotine dependence [20] and the cancer patient tobacco use questionnaire [21] , was asked periodically through a survivor's time in the ttp, and was used as the foundation of the flowsheet with multiple tabs (e.g., independent entries) available per survivor. all treatment tiers had a tab for the initial visit in the ttp, all subsequent follow up visits/calls, and the 3-, 6-and 12-month follow up visits/calls. within the flowsheet, "smart phrases" were developed with drop down choices and typical clinical reporting sentence structure for more consistent documentation of survivor encounters. for example, instead of documenting number of cigarettes smoked per day as part of a general comment, the smart phrase, "current number of cigarettes per day?" with specific response options of "10 or fewer", "11-20", "21-30", and "31 or more" was added as a specific question. another smart phrase is "potential barriers to quitting smoking" with response options, "bad cravings", "boredom", "depression", "lack of willpower", "sudden impulses", and "weight gain". the flowsheet and smart phrases created a systematic progression of survivors through the program and allowed for streamlined reporting and improved communication of treatment plans with clinical partners; thus, addressed several other downstream priorities from the gap analysis. the new program is as follows: tobacco use is assessed at each visit to the ecccc by an lpn rooming nurse who is responsible for beginning the conversation about the ttp to all identified tobacco users. information about survivors who are interested in cessation is sent to a care coordinator, who refers survivors to the ttp using an e-referral through the ehr. survivors are triaged to designate immediacy of need for cessation services ( table 2 ). for survivors most in need of immediate cessation, a tts is paged to attempt a same day appointment. survivors who are not required to quit due to a medical procedure work with the cancer center scheduling staff to schedule an in-person initial visit with a tts. after initiating the ttp, survivors are further classified based on readiness to quit smoking, which impacts the type of tobacco treatment they receive. in addition to referrals from the lpn rooming nurses who are responsible initiating a conversation about the ttp, physicians may refer survivors to the ttp, and survivors may self-refer at any time. after the ttp survivors in tiers 1 and 2 receive cessation telephone counseling, with the number of calls varying depending on tier. access to nicotine replacement therapy was included as part of the c3i. since the implementation of the new ttp, assessment of tobacco use is consistently implemented (99%). during the first year of the c3i initiative, 284 survivors received cessation support. the number of survivors receiving cessation treatment rose to 419 and 487 in years 2 and 3, respectively ( figure 2 ). among survivors for whom ehr flowsheet data are available (n = 211 survivors), 30% self-report having quit completely and 34% have reduced their number of cigarettes smoked per day by at least 50% ( figure 3) . this quality improvement study used lean methodology with a3 for gap identification and deep exploration of the ttp in the uva cancer center. multi-level gaps were identified and while a majority of identified gaps fell within the domains of the ehr and the center, the prioritized solutions were more balanced between clinicians, center, and ehr gaps. this highlights the interdependence between these elements of providing care, as one solution had the potential to impact gaps across domains, and how the gap analysis can assist in solution prioritization. solutions also demonstrated the use of lean methodology as several solutions were specifically designed to increase efficiency of the tts. specifically, implementing the updated tiered triaged system and staff training to improve correct tier designation, the number of high-risk survivors dropped significantly. with fewer survivor being referred as urgent, the tts was paged less often for same day in-person clinic visits which optimized the tts availability to treat more survivors. additionally, the implementation of the ttp flowsheet and smart phrases reduced charting time for the tts, which also increased availability to treat more survivors. by improving efficiency, the total number of patients served could increase without requiring additional personnel. lean methodology also provides maximum versatility for quality improvement. for example, other c3i sites have also used lean methodology, using rapid experiments of process changes [22] . rapid experimentation was not a component of the uva c3i. the differences in use of specific lean methodology strategies might represent differences in how well-established each cancer center's ttp was at the start of the c3i. for example, clinic settings that have well-established programs may be able to move quickly through process mapping and into experimentation, whereas newer programs might be better served by dedicating significant time to process mapping to identify the full suite of existing gaps. importantly, assessment of tobacco use and use of tobacco treatment services increased this quality improvement study used lean methodology with a3 for gap identification and deep exploration of the ttp in the uva cancer center. multi-level gaps were identified and while a majority of identified gaps fell within the domains of the ehr and the center, the prioritized solutions were more balanced between clinicians, center, and ehr gaps. this highlights the interdependence between these elements of providing care, as one solution had the potential to impact gaps across domains, and how the gap analysis can assist in solution prioritization. solutions also demonstrated the use of lean methodology as several solutions were specifically designed to increase efficiency of the tts. specifically, implementing the updated tiered triaged system and staff training to improve correct tier designation, the number of high-risk survivors dropped significantly. with fewer survivor being referred as urgent, the tts was paged less often for same day in-person clinic visits which optimized the tts availability to treat more survivors. additionally, the implementation of the ttp flowsheet and smart phrases reduced charting time for the tts, which also increased availability to treat more survivors. by improving efficiency, the total number of patients served could increase without requiring additional personnel. lean methodology also provides maximum versatility for quality improvement. for example, other c3i sites have also used lean methodology, using rapid experiments of process changes [22] . rapid experimentation was not a component of the uva c3i. the differences in use of specific lean methodology strategies might represent differences in how well-established each cancer center's ttp was at the start of the c3i. for example, clinic settings that have well-established programs may be able to move quickly through process mapping and into experimentation, whereas newer programs might be better served by dedicating significant time to process mapping to identify the full suite of existing gaps. importantly, assessment of tobacco use and use of tobacco treatment services increased this quality improvement study used lean methodology with a3 for gap identification and deep exploration of the ttp in the uva cancer center. multi-level gaps were identified and while a majority of identified gaps fell within the domains of the ehr and the center, the prioritized solutions were more balanced between clinicians, center, and ehr gaps. this highlights the interdependence between these elements of providing care, as one solution had the potential to impact gaps across domains, and how the gap analysis can assist in solution prioritization. solutions also demonstrated the use of lean methodology as several solutions were specifically designed to increase efficiency of the tts. specifically, implementing the updated tiered triaged system and staff training to improve correct tier designation, the number of high-risk survivors dropped significantly. with fewer survivor being referred as urgent, the tts was paged less often for same day in-person clinic visits which optimized the tts availability to treat more survivors. additionally, the implementation of the ttp flowsheet and smart phrases reduced charting time for the tts, which also increased availability to treat more survivors. by improving efficiency, the total number of patients served could increase without requiring additional personnel. lean methodology also provides maximum versatility for quality improvement. for example, other c3i sites have also used lean methodology, using rapid experiments of process changes [22] . rapid experimentation was not a component of the uva c3i. the differences in use of specific lean methodology strategies might represent differences in how well-established each cancer center's ttp was at the start of the c3i. for example, clinic settings that have well-established programs may be able to move quickly through process mapping and into experimentation, whereas newer programs might be better served by dedicating significant time to process mapping to identify the full suite of existing gaps. importantly, assessment of tobacco use and use of tobacco treatment services increased dramatically in both cancer centers sites, showing the success that a personalized implementation of lean methodology can have. other clinical settings have employed lean methodology to increase delivery of cessation services and prescribing nicotine replacement therapy to cancer survivors using national survey data to inform plan do study act cycles [23] . the uva c3i occurred within the context of 42 other funded c3i cancer centers located across the country. it is important to note that many of the c3i sites were located in and around urban centers across the country, while uva cancer center is located in a small town with a predominately rural catchment area. this unique context in geography and culture is relevant when thinking about how to continue to build upon the success of the new ttp. for example, there are increased rates of dual and poly use among adults in rural areas [4] , however at present, the ttp focuses primarily on smoking cessation (although a few poly-tobacco users have participated in the program). thus, there is potential benefit of the uva ttp more directly addressing multiple tobacco product use. in addition, survivors living in rural areas lack access to care and must sometimes travel great distances for care. this may make scheduling non-treatment related visits, such as the initial visit of the ttp, difficult for some survivors. telemedicine is a potential solution, and one that has been used extensively during the covid-19 pandemic. while medical centers are well-equipped to provide services via telemedicine, it must not be assumed that survivors have access to the equipment and internet bandwidth needed to receive care in this manner. the digital divide still exists in rural parts of the us [24] , which is being considered as the ttp works towards expansion of services and balancing travel time with technology resources. for example, one possibility for telehealth to be effective in a rural area could be to partner with community locations that have telehealth facilities so that survivors have local access to high-speed internet connections and private facilities in which to receive care. additionally, other types of tobacco counseling or intervention delivery that rely less on real-time video or internet voice communication may prove particularly relevant in this population (e.g., telephone or internet interventions). lastly, the ttp developed at uva uses a centralized model to provide care. this model could be useful for future implementation of cessation services beyond the cancer center. for example, the tts within the cancer center could provide cessation services to current smokers referred from primary care or pulmonology clinics. a centralized model like the uva ttp may also be an efficient way for community healthcare systems to provide consistent cessation services while sharing the cost of implementation. the uva c3i continues to employ lean methodology focusing on "creating pull" and "seeking perfection". for example, during the c3i project, funding for nicotine replacement therapies was included for those who did not have insurance. therefore, as most survivors were able to receive medications, access to cessation medications was not an identified priority during the quality improvement study. however, after the implementation of the new ttp, the c3i identified the need to create a more efficient and sustainable pathway for those needing medication assistance. prior to this phase, the tts was responsible for all components of providing medication assistance to survivors and it was clear that this effort needed to be reduced to efficiency and sustainability. to realize this goal, a pre-scripted medication order was added to the ehr which sent an automated request for physician review and signature after the completion of the initial visit with the tts. additionally, the ttp partnered with the uva cancer center pharmacy to include tobacco cessation medications as part their pharmacy patient medication assistance (ppma) program. as part of this program, a ppma flowsheet is completed by the tts which then allows prescriptions to be sent to the main hospitals pharmacy to be filled. the ppma team works through any prior authorizations that might be needed, connects survivors with prescription assistance programs, and provides other means possible to assist survivors with obtaining tobacco cessation products free or at a reduced cost. the impact of quality improvement studies has been dramatically successful at increasing delivery of tobacco treatment to cancer survivors [22, 23, 25, 26] . however, many of these studies have only examined short-term outcomes. it is less certain if these improvements will continue. therefore, the use of a continuous quality improvement framework and sustainability is essential to realize the potential population health impact of comprehensive tobacco control within cancer centers [6] . while originally supported by c3i funded, the ttp has become systematically embedded into the cancer center making tobacco treatment an important part of all encounters with cancer survivors. by removing inefficiencies throughout the program, it is now is more sustainable. resources, including staff time is maximized resulting in an increase of survivor referrals and appropriate triage to the program treatment levels. the time and effort used to build new ehr processes and flowsheets has created a system that is self-sufficient and provides the ability to scale-up if needed based on survivor load. the sustainable use of pharmacotherapy results in most survivors being able to receive medication therapy without requiring significant financial burden or ttp resources. with a systematic and stable workflow now in place, the ttp has also begun to focus more on "creating pull". the sustained implementation and regular evaluation of the new ttp provides an opportunity to learn more about tobacco cessation interventions that might prove particularly useful for cancer survivors and increase enrollment in the ttp. for example, even using an opt-out model recently implemented at the mayo clinic cancer center, only 17% of survivors attended a scheduled tobacco treatment appointment [25] . at the uva cancer center, while assessment of tobacco use and referral to the ttp have both increased substantially, this increase has not produced an equivalent increase in survivor enrollment in the ttp. thus, there continues to be an opportunity to increase the reach of tobacco cessation within cancer centers. additionally, there is a need to maintain engagement with cessation, particularly as many smokers must make multiple attempts before successfully quitting. future iterations of our ttp will attempt to modify existing services to better support smokers who relapse and evaluate its impact on long-term cessation. one potential barrier to increasing enrollment in ttp is the lack of repeat assessments of survivors' readiness to quit. singer et al. found that only 43% of tobacco using survivors assessed by a radiation oncologist about cessation expressed readiness to quit [26] . the myriad complexities (personal and medical) surrounding cancer treatment may mean that success in motivating a survivor to quit varies over time, reflecting a personal process of coping with a diagnosis of cancer, making it imperative that readiness to quit is frequently assessed and counseled. providing additional resources or treatment options for smokers who are not ready to quit might prove particularly beneficial in a survivor population with heightened guilt and anxiety around smoking. this study has several strengths and limitations that need to be considered. first, this quality improvement study focused on clinician, and ehr gaps to the implementation of comprehensive tobacco cessation within the uva cancer center; as a result, cancer survivor barriers to cessation were not examined. however, continued evaluations of the current ttp could include patient reported outcomes and assessment of barriers to cessation. second, this quality improvement study took place in one cancer center and as a result, findings may not be generalizable to other cancer centers or clinical settings. however, the implementation of lean methodology can occur regardless of the clinical setting and is designed to produce unique results by site. third, as uva cancer center is located in a small town, the total patient population may be lower than other academic medical centers located in more populous areas. however, the patient population served by uva as a c3i site is relatively unique in that the catchment area includes many rural counties, which usually have a higher prevalence of tobacco use than non-rural areas. lastly, the current study focused on the quality improvement process; thus, the study is more descriptive with a particular emphasis on lessons learned and identifying gaps. however, the new ttp is poised for future studies to undertake a formal program evaluation. this article demonstrates the implementation of lean methodology to evaluate and improve smoking cessation within uva cancer center, reviewed top barriers, and described solutions that have resulted in a robust, comprehensive, and sustainable tobacco treatment program. by identifying the interdependence of identified gaps, it became clear that relatively small solutions had the potential for large downstream effects. the new ttp is poised to provide excellent care and serve as a platform for future cessation research with the potential to positively impact the health of survivors who use tobacco, particularly those living in rural areas. county health rankings and roadmaps: virginia. available online us department of health and human services. the health consequences of smoking-50 years of progress: a report of the surgeon general centers for disease control and prevention, national center for chronic disease prevention and health promotion substance abuse and mental health services administration center for behavioral health statistics and quality rural versus urban use of traditional and emerging tobacco products in the united states cutting tobacco's rural roots: tobacco use in rural communities addressing a core gap in cancer care-the nci moonshot program to help oncology patients stop smoking tobacco and lung cancer: risks, trends, and outcomes in patients with cancer health behaviors influence cancer survival successes and failures of the teachable moment tobacco cessation guide for oncology providers tobacco use assessment and treatment in cancer patients: a scoping review of oncology care clinician adherence to clinical practice guidelines in the u identifying targeted strategies to improve smoking cessation support for cancer patients how can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? a mixed-methods study of four acute hospitals successful implementation of lean as a managerial principle in health care: a conceptual analysis from systematic literature review lean leadership attributes: a systematic review of the literature. j. health organ manag where the real work happens the a3 problem solving report: a 10-step scientific method to execute performance improvements in an academic research vivarium do smoking reduction interventions promote cessation in smokers not ready to quit? the fagerström test for nicotine dependence: a revision of the fagerstrom tolerance questionnaire cognitive testing of tobacco use items for administration to patients with cancer and cancer survivors in clinical research a lean quality improvement initiative to enhance tobacco use treatment in a cancer hospital using lean quality improvement tools to increase delivery of evidence-based tobacco use treatment in hospitalized neurosurgical patients digital gap between rural and nonrural america persists design and pilot implementation of an electronic health record-based system to automatically refer cancer patients to tobacco use treatment quality improvement initiative to improve tobacco cessation efforts in radiation oncology the authors declare no conflict of interest. key: cord-332828-a4ck2ddp authors: alboaneen, dabiah; pranggono, bernardi; alshammari, dhahi; alqahtani, nourah; alyaffer, raja title: predicting the epidemiological outbreak of the coronavirus disease 2019 (covid-19) in saudi arabia date: 2020-06-25 journal: int j environ res public health doi: 10.3390/ijerph17124568 sha: doc_id: 332828 cord_uid: a4ck2ddp the coronavirus diseases 2019 (covid-19) outbreak continues to spread rapidly across the world and has been declared as pandemic by world health organization (who). saudi arabia was among the countries that was affected by the deadly and contagious virus. using a real-time data from 2 march 2020 to 15 may 2020 collected from saudi ministry of health, we aimed to give a local prediction of the epidemic in saudi arabia. we used two models: the logistic growth and the susceptible-infected-recovered for real-time forecasting the confirmed cases of covid-19 across saudi arabia. our models predicted that the epidemics of covid-19 will have total cases of 69,000 to 79,000 cases. the simulations also predicted that the outbreak will entering the final-phase by end of june 2020. coronaviruses are a large family of viruses that are distributed among humans and animals such as livestock, birds, bats and other wild animals. these viruses cause serious illnesses for human when infecting respiratory, hepatic, gastrointestinal and neurological [1] [2] [3] . in december 2019, china notified the world health organization (who) about a novel coronavirus-severe acute respiratory syndrome coronavirus 2 (sars-cov-2)-that caused many cases of respiratory illnesses that were mostly related to people who had visited a live animal seafood market in wuhan city [4] . the disease, now formally called covid-19 (coronavirus disease 2019), caused an outbreak of a typical pneumonia through human-to-human transmission starting from wuhan, a highly populated city with more than eleven million residents, then rapidly spread in china [5] . the chinese authority put wuhan city and several cities in hubei province on lockdown, and all the public transportation was stopped to prevent any further spread of the virus [6, 7] . however, the confirmed cases have increased daily in china and in many countries around the globe. on 11 march 2020, who officially declared covid-19 outbreak as a global pandemic as the virus has spread to well over 200 countries around the world [8] . to date, covid-19 has infected more than 4.5 million people and killed over 300,000 people across the world [8] . saudi arabia was among the countries that was affected by the virus. on 2 march 2020, the saudi ministry of health reported the first confirmed covid-19 case in the country. from the beginning of march, the number of confirmed covid-19 cases gradually increased and the highest number of cases reported in one day was 2307 on 15 may 2020 with a total of 49,176 confirmed cases of covid-19 infections and 292 deaths have been confirmed in saudi arabia (see figure 1 ). (a) confirmed cases (b) recovered cases (c) deaths cases mathematical models and simulations are considered an important tools to predict the possibility and severity of disease outbreak and provide main information for determining the type and intensity of disease intervention. resulting in decreasing the transmission of the diseases and a more accurate approaches to manage the epidemic. recently, mathematical modeling has been used to predict epidemics such as foot-and-mouth disease (fmd), sars, zika and ebola [9] [10] [11] [12] . this article aims to give a local prediction of the epidemic peak for covid-19 in saudi arabia by using the real-time data from 2 march 2020 to 15 may 2020. the remainder of this article is arranged as follows. section 2 presents the related work on covid-19. section 3 describes data and the models used in prediction of the epidemic peak for covid-19 in saudi arabia. section 4 presents our simulation results. finally, section 5 draws the conclusion. in [13] , a model called fpassa-anfis was proposed to predict the number of the confirmed covid-19 cases for the upcoming 10 days after previous cases until 8 february 2020 in china in order to take the right course of action. the main idea of the model was to enhance the performance of adaptive neuro-fuzzy inference system (anfis) using parameters from the output of fpassa, namely, flower pollination algorithm (fpa) and salp swarm algorithm (ssa). the result of the model was outstanding with regards to mean absolute percentage error, root mean squared relative error, root mean squared relative error, and coefficient of determination (r 2 ). moreover, the proposed model was evaluated with two other data sets, and the result showed good performance. in [14] , the end and the infection turning point of the covid-19 epidemic in china and hubei province were predicted. a proper model was used and parameterized with the latest data of the daily and total infections in hubei and china from nhc. the model predicted the end of the epidemic to be after march 10 with 51,600 infections, while the daily case turning points were predicted to be between 1 and 6 february 2020. roosa et al. in [15] generated a real-time prediction of cumulative confirmed covid-19 cases in hubei and china in general for the few upcoming days after 5 and 9 february 2020. they used three phenomenological models that were previously utilized to predict the epidemics of several other diseases. these models were the generalized logistic growth model, richards model, and sub-epidemic wave model. the models predicted that the average number of the additional cases would be from 7409 to 7496 in hubei and 1128 to 1929 in china. moreover, they concluded that by the end of 24 february, the predicted cases would be from 37,415 to 38,028 in hubei and 11,588 to 13,499 in china. in [16] , the case fatality rate (cfr) for covid-19 in china was measured. they collected the confirmed and death cases from 10 january to 3 february then applied simple statistics technique such as linear regression to find the estimation. they found that the cfr of novel covid-19 is lower than those of the previous sars-cov and middle east respiratory syndrome coronavirus (merscov). batista in [17] predicted the final infection numbers of covid-19 in china. the logistic growth model and classic susceptible-infected-recovered (sir) dynamic model were used with data from worldmeters website. the model predicted that the final estimation of coronavirus epidemic will be approximately 83,700 cases. in [18] , a mathematical model was developed to predict the effects of implementing government restrictions to contain covid-19 epidemic on the number of infection cases in china. the model showed that the number of infection cases decreased if high restrictions are taken earlier instead of later. when the novel covid-19 started to spread in china in the first half of january 2020, many cases went unreported. in [19] , a model was generated to estimate the real number of unreported cases with the help of existing information from the serial intervals (si) of infection caused by the two previous coronaviruses (sars and mers). the model results showed that the unreported cases from 1 to 15 january 2020 were approximately 469 cases. in addition, they found that the cases increased by 21-fold after 17 january 2020. moreover, in [20] , they proposed a statistical model to estimate the rate of covid-19 cases in china. in this model, they used the data of the evacuated japanese citizens from wuhan from 29 to 31 january 2020. the model estimated the infection rate to be 9.5, and the death rate to be from 0.3 to 0.6. the japanese citizens totaled 565, and this number is insufficient to estimate an accurate rate. in [21] , the risk of transmission of covid-19 was estimated. they proposed a model based on clinical information of the disease and confirmed cases of individuals. the estimated result of the reproduction number was higher than 6.47. in addition, the model predicted the confirmed cases in seven days (23 to 29 january 2020). thompson in [22] developed a mathematical model to estimate the sustained human-to-human transmission. the data of 47 patients were used, and the estimated result showed that the transmission rate is 0.4. moreover, the transmission is only 0.012 in case the symptoms have not yet manifested in half of the tested data. in [23] , they proposed a model to estimate the covid-19 death risk based on the data of 20 cases reported by 24 january 2020. two different scenarios were estimated, and the results are 5.1 and 8.4. moreover, the estimation of the reproduction for both scenarios are 2.1 and 3.2. the results indicated that the covid-19 epidemic could become a pandemic. we collected the daily number of confirmed, recovered, and deaths covid-19 cases released by saudi ministry of health's twitter account from 2 march 2020 to 15 may 2020 to construct a real-time database. the data were organized in a matrix with the rows representing the date and columns representing the number of the new confirmed cases, the number of accumulated cases, the number of accumulated recovered cases and the number of accumulated deaths cases as shown in tables 1 and 2 . we generated short-term forecasts in real-time using two models namely, the logistic growth and sir models. the phenomenological logistic growth model has been widely used to model population growth with limited resources and space. the model was originally developed by haberman in [24] and have been used to predict 2015 ebola epidemic [11, 12] . the dynamics of the epidemic, typically expressed as a cumulative number of cases, can use the similar model when the primary method of control is quarantine-as in the case of a novel viral infection such as covid19. in the logistic growth model, the epidemic can be defined by the differential equation where c is the cumulative cases at time t, r is the early growth rate, and k is the final epidemic size. for comparison, we also simulate the well-known sir model to represent the spreading process of covid-19 epidemic in saudi arabia. sir model framework is an epidemic spreading model inspired by the seminal work of kermack and mckendric [25] . in epidemiology, sir model is belong to compartmental epidemic models. the basic in compartmental epidemic model is proposed by hamer in 1906 where he suggested that the infection spread should depend on the number of susceptible population and the number of infected population [26] . we estimate the parameters of model to get a best fit on reported data of covid-19 outbreak in saudi arabia. in sir model, we assume that the modeling timescale is short, no vital dynamics (births and deaths), and the host population size (n) is constant. in sir-type models, individuals are classified into three separate groups (or compartments) based on their infectious status: • susceptible (s): group of individuals that not currently infected but may catch the disease. the sir model is represented by the following system of nonlinear ordinary differential equations (odes) [27] : where t is time (in day), β is the contact rate, gamma is the remove rate or the inverse of infectious period, s(t) is the number of susceptible population at time t, i(t) is the number of infected population at time t, and r(t) is the number of recovered population at time t (see figure 2 ). in the sir model, one key parameter to understand the basic epidemiological characteristics of the epidemic is the basic reproduction number (r 0 ). r 0 is the average number of secondary persons in a complete susceptible population infected by a single infected person during its spreading life. it indicates how contagious is the infectious diseases. the true value of r 0 is uncertain until the outbreak is over. r 0 depends on three factors: duration of infectiousness; • probability of infection being transmitted during contact between an infected person and a susceptible person; • the average rate of contact between infected and susceptible individuals. r 0 is represented as when r 0 > 1 virus is currently spreading in the population and when r 0 < 1 virus is stop spreading due to run out of susceptible and the decrease of new cases. we used matlab to simulate the logistic growth and sir model based on [17, 28] models. in the epidemic simulation graphs, regions color separate epidemic into three phases: the simulation is data-driven which is rely on the historical time-series data. from the simulations, it is shown that the logistic growth prediction is more optimistic compare to the other models. from the logistic growth model prediction, the peak of the infection rate is 7 may 2020 (see figure 3 ). the transition to steady-state phase starts on 28 may 2020 and the ending phase starts on 14 june 2020. the logistic growth model predicts that final number of case is around 69,000 cases. several assumptions were taken in the simulation of sir model: constant total population, uniform mixing of the people, and equally likely recovery of infected. the sir model of covid-19 epidemic simulation in saudi arabia are shown in figures 5 and 6 . in sir-model the parameters β and γ are estimated from the actual number of confirmed cases. the variable r 0 changes with respect to time. it will change every day based on the number of cases confirmed. from the sir-model prediction, the peak of the infection rate is 1 may 2020. the transition to steady-state phase starts on 2 june 2020 and the ending phase starts on 24 june 2020. the sir-model predict that final number of case is around 79,000 cases. predicting the epidemic evolution based on limited data and with no past epidemiological data is not trivial task. we present predictions for reported cases of covid-19 in saudi arabia from 2 march to 15 may 2020 using mathematical modeling and simulation. we used two models: logistic growth and sir models. across both predictions, logistic growth and sir-model provide different results (figures 3 and 5) . both models are similar in predicting the epidemic trends but with a slightly different timing, the sir model predicts about a few days late than the logistic growth. both models also have a gap in predicting the final number of cases with sir model has a higher number of cases compared to the logistic growth. in conclusion, while our models predict the covid-19 outbreak in saudi arabia still in fast growth phase, our predictions need to be interpreted with caution given the dynamic case definition and reporting patterns. without mass testing, the confirmed case number might be only a subset of the true total infected cases. also, the asymptomatic infected individuals who are not tested and then recovered do not get counted. under-reporting and asymptomatic people are observed in many countries worldwide and may lead to under-estimation of the accumulated cases. therefore, mass testing is needed to identify patients and to contain the spread of the disease. our prediction based on current data suggests that the epidemic continue to spreading in saudi arabia. it is suggested that warmer weather may contribute to slowing down the spread of coronavirus but this would need further investigation when more data is available. it should be noted that the mers coronavirus has spread in saudi arabia in the summer (august) [29] . the authors declare no conflict of interest. emerging coronaviruses: genome structure, replication, and pathogenesis isolation and characterization of a bat sars-like coronavirus that uses the ace2 receptor novel coronavirus clinical features of patients infected with 2019 novel coronavirus in risk for transportation of 2019 novel coronavirus (covid-19) from wuhan to cities in china nowcasting and forecasting the potential domestic and international spread of the 2019-ncov outbreak originating in wuhan, china: a modelling study covid-19 coronavirus pandemic. available online forecasting the 2001 foot-and-mouth disease epidemic in the uk simulating the sars outbreak in beijing with limited data is west africa approaching a catastrophic phase or is the 2014 ebola epidemic slowing down? different models yield different answers for liberia using phenomenological models for forecasting the optimization method for forecasting confirmed cases of covid-19 in china trend and forecasting of the covid-19 outbreak in china real-time forecasts of the covid-19 epidemic in china from early estimation of the case fatality rate of covid-19 in mainland china: a data-driven analysis estimation of the final size of the covid-19 epidemic predicting the cumulative number of cases for the covid-19 epidemic in china from early data estimating the unreported number of novel coronavirus (2019-ncov) cases in china in the first half of january 2020: a data-driven modelling analysis of the early outbreak the rate of underascertainment of novel coronavirus (2019-ncov) infection: estimation using japanese passengers data on evacuation flights estimation of the transmission risk of the 2019-ncov and its implication for public health interventions novel coronavirus outbreak in wuhan, china, 2020: intense surveillance is vital for preventing sustained transmission in new locations real-time estimation of the risk of death from novel coronavirus (covid-19) infection: inference using exported cases mathematical models: mechanical vibrations, population dynamics, and traffic flow a contribution to the mathematical theory of epidemics epidemic disease in england: the evidence of variability and of persistency of type the mathematics of infectious diseases estimation of the final size of the second phase of the coronavirus epidemic by the logistic model will heat kill the coronavirus? key: cord-338580-zszeldfv authors: chang, yu-kai; hung, chiao-ling; timme, sinika; nosrat, sanaz; chu, chien-heng title: exercise behavior and mood during the covid-19 pandemic in taiwan: lessons for the future date: 2020-09-28 journal: int j environ res public health doi: 10.3390/ijerph17197092 sha: doc_id: 338580 cord_uid: zszeldfv the coronavirus disease 2019 (covid-19) pandemic and its associated governmental recommendations and restrictions have influenced many aspects of human life, including exercise and mental health. this study aims to explore the influence of covid-19 on exercise behavior and its impact on mood states, as well as predict changes in exercise behavior during a similar future pandemic in taiwan. a cross-sectional online survey was conducted between 7 april and 13 may 2020 (n = 1114). data on exercise behavior pre and during the pandemic and mood states were collected. a cumulative link model was used to predict changes in exercise frequency during a similar future pandemic by exercise frequency during the pandemic. a linear model was used to predict the influence of exercise frequency before and during the pandemic on mood states during the pandemic. a total of 71.2%, 67.3%, and 58.3% of respondents maintained their exercise intensity, frequency, and duration, respectively, during the pandemic. frequent exercisers are more likely to maintain their exercise frequency during a similar pandemic (p < 0.001). higher exercise frequencies during the pandemic were associated with better mood states (p < 0.05). moreover, the effects of prepandemic exercise frequency on mood states are moderated by changes in exercise frequency during the pandemic (p < 0.05). additionally, maintenance of exercise frequency during a pandemic specifically for frequent exercisers are recommended to preserve mood states. these results may provide evidence for health policies on exercise promotion and mental health before and during a future pandemic. coronavirus disease 2019 , generated by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) [1] , has spread rapidly and globally, with 12,552,765 confirmed cases and 561,617 deaths reported worldwide as of 12 july 2020 [2] after the first case reported in wuhan, china in december 2019 [3] . this crisis, yet, has affected each country differently. taiwan was anticipated to have the second-highest number of cases because of proximity and frequent travels to and from china [4] . however, learning from severe acute respiratory syndrome (sars), taiwan took speedy responses, proactive deployments, as well as novel strategies to identify and contain the participants were recruited through social media, including facebook, line, instagram, twitter, as well as personal referrals. we did not use any screening questionnaire for underlying psychological conditions to exclude respondents from participating in the survey. no statistical method was used to predetermine the sample size and as many participants as possible were sampled during the time period of global lockdown. a post-hoc power analysis revealed that our sample (n = 1104) corresponds to the recommendation for sufficient power in linear models [29] . all participants completed an informed consent before participating in the survey. the participants did not receive any incentive for their participation. additionally, they were able to skip any questions they did not want to answer or stop answering all questions at any point in time. we collected information on the presence of covid-19 symptoms or a positive diagnosis to exclude these individuals from the analysis. information on age, gender, educational level, income level, and living environment was collected. income was measured with the question "compared with the average income in your country, which one is your household income?" for statistical analysis, the answers "i don't have an income at the moment", "very low income", and "low income" were combined as "low income", "high income", and "very high income" were combined as "high income", and "medium income" stayed the same. in order to demonstrate the unique influence of covid-19 on human behaviors in taiwan, the presence of governmental pandemic control strategies (i.e., restrictions and recommendations) and the status of recreational facilities (e.g., gyms, clubs, and outdoor facilities) internationally were compared. additionally, participants' compliance with those regulations were presented. exercise frequency during the covid-19 pandemic was measured with one question on how often people exercised during the pandemic. we defined exercise for participants as any activity they chose to do as their exercise (e.g., workouts at home, running outside, etc...). participants were also informed that any physical activity as part of their occupation must not be included unless they are a professional fitness coach or have a similar profession. for statistical analysis, the answers "never", "once in a while" and "1 day per week" were combined as "1 day or less", the answers "2 days per week" and "3 days per week" were combined as "2-3 days per week", and "4-5 days per week", and "6 days per week", and "every day" answers were combined as "4 days per week or more". exercise frequency before the covid-19 pandemic was measured and processed in the same format. participants were also asked about their exercise intensity both during and prepandemic, and they could respond by choosing "low", "moderate", "high", or "very high" intensity. the options "high" and "very high" intensities were combined as "high intensity" for the analysis. participants were also asked about their exercise session length during the covid-19 pandemic compared to prepandemic and could choose between "shorter", "longer", or "they were of about the same duration". mood was measured with 16 items from the profile of mood states (poms; [30] ). the poms is a heavily used psychometric questionnaire that measures general well-being in the clinical field both with the general population and people with chronic disease, as well as in sport and exercise psychology research [31] . in this study, participants were asked to report how they felt in the last few days during the pandemic. for this study, we used the 16-item poms from a german short screening version, which was psychometrically tested using data from a large national and representative sample [32] . the german items were then matched with the english originals as thoroughly as possible, and then translated from english into traditional chinese by the research group in taiwan. these 16 items allow subscores for "depression/anxiety", "vigor", "fatigue", and "irritability"; however, we only used the total score in our analysis. the higher values on poms indicate more positive mood states. in our study, the 16-item poms total score achieved an internal consistency (reliability) of cronbach's α = 0.88. mean total scores were calculated if at least 10 items of the scale were answered by the participants. cumulative link models (clm) were employed to analyze which variables were significant predictors of the exercise frequency during a similar pandemic condition. three levels of exercise frequency per week during the pandemic (i.e., "1 day or less", "2-3 days", "4 or more days") were predicted by three levels of exercise frequency per week prepandemic (i.e., "1 day or less", "2-3 days", "4 or more days") with covariates such as age, gender, and income. a linear model with a priori contrasts was used to analyze the influence of exercise behavior on mood states. this model was run with mood as the numerical response variable and "prepandemic exercise frequency" and "exercise frequency during the pandemic" as categorical predictors (with three levels of "1 day or less", "2-3 days", "4 or more days"). we specified a priori contrasts to compare mood scores of different levels of exercise frequency pre and during the covid-19 pandemic, with exercising "1 day or less" as the intercept. the significance level was set to α = 0.05. all analyses were performed with r software [33] and the ordinal package [34] for cumulative link models. a total of 1174 participants filled out the questionnaire in taiwan. we excluded participants who reported either presence of covid-19 symptoms or diagnosis at the time of this study (n = 60). therefore, a total of 1114 participants (mean (m) age = 35.90, standard deviation (sd) age = 15.16, 53.9% female) were included in the analysis. descriptive statistics of the participants, including gender distributions, age, educational level, living environment, and income, are summarized in table 1 . participants were also asked about the presence of social restrictions and recommendations and their level of compliance. although participants reported almost no formal restrictions (92.4%), 81.8% reported that there were recommendations on social distancing, and the majority (86.1%) stated that they did their best to follow these recommendations. this is in contrast to the international data of the irg on covid and exercise project, indicating that the majority of participants (79.7%) reported the presence of strict formal restrictions by their governments. participants were also asked about the status of the recreational facilities (e.g., gyms, clubs, outdoor facilities, and parks) where they live. a total of 34.2% reported that the gyms and clubs were closed and only 9.5% reported that the outdoor facilities and parks were closed. this is in contrast with the international data indicating 91.1% reported closures of gyms and clubs, and 76.3% reported closures of outdoor facilities and parks. table 2 provides more detail on this information in taiwan and a comparison with the international data. note: participants were asked: "do you live under any type of socially limiting formal restrictions that were established by your government or regional/local authorities?"; "are there recommendations from governmental, regional, or local authorities regarding 'social distancing' or 'social isolation' where you live?". the results show that 67.3% of participants reported the same exercise frequency, 19 .7% reported a decrease in exercise frequency, and 12.9% reported an increase in exercise frequency during the covid-19 pandemic compared to prepandemic. of those who exercised during the covid-19 pandemic, 71.2% reported being physically active at similar, 16.7% at lighter, and 4.8% at higher exercise intensities. additionally, 58.3% reported the same exercise duration, 23.3% reported shorter, and 11.1% reported longer exercise duration. this information is presented in figure 1 in more detail. the results show that 67.3% of participants reported the same exercise frequency, 19.7% reported a decrease in exercise frequency, and 12.9% reported an increase in exercise frequency during the covid-19 pandemic compared to prepandemic. of those who exercised during the covid-19 pandemic, 71.2% reported being physically active at similar, 16.7% at lighter, and 4.8% at higher exercise intensities. additionally, 58.3% reported the same exercise duration, 23.3% reported shorter, and 11.1% reported longer exercise duration. this information is presented in figure 1 in more detail. a clm was employed to predict changes in exercise frequency during a pandemic from prepandemic exercise frequency for use in future conditions similar to the current pandemic. the results show that those who exercise 2-3 days per week before a similar pandemic have a significantly higher probability of maintaining their exercise frequency or do more during such pandemics compared to people who exercise one day or less before a similar pandemic (beta coefficient (b)pre2-1 = 1.95, p < 0.001). those who exercise four days or more per week before a similar pandemic have a significantly higher probability of maintaining their exercise frequency or do more during such pandemics compared to those who exercise 2-3 days per week before a similar pandemic (bpre3-2 = 3.01, p < 0.001). prepandemic exercise behavior could explain 56.4% of the variance in exercise behavior during a pandemic (r 2 nagelkerke). calculating the category probabilities from the models' prediction and location coefficients, we can see that the majority of the taiwanese will maintain their prepandemic exercise frequency during similar pandemics ( figure 2 ). specifically, the probabilities of maintaining exercise frequency during a similar pandemic for those who exercise one day or less per week, 2-3 days per week, and four days or more per week, are 73.3%, 56.8%, and 78.3%, respectively. a clm was employed to predict changes in exercise frequency during a pandemic from prepandemic exercise frequency for use in future conditions similar to the current pandemic. the results show that those who exercise 2-3 days per week before a similar pandemic have a significantly higher probability of maintaining their exercise frequency or do more during such pandemics compared to people who exercise one day or less before a similar pandemic (beta coefficient (b) pre2-1 = 1.95, p < 0.001). those who exercise four days or more per week before a similar pandemic have a significantly higher probability of maintaining their exercise frequency or do more during such pandemics compared to those who exercise 2-3 days per week before a similar pandemic (b pre3-2 = 3.01, p < 0.001). prepandemic exercise behavior could explain 56.4% of the variance in exercise behavior during a pandemic (r 2 nagelkerke ). calculating the category probabilities from the models' prediction and location coefficients, we can see that the majority of the taiwanese will maintain their prepandemic exercise frequency during similar pandemics ( figure 2 ). specifically, the probabilities of maintaining exercise frequency during a similar pandemic for those who exercise one day or less per week, 2-3 days per week, and four days or more per week, are 73.3%, 56.8%, and 78.3%, respectively. we also included gender, age, education, and income as covariates in separate models to predict exercise behavior during similar future pandemics. the results show that there was a main effect of age (b age = 0.01, p < 0.01) for exercise frequency during a pandemic. this means that older individuals are more likely to have higher exercise frequency during similar pandemics compared to younger individuals. there were no significant main effects of gender or education. however, levels of these covariates showed significant interaction effects, meaning that the relationship between exercise behavior before a pandemic and exercise behavior during a pandemic is different for specific predictor levels. specifically, females who exercise one day or less before a pandemic are more likely to stay inactive compared to others (b pre2-1*female = 0.63, p = 0.03). additionally, those who have "completed vocational school or college" and exercise one day or less before a pandemic are more likely to increase their exercise frequency during similar pandemics (b pre2-1*education4 = -0.88, p < 0.01) compared to other respondents. we also included gender, age, education, and income as covariates in separate models to predict exercise behavior during similar future pandemics. the results show that there was a main effect of age (bage = 0.01, p < 0.01) for exercise frequency during a pandemic. this means that older individuals are more likely to have higher exercise frequency during similar pandemics compared to younger individuals. there were no significant main effects of gender or education. however, levels of these covariates showed significant interaction effects, meaning that the relationship between exercise behavior before a pandemic and exercise behavior during a pandemic is different for specific predictor levels. specifically, females who exercise one day or less before a pandemic are more likely to stay inactive compared to others (bpre2-1*female = 0.63, p = 0.03). additionally, those who have "completed vocational school or college" and exercise one day or less before a pandemic are more likely to increase their exercise frequency during similar pandemics (bpre2-1*education4 = -0.88, p < 0.01) compared to other respondents. finally, income was a significant predictor of exercise frequency during similar pandemics with those reporting a high level of income (compared to the average income level) being more likely to have higher exercise frequency compared to those with low levels of income (bincomehigh = 0.43, p = 0.03). however, when taking prepandemic exercise frequency into account, income is no longer a significant predictor of exercise frequency during a pandemic (bincomehigh = 0.23, p = 0.37). importantly, prepandemic exercise frequency remained a significant predictor of exercise frequency in all models when controlling for possible covariates. complete statistical results can be seen in table 3 . finally, income was a significant predictor of exercise frequency during similar pandemics with those reporting a high level of income (compared to the average income level) being more likely to have higher exercise frequency compared to those with low levels of income (b incomehigh = 0.43, p = 0.03). however, when taking prepandemic exercise frequency into account, income is no longer a significant predictor of exercise frequency during a pandemic (b incomehigh = 0.23, p = 0.37). importantly, prepandemic exercise frequency remained a significant predictor of exercise frequency in all models when controlling for possible covariates. complete statistical results can be seen in table 3 . note: prepandemic exercise levels: 1 = "1 day or less"; 2 = "2-3 days"; 3 = "4 days or more". education levels: 1 = "doctoral degree", 2 = "master's degree", 3 = "some graduate school", 4 = "completed vocational school or college", 5 = "some vocational school or college", 6 = "high school graduate or ged", 7 = "less than high school. in this analysis, the mood state was predicted by both prepandemic exercise frequency and exercise frequency during the covid-19 pandemic. the results show that there was a significant main effect of exercise frequency during the pandemic on mood states. those who exercised four days or more had significantly higher mood states compared to those who exercised for 2-3 days (b during3-2 = 0.14, p = 0.04), and those exercised for 2-3 days had significantly higher mood states compared to those who exercised one day or less per week during the pandemic (b during2-1 = 0.29, p < 0.001). there was also a significant main effect of prepandemic exercise frequency on mood states. specifically, those who exercised four days or more per week prepandemic had a significantly lower mood state during the pandemic, compared to those who exercised for 2-3 days per week prepandemic (b pre3-2 = −0.16, p = 0.03). however, there was a significant interaction effect on exercise frequency levels during the pandemic × prepandemic exercise frequency levels on mood (b pre*during = −0.48-0.42, p = 0.01-0.03). meaning, the effects of prepandemic exercise frequency on mood were dependent on exercise frequency during the pandemic (figure 3 ). table 4 summarizes the complete statistical results. exercisepre3-2 × income high −1.81 (0.53) 0.13 note: prepandemic exercise levels: 1 = "1 day or less"; 2 = "2-3 days"; 3 = "4 days or more". education levels: 1 = "doctoral degree", 2 = "master's degree", 3 = "some graduate school", 4 = "completed vocational school or college", 5 = "some vocational school or college", 6 = "high school graduate or ged", 7 = "less than high school. in this analysis, the mood state was predicted by both prepandemic exercise frequency and exercise frequency during the covid-19 pandemic. the results show that there was a significant main effect of exercise frequency during the pandemic on mood states. those who exercised four days or more had significantly higher mood states compared to those who exercised for 2-3 days (bduring3-2 = 0.14, p = 0.04), and those exercised for 2-3 days had significantly higher mood states compared to those who exercised one day or less per week during the pandemic (bduring2-1 = 0.29, p < 0.001). there was also a significant main effect of prepandemic exercise frequency on mood states. specifically, those who exercised four days or more per week prepandemic had a significantly lower mood state during the pandemic, compared to those who exercised for 2-3 days per week prepandemic (bpre3-2 = −0.16, p = 0.03). however, there was a significant interaction effect on exercise frequency levels during the pandemic × prepandemic exercise frequency levels on mood (bpre*during = −0.48-0.42, p = 0.01-0.03). meaning, the effects of prepandemic exercise frequency on mood were dependent on exercise frequency during the pandemic (figure 3 ). table 4 summarizes the complete statistical results. . each column indicates exercise frequency before the pandemic, and exercise frequency levels within each column are exercise frequency levels during the pandemic. error bars indicate 95% confidence intervals. there was a significant difference in mood for those who exercised 4 days or more before the pandemic (right columns) and decreased their exercise frequency during the pandemic. for those, who exercised for 2-3 days before the pandemic (middle column), only those who exercised 1 day or less reported significantly lower mood than those who maintained their exercise frequency. note: exercise levels pre and during the pandemic: 1 = "1 day or less"; 2 = "2-3 days"; 3 = "4 days or more". along with post-hoc contrasts (see table 5 ), figure 3 shows that those who exercised four days or more before the covid-19 pandemic and decreased their exercise frequency during the pandemic experienced a decline in their mood states. specifically, individuals who decreased their exercise frequency to 2-3 days per week, had significantly lower mood states than those who maintained their exercise frequency (b pre3: during2-3 = −0.20, p = 0.01), and if they decreased their exercise frequency to one day or less per week, they experienced even a more significant decline in mood states (b pre3: during1-3 = −0.88, p < 0.001). those who exercised for 2-3 days per week prepandemic and were able to maintain their exercise frequency, had higher mood states compared to those who decreased their exercise frequency to one day or less during the covid-19 pandemic (b pre2:during1-2 = −0.25, p < 0.01). exercise frequency during the covid-19 pandemic had no significant effect on mood states for those who exercised one day or less prepandemic (p > 0.05). overall, exercise behavior could explain 5.2% of the variability in mood states. the study presents the data from a larger study, "irg on covid and exercise", to examine changes in exercise behavior and its relation to mood in taiwan during the covid-19 pandemic. our results showed that the majority of respondents were able to maintain their exercise behavior during this pandemic. prediction analysis further revealed that taiwanese are likely to maintain their prepandemic exercise frequency during future similar pandemics. additionally, those who exercise more frequently before a similar pandemic have higher probabilities of maintaining their exercise frequency during such pandemics. notably, individuals who "completed vocational school or college", and are rarely active (i.e., exercise one day or less) before a pandemic are more likely to increase their exercise frequency during a future pandemic, while females who are rarely active (i.e., exercise one day or less) before a pandemic tend to maintain their exercise frequency during a future pandemic. additionally, it seems that older individuals and those with higher levels of income are more likely to engage in higher exercise frequencies. the relationship between exercise frequency and mood during the covid-19 pandemic was dependent on the change in exercise behavior (before vs. during). in general, higher frequencies of exercise during the covid-19 pandemic resulted in better mood states. additionally, exercising "2-3 days" or "four days or more" before a pandemic was associated with worse mood states if these individuals reduced their exercise frequency during the pandemic. generally, a decline in exercise levels is expected during the covid-19 pandemic and our study indicated that nearly 20% of individuals decreased their exercise frequency. however, our results are inconsistent with previous studies showing a dramatic decrease in physical activity during the covid-19 pandemic in other parts of the world [8, 23, 35] ; that is, the majority of taiwanese maintained their exercise frequency, duration, or intensity during the covid-19 pandemic. these differences may be partially the result of a relatively safe living environment and taiwanese self-discipline in epidemic prevention. given the geographical proximity to and the number of visits from mainland china, taiwan central epidemic control center (cecc) of taiwan centers for disease control has been on constant alert about the epidemic in china. after the initial suspicious unknown acute respiratory syndrome case reported in december 2019 in china [3] , taiwan cecc has quickly mobilized and established comprehensive and proactive deployments to counteract and reduce the transmission of covid-19. these included air and sea border control (e.g., assessing passengers for fever and pneumonia symptoms and restrictions at entries of international and cross-strait ports), case identification and containment (e.g., rapid screening tests for covid-19, digital contact tracing, and quarantining suspicious cases), increase production rates and control of the domestic market price of medical face masks, and measuring body temperature at all entrances [4] [5] [6] [7] 36] . furthermore, a high percentage of taiwanese (86.1%) reported that they were willing to comply with taiwan cecc derived public propaganda and school education for covid-19 (e.g., maintaining social distance, regular disinfected living areas, and wearing medical face masks in public places) during the early days of the outbreak, which further decreased the spread of covid-19. therefore, taiwan remained free from lockdown restrictions and kept the majority of health and fitness gyms and outdoor recreation facilities (e.g., parks, and playgrounds) open, and was able to maintain social activities per usual which reflect the successful containment of covid-19. the prediction analysis demonstrates that exercise frequency during the pandemic is dependent on prepandemic exercise frequency. specifically, those who are more frequent exercisers prepandemic are more likely to stay active during a similar future pandemic. this finding reflects the importance of "prevention is better than cure" for exercise behavior during a future pandemic (e.g., second wave of the covid-19 pandemic). notably, some demographic variables might moderate exercise behavior. specifically, older individuals are more likely to have higher exercise frequency during similar pandemics. the result is similar to other studies showing that older adults in taiwan and mainland china exercise more regularly compared to younger individuals [35, 37] . additionally, our data show that inactive individuals who have "completed vocational school or college" are more likely to increase their activity levels compared to the rest of our sample. this is not surprising as generally, individuals with higher educational levels might have better financial resources [38] and more access to health information [39, 40] . finally, we observed that females who are rarely active are more likely to maintain their low levels of exercise frequency. a lower prevalence of physical activity among females compared to males has been previously reported [41, 42] . it is plausible that females, in general, perceive more barriers to exercise, such as lack of time due to multitasking (e.g., requiring to take care of others while working) and therefore, they are less likely to change their exercise behavior during such pandemics [43, 44] . collectively, given that age, education, and gender can influence exercise behavior, specific strategies are required to consider and implement for these populations. interestingly, approximately 13% of participants reported an increase in exercise frequency and the prediction analysis showed that 26.8% of the individuals who exercise one day or less per week, and 15% of individuals who exercise 2-3 days per week, might increase their exercise frequencies during a future similar pandemic. this shows that inactive or rarely active individuals might increase their exercise frequency or adopt exercise behavior during a pandemic. our finding is similar to data that showed increased health-seeking behavior (e.g., spending more time exercising) after the sars epidemic in hong kong [45] . additionally, the perceived severity and susceptibility to disease is associated with both increased likelihoods of conducting health-seeking behavior according to the health belief model [46] , and moving to the higher stages of the transtheoretical model of behavior change (e.g., stages of action and maintenance) [47] . that is, covid-19 or a similar pandemic would increase awareness of health-seeking behavior such as exercise, and further facilitate the motivation to initiate and maintain the behavior. therefore, public health policy-makers should not only consider strategies to encourage exercise before a pandemic, but also take this pandemic as an opportunity to promote exercise for future similar pandemics. we observed that exercise frequency both pre and during the covid-19 pandemic impacts mood states. generally, higher exercise frequency during covid-19 was associated with better mood states, while the effect of prepandemic exercise frequency on mood states was moderated by the change in exercise frequency (before vs. during). specifically, those who frequently exercised before the pandemic (i.e., exercised for 2-3 days or four days or more) experienced a significant decline in their mood states when they decreased their exercise frequency during the pandemic. these results are in line with other research on the positive psychological benefits of exercise. for example, a meta-analytic study indicated an association between exercise and improved mood states, with an overall effect size of 0.24 and a mean change effect size of 0.38 for the treatment versus the control group and pretest-posttest studies, respectively [48] . frequent exercise or physical activity might lead to adaptation of biological systems, including changes in neural hormones and endorphins [49] , increasing density and efficiency of mineralocorticoid receptors and diminishing the cortisol synthesis [50] , as well as improving cardiorespiratory fitness and strength [51] . furthermore, exercise also elevates self-efficacy, self-esteem, feelings of mastery [51] [52] [53] , and cognitive function [54] [55] [56] . these positive physiological and psychological changes might be the mechanisms for improvements in mood states associated with both exercise before and during the pandemic. notably, higher total poms scores reflect either higher positive mood states (e.g., vigor) or less negative mood states (e.g., depression/anxiety, fatigue, or irritability). research has shown that the ratings of the arousing emotional pictures were significantly decreased after an exercise session [57] , suggesting exercise reduces anxiety and increases resilience toward emotional stressors. additionally, alleviation of negative mood states [58] , a decrease in trait anxiety [59, 60] , and a decrease in the emergence of depression [61] have also been observed with exercise. based on the cross-stressor adaptation hypothesis [62] , exercise might result in the adaptation of the sympathetic nervous system and the hypothalamus-pituitary-adrenal axis [49, 63, 64] , which in turn lead to anxiolytic effects. this suggests that frequent exercisers might benefit from anxiolytic effects of exercise, especially during the covid-19 pandemic [65] [66] [67] . it should be noted that prepandemic frequent exercisers (e.g., frequency of four days or more) experienced worse mood states if they decreased their exercise frequency during the pandemic. decrease in exercise levels, known as detraining [68] , can have adverse effects both on exercise-induced physiological adaptation [69, 70] , as well as psychological adaptations [71] . other studies have shown that the cessation of regular exercise is linked to negative mood states [72, 73] , as well as increases in somatic depressive symptoms (e.g., fatigue, berlin, kop, and deuster [72] ). it is possible that a decrease in cardiorespiratory fitness [72] , self-efficacy [51, 74] , or changes in obligatory exercise beliefs [75] contributed to declines in mood states when frequent exercisers decreased their exercise frequency during the covid-19 pandemic. in sum, maintenance of exercise behavior patterns, particularly in the active population, is essential to preserve mood states during the covid-19 pandemic or any similar future pandemics. some drawbacks of the study should be acknowledged. the translated questionnaires used in this study were not validated due to time limitations. in order to conduct this study during the brief window of governmental recommendations and restrictions related to covid-19, the questionnaires were translated from english into 18 different languages including traditional chinese for use in taiwan, resulting in the lack of time to proceed with the validation of the questionnaires as well as cultural adaptations. an additional limitation is the cross-sectional design of the study and the use of self-report data. however, the "irg on covid and exercise study" is planning to conduct a second wave after the cessation of the covid-19 pandemic to investigate the trends of exercise behavior and mood states of the respondents over time. finally, collecting data through the internet might potentially limit the participation of certain groups (e.g., individuals who do not have internet access). however, the internet penetration rate in taiwan reached 89.6% in 2019, and the internet access rate for individuals aged 12 and above is as high as 88.8% [76] , suggesting the high accessibility and usage of the internet by taiwanese. our findings indicate that exercise behavior before a pandemic outbreak is likely to affect exercise behavior and mood states during a pandemic. specifically, the results show that age, gender, and educational level played a role in exercise behavior change during the pandemic. therefore, exercise professionals and policy-makers should work together to provide comprehensive and practical strategies specifically for the populations who are at risk of decreasing their exercise frequency before a similar pandemic in the future. for example, exercise training sessions can shift from in-person to online settings [77] . this shift might require exercise practitioners acquiring several new skills such as online communication strategies, online exercise program design, and online evaluation of the clients' progress. additionally, sending motivational messages through the internet, such as edtech [78] and social media (e.g., facebook, wojcicki et al. 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in low-active adolescents via facebook: a pilot randomized controlled trial to test feasibility this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we thank ralf brand to initiate the international research group (irg) on covid and exercise. the authors report no conflicts of interest.data availability statement: data are available upon request. key: cord-310215-11srk6iq authors: bielinis, ernest; xu, jianzhong; omelan, aneta anna title: a novel anti-environmental forest experience scale to predict preferred pleasantness associated with forest environments date: 2020-09-16 journal: int j environ res public health doi: 10.3390/ijerph17186731 sha: doc_id: 310215 cord_uid: 11srk6iq in this study, a method for predicting the preferred pleasantness induced by different forest environments, represented by virtual photographs, was proposed and evaluated using a novel anti-environmental forest experience scale psychometric test. the evaluation questionnaire contained twenty-one items divided into four different subscales. the factor structure was assessed in two separate samples collected online (sample 1: n = 254, sample 2: n = 280). the internal validity of the four subscales was confirmed using exploratory factor analysis. discriminant validity was tested and confirmed using the amoebic self scale (spatial–symbolic domain). concurrent validity was confirmed using the connectedness to nature scale. predictive validity was based on an assessment of pleasantness induced by nine different photographs (control—urban landscapes, forest landscapes, dense forest landscapes), with subscales differently correlated with the level of pleasantness assessed for each photograph. this evaluation instrument is appropriate for predicting preferred pleasantness induced by different forest environments. experiencing the natural landscape in everyday life is an important factor associated with human wellbeing [1] [2] [3] [4] . contact with nature is also crucial for psychological health since there are many nature-based therapies, including horticulture therapy [5, 6] and forest therapy [7] [8] [9] , which are useful in treating depression and other diseases. the importance of forests, as a special type of natural environment, is also high. for example, in poland, a medium-sized central european country located in the range of temperate forest biomes, forests cover close to 29% of the landscape [10] . much of this area is natural and free from significant human infrastructure. forest areas have great accessibility and potential for use in forest therapy experiences, an outdoor recreational activity which might be used as a remedy for stress [11, 12] . in poland, this activity is used as therapy in different seasons [13, 14] . thus, poland is a good example of a country with accessible forest resources for forest therapy. the forest landscape can also be represented by virtual natural environments, i.e., by viewing images of forest landscapes on electronic devices, when real natural experiences are not accessible. viewing virtual forest environments also has a positive influence on psychological relaxation [15] [16] [17] [18] . nevertheless, because viewing forest landscapes is critical to reducing stress and obtaining an optimal psychological state, it is also important to know if subjects obtain similar psychological benefits from viewing a virtual representation of these environments. methods for predicting the extent of this benefit are in an early stage of development [19] . currently, there is no available questionnaire which can predict the level of psychological relaxation obtained by each subject. it is easy to imagine that, in the future, when physicians want to prescribe a treatment for a patient, they will be able to administer a questionnaire to see if a person will benefit from a specific treatment such as viewing a virtual or real forest. this situation will be possible if an instrument for predicting the psychological impacts of different forest experiences has been developed. the anti-environmental forest experience scale (aefes) questionnaire can also be used to predict the effects that different forms of activity may have during forest therapy. looking at the forest, walking in the forest and touching various objects in the forest may be associated with different levels of experienced benefits from such an activity, which can be predicted by using the aefes questionnaire in advance in patients participating in these activities. there are two promising theories for determining the fundamental psychological indices of an individual which might be usable for prediction of the level of psychological relaxation experienced in forest environments or in virtual reality. the first is amoebic self theory [20] , which describes the human self as similar to the construction of amoebas, in that the task of the amoeba is to assess differences between self and non-self (the physical domain of amoebic self), the difference between friend and foe (the social domain of amoebic self) and mine versus non-mine (the spatial-symbolic domain of amoebic self). the most important (from the point of view of our considerations) are the names of objects which might be seen, touched, smelled or heard in the forest. these kinds of objects might include trees, shrubs, plants, etc. in the forest, which might be seen as non-self objects. however, according to this theory, these objects might be involved in the self of the object on a different level; hypothetically, if the object is further away, then its influence on the boundaries of the amoebic self is lesser. so, according to these considerations, objects which touch the body, like insects, should generate more potential discomfort (as the boundaries of the self are more vulnerable to violation), while seeing herbivores, like deer, from a distance should generate a lower level of discomfort. reactions to objects also have evolutionary backgrounds, because it is important to survive and to protect oneself from a potentially dangerous phenomenon, such as insects, which could spread a disease [21] . however, none of the domains of the amoebic self scale exactly connect with phenomena that occur in forest environments. the closest is the spatial-symbolic domain, which involves categorizing objects as mine versus non-mine. the other theory connected with the reactions of individuals in forest landscapes is the prospects and refuges theory [22] . according to this theory, people feel safe when they have an open (prospect) view of the landscape and also feel safe if the landscape does not have places in which carnivorous or other dangerous animals can hide (no refuges). this reaction also has an evolutionary background because this is a mechanism for surviving in the dangerous natural environment. this theory suggests that only high-prospect and low-refuge landscapes will induce optimal psychological relaxation [23] . insofar as there is some possibility of predicting the level of psychological relaxation and therefore preferred pleasantness induced by viewing different forest landscapes, it is important to propose new concepts for these contexts. biodiversity of urban green spaces is a predictor of their psychologically restorative benefits [24] . other research has shown that amenities, incivilities and usability are predictors of park satisfaction [25] . environment preference and environment type congruences may also be used to predict effects on perceived restoration potential and restoration outcomes [26] . it may also be possible to use the natural environment scoring tool to assess the impact of natural environments on psychological relaxation, but this tool was not applied in the forest and is not designed to test this environment [27] . there are few research tools for assessing how individual preferences predict the potential preferred pleasantness or other indices of psychological relaxation obtained by visual stimulation from forest landscapes, although life satisfaction tools may be used to predict the effect of forest environments on psychological relaxation [28] . other personality indices, such as the big five personality tool or myers-briggs type indicator (mbti) personality tools, may be successfully used as predictors of psychological satisfaction in the forest [29, 30] . the anti-environmental forest experience approach proposed here may provide a way of integrating the amoebic self theory and prospect and refuge theory into a unified theory, something currently missing in the literature. the term "anti-environmental" for this new scale has been chosen in order to emphasize the fact that the attitude of those who are less likely to benefit from being in a forest environment is against (anti) features of that environment-features of the forest environment, such as the presence of plants, forest litter, animals and insects, are viewed as negative and potentially discomforting. an anti-environmental forest experience proposes that the human self has an integrated psychological mechanism which works like the membrane of an amoeba, and this membrane divides the self from the environment. in this respect, it is similar to the amoebic self theory, in which objects are separated from the self [20] . the anti-environmental forest experience has an evolutionary background similar to the prospect and refuge theory, because being able to distance oneself from the environment might increase chances of survival, especially in dense forests, in which potentially dangerous animals such as carnivores, poisonous snakes or spiders might be hidden [22] . this boundary might also provide protection against potential pathogens in the environment. things that provoke disgust or fear of violating the boundary of the self are aspects of the anti-environmental forest experience that work to protect the self from danger [21] . this study considered the possibility of contact in the temperate forest with different environmental interactions. these interactions were (1) contact with plants and litter, including contact with plants growing in the forest, such as touching trees, shrubs and other plants, or the smell of leaf litter; (2) seeing animals, particularly those which are skittish and usually visible only from a distance; (3) unpleasant situations such as coming across the carcass of a dead animal; (4) contact with insects and other signs of small animals, such as finding ticks or spider webs. one might also encounter other humans in the forest [31] -for example, human-made infrastructures such as huts, buildings, forestry machines, pylons-but this possibility was not considered in this study, because this is not an interaction with an object in the natural environment. in these studies, based on the authors' considerations and people's relations to the forest, four factors were selected that may best reflect the interaction of the human body with the forest environment. during the construction of the aefes questionnaire, a list of situations that may occur in the forest and that may potentially cause discomfort to participants of the walk in the forest was made; the conditions of the forest from the temperate zone were taken into account. thus, in a temperate forest, the body may interact with the forest litter and plants, because people walking in the forest reported discomfort from the plants that touched them, and the smell and consistency of the forest litter, so a set of statements for factor 1 was created. participants in forest walks reported their interaction with animals in the forest, which is an example of a situation where discomfort is caused by objects that are far away from the body but can potentially damage them in the interaction, so the items were selected to create factor 2. during the walk in the forest, participants also reported discomfort related to the feeling of disgust in the forest, which could cause discomfort with potential closer contact with the body; therefore, a set of statements for factor 3 was created. many people who took walks in the forest reported their discomfort in contact with insects in this environment and created a set of statements presenting the situation of contact with insects, forming factor 4. the proposed four factors may allow for a better understanding of the phenomenon of "discomfort" felt in the forest, because they explain psychometric scales measuring such traits as emotions better than previously used in research on psychological relaxation (positive and negative affect schedule), mood (profile of mood states, including the item "comfort") or restorativeness (perceived restorativeness scale) [12] [13] [14] 28, 29] . these scales only allow respondents to express discomfort experienced in the forest environment in general terms, but the proposed aefes scale factors allow for a deeper understanding of this phenomenon, because the example "comfort" from the profile of mood state (poms) scale captures this issue in one statement, and the aefes scale breaks them down into twenty-one statements and four factors. this allows a deeper understanding of the issue of discomfort in the forest environment. based on this consideration, it is probable that humans have self-boundaries vulnerable to violation in each of these four aspects. the anti-environmental forest experience scale (aefes) was created to test the hypothesis that human self-boundaries are vulnerable to violation by each of these four aspects. an explanatory factor analysis (efa) was conducted on two samples, as were reliability, concurrence, discriminant and predictive validity tests. the efa analysis was designed to test the extent to which the four proposed subscales of aefes confirm the anti-environmental forest experience theory. the reliability of these four aspects should consider their viability as integrated constructs and their correlation with other scales. the reliability of these scales provides evidence that an anti-environmental forest experience can help predict the pleasantness induced by viewing forest landscapes and can be useful in predicting potential benefits that might be obtained by a subject from nature-based therapy. preferred pleasantness can be combined with a feeling of violation of self-boundaries because this violation of self-boundaries is seen in this work as one of the determinants of preferred pleasantness-the more natural self-boundaries are sensitive to factors that can be supplied from outside (caused by viewing photos of landscapes), the less will be the perceived preferred enjoyment of these landscapes. high values obtained on the scale measuring the sensitivity of self-boundaries will be associated with the prediction of a low level of benefits that will be achieved by viewers of the forest landscape. certain expectations about concurrent validity were made. among these was the expectation that the amoebic self scale (spatial-symbolic domain, amss-ss) and aefes should both measure vulnerability to violations of self-boundaries. because, in social psychology, there are sometimes small correlations between constructs [20] and also because amss-ss measures similar, but not identical, things (amss-ss measures identification with self and non-self-objects, while aefes measures hypothetical anti-environmental attitudes of the self rather than identification), the supposition was made that the correlation between these two scales should be significant, positive and with pearson's r values in the range of 0.2-0.4. in a discriminant validity verification procedure, the scale should be inversely correlated with another construct, not measuring the same thing or measuring something opposite. the correlation between aefes concurrent construct should be significantly negatively correlated with a moderate pearson's r correlation coefficient of more than 0.1 but not more 0.4. in this study, the connectedness to nature scale (cns) [32] was used as a discriminate validity scale. this scale measures emotional connectedness with the environment and relates to an individual's attachment with the environment. because place attachment, one of the primary constructs in environmental psychology, was correlated significantly with cns at a level of r = 0.25 [33] , it is assumed that cns will be negatively correlated with aefes as it measures the subject's self and personal attachments. since, theoretically, the pro-environmental construct should be cns, a negative correlation should be obtained with anti-environmental aefes, which measures anti-environmental forest experiences. the predictive validity of the scale depends on its ability to predict values of importance to the researcher or practitioner. in this case, evaluating the aefes scale depends on its ability to predict preferred pleasantness. subscales of aefes should be negatively correlated with the positively evaluated construct, such as the level of pleasantness which a subject obtains from viewing forest landscapes. it is also possible to see a positive correlation compared to control, urban landscape images. the forest landscape might be viewed by subjects as non-preferred by images, with high levels in aefes; thus, a negative correlation might be observed. because the urban landscape is not associated with plants, litter, animals and insects, no correlation or even a positive correlation should be observed with preferred pleasantness and aefes. this study used only the photographic representation of a landscape for research; thus, the magnitude of the expected correlation is not high, yet it is still significant. it should be in a range between 0.1 and 0.4, though it is likely that it would be higher in the real, natural environment. looking at the virtual forest landscape may evoke various impressions, usually positive, which has been proven in research [15] [16] [17] [18] . in the study by korpela [19] , it was shown that looking at photos of a forest landscape is associated with higher values of preferred pleasantness, which was correlated with perceived restorativeness (r = 0.72-0.87). since looking at pictures of the forest evokes positive feelings (compared to pictures of an urbanized area), for this reason, it was decided in this experiment to use virtual pictures to produce an effect that could be predicted using the proposed aefes scale. two groups of participants participated in this study. the first group, designated as "study 1", had 254 participants. these participants were invited to participate via personal invitations extended by a forestry student at the university of warmia and mazury in olsztyn on social media. participants filled in a questionnaire on a specifically prepared website. the data of two respondents are not included in the study, because they did not give permission to use the data for research purposes. data were collected between 22 january 2020 and 2 march 2020. the second group involved, "study 2", had 280 participants. these participants were also recruited via social media, with technical assistance from the department of forestry and forest ecology. responses were collected between 4 february and 27 february 2020. the forestry and forest ecology department webpage was also used to advertise the questionnaire. all participants in study 2 agreed to share their responses for this study. participation in both study groups was voluntary. all participants were polish nationals. in both study groups, half of the respondents had backgrounds in nature education or work, while the other half did not. the online questionnaires were prepared on two special websites. the first questionnaire contained demographic questions about the participant, the aefes, cns and other scales that are not significant for this study. the second questionnaire contained questions about the demography of the participants, the aefes, cns, spatial-symbolic aspects of the amoebic self scale and nine photographs used to evaluate pleasantness using a scale of 1-3. each photograph was presented on a separate page, with the photographs displayed in random order. to avoid the bias of viewing the photographs of the landscape before filling the questionnaire, it was possible to see and evaluate each photograph on the pleasantness scale only after filling in the other scale. because the study involved human subjects, it was reviewed and approved by the ethical review board at the university of warmia and mazury in olsztyn. the number of the ethical statement is 06/2019. all procedures performed in this study were in accordance with the ethical standards of the polish committee of ethics in science and with the 1964 helsinki declaration's later amendments. participants in both study groups were asked to fill in demographic data on the questionnaire, including their gender, age, type of residence (ranging from a village to a big city of more than 250,000 inhabitants), educational background (from primary school to more than bachelor degree), self-evaluation of material standing (on a five-point likert scale, from "1-very bad" to "5-very good") and employment (working, unemployed or student). after filling in these data, participants proceeded to the other website for further questions (each visible on a separate page). the demographic information about each study group is shown in table 1 . based on previous theoretical considerations, a questionnaire was designed to measure the level of discomfort experienced by a subject. participants were asked to imagine that they were hypothetically involved in an exceptional situation. on a seven-point likert scale from "1-strongly disagree" to "7-strongly agree", the participants evaluated whether this exceptional situation induced discomfort. four a priori groups were proposed: (1) contact with plants and leaf litter in the forest (plants and litter), with participants asked about the level of discomfort induced by six specific situations, such as "head hit by a falling cone" or "body hit by a branch"; (2) encounters with animals in the forest (animals), such as "seeing a deer with antlers from afar" or "seeing a fox from afar"; (3) seeing a disgusting thing in the forest (disgust), with five encounters proposed, i.e., "seeing a slithering snake" or "finding a dead animal"; (4) contact with insects in the forest (insects), with six encounters proposed, including "being bitten by a 'horse fly'" and "being swarmed by insects". it is worth mentioning that these items are connected with real discomforts which might feasibly happen in the forests of central europe. in other parts of the world, these encounters might be different, depending on the circumstances of the local environment. sensitivity to discomfort may measure the hypothetical boundaries of the self, which may vary for each participant. in this case, the involuntary violation of these boundaries by the forest environment was measured, because situations occurring in the forest are not wanted by each subject and subjects have individual reactions to the environment which are connected with their self-boundaries [20] . burris and rempel [20] proposed that the human's amoebic self has several domains. one of these domains is the spatial-symbolic domain, which is connected with feelings of fear and disgust [34] . this domain describes the relationship between mine and non-mine objects and allows the recognition that different subjects have different degrees of vulnerability to these self-boundaries being violated. this vulnerability is possible to measure by the amoebic self scale, in which the subject provides answers to a list of hypothetical involuntary situations that might occur in their life and influences their identity. there is a polish adaptation (with some modifications) of these domains containing a list of 10 hypothetical situations which might induce discomfort. the reported cronbach's α was varied between 0.7 and 0.71 for these domains [34] . the discomfort induced by each situation was evaluated by subjects on a 7-point likert scale (from "1-strongly disagree" to "7-strongly agree"). examples of items used in this scale are "the thought of getting amnesia, of forgetting who i am, is really disturbing to me" and "i am disturbed when i think that there may be aliens or extraterrestrials who will someday invade earth". this domain has not previously been examined in the context of the temperate forest environment. the authors suppose that this domain is only slightly correlated with other aspects connected with the self: the anti-environmental forest experience. admittedly, this scale measures some aspects of the vulnerability of self-boundaries but not other aspects connected with vulnerability to contact with the natural environment. as such, the authors suppose that only a slight correlation will occur, but such a correlation will be present. thus, the correlation between these two scales will be used as a concurrent validity example in the current investigation. cns is a psychometric tool which can be used to measure an individual's emotional connection to the natural world [32] . this scale is reliable and valid, with an internal consistency of α = 0.72 [32] . the polish adaptation of the scale is also available [35, 36] . participants responded on a 5-point likert scale from 1 being "completely disagree" to 5 being "completely agree". example items for this measurement are "my personal welfare is independent of the welfare of the natural world" and "i think of the natural world as a community to which i belong". this scale is connected with experiences of people's relationship to the natural world but not related seriously to the boundaries of the self. thus, cns is used in the current study as a measure to assess the discriminant validity of the main instrument. photographic representations of landscapes were used to assess the suitability of aefes. for these purposes, nine photographs of three types of landscapes were prepared. type 1 contained three photographs of an urban environment (views of three urban points near the campus of the university of warmia and mazury in olsztyn were photographed for this purpose). type 2 contained three photographs of forest landscapes (three different forest landscapes were photographed: the first in central park in helsinki, the second and third near the campus in olsztyn). type 3 contained three photographs of a dense forest located near the campus. the use of these three groups was based on the results of a previous scientific study because, as was supposed, the study suggested that photographs from urban environments would induce low pleasantness, photographs of forests will induce high pleasantness, and photographs of a dense forest will produce high pleasantness (but lower than the forest landscape without disturbing factors like shrubs or undergrowth) [23, 37] . for preparing all landscape photographs, a smartphone iphone 6 was utilized. during landscape photographing, the operator was focused on representing the possible maximal natural experience of the viewer of the landscape by keeping the smartphone at eye level. the photographs were prepared with the same resolution and size. all photographs were displayed for participants on their own devices. it is known that each photograph transmits unique information about the landscape for participants which, in this case, might be used for the online evaluation method [38] . photographs grouped into their three types are presented in figure 1 . for evaluation of each landscape photograph, the participants saw photographs on a separate page in the questionnaire. under each photograph there was the possibility to fill in a preferred pleasantness scale containing three pairs of opposite adjectives: "unpleasant/pleasant", "i don't like it/i like it" and "ugly/beautiful". pairs were rated on a 7-point likert scale, from one to seven, with seven indicating the highest level of pleasantness [19] . this scale was correlated with other scales which might measure the restorative quality of the environment and, thus, it helps to predict the usefulness of the landscape for nature-based therapy [39] . the number of a priori factors in the scale should be confirmed by exploratory factor analysis (efa) in a validation process [40] . because the analyzed scale is new, the effects of previous factor analysis are not known. two studies were carried out (study 1: 254 participants, study 2: 280 participants) to allow the possibility of making comparisons; thus, efa was applied in each study. responses to 21 items for both groups were used in a separate analysis, with the maximum likelihood method using direct oblimin rotation (delta = 0) in each case. the decision of the identification of factors in these two studies was based on multiple methods. the factor was classified as importantly occurred if the eigenvalue was higher than 1.0. the scree plot was used for consideration of conceptual meanings of items on each factor. parallel analysis was also carried out (based on [41] ) but, in these analyses, the effect was assessed as too conservative. for evaluation of each landscape photograph, the participants saw photographs on a separate page in the questionnaire. under each photograph there was the possibility to fill in a preferred pleasantness scale containing three pairs of opposite adjectives: "unpleasant/pleasant", "i don't like it/i like it" and "ugly/beautiful". pairs were rated on a 7-point likert scale, from one to seven, with seven indicating the highest level of pleasantness [19] . this scale was correlated with other scales which might measure the restorative quality of the environment and, thus, it helps to predict the usefulness of the landscape for nature-based therapy [39] . the number of a priori factors in the scale should be confirmed by exploratory factor analysis (efa) in a validation process [40] . because the analyzed scale is new, the effects of previous factor analysis are not known. two studies were carried out (study 1: 254 participants, study 2: 280 participants) to allow the possibility of making comparisons; thus, efa was applied in each study. responses to 21 items for both groups were used in a separate analysis, with the maximum likelihood method using direct oblimin rotation (delta = 0) in each case. the decision of the identification of factors in these two studies was based on multiple methods. the factor was classified as importantly occurred if the eigenvalue was higher than 1.0. the scree plot was used for consideration of conceptual meanings of items on each factor. parallel analysis was also carried out (based on [41] ) but, in these analyses, the effect was assessed as too conservative. cronbach's α [42] reliability coefficient was used to assess the reliability of the subscales of aefes. nunally [43] recommended the criteria to evaluate the adequacy of obtained reliability coefficient, with α greater than 0.70. this criterion was used in the current study. concerning concurrent, discriminant and predictive validity, the pearson correlation between aefes and the cns, amss-ss and preferred pleasantness measured for each of nine photographs was calculated and analyzed. demographic characteristics for both study groups are included in table 1 . the main difference between study 1 and study 2 was that study 2 involved more young people (55% vs. 35% of participants between 18 and 25 years old). in study 2, there were also more participants from villages (28.3% in study 1, 39.60% in study 2). the mean values (±sd) for each scale and subscale as well as values for preferred pleasantness for each of nine photographs are shown in table 2 . for the values of aefes subscales, the value for "contact with insects in the forest" was the highest; for "plants and litter" and "disgust", it was moderate, and for "animals", it was the lowest. this is connected with distance: animals are far away, whereas insects are very close, on the skin. the mean values of preferred pleasantness were lower for control environments (urban landscape a, b, c), high for forest landscape (d, e, f) and high, but lower than for forest, in the case of a dense forest landscape (g, h and i). in study 1, the item-total correlations (each item in subscale correlated with mean values calculated from total items for subscale) for aefes ranged from 0.707 to 0.789 for "plants and litter", from 0.748 to 0.895 for "animals", from 0.657 to 0.841 for "disgust" and from 0.683 to 0.841 for "insects". in study 2, the item-total correlations for aefes were, respectively, 0.560-0.796, 0.726-0.851, 0.709-0.743 and 0.695-0.853, indicating that good homogeneity occurred in both studies. for study 1 (n = 254), the kaiser-meyer-olkin (kmo = 0.895) measure of sampling adequacy proves that data from study 1 were predestined to obtain efa, and kmo values between 0.8 and 1 indicate that the sampling is adequate (meritorious) [44] . the efa findings indicated a four-factor solution for the 21 items measured, explaining 61.87% of the total variance in the item scores. all 21 items are appropriately labeled within the four factors as a group of activities inducing discomfort in forest environment: (1) plants and litter, (2) animals, (3) disgust, (4) insects. for study 2 (n = 280), the kmo value was = 0.883; thus, these data were adequate for efa. a four-factor solution was also indicated, explaining 60.14% of the total variance in the item scores. nineteen items were appropriately loaded within the four factors and labeled as four groups of activities in the forest. two items had high loadings in many factors and were thus assigned to the same groups as in study 1 as well as a different factor. the factor pattern coefficients for study 1 and study 2 are shown in table 3 . the reliability coefficient (cronbach's α) was calculated for 21 items for study 1 (α = 0.910) and study 2 (α = 0.905). the reliability estimates for study 1 and study 2 for the factors "plants and litter", "animals", "disgust" and "insects" are shown in table 4 . cronbach's α values for cns and amss-ss are also presented in table 4 . values of cronbach's α obtained in the current research ranged from 0.783 to 0.910 and are seen as high [45, 46] . to judge the concurrent validity of the aefes questionnaire, the relationship between aefes subscales and amss-ss was calculated ( table 4 ). subscales of aefes were positively correlated with values of amss-ss. this correlation was not high but was higher in study 2 than the discriminately validated scale. the most correlated were subscales "insects" and "disgust"; the lowest was a correlation with the subscale "animals". to assess the concurrent validity as evidence for the validity of aefes, the relationship between aefes and the theoretically suited cns was calculated. the results of these findings are presented in table 4 . the relationships between these two measures are highly significant or very highly significant or there is no relationship. if a relationship occurs, this will have a negative value. the values of pearson's r are not high, indicating that these scales are not perfectly correlated, which is expected in the case of discriminant validity. there are differences between studies; in study 2, the values of pearson's r are lower. the goal of this research was to judge the possibility of predicting the preferred pleasantness induced by forest landscapes. thus, the correlations between nine landscape examples were assessed (with three as a control urban landscape). all four subscales of aefes were not correlated or were slightly positively correlated with the preferred pleasantness of urban landscapes. all subscales were also correlated negatively with preferred pleasantness for all six photographs of a forest landscape. dense forest landscape was usually connected with slightly higher significant correlation than non-dense forest. the highest correlation is between preferred pleasantness of forest and the "animals" subscale and the lowest correlation is with the "insects" subscale. the predictive validity of subscales of aefes is a fact because the correlations are significant. all correlations are presented in table 4 . the current study aims to describe a new method of assessing the preferred pleasantness induced by urban and forest environments and to validate the instrument developed for this purpose: the aefes. it is worth noting that preferred pleasantness is a construct that consists of many dimensions and the aefes scale captures only some of them. the four-factor structure of the questionnaire was confirmed in an exploratory factor analysis using excluded factors that suggest the vulnerability of self-boundaries of subjects for contact with plants and litter in the forest, animals in the forest, disgust in the forest and insects in the forest. the subscales used have high reliability (αs = 0.783 to 0.859). this relevance was confirmed in two independent online studies. as theoretically expected, the instrument showed that four subscales were positively correlated to the amoebic self scale's spatial-symbolic domain (concurrent validity) and negatively correlated with the cns (discriminant validity), and three of the four subscales were correlated negatively with preferred pleasantness (predictive validity). this suggests that aefes might have the potential to measure real phenomena, as it is connected with the preferred pleasantness induced by forest environments. to sum up, the aefes is a reliable and valid instrument with practical use for measuring an anti-environmental forest experience, which might be useful for the prediction of the preferred pleasantness of subjects towards forest environments. it is worth mentioning that there is probably some psychological mechanism which, by inducing fear or disgust, divides the body of a subject from the natural environment in the forest. contact in these other situations might be harmful or dangerous to the health of a subject's body, so fear or disgust responses protect the body before it comes into contact with a potentially dangerous environment. the "plants or litter" subscale of aefes provides information about the vulnerability of a subject's hypothetical self for contact with trees, other plants and litter in the forest environment. the mean values of this scale in both analyzed studies were moderate, which indicates that this environmental feature might have a moderate level in the analyzed samples. the subscale "animals" had the lowest mean values in both samples (in comparison to other subscales); thus, components of the forest environment like large herbivores or small mammals, which are not dangerous, are not seen as harmful from the perspective of self-boundaries. this subscale is also slightly correlated with amss-ss, the slightest values from all subscales of aefes, but this subscale has good predictive validity and might also be used for prediction of the level of preferred pleasantness of subject. the subscale "disgust" had moderate values and was significantly correlated with amss-ss. this subscale measures self-boundaries which are vulnerable for interaction with disgust or undesirable items, which might be seen, touched or smelled in the forest. this subscale has good predictive validity. the last subscale, "insects", contains items which describe the interaction with insects in the forest and also concerns other organisms like ticks or spiders (from other groups of animals). this scale had the highest mean values but has the least predictive validity. this means that subjects observing photographs of forest environments have the worst ability to predict the occurrence of lower values of preferred pleasantness but can have some negative attitude against "insects". this finding supports both theories included in the introduction: if the object is far from a subject's skin, it is probably far from the self-boundaries, so it is connected with amoebic self theory; if the object is far from a subject's skin, there is some prospect (distance between subject and object), showing that the prospect and refuge theory may be relevant. that these two theories address and allow measurement of the same things was only possible to ascertain after this research and discussion. as mentioned in the introduction, other questionnaires cannot be used in these studies for various reasons. the subiza-pérez [47] study used the natural environment scoring tool and the place attachment and place identification scale [48] questionnaire to predict the restorative quality of the environment. however, these questionnaires were not used in relation to the forest environment of the temperate zone and they did not mention an important aspect-the proximity to the body of the examined objects. therefore, the analyzed aefes scale is much more comprehensive in this respect. the aforementioned research also does not address issues related to the different perceptions of forest landscapes resulting from the density of vegetation and therefore the possibility of hiding insects and potential predators. in the current research, it was proven that dense forest is less pleasant for the respondents, which explains, among other things, the observed correlation between preferred pleasantness and the values of the "insects" subscale. presumably, aefes can also be used to predict psychological relaxation. this prediction can be made by qualified personnel who would like to determine whether a hypothetical participant of forest recreation can benefit from this activity in the form of psychological relaxation, i.e., improved mood, an increased level of positive emotions, a decreased level of negative emotions and regeneration of mental strength (increased restorativeness). other studies have predicted the level of psychological relaxation of the natural environment using scales measuring place attachment and place identification [47] , so the aefes scale will also probably be a scale that can be used for this purpose, but this requires further research. since preferred pleasure is correlated with restorativeness [19] and restorativeness is related to the positive properties caused by the forest, among other things, in the examined patients of a psychiatric hospital [48] , it can be concluded that the subjects experiencing the pleasure of viewing pleasant pictures of the forest landscape will experience beneficial effects on their health. however, confirmation of this fact requires future studies in order to verify whether the aefes scale may be useful in predicting the therapeutic effect for patients. the aefes questionnaire can also be used to predict the benefits that participants of forest therapy may derive in various areas that may be affected by the forest: psychological effects, physiological effects and effects on social wellbeing. in addition, different features of the forest may have a different impact on the respondents (different forms of forest use, different species or different types of forests, including those resulting from geographic diversity), which can be predicted using the aefes scale [49, 50] . the limitation of this study may be the use of virtual examples of the forest environment in the form of photos, instead of landscape in a natural environment. however, looking at a virtual forest landscape is also associated with many benefits that can be derived by the respondents. a good example is a study in which people looking at films from forest areas experienced relaxation, but this also decreased their willingness to procrastinate [51] . in other studies, looking at a virtual forest reduced stress in adults [52] , and the respondents' relationships to the virtual forest environment were varied [53] . it is also worth noting that different environments will not necessarily be suitable for forest therapy, which is an implication of the prospects and refuges theory [22] . on the other hand, the diversity of the environments in which the participants of forest therapy stay is of great importance for the therapy, where the diversity of the environment and the presence of open space is also important [54, 55] . the aefes questionnaires are not the only tool to predict the expected benefits that contact with nature may bring to its participants. subjects with acute depressive symptoms preferred dark and dense forest landscapes [56] ; experts and laypeople might have different perceptions of tree features [10] . in addition, individual preferences were important in the mental and physical reactions of the respondents to the forest environment [9] . future research should be carried out to check whether, for example, the statement "feel one with nature" included in the cns scale will be related to receiving psychological benefits related to nature. the analysis of the available literature shows that this relationship has not yet been studied. it is possible that not all of the statements in the aefes scale will always reflect real fear in the forest. for example, a person who claims to experience discomfort in the forest as a result of contact with a snake may not feel this discomfort in the real environment, and vice versa. this requires empirical testing in future research. in these studies, however, an image of the situation in the forest was presented, and it is highly likely that this image of discomfort is real, as evidenced by different responses to different landscapes viewed. on this scale, items about discomfort that could be caused by deadwood were not included. neither of the items concerned this. it is planned in future studies to supplement the aefes scale with statements regarding possible discomfort resulting from the perception of deadwood in the forest. in these studies, half of the respondents were people using forest areas regularly and half of the respondents did not use forest areas (in both groups). therefore, some of the respondents are representative people using the forest and some are not. this diversification was intended to ensure that all groups are considered equally, which makes the results plausible-as they show the distribution of actual use of the forest environment by social media society. additionally, the respondents presented different levels of education, which was also intended to reflect the society using social media, which could potentially benefit from computer-mediated forest therapy in the future. the ability to predict the restorativeness of the environment (which is correlated with pleasantness [57] ) is used in a small number of scientific articles regarding the possibility to predict pleasantness or restorativeness [19, 58] . this study is innovative in the creation of a novel instrument designed exactly for the prediction of benefits taken from natural forest environment. the study showed that it was possible to predict social media users' possibility to like or evaluate positively each forest environment. the aefes also has potential to be used by physicians or therapists working with depression or anxiety because forest environments might be an additional remedy for those patients with psychological problems [48] , and prediction of pleasantness felt by each patient from described contact with forest environment is possible with the use of this instrument. future research is needed concerning aefes. in the current study, only the prediction of preferred pleasantness was tested. because other measurements of the impact of forest or natural environments are also possible, it is worth considering the verification of the predictive potential of aefes for this measure. restorativeness is one possible measure of effects. the current study also only verified the photographic illustration of the forest environment influence in relation to aefes vs. preferred pleasantness. in future studies, it will be very important to use the proposed instrument to predict effects in real forest environments. moreover, in future research, the usage of confirmatory factor analysis (cfa) for analysis should be considered. this research planned and performed comparisons of two samples for efa, but because cfa cannot be done on the same sample as efa, cfa could not be done in this research. the current problems with the covid-19 pandemic [59] also bring new possibilities for environmental studies on the influence of virtual forest environments on humans. many people are living in isolation during the pandemic, sometimes with no contact with the outside environment. some form of replacement of interaction with these outside environments, such as photographs of a forest environment, might be needed because of the natural need of people to be in contact with nature [60] . thus, the instrument is needed to personalize these photographs or films to increase the pleasantness experienced by the subjects. it can be imagined that a tree stand (landscape) with different characteristics may be better suited to the needs of the person who would benefit from viewing it. for example, a given person gains the benefits of viewing both the stand and the dense stand (which was predicted by the aefes scale); therefore, for such a person, there are no contraindications for practicing forest therapy in both stands. in the current study, the new questionnaire designed for the prediction of preferred pleasantness induced by photographs of forest environments was proposed and psychometrically validated. aefes was demonstrated to be reliable and valid. factor analysis confirmed that the four-factor structure is relevant; thus, four subscales were proposed: "plants and litter", "animals", "disgust" and "insects", with each subscale relevant to one of four groups of experiences which might occur in the temperate forest environment. two theories were also discussed and tested for their applicability for use in explaining the results of prediction. further studies are needed to test the psychometric predictive validity of the instrument for restorativeness of virtual and natural environments, and usability in the covid-19 era should be considered. it is worth summarizing, however, that the aefes scale has some limitations mentioned in this manuscript that should be investigated in future experiments. this scale, however, may explain some of the dependencies that account for the preferred pleasure experienced by people viewing pictures of the forest, videos of the forest or finally the forest itself. this relationship needed to be investigated and the results show that it is a significant relationship. restorative effects of urban green environments and the role of urban-nature orientedness and noise 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thank michał jaśkiewicz for valuable comments in the field of environmental psychology. the authors declare no conflict of interest.int. j. environ. res. public health 2020, 17, 6731 key: cord-337581-3rmrkq1k authors: ramos-morcillo, antonio jesús; leal-costa, césar; moral-garcía, josé enrique; ruzafa-martínez, maría title: experiences of nursing students during the abrupt change from face-to-face to e-learning education during the first month of confinement due to covid-19 in spain date: 2020-07-30 journal: int j environ res public health doi: 10.3390/ijerph17155519 sha: doc_id: 337581 cord_uid: 3rmrkq1k the current state of alarm due to the covid-19 pandemic has led to the urgent change in the education of nursing students from traditional to distance learning. the objective of this study was to discover the learning experiences and the expectations about the changes in education, in light of the abrupt change from face-to-face to e-learning education, of nursing students enrolled in the bachelor’s and master’s degree of two public spanish universities during the first month of confinement due to the covid-19 pandemic. qualitative study was conducted during the first month of the state of alarm in spain (from 25 march–20 april 2020). semi-structured interviews were given to students enrolled in every academic year of the nursing degree, and nurses who were enrolled in the master’s programs at two public universities. a maximum variation sampling was performed, and an inductive thematic analysis was conducted. the study was reported according with coreq checklist. thirty-two students aged from 18 to 50 years old participated in the study. the interviews lasted from 17 to 51 min. six major themes were defined: (1) practicing care; (2) uncertainty; (3) time; (4) teaching methodologies; (5) context of confinement and added difficulties; (6) face-to-face win. the imposition of e-learning sets limitations for older students, those who live in rural areas, with work and family responsibilities and with limited electronic resources. online education goes beyond a continuation of the face-to-face classes. work should be done about this for the next academic year as we face an uncertain future in the short-term control of covid-19. the fast propagation of the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) led to its definition as a pandemic on 13 march 2020 by the who [1] , as it met the epidemiological criteria and had infected more than 100,000 people in 100 countries [2] [3] [4] . the main public health recommendation was to remain at home and stay safe within it [5] . the world, in a globalized manner, is facing an extraordinary public health emergency in which the nurses are, as always, on the front line. challenges are even greater in this period of pandemic [6, 7] , and nurses have the knowledge and aptitudes for providing the care necessary in the different clinical scenarios [5] that are emerging. this research study was conducted in its entirety during the first month of the state of alarm in spain (which began on 14 march 2020). the state of alarm implied the confinement of the entire population, the closing of all the schools and universities, closing of non-essential businesses, closing of borders and ceasing all non-essential activities. the people were only allowed to go out to the street for essential matters: shopping of food, going to pharmacies, banks, and to care for older people who were dependent, etc. in spain, bachelor's degree in nursing has a duration of four years (240 european credit transfer system, ects) and it is common for a master's degree to have a duration of one year (60 ects). the reference population in this study was students from every academic year in the bachelor´s degree in nursing, or nurses who were conducting their master's studies, enrolled in universities in murcia and granada (spain). the participants were selected through the use of a maximum variation sampling strategy [13] to obtain heterogeneous and rich information that represented the main sociodemographic variables: gender, age, academic year, rural/urban, children, bachelor's/master's, university of murcia and granada. the maximum variation strategy is utilized to find the greatest diversity of discourses possible to identify and analyze the largest volume possible of expressions/presentation of the phenomenon studied to explain conditions/contexts where each one of them takes place. if one did not answer the request, the students themselves proposed a replacement with another participant with similar characteristics. none of the students contacted disagreed to participate. the students were invited to participate through the student delegation at the university, utilizing snowball sampling. this technique allowed us to build the sample by asking each interviewee for suggestions of people who had a similar or different perspective. this is an approach for locating information-rich key informants [13] . the saturation criterion was applied to establish the number of informants needed, an accepted method to estimate the sample size [14] . semi-structured interviews were conducted to obtain the information. the semi-structured interview is normally based on a script, where the subject matter and part of the questions have been planned before starting, but it also offers the possibility of changing or adding new questions as the interview and/or the research study moves forward, with new interviews conducted. it is the most common type of interview utilized in qualitative research on health. data were collected from 25 march to 20 april 2020. this was done in the first month as it the period of time with the greatest cognitive and social impact on learning and to obtain results that could be used to support, or not, the education measures that were utilized. all the interviews were individual and were performed online through electronic resources after agreeing on a day and time. the interviews were recorded and notes were made after each interview. all the interviews were conducted by researchers who had sufficient training and experience in semi-structured interviews (a.j.r.-m., m.r.-m.). the interviewers did not have an academic relationship with the informants. the interview followed a script which shifted from general to specific matters, and dealt with general aspects of the confinement, teaching methodologies utilized, learning and expectations (table a1) . a prior pilot study of the script was conducted [15] . the 6 phases proposed for the thematic analysis were followed [16] : (1) familiarizing yourself with your data; (2) generating initial codes; (3) searching for themes; (4) reviewing themes; (5) defining and naming themes; (6) producing the report. the recorded interviews were transcribed verbatim. once transcribed, the interviews were imported to the maxqda 12 program for its posterior analysis. a.j.r.-m., m.r.-m., c.l.-c. and j.e.m.-g. coded the data. the transcriptions, coding and themes-subthemes were discussed by the research team for their verification. finally, participants provided feedback on the findings. the study was reported according to the consolidated criteria for reporting qualitative research (coreq) [15] . this research study was approved by the research ethics commission from the university of murcia (id: 2800/2020). all the participants received an informational electronic document about the purpose and research process, which they later kept. they were advised that their participation was voluntary. they could ask and reflect prior to the interview. each participant was given a code to maintain anonymity. a total of 32 interviews were conducted, and they lasted between 17 and 51 min. the shortest interviews corresponded to the more advanced academic years (3rd and 4th year students). of these participants, 75% were women and 25% men. the age of the participants oscillated between 18-50 years old, with an average age of 25.3, and with a participation rate of 69% for the students from the university of murcia, and 21.8% for the university of granada students. the sample was composed by 18.75% of the students enrolled in their 1st or 2nd academic year or in the master's program, which accounted for about 57% of the sample, and 21.8% from the 3rd and 4th academic years, for a total of about 43%. of those interviewed, 21.8% had children and 21.8% lived in a rural setting. some of the characteristics of the participants are found in table 1 . six major themes were defined: (1) practicing the nursing care; (2) uncertainty; (3) time; (4) teaching methodologies; (5) the context of confinement and the added difficulties; (6) face-to-face education win. a detailed description of the themes and sub-themes can be found in table 2 . the outstandingly practical component of care in nursing education was the most emotional aspect for the students. the experiences found were differentiated according to the group of students, depending if they had or not practice-based subjects during the education period affected by the state of alarm, the proximity to ending their training as nurses, or if they were health professionals who were conducting post-graduate studies. for 1st and 2nd year students, the learning is normally done with courses that are eminently theoretical or theory/practical. the informants indicated that this transitory e-learning will not have a special influence on their training, as long as all the clinical training on health care institutions is present: "in think that it's not something that will affect us excessively for good or bad. in my year [1st] . in other years it will, because they have clinical training" p5 by contrast, 3rd and 4th year students whose coursework is mainly based on clinical training in health care institutions placed value on clinical training. they linked it with the acquisition of competences and referred to it as being an essential part of health sciences degrees: "my education would not be good if clinical training was missing" p15; "without the clinical training, we can't acquire competences" p19; "especially in our degree, the clinical training . . . " p21 clinical training provides them with security in the learning of nursing care in health care services. part of the students in their last year (4th year) indicated that they would rather not graduate in july to do all the clinical training, therefore graduating later: "i don't feel prepared. my erasmus in italy was really bad because i was a nursing student and a foreigner. at the hospital, i don't feel confident" p10; "some of us prefer not to graduate in june and to do the clinical training" p14 the master's students indicated that not being able to do the clinical training implied the loss of job opportunities: "if you cannot do the clinical training, you will lose job opportunities" p22 all the participants expressed their wish to help during the pandemic. they expressed their desire to be nurses to help. at the university of granada, a list of volunteers in their 4th year was even created. the expectation was present that the government could mobilize them in case of need. independently of the academic year, for all the students, this crisis re-enforced their wishes to become nurses: "i wish i already had my degree" p17; "i wish to be a nurse already, too bad i wasn't in 4th year so i could go" p16; "if this happens in the future, i would like to be helping" p25; "i feel like left out, i can't be in the battlefield helping" p21; "now i really feel like being a nurse. it is a shame that we cannot help. in granada there is a list of volunteers. i really feel like helping" p14 master's students who work feel satisfied to be able to help (aside from being satisfied because they can work): "i feel very well with myself because i can help, even though is very difficult . . . " p23; "i really feel like being in the middle of it and help. i've seen that help is really needed, it is very important work, although not very much appreciated." p24 the lack of concretion about the different aspects related with their studies is mentioned by all the interviewees. this uncertainty is accompanied by unpleasant situations due to the possible outcomes. they are mainly related with matters that could not be resolved relatively fast, such as the clinical practice and the adaptation of evaluation processes: "we don't know how they are going to evaluate us. they will for sure evaluate what we have done in the last month of clinical practices" p6; "we don't know what's going to happen. i hope they don't give a general pass. i want to take the exams and the other things. i don't want them to evaluate me with just one work submitted" p5; "not knowing how things will be done. not getting the grades i want to get because of these circumstances" p16 this is especially important for the 4th-year students, who reported a great feeling of wasting time. they cannot go to the clinical practices and they only have, as well, one subject: the final project (tfg). one of the alternatives to not waste time completely and that is being done by the participants is to prepare for the access exam for clinical nurse specialist training (national post-graduate residency program, eir). some of the participants indicated that preparing for the eir exam was a means of escape from a situation of wasting time and total paralysis: "it takes my motivation away, and (finishing my degree) is getting really hard, because i don't see the end of it" p10; "i am not taking advantage of the time" p3; "i'm preparing for the eir exam at the academy as a means of escape. with the only the tfg . . . i need something else. right now all my time is tfg and the subjects from the eir" p4 the 3rd-year students find themselves in the same situation but without any subjects: "the 3rd years clinical training has been abandoned. they don't know if we are going to recover them" p6 the masters' students have a different point of view. the differences are many. the masters' degree can provide job opportunities, the change from traditional education to e-learning practically affects an entire trimester (half of the master's program), and in their discourse, they have fewer demands and less pressure for obtaining the degree. at the same time, they are the only ones who speak about the teaching guidelines, indicating that they are truly being followed. in comparison, only one bachelor's degree student referred to the teaching guidelines: "if the clinical training cannot be done, you miss job opportunities" p22; "i don't know how the teaching guidelines have changed" p16; "the clinical training have been postponed until september, and it bothers me some because it interferes with the summer contract for working as a nurse" p24 time is a determinant transversal aspect. two differentiated phases are observed as the state of alarm moved forward (1st shock and 2nd normalization). besides, participants reflected regarding a necessary time management and the influence in the future. two well-differentiated phases are distinguished in the timeline. on the first days, the shock phase appears (1st phase), within which we find "disorientation". this first phase lasts between 7-10 days. during this first week, it is observed that mental performance decreases, along with the ability to concentrate. this is a subtle expectant phase, where the situations are not well defined: "you think that the first week is for you, for resting, you take care of unfinished business and uncertainty increases" p11; "the first week was not assimilated, i didn't have routines" p19; "during the first week, i had less concentration and studies less" p5; "the timetable is different, it's more chaotic" p21 after the first phase, the students enter a normalization phase (2nd phase) in which they acquire new routines, attend online classes and seminars. the conditions of confinement start to be assimilated and the new everyday life is normalized: "now i do more things than before, i take more notes. it is very different from the first week, now it is easier" p25; "now i have the habits. before i didn't do anything, and now i do everything, it is as if i'm getting used to it" p28 the first phase, as well as the second phase also coincide with the period in which the university ensured that the online tools were fully functioning and instructions were given to the professors about how to continue with their teaching tasks: "only 2 out of 5 teachers give online classes, the rest upload presentations that we have to understand" p13; "the teachers do not agree with each other. one says one thing and another something else" p6 the 1st and 2nd year students, as well as the masters' students, have classes. this forces them to manage their time differently. the 1st and 2nd year students interviewed indicated that time management was necessary. they indicated that this was beneficial for having good "mental health", and that having due dates helped them with managing their time: "having self-discipline and a timetable. not rigid, but saying that the mornings were for university and the afternoons for watching t.v. series or exercising. if you don't organize your time, work accumulates" p20; "my planning is monday to friday mornings for work, and the afternoon for group work or leisure. i rest on the weekends. having due dates has helped me organize" p13; "the homework is good, because they help with following the course" p11 all of the participants, except for the ones who worked, indicated that they had changed their sleep schedule and go to bed much later, between 1:30 and 3 a.m. the main reason mentioned was that the lack of activity did not make them tired, although this argument was ambivalent, as they went to bed later and got up later as well, so they slept the same number of hours: "it takes me longer to fall sleep. i'm not tired because i don't do anything during the day" p11; "i go to bed later and i get up later. i go to bed at 2-2:30 a.m. and i get up at 10" p5; "i fall sleep very late. at 2:00 a.m. the hours have changed, you sleep when you shouldn't" p19 the participants indicate that this situation affects their future plans and expectations related with obtaining their degree and work. they believe that they can be singled out for being the promotion with missing education, their international training is paralyzed, and they are afraid. their professional expectations are also affected: "i'm afraid of having bad training and that the work exchange says that this year's promotion from the university of granada do not have the competences necessary" p6; "the plans for earning money to go to an erasmus program are cancelled . . . " p13; "the practices have been postponed to september, and yes, it bothers me because it interferes with the summer contract for working as a nurse" p24 the participants indicate that as for the teachers, different teaching methodologies are being utilized: real-time videoconferences (including chats), lessons recorded on video and uploaded to the e-learning platform, audio podcast, chat (exclusively), homework and uploading of documents (word, ppt, pdf). they also mention that as time goes on, the teacher's adaptation to the online resources continuously improve. it is without a doubt the best evaluated. this is because they think it is the most similar to a traditional class (face-to-face), and allow interaction with the professor, and provides them with nearness. another aspect they indicate as being valuable is that this methodology helps with the teacher's explanation of the subject that is more comprehensible as compared to other methodologies. the interaction is also valued, as it allows them to say that something has not been understood and that it should be explained in another way. lastly, they would like all the videoconferences to be recorded so they could be watched again whenever needed. this last aspect was pointed out by the students who were also working: "the interaction in the videoconferences is not the same, because the questions are written and it is not the same to write something than when you talk" p26; "the videoconference is where we receive feedback. you can say that you don't understand something and if it could be explained once again" p16; "it is a way to stay in touch. doubts emerge and the teacher can resolve them" p7 the master's students indicate that on some occasions, the duration of the videoconference classes is excessive. it is interesting to highlight that the bachelor's students did not state this at any time: "we've had videoconferences that lasted 5 h. this can be done better. we had one who did a good summary and it lasted 2 h. this is more relaxing, and then you broaden the knowledge with the documents provided" p24 despite the value of the videoconferences, the discourse is ambivalent, as negative aspects are identified, especially related with the quality of interaction with the professor. the traditional classwork contributes fundamental elements in the quality of communication, and this how it is felt by the participants. "it is worse. when the teacher sees you asking about a doubt, she/he knows where you are coming from. this is lost with e-learning. information is lost and the student does not obtain the same information as in the face-to-face class. the teacher doesn't see your face." p24; "i'm much more in favor of traditional classes. i always obtain more information in them and i'm more comfortable." p24 except for the recorded lessons, the rest of the methodologies are catalogued as sub-standard. the chats (exclusively) and the homework are not attractive, although they value them as positive aspects because it lets them stay connected with the subject and the university: "the worse thing is when they only upload class notes, no one forces you to read them" p25; "in the homework, there are questions because they are not easy to understand, with the explanation it is easy, but when you are going to do it, it is more difficult" p25 among the limitations, they point out that in some asynchronous methodologies and with a rigid format, limited learning is obtained, interaction is needed for explanation, and a certain amount of pressure is needed. another limitation is the lack of feedback with the homework: "we are going to learn the minimum, but not all, because they don't explain it to you, they don't explain it in different ways. the text [from the documents] is only written in one way . . . " p7; "the works that don't have feedback give you half the knowledge" p13; "if you only upload notes, no one is forcing you to read them. it is very easy to fall into laziness when they only upload notes" p25 a limitation of e-learning that was pointed out by all the participants was that everything that was practice-related could not be learned. they identified this as a great limitation, and point out that in nursing, practice was vital: "many things are not understood through the computer. for example, the basic care laboratories have to be observed and practiced" p7; "the practical things not, but the theoretical yes. they can make a video, but it's not the same. they can tell us how to give a bath on a bed, but if you don't do it . . . " p5; "it is impossible to learn the practical part. until you are not in that role, it is impossible to learn" p24 the students are not able to propose other methodologies that are distinct from the ones offered. two students pointed out that it could be completed with gamification (kahoot): "gamification would be good, for example when calculating the dose" p19 within the methodologies, it was found that the least complex, for example, providing word, ppt or pdf documents, were related to the older teachers. the videoconferences and recorded classes were given by younger teachers in general. at the same time, they indicated that teachers from other non-nursing departments utilized the least complex methodologies: "it depends on the difficulty of the course. physiology has only uploaded documents" p16; for example, pharmacology is a very dense and complicated subject, and you need someone to explain it to you, and until now, we have not received anything, only notes. i don't think it's enough, they are too schematic and hard to understand". p1; "the younger ones (teachers) feel like doing more things" p19; "it is more difficult for some teacher, especially those who are older" p5 they pointed out that it is good in the videoconferences. an inconvenience is that sometimes the teacher is not aware of the doubts posted on the chat if there are too many messages. in the chat, the interaction is good, but the interruptions, even though they may be short, makes it impossible to follow it. lastly, the students are surprised about how fast the teachers answers the e-mails: "the chat, if you miss 5 min, you get lost" p22; "there is a good reception by the teacher for communicating" p11; "[tutoring} they are good, the answer sooner. they have improved" p21 the context of confinement has created some limitations for following e-learning education. these are related with internet access, access to electronic devices, and work and family responsibilities. in rural environments, situations exist where internet access is lacking, which creates problems with being up to date with the classes. another problem indicated is that not all had internet at home, and situations exist in which a person only has the limited amount of data available from a smartphone: "some people do not have all the means" p25; "i don't have internet at home, i only have data from the smartphone" p27 "i live here in the countryside, and the internet does not always work well, and if my kids are connected, then i can't do anything" p17 the confinement has obliged working from home whenever possible. this implies that it is possible for a family with three children to need an internet connection at the same time and the availability of five electronic devices simultaneously to be able to work and follow the classes. this availability is not very common. another limitation that was pointed out was working in the presence of children/siblings at home: "with the children at home, things cannot be done [mothers]" p25; "studying at home when the entire family is at home, it is very hard to concentrate sometimes, they make noise, i can't print, etc." p25 part of the students pointed out that is inconvenient, as they are used to studying in public libraries and have had to study at home: "i always study at the library, not at home" p19; "i used to go to the library to study or do homework. no one bothers me there. at home, i set the washer, put on my pajamas and go to sleep" p28 another difficulty added by the confinement is that one is not "trained" for shifting to e-learning. one has experience with an education system that has never been 100% online and where the traditional class is the learning stage. with respect to online exams, they do not feel secure either: "we are used to traditional classes. this has been difficult for everyone, and more for the bachelor students than the masters ones" p23; "i supposed they will give multiple-choice exams in a short time. it is the first time it will be online and one could be tense" p13; "if i hear it from the teacher beforehand, i understand it better, and now it's different. you take notes and then you have to understand them . . . " p16 3.6. face-to-face win 3.6.1. face-to-face is better . . . for everything the participants clearly preferred face-to-face to e-learning education. when faced with the possibility that some percentage of online classes will be provided along with traditional classes in future academic years, they do not think it is an option that will contribute much or needed. an exception is provided by students who have family or work responsibilities, who, exclusively for the theoretical classes, prefer them to be online and recorded, in order to be able to watch them at any time. another aspect that was underlined was that the traditional system of education is the one they know and are used to, and changing it is difficult: "face-to-face is better . . . for everything" p17; "the university of murcia is traditional, and we come from the same type of learning. it takes some time to adapt" p22; "face-to-face is better in every aspect. for example, you learn the lesson and the teacher can provide examples, it can go further than the powerpoint presentation. it is better to be face-to-face with the professor than through a screen" p23 the older students seem to be the most vulnerable group, and various problems are observed. on the one hand, they have to tend to their children now that they are all at home, they have more responsibilities at home, plus certain digital competences that they have yet to incorporate. the management of their time is a great problem, which is influenced by the use of time, space and the electronic devices by the rest of the family, to which they grant them priority without being aware: "for me the chat is not good, because i can't write that fast. i see the limitation in me. i miss the traditional classes. face-to-face classes are better . . . for everything" p17; "you have to be very alert with the online classroom, that you do not ignore the messages. yesterday there was a class, and did not know" p9; "some classmates are much older, and this is difficult. they write to the group [whatsapp] sending pictures, and asking "what do i do? where should i click?"" p25; "i'm much more in favor of face-to-face classes. i always obtain more information in them and i'm more comfortable" p24 it is necessary to underline that all the results and discussion are centered on the first month of confinement after the start of the state of alarm, and this brings with it very specific cognitive and social states that are needed for the proper understanding of the discussion of the present research study. although the sample included a greater number of students from the university of murcia as compared to those from the university of granada, and different percentages of men and women of different ages, we believe that the main sociodemographic variables were well represented through the use of maximum variation sampling. the nurses usually become nurses due to their desire to help other people to recover and maintain optimal health, and here we find ourselves in a situation in which not many options are available to help those who are severely sick due to covid-19 [5] . vocation is a determinant factor for those who decided to study nursing, and the main drive is the opportunity to care for others [17] . our results support these two ideas in two ways: (1) they indicate that this attitude towards their professional life is still true in the new generations, with the remarkable fact that all the participants are so committed and wishing to help. (2) the pandemic has positively re-enforced their wishes to become nurses, obtaining similar results as other authors [18] . although, the state of alarm decree includes the possible mobilization of students in their last year at university, their mobilization was principally needed in a small scale in madrid and catalonia, the areas greatly affected by covid-19 [19] . the fast shift to e-learning education has not ceased to be a continuation of teaching and education through online resources, although it has not been clearly planned and adapted for e-learning [10] . our results clearly present various relevant ideas related to this. in first place, and related with the clinical training, the health science degrees and more specifically the nursing degree have an essential need to be developed in clinical context. this element clearly cannot be substituted, and is perceived by all the students as being essential. nevertheless, at present, a discussion exists about how high-fidelity clinical simulation could substitute the clinical training in real-world environments [20, 21] . this methodology, which facilitates an intermediate learning between the theoretical dimension and the practical dimension, is proposed, aspiring to construct a real environment. however, and despite it being a type of learning established and known by the student body at the university of murcia as well as the granada, it is striking that this type of learning has not been described as an alternative. we interpret this finding as the clinical training being indispensable for the students. also, it forces us to reflect if this is the new reality of health care, and if the future nursing professionals should learn how to navigate in these conditions. the debate regarding the return of the nursing students to clinical environments is open and some recommendation has been provided [22] . the question now for the universities and nursing educators is that if as soon as the resources are provided and an adequate organization and adaptation occurs, the students should return to the health care services, what is the balance between the potential risk for the students and the importance of the clinical training? in second place, and related with the teaching of theory, the students prefer face-to-face teaching as opposed to the e-learning. they believe that the interaction is higher in quality and learning is greater. at present, another debate is open, as shown by two systematic reviews that do not provide concluding results on the existence of the greater learning linked to e-learning education of health professionals and students, highlighting the poor quality of existing studies and the importance of contextual factors [23, 24] . perhaps due to these reasons, the videoconference, distance learning, but synchronous and bi-directional, is the best assessed. another critical aspect is that the change to the online methodology was not chosen by the students, and the expectations they have with respect to their studies have been clearly disrupted. their entire academic life has been marked by a specific style of teaching, and they have become organized to continue with it, but the pandemic has imposed a different one with which they do not feel comfortable yet, thereby creating uncertainty and little security. this worries a great part of the health science academics [25] . it therefore absolutely necessary to start to work on the adaptation to e-learning that takes into account the previously-mentioned aspects so that the student's uncertainty decreases, especially in light of the evaluations. academics have already expressed awareness of the students' concerns that are centered on their future degree and career progression [25] . the university counted with a technological infrastructure that has been able to deal with a drastic and fast change to distance teaching. however, the urgency of adapting this type of teaching has highlighted some situations of disadvantage. thus, the older students, as compared to the younger ones, and in great part women and mothers, do not possess the most basic digital competences. this finding is robust, as the older students themselves, as well as the younger ones, are able to point this out in agreement with each other. they also point out that there is a small percentage of students who do not have the electronic resources or a connection to the internet necessary for adequately following the teaching. universities are trying to provide answers to some of these problems. it could be said that the phases of shock and normalization described by the students coincided with the period of reaction and acts of implementation by the institutions. there are activities that allow for fast implementation. for example, the universities of murcia and granada freely loaned laptop computers with software to 100% of the students who requested them [26] , with this number being more than 300 students in murcia alone, as well as mobile internet-access devices [27] . however, the implementation of activities related with the evaluation has required conscientious reflection and consensus that has forced their implementation later in time [11] . in any case, once this first stage has been overcome, and faced with the absence of permanent solutions for this pandemic in the short term, it is necessary to propose distance learning strategies with a robust design, with the time necessary to create study plans that are well thought-out and durable [10, 28] . we should be aware that we are currently undergoing an "emergency" education, a temporary shift of instructional delivery to an alternate delivery mode due to crisis circumstances [29] . the reality is that this transition to e-learning under these circumstances has nothing to do with a design that takes the maximum advantage and possibilities of the online format. we should reflect on the differences in the rhythm, the student-instructor relationship, pedagogy, the role of the instructor, the role of the student, the synchronicity of online communication, the role of online evaluations, and the source of feedback [30] . among the limitations of the study, we find that a thorough discussion and comparison with the opinions of other authors has not been possible, given the novel and exceptional situation we are currently living in. on the other hand, we should be aware that the sample studied cannot be representative of the reference population, and this can evidently affect the generalization of the results. after the first week of adaptation to the conditions of confinement and the establishment of new online teaching systems, the students begin a new normality. the imposition of e-learning brings more limitations to students who are older, with work and family responsibilities, living in a rural environment and with limited electronic resources. online teaching has allowed substituting the teaching of theory, although face-to-face teaching is preferred, at the same time it has shown that clinical practices are indispensable for the training of the nursing students. online education goes beyond the online continuation of the classes. the parties responsible should already be working on this for the next academic year, in light of the uncertain future of a short-term control of covid-19. acknowledgments: our most sincere thanks to the people who agreed to participate in this research. the authors declare no conflict of interest. 4th year students -aa1 what is going to happen? -aa2 what are you afraid of? -aa3 what do you think will happen with the practice? -aa4 what do you think will happen to your degree? -aa5 if you miss a practicum how good is your training? life expectancy -how does the situation caused by the crisis in the professional field affect your desire to become a nurse? world health organization. who director-general's opening remarks at the media briefing on covid-19-11 covid-19 and italy: what next? italian public health response to the covid-19 pandemic: case report from the field, insights and challenges for the department of prevention public health emergency and crisis management: case study of sars-cov-2 outbreak life in the pandemic: some reflections on nursing in the context of covid-19 covid-19: a potential public health problem for homeless populations impact of the burden of covid-19 in italy: results of disability-adjusted life years (dalys) and productivity loss unesco & iesalc covid-19 and higher education: today and tomorrow teaching in times of pandemic nursing education after covid-19: same or different? using thematic analysis in psychology qualitative evaluation and research methods the significance of saturation consolidated criteria for reporting qualitative research (coreq): a 32-item checklist for interviews and focus groups thematic analysis of qualitative data: amee guide no. 131 why did i become a nurse? personality traits and reasons for entering nursing covid-19 and student nurses: a view from england nursing students are already risking their lives against covid-19 with precarious contracts [las estudiantes de enfermería ya se juegan la vida contra el covid-19 con contratos precarios suzie) emerging evidence toward a 2:1 clinical to simulation ratio: a study comparing the traditional clinical and simulation settings simulation in nursing education: current regulations and practices pre-registration undergraduate nurses and the covid-19 pandemic: students or workers? efficacy of adaptive e-learning for health professionals and students: a systematic review and meta-analysis conventional vs. e-learning in nursing education: a systematic review and meta-analysis forced disruption of anatomy education in australia and new zealand: an acute response to the covid-19 pandemic university of granada 1,000 internet connection lines for students who have difficulty connecting líneas de conexión a internet para los estudiantes con dificultades para conectarse what value nursing knowledge in a time of crisis? the difference between emergency remote teaching and online learning what research tells us about whether, when and how key: cord-326643-obfvi3ms authors: lo giudice, roberto title: the severe acute respiratory syndrome coronavirus-2 (sars cov-2) in dentistry. management of biological risk in dental practice date: 2020-04-28 journal: int j environ res public health doi: 10.3390/ijerph17093067 sha: doc_id: 326643 cord_uid: obfvi3ms the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is a novel coronavirus first identified in wuhan, china, and the etiological agent of coronavirus disease-2019 (covid-19). this infection spreads mainly through direct contact with flügge micro droplets or core droplets that remain suspended as aerosol. moreover, it has been reported that infected subjects, both with and without clinical signs of covid-19, can transmit the virus. since the infection typically enters through mouth, nose, and eyes, dentistry is one of the medical practices at highest risk of infection due to the frequent production of aerosol and the constant presence of saliva. the world health organization (who) has suggested that only emergency/urgent procedures should be performed during the coronavirus outbreak. considering the virus’ route of transmission, a specific protocol should be applied to reduce the risk of infection in addition to measures that prevent the spread of infection from a patient to another person or medical tools and equipment (cross-infection). this protocol should be implemented by modifying both patient management and clinical practice, introducing particular devices and organizational practices. this paper aims to discuss and suggest the most appropriate procedures in every aspect of dental practice to reduce infection risk. the severe air respiratory syndrome (sars) coronavirus 2 (sars-cov-2) is a single-stranded rna virus (+ssrna) of 60-140 nm, belonging to the β-coronavirus genus (subgenus sarbecovirus, orthocoronavirinae subfamily), and the etiological agent of coronavirus disease-2019 (covid-19). the virus has a crown-like appearance due to the presence of spike glycoproteins on the envelope, and is considerably different genetically from sars-cov and mers-cov [1, 2] . the outbreak of sars-cov-2 was first reported on 12 december 2019 in wuhan, china, possibly related to a seafood market [2] . based on data retrieved from the world health organization (who), at the date of the present article (22 april 2020), there are 2,471,136 confirmed cases, with 169,006 deaths, and the virus is present in 213 countries, areas, or territories [3] . the median age of patients is 47-59 years and 41.9%-45.7% of patients are female [2] . due to the widespread and rapid growth of infection, who declared that the global outbreak of the new coronavirus infection sars-cov-2 can be considered a pandemic [3] . genetic and epidemiologic research shows that the covid-19 outbreak likely started through animal-to-human transmission, followed by human-to-human diffusion [2] . the coronavirus exploits angiotensin-converting enzyme 2 receptor (ace2), which is found in the lower respiratory tract. this is similar to the route of infection in humans for sars-cov, which mainly spreads through the respiratory tract [2] . the virus is transmitted through flügge micro droplets (droplets) and core droplets (aerosol) [1] . diffusion mainly occurs through coughing, sneezing, and saliva. the distance and length of time that particles remain suspended in the air is determined by particle size, settling velocity, relative humidity, and air flow [1] . flügge droplets that are >5 µm in diameter can spread up to 1 m. the nuclei of the droplets which have a diameter <5 µm, create an aerosol which has a diffusion capacity greater than 1 m (figure 1 ) [4] . genetic and epidemiologic research shows that the covid-19 outbreak likely started through animal-to-human transmission, followed by human-to-human diffusion [2] . the coronavirus exploits angiotensin-converting enzyme 2 receptor (ace2), which is found in the lower respiratory tract. this is similar to the route of infection in humans for sars-cov, which mainly spreads through the respiratory tract [2] . the virus is transmitted through flügge micro droplets (droplets) and core droplets (aerosol) [1] . diffusion mainly occurs through coughing, sneezing, and saliva. the distance and length of time that particles remain suspended in the air is determined by particle size, settling velocity, relative humidity, and air flow [1] . flügge droplets that are >5 µm in diameter can spread up to 1 m. the nuclei of the droplets which have a diameter <5 µm, create an aerosol which has a diffusion capacity greater than 1 m (figure 1 ) [4] . infection entry points are the mouth, nose, and eyes. in rare cases, the virus can be transmitted by the oro-fecal route [1, 4] . the propagation of infected droplets occurs through contact with infected subjects, with or without clinical signs of covid-19. many observations have reported that even asymptomatic patients in the incubation phase or healthy carriers can transmit the virus [5, 6] . infection can occur as a result of close direct interpersonal proximity (distance less than 2 m and duration greater than 15 min. or following contact with hands which have come into contact with contaminated surfaces or airborne particles [4] . sars-cov-2 could present an asymptomatic incubation period for infected individuals that varies from 5 or 6 to 14 days. backer has reported that virus identification in human respiratory epithelial cells could be positive about 96 h from exposure and 24−48 h before the onset of symptoms [7, 8] . the most frequent symptoms are: body temperatures >37.4 °c, dry cough, dyspnea, asthenia, muscle pain, headache, sore throat, diarrhea, and vomiting [9] . in relation to the symptoms, the disease can be classified as follows [10] . mild form: mild symptoms, no signs of pneumonia are observed at radiology. moderate form: body temperature >37.4 °c, respiratory symptoms, signs of pneumonia are observed with radiology. severe and very severe form: usually occurs seven days after the infection. dyspnea and/or hypoxemia may occur in patients with severe forms of the disease, with rapid progression to acute infection entry points are the mouth, nose, and eyes. in rare cases, the virus can be transmitted by the oro-fecal route [1, 4] . the propagation of infected droplets occurs through contact with infected subjects, with or without clinical signs of covid-19. many observations have reported that even asymptomatic patients in the incubation phase or healthy carriers can transmit the virus [5, 6] . infection can occur as a result of close direct interpersonal proximity (distance less than 2 m and duration greater than 15 min. or following contact with hands which have come into contact with contaminated surfaces or airborne particles [4] . sars-cov-2 could present an asymptomatic incubation period for infected individuals that varies from 5 or 6 to 14 days. backer has reported that virus identification in human respiratory epithelial cells could be positive about 96 h from exposure and 24−48 h before the onset of symptoms [7, 8] . the most frequent symptoms are: body temperatures >37.4 • c, dry cough, dyspnea, asthenia, muscle pain, headache, sore throat, diarrhea, and vomiting [9] . in relation to the symptoms, the disease can be classified as follows [10] . mild form: mild symptoms, no signs of pneumonia are observed at radiology. moderate form: body temperature >37.4 • c, respiratory symptoms, signs of pneumonia are observed with radiology. severe and very severe form: usually occurs seven days after the infection. dyspnea and/or hypoxemia may occur in patients with severe forms of the disease, with rapid progression to acute respiratory distress syndrome (ards), septic shock, and acidosis. in critical/very severe patients, severe metabolic alterations, coagulation deficiency, and multiple organ failure can occur. the rise in body temperature in these patients may be mild or absent. the symptoms of the mild form of covid-19 are nonspecific. differential diagnosis should be made using a wide range of infectious (e.g., adenovirus, influenza, human metapneumovirus (hmpv), parainfluenza, respiratory syncytial virus (rsv), rhinovirus (common cold)) and non-infectious (e.g., vasculitis, dermatomyositis, organized cryptogenetic pneumonia) common respiratory disorders. rapid antigen detection in the nasal and throat cavity or other respiratory tracts is currently the best clinical diagnosis method of covid-19. this method and other investigations should be performed to differentiate covid-19 from common respiratory pathogens and other non-infectious conditions [2, 11] . scientific knowledge on its clinical evolution is constantly being updated. biological risk is an intrinsic threat in dental practice, to which patients, doctors, assistants, hygienists, and all other staff may be exposed. medical activities carried out in dental practice must always refer to procedures for the assessment and prevention of risks posed by the potential transmission of an infectious biological agent. however, the procedures adopted routinely to date have not been specifically designed for the prevention of pathogens transmissible by aerosol. therefore, there are currently no specific guidelines for the protection of dentists against sars-cov-2 [3] . due to the transmission route, in addition to measures that prevent diffusion of the infection from a patient to another person or medical tools and equipment (cross-infection), it is advisable to add further airborne and contact precautions to the routine standard hygienic procedures in order to reduce the risk of sars-cov-2 transmission. in a dental practice, the prevention, control, and reduction of infection transmission risk commonly takes place through: the use of personal protective equipment (ppe) such as gloves, masks, visors, goggles, dental uniform, and surgical gown and shoes (see section on ppes below). • a set of decontamination, disinfection, and sterilization procedures aimed at inactivating, destroying, or removing pathogens from any surface or instruments [12] . prevention of sars-cov-2 infection must consider its spread through air and the size of droplets (<5 µm or >5 µm). the disease prevention measures should also take into account the potential ability of the virus to contaminate surfaces [4] . although certain data are not available, the who reports that virus persistence on surfaces can vary from a few hours to a few days in relation to environmental parameters and the contaminated surface [13] . an environment with low relative humidity is reported to decrease the persistence of sars-cov-2 [13] . the sars-cov-2 virus is sensitive to ultraviolet rays and heat, and can be inactivated at a temperature of 56 • c for 30 min, as well as by lipid solvents such as ether, 75% ethanol, and disinfectants containing chlorine, peracetic acid, and chloroform. it is not sensitive to chlorhexidine [13] . the aim of this article is to focus on hygienic procedures within the dental practice during a coronavirus pandemic. to reduce the risk of sars-cov-2 infection, given how the disease spreads and the current health crisis, the following prevention measures are suggested in addition to what is already generally performed: • inform patients of the procedures for accessing the dental office. inform the patient that a telephone triage will be administered and any suspicious case will be reported to competent health authorities for further investigation. carry out a preliminary telephone triage upon patient access to the office in order to assess whether: 1. the patient who is entering the office has symptoms of sars-cov-2 infection; 2. has come into contact with potentially infected people; 3. has been in areas with high risk of infection ( figure 2 ). to reduce the risk of sars-cov-2 infection, given how the disease spreads and the current health crisis, the following prevention measures are suggested in addition to what is already generally performed: • inform patients of the procedures for accessing the dental office. • inform the patient that a telephone triage will be administered and any suspicious case will be reported to competent health authorities for further investigation. • carry out a preliminary telephone triage upon patient access to the office in order to assess whether: 1. the patient who is entering the office has symptoms of sars-cov-2 infection; 2. has come into contact with potentially infected people; 3. has been in areas with high risk of infection ( figure 2 ). in the event of a positive response, do not schedule appointments. instead, inform the patient of the possible risk of being infected, the personal hygienic measures they need to follow, and that they will be reported to the competent health authorities for further investigations. • only schedule an appointment in the dental office if the patient cannot be deferred or in urgent cases and according to the equipment and disposable materials available. • assess the actual need for dental intervention before planning visits of the most vulnerable subjects (elderly or patients with respiratory, cardiovascular, or immune system diseases, etc.). where appropriate, postpone visits [14] . • avoid crowding by spreading appointments over time, maintaining distance in the waiting room and/or in the operating rooms (minimum safety distance of 2 m with a stay of less than 15 min) [4] . • arrange entry into the operating rooms of individual patients and a single companion for minors, without overcoats, electronic devices, and bags, which must be left in the waiting room. in the event that personal effects should enter the operating rooms, these objects must be placed in special sealed bags. • ensure that hand sanitizer is available to patients and companions, possibly at the entrance of the practice or anywhere before entering the operating rooms. • in the patient's medical history, record the results of the telephone triage regarding the presence of suspicious and actual symptoms, potential contact with people who have been to risk areas, and the patient's own transit/permanence in risk areas (figure 2 ). • remind the patient that, in case of necessity, it is mandatory to cough by covering their mouth and nose, possibly with a tissue. the tissue must be disposed of immediately in a special waste container. following this, they must proceed to wash and disinfect hands. in the event of a positive response, do not schedule appointments. instead, inform the patient of the possible risk of being infected, the personal hygienic measures they need to follow, and that they will be reported to the competent health authorities for further investigations. only schedule an appointment in the dental office if the patient cannot be deferred or in urgent cases and according to the equipment and disposable materials available. assess the actual need for dental intervention before planning visits of the most vulnerable subjects (elderly or patients with respiratory, cardiovascular, or immune system diseases, etc.). where appropriate, postpone visits [14] . avoid crowding by spreading appointments over time, maintaining distance in the waiting room and/or in the operating rooms (minimum safety distance of 2 m with a stay of less than 15 min) [4] . arrange entry into the operating rooms of individual patients and a single companion for minors, without overcoats, electronic devices, and bags, which must be left in the waiting room. in the event that personal effects should enter the operating rooms, these objects must be placed in special sealed bags. ensure that hand sanitizer is available to patients and companions, possibly at the entrance of the practice or anywhere before entering the operating rooms. in the patient's medical history, record the results of the telephone triage regarding the presence of suspicious and actual symptoms, potential contact with people who have been to risk areas, and the patient's own transit/permanence in risk areas ( figure 2 ). remind the patient that, in case of necessity, it is mandatory to cough by covering their mouth and nose, possibly with a tissue. the tissue must be disposed of immediately in a special waste container. following this, they must proceed to wash and disinfect hands. always allow fresh air in between one patient and another, and frequently in the waiting room. this action could be performed by opening the windows, taking care of the air influx, or using medical-grade air purifiers as recommended by the manufacturer. consider all material that comes into direct or indirect contact with the patient and all material that has been used for patient treatment or has come in contact with any biological fluid as special waste. • always allow fresh air in between one patient and another, and frequently in the waiting room. this action could be performed by opening the windows, taking care of the air influx, or using medical-grade air purifiers as recommended by the manufacturer. • consider all material that comes into direct or indirect contact with the patient and all material that has been used for patient treatment or has come in contact with any biological fluid as special waste. manage it according to the proper disposal techniques to ensure that any infectious materials cannot contaminate or spread to other areas. before performing hand hygiene procedures, it is suggested to: expose forearms (bare below the elbows); 2. remove all hand and wrist jewelry; 3. ensure fingernails are clean and short. artificial nails or nail products are not recommended; 4. cover all cuts or abrasions with a waterproof dressing. • remove potentially contaminating objects from waiting rooms and operating rooms (magazines, etc.). regularly sanitize common and operational areas, non-medical furnishings and equipment, and surfaces accessible to the public (handles, etc.). place protections on points of sale (poss), keyboards, etc. and change them after each use. a single-use protection could be a disposable barrier (plastic film or cover) that must be replaced after every use. arrange the use of respiratory protective devices (rpds) for all staff including secretarial staff (see section on ppes below). inform doctors and collaborators concerning the clinical triage for covid-19 and train them to evaluate themselves. if they have manifested symptoms of a coronavirus infection (cough, cold, diarrhea, flu symptoms, temperature >37.5 • c) in the last 14 days, they should not come into the dental office and should report themselves to the competent health authorities [9] . • suggest intensifying personal hygiene procedures at the end of the work shift. considering that each of the various dental disciplines has its operating peculiarities, it is appropriate to distinguish between particular precautions as follows. the following procedures should be adopted: protect the surfaces of all equipment and instruments with single-use disposable barriers, and dispose of the protections among the special waste after use. arrange only strictly necessary material on the surfaces of operating areas. clean the operative surfaces with hydroalcoholic disinfectants at concentrations above 60%. wear a uniform with long sleeves and shoes, and avoid exposed body parts. • wear a disposable lab coat/overcoat. it is also suggested that the patient mouth-rinse for 30 s with a 1% solution of hydrogen peroxide (1 part at 10-volume/3% hydrogen peroxide and 2 parts of water) or with 1% iodopovidone. this pre-operative treatment could lower the virus concentration in the patient's mouth [3] . give preference to extra-oral radiological examinations over intra-oral ones to avoid the stimulation of coughing or vomiting [15] . the following procedures should be adopted in addition to the ones described above: • replace and sterilize the high-and low-speed hand-pieces after each use between one patient and the next; the use of 3-way turbines and dental units equipped with valves and anti-reflux systems is recommended [8] . use rpds and protective glasses for eye protection or full visors for all medical and paramedical staff in contact with the patient. if not available, surgical masks with full visors can be used for all medical and paramedical staff in contact with the patient [3, 16] (see section on ppes below). when possible, apply a rubber dam to reduce possible aerosol production [17, 18] . wearing ppe provides a physical barrier that could prevent contact between medical and paramedical staff and the pathogen, as well as potentially infected biological material. they must be worn and replaced at the end of each operating phase and disposed of in the special waste. all protective devices must be replaced as soon as they are damaged or before loss of effectiveness. respiratory protective devices are commonly used to protect wearers from chemical, biological, and radioactive materials. these devices have been classified by the us national institute for occupational safety and health (niosh), which sorts particulate filtering face-piece respirators (ffrs) into nine categories (n95, n99, n100, p95, p99, p100, r95, r99, and r100) [19] . the european standard (en 149:2001) classifies ffrs into three classes, ffp1, ffp2, and ffp3, with minimum respective filtration efficiencies of 80%, 94%, and 99% of the particles with a dimension up to 0.6 µm. an ffp2 is comparable to a n95 ffr [20] . the various indications of how to use ffrs is related to their different capacity and quality of filtration. surgical masks (sms) can filter particles of 0.04-1.3 µm, and are commonly used to physically block particles such as droplets. their principal limitation is due to poor quality of face fit and the consequent possibility of aerosol aspiration. the use of sms protects the patient from saliva and respiratory secretion produced by healthcare workers. the ffp1 and ffp2 masks are available with or without an exhalation valve, and ffp3 masks always have a valve. the ffp2 and ffp3 masks are the most appropriate barriers against aerosol because they provide a tight seal to the facial skin. considering that the air flow is filtered in the inhalation phase, but not filtered during exhalation (which is expelled from the valve), the infection risk is moved from operator to patient. masks with exhale valves are therefore not recommended for use in dentistry as this will increase the patient's risk if the professional is infected with the virus, especially considering that the latter could be asymptomatic. • wear a surgical mask in all eventualities where there is contact between the patient and other people less than 2 m away and for more than 15 min. wear an ffp2 or ffp3 mask in procedures with a risk of aerosol droplet production. if not available, use a surgical mask with a face shield [3] . remove the mask after each aerosol risk procedure by touching only the strings. • removing the mask by touching the possibly contaminated surface. the correct procedure is as follows: after removing the gloves, put on a new pair of gloves, and remove the mask by the strings. • disposable gloves must be used in all operating phases that involve contact with potentially infected surfaces and for direct patient assistance. gloves should be inspected before use. • a double pair of gloves can serve as additional protection. • before putting on gloves, cover any cuts or damaged portions of hand skin as an additional precaution. after use, gloves should be removed using appropriate techniques to prevent hand contamination. gloves should be removed by rolling from the wrist towards the fingers to avoid contact with skin. it is necessary to remove gloves by touching only the external part ( figure 6 ). use sterile gloves for invasive procedures that require surgical asepsis. • use sterile gloves for invasive procedures that require surgical asepsis. • using the same pair of gloves for different operations and/or for different patients. • not washing hands before and after using gloves. • eyes should be protected with goggles or a full-face shield in all procedures at risk of aerosol/droplet production. • glasses, visors, or face shields can be used. • after every operation, depending on the kind of procedure, protections must be disposed of or sterilized. • only using common prescription glasses. • only using medical loupes. • removing protections after each procedure by touching the external surface. strings must be used for removal. • using the same pair of gloves for different operations and/or for different patients. not washing hands before and after using gloves. • eyes should be protected with goggles or a full-face shield in all procedures at risk of aerosol/droplet production. • glasses, visors, or face shields can be used. after every operation, depending on the kind of procedure, protections must be disposed of or sterilized. • only using common prescription glasses. • only using medical loupes. removing protections after each procedure by touching the external surface. strings must be used for removal. • always use a uniform with long sleeves and shoes. change the uniform every day. • before washing, disinfect with a chlorine solution (500 mg/l) for 30 s [18] . wear a surgical gown (over the uniform) for each procedure at risk of contamination with aerosol/droplets. • dispose of the surgical gown after each visit. remove the surgical gown before glove removal and touch it only from the outside. remove the surgical gown by folding it with the potentially contaminated external surface inside. in case of contamination, replace the dental uniform as soon as possible. • applying standard precautions when handling and replacing clothing. replacing the surgical gown after glove removal. removing the dental uniform without a new pair of gloves. remove any overcoat. remove the gloves by rolling them up from the wrist, without touching the skin. 3. wash hands. wear a new pair of gloves to avoid accidental contact. remove the protective goggles or visor and mask, taking care to touch only the strings and not the contaminated surface. 6. remove the gloves. 7. wash hands. the pandemic infection of sars-cov-2 could have a profound impact on dentistry, mainly due to the way the pathogen is passed on, which poses a danger in almost all dental procedures. the virus predominantly spreads through droplets and aerosol, requiring a revision of the cross-infection prevention protocol to include sars-cov-2 related risks [3] . especially when treating in urgent situations or emergencies during the virus pandemic [6] , clinicians should not underestimate the possibility of infection from asymptomatic patients, and all dental treatment should be considered high-risk. the dentist should always use the recommended personal protective equipment, including filtering face-piece respirators that could prevent aerosol infection and protective glasses or face shields that could prevent droplets from coming into contact with the eye mucosa. the management of patients should include a proper pre-treatment telephonic triage to screen out patients at risk of contagion and follow an appropriate schedule to avoid crowding. in this paper, the most appropriate procedures were discussed and suggested to minimize the risk of infection in every aspect of dental practice. transmission routes of 2019-ncov and controls in dental practice the origin, transmission and clinical therapies on coronavirus disease 2019 (covid-19) outbreak-an update on the status who.int. 2020. coronavirus situation report-83. available online transmission of sars and mers coronaviruses and influenza virus in healthcare settings: the possible role of dry surface contamination a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster transmission of 2019-ncov infection from an asymptomatic contact in germany incubation period of 2019 novel coronavirus (2019-ncov) infections among travellers from wuhan, china covid-19): emerging and future challenges for dental and oral medicine epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study chinese clinical guidance for covid-19 pneumonia diagnosis and treatment, 7th ed.; china national health commission features, evaluation and treatment coronavirus (covid-19) covid-19 outbreak: an overview on dentistry suggestions on the prevention of covid-19 for health care workers in department of otorhinolaryngology head and neck surgery evaluation and treatment coronavirus modern dental imaging: a review of the current technology and clinical applications in dental practice ecdc technical report infection prevention and control for covid-19 in healthcare settings march the efficacy of rubber dam isolation in reducing atmospheric bacterial contamination the prevention and control of a new coronavirus infection in department of stomatology niosh guide to the selection and use of particulate respirators certified under 42 cfr 84; national institute for occupational safety and hygiene (niosh) particle size-selective assessment of protection of european standard ffp respirators and surgical masks against particles-tested with human subjects funding: this research received no external funding. the author declares no conflict of interest. key: cord-294593-mh1uh1b3 authors: boloori, alireza; arnetz, bengt b.; viens, frederi; maiti, taps; arnetz, judith e. title: misalignment of stakeholder incentives in the opioid crisis date: 2020-10-16 journal: int j environ res public health doi: 10.3390/ijerph17207535 sha: doc_id: 294593 cord_uid: mh1uh1b3 the current opioid epidemic has killed more than 446,000 americans over the past two decades. despite the magnitude of the crisis, little is known to what degree the misalignment of incentives among stakeholders due to competing interests has contributed to the current situation. in this study, we explore evidence in the literature for the working hypothesis that misalignment rooted in the cost, quality, or access to care can be a significant contributor to the opioid epidemic. the review identified several problems that can contribute to incentive misalignment by compromising the triple aims (cost, quality, and access) in this epidemic. some of these issues include the inefficacy of conventional payment mechanisms in providing incentives for providers, practice guidelines in pain management that are not easily implementable across different medical specialties, barriers in adopting multi-modal pain management strategies, low capacity of providers/treatments to address opioid/substance use disorders, the complexity of addressing the co-occurrence of chronic pain and opioid use disorders, and patients’ non-adherence to opioid substitution treatments. in discussing these issues, we also shed light on factors that can facilitate the alignment of incentives among stakeholders to effectively address the current crisis. from 1999 to 2018, the total number of drug-related deaths in the u.s. increased from 16,849 to 67,367. among them, opioid analgesics have contributed the most, from 8048 to 46,802, a 481.54% increase [1] . this dramatic change has contributed to a substantial drop in the average life expectancy in the u.s. for consecutive years, particularly among men [2, 3] . a myriad of factors have been attributed to the opioid crisis. these include: • regulations on reimbursement policies, such as the hospital consumer assessment of healthcare providers and systems (hcahps) survey, which partially rewards healthcare systems and providers when patients score high on pain management experience of care, thus making providers more inclined towards opioid analgesics [4] ; • lack of a comprehensive multi-modal pain management strategy [5] ; • barriers in adopting treatments for opioid /substance use disorders [6] ; • efforts that have influenced downplaying the negative impacts of opioids, such as marketing by pharmaceutical companies and professional associations promoting opioids [7] or pain being declared as the fifth vital sign [8] ; • regarding the novel coronavirus 2019 (covid-19) pandemic, we note that second-order effects have been reported on the opioid crisis; e.g., an increase in rates of opioid use disorders [9] and opioid use in intensive care units during mechanical ventilation [10] . to address the opioid crisis, many remediation actions and policies have been implemented. for example, the centers for disease control and prevention (cdc) have proposed a set of guidelines for prescribing opioids for chronic pain conditions [11] , with the main focus being on avoiding such medications to the greatest possible extent. as of 1 october 2019, the centers for medicare and medicaid services (cms) removed pain management questions from the hcahps survey [12] . although the pain management measure in the survey accounts for a small portion of medicare's reimbursements/incentives paid to hospitals, it may have incentivized providers to prescribe opioid medications [4] . these actions have been part of a concerted effort to curb the prescription of opioids [13] . as reported by the national institute on drug abuse [1] , the number of deaths in the u.s. caused by prescription opioids dropped from 17,087 in 2016 to 14,975 in 2018. despite this decrease, limiting opioid prescriptions may already have had other repercussions, such as a dramatic increase in deaths from synthetic opioids (e.g., fentanyl), from 19,413 to 31,335 during the same period [1] . based on these premises, we pose that one of the main issues that contributes to the opioid crisis is the absence of a systemic perspective where (dis)incentives of various stakeholders are taken into consideration in promoting patients' health and safety. it is imperative to understand the incentive misalignment from a system perspective if we are to effectively combat the epidemic. to this end, we pursue the following objectives in this review: (1) we evaluate evidence in the extant literature surrounding factors that can potentially cause misalignment among stakeholders by compromising either cost, quality, or access to care in this epidemic and (2) identify efforts and strategies that may contribute to alleviating such misalignments. we conducted a literature review by addressing and summarizing potential sources of incentives' misalignment and their impacts on the opioid crisis [14] . in conducting this review, we searched two databases: medline (pubmed) and web of science. for our search mechanism, we identified three main categories based on the type of medication originating the epidemic, the type of problem/objective we attempt to address in this review, and the type of stakeholders involved along with some of their strategies. for these categories, we also used a series of search terms. these categories are represented as follows, respectively: • category 1: "opioid". • category 2: "alignment", "misalignment", "align", "misaligned", and "incentive". • category 3: "stakeholder", ("societal planner", "payer", "insurer", "insurance", or "coverage"), ("payment", "reimbursement", "fee-for-service", "capitation", "capitated", "pay-for-performance", "bundled payment", "accountable care", or "value-based"), ("provider", "physician", or "hospital"), "patient", ("employer" or "employment"), ("pharmaceutical" or "drug"), ("pharmacologic", "non-pharmacologic", or "nonpharmacologic"), ("barrier" or "facilitator"), and ("contingent" or "contingency"). to search key terms/words in the title, abstract, or main body of studies, we then used a combination of categories 1-3. for example, one option is the combination of "opioid", "alignment", and ("provider" or "physician" or "hospital"). the timeline for our search encompassed studies published (online) between 1 january 2000 and 31 december 2019. only studies published in english were included. of note, to account for the sheer number of references in the literature, we limit the number of databases to two, our search timeline, and the number of search terms for category 1. from a total of 5697 articles identified, our review resulted in 115 studies (see figure 1 ). among the original 5697 articles that we identified, we sequentially filtered out 4750 by screening of titles, 177 due to duplicate references in our two databases, 483 by screening of abstracts, and 184 by full article review. in reviewing the 115 studies, we noted that factors and dynamics that typically cause misalignment can be dichotomized into two stages, depending on whether or not a patient has been diagnosed with (or is in danger of) opioid/substance use disorder (oud/sud). our review identified five categories of stakeholder misalignment prior to oud onset and two sources of misalignment subsequent to oud (table 1 ). in sections 3.1 and 3.2, we separately discuss the literature for each of these prevention and intervention stages, respectively. in table 1 , we also present a summary of these studies along with types of stakeholders, sources of misalignment addressed, and number and date ranges of studies published under each topic. to this end, we note that the vast majority of papers have been published within 2010-2019 (the second half of our search timeline). in table 2 , we provide the glossary of some terms used commonly throughout the paper. an entity who plays a role in navigating a healthcare-related problem, e.g., payer, provider, patient, employer, pharmaceutical company, etc. an interest for a stakeholder, e.g., monetary (revenue), health-related (quality of life), political (implications of a proposed healthcare bill), organizational (e.g., integrity and power issues), or behavioral (e.g., psychological factors). a condition caused by competing and/or conflicting interests between two or more stakeholders resulting in either an increase in the cost of care, a reduction in the quality of care, or less access to care. alignment a condition where devising mechanisms among stakeholders can either lower the cost, improve the quality, or enhance the access to care. this is a relative notion in that a "complete" alignment may not be attainable in reality. fee-for-service a payment mechanism where a provider is separately reimbursed for every service delivered to a patient. a payment mechanism where a provider is reimbursed per patient per time period. pay-for-performance the general class of payment mechanisms where the provider(s) is reimbursed based on the quality of care delivered to patients. some examples include "bundled payment" and "accountable care". bundled payment a payment mechanism where a bundled payment is paid to a group of providers per patients per episode of care. accountable care a payment mechanism where a group of providers shares benefits/savings (upon high-quality delivery of care) or is penalized in reimbursements otherwise. managed care health insurance plans that provide care for enrollees at lowered cost. different types include health maintenance organizations, preferred provider organizations, and point of service. care fragmentation care that is delivered to a patient via multiple providers while there is little to no coordination between providers. there is evidence that outcomes such as inappropriate prescribing of opioids and diagnosed opioid misuse are more prevalent among fee-for-service (ffs) enrollees compared to patients with other health insurance plans like managed care [15, 16] . this is in part due to the fact that payment mechanisms, such as ffs and capitation, would not incentivize providers to allocate more resources (e.g., time) to properly evaluating pain conditions [17] . hence, they could prompt providers to prioritize opioid medications over non-opioid or non-pharmacologic treatments [18] [19] [20] [21] . on the other hand, incentivizing providers may not necessarily yield the most desirable outcomes. for example, incentivizing based on patient's satisfaction/experience of care might have propelled providers to opioid prescription [4, [22] [23] [24] . for other instances where considering monetary incentives for providers has resulted in mixed outcomes, see [25, 26] . the literature has raised three issues with existing guidelines for opioid prescription, particularly the cdc guidelines [11] : • providers do not have a clear idea about how to easily implement these guidelines in their practices or there exist uncertainties surrounding the impact of the recommendations on patient pain levels, particularly in the presence of comorbidities [27] . across different specialties/medical conditions, (i) there is no consensus among providers in selecting optimal treatments, and (ii) there are various perspectives on how opioids are deemed appropriate, resulting in many of the providers not aligning with the guidelines and/or significant variations among them in opioid prescription [28] [29] [30] . on a similar note, emergency departments (eds) are shown to be more aligned with the cdc guidelines than non-eds [31] . • even for the same medical condition, there is substantial variation in opioid prescription among providers. this can be a direct consequence of the issue raised under the first item in this list [32, 33] . furthermore, regarding the system structure, we note the dual drug benefit use among veterans affairs (va) and medicare part d enrollees, where about 25% of va enrollees who use opioids are reported to also obtain opioid prescription from dual sources [34, 35] . non-opioid pharmacological (e.g., acetaminophen and nonsteroidal anti-inflammatory drugs) and non-pharmacological treatments (e.g., physical therapy, chiropractic, acupuncture, relaxation techniques, etc.) are not only shown to be associated with lower rates of opioid prescription and misuse [36-39], but reported to be as effective as opioids in managing pain conditions, especially chronic conditions [40-42]. as another medium, cannabis use or legalizing it in many u.s. states has been shown to be associated with lower rates of opioid prescriptions [43-46]. however, there is also evidence that using cannabis may not completely replace opioids in addressing pain complications [47] . that said, despite patients' willingness to be engaged with alternative non-opioid treatments and healthcare organizations (e.g., va) that have already started adopting such treatments [48, 49] , there are barriers in their uptake such as high cost, poor reimbursements to providers under payment mechanisms such as ffs, lack of coverage for some treatments such as acupuncture and psychological interventions, skepticism of patients towards these treatments once they have started taking opioids, and nonadherence to these treatments in the long term among patients with chronic pain [21, [50] [51] [52] [53] . numerous efforts have been reported to reduce the prescribing of opioids and/or incidence of oud/sud. these include the implementation of prescription drug monitoring programs [54, 55] , statewide medicaid program initiatives such as coordinated care organizations [56] [57] [58] , educational outreach and academic detailing for providers [59] [60] [61] , advances in medicine/surgery that lower post-surgical dependence on narcotics [62, 63] , the fentanyl patch-for-patch program [64] , pharmacy consult intervention [65] , quality measure development and/or quality improvement [66] , using data analytics to predict the risk of overdose [67] , and schedule change of opioid analgesics [68] . other initiatives have been reported to be less successful in this regard; for example, the adoption of controlled substance laws, which are reported to not be associated with lowering the prescription of opioids or overdose incidence among disabled medicare beneficiaries [69] . in pain management, the misalignment between physicians and patients on treatment goals is reported to adversely impact pain management outcomes, mainly because patients' first objective is typically to reduce pain intensity, while providers' first priorities are to enhance functioning and diminish medication side effects [70] . it has also been reported that pain management quality may be associated with the quality of the physician-patient interaction, and this is impacted by factors like provider experience and knowledge, proper prioritization of discussing pain severity among provider's activities, and providers' past unpleasant encounters with patients [71] . when patients are at risk for or diagnosed with oud/sud, interventions center on harm reduction programs, including medication assisted treatment (mat) and opioid substitution programs-both benefiting from medications such as methadone, naltrexone, buprenorphine, and naloxone, syringe access/exchange programs, and other initiatives such as screening, brief intervention, and referral to treatment [72] [73] [74] [75] . despite their efficacy, the majority of people suffering from oud/sud lack access to treatments [76] . therefore, the literature has mainly focused on barriers and facilitators to adopting these medications. we present these studies in sections 3.2.1 and 3.2.2. induced by the healthcare system: the barriers include lack of full or proper insurance coverage (e.g., in the california medicaid program, naloxone is covered as an ffs medication, and managed care plans like capitation do not cover the drug), high costs of medications, limited number of providers/counselors resulting in a dearth of programs or long waiting lists, a low percentage of licensed physicians having a secured waiver that is required to provide mat or the majority of counties lacking a treatment-waivered physician, insufficient education among pharmacists (this can be resolved by educational materials through improved fda-approved formulations), the short-term period of opioid substitution programs, and bureaucratic requirements for program entry/enrollment [73, [77] [78] [79] [80] [81] [82] [83] [84] . induced by providers and patients: the barriers include competing time for providers' limited practice time, preventing them from allocating enough time to properly evaluate patients' risk of oud/sud, lack of interest in treating oud/sud, care fragmentation and distrust in the quality of care between pcps and specialists, stigma surrounding the use of these treatments among patients and providers, provider's stigma in dealing with oud/sud patients, being less receptive to patients' treatment preferences (magnifying the importance of shared decision-making and physician-patient interaction), and nurses having low motivation/role support in working with patients [77, 81, 82, [85] [86] [87] [88] . patients also deem transportation/mobility as a barrier in seeking treatments, especially in rural settings [88] . in addition, patients' demographic and physiological characteristics (e.g., male gender, minority race, history of opioid overdose, and hepatitis c) are shown to be associated with a higher likelihood of abrupt discontinuation of treatments [80] . expanding capacity of treatments and providers: adequate monetary incentives and reimbursement for providers, reducing regulatory burdens, providers' education, private insurance coverage, and utilizing state subsidies are reported to impact the successful recruitment of providers [89] [90] [91] . real-world instances of initiatives include the substance abuse and mental health services administration and health resources and services administration (samhsa-hrsa) joint project on expanding the use of medications in safety-net settings [92] , samhsa's addiction technology transfer center network [93] , cvs pharmacy providing naloxone without prescriptions in most states [94] , california implementing a state-wide hub-and-spoke model to improve access to oud treatments [95] , improving the rate of follow-up treatments among medicaid enrollees in pennsylvania by offering incentives to providers [96] , and the supportact expanding medicare coverage to include bundled payment for treatments [97] . by contrast, in the first three year implementation of global payment and accountable care by blue cross blue shield of massachusetts, no significant impact on using treatments was observed [98] . improving treatment adherence and program retention: to improve retention in treatment programs or increase the number of days of opioid/drug abstinence, initiatives have included contingency management and financial incentives for patients [99] [100] [101] [102] [103] [104] [105] [106] [107] (see [108] for a review). challenges associated with these initiatives include the use of monetary incentives to buy drugs [109, 110] and diversion or misuse of methadone and buprenorphine [111, 112] . goods-based incentives may lower such risks; however, they impose higher operational costs [113] . in addition, counselors may exhibit resistance towards contingency management and financial incentives, which could necessitate educational outreach and training [114] . as other initiatives have been demonstrated to yield positive outcomes, one can refer to syringe access/exchange programs [74, 115, 116] and the use of technology such as therapy observation via a mobile application [117] [118] [119] . role of employers: employment rates among drug-dependent people are far lower than average rates for the u.s. population [120] . to this end, employers are deemed effective sources for establishing reinforcement strategies for drug abstinence and treatment adherence [121] . tools, such as employment-based behavioral reinforcement and vocational problem-solving training, are reported to positively impact employment rates, opioid abstinence, and treatment adherence among opioid-dependent workers [122] [123] [124] [125] [126] . there is also evidence that employers who have educated workers and monitored opioid use among them, expanded capacity on oud/sud treatments, and limited opioid availability via modified health plans have observed little to no negative impact on their productivity levels [127] . furthermore, the roles of employers along with the government and work associations in addressing oud/sud and providing treatments for workers were discussed in [128] . this review highlights the misalignment of incentives across stakeholders as an important, but, to date, often overlooked contributor to the ongoing opioid epidemic. in this review, we identified various conditions, surrounding the roles of stakeholders, that have contributed to misaligned incentives by compromising the cost, quality, or access to care in the opioid crisis. prior to experiencing oud/sud (the prevention stage), misalignment typically occurs between: • payers, providers, and patients due to conventional payment mechanisms such as ffs and capitation, lack of proper insurance coverage for multi-modal pain management, and system structures such as dual drug benefit programs for va and medicare part d enrollees resulting in care fragmentation; • policy makers and providers due to guidelines that are not easily translatable for implementation in practice; • providers and patients due to lack of shared decision making on treatments, which is also common in the intervention stage. all of the studies characterized as prior to the development of the patient's oud/sud (prevention) and related to multi-modal pain management and initiatives for opioid prescription concerned all three potential misalignment sources, i.e., cost, quality, and access. none of the five prevention categories encompassed all of the stakeholder categories identified by our search, although the majority concerned payers, providers, and patients. after experiencing oud/sud (the intervention stage), misalignment typically exists between: • payers, providers, and patients due to lack of proper insurance coverage for oud/sud treatments, the limited number of providers for prescribing treatments, and lack of effective incentives and reimbursements for providers; • pharmaceutical companies, payers, and patients due to the high cost of medications; • providers (pcps and specialists) due to care fragmentation and lack of proper guidelines to streamline pathways for patients. in contrast to the studies categorized as the prevention phase, those related to barriers and facilitators of adopting treatments after development of the patient's oud/sud (intervention phase) all involved misalignment related to cost, quality, and access. although we have not carried out a formal systematic literature review, we would like to point out that, overall, many of the studies, including those driving changes in practice guidelines and reimbursement or confirming/purporting disincentive mechanisms, are of a moderate quality. furthermore, the majority of studies analyzed in this review have been published within 2010-2019 (the second half of our search timeline). therefore, the results presented here are less impacted by some of the developments in the early 2000s (e.g., unregulated marketing strategies of pharmaceutical companies) [129] . nevertheless, our findings support the hypothesis that misaligned incentives play a significant role in the opioid epidemic. that said, they would not solely explain the totality of the current opioid crisis, in that efforts to aligning incentives among stakeholders may not always alleviate this crisis or, while improving one aspect, could worsen another dimension in this epidemic. for example, ineffective performance-based payment mechanisms do not necessarily promote quality of care in pain management, such as those utilizing patients' satisfaction scores or experience of care. perhaps, this is one of the reasons that mechanisms like bundled payments are becoming more common in pain management among both cms and private insurance companies [130] . as another example, we note that many initiatives aimed at curbing the supply of opioids have not addressed how patients in dire pain conditions have been impacted [131] . therefore, we stipulate that any effort that fails to account for both ends of the spectrum (e.g., valuing the risk of oud/sud while downplaying the risk of un-/under-treated pain) will likely fail in alleviating the opioid crisis thoroughly. in addition to the foregoing issues, there are other factors that have received little to no attention in the literature, and accounting for them in incentive mechanisms can yield more impactful outcomes: (1) the co-occurrence of oud/sud and chronic pain can impose pressure on providers due to multi-layered and complex treatment requirements, lack of patient improvement for either condition, and care fragmentation caused by ineffective pain management referrals [6] . (2) guidelines that promote curbing the supply of opioids may have unintended consequences such as the increase in the number of deaths caused by fentanyl misuse. in the presence of conflicting interests, one can investigate how facilitating aligning incentives can contribute to remedying such effects. (3) stigma and discrimination against people with concurrent oud/sud and mental health disorders can stymie an effective care delivery process [132] . (4) although incurred medical expenditures for oud/sud would be higher than that for under-treated pain [133] , employers' cost of lost productivity would not be much different, because their employees could miss work due to both oud/sud and unrelieved pain [134, 135] . hence, the role of employers should not be limited to expanding access to oud/sud treatments. indeed, employers' contribution to employment-based insurance coverage would impact the availability of treatment options and the cost of prescription drugs [136] , which, in turn, affects pain management outcomes. (5) strategies like contingency management, aimed at improving oud/sud treatment adherence and retention in opioid substitution programs, have been reported to be effective only in the short term (due to financial/resource limitations), and their efficacy over the long term is yet to be investigated [137] . (6) the timing of initiating oud/sud treatments is a deciding factor in their success. however, patients at higher risk may not be always easy to identify. to address this, one can benefit from points of access to patients to potentially initiating treatments. these include ed visit/hospital admission [138] [139] [140] [141] [142] and incarceration [143] [144] [145] [146] [147] [148] [149] . employing techniques like screening, brief intervention, and referral to treatment (sbirt) can also be helpful in this regard [75] . (7) behaviors like opioid injections can increase the risks of hiv and hepatitis c virus (hcv) infection. the co-occurrence of these conditions could make patients more vulnerable against the risks of oud/sud, and hence, extra care should be taken when dealing with such instances [150] [151] [152] [153] [154] . (8) as a result of opioid consumption ramping up during the covid-19 pandemic [9, 10] , the long-term rates of oud/sud can be impacted as well, which can inevitably aggravate misaligned incentives. in addition to the avenues discussed thus far, this is another stream that warrants further investigation and knowledge production. our review has some limitations. first, even though we cover a wide range of topics associated with misaligned incentives, our method for including articles may prevent us from generalizing our findings across the whole opioid epidemic. second, we did not conduct a systematic literature review, and hence, caution should be exercised with respect to the quality of reviewed articles or recommendations made with respect to mechanisms that trigger misaligned incentives among stakeholders. third, in many of the studies reviewed, we construed the notion of misaligned incentives by exploring evidence on the main driving factor behind this misalignment: triple aims (cost, quality, or access) being compromised in the epidemic. this may be related to lack of empirical evidence where such misalignments are brought further to the center of attention. this could warrant investigations by conducting survey analyses among all parties involved (e.g., payers, providers, patients, etc.). fourth, although our objective in this paper was to review the literature for evidence of misalignment, we did not quantify this notion (e.g.: how much misalignment is acceptable?). this is another avenue that is worth investigation for future research. our review sheds light on a body of literature suggesting several factors that can stir misaligned incentives between various stakeholders in the opioid epidemic. we further summarize these factors by whether or not a patient has been diagnosed with oud/sud yet. along with potential challenges, we also address opportunities and strategies that have been shown to be successful in contributing to mitigating the epidemic. of 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among medicare beneficiaries, united states national trends in hepatitis c infection by opioid use disorder status among pregnant women at delivery hospitalization-united states key: cord-302239-2sxy3spd authors: zhang, xiaojun; wang, fanfan; zhu, changwen; wang, zhiqiang title: willingness to self-isolate when facing a pandemic risk: model, empirical test, and policy recommendations date: 2019-12-27 journal: int j environ res public health doi: 10.3390/ijerph17010197 sha: doc_id: 302239 cord_uid: 2sxy3spd infected people are isolated to minimize the spread of pandemic diseases. therefore, the factors related to self-isolation (si) should not be neglected, and it is important to investigate the factors leading the infected (or possibly infected) people to choose to self-isolate. in this paper, we tried to show that the theory of planned behavior provides a useful conceptual framework for si when facing a pandemic risk, and a regression method with chinese provincial (guangdong province) data was applied to investigate how attitude (att), subjective norms (sn), and perceived behavioral control (pbc) influence si when facing a pandemic emergency. the results and the robustness tests confirm that att, sn, and pbc have a significant positive influence on si when facing a pandemic emergency. att plays the most important role, followed by sn and then pbc. based on the factors of si, we found, through theoretical and empirical analyses, at least three important aspects that local governments need to consider to encourage citizens to self-isolate when facing a pandemic. alongside wars and natural disasters, plagues and epidemic (pandemic) diseases have had the highest death tolls in human history [1] . the who reported that the next influenza pandemic "is a matter of when, not if" [2] , and the world must prepare for the next inevitable flu pandemic. what can we do when the pandemic comes? outside pharmaceutical interventions, non-pharmaceutical interventions (npis) play an important role in delaying the first wave, reducing its peak and the spreading of new influenza cases across time [3, 4] because a pandemic vaccine will not be in place when a pandemic starts. npis include more actions than just self-isolation (si), such as quarantining infected populations; the closing of borders, schools, and work places; hand-washing; the cleaning of surfaces; and so on [5] . the isolation of infected people has been applied to minimize the spread of pandemic diseases at least since the old testament period as an instrument for controlling and quelling the spread of viruses and contamination agents [6] . hence, isolation is seen as a critical part of public health interventions, as it protects people by separating those who have been infected by communicable diseases from the general population [7] . many scholars believe that isolation has a great impact on preventing or delaying the spread of pandemics [8, 9] . si means symptomatic individuals confine themselves to their homes [10] . generally, isolation can take two forms: mandatory and voluntary [11, 12] . voluntary si means that infected (or possibly infected) individuals choose to confine themselves to their homes; this intervention is generally considered capable of limiting the transmission of pandemic influenza [13, 14] and is recommended by the european centre for disease prevention and control [15] . the early initiation of voluntary si can overcome the negative effects of a delay in antiviral drug distribution when enough symptomatic individuals comply with home confinement at symptom onset [14] . overall, si is of great importance for hampering the spread of pandemics and has been widely studied based on different methods. the effectiveness of voluntary si largely depends on public adherence to this intervention measure [14] . unfortunately, voluntary si strategies may inconvenience individuals, lead to economic losses, or even contribute to moral conflicts; thus, voluntary si remains a controversial strategy [15, 16] . to date, many scholars have demonstrated the relationship between si and the prevention of pandemics [8, 10, 12, 16] . however, the factors involved in si should not be neglected, and it is important to investigate which factors will encourage infected (or possibly infected) people to choose self-isolation. surveys conducted in the united states (us) and australia during the 2009 pandemic showed that more than 80% of people were willing to stay home from work or school [17, 18] , while 53-76% of people were willing to self-isolate [17, 19] . according to the self-reported behavioral intention regarding the h1n1 influenza of university students in southwestern us, mas et al. (2012) claimed that an array of issues may influence students' decision to self-isolate, including interpersonal, academic, environmental, and social factors [20] ; however, their analysis lacks an empirical basis. risk perception has been widely established as a significant predictor of engagement in preventive health behaviors, including si [21] ; those who report being unfamiliar with the term "pandemic influenza," male respondents, and employed people who are not able to work from home have been found to be less willing to comply [22] . a survey in two counties in north carolina showed that 50% of households with children under 18 and 65% of working adults reported the ability to comply with si at home for 7-10 days if recommended to do so by the authorities [23] . concomitantly, recent polls have shown that the willingness to comply with an si period strongly depends on the social condition and literacy of the individual [24] . therefore, we seek an answer to the fundamental question about what factors affect the willingness to self-isolate. the remainder of the paper is organized as follows. section 2 develops a conceptual model to explain the behavior. the data description, empirical results, and regional heterogeneity test are presented in sections 4 and 5. finally, section 6 presents our conclusions. several theories explain social behaviors [25] . one is the theory of planned behavior (tpb), which is widely applied to explain many types of behaviors. the tpb is a cognitive theory that provides a useful framework for predicting and identifying health-related behaviors, which are usually found to predict behavioral intentions with a high degree of accuracy. the tpb proposes that the individual is influenced by three factors (see figure 1 ): attitudes toward the behavior (att), subjective norms with respect to the behavior (sn), and perceived control over the behavior (pbc) [26, 27] . the tpb has been explored in relation to behaviors such as counterproductive work behaviors [28] , safe sexual behaviors among drug users [29] , consumption of a low-fat diet [30] , and healthy eating behaviors [31] . for all of these reasons, it is appropriate to apply the tpb to the study of si intention when facing pandemic risk. in the present study, we sought to build upon the conceptual model and analyze factors correlated with si behavior based on the tpb. att refers to the degree to which a person has a favorable or unfavorable evaluation or appraisal of the behavior in question [26] . the tpb is an extension of the theory of reasoned action [32, 33] , and the individual's intention is a central factor of performing a given behavior: when the intention to engage in a behavior is stronger, the behavior is more likely to be adopted [26] . consequently, the effect of att on si can be positive or negative. sn refers to the perceived social pressure to perform a behavior or not [26, 34] . people are sensitive to the conformity pressures associated with real and perceived social norms as related to risk behavior [35] . as many studies have noted, sn and att are suggested to exert their effects on behavior through intentions [27] . pbc refers to the perceived ease or difficulty of performing the behavior, and it is assumed to reflect past experience as well as anticipated obstacles [26] . pbc has been found to influence both behavioral intentions and actual behavior [36] . the resources and opportunities available to a person must, to some extent, dictate the likelihood of behavioral achievement [26] . influence both behavioral intentions and actual behavior [36] . the resources and opportunities available to a person must, to some extent, dictate the likelihood of behavioral achievement [26] . besides, several other factors may affect the willingness to self-isolate. gender differences are significant in the attitudes and behaviors related to pandemics [37] [38] [39] . here, the factors that affect si are similar to those identified at the beginning of a pandemic, such as h1n1, hiv, and sars, suggesting that gender has an effect on si [40] . a strong intention to comply with governmentadvised preventive measures in the future is associated with higher age [41, 42] . education (edu) plays an important role in individual choice. people with less education receive less information about pandemics than people with higher education, which indicates that less educated groups are less likely to understand the importance of si [43] . personal behavior during an epidemic depends on an individual's socioeconomic status (ss), as well as his or her perception of the epidemic in the community [44] . married people enjoy better physical and mental health than people who are not married [45] , so marital status may play a role in people's behavior. family members in need of special care (fnsc) are children, the elderly, those with disabilities, and those with chronic diseases. respondents who live with people with these conditions have a higher risk perception concerning health [46] [47] [48] . therefore, we assume that respondents with family members in need of special care have higher perceived risks. furthermore, government trust (gt) [49] [50] [51] , community resources (crs) [52, 53] , and emergency services (es) [49] are among the other variables affecting si. sars was first recognized in guangdong province, china, in november 2002, and the virus quickly spread; more than 7900 patients were infected in 30 countries [50] . this situation prompted us to explore the factors affecting the willingness of patients to self-isolate who may be infected in guangdong province. a market research company, ltd, which has a professional computerized database, was entrusted to carry out an online survey of pandemic prevention from 14 october to 3 november in 2018. the survey included the following steps. first, we determined the basic demographic characteristics such as gender, age, and education status of the respondents based on the 2017 guangdong internet industry development report, which was published by the guangdong communications administration. second, a questionnaire was designed, which involved many aspects of si. third, 121 county-level units and 21 county-level city units were selected according to the statistical yearbook of guangdong province 2018. fourth, we transformed the designed questionnaire into a network questionnaire and sent it to the random sampling objects (2500 questionnaires) through a network link. each interviewee was asked to provide a contact phone number. finally, 2155 questionnaires were collected in guangdong province, which gives a gross besides, several other factors may affect the willingness to self-isolate. gender differences are significant in the attitudes and behaviors related to pandemics [37] [38] [39] . here, the factors that affect si are similar to those identified at the beginning of a pandemic, such as h1n1, hiv, and sars, suggesting that gender has an effect on si [40] . a strong intention to comply with government-advised preventive measures in the future is associated with higher age [41, 42] . education (edu) plays an important role in individual choice. people with less education receive less information about pandemics than people with higher education, which indicates that less educated groups are less likely to understand the importance of si [43] . personal behavior during an epidemic depends on an individual's socioeconomic status (ss), as well as his or her perception of the epidemic in the community [44] . married people enjoy better physical and mental health than people who are not married [45] , so marital status may play a role in people's behavior. family members in need of special care (fnsc) are children, the elderly, those with disabilities, and those with chronic diseases. respondents who live with people with these conditions have a higher risk perception concerning health [46] [47] [48] . therefore, we assume that respondents with family members in need of special care have higher perceived risks. furthermore, government trust (gt) [49] [50] [51] , community resources (crs) [52, 53] , and emergency services (es) [49] are among the other variables affecting si. sars was first recognized in guangdong province, china, in november 2002, and the virus quickly spread; more than 7900 patients were infected in 30 countries [50] . this situation prompted us to explore the factors affecting the willingness of patients to self-isolate who may be infected in guangdong province. a market research company, ltd, which has a professional computerized database, was entrusted to carry out an online survey of pandemic prevention from 14 october to 3 november in 2018. the survey included the following steps. first, we determined the basic demographic characteristics such as gender, age, and education status of the respondents based on the 2017 guangdong internet industry development report, which was published by the guangdong communications administration. second, a questionnaire was designed, which involved many aspects of si. third, 121 county-level units and 21 county-level city units were selected according to the statistical yearbook of guangdong province 2018. fourth, we transformed the designed questionnaire into a network questionnaire and sent it to the random sampling objects (2500 questionnaires) through a network link. each interviewee was asked to provide a contact phone number. finally, 2155 questionnaires were collected in guangdong province, which gives a gross response rate of 86.2% (2155/2500). after the survey, we made random checks of the respondents' urls and contacted some interviewees to ensure that every respondent was unique. finally, we cleaned the data and obtained 1925 respondents; some subjects were excluded due to missing values. the net response rate was thus 77% (1925/2500). all of the variables were measured by the survey questions (see table 1 ). we divided sn into two kinds of social pressure, from neighbors and from the health department, which were measured by the two questions below. an additional three questions were used to describe pbc, which include the individual and family's risk perception of pandemics, and confidence to protect the family from a pandemic. (1) absolutely not, (2) gt "do you agree or disagree with local leaders?" (1) strongly disagree, (2) disagree, (3) it does not matter, (4) agree, (5) strongly agree "do you agree or disagree that local government works well?" (1) strongly disagree, (2) disagree, (1) strongly disagree, (2) disagree, we first examined the descriptive statistics of the variables and mapped the average scores of the willingness for si using arcgis. then, a correlation matrix was determined to examine these relationships and influences, in which 12 quantitative variables were included. third, multiple linear regression models were adopted to explore the effects of att, sn, and pbc on si. finally, we explored the effects of these influencing variables on si in different regions to test the stability of the results and identify the differences between regions. the statistical analysis was implemented using the statistical software stata/mp, version 14.0 (statacorp lp., texas city, usa). table 2 provides descriptive statistics for the dependent and independent variables. overall, the average age of the participants was 35.12, with most between the ages of 18 and 66. of the participants, 45.71% were female and 54.29% were male. most of the participants had a college education or above, and 66.5% of them were married or cohabiting. in terms of economic status, most of the participants were in the middle class. the average fnsc was 2.025, which means at least two members per family were in need of special care. the participants were asked: "if you were advised by the health department to isolate yourself at home for 10 days because of exposure to large-scale infectious disease patients, do you think you could do it?" of those sampled, 8.83% said they could not isolate themselves, 75.69% said that they could, and 15.48% were unsure (see figure 2 ). the participants were asked: "if you were advised by the health department to isolate yourself at home for 10 days because of exposure to large-scale infectious disease patients, do you think you could do it?" of those sampled, 8.83% said they could not isolate themselves, 75.69% said that they could, and 15.48% were unsure (see figure 2 ). the mean score of si by municipality is mapped in figure 3 . overall, the mean score of si in guangdong prefecture-level cities was between 3.4 and 4.1 out of 5, which indicates people have more willingness to self-isolate than they do in other regions. the cities exhibited some differences, with five cities (shantou, meizhou, shanwei, chaozhou, and zhuhai) having a mean score greater than 4. shantou city ranks first, with a mean score of 4.088, and yunfu city ranks last, with a mean score of 3.417. the mean score of si by municipality is mapped in figure 3 . overall, the mean score of si in guangdong prefecture-level cities was between 3.4 and 4.1 out of 5, which indicates people have more willingness to self-isolate than they do in other regions. the cities exhibited some differences, with five cities (shantou, meizhou, shanwei, chaozhou, and zhuhai) having a mean score greater than 4. shantou city ranks first, with a mean score of 4.088, and yunfu city ranks last, with a mean score of 3.417. before a formal linear regression, the correlation matrix must be determined and the correlation of variables must be tested. these results are shown in table 3 , and a significant association was observed for 13 of the 16 indicators of si. in particular, att, sn, and pbc were positively related to si. before a formal linear regression, the correlation matrix must be determined and the correlation of variables must be tested. these results are shown in table 3 , and a significant association was observed for 13 of the 16 indicators of si. in particular, att, sn, and pbc were positively related to si. we first regressed on si with the control variables as a benchmark model (1) . then, we added pbc, att, and sn sequentially to the model. table 4 shows the crude and adjusted models for the multiple regressions of changes in the willingness to self-isolate when facing a large-scale infectious disease according to changes in pbc, att, and sn. the adjusted r 2 of the benchmark model is lower than that of models (2)-(4), which means that those models are more appropriate than model (1) and that pbc, att, and sn are important factors of si. overall, respondents with a higher education level had a higher willingness to self-isolate when facing a pandemic. pbc, att, and sn are the key factors influencing si (significant at p < 0.001), and they have different effects according to the estimated coefficients. att has the most important effect on si; when att increases by 1%, the willingness to self-isolate will increase by 0.443%. when sn increases by 1%, the willingness to self-isolate will increase by 0.162%. finally, when pbc increases by 1%, the willingness to self-isolate will increase by only 0.082%. the social-economic status in guangdong province is unbalanced, which manifests as differences in the population, economy, industrialization, and lifestyle. guangdong province is often divided into four parts: the pearl river delta and eastern, western, and northern guangdong (the pearl river delta includes guangzhou, shenzhen, zhuhai, foshan, jiangmen, dongguan, zhongshan, huizhou, and zhaoqing; eastern guangdong includes chaozhou, jieyang, shantou, and shanwei; western guangdong includes zhanjiang, maoming, and yangjiang; and northern guangdong includes shaoguan, heyuan, meizhou, qingyuan, and yunfu) [51] . regional differences may influence the willingness to self-isolate when facing a pandemic. some researchers have explored the different influences of cancer risk [52] , enteroviruses [53] , epidemics [54] , and diabetes mellitus [55] , among other health issue, in these four parts. therefore, we regressed on si across different regions. the coefficients and the significance levels of pbc, att, and sn in every model in table 5 are similar to those in table 4 (except the effect of sn is not significant in western guangdong). however, there are some regional differences. the control variables (including community resources, emergency services, and families with old people) have significant influences on si in the pearl river delta. in eastern guangdong, age, education, socioeconomic, trust in leadership, and families with children have important influences on si. however, only trust in leadership and families with old people have significant effects on si in western guangdong. moreover, si in northern guangdong is only affected by age. the positive and negative influences of these control variables are similar to those in table 4 . no substantial changes in the independent and control variables can be detected, proving the robustness of our results mentioned above. in this paper, we built a conceptual model based on the tpb theory and regression method with chinese provincial (guangdong province) data to investigate how att, sn, and pbc influence si when facing a pandemic emergency. theoretically, att, sn, and pbc are very different concepts; however, each plays an important role in social and behavioral research [26] . we ran multiple linear regression models to test the efficiency of the conceptual model we built based on the tpb. the coefficients of si on att, sn, and pbc passed the significance test, and all were positive; these results were confirmed by the robustness checks, indicating that the tpb can be used to explain si. of the three considered factors, att plays the most important role, followed by sn and then pbc. the influence of sn on forming intention proved to be generally weaker in previous studies than the influence of att [56] . the coefficients of education on si in models (1)â��(4) were significant and positive, even if the significance levels are different. therefore, when the participant's educational level was higher, so was his or her willingness to self-isolate. in models (1) and (2), marriage had a significant and positive effect on si, which means married individuals have a higher willingness to self-isolate. socioeconomic status also had a significant and positive effect on si in models (1) and (2), which means people of high socioeconomic status may have a higher willingness to self-isolate. as for government trust, trust leadership and trust government had significant positive impacts on si, indicating that a higher degree of government trust promotes people's willingness to self-isolate. emergency services also had a significant positive influence on si. conversely, community resources are not useful for si. one possible explanation is that if a community has more resources-such as money, food, and technology-the community will be more resilient, and people will be less willing to self-isolate because people believe that the community will address the risk of the infectious disease. for family members in need of special care (children, old people, those with disabilities, or those with chronic diseases), the effects on si of having a family member who is old or has a disability were significant and negative, which means such individuals may have less willingness to self-isolate. these people likely need to provide for the people in their family who need special care, and they have little chance to self-isolate. in contrast, the effect of having a family member with a chronic disease was significant and positive, indicating a higher willingness to self-isolate. reasons for this finding may include the following: vaccinations are recommended for those with chronic diseases, or those with a family member who has a chronic disease may have more medical knowledge and better understand the dangers of a pandemic. those in a family with a child were less willing to self-isolate, but the effect was not significant. there may be a conflict of interest concerning the use of isolation, as measures must be balanced against the potential to compromise individuals' liberty and autonomy [57] . intention, pbc, att, and sn each reveal a different aspect of behavior and each can serve as a basis for attempts to change behavior [36] . public health policies that encourage infected people to self-isolate can be beneficial to the community by lowering disease prevalence [58] . behavioral science theory and research provide a perspective for understanding the factors contributing to people's behavior. consequently, the more we know about any given behavior, the more we can do to influence and change the behavior. interventions to strengthen the willingness to follow si instructions have timely relevance for the prevention and control of pandemic risk. based on the factors of si, we found that, through theoretical and empirical analyses, our study identifies at least three important aspects that local governments need to consider when encouraging citizens to self-isolate when facing a pandemic. our study has several implications for public health policy as well. first, extensive publicity in various forms is necessary to help residents better understand the pandemic and raise awareness about early treatment when facing a pandemic risk. greater understanding of pandemic influenza significantly increases compliance with public health containment measures [22] . however, some studies have indicated that si does not solve all problems, and encouraging infected people to self-isolate does not always reduce the number of infections [58] . therefore, we also need to classify the types of pandemic diseases and report to residents the correct solution to prevent a pandemic risk. it is of great importance to establish an early warning system to provide information about pandemics and to maintain communication with residents. second, the social norms of public health must be improved through joint efforts of the government, civil society, and the media. in contemporary political and legal life, law and policy play unique roles as two social norms and two means of social adjustment. on the one hand, relevant laws and regulations must be formulated to regulate behavior when facing a pandemic risk; on the other hand, public supervision and participation should be encouraged. third, although an influenza pandemic is perceived as a real risk in all countries, the level of self-efficacy appears to be rather low [59] . therefore, when developing preparedness plans for an influenza pandemic, specific attention should be paid to risk communication and increasing perceived self-efficacy; otherwise, adherence to preventive measures may be low [59] . therefore, residents should be given sufficient training to reduce the difficulty of applying health behavior through better public service. in addition to the application of tpb, we found that some participants' characteristics might also be factors related to si. from the perspective of social assistance, residents have different demands; however, the characteristics of different people must be classified to make future social assistance more precise. voluntary home isolation and quarantine are effective and acceptable measures [8] ; however, various factors may affect individuals' willingness to self-isolate when facing a pandemic risk. in this article, we tried to show that the tpb provides a useful conceptual framework for si when facing a pandemic risk. using chinese provincial (guangdong province) data, we investigated how att, sn, and pbc influence the willingness of self-isolate when facing a pandemic emergency. the results confirmed by the robustness checks show that att, sn, and pbc have significant positive influences on si when facing a pandemic emergency, with att playing the most important role. furthermore, we found that family members in need of special care have different effects on the willingness to self-isolate. the effects on si of having a family member who is old or who has a disability are significant and negative, while the effect of having a family member with a chronic disease is significant and positive. these intentions, in combination with pbc, can account for a considerable proportion of variance in behavior. based on these findings, we provided several implications for public health policy. author contributions: conceptualization, x.z.; methodology, x.z. and f.w.; software, x.z. and f.w.; validation, z.w. and x.z.; formal analysis, c.z. and x.z.; investigation, x.z.; resources, c.z. and x.z.; data curation, c.z. and x.z.; writing-original draft preparation, x.z.; writing-review and editing, z.w. and x.z.; visualization, x.z.; supervision, z.w.; project administration, z.w.; funding acquisition, z.w. all authors have read and agreed to the published version of the manuscript. acknowledgments: the authors would like to thank the anonymous reviewers for their constructive comments regarding this article. the authors declare no conflicts of interest. probing into the effectiveness of self-isolation policies in epidemic control world must prepare for inevitable next flu pandemic, who says. reuters pandemic influenza: studying the lessons of history nonpharmaceutical interventions implemented by us 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2009 human enterovirus surveillance in the slovak republic from an enterovirus 71 epidemic in guangdong province of china, 2008: epidemiological, clinical, and virogenic manifestations this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-332673-av2vt54r authors: alwashmi, meshari f. title: the use of digital health in the detection and management of covid-19 date: 2020-04-23 journal: int j environ res public health doi: 10.3390/ijerph17082906 sha: doc_id: 332673 cord_uid: av2vt54r digital health is uniquely positioned to enhance the way we detect and manage infectious diseases. this commentary explores the potential of implementing digital technologies that can be used at different stages of the covid-19 outbreak, including data-driven disease surveillance, screening, triage, diagnosis, and monitoring. methods that could potentially reduce the exposure of healthcare providers to the virus are also discussed. in december of 2019, hospitals began to report cases of unidentified pneumonia among patients with a history of exposure to the huanan seafood market in wuhan, hubei, china. researchers rapidly isolated a novel coronavirus (sars-cov-2, also referred to as covid-19) from confirmed infected pneumonia patients [1] . attracting great attention nationally and worldwide, confirmed cases of covid-19 exceeded those of severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers). as of 13 april 2020, confirmed cases of covid-19 had exceeded 1,800,000 cases and 117,000 fatalities. the world health organization (who) has recently declared covid-19 as both a pandemic and public health emergency of international concern. during the outbreak of ebola and severe acute respiratory syndrome (sars), digital health (dh) demonstrated its potential in detecting and fighting global epidemics [2] [3] [4] . dh is defined as technology that, "connects and empowers people and populations to manage health and wellness, augmented by accessible and supportive provider teams working within flexible, integrated, interoperable, and digitally-enabled care environments that strategically leverage digital tools, technologies, and services to transform care delivery" [5] . recently, a significant number of dh efforts have emerged because of the unprecedented global strain of covid-19 on healthcare systems. this article reveals that digital technologies can be used at different stages of the covid-19 outbreak, including data-driven disease surveillance, screening, triage, diagnosis, and monitoring. methods that could potentially reduce the exposure of healthcare providers to the virus will also be discussed. the review aims to guide further development in dh to improve infectious disease control. the who defines public health surveillance as, "the continuous, systematic collection, analysis, and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice" [6] . advancements in information technology and information sharing is giving rise to a new field known as infodemiology. infodemiology is defined as, "the science of distribution and determinants of information in an electronic medium, specifically the internet, with the ultimate aim to inform public health and public policy" [7] . the allen institute for artificial intelligence (ai) is currently offering free access to a collection of machine-readable literature that includes information regarding the group of coronaviruses [8] . the allen institute database currently contains more than 44,000 articles, of which 29,000 are full-text publications. combining this database with other unstructured data from websites or social media can be used to expand our knowledge further regarding the early detection and containment of future outbreaks of covid-19 and other emerging infectious diseases. online surveillance-mapping tools, such as the surveillance and outbreak response management and analysis system (sormas) [9] , as well as healthmap [10] , have the potential to improve the early detection of infectious diseases in comparison to traditional epidemiological tools [2] . sormas and healthmap are currently being used for the surveillance of covid-19. similarly, bluedot's outbreak risk software, a modern epidemiological tool, was reported as the first organization to reveal news of the outbreak [11] . both medical devices and wearables have the potential to be repurposed to detect emerging patterns that are indicative of disease outbreaks. for example, fitbit devices have been used to inform timely and accurate models of population-level influenza trends [12] . additionally, smart thermometers have provided a novel source of information for influenza surveillance and forecasting [13] . colubri et al. [14] used machine learning to harmonize several data sets from the ebola virus epidemic to provide informed access to evidence-based guidelines. these guidelines were then incorporated in the ebola care guidelines app [14] . many of these lessons and models can be re-applied to develop a similar app for covid-19. the app has the potential to include real-time updates of evidence-based guidelines during a global pandemic to inform the general population and healthcare providers. the integration of real-time updates into electronic medical records can also act as a dependable resource for practicing healthcare providers. the current covid-19 outbreak has spread internationally, which has prompted the who to demand the detection and management of suspected cases at points of entry into a country [15] . screening travelers based on flight or cruise origin and travel history for cases of covid-19 could allow individuals to receive the necessary treatment sooner and may limit the spread of the disease. the use of technology has the potential to screen travelers based on symptoms and travel history. for example, taiwan integrated its national health insurance database with its immigration and customs database to create a "big data" resource for analytics [16] . the database was used to classify travelers' infectious risks and it generated real-time alerts during clinical visits to aid in case identification [16] . it can also be utilized to test patients for covid-19 who had previously tested negative for influenza; one covid-19 case was confirmed from 113 patients who had already undergone influenza screening [16] . during the sars pandemic, many countries instituted border measures to control the outbreak [17] . several researchers stated that thermal image scanning has the potential to enhance screening for infectious diseases [17] [18] [19] . a mass temperature screening solution utilizing ai was developed to reduce the need for manual temperature screening. integrated health information systems and kronikare are currently piloting a screening solution that automatically screens and identifies patients with symptoms such as fever [20]. sun et al. [21] recommend using a microwave radar to capture heart rate and respiratory rate to enhance the accuracy of mass screening. additional research is needed to validate and develop mass temperature screening solutions. in response to the viral outbreak, many countries have transitioned to virtual medical care. online tools are used to prioritize the treatment of patients based on the severity of their condition. digital stethoscopes, such as those from tytocare [22] and eko [23] , could enhance the quality of remote medical exams. such dh interventions aim to prove early access to healthcare and reduce the risk of transmission to other patients and healthcare providers in the hospital setting. many countries and health institutions are offering free triage telehealth assessments for covid-19. the telehealth assessments provide patients with access to websites or mobile apps, which consist of a short survey regarding the patient's current condition. the survey includes questions about age, symptoms, and travel history. based on their results, the respondents will be provided with tips, asked to visit a nearby mobile covid-19 testing site or hospital, or become connected digitally with a healthcare provider. furthermore, health-focused chatbots, such as buoy health [24] and lark health [25] , can also help individuals interpret their symptoms and suggest appropriate next steps. survey results could potentially be integrated with electronic medical records to assure continuity of care. following digital triage, patients could benefit from an at-home diagnostic service. similar to over-the-counter genetic or urinary tract infection tests, patients could receive a test kit via mail. the use of a drone delivery method could also be considered as a potential and efficient solution to ensure both a timely diagnosis and patient confidentiality. some test kits may require laboratory analysis [26, 27] , while other tests could utilize a smartphone to assist in the interpretation of test results [28] . if results are positive, patients could receive a virtual consultation to explain the next steps. additionally, all positive results should be communicated and reported to the appropriate agency. at-home diagnostic test kits seem promising and have the potential to reduce the pressure on the healthcare system. however, the united states food and drug administration stated that as of 20 march 2020, there had been no authorization for the use of an at-home diagnostic tool for covid-19 [29] . computed tomography (ct) images are currently being used to confirm cases of covid-19 [30] . researchers were able to develop a deep learning model that can accurately detect covid-19 and differentiate it from community-acquired pneumonia and other forms of lung disease [31] . the deep learning model can also be used remotely by medical professionals outside of the epidemic areas. furthermore, significant advancements in dh, specifically in the field of personalized medicine, have evolved in recent years. researchers are currently working on developing rapid diagnostic tools, vaccines, and medications to cure and limit transmission of covid-19 [32] . a patient's measurements can be directly transmitted to healthcare providers or other monitoring entities through the use of remote monitoring technology. remote monitoring technologies can connect wirelessly to networks via bluetooth, wifi, or cellular connection. an extensive body of literature exists regarding the use of dh in the remote monitoring of chronic diseases [33, 34] . the same concept could also be applied to the monitoring of infectious diseases. remote monitoring can be used to monitor individuals exposed to covid-19 as well as close contacts of the individual. remote monitoring can also be used to monitor the exposure of healthcare providers and high-risk patient populations. in essence, similar technology infrastructure currently used by remote monitoring programs can also be used to incorporate a thermometer for monitoring patients that are suspected of having covid-19. the sense followup ebola app has an automatic alert system for temperature readings ≥38 • c for individuals receiving follow-up care [35] . a similar feature could also be incorporated in future covid-19 apps. furthermore, the app could pair with advanced thermometers that allow continuous and real-time monitoring of changes in body temperature [36, 37] . other dh interventions have the potential to provide unique data to help us understand the possible effects of covid-19 on patients with comorbidities. steinhubl et al. [38] studied the use of a wearable, wireless "band-aid" sensor to monitor patients exposed to the ebola virus. additionally, hexoskin repurposed biometric shirts that are capable of continuously measuring vital signs, including temperature, respiration effort, and cardiac activity, to better understand the evolution of covid-19 and its effects on lung function [39] . the use of data from glucometers among patients with diabetes could also be used as an objective indicator of infection, as high glucose levels correlate with signs and symptoms of infection [40] . infectious respiratory diseases, such as covid-19, have the potential to worsen symptoms of pre-existing lung disease, and thus exacerbate the use of emergency medications. increased use of inhaled emergency medication can be detected using a smart inhaler [41] . as researchers continue to work on vaccines and methods of treatment for covid-19, the primary measure of containment is the interruption of human-to-human transmission. contact tracing is the process of identification and follow-up of individuals who have been in contact with a person confirmed to have been infected with covid-19. traditional paper-based methods of contact tracing during the ebola outbreak have been proven to be insufficient. such methods caused incomplete identification of contacts and delays in contact tracing steps, such as the identification of contacts involved in suspected cases that required isolation [42] . our smartphones are increasingly unlocking the power of ai and machine learning to provide accurate and real-time insight into various aspects of healthcare. smartphones can utilize gps or bluetooth technologies for contact tracing purposes. although contact tracing may seem challenging, previous epidemics have been effectively controlled through contact tracing and isolation initiatives [3, 42] . to assist in covid-19 contact tracing, a mobile app called tracetogether is currently being used in singapore [43] . the app uses bluetooth technology to identify individuals that have been in close contact with patients who have been diagnosed with covid-19. healthcare providers are considered a high-risk group for contracting covid-19 [44] . the aim of dh implementation during a global pandemic is to reduce the risk of transmission to healthcare providers. the technology applications mentioned above have the potential to reduce transmission by minimizing face-to-face contact between clinicians and patients. furthermore, dh interventions enable healthcare providers to fight the global pandemic, even if they are practicing self-isolation measures or working remotely. both aiva [45] and deloitte assistant [46] have created an ai-enabled patient communication solution that allows patients to request assistance, via amazon alexa or google home, without the need to press the traditional call bell button. such interventions have the potential to reduce transmission because healthcare providers may be able to respond to many of the patient's needs without having to enter the patient's room. thus, potentially reducing the frequency of a healthcare provider's exposure. it is important to note that the dh implementation process is likely to be challenging and resource-intensive. for example, the lack of homogenous interventions poses a significant challenge in applying dh interventions. the lack of homogeneity leads to variations in the nature of dh interventions and data collection methods. such differences could limit model generalizability and limit understandings of the effectiveness of dh. governments will need to work with all experts and stakeholders to embed secure dh interventions into practice while maintaining the privacy and confidentiality of patients. it is also important to consider that some countries may not have the technological infrastructure to support dh. furthermore, there will be a significant proportion of the population who will not have access to technology or internet connectivity. this commentary provides valuable insights regarding various dh interventions that can be implemented to enhance the detection and spread of infectious diseases, such as covid-19. this information may help a variety of stakeholders-including epidemiologists, healthcare professionals, and policymakers-who are planning to use dh to tackle infectious diseases. the majority of dh interventions have already been developed for other infectious diseases, such as ebola, sars, and the flu. however, many governments and health systems have been slow in adopting these technologies. government, professional associations, and health organizations should take an active role in dh adoption. the united nations established the panel on digital cooperation to address challenges in the digital age and propose modalities for working cooperatively across sectors, disciplines, and borders, to address challenges in the digital age [47] . this panel could work closely with the who to help address the challenges of implementing digital health in the context of infectious diseases. these organizations could help in addressing the digital divide among countries with limited technological infrastructure. this can be accomplished by sharing the research and development protocols and source codes, similar to sromas [9] and colubri et al. [14] . additional research is required to further assess the effectiveness of dh in detecting and managing arising infectious diseases. in addition, cost-effectiveness analysis is required to assess the impact of dh on healthcare resources. digital health provides an opportunity to use real-time data to improve the prevention and control of the rapidly changing nature of epidemics. recent sars, h1n1, and ebola outbreaks offer many lessons about the use of dh for public health emergencies. these learnings can be transferred to new effective technologies to enhance our response against the covid-19 pandemic. dh has the potential to strengthen our preparedness for the next pandemic. we need to have these tools locked and loaded for our next war against infectious disease. a novel coronavirus from patients with pneumonia in china precision global health-the case of ebola: a scoping review assessing the concepts and designs of 58 mobile apps for the management of the 2014-2015 west africa ebola outbreak: systematic review sars and population health technology himss defines digital health for the global healthcare industry. healthcare information and management systems society public health surveillance. world health organization semantic scholar outbreak response management and analysis system contagious disease surveillance. healthmap potential for global spread of a novel coronavirus from harnessing wearable device data to improve state-level real-time surveillance of influenza-like illness in the usa: a population-based study a smartphone-driven thermometer application for real-time population-and individual-level influenza surveillance machine-learning prognostic models from the 2014-16 ebola outbreak: data-harmonization challenges, validation strategies, and mhealth applications management of ill travellers at points of entry ( international airports, seaports, and ground crossings) in the context of covid-19, interim guidance response to covid-19 in taiwan evaluation of border entry screening for infectious diseases in humans fever screening and detection of febrile arrivals at an international airport in korea: association among self-reported fever, infrared thermal camera scanning, and tympanic temperature thermal image scanning for influenza border screening: results of an airport screening study remote sensing of multiple vital signs using a cmos camera-equipped infrared thermography system and its clinical application in rapidly screening patients with suspected infectious diseases check your symptoms in real time digital disease management & prevention platform. lark health innovative at-home health testing modern primary & urgent care. carbon health at home medical testing kits update: fda alerts consumers about unauthorized fraudulent covid-19 test kits relationship to duration of infection potential rapid diagnostics, vaccine and therapeutics for 2019 novel coronavirus (2019-ncov): a systematic review abu ashour, w. the effect of smartphone interventions on patients with chronic obstructive pulmonary disease exacerbations: a systematic review and meta-analysis impact of remote patient monitoring on clinical outcomes: an updated meta-analysis of randomized controlled trials remote sensing of vital signs: a wearable, wireless "band-aid" sensor with personalized analytics for improved ebola patient care and worker safety type 2 diabetes and its impact on the immune system use of a mobile application for ebola contact tracing and monitoring in northern sierra leone: a proof-of-concept study tracetogether-behind the scenes look at its development process. govtech singapore a novel coronavirus outbreak of global health concern virtual health assistant. aiva health the high-level panel on digital cooperation funding: this research received no external funding. the authors declare no conflict of interest. key: cord-308957-s2hjge6s authors: burns, ryan d.; bai, yang; pfledderer, christopher d.; brusseau, timothy a.; byun, wonwoo title: movement behaviors and perceived loneliness and sadness within alaskan adolescents date: 2020-09-20 journal: int j environ res public health doi: 10.3390/ijerph17186866 sha: doc_id: 308957 cord_uid: s2hjge6s physical activity, screen use, and sleep are behaviors that integrate across the whole day. however, the accumulative influence of meeting recommendations for these 24-h movement behaviors on the mental health of alaskan adolescents has not been examined. the purpose of this study was to examine the associations between movement behaviors, loneliness, and sadness within alaskan adolescents. data were obtained from the 2019 alaska youth risk behavior survey (yrbs). the number of adolescents participating in the 2019 alaska yrbs was 1897. associations between meeting recommendations for movement behaviors with loneliness and sadness were examined using weighted logistic regression models, adjusted for age, sex, race/ethnicity, and body mass index (bmi). approximately 5.0% of the sample met recommendations for all three movement behaviors. meeting 2 or 3 movement behavior recommendations was associated with lower odds of loneliness (odds ratio (or) range = 0.23 to 0.44, p < 0.01). additionally, meeting 1 to 3 movement behavior recommendations was associated with lower odds of sadness (or range = 0.29 to 0.52, p < 0.05). joint association analyses determined that these relationships were primarily driven by meeting the sleep recommendation for loneliness and meeting the screen use recommendation for sadness. the results support use of multiple movement-based behavior programming to attenuate feelings of loneliness and sadness within alaskan adolescents. the analysis of 24-hour movement behaviors has recently shown that physical activity, sedentary behaviors, and sleep are associated with a number of health outcomes within the pediatric population [1] [2] [3] [4] . the 24-hour movement behavior recommendations are relevant to the pediatric population regardless of sex, race/ethnicity, or socioeconomic status [1, 2] . an optimal composition of these movement behaviors includes achieving at least 60 min of physical activity per day including at least 3 days per week of muscle strengthening activities, limiting screen use to 2 h or less per day, and receiving an adequate amount of sleep (e.g., 8-10 h per night for adolescents aged 14 years old or older) [1] . because many populations of youth do not meet recommendations for these movement behaviors [1, 2] , the examination of these behaviors concurrently using various analytic approaches is of importance to yield new information that can be applied within school-and community-based settings. indeed, novel analytic approaches such as compositional data analysis have shown that the 24-hour composition of movement behaviors correlate with cardiometabolic risk, health-related fitness, weight status, and academic performance outcomes [5] [6] [7] [8] . however, the relationships between the additive influences of movement behaviors on mental health outcomes is not as well researched [2] . given the current global covid-19 pandemic and the associated social/physical distancing recommendations, mental health is a significant public health concern now more than ever within the pediatric population. elevated levels of loneliness and sadness can have detrimental effects on the health and well-being of youth [9, 10] . adolescents with higher levels of anxiety and depression resulting from loneliness and sadness are more likely to have these mental health conditions in adulthood, where it can negatively affect work production and overall health and well-being [11, 12] . adolescents with poor mental health are also more likely to have poorer academic performance [13] and increased risk of suicide [14, 15] . pfledderer et al. [16] found that meeting physical activity guidelines and hours of sleep per night significantly predicted suicidal ideation in a national sample of u.s. adolescents. using data from the ontario child health study, kim et al. [17] found that adolescents reporting 4 or more hours of passive screen use time per day, compared to those reporting less than 2 h per day, were three times more likely to meet criteria for a major depressive episode, social phobia, and generalized anxiety disorder. however, active screen time did not significantly associate with mental health disorders. in a large longitudinal study, boers et al. [18] found that for every 1 hour spent on social media and general computer use, adolescents showed a significant increase in depressive symptoms. the authors concluded that these time-varying associations were partially explained by upward social comparisons. these studies suggest that individually, higher levels of physical activity, low levels of sedentary behaviors such as television watching and non-academic computer use, and adequate levels of school-night sleep have been shown to associate with lower suicidal ideation [16] , anxiety [17] , and depressive symptoms in adolescents [18] . however, only a few studies have thoroughly examined the accumulative influences of these movement behaviors within specific populations of youth [19, 20] . meeting recommendations for all 24-hour movement behaviors may be associated with a significantly lower probability of poor mental health compared to that when just meeting one movement recommendation. within the u.s., much research has focused on health behaviors and health outcomes in youth residing within the lower 48 states. adolescents within the u.s. state of alaska have not been as well researched, especially on the links between movement behaviors and mental health outcomes [21] . alaskan adolescents reside in unique climates that may not be conducive to achieving recommended levels of physical activity, screen time, and school-night sleep. temperatures in alaska tend to be colder than temperatures observed within the lower 48 states, especially within the sub-artic and arctic climate regions, and alaskan daylight hours during the winter months are fewer due to its geographical location within the northern hemisphere [22] . therefore, patterns of movement-based behaviors of alaskan youth may be different compared to those of youth residing within the lower 48 states. the alaskan demographic is also characterized by having a higher proportion of youths who are of american indian and alaskan native race/ethnicity [23] . these youths have been found to have a higher prevalence of mental health issues compared to youth within the general u.s. population [21] . the examination of movement behaviors within this specific pediatric population is lacking. furthermore, feelings such as loneliness and sadness can contribute to mental health issues such as depression, personality disorders, and alzheimer's disease [24, 25] . sadness tends to share the same clinical correlates as major depressive disorder [25] . examining the association between movement-based behaviors and these mental states can provide important evidence for potential protective effects within a unique sample of alaskan youth that can be used in future school-and community-based intervention efforts. therefore, the purpose of this study was to examine the associations of movement-based behaviors with loneliness and sadness within a sample of alaskan adolescents. the sample's demographic characteristics are presented in table 1 . the average age of the sample was 15.8 ± 1.3 years old. the sex distribution was approximately homogenous with the majority of the sample being non-hispanic whites. american indians and alaskan natives comprised of nearly one-quarter of the sample, with a weighted prevalence of nearly one-third of the sample. based on self-reported height and weight, the average body mass index (bmi) was 23.6 ± 5.2 kg/m 2 . using the 2000 centers for disease control and prevention (cdc) bmi-for-age growth charts, the average bmi z-score was 0.61 ± 0.96. the alaska youth risk behavior survey (yrbs) is part of a data collection system established by the centers for disease control and prevention (cdc) in 1990, which was first implemented in alaska in 1995. the yrbs includes questions on current health and risk behaviors such as physical activity; nutrition; tobacco, alcohol, and drug use; safety, violence, and bullying; suicide; sexual behaviors; and connections with peers, adults, and the community. the alaska yrbs is an anonymous and voluntary survey of students in grades 9-12 in public schools and is administered throughout the state of alaska in odd-numbered years. the 2019 alaska yrbs response rates yielded 39 out of 43 (91%) sampled traditional high schools and 1897 of 2824 (67%) sampled traditional high school students. the overall response rate was 61% (91% × 67%). the procedures for collecting yrbs data on human subjects were approved by cdc's institutional review board (#1969.0). parental written consent was obtained prior to data collection on a respective alaskan adolescent [23] . the alaska statewide traditional high school sample includes students in traditional public high schools with an enrollment of at least 10 students. the sample excluded boarding, correspondence, home study, alternative, and correctional schools. adolescents were selected using a two-stage cluster sample design. the first stage consisted of selecting schools with a probability proportional to the school enrollment size. the second stage consisted of randomly selecting classes within each school. the alaska yrbs statewide data are weighted by sex within race/ethnicity. alaskan yrbs data are representative of all alaska traditional high school students [23] . there were two separate outcome variables within the current study consisting of perceived loneliness and prolonged sadness. the perceived loneliness item stated, "i feel alone in my life" with 5-point likert-type responses ranging from "strongly agree" to "strongly disagree". the perceived loneliness item was recoded as 0 = not sure, disagree, and strongly disagree and 1 = agree and strongly agree for analysis. the prolonged sadness item asked, "during the past 12 months, ever feel so sad for two weeks or more and stop usual activities?" with a binary yes/no response. the prolonged sadness item was recoded as 0 = no and 1 = yes for analysis. four binary coded movement-based behaviors were the predictor variables, specifically derived from items asking about the weekly frequency of 60 min of physical activity per day, weekly frequency of muscle strengthening activity, hours per day of television watching and non-academic computer screen use, and hours of school-night sleep. the physical activity binary predictor was derived by combining the 60 min of physical activity per day item and the muscle strengthening item (0 = did not meet both recommendations, 1 = met both recommendations, i.e., 60 min per day of physical activity and 3 days per week or more of muscle strengthening). the screen use binary predictor variable was derived by combining the television and computer use predictors so that 0 = more than 2 h of combined screen use per day and 1 = 2 h or less per day. the sleep duration binary predictor was coded as 0 = less than 8 h per school night and 1 = 8 or more hours per school night. these cut-points were based off of current 24-hour movement-based recommendations for physical activity, screen use, and sleep [1, 2] . the complex yrbs survey design, including assigned stratum and primary sampling unit, was accounted for using stata's "svyset" prefix command. missing data were not imputed. weighted analyses used the taylor series linearization variance estimation. for all categorical variables, unweighted and weighted prevalence statistics were reported. to examine the associations between each movement-based behavior and perceived loneliness and prolonged sadness, weighted logistic regression models were employed. separate models were employed for each outcome variable. crude and adjusted parameter estimates (odds ratios) with 95% confidence intervals (cis) were calculated and reported. within the adjusted models, age, sex, race/ethnicity, and bmi z-scores were included as covariates to adjust for potential confounding influences. additional analyses consisted of examining the relationship between meeting accumulative (0 to 3) healthy movement-based behavior recommendations and the odds of perceived loneliness and prolonged sadness. a healthy movement-based behavior composite variable was derived by adding intraindividual counts of meeting recommendations of movement-based behaviors (i.e., physical activity, screen use, sleep). a weighted logistic regression model was then run using the derived composite variable as the primary predictor, adjusting for age, sex, race/ethnicity, and bmi z-scores. the reference level for comparison was meeting 0 movement-based recommendations. to determine specific joint associations, a final analysis was employed testing possible two-way and three-way interactions on both perceived loneliness and prolonged sadness. meeting no recommendations was again used as the reference level. all analyses had an alpha level of p < 0.05 and were carried out using stata v15.0 statistical software package (statacorp, college station, tx, usa). table 2 presents the descriptive statistics for perceived loneliness, prolonged sadness, and movementbased behaviors. approximately 20.9% of the sample did not meet any movement recommendations, 49.7% met 1 recommendation, 24.4% met 2 recommendations, and 5.0% of the sample met all 3 movement recommendations. the relationships between movement-based behaviors, perceived loneliness, and prolonged sadness are presented in tables 3 and 4 , respectively. within the adjusted models, sleeping for at least 8 h per school night was significantly associated with lower odds of perceived loneliness (or = 0.43, 95% ci: 0.24-0.75, p = 0.004) and lower odds of prolonged sadness (or = 0.48, 95% ci: 0.33-0.70, p < 0.001). physical activity and screen use were not significantly associated with either outcome within the adjusted models. across the number of met movement behavior recommendations. referent level is meeting 0 movement recommendations; models adjusted for age, sex, race/ethnicity, and bmi zscore; * denotes statistical significance, p < 0.05. table 5 presents the joint associations for predicting perceived loneliness and prolonged sadness. all joint effects including meeting sleep duration recommendations significantly predicted perceived loneliness (p < 0.05). all joint effects including meeting screen use recommendations significantly predicted prolonged sadness (p < 0.05). table 5 . joint associations for predicting perceived loneliness and prolonged sadness. recommendations met adjusted or 1 (95% ci) figure 1 . odds ratios for predicting perceived loneliness (a) and prolonged sadness (b) across the number of met movement behavior recommendations. referent level is meeting 0 movement recommendations; models adjusted for age, sex, race/ethnicity, and bmi z-score; * denotes statistical significance, p < 0.05. table 5 presents the joint associations for predicting perceived loneliness and prolonged sadness. all joint effects including meeting sleep duration recommendations significantly predicted perceived loneliness (p < 0.05). all joint effects including meeting screen use recommendations significantly predicted prolonged sadness (p < 0.05). the purpose of this study was to examine the associations of movement-based behaviors with perceived loneliness and prolonged sadness within a sample of alaskan adolescents. the results indicated that school-night sleep duration was the only single movement behavior that was significantly associated with perceived loneliness and prolonged sadness. however, the derived composite movement behavior predictor variable was significantly associated with both perceived loneliness and prolonged sadness in a dose-dependent manner. joint association analyses determined that the accumulative relationships were primarily driven by meeting the sleep recommendation for loneliness and meeting the screen use and sleep recommendations for sadness. the results indicate that there may be an additive effect of these movement behaviors that when considered together can serve as protection against perceived loneliness and prolonged sadness in alaskan adolescents. interpretations of these findings and implications for alaskan school and community health programming are provided further. a primary finding from the current study was that sleep was the only single movement-based behavior that was significantly associated with both perceived loneliness and prolonged sadness in alaskan adolescents. studies have shown that both quantity and quality of sleep correlate with mental health outcomes in adolescents [26] [27] [28] . interestingly, subjective sleep markers have been found to be more consistent and common across pediatric mental health disorders than objective sleep measures [29] . proposed mechanisms as to why poor sleep is associated with mental health disturbances include reduced latency to rapid eye movement (rem)sleep, high sleep onset latency, and a high number of sleep arousals [29] [30] [31] . adolescents with depression have showed higher peri-sleep onset of the stress hormone cortisol [32] . children and adolescents with anxiety show higher bedtime fears and greater wake after sleep onset durations [30] [31] [32] . although the items used in the current study did not specifically examine anxiety and depression, loneliness and sadness may be associated with these mental health disorders [33, 34] , making it plausible that similar physiological and behavioral mechanisms are involved in the association between sleep, loneliness, and sadness. even though school-night sleep duration significantly correlated with loneliness and sadness, the movement behaviors of physical activity and screen use did not correlate within any of the adjusted models. in a longitudinal study using a cohort of 928, 12-to 13-year-old youths from england, no significant association was found between objectively measured physical activity at baseline and mental well-being assessed 3 years later [35] . additionally, a recent review has indicated that physical activity may have significant but small associations with anxiety in adolescents [36] . a review of longitudinal studies examining the association between physical activity and loneliness yielded mixed findings, with only a few studies showing a direct inverse relationship between the two constructs and other studies showing indirect effects with mediated mechanisms [37] . within the current study, physical activity was associated with loneliness and sadness within the crude models, but after covariate adjustment, these significant associations were not present. at least within the general alaskan adolescent population, self-reported physical activity does not seem to be a significant correlate of loneliness and sadness. the prevalence of meeting screen use recommendations in the current sample of alaskan adolescents is much higher (>50%) compared to that among other population-based studies. for example, using the canadian compass survey, only 6.4% of students within grade 9 met screen use recommendations [38] . it is unclear why the prevalence of meeting screen use recommendations in alaskan adolescents is so much higher than that among other populations. this may be due to a relative lack of access to television and/or computer screens/devices within the home environment, possibly related to socioeconomic status, although this information is not collected on the yrbs. it may also be associated with cultural differences, especially within the american indian and alaskan native population. nevertheless, another recent alaskan descriptive survey indicated that adolescent screen use during covid-19 is drastically higher than that before covid-19 [39] . even though the prevalence of meeting screen use recommendations from the 2019 alaskan yrbs is relatively high, excessive screen use in this population is still a major concern, especially within the current covid-19 climate. again, concerning screen use, the null findings relating screen use with mental health outcomes from the current study do conflict with past survey-based research. using the parent-reported national survey of children's health, it was found that more than 1 hour of screen use per day was associated with lower psychological well-being, including less curiosity, lower self-control, more distractibility, more difficulty making friends, less emotional stability, being more difficult to care for, and inability to finish tasks among a large representative sample of children and adolescents [40] . additionally, other authors have observed time-varying associations between social media use, television watching, and depression in adolescents [18] . data from the global school-based student health survey indicates that being sedentary for more than 8 h per day was associated with a twice-as-high risk for feeling lonely among a large sample of adolescents [41] . within the current study, even though television watching, and computer use did not significantly associate with either loneliness or sadness within the adjusted models, point estimates do suggest perhaps some protective effect. the lack of statistical significance may be due to large variability within the alaskan sample. this variability may be due to distinct cultural differences among the racial/ethnic groups within the alaskan population, large variation in socioeconomic status within the alaskan population, and/or possibly, self-report measurement issues. because the yrbs is self-report based and social desirability bias is possible, a larger sample size may yield statistical associations between screen use variables, loneliness, and sadness. an important secondary finding within the adjusted model was that american indian and alaska native adolescents had higher odds of reporting prolonged sadness compared to non-hispanic white adolescents. this specific finding is in accordance with information presented in other work and stresses the importance of deriving potential future multi-behavioral health programming within this pediatric population [21] . the most salient finding from the current study was that a movement-based behavior composite variable correlated with both perceived loneliness and prolonged sadness in a dose-dependent manner. joint association analyses determined that these relationships were primarily driven by meeting sleep recommendations for loneliness and meeting screen use recommendations for sadness. other studies have shown that movement-based behaviors may have additive effects on mental health outcomes within the pediatric population. zhu et al. [19] found that meeting recommendations for physical activity, screen use, and sleep yielded lower odds of anxiety in children and lower odds of depression in adolescents using the parent-reported nation survey of children's health. sadness and depression are closely linked; therefore, the current study's findings support this previous work. ogawa et al. [20] found significant joint effects between physical activity and sleep on anxiety and depression using an adolescent sample of japanese adolescents. using data from the u.k.-millennium cohort study, pearson et al. [42] found that only 9.7% of the sample met concurrent recommendations for physical activity, screen use, and sleep. pearson et al. [42] also found that adolescent boys who were obese and those with depressive symptoms were significantly less likely to meet all three movement recommendations. within the current study, the aggregate movement behavior variable correlated more strongly with prolonged sadness than with perceived loneliness. this finding is in accordance with the aforementioned previous work, assuming self-reported prolonged sadness and depression are related. the current study also provides some evidence of a dose-response mechanism, although only a small proportion of the alaskan adolescent sample met all three movement recommendations (approximately 5%), making it difficult to draw definitive conclusions regarding the form of the relationship. it is concerning that over a quarter of adolescents who took part in this study reported feelings of perceived loneliness and even more reported feelings of prolonged sadness. both loneliness and prolonged sadness have been linked to more serious issues in adolescents, including anxiety, depression, and suicidal ideation. in a recent meta-analysis, maes et al. [43] found a strong, positive cross-sectional association between loneliness and social anxiety and also found that this relationship held over time when considering the associations longitudinally. another recent meta-analysis found that loneliness was a significant predictor of suicidal ideation/behavior and that being aged 16-20 years increased the likelihood that the relationship between loneliness and suicidal ideation would be significant [44] . having feelings of sadness has also been linked to myriad risk behaviors among adolescents including binge drinking, gang membership, suicidal ideation, and suicide attempt [45] . while our study did not investigate these other risk behaviors, it is important to understand the wide range of implications that perceived loneliness and/or prolonged sadness might have on alaskan youth. additionally, as more schools transition from face-to-face instruction to online formats during the current covid-19 pandemic, it is imperative that youth who already experience feelings of loneliness and/or prolonged sadness receive the support they need. the findings also have important implications for schools. during adolescence, circadian rhythms change, which leads to later sleep and wake times [46] . as a result, the american academy of sleep medicine recommends school starts times of 8:30 a.m. or later [47] , which is supported by a growing body of literature highlighting how later school start times are correlated to increases in sleep times [48] . beets and colleagues [49] suggest that most physical activity interventions that are successful fall into one (or more) of three categories: providing new opportunities for youth to be active (expansion), increasing the time available for youth to be active (extension), or improving the opportunity beyond what is typically offered (enhancement). more specifically, schools and community programs should focus on providing additional or expanded physical activity opportunities for youth that are innovative, well equipped, and of interest to the participants are more likely to change/increase physical activity behaviors. increasingly, screen time is an important component of daily life for many adolescents. parents and youth must work together to identify rules, limits, and a monitoring system to change screen behaviors [50] to possibly mitigate detrimental effects on mental health. strengths of this study include use of a representative of alaskan traditional high school students, the examination of accumulated movement behaviors, and examining two mental health states, loneliness and sadness, that are pertinent within the current covid-19 social/physical distancing climate. limitations to this study includes the use of a cross-sectional research design that precludes cause-and-effect inferences and manifests concerns regarding the true directionality of the observed associations. additionally, this study used adolescent self-report for all variables that were collected; therefore, social desirability bias may have mitigated the validity of the responses. the use of crude assessment tools may also attenuate the validity of the findings. third, all of the movement predictor variables were dichotomized for analysis, which may lead to loss of information from the original measurement scale. fourth, the 24-hour movement guideline for sleep has an upper limit of 10 h per night for adolescents 14 years old and older. the 2019 yrbs does not assess specific hours of sleep over 10 h per night, precluding analysis of the influence of engaging in excessive sleep durations on loneliness and sadness. fifth, it is likely that other variables, such as socioeconomic status, which was not collected on the yrbs, may be an important effect modifier. finally, the 2019 alaskan yrbs only asked respondents about physical activity frequency, not intensity, and only asked about sleep quantity, not quality, which may play a very important role in the association with adolescent loneliness and sadness. in conclusion, school-night sleep duration was significantly associated with perceived loneliness and prolonged sadness. additionally, a movement behavior composite variable was significantly associated with perceived loneliness and prolonged sadness in a dose-dependent manner. these joint relationships were primarily driven by meeting sleep recommendations for loneliness and meeting screen use and sleep recommendations for sadness. these results communicate the importance of considering multiple movement behaviors when examining determinants of adolescent mental health. the findings also highlight the need to infuse multi-behavioral health programming for alaskan adolescents, with particular cultural considerations for american indian and alaskan native students. meeting multiple movement behavior recommendations show promise for facilitating good mental health in alaskan adolescents. canadian 24-hour movement guidelines for children and youth: an integration 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components of canada's new 24-hour movement guidelines over time in the compass study survey reveals alaska children are playing less during the pandemic, which is concerning for their physical and mental health/play every day blog. alaska department of health and social services division of public health website associations between screen tie and lower psychological well-being among children and adolescents: evidence from a population-based study leisure-time sedentary behavior and loneliness among 148,045 adolescents aged 12-15 years from 52 low-and middle-income countries prevalence and correlates of meeting sleep, screen-time, and physical activity guidelines among adolescents in the united kingdom loneliness and social anxiety across childhood and adolescence: multilevel meta-analyses of cross-sectional and longitudinal associations loneliness as a predictor of suicidal ideation and behaviour: a systematic review and meta-analysis of prospective studies the association between adolescent risk behaviours and feelings of sadness or hopelessness: a cross-sectional survey of south african secondary school learners sleep, circadian rhythms, and delayed phase in adolescence delaying middle school and high school start times promotes student health and performance: an american academy of sleep medicine position statement later high school start times associated with longer actigraphic sleep duration in adolescents the theory of expanded, extended, and enhanced opportunities for youth physical activity promotion reducing youth screen time: qualitative meta-synthesis of findings on barriers and facilitators the authors would like to thank the alaskan adolescents who participated in the 2019 yrbs. the authors would also like to thank the alaskan department of health and social services, division of public health for providing the datasets and codebook for secondary data analysis of the 2019 alaska yrbs. the authors declare no conflict of interest. key: cord-340889-ff35696d authors: ko, nai-ying; lu, wei-hsin; chen, yi-lung; li, dian-jeng; chang, yu-ping; wu, chia-fen; wang, peng-wei; yen, cheng-fang title: changes in sex life among people in taiwan during the covid-19 pandemic: the roles of risk perception, general anxiety, and demographic characteristics date: 2020-08-11 journal: int j environ res public health doi: 10.3390/ijerph17165822 sha: doc_id: 340889 cord_uid: ff35696d this study used data collected from an online survey study on coronavirus disease 2019 (covid-19) in taiwan to examine changes in sex life during the pandemic and the factors affecting such changes. in total, 1954 respondents were recruited from a facebook advertisement. the survey inquired changes in sex life during the pandemic, including satisfaction with the individual’s sex life, frequency of sexual activity, frequency of sex-seeking activity, and frequency of using protection for sex. the associations of change in sex life with risk perception of covid-19, general anxiety, gender, age, and sexual orientation were also examined. for each aspect of their sex life, 1.4%–13.5% of respondents reported a decrease in frequency or satisfaction, and 1.6%–2.9% reported an increase in frequency or satisfaction. risk perception of covid-19 was significantly and negatively associated with frequencies of sexual and sex-seeking activities. higher general anxiety was significantly and negatively associated with satisfaction of sex life and frequencies of sexual and sex-seeking activities. sexual minority respondents were more likely to report decreased satisfaction with sex life and frequencies of sexual activity and sex-seeking activities during covid-19. health care providers should consider these factors when developing strategies for sexual wellness amid respiratory infection epidemics. covid-19 emerged in wuhan, china, at the end of 2019 and has been spread to over 200 countries and territories around the world, with the total number of infected cases having risen to over 14,000,000 and more than 590,000 deaths, as of 17 july 2020 [1] . given the geographical proximity and busy transportation between taiwan and china, taiwan was predicted to have the second highest number of covid-19 cases early in the outbreak [2] . after all, taiwan experienced the severe outbreak of 2002-2003 severe acute respiratory syndrome (sars), which also originated from china; globally, taiwan had the third highest number of sars cases, after china and hong kong [3] . the experience with sars made the taiwanese government and people vigilant against covid-19. early since december 31, 2019, taiwanese officials began to assess passengers on direct flights from wuhan for fever and pneumonia symptoms before passengers could deplane. the first covid-19 case in taiwan was confirmed on 21 january 2020 [4] . during the period from january 20 to february 24, the taiwan centers for disease control rapidly produced and implemented a list of at least 124 action items including border control, case identification, quarantine of suspicious cases, proactive case finding, resource allocation, reassurance and education of the public while fighting misinformation, negotiation with other countries and regions, formulation of policies toward schools and childcare, and relief to businesses [5] . with proactive containment efforts and comprehensive contact tracing, the number of covid-19 cases in taiwan remained low, as compared with other countries that had widespread outbreaks [6] . therefore, there was no social lockdown in taiwan. as of 17 july 2020, taiwan had tested a total of 79,395 persons showing 454 confirmed cases, of which only 55 were domestic. six patients died, and 440 people were released from hospital after testing negative three times subsequently [1] . the covid-19 pandemic results in widespread and wide-ranging concerns spanning the issues of physical morbidity and mortality [2] , mental health [7, 8] , the economy [9] , education [10] , and interpersonal relationships [11] . sexual health in the context of the pandemic, however, warrants investigation [12] . according to the world health organization, sexual health is a state of physical, mental, and social well-being in relation to sexuality [13] ; sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious, and spiritual factors [13] . accordingly, it is reasonable to hypothesize that sex life would be deeply influenced by the impacts of the covid-19 pandemic on personal and environmental levels. regarding the personal level, all forms of in-person sexual contact carry the risk of viral transmission [12] . people may abstain from sexual intercourse because they fear contracting covid-19. the covid-19 pandemic may adversely influence individuals' mental and physical health [2, 7, 8] and further compromise sex life. regarding the environmental level, the pandemic prevention measures of social distancing may jeopardize an individual's sex life. governments of many countries ordered to close down gathering spaces and promote social distancing to prevent the spread of covid-19. not being able to physically meet with others may change people's sexual habits [14] . a social atmosphere of collective anxiety about the covid-19 pandemic may also result in detriment of the mood to enjoy sex. conversely, yuksel and ozgor proposed people may spend more time at home during the covid-19 pandemic and therefore increase the frequency of sexual behaviors with their partners [15] . a few studies have examined the effect of the covid-19 pandemic on sexual behaviors. a study comparing sexual behaviors among turkish women during the pandemic with 6-12 months prior to the pandemic found that sexual desire and frequency of intercourse significantly increased during the covid-19 pandemic, whereas quality of sexual life significantly decreased; the pandemic is associated with decreased desire for pregnancy, decreased female contraception, and increased menstrual disorders [15] . an online study in three south-east asian countries (bangladesh, india, and nepal) found that although 45% of the participants reported that the lockdown affected their sexual life, there was no substantial difference in sexual activity between before and during the lockdown period of the covid-19 pandemic [16] . however, the study of yuksel and ozgor focused on women and did not examine sexual behaviors in men [15] . the sample size in the study of arafat et al. was small (120 respondents) [16] . given the importance of sexuality to health, further study is needed to examine how the covid-19 pandemic has changed peoples' sex life and what factors are associated with such change [12] . risk perception of covid-19 may influence individuals' engagement in sexual activity during the pandemic. risk perception of covid-19 refers to people's intuitive evaluations of how likely they are to contract covid-19 [17] . according to stage theory, risk perception acts as a trigger for precautionary action [18] . leung et al. reported that people with higher risk perceptions of severe acute respiratory syndrome (sars) were more likely to take comprehensive precautionary measures against infection [19] . the fear of contagion itself may reduce physical contact within couples, from simple kissing to full sexual intercourse [14] . if the risk perception is excessive, particularly when a person is overwhelmed with negative sars-related information, it will lead to irrational fear [20] . psychological disturbances, such as anxiety and depression, may also reduce satisfaction with an individual's sex life and increase sexual dysfunction [21, 22] . the prevalence of anxiety symptoms was high among the public during the sars [23] and covid-19 outbreaks [24] . both risk perception and anxiety can result in psychological stress. stressful lifestyle is a factor that may negatively impact people's sexual desire, though the results of previous studies were mixed [25] [26] [27] . given that the covid-19 is a novel respiratory infectious disease resulting in global impacts on human lives worldwide, additional studies are required on whether risk perception of covid-19 and general anxiety are significantly associated with changes in sex life during the covid-19 pandemic. gender and age have been found to influence the degree of sex-related quality of life. forbes et al. reported that unlike quality of life in other life domains [28] , sex-related quality of life tends to decline with age. pinxten and lievens also noted a considerable gender gap in the propensity to engage in sexual activity [29] , with this gender gap throughout the life course being smaller in more gender-equal societies. the roles of gender and age in changes in sex life during epidemics of novel infectious diseases, such as sars, ebola, or h1n1 influenza, have yet to be examined. in addition to gender and age, sexual orientation should also be analyzed as an influence on changes in sex life during epidemics. a study hypothesized that in times of a pandemic when people are particularly susceptible to mental health difficulties, messaging that frames sex as being dangerous has adverse psychological effects [12] . there is no evidence that the covid-19 can be transmitted via either vaginal or anal intercourse; however, there is evidence of oral-fecal transmission of the covid-19 and that implies that anilingus may represent a risk for infection [30] . in this case, sexual stigma may have a negative role for sex life of sexual minority individuals [12] . from a historical perspective, human immunodeficiency virus and acquired immunodeficiency syndrome (aids) was conceived of as a "gay plague," by analogy with the sudden, devastating epidemics of the past [31] . considering the historical trauma of the aids epidemic, sexual minority individuals may voluntarily or involuntarily restrict their sex life. in addition to sexual stigma, sexual minority individuals may experience more severe impacts of the covid-19 pandemic on their daily lives. a study on 1051 men who have sex with men (msm) in the united states found that most of the participants had no change in condom access or use, many participants had adverse impacts of the covid-19 pandemic to general wellbeing, social interactions, money, food, drug use, and alcohol consumption; especially many reported fewer sex partners and covid-19-related barriers to hiv and sexually transmitted diseases testing, pre-exposure prophylaxis access, and hiv treatment [32] . the authors also suggested that additional studies of covid-19 epidemiology among sexual minority populations are needed [32] . whether the covid-19 pandemic has affected the sex lives of sexual minority individuals differently than that of their heterosexual counterparts warrants further study. the online survey study on covid-19 in taiwan was conducted to assess the life experiences of people in taiwan during the covid-19 outbreak. the survey examined changes in sex life, including satisfaction with the individual's sex life, frequency of sexual activity, frequency of sex-seeking activity, and frequency of using protection for sex. the present study used data from this survey to examine three issues. first, we compared changes in sex life prior to and during the covid-19 pandemic. second, we examined the associations of gender, age, sexual orientation, risk perception of covid-19, and general anxiety with changes in sex life. third, we determined what the moderators are in the associations between the aforementioned factors and changes in sex life. participants were recruited through a facebook advertisement from april 10 to 20, 2020. during the study period, the total number of confirmed cases contracting covid-19 in taiwan increased from 382 to 422 without no new deaths. of the 40 newly confirmed cases, only 1 was domestic. it indicated that this study was conducted during the period of covid-19 mitigation in taiwan. however, a collective covid-19 infection among the members of the navy serving on a three-ship fleet broke out during the period. meanwhile, the total number of infected cases all over the world massively increased to nearly 800,000. the domestic and foreign situations intensified worry about covid-19 among people in taiwan. facebook users were eligible for this study if they were at least 20 years of age and living in taiwan. the facebook advertisement included a headline, main text, pop-up banner, and link to the research questionnaire website. we designed the advertisement to appear in the facebook users' "news feeds," which is a continually updated list of updates from advertisers and the user's connections (such as friends and the facebook groups that they have joined). our advertisement was placed only in the targeted users' news feed, rather than other advertising locations (e.g., right-hand column), on facebook because news feed advertisements are most effective in recruiting research respondents [33] . we targeted the advertisement to facebook users by location (taiwan) and language (chinese), where facebook's advertising algorithm determined which users to show our advertisement to. to ensure that sexual minority individuals were recruited, we also posted the link of the facebook advertisement to the facebook pages of three taiwanese health promotion and counseling centers for lesbian, gay, and bisexual individuals. this study was approved by the institutional review board (irb) of kaohsiung medical university hospital (kmuhirb-exempt(i) 20200011). because participation was voluntary and survey responses were anonymous, the irb ruled that this study did not require informed consent. our study respondents were given no incentive for participation. we provided links to covid-19 information from the taiwan centers for disease control (taiwan cdc), kaohsiung medical university hospital, and medical college of national cheng kung university for respondents to learn more about covid-19. the survey comprised the following sections. we measured four aspects of self-reported changes in sex life using four questions, which were adopted from a previous study's questionnaire on an individual's sex life [34] . first, change in satisfaction with sex life was asked about in "compared with that before the covid-19 outbreak, how has your satisfaction with sex life changed in the past 1 month?" second, change in sexual activity was asked about in "compared with that before the covid-19 outbreak, how has your sexual activity changed in the past 1 month?" third, change in sex-seeking activity was asked about in "compared with that before the covid-19 outbreak, how has your sex-seeking activity, such as using dating apps or visiting a sex worker, changed in the past 1 month?" fourth, change in using protection for sex was asked about in "compared with that before the covid-19 outbreak, how has your use of protection during sex, such as wearing a condom or taking pre-exposure prophylaxis, changed in the past 1 month?" each question was rated as 0 (obviously decreased), 1 (slightly decreased), 2 (no change), 3 (slightly increased), and 4 (obviously increased). to measure risk perception of covid-19, we used the 5-item questionnaire that was developed by liao and colleagues to measure worry toward h1n1 influenza [35] . the first question was "if you were to develop flu-like symptoms tomorrow, you would be ___," where respondents filled in the blank with a number from 1 (not at all worried) to 5 (extremely worried). the second question was "in the past 1 week, have you ever worried about getting covid-19?" this question was scored from 1 (no, i have never thought about it) to 5 (i worry about it all the time). the third question was "please rate the current level of your worry toward covid-19." this question was rated from 1 (very mild) to 10 (very severe). the fourth question was "how likely do you think it is that you will contract covid-19?" this question was scored from 1 (never) to 7 (certain). the fifth question was "what do you think are your chances of getting covid-19 over the next 1 month compared with others outside your family?" this question was rated from 1 (not at all) to 7 (certain). the scores for the first two, the third, and the last two questions were divided by 5, 10, and 7, respectively. these five quotients were then summed to obtain a score representing the level of risk perception of covid-19, with higher scores indicating greater risk perception. cronbach's α was 0.759 for this measure. general anxiety in the past 1 week was measured using a previously validated state anxiety scale from the state-trait anxiety inventory wherein respondents rate their feelings in response to 10 general statements; these statements inquire into feelings of being rested, contented, comfortable, relaxed, pleasant, anxious, nervous, jittery, highly strung, and over-excited and "rattled" [35] [36] [37] . each question was rated as 1 (not at all), 2 (sometimes), 3 (moderately so), and 4 (very much so). statements reflecting positive feelings were reversely coded. a higher total score of the 10 items represented greater general anxiety. the cronbach's α was 0.921 for this measure. data on sexual orientation (heterosexual, homosexual, bisexual, pansexual, asexual, or unsure), gender (female and male), and age were collected. respondents were categorized into heterosexual and sexual minority individuals. data analysis was performed using the statistical software spss (version 22.0; spss inc., chicago, il, usa). we noted the percentages of participants reporting no change, an increase, and a decrease for changes in each aspect of their sex life. the associations of changes in each aspect of sex life with sexual orientation, gender, age, risk perception of covid-19, and general anxiety were examined using multivariate logistic regression. the p value, odds ratio (or), and 95% confidence interval (ci) were used to indicate significance. a two-tailed p value of <0.05 indicated statistical significance. moreover, the moderators of the associations between sexual orientation and changes in sex life were examined based on the criteria proposed by baron and kenny [38] . the data of 533 sexual minority and 1421 heterosexual individuals were analyzed, with 77 of the initial 2031 respondents excluded due to missing data. among sexual minority respondents, 320 identified as homosexual, 164 identified as bisexual, and 49 identified as pansexual, asexual, or unsure. table 1 presents descriptive statistics for demographic characteristics, risk perception of covid-19, general anxiety, and changes in sex life among respondents. the mean age was 37.9 years (standard deviation [sd] = 10.8 years); and 66.8% were female. the mean scores for risk perception of covid-19 and general anxiety were 2.9 (sd = 0.7) and 23.1 (sd = 6.6), respectively. as for changes in sex life, respondents reported decreases in their satisfaction with their sex life (13.4%), their sexual activity (13.5%), their sex-seeking activity (6.7%), and their use of protection for sex (1.4%) during the covid-19 pandemic. by contrast, respondents reported increases in their satisfaction with their sex life (1.9%), their sexual activity (2.9%), their sex-seeking activity (1.9%), and their use of protection for sex (1.6%) during the covid-19 pandemic. table 2 presents the multivariate logistic regression results for the associations of changes in each aspect of sex life (dependent variables) with sexual orientation, gender, age, risk perception of covid-19, and general anxiety (independent variables). the results indicated that decreased satisfaction with sex life was significantly associated with being male, being a sexual minority, and having a higher level of general anxiety; no factor was significantly associated with increased satisfaction with sex life. regarding frequency of sexual activity, decreased frequency was significantly associated with being male, being a sexual minority, having a higher risk perception of covid-19, and having greater general anxiety; increased frequency was significantly associated with being male, being younger, and having a lower risk perception of covid-19. regarding frequency of sex-seeking activity, decreased frequency was significantly associated with being male, being a sexual minority, having a higher risk perception of covid-19, and having greater general anxiety; increased frequency was significantly associated with being male and being a sexual minority. finally, being male was significantly associated with both decreased and increased frequency of the use of protection for sex. the product interaction terms between gender, age, sexual orientation, risk perception, and general anxiety that were significantly associated with each aspect of change in sex life were selected into multiple logistic regression models to examine the moderators ( table 3 ). the results indicated that the interaction between gender and sexual orientation was significantly associated with decreased frequencies of sexual activity and sex-seeking activity. further analysis revealed that the significant association between being sexual minority and decreased frequency of sexual activity was only true for men (or = 2.466, 95% ci: 1.573-3.868, p < 0.001) but not for women (or = 1.098, 95% ci: 0.690-1.748, p = 0.692). moreover, the significant association between being a sexual minority and decreased frequency of sex-seeking activity was only true for men (or = 7.281, 95% ci: 3.975-13.339, p < 0.001) but not for women (or = 1.983, 95% ci: 0.988-3.978, p = 0.054). most respondents reported no change in their sex life during the covid-19 pandemic, whereas 13.4% reported the decrease satisfaction with their sex life, 13.5% decreased sexual activity, 6.7% decreased sex-seeking activity, and 1.6% reported the increased use of protection for sex. by contrast, 1.9% reported the increased satisfaction with their sex life, 2.9% increased sexual activity, 1.9% increased sex-seeking activity, and 1.4% reported the decreased use of protection for sex. sexuality is a central aspect of human health [12] . considering the ineffectiveness of recommendations of long-term sexual abstinence [39] , health care providers should consider counseling people on their sexual health whenever possible to help them maintain or even improve their sexual wellness amid the covid-19 pandemic; in general, the human need for intimacy should be balanced with personal safety and pandemic control [12] . further study is also warranted to understand the psychological mechanisms underlying sexuality during a pandemic. although only 1.4% of respondents reported the decreased use of protection for sex in the present study, the increased risk of contracting covid-19 and sexually transmitted diseases should also be investigated in people who engage in sexual activity more but use protection less during the pandemic. the present study found that risk perception, general anxiety, gender, age, and sexual orientation related to various aspects of changes in sex life during the covid-19 pandemic. firstly, a higher risk perception of covid-19 was significantly associated with decreased frequencies of sexual activity and sex-seeking activities. because in-person sexual contact carries the risk of covid-19 transmission [12] , we can hypothesize that people with a high risk perception of covid-19 reduce their sexual activity, whether casual or with long-term partner, as a means to protect themselves against getting covid-19. however, leung et al. noted that the self-perceived likelihood of contracting or surviving sars did not predict personal protective behavior [36] . in addition to sexual inactivity as a personal protective behavior, other reasons may also account for the association between risk perception of covid-19 and the decreased frequencies of sexual activity and sex-seeking activities. people who perceive a high risk of covid-19 tend to invest greater time and effort to learning more about pandemic prevention and using facemasks and disinfectant alcohol. moreover, as with governments in many other countries, the taiwanese government has suspended the sex industry to prevent the spread of covid-19. this policy may have led people with a high risk perception of covid-19 to perceive having sex in general as being unsafe during the pandemic. these personal and environmental factors may have contributed to the decreased frequencies of sexual activity and sex-seeking activities during the pandemic. the present study found that higher general anxiety was significantly associated with decreased satisfaction of sex life and frequencies of sexual activity and sex-seeking activities during the covid-19 pandemic. greater general anxiety may result in less pleasurable sex or make sex difficult, which depresses a person's interest in sex; sexual dysfunction may further exacerbate anxiety [40] . however, anxiety is one of most common affective responses to the respiratory infectious disease epidemics or pandemics [41] . during the respiratory infectious disease outbreaks, social distancing and quarantine are inevitable methods to prevent spreading of the illness; however, both may precipitate anxiety [42] . thus, health care providers should help people manage their anxiety in particular and mental health in general. a study on turkish women found that despite the increased frequency of sexual intercourse during the covid-19 pandemic, quality of sexual life decreased during the pandemic [15] . the present study extends the scope of genders in participants and found that men were more likely to report a change, whether an increase or decrease, in their frequencies of sexual activity, sex-seeking activities, and use of protection for sex. a uk study also noted that men in the general population were more likely to engage in sexual activity during covid-19 self-isolation [27] . both biological and socioenvironmental factors may influence sexual behaviors across genders. research on 3-to 6-year-old children found significant gender differences in sexual behavior [43] . gender stereotypes in societies may also affect the way people behave in sexual activities [44, 45] . there might be multiple etiologies accounting for gender difference in changes of sexual activities during the covid-19 pandemic that warrant further study. moreover, research in china has demonstrated that women tend to be more psychologically affected by the covid-19 outbreak with respect to stress, anxiety, depression, and posttraumatic stress symptoms [46, 47] . the results of previous and present study indicated that the covid-19 pandemic might have various impacts on sexual activities differently compared with and psychological wellbeing, as well as that changes in sex life might not be influenced by psychological status only. younger people were noted to be at greater risk of mental illnesses, such as general anxiety disorder, during the covid-19 pandemic [24] . consistent with the aforementioned study, the present study found that older respondents were less likely to have increased sexual activity during covid-19 pandemic [48] . gender and age differences in sexual activity have already been noted by a taiwanese study before the pandemic; these differences include men being more likely to have multiple sexual partners and older people being more likely to have a lower frequency of sexual activity [49] . the results of the present study demonstrate that the covid-19 pandemic has had differential effects on sex life across gender and age. the factors that explain the reason that men are more likely to have a pandemic-induced change in their sex life-whether an increase or decrease in the aspects analyzed in this study-should be investigated further. the present study found that sexual minority respondents were more likely to report decreased satisfaction with their sex life and decreased frequencies of sexual activity and sex-seeking activities during the pandemic; a gender difference with respect to the aforementioned frequencies was also noted. sexual minority individuals have faced the threat of hiv infection since the 1980s [50] , and health information pertaining to hiv prevention and treatment strategies is transferable to knowledge on covid-19 [51] . thus, being more knowledgeable about pandemic prevention, sexual minority individuals may reduce their sexual activity, albeit at the expense of reducing their satisfaction with their sex life. however, the decreases in sexual activity could also be explained by sexual stigma, which sexual minority communities have experienced since the aids pandemic [52] . recommendations for sexual abstinence during the covid-19 pandemic may elicit memories of the widespread stigmatization of sexual minorities during the aids crisis [12] . such sexual stigma contributes to a hostile social environment against sexual minority individuals and makes mental health problems more likely [53] . sexual minority individuals may reduce their sexual activity under the interpersonal strain caused by the covid-19 pandemic. however, a group of sexual minority individuals have increased their sex-seeking activity during the covid-19 pandemic. whether this is a response to the unhappy atmosphere during the pandemic warrants further study. the present study has some limitations. first, the present study did not ask participants about their current sexual relationship status or relationship quality, which are major factors affecting people's sexual satisfaction during a pandemic like covid-19 where people's social lives may have been curtailed. sex between intimate couples can be an activity to support psychologically fragile people living in restricted areas for longer quarantine periods [54] . second, although recruiting respondents through facebook is a promising research method for targeting the general public during fast-moving infectious disease outbreaks [55] , facebook users may not be representative of the population. a review of a study that recruited respondents through facebook reported a bias in favor of women, young adults, and people with higher education and incomes [56] . third, the cross-sectional design of this study limited causal inference between changes in sex life and general anxiety. fourth, this study did not survey the various aspects of respondents' sex life before the pandemic. this study also did not follow-up on the changes in respondents' sex life during the mitigating period of the covid-19 pandemic. last, some factors such as physical health and self-confidence that might influence sex life in the covid-19 pandemic were not examined in the present study. although most respondents reported no change in their sex life during the covid-19 pandemic, 1.4%-13.5% of respondents reported a decrease and 1.6%-2.9% reported an increase in various aspects of their sex life. risk perception of covid-19, general anxiety, gender, age, and sexual orientation were associated with greater change in various aspects of an individual's sex life. considering that sexuality is a central aspect of human health, human needs for intimacy should be balanced with personal safety and pandemic control [12] . health care providers should consider the factors related to changes in sex life reported in this study when formulating strategies for maintaining sexual wellness amid respiratory infection epidemics. funding: this research did not receive any specific grant from funding agencies in the public, commercial, or nonprofit sectors. the authors declare no conflict of interest. summary of probable sars cases with onset of illness from 1 first case of coronavirus disease 2019 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intersectional effects of cohort, gender, education, and marital status marginalization and social change processes among lesbian, gay, bisexual and transgender persons in swaziland: implications for hiv prevention social and behavioral health responses to covid-19: lessons learned from four decades of an hiv pandemic journals of the plague years: documenting the history of the aids epidemic in the united states prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence covid-19 pandemic and its implications on sexual life: recommendations from the italian society of andrology use of rapid online surveys to assess people's perceptions during infectious disease outbreaks: a cross-sectional survey on covid-19 the use of facebook in recruiting respondents for health research purposes: a systematic review key: cord-306304-2yf3f1kg authors: woo, jong-min; okusaga, olaoluwa; postolache, teodor t. title: seasonality of suicidal behavior date: 2012-02-14 journal: int j environ res public health doi: 10.3390/ijerph9020531 sha: doc_id: 306304 cord_uid: 2yf3f1kg a seasonal suicide peak in spring is highly replicated, but its specific cause is unknown. we reviewed the literature on suicide risk factors which can be associated with seasonal variation of suicide rates, assessing published articles from 1979 to 2011. such risk factors include environmental determinants, including physical, chemical, and biological factors. we also summarized the influence of potential demographic and clinical characteristics such as age, gender, month of birth, socioeconomic status, methods of prior suicide attempt, and comorbid psychiatric and medical diseases. comprehensive evaluation of risk factors which could be linked to the seasonal variation in suicide is important, not only to identify the major driving force for the seasonality of suicide, but also could lead to better suicide prevention in general. several epidemiological studies have described a seasonal variation of suicide rates, with a highly replicated suicide peak in springtime [1,2]. however, recent studies have shown that the amplitude of open access the spring peak is on the decline, while new small peaks are occurring at other times of the year, especially in industrialized western countries [3, 4] . in spite of it being a well replicated phenomenon, the empirical finding of seasonal peaks in suicide is poorly understood. to date many risk factors for suicide have been reported and they can be categorized by demographic, social and clinical characteristics. such risk factors include age, gender, rural/urban area of residence [5] , race [6] , month of birth [7] , socioeconomic factors [8] , marital status [9] , inter-personal relationships or life events [10, 11] , comorbid medical conditions, current or history of psychiatric illness [12] , allergy [13] , and most importantly, previous suicide attempts and violent methods of prior suicide attempt [2, 14] . physical environmental factors, e.g., sunshine, temperature [15] , chemical (e.g., air pollutants) [16] and biological factors such as viruses [17] , parasites such as toxoplasma gondii, and aeroallergens [18, 19] have also been associated with suicide risk. among the numerous risk factors for suicide, it is important to define those that are fluctuating, modifiable, and potentially treatable. since the seasonal fluctuation in suicide has become a recognized and significant phenomenon, it is desirable to identify variables that consistently demonstrate an association with the seasonal variation of suicidal behaviors as well as completed suicide. for example, environmental factors such as the amount of sunshine and distribution of aeroallergens vary with the seasons. moreover, clinical variables such as allergic illness, viral infections and mood disorders also manifest seasonal variations and such variations could potentially be associated with the seasonal variation of suicide rate. a better understanding of the underlying mechanisms responsible for the seasonal variations in suicide could lead to improved and novel suicide prevention strategies. therefore we comprehensively evaluated published papers, focusing on the potential association between suicide risk factors and seasonal fluctuation of suicide completion in various demographic groups and geographic locations. we also discuss the presence of seasonality of suicide, the strength and the clinical implication of the association for each risk factor. this is a comprehensive narrative review of journal papers on suicide seasonality published from 1979 to 2011. we carried out a comprehensive search of pubmed/medline (1979-2011) using the keywords: "suicide" and "seasonality", cross-referenced with the terms "age", "gender", "methods of suicide", "socioeconomic status", "sunshine", "temperature", "geographic region", "comorbid disease", "allergy", "mental illness", "infection", and "cytokine". after we had identified potential publications of interest we read through the titles and abstracts and those selected were subsequently reviewed and categorized by suicide risk factors of interest. we only included articles in english. among those, reports dealing with seasonality or monthly fluctuation were taken to review the relationship between seasonality and suicide. environmental factors have been considered as possible mediators of the seasonal variation in human behaviors and therefore may also influence suicidal behaviors. here we review physical (i.e., bioclimatic factors such as sunshine, temperature and rainfall), chemical (i.e., pollutants), and biological (i.e., viruses, bacteria, protozoa and allergens) factors as potential triggers of suicidal behaviors in spring or fall. bioclimatic factors have been suggested to be potential mediators of the seasonal variation in suicide, though this concept is controversial. some researchers have documented a positive association between sunshine/temperature/humidity and suicide [20] [21] [22] [23] [24] [25] [26] , while others dispute this relationship [27] [28] [29] [30] . in addition, a few studies concluded that a positive association between climatic factors and seasonal variation of suicide was present only for suicide by violent methods [14, 31] . petriduo et al. [32] suggested that sunlight may act as a trigger of suicide. in addition, suicide rates are greater in rural areas than in urban areas [2, 4, 33, 34] and higher among outdoor workers compared to indoor workers [35] . some empirical findings support the notion that the intensity of sunlight may play a role in the triggering of suicide and therefore provide a potential link to the seasonal variation in suicide. hiltunen et al. reported the association between increased suicide mortality and the period with the longest day length (which was between may and july) i.e., late spring/early summer [36] . another study in greenland reported a similar pattern. however, both studies suggested the role of latitude and other signals besides the variation in daylight, as the suicide peak of the northern area of finland (oulu) was delayed when compared to the southern area (helsinki) and the strength of the suicide peak was more pronounced at higher latitudes [36, 37] . a recent analysis of data from finland suggested a correlation between solar radiation and suicide mortality [38] but other studies have also suggested that seasonal suicide peak in spring occurs significantly later than the interval of change in day length [39] [40] [41] . furthermore, papadopoulos et al. [42] hypothesized that a time lag exists for the effect of solar radiance on suicidality. in summary, seasonal changes in sunlight seem unlikely to fully account for the seasonal variation in suicide. with regard to temperature, a study performed by volpe et al. [25] found that suicide rates in brazil not only showed a higher peak in december and january than the rest of the year, but were also significantly correlated with increasing temperature. in addition, kim et al. [15] reported a 1.4% increase in suicide when temperature goes up by 1 degree celsius. temperature could either be a marker of seasonal change, or the mediator of it. in addition, specific meteorological conditions such as temperature and thunderstorm for the preceding day could contribute to increased risk of suicide in individuals [26] . precipitation (rainfall and snowfall) is another climatic factor that shows seasonal variation and has thus been postulated to possibly be predictively associated with seasonality of suicide. when ajdacic-gross et al. [28] modeled monthly data on suicide and precipitation in switzerland precipitation did not show any noteworthy effects on suicide frequencies. lin et al. also examined the association between monthly suicide rates and climatic influences including atmospheric pressure, temperature, sunshine, humidity, and rainfall in taiwan; however, they only found evidence of an association of temperature with seasonality, but reported no significant association between rainfall and seasonal peaks of suicide in spring/early summer [43] . chew and mccleary [4] comprehensively compared the seasonal variation of suicide across 28 nations and found well replicated seasonal spring peaks in suicide rates from the various nations regardless of the location of the countries. they also observed wide cross-sectional variation in degree of suicide seasonality. for instance, when comparing canada to portugal they demonstrated a narrow range of seasonal fluctuation in canada (ratio of average spring to average winter = 1.08) versus wide fluctuation of seasonal suicide rates in portugal (ratio of average spring to average winter = 1.70) implicating a more prominent seasonal spring peak in portugal. consistent with the pattern in the northern hemisphere, flisher et al. [44] reported a mirror image spring or summer peak of suicide and a trough in fall in south africa, especially for less urbanized subpopulations. similarly, studies in australia [24] are concordant with studies conducted in the northern hemisphere in europe [1, 10, 11, 32, [45] [46] [47] [48] and asia [18, 49, 50] , identifying a seasonal spring suicide peak. allergy has been previously linked to suicide [13] . the seasonality of suicide has been shown to co-occur with the seasonal peaks in ambient pollen concentration during spring (i.e., tree pollen), summer (i.e., grass pollen), and fall (i.e., ragweed) [19] . pollens are aeroallergens and are capable of inducing an allergic inflammatory reaction when they reach the intranasal mucosa of susceptible individuals. the inflammatory reaction induced by aeroallergens involves the production of th2 cytokines which, in animal models, have been associated with increased anxiety-like behavior, reduced social interaction [51] and aggressive behavior [52] all of which can be considered as endophenotypes for suicidal behavior [53] . furthermore, the seasonal peak in aeroallergens resulting in the concomitant worsening of allergy symptoms could (via inflammatory mediators of worsening allergy symptoms) potentially worsens depressive symptoms, anxiety and impulsivity in mood disorder patients, resulting in exacerbated risk of suicidal behavior. consistent with this notion, manalai et al. [54] recently reported that in bipolar patients pollen-specific ige positivity and worsening of allergy symptoms are associated with worsening of depression scores during exposure to aeroallergens. in addition, changes in allergy and anxiety (anxiety representing a potentially independent suicide risk factor) in patients with mood disorders exposed to seasonal peaks of aeroallergens were observed to be correlated [54] . in essence, the current available evidence makes seasonal fluctuation of aeroallergens a possible factor involved in the underlying mechanisms responsible for seasonality of suicide. this is particularly important from a neuroimmune perspective, considering a previous study showed an increased gene expression for cytokines involved in allergic reactions in the orbitofrontal cortex (a region previously implicated histopathologically with suicide) in victims of suicide [53] . the human immunodeficiency virus (hiv) has been associated with suicide [55] but no seasonal pattern has been reported in relation to hiv-related suicide rates neither has hiv been known to manifest a seasonal pattern of infectivity. the influenza virus, on the other hand, has a seasonal pattern of infectivity. however the only report of an association of influenza with suicidal behavior [17] did not include an evaluation of seasonality effect on suicide. more studies on the association of seasonal viruses and suicide are needed. air pollutants have been correlated with rates of visits to the emergency room as well as inpatient admission rates of patients with mental illness [56] . recently kim et al. [16] found that the rate of completed suicide in the republic of korea was elevated when there was an increase in the ambient particulate matter two days prior to the day of suicide. the two aforementioned studies did not take into consideration the impact of the season on elevation of suicide risk. szyszkowicz [57] , however, carried out an analysis of data on air pollution effect on emergency room (er) visit for worsening depression by season and found that the highest percentage of depression-related er visits were during periods of increased concentration of ambient particulate matter during the cold season and the finding was limited to only females. however, the findings by szyszkowicz should be interpreted with caution (in terms of elucidation of the seasonality effects of air pollutants on depression), since the analysis did not include an assessment of an interaction between season and pollutant but rather an analysis by season was carried out. it therefore appears that the literature on the potential contribution of pollutants to the seasonality of suicide is sparse and no generalization can be made at this time. it has been well described that psychiatric disorders are associated with suicide and at the time of suicide completion, more than 90% of suicide victims suffer from a psychiatric disorder [58] . reports from finland showed an association between time patterns of attempted suicides and psychiatric disorders (e.g., mood disorders, substance use disorders and schizophrenia-related disorders [59, 60] . however, studies on the relationship between seasonal variation in the occurrence or exacerbation of mental disorders and suicide seasonal peaks are limited [45, 61, 62] . a study [61] conducted in sweden showed a seasonal spring/early summer peaks among patients diagnosed with neurotic, stressrelated, or somatoform disorder; however, only patients with symptoms severe enough to require hospitalization were studied. consistent with this study, brådvik et al. [62] demonstrated a seasonal spring peak of suicide in a study of male patients with alcohol addiction. rocchi et al. [45] also reported on the seasonality of suicide completion among patients with psychiatric illnesses. recently, postolache et al. [63] reported an increased amplitude of the suicide peak in spring among victims of suicide with a history of mood disorders (see figure 1) . another study carried out by kim et al. [64] demonstrated seasonal spring/summer peak of suicide completion in depression and fall/winter peak in schizophrenia. in addition, significant seasonal peaks were reported in allergy-related asthma, rhinitis, and atopic dermatitis. as allergy-related diseases are associated with suicide completion, seasonal changes in allergens may lead to seasonal increase in incidence and exacerbation of allergic disorders which in turn could potentially be associated with peak in suicide rates, mediated through molecular and cellular components of allergic inflammation affecting the brain [13] . indeed, timonen et al. [65] revealed an association between prior hospitalization for atopic disorders and seasonal variation of suicide. the authors estimated the monthly rate ratio of suicide relative to december. conditional logistic regression analyses with adjustment for place of residence, marital status, income, and method of suicide were used to compare seasonality of suicide in victims with versus without hospitalization for mood disorders. a statistically significant spring peak in suicide was observed in both groups. a history of mood disorders increased the risk of suicide in spring (for males: rr = 1.18, 95% ci 1.07-1.31; for females: rr = 1.20, 95% ci 1.10-1.32). reproduced from [19] with permission. several studies have found associations between age and seasonal variation in suicide. maes et al. [2] reported that the suicide rate among younger people was increased in spring (i.e., march and april), whereas the rate within older adults was raised in late summer (i.e., august). however, lahti et al. [66] observed a suicide peak in fall among adolescents, particularly for those dying by shooting. furthermore, mccleary et al. [67] documented that a suicide peak was observed in younger aged individuals in winter and fall, while suicide among the very old was elevated towards the summer period. the inconsistency between studies may reflect methodological or environmental differences between studies and at the moment, no conclusion can be drawn. although seasonality of suicide completion is seen both in men and women, the seasonal patterns differ between genders. for example, only a single spring peak is found in men, while two peaks in spring and fall have been reported in women [4, 33, 34, 40, 68] . in england, middle aged women who had school-aged children were more likely to commit suicide in fall, which was the beginning of the school year [4, 69] . though speculative, it may be that a sudden reduction in the duration of direct contact with a dependent represents a type of suicide risk in these women. gender effect on seasonality of suicide was also noted in hungary where a steadily increasing prescription rate for antidepressants was associated with a decrease in national suicide rate but significantly decreased seasonality of suicide only in males [70] . the suicide peak in spring has been considered to be a consequence of seasonal occurrence of depression-related suicides and the decreased seasonality of suicide in this hungarian study was suggested to be a marker of lowering depression-related suicides (especially among men) as a result of increased antidepressant utilization in the population [70] . seasonality of suicide attempts is also shown to be associated with gender [71] . studies performed in scotland and in oxford revealed a seasonal variation of female suicide attempts with increased rates during summer and decreased rates in winter, but no significant seasonal variation of male suicide attempts was found [72, 73] . in addition, the results of the who/euro multicenter study on parasuicides indicated that the seasonal pattern of suicide attempts in women showed a peak in spring and nadir in winter, but no significant variation of suicide attempts was observed within the male subpopulation [74] . however, there have been negative reports as well. mergl et al. analyzed suicide attempts in nuremberg and wuerzburg from 2000 to 2004 and they failed to confirm the significant gender difference in seasonality of suicide attempts [71] . kreitman et al. also reported no considerable gender difference in seasonality of suicide attempts in the u.s. [75] . while several studies have reported season of birth effect on suicide or suicidal behavior [7, [76] [77] [78] , there is lack of evidence to indicate an association between month of birth and seasonality of suicide completion. dome et al. [76] found a significantly increased risk of suicide completion among those individuals who were born in spring and summer, however, this study did not show any relationship between season of birth and seasonal variation of suicide. another study which evaluated the effect of birth month on suicidal behavior in western australia reported a notable spring peak of deliberate selfharm and a significantly increased birth in spring within the deliberate self-harm group [7] . however, no season-of-birth effect was observed in relation to completed suicide in the study. socioeconomic status can affect suicide rates. social discrepancy, disputes, socio-economic gradient (urban-rural income gradient, etc.), divorce and resulting single parent family environment can be related with seasonality of suicide. the majority of research findings indicated that the seasonal spring peaks are greater in rural areas compared to urban areas [2, 4, 79] . in particular, micciolo et al. [79] evaluated the seasonality of suicide in italy from 1969 to 1984 and found the suicide peaks in spring to be more notable in rural areas than in urban areas, although the suicide rates was higher in urban regions. a review by christodoulou et al. [80] suggested that this phenomenon might plausibly be related to intensity of seasonal activities such as agricultural work in the rural areas. in fact, chew and mccleary [4] reported that the spring peak of suicide is relatively larger in agricultural countries compared to industrial countries. they also found that the larger amount of agricultural work is significantly correlated with the greater spring peak of suicide. ajdacic-gross et al. [81] further posited that as the traditional rural society is disappearing with industrialization, the seasonal variation of suicides might be attenuated. in addition, seasonality of suicide has been shown to be related to occupational differences. the agricultural and construction sectors usually have intense activity from spring to fall. näyhä [40] found that suicide committed by people who served in technical, administrative, and service work (i.e., modern occupations) usually peaked in late fall, while people who engaged in traditional occupations (e.g., agriculture, transport, or manufacturing work) showed seasonal peaks of suicide in spring/ summer. koskinen et al. [35] also examined seasonality of suicide in different occupations including farmers, forest workers, construction, and indoor workers. they documented that spring peak and winter trough of suicide pattern was observed in groups of farmers and forest workers. on the contrary, a significant summer nadir was shown within indoor workers. moreover, in their sub-group analyses by suicide methods, 90.5% of farmers used violent methods, followed by forest workers (79.1%), construction (73.2%), and indoor workers (69.2%), indicating violent suicides decreased among indoor workers. considering suicides by violent methods show remarkable peaks in spring [2, 43, 47] , it is plausible to expect seasonal spring peaks with people who are more likely to spend time in outdoor settings [82] . migrant workers can be exposed to higher mental distress and suicide risk as dramatically depicted in the series of attempted or committed suicides in foxconn production facilities in china between jan and may 2010 [83] [84] [85] . however, seasonal variation of suicide in migrant populations needs to be further studied. these findings seem to indicate that people who are more exposed to the outdoor environment have a greater seasonal spring peak in suicide-thus, suggesting that factors driving seasonality may be more abundant in the outdoor environment. for example, increased seasonal work related-stress in farmers and increased exposure to outdoor physico-chemico-biological factors such as day length, light, temperature, pollution, pathogens or allergens may contribute to more ample seasonal suicide peaks. suicide methods can be classified as either violent (i.e., hanging, firearms, drowning, jumping, cutting, or self-immolation) or non-violent (i.e., ingestion of poisons, drugs, gases, or vapors) in terms of lethality based on the international classification of diseases [80] . there appears to be seasonal variation of suicide completion by suicide methods. a number of researchers have reported seasonal variation of suicide by violent methods including hanging, jumping from a height, drowning, poisoning, and firearms [3, 41, 47, 66, 86, 87] . suicide rates by violent methods peak in spring/early summer and dip in winter, which is consistent with the general pattern of suicide seasonality. hakko et al. [39] reported that suicide rates by violent methods increased by 16% in may, while it correspondingly decreased by 15% in december. the patterns of seasonal fluctuation in violent suicides are well replicated, regardless of geographical region. studies conducted in europe including finland [39, 88] , italy [47, 68] , greece [48] , belgium [2, 89] , greenland [37, 90] , switzerland [1,81], uk [91] , australia, new zealand [92] , asia [43] , and the u.s. [93, 94] found seasonal spring peaks in violent suicide rates. in taiwan, however, the violent suicide peaks in summer rather than in spring [43] . gender differences have been reported with the use of violent suicide methods. lester and frank analyzed a u.s. population-based data and reported seasonal spring peaks of suicide by poison, hanging, or firearms, in addition to seasonal autumn peaks for hanging or firearms among male victims [94] . in contrast, in female victims, they observed seasonal variation of suicide completion with spring and fall peaks by poison or hanging and with summer/late fall peaks by firearms. furthermore, the study conducted by yip et al. in which they evaluated australia-new zealand population based data, revealed a significant seasonal variation of suicide by hanging in australian and new zealand in males only [92] . regarding non-violent methods, hakko et al. [39] found two peaks of suicide rates within the non-violent subgroup approximately a 9% increase in spring and an 8% increase in fall. however, the majority of studies did not observe any significant seasonal spring peaks in suicides by non-violent methods [2, 43, 68, 89] . pollen counts have been particularly related to nonviolent suicides in women [19] . as one of the possible mechanisms to explain the significant spring peaks of violent suicides, we can consider the role of neurotransmitters in violent behaviors. for example, serotonin concentration, is often associated with impulsive and aggressive behaviors [95] and tryptophan (the main precursor of serotonin) concentration in the brain shows a prominent seasonal rhythm with lower plasma levels measured in spring in comparison to other seasons [96] . thus, researchers have postulated that low levels of serotonin in the brain could possibly have an influence on impulsive drives, violent behaviors, and potentially result in an individual committing suicide by violent methods [68, 96] . a counter argument against the proposition of serotonin mediation of violent suicide could stem from the findings from an australian study in which hours of bright sunlight exposure were directly correlated with serotonin turnover in the brain, measured invasively [97] . brain serotonin turnover was seven times higher during the summer than during the winter, thus not entirely consistent with a hypothesis of a serotonergic mediation of suicide seasonality (i.e., low serotonin in spring). a number of researchers have argued that seasonal variation of suicide by specific methods was determined by the opportunities to access the methods [3] . ajdacic-gross et al. [3] reported that whereas firearms and knives are normally available during the whole year, poisoning (especially pesticides) occurred in the planting season and drowning and jumping are mostly used in outdoor activity season. lahti et al. [66] found that suicide by shooting among finnish adolescents occurred more frequently from august to october and its monthly pattern was positively related to the duration of daily sunshine hours, which were suggested to be related to increased firearm availability during the hunting season in addition to other psychosocial factors. seasonality of suicide by methods can vary across different time frames. ajdacic-gross et al. [81] looked at 120 year trends of suicide seasonality in switzerland and determined that there was a decline of overall seasonal variation during 1969-2000 compared to 1881-1920. the most significant difference between the two periods was the attenuation of suicides by hanging and drowning, both of which previously had strong seasonal effects on suicide. although statistically significant seasonal one of studies [29] which canno ncluding p [26] . unfortunately, many studies assessed seasonality over a relatively short period of time with data gathered in only one country or even smaller geographic unit [29] . also, it will be important to establish a consistent set of multilevel variables all studies must account for when analyzing seasonal effects. for instance, in our recent study, after adjusting for the density of psychiatrists, urban vs. rural location and income, significant relationships between airborne allergens and suicide across space have been lost, suggesting a spurious relationship [98] . in some countries, seasonal suicide peaks have a tendency of being flattened in terms of reduced amplitude and smaller proportion of variance accounted for by the season. recent studies using data from england and wales [99] , hong kong [100] , sweden [101] , and denmark [102] have demonstrated a diminishing seasonality tendency on suicides. however, this phenomenon does not apply in some other countries, such as finland [20, 39, 41] and the united states [103] , where a resilient seasonality pattern continues to be found for suicides or parasuicides. overall, there might be a possibility that the contribution of season, while present, is so small that it can be irrelevant when other risk factors, such as gender and mental illnesses, are adjusted for. few studies have examined seasonality in the context of other risk factors [104] [105] [106] . a better understanding of the mechanisms leading to seasonal peaks of suicide attempts and completions, may lead to 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in suicide in the united states seasonal and socio-demographic predictors of suicide in ireland: a 22 year study temporal variation in irish suicide rates a unique monthly distribution of suicide and parasuicide through firearms among israeli soldiers teodor t. postolache was supported by r01mh074891 from nih and, the american foundation for suicide prevention. jong-min woo was supported by the "forest science & technology projects (s111111l020100)" from republic of korea forest service (pi, woo) and by the national evidencebased healthcare collaborating agency (nm 11-003). olaoluwa okusaga was supported by the psychiatry residency training program/st.elizabeth hospital, washington dc. we also thank uttam raheja for his help with figure 2 . the authors thank christine ballwanz for her indispensable assistance. the authors report no competing interests. key: cord-339517-93nuovsj authors: consolo, ugo; bellini, pierantonio; bencivenni, davide; iani, cristina; checchi, vittorio title: epidemiological aspects and psychological reactions to covid-19 of dental practitioners in the northern italy districts of modena and reggio emilia date: 2020-05-15 journal: int j environ res public health doi: 10.3390/ijerph17103459 sha: doc_id: 339517 cord_uid: 93nuovsj the outbreak and diffusion of the severe acute respiratory syndrome-coronavirus-2 (sars-cov-2) and coronavirus disease 19 (covid-19) have caused an emergency status in the health system, including in the dentistry environment. italy registered the third highest number of covid-19 cases in the world and the second highest in europe. an anonymous online survey composed of 40 questions has been sent to dentists practicing in the area of modena and reggio emilia, one of the areas in italy most affected by covid-19. the survey was aimed at highlighting the practical and emotional consequences of covid-19 emergence on daily clinical practice. specifically, it assessed dentists’ behavioral responses, emotions and concerns following the sars-cov-2 pandemic restrictive measures introduced by the italian national administrative order of 10 march 2020 (dm-10m20), as well as the dentists’ perception of infection likelihood for themselves and patients. furthermore, the psychological impact of covid-19 was assessed by means of the generalized anxiety disorder-7 test (gad-7), that measures the presence and severity of anxiety symptoms. using local dental associations (andi-associazione nazionale dentisti italiani, cao-commissione albo odontoiatri) lists, the survey was sent by email to all dentists in the district of modena and reggio emilia (874 practitioners) and was completed by 356 of them (40%). all dental practitioners closed or reduced their activity to urgent procedures, 38.2% prior to and 61.8% after the dm-10m20. all reported a routinely use of the most common protective personal equipment (ppe), but also admitted that the use of ppe had to be modified during covid-19 pandemic. a high percentage of patients canceled their previous appointments after the dm-10m20. almost 85% of the dentists reported being worried of contracting the infection during clinical activity. the results of the gad-7 (general anxiety disorder-7) evaluation showed that 9% of respondents reported a severe anxiety. to conclude, the covid-19 emergency is having a highly negative impact on the activity of dentists practicing in the area of modena and reggio emilia. all respondents reported practice closure or strong activity reduction. the perception of this negative impact was accompanied by feelings of concern (70.2%), anxiety (46.4%) and fear (42.4%). the majority of them (89.6%) reported concerns about their professional future and the hope for economic measures to help dental practitioners. from the beginning of 2020, a new pathogen spread from china to europe and around the globe, and in march 2020, the world health organization (who) had to officialize a pandemic alert. this highly infective new virus, named severe acute respiratory syndrome-coronavirus-2 (sars-cov-2), is a coronavirus responsible of an acute respiratory syndrome, often asymptomatic but potentially lethal [1] , named coronavirus disease 19 . sars-cov-2 has an incubation period of two weeks and covid-19 clinical manifestations mainly include cough, fever and dyspnea [2] , but also anosmia, ageusia and, in few cases, diarrhea have been reported [3] . recently, also cutaneous manifestations have been observed: acral areas of erythema with vesicles or pustules (often after other symptoms) (19%), other vesicular eruptions (9%), urticarial lesions (19%), maculopapular eruptions (47%) and livedo or necrosis (6%) [4] . airborne and direct contact contamination are the major infection pathways of sars-cov-2 [1] . airborne contamination is due to droplets released through exhalation, cough or sneeze [1] ; direct infection instead is due to contact with contaminated surfaces and eye, nose or mouth mucosa [5] . the distance and length of time that particles remain suspended in the air is determined by particle size, settling velocity, relative humidity, and air flow. droplets that are >5 µm in diameter can spread up to 1 m. the nuclei of the droplets which have a diameter <5 µm, create an aerosol which has a diffusion capacity greater than 1 m [6] . moreover, it has been reported that virus spread can also happen in absence of clinical symptoms [7, 8] . the outbreak and diffusion of sars-cov-2 and covid19 have caused an emergency status in the worldwide health system. italy has seen a rapid and massive diffusion of covid-19 and, as of the 7th of april 2020, italy registered the third highest number of covid-19 cases and the second official number of deceased subjects worldwide. the number of italian cases accounted for 9.47% of total cases worldwide, with 183,957 cases. of this sample, 94,067 were currently infected (69.37%), 24,391 (17.99%) had recovered, and 17,127 (12.63%) had died [9] . health care workers are the category with the highest diffusion of the contagion, as the italian national institute of health reports 13,121 cases of infection [9] . due to droplet production and exposure to saliva and blood, dental practitioners are at high risk of contagion during their routine procedures [1, 8, 10, 11] . sars-cov-2 transmission during dental procedures can therefore happen through the inhalation of aerosol/droplets from infected individuals or direct contact with mucous membranes, oral fluids, and contaminated instruments and surfaces [8, 9, 12] . the aim of this study is to investigate dentist behavior and to analyze their reactions in relation to sars-cov-2 pandemic professional restrictive measures due to italian national administrative order of 10 march 2020 (dm-10m20). an online structured survey composed of 40 questions has been sent to dental practitioners in order to investigate dentist behavior and to analyze their reactions in relation to sars-cov-2 pandemic restrictive measures introduced by the italian national administrative order of 10 march 2020 (dm-10m20). the survey focuses mainly on a specific geographical area, the provinces of modena and reggio emilia (the relevant area of our academic institution), one of the areas most involved in the covid-19 epidemic in italy. through the lists of local dental associations (andi -italian dental association, cao -commissione albo odontoiatri) it was sent to all dentists in the area and 40% of them replied. the survey was created using the free-access google forms application and the link to the online survey was sent through an anonymous mailing list to all dentists registered in the dental board commission (cao) of modena and reggio emilia district. participants provided their informed consent before completing the survey. data collection took place in the time period from 2 april to 21 april 2020. the structured survey was composed of 40 questions, divided into five sections (table 1) . section 1 included questions aimed at gathering demographic data (age and gender), and assessing the type of activity and level of experience of the respondents. section 2 was composed of questions assessing whether practitioners closed their dental practice or reduced their clinical activity following the outbreak of the emergency, whether this occurred before or after the restrictive measures introduced by the italian government in 10 march 2020 (dm-10m20), which modalities were used to inform patients, and whether patients understood the reasons for the closure/activity reduction. section 3 was composed of questions investigating the impact of the covid-19 outbreak on dental practice, which were the most common protective personal equipment (ppe) used before the covid-19 outbreak and whether habitual ppe had been changed after the outbreak. section 4 assessed practitioners' direct or indirect contact with covid-19, the feelings and emotions experienced while thinking at the covid-19 outbreak, the dentists' perception of infection likelihood for themselves and patients. it also assessed the presence of symptoms of anxiety by means of the generalized anxiety disorder 7-item (gad-7) scale [13] , which is commonly used to assess the presence of general anxiety symptoms across various populations and settings. it consists of seven items assessing how often, considering the previous two weeks, individuals have been bothered by covid-19 related problems: (1) feeling nervous, anxious, or on edge; (2) being able to stop or control worrying; (3) worrying too much about different things; (4) trouble relaxing; (5) being restless; (6) becoming easily annoyed or irritable; (7) feeling afraid as if something awful might happen. finally, section 5 of the survey assessed the practitioners' main concerns about the professional future, which measures they considered as helpful to support practitioners during and after the emergency, which protective measures they intended to use in the future to prevent the risk of infection for themselves and patients, and whether they believed the emergency situation could lead to improvements. given the nature of our survey we computed descriptive statistics for most of the questions. for each question, we computed the percentage of respondents that gave a particular answer with respect to the number of total responses to the question. for the questions "how worried are you of contracting covid-19 during your clinical activity?", "in your opinion, how likely is it that a patient can contract covid-19 during a dental service?", "how much do you think your patients are worried of contracting covid-19 during a dental service?" and "how worried are you for your professional future?", response categories were assigned a score ranging from 0 to 4 (0 = "not at all"; 4 = "extremely"). for the question "which of the following emotions (fear, anxiety, threat, concern, sadness, anger) do you feel when thinking about covid-19?" response categories were assigned a score ranging from 0 to 4 (0 = "i do not feel it", 4 = "i feel it intensely"). for each of the 7 items of the gad-7 scale, we assigned the scores 0, 1, 2, and 3 to the response categories "not at all," "several days," "more than half the days," and "nearly every day", respectively. the scores for each item were then summed to obtain a total score ranging from 0 to 21. scores from 0 to 4, from 5 to 9, from 10 to 14 and from 15 to 21 are indicative of minimal, mild, moderate and severe anxiety, respectively. we computed the pearson correlation coefficient to investigate the association between general anxiety level, as indexed by the gad-7 general score, level of concern for the professional future, level of concern of contracting the covid-19, perceived patient's likelihood of contracting the infection, and the level of concern of contracting the infection attributed to the patient. we also investigated the association between the impact of covid-19 on dental practice and level of concern about the professional future. furthermore, to assess potential differences between age groups, we submitted the mean scores obtained in the questions reported above and the gad-7 score to a one-way analysis of variance (anova) with age group (<35 years, 35 and 55 years, and >55 years) as a between-participants factor. statistical analyses were performed using the spss version 26.0 statistical software. the survey was sent to 874 practitioners and 356 of them completed it. with this sample size, the margin error at a 95 level of confidence is lower than 5%. of the respondents, 60.4% were male and 39.6% were female. the majority of participants were aged between 35 and 55 (48.6%); 34.8% were over 55 years old, while only 16.6% of them were under 35 years old. consequently, most had been working for more than 15 years (61.2%), 28.4% had been working for 6-14 years, while 10.4% had been working for less than 5 years. a large number of dentists (226; 63.5%) reported working 30-40 h or more per week, while the remaining 130 (35.5%) reported working less than 30 h per week. the majority of the compilers were practice owners (64.3%), while the others were private (34.6%) or public (1.1%) structures employees ( table 2) . all of the respondents closed or highly reduced their activity to urgent procedures, 38.2% before and 61.8% after the dm-10m20. patients were contacted mainly by phone (95.8%), only 4.2% through social channels or websites. most of them understood the reasons for the closure of dental practices or for the reduction in clinical activity (93%). a high percentage of patients (92.7%) canceled their previously-taken appointments after the dm-10m20. a large number of dentists (342, 96.1%) guaranteed telephone availability for dental emergencies. almost the totality of compilers (321, 90.2%) reported the willingness to personally take care of emergency situations. when an emergency occurred, 45% of respondents took care of it alone, and 55% of them were helped by an assistant. approximately 70% of practice owners reported an average number of 6 to 15 patients a day before the pandemic, that shifted to 0 to 5 a week in 90% of the sample. each practitioner asserted a routinely use of the most common protective personal equipment (ppe), such as gloves, masks, disposable gowns and protective glasses before the sars-cov-2 pandemic (table 3) . however, they also admitted that they had to increase the use of ppe or to modify kinds of ppe during the covid-19 pandemic (77%), or that they were still awaiting directives to do so (12.9%). only 10% have not changed their ppe, probably because they were already applying maximal ppe before the pandemic. since the beginning of coronavirus pandemic, 86% of the respondents reported difficulties in finding ppe, and 57.9% reported problems in the delivery time of dental materials. most of the interviewees (279, 78.4%) report having held information sessions dedicated to the staff on the correct use of ppe, 13.2% did not, but 8.4% said that they will soon. fortunately, only four (1.1%) respondents contracted covid-19, while 68.6% knew at least one person who has been infected. in total, 20.8% did not know anyone who has contracted the disease. for 74.4% of the respondents, covid-19 was having a highly negative impact on their professional activity (mean (m) = 3.7, standard deviation (sd) = 0.7) and the majority of them (89.6%) was quite concerned about their professional future (m = 2.7, sd = 1.02), mostly due to the uncertainty about the end of the emergency situation. the level of concern about the future was positively correlated to the reported level of negative impact (pearson's correlation index: r = 0.17, p < 0.001). dentists reported being quite concerned of contracting covid-19 during their clinical activity (m = 2.52, sd = 1.02). more precisely, 20.2% were extremely concerned, 29.2% were very concerned and 35.7% quite concerned. only 12.6% were little concerned while 2.2% were not concerned at all. 38.2% of them believed patients' concern of contracting the infection during a dental visit was quite high (m = 1.73, sd = 1.06), even though they overall considered the patient's likelihood of infection as low (m = 1.25, sd = 1.11) ( table 4 ). table 4 . dentists' concern of contracting covid-19, perception of the infection likelihood for patients and level of concern attributed to patients. when thinking about covid-19, only 4.2% of the respondents reported to experience fear intensely, while the majority reported to feel lightly (41%) or moderately (23.9%) scared. only 6.2% reported to experience anxiety intensely, while the majority reported to feel lightly (37.4%) or moderately anxious (23.6%). only 16% reported to experience concern intensely, while the majority reported levels of concern ranging from light (26.4%) to moderate (29.8). only 12.6% of respondents felt intensely sad, while 25.3% did not experience sadness at all. anger was experienced in an intense way by only 9.3% of respondents, while 44.1% of respondents did not experience anger at all. overall, these results indicate that thinking about covid-19 mostly caused concern (m = 2.23, sd = 1.11) ( table 5 ). the mean gad-7 score was 6.56 (sd = 4.48) indicating an overall mild level of general anxiety. more precisely, 42.7% of the respondents showed minimal anxiety (score 0-4), 33.3% showed mild anxiety (score 5-10), 15.2% showed moderate anxiety (score 10-14), while 8.7% showed a score indicative of a severe level of anxiety (score [15] [16] [17] [18] [19] [20] [21] . the gad-7 score was positively correlated to the level of concern about the professional future (r (356) = 0.32, p < 0.001), the level of concern of contracting the covid-19 shown by the dentists (r (356) = 0.26, p < 0.001), the perceived patient's likelihood of contracting the infection (r(356) = 0.23, p < 0.001), and to the level of concern attributed to patients (r(356) = 0.28, p < 0.001). the one-way anova showed a main effect of age group for perceived patient's likelihood of contracting the infection (f 2,353 -statistic = 1157, p < 0.001), and reported levels of concern about the professional future ( to the question "during clinical activity, which measures do you use to prevent covid-19 infection?", dentists replied highlighting a good knowledge of what is reported in the most recent indications from the literature. this question could be answered by placing multiple preferences: the highest frequency of answers concerned "reduction of number of patients in the waiting room" (87.1%) and "telephone screening/anamnesis to exclude covid-19 related symptoms" (86.5%). less frequently, "environment aeration" (77.5%), "use of ppe" (73.3%) or "disinfectant agents and surgical mask supply to all patients while waiting in waiting room" (68.8%) were indicated. other indications, provided by medical organizations and media-"environment sanitation" and "telephone screening/anamnesis to identify possible critical cases"-received 65.5% and 43.5%, respectively. the answer "body temperature measurement" received the lowest frequency of preferences (21.3%). the same question, repeated at the end of the questionnaire with reference to future behaviors, highlighted percentage variations: "reduction of number of patients in the waiting room" (84.8%), "use of ppe" (82.6%), "telephone screening/anamnesis to identify possible critical cases" (78.4%), "environment aeration" (75.3%), "environment sanitation" (74.7%), "disinfectant agents and surgical mask supply to all patients while waiting in waiting room" (66%) and "body temperature measurement" (35.7%). to the question "which aids do you think could help dental professionals during covid-19 pandemic?", for which two preferences could be expressed, the dentists replied indicating "economic relieves from italian government" (65.7%), "social security institutions support and subsidy" (44.1%)," economic relieves from dental associations" (32.1%) and "improvement of communication with patients" (8.1%). the answers to the successive question, which analyzes the category aid measures to be adopted after the emergency, maintained almost the same order of frequency in the answers. there was a decrease in the percentage for "social security institutions support and subsidy" and 9.6% for "bank account support", which was not represented in the answers to the previous question. in descending order, the percentages were: "economic relieves from italian government" (73.9%), "economic relieves from dental associations" (31.2%), "social security institutions support and subsidy" (26.1%), "improvement of communication with patients" (16%) and "bank account support" (9.6%). greater importance was given to communication campaigns with patients. the last question asked "which improvements do you think can result from the covid-19 emergency?" and multiple answers could be indicated. most of the interviewees considered "prevention procedures standardization" very important (66.9%) and a high percentage answered that there will be a "professional rhythm slow down" (36.8%) and "improvement of communication with patients" (23%). lower preferences resulted for "no improvements" (19.9%) and "stabilization of relationship with dental associations" (16.9%). dentists considered the "reduction of dental practices competition" irrelevant, which received the smallest number of indicated preferences (5.1%). since the sars-cov-2 pandemic, other surveys have been proposed by other international institutions, aimed at measuring the impact of this turmoil on dental professionals. one inquiry was performed in israel [14] , a nation where the impact of the covid-19 has been much more contained than in italy. another survey, form saudi arabia [15] , had a more global reach: 650 dentists spread out in many countries, mostly in pakistan, india and malaysia, where the dental setting might differ from western standards and where the majority of the colleagues are employed in public settings. our survey is exclusively focused on a specific geographical area, the province of modena and reggio emilia (the pertinent area of our academic institution) in northern italy, one of the most involved areas in the covid-19 outbreak in italy and, perhaps, in europe. it reached out to 874 dentists, through the lists of the local dental associations (andi, cao), and 40% of them responded. the questions on the survey were developed after reviewing pertinent literature and international guidelines [10, [14] [15] [16] . the questionnaire was designed in the italian language and comprised of questions pertaining to socio-demographic characteristics, dentists' attitudes and perceptions toward covid-19 and infection control in dental clinics. moreover, the investigation was also focused on the psychological impact and changes on the everyday dental practice. the survey was a structured multiple-choice questionnaire divided into four sections. section 1 section centered on practice and owner socio-demographical characterization: age, gender, years of service, number of operative units, number of dental assistants and collaborators. among respondents, the majority were male (60.4%) and private practice owners (64.3%), working on average in 2-3-unit offices, whilst the other part were private or public structures employees. almost half of the sample was aged between 35 and 55. young dentists, aged 35 years old or less, accounted for 16.6%. section 2 is focused on the actual and real impact of the covid-19 outbreak on dental practice nowadays: the totality (100%) of owners closed their dental offices (38.2% before the dm-10m20 and 61.8% after), assuring telephone availability in 96.1% of cases. it was not only the colleagues that were afraid of the situation, but also patients were probably aware of the risks in the dental office, since 92.7% reported cancellation directly from patients, just before the dm-10m20. as a matter of fact, three-fourths of the interviewees reported that there has been an extremely negative impact on their practices. section 3 is about the adaptive behavior to the pandemic outbreak and risk perception. this has been evaluated through the need for ppe implementation, the need for informative sessions about their correct utilization and through a generalized anxiety disorder-7 test (gad-7). sars-cov-2 has been demonstrated to remain aerosolized for 3 h after contamination and on plastics and stainless steel for up to 72 h [17] . this makes the dental community a relatively high-risk population [1] . there are practical guidelines recommended for dentists and dental staff by the centers for disease control and prevention (cdc), the american dental association (ada) and the world health organization to control the spread of covid-19 [18] [19] [20] . like with other contagious infections, these recommendations include personal protective equipment, hand washing, detailed patient evaluation, rubber dam isolation, anti-retraction handpiece, mouth rinsing before dental procedures, and disinfection of the clinic. in our survey, the vast majority performed a telephonic triage the day before the appointment, along with a full-body protection during the operative procedure. the necessity to reduce the number of incoming patients in the waiting room was held important by 87.1% of the colleagues. the way patients are received in the dental office has been modified as well, since 68.8% is providing patients with surgical mask and hand sanitizer upon arrival. surprisingly, only a small minority is considering the body temperature check upon entrance as a valid method for critical case detection notwithstanding the low cost and the good reliability of this procedure. it must be remembered that the current approach to covid-19 is to control the source of infection; use infection prevention and control measures to lower the risk of transmission and provide early diagnosis, isolation, and supportive care for affected patients. based on relevant guidelines and research, dentists should take strict personal protection measures and avoid or minimize operations that may produce droplets or aerosols [21] . only 1.1% of the practitioners referred positivity to covid-19, whereas 68.6% has at least one patient/collaborator/friend that tested positive, so this pandemic is definitely a reality in our settings. it is of interest to note that the majority of practitioners fear infection, but only a minority group is concerned about the possibility that their patients might acquire the infection. the fear of contracting covid-19 from a patient is strongly associated with elevated psychological distress. similar results are reported in a survey conducted in israel: dentists' responses to prevention measures seem better for personal protective equipment, disinfection and sanitation procedures than for measures applied to patients [14] . this could mean that the majority of the interviewees are more concerned about protecting themselves than their patients. measuring anxiety by the means of self-report questionnaires is useful [22] and has been already performed among dental practitioners and patients [23] . in this survey, fear, anxiety, concern, sadness and anger are commonly reported, but fortunately only a minority group reported intense feelings of anger (9.3%) and, as resulting from the gad-7 scale, inability to manage anger and anxiety (10.3%). overall, only 8.7% of the respondents showed a score to the gad-7 scale indicative of a severe level of anxiety. the overall level of general anxiety can be considered as mild (mean gad-7 score was 6.56, sd = 4.48). these data are consistent with those reported by another survey in israel in which elevated psychological distress was found in 11.5% of the sample [14] . what is most expected is the receipt of prompt support from both the national government and the physicians' social security institution (enpam-ente nazionale di previdenza ed assistenza). informative communication for patients is believed to be important to let them know how problems in dental offices are being ameliorated. section 4 of the essay is about the perception of our professional future. a pandemic often brings economic recession, and this is what happened during the first quarter of 2020. this pandemic will have an impact on every aspect of our global economy. some analysts have predicted that-owing to the measures enacted to stop the spread of this pandemic, such as large-scale quarantines, travel restrictions, and social-distancing measures-there will be a sharp decrease in consumer and business spending capacity until the end of 2020 and part of 2021 [24] . this will ultimately lead to a global recession. as health-care professionals, dentists have responsibilities and should explore long-term measures to avoid recrudescence and future outbreaks. this situation will be challenging for medicine and dentistry, and the financial impact on dental practices will be experienced in both the shortand long-term. it is important to note that the vast majority of the respondents reported apprehension about the professional future. what is alarming the most is the inability to prevent the end of the pandemic, followed by the impaired economy that might affect future patient turnover and the capability to pay for the dental practice expenses. moreover, one third of the interviewees expressed concern about the need to buy further devices and to adequate to new clinical protocols to counteract the spreading of sars-cov-2. this will probably result in some physicians and dentists going out of business, especially the oldest (and more experienced) ones, and might also prevent new generation dental practitioners to get into business. dentists aged between 35 and 55 years were the most concerned about their professional future. what colleagues expect as a support to adequately face their professional future is the receipt of benefits from the italian government and social security institutions, as well as from italian dental associations (cao, andi). the government will pay laid off staff for a period; however, this is only a portion of most doctors' overall costs. the dental private sector is already facing a financial crisis and this is expected to worsen, primarily due to the need of providing a better and safer working environment to our patients, staff, and ourselves. this will potentially increase business overheads and reduce profit margins even further. alternatively, professionals could start to conceptualize new paradigms and a new vision about their profession. telehealth has become an essential tool for providing care to patients [10] . it is already allowing physicians to connect with patients sparing costs and time. its use will definitely exponentially increase over time and it might become an interesting tool for dental care providers as well. dentists and oral surgeons could integrate it into their clinical practice. potential uses include preoperative and postoperative visits as well as follow-up controls, thus reducing patient coming and going in our offices. this innovation has actually received good acceptance from patients, government and health-care providers in the u.s. and can represent a new business opportunity for our colleagues [25] . the general feeling among our respondents is such that their profession will change for a long time: harsh preventive measures are felt to be necessary in the near future, such as access limitation to the waiting room, more adequate protection devices, decontamination of the working environment, but still, the body temperature check, upon patient arrival, is considered necessary only by a minority of colleagues. the answers collected by our survey are quite consistent with general recommendations provided to dentists and to other health-care providers world-wide [10, 16, [18] [19] [20] [21] . patients should be asked about their health status and any history of recent contact or travel; patients and their accompanying persons should be provided with medical masks upon entry to the clinic. patients with body temperature >37 • should be registered and referred to designated family doctors. if a patient has been to any epidemic regions within the past 14 days, quarantining for at least 14 days is recommended. at last, our survey is focused on the perception of the professional improvement: what could positively change as a consequence of the pandemic. only less than 20% believe that no improvements will occur. the majority believes that some ameliorations will arise: new standardized preventive procedures, a slow-down in the working-schedule, improvements in communicating with patients and even a diminished competition between dental practices. it is possible to foresee a better awareness about new and strict preventive protocols among dentists as a positive achievement for the category. the aids pandemic resulted in acceptance of solutions that revolutionized the standard of care throughout medicine. prior to hiv/aids, dentists did not commonly wear gloves, masks or eye protection [26, 27] . in the late 1980s and early 1990s, in an attempt to protect health care workers, cdc proposed guidelines to reduce exposure to blood-borne pathogens such as hiv and hepatitis b [28] . dentistry curbed this change at every step but these standards of protections are widely accepted and used nowadays. what will come of this pandemic? commercial air purifiers and air exchange devices are also being explored for dental settings [29] . creating negative pressure operatories may seem a drastic and expensive approach now, but it may become a normal standard a few years from now. despite the findings discussed above, it is important to stress that this survey had a major limitation, due to the fact that our investigation regarded a relatively small area in north italy-the province of modena and reggio emilia-and this prevents us being able to generalize our results. the covid-19-related emergency condition is having a highly negative impact on dental practices in the area of modena and reggio emilia-the area of our academic institution. all of the dentists that completed the survey reported practice closure or reduction, a high level of concern about the professional future and the hope of economic funding for all dental practitioners. concerns related to professional activity were accompanied by severe anxiety levels for a small percentage of respondents. this essay must be contextualized with the geographical area, northern italy-one of the most involved in terms of pandemic-and was delivered during the most critical period of the pandemic. this might have brought a sort of bias in the psychological profiling: probably more pessimistic answers could be anticipated. importantly, some improvements are expected to be derived from the actual emergency situation, such as the adoption of standardized preventive procedures, a slow-down in working-schedule, and even diminished competition between dental practices. transmission routes of 2019-ncov and controls in dental practice epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study anosmia and ageusia are emerging as symptoms in patients with covid-19: what does the current evidence say? classification of the cutaneous manifestations of covid-19: a rapid prospective nationwide consensus study in spain with 375 cases surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) the severe acute respiratory syndrome coronavirus-2 (sars cov-2) in dentistry. management of biological risk in dental practice clinical features of patients infected with 2019 novel coronavirus in being a front-line dentist during the covid-19 pandemic: a literature review covid-19 transmission in dental practice: brief review of preventive measures in italy coronavirus disease 2019 (covid-19): emerging and future challenges for dental and oral medicine high expression of ace2 receptor of 2019-ncov on the epithelial cells of oral mucosa persistence of coronaviruses on inanimate surfaces and its inactivation with biocidal agents a brief measure for assessing generalized anxiety disorder covid-19 factors and psychological factors associated with elevated psychological distress among dentists and dental hygienists in israel fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak cross-infection and infection control in dentistry: knowledge, attitude and practice of patients attended dental clinics in king abdulaziz university hospital aerosol and surface stability of sars-cov-2 as sompared with sars-cov-1 clinical management of severe acute respiratory infection when covid-19 is suspected centers for disease control and prevention. cdc recommendation: postpone non-urgent dental procedures, surgeries, and visits the american dental association. coronavirus frequently asked questions the american dental association. ada recommending dentists postpone elective procedures dental phobia in dentistry patients self-assessed bruxism and phobic symptomatology the socio-economic implications of the coronavirus and covid-19 pandemic: a review the future of our specialty: is oral and maxillofacial surgery in jeopardy? gloves: some unknowns evaluation of the permeability of latex gloves for use in dental practice occupational exposure to bloodborne pathogens: osha-final rule respiratory protection against bioaerosols: literature review and research needs funding: this research received no external funding. the authors declare no conflict of interest. key: cord-346194-l8svzjp2 authors: nazir, mehrab; hussain, iftikhar; tian, jian; akram, sabahat; mangenda tshiaba, sidney; mushtaq, shahrukh; shad, muhammad afzal title: a multidimensional model of public health approaches against covid-19 date: 2020-05-26 journal: int j environ res public health doi: 10.3390/ijerph17113780 sha: doc_id: 346194 cord_uid: l8svzjp2 covid-19 is appearing as one of the most fetal disease of the world’s history and has caused a global health emergency. therefore, this study was designed with the aim to address the issue of public response against covid-19. the literature lacks studies on social aspects of covid-19. therefore, the current study is an attempt to investigate its social aspects and suggest a theoretical structural equation model to examine the associations between social media exposure, awareness, and information exchange and preventive behavior and to determine the indirect as well as direct impact of social media exposure on preventive behavior from the viewpoints of awareness and information exchange. the current empirical investigation was held in pakistan, and the collected survey data from 500 respondents through social media tools were utilized to examine the associations between studied variables as stated in the anticipated study model. the findings of the study indicate that social media exposure has no significant and direct effect on preventive behavior. social media exposure influences preventive behavior indirectly through awareness and information exchange. in addition, awareness and information exchange have significant and direct effects on preventive behavior. findings are valuable for health administrators, governments, policymakers, and social scientists, specifically for individuals whose situations are like those in pakistan. this research validates how social media exposure indirectly effects preventive behavior concerning covid-19 and explains the paths of effect through awareness or information exchange. to the best of our knowledge, there is no work at present that covers this gap, for this reason the authors propose a new model. the conceptual model offers valuable information for policymakers and practitioners to enhance preventive behavior through the adoption of appropriate awareness strategies and information exchange and social media strategies. several patients with symptoms of pneumonia of unknown facts were reported in mid of december, 2019 in wuhan, hubei province, china [1] . after an investigation by world health organization (who), it was identified as a new virus called covid-19, and with time, it spread rapidly throughout china and other countries [2] . according to who, it has been reported that there are 2.6 million confirmed cases, 0.184 million deaths, and 0.722 million recoveries from 2019-ncov worldwide. as evidence of this spread, one such case was reported on january the 24th, 2020 when a person reportedly from china came to pakistan on 21st of january 2020 via dubai. on the 24th he was examined and was found to be positive for covid19 . it was then that pakistan for the first time was exposed to the virus and became part of the affected countries globally. according to the government of pakistan's reports, today the number of confirmed cases in pakistan is 27,474 and the number of confirmed deaths is 618. punjab and sindh are the two mainly affected provinces. moreover, due to the lack of medical resources in developing nations, pakistan also faces challenges in preventing the spread of re-emerging and new infectious diseases. thus, during the outbreak of infectious disease, these countries focus on alternatives to medical facilities to overcome its spread. awareness and accurate information bring the behavioral changes among the people; they can be perceived as half treatment without any expense. social media has become an important source to broadcast awareness and information regarding control of infectious disease [3] . according to [4] , social media consists of different applications, including social networking sites, and blogs, that are founded on the scientific and ideological foundation of web 2.0 (for example, facebook, youtube, and twitter) that allow users to make, share content, and participate in different activities. social media itself is a catch-all expression for sites that may consist of various social actions. social media is designed of an electronic-mediated platform relying upon web-based innovations that permit users to make a profile and share ideas, imagines/clips, and information in the virtual networks system. even though many cases which were initially reported exposed the seafood market in wuhan, according to the current epidemiologic information, this virus is spreading from one individual to another at a very high rate of transfer [5] . with time, 2019-ncov has infected almost all countries on the planet. iafusco, ingenito [6] argued that in these critical circumstances, it has been very difficult for developing nations to communicate with uninfected individuals along with infected persons because this virus can spread quietly from one person to another. it has become complicated for the governments and doctors to communicate with their citizens during an infectious disease outbreak, therefore, social networking sites are playing a critical role in enabling the populations to connect virtually. some years ago, several disease outbreaks of the same nature, for example, ebola, zika flu, and dengue fever, around the globe revealed insights into the significant power of communication strategies concerning such diseases [7] . researchers said that social networking sites (sns) are a scoping evaluation of the utilization of search queries in disease surveillance [8] . first reported in 2006, the viewed literature highlighted accuracy, speed, and cost performance that was comparable to existing disease surveillance systems and recommended the use of social media programs to handle all circumstances of infectious disease systems. now, due to the advanced innovation of web 2.0, sns have appeared to play an essential role for public health specialists to control the spread of such infectious disease. it has been observed that social networks perform an excellent evaluation of real-time data reporting which keeps the state and people posted for the possible solutions of public health safety during epidemics [9] . with this recognizable increase in infectious outbreak in pakistan, public health centers are facing severe problems and challenges at work to act for the prevention of disease at various levels. due to a lack of time and resources, it has become complicated for the nations to address these issues and challenges in a short time. a fear of physical spread hinders health sector workers to interact with patients and suspects in person. therefore, the response time of governments and health departments to tackle the sign and symptoms which lead to the detection of both infectious and noninfectious diseases and their preventions, respectively, is affected by the updates and real-time reporting of social media. in this study, the researchers determined the outcome of social media on the preventive behavior among people about covid-19, how individuals gain information and awareness knowledge through social media to control covid-19. the study also analyzed the direct effect of social determinants on the preventive behavior of such conditions. the study was structured into five sections. after the introduction, the researches present thorough and critical analysis of current and most relevant literature along with hypotheses development. the third section contains material and methods used in this study to achieve the stated study objectives. the next section is about the main results of the study and discussions related to these results. the final section is about the main conclusions, findings, and the future research options. undeniably, online communication is used as an outlet for individuals to freely make and post data that is dispersed and extended worldwide after the advanced foundation of web 2.0. news media, conventional scientific outlets, and online networking sites create a platform for minority perspectives and individuals who are sometime, not being captured by other sources. individuals seek information from an assortment of sources and continually update it from the health sector. conventional news media has become recognizable as a comprehensive source of health information to prevent infectious disease in the public health sector. they provide information and awareness widely through social networking sites for reducing infectious diseases [10] . a few years ago, people did not have any communicational access to exchange their information directly with the government and health sectors, at that time, traditional media, such as newspaper, television, and so forth, played a critical role as a source of information exchange to the public [11, 12] . traditional media provided information about the disease to the public regarding public health issues [13] . therefore, citizens relied on traditional media as a foundation of knowledge which helped them to understand the critical condition of risk and receive precautions about the issues. however, after the advanced foundation of web 2.0, there became a rapid change in the use of media technology, and people have increased their social media usage by registering in almost all the social network accounts, for example, facebook, twitter, and youtube. this can also be seen from the increasing number of registered subscribers on all social web services to exchange their health information during any infectious disease outbreak [14] . unlike traditional media, which just engaged users to a limited amount of used and obtained information, in social media people make their profile and share health-related information to others, also making comments on health-related posts, and these sites also give the users the opportunity to join any public health-related groups [15] . for example, at the time of the h1n1 flu virus outbreak, people used social networking sites as an information exchange medium and gave opinions related to health [16, 17] . however, with the fast use of social networking sites, information access has changed, now people do not rely exclusively on the traditional or government news media, instead they trust sns to get essential information from the public health sector. for example, twitter was primarily utilized by the public for the exchange of experience, opinion, and knowledge among individuals during infectious disease [11] . specifically, sns have become a common source for general society to interchange their information when conventional news media offer very restricted information about an infectious disease outbreak due to some official pressure and limitations [18] . as per media policies, the public's reliance on media will, in general, escalate at the time of significant emergencies. when information is not promptly accessible from traditional news media, people, as information makers and disseminators themselves, assemble electronic methods such as social media for information exchange [19] . digital observation is an internet-based observation system that provides a current situation of public health problems by evaluating data stored digitally [20] . there are now numerous infectious disease observations in an epidemiological practice by which the predominance, outbreak, and extent of infectious disease are checked to build up patterns of active actions and advancements for management and control systems. the fundamental role of infectious disease observation is to observe, forecast, and reduce the harm caused by outbreak and epidemics situation as well as enhance the information system for specialists and the population concerning factors which could possibly be used in such conditions [21] . revealing occurrences of outbreaks has been shifted from manual record-keeping systems to worldwide online communication networks through sns [22] . therefore, we can draw our first hypothesis as the following: there is a significant relationship between social media and preventive behavior among people about covid-19. it is critical for public health sectors and government agencies to take any effective initiatives for the control of diseases, however, it is very difficult for developing countries to detect the infectious disease outbreak. observational capacity for detection of infectious diseases could be very costly and the developing countries lack resources to measure the outbreak of infectious disease at the time of exposure. hence, some social networking websites provide solutions to handle some of these challenges during an outbreak. online networking sites provide a source of information to detect infectious outbreaks earlier with very cheap cost and provide a way to increase their reporting clearly [23] . the exchange of health information on social networking sites has been seen as an opportunity for health sectors to increase public health observation [24] and to predict and control infectious diseases [25] . due to insufficient medical services in developing nations like pakistan, the authorities face severe complications to contain and eradicate the chances of spread of such infectious diseases. consequently, in case of an emergency, such communities start practicing alternatives to medical facilities to control the spread. therefore, we can safely propose the following: there is a significant relationship between social media exposure and information exchange about covid-19 among people. information exchange mediates the relationship between social media exposure and preventive behavior among people about covid-19. awareness regarding control of the infectious disease can overcome the financial burden for precautions. earlier knowledge about the outbreak of disease can overcome the level of its spread [26] . several methods can be used, like social media, internet access, tv, and so forth, by the nations to spread awareness about the precautions of disease. at present, mostly social networking platforms are being used as an important source to spread awareness of emergency to control an epidemic [27] . in the past, some researches have been conducted to evaluate the effect of social media to minimize the spread of infectious disease through preventive behavior. the results prove that social media is playing an essential role in overcoming the prevalence through prevention and reducing infection spread by awareness [28] . awareness brings behavioral changes among communities. as the phrase states, "prevention is better than cure". such awareness may be considered as half treatment without any expense. therefore, the researcher draws their next hypotheses as the following: there is a significant relationship between social media exposure and awareness knowledge. awareness knowledge mediates the relationship between social media exposure and preventive behavior among people about covid-19. many researchers have proved that during the infectious outbreak, socio-economic factors profoundly influence the prevention behavior towards diseases. the individuals with high income and education level have shown to be connected more with social media for the preventive measures [29] [30] [31] . furthermore, numerous studies argued that aged people followed better precautions by wearing a mask, using sanitizer, and keeping healthy respiratory hygiene [32, 33] . likewise, the relationships between the social determinants and prevention behaviors have presented that females [34] , individuals with high literacy [29] , and aged people [35] preferred to stay at home instead of visiting public places during an infectious period. however, according to the research conducted in the uk during a swine flu outbreak, individuals who have a low literacy rate/income level or are unemployed have avoided using public transport and visiting crowded places, in comparison with those individuals who have a high level of social determinants [33] . so, we can formulate following hypotheses. there is no significant relationship between high-income individuals and preventive behaviors among people about covid-19. there is no significant relationship between aged individuals and preventive behaviors among people about covid-19. there is no significant relationship between gender of individuals and preventive behaviors among people about covid-19. there is no significant relationship between high-educational individuals and preventive behavior among people about covid-19. research methodology, the principles and techniques used for gathering and analyzing data, plays an essential role in achieving the objectives of the study. this section presents the overall data sampling, research design, and data collection method used to find the objectives of the current study. an online survey was conducted by researchers in march 2020 during the covid-19 outbreak using social media tools like facebook, twitter, whatsapp, and email. a link was developed, and the structured survey was shared with participants on this link through different social media tools like facebook, twitter, whatsapp, and email. the intention behind the selection of online data collection using social media tools was maintaining the social distancing principle. this research is based on individuals from different geographical areas of punjab and azad jammu and kashmir, pakistan. the study was conducted on social media during 5 march 2020 to 25 march 2020. the sample size of 500 respondents was used through a random sampling method and examined with spss amos. the main reason for choosing this sampling method was that the researcher placed the questionnaire online. the researcher used a likert scale of 5 points. the hypotheses were measured using a scale by [36] . social determinants are considered very important in social science research and these were measured to check the significant direct effect of these control variables on preventive behavior among people about covid-19. the essential statistical components are age, gender, education, and income. these demographic components were necessary for the assessment of our objectives. the details of these variables are given in table 1 . the proposed model and variables investigated in this study are demonstrated in figure 1 . the proposed model and variables investigated in this study are demonstrated in figure 1 . sem technique was performed to examine the hypotheses discussed above. tables 2-4 show the key consequences for the hypotheses. researchers used path models to check the impact of social media on mediating variables, that is, information exchange and awareness knowledge regarding preventive behavior among people about covid-19 as a dependent variable and checked the direct effect of control variables on preventive behavior among people about covid-19. additionally, path analysis and maximum likelihood method were used to verify the mediated impact of health communication (awareness knowledge and information exchange) among social media and sem technique was performed to examine the hypotheses discussed above. tables 2-4 show the key consequences for the hypotheses. researchers used path models to check the impact of social media on mediating variables, that is, information exchange and awareness knowledge regarding preventive behavior among people about covid-19 as a dependent variable and checked the direct effect of control variables on preventive behavior among people about covid-19. additionally, path analysis and maximum likelihood method were used to verify the mediated impact of health communication (awareness knowledge and information exchange) among social media and preventive behavior. amos version 24 was used to check the statistical relationship between variables. initially, we tested the model fit index with comparative fit index (cfi) and root mean square error of approximation (rmsea); a cfi ≥0.97 and rmsea ≤0.055 mean the fit was acceptable (hu and bentler, 1999). the indirect effect of social media on behaviors was calculated using the same statistical tool through 2000 bootstrap samples. critical factor analysis (cfa) was used to test the discriminant and convergent validity of every construct of the measurement model. we also checked the factor score of each item, and all items exceeded the threshold of 0.6 (p < 0.001). the value of ave ranged from 0.55 to 0.79 (all values are exceeding the threshold 0.5), and cr ranged from 0.82 to 0.92 (all exceeding the threshold of 0.7). according to the parameter estimation results of table 4 , the direct impact of social media exposure on preventive behaviors concerning h1 (β = −0.097 p < 0.001) showed an insignificant direct relationship between independent variable and dependent variable. therefore, h1 was not supported. according to the results of h4 (β = 0.389, p < 0.01) and h2 (β = 0.377, p < 0.01), both showed significant direct effect of social media on awareness knowledge and information exchange. so, we accepted these two hypotheses. therefore, we can say that social networking sites have been used as an important strategy to spread awareness and information at the time of emergency to control the covid-19 outbreak. health communications via social media were positively significantly influenced by awareness and information exchange and indirectly influenced the adoption of preventive healthcare behavior. h6, h7, h8, and h9 tested whether age, gender, income, and education would be insignificantly associated with preventive behaviors. the parameter estimates showed that h9 education (β = 0.106, p < 0.01), h7 age (β = −0.052, p < 0.01), h8 gender (β = 0.041, p < 0.01), and h6 income (β = 0.023, p < 0.01) have negatively insignificant relationships with preventive behaviors. all these control variables were supported according to our theory. it is not necessarily individuals with high literacy/income and aged people who avoid using public transport and crowded places. the effects of high social components were directly insignificant on preventive behavior to control the epidemic disease of covid-19. according to the study findings, every type of individual can acquire an advantage through social media campaigns regarding the preventive behavior against covid-19. h5 and h3 tested whether awareness knowledge and information exchange directly influenced preventive behavior during an infectious disease outbreak like covid-19. estimated parameters in table 2 illustrated that awareness knowledge (β = 0.454, p < 0.001) and information exchange (β = 0.199, p < 0.001) have a positive significant direct relation with preventive behavior and have a full mediating effect between the social media and preventive behavior, as illustrated in tables 2 and 3 and figure 2 . social media provides the possibility for individuals to be aware of private or public awareness campaigns. eke [37] supported this theory that public awareness affects an individual behavior during an infectious disease outbreak to control its spread. our study showed that public or private awareness through social media could overcome the spread of infectious disease. the connectivity between the constructed hypotheses of our theory test is shown in table 4 , table 5 and figure 2 . according to the results of direct relation, no direct relationship exists between social media exposure and preventive behavior, however, awareness knowledge and information exchange create a mediating effect between the social media exposure and preventive behavior, so there exists a strong relationship between social media exposure and preventive behavior with the full mediation of awareness knowledge and information exchange. in conclusion, the covid-19 outbreak in china significantly damaged the human population across the globe. this included widespread distrust, a high number of deaths, high public stress, and economic damage. this study analyzed the effect of social media on preventive behavior during the covid-19 outbreak in pakistan. firstly, it should be counted that social media has become an increasingly popular source of awareness and information for health communications, especially the connectivity between the constructed hypotheses of our theory test is shown in table 4, table 5 and figure 2 . according to the results of direct relation, no direct relationship exists between social media exposure and preventive behavior, however, awareness knowledge and information exchange create a mediating effect between the social media exposure and preventive behavior, so there exists a strong relationship between social media exposure and preventive behavior with the full mediation of awareness knowledge and information exchange. in conclusion, the covid-19 outbreak in china significantly damaged the human population across the globe. this included widespread distrust, a high number of deaths, high public stress, and economic damage. this study analyzed the effect of social media on preventive behavior during the covid-19 outbreak in pakistan. firstly, it should be counted that social media has become an increasingly popular source of awareness and information for health communications, especially during an outbreak. the data have been collected and analyzed as the outbreak started in pakistan in 2020. this study examined how social media plays an essential role in formulating preventive behavior during the covid-19 outbreak in pakistan. the results of this research revealed that social media exposure is associated with two relevant variables, awareness knowledge and information exchange, and these variables mediate the relationship between social media exposure and preventive behavior among people regarding covid-19. social media reinforces and enhances health-related communication by raising awareness campaigns and disseminating reliable information to the users in an emergency regarding preventive behaviors. social media has become a source of rapid information and can be updated promptly. if the utilization of social media becomes more accurate or scientific then the social media can provide a very efficient and user-friendly way of monitoring the facts and figures of epidemic both locally and at an international level. the use of social media as a communicating tool during the infectious disease outbreak is a new method of observation, but provides a potential source of an accurate and quick assessment of progression of the current condition of disease within communities. social media has also become the most accessible and valuable tool, particularly in a social-economic and climatic context [36] . mostly, developing nations like pakistan do not have any excess to maintain and control the surveillance system in a timely manner during an infectious disease outbreak. therefore, due to lack of resources, most developing nations use social media networks for health communication tools to prevent and control the spread of infectious disease in a community [37] . thus, social media can afford a fast method of surveillance that forecasts the real-time burden of infectious disease and hence also can guide preventive strategies to control the epidemic. the study has some limitations as only data from pakistan were collected. therefore, the results may not be easily generalized to other developing countries, but are useful for politicians, health administrators, governments, policymakers, and social scientists, especially for those whose circumstances are like those in pakistan. the conceptual structural equation model provides useful information for policymakers and practitioners to enhance preventive behavior through the adoption of appropriate awareness strategies and information exchange and social media policies. the study demonstrates how social media exposure indirectly impacts preventive behavior and illustrates the paths of influence through either awareness or information exchange. to the best of our knowledge, the study is probably the first in the concerned area. the study investigated how only some social variables can help prevent covid-19. future researchers can investigate other variables lying under the category of social sciences and their role in dealing with covid-19 and its impacts. the future studies can also specify the sectors, like health workers, education, police, and other security agencies. the authors declare no conflict of interest. the effect of control strategies to reduce social mixing on outcomes of the covid-19 epidemic in wuhan, china: a modelling study a novel covid-19 from patients with pneumonia in china modeling the role of information and limited optimal treatment on disease prevalence users of the world, unite! the challenges and 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awareness, and local behavioural response evaluation of internet-based dengue query data: google dengue trends using social media for research and public health surveillance key: cord-330583-ltkpt80u authors: lee, kyu-myoung; jung, kyujin title: factors influencing the response to infectious diseases: focusing on the case of sars and mers in south korea date: 2019-04-22 journal: int j environ res public health doi: 10.3390/ijerph16081432 sha: doc_id: 330583 cord_uid: ltkpt80u following the 2003 the severe acute respiratory syndrome (sars) and the 2015 middle east respiratory syndrome (mers) outbreak in south korea, this research aims to explore and examine the factors influencing the response to infectious diseases, which encompasses both communicable and non-communicable diseases. through a qualitative research method, this research categorizes the factors as inputs, processes and outputs and applies them into the 2003 sars and mers outbreak in south korea. as the results conducted meta-analyses to comprehensively analyze the correlations of factors influencing disaster response from a korean context, the findings show that the legislative factor had direct and indirect influence on the overall process of infectious disease response and that leadership of the central government, establishment of an intergovernmental response system, the need for communication, information sharing and disclosure and onsite response were identified as key factors influencing effective infectious disease response. recently, a wide array of disasters, including earthquakes, forest fires, various infectious disease outbreaks and marine accidents have occurred in korea. accordingly, the importance of disaster response has drawn more attention than it ever has in korea, which was once considered a safe zone from various disasters. however, following the recent and sudden increase in the frequency of disasters, sufficient learning and legislature, as well as policy-making processes in korea have exposed limitations in the disaster management system, relative to other countries and regions where disasters have occurred more frequently. the recent efforts to change the disaster response system after certain disasters has exposed many limitations. under such circumstances, it is difficult to respond appropriately to disasters and there are limitations to avoiding or reducing social and economic losses caused by disasters. after the sinking of mv sewol, also called the sewol ferry disaster, in 16 april 2014, the korea coast guard was dissolved and the ministry of public safety and security (mpss) took on the role of a control tower. every episode of failed disaster response was always blamed on the lack of a control tower. therefore, the introduction of mpss was expected to be a panacea for effective disaster response. however, the initial response still failed during subsequent disasters, including in the middle east respiratory syndrome (mers) outbreak, the geyongju earthquake and various marine accidents, which confirmed that the disaster response was still not being effectively executed. when president the present study conducted an in-depth review of the concept of infectious disease and infectious disease response, which are the subjects of its theoretical review. in the past, the terms "contagious" or "communicable disease" were generally used. however, because the term "communicable diseases" implied diseases that were transmitted from one person to another, which further implied difficulties in controlling them, the term was changed to "infectious diseases," which encompasses both communicable and non-communicable diseases. for effective prevention and management of infectious diseases, the existing "parasitic disease prevention act" and "communicable disease prevention act" were merged. according to the "infectious disease control and prevention act," infectious diseases include class 1-5 of infectious diseases, designated infectious diseases, who-monitored infectious diseases, bioterror infectious diseases, sexually transmitted diseases, zoonotic infectious diseases and healthcare-associated infections. korea has experienced outbreaks of diseases that were traditionally regarded as "diseases that occur in developing countries," such as hepatitis a, tuberculosis, chicken pox and malaria, while cholera patients were identified for the first time in 15 years in 2016. moreover, despite continued outbreaks of emerging infectious diseases since the sars outbreak, there have been no noticeable changes in prevention and response measures. with the subsequent occurrence of the mers and zika virus in korea and the re-emergence of cholera, an infectious disease that had not been experienced for a while, public anxiety about health safety is growing. according to the infectious diseases surveillance yearbook published by the korea center for disease control and prevention (kcdc), the level of imported infectious diseases has been increasing every year, with 300-400 newly reported cases every year since 2010. experts have warned that this is only the beginning of the war against infectious diseases, due to the following reasons. with the changing global environment and increased human migration, prevention of emergence or re-emergence of infectious diseases is fundamentally impossible. moreover, infectious diseases tend to evolve along with advances in medical technology and emerging infectious diseases are difficult to handle since they spread quickly and have no readily available treatment. in particular, knowledge about the characteristics, route of infection and control measures of emerging infectious diseases are lacking or uncertain and it is difficult to predict when, where and how these diseases may emerge. moreover, globalization has brought with it an increased level of international trade and travel. therefore, korea, which has a high foreign trade dependency, is constantly exposed to the risk of imported infectious diseases. despite the growing anxiety and concerns about infectious diseases, studies on infectious disease response and control are lacking. after the mers outbreak, numerous studies on the response to this outbreak were conducted . however, most of the studies focused mostly on medicine and communication, with relatively fewer studies focusing on administrative fields [38] [39] [40] [41] [42] [43] [44] [45] [46] . studies in the medical field must precede the response to infectious diseases, so that information and knowledge about the infectious disease can be applied in response measures. however, if the national infectious disease response system is not ready when an actual infectious disease outbreak occurs, then medical determination and response, as well as crisis management and communication cannot be executed properly. this is because medical response, crisis management and communication are sub-elements in such a national-scale system. therefore, it is important to conduct studies on infectious diseases and responses in every specialty. however, there is also need for comprehensive discussions that include the establishment of laws; regulations; resources; information on infectious disease response from administrative and policy perspectives; information sharing system; and the establishment of an international cooperation system and national response system involving the central government, the regional government, private organizations and the public for effective response when an actual infectious disease outbreak occurs. in addition to infectious diseases being difficult to handle, the mers outbreak in 2015 also revealed that even if prevention and response measures are in place, a failed initial response can lead to an unanticipated increase in the rate and scope of infection transmission. moreover, disaster responses do not always pan out as planned and uncertainties and complexities that emerge after the disaster must be handled. therefore, it is necessary to identify government-level responses and make effort to improve the response system. however, previous studies on responses to infectious diseases are still lacking despite the importance of this issue. accordingly, the present study was conducted with the consciousness of the need to analyze response systems based on past response experiences in order to effectively respond to future infectious diseases, which are a threat. the present study analyzed two cases of infectious disease outbreaks based on the factors that influence response to disaster, as identified through existing studies and theories and aimed to derive factors that have a strong influence on the effectiveness of actual disaster response. in the following section, the factors that influence disaster response will be categorized from a system theory perspective to form a categorization framework. factors that influence disaster response have been identified through numerous studies over several years. most of the studies on disaster response analyzed actual cases by applying analytical tools based on major variables presented in existing studies and theories [14, [47] [48] [49] [50] [51] [52] [53] [54] or they analyzed the factors that influence disaster response by administering questionnaire surveys to members of agencies associated with disaster response [12, 55, 56] . therefore, instead of comprehensively examining the factors influencing disaster response, these studies handled the subject at a macroscopic level, focusing on the major variables. the present study aimed to organize factors and variables that influence the entire process of disaster response from a comprehensive and systematic perspective and categorize these factors and variables based on a system theory perspective in order to present an analytical framework. this concept and context are similar to those of perry [57] , who claimed that influencing factors of disaster response that are derived without classifying according to disaster types do not need different analytical frameworks since they can be described and analyzed according to the factors presented and they only differ in intensity according to the type of disaster. the present study reviewed existing studies, focusing on those with "disaster response" and "effective disaster response" as the outcome variables. the factors that influence disaster response can be broadly categorized into financial resources, human resources, physical resources, information, education and training, leadership, intergovernmental relationships, onsite response, information sharing, environmental context, characteristics of disaster and the legal/institutional environment. resources that influence disaster response can be categorized into financial, human and physical resources. financial resources include the government's budget for disaster response, funding to support processes involved in disaster response and support from the government or community [50] [51] [52] [53] . therefore, financial resources can be regarded as the disaster-related budget, the disaster management fund and financial support measures for processes entailed in korea's disaster response system. human resources included disaster response-related organizations and agencies, education and training of relevant organizations and the general public and utilization of specialists. existing studies have pointed out that the establishment of disaster response-related organizations or crisis management centers and the securement of specialists have a very significant influence on disaster response [49, 51, 52, 55, 58, 59] . this is because identification of disaster response-related organizations and agencies must come first to allow effective communication about disaster response and secure accountability in disaster response [55] . moreover, education and training for disaster response organizations and their members has been mentioned as an element that allows effective disaster response [49, 51] . lastly, physical resources refer to securement of disaster management-related resources and establishment of disaster management facilities. as indicated in the study by lindell et al. [51] , securement of disaster response and management resources within the organization allows timely and accurate disaster response, which was expressed as disaster response equipment in the study by jung [56] . such physical resources can be viewed as disaster management resources and facilities and whether the expansion of negative-pressure units and emergency isolation units have occurred also influences the response to infectious diseases. other influencing factors besides resource-related factors include education and training. knowledge can be explained as a collection of disaster-related information and information sharing in advance, where information about different types of disasters must be collected before the occurrence of a disaster. factors associated with disaster information have a positive effect on disaster response, as indicated in the study by kim [60] , which reported that when a disaster information system is established the recognition of the importance of information quality and higher information quality had a positive effect on achieving disaster management duties. next, leadership, intergovernmental relationships and communication, onsite response and information sharing have been identified as factors that influence disaster response. first, leadership in the context of this paper refers to leadership in the central government, which can be divided into leadership from the president and leadership from central organizations and agencies. the president's level of interest in disaster management and response and the governance style in running an organization, were analyzed as factors that have significant influence on disaster response [61] . moreover, onsite leadership by the heads of organizations and agencies must be demonstrated in a timely manner, especially in initial disaster response, in order to prevent the disaster from spreading [50, 53, 56, 59, 62] . second, intergovernmental relationships and communication are also factors that influence effective disaster response [50, 52, 53, 63, 64] . in addition, network was also pointed out as a factor that influences disaster response. existing studies tended to use the concepts of network and inter-organizational cooperation without clearly differentiating them but both network and inter-organizational cooperation were analyzed as factors that positively influence disaster response [54, 63, 64] . one of the reasons inter-organizational communication and coordination, network and cooperation have been identified as important influencing factors is that appropriate allocation and utilization of disaster response-related resources are essential for effective disaster response. accordingly, the present study analyzed intergovernmental relationships in order to comprehensively examine intergovernmental and inter-organizational relationships, communication and cooperation. information sharing has also been identified as an important factor in disaster response. information sharing between organizations and with the general public after a disaster was found to have a positive influence on actual disaster response. in particular, a study by hyun [6] found that information disclosure-related legislation, the organization's budget, personal awareness and attitude and information quality influenced the effectiveness of disaster management. among various factors influencing disaster management and response, factors associated with disaster-related information disclosure and sharing were tested for their influence on the effectiveness of disaster management. the results showed that greater information quality in information disclosure and sharing and greater personal awareness and attitude positively influenced the effectiveness of disaster management. effective disaster response may comprise sub-variables from its outcome aspect. in a study by denise [65] , the effectiveness of disaster response was determined by measuring life loss, property damage, satisfaction of stakeholders, society's resilience, operational efficiency and budget maximization. moreover, a study by byun (2014) examined fire service organizations and thus effectiveness was determined by evaluating fire containment and rescue, while efficiency was represented by reduction in damage and cost-effectiveness. other factors influencing disaster response include environmental factors [55, 56, 58, 59] , disaster characteristics [51, 55, 59] and legislative factors [3, 51, 55, 66 ]. sars stands for severe acute respiratory syndrome. it has a latency period of 10 days, after which the victim experiences high fever (â�¥38â°c), coughing and respiratory distress. it is transmitted by respiratory routes to medical staff and family members who come in close contact with the patient. complete cure is possible if treatment is administered early, where approximately 90% of infected patients recover easily within one week. however, sars may rapidly become severe for elderly or frail patients or for patients with chronic illness, yielding a mortality rate of approximately 3.5%. sars became known worldwide on 11 february 2003, when the chinese health authority announced that 305 patients with sars had been identified in china between november 16, 2002 and 9 february 2003, five of whom had died. who, which had strengthened its surveillance activities in the asian region after identifying the likelihood of the emergence of influenza, issued a worldwide warning on 12 march 2003. according to the official statistics released by who in november 2003, between november 2002 and july 2003, a total of 8098 suspected sars cases from a total of 28 countries were identified and a total of 774 sars related deaths were reported. consequently, sars emerged as the first new disease in the 21st century that was highly contagious and severe and its transmission through international air travel received special attention. since february 2003, when sars became known for the first time, korea continued to monitor sars outbreak trends through who data and recognized the need for national quarantine measures. accordingly, guidelines for strengthening nationwide sars quarantine measures were passed down on 12 february 2003 and on march 16 the korean government issued a sars alert, in keeping with the announcement of the global sars alert by who and established a quarantine system. with nih playing a central role, all healthcare institutions, including 12 national quarantine stations and 242 health centers, maintained a 24-hour emergency operation-ready status as part of the emergency sars quarantine measures. moreover, a quarantine system was established by designating 41 hospitals as isolation treatment hospitals according to regions. in addition, the policy of measuring people's body temperature as they entered the country through airports and sea ports was implemented in order to detect sars inflow from overseas and to prevent the disease from spreading. furthermore, follow-up investigations were conducted on people who entered korea from sars-risk regions and a system through which patients suspected of being infected could be transported immediately for isolation and treatment was put in place. moreover, additional isolation measures were implemented for people who came in contact with infected patients to prevent the disease from spreading further, in addition to preventing the import of sars. recommendations were made to refrain from traveling to high-risk regions to further prevent the import of sars into korea and to encourage precautions during travel. during the response process to the outbreak, a meeting for city and provincial quarantine officials and experts was held on 3 april 2003. on 23 april 2003, a discussion was held on measures of blocking the importation of sars and preventing its spread. the decision to implement government-wide response measures by setting up a central sars measures headquarter, led by the minister of health and welfare and satellite stations at city and province levels was made. subsequently on 28 april 2003, a government-wide comprehensive sars situation room was introduced and prime minister kun goh released a general public statement, urging active cooperation from the general public regarding the response measures taken by the government. eventually, who declared on 17 june 2003 that korea had won the war against sars, effectively subduing sars in less than 100 days after the global sars alert was issued [67] . mers stands for middle east respiratory syndrome. the outbreak of mers coronavirus started on 24 april 2015 following its introduction into korea by a 68-year-old male, who worked in floriculture and was returning home to korea after a visit to the middle east. the patient was treated at a clinic for a fever he developed seven days after arriving in korea but his condition did not improve. after his visit to the clinic, he received inpatient treatment for three days at pyeongtaek st. mary's hospital and was subsequently discharged. because of continued symptoms of high fever and respiratory distress, he visited another clinic and was eventually admitted to a single-bed unit at the samsung medical center in seoul on 18 may 2015. the staff at samsung medical center had learned that the patient had visited the middle east and based on a suspicion of mers, the doctor in charge requested kcdc to perform further testing on the patient the following day (19 may 2015) . the diagnostic test performed by nih detected middle east respiratory syndrome coronavirus: (mers-cov) genes in the patient. following the announcement of these findings on 20 may 2015, identification of the first mers patient in korea was officially reported [68] . as shown in figure 1 , the first mers patient in korea visited multiple clinics and large hospitals for treatment over a 10-day period since the symptoms first appeared, during which time he came in contact with family members, other patients and medical staff, resulting in many cases of secondary infection. [68] . as shown in figure 1 , the first mers patient in korea visited multiple clinics and large hospitals for treatment over a 10-day period since the symptoms first appeared, during which time he came in contact with family members, other patients and medical staff, resulting in many cases of secondary infection. as shown in the graph above, the highest number of confirmed mers cases outside of the middle east region was found in korea. the response to mers completely exposed contradictions in the national quarantine system, as well the healthcare system. kcdc and local government entities all proved inadequate in their ability to respond to the public health crisis caused by this infectious disease. there was confusion due to lack of clarity in the delegation of roles between the central and regional governments and the cooperation system between health authorities and medical institutions did not operate smoothly either. most medical institutions, including general hospitals, small-to-medium-sized hospitals and clinics, were not prepared to deal with healthcare-associated infections and as a result the infection continued to spread among patients and medical staff. in addition, problems in the transport and referral system for confirmed or suspected patients were discovered, while compensation for medical institutions and research and development of emerging infectious diseases became points of contention. moreover, medical staff who participated in the isolation and treatment of mers patients complained about job-related burden and stress. the mers outbreak exposed fundamental problems in the public healthcare system and vulnerabilities in the national quarantine system but the solutions to these problems have not been clearly identified to date. the mers outbreak caused restrictions in korean citizens' day to day lives and significantly impacted the national economy. the socioeconomic impact of mers has still not as shown in the graph above, the highest number of confirmed mers cases outside of the middle east region was found in korea. the response to mers completely exposed contradictions in the national quarantine system, as well the healthcare system. kcdc and local government entities all proved inadequate in their ability to respond to the public health crisis caused by this infectious disease. there was confusion due to lack of clarity in the delegation of roles between the central and regional governments and the cooperation system between health authorities and medical institutions did not operate smoothly either. most medical institutions, including general hospitals, small-to-medium-sized hospitals and clinics, were not prepared to deal with healthcare-associated infections and as a result the infection continued to spread among patients and medical staff. in addition, problems in the transport and referral system for confirmed or suspected patients were discovered, while compensation for medical institutions and research and development of emerging infectious diseases became points of contention. moreover, medical staff who participated in the isolation and treatment of mers patients complained about job-related burden and stress. the mers outbreak exposed fundamental problems in the public healthcare system and vulnerabilities in the national quarantine system but the solutions to these problems have not been clearly identified to date. the mers outbreak caused restrictions in korean citizens' day to day lives and significantly impacted the national economy. the socioeconomic impact of mers has still not been accurately assessed. what is clear at this point is that the entire korean society has become more interested in infectious diseases and that infectious diseases have become an agenda directly linked to public safety. moreover, people recognized that in order to respond to emerging infectious diseases it is necessary to continually assess and monitor infectious diseases that occur worldwide and establish manuals based on up-to-date knowledge through research, specialists and timely crisis analysis during the response process. in addition, the need to establish an infectious disease response network and partnerships between medical institutions and local government, as well as a central government, was also presented. the objective of this study was to inductively explore the factors that influence response based on studies related to disaster and infectious disease response. for this, a meta-analysis method called successive approximation was used [69] . prior to inductive exploration of the factors that influence disaster response, sample articles were used to categorize these factors. the study also aimed to perform successive meta-analyses to present a model based on detailed explanation and revision of the previously established factors influencing disaster response. accordingly, the present study used a rough model based on the categorization of the factors influencing disaster response presented in existing studies to perform meta-analyses on sars and mers cases. in summary, after establishing the initial model, several rounds of meta-analyses were performed to refine the model. accordingly, the incomplete preliminary theoretical framework, which can be viewed as the initial model, represented simplification and categorization of major factors through existing disaster response-related studies. the study aimed to conduct successive analyses based on the incomplete framework to present a refined model by revising the factors and the relationships between them. accordingly, precedent studies previously examined in chapter 2 were used to derive the factors influencing disaster response from a system perspective. on a review of numerous studies, it was discovered that the duties assigned to various organizations and agencies and the factors that actually influence disaster response show regularity [47, 70, 71] . therefore, based on such regularity, the study aimed to categorize these factors according to timelines from a system theory perspective. first, the studies that presented communication, coordination, cooperation and network from the process level as the mediating variables for effective disaster response included those by [3, 50, 55, 71] . other studies selected the process level variable as one variable among many independent variables in analyzing the influence on effective disaster response. it was commonly pointed out that resources related to disaster response influenced the outcome of disaster response through the interactions and coordination between organizations and agencies in the response process. kapucu [71] analyzed the influence of the system, organizational environment, tools for organizational capability and cooperation and the decision-making process of actors in the entire process on effective disaster response. the system was a variable that included organizational structure, culture and goals, while the environment included time pressure, uncertainty and complexity of the situation. capability was a factor that involved decision-making support, communication tools, previous cooperation experience, flexibility in responding to disaster and immediate response capability, while actors included the number of stakeholders, experts, interdependence and trust. the study examined whether these independent variables influenced effective disaster response through cooperative decision-making processes, meaning open and honest exchange of opinions, shared model construction, negotiation and utilization of relevant knowledge and information. the proposed research model was used to conduct social network analysis through content analysis, in addition to in-depth case analysis on countries that were victims of terrorist attacks, including the us, indonesia, turkey, spain and the uk. moreover, a study by lindell et al. [51] also revealed that various resources influenced disaster planning and such process had a significant influence on the efficiency of disaster response. on the basis of these studies, a framework consisting of independent variables having an influence on the effectiveness of disaster response through the disaster response processes was constructed. even in studies that do not present process variables as mediating factors, the majority of process variables were selected as independent variables for analysis and thus it is necessary to reorganize and categorize the variables that were presented in previous studies. as shown in figure 2 the present study selected the factors influencing disaster response presented in existing studies and categorized them largely into environment, inputs and process based on system theory. this model was presented because disasters act as a single system that includes the aforementioned factors, regardless of their type (natural or social disaster) [54, [72] [73] [74] . the strength of the influencing factors may vary depending on the type of disaster but because they were described and analyzed by the factors that are presented below, analyzing or describing social and natural disasters using different frameworks is unnecessary [57] . based on the categorization of the influencing factors shown in the figure below, the study aimed to conduct future meta-analyses to explore detailed factors and identify the relationships between these factors. had a significant influence on the efficiency of disaster response. on the basis of these studies, a framework consisting of independent variables having an influence on the effectiveness of disaster response through the disaster response processes was constructed. even in studies that do not present process variables as mediating factors, the majority of process variables were selected as independent variables for analysis and thus it is necessary to reorganize and categorize the variables that were presented in previous studies. as shown in figure 2 the present study selected the factors influencing disaster response presented in existing studies and categorized them largely into environment, inputs and process based on system theory. this model was presented because disasters act as a single system that includes the aforementioned factors, regardless of their type (natural or social disaster) [54] , [72] , [73] [74] . the strength of the influencing factors may vary depending on the type of disaster but because they were described and analyzed by the factors that are presented below, analyzing or describing social and natural disasters using different frameworks is unnecessary [57] . based on the categorization of the influencing factors shown in the figure below, the study aimed to conduct future meta-analyses to explore detailed factors and identify the relationships between these factors. for inductive exploration of the factors influencing infectious disease response, meta-analyses were performed based on the aforementioned factor categorization framework and in-depth interviews were conducted for testing and supplementation. the present study used previous studies on disaster response to compile a list of the factors influencing disaster response and presented a theoretical framework. moreover, the factors influencing disaster response were explored through case review, while qualitative meta-analysis was performed to identify the correlations between the factors. qualitative meta-analysis was conducted to allow a comprehensive analysis of qualitative studies [60] . this method of analysis is different from meta-analysis which integrates results from existing empirical studies using a quantitative method [75] , [76] . the approach in qualitative meta-analysis involves interpretive analysis, which strives to include major concepts that appeared in individual qualitative studies but at the same time, generate a higher-level concept that can connect these concepts to a higher dimensional theoretical structure to allow for comprehensive understanding of the phenomenon and possibility of new interpretation and theoretical creation [77] . therefore, the major goal of qualitative meta-analysis is to contribute to knowledge. from this perspective, schreier et al. [78] listed theory building, theory explication and theory development as the three overlapping goals of qualitative meta-analysis. in the present study, the factors influencing disaster response were reviewed from existing studies in the theory building process and organized from a system theory level. subsequently, meta-analysis was performed to explore factors through for inductive exploration of the factors influencing infectious disease response, meta-analyses were performed based on the aforementioned factor categorization framework and in-depth interviews were conducted for testing and supplementation. the present study used previous studies on disaster response to compile a list of the factors influencing disaster response and presented a theoretical framework. moreover, the factors influencing disaster response were explored through case review, while qualitative meta-analysis was performed to identify the correlations between the factors. qualitative meta-analysis was conducted to allow a comprehensive analysis of qualitative studies [60] . this method of analysis is different from meta-analysis which integrates results from existing empirical studies using a quantitative method [75, 76] . the approach in qualitative meta-analysis involves interpretive analysis, which strives to include major concepts that appeared in individual qualitative studies but at the same time, generate a higher-level concept that can connect these concepts to a higher dimensional theoretical structure to allow for comprehensive understanding of the phenomenon and possibility of new interpretation and theoretical creation [77] . therefore, the major goal of qualitative meta-analysis is to contribute to knowledge. from this perspective, schreier et al. [78] listed theory building, theory explication and theory development as the three overlapping goals of qualitative meta-analysis. in the present study, the factors influencing disaster response were reviewed from existing studies in the theory building process and organized from a system theory level. subsequently, meta-analysis was performed to explore factors through korean studies and articles and interviews. the protocol was constructed through data collection and analysis and effort was made to ensure reliability and validity of the study [79] . using this approach, the study was conducted systematically, from the data collection stage to the final analysis. after comprehensively collecting data, including domestic research articles, media reports and audit reports from the board of audit and inspection (bai) of korea related to sars and mers cases, data to be analyzed were selected on the basis of the inclusion and exclusion criteria. the data collection method will be discussed in more detail in the data collection section. the collected data were codified and categorized on the basis of the meta-analysis framework consisting of the factors influencing disaster response extracted from existing studies and theories. as shown in figure 3 , for the influencing factors identified from the data, the factor and source were recorded, and evidence of the correlation was identified. the evidence included statistical data, media reports, interviews with experts and claims made by authors. with this coding process, consistency of the results when the same analysis is performed by different researchers can be maintained and this can be used to ensure reliability. data for meta-analysis were collected from various sources, including listed academic journals, articles from daily and weekly periodicals and audit reports from bai. duplicate items were eliminated based on search results and data that met the objective of the present study were selected through in-depth reviews and discussions with fellow researchers. academic articles were limited to those published in journals listed in the national research foundation of korea, while duplicate articles and articles with low correlation to the research question were excluded. the period of data of academic articles was from 2003 (sars outbreak) to 2017 (at the time of the research). all searched articles were tallied and data were selected through validity testing and unanimity with fellow researchers. media reports were collected from daily and weekly periodicals to provide information that was not covered in academic articles. the search process used the naver news site and the official home pages of each newspaper. the search keywords were disaster case names: sars, mers and different variations of these terms in korean. additionally, data that mentioned a disaster name along with the term "response" were reviewed. to eliminate political bias, chosun ilbo, donga ilbo, kyunghyang shinmun and hankyoreh were selected from daily periodicals, while weekly chosun, weekly donga, weekly kyunghyang and hankyoreh 21 were selected from weekly periodicals. the period included in data collection was set to one year to include the infection outbreak and response period between january and december 2003 for sars and between january and december 2015 for mers. lastly, the homepage of bai was searched for bai audit reports on sars and mers but since audit reports for sars did not exist only mers cases were analyzed. among the 59 cases that appeared as search results for mers, the results that were unrelated to the selected cases were excluded. as a result, a total of 38 cases of audit reports for various organizations were selected for the analysis (table 1) . the results of factors coded and explored based on aforementioned media reports, bai audit reports, academic articles and in-depth interviews are provided here. to effectively demonstrate the results of exploring the factors influencing disaster response, analysis was performed by identifying how each factor, as an independent factor, influenced other factors; and by gathering evidence of the relationship between time, cause and outcomes. the present study underwent the process of identifying and testing correlations through a meta-analysis of the factors influencing infectious disease response. the analysis results on the factors influencing infectious disease response were as follows. legislation, sociocultural factors and disaster characteristics were identified as the environmental factors influencing disaster response. with respect to sars, although there was no legislative system for disaster response and management, some respiratory transmission diseases, including sars, were temporarily designated as "infectious diseases subject to quarantine and surveillance" for onsite response. enactment and amendment of laws have procedural and time requirements and thus quarantine or isolation was made possible by presenting them as subjects of quarantine and surveillance following the decree of the minister of health and welfare, which actually had a positive influence on onsite response. moreover, while legislation for mers was in place, it was incomplete and not detailed enough. this caused confusion in the response process because of the possibility of arbitrary decisions and because it contained inaccurate information about infectious diseases, it had a negative influence on onsite response. consequently, mers spread to other patients, leading to a failed initial response. moreover, unlike the sars outbreak, when international public health crisis was declared, there was no announcement of an international public health crisis with mers, which caused a lack of awareness on the importance of prevention and response. financial resources, human resources, physical resources, information and education and training were identified as the input factors influencing disaster response. human resources also acted as a mediating factor in the relationship between legislation and the effectiveness of response to infectious diseases. in the processes of responding to sars and mers, problems related to human resources, especially epidemiologists, were identified. this was also very apparent in the correlations. although epidemiological investigation in infectious disease response is very important for preventing the spread of infectious diseases and for timely response, an insufficient number of epidemiologists made it impossible to keep up with the rate at which the disease was spreading and since public health physicians were mostly responsible for epidemiological investigation, a lack of specialization was also a serious problem. moreover, budget, the proportion of public healthcare and infection control infrastructure, such as negative-pressure units, were also found to be insufficient during both sars and mers outbreaks. one of the factors that was identified as being important in the correlation analysis was education and training. since everyone may experience an actual disaster, simulated training according to given scenarios and education for response personnel are very important. leadership, intergovernmental relationships, information sharing and onsite response were identified as the process factors influencing response to infectious disease outbreak, while information sharing was found to influence stakeholder satisfaction. with respect to leadership, as mentioned earlier, the role of the prime minister and the president was an important factor in the implementation of timely and effective disaster response. during the sars outbreak, prime minister kun goh was at the forefront, urging the public and departments to cooperate. on the other hand, during the process of responding to mers, the control tower changed at least twice and the president made it clear through the spokesperson that the blue house was not the control tower. during this process, the intergovernmental relationship was not smooth either. moreover, poor information sharing and communication between departments and between the central and local government caused confusion and increased the level of distrust among the general public. among the process factors, intergovernmental relationships, information sharing and onsite response were independent variables that influenced the outcome and acted as mediating factors between legislation and outcome. lastly, although not presented in existing analytical frameworks, the factors identified through meta-analysis and interviews were interest and cooperation from the private sector (volunteerism). with respect to interest, an analysis of sars cases showed that the interest of local citizens, meaning regional self-centeredness, caused the designation of sars quarantine hospitals to be nullified, acting as a factor that interfered with infectious disease response. these factors were confirmed in the interview results. the interest of the agency in charge of the control tower emerged as a factor that interfered with the infectious disease response, albeit at a different level than the interest of local citizens. the agency in charge of determining the disclosure of information was the mohw and because the same agency was responsible for both promoting actual related projects and managing disaster, conflict of interest did not allow immediate response measures to be implemented. cooperation from the private sector (volunteerism) was a factor that did not appear in the meta-analysis but was identified in interviews with workers. its correlations were not analyzed in the meta-analysis data of the present study and existing studies did not discuss the role of volunteers in infectious disease response either. however, resource support for self-quarantine patients in actual infectious disease response was lacking but active participation by volunteers played a major role in helping to slow the spread of mers and to successfully implement self-quarantine. moreover, the hidden context of correlations identified through interviews, which was not identified in existing articles, was education and training. education and training was analyzed as a factor influencing infectious disease response, while the interview results revealed that education and training not only had a direct influence on response but also had an impact on the relationship between the people in charge of disaster response. timely response was made possible by relationships built between people in charge of disaster response through continued training, which may be attributed to the uniqueness of korean culture. as shown earlier, the factors influencing infectious disease response in korea were very diverse and they became more refined and detailed when compared to categorization of factors presented in the introduction of this paper. these were factors identified through meta-analyses and in-depth interviews and should be considered in the improvement of the infectious disease response system in korea. a comprehensive model that summarizes the aforementioned exploration of the influencing factors is shown in figure 4 . factor influencing infectious disease response, while the interview results revealed that education and training not only had a direct influence on response but also had an impact on the relationship between the people in charge of disaster response. timely response was made possible by relationships built between people in charge of disaster response through continued training, which may be attributed to the uniqueness of korean culture. as shown earlier, the factors influencing infectious disease response in korea were very diverse and they became more refined and detailed when compared to categorization of factors presented in the introduction of this paper. these were factors identified through meta-analyses and in-depth interviews and should be considered in the improvement of the infectious disease response system in korea. a comprehensive model that summarizes the aforementioned exploration of the influencing factors is shown in figure 4 . the present study conducted meta-analyses to comprehensively analyze the correlations of factors influencing disaster response from a korean context. for inductive exploration of the factors influencing infectious disease response in korea, the present study collected and selected reliable data from academic research on infectious disease response conducted in korea, newspaper articles and audit reports from bai. the reason for limiting the studies to those conducted within korea was based on the determination that it was necessary to review how well domestic studies and articles explained domestic cases. the objective was to use the findings to point out the limitations of infectious disease-related studies in korea and to present factors influencing infectious disease response within a korean context. the analysis results confirmed that, overall, the studies korea focused on factors from the process aspect when analyzing the factors influencing infectious disease response. a summary of other major findings are as follows: first, among environmental factors, the legislative factor had direct and indirect influence on the overall process of infectious disease response. other environmental factors were regarded as factors influencing disaster response based on their correlations but the legislative factor was considered especially important. disaster-related legislation enacted in various forms including basic laws, manuals and code of conduct should be systematic and exhibit high integrity to allow timely and accurate response in crisis situations. however, owing to insufficiencies in many aspects, it had a negative influence throughout the entire response process. the present study conducted meta-analyses to comprehensively analyze the correlations of factors influencing disaster response from a korean context. for inductive exploration of the factors influencing infectious disease response in korea, the present study collected and selected reliable data from academic research on infectious disease response conducted in korea, newspaper articles and audit reports from bai. the reason for limiting the studies to those conducted within korea was based on the determination that it was necessary to review how well domestic studies and articles explained domestic cases. the objective was to use the findings to point out the limitations of infectious disease-related studies in korea and to present factors influencing infectious disease response within a korean context. the analysis results confirmed that, overall, the studies korea focused on factors from the process aspect when analyzing the factors influencing infectious disease response. a summary of other major findings are as follows: first, among environmental factors, the legislative factor had direct and indirect influence on the overall process of infectious disease response. other environmental factors were regarded as factors influencing disaster response based on their correlations but the legislative factor was considered especially important. disaster-related legislation enacted in various forms including basic laws, manuals and code of conduct should be systematic and exhibit high integrity to allow timely and accurate response in crisis situations. however, owing to insufficiencies in many aspects, it had a negative influence throughout the entire response process. the legislative factor indirectly influenced disaster response, making it an important factor that influences the overall disaster response process. in other words, human resource was identified as the mediating factor in the relationship between the legislative factor, human resources and onsite response. on the other hand, intergovernmental relationships, information sharing and onsite response were identified as the mediating factors in the relationships between the legislative factor, intergovernmental relationships and the effectiveness of disaster response; the relationship between the legislative factor, information sharing and the effectiveness of disaster response and the relationship between the legislative factor, onsite response and the effectiveness of disaster response, respectively. along with the determination of mediating factors, the study also found that the establishment of legislation had an overall impact on infectious disease response. second, the results showed that most input factors, including physical resources, human resources and information were insufficient. within a korean context, it is believed that this problem stemmed from the lack of a disaster response system or many studies related to disaster response, as indicated by the fact that basic laws about disaster management were implemented in korea from 2004. considering that the systematization of disaster response following the passing of basic related laws was relatively recent, more detailed issues, such as securement of resources, did not draw attention until a disaster actually occurred, leading to gradual improvement. therefore, factors related to these resources showed insufficiencies no matter which case was reviewed. however, considering the differences in the timeframes of the cases raises concern on whether the experience gained from the disaster response system is actually being used as an asset to improve the disaster response system in korea. third, major findings regarding process factors were as follows. leadership of the central government, establishment of an intergovernmental response system, the need for communication, information sharing and disclosure and onsite response were identified as key factors influencing effective infectious disease response. existing studies have found that information sharing occurred top-down, from the central government to local government [80] . even so, information sharing was correlated with process factors. nondisclosure of hospital names by the government had an impact on the spread of infectious diseases and on failed initial response. further, the general public voluntarily shared information and made the effort to share accurate information, such as creating a mers map and sharing information on websites. in addition, the interests of local citizens and departments also acted as a factor that interfered with effective infectious disease response. by analyzing the factors influencing infectious disease response within a korean context, the present study presents the following theoretical and policy implications. theoretically, the study established a model of factors influencing infectious disease response by performing inductive exploration on the factors influencing infectious disease response in korea, which was utilized for comprehensive analysis. policy-wise, the study aimed to emphasize the need 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comparing conservative and progressive news media qualitative meta-synthesis on training and workplace experiences of individuals with disabilities: focusing on practical issues of applying qualitative meta-synthesis secondary and meta-analysis of research focus on qualitative methods qualitative metasynthesis: issues and techniques public health network structure and collaboration effectiveness during the 2015 mers outbreak in south korea: an institutional collective action framework the authors declare no conflict of interest. key: cord-329640-10trdf87 authors: jeong, hyun-chul; so, wi-young title: difficulties of online physical education classes in middle and high school and an efficient operation plan to address them date: 2020-10-05 journal: int j environ res public health doi: 10.3390/ijerph17197279 sha: doc_id: 329640 cord_uid: 10trdf87 this study examined the difficulties of running online physical education classes in the context of coronavirus disease 2019 (covid-19) and used the findings to develop an efficient operation plan to address these difficulties. six middle and high school physical education teachers participated; three were experts in online physical education and active in the korea council school physical education promotion, and three were recommended teachers making efforts to improve the online classes offered by the korea ministry of education. a qualitative case study method employing phenomenological procedures to collect and analyze the data was used. the difficulties of operating middle and high school online physical education classes for the first time included (1) the monotony of the classes within their limited environmental conditions and limited educational content that did not adequately convey the value of physical education, (2) trial-and-error methods applied nationwide, resulting from a lack of expertise in operating online physical education classes, and (3) very limited evaluation guidelines proposed by the korea ministry of education, which made systematic evaluation with online methods impossible. to address the identified problems and facilitate the efficient operation of online physical education classes, changes in strategic learning methods are needed to understand online physical education characteristics and thereby better communicate the value of physical education. it is also necessary to cultivate teaching expertise through sharing online physical education classes, where collaboration among physical education teachers is central. in addition, evaluation processes should be less formal to encourage active student participation. the entire world is currently facing a catastrophic situation resulting from the coronavirus disease 2019 (covid19) pandemic, which has affected the daily lives of people worldwide. since the world health organization declared a pandemic on 11 march 2020, avoiding face-to-face activities and engaging in social distancing have become a part of everyday life. the pandemic has also induced changes in many countries' educational environments as they began instituting online classes, including south korea (hereinafter korea), whose schools failed to begin the regular school year in march, for the first time in history. despite this unprecedented situation, korea is actively responding to social changes by offering a diverse school curriculum through online classes and developing new approaches to education. the changes required by the crisis may present an opportunity to adapt to the education needs of the incipient fourth industrial revolution. in many studies preceding covid-19, the possibility of online classes has been examined as a part of future education, in that online classes can provide highly efficient and diverse elective classes to self-directed students [1] [2] [3] [4] [5] [6] . physical education centers on physical activity and is clearly distinct from general knowledge-based subjects. therefore, online physical education classes require special preparation and operation to communicate and practice the values of physical education well. currently, as in-person school attendance and online classes are occurring in tandem around the world, there is a need to examine whether online physical education classes are being held and conveying the values of physical education appropriately. prior studies on the efficiency and potential of online physical education classes, however, are limited [7] [8] [9] . one such study focused on physical education textbooks published by the university of north carolina at greensboro and suggested employing direct and indirect experiential activities in addition to physical activities [8] . it further proposed a teaching and learning strategy for the management of interaction and motivation, learner-centered classes, and the application of a blended learning strategy in middle school physical education classes [9] . however, most existing studies have only examined the efficiency of college classes, within limited areas; to the best of our knowledge, no studies have investigated the difficulties or efficient operation plans of middle and high school online physical education classes. thus, there is a need to identify the existing practices of and best directions for future online physical education classes, both during and after the pandemic. this study identifies the difficulties of middle and high school online physical education classes and suggests ways to efficiently manage future online physical education classes. the results may serve as basic material to help revitalize online physical education classes in the future. the study employed a qualitative case study method using phenomenological procedures to collect and analyze the data [10] . "turning to the nature of lived experience" of research participants' online physical education classes, the study explored the experience of conducting these classes, discussed and reflected on their efficient operation and difficulties experienced therein, and examined the data by "writing and rewriting". to find a generalized representation of middle (14-16 years old) and high (17-19 years old) school online physical education classes in korea, the researcher selected six participants for this study, who were recommended by the korea ministry of education and the council for school physical education promotion, which pursues the revitalization of physical education in korea. three participants were middle and high school physical education teachers who were experts in online physical education; the other three had worked to improve the three types of online classes offered by the korea ministry of education. all participants provided informed consent to participate in the study, which was approved by the korea jeonbuk national university high school. table 1 shows the characteristics of the research participants. as a physical education teacher at "s" middle school in the 7th year of his educational career, he runs a "physical enhancement program", an interactive pe class of about 20 students, utilizing zoom. he is a training instructor for online pe content for physical education teachers nationwide and has a good understanding of the pros and cons of interactive pe classes. "i" high school (9 classes) female a as a physical education teacher for "i" high school in the 20th year of her educational career, she runs a "home training and yoga program" using microsoft teams, for a class of 15. while operating interactive teacher/student physical education classes, she tries to motivate student participation by using various video content and constantly strives for immediate feedback and interaction with students by asking questions via video. content-oriented physical education class "j" middle school (32 classes) female b as a physical education teacher for "j" middle school in the 11th year of her educational career, she runs a content-oriented physical education class using ppt and open broadcaster software (obs studio) programs for a class of 30. she switched to a content-oriented physical education class after initially running an interactive pe class, in which many students found it difficult to participate. "j" high school (24 classes) male b as a physical education teacher at "j" high school in the 15th year of his educational career, he runs a content-oriented physical education class using youtube and videos he has produced for a class of 30. he runs a class that combines theory and practice using physical education textbooks. he also works as a lecturer for the j-region physical education research association. assignment -oriented physical education class "h" middle school (23 classes) male c as a physical education teacher at "h" high school in the 23rd year of his educational career, he runs an assignment-oriented physical education class using basic lecture-type content for a class of over 30. in addition to physical activity assignments, he offers online group learning assignments to students and provides feedback during class. currently, he works as a lecturer in the operation of assignment-oriented physical education classes nationwide. "g" high school (30 classes) female c as a physical education teacher at "g" high school in the 4th year of her educational career, she runs an assignment-oriented physical education class for 30 students. the class is interactive and includes feedback from the teacher and focuses on "national health gymnastics" and "creative gymnastics" developed and practiced by students. the class uses google classroom and is equipped with assignment videos and explanations. pe, physical education. the collected data included material directly produced by the research participants and online videos of their physical education classes. in-depth individual and group interviews were conducted to examine experiences emerging in the participants' journals. we examined the participants' personal diaries and their online physical education class operations. five in-depth individual participant interviews lasting 50-70 min were conducted between march and june 2020. the interviews began with participants describing individual operation plans and were centered on the operation of these cases. five group interviews lasting 60-90 min were also conducted from april to june 2020, focused on difficulties that were encountered and overcome in the online physical education classes. the group interviews were comprised of open discussions among the research participants, which allowed collaborative and interpretive reflection within a seminar format. an inductive category analysis was employed, focusing on open coding, axial coding, and core coding [11] . the researcher worked to understand the overall flow and true meaning of the material through repeated reading. the meanings were classified and grouped by subject and analyzed through technical, reflective, and interpretive writing; then, the relationships between the essential elements of the results were identified to determine the overall structure. finally, an iterative process of reinterpretation, modification, and integration was applied to ensure that the generated categories reflected the purpose of the study. to enhance the validity of the study and test the consistency of the findings, a triangulation technique cross-verified data through an in-depth description from various angles using the collected data and the researcher's notes. the derived results were reviewed by the participants to ensure that their meanings were accurately expressed. the quality of the study was ensured through continuous feedback from two qualitative research experts (professor "s" of "j" university and professor "l" of "s" university), who reviewed the entire study process. difficulties in conveying the value of sports in online physical education classes remained in the modified technical practice. this value included maintaining health through physical activities, cultivating community consciousness through physical activities with friends, and developing sports etiquette through sports participation. students engaged in online physical education classes often cannot secure enough space to effectively take part in physical activity and also have limited access to supplies and equipment needed to follow online physical education classes. thus, the participants running the online physical education classes used supplies that were readily available at home, which necessarily reduced the physical education units that could be taught. this led to a shift in focus from competition, which is a major part of in-school physical education, to health and physical activity challenges in online instruction. teacher "a": in online physical education classes, students had to participate alone and use the supplies at home, so it was inevitable that classes were limited. however, it was easy for me to give feedback because i run a real-time interactive class and students practice it immediately in line with my fitness program. teacher "c": real-time interactive classes can be effectively used in a small class, but it seems inefficient in a class of about 30 students. thus, i used lecture-type content to provide explanations and demonstrations, present assignments, and give feedback. teacher "b": i run a content-oriented class, but i had doubts about whether the values of physical education that we wanted to deliver were being conveyed well, given the limited environment and the fact that students had to practice alone. teacher "c": i agree. i had actually planned a class in the competition area, but i could only do classes in the health area. i was worried that the students would feel too complacent about physical education through such classes. teacher "a": i had no choice but to run really monotonous classes like juggling and "challenging" stay-at-home challenges that could be done in students' own houses. (from the first group interview). in contrast to the general knowledge focus of core subject courses, physical education focuses on physical activity, an emotional domain. all participants had concerns about how to convey physical activities in online physical education classes and how to make the online physical education class a meaningful educational activity. in a study of physical activity limitation, kim et al. [12] reported that various physical educational activities geared toward health should be included in an online class, as most participants, despite various ages and genders, had health problems. it is possible that online physical education classes can be made more efficient if students receive feedback through viewing their own or their classmates' actions. this is in contrast to face-to-face physical education classes, where students can immediately receive feedback on their motor skills or their success completing physical activities. in contrast, students cannot modify their own activities by viewing a video of them, so they receive limited feedback. immediate feedback is needed to motivate students to learn and strengthen their active class attitude. the participants tried to provide feedback across time and space through online media; however, this was difficult, because basic rapport between the teacher and the students and among the students themselves was not able to develop well through the online approach. in addition, the lack of interaction between the teacher and students in online courses made it difficult to convey the value of physical education. there was an interaction between teachers and students when the teacher provided feedback by checking students' online assignment performance. this interaction became an advantage of interactive physical education classes and assignment-oriented physical education classes. however, this was difficult because basic rapport was not developed through the online approach. in addition, the lack of interaction between the teacher and students in online courses made it difficult to convey the value of physical education. (from the in-depth interview of teacher "a"). like the result of the in-depth interview with teacher "a," the interaction between the teacher and the student becomes an important factor for the realization of the value of physical education. this experience suggests that attempts to convey the value of physical education should be initiated later in the semester, after rapport has been developed between the teacher and their students and after the technical skills for various sports have been reviewed [13] . online physical education classes, instituted nearly worldwide during the 2020 pandemic, were a wholly new experience for both teachers and students. the sudden shift to online classes left teachers unprepared and struggling with unfamiliar teaching methods, forcing them to resort to trial-and-error approaches. inadequate online teaching strategies and low teacher and student readiness for online classes made the transition difficult [14] . i had to think about the content of physical education classes that i could do online with the start of online classes due to covid-19, and about the content of the class that could be evaluated when students came to school later. the content of online physical education classes were selected based on individual sports that can be done while maintaining social distancing after school starts. however, as the use of various evaluations (individual evaluation, group evaluation, etc.) was limited due to restrictions on class activities by group, i was very worried about what to do. (from the in-depth interview of teacher "b"). the filming and production of online class materials by the physical education teacher himself took two to three times longer to prepare (e.g., production and editing) than the existing physical education classes. even if various content (youtube, internet materials, etc.) was used, it took a lot of time and effort to search for videos and materials that matched the teaching content of the physical education teacher's class. (from the in-depth interview of teacher "c"). the participants' principal concerns about running online physical education classes centered on the lack of efficient content and difficulties in using the content. they worried about the students' ability to participate in sufficient physical activities given space restrictions and the online course content they created, and whether the course content was educationally meaningful. the availability of media to capture and edit various physical activity photos and videos was absolutely essential for online course preparation. the participants experienced considerable confusion in their initial attempts at online instruction, although the ministry of education and the municipal and provincial education offices provided guidance and training on operating online classes and copyright issues after the switch to online classes. i feel that it is more important than anything else for physical education teachers to develop their ability to efficiently use content in the areas where various aspects of physical activity are expressed and where the content of explanation, demonstration, and feedback is provided. this is an important point that i realized while lecturing in the content utilization training course due to the fact that physical education is unlike the general subjects. i believe that my experience in online physical education classes will definitely be an opportunity. (from the research journal of teacher "a"). the physical education teachers had to revise their education plans, courses, and evaluations several times in their online physical education classes. it is true that it is very confusing. i am going through a lot of difficulties because it is my first time using the content of online physical education classes and making evaluations. (from the in-depth interview of teacher "b"). physical education teachers who were familiar with online content could easily incorporate it. however, others had difficulties even with simple tasks, such as uploading lectures and linking videos from different sites. those who developed their own lectures experienced difficulties preparing for online physical education classes, because they lacked the necessary equipment (cameras, microphones, laptops, etc.), had no access to software for editing images and coding video files, and/or lacked experience in using such software. to maximize the efficiency of online physical education classes, both teacher effort and collaboration with online experts were essential [7] . the ministry of education presented guidelines for evaluating online classes [15] , which specified that teachers were to refrain from conducting evaluations unless they could be done face-to-face and recommended conducting evaluations after the return to in-class instruction to the extent possible. participants found it difficult to apply evaluations to online physical education classes. it seemed unreasonable to evaluate students on what they had learned in school following a long period of online classes-especially if these were conducted solely through lectures and assignments without the students actually performing and practicing the activities to be evaluated-particularly because the proportion of the evaluation based on physical activity was high, given the nature of the subject of physical education. this differs from general subject evaluations, where written examinations based on online course work can be administered after the return to in-school classes. although students could submit physical education performance evaluations in the form of videos and written assignments, it would be very time-consuming for large schools to determine whether students had submitted the evaluation materials and then to actually evaluate those materials. in order to evaluate a gymnastics movement, i asked the students to take a picture of themselves doing the gymnastics movement and upload it. however, there were limits in uploading the entire gymnastic movement, and so the evaluation was made in partial movements. in addition, there was too much restriction in providing feedback and evaluation for all images. (from the in-depth interview of teacher "c"). it has been a while since online physical education classes started, but i don't believe that the performance evaluation proposed by the ministry of education is a concrete plan yet. evaluations must be done in terms of efficiency and expandability of online physical education classes. (from the in-depth interview of teacher "b"). teacher "c", who had been conducting performance evaluations based on assignments, found it difficult to complete the evaluations, because performance assessment was not conducted in real time. in addition, she felt that the diversity and specificity of the evaluation was very poor because they were limited to evaluating individual activities through videos. each study participant completed evaluations according to the type of online physical education classes they conducted, and all participants described encountering specific difficulties in completing the evaluations. teacher "a": it is very difficult to check the performance of what students practiced in real-time interactive classes. teacher "a": the home training and yoga practice scenes were evaluated in real time, but the evaluation took too long. teacher "b": the performance assignment was checked through simple quizzes and discussions during the content-oriented class, but there were many difficulties in evaluating the actual activities and conducting detailed evaluations. teacher "b": i believe that the evaluation is essential for online physical education classes. for self-directed learning, the evaluation parts associated with the assignment should be presented in various forms. teacher "c": many teachers spend too much time giving feedback and evaluations in assignment-oriented classes. systematic supplementation is needed online. teacher "c": since there is a very limited amount of information that can be recorded in the student record in the existing evaluation, a new evaluation method that can evaluate and record the learning process should be introduced. (summary of the discussion on evaluations in the second and third group interviews). in the second and third group interviews, participants discussed the difficulties of the evaluation and argued that evaluation concepts and practices for online physical education classes should be re-established based on the current evaluation results. they likewise argued that these concepts and practices should include measures that confirm whether students actively participated in the online physical education classes. in addition, physical activity content that can be viewed online needs to be expanded. online physical education classes need to teach the value of physical activity as an important element of health [16] . however, before teaching students the value of physical education, teachers should focus on physical education concepts while preparing students to actively participate in the online class. online physical education classes should teach students to subjectively develop future physical activity plans and self-directed competencies. although the internet delivers classes without time and space constraints that nearly everyone can access, such classes are ineffective and inefficient if students do not actively and responsibly participate. in other words, the students' attitude toward self-directed learning is an important factor in the efficient operation of online physical education classes. therefore, teachers need to develop educational strategies for online classes that help students form a learning attitude. engaging and motivating students to participate in physical activities can help convey the value of physical education [17] . teacher "b": when conducting training for teachers, the issue was raised that no matter how much effort is made by the teacher to conduct a good class, it will be of no use if the students are not willing to listen. in such a case, the plan needs to be re-examined. teacher "c": yes, that is correct. if the online physical education class begins and no assignments are given, it would not be possible to check if the student is listening to the online class. actually, some students do assignments without listening to assignments, which means you can set a group for the class and complete the group work outside of class. thus, i have tried interactive classes among students to complete a set of assignments as a group. teacher "a": that's a good idea. before discussing the value of physical education, it should be preceded by many educational devices and materials so that students can listen to online classes with an attitude toward self-directed learning. teacher "b": yes, i agree. the value of physical education should be naturally achieved in class, and a good class will be meaningless if the students do not have active learning attitudes. teacher "c": yes, i have tried to make changes in the existing physical education class by making students submit reports and videos based on their activities to make them actively participate in class. (from the fourth group interview). in the group interviews, participants discussed the buzz learning method as a way to increase student participation in online classes [18] . changes are essential for developing and applying group assignments that encourage student participation to overcome the disadvantage of online physical education classes [18] . new assignment content needs to be developed in the future that will allow teachers to identify an individual student's learning status, just as the research participants developed different educational strategies to increase the value of the class. physical activity does not necessarily need to be central in the actual class to establish the value of physical education; park et al. [19] reported that the establishment of the value of physical education based on various types of materials is necessary in online physical education classes, as various audiovisual aids and activity equipment are provided to support the positive health behavior of university students. there is a need to develop ways to link the emotional areas while expanding the cognitive and defining areas, which can be an advantage of online physical education classes. teacher "b" made great efforts to motivate and interest students by using physical education textbooks to explain theoretical aspects and presenting images to help students understand the material. indirect experience based on direct experience of physical activity and the value of physical education were delivered through intensive classes in cognitive areas using physical education textbooks. (analyzing the content of teacher "b's" online physical education class). i do not think that it is necessary to teach the value of physical education centered on physical activity. rather, i think that by running this online physical education class, i was able to deliver the value of integrating various topics through theoretical classes in physical education textbooks. i tried to convey the value of physical education by using various video images, arguments, discussions, and reporting that were not well utilized in existing physical education classes. (from the in-depth interview of teacher "b"). online physical education classes are clearly different from traditional physical education classes. participants made changes while running online physical education classes and conveyed the value of physical education in different ways. participants pointed out that one change driven by online physical education classes was the active progress made by physical education teachers through collaboration, which provided training and help to teachers who had difficulty creating content in the early stage of online classes. this collaboration naturally expanded as they produced class videos and shared ideas on assignment methods and structures and class content. this collaboration was driven by the power of collective intelligence within the physical education community and demonstrated a culture of sharing based on the autonomy of the physical education research society and networks among colleagues [20] . considering that this is my first online class this year, the most distinguishing feature is that there is a place where physical education teachers from a variety of schools share the materials, content, and concerns regarding online physical education classes. would you say that we were tightly united in a crisis? it seems to have served as an opportunity for physical education teachers to reduce the trial-and-error and to develop better physical education classes. (from the in-depth interview of teacher "c"). the research participants' videos showed that physical education teachers collaborated on making demonstrations and teaching, thereby producing more professional content by producing a joint video that fit the class subject. (from the researcher's journal) . the importance of the teacher learning community is reported in many studies on the development of teacher expertise [21] [22] [23] . physical education class videos continue to be produced and teachers continue to cultivate their expertise as they develop and produce these class videos. research participants continued to develop their expertise by searching for educational materials, including carefully examining materials from the council school physical education promotion and the physical education research society, while developing online physical education classes. they further developed their expertise by producing and editing their own videos. the results of their efforts provide a good example of how to effectively prepare for future physical education. i was at a loss when i first started preparing for online physical education classes, but i received a lot of help from the teachers at the physical education research society. in addition, it really helped me cultivate my expertise while reflecting on my class. it was also very helpful to be able to view the classes of other physical education teachers, which used to be hard to see before. (from the in-depth interview of teacher "a"). it was great to be able to look at the really valuable materials in the council school physical education promotion and the national physical education teacher group's "katokbang". it was good to see many physical education teachers collaborate and build their expertise in "an opportunity that lies in a crisis". that is why i became confident in my class, too. (from the in-depth interview of teacher "c"). physical education teachers who strive to improve their expertise give students faith in the subject. faith creates interdependence through communication between the teacher and the students and also acts as an "invisible bridge" in physical education classes [24] . faith between the teacher and students can also be indirectly formed by the teacher's demonstrating instructional content and expertise while running an online class. efforts are needed to cultivate professional and practical knowledge suitable for online physical education classes through changes in teaching and learning methods, interaction with students, a broad understanding of the area, and expanded knowledge. online physical education performance is difficult to evaluate. traditional evaluations are extremely limited, including online and offline integrated evaluations, process-oriented evaluations, and physical activity-oriented evaluations. the research participants adapted their evaluation methods to determine whether the student achievement standards were met and whether advancement to the next class was appropriate. teacher "a": teacher evaluation is conducted by looking directly at the student's activities. peer evaluation is conducted by students looking at one another. teacher "a": our evaluation method entails showing various videos that fit the topic of the class and talking about the feelings they elicit in real time. teacher "b": there is no direct evaluation, and the achievement standards are reviewed by looking at the class and simply writing the overall content in the form of a report. teacher "b": a self-assessment is conducted to determine whether the student has participated in class with an attitude toward self-directed learning, and whether the student has completed the assignments, but they are not reflected in the student's score. teacher "c": evaluations cannot be made because it is an assignment-oriented class. images of the student's physical activity are used to deliver feedback through student self-assessment and teacher evaluation. teacher "c": based on the attached content of assignments carried out by the student, the course is recorded in the physical education section of the student's study record. (summary of evaluation discussion in the fourth and fifth group interviews). one characteristic of online education is that students can develop unique thinking through learning activities that meet their needs and cultivate creativity through the process of thinking [25] . evaluation methods need to be improved to capture the process of verbalizing students' thoughts. it is necessary to conduct evaluations in the form of an inspection to understand the educational value of online physical education classes, much like the way in which the research participants expanded the evaluation to assess diagnosis, formation, and achievement in addition to performance. the above student faithfully carried out the assignments regarding national health gymnastics during online physical education classes, understood and analyzed teacher and peer evaluation feedback, and faithfully participated in the assignments. (from the examples of study records by teacher "c"). teacher "a" evaluated interactive lessons in real time, but emphasis was placed on the students who delivered feedback and made corrections according to the feedback. in addition, a peer evaluation method was applied to the class in which feedback was provided by watching videos that in real-time interactive class, meaning other students watch the monitor video between students through informal evaluation. (analyzing the content of teacher "a's" online physical education class). research participants used informal evaluations to record student participation in the study record as a way to induce active participation. this was done while using the performance evaluation content required in physical education classes as a learning strategy. evaluation of the online classes, which was conducted for the first time in 2020, is not yet concrete, and efficient evaluation methods and content should be examined in future studies. this study examined the difficulties teachers experienced in running online physical education classes following the start of online schooling in korea in the context of covid-19 and presented an efficient operation plan for future online physical education classes. the difficulties of operating online middle and high school physical education classes included monotony related to limited environmental conditions and educational content, which ultimately decreased the effectiveness of conveying to students the value of physical education. it is necessary in this light to discuss the value of physical education during online classes. second, physical education teachers across the country lacked expertise in employing online content and had to resort to trial-and-error methods. to address problems like these, we expect that effective content will develop in various directions due to the covid-19 outbreak. third, student evaluations conducted in accordance with the evaluation guidelines proposed by the korea ministry of education were very limited, and a systematic evaluation was not possible because of the online nature of the classes. there is a possibility that a new evaluation method that can be operated effectively in online classes will need to be constructed. in addition, to develop effective online physical education classes, strategic learning methods that incorporate online physical education characteristics are needed to help teachers communicate the value of physical education. in delivering the values of physical education, which is the goal of physical education in korea, addressing the psychodynamic domain and affective domain, which are lacking in online classes, will certainly improve the efficiency of online physical education classes. second, physical education teachers need to prepare for the future methodology of physical education and acquire professional practical knowledge through sharing online physical education content. this collaboration among physical education teachers is central and should incorporate expertise from the korea physical education research society. third, it is necessary for students to make an effort to actively participate in online physical education classes and record the process in their life record books through discussion of evaluation methods and methods suitable for an online physical education class. in this study, the research participants did not have extensive experience in information and communication technology coming into the pandemic and the advent of online education, but they nevertheless actively participated in online physical education classes and played the role of representatives of korea, making the active efforts required by the times. finally, the need is apparent to explore various cases of online physical education, teachers' and students' experiences, and their meaning, to improve the generalizability of the lessons learned. the study findings had several implications. first, it is necessary to study the state of different countries' experiences in online instruction physical education instruction, comparing and analyzing how online physical education classes are conducted worldwide. accordingly, there is a need to review and systematize approaches to online physical education classes that highlight each country's cultural and educational characteristics and to examine the effectiveness of online physical education classes as a whole. second, there is a need to explore the potential of online physical education classes linked to face-to-face physical education classes to examine their respective effectiveness and potential possibilities in light of physical education teachers' increased expertise gained through their operation of online physical education classes. third, future studies should establish a theoretical framework for online physical education classes by examining the educational value of modifying existing pedagogical methods, content, evaluations, and so on to more effectively teach online physical education classes. fourth, future studies should also examine the efficiency and affordances of different online platforms employed by physical education teachers and evaluate their generalizability across actual school sites, especially as novel tools are developed. interaction and presence in the virtual classroom: an analysis of the perceptions of students and teachers in online and blended 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management experience of learner-centered physical education characteristics of online teaching in post-secondary, formal education funding: this research received no external funding. the authors declare no conflict of interest. key: cord-321913-zie2uv21 authors: godio, alberto; pace, francesca; vergnano, andrea title: seir modeling of the italian epidemic of sars-cov-2 using computational swarm intelligence date: 2020-05-18 journal: int j environ res public health doi: 10.3390/ijerph17103535 sha: doc_id: 321913 cord_uid: zie2uv21 we applied a generalized seir epidemiological model to the recent sars-cov-2 outbreak in the world, with a focus on italy and its lombardy, piedmont, and veneto regions. we focused on the application of a stochastic approach in fitting the model parameters using a particle swarm optimization (pso) solver, to improve the reliability of predictions in the medium term (30 days). we analyzed the official data and the predicted evolution of the epidemic in the italian regions, and we compared the results with the data and predictions of spain and south korea. we linked the model equations to the changes in people’s mobility, with reference to google’s covid-19 community mobility reports. we discussed the effectiveness of policies taken by different regions and countries and how they have an impact on past and future infection scenarios. we present an updated version of the predictive model of epidemic phenomena based on the approach called seir (susceptible-exposed-infective-recovered), widely used to analyze infection data during the different stages of an epidemic outbreak. the seir model represents one of the most adopted mathematical models to characterize the epidemic dynamics and to predict possible contagion scenarios. the seir model can be useful to assess the effectiveness of various measures, such as lock-down, since the infectious disease outbreak. it is based on a series of dynamic ordinary differential equations that consider the amount of the population subject to contagion, the trend over time of individuals who recover after infection, and the individuals who unfortunately die [1] . this work was carried out during the crucial development phase of the epidemic in italy (mid-april 2020), with the operational difficulties linked to the impossibility of verifying and validating the databases, and with the difficulty of comparing and calibrating the results with other studies. the purpose, however, is to provide an easy-to-read and useful tool that can help the policymakers, responsible for strategic choices, in assessing the social and economic scenarios related to the development of the epidemic. we are conscious that it is a predictive model which, although based on a scientific approach, is conditioned by a series of intrinsic and endogenous factors that can affect its medium-term reliability. nevertheless, we are also aware that any political decision potentially lacking any rational and critical evaluations of all the available data risks being based on mere sensations, often dictated by sentimental suggestions [2] . the generalized seir model is based on a system of differential equations, as discussed by peng et al. (2020) [3] in the analysis of the sars-cov-2 outbreak in china. the model, that adds complexity to the classical sir or seir models, represents the various conditions of susceptible the seir model simulates the time-histories of an epidemic phenomenon. in its classical form, it models the mutual and dynamic interaction of people between four different conditions, the susceptible (s), exposed (e), infective (i), and recovered (r). the classical seir model can be described by a series of ordinary differential equations: dr(t) dt = (λ + κ)i(t) the susceptible (s) is the part of the population that could be potentially subjected to the infection: at the initial time, without further information, it is represented by the whole population. the exposed (e) is the fraction of the population that has been infected but does not show symptoms yet: it can be called a latent phase, and at this stage, a disease can be infectious, partially infectious or not infectious [8] . the infective (i) represents the infective population after the latent period. the recovered (r) are the people after healing, and they are generally not reintroduced into the susceptible category if it is supposed that they became immune to the disease. this aspect is strongly debated, as in some countries a second infection of recovered people has been recorded. at this stage of our study, we do not have enough data to include this effect on the model; this would require the introduction of another term in the previous system of equations, including another coefficient that takes into account the re-population of the susceptible compartment. in the classical seir model, the r category also comprehends the individuals who died of the disease. a characteristic of this model is that the sum of the four categories is equal to the total population (n) at any time: as can be seen, it does not consider the natural births and deaths of the population during the time span of the disease. the equations of the classical seir model are governed by the parameters β, γ, λ and κ. we adopt the symbols used in peng et al. (2020) [3] . as usual in this field, the following parameters have day −1 as a unit of measurement. • β is called infection rate. it is the number of people that an infective person infects each day. it is equal to p, where b, or the contact rate, is the number of people an average person enters into contact with each day, and p is the probability that a contact provokes the transmission of the disease. in the seir model, β is the vector which transports people from the s category to the e category. it is multiplied by the ratio s/n to avoid counting contacts between two people who cannot infect each other (e.g., because one of them has already recovered, or because both are infective). • γ is the inverse of the average latent time and governs the lag between having undergone an infectious contact and showing symptoms: in the equations, it brings people from the e category to the i category. • λ and κ are the recovery rate and the death rate, respectively, and they are united together in a single parameter in the classical seir model. they give information about how fast the people may recover from the disease (1/λ is the average recovery time), and how many of them, unfortunately, die. given the complexity of the disease, many authors have implemented different variations of the classical seir model, regarding both the equations and the parameters, or managing different fitting techniques to make the model representing the reality as close as possible. we adopted a generalized seir model following the recent publication by peng et al. (2020) [3] , who studied the covid-19 infection in several chinese provinces. we applied the model of peng et al. (2020) to the italian situation, following this system of equations: this seir model adds some features to those of the classical seir model (equations (1)-(4)): it supposes that the susceptible population decreases thanks to lockdown policies and improvements in public health behaviors, such as wearing face masks. each day, several individuals (s·α) passes from the susceptible category to the protected category (p), being α the protection rate. it adds the category of quarantined people (q). the passage from the infective to the quarantined category is done through the parameter δ, which is the inverse of the average time required to quarantine a person with symptoms: this happens usually after the person has been tested positive. the quarantined people are hence excluded from the infective category (i) because they are supposed not to have had any contact with others. the quarantined category matches the "active confirmed cases" in italian official datasheets, and, according to the common habit of quarantining positive people, it is true also for data from most developed countries. this is a critical point for the system of equations, that according to us should be better defined. in fact, an infected individual is not automatically quarantined, because the authorities were often unable to test enough people while keeping pace with the spread. this is especially difficult because many people do not develop symptoms at all, but can transmit the infection to others. so, we think that δ also contains some information about the percentage of the detected infective people. a study from calafiore et al. (2020) [5] proposed the introduction of an additional parameter to better understand this issue. it separates the categories of recovered (r) and dead (d) people, linked to the quarantined category through the λ and κ parameters, the cure rate, and the mortality rate respectively. λ and κ are time-dependent because the health system can improve its capability to treat people over time, e.g., with the introduction of a new therapy. based on the data collected from chinese reports in peng et al. (2020) [3] , which suggested an exponential evolution of the two parameters, we constrained λ and κ to fit an exponential trend. similarly to cheynet (2020) [9] , the assumption is that the death rate should become closer to zero as time increases, while the recovery rate converges toward a constant value: the λ 0 represents the final asymptotic value of the cure rate. it is related to the health system's ability to tackle the infection after adapting to the new outbreak and depends also on other factors like the good health of the citizens. λ 1 is related to how fast the adaptation to the emergency was. at the beginning of april, south korea was already in a post-peak phase of the disease spread. from our initial tests, equation (13) did not ideally match the data of south korea, probably because of the more complicated trend, compared to other countries. therefore, only for the south korean model, the λ parameter was not constrained by an exponential law. we increased the degrees of freedom of its trend by imposing a sinusoidal law: the fitting of the six parameters was performed by rearranging equation (11): where r and q are the data series of recovered and quarantined people. this approach was successful in providing a better fitting of the model prediction to the data. the parameter κ 0 represents the initial value of the mortality rate. the κ 0 value is related to the initial health system's ability to tackle the infection and depends on the good health of the citizens. the κ 1 value measures how the rate has changed with time. the mortality rate is supposed to decrease over time, and the higher κ 1 is, the faster this decrease. we introduced an improvement to the β parameter, compared to peng's model, that is, its time dependency. since the infection rate β is proportional to the contact rate b, as stated before, we estimated the variation in the contact rate according to the recent publication of google's covid-19 community mobility reports [6] , a database built on gps data collected from mobile devices with the "location history" option turned on. it provides data about the reduction in the mobility of people over the recent few months. for each investigated region, we calculated the average mobility decrease over time, and we fitted the curve with a second-order polynomial trend line. then, we constrained β to be proportional to that specific trend line. in a preliminary test on a simple data set, we noticed how the introduction of this constraint allowed the model to obtain a better data fitting. therefore, we applied this approach to the seir model to ensure good data fitting for all the regions and countries investigated. we noticed that the mobility data of south korea did not show a significant decrease in people's mobility, because the government adopted a different strong approach in lockdown policies compared to most european countries. strict lockdowns were not imposed, but efforts were addressed to track the infection spread at the early stages, with tight controls and strict quarantine protocols for infected individuals. for the 30 days of model prediction, the time-dependent β parameter had the same value of the last observed day (i.e., mid-april) since we did not have reliable predictions about future mobility. this means that the lockdown policies will continue, or the reopening of business will be made paying close attention to health protection procedures. the generalized seir-model scheme is described in figure 1 . the expected evolution of the equation terms is: the susceptible category decreases over time, feeding the exposed (e) category through the beta parameter β and the protected (p) category through the α parameter; the latter represents the part of the population who for various reasons becomes insusceptible to the disease. the exposed (e) category is only a temporary category: its individuals pass into the infective (i) category after a latent time (1/γ), on average. the infective category generates newly infected people over time, removing them from the susceptible category. the detected infected individuals are quarantined (q) to avoid spread. then, they evolve into recovered (r) or death (d) cases, according to various causes, like health care system effectiveness, age, co-morbidity of other diseases. it is important to note that the most reliable data series provided by national agencies are q(t), r(t), and d(t). the fitting of these data in the structure of the generalized seir model allows the trend of other categories to be estimated with some degrees of uncertainty, as well as their prediction for the subsequent 30 days. the main outputs of the model are the following data series: • s, target time-histories of the susceptible cases, • e, the target time-histories of the exposed cases, • i the target time-histories of the infective cases, • q, the target time-histories of the quarantined cases, • r, the target time-histories of the recovered cases, • d, the target time-histories of the death cases, • p, the target time-histories of the insusceptible cases. the α, β, γ, δ, λ and κ parameters can be considered a major output of the model. in particular, the evolution over time of λ and κ could provide information about the changes in the health system response to the contagion. β is also time-dependent, and it is constrained to be proportional to the people's mobility trend extrapolated from google's big data. the α-value is also related to policies, although it is not closely related to a precise aspect of the government strategies, as the β parameter. the α-value was not forced to follow any particular law during the modeling since we tested no significant improvement by modifying it from a constant to a time-dependent parameter. the α, β, γ, δ, λ and κ parameters can be considered a major output of the model. in particular, the evolution over time of λ and κ could provide information about the changes in the health system response to the contagion.  is also time-dependent, and it is constrained to be proportional to the people's mobility trend extrapolated from google's big data. the -value is also related to policies, although it is not closely related to a precise aspect of the government strategies, as the  parameter. the -value was not forced to follow any particular law during the modeling since we tested no significant improvement by modifying it from a constant to a time-dependent parameter. the various researches about seir-like models applied to the current sars-cov-2 epidemic have introduced minor or major changes to the classical seir model. it can be useful to overview the values of the main parameters, to define a realistic range of values, and to understand their meaning. we used the coefficient values found in literature to set the lower and upper boundaries of the parameters in our modeling. the values of these parameters are related to different methods. therefore, the bibliographic research summarized in table 2 should be only considered as a qualitative benchmark. we highlight some peculiarities of the various studies. the various researches about seir-like models applied to the current sars-cov-2 epidemic have introduced minor or major changes to the classical seir model. it can be useful to overview the values of the main parameters, to define a realistic range of values, and to understand their meaning. we used the coefficient values found in literature to set the lower and upper boundaries of the parameters in our modeling. the values of these parameters are related to different methods. therefore, the bibliographic research summarized in table 2 should be only considered as a qualitative benchmark. we highlight some peculiarities of the various studies. table 2 . values of α, β, γ, δ, λ, and κ describing sars-cov-2 outbreak in the recent literature. the study by calafiore et al. [5] presents the values of the parameters also for each italian region. the peculiar seir model used here introduces two new parameters: α (with a meaning different from ours) and ω. α represents how many times the real number of infected people is higher than the number of detected infected people, and it is estimated to be about 63. the ω parameter defines a fixed percentage of total people susceptible to the disease, and according to this model, it is about 0.124 (12%). one of the who reports [10] shows a list of estimates of serial interval, which is the average time between infection and subsequent transmission. we reported the latter since it is closely related to the inverse of β. it ranges from 5 to 9 days, according to the various studies considered. dandekar et al. [11] calculates the change over time of a term, called quarantine strength (q(t)), fitted thanks to a neural network-based approach. shaikh et al. [12] considers as separated the asymptomatic and symptomatic categories. the most interesting feature of the model proposed by lin et al. [13] is the time-dependent β, implemented with a different design compared to our model: where α is a stepwise function that represents the governmental action, estimated to range from 0 to 0.85 according to the strength of lockdown policies. while k is the citizen response, estimated to be about 1100. iwata et al. [14] proposes a model which does not fit real data but investigates possible scenarios deriving from a different combination of parameters. their range is reported as a credible range reference. the model equations were implemented on the basis of the matlab code provided by [9] , available in matlab file exchange. the data are extracted from the official repository and are composed of: confirmed, recovered, and death cases (q, r, and d, respectively). these values represent the initial assumptions, while the parameters α, β, γ, δ, λ, and κ are the problem unknowns. the differential equations are numerically solved by means of the runge-kutta method. the standard approach of the source code uses as default a least-square fitting solver to match the observed data and the calculated response (of q, r, and d). at the beginning of modeling, the initial values of the six parameters are given as first esteem. then, their values are calculated following a least-square solver that considers the observed data (q, r, d) with time. we modified the standard release of the code by introducing a new solver, the pso algorithm, belonging to the family of computational swarm intelligence (population-based nature-inspired metaheuristics) [15, 16] . this optimization solver minimizes an objective function, which is set to decrease the misfit between observed data and calculated responses of q, r, and d by varying the six parameters, i.e., the problem unknowns. the main advantages of the stochastic approach over the deterministic method to solve the seir model are briefly discussed. the adaptive exploration and exploitation of the search space of the model solutions avoids the risk of being trapped in some local-minima solutions and also enhances the independence from the initial assumption of the six parameters which could bias the final solution. the solution search-space is sampled by a set of 200 particles, representing the possible solutions, which are randomly initialized. the adaptive behavior and the convergence and stability of the final solution are ensured by using a pso variant, the hierarchical pso with time-varying acceleration coefficients (hpso-tvac) [17] . convergence was achieved in 150 iterations. each run of 150 iterations was repeated for 50 trials to test the variability of the solutions due to the random initialization of the parameters. finally, the trial showing the minimum normalized root mean square error (nrmse) was selected as the best solution. the solutions from the remaining trials were a-posteriori evaluated with their probability density distribution. the solutions within 5% of the minimum nrmse were chosen as representative of other probable scenarios. deploying a stochastic approach increased the computational cost of the modeling. therefore, the code was parallelized to be run on multiple cores. the simulations ran on the academic high performance computing (hpc) cluster of politecnico di torino. the sustained performance of the cluster is globally 20.13 tflops and the cpu model of one node is 2x intel xeon e5-2680 v3 2.50 ghz 12 cores. we adopted 24 cores of a single node. here we present the time series obtained by the standard deterministic approach and the data series obtained by the stochastic approach, based on the particle swarm optimization (pso) algorithm. first, we analyze the italian framework at a national and regional scale. then, we provide the results of seir modeling for two other countries: spain and south korea. spain was chosen because the epidemic spread is similar to the italian one, while south korea represented a testing data set as the epidemic peak had already been overcome. the final nmrse of the modeling and the values of the seir coefficients are supplied in table 3 . the prediction of the italian situation according to the deterministic solver shows the trends given in figure 2 . the result of the pso approach is shown in figure 3 . observed data of quarantined, recovered, and death cases are marked in red, green, and black circles, respectively. the individuals tested positive and placed in quarantine (at home, or hospitalized, or in intensive care) are plotted in red color. the sum of quarantined, recovered, and deaths, at a certain date, represents the total confirmed cases at that moment. the italian data set starts from 1st march, because we start to model from the day when the confirmed cases were 1% of the maximum counted cases. the predicted curves are plotted with solid lines in figures 2 and 3 . the set of most probable pso solutions (within 5% of the minimum nmrse) is plotted with dashed lines in figure 3 . the predicted peak in the red curve represents the status in which the rate of recoveries becomes greater than the rate of infection. it reflects the most relevant impact on the health system, because the numbers of quarantined people, both at home and in the hospitals, are at their maximum. for the italian situation, the maximum number of the predicted quarantined cases is expected after 27th april according to the deterministic approach and some days before the day according to the best solution of the pso approach. the curves of recovered and deceased cases in figures 2 and 3 are similar. the final nrmse was 0.035 and 0.043 for pso and deterministic modeling, respectively (table 3 ). confirmed cases were 1% of the maximum counted cases. the predicted curves are plotted with solid lines in figures 2 and 3 . the set of most probable pso solutions (within 5% of the minimum nmrse) is plotted with dashed lines in figure 3 . the predicted peak in the red curve represents the status in which the rate of recoveries becomes greater than the rate of infection. it reflects the most relevant impact on the health system, because the numbers of quarantined people, both at home and in the hospitals, are at their maximum. for the italian situation, the maximum number of the predicted quarantined cases is expected after 27th april according to the deterministic approach and some days before the day according to the best solution of the pso approach. the curves of recovered and deceased cases in figures 2 and 3 are similar. the final nrmse was 0.035 and 0.043 for pso and deterministic modeling, respectively (table 3 ). the italian data set starts from 1st march, because we start to model from the day when the confirmed cases were 1% of the maximum counted cases. the predicted curves are plotted with solid lines in figures 2 and 3 . the set of most probable pso solutions (within 5% of the minimum nmrse) is plotted with dashed lines in figure 3 . the predicted peak in the red curve represents the status in which the rate of recoveries becomes greater than the rate of infection. it reflects the most relevant impact on the health system, because the numbers of quarantined people, both at home and in the hospitals, are at their maximum. for the italian situation, the maximum number of the predicted quarantined cases is expected after 27th april according to the deterministic approach and some days before the day according to the best solution of the pso approach. the curves of recovered and deceased cases in figures 2 and 3 are similar. the final nrmse was 0.035 and 0.043 for pso and deterministic modeling, respectively ( table 3) . the analysis of the situation of lombardy, veneto, and piedmont regions is depicted in figures 4-6 , respectively. lombardy was strongly impacted by sars-cov-2, as at the end of march, nearly 40,000 novel infected cases and more than 5000 deaths were recorded in a population of 10 million. on the contrary, the veneto region evidenced 7000 cases and about 300 deaths in a population of 5 million people. the analysis of the situation of lombardy, veneto, and piedmont regions is depicted in figures 4-6 , respectively. lombardy was strongly impacted by sars-cov-2, as at the end of march, nearly 40000 novel infected cases and more than 5000 deaths were recorded in a population of 10 million. on the contrary, the veneto region evidenced 7000 cases and about 300 deaths in a population of 5 million people. the prediction of the situation in lombardy, according to the deterministic approach ( figure 4a) , appears rather optimistic, as the trend of the quarantined should start to decrease in a few days (red solid line). this probably does not reflect the evolution of the true situation in that region, even if the rate of the recovered generates positive feelings. if we look at the most probable scenarios predicted according to the pso analysis (dashed lines in figure 4b) , the wide spreading of the trend of the quarantined indicates how any eventual less-restrictive policy must be evaluated with great care in the next days. the set of most probable solutions from pso presents a wide range of solutions, wider than that for italy (figure 3 ). the final nrmse was 0.062 and 0.061 for pso and deterministic modeling, respectively (table 3) . the prediction of the situation in lombardy, according to the deterministic approach (figure 4a) , appears rather optimistic, as the trend of the quarantined should start to decrease in a few days (red solid line). this probably does not reflect the evolution of the true situation in that region, even if the rate of the recovered generates positive feelings. if we look at the most probable scenarios predicted according to the pso analysis (dashed lines in figure 4b) , the wide spreading of the trend of the quarantined indicates how any eventual less-restrictive policy must be evaluated with great care in the next days. the set of most probable solutions from pso presents a wide range of solutions, wider than that for italy ( figure 3 ). the final nrmse was 0.062 and 0.061 for pso and deterministic modeling, respectively (table 3) . approach. in (b) the solid line refers to the best pso solution, the dashed lines refer to the most probable solutions (i.e., the solutions within 5% of the minimum nrmse). figure 5a ,b shows the seir model prediction for the veneto region, according to the deterministic and pso approaches, respectively. while the predicted recovered and death cases are in accordance, the curves of quarantined cases present a slightly different estimate of the predicted peak, which is comprised between 11th and 25th april. the final nrmse was 0.035 and 0.04 for pso and deterministic modeling, respectively (table 3) . the seir modeling for the piedmont region is shown in figure 6a ,b, where the solution using the deterministic and pso prediction are reported, respectively. the scenarios predicted from pso are a little worse than those of the deterministic solutions. however, the observed data of piedmont yield a wide range of probable solutions (dashed lines), which can be overlapped to the deterministic solution in some cases. the final nrmse was 0.056 and 0.05 for pso and deterministic modeling, respectively (table 3 ). figure 5a ,b shows the seir model prediction for the veneto region, according to the deterministic and pso approaches, respectively. while the predicted recovered and death cases are in accordance, the curves of quarantined cases present a slightly different estimate of the predicted peak, which is comprised between 11th and 25th april. the final nrmse was 0.035 and 0.04 for pso and deterministic modeling, respectively ( table 3) . the seir modeling for the piedmont region is shown in figure 6a ,b, where the solution using the deterministic and pso prediction are reported, respectively. the scenarios predicted from pso are a little worse than those of the deterministic solutions. however, the observed data of piedmont yield a wide range of probable solutions (dashed lines), which can be overlapped to the deterministic solution in some cases. the final nrmse was 0.056 and 0.05 for pso and deterministic modeling, respectively (table 3) . the epidemic situation in spain is shown in figure 7 . the crisis exploded in a few days after the italian collapse, as the direct consequence of the delay in undertaking restrictions in business and social activities to limit the spreading of the infection. at this stage of the evolution of the phenomenon in spain, after one month, the results obtained by the deterministic approach forecast a trend of the recovered that seems very optimistic if compared with the italian situation. we can assume that the spanish health system will react promptly to the last round of the infectious. the result of pso modeling is shown in figure 7b . the final nrmse was 0.046 and 0.052 for pso and deterministic modeling, respectively (table 3 ). the epidemic situation in spain is shown in figure 7 . the crisis exploded in a few days after the italian collapse, as the direct consequence of the delay in undertaking restrictions in business and social activities to limit the spreading of the infection. at this stage of the evolution of the phenomenon in spain, after one month, the results obtained by the deterministic approach forecast a trend of the recovered that seems very optimistic if compared with the italian situation. we can assume that the spanish health system will react promptly to the last round of the infectious. the result of pso modeling is shown in figure 7b . the final nrmse was 0.046 and 0.052 for pso and deterministic modeling, respectively (table 3 ). the trend of the cases and the predicted response of south korea's situation is presented in figure 8 . the analysis of the data about south korea is useful to look at the italian situation with respect to a country where, for many reasons, the infection was limited, even if the crisis seemed very dramatic at the early stage. the abrupt changes of the recovered and quarantined trend required a careful analysis of the seir coefficients and their temporal variation. the final data fitting was indeed not ideal because of the marked oscillations in both the time-series of quarantined and recovered cases. the final nrmse was 0.074 and 0.078 for pso and deterministic modeling, respectively (table 3 ). the trend of the cases and the predicted response of south korea's situation is presented in figure 8 . the analysis of the data about south korea is useful to look at the italian situation with respect to a country where, for many reasons, the infection was limited, even if the crisis seemed very dramatic at the early stage. the abrupt changes of the recovered and quarantined trend required a careful analysis of the seir coefficients and their temporal variation. the final data fitting was indeed not ideal because of the marked oscillations in both the time-series of quarantined and recovered cases. the final nrmse was 0.074 and 0.078 for pso and deterministic modeling, respectively (table 3) . we adopted a generalized seir model to offer a quantitative overview of the complex analysis of the sars-cov-2 epidemic, meanwhile the disease is still running. the parameters were fitted in a least-square sense with a deterministic approach, and then with a stochastic approach, using a particle swarm optimization (pso) algorithm, a novelty in the field of epidemiological studies. the analysis of the results from the stochastic approach gives an overview of the most probable scenarios selected among the solutions within 5% of the normalized root mean square (nrmse) of the best solution. for each investigated area, we performed 50 trials of pso simulations and from 5 to 15 trials belonged to the most probable set. it is noticeable that the predicted model responses led to an approximately equivalent the data fitting (normalized with respect to the mean value within an l2-norm < 0.05). the probable scenarios sometimes presented a wide range of possible solutions because of the intrinsic setting of the stochastic approach. the different scenarios were achieved thanks to a deeper investigation of the model-space domain where the solutions are not driven and influenced by the initial guess of the seir model coefficients. one of the main limits of the we adopted a generalized seir model to offer a quantitative overview of the complex analysis of the sars-cov-2 epidemic, meanwhile the disease is still running. the parameters were fitted in a least-square sense with a deterministic approach, and then with a stochastic approach, using a particle swarm optimization (pso) algorithm, a novelty in the field of epidemiological studies. the analysis of the results from the stochastic approach gives an overview of the most probable scenarios selected among the solutions within 5% of the normalized root mean square (nrmse) of the best solution. for each investigated area, we performed 50 trials of pso simulations and from 5 to 15 trials belonged to the most probable set. it is noticeable that the predicted model responses led to an approximately equivalent the data fitting (normalized with respect to the mean value within an l 2 -norm < 0.05). the probable scenarios sometimes presented a wide range of possible solutions because of the intrinsic setting of the stochastic approach. the different scenarios were achieved thanks to a deeper investigation of the model-space domain where the solutions are not driven and influenced by the initial guess of the seir model coefficients. one of the main limits of the deterministic approach, instead, is that the results are biased by the selection of the starting point of model parameters. the data seem to confirm that while lombardy and piedmont applied similar approaches to social distancing and retail closures, veneto's strategy applied a much more proactive effort to limit the contagion, by means of extensive testing of symptomatic and asymptomatic cases early on, jointly with an effective tracing of potential positives. the different actions undertaken by the regions are well depicted in the future trend of the model, with evident advantages in an earlier end of the infection spreading in veneto (compare figures 4 and 6 with figure 5 ). in fact, the peak of quarantined in veneto lies before those of lombardy and piedmont. the descending curve in veneto has a sharper trend than that of the other two regions. moreover, in veneto, the predicted fatalities are ten times lower and the recovered are five times lower than those in lombardy. the behavior of piedmont ( figure 6 ) deals with a peculiar trend, introducing a time-delay of the recovered (green curve) with respect to the death cases (black curve), since the number of the recovered in the month of march is always lower than the deaths. this is because the intersection of the trends of recovered and death cases is reached later than the other regions herein analyzed, i.e., 7th april. this probably resulted from the regional testing policy that tested (and counted as confirmed) only patients with severe symptoms or at high risk. the high rate of fatalities that occurred in march was also due to the unexpected stress on the health system and the scarcity of intensive-care units. differently, lombardy and veneto experienced a higher rate of recovered patients at the early stage of the epidemic outbreak. a recent analysis [18] has pointed out how, according to the guidance from public health authorities in the central government, lombardy's actions involved a more conservative approach mainly focusing on the symptomatic cases. they also suppose that the set of policies enacted in veneto minimized the burden on hospitals and minimized the risk of spreading in medical facilities. veneto's strategy tried to prevent the diffusion by capillary actions at the local scale, to limit the contagious with additional measures in the hot spots of the infection at the early stage of the epidemic. the expected trend of these regions was controlled by many factors outside the control of policymakers, including lombardy's greater population density and a higher number of cases at the explosion of the crisis. nevertheless, the different public health policies at the early stage of the epidemic phenomena also had an impact, and it seems that tailored capillary actions, as in the example of veneto, obtained better results than applying only a regional lockdown. the difference in the approaches can be underlined by observing that many municipalities or provinces declared "red zones", where, due to high transmission of the infection, additional restrictive measures were introduced, compared to the rest of the regional territory. in the red zones, the different policies acted in response to local epidemiological situations. instead, in piedmont and lombardy, no red zone was established, but restrictive individual distancing measures were regulated on a regional scale. according to the evidenced results of different policies, in the next phase of governmental policies, the reopening of business and activities should be tailored to the local situations, focusing on the organization and integration of all figures of the health system. in particular, the central government should require from the regions an effort to provide local epidemiological data in real-time, to lockdown only limited areas, while the reopening of regional-scale business can be eased. the estimated parameters that regulate the equations of the seir model are reported in table 3 . for the parameters obtained with stochastic approach, the best-solution is shown in bold, while in brackets the mean and the variance of the solutions within 5% of the minimum nrmse in brackets. in table 3 we compare the parameters among different regions, and between the stochastic and deterministic approach. both approaches provided models that fitted the observed data with good accuracy, although the stochastic approach has, in general, a slightly lower nrmse. the parameters calculated with pso are reported with the best-solution value, mean, and variance. we can observe that α, β, γ and δ had a high variance due to the intrinsic variability due to the stochastic approach. sometimes the best solution is not aligned with the mean value. λ and κ values, instead, are strictly gathered around the mean in almost all pso solutions, hence the low variance. this is explained by considering that, since the number of parameters is higher than the available data series (q, r, and d), the problem is underdetermined, so that the stochastic approach can find more than one series of parameters which fits the data within an acceptable misfit. then, λ and κ do not show large variability among the most-probable scenarios because they govern the equations that correlate q with r and d, that is the official data series. therefore, the estimated λ and κ were always found in the same region of the search space of solutions. south korea and veneto show the highest recovery rates (λ 1 ) with values around 0.05, followed by spain (0.044). this confirms the reports which praise the veneto model, because its administration had the capabilities of testing more quickly than other italian regions, and the family doctors worked in a stronger synergy with the health structures. it also evidences a lower death rate (κ 0 ), probably due to the better health system efficiency to treat patients, but also to the greater number of tests. in both data and policies, the veneto region is more like south korea than other parts of italy. these aspects had an impact on the outbreak of the epidemic, as can be seen comparing figures 4-6 : the veneto region is more likely to reach the peak of active cases (q) before the other regions. even though the pso results may seem to provide a wide range for the seir parameters, we stress two important aspects: • as we already stated, the problem is underdetermined, so it is preferable to have an acceptable range of values than a unique point value, that could result in being uncertain, as could happen considering only a deterministic approach solution; • the set of possible predicted scenarios, although related to different solutions with different sets of parameters, are quite similar, thus offering an acceptable level of variability of future predictions. while it would be very useful to estimate a more narrow range of parameters like the infection rate β or the latent time (1/γ), this is beyond the goals of our study, and the topic is being explored by researchers who focus also on the clinical aspects of the disease. the model has some limitations, as previously discussed. we summarize them to highlight possible needs in the further development of the modeling. we have currently not sufficient information to say that, after recovery, an individual becomes totally immune to the disease, but we made this assumption: the model did not allow the passage from the recovered category to the susceptible category. the model does not consider that the exposed category may have a partial infection ability, as described in shi (2020) [8] , nor distinguishes symptomatic from asymptomatic people, as studied in shaikh (2020) [12] . the model does not consider the testing differences between different health system structures and country policies. • while italian and spanish data are well fitted, the south korean data fitting presents some issues. this evidences that different policies between countries can induce different trends in the spread of the epidemic and that the models should be adapted to different situations, with the introduction or removal of parameters. this would be especially valid in analyzing the situation of the least developed countries, that are not able to afford strict lockdown policies like the developed countries. except for the death rate parameter, the model does not have a strong link to the health resiliency of citizens. the death rate parameter could also be related to external factors like air pollution, which makes people more sensitive to respiratory diseases [19] . the introduction of google's covid-19 community mobility report represents a constraint that was easily implemented in the model. further studies on the quality of those data and a rigorous implementation could represent a novel and interesting research topic. we think that many of these issues could still remain open, but the critical point of the study is not to determine exactly in which way each external factor influences the trend of infectious cases, because we are analyzing a multifaceted problem from a global point of view. moreover, the official data we consider are suspected to be not enough accurate to be the basis of a very detailed study. we applied two different approaches for solving the equations of the seir model to describe the evolution of the epidemic phenomenon in italy and in the most impacted regions of the north of italy (lombardy, veneto, and piedmont). we considered all the possible available data on the 15 april 2020. the main findings indicate that the deterministic approach is not appropriate to explore the possible solutions of the space-domain because the mathematical problem is underdetermined. we recommend fitting the data of this epidemic using a stochastic approach, such as the pso method. taking advantage of the pso approach, we estimated different scenarios for a 30-day epidemic evolution. every scenario refers to a different set of parameters estimated by the algorithm. the predicted scenarios are fairly similar and suggest that every italian region will reach the peak of the epidemic by mid-may. the influence of the time-varying infection rate βon the model prediction may open interesting discussions about the effect of lockdown policies on the evolution of the epidemic in the near and far future. because the model was provided rapidly and the study was performed during the international emergency, we did not explore further the implications of different "reopening" scenarios. we can say that, if the β parameter remains at current values, e.g., if the lockdown policies are maintained or, better, the reopening of business is done with particular attention to health safety procedures, the prediction of the trend of the recovered and deaths could be considered reliable, with the approximations and the uncertainties that the pso model has pointed out. at the italian level, despite the great dispersion in the prediction of the quarantined and recovered cases, the number of deaths will reach a number of around 33,000-35,000 cases at the end of may and the number of active cases will gradually decrease. this prediction cannot consider the impact of future decisions on social distancing. the data and the model predictions confirm that some valuable lessons should be learned from the approaches of south korea, which was able to contain the contagion very soon before a wide spread of the infection. the veneto region was one of the best examples in italy about how integrated and synergic regional policies in social distance and the health system can tackle the epidemic, and its epidemiological scenario is now more optimistic than those of lombardy and piedmont. we stress that tailored actions provide much better epidemiological outcomes than wide lockdowns, keeping in mind also the example of south korea. the main purpose of our work was to provide a fresh discussion and new tools able to support the policymakers in their decision about the action to minimize the impact of the disease. the analysis demonstrates that, because the italian health care system is highly decentralized, different regions managed different policies, which highly influenced the evolution of the epidemic in its first months: the data and the model prediction well reflected the different approaches taken by lombardy and veneto, two regions with similar socio-economic tissue. the overall lesson that could be learned from this analysis goes beyond the mathematical modeling itself, and will require a wider evaluation on all the possible socio-economic and political factors, even if the data analysis of the veneto situation could be used to revisit regional and central policies early on. if so, the regions are going to emulate the virtuous approach of veneto, including more demanding requests to improve their diagnostic capacity that will weight on the central government. outbreak properties of epidemic models: the roles of temporal forcing and stochasticity on pathogen invasion dynamics early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia epidemic analysis of covid-19 in china by dynamical modeling a short history of mathematical population dynamics a modified sir model for the covid-19 contagion in italy covid-19 community mobility report particle swarm optimization seir transmission dynamics model of 2019 ncov coronavirus with considering the weak infectious ability and changes in latency duration generalized seir epidemic model (fitting and computation) who 2019 novel coronavirus: overview of the state of the art and outline of key knowledge gaps/slides. available online neural network aided quarantine control model estimation of global covid-19 spread a mathematical model of covid-19 using fractional derivative: outbreak in india with dynamics of transmission and control a conceptual model for the coronavirus disease 2019 (covid-19) outbreak in wuhan, china with individual reaction and governmental action a simulation on potential secondary spread of novel coronavirus in an exported country using a stochastic epidemic seir model self-organizing hierarchical particle swarm optimizer with time-varying acceleration coefficients particle swarm optimization of 2d magnetotelluric data lessons from italy's response to coronavirus exposure to air pollution and covid-19 mortality in the united states: a nationwide cross-sectional study author contributions: all authors provided a contribution to the development of the methodology and conceptualization. code implementation and modeling: f.p. and a.g; validation and interpretation, a.g. and a.v.; writing-original draft preparation, a.g.; writing-review and editing, f.p. and a.v.; supervision, a.g. all authors have read and agreed to the published version of the manuscript.funding: this research received no external funding. we are grateful to three anonymous reviewers for their useful comments, which have enriched this work. we are indebted to the team of meisino's boys for their useful discussion on the epidemic evolution in italy. computational resources provided by hpc@polito (http://hpc.polito.it). the authors declare no conflict of interest. key: cord-302704-rj4le1qn authors: felknor, sarah a.; streit, jessica m. k.; chosewood, l. casey; mcdaniel, michelle; schulte, paul a.; delclos, george l. title: how will the future of work shape the osh professional of the future? a workshop summary date: 2020-09-30 journal: int j environ res public health doi: 10.3390/ijerph17197154 sha: doc_id: 302704 cord_uid: rj4le1qn rapid and profound changes anticipated in the future of work will have significant implications for the education and training of occupational safety and health (osh) professionals and the workforce. as the nature of the workplace, work, and the workforce change, the osh field must expand its focus to include existing and new hazards (some yet unknown), consider how to protect the health and well-being of a diverse workforce, and understand and mitigate the safety implications of new work arrangements. preparing for these changes is critical to developing proactive systems that can protect workers, prevent injury and illness, and promote worker well-being. an in-person workshop held on february 3–4, 2020 at the university of texas health science center (uthealth) school of public health in houston, texas, usa, examined some of the challenges and opportunities osh education will face in both academic and industry settings. the onslaught of the covid-19 global pandemic reached the united states one month after this workshop and greatly accelerated the pace of change. this article summarizes presentations from national experts and thought leaders across the spectrum of osh and professionals in the fields of strategic foresight, systems thinking, and industry, and provides recommendations for the field. the world is undergoing major changes in the way work is performed, the workforce, and the workplace. with the goal of increasing productivity and the greater incorporation of technology, the pace of work has intensified. while short-term, temporary employment arrangements represent greater flexibility for employers, they can translate into more precarious situations for workers; lower pay for equivalent education, skills, and experience compared to those with long-term contracts; fewer benefits; and greater turnover [1] [2] [3] . thirty percent of the u.s. workforce now engages in nonstandard work arrangements, such as contingent work, temporary contracts, and part-time work [4] . additionally, estimates of teleworking under the covid-19 pandemic reached upwards of 50% of all employed u.s. adults, and that number is expected to increase long after the pandemic [5] . future of work scenarios describe an increasing global reliance on the informal sector and hazardous work exposures that are exacerbated by work-life stress and health consequences of precarious work [6] . this first workshop examined how the future of work will likely shape education and training for the next generation of osh professionals. the objectives were to (a) examine the impact of future of work (fow) on how we train the osh professional workforce; (b) identify gaps and needs related to training and education; and (c) inform the agenda of the 2021 international conference. workshop attendees represented a broad cross-section of stakeholders, including adult educators, worker representatives, government employers, industry professionals, the academic community, and consultants. participants were identified using a modified snowball technique. the organizing committee generated an initial list of experts who were asked to nominate additional participants from a wide range of disciplines and professions relevant to the topic of the workshop. a final list of invited participants included experts from public, private, and non-governmental agencies representing the following sectors: academic research, education, construction, government, healthcare, management, organized labor, and workers' rights. most of the participants were from academic institutions (48%), followed by government (21%), industry (15%), non-governmental agencies (6%), and labor (4%). internationally recognized niosh thought leaders first provided an overview of the fow and its likely impacts on worker health and well-being. thereafter, the workshop format was structured along three themes: (1) innovative approaches to adult education, (2) the role of systems thinking in osh education and training, and (3) what the future osh professional "should" or "will" look like. keynote speakers introduced each of these three themes and then facilitated small group discussions where participants addressed specific questions or challenges posed by the speakers. to foster greater interprofessional interaction, the small group composition was randomized and changed for each breakout session so that, by the end of the workshop, participants had worked with virtually all other attendees. debriefing sessions provided an opportunity to link the discussions back to the workshop objectives, summarize gaps and needs, and generate conclusions. workshop notes and recordings were transcribed and edited by the authors. thematic analysis was carried out on small group discussion transcriptions using an inductive multi-phased approach to synthesize input and identify axial themes and representative statements. the results of the thematic analysis are shown in tables 1-3 . cooperates with other disciplines and professional fields -identify a broad set of osh collaborators, such as policymakers; professional societies and groups (e.g., acoem, acgih, asa); employers (including small, medium, and large enterprises); city, county, and state governments; public health professionals; medicine and nursing professionals; environmental health and safety professionals; social scientists; and wellness/health promotion groups -provide strategies to identify key conceptual overlaps with stakeholders and approaches for capitalizing on shared interests advocates for the osh cause at all times and to all audiences -embed osh professionals into industry in order to bring recognition to the relevance and importance of osh, build leadership support, raise employee awareness, and purposefully prioritize organizational problems -encourage interaction between osh and non-osh professionals to engage wider group of professionals to advocate for and support frontline osh activities. -lead by example, leveraging major public health events (e.g., floods, pandemics) to highlight community-wide relevance of osh. * attributes and strategies reflect an integrated summary of the input provided by workshop breakout groups. this section provides a summary of all workshop presentations and the results of group discussions that identified the challenges, gaps and needs of the three workshop themes described above. the niosh fow initiative was launched in 2019 and applies the total worker health ® (twh) framework by encouraging collaboration across organizational policies, programs, and practices. central to both of these niosh futures-oriented priorities is the concept of worker well-being, which integrates the traditional osh goal of protecting workers from occupational hazards with the promotion of health and illness prevention in the workplace and is being operationalized by niosh through its twh program [10, 11] . twh promotes using more holistic approaches to broaden the focus from one narrowly centered on workplaces to those which incorporate both work-related and non-work-related factors that impact worker well-being, either positively or negatively [7] . therefore, according to this contemporary conceptual framework, worker well-being emphasizes quality of life and is driven by the relationship between individual worker health and factors both at and outside the workplace, in order to have workers thrive and achieve their full potential [7] . since the start of niosh twh activities (https://www.cdc.gov/niosh/twh/) in 2011, there has been progress in advancing this niosh priority. examples include funding and establishing twh centers of excellence, improving the definitions and conceptual frameworks for well-being (noted in the previous paragraph), and identifying gaps and needs in research and applied interventions [7,10,12,13]. however, as knowledge advances, new needs and existing gaps emerge, and niosh seeks to build on these advances and identify current needs and gaps. niosh's new fow initiative (https: //www.cdc.gov/niosh/topics/future-of-work/default.html) was launched to compile what is known about fow scenarios and emerging trends and support new research, with an eye towards being able to forecast and anticipate risks that fow may bring. priority areas of focus include organizational design, changes in work arrangements, emerging technological demands (including job displacement), artificial intelligence, robotics, and other innovative technologies. the effort will highlight demonstration projects aimed at enhancing skills and economic security [14] . the unprecedented expansion of the use of ai in the workplace and its potential impacts on worker safety will change tasks workers perform and how they are protected from new and existing workplace hazards. ai will bring expanded use of sensors to detect and mitigate exposures, increased risks of human-robot interaction and autonomous vehicles, anticipated technological displacement, and greater incorporation of the internet of things into our lives. the large amount of data generated through technological advances will result in a greater need for occupational analytics and decision-making by decision data scientists and ai systems. ai will pose new challenges for osh professionals as they prepare to respond technically and ethically to these changes [15] . the osh field will need an expanded, more holistic focus to address challenges and changes posed by fow scenarios to prepare the professionals of the future. this paradigm shift challenges traditional osh systems by focusing on worker well-being as an outcome, goes beyond the prevention of workplace injury and illness or health promotion, and expands the types of hazards typically considered in the traditional osh paradigm. the world health organization (who) model for action, various european efforts at well-being, and the niosh twh program provide important foundations for addressing changes in the world of work [9] . beyond this, though, we need a more expansive paradigm to include greater recognition of both individual worker and workforce well-being as important osh outcomes. embracing this paradigm shift mandates a more expansive, systems thinking approach to better integrate traditional osh with personal and socioeconomic risk factors, both horizontally (broadening the range of factors to examine their impact on health) and vertically (from a short-term, single job perspective to a work life continuum perspective encompassed by the overarching concept of well-being) [9] . this will require greater interprofessionalism, collaborative organizational leadership, proactive company policies, accountability, training, and engagement of management and employees, as well as following benchmarks over time and identifying opportunities for early corrective or enhancing interventions [13] . moreover, as the paradigm expands, there will be a need for greater integration of systems thinking and transdisciplinary efforts, and for finding innovative ways to attract and train students into osh professions. systems thinking is the process of understanding the interconnection of elements (systems) that are organized to achieve a specific purpose [16] . transdisciplinary efforts are those that cross multiple disciplines and professions and result in a broader and more holistic approach to problems solving strategies [17] . it is therefore likely that there will be a need for new disciplines and specialties in osh or, at a minimum, a broader skill set and expanded training of traditional osh professions to include occupational health psychology, human resource management, and twh [18] . the model for this expanded focus for osh was modified from schulte et al. [9, 19] and is presented in figure 1 . systems thinking approach to better integrate traditional osh with personal and socioeconomic risk factors, both horizontally (broadening the range of factors to examine their impact on health) and vertically (from a short-term, single job perspective to a work life continuum perspective encompassed by the overarching concept of well-being) [9] . this will require greater interprofessionalism, collaborative organizational leadership, proactive company policies, accountability, training, and engagement of management and employees, as well as following benchmarks over time and identifying opportunities for early corrective or enhancing interventions [13] . moreover, as the paradigm expands, there will be a need for greater integration of systems thinking and transdisciplinary efforts, and for finding innovative ways to attract and train students into osh professions. systems thinking is the process of understanding the interconnection of elements (systems) that are organized to achieve a specific purpose [16] . transdisciplinary efforts are those that cross multiple disciplines and professions and result in a broader and more holistic approach to problems solving strategies [17] . it is therefore likely that there will be a need for new disciplines and specialties in osh or, at a minimum, a broader skill set and expanded training of traditional osh professions to include occupational health psychology, human resource management, and twh [18] . the model for this expanded focus for osh was modified from schulte et al. [9, 19] and is presented in figure 1 . [20] , eurofound [21] , and twh [22, 23] . the future of learning and education must consider three major shifts in adult education that are shaping how we meet the learning needs of an increasingly diverse workforce in the future. these include new types of learners, new ways of learning, and new things to learn. changes in the nature of work are presenting challenges to the educational institutions to adapt or face the consequences. the increasing diversity of the workforce is also changing education and learning needs. there is a shifting balance of power between students and institutions, with the former carrying an increasingly greater weight and demanding novel approaches to learning [24] . student types are transitioning from a traditional sequential learning pathway (e.g., from high school straight to college) to working students who attend part-time; are often older; come from diverse backgrounds; and have a need to balance work, study, and home life. over time, they may have accumulated bits and pieces of educational credits and work experiences from different places. they are also more attuned to "on-demand" education, at a pace that fits more of a "just-in-time" lifestyle. and there is a transition from traditional major-based college tracks to more personalized learning, where students focus primarily on a declared life mission and seek to combine their educational experiences with the purpose of fueling that mission [24, 25] . the covid-19 pandemic has abruptly changed the education paradigm in the united states to essentially an entirely online platform, and this learning delivery method can be expected to see increasing demand in the future. new approaches to learning are needed to more effectively engage nontraditional working students. in response, learning offerings are diversifying and moving towards faster, cheaper alternatives. examples include more online, virtual, and micro-courses; massive open online courses (moocs) and other open courseware; certificate (rather than traditional degree) programs; expanded opportunities for applied/hands-on training; and models that support lifelong learning [26] . an important consequence of these changes will be their impact on accreditation of education programs, which are vital to osh professional training (e.g., who will certify that coursework is adequate or that competencies have been achieved?). finally, there are new things to learn, much of it driven by the digital transformation that characterizes the fourth industrial revolution, and the need for greater ai-human interfacing at work and augmentation of human skills with technology. new skills that will be valued include systems thinking, human creativity and innovation, cultural and technological literacy, data analysis, problem-solving, working from a transdisciplinary perspective, social networking, and dealing with uncertainty, among others. there is a strong case to be made that many of these skills should start to be acquired early in life (e.g., during the k-12 experience) and solidified thereafter during higher education [25] . it is important to note that the workshop was designed to identify challenges, gaps, and needs facing the future of education and training of osh professionals and not necessarily to provide concrete answers or next steps in the development of curricula, credentialing of osh professions, or evaluation of new training methods. therefore, the following questions were used to frame discussion of the key changes that are needed in education and learning in the future: (1) how can we more effectively meet the education and learning needs of an increasingly diverse osh workforce? (2) in what ways can we expand our learning offerings to more effectively engage future osh professionals? (3) with the rapid pace of change, including the rise of intelligent software and machines, what content is important for future osh professionals to learn? the discussion groups identified major challenges facing education and learning for future osh professionals, such as diversity, technology, evaluation, and the decline in the number of current osh professionals. challenges around diversity include the growing heterogeneity in the characteristics and needs of osh trainees and workers. rapidly evolving technology will challenge how osh trainees learn and how training is delivered. evaluation challenges include the ways in which we measure, assess, or certify learning and skills development. moreover, the decline in the number of osh professionals challenges the training of the next generation of osh professionals and opportunities for mentoring and meaningful placement of graduates. participants then identified gaps and needs for osh education, conceptualizing them as key changes and important implications for the future of osh training. a summary of these small group discussions is provided in table 1 . first changes to recruitment, educational approaches, classroom power dynamics, resilience training, and credentialing will be needed to more effectively serve future osh learners; however, these changes will have implications for osh core competencies, the security and longevity of osh training programs, and approaches to quality control in osh education. next, changes to training diversity and interpersonal connectedness will be needed to more effectively engage nontraditional osh learners with new types of learning, and these changes will have implications for osh advocacy, community-based learning, and the realities experienced by both educators and learners. finally, curricula should expand to include important new content and foster the development of a transdisciplinary workforce. examples of new training content include an ecological model for worker health, the causes and consequences of new technologies at work, interpersonal skills, and advanced data analytics. such changes will have implications for osh culture, osh training evaluation systems, and osh educator preparation programs. systems thinking provides an approach that can be applied to better understand how employers and workers are responding, often in counterproductive ways, to the connected problems of global competition, technology disruption, and stress-related illness. a systems approach to better understanding organizations has long been advocated by social psychologists [27] . system refers to an interconnected set of elements coherently organized in a way that achieves something [16] . systems thinking, then, is the ability to understand these interconnections in such a way as to achieve a desired purpose, with the goal of knowing more about the whole system. conventional thinking typically assumes problems and causes are clearly connected; that others are to blame; that short-term, often multiple, interventions result in long-term success; and that individual components of a problem can be optimized. in contrast, systems thinking does not assume an obvious connection between problems and causes; understands that quick fixes may not improve (and, in fact, may worsen) matters over time because of unintended consequences; places a greater emphasis on understanding and improving relationships among the individual components of a problem; and seeks to focus on a few coordinated changes and leverage points, implemented over time to assure sustainability [28] . a systems thinking approach can be useful in addressing complex issues in osh directly related to the fow as well as current osh issues that will carry forward. because of this, the european union has added systems thinking to the core competencies for the public health professional [29] . in the u.s., schools of public health are shifting the traditional public health education paradigm to emphasize both systems thinking and interprofessionalism, which is defined as working with professionals outside the disciplines of public health and closely linked to transdisciplinarity [30, 31] . to better understand interrelationships relevant to osh in fow and as an initial step towards affecting change, the following systemic questions should be considered: (a) who are the stakeholders and how might they view the issue? (b) what changes in systems structure (e.g., policies, practices, power dynamics, perceptions or mental models, purpose) can be proposed to help organizations address the issue? (c) what might be the unintended consequences of these proposed changes? these questions were considered in the context of three fow challenges that will impact osh: (1) technology disruption-innovations that have significantly altered the way consumers, industries, and businesses operate; (2) global competition-competing organizations serving international customers; and (3) changing worker demographics-shifts in historic worker characteristics. several key stakeholder groups were identified as potentially impacted by challenges facing osh in the future in the areas of technology, globalization, and demographics. these stakeholder groups include employers; specific subgroups of workers such as immigrants and seasonal, older, and younger workers; unions; recruiters and other human resource professionals; the tech industry; unemployment agencies; policymakers; governmental agencies; share-and stockholders; academic institutions; consumers; and the general public. changing worker demographics challenge communication and training needs. challenges identified by technological disruption are brought on by innovations that have significantly altered the way consumers, industries, or businesses operate. global competition is challenged by competing organizations, a decline in unionization, cross-cultural issues including miscommunication and changing values, and disparities in health and equality across companies and populations. a summary of the small group discussions around proposed changes and possible unintended consequences for each current issue is provided in table 2 . the following gaps and needs were identified related to integrating a systems thinking approach into training the next generation of osh professionals. systems thinking should be taught early on and as part of a core curriculum versus an on demand soft skill. it should be viewed as not only a purely cognitive skill but one that includes broader skill sets of facilitation, spiritual work, and emotional intelligence. interdisciplinary leadership and guidance will be important. public health tends to still look at cause and effect linearly, while a systems approach would encourage a big picture view that understands other perspectives. strong problem-solving skills will be needed to anticipate and adapt as change happens. issues related to the profile of the future osh professional were presented from an employer perspective, with particular emphasis on environmental health sciences in business, the realities of a more distributed and mobile workforce, and the need for alignment with non-osh professions. recognition of the need to address environmental health issues on a global scale is increasing within the business world [32] . climate-related changes, such as extreme weather events, can have simultaneous effects on business operations and the surrounding community, creating a mutual dependence and responsibility for coordinated responses. company statements of purpose are now more likely to go beyond simply assuring returns to shareholders, incorporating commitments to stewardship, global sustainability, and duties to community [33] . workforces are more distributed, oftentimes around the world, and increasingly mobile. the increase in the use of short-term contracts results in workers having an increased number of jobs over a lifetime, at times coupled with several changes in career paths. this raises important questions for companies in terms of retaining critical skills and institutional memory [34] . potential solutions include hiring based more on desired skill sets than educational background and combining subject matter experts with an empowered workforce. additionally, the lines between work, home, and community are evermore blurred; and there is evidence that good health-including mental health-and happiness are drivers of productivity [35, 36] . a significant challenge facing the osh field is the risk of being marginalized if it cannot embrace and adapt to fow, including how to deal with uncertainty. there are opportunities, but they will likely require important changes in how we educate the osh professionals. one important question for the osh community to consider includes how to best integrate the need for training in specific skills in osh and allied disciplines with the need for training in "softer" skills, including leadership, corporate culture, and well-being. additional challenges include how to manage the transactional/gig nature of the new workforce. how do we protect the institutional knowledge when people are working shorter periods in any one company? with shorter tenure and more rapid turnover, it becomes increasingly challenging to find ways to retain knowledge and transfer it to a new and changing workforce. another challenge that is not new to osh is developing strategies for how to "sell" or promote the value of osh to non-osh audiences. the attributes osh professionals of the future will need in order to combat these challenges and the strategies to foster development of such attributes are summarized in table 3 . there is a need to incorporate multiple perspectives of different professions into osh training and integrate different disciplines to create a transdisciplinary approach to problem solving. osh professionals need greater interpersonal skills to help communicate up and down the line as well as translate across professions and stakeholder groups. the osh profession needs a balance of topical specialists and broadly trained health and safety generalists. all osh professionals need increased opportunities for cross-training and soft skills development. additionally, there is a need for greater problem recognition and problem-solving skills in osh that are transdisciplinary and anticipates new risks in the fow. the osh professional of the future needs to take a more holistic approach that brings several opportunities to engage leadership in the development of company/agency statements of purpose that goes beyond shareholders. interacting with finance and insurance systems will be necessary to support a healthy workforce. osh should pay attention to and anticipate new risks posed by different fow challenges. how the field responds to these challenges can help address the gradual marginalization of osh by creating a proactive rather than responsive profile. academic osh programs should develop new approaches and methods, creating opportunities for targeted and focused training that can be personalized. central to this is using a transdisciplinary perspective to incorporate multiple disciplines, professions, and technology into osh academic training. an area of curriculum that is missing from many mainstream osh training programs is the health and safety of the informal sector. these workers labor under precarious conditions with non-traditional exposures that are not well characterized nor understood. as reliance on this sector increases, the need for and expanded focus for osh to address this important part of the labor market increases as well. training programs should also integrate osh practice earlier in the degree pathway and re-engineer competency-based learning to achieve personalized learning objectives. developing modular or standardized training units that "fit" together as needed based on a menu-driven curriculum could serve to support both learner-centered specialty and core competencies without necessarily being based on the traditional formal degree pathway. for this to be successful, however, we must value and accept learning that occurs outside traditional academic degree programs and have a mechanism by which to evaluate and certify learning obtained with this approach. finally, regardless of the learning pathway, we must find ways to incorporate osh tenets earlier into the education and career decision-making process. responding to shifts in historic worker characteristics will create opportunities to change human resource practices and selection practices. unions and organized labor will need a more diverse representation of the changing worker demographics to continue to be a sustained voice for workers. managing innovations that have significantly altered the way consumers, industries, or businesses operate will be critical in the fow. new policies and practices will need to shift to accommodate increasing demand for flexible work arrangements, and research will be needed to fill knowledge gaps through a collaborative effort that creates a shared understanding of what motivates a given industry. combatting the unintended consequences of global competition including a decline in union power, cultural issues that result in changing values in work and life, and disparate health and equality between companies and people will require new and more legal protections, financial support systems to fund education, expanded health and retirement benefits, and harmonization of work standards and work-life fit. these recommendations will help develop a roadmap toward an expanded focus for osh, built on the traditional osh paradigm and the twh framework, to anticipate future education and training needs. a new approach to training osh professionals that anticipates changes the future of work will bring is a critical next step to developing systems that not only protect workers by preventing potential injury and illness but also promote worker well-being over the work-life continuum to optimize a productive and healthy life course. the conclusions and recommendations presented in this paper are based on the work of a limited number of subject matter experts. a majority of participants were from u.s. academic institutions with existing osh training programs, and their opinions may be influenced by existing academic paradigms that focus on osh issues of workers in the u.s. a small number of participants were from workshop participants: bethany alcauter, mph (workers' defense project cih (board for global ehs credentialing scd (cpwr the center for construction research and training well-being at work-overview and perspective a study of the extent and potential causes of alternative employment arrangements. ind. labor rev contingent workers and contingent health: risks of a modern economy government accountability office telecommuting will likely continue long after the pandemic potential scenarios and hazards in the work of the future: a systematic review of the peer-reviewed and gray literatures. ann. work expo. health 2020. epub ahead of print uscher-pines, l. expanding the paradigm of occupational safety and health a new framework for worker well-being measuring well-being and progress: well-being research national institute for occupational safety and health [niosh]. niosh total worker health® future of work initiative advancing worker safety, health and well-being research methodologies for total worker health®: proceedings from a workshop the niosh future of work initiative and the total worker health®approach artificial intelligence and worker safety thinking in systems: a primer education and training to build capacity in total worker health®proposed competencies for an emerging field towards an expanded focus for occupational safety and health healthy workplaces: a model for action for employers, workers, policy-makers, and practitioners; world health organization sustainable work throughout the life course: national policies and strategies; publications office of the european union: luxembourg the niosh total worker health™ program: an overview emerging student needs disrupting higher education the future of learning and education the social psychology of organizations introduction to systems thinking aspher's european list of core competences for the public health professional accreditation criteria: schools of public health public health programs public health 3.0: a call to action for public health to meet the challenges of the 21st century world economic forum. the global risks report transforming our world: the 2030 agenda for sustainable development number of jobs, labor market experience, and earnings growth: results from a national longitudinal survey summary mental health and productivity at work: does what you do matter? labour econ employer perspective on training of future osh/has professionals the authors thank the workshop speakers, participants, and organizing committee for their contributions to the discussion of challenges, gaps, and needs. the authors thank leslie hammer and lee newman for providing input into the final draft. the authors declare they have no conflict of interest. the findings and conclusions in this report are those of the authors and do not necessarily represent the views of the national institute for occupational safety and health. this appendix provides the names and affiliations of the workshop speakers, participants, and organizing committee. key: cord-302411-unoiwi4g authors: yu, jingyuan; lu, yanqin; muñoz-justicia, juan title: analyzing spanish news frames on twitter during covid-19—a network study of el país and el mundo date: 2020-07-28 journal: int j environ res public health doi: 10.3390/ijerph17155414 sha: doc_id: 302411 cord_uid: unoiwi4g while covid-19 is becoming one of the most severe public health crises in the twenty-first century, media coverage about this pandemic is getting more important than ever to make people informed. drawing on data scraped from twitter, this study aims to analyze and compare the news updates of two main spanish newspapers el país and el mundo during the pandemic. throughout an automatic process of topic modeling and network analysis methods, this study identifies eight news frames for each newspaper’s twitter account. furthermore, the whole pandemic development process is split into three periods—the pre-crisis period, the lockdown period and the recovery period. the networks of the computed frames are visualized by these three segments. this paper contributes to the understanding of how spanish news media cover public health crises on social media platforms. as covid-19 is becoming a global health crisis, it has been announced as pandemic by world health organization (who, geneva, switzerland) on 11 march [1]. three days after, being one of the most infected countries, spanish prime minister pedro sanchez declared state of alarm. this is the second time that spain declared a national lockdown, so the influence of the pandemic on spain is substantial. as the situation of the pandemic became stable, the spanish government announced a 4-step plan for the transition to a new normality on 3 may (plan para la transición hacia una nueva normalidad), signaling that the pandemic is gradually becoming under control. news media are important information sources for the public during epidemic crisis [2] , serving as interactive community bulletin boards, as well as global or reginal monitors [3] . with the prevalence of social media, news media organizations have been using these emerging tools to reach and engage boarder audiences during crises [4] . twitter, being one of the most popular social media, has attracted a great number of traditional newspapers to digitalize real-time core information within 280 characters. while newspaper articles tend to use conflict, responsibility, consequence and savior frames in the coverage of epidemics, their twitter accounts often post real-time updates, scientific evidence and actions [5] . the tones adopted in the two kinds of news are also different, with newspaper articles using more alarming and reassuring tones and twitter updates using more neutral tones [5] . scholars have been using the network analysis techniques to study news content. for example, guo [6] proposed a network agenda setting model (nas) to analyze the salience of the network relationships among objects and/or attributes. inspired by this method, this study conducts network analysis on the twitter posts, analyzing and comparing the news frames of the two most important general-interest and nationally-circulated spanish newspapers (el país and el mundo) during different stages of the covid-19 crisis. the two selected newspapers are considered different regarding their political stance [7] , with el país representing the political center-left media and el mundo seen as a political center-right media outlet [8, 9] . discussion on the two media would allow us to better explore their particular news focus regarding their divergent political ideologies, thus illustrating a more comprehensive landscape of spanish news coverage on the pandemic. moreover, as this study focuses on the analysis of their twitter content, compared with other newspapers, el país and el mundo have the largest number of online followers, reflecting their substantial influence online. two research gaps are filled in this paper. from the empirical approach, despite the fact that the two spanish newspapers have been widely studied in the past epidemic crisis [10] [11] [12] , their news posts on twitter deserves more investigation in communication research. from the methodological perspective, manual coding process is generally applied in most of the network news agenda and news frame studies [13, 14] . to enhance efficiency and minimize the biases involved in manual coding, this study combines unsupervised machine learning technique and network visualization method to make a fully automatic network study, which is a major methodological contribution to the news frame literature. framing is an important research focus in communication studies because how an issue is reported in news can influence how it is understood by audiences [15] . entman [16] defined framing as "to select some aspects of a perceived reality and make them more salient in a communication text, in such a way as to promote a particular problem definition, causal interpretation, moral evaluation, and/or treatment recommendation for the item described" (p. 52). frames in news media coverage can affect the topical focus and evaluative implications perceived by the audience, as well as their subsequent decision making about public policy [17] . news frames about health issues and diseases have been found to affect audiences' understanding of health problems and their attitudes and behaviors [18, 19] . regarding the ongoing covid-19 pandemic, the severity of the virus and preventive actions should be communicated to the public effectively. in this case, news media play an important role in enhancing public's understanding of the highly contagious disease, as well as in influencing the attitudinal and behavioral response on the prevention, containment, treatment and recovery [18] . empirical studies about news frames have been conducted during the past epidemic crisis. for example, lee and basnyat [18] focused on the news articles of singaporean straits times during h1n1 pandemic and identified nine dominant frames via manual coding-basic information, preventive information, treatment information, medical research, social context, economic context, political context, personal stories and other (open-ended). their study revealed that the news coverage focused more on h1n1 information updates and prevention than on other frames. in another one of their articles [20] , four additional news themes were found-imported disease, war/battle metaphors, social responsibility and lockdown policy. shih, wijaya and brossard [21] focused on news coverage about the mad cow disease, west nile virus and avian flu from the new york times by examining six frames-consequence, uncertainty, action, reassurance, conflict, new evidence. the results of their study revealed that the newspaper emphasized the consequence and action frames consistently across diseases but media concerns and journalists' narrative considerations regarding epidemics did change across different phases of development and across diseases. according to the association for media research (asociación para la investigación de medios de comunicación, http://reporting.aimc.es/index.html#/main/diarios), el país and el mundo are the two most read general-interest newspapers in spain in the first quarter of 2020. comparative studies about these two newspapers have been conducted in various context. for example, baumgartner and chaqués-bonafont [7] found that there are important news coverage differences between these two newspapers when they make explicit reference to individual political parties. regarding negative news about corruption, el país tends to mention right-wing political party, while el mundo mentions left-wing political party more often. the comparison between these newspapers in their news coverage about cannabis have also shown significant differences, el país focused more on the news about marijuana legalization, while el mundo focused more on police and crime news on drug consumption [22] . during the ebola outbreak, ballester and villafranca [12] studied the two newspapers together by comparing their news coverage of ebola with other rare diseases. the word "terror" appears more frequently in ebola related news, generating a higher level of anxiety toward ebola than other diseases. catalan-matamoros et al. [10] studied the visual contents of the two newspapers, two main conclusions are made by the authors. first, the "conflict" frame dominates the portal of the two newspapers, which revealed alarming messages for the audience. second, they found the total number of visual content increased rapidly in the first two days of the crisis and decreased from the fifth day. in sum, the authors described the first two days as "high risk phase" of the epidemic outbreak and from the fifth day onward the "less severe phase." regarding the ongoing covid-19 crisis, researchers have found that there is a significant increase of coronavirus news in spanish state of alarm phase than the pre-alarm period and the total number of relevant news reported by el mundo is much more than el país [23] . thanks to the ease of information exchanges on social media platforms, masip et al. [2] indicates that spanish citizens are more informed during the coronavirus crisis than before. in this case, an in-depth analysis of social media news is warranted. latent dirichlet allocation (lda) is frequently used to extract latent topics from large scale textual data and has also been widely applied for social media studies [24] [25] [26] . according to the developers of this technique, "lda is a three-level hierarchical bayesian model, in which each item of a collection is modeled as a finite mixture over an underlying set of topics. each topic is, in turn, modeled as an infinite mixture over an underlying set of topic probabilities. in the context of text modeling, the topic probabilities provide an explicit representation of a document" [27] (p. 993). previous research has suggested lda an appropriate method to study news media coverage [28] . for example, heidenreich, lind, eberl and boomgaarden [29] used this method to identify 16 frames from european refugee crisis news across five countries. for the covid-19 related studies, poirier et al. [30] applied lda to identify six news frames (chinese outbreak, economic crisis, health crisis, helping canadians, social impact, western deterioration) from 12 canadian media sources. in addition, network analysis methods have been widely adopted on communication studies. for example, regarding the mad cow disease, lim, berry and lee [31] visualized the core word network of four groups (bureaucrats, citizens, scientists and interest groups) across four policy stages based on 6400 newspaper articles. they found the four groups focused on different policy issues and the news coverage did change over different stages. this study demonstrated that semantic network analysis is a powerful method for understanding issue framing in the policy process. fu and zhang [32] used word co-occurrence network to study ngos' hiv/aids discourse on social media and website. their study revealed overlapping themes about hiv/aids across social media and website and ngos use social media to engage with the government, as well as other health care resources. kang et al. [33] examined the vaccine sentiment on twitter by constructing and analyzing semantic networks of related information and found that semantic network of positive vaccine sentiment has a greater cohesiveness than the less-connected network of negative vaccine sentiment. this study sheds the light on discovering online information with a combination of natural language processing and network methods. on the other side, bail [34] conceptualized a method to combine natural language processing and network analysis to examine how advocacy organizations stimulate conversation on social media. the author's idea is to convert the content of different documents into bag-of-words and then find the similarities (edges) between the documents by word co-occurrence. this method is further developed as a visualization tool to display a text network at group-word level [34, 35] . in our case, each of the computed news frame (latent topic) is considered as a group of their relevant content, represented as nodes on the network and the edges between the frames are visualized according to the co-occurrence of the content and weighted by term frequency-inverse document frequency (tf-idf). to be clearer, the tf-idf is a numerical statistic to measure how relevant a word to a document in a corpus [36] , it has been widely applied in text mining research, also in the abovementioned bail's work [34] . our data are hydrated from open access institutional and news media tweet dataset for covid-19 social science research [37] , which includes the twitter posts from the two selected spanish newspapers from the end of february. the first step is data cleaning, in which all the retweets are removed. then we deleted all the attached external website addresses, hashtags (#hashtags), mentions (@mentions), emojis, arabic numbers and stopwords (e.g., prepositions, pronouns etc.), because such information is considered less meaningful in computational text analysis [38] . in addition, all the capital letters were converted to lower case (to standardize all the words) and we normalized the text with lemmatization (which refers to group together the inflected forms of a word) before the data are ready for the lda model analyses. using the lda function of r package "topicmodels" [39] , we computed eight topics for each newspaper's twitter posts. the decision made on the number of topics is because too few topics make news frames less specific and too many topics make the network less interpretable [40] . in order to make the performance of the topic model more efficient, we used the gibbs sampling method [39, 41] , one of the most widely used statistical sampling techniques for probabilistic models and short-text classification [42] [43] [44] [45] . after having obtained the computed topics (news frames), we re-assigned each of the news tweets into their belonging frames, so we have a new dataset with the tweets of each newspaper categorized by the news frames. as the news focus regarding epidemics did change across different phases of the pandemic's development [21] , following the work of pan and meng that adopted a three-stage model to analyze news frames during a previous pandemic [46] , we split each dataset by three periods. the pre-crisis period includes tweets before march 14 when spanish national lockdown was announced. this is the period that the pandemic information has been reported but not been officially alarmed by spanish government. the lockdown period includes tweets between 14 march and 11 may, the period that the spanish government adopted a strict national confinement. the recovery period includes the tweets from 11 may (the day when spain stepped into the first stage of social recovery) to 3 june (the last day of data collection). finally, a network of relationships between news frames has been generated from their word co-occurrence matrix for each newspaper during each time period. therefore, a total of six networks are constructed. for the el país dataset, a total number of 22,223 tweets are collected from 25 february 2020 to 3 june 2020. after removing retweets, 14,800 original tweets are saved for our in-depth analysis. eight news frames have been successfully computed, they are "livelihood" (family life and children), "public health professional" (news about the department of public health), "pandemic update" (contagion and death poll), "madrid" (news about madrid), "politics" (general political news), "state of alarm" (spanish government and pm's announcement and policy update), "economy" (the effect of the pandemic on spanish economy) and "covid information" (general information about the pandemic). table 1 presents the details of the eight news frames of el país with their top seven relevant words. figure 1 presents the news frame network of the three segmented periods. each of the nodes represents a news frame and the size of nodes indicates the strength of the node, also known as weighted node degree, it is the sum of the edge weights of the adjacent edges for each node [47] , reflecting the importance of a node in a weighted network. the edges between the nodes represent the connection strength between two frames (normalized by tf-idf), it is the sum of the tf-idf value of the co-words. table 2 presents the detailed information about the news frames in each of the three periods, with the node strength, number of tweets in each news frame and their proportion of the total number in each segment. table 3 presents the table of the most weighted edges in the three time segments; it is able to provide us the news frames with the highest similarity ties. overall, "livelihood," "public health professional," "pandemic update" and "politics" are the most important news frames of el país. as the crisis is gradually under control, the "pandemic update" turned to be less prominent in the recovery period. "livelihood" is the most prominent news frame of el país and it shows a strong connection with "politics," "economy" and "public health professional" in the pre-crisis stage, suggesting a close connection with government policy and economic situation. in the next two periods, it started to have a more significant relation with "madrid." this is understandable because the spanish capital suffered the most during the covid-19 pandemic. according to the actual policy, the community of madrid is one of the last regions that stepped into the recovery plan [48] and this can also explain why the proportion of "madrid" increased across the three time segments. in addition, we indeed observed a news framing change in different stages of the pandemic outbreak. for example, the "politics" frame is less reported in the second period while the "state of alarm" and "covid information" frames have been paid higher attention during this stage. it is worth noting that although both frames have connections with others, no connections are observed between these two during the three periods, suggesting they are independent from each other. "state of alarm" is a policy oriented news frame while "covid information" focused more on general sanitary information. as the crisis is gradually controlled, the pandemic related news frames ("pandemic update," "state of alarm," "public health professional" and "covid information") are becoming less prominent in the recovery period. the media interests in general political news ("politics") decreased during the most difficult time but soon recovered with the crisis situation becoming stable. regarding the network, the "politics" frame has the strongest connection with "livelihood" during all of the three periods. it also has significant relation with "public health professional" (weight: 236.60) and "economy" (weight: 154.96) during the pre-crisis period but the two connections have been developing in different trends. while "politics" and "public health professional" remained connected in the other two periods, the connection between "politics" and "economy" turned to be less significant. instead, the "politics" frame becomes more connected with "state of alarm" and "madrid." for the el mundo dataset, a total number of 17,577 tweets are collected from 19 february 2020 to 3 june 2020. after removing retweets, 14,290 original tweets are saved for our in-depth analysis. eight news frames are computed, six of which are considered the same as el país. they are "madrid," "state of alarm," "covid information," "economy," "pandemic update," "politics." the two unique el mundo frames are "lockdown" (news about the confinement) and "hospital" (news related to hospital, doctor and patient). table 4 presents the news frames with their most relevant keywords. figure 2 presents the network of the three segmented periods, table 5 provides the detailed information of the news frames across time and table 6 presents the detailed information of the most weighted edges. generally speaking, "madrid," "state of alarm" and "lockdown" are the three most prominent news frames during the pre-crisis period, along with the crisis becoming more severe, "covid information" is paid more attention by the newspaper. and finally these four frames are the most prominent news frames during the recovery period. table 5 provides the detailed information of the news frames across time and table 6 presents the detailed information of the most weighted edges. generally speaking, "madrid," "state of alarm" and "lockdown" are the three most prominent news frames during the pre-crisis period, along with the crisis becoming more severe, "covid information" is paid more attention by the newspaper. and finally these four frames are the most prominent news frames during the recovery period. pre-crisis period lockdown period recovery period "madrid" is the most prominent news frame of el mundo of all the time. the proportion of this topic is greatly changed from the second period to the third. as we have explained in the previous section, madrid is the last region that stepped into recovery plan, so this change is understandable. the "madrid" frame has the strongest connection strength with "lockdown" and "state of alarm" during the first two periods and the association between "madrid" and "covid information" becomes more and more eye-catching during the last two periods. the second most important news frame is "state of alarm," it has been paid less attention during the lockdown period but still, shared a significant proportion of the total news coverage. the "state of alarm" frame has the highest connection strength with "madrid" and "lockdown," similar to "madrid," the relation between "state of alarm" and "covid information" is becoming stronger during the second and third time segments (weight in the 2nd period: 259.72, in the 3rd period: 139.42). as spain started to get recovered from the strict national lockdown, the proportion of the relevant news frames "lockdown" and "hospital" decrease during the recovery period but the connection between these two topics have been strengthened in this stage. as the "lockdown" frame is highly associated with "madrid" and "state of alarm," we assume this frame is strongly policy orientated. on the other hand, the "hospital" frame includes both health and social news, so it is naturally associated the most with "madrid" and "lockdown." regarding the "economy" frame, the proportion of this topic arrived its peak at the second period. it is significantly different from the frame "politics," which has been less adopted during the same period. both of them have strong ties with "madrid" and "state of alarm" but no significant connections have been exposed between these two frames. given that the frames "covid information" and "pandemic update" have almost no proportion changes during the three time periods, these two news frames are considered as stable news frames, tweets about "pandemic update" is slightly fewer than "covid information." regarding the network, like many other el mundo news frames, both of the two have the strongest connection with "madrid" and the tie between these two frames is getting more and more meaningful over time. significant differences are observed between el país (ep) and el mundo (em) in the frames used in their twitter news posts. first, the most prominent news frame of the two spanish newspapers are different. while ep focused on "livelihood," em tended to adopt the "madrid" frame most frequently. despite the fact that "madrid" is also a frame in the ep dataset, it is considered as a peripherical news frame. both of the two frames have the strongest connections with other topics in the networks, so these two frames can be seen as the motor themes of their newspapers on twitter. second, both of the newspapers have two unique news frames. while the ep news coverage on twitter focuses on "livelihood" and "public health professional," we observed the "lockdown" and "hospital" frames in the em twitter posts. the "livelihood" frame is somewhat similar to "hospital," because both of the two news frames contain social and living attributes. nevertheless, their connection strength with the other common frames are different. while "livelihood" associates the most with "politics" and "public health professional" in the ep networks, "hospital" associates the most with "madrid" and "lockdown" in the em networks. a possible interpretation of this difference is "livelihood" is linked to government (including relevant government departments) policy but "hospital" is more linked to the news about specific regions. also, ep shows higher attention to the ministry of health and professional perspective by adopting the "public health professional" frame while em focuses more on the effect of confinement from social perspectives with the "lockdown" frame. third, although there are six common news frames identified in the twitter posts of both newspapers but the longitudinal changes in their proportion over time are different. for example, the "economy" related news tweets are increasingly scarce over time in the ep dataset but for em, such information is more posted during the second time period (the lockdown period). another significant example can be seen from the "politics" frame. the ep twitter account posted more politics-related news during the recovery period than during the lockdown period. but for em, the increasing trend during the same periods is not so salient as ep. "state of alarm" is the second most important news frame for em on twitter but this frame is not so prominent in ep twitter posts. although the most relevant keywords of this frame in the two datasets are almost the same but the connections are different in the networks. during the first two periods, "state of alarm" is considered most associated with "lockdown" and "madrid" in the em network, while it is mostly linked to "livelihood" and "public health professional" in the ep network. during the recovery period, the link between "state of alarm" and "politics" is strengthened in ep network, while the connection between "state of alarm" and "covid information" is more eye-catching in the em network. this finding implies that, with the pandemic crisis getting under control, twitter posts about "state of alarm" is more related to political news on ep but connected to health news more closely in the em twitter coverage. this study analyzed and compared the frames of twitter news posts in the two most important spanish newspapers during covid-19 pandemic crisis. with a combination of topic modeling and network analysis method, a general landscape of the news coverage of the two newspapers has been illustrated. we found that the center-left media focused the most on family life and living issues ("livelihood"), while the center-right media focused the most on the spanish capital news ("madrid"). from the distribution and proportion of news frames, it can be concluded that el país focused the most on public health professionals and real-time alarming ("pandemic update") information during the first two periods. the el mundo coverage on twitter focused on the state of alarm and confinement ("lockdown") related information. during the recovery period, the proportion of general political news ("politics") update is largely increased in el país, being the third most prominent news frame in this stage. nevertheless, no such changes are observed in the results of el mundo. our results are consistent with the thesis proposed by shih et al. [21] that media coverage about epidemics did change across different phrases of the crises. given our limited data collection timespan and the unique characteristics of twitter data, a more comprehensive analysis is needed for future studies. from the methodological approach, our method combination provides a dynamic overview of news frames' evolution over time. the weighted node degree and the most weighted edges in each of the stages have been reported. each of the motor themes ("livelihood" for el país, "madrid" for el mundo) is the leading topics of all of the three time segments. given the strong connections of the two topics with other frames, we observed a more unbalanced network structure in el mundo dataset. specifically, a second-level community is identified, which consisted of "madrid," "lockdown" and "state of alarm" in the pre-crisis period. the community is enlarged with "covid information" included in the last two periods. it implies that the content of the four news frames have a high degree of co-occurrence, they are relatively more independent from other frames. but the second-level community cannot be clearly observed in the el país network, thus, we believe that the news frames of el mundo is more centralized than el país. finally, several limitations of our study should be mentioned. first, previous literature has indicated that twitter based short-text news updates are different from their full length articles [5] . in this case, it is worth noting that our results are solely based on the twitter posts, which may not be generalized to the comparison between the contents of the two newspapers' articles. second, as the news coverage may less focus on the health issue in the pre-crisis period than in later stages and our adopted topic modeling method is highly depended on the vast dataset, the number of tweets in the pre-crisis period is much less than the two other periods, news frames on the first period may not be perfectly classified. 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of complex weighted networks así llega madrid a la fase 1: paro disparado, sin turistas y con miles de ciudadanos en las colas del hambre this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license acknowledgments: this work belongs to the framework of the doctoral programme in person and society in the contemporary world of the autonomous university of barcelona. the authors declare no conflict of interest. key: cord-351100-llyl97ry authors: cariani, lisa; orena, beatrice silvia; ambrogi, federico; gambazza, simone; maraschini, anna; dodaro, antonella; oggioni, massimo; orlandi, annarosa; pirrone, alessia; uceda renteria, sara; bernazzani, mara; cantù, anna paola; ceriotti, ferruccio; lunghi, giovanna title: time length of negativization and cycle threshold values in 182 healthcare workers with covid-19 in milan, italy: an observational cohort study date: 2020-07-23 journal: int j environ res public health doi: 10.3390/ijerph17155313 sha: doc_id: 351100 cord_uid: llyl97ry background: coronavirus disease 2019 (covid-19) has rapidly spread worldwide, becoming an unprecedented public health emergency. rapid detection of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) suspected cases is crucial to control the spread of infection. we aimed to evaluate the time length of negativization from the onset of symptoms in healthcare workers (hcws) with covid-19, and to evaluate significant variations in cycle threshold (ct) values and gene positivity (e, rdrp, and n genes) among positive individuals who returned to work. methods: we retrospectively analyzed a consecutive cohort of 182 sars-cov-2-positive hcws in milan, from 16 march to 30 april 2020. nasopharyngeal swabs were tested by rt-pcr. results: asymptomatic hcws were 17.6% (32/182), and 58 healed at 30 april 2020. the median time length of negativization was 4 weeks (35% of symptomatic versus 40% of asymptomatic hcws). four hcws, healed at 30 april, turned positive within three weeks during controls set up in the work unit. three-gene positivity had the greatest variability, and increasing ct values from singleto three-gene positivity among all age groups were observed. conclusions: self-isolation longer than two weeks and prolonged follow-up periods for the staff returning to work after covid-19 could be the most suitable choices to counter the sars-cov-2 spread. further studies are needed to investigate infectiousness profiles among positive individuals. the novel severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is the aetiological agent of the severe acute respiratory syndrome named coronavirus disease 2019 . because of its rapid and uncontrolled global spread, covid-19 was declared a pandemic by the world health organization with a total of 3,672,238 cases and 254,045 deaths since the first cases were reported in wuhan (hubei province, china) in december 2019 (data updated to 7 may 2020) [1, 2] . sars-cov-2 is a β-coronavirus, enveloped, non-segmented, and positive-sense single-stranded rna virus, belonging to the subfamily of the orthocoronavirinae [3] . covid-19 shows similarities in symptoms with earlier β-coronavirus diseases, such as fever, dry cough, dyspnea, fatigue, headache, sputum production, hemoptysis, lymphopenia, and bilateral ground-glass opacities on chest computed tomography scans. it is known that sometimes patients with sars-cov-2 infection also develop gastrointestinal symptoms like diarrhea, unlike patients with middle east respiratory syndrome coronavirus (mers-cov) and sars-cov [4, 5] . the course of covid-19 is long, and the disease is highly contagious even during the incubation period (an estimated period ranging from 2 to 14 days, most commonly 5.2 days). furthermore, asymptomatic carriers of sars-cov-2 account for 1-18% of the laboratory-confirmed cases of covid-19 [6, 7] , even though studies on estimation of asymptomatic prevalence report higher rates up to 30.8% [8] [9] [10] . italy became a hot spot for the covid-19 pandemic after china, with 223,096 cases and 31,368 deaths recorded by mid-may 2020. among these, healthcare workers (hcws) counted for 11% of all covid-19 cases in italy [6, 11] . during sars and mers outbreaks, the spread of infection to hcws was a significant concern. systematic implementation of public health measures, such as active case detection, rapid case and contact isolation, as well as strict application of disease prevention and control procedures, have been successful in epidemic control. in addition, rapid collection and testing of appropriate samples of covid-19 suspected cases (those with typical respiratory symptoms or in the case of documented close contact with sars-cov-2 patients, co-workers, or relatives) are crucial for clinical management of healthcare staff, and to avoid the collapse of the healthcare system [12, 13] . global guidelines recommend nucleic acid amplification tests, such as real-time reverse transcription polymerase chain reaction (rt-pcr), as the standard of reference for the diagnosis of sars-cov-2 infection. the viral genes detected include: nucleocapsid (n) and envelope (e) proteins [14] [15] [16] that play a key role in viral self-assembly, rna-dependent rna polymerase (rdrp) [15] , and spike (s) glycoprotein that interacts with the host cell's ace2 receptors [17, 18] . in this study, we retrospectively analyzed rt-pcr test results of a consecutive cohort of hcws from the fondazione irccs ca' granda ospedale maggiore policlinico in milan, italy. our aims were to evaluate the time length of negativization from the onset of symptoms, and to evaluate variations of cycle threshold (ct) values and gene positivity (e, rdrp, and n genes) among positive individuals who returned to work. nasopharyngeal samples were collected with flocked swabs in 3 ml of universal transport medium. after collection, total rna was extracted using a seegene starmag 96 × 4 universal cartridge kit, an automatic nucleic acid purification system. the presence of sars-cov-2 was analyzed by rt-pcr. sars-cov-2 envelope (e) proteins, nucleocapsid (n) proteins, and rna-dependent rna polymerase (rdrp) gene fragments were detected by a seegene allplex tm 2019 n-cov assay. the first assessment of kit performance by the manufacturer demonstrated a specificity of 100% and a sensitivity of 100 rna copies/pcr reactions [19] . the conditions for amplification were 50 • c for 15 min, 95 • c for 15 min, followed by 45 cycles at 94 • c for 15 sec, and 58 • c for 30 sec. a cycle threshold value of less than 40 is defined as a positive test, while a ct value of 40 or more is defined as a negative test. a ct value less than 40 for only one of the three targets is defined as weak positive, whereas a ct value less than 40 for two or more targets is considered positive. the ct value is inversely proportional to the amount of viral nucleic acid in specimens (meaning that a lower ct value indicates a higher amount of virus) and it can be used to estimate viral load. metrics were reported as mean and standard deviation, or counts and percentage. considering hcws recovered by 30 april 2020 in the sample under study, the proportion of tests turned negative was represented by means of cumulative incidence plots. only healthcare professionals who turned negative were analyzed. time was discretized in weeks: 1 means from beginning of symptoms (or the first positive test in asymptomatic subjects) and the next 7 days, 2 means from day 8 since the beginning of symptoms (or the first positive test in asymptomatic subjects) through to the 14th day, and so on. this was due to the fact that the exact days of test administration to evaluate the negativity were affected, not only by clinical considerations, but also for logistic reasons. moreover, after a negative test, it is not known the exact time when negativization occurred. the association between categorical variables for hcws who tested sars-cov-2 positive was assessed using chi-square statistics. a non-parametric anova was used to analyze the difference in the viral load at baseline between subjects. for healthcare workers healed during the period of study, the association of the gene numbers (positivity for three, a, versus two, b, genes) with the viral load after controlling for basal ct values was assessed by the analysis of covariance. for all analyses, p-values were two-sided, and p < 0.05 was considered to be statistically significant. all of the current analyses were performed using r core team, version 3.6.2. (r foundation for statistical computing, vienna, austria). twenty-seven hcws out of 182 (14.8%) were tested for sars-cov-2 infection because of close contact with covid-19 cases, and resulted negative at the first test. they repeated the test at the beginning of respiratory symptom onset (with a mean of 5.6 days after the negative rt-pcr results) and the nasopharyngeal specimens resulted positive for sars-cov-2. at the time of writing, we have complete information about negativization on 58 out of 182 hcws healed by april 30, 2020 (absence of clinical symptoms and two negative rt-pcr test results during the period of study). among these, 48 hcws were symptomatic at the moment of nasopharyngeal swabs, 10 hcws were asymptomatic, and only 1 developed symptoms three days after specimen collection. table 1 reports the demographic characteristics of hcws who tested positive, as well as hcws who healed by april 30, 2020. the healthcare workers most affected were physicians (43%). overall, the main symptoms reported by 182 hcws were: fever (48.3%), cough (20.7%), headache (19%), rhinitis (17.2%), sore throat/tracheitis (15.5%), muscle/joint pain (12.1%), anosmia (12.1%), ageusia (10.4%), conjunctivitis (3.5%), dyspnea (3.5%), and gastrointestinal symptoms (1.7%). considering the 58 subjects healed by 30 april 2020, the time length of negativization was calculated from the beginning of symptom onset to the two consecutively negative rt-pcr test results, collected at least 24 h apart after the disappearance of symptoms. in the case of asymptomatic hcws, the calculation was carried out from the first positive rt-pcr test result. the majority of subjects became negative at three weeks or later. more than 70% of hcws with symptoms became test-negative within four weeks; this proportion rises to 80% in the asymptomatic group. moreover, 29.2% of symptomatic versus 20% of asymptomatic hcws became test-negative at five weeks. in addition, it is worth reporting that four out of 58 (6.9%) hcws, who went back to work after the two consecutive negative tests, were found positive in a rt-pcr test for sars-cov-2 during controls set up in the unit of work within 3 weeks. we collected cycle threshold values of the first sars-cov-2-positive nasopharyngeal swabs (t0) for all 182 hcws and ct values at one week before the two negative rt-pcr tests (t1) for the 58 subjects who healed by 30 april 2020 (figure 2 ). looking at the distribution of gene positivity and mean ct values among four age-groups, we observed a constant pattern of viral load across different age-groups ( figure 3a) . particularly, e-rdrp-n shows the greatest variability ( figure 3b ); the mean ct significantly differs across age groups (p = 0.01637). in addition, we observed increasing ct values from single-gene to three-gene positivity among all age groups. n-rdrp shows ct values very close to n, even though they are reported as positive and single-gene positive tests, respectively. furthermore, the 58 hcws healed by april 30, 2020 were divided into three groups based on the gene positivity at t1. group a includes hcws with positivity to all three genes (e-rdrp-n). groups b and c include hcws with single-gene positivity and those who tested negative at t1, respectively (table 2 ). there was no evidence of variation of the viral load at t0 (p = 0.1307). however, after adjusting for the baseline viral load, there was a statistically significant difference in viral load at t1 between groups a and b (f(2,26) = 16.51, p < 0.001)). figure 4 shows that the time length of negativization of groups a and b varied from 4 to 5 weeks. in contrast, the majority of hcws in group c became negative earlier. health-care-associated amplification of transmission is alarming, as is always the case for emerging infections. since the first positive laboratory test result in italy, on 21 february 2020, the italian healthcare system has been fighting covid-19 [20] . in the present study, we analyzed 2443 nasopharyngeal swabs from 1683 hcws by molecular laboratory testing for suspected sars-cov-2 infection in a large university hospital in milan, showing 10.8% positive hcws. overall, the majority of hcws with covid-19 were physicians, and the main reported symptoms were fever, cough, and headache. in contrast to rothan's study, only one subject experienced gastrointestinal symptoms [5] . the prevalence of asymptomatic carriers (17.6%) among hcws with covid-19 is similar to national data reported by the istituto superiore di sanità, which detected 17.1% of asymptomatic carriers in 53,919 sars-cov-2-positive cases [6] . we observed that 35% of subjects with symptoms, versus 40% without symptoms, had recovered at four weeks. absence of symptoms corresponds to an undefined onset of covid-19, and the time length of negativization of asymptomatic individuals could be longer. our findings are supported by a recent study conducted by zhou and colleagues [21] , in which they detected sars-cov-2 for a median of 20 days, up to 37 days after symptom onset, in respiratory samples. taken together, these results show how the original recommendation of 14 days of self-isolation was probably an underestimate of the time needed to recover. we also reported that 14.8% (27/182) of hcws tested positive to sars-cov-2 only at the beginning of symptom onset, within 5.6 days after the first negative rt-pcr test result. our data seem to differ from a recent study in which xi and colleagues suggested that viral shedding could begin two or three days before symptom onset [22] . the proportions of asymptomatic and initially negative cases represent major issues for the control of outbreaks, both in hospital and in social environments, as they are able to infect a large amount of the population due to the highly contagious nature of sars-cov-2. rt-pcr assay plays a central role in the detection of covid-19 infection, but it might be insufficient to accurately estimate the overall infected population. as regards the mean ct values at t0 for 182 positive hcws, there was no significant association in viral loads between sex, nor a statistically significant variation among age groups. hcws with e-rdrp-n gene positivity showed the highest viral loads in every age group. furthermore, we observed a close similarity between viral loads of positive subjects with two-gene positivity (n+rdrp), and subjects with single-gene positivity (n). it could be of interest to further investigate differences and similarities between infectiousness profiles. additionally, we observed that about 70% of hcws having the lowest viral loads became test-negative at three weeks, while about 50% of hcws from groups a and b became test-negative after at least one more week. the case of the four hcws who tested positive within of 3 weeks of rt-pcr tests for sars-cov-2 and after two consecutive negative results suggested that in some individuals viral shedding may continue at a very low titer for some time or that rt-pcr had detected only rna fragments without clinical significance. a growing number of studies have reported a significant portion of patients turning positive, suggesting that a longer observation period should be considered for covid-19 patients [23] . this study has several limitations. firstly, it analyzed a limited cohort. larger studies on hcws should be done to improve the management of healthcare staff with covid-19, and consequently in the entire population, in order to better control the viral outbreak. additionally, we were able to consider healed, just over 30% of positive hcws with respect to the period of study. secondly, symptom details rely on patient self-assessment at the moment of specimen collection for sars-cov-2 diagnosis. wrong epidemiological data can lead to an improper estimation of covid-19 incubation periods and asymptomatic prevalence. thirdly, the rt-pcr test can be affected by many external factors, such as specimen source, sampling collection (sample quality) and timing (a virus may not be detected at early stages of infection), and kit performance (specificity and sensitivity). rt-pcr is one of the most well-established laboratory diagnosis tests for use in a new viral pandemic, even though several authors have remarked on the poor sensitivity of this method [13, 24] . the combination of several tools, like a detailed anamnestic report, and molecular and serological sars-cov-2 diagnosis, could be considered to be the next best laboratory approach in order to reduce the rate of false-negative rt-pcr results. furthermore, it is known that a significant proportion of individuals infected by sars-cov-2 presented with gastrointestinal disorders [23, 25] . consequently, it seems to be important to integrate sars-cov-2 detection with stool samples, especially considering that oral-fecal transmission could occur even after viral clearance in the airways [5, 26] . all these considerations suggest the need for an improved diagnostic process, to identify and isolate at early stages all sars-cov-2-positive hcws, both symptomatic and asymptomatic. furthermore, viral particles detected by rt-pcr are not necessarily correlated with the ability of transmission. it could be important to estimate the infectiousness of a patient with a ct value close to a value considered negative, and to perform a cell culture. indeed, recent studies reported that a live virus could no longer be cultured from 8 days after symptom onset, and that the infectiousness profile of sars-cov-2 seems to be more like influenza than sars [21, 27] . self-isolation longer than two-weeks and a prolonged follow-up period for staff who have returned to work after testing positive for covid-19 could be the most suitable choices to counter the spread of sars-cov-2. according to our results, we suggest an isolation period of 28 days. further studies are needed to investigate the correlation between ct values and sars-cov-2 infectivity. the 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china covid-19) in suspected human cases the sars coronavirus nucleocapsid protein forms and functions corona virus envelope protein: current knowledge pharmacological therapeutics targeting rna-dependent rna polymerase, proteinase and spike protein: from mechanistic studies to clinical trials for covid-19 covid-19, coronavirus, sars-cov-2 and the small bowel sars-cov-2 foch hospital study group. the allplex 2019-ncov (seegene) assay: which performances are for sars-cov-2 infection diagnosis? protecting healthcare workers from sars-cov-2 infection: practical indications clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study temporal dynamics in viral shedding and transmissibility of covid-19 false-negative of rt-pcr and prolonged nucleic acid conversion in covid-19: rather than recurrence should rt-pcr be considered a gold standard in the diagnosis of covid-19? viral load dynamics and disease severity in patients infected with sars-cov-2 in zhejiang province evidence for gastrointestinal infection of sars-cov-2 virological assessment of hospitalized patients with covid-2019 funding: this research received no external funding. we thank the personnel of the virology unit for technical assistance and data collection. simone gambazza received personal fees from vertex pharmaceuticals, outside the submitted work. the study was conducted in accordance with the declaration of helsinki, and it was approved by the ethics committee of fondazione irccs ca granda ospedale maggiore policlinico milan, italy (368_2020bis). key: cord-316990-kz9782rj authors: han, xuehua; wang, juanle; zhang, min; wang, xiaojie title: using social media to mine and analyze public opinion related to covid-19 in china date: 2020-04-17 journal: int j environ res public health doi: 10.3390/ijerph17082788 sha: doc_id: 316990 cord_uid: kz9782rj the outbreak of corona virus disease 2019 (covid-19) is a grave global public health emergency. nowadays, social media has become the main channel through which the public can obtain information and express their opinions and feelings. this study explored public opinion in the early stages of covid-19 in china by analyzing sina-weibo (a twitter-like microblogging system in china) texts in terms of space, time, and content. temporal changes within one-hour intervals and the spatial distribution of covid-19-related weibo texts were analyzed. based on the latent dirichlet allocation model and the random forest algorithm, a topic extraction and classification model was developed to hierarchically identify seven covid-19-relevant topics and 13 sub-topics from weibo texts. the results indicate that the number of weibo texts varied over time for different topics and sub-topics corresponding with the different developmental stages of the event. the spatial distribution of covid-19-relevant weibo was mainly concentrated in wuhan, beijing-tianjin-hebei, the yangtze river delta, the pearl river delta, and the chengdu-chongqing urban agglomeration. there is a synchronization between frequent daily discussions on weibo and the trend of the covid-19 outbreak in the real world. public response is very sensitive to the epidemic and significant social events, especially in urban agglomerations with convenient transportation and a large population. the timely dissemination and updating of epidemic-related information and the popularization of such information by the government can contribute to stabilizing public sentiments. however, the surge of public demand and the hysteresis of social support demonstrated that the allocation of medical resources was under enormous pressure in the early stage of the epidemic. it is suggested that the government should strengthen the response in terms of public opinion and epidemic prevention and exert control in key epidemic areas, urban agglomerations, and transboundary areas at the province level. in controlling the crisis, accurate response countermeasures should be formulated following public help demands. the findings can help government and emergency agencies to better understand the public opinion and sentiments towards covid-19, to accelerate emergency responses, and to support post-disaster management. as of march 7 2020, the global number of confirmed cases of corona virus disease 2019 (covid19) surpassed 100,000, covering more than 100 countries [1] . covid-19 is a respiratory disease caused by sina-weibo (http://us.weibo.com), often referred to as weibo, is one of the most popular social media platforms in china. weibo had over 516 million active users each month in 2019. this study acquired weibo texts related to covid-19. using weibo application programming interfaces (apis), weibo messages related to covid-19 were collected with "pneumonia" and "coronavirus" as the keyword with timestamps between 00:00 on january 9, 2020 and 24:00 on february 10, 2020. the following information was extracted: user id, timestamp (i.e., the time at which the message was posted), text (i.e., the text message posted by a user), and location information. the original weibo texts contain interfering information such as http hyperlinks, spaces, punctuation marks, hashtags, and @users. text filtering was thus necessary to eliminate noise and improve the efficiency of word segmentation. these types of interfering information were removed by regular expression operations ("re" module) in python (python software foundation, beaverton, or, usa). very short weibo texts (less than four words) and duplicated weibo texts were deleted. that left 1,413,297 weibo messages, including 105,330 texts with geographical location information. a time series analysis of weibo texts was used to investigate the temporal diversification of the number of weibo texts during covid-19. the original time series of social media data fluctuated in cycles of days [20] . to explore further the temporal trend of weibo texts, the original time series was decomposed using the seasonal-trend decomposition procedure based on loess (stl), using statistical product and service solutions (spss inc., chicago, il, usa) software. as expressed in equation (1), the time series can be considered the sum of three components: a trend component, a seasonal component, and a remainder in stl: x t = t t + s t + r t . (1) where x t is the original time series of interest. t t is the trend component. s t is the seasonal component. r t is the residual component. a topic extraction and classification model combining the lda model and the random forest (rf) algorithm was used to hierarchically process covid-19-related weibo texts. existing research has already proved that the lda model has obvious superiority in identifying semantic topic information from massive text automatically [16, 18] . due to their high computational efficiency in both training and evaluation, in addition to their ability to achieve state-of-the-art results, random forests (rf) are frequently used in text classification [21] . the first step was to mine and generalize the topics from the covid-19-related weibo sample using the lda model. then, topic extraction results were utilized as training samples for the rf algorithm to classify the weibo data. as shown in figure 1 , the covid-19-related weibo texts were generalized into seven topics: "events notification", "popularization of prevention and treatment", "government response", "personal response", "opinion and sentiments", "seeking help", and "making donations". a secondary classification was implemented to divide "personal response", "opinion and sentiments", and "seeking help" into 13 more detailed sub-topics, including "fear and worry", "questioning the government and media", "condemning bad habits", "objective comment", "taking scientific protective measures", "blessing and praying", "appealing for aiding patients", "willing to return work", "staying at home and taking necessary precautions", "popularizing anti-epidemic knowledge in family", "seeking medical help", "seeking relief materials", and "other". the processes of topic extraction and classification are shown in figure 2 , including the steps of word segmentation and topic extraction using the lda and rf models. the processes of topic extraction and classification are shown in figure 2 , including the steps of word segmentation and topic extraction using the lda and rf models. the processes of topic extraction and classification are shown in figure 2 , including the steps of word segmentation and topic extraction using the lda and rf models. chinese word segmentation was necessary because there are no obvious separators between chinese words. a python package for chinese text segmentation called "jieba" was utilized. by building a user dictionary including keywords related to covid-19, the package segmented words efficiently. after this process, the most common stop words that lacked valuable information were removed. lda is a bayesian probability model that has three layers-"document-topic-word" [22] , with which to identify semantic topic information in large-scale document sets or corpora. in lda, documents are represented as random mixtures of latent topics, each of which is characterized by a distribution of words [23] . this unsupervised machine learning technique has recently emerged as a preferred method for working with large collections of text documents. the "gensim" package in python was used to implement the lda model. through repeated experiments, the optimal number of initial topics was set as 20. the topic-terminology lists obtained from the lda model contain the vocabularies of each initial topic and the frequency with which those vocabularies occur. the document-topic lists show the probability that each weibo text is associated with each of the initial 20 topics. we assigned each weibo text to the topic that it most closely resembled according to the probabilities in the document-topic lists. based on the topic-terminology lists, 20 topics were generalized into seven ("thirteen" in the secondary classification) by merging similar topics and discarding irrelevant topics. the rf classifier is considered a top-notch supervised algorithm in a wide variety of automatic classification tasks [24] . random forests are a combination of tree predictors, wherein each tree depends on the values of a random vector sampled independently and all trees in the forest have the same distribution [25] . the rf algorithm was used to classify the weibo texts into different topics. this was implemented using a machine learning package called "scikit-learn" in python. based on the document-topic lists, 7000 annotated weibo texts were used as training samples and 1400 annotated weibo texts were used as test sets. the number of classification trees (n estimators) was an important parameter for classification accuracy [23] . we used the out-of-bag (oob) outputs to determine the optimized values of the parameters at 200. kernel density estimation is generally used to detect the intensity of events by generating a smooth surface using a quadratic kernel function [26] . let (s 1 , . . . , s i , . . . ,s n ) be a series of event samples distributed with an unknown densityλ(s), which can be estimated by equation (2): where k is the kernel function, τ is a smoothing parameter called the bandwidth, that is, the search radius within which to calculate density, and s − s i is the distance between s and s i . to identify the hot spots of weibo texts, kernel density estimation was performed using arcgis software. there are two parameters: the kernel search radius (bandwidth) for calculating the density and cell size for the output raster data. a kernel search radius (100-500 km) was used to analyze spatial characteristics at different scales. a cell size of 5 km was used to show the output raster map. spearman's rank correlation coefficient or spearman correlation is a nonparametric measure of rank correlation (statistical dependence between the rankings of two variables). it assesses how well the relationship between two variables can be described using a monotonic function. the spearman correlation coefficient is defined as the pearson correlation coefficient between the rank variables [27] . for a sample of size n, the n raw scores x i ,y i are converted to ranks rgx i , rgy i , and spearman correlation (r s ) is computed as equation (3): where ρ denotes the usual pearson correlation coefficient, but applied to the rank variables. cov(rgx, rgy) is the covariance of the rank variables. σ rgx and σ rgy are the standard deviations of the rank variables. precision, recall, and the f1-measure were used to evaluate the accuracy of the classification. precision is the fraction of correctly classified positive items among the total. recall measures the proportion of actual positives that are correctly identified. the f1-measure is a weighted harmonic mean of precision and recall. higher values of the f1-measure indicate that the classification method is more effective [28] . precision (p), recall (r), and f1-measure (f1) are defined as equations (4)-(6): where t p is the number of correctly classified positive items. f p is the number of incorrectly classified positive items. f n is the number of incorrectly classified negatives. the results of the time series analysis of covid-19-related weibo texts are shown in figure 3 . figure 3a shows the original time series of the number of weibo texts. split by day, it shows that the lowest point of the weibo number on the curve for each day appeared at 06:00, after which the curve began to rise sharply. figure 3b shows part of the cyclical change in the number of covid-19-related weibo posts. the lowest point of cyclical change occurred at 06:00 every day, with two daily peaks around 11:00 and 23:00. figure 3c shows the seasonally adjusted time series, which shows the trend of the number of covid-19-related weibo texts after eliminating the seasonal factor. figure 3d shows the trend component reflecting the trends of the number of covid-19 related weibo. after covid-19 occurred, a slight increase appeared for a short time, then the amount increased sharply on 20 january. the fluctuation reached a peak on 21 january, and then began to decrease but fluctuated until 29 january. the curve rose obviously on 31 january and reached a peak on 1 february. it then steadily fluctuated from 2 february to 5, started to climb on 6 february, and then steadily declined after reaching the highest peak on 7 february. as can be seen from figure 4 , the rising trend of daily weibo numbers and that of the confirmed cases of epidemics is very similar in this early stage. they both rapidly rose around january 19. however, the overall weibo response was quick and higher than the number of confirmed cases. since then, the number of confirmed cases continued to rise, but due to the chinese new year holiday, weibo data remained stable (or even slightly decreased) and continued to rise steadily after 29 january in line with the trend of confirmed cases. as can be seen from figure 4 , the rising trend of daily weibo numbers and that of the confirmed cases of epidemics is very similar in this early stage. they both rapidly rose around january 19. however, the overall weibo response was quick and higher than the number of confirmed cases. since then, the number of confirmed cases continued to rise, but due to the chinese new year holiday, weibo data remained stable (or even slightly decreased) and continued to rise steadily after 29 january in line with the trend of confirmed cases. the spatial distribution of weibo related to covid-19 is shown in figure 5 . the weibo numbers were mainly concentrated in the east-central parts of china, as shown in figure 5a . there were more than 5000 weibo texts in shandong province (the capital of jinan), hubei province (capital of wuhan), henan (capital of zhengzhou), guangdong (capital of guangzhou), sichuan (the capital of chengdu), and jiangsu (capital of nanjing), anhui province (capital of hefei), hebei province (capital of shijiazhuang), beijing, shaanxi (capital of xi'an), liaoning (capital of shenyang), hunan (capital of changsha), and shanxi (capital of taiyuan). figure 5b shows the spatial distribution of the kernel density with a search radius of 200 km, indicating that the high-density areas of weibo related to covid-19 were in wuhan, beijing, shanghai, guangzhou, chengdu, xi'an, and zhengzhou, and presents a continuous trend among the hot points of wuhan, beijing, and shanghai. in order to explore the correlation between public opinion and the epidemic situation, this study used statistical product and service solutions (spss inc., chicago, il, usa) software to perform spearman correlation analysis on the number of relevant weibo texts and confirmed cases in provincial level (number is 34). the descriptive statistics of two variables (the number of weibo texts the spatial distribution of weibo related to covid-19 is shown in figure 5 . the weibo numbers were mainly concentrated in the east-central parts of china, as shown in figure 5a . there were more than 5000 weibo texts in shandong province (the capital of jinan), hubei province (capital of wuhan), henan (capital of zhengzhou), guangdong (capital of guangzhou), sichuan (the capital of chengdu), and jiangsu (capital of nanjing), anhui province (capital of hefei), hebei province (capital of shijiazhuang), beijing, shaanxi (capital of xi'an), liaoning (capital of shenyang), hunan (capital of changsha), and shanxi (capital of taiyuan). figure 5b shows the spatial distribution of the kernel density with a search radius of 200 km, indicating that the high-density areas of weibo related to covid-19 were in wuhan, beijing, shanghai, guangzhou, chengdu, xi'an, and zhengzhou, and presents a continuous trend among the hot points of wuhan, beijing, and shanghai. the spatial distribution of weibo related to covid-19 is shown in figure 5 . the weibo numbers were mainly concentrated in the east-central parts of china, as shown in figure 5a . there were more than 5000 weibo texts in shandong province (the capital of jinan), hubei province (capital of wuhan), henan (capital of zhengzhou), guangdong (capital of guangzhou), sichuan (the capital of chengdu), and jiangsu (capital of nanjing), anhui province (capital of hefei), hebei province (capital of shijiazhuang), beijing, shaanxi (capital of xi'an), liaoning (capital of shenyang), hunan (capital of changsha), and shanxi (capital of taiyuan). figure 5b shows the spatial distribution of the kernel density with a search radius of 200 km, indicating that the high-density areas of weibo related to covid-19 were in wuhan in order to explore the correlation between public opinion and the epidemic situation, this study used statistical product and service solutions (spss inc., chicago, il, usa) software to perform spearman correlation analysis on the number of relevant weibo texts and confirmed cases in provincial level (number is 34). the descriptive statistics of two variables (the number of weibo texts in order to explore the correlation between public opinion and the epidemic situation, this study used statistical product and service solutions (spss inc., chicago, il, usa) software to perform spearman correlation analysis on the number of relevant weibo texts and confirmed cases in provincial level (number is 34). the descriptive statistics of two variables (the number of weibo texts and confirmed cases in provinces) is shown in table 1 . figure 6 shows that the spearman correlation coefficient is 0.84 and significant statistical significance (p = 0.00 < 0.01), so public opinion and epidemic situation have a significant positive correlation with a confidence degree of 0.01. and confirmed cases in provinces) is shown in table 1 . figure 6 shows that the spearman correlation coefficient is 0.84 and significant statistical significance (p = 0.00 < 0.01), so public opinion and epidemic situation have a significant positive correlation with a confidence degree of 0.01. the spatial kernel density characteristics of weibo texts at different scales can be shown by setting different search radii (figure 7) . the result with a search radius of 100 km shows that wuhan was the focus center, surrounded by beijing, shanghai, guangzhou, chengdu, and xi'an, which were star-shaped and supplemented by prominent weibo high-value areas of provincial capitals. the result with a search radius of 200 km reflects that wuhan, beijing, shanghai, and guangzhou are the core, chengdu, xi'an, zhengzhou, jinan, and shijiazhuang are prominent, and the triangular region of wuhan, beijing, and shanghai is in a continuous trend. the result with a search radius of 300 km shows a contiguous regional pattern with core nodes of the beijing-tianjin-hebei junction region, the whole area of the east hubei province and adjacent province region, and the cross-border region of jiangsu, zhejiang, and anhui as well as two independent core regions of guangzhou and chengdu. the result with a search radius of 400 km highlights the contiguous areas in which the cross-border area of hebei-shandong, hubei-hebei, and the jiangsu-zhejiang-shanghai-anhui border area are core nodes, and guangzhou and chengdu are two independent core areas. the result with a search radius of 500 km shows the core area as a triangular region, with beijing, hebei, shandong, henan, hubei, anhui, jiangsu, zhejiang, and anhui connected, and gradually connected with guangdong and sichuan. the spatial kernel density characteristics of weibo texts at different scales can be shown by setting different search radii (figure 7) . the result with a search radius of 100 km shows that wuhan was the focus center, surrounded by beijing, shanghai, guangzhou, chengdu, and xi'an, which were star-shaped and supplemented by prominent weibo high-value areas of provincial capitals. the result with a search radius of 200 km reflects that wuhan, beijing, shanghai, and guangzhou are the core, chengdu, xi'an, zhengzhou, jinan, and shijiazhuang are prominent, and the triangular region of wuhan, beijing, and shanghai is in a continuous trend. the result with a search radius of 300 km shows a contiguous regional pattern with core nodes of the beijing-tianjin-hebei junction region, the whole area of the east hubei province and adjacent province region, and the cross-border region of jiangsu, zhejiang, and anhui as well as two independent core regions of guangzhou and chengdu. the result with a search radius of 400 km highlights the contiguous areas in which the cross-border area of hebei-shandong, hubei-hebei, and the jiangsu-zhejiang-shanghai-anhui border area are core nodes, and guangzhou and chengdu are two independent core areas. the result with a search radius of 500 km shows the core area as a triangular region, with beijing, hebei, shandong, henan, hubei, anhui, jiangsu, zhejiang, and anhui connected, and gradually connected with guangdong and sichuan. figure 8 illustrates the statistical results of the percentage of first-level topics of covid-19. "opinion and sentiments" accounted for 34.42% of all topics. "popularization of prevention and treatment" and "government response" were the second and third most frequent, at 18.97% and 16.29%, respectively. the proportion of "events notification" and "personal response" comprised 13.94% and 12.82%, respectively. "seeking help" and "making donations" then accounted for 2.01% and 1.55%, respectively. figure 8 illustrates the statistical results of the percentage of first-level topics of covid-19. "opinion and sentiments" accounted for 34.42% of all topics. "popularization of prevention and treatment" and "government response" were the second and third most frequent, at 18.97% and 16.29%, respectively. the proportion of "events notification" and "personal response" comprised 13.94% and 12.82%, respectively. "seeking help" and "making donations" then accounted for 2.01% and 1.55%, respectively. a more in-depth analysis of the proportions of sub-topics is presented in figure 9 . "staying at home and taking necessary precautions", "blessing and praying", and "objective comment" were the three most widespread sub-topics, accounting for 23.26%, 20.89%, and 14.99% of texts. the proportion of "taking scientific protective measures" and "fear and worry" comprised 12.48% and 10.47%, respectively. this was followed by "condemning bad habits" and "seeking medical help", which accounted for 6.02% and 4.14%. the proportion of other sub-topics was less than 3%. after computing precision, recall, and f1-measure values, the classification accuracy of the topics and sentiments is presented in table 2 . for the seven topics, the precision was found to be 83% and f1 was 82%. for the 13 sub-topics, the precision and f1 values were 78% and 76%, respectively. a more in-depth analysis of the proportions of sub-topics is presented in figure 9 . "staying at home and taking necessary precautions", "blessing and praying", and "objective comment" were the three most widespread sub-topics, accounting for 23.26%, 20.89%, and 14.99% of texts. the proportion of "taking scientific protective measures" and "fear and worry" comprised 12.48% and 10.47%, respectively. this was followed by "condemning bad habits" and "seeking medical help", which accounted for 6.02% and 4.14%. the proportion of other sub-topics was less than 3%. a more in-depth analysis of the proportions of sub-topics is presented in figure 9 . "staying at home and taking necessary precautions", "blessing and praying", and "objective comment" were the three most widespread sub-topics, accounting for 23.26%, 20.89%, and 14.99% of texts. the proportion of "taking scientific protective measures" and "fear and worry" comprised 12.48% and 10.47%, respectively. this was followed by "condemning bad habits" and "seeking medical help", which accounted for 6.02% and 4.14%. the proportion of other sub-topics was less than 3%. after computing precision, recall, and f1-measure values, the classification accuracy of the topics and sentiments is presented in table 2 . for the seven topics, the precision was found to be 83% and f1 was 82%. for the 13 sub-topics, the precision and f1 values were 78% and 76%, respectively. after computing precision, recall, and f1-measure values, the classification accuracy of the topics and sentiments is presented in table 2 . for the seven topics, the precision was found to be 83% and f1 was 82%. for the 13 sub-topics, the precision and f1 values were 78% and 76%, respectively. to display accurate temporal changes in the different topics, the number of weibo texts for each topic was counted using one-hour time intervals as shown in figure 10 . the topics of "events notification", "popularization of prevention and treatment", "personal response", and "opinion and sentiments" all climbed from 19 january reaching a peak on the 21st. the curve then steadily declined towards the 29th and rose slowly to 1 february. there was a small peak on february 1, then it stabilized and reached a peak again on 5 february. the topics of "government response" and "making donations" started to rise steadily from 20 january, then declined after showing a small peak around 26 january, after which it started to climb on 4 february and reached a peak on 5 february. "seeking help" started to rise suddenly on 22 january showing a small peak before and after wuhan was placed under lockdown on the 23rd, then climbing on 4 february reaching a peak on 6 february and then levelling off. figure 11 presents the time series of all sub-topics except "other". from the perspective of the general trends, the three sub-topics, "questioning the government and media", "staying at home and taking necessary precautions", and "taking scientific protective measures" showed a similar variation tendency over time. the numbers of texts on those three sub-topics improved quickly on 20 january and peaked on the 21st, then gradually decreased but fluctuated towards 29 january, rose obviously on 31 january, and reached a peak on 1 february. since then, the curve has been steadily fluctuating, beginning to rise on 5 february. "fear and worry", "objective comment", and "blessing and praying" climbed from 20 january, reached their peak on 21, fell steadily, then rose again on 5 february and figure 11 presents the time series of all sub-topics except "other". from the perspective of the general trends, the three sub-topics, "questioning the government and media", "staying at home and taking necessary precautions", and "taking scientific protective measures" showed a similar variation tendency over time. the numbers of texts on those three sub-topics improved quickly on 20 january and peaked on the 21st, then gradually decreased but fluctuated towards 29 january, rose obviously on 31 january, and reached a peak on 1 february. since then, the curve has been steadily fluctuating, beginning to rise on 5 february. "fear and worry", "objective comment", and "blessing and praying" climbed from 20 january, reached their peak on 21, fell steadily, then rose again on 5 february and stabilized. "appealing for aiding patients" and "seeking medical help" suddenly increased from 6 february and reached a peak around 8 february. after that, the "appealing for aiding patients" showed a downward trend, and the "seeking medical help" remained a high concern. "popularizing anti-epidemic knowledge in family" and "condemning bad habits" both started to climb on 20 january. after reaching a summit on the 21st, the decline since stabilized. "seeking relief materials" began to rise on 22 january, fell to a peak on 23, then stabilized after rising on 5 february. "willing to return work" had a slight increase and fluctuation since 20 january and has shown a significant upward trend since 4 february. kernel density analysis (radius of 200 km) was carried out on weibo with geographical locations in each topic, as shown in figure 12 . the spatial distribution of "events notification", "popularization of prevention and treatment", "government response", "personal response", and "opinion and sentiments" is similar to the general characteristics of figure 5b , forming hot spots in beijing-tianjin-hebei, shandong, henan, hubei, yangtze river delta, sichuan, and guangdong, but there are differences within the topics. "events notification" takes beijing, wuhan, shanghai, and sichuan as prominent high-value areas, and the areas of the beijing-tianjin-hebei cross border area, east hubei, and the jiangsu-zhejiang-shanghai cross border areas are the main nodes in a continuous pattern. "popularization of prevention and treatment" is presented with beijing, guangzhou, and shanghai as the prominent high values, supplemented by wuhan, chengdu, hefei, zhengzhou, and other high-value areas. "government response" has beijing, sichuan, and xi'an as high values, though zhengzhou, wuhan, changsha, shanghai, guangzhou, haikou, and other cities have responded significantly. "personal response" is prominently reflected by beijing, shanghai, guangzhou, and wuhan, with beijing, wuhan, and shanghai as the center and guangzhou and chengdu as relatively kernel density analysis (radius of 200 km) was carried out on weibo with geographical locations in each topic, as shown in figure 12 . the spatial distribution of "events notification", "popularization of prevention and treatment", "government response", "personal response", and "opinion and sentiments" is similar to the general characteristics of figure 5b , forming hot spots in beijing-tianjin-hebei, shandong, henan, hubei, yangtze river delta, sichuan, and guangdong, but there are differences within the topics. "events notification" takes beijing, wuhan, shanghai, and sichuan as prominent high-value areas, and the areas of the beijing-tianjin-hebei cross border area, east hubei, and the jiangsu-zhejiang-shanghai cross border areas are the main nodes in a continuous pattern. "popularization of prevention and treatment" is presented with beijing, guangzhou, and shanghai as the prominent high values, supplemented by wuhan, chengdu, hefei, zhengzhou, and other high-value areas. "government response" has beijing, sichuan, and xi'an as high values, though zhengzhou, wuhan, changsha, shanghai, guangzhou, haikou, and other cities have responded significantly. "personal response" is prominently reflected by beijing, shanghai, guangzhou, and wuhan, with beijing, wuhan, and shanghai as the center and guangzhou and chengdu as relatively independent high-value areas. "opinion and sentiments" was more prominent in high-value areas around wuhan, followed by the yangtze river delta, beijing-tianjin-hebei, and the pearl river delta urban agglomeration. "seeking help" and "making donations" show totally different characteristics. "seeking help" appears significantly around wuhan and shows a trend of diffusion to the surrounding areas, especially to the north. "making donations" has beijing and hainan as high values and spreads across the country, but is relatively concentrated in urban areas around wuhan, the yangtze river delta region, chengdu-chongqing region, guangzhou, zhengzhou, and even haikou in the south. the spatial distributions of the kernel density estimation of the 13 sub-topics are shown in figure 13 . except for "appealing for aiding patients", "seeking medical help", and "seeking relief materials", the spatial distribution of most topics is similar to the general characteristics of figure 5b . "fear and worry" formed high-value areas in wuhan, shanghai, suzhou, jiaxing, and other cities. "questioning the government and media" is mainly reflected in wuhan, supplemented by the beijing-tianjin-hebei transboundary area, east hubei, the jiangsu-zhejiang-shanghai neighborhood area, and guangzhou and chengdu, two relatively independent high-value areas. "condemning bad habits" is distributed in dots as a whole. beijing is a high-value region with prominent dots, and east hubei, the jiangsu-zhejiang-shanghai cross border area, guangzhou, and wuhan are independent high-value regions. "objective comment" takes wuhan as a prominent high-value area, supplemented by beijing, shanghai, guangzhou, and other high-value areas. "taking scientific protective measures" is a prominent spot-shaped high-value area in beijing, wuhan, and shanghai, and the areas within the beijing-tianjin-hebei neighborhood area, east hubei, the jiangsu-zhejiang-shanghai transboundary areas are the main nodes in a continuous pattern. "blessing and praying" is centered on the contiguous areas of beijing, wuhan, and shanghai, while guangzhou, chengdu, and zhengzhou are relatively independent high-value areas. "appeal for aiding patients" takes wuhan as the center of east hubei as the high-value area, and beijing, shanghai, and the neighborhood area as relatively high-value areas. "willing to return work" shows that beijing, guangzhou, and shanghai are prominent high-value areas, supplemented by wuhan, chengdu, hefei, jinan, and other relatively high-value areas. 'staying at home and taking necessary precautions' is led by wuhan, with beijing, wuhan, shanghai, and guangzhou as the highlighted high-value areas, and the beijing-tianjin-hebei cross border area, east hubei, the yangtze river delta, and the pearl river delta as the main nodes, showing a continuous trend. "popularizing anti-epidemic knowledge in family" is concentrated in wuhan and its surrounding cities, supplemented by relatively high-value areas such as beijing, shanghai, and guangzhou. "seeking medical help" and "seeking relief materials" are prominently concentrated in hubei. "seeking medical help" appears in wuhan and spreads to the surrounding area, especially to the east. the overall distribution of "seeking relief materials" and "seeking medical help" showed a similar distribution trend, with wuhan and its surrounding areas as high-value areas. "appealing for aiding patients" is mainly distributed in wuhan, beijing, shanghai, and other regions. in terms of the time series analysis, the number of relevant weibo texts under the covid-19 event shows a certain periodicity. there are two peaks at which weibo are sent every day. the peak in the morning usually appears around 11 o'clock, and the peak in the evening usually appears around 23 o'clock. in addition, the number of relevant weibo has a good correspondence with the development time node of the coronavirus event (shown in figure 4 ). since the characteristics of person-to-person infections for covid-19 were clarified on 20 january and the central government of china demanded high attention from the public, the number of weibo texts began to rise significantly, and the fluctuations dropped after reaching a peak on the 21st. by the early hours of 31 january, when the world health organization (who) announced the epidemic as a "public health emergency of international concern", the number of texts had risen markedly, and fell back after reaching its peak on 1 february. on 3 february huoshenshan hospital (wuhan) was officially put into use in response to the epidemic. on the afternoon of 5 february, the online help channel in people's daily was opened, and the number of weibo texts began to climb. when the "whistleblower" dr. wenliang li passed away on 7 february the number of weibo reached the highest level, exceeding 110,000 times a day. it then fluctuated, falling back but still at extremely high values. as shown in figure 4 , there were an increasing number of confirmed cases around january 19 which aroused substantial public concern, and weibo posts emerged in large numbers. then, the number of confirmed cases continued to increase while weibo texts maintained a stable and slightly downward trend, because of the chinese new year holiday. after january 29 weibo texts increased, with fluctuations. changing trends in public opinion, as expressed on weibo, reflect actual changes in confirmed cases. furthermore, other scholars obtained similar findings in different disaster events. in terms of the time series analysis, the number of relevant weibo texts under the covid-19 event shows a certain periodicity. there are two peaks at which weibo are sent every day. the peak in the morning usually appears around 11 o'clock, and the peak in the evening usually appears around 23 o'clock. in addition, the number of relevant weibo has a good correspondence with the development time node of the coronavirus event (shown in figure 4 ). since the characteristics of person-to-person infections for covid-19 were clarified on 20 january and the central government of china demanded high attention from the public, the number of weibo texts began to rise significantly, and the fluctuations dropped after reaching a peak on the 21st. by the early hours of 31 january, when the world health organization (who) announced the epidemic as a "public health emergency of international concern", the number of texts had risen markedly, and fell back after reaching its peak on 1 february. on 3 february huoshenshan hospital (wuhan) was officially put into use in response to the epidemic. on the afternoon of 5 february, the online help channel in people's daily was opened, and the number of weibo texts began to climb. when the "whistle-blower" dr. wenliang li passed away on 7 february the number of weibo reached the highest level, exceeding 110,000 times a day. it then fluctuated, falling back but still at extremely high values. as shown in figure 4 , there were an increasing number of confirmed cases around january 19 which aroused substantial public concern, and weibo posts emerged in large numbers. then, the number of confirmed cases continued to increase while weibo texts maintained a stable and slightly downward trend, because of the chinese new year holiday. after january 29 weibo texts increased, with fluctuations. changing trends in public opinion, as expressed on weibo, reflect actual changes in confirmed cases. furthermore, other scholars obtained similar findings in different disaster events. ye found that the developmental trend of dengue disease outbreak events and the trend of the number of weibo texts was highly correlated [11] . there is a synchronization between daily discussion frequencies on weibo and the real-world trend of the covid-19 outbreak. furthermore, the number of epidemic-related weibo texts is also influenced by social events, such as the spring festival holiday, the seal-off of wuhan, and the death of public personalities. time series analysis of various topics shows that the "events notification", "popularization of prevention and treatment", "personal response", "opinion and sentiments", and "government response" are similar to the overall trend of weibo. since 20 january, they have shown an upward trend during the shock. "making donations" and "seeking help" are relatively lagging behind. in the early stage of the covid-19 outbreak, a sudden increase in the confirmed cases caused a shortage of hospital beds. due to this, patients with suspected cases of covid-19 had to be in isolation at home. this demonstrated that the planning and allocation of medical resources was under enormous pressure in the early stage of the epidemic. then, with the establishment of the huoshenshan and leishenshan hospitals (wuhan) in early february, this situation was relieved but not resolved thoroughly. on 23 january wuhan was on lockdown, the "making donations" began to rise steadily and rose significantly after 4 february. "seeking help" started to significantly climb after 4 february and on 5 february, the curve reached its peak when an additional online help channel was opened. the above characteristics indicate that public expressing opinions in emergencies is not random but has periods of silence and noise that are highly volatile and vulnerable to external influences. these results are consistent with previous studies of public responses in emergency situations. the public sentiment in twitter was highly correlated with external factors, such as the impact from official mass media, important social events, extreme weather, and public holidays [29, 30] . the results of spatial kernel density analysis showed that epidemic-related weibo texts were mainly concentrated in hubei province, beijing-tianjin-hebei, the yangtze river delta, the pearl river delta, chengdu-chongqing, and shandong and henan. wuhan, hubei province, as the heart of the outbreak of covid-19, is undoubtedly a hot spot of public concern. most of the other regions mentioned above are densely populated areas and areas of economic development. in 2018, the proportion of the resident population in urban agglomerations such as beijing-tianjin-hebei, the pearl river delta, the yangtze river delta, and chengdu-chongqing reached 30.8%, and the gdp of these areas accounted for 53.7% of the country. high levels of economic development and population density do not only mean that these regions have a convenient transportation infrastructure network, as these factors may increase the possibility of the epidemic spreading among people more rapidly, which makes epidemic prevention and control more difficult. improving emergency management and social governance in urban areas during outbreak responses is an issue that should be emphasized. with regard to the spearman correlation coefficient, the epidemic situation has a high correlation with the spatial distribution of public opinion. thus, the spatial distribution of weibo texts could be related to the severity of the epidemic, the degree of population aggregation, and the level of economic development. these findings are similar to existing research outcomes. for example, the discussions of dengue fever in cyberspace have a strong degree of spatial correlation with real-world epidemic dengue activity [11] . areas with better socioeconomic conditions generally exhibit higher disaster-related twitter usage [29] . on a different spatial scale, the spatial kernel density analysis results ( figure 6 ) indicate that there should be different emergency response strategies at different administrative levels. when the search radius is less than 200 km, the hotspots of weibo texts are mainly at the city level. when the search radius is 300 and 400 km, there is a significant provincial transboundary area spatial agglomeration of weibo texts. thus, enhancing the emergency response at boundary zones among different provinces is the key governance point at the province level. the result with a search radius of 500 km shows a regional spatial hotspot. at the national level, the government should strengthen the response in key urban agglomerations. considering the differences in the risk levels of covid-19 among different spatial scales, establishing a hierarchical emergency response mechanism of "region-province-city" is expected to be of substantial significance. the spatial distribution of each topic is similar to the overall distribution of weibo, but the aggregation degree of each topic is different. the "events notification" and "popularization of prevention and treatment", respectively, show high-value areas with beijing as the core. as the capital and political center of china, beijing is also the headquarters of many public media. a report on the epidemic can play a role in stabilizing public sentiment. therefore, it is crucial for the government to take initiatives to make information transparent and to make an appeal for scientific prevention. the distribution of "government response" and "personal response" is similar, but the intensity and scope of the former is higher than that of the latter. in china, local governments responded very strongly and quickly to covid-19 by following the instructions of the central government. "seeking help" is concentrated around wuhan, and "making donations" is more plentiful than "seeking help" in quantity and is distributed globally, reflecting the emergency relief tradition of china: "when trouble occurs at one spot, help comes from all quarters". "seeking medical help", "seeking relief materials", "appealing for aiding patients", and "popularizing anti-epidemic knowledge in family" are mainly concentrated around wuhan, which is related to the severe epidemic situation and the lack of materials in wuhan. the spatial distribution of 'willing to return work' shows that there is a strong willingness to return to work in first-tier cities such as beijing, guangzhou, shanghai, and chengdu, which have more job opportunities or labor resources. in the early stage of covid-19 in china, the most expressed topic was 'opinion and sentiments', with a proportion of 34.42%. this shows that social media is an important channel through which the public carried out risk perception and shared opinions and emotions during the outbreak of covid-19. the proportion of "events notification", "popularization of prevention and treatment", and "government response" are more than 60%, suggesting that the public are mainly focused on fighting the epidemic, and the timely authoritative information released by the chinese government is targeted and effective. since 23 january over 30 provinces successively launched first-level responses to major public health emergencies within three days. as of 30 january, all provinces, including provinces with a few confirmed cases that were substantially distant from wuhan, had activated a first-level public health emergency response. in the meantime, china strengthened logistics and online platforms to facilitate the online ordering and shopping of goods via contactless delivery. many cities also issued notices regarding "closed management" to communities in their region, calling for avoiding unnecessary transportation and for working from home. these findings show that the government's timely release of targeted and effective authoritative information helped eliminate panic and promote the stability of public sentiment. meanwhile, less than 10% of "seeking help" and "making donations" indicate that more attention should be paid to information directly related to disaster relief: "seeking help" and "making donations" are extremely important, although in small quantities. paying more attention to vulnerable minority groups should also be considered a crucial aspect of social governance. in the sub-topics, "staying at home and taking necessary precautions", "blessing and praying", "taking scientific protective measures", and "popularizing anti-epidemic knowledge in family" accounted for more than 50%, indicating that the public opinion in the early stage of covid-19 was generally positive. in response to the government's requirements, most people stayed at home and actively took protective measures. many people paid tribute to medical staff and prayed for the epidemic to pass. some objective opinions about covid-19 were also expressed by weibo users, for example, "objective comment", "appealing for aiding patients", and "willing to return work". however, 19.17% of weibo texts concerned "fear and worry", "questioning the government and media", and "condemning bad habits", showing negative emotions during the epidemic. people expressed their fears about covid-19, condemned the consumption of wild animals, and expressed anger at the spread of rumors. when "whistle-blower" doctor li wenliang passed away, most people expressed their respect and condolences to him, but some expressed their dissatisfaction, considering that the government's response was too slow or that media reports were untrue. it can be inferred that the timely release and updating of epidemic-related information is an effective measure to avoid public panic and stop the spread of misinformation. this study comprehensively analyzed social media data in the early stage of covid-19 in china and proposed a topic extraction and classification model. the results of the evaluation show that the approach for topic extraction is accurate and viable for understanding public opinions. we obtained seven topics and 13 sub-topics related to covid-19 from weibo texts and analyzed their temporal-spatial distributions. (1) the topics with a proportion of more than 60% were "events notification", "popularization of prevention and treatment", and "government response". in the subtopics, "staying at home and taking necessary precautions", "blessing and praying", "taking scientific protective measures", and "popularizing anti-epidemic knowledge in family" was the most-expressed sub-topic. this finding indicates that timely release of information from the government was helpful in stabilizing public opinion in the early stage of covid-19. (2) the temporal changes in weibo texts are synchronous with the development of the covid-19 outbreak. public opinions during epidemic outbreaks are volatile and vulnerable to external influences. the spatial distribution of covid-19-related weibo texts shows a distribution pattern that beijing-tianjin-hebei, the yangtze river delta, the pearl river delta, and the chengdu-chongqing urban agglomeration were significant high-value areas besides wuhan. this means that the temporal-spatial distribution of opinions was related to the severity of the epidemic, the degree of population aggregation, and the level of economic development. (3) the spatial distribution of public opinions is regionally different and has a scale feature, exhibiting aggregation characteristics in cities, provincial border areas, and key urban agglomeration regions. though in small quantities, the "seeking help" and "making donations" topics can directly provide support for emergency response and post-disaster management. it is suggested that the government should strengthen the public opinion response and epidemic prevention and control in the key epidemic areas, urban agglomerations, and transboundary areas at the province level; in addition, it should formulate accurate response countermeasures following the public's demands in controlling the crisis. this study contributes to existing research on uncovering knowledge regarding emergencies from social media by presenting a reliable approach to mining people's detailed opinions about covid-19. the findings of this research could provide a rapid situational assessment, help decision makers to better understand public opinions toward covid-19, and support analysts in planning and executing appropriate resource allocation. nevertheless, this study has some limitations. first, the specific reasons for the temporal-spatial distribution of covid-19-related weibo texts need further exploration with more information. second, the paper only analyzed texts from social media, while other content, such as pictures and videos in blogs, may also be informative. third, there are manipulated opinions on social media (e.g., "fake news" and "troll opinions"). thus, the better quantification of the noise caused by manipulated opinions needs further investigation. in addition, reducing the noise caused by manipulated opinions in social media data needs to be explored further. with covid-19, which has been characterized as a pandemic by who [31] , we will continually acquire new data from weibo, train and improve the model, analyze the changes and driving mechanisms of public opinion, and provide active references for governmental responses. author contributions: x.h. drafted the manuscript and was responsible for data preparation, data processing, and analysis; j.w. was responsible for the research design, result analysis, and review of the manuscript; m.z. was responsible for spatial distribution analysis and mapping. x.w. was responsible for time series analysis and mapping. all authors have read and agreed to the published version of the manuscript. world health organization. who statement on cases of covid-19 surpassing 100,000 real-time estimation of the risk of death from novel coronavirus (covid-19) infection: inference using exported cases national health commission of the people's republic of china. announcement of the national health commission of the people's republic of china what is the reason for wuhan's "closing the city international opinion praises china's completion of huoshenshan hospital on the 10th two mountain hospitals": china construction three bureau undertakes the maintenance tasks of vulcan mountain and thunder mountain hospital national health commission of the people's republic of china. the latest situation of the new coronavirus pneumonia epidemic situation as of 24:00 on february 10 using social media to mine and analyze public sentiment during a disaster: a case study of the 2018 shouguang city flood in china social media analytics for natural disaster management study on disaster information management system compatible with vgi and crowdsourcing crowdsourcing geographic information for disaster response: a research frontier public behavior response analysis in disaster events utilizing visual analytics of microblog data exploration of spatiotemporal and semantic clusters of twitter data using unsupervised neural networks data-driven geography spatio-temporal distribution of negative emotions in new york city after a natural disaster as seen in social media topic modeling and sentiment analysis of global climate change tweets spatial, temporal, and content analysis of twitter for wildfire hazards use of social media for the detection and analysis of infectious diseases in china behavior of social media users in disaster area under the outburst disasters: a content analysis and longitudinal study of explosion in tianjin 12(th) using social media for emergency response and urban sustainability: a case study of the 2012 beijing rainstorm on-line random forests finding scientific topics latent dirichlet allocation improving random forests by neighborhood projection for effective text classification random forests a kernel density estimation method for networks, its computational method and a gis-based tool more about correlation information extraction: past, present and future. in multi-source, multilingual information extraction and summarization using twitter to better understand the spatiotemporal patterns of public sentiment: a case study in massachusetts, usa social and geographical disparities in twitter use during hurricane harvey world health organization. who characterizes covid-19 as a pandemic this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license acknowledgments: a special acknowledgement should be expressed to the china-pakistan joint research center on earth sciences. the authors declare no conflict of interest. key: cord-337219-d81v8b4j authors: cheong, chang heon; lee, seonhye title: case study of airborne pathogen dispersion patterns in emergency departments with different ventilation and partition conditions date: 2018-03-13 journal: int j environ res public health doi: 10.3390/ijerph15030510 sha: doc_id: 337219 cord_uid: d81v8b4j the prevention of airborne infections in emergency departments is a very important issue. this study investigated the effects of architectural features on airborne pathogen dispersion in emergency departments by using a cfd (computational fluid dynamics) simulation tool. the study included three architectural features as the major variables: increased ventilation rate, inlet and outlet diffuser positions, and partitions between beds. the most effective method for preventing pathogen dispersion and reducing the pathogen concentration was found to be increasing the ventilation rate. installing partitions between the beds and changing the ventilation system’s inlet and outlet diffuser positions contributed only minimally to reducing the concentration of airborne pathogens. emergency departments (ed) are visited by patients with various diseases, and thus, are vulnerable to the dispersion of airborne pathogens [1] [2] [3] . in particular, if the hospital does not have isolation rooms [4] [5] [6] for the treatment of patients carrying airborne pathogens or has more respiratory patients visit the hospital than the number of beds available in the isolation rooms, it is possible that patients with respiratory problems will be assigned to normal beds in the ed. in this situation, it is anticipated that the possibility of airborne pathogen dispersion in the ed increases. airborne pathogens are particles that are 5 µm or smaller (aerosol) [7] . as they travel in the air, their dispersion to nearby areas is possible, depending on the indoor air conditions. controlling the indoor air patterns, installing partitions between units to prevent airborne pathogen dispersion, and installing uv lamps to sterilize the pathogens can be considered as alternatives to prevent the dispersion of airborne pathogens inside eds. partitions are used in target ed in hospitals as a means to control the dispersion of airborne pathogens [8] . among these options, we focused on the effects of arrangement of diffusers, the installation of partitions between beds, and increased ventilation rate affect the airflow patterns in an ed. each of these factors was applied to the bed areas of an ed, and the evolution of airborne pathogen dispersion was analyzed through a cfd (computational fluid dynamics) simulation. as mentioned previously, the objectives of the research were to investigate the effects of the locations of ventilation system diffusers, the presence of partitions between beds, and increased ventilation rate on the dispersion of airborne pathogens. therefore, the following scenarios were analyzed. first, the ventilation around the beds in the ed was increased from the regulated ventilation level of three air change per hour (ach) to the ventilation level of six ach, which is required for a negative-pressure isolation chamber. isolation rooms for patients with airborne pathogens require a minimum ventilation rate of 6-12 ach [5, 6] . then, the effect on the pathogen dispersion control was analyzed. second, the location of diffusers was changed around the beds in the ed, and the consequential changes observed in the pathogen dispersion patterns were analyzed. in this case, the conditions were largely in one of two categories: supplying and exhausting the air over the respiratory system of a patient. an alternative was designed by considering the general design of inlets and outlets for negative pressure chambers, in which the air is exhausted at the restroom side or around the respiratory system of the patient. last, an additional partition was installed between the ed beds, and the degree of change observed in the pathogen dispersion patterns was analyzed. this approach is thought to be an alternative that can prevent the dispersion of airborne pathogens to adjacent beds. in south korea, generally, ed is designed with an open plan and the airborne pathogen can freely migrate from infected patient to any place in ed. the conventional fabric partition or curtains between beds easily pass the airborne pathogens smaller than 5 µm. the impermeable partitions that have benefits such as easy installation and cheap price are thought to be useful to prevent the air pathogen transfer from a bed to another. however, airflow pattern and ventilation rate can influence the effects of the partition regarding airborne pathogen dispersion. this study investigates the combined effects of ventilation rate, inlet/outlet location and existence of partition in ed on airborne pathogen dispersion and consequent infection risk. the results of this study are expected to provide an effective architectural design guide for ed to prevent airborne infections. the subject for analysis was an ed based in seoul. the ed was consisted of faculty area, nurse station, laboratory, family waiting area, acute treatment area and general treatment area. the general treatment area where the emergency beds were located in the ed was selected as the analysis model. figure 1 illustrates target area with ten beds without partitions. in the actual conditions, the space was open to some other areas in the department. the conditions concerning the surrounding areas, which cannot be specified, were excluded and the subject space was independently modeled in the analysis. a cfd analysis program, star-ccm+ v10, was used to achieve the research objectives. star-ccm+ is a cfd simulation tool to fluid dynamics, particle/gas flow and heat transfer in a controlled volume. this software provides lots of physics models and analysis tools for the investigation. the airflow dispersion patterns and the airborne pathogen density distribution were analyzed in the study to estimate airborne infection risk. the subjects of the cfd analysis were the airflow and ventilation conditions of the bed area in the ed, and variation in the pathogen dispersion trend with the installation of partitions between the beds. for the star-ccm modeling, only the indoor air area was modeled as a solid object in autocad 2015 (computer-aided design, autodesk, san rafael, ca, usa), and imported to star-ccm+. a polyhedral mesh was selected for the analysis model, and a prism layer mesh was applied. for the equations governing the flow field of the three-dimensional model, the continuity equation, momentum equation, and equations related to the degree of turbulence were applied. for the turbulence analysis, the realizable k-ε turbulence model was used. the segregated flow model was selected for the fluid model. the three-dimensional model, the continuity equation, momentum equation, and equations related to the degree of turbulence were applied. for the turbulence analysis, the realizable k-ε turbulence model was used. the segregated flow model was selected for the fluid model. in this research, two analysis models were established based on the installation of partitions. figure 2 shows the image of each simulation model with and without partition. the images of meshing conditions are also depicted in figure 2 . the mesh and number of cells for each condition, and the boundary conditions are listed in tables 1 and 2 , respectively. the air supply and exhaust were in the upper area shown in figure 2 . all patients were lying in the beds with their heads near the wall. according to the literature by sung (2015) , the minimum ventilation requirements for hospitals in south korea, as defined by current regulations, is approximately 2.4 ach. based on this, the baseline ventilation condition without airborne pathogen control was set at 3 ach in this study. the entire air supply was assumed to come from the outside [9] . the ventilation condition for pathogen control was set at 6 ach. this is the minimum value in the range of 6 ach-12 ach, which is the required ventilation rate inside negative pressure units suggested by the "plan for extended installation of negative pressure units at nationally designated isolation hospitals" published by the korea centers for disease control & prevention in 2015 [10] . in this research, two analysis models were established based on the installation of partitions. figure 2 shows the image of each simulation model with and without partition. the images of meshing conditions are also depicted in figure 2 . the mesh and number of cells for each condition, and the boundary conditions are listed in tables 1 and 2 , respectively. the air supply and exhaust were in the upper area shown in figure 2 . all patients were lying in the beds with their heads near the wall. according to the literature by sung (2015) , the minimum ventilation requirements for hospitals in south korea, as defined by current regulations, is approximately 2.4 ach. based on this, the baseline ventilation condition without airborne pathogen control was set at 3 ach in this study. the entire air supply was assumed to come from the outside [9] . the ventilation condition for pathogen control was set at 6 ach. this is the minimum value in the range of 6 ach-12 ach, which is the required ventilation rate inside negative pressure units suggested by the "plan for extended installation of negative pressure units at nationally designated isolation hospitals" published by the korea centers for disease control & prevention in 2015 [10] . in this research, two analysis models were established based on the installation of partitions. figure 2 shows the image of each simulation model with and without partition. the images of meshing conditions are also depicted in figure 2 . the mesh and number of cells for each condition, and the boundary conditions are listed in tables 1 and 2, respectively. the air supply and exhaust were in the upper area shown in figure 2 . all patients were lying in the beds with their heads near the wall. according to the literature by sung (2015) , the minimum ventilation requirements for hospitals in south korea, as defined by current regulations, is approximately 2.4 ach. based on this, the baseline ventilation condition without airborne pathogen control was set at 3 ach in this study. the entire air supply was assumed to come from the outside [9] . the ventilation condition for pathogen control was set at 6 ach. this is the minimum value in the range of 6 ach-12 ach, which is the required ventilation rate inside negative pressure units suggested by the "plan for extended installation of negative pressure units at nationally designated isolation hospitals" the numbers of inlets and outlets, as shown in figures 2 and 3 , were slightly different in the base model and the type 1 model. this was because the diffusers were placed in the spaces between the beds in the base model so that the ventilation would not occur directly in the face of the patient. the type 1 model applied walls between each bed, and the ventilator supply was placed at every bed. the inlet condition for the star-ccm+ simulation model was set to the velocity inlet, and the outlet condition was set as a split ratio outlet. the buoyancy effect was considered, and the detailed thermal conditions of the simulation models are shown in table 1 . assuming that the patient breathed 18 times/min, had a breathing capacity of 500 ml (about 9 l/min), and their mouth measured 0.04 m × 0.02 m, the average air velocity of exhalation was calculated to be approximately 0.19 m/s. based on this, therefore, the average exhalation velocity was set in the model to be 0.2 m/s (red arrow in figure 3 .). patients were assumed to be lying in the center of their beds. the exhalation was emitted from one patient, and the analysis was conducted accordingly. a passive scalar was selected to represent the pathogen included in the exhalation, and the concentration was 1.0. according to previous study [11] , the passive scalar method is also a good approach of small particles bioaerosols. the airborne pathogen dispersion pattern resulting from the exhalation, mixing of airflows, and turbulence patterns was visualized for analysis. figure 4 shows the data measuring points for the analysis of pathogen concentration. the points were set at a height of 1.0 m, in consideration of the location of the respiratory system of a patient lying in a bed. the meshing conditions of the base (2,405,265 cells) and type 1 (2,691,618 cells) models are provided in table 2 . the black boxes above the beds are inlets and outlets of the ventilator. the bulge of the bed is 2.0 m × 0.9 m × 0.5 m. human body is expressed in figure 2 and mouth is modeled top of the human body(0.04m × 0.02 m, 0.7 m height). simulation cases for analysis were established, as shown in table 3 , to conduct a case study that analyzed the range of airborne pathogen dispersion according to the location of diffusers in the bed area of the ed, the ventilation rate, and the installation of partitions between beds. case 1 is the condition that best represents the usual bed conditions of existing eds. the ventilation rate was 3 ach, per regulation, with no partitions between the beds. fabric curtains are usually installed between the beds, but it was assumed that the curtains were left open, as in situations where undressing or exposing the body was not necessary. the inlets were around the periphery of the ed (region a), and the outlets were in the central area (region b). the inlet was located near the side of the patient's respiratory system. the conditions of case 2 were the same as in case 1, only with the locations of the inlet and outlet switched, so that the outlet was located over the patient's respiratory system. cases 3 and 4 were the same as cases 1 and 2, respectively, with the ventilation rate increased to 6 ach. cases 5-8 had the same conditions as cases 1-4, except for having partitions in place between the beds. as in the previous explanation of the analysis model, the total number of inlets and outlets was increased, and the air velocity at the inlets decreased accordingly with the installation of a diffuser for every bed. simulation cases for analysis were established, as shown in table 3 , to conduct a case study that analyzed the range of airborne pathogen dispersion according to the location of diffusers in the bed area of the ed, the ventilation rate, and the installation of partitions between beds. case 1 is the condition that best represents the usual bed conditions of existing eds. the ventilation rate was 3 ach, per regulation, with no partitions between the beds. fabric curtains are usually installed between the beds, but it was assumed that the curtains were left open, as in situations where undressing or exposing the body was not necessary. the inlets were around the periphery of the ed (region a), and the outlets were in the central area (region b). the inlet was located near the side of the patient's respiratory system. the conditions of case 2 were the same as in case 1, only with the locations of the inlet and outlet switched, so that the outlet was located over the patient's respiratory system. cases 3 and 4 were the same as cases 1 and 2, respectively, with the ventilation rate increased to 6 ach. cases 5-8 had the same conditions as cases 1-4, except for having partitions in place between the beds. as in the previous explanation of the analysis model, the total number of inlets and outlets was increased, and the air velocity at the inlets decreased accordingly with the installation of a diffuser for every bed. simulation cases for analysis were established, as shown in table 3 , to conduct a case study that analyzed the range of airborne pathogen dispersion according to the location of diffusers in the bed area of the ed, the ventilation rate, and the installation of partitions between beds. case 1 is the condition that best represents the usual bed conditions of existing eds. the ventilation rate was 3 ach, per regulation, with no partitions between the beds. fabric curtains are usually installed between the beds, but it was assumed that the curtains were left open, as in situations where undressing or exposing the body was not necessary. the inlets were around the periphery of the ed (region a), and the outlets were in the central area (region b). the inlet was located near the side of the patient's respiratory system. the conditions of case 2 were the same as in case 1, only with the locations of the inlet and outlet switched, so that the outlet was located over the patient's respiratory system. cases 3 and 4 were the same as cases 1 and 2, respectively, with the ventilation rate increased to 6 ach. cases 5-8 had the same conditions as cases 1-4, except for having partitions in place between the beds. as in the previous explanation of the analysis model, the total number of inlets and outlets was increased, and the air velocity at the inlets decreased accordingly with the installation of a diffuser for every bed. the wells-riley model is a method of expressing the probability of air-borne infection using the concentration of a steady-state infection source and thread ventilation [12] [13] [14] [15] [16] . equation (1) shows the expression of the wells-riley model. equation (2) shows the modified wells-riley model for infection risk by spatial area. where: p i : airborne infection probability of a susceptible person; c: number of infection cases; i: number of infectors; p: breathing rate of a susceptible person; and q: quantum generation rate by an infector. where n: expected number of quanta. the quanta generation rate of influenza was set to 515 particles/h [17, 18] . the existing literature suggests that the quanta generation rate of influenza is 15-500 particles/h [19] . in south korea, after the middle east respiratory syndrome (mers) outbreak in 2015, only one patient companion can stay in the ed and take care of the patient near their bedside. other patient companions must wait in the waiting room. the duration of a patient's stay in the emergency room depends on the patient's condition, but in the worst case, a patient may stay for two or three days. however, in this study, we assumed that the condition is treated for 4 h:2 h for blood tests and 2 h of other medical treatments by hospital members' interview. the quanta generation scenario is depicted in figure 5 . airborne pathogen concentration of each monitoring point is used to calculate airborne infection risk of neighboring non-infected patient. airborne pathogen concentration at x3-y1 is used to evaluate companions' airborne infection risk. figure 4 . figure 6 shows the average concentration at all measuring points together with the beds of the patient with a respiratory problem who generated the pathogen (x3-y1 and x3-y2), the beds opposite to the pathogen source patient (x3-y4 and x3-y5), and the average pathogen concentration at the rest of the beds. according to figure 6 , there was a large difference between the pathogen concentrations at the pathogen source bed and that at the rest of beds. first, the reduction of pathogen concentration with increased ventilation rate is well demonstrated in all cases analyzed (cases 1 and 2 vs. cases 3 and 4 and cases 5 and 6 vs. cases 7 and 8). the effect of switching the ventilation outlet from region b to region a varied depending on the existence of partitions. in the condition without partitions, there was minimal effect on the average concentration at the periphery, and the pathogen concentration at the pathogen source bed showed a slight increase (x3). however, the change of outlet location (from region b to region a) reduced the dispersion of the pathogen to the adjacent beds (x1, x2, x4, and x5). placing a partition between the beds when the outlet location was at region b did slightly decrease the concentration at the pathogen source beds (x3-y1) as compared to the condition without partitions. in the case of the condition with the partitions, switching the outlet location from region b to region a increased the concentration at the pathogen source bed. in addition, comparing cases 5 and 6, changing the outlet location from region b to region a when partitions were between the beds contributed to a significant increase in the pathogen concentration at the adjacent bed (x1-x5). the pathogen concentration at x2-y5 and x3-y5 in case 6 exceeded the corresponding values in case 1 and 2. however, installing partitions between the beds (case 6 vs. cases 1 and 2) was confirmed to slightly reduce the average concentration levels at the rest of the beds on the periphery. figure 7 shows the expected infection risk at each measuring point. the infection risk reflects the tendencies of the pathogen concentrations in each case; a higher pathogen concentration means a higher infection risk. increasing the ventilation rate is always desirable for the reduction of infection risk. figure 7 illustrates that installing partitions contributed to a reduced infection risk in the periphery (a) and a clear reduction in the average infection risk at the increased ventilation rate of 6 ach. however, the increased infection risk at the bed adjacent to the airborne pathogen generation source should not be neglected in the cases with partitions between the beds. estimated number of airborne pathogens and airborne infection risk at each monitoring point is demonstrated in appendix a. figure 4 . figure 6 shows the average concentration at all measuring points together with the beds of the patient with a respiratory problem who generated the pathogen (x3-y1 and x3-y2), the beds opposite to the pathogen source patient (x3-y4 and x3-y5), and the average pathogen concentration at the rest of the beds. according to figure 6 , there was a large difference between the pathogen concentrations at the pathogen source bed and that at the rest of beds. first, the reduction of pathogen concentration with increased ventilation rate is well demonstrated in all cases analyzed (cases 1 and 2 vs. cases 3 and 4 and cases 5 and 6 vs. cases 7 and 8). the effect of switching the ventilation outlet from region b to region a varied depending on the existence of partitions. in the condition without partitions, there was minimal effect on the average concentration at the periphery, and the pathogen concentration at the pathogen source bed showed a slight increase (x3). however, the change of outlet location (from region b to region a) reduced the dispersion of the pathogen to the adjacent beds (x1, x2, x4, and x5). placing a partition between the beds when the outlet location was at region b did slightly decrease the concentration at the pathogen source beds (x3-y1) as compared to the condition without partitions. in the case of the condition with the partitions, switching the outlet location from region b to region a increased the concentration at the pathogen source bed. in addition, comparing cases 5 and 6, changing the outlet location from region b to region a when partitions were between the beds contributed to a significant increase in the pathogen concentration at the adjacent bed (x1-x5). the pathogen concentration at x2-y5 and x3-y5 in case 6 exceeded the corresponding values in case 1 and 2. however, installing partitions between the beds (case 6 vs. cases 1 and 2) was confirmed to slightly reduce the average concentration levels at the rest of the beds on the periphery. figure 7 shows the expected infection risk at each measuring point. the infection risk reflects the tendencies of the pathogen concentrations in each case; a higher pathogen concentration means a higher infection risk. increasing the ventilation rate is always desirable for the reduction of infection risk. figure 7 illustrates that installing partitions contributed to a reduced infection risk in the periphery (a) and a clear reduction in the average infection risk at the increased ventilation rate of 6 ach. however, the increased infection risk at the bed adjacent to the airborne pathogen generation source should not be neglected in the cases with partitions between the beds. estimated number of airborne pathogens and airborne infection risk at each monitoring point is demonstrated in appendix a. case 1 and 2 had the same ventilation rate of 3 ach, but the ventilation system inlet and outlet locations were switched to compare the consequent pathogen dispersion patterns. figure 8 shows the analysis results for cases 1 and 2 in plan (at 1.0 m height) and sectional (x3) views. figure 8a ,b are the analysis results, in plan and sectional views, respectively, for case 1, in which the air was supplied from the periphery and exhausted at the center of the room. figure 8c ,d show the results of a central air supply and peripheral exhaust, in other words, exhaust over the respiratory systems of patients, as in the conditions of case 2. white parts of figure 8b ,d are the bed and human body section. in terms of the pathogen concentration distribution, the pathogen normally dispersed towards the adjacent beds, in both cases 1 and 2. the concentration in the area near the bed of the patient who released the airborne pathogen was slightly higher in case 1, where the air was supplied from the periphery (region a) that was above the patients' respiratory systems. the same pattern can be observed in figure 8a ,c, which show the sectional views. these figures show that, in both cases 1 and 2, the pathogen dispersed towards the beds on the opposite sides. the pathogen concentration at the hallway side was higher in case 1 than in case 2. it is therefore anticipated that the probability of infection for the people in the hallway and the patient on the other side would be greater in case 1 than in case 2. case 1 and 2 had the same ventilation rate of 3 ach, but the ventilation system inlet and outlet locations were switched to compare the consequent pathogen dispersion patterns. figure 8 shows the analysis results for cases 1 and 2 in plan (at 1.0 m height) and sectional (x3) views. figure 8a ,b are the analysis results, in plan and sectional views, respectively, for case 1, in which the air was supplied from the periphery and exhausted at the center of the room. figure 8c ,d show the results of a central air supply and peripheral exhaust, in other words, exhaust over the respiratory systems of patients, as in the conditions of case 2. white parts of figure 8b ,d are the bed and human body section. in terms of the pathogen concentration distribution, the pathogen normally dispersed towards the adjacent beds, in both cases 1 and 2. the concentration in the area near the bed of the patient who released the airborne pathogen was slightly higher in case 1, where the air was supplied from the periphery (region a) that was above the patients' respiratory systems. the same pattern can be observed in figure 8a ,c, which show the sectional views. these figures show that, in both cases 1 and 2, the pathogen dispersed towards the beds on the opposite sides. the pathogen concentration at the hallway side was higher in case 1 than in case 2. it is therefore anticipated that the probability of infection for the people in the hallway and the patient on the other side would be greater in case 1 than in case 2. cases 3 and 4 are the same as cases 1 and 2, respectively, except for the ventilation rate. the ventilation rates for cases 3 and 4 were increased to 6 ach. the analysis results for cases 3 and 4 are depicted in figure 9 . the concentrations of airborne pathogens in cases 3 and 4 were clearly lowered when the ventilation rate was 6 ach, as compared to 3 ach. in other words, pathogen control by increasing the ventilation rate would have a greater effect on the pathogen concentration than changing the ventilation inlet and outlet locations would. cases 3 and 4 are the same as cases 1 and 2, respectively, except for the ventilation rate. the ventilation rates for cases 3 and 4 were increased to 6 ach. the analysis results for cases 3 and 4 are depicted in figure 9 . the concentrations of airborne pathogens in cases 3 and 4 were clearly lowered when the ventilation rate was 6 ach, as compared to 3 ach. in other words, pathogen control by increasing the ventilation rate would have a greater effect on the pathogen concentration than changing the ventilation inlet and outlet locations would. cases 5 and 6 have the same ventilation conditions as cases 1 and 2, respectively, with partitions added between the beds. the upper and lower parts of these partitioning walls were fixed to the ceiling and the floor, thus spatially separating the pathogen source bed from the adjacent beds. the front side remained open. this partitioning format not only controlled the dispersion of airborne pathogens from the source bed to the neighboring beds but also limited the visual field of the medical personnel. figure 10a ,c show, in plan view, the pathogen dispersion for the conditions of changing the inlet locations at the ventilation rate of 3 ach. in case 5, the air was supplied over the patient's respiratory system (region a), and the air supply pattern in sectional view was as shown in figure 10b . the pathogen concentration for case 5 in plan view is shown in figure 10a . in case 6, the air was supplied from the hallway side (region b), resulting in concentrations in sectional view as shown in figure 10d , and plan view as shown in figure 10c . considering figure 10 , it is evident that the partition delayed the airborne pathogen dispersion to the adjacent beds. when the ventilation system inlets were installed over the patients' respiratory systems (region a), the airflow into the inlet acted like an air-curtain and prevented the airborne pathogen dispersion from the emitting source to other places, and the outlet at the hallway provided a secondary barrier (case 5). interestingly, in case 6, with a 3 ach ventilation rate, the airborne pathogens were not sufficiently exhausted at the outlet above the patients' respiratory organs. the rest of the airborne pathogen moved to the hallway, and the airflow from the inlet installed in the hallway accelerated the dispersion of the airborne pathogen to the adjacent beds. as a result of these dispersion patterns, installing partitions caused airborne pathogen concentration to increase at x2 and x4. however, installing partitions contributed to a decrease in the airborne pathogen concentrations at x1 and x5. in case 6, the pathogen concentration in the pathogen source bed greatly increased compared to the other cases, which could increase the infection risk for medical staff working in the source bed area. cases 5 and 6 have the same ventilation conditions as cases 1 and 2, respectively, with partitions added between the beds. the upper and lower parts of these partitioning walls were fixed to the ceiling and the floor, thus spatially separating the pathogen source bed from the adjacent beds. the front side remained open. this partitioning format not only controlled the dispersion of airborne pathogens from the source bed to the neighboring beds but also limited the visual field of the medical personnel. figure 10a ,c show, in plan view, the pathogen dispersion for the conditions of changing the inlet locations at the ventilation rate of 3 ach. in case 5, the air was supplied over the patient's respiratory system (region a), and the air supply pattern in sectional view was as shown in figure 10b . the pathogen concentration for case 5 in plan view is shown in figure 10a . in case 6, the air was supplied from the hallway side (region b), resulting in concentrations in sectional view as shown in figure 10d , and plan view as shown in figure 10c . considering figure 10 , it is evident that the partition delayed the airborne pathogen dispersion to the adjacent beds. when the ventilation system inlets were installed over the patients' respiratory systems (region a), the airflow into the inlet acted like an air-curtain and prevented the airborne pathogen dispersion from the emitting source to other places, and the outlet at the hallway provided a secondary barrier (case 5). interestingly, in case 6, with a 3 ach ventilation rate, the airborne pathogens were not sufficiently exhausted at the outlet above the patients' respiratory organs. the rest of the airborne pathogen moved to the hallway, and the airflow from the inlet installed in the hallway accelerated the dispersion of the airborne pathogen to the adjacent beds. as a result of these dispersion patterns, installing partitions caused airborne pathogen concentration to increase at x2 and x4. however, installing partitions contributed to a decrease in the airborne pathogen concentrations at x1 and x5. in case 6, the pathogen concentration in the pathogen source bed greatly increased compared to the other cases, which could increase the infection risk for medical staff working in the source bed area. figure 11 shows the analysis result of the cases considering the conditions of installing partitions between the beds, changing the ventilation system inlet/outlet locations, and increasing the ventilation rate to 6 ach. the simulated results of cases 7 and 8 demonstrate that the increase in airborne pathogen concentration occurred mainly at x3. the increased ventilation ensures a solution for airborne infection prevention. the effects of installing partitions at a ventilation rate of 6 ach varied depending on the ventilation system's inlet and outlet locations. locating the inlets above the patients' respiratory organs still generated turbulence and increased the airborne pathogen concentration at the adjacent beds. the simulation results of case 8 clearly show that the increased ventilation rate of 6 ach and partition installation effectively reduced the airborne pathogen figure 11 shows the analysis result of the cases considering the conditions of installing partitions between the beds, changing the ventilation system inlet/outlet locations, and increasing the ventilation rate to 6 ach. figure 11 shows the analysis result of the cases considering the conditions of installing partitions between the beds, changing the ventilation system inlet/outlet locations, and increasing the ventilation rate to 6 ach. the simulated results of cases 7 and 8 demonstrate that the increase in airborne pathogen concentration occurred mainly at x3. the increased ventilation ensures a solution for airborne infection prevention. the effects of installing partitions at a ventilation rate of 6 ach varied depending on the ventilation system's inlet and outlet locations. locating the inlets above the patients' respiratory organs still generated turbulence and increased the airborne pathogen concentration at the adjacent beds. the simulation results of case 8 clearly show that the increased ventilation rate of 6 ach and partition installation effectively reduced the airborne pathogen the simulated results of cases 7 and 8 demonstrate that the increase in airborne pathogen concentration occurred mainly at x3. the increased ventilation ensures a solution for airborne infection prevention. the effects of installing partitions at a ventilation rate of 6 ach varied depending on the ventilation system's inlet and outlet locations. locating the inlets above the patients' respiratory organs still generated turbulence and increased the airborne pathogen concentration at the adjacent beds. the simulation results of case 8 clearly show that the increased ventilation rate of 6 ach and partition installation effectively reduced the airborne pathogen dispersion. however, the large increase in the pathogen concentration at the pathogen generation bed must be mitigated. the study focused on the effects of some potential solutions for preventing the spread of airborne pathogens in eds: changing the ventilation inlet/outlet locations, installing partitions, and increasing the ventilation rate. in terms of ventilating the ed, supplying the air from the center (region b) and exhausting over the patients' respiratory systems (region a) helped prevent dispersion of the airborne pathogen when partitions were not present. changing the ventilation inlet and outlet locations in conditions of low ventilation rate and partition installation could cause the undesirable dispersion of the airborne pathogen (case 6). installing the outlet of the ventilation system over the patients' respiratory systems was found to greatly increase the pathogen concentrations around the airborne pathogen source. yang et al. (2017) analyzed by cfd, it was said that setting the parallel bed layout and the exhaust port near the patient's head will lower the probability of air infection in the isolating room [20] . hospital managers should be considered the placement of beds and the direction of airflow to reduce airborne infections. ordinary breathing generates lots of bio-aerosol (1 µm or smaller) that can be transferred via air [21] [22] [23] . thus, it is concluded that switching the ventilation inlet/outlet locations presents a high risk of increasing the probability of infection for medical staff providing medical treatments, such as endotracheal intubation [24, 25] and nebulizing [26] , to patients. installing partitions between the beds generally offered the advantage of reducing the average concentrations of pathogens in the ed (cases 5, 7, and 8). however, it also had the shortcoming of increasing the pathogen concentration at the beds opposite and adjacent to the pathogen-source bed. these results suggest that patients who are at high risk of airborne infections may be able to provide appropriate patient placement in the ed. physical blocks primarily prevent the spread of airborne pathogen between the emergency beds [9] . according to the cfd analysis, hospital curtains were presented in a simple and effective way for the spread of infection [27] . thus, the airborne pathogens tend to accumulate around the source. increased ventilation should, therefore, accompany partition installation in the ed. it should be 6 ach recommended by who rather than korean ventilation's criteria. increasing ventilation rate requires additional hvac system installation and surplus energy consumption. natural ventilation or hybrid ventilation method may be implemented to reduce energy consumption. however, natural ventilation has limitation or disadvantage regarding airflow control, heat recovery, outdoor contaminants incoming [28] , difficulty in securing sufficient and consistent ventilation rate by season changing [29, 30] . to reduce energy consumption, partial fan assisted natural ventilation with appropriate filtering system, dedicated outdoor air system (intermediate season) and heat recovery system (heating season) in hvac system can be good solutions. most hospitals use partitions, but each hospital has a different material. future research of the effect of airborne infection of the partition is also necessary. future research needs to investigate the influence of airborne infection depending on the material, installation structure and usage method of the partition. the south korean government tries to enhance the quality of ed facilities in major hospitals to prevent airborne pathogen infections. however, the korean building code still does not require the performance enhancement of small hospital and ed building equipment with respect to airborne infection prevention. this study provides the basis for design guidelines for airborne-infection prevention for small hospitals and eds. the limitation of this study did not take into account the various factors affecting the airflow, such as natural ventilations. future research needs to consider the airflow around the ceiling diffuser and approach the multidisciplinary research on hospital facilities and built environment will be conducted. our research investigated the effect of various architectural features in eds on indoor pathogen concentration distribution. the major variables considered were ventilation rate, installation of partition walls between beds, and changing ventilation inlet/outlet locations. the overall analysis is summarized as follows. (1) the most effective method for controlling airborne pathogen dispersion is increasing the ventilation rate. (2) changing the ventilation inlet/outlet locations generally results in good prevention of airborne pathogen dispersion. however, it can also cause undesirable airborne pathogen dispersion in conditions with low ventilation rates and partitions (case 6). (3) installing partitions could contribute to decreasing the average airborne pathogen concentration (cases 5, 7 and 8). however, it was also observed that the partitions could increase the pathogen concentrations in the beds opposite and adjacent to the pathogen source. increasing the ventilation rate can enhance the effect of installing partitions. (4) in the analysis, the most effective method for pathogen control was to use all the methods studied: increasing the ventilation rate, installing partitions, and positioning the ventilation system outlets over the patients' respiratory organs (region a). further research will be conducted to improve architectural techniques for preventing the dispersion of airborne pathogens. our research only analyzed the concentrations of the airborne pathogen; therefore, it has the limitation of not indicating the real probability of infection. in our future research, an analysis of the probability of infection by the airborne pathogen will be included. author contributions: chang heon cheong designed the research plan, performed the cfd simulation and drafted the manuscript. seonhye lee reviewed the results of the study relating to the hospital environment, airborne infection, and public health. all authors read and approved the final version of the manuscript. the authors declare no conflict of interest. emergency nurses' perception and performance of tuberculosis infection control measures influencing factors on the compliance about standard precautions among icu and er nurses press release for 278th regular session of the national assembly of korea guidelines for preventing the transmission of mycobacterium tuberculosis in health-care settings american institute of architects (aia). 1996-1997 guidelines for design and construction of hospitals and health care facilities isolation rooms: design, assessment, and upgrade hvac system and contamination control in hospital relating mers natural ventilation for infection control in health-care settings improvement of airborne infection prevention methods in emergency room by design case study korea centers for disease control & prevention. plan for extended installation of negative pressure units at nationally designated isolation hospitals cfd simulation of airborne pathogen transport due to human activities an advanced numerical model for the assessment of airborne transmission of influenza in bus microenvironments modelling the risk of airborne infectious disease using exhaled air risk of indoor airborne infection transmission estimated from carbon dioxide concentration airborne contagion and air hygiene spatial distribution of infection risk of sars transmission in a hospital ward influenza outbreak related to air travel review and comparison between the wells-riley and dose-response approaches to risk assessment of infectious respiratory diseases hvac filtration for controlling infectious airborne disease transmission in indoor environments: predicting risk reductions and operational costs simulation of the aii-room for preventing spread of the air-borne infection in hospital inhaling to mitigate exhaled bioaerosols the size distribution of droplets in the exhaled breath of healthy human subjects airborne infectious disease and the suppression of pulmonary bioaerosols compliance with nosocomial infection control and related factors among emergency room nurses the relationship between empowerment and performance of infection control by emergency department nurses evaluation of droplet dispersion during non-invasive ventilation, oxygen therapy, nebulizer treatment and chest physiotherapy in clinical practice: implications for management of pandemic influenza and other airborne infections reducing risk of airborne transmitted infection in hospitals by use of hospital curtains quantifying the impact of traffic-related air pollution on the indoor air quality of a naturally ventilated building assessment of natural ventilation potential for residential buildings across different climate zones in australia the effect of the london urban heat island on building summer cooling demand and night ventilation strategies key: cord-318336-hslnkv6p authors: ke, kai-yuan; lin, yong-jun; tan, yih-chi; pan, tsung-yi; tai, li-li; lee, ching-an title: enhancing local disaster management network through developing resilient community in new taipei city, taiwan date: 2020-07-24 journal: int j environ res public health doi: 10.3390/ijerph17155357 sha: doc_id: 318336 cord_uid: hslnkv6p large-scaled disaster events had increasingly occurred worldwide due to global and environmental change. evidently, disaster response cannot rely merely on the public force. in the golden hour of crisis, not only the individuals should learn to react, protect themselves, and try to help each other, but also the local school, enterprise, non-government organization (ngo), nonprofit organization (npo), and volunteer groups should collaborate to effectively deal with disaster events. new taipei city (ntpc), taiwan, was aware of the need for non-public force response and therefore developed the process of enhancing local disaster management networks through promoting the resilient community since 2009. the concept of a resilient community is to build community-based capacity for mitigation, preparedness, response, and recovery in an all-hazards manner. this study organized the ntpc experience and presented the standard operation procedure (sop) to promote the resilient community, key obstacles, maintenance mechanism, and the successful formulation of the local disaster management network. the performance of the promotion was evaluated through a questionnaire survey and found that participants affirmed the positive effect of building community capacity through the entire process. in general, the resilient community as the center of the local disaster management work is shown promising to holistically bridge the inner/outer resources and systematically respond to disaster events. global warming and environmental changes have led to more frequent and extreme weather events and resulted in disasters of a greater magnitude worldwide. serious disaster events accompanied by significant casualties repeatedly occurred, such as the 1995 great hanshin earthquake in japan, the 1999 chi-chi earthquake in taiwan, the 2004 indian ocean earthquake and tsunami, 2005 hurricane katrina in the usa, 2008 sichuan earthquake in china, 2009 typhoon morakot in taiwan, as well as 2011 tohoku earthquake and tsunami in japan. exposure of persons and assets in all countries has increased faster than vulnerability has decreased, thus generating new risks and a steady rise in disaster-related losses, especially at the local and community level. the impact could be short, medium, and long term and appears in terms of economic, social, health, cultural, and environmental aspects [1] . in the 1995 great hanshin earthquake, during the early stage, 34.9% of those in danger survived by themselves, 31.9% escaped with assistance by family members, 28.1% by neighbors/friends, and 2.6% by passerby [2] . only less than 1.7% of those in need of help were saved by the public in the 1995 great hanshin earthquake, during the early stage, 34.9% of those in danger survived by themselves, 31.9% escaped with assistance by family members, 28.1% by neighbors/friends, and 2.6% by passerby [2] . only less than 1.7% of those in need of help were saved by the public force. this investigation indicated that, in such a great-scaled disaster, public force usually could not timely reach all the affected areas. therefore, the community must be resilient enough to respond by themselves and help each other in the golden hour of crisis events. community resilience refers to the capacities and capabilities of a human community to "prevent, withstand, or mitigate" any traumatic event [3] . to strengthen community resilience, not only the residents but also neighboring stakeholders, no matter the public sector or private sector, units, or individuals, should join together to form a local disaster management network. it is not easy for the community to organize such a network by itself; hence, the government must invest funding and resources to accomplish this goal. many studies have shown that to deal with disasters, whether pre-disaster [4, 5] , in-disaster [6] , or post-disaster [7] , awareness raising [8] and capacity building [9] are of significant importance, especially at the community level. this study aims to present how new taipei city (ntpc) government, taiwan, integrated the resources at the local government level and enhance the local disaster management by building a significant amount of resilient community, and begins with why the promotion of resilient community is necessary and how the promotion links to the local disaster management network. the performance is assessed through a questionnaire survey. two successful cases of community operation are introduced. from the ntpc government's angle, its experience from nowhere to somewhere is investigated and key obstacles, as well as solutions, are finally identified. new taipei city, taiwan, covers an area of 2053 km 2 with a population of 4 million. there are 29 districts and 1032 villages under ntpc authority. districts can be categorized into 3 types, i.e., 8 in the urban areas, 15 in the rural areas, and 6 in urban-rural areas. geologically, ntpc is extremely vulnerable to earthquakes due to the direct pass-through of active shanchiao fault from the southwest to the north-east. from a topographical perspective, 88% of ntpc is the mountainous area (partly covered by tatun volcano), and the entire coastline is 126 km long, which means ntpc is prone to geohazards such as debris flows, landslides, volcano eruptions, and tsunamis. flooding is another disaster event happening frequently due to annual typhoon and torrential rain. furthermore, two nuclear power plants are situated in ntpc, implying possible nuclear hazards ( figure 1 ). according to the report by the national fire agency, ministry of interior, taiwan [10] , a total of 42,308 (partly) collapsed buildings, 20,843 casualties, and 87,949 citizens in need of shelter are likely to happen if a large earthquake of scale 6.6 occurred in the center of taipei basin. with such kind of catastrophic damage, the public force is unlikely to give support for all affected areas fully and timely. more assistance from private sectors or citizens is necessary, especially those in or nearby the disaster hotspots. ntpc's disaster management system can be divided into three levels, i.e., local government, district office, and community, from the top down. ntpc government was aware of the complex and hazard-prone environment, as well as the abovementioned potential damage which cannot rely on merely the government's capacity. therefore, the government thought of enhancing the local disaster management network through matching cooperation between the local units and individuals. to do so, the promotion of the resilient community was considered as the cornerstone. seven standardized steps were taken to develop a resilient community in ntpc as follows [11] . stakeholders in the resilient community include the public sector, community residents, and at least one expert in the disaster management field. to coordinate the resilient community promotion, the start-up meeting is hosted. in the meeting, it is vital to make sure the key person in the community, usually the village chief or community committee chairman, understands the benefit of the resilient community and has the willingness to cooperate in the future activities to be hosted. to encourage community participation, it is necessary to arouse public interest through the activation workshop in which the invited expert would give the lecture on the resilient community. because not all the community had experienced a serious disaster event, the lecture material usually includes not only the concept of the resilient community but also some case studies about disaster scenarios and associated casualties in taiwan or worldwide. successful cases of resilient community operation were also delivered to construct the vision and inspire the residents' participation in future activities. all lecture materials are prepared for the layperson rather than for an expert in order to ensure the lecturer and participants are on the same page. there has to be a broader and more people-centered preventive approach to disaster risk. disaster risk reduction practices need to be multi-hazard and multi-sectoral, inclusive, and accessible to be efficient and effective [1] . therefore, community residents are invited to jointly investigate the environment. accompanied by experts, residents learn to identify potential/historical disaster hotspots and resources, such as shelter, convenience stores, and public facilities, useful for responding to the disaster event. after the site survey, all participants will furtherly discuss associated strategies through following 4 minor steps ( figure 2 ): sorting photo: during the site survey, photos are taken and printed. participants are asked to sort out the photos into two categories, i.e., disasters hotspot and resource points. mapping photo: those photos sorted in the previous step are pasted on the aero map with stickers near the photo. if the photo is a disaster hotspot, its condition, such as the location and cause/effect of the potential disaster is written down on the stickers; if the photo is a resource point, its function is described. strategy discussion: with possible disaster conditions and resource points at hand, the expert will help participants discuss strategies to deal with issues from the perspective of the individual, the community, and the local government level. for example, trash sometimes jams the gutter and causes flooding; therefore at the individual level, every resident should be made aware of not dropping trashes in the gutter; at the community level, residents should team up to clean the gutter regularly especially before the flooding season; at the local government level, district office can ask the cleaning contractors to dredge the cutter or provide the community with equipment needed to clean it. local enterprises and schools can be invited to discuss their role as outer resources to help the community respond to disasters. 4. experience sharing: the goal of this workshop is to finalize valid strategies mainly by the community; therefore, resident representatives are asked to report the discussed strategies to all the participants and try to reach consensus. aware of not dropping trashes in the gutter; at the community level, residents should team up to clean the gutter regularly especially before the flooding season; at the local government level, district office can ask the cleaning contractors to dredge the cutter or provide the community with equipment needed to clean it. local enterprises and schools can be invited to discuss their role as outer resources to help the community respond to disasters. 4. experience sharing: the goal of this workshop is to finalize valid strategies mainly by the community; therefore, resident representatives are asked to report the discussed strategies to all the participants and try to reach consensus. to efficiently carry out strategies in the previous step, the resilient community response team is organized. the typical structure of the response team is shown in figure 3 . it contains five divisions, namely, patrol, evacuation, rescue, medical, and logistics, with their general function as table 1 . the commander, usually the village chief or community committee chairman, supervises the deputy commander and executive secretary, as well as oversees outsourcing and leads the team. the deputy commander supervises the heads of every division and the executive secretary assists the commander and the deputy commander. to efficiently carry out strategies in the previous step, the resilient community response team is organized. the typical structure of the response team is shown in figure 3 . it contains five divisions, namely, patrol, evacuation, rescue, medical, and logistics, with their general function as table 1 . the commander, usually the village chief or community committee chairman, supervises the deputy commander and executive secretary, as well as oversees outsourcing and leads the team. the deputy commander supervises the heads of every division and the executive secretary assists the commander and the deputy commander. aware of not dropping trashes in the gutter; at the community level, residents should team up to clean the gutter regularly especially before the flooding season; at the local government level, district office can ask the cleaning contractors to dredge the cutter or provide the community with equipment needed to clean it. local enterprises and schools can be invited to discuss their role as outer resources to help the community respond to disasters. 4. experience sharing: the goal of this workshop is to finalize valid strategies mainly by the community; therefore, resident representatives are asked to report the discussed strategies to all the participants and try to reach consensus. to efficiently carry out strategies in the previous step, the resilient community response team is organized. the typical structure of the response team is shown in figure 3 . it contains five divisions, namely, patrol, evacuation, rescue, medical, and logistics, with their general function as table 1 . the commander, usually the village chief or community committee chairman, supervises the deputy commander and executive secretary, as well as oversees outsourcing and leads the team. the deputy commander supervises the heads of every division and the executive secretary assists the commander and the deputy commander. pre-disaster in-disaster and post-disaster patrol 1. understanding and periodically patrolling the disaster potential area and hotspot. eliminating disaster factors in advance, such as cleaning gutters. monitoring weather and patrolling disaster potential area. if a disaster condition is spotted, send messages to the community command center and make records. setting up a cordon around a disaster point and prevent from a passerby in. tabulating and periodically updating the vulnerable residents, such as elderly, incapable people and those living in disaster potential areas. planning evacuation route. making and periodically updating the evacuation map. reminding and assisting the residents, especially the vulnerable residents, to evacuate in an emergency. making sure the evacuation route is safe and not blocked. helping traffic control in vital traffic intersection and direct the evacuating people. maintaining existing equipment and assess the need for additional equipment based on disaster type and potential in the community. being familiar with the equipment operation through periodically training. keeping smooth telecommunication by preparing walkie-talkie. preparing the equipment and applying it in a small-scaled disaster event, such as putting out a small fire with a fire extinguisher or sawing a fallen tree into pieces and removing it to avoid traffic congestion. if residents were trapped due to serious events, trying to identify their location and asking support from the authority concerned. being proficient in first aid and caring skills 2. periodically training residents with those medical skills. preparing items for medical purposes, such as first-aid kit and stretcher. helping injuries in need of first aid. guide outside medical resources to people in need. helping local governments open shelters and prepare living supplies. mentally comforting the refugees scared by disasters. assessing the living material, such as drinking water, food, and medical needs, required during a disaster event. tabulating and periodically updating the community response team members. helping the local government maintain shelters. helping local governments open shelters and prepare living supplies. helping refugees register when they arrive at the shelters and distributing living supplies. supporting the other four response team divisions. based on the characteristics of the potential disaster, the community action plan is suggested to include but not limited to the following items. environmental and disaster risk assessment the environmental assessment should cover the location of the community, its neighboring geography, social condition, and historical disaster hotspots. the disaster risk assessment must include disaster type the community is facing and associated risk map drawing. the community usually has no capacity of drawing such kind of risk map; therefore, it is advised to utilize some government resources. in taiwan, the national science and technology center for disaster reduction (ncdr) developed the risk map platform (https://dmap.ncdr.nat.gov.tw/) for the public to have access to risk maps of earthquake, landslide, debris flow, flooding, tsunami, and nuclear event nationwide. community response team and local disaster management network the community response team is the frontline force to deal with the disaster. according to the experience of all resilient communities promoted by the ntpc government, the general functions of the team were organized as in table 1 . in addition to the community's strength, outer resources, such as district office, fire department, police department, school, enterprise, volunteers, ngo, and npo could be invited to formulate a local disaster management network and cooperate pre-disaster, in-disaster, and post-disaster. community resources mean the equipment such as pump, power generator, fire extinguisher, and power saw owned by the community or facility such as activity center, shelter, and community office managed by the community. however, those existent resources might not fully meet the need in terms of disaster response. the community should periodically update resources inventory and proactively assess the extra demand for resources to deal with the possible disaster. all the resources must have someone be appointed to manage. some of the duties could be assigned to the community response team member as a suggested division task in table 1 . after the resilient community is established, the top issue is that the community sometimes does not keep on its work due to not having a sustainable operation mechanism to follow. the standard sustainable operation mechanism for the resilient community in ntpc includes the following items: (1) regular training: it defines the courses and skill training to behold and its frequency; (2) community disaster management database update: it includes the response team member recruitment/retirement, vulnerable residents list update, and equipment maintenance frequency; (3) disaster processing record: the community should record the action taken pre-disaster, in-disaster, and post-disaster. it helps review the community action as well as identify defects and weak points of the plan. the community action plan was discussed and instituted by the residents and the community response team. stakeholders, such as the school, enterprise, or vulnerable individual/groups in the neighboring area, were welcome to join the discussion. the role of each stakeholder was be identified, e.g., community response team as helpers; residents and vulnerable individuals/groups as help receivers; enterprise as helpers and living material supplier; school as shelter accommodators. education and training aim to develop the knowledge and basic skills for community residents responding to disasters and specifically enhance the response team's capacity to execute their tasks. for the basic knowledge, the courses include disaster response concepts according to the community disaster characteristics. the required skills include basic first aid, such as cpr (cardiopulmonary resuscitation), heimlich maneuver, and aed (automated external defibrillator) and operation of equipment such as fire extinguishers, pumps, power saws, etc. this course is suggested to be hosted at least once per year. the community response team members could practice their tasks and skills through the war game or drill. war game helps test the validity of the action plan established in step 4, and the drill can further test the skills learned from step 5. in ntpc, not only the community response team but also stakeholders in the neighboring area, such as staff from the district office, the local fire department, school staffs, and enterprise partners are role players. table 2 is the typical scenario designed for an earthquake drill in ntpc. a few key principles are suggested as follows: 1. scenarios must correspond to community characteristics in terms of single disaster or complex disaster. 2. self-protection skills of individuals could be exercised, such as "drop", "cover", "hold on" during the earthquake. the disaster scale should be designed properly so that the community must and could react. if the scale is too small, then no significant damage will highlight the necessity for community response; if the scale is too large, most community members might lose their capability due to casualties resulting in malfunction of the team. every division in the community response team should have the chance to familiarize themselves with their tasks and required skills. coordination and communication among the response team, stakeholders, and public/private agencies should be tested. 6. the community should understand the evacuation routes to the shelter as well as arrange and test the transportation for evacuation. 7. collaboration between the district office and the community team to open the shelter should be exercised. scenario 1 self-protection, such as "drop", "cover", "hold on" exercise at the time of an earthquake. community response team mobilization and preparedness. preparedness for opening shelter by logistic division. the assistance of refugee evacuation to the shelter by evacuation division. patrol division surveys the area and calls for help from the rescue division upon locating damage. assistance by logistics division in shelter opening, such as registration, food sharing, and related operations. living supply may come from the enterprise. first-aiding the physically wounded people or caring for the traumatized people by medical division. rescue division puts out small-scaled fire induced by the earthquake scenario 9 recovering the environment by the entire response team and community residents. upon completion of resilient community development, posters and videos are made showing the annual activities and joint efforts achieved by the community, government, school, and enterprise. the community response team member share experiences with those from other communities/villages who have never joined the resilient community workshop. the purpose is to not only encourage the ongoing involvement in this developed resilient community but also inspire other villages' participation shortly. to evaluate the effect and performance of promoting a resilient community, an anonymous physical questionnaire survey was conducted after we finished each resilient community for that year. the participants were informed that participation was voluntary and the participants' willingness to return the completed questionnaire indicated their consent to participate in this study. eight key questions were asked as follows: q1: do you understand the disaster risk of your community after the workshop? q2: do you feel developing a resilient community and building capacity is necessary? q3: has your community built a feasible action plan after the workshop? q4: do you understand the tasks of the response team? q5: are you willing to become a member of the response team? q6: have you learned basic medical skills and been capable of performing it when necessary? q7: have you learned the fire-fighting skills and been capable of performing it when necessary? q8: is retraining necessary for the community? q1 and q2 checked if the participants were aware of the disaster risk and management; q3 checked if the community action plan was built and valid; q4 and q5 checked if the participants understood the tasks they should perform while they became response team members; q6 and q7 checked if basic skills were well taught; q8 checked the necessity of hosting retraining courses, and is linked to the maintenance mechanism in section 4.2. despite the eight key questions, only age and gender information were collected; therefore, no personal information of any specific individual could be exposed. table 3 shows the age distribution of respondents who joined the workshops hosted by the ntpc government in 2019. we kindly asked every participant to do the questionnaire for us right after the workshop; therefore, the response rate was 100%. from a total of 1180 participants, including 520 males and 660 females from 33 communities, more than 80% of them were over 50 years old, and more than 50% were over 60 years old. the aging population phenomenon is very common in rural areas of ntpc which are usually prone to high disaster risks. it implies that their mobility to react to disaster events is relatively low before the promotion of a resilient community. the questionnaire was designed to confirm the contribution of promotion, and results are shown in figure 4 . the survey has shown that, after 7-steps of promotion as described in section 2.2, 93% of the participants realize the risks they are facing and 91% agree with the necessity to develop a resilient community; 91% believe that the action plan we helped them build is feasible; 89% understand the tasks of the response team and 87% are willing to serve the community as a team member; 98% and 94% think that they had well learned and were ready to perform basic medical skills and fire-fighting, respectively; 95% also thinks retraining is important for the community. overall, about 90% of the participants' awareness was raised and the capacity to deal with community-based disaster events the survey has shown that, after 7-steps of promotion as described in section 2.2, 93% of the participants realize the risks they are facing and 91% agree with the necessity to develop a resilient community; 91% believe that the action plan we helped them build is feasible; 89% understand the tasks of the response team and 87% are willing to serve the community as a team member; 98% and 94% think that they had well learned and were ready to perform basic medical skills and fire-fighting, respectively; 95% also thinks retraining is important for the community. overall, about 90% of the participants' awareness was raised and the capacity to deal with community-based disaster events was established. it indicates the triumph of resilient community promotion and implies its contribution to the successful community operation introduced in the next section. two case studies are introduced to demonstrate how the established resilient community reacts pre-disaster, in-disaster, and post-disaster. those cases may not have been catastrophic events but showed how the community spontaneously mobilized after the training received through building community resilience. jiaqing village, an urban village located in zhonghe district, is the resilient community that started in 2019. this village was prone to flooding, earthquake, and fire. after the village was trained and the community response team was organized, it progressively operates whenever there is a typhoon coming ( figure 5 ). the village chief, as the response team commander will host a preparedness meeting and assign tasks for the team. the biggest concern is to prevent the low-lying area from flooding; therefore, team members were sent to the gutter and drainage outlet where garbage is easily accumulated. once waste was found stuck in the drainage system, the team notified the district cleaning contractor and cleaned the site together. occasionally, if the cleaning of the drainage system could not prevent the flooding from happening, the team recorded the situation for the village chief to discuss improvement measures thereafter. respectively; 95% also thinks retraining is important for the community. overall, about 90% of the participants' awareness was raised and the capacity to deal with community-based disaster events was established. it indicates the triumph of resilient community promotion and implies its contribution to the successful community operation introduced in the next section. two case studies are introduced to demonstrate how the established resilient community reacts pre-disaster, in-disaster, and post-disaster. those cases may not have been catastrophic events but showed how the community spontaneously mobilized after the training received through building community resilience. jiaqing village, an urban village located in zhonghe district, is the resilient community that started in 2019. this village was prone to flooding, earthquake, and fire. after the village was trained and the community response team was organized, it progressively operates whenever there is a typhoon coming ( figure 5 ). the village chief, as the response team commander will host a preparedness meeting and assign tasks for the team. the biggest concern is to prevent the low-lying area from flooding; therefore, team members were sent to the gutter and drainage outlet where garbage is easily accumulated. once waste was found stuck in the drainage system, the team notified the district cleaning contractor and cleaned the site together. occasionally, if the cleaning of the drainage system could not prevent the flooding from happening, the team recorded the situation for the village chief to discuss improvement measures thereafter. baiyun village, a mountainous village located in xizhi district, is a resilient community stated in 2016. after six months of solid training and immediately after the community drill was performed on 8 october 2016, a landslide event occurred due to typhoon aere in the early morning of 9 october. the village chief, jun-di chen, immediately assembled the community response team as well as reported the situation to the xizhi district office and ntpc fire department as soon as he was notified by the residents who spotted the event. eight team members were called in and approached baiyun village, a mountainous village located in xizhi district, is a resilient community stated in 2016. after six months of solid training and immediately after the community drill was performed on 8 october 2016, a landslide event occurred due to typhoon aere in the early morning of 9 october. the village chief, jun-di chen, immediately assembled the community response team as well as reported the situation to the xizhi district office and ntpc fire department as soon as he was notified by the residents who spotted the event. eight team members were called in and approached the disaster site to evacuate people by knocking on doors one after another. once the government forces arrived and took over the frontline, the community response team helped set up the cordon to prevent residents from entering the disaster site. the team also helped the public force establish the command post in the nearby area to monitor disaster development and timely response. finally, when the situation was under control, the response team moved to the shelters and took care of the residents who had evacuated earlier. in total, 34 people took shelter in the baiyun activity center with no casualties reported. the resilient community developed in ntpc has by far been running for three phases as follows. most problems were identified in phase 1 and solutions were given accordingly in phases 2 and 3. ntpc has launched the resilient community since 2009. until 2015, only 13 resilient communities were developed by a few ntpc departments. the speed of promotion is quite slow because the nptc government was unfamiliar with the concept of the resilient community and need help from certain universities who have associated expertise and enough manpower to host the workshops and activities described in section 2.2. during the first phase, key factors impeding the promotion were identified as follows: in general, residents usually lack the willingness to participate in the resilient community workshop from the beginning due to three reasons. first of all, they think that if no serious disaster happened before then why would there be one in the future. next, there is already some structural protection in the community such as the dike or pumping stations/machines to prevent flooding and the retaining wall to prevent from hillslope disaster. they feel quite safe with those protection measures. finally, even if a disaster indeed happened, the government would come and help because the government must save the citizens. there are varying conditions in different communities. the community is usually prone to hillside disaster and debris flow in the rural area especially in the mountainous area; prone to earthquake and fire in the urban area especially with densely distributed old buildings; and prone to flooding in the low-lying area. therefore, there is no "one size fits all" approach for community resilience building [12] . although the goal of the resilient community is building capacity for it, the ntpc government specifically asks the public sector such as district office and local fire department corps and branch to progressively join associated activities. therefore, a great amount of time and involvement from the community and public sectors is required. it usually takes a minimum of 3-6 months to develop a base-type resilient community and up to 2 years to finish the complete-type resilient community. the minimum requirement for a base-type resilient community is to raise the residents' awareness and train their basic skills. for the complete-type resilient community, the 7 steps in section 2.2 should be strictly followed and their performance tracked to ensure a fully built capacity. it would cost 10,000 to 13,000 usd to hire the expert/team to finish one complete-type resilient community. there are 1032 villages in ntpc, and the total expense would exceed 10 million usd for all. the different authorities concerned are entitled to deal with different disaster types. for example, in ntpc, the water resources department and the agriculture department promote resilient communities prone to flooding and debris flow, respectively. it is not be a problem if the community has only a single disaster type. however, it is very common that the community has more than one disaster potential. more than one department can invest in the same community if they wanted to, resulting in the duplicate investment and waste of government resources, furthermore, harming the government's general interest. one other issue is that every department in the local government is a subordinate agency of certain authority in the central government which institute the policy to promote the resilient community. for example, the soil and water conservation bureau (swcb) under the council of agriculture supervises the agriculture department in ntpc. they focus only on debris flow and train the residents accordingly. on the other hand, the water resources agency supervises the water resources department in ntpc to build flood-proof capacity for the community. as a result, not all communities receive the same training and build the all-hazards response code. the abovementioned four obstacles account for the "integrated resilient community program" launched by the ntpc government in phase 2 and the necessity of establishing a maintenance mechanism, as shown in the following section. the different authorities concerned are entitled to deal with different disaster types. for example, in ntpc, the water resources department and the agriculture department promote resilient communities prone to flooding and debris flow, respectively. it is not be a problem if the community has only a single disaster type. however, it is very common that the community has more than one disaster potential. more than one department can invest in the same community if they wanted to, resulting in the duplicate investment and waste of government resources, furthermore, harming the government's general interest. one other issue is that every department in the local government is a subordinate agency of certain authority in the central government which institute the policy to promote the resilient community. for example, the soil and water conservation bureau (swcb) under the council of agriculture supervises the agriculture department in ntpc. they focus only on debris flow and train the residents accordingly. on the other hand, the water resources agency supervises the water resources department in ntpc to build flood-proof capacity for the community. as a result, not all communities receive the same training and build the all-hazards response code. the abovementioned four obstacles account for the "integrated resilient community program" launched by the ntpc government in phase 2 and the necessity of establishing a maintenance mechanism, as shown in the following section. (figure 6 ). it ensures not only the optimal utilization of the local government's resources but also the consistent procedures for all departments to follow and promote resilient communities. in phase 2, the school played quite an important role in the local disaster management network. the ministry of education had initiated the campus safety program in 2003, and the focus was on building school internal capacity until 2010. after 2011, schools were asked to gradually cooperate with nearby villages and communities in the context of disaster management. school and district activity centers are two major facilities in taiwan to shelter the refugees in a disaster event. the community and school must work together while opening the shelter. besides, both of them could in phase 2, the school played quite an important role in the local disaster management network. the ministry of education had initiated the campus safety program in 2003, and the focus was on building school internal capacity until 2010. after 2011, schools were asked to gradually cooperate with nearby villages and communities in the context of disaster management. school and district activity centers are two major facilities in taiwan to shelter the refugees in a disaster event. the community and school must work together while opening the shelter. besides, both of them could collaborate in medical service, mental caring, patrolling disaster hotspots, and dealing with small-scaled disaster events if needed. such cooperation is practically valid because most students, even teachers, are from a neighboring community and therefore a tight bonding already exists. the only movement needed to enhance the link and push forward is asking both parties to attend the resilient community workshop and discuss the terms of cooperation in the context of the local disaster management network. schools, especially at the university level, can also help build resilience capacity for the community [13] . in phases 1 and 2, all of the resilient communities were promoted by the local government's departments with help from certain universities. however, building community capacity to deal with disasters is the legal duty of the district office in taiwan. to help the district office learn and promote the resilient community by itself, the community consultant team was organized by the ntpc government in 2018. it hires experts specialized in community disaster management to train the district offices to promote the resilient community through the seven-step process. besides, the resources from enterprises were specifically introduced to the community in phase 3. as is well known, the key to successful enterprise disaster management is the development of business continuity planning (bcp). however, bcp functions more internally than externally. it means, with bcp, the enterprise knows how to deal with disaster by itself whether in terms of mitigation, preparedness, response, or recovery. what the ntpc government tries to achieve is to develop a cohesive local disaster management network that involves the collaboration of community, public sector, schools, and enterprises. the enterprise is the last piece to complete such a network. not all enterprises are suitable to join the network. the enterprise must meet three ntpc criteria such as positive image, enough scale, and high willingness. the ntpc government or district office will sign the mou with the enterprise after it is chosen. to build tighter bonding among stakeholders, the enterprise is invited to join the resilient community activity and discuss cooperation or action plan as mentioned in section 2.2.4. other than direct financial support to the community or public sector, there are various ways in which the enterprise can play a role in the local disaster management network. for example, the mitsui outlet park in linkou joined the drill hosted by the linkou district office and provided hot meals and medicines for nearby communities; yulon group, well known for its yulon motor co., ltd. offered xindian district office vehicles to evacuate community refugees. through helping the local government and community, the enterprise can not only fulfill corporate social responsibility (csr) but also enhance its image from the public sector's media propaganda. the maintenance of the resilient community is usually harder than its development; therefore, it is suggested to employed four measures as the ntpc government did and keep the heat on. retraining is vital as shown by the questionnaire survey (q8). various courses could be chosen from the following depending on the community's needs. tasks review of the community response team: new members will join the community response team now and then. it is of great importance to make sure each member, whether senior or newcomer, knows his/her task well. collection and reporting of disaster information: with the popularization of smartphones, more apps are available for collecting disaster information and uploading it to the cloud platform. the community should learn which technical tool is more suitable to the community and how it functions. all disaster information collected could be reserved in a community database for future review. advanced disaster response skills: basic skills such as cpr, heimlich maneuver, and fire extinguisher operation were taught while developing a resilient community. advanced skills, such as patient moving, escape from the fire scene, and responding with the tool at hand (e.g., making slippers with old newspapers; making simple toilets with paper box and plastic bag) are suggested in the retraining courses. considering the covid-19 pandemic in 2020, epidemic prevention is also suggested to be included in the retraining. thereby, every trainee could be a community watcher and help spread epidemic prevention knowledge and support the government's action if necessary. the selection of skills is not limited to specific disaster types that the community is most likely to confront. the advanced skill training aims to make the community function in an all-hazards response manner. 4. war game: every disaster management action plan should be periodically reviewed and tested. at the community level, war game is a less costing and less time-consuming way to validate the plan compared to drill. however, the design of a proper war game is still not easy for the community. they should deeply consider the potential risk and transform it into disaster scenarios for strategy discussion. they will also have to manage inner resources and seek additional outer resources. usually, inviting experts or public sector personnel to join the war game would help the community deliver more insightful outcomes. skills training and raising awareness are compulsory for community residents to increase their chance of survival in the catastrophic disaster event. with the right tools and equipment, the core function of self-help and mutual help could be even more effective. the ntpc government supports certain funding for the community to purchase equipment upon the completion of a resilient community establishment. the community could buy the equipment according to a predefined list which includes evacuation bag, disaster prevention hood, helmet, first-aid kit, stretcher, walkie talkie, pumps, fire extinguisher, trolley, power saw, power generator, emergency ration, etc. the purchased equipment should be listed in the community action plan and be maintained regularly. the response team member must be trained to operate it. issuing the resilient community certificate to those progressively engaged in associated activities and who made solid achievements would raise the community's sense of honor and make it more likely to keep on the operation. ntpc government initiated the certificate application program in 2018. the community receives the ntpc certificate (figure 7) , and it proves the following criteria have been met: environmental risk assessment: the identification of disaster potential and associated strategies must be delivered. community disaster management database: including the identification of vulnerable people in the community, inventory of equipment, list of community residents with special skills and who can help respond to disaster, and contact list of outer resources such as police department, fire department, volunteer, school and enterprise. 3. community response team: including the head and crew of the five-response team divisions. it is batter if the enterprise and school can join as a support division. skill training: including basic skills introduced in section 2.2.5. drill: including the script with properly designed disaster scenarios and the actual role-playing of 5 team divisions. ideally, after the resilient community is established, it should consistently and spontaneously operate by itself; nevertheless, this is usually not the case in reality. without the government's supervision or expert's assistance, some communities fail to keep on with the work. to avoid it, the ntpc government designed a simple performance tracking table (table 4 ) and asks the community to fill it in whenever a disaster happens or is expected to come. the table is separated into 5 operation types, valid not only for operation during the disaster event but also for mitigation measures on normal days. the following are some suggested actions that the community can take. 1. mitigation: including routine education, skill training, drill/war game, environment patrol, disaster information; 2. preparedness: including hosting preparedness meeting, equipment inventory, real-time weather monitoring and early warning, checking vulnerable people's condition and need, patrolling areas prone to disasters, and shelter opening preparedness; 3. report in: once the disaster is spotted, reporting to the community and the authority concerned for timely response, as well as to associated private sectors such as water company or power company for assistance; 4. response: including dealing with disasters such as removing fallen trees, fire-fighting, identifying risk area and setting up cordon; evacuating people in the high-risk area; helping public sectors such as opening shelter, traffic control, and setting up command post; taking care of wounded by first-aid, caring for, and moving patients; 5. recovery: including environment cleaning, recovery, and rebuilding. ideally, after the resilient community is established, it should consistently and spontaneously operate by itself; nevertheless, this is usually not the case in reality. without the government's supervision or expert's assistance, some communities fail to keep on with the work. to avoid it, the ntpc government designed a simple performance tracking table (table 4 ) and asks the community to fill it in whenever a disaster happens or is expected to come. the table is separated into 5 operation types, valid not only for operation during the disaster event but also for mitigation measures on normal days. the following are some suggested actions that the community can take. checking the drainage fence the water level is normal in the drainage system near jiaqing bridge as shown in table 3 , the population is aging in ntpc rural areas. young people leave their hometown to seek more work opportunities, which leave the elders more vulnerable to disasters. the aging population is not a unique problem to taiwan. many developed countries, such as japan, italy, finland, portugal, and greece, have this kind of social problem. responding to disaster requires mobile manpower to execute the tasks as designated in table 1 . to have more young people engage as shown in table 3 , the population is aging in ntpc rural areas. young people leave their hometown to seek more work opportunities, which leave the elders more vulnerable to disasters. the aging population is not a unique problem to taiwan. many developed countries, such as japan, italy, finland, portugal, and greece, have this kind of social problem. responding to disaster requires mobile manpower to execute the tasks as designated in table 1 . to have more young people engage in community-based disaster management, the government should help improve the employment market in rural areas to attract young residents' return or stay. it also implies the inseparability of disaster-related and social-economic issues in the era of public engagement in disaster management. it takes a disaster to learn a lesson. however, most people never really suffer from a medium to large scale disaster, not to mention a catastrophic one. what is taught in the resilient community workshop is the concept of self-help and mutual-help, as well as basic response skills. we never know if the residents could apply the concepts and skills perfectly during a disaster event. therefore, the retraining courses should be hosted persistently. moreover, most of the public lacks the experience of dealing with post-disaster recovery. it is time for the community to participate in pre-disaster recovery planning with the government to envision the potential damage and associated recovery work. after the entire training of a resilient community, most residents recognize its necessity and are willing to continue running it. the only problem is where the funding support comes from for consistent operation. although the ntpc government offers the community certain equipment, it is usually not enough regarding the regular operation, emergency response, and administrative works. more funding contributions from public and private sectors shall be needed. the government should put more effort into matchmaking between the needs of the communities and the resources from enterprises. extracting from ntpc experience, this research has proposed the sop to promote the resilient community, identified the key obstacles, suggested the maintenance mechanism, and shown the successful formulation of the local disaster management network. the policy to deal with disaster in ntpc is the "top-down" guidance with "bottom-up" implementation. in this manner, responsibilities and initiatives could be well balanced between residents and the government [14] . the network involves the community, local government, district office, school, and enterprise. those network members are invited to join the workshops and associated training for collaborative learning and developing a viable joint action plan. therefore, it is expected that, during a major incident or disaster (mid), the resilient community, school and enterprise could all play a role when the local government requires flexible surge capacity (fsc). surge capacity (sc) means the ability to increase staff, stuff, structure, and system (4s) rapidly and effectively in the affected areas. fsc indicates the capability to scale up and down resources in a fast, smooth, and productive way [15] . the community could provide manpower to help local government in many ways such as, but not limited to, evacuating vulnerable people, opening shelters, managing living supplies/materials, and identifying disaster hotspots. with that assistance, the government could focus more on addressing hardest-hit areas and situations. since this study shows a promising non-structural method to enhance the local disaster management network, any country or government willing to intensify the capacity of disaster management at the community level could follow ntpc's steps and avoid the obstacles. mitigation: including routine education, skill training, drill/war game, environment patrol, disaster information; 2. preparedness: including hosting preparedness meeting, equipment inventory, real-time weather monitoring and early warning, checking vulnerable people's condition and need once the disaster is spotted, reporting to the community and the authority concerned for timely response, as well as to associated private sectors such as water company or power company for assistance response: including dealing with disasters such as removing fallen trees, fire-fighting, identifying risk area and setting up cordon; evacuating people in the high-risk area; helping public sectors such as opening shelter, traffic control, and setting up command post; taking care of wounded by first-aid, caring for recovery: including environment cleaning, recovery, and rebuilding. operation process note central weather bureau issued the land waring of typhoon mitag at 20:30 garbage accumulated at the drainage fence in lane 518, liancheng rd. was reported to the district office, and removed by the cleaning contractor no garbage spotted in the gutter along lane 456 the water level is normal in the drainage system near jiaqing bridge united nations office for disaster risk reduction (undrr, formally unisdr) japan association for fire science and engineering. fire investigation of southern earthquake in hyogo prefecture in 1995, japan community capitals as community resilience to climate change: conceptual connections community advantage and individual self-efficacy promote disaster preparedness: a multilevel model among persons with disabilities applying community resilience theory to engagement with residents facing cumulative environmental exposure risks: lessons from louisiana's industrial corridor analysis of the actions and motivations of a community during the 2017 torrential rains in northern kyushu building resilience during recovery: lessons from colorado's watershed resilience pilot program. environ. manag. 2020, 66, 15 are cities aware enough? a framework for developing city awareness to climate change a typology of community flood resilience ministry of the interior. assessment of the problem and preparedness of metropolitan taipei during a large scale earthquake new taipei city fire department. resilient community operation manual understanding the operational concept of a flood-resilient urban community in jakarta, indonesia, from the perspectives of disaster risk reduction, climate change adaptation, and development agencies a case study of university involvement in community-based reconstruction: in the coventry university model. community-based reconstruction of society bottom-up citizen initiatives as emergent actors in flood risk management: mapping roles, relations and limitations flexible surge capacity-public health, public education, and disaster management this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license acknowledgments: this research was supported by the ministry of science and technology (most), taiwan, through project most 108-2119-m002-015. the authors declare no conflicts of interest.int. j. environ. res. public health 2020, 17, 5357 garbage accumulated at the drainage fence in lane 518, liancheng rd. was reported to the district office, and removed by the cleaning contractor. no garbage spotted in the gutter along lane 456, liancheng rd. the water level is normal in the drainage system near jiaqing bridge. no flooding in the mrt construction site. the water level is normal in the drainage system near jiaqing bridge as shown in table 3 , the population is aging in ntpc rural areas. young people leave their hometown to seek more work opportunities, which leave the elders more vulnerable to disasters. the aging population is not a unique problem to taiwan. many developed countries, such as japan, italy, finland, portugal, and greece, have this kind of social problem. responding to disaster requires mobile manpower to execute the tasks as designated in table 1 as shown in table 3 , the population is aging in ntpc rural areas. young people leave their hometown to seek more work opportunities, which leave the elders more vulnerable to disasters. the aging population is not a unique problem to taiwan. many developed countries, such as japan, italy, finland, portugal, and greece, have this kind of social problem. responding to disaster requires mobile manpower to execute the tasks as designated in table 1 as shown in table 3 , the population is aging in ntpc rural areas. young people leave their hometown to seek more work opportunities, which leave the elders more vulnerable to disasters. the aging population is not a unique problem to taiwan. many developed countries, such as japan, italy, finland, portugal, and greece, have this kind of social problem. responding to disaster requires mobile manpower to execute the tasks as designated in table 1 key: cord-313591-hb3gqksg authors: pek, kalene; chew, justin; lim, jun pei; yew, suzanne; tan, cai ning; yeo, audrey; ding, yew yoong; lim, wee shiong title: social frailty is independently associated with mood, nutrition, physical performance, and physical activity: insights from a theory-guided approach date: 2020-06-14 journal: int j environ res public health doi: 10.3390/ijerph17124239 sha: doc_id: 313591 cord_uid: hb3gqksg notwithstanding the increasing body of evidence that links social determinants to health outcomes, social frailty is arguably the least explored among the various dimensions of frailty. using available items from previous studies to derive a social frailty scale as guided by the bunt social frailty theoretical framework, we aimed to examine the association of social frailty, independently of physical frailty, with salient outcomes of mood, nutrition, physical performance, physical activity, and life–space mobility. we studied 229 community-dwelling older adults (mean age 67.22 years; 72.6% females) who were non-frail (defined by the frail criteria). using exploratory factor analysis, the resultant 8-item social frailty scale (sfs-8) yielded a three-factor structure comprising social resources, social activities and financial resource, and social need fulfilment (score range: 0–8 points). social non-frailty (snf), social pre-frailty (spf), and social frailty (sf) were defined based on optimal cutoffs, with corresponding prevalence of 63.8%, 28.8%, and 7.4%, respectively. in logistic regression adjusted for significant covariates and physical frailty (modified fried criteria), there is an association of spf with poor physical performance and low physical activity (odds ratio, or range: 3.10 to 6.22), and sf with depressive symptoms, malnutrition risk, poor physical performance, and low physical activity (or range: 3.58 to 13.97) compared to snf. there was no significant association of spf or sf with life–space mobility. in summary, through a theory-guided approach, our study demonstrates the independent association of social frailty with a comprehensive range of intermediary health outcomes in more robust older adults. a holistic preventative approach to frailty should include upstream interventions that target social frailty to address social gradient and inequalities. frailty is characterized by a loss of physiological reserves, leading to increased vulnerability of the older adult with stressor events [1] . frailty is widely regarded as a multidimensional construct with physical, cognitive, psychological, and social components. among these dimensions, social frailty is arguably the least explored. given the complex interplay between the dimensions of frailty and increasing appreciation of the contribution of social factors to health outcomes [2] , it is not surprising that social frailty has been gaining recognition and traction in recent years. however, the study of social frailty has been far from straightforward, being often intertwined with contextual, societal, and cultural considerations. the field has been hampered by the lack of theoretical frameworks to guide the conceptualization of social frailty. using the theory of social production function (spf) [3, 4] , bunt et al. recently proposed a conceptual framework whereby social frailty is defined as a continuum of being at risk of losing, or having lost, social resources, general resources, and social activities or abilities that are important for fulfilling one or more basic social needs during the life span ( figure 1 ) [5] . subsequent to this, a systematic review studying the operationalization of the social component of frailty revealed only three exclusive social frailty tools out of 27 frailty instruments, and a weight of 5-43% for the social dimension in the other instruments [6] . although the concepts of social isolation, loneliness, social network, social support, and social participation were identified through this effort, the review did not propose an overarching theoretical framework of social frailty. subjective well-being ("positive affect" as a higher-level outcome of social need fulfilment) fulfilment of basic social needs such as sense of belonging, social cohesion, social loneliness*, social support*, emotional support, experience of warm, trusted relationships [5] . this figure, adapted from bunt's social frailty concept, shows the categories of 'general resources', 'social resources', and 'social behavior/activities' that lead to the 'fulfilment of basic social needs', which in turn lends a positive impact to subjective well-being when needs are met. examples of elements in the categories are included, some of which are included in this study. * denotes elements included in our analysis. within asia, where many societies are aging rapidly, social frailty is especially germane due to challenges such as changing structures and attitudes towards older members of the familial unit [7] , social participation, and environments. prior asian studies examining the impact of social frailty have done so using brief questionnaires of 5-7 items which are primarily modeled after the 5-item [5] . this figure, adapted from bunt's social frailty concept, shows the categories of 'general resources', 'social resources', and 'social behavior/activities' that lead to the 'fulfilment of basic social needs', which in turn lends a positive impact to subjective well-being when needs are met. examples of elements in the categories are included, some of which are included in this study. * denotes elements included in our analysis. within asia, where many societies are aging rapidly, social frailty is especially germane due to challenges such as changing structures and attitudes towards older members of the familial unit [7] , social participation, and environments. prior asian studies examining the impact of social frailty have done so using brief questionnaires of 5-7 items which are primarily modeled after the 5-item fried's frailty phenotype score. for instance, using a 5-item social frailty questionnaire, studies in japan and korea reported that social frailty increased the risk of disability and depressed mood, and was associated with cognitive and physical deficits in older adults [8] [9] [10] . similarly, social frailty measured using a 5-item scale was associated with subjective memory decline, cognitive impairment, depression, and physical functioning, and predicted mortality in china [11] . a singapore study utilized a 7-item index to demonstrate that social frailty increased the prevalence and incidence of functional disability, independently and when combined with physical frailty [12] . though these studies revealed significant associations with the measured outcomes, they were not premised on a conceptual framework of social frailty. the construct validity of the social frailty brief scales was also not delineated through empirical statistical techniques such as factor analysis. furthermore, these studies mainly comprised less robust community-dwelling older adults, such that the relationship between social and physical aspects of frailty may potentially be confounded. in addition, other salient outcomes such as nutrition, physical performance, physical activity, and life-space mobility were not studied. lastly, in asian societies where traditional family values are cherished, commensality (the act of eating together) is generally considered a form of social engagement during mealtimes, with family or friends. however, earlier asian studies did not include any item that pertained to 'eating alone' when examining the association of social frailty with adverse outcomes [13] . we therefore conducted this study to examine the independent association of social frailty with a comprehensive range of intermediary outcomes in a representative cohort of non-frail community-dwelling asian older adults. there are two parts to our study. firstly, using validated items identified from prior asian studies, we performed exploratory factor analysis (efa) to derive a social frailty scale grounded in bunt's proposed conceptual framework. next, using the empirically developed social frailty scale, we studied the association of social pre-frailty and social frailty, independently of physical frailty, with outcomes of mood, nutrition, physical performance, physical activity and life-space mobility. through this, we aim to anchor understanding of the impact of social frailty on pertinent outcomes in an asian setting from a theory-based framework. the "longitudinal assessment of biomarkers for characterization of early sarcopenia and osteosarcopenic obesity in predicting frailty and functional decline in community-dwelling asian older adults study" (gerilabs 2) is a prospective cohort study involving cognitively intact and functionally independent adults aged 50 years and older residing within the community. we recruited 230 participants from december 2017 to march 2019. in this cross-sectional analysis, one participant was excluded due to missing values in the data. the final sample comprised 229 participants who completed all baseline clinical assessments. participants were included if they were (i) aged 50 to 99 years at study enrolment, (ii) community-dwelling, (iii) independent in both activities of daily living (adls) and instrumental adls, and (iv) non-frail as defined by the frail criteria [14] . we excluded participants with a known history of dementia or evidence of cognitive impairment (modified chinese version of mini-mental state examination (cmmse) score ≤21) [15] ; who are unable to walk 8-m independently; and living in a sheltered or nursing home. all participants provided written informed consent for inclusion before they participated in the study. the study was conducted in accordance with the declaration of helsinki, and the protocol was approved by the domain specific review board of the national healthcare group (dsrb ref: 2017/00850). we collected demographic data and comorbid vascular risk factors. anthropometric measurements including standing height and body weight were measured to calculate body mass index, in addition to waist, mid-arm, and calf circumferences. cognitive performance was assessed using the modified chinese version of mini-mental state examination (cmmse). functional status was evaluated using barthel's basic activities of daily living (badl) index [16] and lawton and brody's instrumental adl (iadl) index [17] . physical frailty was assessed using the modified fried phenotypic criteria [18] . the modified fried criteria were operationalized as follows [19] : (1) body mass index less than 18.5; (2) handgrip strength <26 kg for men and <18 kg for women measured using a hydraulic hand dynamometer (north coast exacta™ hydraulic hand dynamometer; north coast medical, inc., morgan hill, ca, usa) [20] ; (3) usual gait speed <0.8 m/s on the 3-m walk test; (4) low physical activity defined using the pentile cutoff of ≤29 on the frenchay activities index [21] ; and (5) fatigue endorsed on either of two questions from the center for epidemiologic studies-depression scale (ces-d) modified to assess fatigue. the five items were added to yield a total score (range 0-5), which corresponded respectively to a status of robust (0), pre-frail (1-2), and frail (3-5). we performed a literature search on social frailty in asia for studies with social frailty scales published before november 2017, supplemented by a reference search of retrieved articles and recommendations from experts in the field. the items identified from these published asian studies were used in our analysis. altogether, nine items were identified, comprising five items from makizako et al. [8] and tsutsumimoto et al. [9] ; two items from tanaka et al. [13] ; and two items from teo et al. [12] . the combined 9-item social frailty questionnaire was administered, with equal weightage of one point assigned to each item: (1) "do you live alone?"; (2) "do you go out less frequently compared with last year?"; (3) "do you sometimes visit your friends?"; (4) "do you feel you are helpful to friends or family?"; (5) "do you talk with someone every day?"; (6) "do you turn to family or friends for advice?"; (7) "do you eat with someone at least one time in a day?"; (8) "do you have someone to confide in?"; and (9) "are you limited by your financial resources to pay for needed medical service?". from teo et al., questions demonstrating duplication such as infrequent contact and social activities were removed. similarly, demographic questions on education and housing type were removed and captured under clinical assessment. mood was assessed using the 15-item geriatric depression scale (gds), with a locally validated cutoff score of ≥4 to distinguish presence of depressive symptoms [22] . nutrition was measured with the mini nutritional assessment (mna), with a cutoff score of <24 indicating malnutrition risk [23] . other nutritional parameters assessed included the simplified nutritional appetite questionnaire (snaq) [24] , as well as vitamin d and albumin levels. physical performance was measured using the short physical performance battery (sppb), which comprised balance, gait speed, and chair stand tests; a cutoff of <10 denoted poor physical performance [25] . physical activity was derived from the international physical activity questionnaire (ipaq) [26] after converting responses to metabolic equivalent task (met) minutes per week. life-space mobility was measured using the life-space assessment (lsa) [27] comprising spatial areas, frequency, and level of independence required. there are five life-space levels, which represented activities outside the bedroom, home, neighborhood, town, and beyond respectively. to ascertain the factor structure of the combined 9-item social frailty questionnaire, we conducted exploratory factor analysis (efa) using the kaiser-meyer-olkin (kmo) statistic as a measure of sampling adequacy and the bartlett test of sphericity to ascertain necessity to perform a factor analysis. we performed principal component analysis with varimax rotation to ascertain the underlying factor structure. the number of factors to be retained was determined by parallel analysis, a more robust and accurate method of factor retention that was less likely to overestimate the number of factors [28] . we eliminated items with loadings <0.4. the retained factors were interpreted using bunt's conceptual framework. using the resultant factors and items in the social frailty questionnaire, we derive optimal cutoffs to categorize participants into three subgroups: social non-frailty, social pre-frailty, and social frailty. the cutoffs were empirically determined based on distribution to match the trend seen in earlier asian studies. we performed univariate analyses to compare baseline demographics, cognitive performance, functional and frailty status, and outcome measures of mood, nutrition, physical performance, physical activity, and life-space mobility across the three subgroups. we used a one-way analysis of variance with bonferroni correction for post-hoc comparison and kruskal-wallis test respectively for parametric and non-parametric continuous variables, and a chi-square test for categorical variables. to determine the independent association of social pre-frailty and social frailty to our pre-specified outcomes, we performed hierarchical logistic regression, adjusting for age, gender, variables which were significant on univariate analysis, and physical frailty (modified fried phenotypic criteria). due to low numbers in the frail category by fried scoring, we used the total score instead in the logistic regression model. cutoffs for gds, mna, and sppb were defined using validated cutoffs as described, while low physical activity and low life-space mobility were defined using the cohort quintile cutoffs of ipaq < 2826 mets and lsa < 76 respectively. in model 1, we adjusted for age, gender, and other significant variables. in model 2, we adjusted for physical frailty in addition to the variables in model 1. for comparison, we performed logistic regression with physical frailty as the independent variable adjusting for age, gender and significant variables ( figure 2 ). using the resultant factors and items in the social frailty questionnaire, we derive optimal cutoffs to categorize participants into three subgroups: social non-frailty, social pre-frailty, and social frailty. the cutoffs were empirically determined based on distribution to match the trend seen in earlier asian studies. we performed univariate analyses to compare baseline demographics, cognitive performance, functional and frailty status, and outcome measures of mood, nutrition, physical performance, physical activity, and life-space mobility across the three subgroups. we used a one-way analysis of variance with bonferroni correction for post-hoc comparison and kruskal-wallis test respectively for parametric and non-parametric continuous variables, and a chi-square test for categorical variables. to determine the independent association of social pre-frailty and social frailty to our prespecified outcomes, we performed hierarchical logistic regression, adjusting for age, gender, variables which were significant on univariate analysis, and physical frailty (modified fried phenotypic criteria). due to low numbers in the frail category by fried scoring, we used the total score instead in the logistic regression model. cutoffs for gds, mna, and sppb were defined using validated cutoffs as described, while low physical activity and low life-space mobility were defined using the cohort quintile cutoffs of ipaq < 2826 mets and lsa < 76 respectively. in model 1, we adjusted for age, gender, and other significant variables. in model 2, we adjusted for physical frailty in addition to the variables in model 1. for comparison, we performed logistic regression with physical frailty as the independent variable adjusting for age, gender and significant variables ( figure 2 ). statistical analyses were performed using ibm spss statistics version 23.0 (ibm corporation, armonk, ny, usa). all statistical tests were two-tailed, with p < 0.05 considered statistically significant. statistical analyses were performed using ibm spss statistics version 23.0 (ibm corporation, armonk, ny, usa). all statistical tests were two-tailed, with p < 0.05 considered statistically significant. we studied 229 participants with a mean age of 67.22 ± 7.43 years, of which 167 (72.6%) were females (table 1) . participants received a mean 10.73 ± 4.36 years of education, with the majority (71.2%) residing in public housing apartments. comorbidities include hypertension (35.8%), hyperlipidemia (56.8%), and type ii diabetes mellitus (14.4%). the high cognitive score (cmmse, mean ± sd: 26.12 ± 1.73) and functional status (badl and iadl had respective median scores of 100 and 23, corresponding to the maximum score) attested to the relatively robust health of the participants. there were 196 (85.6%) robust and 33 (14.4%) pre-frail participants identified using the frail criteria. based on the modified fried criteria, only two (0.9%) participants were physically frail, with 95 (41.5%) physically pre-frail and 132 (57.6%) robust. factor analysis was appropriate as the kmo statistic was 0.586, and the bartlett test of sphericity was 186 (p < 0.0001). we chose a three-factor solution, as per the optimal number recommended by parallel analysis, which accounted for 50.5% of total variance ( table 2 ). taking reference from bunt's conceptual framework, the first factor (22.4% of variance) had three items which represented social resources; the second factor (15.5% of variance) had three items corresponding to social activities and financial resource; and the third factor (12.6% of variance) with two items denoted social need fulfilment. the question "do you feel you are helpful to friends or family?" was eliminated due to its low loading of 0.490 and non-discriminatory nature of having only six (2.6%) participants endorsing this item. thus, there were eight items in the final version of the social frailty scale (sfs-8). the items were summed to yield a total score which was used to categorize participants into three subgroups of social non-frailty (snf; 0-1 point), social pre-frailty (spf; 2-3 points) and social frailty (sf; 4-8 points). using these cutoffs to categorize the subgroups, 146 (63.8%) of participants were classified as snf, 66 (28.8%) as spf, and 17 (7.4%) as sf, which is consistent with the distribution trend seen in previous asian studies [8, 9] . table 2 . exploratory factor analysis (efa; varimax rotation, three-factor extraction, loadings >0.400). mean ± sd 1 2 3 comparing baseline characteristics across the three subgroups (table 1) , age increased and was significantly higher in sf subgroup compared with snf. educational level decreased and was significantly lower in spf compared with snf. there was no significant difference in gender, housing type, and anthropometric measurements. among comorbidities, only hypertension was significantly different across the three subgroups. badl was significant lower in the sf subgroup but there was no significant difference in cmmse and iadl. modified fried score was also significantly higher in sf and spf subgroups compared with snf, corresponding to the higher proportion of physical pre-frailty and frailty observed in these two subgroups. for the 8-item social frailty scale (sfs-8), total score increased significantly across the three subgroups (p < 0.001), with the post-hoc analysis indicating significantly higher scores in sf subgroup compared with spf and snf, and spf compared with snf (table 3) . likewise, all factor scores were significantly different across the three subgroups (all p < 0.001), with significant post-hoc differences when comparing sf with both spf and snf, and spf compared with snf. across the three subgroups (table 4) , gds score was significantly higher comparing sf with both spf and snf, and spf with snf (snf 0 (interquartile range, iqr: 0-1.00) vs. spf 1.00 (iqr: 0-2.00) vs. sf 2.00 (iqr: 1.00-3.00), p < 0.001). for nutrition, mna, snaq, and albumin level were significant (all p < 0.05), with post-hoc analyses indicating significant differences between spf and snf for mna and albumin level. for physical performance, sppb, gait speed, 5-time repeated chair stand, and handgrip strength were all significant across the three subgroups (all p < 0.05). post-hoc comparisons showed the sf and spf groups performing significantly worse than snf in sppb and 5-time repeated chair stand. gait speed was significantly slower in sf compared to snf, while handgrip strength was significantly lower in spf when compared to snf. in terms of physical activity and life-space, ipaq was significantly different across the three subgroups (p = 0.001), with post-hoc comparisons revealing significantly lower activity in sf and spf compared to snf. life-space mobility was significantly lower for life-space levels 2 and 5, corresponding to being in areas outside one's home and places outside one's town (p = 0.026 and p = 0.006, respectively), with significant difference between spf and snf in post-hoc analyses. we performed logistic regression analyses to examine the independent association of social frailty with outcome measures (table 5 ). in model 1, adjusting for age, gender, education, hypertension and albumin, spf was significantly associated with poor physical performance measured by sppb (odds ratio, or = 7.66, 95% confidence interval, ci = 1.43-41.14) and low physical activity (or = 3.66, 95% ci = 1.67-8.02), whereas sf was significantly associated with low mood (or = 6.88, 95% ci = 1.23-38.66); malnutrition risk (or = 11.13, 95% ci = 1.91-64.97); poor physical performance (or = 17.51, 95% ci = 2.63-116.58); and low physical activity (or = 4.46, 95% ci = 1.37-14.54). there was no significant association with life-space. when additionally adjusted for physical frailty in model 2, the significant association with poor physical performance and low physical activity remained for spf (or range: 3.10 to 6.22), and with low mood, malnutrition risk, poor physical performance, and low physical activity for sf (or range: 3.58 to 13.97). we repeated logistic regression analyses to examine the association of physical frailty with outcome measures. physical frailty was significantly associated with malnutrition risk (or = 3.47, 95% ci = 1.33-9.05), low physical activity (or = 1.78, 95% ci = 1.04-3.07), and decreased life-space (or = 2.19, 95% ci = 1.26-3.81), but not with low mood or poor physical performance. in the present study, using a theory-guided social frailty scale that is grounded in the bunt conceptual framework, we build upon growing body of evidence about the paramount importance of social frailty by demonstrating the independent associations of spf and sf with mood, nutrition, physical performance, and physical activity in non-frail community-dwelling older adults. even after adjusting for physical frailty, both spf and sf were associated with poor physical performance and low physical activity, with sf also associated with low mood and malnutrition. this increase in odds from snf to sf attests to a dose-response relationship for these outcomes, lending credence to the validity of our findings. with the significant prevalence of spf and sf at 28.8% and 7.4%, respectively, in our cohort of non-frail older adults, the independent associations of social frailty with intermediary outcomes which precede the onset of frailty and disability corroborate the contributory role of social components towards increased vulnerability in older adults [6] and emphasize the importance of evaluating social dimensions as part of a comprehensive geriatric assessment. the theoretical framework and definition of social frailty proposed by bunt et al. [5] reinforced our approach in understanding this complex construct. from the initial 9-item questionnaire, we excluded the item "do you feel you are helpful to friends or family?" despite it being an element under bunt's 'general resources' category. the non-discriminatory response with this item may either represent under-reporting due to desirability bias or the lack of relevance of feeling helpful to friends or family in the overall construct of social frailty. the resultant sfs-8 items cohered to our three factors of 'social resources', 'social activities and financial resource', and 'social need fulfilment', which addressed the various components when mapped onto bunt's social frailty concept. interestingly, the items grouped under factor 2 ( table 2 ) may suggest a relationship between constraints on financial resources for medical services with social activities of going out and eating with someone. alluding further to bunt's 'general resources' category, the trends observed in baseline characteristics, such as education, housing, badl performance and cognitive performance moving from snf to sf subgroups, also support the known-group validity of the sfs-8 cutoffs used to define subgroups. while a recent study considered the bunt's social frailty conceptual model when using a 4-item social frailty assessment tool to evaluate the impact on incident disability and mortality [29] , it only had one item per bunt category and did not comprehensively delineate the components that underpin social frailty [5] . notwithstanding differences in countries and cultures, our study provides a starting point for a theory-driven approach with reference to asian evidence, in examining the impact of social frailty on salient outcomes in older adults. as far as we are aware, this is the first study to examine the association between social frailty and nutrition in older adults, illuminating the magnitude of its impact on malnutrition risk. previous studies examining the relationship between frailty and nutrition [30, 31] placed heavy emphasis only on the physical aspect of frailty. in addition, our results showing the association between social frailty and depressive symptoms paralleled similar findings from a previous study [11] . indeed, insights from these findings can explicate the potential protective role of commensality against social frailty. besides leading to depressive mood and enhancing feeling of loneliness [32] , eating alone among older adults can also result in lower food diversity [30] and poorer nutritional status [33] , due to the lack of social companionship during mealtimes [34] . in the communal dining culture of asia, commensality thus serves as an important avenue for socialization where older adults enjoy interactions and gain valuable opportunities for companionship [35, 36] . in our study, although the majority (88.6%) of participants lived with others, it is disconcerting that 24.5% constantly ate alone and 28.4% did not talk to others daily. the reasons for these findings are unclear and warrant further studies to ascertain if the prevalence of eating alone and decreased social interaction is even higher amongst less robust populations of community-dwelling older adults. as an antecedent to functional decline and/or disability, physical activity is considered an important interventional target in the prevention of frailty in older adults [37, 38] . building upon emerging evidence that social frailty is an important risk factor of physical deficits [9] and disability [12] that may lead to the subsequent development of physical frailty in non-frail older adults [39] , our results showing significant associations of both spf and sf with physical performance and physical activity mirrored this trend. although physical performance and physical activity have been reported to be independently associated with life-space mobility in older adults [40, 41] , we did not find a similar association of social frailty with life-space mobility. interestingly, in our non-frail cohort (defined by frail score), social frailty was associated with adverse outcomes even after adjustment for physical frailty (modified fried), and conferred increased odds for gds, mna, sppb, and ipaq. taken together, our results suggest the preeminence of social frailty in assessing the risk profile of adverse health outcomes in robust populations of older adults. notably, three of the outcomes (gds, mna, and sppb) associated with social frailty are components of the novel construct of intrinsic capacity, which emphasizes on the more positive attributes of reserves and residual capacities, as opposed to deficits and limitations accumulated with aging in frailty [42, 43] . thus, consistent with a life-course approach towards healthy aging, our results suggest the possible role of upstream community-based interventions to target the deleterious impact of social frailty in non-frail older adults, such as programs that promote social interaction, engagement in physical activities, and sharing of nutritious meals to build social capital and intrinsic reserves through social networking and community participation [44, 45] . future studies should further delineate the longitudinal relationship between social frailty and intrinsic capacity and whether social frailty may be the forme fruste of an underlying age-related or even pathological process. in addition, although social determinants of health are often the main driver of health inequalities within and between countries [46] , better recognition of these conditions together with frailty has been mooted [47] . indeed, studies have shown that not only objective measures of socioeconomic status such as education, employment, and income impacted on frailty trajectories [48] , lower subjective social status was also associated with a higher incidence of frailty in men [49] . the specific relationship with social frailty in these studies, however, remains unclear. the increased odds of adverse outcomes associated with social frailty as illuminated in our findings, coupled with many socioeconomic elements contributing towards social frailty as outlined in bunt's framework [5] , become especially pertinent during the current covid-19 climate. the pandemic has galvanized the world into unprecedented efforts of instituting physical distancing, such that social frailty can be amplified due to the secondary effects of social isolation in many older adults [50] . other examples of how pandemic control measures may exacerbate inequalities include the withdrawal of 'non-essential' services that provide support for older adults living alone or with cognitive impairment, or the inequitable access to digital tools to mitigate social isolation amongst older adults from lower socioeconomic background who may have lower digital literacy. further studies are therefore warranted to better understand and address the social gradient and inequalities that may aggravate the impact of social frailty. this study has several limitations. firstly, the cross-sectional analysis precludes definitive conclusions about causality as reverse causation cannot be excluded. a causal relationship should be elucidated in well-conducted prospective studies to examine the longitudinal impact of social frailty on salient outcomes. secondly, our study comprised predominantly chinese older adult participants who were robust and higher functioning. thus, our findings may not be generalizable to non-chinese asian settings with more frail older adults. thirdly, we recognize that bunt's social frailty model supported a further understanding into self-management abilities by which one gains or maintains resources which are necessary for social need fulfilment and its higher-level outcome of subjective wellbeing, both of which were not examined in this study. finally, we utilized questionnaire items from previous asian studies to operationalize social frailty. 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determinants of health frailty, inequality and resilience impact of socioeconomic position on frailty trajectories in 10 european countries: evidence from the survey of health, ageing and retirement in europe socioeconomic inequalities in frailty in hong kong, china: a 14-year longitudinal cohort study meeting the care needs of older adults isolated at home during the covid-19 pandemic we would like to thank all participants who contributed to this study. the authors declare no conflict of interest. the funder had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-350059-c25md0vm authors: delgado, diego; wyss quintana, fernando; perez, gonzalo; sosa liprandi, alvaro; ponte-negretti, carlos; mendoza, ivan; baranchuk, adrian title: personal safety during the covid-19 pandemic: realities and perspectives of healthcare workers in latin america † date: 2020-04-18 journal: int j environ res public health doi: 10.3390/ijerph17082798 sha: doc_id: 350059 cord_uid: c25md0vm healthcare workers exposed to coronavirus (covid-19) may not have adequate access to personal protective equipment (ppe), safety procedures, and diagnostic protocols. our objective was to evaluate the reality and perceptions about personal safety among healthcare workers in latin america. this is a cross-sectional, online survey-based study administered to 936 healthcare professionals in latin america from 31 march 2020 to 4 april 2020. a 12-item structured questionnaire was developed. a total of 936 healthcare workers completed the online survey. of them, 899 (95.1%) were physicians, 28 (2.9%) were nurses, and 18 (1.9%) were allied health professionals. access to protective equipment was as follows: gel hand sanitizer (n = 889; 95%), disposable gloves (n = 853; 91.1%), disposable gowns (n = 630; 67.3%), disposable surgical masks (785; 83.9%), n95 masks (n = 516; 56.1%), and facial protective shields (n = 305; 32.6%). the vast majority (n = 707; 75.5%) had access to personal safety policies and procedures, and 699 (74.7%) participants had access to diagnostic algorithms. on a 1-to-10 likert scale, the participants expressed limited human resources support (4.92 ± 0.2; mean ± sd), physical integrity protection in the workplace (5.5 ± 0.1; mean ± sd), and support from public health authorities (5.01 ± 0.12; mean ± sd). healthcare workers in latin america had limited access to essential ppe and support from healthcare authorities during the covid-19 pandemic. the coronavirus (covid-19) outbreak has fundamentally changed the world and, consequently, is changing the reality of healthcare workers. this pandemic is creating profound changes in governments, the global economy, and healthcare systems. based on current evidence, the covid-19 virus is transmitted between people through close contact and droplets [1] . the people most at risk of infection are those who are in close contact with a covid-19 patient or who care for covid-19 patients. healthcare workers are at significant risk of acquiring the infection; therefore, they are required to protect themselves and prevent transmission in the healthcare setting. precautions to be implemented by healthcare workers caring for patients with covid-19 include using appropriate personal protective equipment (ppe). the world health organization (who) and other national and international public health authorities recommend implementing safety protocols for healthcare workers [2] . however, basic protective equipment and safety protocols are not always available in many medical institutions dealing with covid-19 patients. many medical institutions around the world do not have access to an appropriate number of human resources and diagnostic/therapeutic protocols to care for admitted and ambulatory patients suffering from covid-19. according to the pan american health organization (paho) and the who, the number of confirmed cases in latin america is 26,486, and the number of deaths is 858 as of april 4, 2020 [3] . unfortunately, there is a significant discrepancy in regards to access to ppe, human resources, and healthcare policies in countries in the region of the americas. the speed with which covid-19 is spreading across the word calls for an assessment of the reality of healthcare workers exposed to covid-19 patients. the purpose of this study was to evaluate the reality and perceptions about personal safety among healthcare workers practicing in countries of latin america during the current covid-19 outbreak. this is a cross-sectional, online survey-based study administered to healthcare professionals in latin america. a 12-item questionnaire was developed and distributed using google forms. participants were recruited through social networking websites and applications (twitter, instagram, facebook, linkedin, and whatsapp) and from an existing database of the inter-american society of cardiology (iasc). the questionnaire was conducted from 31 march 2020 and until 4 april 2020. the survey was delivered in spanish, as the targeted study participants were in spanish-speaking countries of latin america. participants were able to complete the survey only once and were allowed to terminate the survey at any time they desired. the survey was anonymous and confidential. an introductory paragraph outlining the purpose of the study was posted along with the survey. the survey was prepared by members of the covid-19 working group of iasc. a 12-item structured questionnaire was developed to evaluate participants' reality and perceptions regarding personal safety. the study questionnaire comprised four sections. section 1 had five items that collected demographic information of the responders. this included age by segments (18-14, 25-35, 36-45, 46-55, >55 years), sex (male or female), occupation (physician, nurse, other healthcare professional), type of practice (hospital, private, or both), and geographic location. section 2 comprised four items and was designed to evaluate access to ppe (gel hand sanitizer, disposable gloves, disposable gowns, disposable masks, n95 masks, facial protective shields), access to personal safety policies and procedures (yes or no), access to covid-19 diagnostic and treatment algorithms (yes or no), access to telemedicine to evaluate and follow up with patients (yes or no), and institutional support with human resources in case healthcare workers are sick (10-point likert scale; 0 = no resources, 10 = full access to resources). section 3 comprised two items designed to evaluate participants' perceptions about their medical institutions taking all necessary measurements to protect physical integrity in the workplace (10-point likert scale; 0 = no support, 10 = full support) and participants' perceptions regarding their local public health authorities taking all necessary measurements to protect physical integrity in the workplace (10-point likert scale; 0 = no support, 10 = full support). descriptive statistics, frequencies, and percentages were used to summarize data. a total of 936 healthcare workers completed the online survey. of them, 890 (95.1%) were physicians, 28 (2.9%) were nurses, and 18 (1.9%) were professionals in other healthcare disciplines. the responders' medical specialties were not reported in this survey. most participants were men (n = 674; 72%), were aged 36-45 (n = 281; 30%), and worked in both hospital-based and private practice (n = 448; 47.9%) ( table 1 ). figure 1 shows the distribution of the participants by geographic location. participants indicated that they had access to the following essential items: gel hand sanitizer (n = 889, 95%), disposable gloves (n = 853; 91.1%), disposable gowns (n = 630; 67.3%), disposable masks (785 83.9%), n95 masks (n = 516; 56.1%), and facial protective shields (n = 305; 32.6%) (figure 2 ). in terms of access to personal safety policies and procedures in the workplace, 707 (75.5%) participants responded that they had access, and 229 (24.5%) did not have access. the majority of the participants (699; 74.7%) had access to covid-19 diagnostic and treatment algorithms, and 237 (25.3%) had no access. regarding access to telemedicine to evaluate and follow up patients, 572 (61.1%) healthcare workers had access, and 364 (38.9%) did not have access. when asked about their own medical institution supporting healthcare workers with additional human resources in case they became sick, the mean ± sd score was 4.92 ± 0.2 on a scale of 1 to 10 ( figure 3) . the participants' perceptions about their medical institutions taking all necessary measurements to protect physical integrity in the workplace was 5.5 ± 0.1 (mean ± sd) ( figure 4) . finally, we asked participants to share their perceptions about their local public health authorities taking all necessary measurements to protect their physical integrity in the workplace. the results show a mean ± sd of 5.01 ± 0.12 ( figure 5 ). the participants' perceptions about their medical institutions taking all necessary measurements to protect physical integrity in the workplace was 5.5 ± 0.1 (mean ± sd) ( figure 4 ). finally, we asked participants to share their perceptions about their local public health authorities taking all necessary measurements to protect their physical integrity in the workplace. the results show a mean ± sd of 5.01 ± 0.12 ( figure 5 ). the participants' perceptions about their medical institutions taking all necessary measurements to protect physical integrity in the workplace was 5.5 ± 0.1 (mean ± sd) ( figure 4 ). finally, we asked participants to share their perceptions about their local public health authorities taking all necessary measurements to protect their physical integrity in the workplace. the results show a mean ± sd of 5.01 ± 0.12 ( figure 5 ). this cross-sectional online survey enrolled 936 healthcare workers in latin america. the majority of the responders were physicians actively based in a hospital or private practice in spanish-speaking countries in north, central or south america. our study indicates that most of the participants had access to basic ppe; however, there were many healthcare professionals who did not have the required equipment recommended by the who, particularly disposable masks and n95 masks. surprisingly, only 32.6% of the participants had access to facial protective shields. these findings highlight the need for essential ppe to care for suspected and/or confirmed cases of covid-19. the who, paho, and other national and international public health authorities recommend implementing social distancing and self-isolation to mitigate the impact of this disease. thus, many suspected/confirmed covid-19 patients and even non-covid-19 patients do not have access to appropriate medical care during this pandemic. remote medical monitoring via phone or the internet is an available tool that assists healthcare providers in delivering care to patients at home [4] . however, this technology was not widely available (61.1%) for the healthcare professionals participating in this study. exceptional efforts have been made by healthcare workers in latin america to apply the latest and most effective safety measurements to protect their health in the workplace. however, based on our findings, many of our colleagues do not have safety policies and procedures in place at the workplace. the perception of healthcare workers about the limited support from medical institutions and local public health authorities in regards to their own safety shows that there is much work to be done in that respect. this study's findings on the reality and perceptions about the safety and resources available for healthcare workers during the covid-19 pandemic could inform medical institutional authorities about the need for urgent implementation of safety policies and deployment of human resources. the findings of this study could also be used to set priorities in terms of safety and human resources allocation by public health authorities. this cross-sectional online survey enrolled 936 healthcare workers in latin america. the majority of the responders were physicians actively based in a hospital or private practice in spanish-speaking countries in north, central or south america. our study indicates that most of the participants had access to basic ppe; however, there were many healthcare professionals who did not have the required equipment recommended by the who, particularly disposable masks and n95 masks. surprisingly, only 32.6% of the participants had access to facial protective shields. these findings highlight the need for essential ppe to care for suspected and/or confirmed cases of covid-19. the who, paho, and other national and international public health authorities recommend implementing social distancing and self-isolation to mitigate the impact of this disease. thus, many suspected/confirmed covid-19 patients and even non-covid-19 patients do not have access to appropriate medical care during this pandemic. remote medical monitoring via phone or the internet is an available tool that assists healthcare providers in delivering care to patients at home [4] . however, this technology was not widely available (61.1%) for the healthcare professionals participating in this study. exceptional efforts have been made by healthcare workers in latin america to apply the latest and most effective safety measurements to protect their health in the workplace. however, based on our findings, many of our colleagues do not have safety policies and procedures in place at the workplace. the perception of healthcare workers about the limited support from medical institutions and local public health authorities in regards to their own safety shows that there is much work to be done in that respect. this study's findings on the reality and perceptions about the safety and resources available for healthcare workers during the covid-19 pandemic could inform medical institutional authorities about the need for urgent implementation of safety policies and deployment of human resources. the findings of this study could also be used to set priorities in terms of safety and human resources allocation by public health authorities. two cross-sectional surveys on covid-19 were recently published. one publication addressed the important factors associated with mental health in healthcare workers exposed to covid-19 [5] . another study analyzed the general public knowledge and perceptions about the covid-19 outbreak [6] . to the best of our knowledge, our study is the first cross-sectional survey conducted among healthcare workers in latin america regarding the reality and perceptions about safety procedures in the workplace. it is important to note that some countries were non-or under-represented in this survey. although knowledge of the disease and updates on covid-19 among healthcare workers are being given full consideration, the framework to safely implement those recommendations is still lacking. this study has several limitations. it was limited in scope. participants were asked to answer very specific questions that might not cover the complex situation of the personal safety of healthcare professionals. no power calculations were undertaken prior to the initiation of the study. however, the purpose of this study was only descriptive and not hypothesis testing. recruitment of participants was based on their willingness to participate and access to social networking websites and applications; therefore, the study population does not encompass participants without those resources. many countries in latin america were not represented or poorly represented in the survey. it is possible that most of the responders work in the cardiovascular field where the exposure to critical covid-19 patients may be limited; therefore, their reality and perspective about covid-19 could differ from those of other specialists. the inability to determine the universe under this study makes the generalizability of our findings quite limited. protecting healthcare workers is a public health priority. in this survey study of healthcare professionals working in latin america, we reported limited access to essential personal protective equipment during the covid-19 pandemic. the poor perception of healthcare professionals about not having enough support from medical institutions and public health authorities raises the need to urgently implement strategies to protect healthcare workers in the time of the covid-19 pandemic. author contributions: d.d. wrote the paper and developed the original idea; f.w.q., g.p., a.s.l., c.p.-n., i.m. and a.b. assisted with the design and distribution of the questionnaire and the revision of the manuscript. all authors have read and approved the final manuscript. funding: this research received no external funding. practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-ncov) patients. can telemedicine in the era of covid-19 factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 use of rapid online surveys to assess people's perceptions during infections disease outbreaks: a cross sectional survey of coivd-19 acknowledgments: francisco delgado provided technical support. we would like to thank the members of the interamerican society of cardiology for participating in this study. the authors declare no conflict of interest. key: cord-334638-au5sqzxw authors: dores, artemisa r.; geraldo, andreia; carvalho, irene p.; barbosa, fernando title: the use of new digital information and communication technologies in psychological counseling during the covid-19 pandemic date: 2020-10-21 journal: int j environ res public health doi: 10.3390/ijerph17207663 sha: doc_id: 334638 cord_uid: au5sqzxw the use of digital information and communication technologies (icts) has enabled many professionals to continue to provide their services during the covid-19 pandemic. however, little is known about the adoption of icts by psychologists and the impact of such technologies on their practice. this study aimed to explore psychologists’ practices related with the use of icts before and during the covid-19 lockdown, to identify the main changes that the pandemic has brought and the impact that such changes have had on their practice with clients, and also identify the factors that potentially have affected such changes. the portuguese psychologists association announced the study, and 108 psychologists responded to an online survey during the mandatory lockdown. the results showed that these professionals continued to provide their services due to having adopted icts. comparing with face-to-face interventions, psychologists recognized that additional precautions/knowledge were needed to use such technologies. despite the challenges identified, they described the experience with the use of icts as positive, meeting clients’ adherence, and yielding positive results. psychologists with the most years of professional experience maintained their services the most, but those with average experience showed the most favorable attitudes toward the use of technologies and web-based interventions. the coronavirus disease (covid-19) pandemic represents an unprecedented global challenge in our era, strongly affecting people's lives, namely, the exercise of various professional activities [1, 2] . this unique circumstance, associated with the current availability of several digital tools, has contributed exponentially to the digital revolution that we have witnessed in recent years, with impact on the social, economic, and professional domains of life [3] . in this scenario, e-health has emerged as one viable solution to allow the continuity of the provision of health services, particularly considering the public health measures that have been taken as a result of the national emergency state, which has limited people's access to in-person services [4] . e-health is broadly defined as the provision of services related to health supported by a safe and cost-effective use of information and communications technologies (icts) [5] . the path toward the progressive adoption of icts in the field of psychology had already begun before the covid-19 pandemic, albeit in varied degrees across different countries. if documentation guiding and/or regulating professional practice is already available in some countries, a legal or normative void still exists in others. this has implications regarding the availability of the psychological services offered, which are still quite scarce in some countries, as is the case in portugal. for example, before the covid-19 pandemic, few portuguese psychologists adopted guided and unguided psychological internet interventions (1.3% and 1.5%, respectively) [6] , despite the already recognized advantages of this type of intervention [7] [8] [9] [10] [11] . many of the guidelines for the online practice of psychology are the result of the work of several national and international associations and bodies (e.g., the american psychological association and european federation of psychologists' associations), in an effort to set forth a consensus about the practices that they aim to guide. in portugal, after a first approval of at-distance interventions by the ordem dos psicólogos portugueses (opp; transl.: portuguese psychologists association) in 2015, the opp issued a document with the guidelines for these types of services very recently, precisely at the peak of the covid-19 pandemic [12, 13] . in its first issue, this association claimed that psychological intervention should always be conducted within the same obligations and responsibilities (i.e., ethical principles and deontological and legal norms), regardless of the format of the intervention, as defined in the code of ethics. although the opp recognized the potential benefits of web-based interventions and use of itcs, it also launched warnings about the need for a better understanding of the effects of the different modalities of remote intervention (e.g., written, audio or audiovisual support) compared to face-to-face intervention. the opp additionally warned of the fact that the specificities of cyber space could elude the means of control available to psychologists, which could put privacy and confidentiality at risk [12] . in its second document, entitled "opp guidelines for professional practice: provision of psychology services mediated by icts" [13] , a set of recommendations for the adoption of these technological and digital resources were presented. in addition to the opp, other projects have been carried out in portugal (and elsewhere) with the aim to issue good practices to be adopted for the use of these digital and technological means in the area of health in general, and of psychology in particular. as an example, the european project therapy 2.0-counseling and therapeutic interactions with digital natives, financed by the erasmus + program, sought to issue the appropriate integration of icts in counseling and therapy, especially for younger populations and refugees [14, 15] . in several countries, an increasing number of studies have also sought to characterize the attitudes of psychologists toward the inclusion of icts in their professional practice and to gather evidence about the efficacy and effectiveness of psychological interventions mediated by icts (e.g., [7, [16] [17] [18] [19] [20] [21] ). regarding the psychologists' attitudes, the results of the studies are not consistent (e.g., [6, 22] ). in portugal, a recent study assessing psychologists' attitudes revealed a slightly negative/neutral position regarding internet interventions and greater acceptability of blended treatment interventions when compared to standalone internet interventions. however, these attitudes seem to depend on different factors, such as knowledge and training [6] . a study in other countries revealed that, among those who have employed any online means of practicing counseling and therapy, 52.97% had a positive or very positive opinion about the use of these tools. in this study, e-mail was the most widely used online tool, and the computer and smart phone were the most frequently used equipment [14] . different circumstances and factors seem to contribute to explain the different attitudes and the adoption (or not) of this type of resources [23] . such factors include the therapist's theoretical model/orientation, geographic area, previous experience with the use of these resources, presence or absence of previous training, perception about the usefulness of these tools, ease with their use, and years of clinical practice [24] [25] [26] [27] [28] [29] [30] [31] . regarding the effectiveness of these online means, in general, studies allow us to conclude that internet interventions may be efficacious and cost-effective [6, 16, 17, 19, 20, [32] [33] [34] [35] . they seemed to be at least as effective as face-to-face interventions in a large group of clients receiving treatment for psychological disorders, namely, for generalized anxiety and other types of anxiety disorders [36] [37] [38] [39] [40] [41] [42] , depression [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] , and stress [53, 54] . the recognized advantages of using icts do not refer merely to their power to compensate for the limitations of traditional interventions (e.g., travelling requirements for customers or therapists), nor to their use as complementary means. there are several advantages associated with implementing internet interventions [8] [9] [10] [11] 13, 14, 55] . these include easy accessibility, high adaptability, flexibility and convenience, evolution at the client's pace, easy adherence and treatment monitoring, privacy and possibility of anonymity, cultural adaptability, low cost, and high potential for dissemination [55] . conversely, the main challenges identified in the use of icts include ethical concerns (e.g., security, privacy, confidentiality, and an absence or lack of deontological orientation), clients' ict illiteracy, and negative attitudes toward internet interventions [6] . others can be added, such as a lack of access to technological and digital tools by some users, technological problems in their use, and changes to the setting and regarding the therapeutic relationship [8, 10, 14, 26, [55] [56] [57] [58] . because different circumstances and factors seem to contribute to explain psychologists' attitudes and the adoption (or not) of this type of resources, it is important to identify potential changes in the use of icts during the covid-19 pandemic. given the measures of physical distance and isolation that most governments imposed with the state of emergency (e.g., [4] ), how have psychologists dealt with the provision of counseling and therapy to their clients? the aims of this work were to (a) analyze how the attitudes of professionals in the field of psychology have changed in relation to the use of icts in the context of psychological monitoring during the lockdown; (b) assess whether the practice of psychological counseling and therapy includes greater use of icts during the lockdown period; (c) identify the factors that potentially have affected such changes; and (d) study the possible adoption of guidelines for at-distance psychological monitoring by psychologists who are using icts during the period of physical distance the sample in this study comprised 108 psychologists who were registered in the opp. most were women (89, or 82.4%). the mean age was 37.20 years old (sd = 10.05; min = 23, max = 65), with 55 (50.9%) in the age group between 23 and 35 years, and 53 (49.1%) in the group between 36 and 65 years. the number of years of professional experience ranged between one or less and 33 (m = 11.52; sd = 8.60). the sample reflects national representation (including continental portugal and islands), with 19 of the 20 portuguese districts participating in the study. the most represented districts were porto (n = 39; 36.8%), lisbon (n = 21; 18.9%), braga (n = 13; 12.3%), and coimbra (n = 9; 8.5%). these cities comprehend the national opp delegations with the most psychologists [59] . most participants held master's degrees (n = 69; 63.9%). most were specialists in clinical psychology (n = 60; 55.6%), and 23 (21.3%) had one or more advanced specialties, including in psychotherapy (n = 13; 12.0%), among others. participants worked mainly with adults (n = 81; 75.0%), followed by adolescents (n = 52; 48.1%), children (n = 46; 42.6%), and the elderly (n = 24; 22.2%), in the areas of anxiety disorders (n = 91; 84.3%), mood disorders (n = 72; 66.7%), personality disorders (n = 37; 34.3%), neurocognitive disorders (n = 30; 27.8%), among others. for more information, see table 1 . a questionnaire was developed for this study and a pilot test was conducted to check its comprehension level and adequacy for the current purposes. the questionnaire included 30 questions divided into three sections: (i) socio-demographic data, with 9 questions; (ii) experience before the covid-19 pandemic, with 7 questions; and (iii) current experience using icts in psychology sessions (namely web-based interventions during the lockdown period), with 14 questions. the questions were designed based on a previous questionnaire developed for the purpose of studying the use of icts in the provision of therapy and counseling [14] , as well as on the advantages and challenges identified in the literature about the use of these technologies on psychological counseling. socio-demographic data included gender, age, education level, number of years of professional experience, district where the respondent was practicing, area of specialization, and targeted population in the respondent's practice (including development stages and most frequent disorders). the remaining two sections of the questionnaire focused on information about the use of icts in the respondents' clinical practice. questions included which tools and devices were used, clients' degree of satisfaction with the use of icts, advantages and difficulties identified by the professionals, impact on clients' adherence and on therapeutic results, among others (cf. appendix a). this study was approved by the local ethics committee (approval no.: ce0003a), and the questionnaire was made available at the web-based survey platform limesurvey [60] . opp sent this anonymous online self-report questionnaire to its members via e-mail and published it on its webpage. the questionnaire was also sent to the authors' professional institutions via their mailing lists and was made available via professional social media, such as linkedin. this procedure ensured that all psychologists registered at opp (a mandatory requirement for practicing psychology in portugal) were invited to take part in this study. the e-mail containing the questionnaire included the study's description and aims, followed by an informed consent form. if the person agreed to participate, a link gave them access to the questionnaire. the data were collected during april and may 2020, precisely at the peak of the covid-19 pandemic, and during the lockdown period. data were exported from limesurvey [60] into ibm spss statistics 25 commuter license [61] for analysis. descriptive statistics (e.g., frequency distributions) were conducted for the sample characteristics (e.g., age, gender, educational and professional background)) and for the data pertaining both to the period before and during the covid-19 pandemic. data before the covid-19 pandemic included aspects such as the use of digital tools in professional practice, professional experience with this type of tool, and adherence of clients to therapeutic activities based on digital technologies. during the covid-19 lockdown, analyses considered the following aspects: maintenance of psychological support services, percentage of clients who have maintained the use of psychological counseling or therapy, frequency and duration of the therapeutic sessions, therapeutic adherence, therapeutic relationship, feedback from the clients, and results of the at-distance sessions. additionally, a thematic analysis for the open-type questions was performed on the open-ended questions. two independent raters (a.g. and i.p.c.) have proceeded to the classification of the categories in each answer. conflicts were solved by a third rater (a.r.d.). to explore the correlations between professional experience, age and the selected outcome variables, point-biserial and spearman correlations were performed. regarding the use of digital technologies for providing at-distance psychological counseling and therapy before the covid-19 pandemic, most (n = 63; 58.3%) had rarely or never used digital tools in clinical practice before the covid-19 pandemic ( table 2) . the reasons pointed out by portuguese psychologists for never or rarely (n = 63) having used digital technologies in psychological counseling and therapy were they considered it very impersonal (n = 28; 44.4%), inefficient (n = 18; 28.6%), ineffective (n = 10; 15.9%), not safe enough (n = 9; 14.3%) or ethical (n = 8; 12.7%), and for their lack of knowledge on how to apply these technologies in psychological counseling and therapy (n = 1; 1.6%). under "other", participants additionally shared that they did not feel the need to use these means of providing counseling and therapy before, that these means were not part of their institutions' policies, and that they preferred in-presence interventions. among the portuguese psychologists who used icts to provide at-distance psychological counseling and therapy (n = 71), the most often used tools were video conferences (n = 50; 70.4%), telephone calls (n = 41; 57.7%), e-mails (n = 31; 43.7%), and social networks (n = 23; 32.4%). other tools used were audio conferences (n = 14; 19.7%), online intervention platforms (n = 6; 8.5%), smartphones and tablet apps (n = 6; 8.5%), online forums (n = 4; 5.6%), chats (n = 3; 4.2%), short-message services (n = 2; 1.8%), and virtual rooms (n = 1; 0.9%). concerning the technological devices used for providing at-distance psychological counseling and therapy, the most frequently used device was a computer (n = 62; 87.3%), followed by a telephone/smartphone (n = 58; 81.7%) and by tablets (n = 9; 12.7%) ( table 2 ). among the psychologists that used digital technologies in psychological counseling and therapy previously to the covid-19 pandemic (n = 71), none considered their experiences with these tools to be negative or very negative. nevertheless, 21 (of these 71) psychologists (29.6%) considered their experiences to be neither negative nor positive. most of the respondents considered their experience with digital technologies to be either positive (n = 37; 52.1%) or very positive (n = 13; 18.3%). regarding the involvement of their patients in the therapeutic activities that were delivered through digital technologies, most of the psychologists rated it as moderate (n = 28; 39.4%), followed by high (n = 18; 25.4%) and low involvement (n = 12; 16.9%). only six psychologists (8.5%) considered their patients' involvement in this type of activities very high, and seven psychologists (9.9%) rated their patients' involvement as very low (table 2 ). with regard to the advantages that portuguese psychologists considered might be experienced or already were experienced through the use of icts in psychological counseling and therapy, geographic flexibility was the most frequently selected advantage (n = 74; 68.5%), followed by scheduling flexibility (n = 55; 50.9%), the possibility of them reaching new groups of people in need of psychological counseling and therapy (n = 36; 33.3%), and by their easier access to some target-groups, such as persons with disability, refugees, among others (n = 28; 25.9%). they added the cost-benefit relationship (n = 27; 25.0%) and the possibility of obtaining new business areas (n = 10; 9.3%). twelve (11.1%) of the respondents considered that they have never benefitted, or will never benefit, from any advantage through the use of icts in psychological counseling and therapy. on the contrary, through the analysis of the challenges that psychologists had already faced or were afraid of facing when using new icts in psychological counseling and therapy, the most frequently referred challenge was the difficulty in establishing and/or maintaining the therapeutic relationship (n = 67; 62.0%), followed by the lack of non-verbal communication (n = 66; 61.1%), reduced therapeutic adherence (n = 52; 48.1%), reduced client engagement in the sessions (n = 50; 46.3%), and reduced privacy (n = 35; 32.4%). other challenges referred by the psychologists were the interruption of the sessions (n = 29; 26.9%), ethical concerns (n = 23; 21.3%), possible misunderstandings (n = 22; 20.4%), difficulties in therapeutically approaching some problems/topics (n = 20; 18.5%), the substantial decrease or increase of the sessions' frequency (n = 20; 18.5%), lack of security (n = 19; 17.6%), establishment of boundaries (n = 19; 17.6%), and time management (n = 12; 11.1%). under the category "other", they also mentioned technical problems. four (3.7%) respondents considered to never have faced or feared to face challenges in the future related to the use of digital technologies in their professional practice (table 2) . during the covid-19 pandemic, and specifically during the lockdown period, only 17 (15.7%) of the 108 psychologists discontinued the provision of psychological counseling and therapy to their clients (table 2 ). these psychologists reported that the main reasons for interrupting their professional activities were the suspension of activities on the part of the institution where they worked, activity suspension on the part of their clients for various reasons (e.g., considering themselves to be info-excluded populations or presenting digital illiteracy, financial difficulties, or sensing that the clinical setting is lacking), psychologists' own personal unavailability during this period (e.g., due to new family responsibilities), and considering that digital means were inadequate for the target population (i.e., children) or clinical condition (e.g., attention deficits) that they were treating. all the other psychologists (n = 91, 84.3%) were able to continue the sessions with their cases due to the use of icts. among the 91 psychologists who continued to provide at-distance psychological services, 71 (84.3%) previously read guidelines and other documents that support their at-distance psychological practice. the documents that these psychologists consulted the most were materials made available by the opp (e.g., written material, videos, and webinars), guidelines from apa and from the international psychoanalytical association (ipa), scientific papers, and manuals about online therapeutic interventions (including the therapy2.0 project). regarding additional cautionary procedures implemented by the psychologists for at-distance interventions, respondents referred the careful definition of rules and ethical limits, namely in terms of privacy, confidentiality, security, schedules, forms of contact, session duration and frequency, as well as how to proceed when unforeseen situations occur (e.g., technical failures such as problems with the internet connection, technology problems such as problems with the tools/equipment used, or interruptions). caution about the type of software and the type of technology used were mentioned, also related with non-exposure of personal life, as well as the conditions of the physical space and the psychologist's personal appearance/presentation, and personal well-being. psychologists also referred several precautions and procedures associated with the actual therapeutic process, namely regarding verbal and non-verbal communication (e.g., minimizing the occurrence of overlaps, interruptions, and misunderstandings), greater session structuration and directivity (which involved greater previous preparation for some of them), avoidance of emotional themes that require in-person support, which distance prevents, parent follow-up in sessions with children, and assessment of clients' level of comfort with the new format. when focusing on the technological tools used to provide at-distance psychological counseling and therapy, video conference was the most frequently used (n = 71; 78.0%), followed by phone calls (n = 48; 52.7%), social networks (n = 35; 38.5%), e-mail (n = 33; 36.3%), audio conference (n = 16, 17.6%), smartphones and tablet apps (n = 7; 7.7%), online intervention platforms (n = 3; 3.3%), chats (n = 3; 3.3%), online forums (n = 1; 1.1%), and virtual rooms (n = 1; 1.1%). computers were the most frequently used technological device to provide psychological services during the covid-19 pandemic (n = 80; 87.9%), followed by telephones/smartphones (n = 66; 72.5%) and tablets (n = 9; 9.9%) ( table 2 ). most of the respondents (n = 53; 58.2%) have continued to provide their services to most of their clients, i.e., twenty-seven (29.7%) of the psychologists continued to provide counseling and therapy to between 51% and 75% of their clients, and 26 psychologists (28.6%) to between 76% and 100% of their clients. however, for 23 psychologists (25.3%), the number of clients decreased to a range of between 0% and 25%, and for another 15 psychologists (16.5%) that number diminished to a range of between 26% and 50%. these psychologists referred, as main reasons for these reductions, low client adherence, lack of client's necessary privacy, confidentiality and non-interruption conditions at home, the fact that clients preferred in-presence contacts (considering such forms of intervention to be more effective than, or feeling uncomfortable with, the new format), had financial difficulties, had difficulties managing the new routines (including caring for the children at home), and lacked the technological means for at-distance sessions. in some cases, the client's condition was stable, and the therapeutic process had come to an end, or it was requiring no immediate sessions. considering the frequency of the counseling and therapy sessions among the clients who continued to use this service, a small majority of the psychologists (n = 48; 52.7%) referred that their clients have maintained the previous frequency, but 29 psychologists (31.9%) reported a decrease in the number of sessions, and six (6.6%) reported a significant decrease in that number. despite that, seven psychologists (7.7%) reported an increase in the number of sessions during the covid-19 pandemic, and one (1.1%) reported a significant increase. the same pattern was found for the duration of the counseling and therapy sessions, with 55 (60.4%) psychologists reporting a maintenance of the duration of each session, 20 (22.0%) reporting a decrease, and 4 (4.4%) reporting a significant decrease in the duration of the sessions. nevertheless, 12 psychologists (13.2%) stated that the duration of the counseling and therapy sessions increased during the covid-19 pandemic. regarding the results of the current therapeutic sessions, when compared to former in-presence sessions, most psychologists (n = 65; 71.6%) considered the results to be more of less the same, four (4.4%) reported obtaining better results with at-distance sessions, and 22 (24.2%) considered that at-distance sessions have yielded worse results than in-presence sessions. similarly, from the points of views that clients shared with their psychologists, at-distance and in-person sessions were more or less the same (n = 71; 78.0%). six (6.6%) of the respondents reported receiving better feedback (i.e., the clients preferred the online sessions), and one (1.1%) received much better feedback. even so, 13 (14.3%) psychologists received worse feedback from their clients about this type of intervention. in what concerns therapeutic adherence to the ict sessions, the majority of psychologists considered it to be more or less the same during the covid-19 pandemic, comparing to the pre-covid sessions (n = 52; 57.1%), and 10 psychologists (11.0%) reported an improvement. nevertheless, other psychologists reported a decrease (n = 24; 26.4%) or a significant decrease (n = 5; 5.5%) in the therapeutic adherence of their clients ( table 2 ). the vast majority of respondents considered that the therapeutic relationship between the psychologists and their clients was maintained (n = 77; 84.6%), with only three (3.3%) psychologists reporting an improvement in those relationships. however, 11 (12.1%) psychologists considered that those relationships have worsened during this period. regarding the advantages that portuguese psychologists viewed as associated with their current use of new icts in psychological counseling and therapy, geographic flexibility was the most frequently selected (n = 73; 80.2%), followed by scheduling flexibility (n = 57; 62.6%) and the possibility of reaching new groups of persons in need of psychological counseling and therapy (n = 30; 33.0%). other advantages that they mentioned were the cost-benefit relationship (n = 24; 26.4%), the easier access of psychologists to some target groups, such as persons with disability and refugees, among others (n = 21; 23.1%), and the possibility of obtaining new business areas (n = 11; 12.1%). under the category "other", they further mentioned the possibility of providing secure interventions in the current covid-19 pandemic context, which ensured the possibility of maintaining the interventions. only two (2.2%) respondents considered that at-distance psychological counseling and therapy does not offer any advantages. through the analysis of the challenges that psychologists currently face when they provide at-distance psychological counseling and therapy sessions, the most frequently referred difficulty was lack of non-verbal communication (n = 58; 63.7%), followed by reduced privacy (n = 36; 39.6%), the difficulty in establishing and/or maintaining the therapeutic relationship (n = 34; 37.4%), session interruptions (n = 31; 34.1%), reduced therapeutic adherence (n = 22; 24.2%), difficulties in approaching some problems/topics therapeutically (n = 19; 20.9%), ethical concerns (n = 19; 20.9%), and a reduction in patient engagement in the sessions (n = 18; 19.8%) ( table 2 ). other challenges that counsellors referred to (under the category "other") were the establishment of boundaries (n = 17; 18.7%), the significant decrease or increase in session frequency (n = 16; 14.8%), the time management of the sessions (n = 15; 16.5%), possible misunderstandings (n = 14; 15.4%), and lack of security (n = 10; 11.0%). under this category, they additionally mentioned technology problems (e.g., equipment adjustments) and technical failures (e.g., internet connection). five respondents (5.5%) did not report any difficulty or challenge in providing at-distance psychological counseling and therapy. in table 2 , the psychologists' practices are presented pre-and post-covid-19 for easy comparison of the main results described previously. significant point-biserial correlation coefficient were positive between the aspect "continue to provide psychological counseling to customers regularly" and years of professional experience, r pb = 0.296, p = 0.002. significant correlations were negative between "frequency of psychological counseling sessions" and both years of professional experience, r s = −0.341, p < 0.001, and age, r s = −0.229, p = 0.017. the aspect, "duration of psychological counseling sessions" also displayed a significant negative correlation with age, r s = −0.209, p = 0.030. thus, regarding respondents' professional experience, psychologists with more years of experience maintained their professional services during the covid-19 pandemic more than professionals with less years of experience. nevertheless, the frequency of the sessions decreased for the professionals who had more years of professional experience. regarding age, older psychologists reported a decrease in session frequency and duration. no significant results were found in any of the other variables analyzed. this study aimed to explore psychologists' attitudes and practices related with the use of icts before and during the covid-19 pandemic lockdown period, for identification of the main changes that have occurred in the provision of counseling and therapy. the impact of age and years of professional experience on the use of icts was also inspected. in this study, psychologists' use of icts in their professional activity before the covid-19 pandemic is in accordance with the literature, namely in terms of previous experience of their use, tools, devices, professionals' satisfaction with their use, advantages, and perceived challenges. these results reproduce those by mendes-santos (2020), in which only 29.6% of the inquired portuguese psychologists admitted to having used digital technologies in their professional practice. the results of the present study also showed that most portuguese psychologists had never or rarely used digital technologies as a means of delivering psychological counseling and therapy before the covid-19 pandemic [6] . there is also a high degree of similarity between the tools most frequently used in our study and the tools used, the resources that psychologists most recommend to their clients (e.g., telephone calls, e-mails, video conferences, social networks, and apps) [6] , and the most used devices (e.g., computers and smart phones) reported in other research (e.g., [14] ). additionally, according to previous studies, accessibility/geographic flexibility, convenience/(scheduling) flexibility, and cost-effectiveness/low cost are amongst the most recognized advantages of using icts (e.g., [6, 55] ). regarding the disadvantages, the major challenges in this study, pertaining to ethical concerns and to the difficulty in establishing and/or maintaining the therapeutic relationship due to different reasons, were also identified in the literature [6, 8, 10, 14, 26, [55] [56] [57] [58] . the analysis of the reasons given for not using icts before the covid-19 pandemic revealed that lack of knowledge and training about the correct use of icts was particularly relevant, which might explain professionals' concerns about efficiency, effectiveness, and ethical issues. these same factors were associated with more negative attitudes toward the use of technologies in a previous study [6] . training thus seems to be a necessary step in order to increase the use of icts. however, before the covid-19 pandemic, available training was scarce, perhaps also because the professionals themselves perceived the use of icts as unnecessary, as they indicated in this study. the emergence of the covid-19 pandemic brought about relevant changes in the use of icts. barriers to their use by both professionals and clients have been reduced, as the availability of information about their use in various formats has increased. the percentage of psychologists who have adopted icts in their practice during the lockdown period was very high in this study, and the vast majority of respondents were able to maintain their professional activity due to the inclusion of these means in their practice. this shows an enormous capacity of adaptation and flexibility, both on the psychologists' and clients' parts. this phenomenon was observed not only in portugal but in other countries too, such as the united states, where the provision of at-distance psychological services has been raised from 7.07% to 85.53% [62] . additionally, other health services are also adopting the online modalities, namely in medicine [63, 64] , with the professionals reporting positive perceptions regarding the telehealth services. however, the implementation of icts in such a short period of time leads to questions about the conditions under which they were implemented. our results showed that more than half of the psychologists have read about the use of icts, and some had already used these tools, even if not exclusively, in their professional practice before, which is consistent with a previous study [6] . they additionally identified a number of materials that were informative of at-distance psychological practice. these materials also contained information on additional care that needs to be adopted in at-distance psychological monitoring sessions and that is different from the procedures that these professionals might have adopted in the use of digital technologies in the context of their social relationships. their concerns about web-based session pertained to a diversity of aspects considered to be critical in the e-health literature (e.g., the clear definition of rules and ethical limits) that can be different from face-to-face services [13] . however, it is noteworthy that most professionals have not offered any input on any additional measures that they might have adopted (e.g., use end-to-end encrypted technology), nor has it been possible, within the scope of this work, to identify how psychologists were capable of responding effectively to the new requirements and specificities that they reported they have adopted. despite the great availability of webinars and the training and specialty documents made available during this period (e.g., [13] ) by accredited entities, often free of charge, little is known about how such information transfer to the professional contexts. this study provides important information in that regard by confirming the pertinence and usefulness of such materials among the psychologists. in general, the tools and devices used before the lockdown period were the same that were used during the covid-19 pandemic, although there was an increase in the use of several of them during the covid-19 pandemic (e.g., video conferences, computers, and telephones/smartphones). the primary use of computers and smartphones in this study is in line with the findings from previous research, although psychologists in our study used mostly video conference and telephone calls, whereas e-mail was the most widely used tool in a previous study [14] . psychologists who do use icts in their practice tended to report a positive or very positive experience regarding the use of these online technologies in counseling and therapy. similarly, a study focused on the attitudes of psychotherapists towards online therapy during the covid-19 pandemic have also found a positive attitude of the professionals with regard to this therapy modality [65] . research has recognized several advantages associated with using icts in such contexts, and participants in our sample identified equivalent advantages [8] [9] [10] [11] 13, 14, 55] . their reported advantages were the same before and during the lockdown period, although they added a new advantage during the lockdown period, i.e., the possibility to conduct secure interventions. the number of professionals who did not see any advantage in the use of icts after the pandemic decreased to a practically residual value. however, the implementation of these modalities was not without difficulties. both before and during the pandemic, psychologists identified a set of challenges in the adoption of dicts in professional practice. some decreased during the pandemic, possibly due to the professionals' increased experience (e.g., establishing/maintaining the therapeutic adherence). however, others were particularly worsened during the period of mandatory lockdown (e.g., loss of privacy and risk of interruption). although generally positive, the results regarding psychologists' experiences/results and clients' adherence to therapeutic activities based on digital technologies were variable, as reported in previous studies (e.g., [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] and [6, 55] respectively). it is important in the future to understand which ingredients explain this variability, both in relation to individual and to disorder aspects, and to work with the group of clients who have failed to adhere to the new format. from the limitations identified in this study, some clients might benefit from better advertisement of this type of services and of the scientific evidence of its effects, together with the possibility of receiving a reduction in the price of the services provided. increasing clients' digital literacy will also contribute to their adherence to web-based interventions. this is already happening among the new generations, whose members are already known as digital natives [14, 15] , but it is still difficult when working with specific populations, such as the elderly and people that live in rural areas, or when performing some psychological acts, such as psychological assessment and rehabilitation practices [62] . additionally, other challenges might be more difficult to overcome, such as the sense that an adequate therapeutic setting is lacking. this aspect has been particularly exacerbated by the situation of mandatory lockdown that has brought together all who live in the same physical space, namely risking privacy. regarding the correlations between the professionals' characteristics (i.e., age and years of professional experience) and the use of icts in professional practice, the results showed that were the professionals with more professional experience who presented greater maintenance of psychological support services, but less frequently. however, because it was also the professionals with more professional experience who presented greater maintenance of psychological support services, the decrease in the frequency of the sessions reported by them might have been an intentional procedure to help their own and their clients' adaptation to the new format. the results failed to show a correlation between age and the use of icts, except for frequency and duration of the therapeutic sessions, which was significantly shorter for the oldest than for the youngest psychologists. the decrease in these aspects in the group of older psychologists from the pre-to the during-lockdown period could be possibly explained by the greater discomfort that these professionals experienced with the use of icts. the influence of the personal characteristics of the professionals in their attitude towards online psychological counseling was also reported in another study [65] , with the psychotherapists who had previous experience with online psychotherapy, who thought that the patients they attend to had positive experiences in this modality, that adopted cognitive behavioral therapy in their practices (in comparison to psychodynamic therapists), and that lives in north america (in comparison to europe) exhibiting a more positive attitude towards online psychotherapy. this work has some limitations, namely the sample size and the use of a questionnaire that has not been previously validated to study the attitudes of psychologists toward icts (namely toward web-based interventions). however, the data collection took place during the period of absolutely unique and exceptional sanitary measures to prevent the pandemic dispersion of the coronavirus sars-cov-2, which causes covid-19. to understand the impact of these circumstances on professionals' practice is of the utmost relevance, despite the fact that these same circumstances have limited the time to conduct the data collection and the availability of participants in the study. still, the collaboration of the opp in this scenario, advertising the study and making the questionnaire available to all its members, contributed to ensure national representation of the participants. the process of adapting an existing instrument, namely obtaining the respective authorizations, would require an extended period of time that would risk missing this window of opportunity. instead, the questionnaire was adapted from an instrument that was previously used by the authors and that was tested in a pilot-study. future studies could focus on exploring the reasons that seem to be interfering either negatively or positively with clients' adherence to, and satisfaction with, ict sessions, so that personalized healthcare services can be provided and tailored to the specificities of each case. it is widely known that the covid-19 pandemic and associated restrictive measures of physical contact have significantly changed many professional activities. the current work has contributed to our understanding of that impact in the practice of psychology and psychotherapy, in close relation with the use of icts. awareness of these changes can guide future professional practice by allowing the replication of the best practices and experiences shared by the psychologists during the period of maximum lockdown. it can also help to overcome the main difficulties and limitations experienced, for example, by guiding future training in this area, stimulating the creation of guidelines for ict-based professional practice in different countries, and of measures to promote knowledge of and adherence to these guidelines that are becoming increasingly available. although the completion of the questionnaire is anonymous, some socio-demographic and professional data will be requested, as well as answers to closed-and open-ended questions. these questions focus on the use of digital technologies in psychological counseling. please read each question carefully. it is important that your answers are sincere. if you accept to participate in this study, please click on "next" to proceed to the informed consent. all data will be collected and processed in an anonymous and confidential way, so you will never be asked for your name, professional number, or other personal data that could identify you. the data will be used for research purposes and will never be analysed at the individual level. your participation is completely voluntary, and your contribution is very important for us, to better understand the role of digital technologies in confinement situations like the one we are going through now. although you can quit answering the survey at any time without any consequences, we really appreciate your collaboration. if you want to clarify any question or if you need more information, please contact: andreia geraldo (andreiageraldo.psic@gmail.com). we appreciate your cooperation. andreia geraldo, researcher artemisa r dores, responsible for the project if you intend to participate in this study, select the option below to proceed to the survey. i declare that i have read the information above, have become aware of the research aims, and agree to participate in this study. socio-demographic and professional data 29 . in case you consider that you have adopted some additional precautions in at-distance psychological counselling, when compared to those you adopt in relation to the use of digital technologies in the context of your social relationships, please indicate them. 30. what are the advantages that you identify in at-distance psychological counselling? geographic flexibility, both for professionals and clients (i.e., they can interact from any location) 32 . what are the difficulties that are reported by your clients in relation to maintaining at-distance psychological counselling? thank you for your collaboration. an early view of the economic impact of the pandemic in 5 charts. international monetary fund imfblog how the economy will look after the coronavirus pandemic: the pandemic will change the economic and financial order forever the long and short of the digital revolution decreto do presidente da república n.º 14-a/2020 portuguese psychologists' attitudes towards internet interventions: an exploratory cross-sectional study internet-delivered psychological treatments advantages and limitations of internet-based interventions for common mental disorders internet and psychological treatment internet interventions for depression: new developments effectiveness, mediators, and effect predictors of internet interventions for chronic cancer-related fatigue: the design and an analysis plan of a 3-armed randomized controlled trial parecer 21/ceopp/2015 da ordem dos psicólogos portugueses (opp) linhas de orientação para a prática profissional opp: prestação de serviços de psicologia mediados por tecnologias da informação e da comunicação (tic). 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internet supported psychological interventions do web-based interventions improve well-being in type 2 diabetes? a systematic review and meta-analysis the effect of technology-based interventions on pain, depression, and quality of life in patients with cancer: a systematic review of randomized controlled trials a systematic review of web-based interventions for patient empowerment and physical activity in chronic diseases: relevance for cancer survivors e-therapy in the treatment and prevention of eating disorders: a systematic review and meta-analysis internet-based psychodynamic versus cognitive behavioral guided self-help for generalized anxiety disorder: a randomized controlled trial effectiveness of internet-based cognitive behaviour therapy for panic disorder in routine psychiatric care predicting long-term outcome of internet-delivered cognitive behavior therapy for social anxiety disorder using fmri and support vector machine learning treatment of social phobia: randomised trial of internet-delivered cognitive-behavioural therapy with telephone support guided internet-de¬livered cognitive behavior therapy for generalized anxiety disorder: a randomized controlled trial individuallytailored, internet-based treatment for anxiety disorders: a randomized controlled trial randomized controlled trial of internet-delivered cognitive behavioral therapy for posttraumatic stress disorder randomised controlled non-inferiority trial with 3-year follow-up of internet-delivered versus face-to-face group cognitive behavioural therapy for depression internet-based treatment of depression: a randomized controlled trial comparing guided with unguided self-help internet-based behavioral activation and acceptance-based treatment for depression: a randomized controlled trial behavioral activation-based guided self-help treatment administered through a smartphone application: study protocol for a randomized controlled trial a randomized controlled trial evaluating a manualized 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emental health by psychologists: the construction of the levels of adoption of emental health model survey of psychologists' telebehavioral health practices: technology use, ethical issues, and training needs south african psychologists' use of the internet in their practices online counseling: an exploratory survey of italian psychologists' attitudes towards new ways of interaction censo dos membros efectivos da opp [association numbers. census of effective members of the opp limesurvey: an open source survey tool the covid-19 telepsychology revolution: a national study of pandemic-based changes in u.s. mental health delivery the effect of the covid-19 pandemic on physicians' use and perception of telehealth: the case of lebanon suddenly becoming a "virtual doctor": experiences of psychiatrists transitioning to telemedicine during the covid-19 pandemic psychotherapists' attitudes toward online therapy during the covid-19 pandemic key: cord-349144-cvmebr3f authors: barca, ida; novembre, daniela; giofrè, elio; caruso, davide; cordaro, raffaella; kallaverja, elvis; ferragina, francesco; cristofaro, maria giulia title: telemedicine in oral and maxillo-facial surgery: an effective alternative in post covid-19 pandemic date: 2020-10-09 journal: int j environ res public health doi: 10.3390/ijerph17207365 sha: doc_id: 349144 cord_uid: cvmebr3f the aim of this work was to demonstrate the advantages of using telemedicine (tm) in the management of the outpatients with maxillofacial surgical pathologies during the covid-19 pandemic. the study was conducted at the maxillofacial surgery unit of “magna graecia” university of catanzaro, on two different groups of patients: a group of follow-up patients (a(1): patients in oncological follow-up after surgical treatment performed before the covid-19 pandemic; a(2): suffering from chronic lesions such as precancerous lesions), and a group b of patients with first urgent visits (b(1): patients with suspected oncological pathology; b(2): patients with suspected urgent disease such as medication-related osteonecrosis of the jaws (mronj), odontogenic abscesses, temporomandibular joint (tmj) dislocation, etc.). participation in the study required possession of a smartphone with internet access, e-mail and the use of a messaging service (whatsapp or telegram) to send photos and messages; completion by the patient of a covid-19 screening questionnaire; submission of a satisfaction questionnaire by the doctors and patients. a total of 90 patients were included in this study. a high percentage of satisfaction emerged from the analysis of the satisfaction questionnaires of both patients and doctors.tm thus represents an excellent opportunity to improve accessibility to oncological and non-management activities, reducing the risk of covid-19 dissemination and should be promoted and implemented in the post-pandemic era. to minimize the interruption of health services during the covid-19 pandemic, especially for urgent outpatient visits and oncological follow-up, tm meetings have been implemented and adopted by many academic medical centres, becoming an important tool in this period of limited face-to-face interaction [1, 2] . tm can be defined as the set of telematic technologies used to provide the patient with health care services-diagnosis, monitoring, therapy-at distance. it is therefore a distance delivery of health services. for the world health organization, tm literally means "remote healing" and indicates the use of technologies, information and communication to improve the health outcomes of patients, increasing access to medical care and information. what qualifies the tm is therefore the prefix "tele", that is the distance from the health worker who provides the service, regardless of the technology with which the contact is made. before the covid-19 pandemic, tm, although available for years, was gradually entering medical practice [3] and in any case used above all in chronic patients to offer home remote monitoring solutions that guaranteed continuity of care by int. j. environ. res. public health 2020, 17, 7365 2 of 11 preventing emergency situations and avoiding hospitalizations. usage was somewhat limited due to numerous regulatory restrictions. in italy as early as july 2012, the superior health council approved the italian guidelines on telemedicine, and according to experts of the time, technological innovation would have been able to reorganize healthcare through innovative care models, which would have facilitated access to services on the national territory. with the stipulation of the pact for digital healthcare in 2016, we continued to talk about tm as a means of providing healthcare services and the need to implement tele-visits, tele-consultations and tele-cooperation healthcare to achieve important system changes, as well as to achieve big savings. but what developments and benefits have there been in the meantime? what real benefits has the use of this "new" technology brought to doctors and patients? unfortunately, it is not easy to find data on the effective implementation of the pact and an emergency like covid-19 was necessary to return to talking about the usefulness of tm, although it is certain that communication technologies, such as smartphones, tablets and laptops, have supported the rapid development of telemedicine as a new concept of health care to provide remote assistance [4] [5] [6] . the most significant advantages of tm are consultation in real time and archiving and forwarding of data; however, tm is not without drawbacks: in fact, the first concern when it comes to telemedicine is always its accessibility because a availability of stable connections in remote areas is often problematic and increases the concern for poorer patients with limited access to the internet [7] . another obstacle is the impossibility of carrying out an adequate clinical examination at a distance, but the main problem is the selection of patients to be visited in the clinic and those to be subjected to remote visits [8, 9] . from the experience acquired by the authors during the covid-19 pandemic, it emerged that tm is indicated above all in the follow-up of cancer patients, because they are immunosuppressed for previous chemo/radiation treatments and therefore subject to greater risk of contagion, and chronic as well as urgent visits for suspected malignancy [10] . certainly, the covid-19 emergency made us talk about the usefulness of tm as it made it essential to resort to tele-medical practices to avoid overcrowding in hospitals and the risk of a massive spread of the virus also in hospitals. more precisely, this study describes its advantages in the management of outpatient maxillofacial surgical pathologies during the covid-19 pandemic. the study was conducted from 29 february to 30 april 2020 at the oral and maxillofacial surgery outpatient of "magna graecia" university of catanzaro, italy. our hospital was designed to be a regional reference centre for covid-19 because represents the only centre that has an intensive care unit with the ability to treat patients with severe forms of infection that require extracorporeal oxygenation (ecmo) techniques and with high specialization in the management of severe forms of acute respiratory distress syndrome (ards). a clinical management protocol for both suspected and confirmed cases was adopted and shared, in order to support the centres that require patients affected by related covid-19 ards forms to be centralized at our covid-19 centre. the study protocol, submitted to the ethical committee of the magna graecia university of catanzaro and with code reference number 146 of 21 may 2020, was conducted in accordance with the "ethical principles for medical research involving human subjects" described in the helsinki declaration. all patients gave their informed consent to their participation in the study and the storage of their data. all patients spontaneously joined the study and gave their consent to the data processing. the inclusion criteria of the study were the following: (1) possession of a smartphone with a video camera and microphone with internet access and an institutional email address in order to send imaging reports and photos to a device; (2) installation of the whatsapp or telegram applications that use end-to-end encryption for telephone messaging; (3) a completed covid-19 screening questionnaire (table 1) ; (4) a satisfaction questionnaire completed by the doctor and the patient ( table 2 ). the exclusion criteria were: (1) suspected or confirmed covid-19 positive patient (patients with claimed symptoms of covid-19); (2) patients with objective difficulties in participating in the study (inability to connect to the internet, the presence of diseases that conditioned the connection); (3) age under 18. the study included two different groups of patients: follow-up patients (group a) and patients with a first urgent visit (group b). (2) currently you prefer telemedicine to "face-to-face" evaluation? (2) was the method used safe? the a group is divided into two subgroups: • a 1 patients in oncological follow-up after surgical treatment performed before the covid-19 pandemic; • a 2 patients suffering from chronic lesions such as precancerous lesions, mronj; the b group is divided into two subgroups: • b 1 patients with suspected oncological pathology • b 2 patients with suspected urgent disease (mronj, odontogenic abscesses, tmj dislocation) before being subjected to a remote visit, all patients were contacted by telephone for adherence to the protocol and to explain the limits of the method related to not performing a physical examination in person and submitting the covid-19 screening questionnaire; the authorization to use telemedicine was obtained via recorded video or signature on a specific consent form and sent on the institutional email. for the scheduled video call, we were asked to dress professionally, minimize ambient sounds, make sure the physical environment was appropriate, hold the webcam directly in front of the face, keep all the imaging documentation related to the disease available. an alternative to "face-to-face" evaluation was offered in a timely manner in cases where the limitation of an incomplete physical examination could increase the risk of an incorrect diagnosis. if patients requested it, an electronic medical prescription could be sent to them at any time. for the patients of subgroup a 1 the evaluation was carried out through cd visualization, clinical photos taken by the patient or a family member, evaluation of symptoms. for the chronic lesions in follow-up (subgroup a 2 ) we considered any signs of deterioration through the modification of the tissue morphological characteristics, in the case of mronj the possible variation of the stage and the presence of infection signs were assessed. for the first visit procedures, for both subgroups, the evaluation of the clinical picture was conducted both through the video call that the evaluation of the clinical photos sent (necessary in the case of pathology of the oral cavity or laterocervical region) and through the display of symptoms. the data collected included: patient demographics, patient photos (head, neck, oral cavity), time consultation, doctor and patient feedback. the photos had to be taken by the patient himself or with the help of a direct relative using the camera of his smartphone to acquire only the following images: (1) a photo of the face and/or neck; (2) a photo of the oral cavity; (3) a photo of the maximum buccal opening with a visible millimeter ruler. this data had to be sent to the examiner's smartphone using a messaging service like whatsapp application that uses end-to-end encryption, so the communication between the sender's phone and the recipient's phone is secure. furthermore, the phone to which the photos were sent was only accessible to a small group of professionals through the use of specific authentication credentials. the photos and imaging reports were recorded in the patient's medical record (electronic or physical), consultations were not recorded. particular attention has been paid to the conservation, transmission and use of patient data, in compliance with the ethical and legal responsibilities of confidentiality and professional secrecy, in full compliance with the general data protection regulation (gdpr) in force since 4 may 2020. patients in both group a and b, for whom a biopsy was required, underwent a preoperational antimicrobial mouth rinse has been performed to reduce the number of oral microbes. however, as instructed by the guideline for the diagnosis and treatment of novel coronavirus pneumonia (the 5th edition) released by the national health commission of the people's republic of china, chlorhexidine, which is commonly used as mouth rinse in oral practice, may not be effective to kill 2019-ncov. since 2019-ncov is vulnerable to oxidation, pre-procedural mouth rinse containing oxidative agents such as 1% hydrogen peroxide or 0.2% povidone has been used, for the purpose of reducing the salivary load of oral microbes, including potential 2019-ncov carriage. healthcare staff used the following personal protective equipment (ppe): n95 or ffp2 mask, eye protection, fluid-resistant gown, and surgical gloves. the surgical therapeutic protocol adopted for surgical procedure included the use of scalpel over monopolar cautery for mucosal or skin incision and bipolar cautery on lower power setting for haemostasis and absorbable sutures. the patients were discharged after a period of observation in an individual room with home cold and medical therapy. descriptive statistical analyses were performed on the recorded data using absolute frequencies and percentages for categorical data. the recorded data were subjected to descriptive statistical analysis. both the central tendency indices (such as mean and median) and the absolute and relative frequencies were calculated using the graphpad program (graphpadcompany, san diego, ca, usa). a total of 90 patients were included in this study from 29 february to 30 april 2020 (table 3 ). in the study 54 patients were males (60%) and 36 females (40%) with a man to female ratio of 1.5:1. the range age was of overall 17 to 95 with a mean age of 62.15 years. of all patients, 37 were resident in the province of catanzaro and 53 were from other provinces of calabria with an average distance of 103 km between home and hospital. the a group included 63 follow-up patients: subgroup a 1 was formed by 54 patients (86%) with oncological pathology after surgical treatment performed before the covid-19 pandemic, subgroup a 2 was formed by nine patients (14%) with chronic lesions of which six were precancerous and three mronj (table 4 ). in the subgroup a 1 , for 44 patients (81%) the video consultation combined with imaging (computed tomography (ct), magnetic resonance imaging (mri), ultrasound neck and salivary lodges) and the clinical photos did not show signs of loco-regional and remote recurrence; for three patients (5%) of subgroup a 1 undergoing recent surgery for oral cancer, the examination of the photos required an advanced dressing ( figure 1 ). in seven cases the video consultation with imaging information and the symptoms that emerged from the interview (pain, burning and difficulty in chewing and speaking) were sufficient to determine the need of in-person consultation and in five cases the need for urgent surgery (figure 2 ). in these cases, the surgery was booked remotely and the final patient assessment was conducted on the day of their operation, reducing the time of surgery and the number of hospital visits. subsequently, the histological report confirmed the recovery of the disease. all group a patients, who underwent biopsy examination, sent photos on the third and seventh day post-surgery to check the locoregional conditions. on average, each consultation required 15 ± 5 minutes. the b group included 27 patients with "first urgent visit": subgroup b1 was formed by 12 (44.4%) patients of which three were for suspected skin cancer; eight for oral cancer and one for submandibular gland cancer; subgroup b2 was formed by 15 patients (55.5%) of which 7 for mronj, two for tmj dislocation, three for odontogenic abscesses, three for suspicion of acute salivary gland pathology (table 4 ). in seven cases the video consultation with imaging information and the symptoms that emerged from the interview (pain, burning and difficulty in chewing and speaking) were sufficient to determine the need of in-person consultation and in five cases the need for urgent surgery (figure 2 ). in these cases, the surgery was booked remotely and the final patient assessment was conducted on the day of their operation, reducing the time of surgery and the number of hospital visits. subsequently, the histological report confirmed the recovery of the disease. all group a patients, who underwent biopsy examination, sent photos on the third and seventh day post-surgery to check the locoregional conditions. on average, each consultation required 15 ± 5 min. in seven cases the video consultation with imaging information and the symptoms that emerged from the interview (pain, burning and difficulty in chewing and speaking) were sufficient to determine the need of in-person consultation and in five cases the need for urgent surgery (figure 2 ). in these cases, the surgery was booked remotely and the final patient assessment was conducted on the day of their operation, reducing the time of surgery and the number of hospital visits. subsequently, the histological report confirmed the recovery of the disease. all group a patients, who underwent biopsy examination, sent photos on the third and seventh day post-surgery to check the locoregional conditions. on average, each consultation required 15 ± 5 minutes. the b group included 27 patients with "first urgent visit": subgroup b1 was formed by 12 (44.4%) patients of which three were for suspected skin cancer; eight for oral cancer and one for submandibular gland cancer; subgroup b2 was formed by 15 patients (55.5%) of which 7 for mronj, two for tmj dislocation, three for odontogenic abscesses, three for suspicion of acute salivary gland pathology (table 4 ). the b group included 27 patients with "first urgent visit": subgroup b 1 was formed by 12 (44.4%) patients of which three were for suspected skin cancer; eight for oral cancer and one for submandibular gland cancer; subgroup b 2 was formed by 15 patients (55.5%) of which 7 for mronj, two for tmj dislocation, three for odontogenic abscesses, three for suspicion of acute salivary gland pathology (table 4) . according to the examination of the clinical photos and conversations with the patients of subgroup b 1 , an outpatient visit and simultaneous biopsy examination (two for the skin and four for the oral cavity) were necessary for six patients (figures 3 and 4) . for six patients of subgroup b 2 , an outpatient visit was necessary in two cases for the reduction of the tmj dislocation, in one for the drainage of a dental abscess ( figure 5 ) and in three for dressing and purulent collection drainage of mronj ( figure 6 ). all b group patients who underwent biopsy examination sent photos on the third and seventh day post-surgery to check the locoregional conditions. on average, each consultation required 15 ± 5 min. according to the examination of the clinical photos and conversations with the patients of subgroup b1, an outpatient visit and simultaneous biopsy examination (two for the skin and four for the oral cavity) were necessary for six patients (figures 3 and 4) . for six patients of subgroup b2, an outpatient visit was necessary in two cases for the reduction of the tmj dislocation, in one for the drainage of a dental abscess ( figure 5 ) and in three for dressing and purulent collection drainage of mronj ( figure 6 ). all b group patients who underwent biopsy examination sent photos on the third and seventh day post-surgery to check the locoregional conditions. on average, each consultation required 15 ± 5 minutes. according to the examination of the clinical photos and conversations with the patients of subgroup b1, an outpatient visit and simultaneous biopsy examination (two for the skin and four for the oral cavity) were necessary for six patients (figures 3 and 4) . for six patients of subgroup b2, an outpatient visit was necessary in two cases for the reduction of the tmj dislocation, in one for the drainage of a dental abscess ( figure 5 ) and in three for dressing and purulent collection drainage of mronj ( figure 6 ). all b group patients who underwent biopsy examination sent photos on the third and seventh day post-surgery to check the locoregional conditions. on average, each consultation required 15 ± 5 minutes. all patients contacted joined the study and were able to submit the requested photos and read and signed the administered satisfaction questionnaire. the analysis of the data obtained from the questionnaire administered to collect patient feedback (figure 7 ) has shown that: 1) 73% of patients found easy to participate in the consultation, 20% medium and 7% difficult. 2) 78% currently preferred telemedicine, 12% indifferent and 10% face-to-face consultation 3) 80% of patients chose video-telephone consultation rather than telephone consultation because they were able to see the doctor's face and because it was easier to describe the symptoms. 4) 92% of patients would recommend video consultation to others. the analysis of the data obtained from the questionnaire administered to collect the feedback from the doctors of maxillofacial surgery unit involved in the telemedicine service ( figure 8 ) has shown that: 1. 97% of doctors found it easy to participate in the consultation, 2% medium and 1% difficult. 2. the method proved to be 92% safe all patients contacted joined the study and were able to submit the requested photos and read and signed the administered satisfaction questionnaire. the analysis of the data obtained from the questionnaire administered to collect patient feedback (figure 7 ) has shown that: (1) 73% of patients found easy to participate in the consultation, 20% medium and 7% difficult. (2) 78% currently preferred telemedicine, 12% indifferent and 10% face-to-face consultation (3) 80% of patients chose video-telephone consultation rather than telephone consultation because they were able to see the doctor's face and because it was easier to describe the symptoms. the new coronavirus pandemic has dramatically affected health organizations around the world the analysis of the data obtained from the questionnaire administered to collect the feedback from the doctors of maxillofacial surgery unit involved in the telemedicine service ( figure 8 ) has shown that: 1. 97% of doctors found it easy to participate in the consultation, 2% medium and 1% difficult. 2. the method proved to be 92% safe 3. the resolution of the video image to evaluate facial asymmetries, the presence of swellings, bone exposures, skin and mucous membrane changes due to the presence of suspected lesion was 89% satisfactory 4. 98% of doctors would recommend video consultation to other colleagues. the new coronavirus pandemic has dramatically affected health organizations around the world and the effect on health systems, their resources and clinical services has been profound. because the new coronavirus is highly contagious, there has been an increasingly urgent need to devise and identify new patterns of care delivery to avoid "face-to-face" consultations between doctors and patient and to reduce the risk of transmission. in particular, maxillofacial surgeons, specialists much more at risk than others for close contact with the mouth and upper airways of patients during diagnosis and treatment, have been forced to find alternative ways of assistance in compliance with the new coronavirus pandemic has dramatically affected health organizations around the world and the effect on health systems, their resources and clinical services has been profound. because the new coronavirus is highly contagious, there has been an increasingly urgent need to devise and identify new patterns of care delivery to avoid "face-to-face" consultations between doctors and patient and to reduce the risk of transmission. in particular, maxillofacial surgeons, specialists much more at risk than others for close contact with the mouth and upper airways of patients during diagnosis and treatment, have been forced to find alternative ways of assistance in compliance with the new restrictions that the italian government has had to adopt for people, requiring them to stay at home and to limit their social life [11] . in italy, tm has played a decisive role in reducing the risk of spreading covid-19; in this period of health emergency, through videoconference and/or photography we were able to: • evaluate the surgical sites (possible presence of visible masses and/or local recurrences, evident lymphadenopathies, etc.), • discuss with the patient about the progress of oncological pathology, • view the cancer surveillance imaging, • allow the patient to ask questions and clear up doubts, • involve other specialists in the video-conference, because, as is known, the treatment of head-neck oncological pathology requires a multi-disciplinary approach (maxillofacial surgeon, radiotherapist, oncologist, nutritionist, etc.). we considered it essential to explain why we did not perform the physical visit, obtaining authorization from the patient to use remote assistance via recorded video, written message or signature of a specific consent form [12, 13] . the study showed that through an adequate anamnesis in the video call and the careful evaluation of the patient's photographic book it was able to satisfactorily check the patients in follow-up for neoplastic and chronic lesions (precancerous lesions, mronj) putting comparing the photos received with those included in the photographic archive of the structure [14] [15] [16] . the 15 patients who requested the first visit were managed with a remote consultation that considered as differentiable pathologies the three cases of sialadenitis, two cases of mronj and two odontogenic abscesses, to which we prescribed cold [17] , antibiotic and anti-inflammatory medical therapy and a subsequent remote revaluation at 7 and 15 days. it should be emphasized that in patients with suspicion of recurrence of neoplastic disease, telemedicine allowed us to recognize in 13% lesions with a high suspicion of malignancy that required immediate surgical intervention confirmed with histological examination in 9%. the high percentage of satisfaction that emerged from the analysis of the satisfaction questionnaires administered to the patient shows that telemedicine was well accepted especially by the patients residing in areas rather far from the structure, who had to travel a long way and above all be exposed to other patients who could be carriers of covid-19 and other more common infectious agents. above contact, although remotely, has positively influenced the patient's state of well-being, motivation and sense of security specially in this uncertain period. of all patients, 37 were resident in the province of catanzaro and 53 were from other provinces of calabria with an average distance of 103 km between home and hospital. in some of these countries, severe restrictions had also been adopted to strengthen the containment of covid-19. without digitization and an online conversation, the imposed social isolation would not have allowed for the follow-up of their clinical development. the limitations to the method were the impossibility of carrying out a complete clinical evaluation and a data connection that is not always reliable. this can be overcome by better documentation, shared decision-making and pragmatic management, because the covid-19 pandemic is an opportunity for healthcare organizations to reassess the crucial role played by telemedicine in the clinical mission, through the optimization of the software and procedures, together with the development of telesurgery due to improvements in 5g data transmission [18] . if implemented, the telemedicine platform will bring a variety of potential benefits for both patients and healthcare organizations [3, 19] . in the field of maxillofacial surgery, it will be possible to think of a wider use as in the traumatology which, as is known, does not represent an emergency condition but a deferrable urgency [20] . through a telematics meeting of a multidisciplinary team, it is possible to plan the treatment, through the visualization of the radiological images, and program the surgical intervention to minimize the duration of the hospital stay beyond that health spending. right now, telemedicine represents an excellent opportunity to improve accessibility to oncological and non-oncological treatments, compensating for the inevitable setbacks and opening a window for the future. the experience acquired by the authors during the covid-19 pandemic suggests that telemedicine is indicated above all in the follow-up of cancer patients, because they are immunosuppressed for previous chemo/radiation treatments and therefore subject to greater risk of contagion, in chronic as well as urgent visits for suspected malignancy and in patients who live far from a hospital. social distancing measures have made it difficult to access health facilities without while eliminating the risk of contagion between health personnel and patients. the government limitations implemented, the patient's awareness of being constantly monitored for his pathology through teleconsultation, contributed both to increasing patient compliance and to establishing a more effective doctor-patient relationship. the post-pandemic role of telemedicine depends on regulatory solutions which, in our opinion, will always have to take into consideration the empathic doctor-patient relationship, which would risk, pushing technology extremely, to a dehumanization of care. although the priority today is to limit the spread of covid-19, also we must think of an optimal and safe recovery of non-urgent medical activities that have been delayed due to the emergency and not to increase the spread of the infection within the healthcare facilities. in fact, the social distancing measures will make access to medical clinics difficult and will not eliminate the risk of contagion between health personnel and patients. telemedicine for cancer patients during covid-19 pandemic: between threats and opportunities covid-19 and telemedicine: immediate action required for maintaining healthcare providers well-being telemedicine and telementoring in the surgical specialties: a narrative review oculoplastic video-based telemedicine consultations: covid-19 and beyond telemedicine: patient-provider clinical engagement during the covid-19 pandemic and beyond telemedicine: its effects on health communication. health commun utilization of telemedicine among rural medicare beneficiaries a double chaotic layer encryption algorithm for clinical signals in telemedicine current use of telemedicine for post-discharge surgical care: a systematic review patient preferences on the use of technology in cancer surveillance after curative surgery: a cross-sectional analysis management in oral and maxillofacial surgery during the covid-19 pandemic: our experience optimizing patient surgical management using whatsapp application in the italian healthcare system a systematic review on the validity of teledentistry surgical approach to parotid pleomorphic adenoma: a 15-year retrospective cohort study jaw osteonecrosis in patients treated with bisphosphonates: an ultrastructural study diagnostic and therapeutic approach to sialoblastoma of submandibular gland: a case report. m effects of cold therapy in the treatment of mandibular angle fractures: hilotherm system vs. ice bag global telemedicine implementation and integration within health systems to fight the covid-19 pandemic: a call to action telemedicine and the covid-19 pandemic, lessons for the future the influence of socioeconomic factors on the epidemiology of maxillofacial fractures in southern italy key: cord-308005-t0bf5nos authors: iglesias-sánchez, patricia p.; vaccaro witt, gustavo fabián; cabrera, francisco e.; jambrino-maldonado, carmen title: the contagion of sentiments during the covid-19 pandemic crisis: the case of isolation in spain date: 2020-08-14 journal: int j environ res public health doi: 10.3390/ijerph17165918 sha: doc_id: 308005 cord_uid: t0bf5nos this study examines how confinement measures established during the covid-19 pandemic crisis affected the emotions of the population. for this purpose, public sentiment on social media and digital ecosystems in spain is analyzed. we identified affective tones towards media and citizens published on social media focusing on six basic emotions: anger, fear, joy, sadness, disgust and uncertainty. the main contribution of this work is the evidence of contagious sentiments and, consequently, the possibility of using this new dimension of social media as a form of a “collective therapy”. this paper contributes to understanding the impact of confinement measures in a pandemic from the point of view of emotional health. this analysis provides a set of practical implications that can guide conceptual and empirical work in health crisis management with an alternative approach, especially useful for decision-making processes facing emergency responses and health crises, even in an unprecedented global health crisis such as the traumatic events caused by the covid-19 disease. undoubtedly, the world is dealing with a health crisis unparalleled in this era that underscores a negative side of globalization. the world health organization (who) declared the covid-19 global pandemic in march 2020. although this kind of respiratory disease had already caused both widespread death and cases of infections in wuhan (china) since 2019, the health crisis did not show its true dimensions in europe up until february and march 2020. from then on, the race to combat the virus escalated worldwide. spain was one of the countries most affected by covid-19, establishing a nationwide state of alarm on march 14, 2020. consequently, the social distancing, self-isolation and quarantine measures in spain were radical and without precedent; such as the strict stay-at-home instruction for most of the citizens lasting almost two months, and ending with a progressive de-confinement process starting in the first week of may 2020. during this confinement period, spanish residents relied on digital ecosystems for disseminating and sharing information from official sources such as the government and health officials; and from the media and other peers. rodin et al. compiled a list of information producers in the case of a public health crisis that includes international and national public health organizations, national governments, non-governmental organizations, activist groups, news media and citizens [1] . furthermore, the communication is public and can be viewed without the need for subscription to the data source or explicit permission from the sender of the communication. the communication does not come from an advertising campaign. the communication has not been generated by automatic procedural methods (bots, fake posts, among others). the data was collected in the period from march 9 to may 1, 2020; thus, covering the beginning, peak and early de-confinement stages of the covid-19 related measures in spain. the collected communications were anonymized, eliminating authorship data, location, source, images, hyperlinks and non-textual components, to leave only the text corpus. the corpus of communications was analyzed using the natural language analysis tools (anl) provided by the ibm watson analytics service [17] . then, the corpus was analyzed again for confirmation purposes using the interval majority aggregation operator (isma-owa) [18] , which is designed for decision making in social media with consistent data, leveraged by the combination of computational intelligence and big data techniques [19] . the objective of the natural language analysis was to represent the subjective emotional response of the population as an objective and quantitative time series. the emotional response time series obtained in this way were: anger, disgust, joy, fear, sadness and uncertainty. the study period ranged from march 9 to may 1, 2020; and was divided into three distinctive stages. stage 1 ranged from march 9 to march 28. this stage covered the events starting with the announcement of the suspension of school activities in the basque and madrid autonomous communities of spain, flight cancellations from italy, nationwide suspension of university activities, the decree of the national state of alarm and the progressive temporary closure of non-essential businesses. stage 2 ranged from march 29 to april 9. this stage covered the events during the peak of the social distancing, self-isolation and quarantine measures in spain. most of the population, as well as non-essential workers remained at home. finally, stage 3 ranged from april 10 to may 1. this stage covered the events after the social distancing peak, including the extension of the state of alarm, the slow but progressive lessening of confinement measurements, some of the non-essential workers returned to their jobs, children were permitted to play outside, as well as asymmetric de-confinement measures, depending on the needs of the spanish autonomous communities. we expected to see significant differences in the emotional response of the population between the confinement stages. to test this, we performed a non-parametric kruskal-wallis h test, considering the stages as the independent variable and the emotional responses as the dependent variables. the normality of the measurement distribution for all the emotional response variables per stage was verified using kolmogorov-smirnov and shapiro-wilk tests. to further improve the qualitative analysis of the quantitative data, we performed a hierarchical linear smooth kernel regression on the emotional response time series, using the epanechnikov quadratic kernel [20] . this approach helps to reduce the noise inherent to data collected from digital ecosystems and provides a graphical representation of the emotion's tendency. the first hierarchy level corresponded to the complete study period, while the second hierarchy level corresponded to the stages separately. finally, we calculated the frequency of the words comprising the complete corpus dataset and determined the emotion polarity (positive or negative) related to them. all the above-mentioned statistical analyses were executed in ibm spss 27 (ibm: armonk, ny, usa). furthermore, the computational algorithms and natural language analyses were implemented in python 3 (python software foundation: wilmington, de, usa), using the natural language toolkit (nltk) [21] . the text corpus contained a total of 80,091 communications that were obtained from twitter (82.1%), youtube (12.3%), instagram (4.2%), official press websites (0.4%) and internet forums (1.0%). a chart of the normalized distribution of communications per day is shown in figure 1 , where 100 represents the maximum amount of communications obtained in a single day. this figure shows an increasing trend in the number of communications during stage 1, followed by a progressive decline in the proportion of communications during stages 2 and 3. the text corpus contained a total of 80,091 communications that were obtained from twitter (82.1%), youtube (12.3%), instagram (4.2%), official press websites (0.4%) and internet forums (1.0%). a chart of the normalized distribution of communications per day is shown in figure 1 , where 100 represents the maximum amount of communications obtained in a single day. this figure shows an increasing trend in the number of communications during stage 1, followed by a progressive decline in the proportion of communications during stages 2 and 3. from a generalized point of view, the kruskal-wallis h test showed that there was a statistically significant difference in emotional response score related to anger (χ2(2) = 17.806, p = 0.000), fear (χ2(2) = 6.462, p = 0.040), sadness (χ2(2) = 6.878, p = 0.032) and uncertainty (χ2(2) = 7.786, p = 0.020). on the other hand, there were no significant differences in the emotional responses related to disgust (χ2(2) = 1.368, p = 0.505) and joy (χ2(2) = 3.229, p = 0.199). due to the inherent differences between social media platforms, we conducted the same analysis on the communications from twitter, youtube, instagram, official press websites and internet forums separately. these results obtained from twitter are analogous to the generalized approach, where the kruskal-wallis h test showed that there was a statistically significant difference in emotional response score related to anger, fear, sadness and uncertainty (p < 0.05); while there were no significant differences in the emotional responses related to disgust and joy (p > 0.05). this phenomenon can be traced back to the fact that twitter provided most of the open-access communications available for this study. in a similar way, the communications obtained from youtube showed that there was a statistically significant difference in emotional response score related to anger, fear and sadness (p < 0.05), but no significant differences in the emotional responses related to uncertainty, disgust and joy (p > 0.05). the communications obtained from the instagram social media platform and online forums only showed statistically significant differences in the emotional response related to anger (p < 0.05), but no significant differences in the emotional responses related to fear, sadness, uncertainty, disgust or joy (p > 0.05). on the other hand, the communications obtained from official press websites did not show significant differences in any the emotional response scores measured (p > 0.05 in all cases). due to the small number of communications provided by these sources, it is difficult to establish the causes for this behavior in the emotional response. however, it is important to note that, the nature of from a generalized point of view, the kruskal-wallis h test showed that there was a statistically significant difference in emotional response score related to anger (χ2(2) = 17.806, p = 0.000), fear (χ2(2) = 6.462, p = 0.040), sadness (χ2(2) = 6.878, p = 0.032) and uncertainty (χ2(2) = 7.786, p = 0.020). on the other hand, there were no significant differences in the emotional responses related to disgust (χ2(2) = 1.368, p = 0.505) and joy (χ2(2) = 3.229, p = 0.199). due to the inherent differences between social media platforms, we conducted the same analysis on the communications from twitter, youtube, instagram, official press websites and internet forums separately. these results obtained from twitter are analogous to the generalized approach, where the kruskal-wallis h test showed that there was a statistically significant difference in emotional response score related to anger, fear, sadness and uncertainty (p < 0.05); while there were no significant differences in the emotional responses related to disgust and joy (p > 0.05). this phenomenon can be traced back to the fact that twitter provided most of the open-access communications available for this study. in a similar way, the communications obtained from youtube showed that there was a statistically significant difference in emotional response score related to anger, fear and sadness (p < 0.05), but no significant differences in the emotional responses related to uncertainty, disgust and joy (p > 0.05). the communications obtained from the instagram social media platform and online forums only showed statistically significant differences in the emotional response related to anger (p < 0.05), but no significant differences in the emotional responses related to fear, sadness, uncertainty, disgust or joy (p > 0.05). on the other hand, the communications obtained from official press websites did not show significant differences in any the emotional response scores measured (p > 0.05 in all cases). due to the small number of communications provided by these sources, it is difficult to establish the causes for this behavior in the emotional response. however, it is important to note that, the nature of official press tends to exhibit a more neutral emotion; therefore, the communications around these topics focus around discussion of facts and less intense emotional opinions. the linear smooth kernel regression of the emotional response time series using the epanechnikov quadratic kernel is shown in figure 2 . the horizontal axis represents the number of days that passed from the start of the study (9 march 2020) and the vertical axis represents the strength of the emotion, normalized from 0 to 1; where 0 is the lowest emotional intensity and 1 is the highest emotional intensity. moreover, the continuous black line represents the first hierarchical level, and the dashed dotted lines represent the second hierarchical level. official press tends to exhibit a more neutral emotion; therefore, the communications around these topics focus around discussion of facts and less intense emotional opinions. the linear smooth kernel regression of the emotional response time series using the epanechnikov quadratic kernel is shown in figure 2 . the horizontal axis represents the number of days that passed from the start of the study (9 march 2020) and the vertical axis represents the strength of the emotion, normalized from 0 to 1; where 0 is the lowest emotional intensity and 1 is the highest emotional intensity. moreover, the continuous black line represents the first hierarchical level, and the dashed dotted lines represent the second hierarchical level. the ratio of communications in isolation increased coinciding with the declaration of the state of alarm in spain, this increment is slightly faster than that of general communications about the covid-19 disease. the frequency of the words and the emotion polarity associated with them is displayed in figure 3 . the frequency ratio between words is expressed as the relative word size. on the other hand, the color represents the polarity in a scale ranging from bright green (absolute positive) to the ratio of communications in isolation increased coinciding with the declaration of the state of alarm in spain, this increment is slightly faster than that of general communications about the covid-19 disease. the frequency of the words and the emotion polarity associated with them is displayed in figure 3 . the frequency ratio between words is expressed as the relative word size. on the other hand, the color represents the polarity in a scale ranging from bright green (absolute positive) to bright red (absolute negative); and where black represents a neutral emotion. the words in the spanish language that expressed the highest frequency, in other words, the highest presence, are "casa" (house), "coronavirus", "cuarentena" (quarantine), "gente" (people), "personas" (people), "salir" (go out) and "termine" (end). moreover, most of the words shown in figure 3 are displayed in red, thus, representing a mostly negative emotion polarity, with a mean polarity of −0.3557 and a standard deviation of 0.2438. the exceptions to this negative trend are the words "mundo" (world), "medidas" (measures), "comer" (to eat) and "mantener" (to maintain); which showed a neutral-positive trend. int. j. environ. res. public health 2020, 17, x 6 of 10 bright red (absolute negative); and where black represents a neutral emotion. the words in the spanish language that expressed the highest frequency, in other words, the highest presence, are "casa" (house), "coronavirus", "cuarentena" (quarantine), "gente" (people), "personas" (people), "salir" (go out) and "termine" (end). moreover, most of the words shown in figure 3 are displayed in red, thus, representing a mostly negative emotion polarity, with a mean polarity of -0.3557 and a standard deviation of 0.2438. the exceptions to this negative trend are the words "mundo" (world), "medidas" (measures), "comer" (to eat) and "mantener" (to maintain); which showed a neutral-positive trend. the amount of user-generated content and social-media communications related to the social distancing, self-isolation and quarantine measures in spain increased rapidly and steadily during stage 1 of the study period. this coincided with the declaration of the sanitary state of alarm and the first of isolation measurements. a slight first peak in the raw amount of communications during this stage occurred between march 9 and 12, triggered by the suspension of academic activities in madrid and the announcement of the isolation measurements, respectively. moreover, the days near the end of the stage 1, around march 22, reported the highest amount of communications; matching the discussion about the first extension of the state of alarm. the communications gathered from stage 2 were focused around two main discussion areas. firstly, people were talking about the causes and effects of isolation; and secondly, the social media flourished with interesting proposals to cope with the isolation and stress of not being allowed to leave home. on the other hand, there was an increase in the amount of communications criticizing the government-imposed isolation measurements. stage 3 was the longest of the three stages, and marked the progressive lessening of the confinement measurements. the communications posted in online ecosystems during stage 3 showed an increased interest in the economic effects of the confinement in spain. then again, social media conversations gradually declined along with the reduction of the confinement measures ( figure 1) . results suggest that the isolation measures in spain significantly affected the emotions of the population. this effect is more noticeable through the anger emotional response. the smooth kernel regression of the anger timeline ( figure 2 ) shows its highest peak around the beginning of stage 2, the amount of user-generated content and social-media communications related to the social distancing, self-isolation and quarantine measures in spain increased rapidly and steadily during stage 1 of the study period. this coincided with the declaration of the sanitary state of alarm and the first of isolation measurements. a slight first peak in the raw amount of communications during this stage occurred between march 9 and 12, triggered by the suspension of academic activities in madrid and the announcement of the isolation measurements, respectively. moreover, the days near the end of the stage 1, around march 22, reported the highest amount of communications; matching the discussion about the first extension of the state of alarm. the communications gathered from stage 2 were focused around two main discussion areas. firstly, people were talking about the causes and effects of isolation; and secondly, the social media flourished with interesting proposals to cope with the isolation and stress of not being allowed to leave home. on the other hand, there was an increase in the amount of communications criticizing the government-imposed isolation measurements. stage 3 was the longest of the three stages, and marked the progressive lessening of the confinement measurements. the communications posted in online ecosystems during stage 3 showed an increased interest in the economic effects of the confinement in spain. then again, social media conversations gradually declined along with the reduction of the confinement measures ( figure 1) . results suggest that the isolation measures in spain significantly affected the emotions of the population. this effect is more noticeable through the anger emotional response. the smooth kernel regression of the anger timeline ( figure 2 ) shows its highest peak around the beginning of stage 2, roughly around march 29. it is important to notice that results also suggest that the isolation measures did not affect the joy or the disgust emotional responses of the population. the smooth kernel regression of the joy timeline ( figure 2) shows a steady increase during stage 1 and a horizontal stabilization during stages 2 and 3. the results show that all the studied emotional responses have an important presence during the analyzed isolation period; apart from disgust, that registered a minimal presence. the highlights of the emotional responses are detailed in table 1 , alongside the date that is most closely related to each event. some of the countries most affected by covid-19 experienced a decrease in infection rates, e.g., germany, and others; that started to implement some measures in order to lessen the impact of isolation in the economy. a new procedure to count the covid-19 cases was implemented and suggested a possible decline in the number of real cases reported. children under 14 years of age were allowed to play outside for one hour per day. the spanish government declared a national state of alarm and launched an advertising campaign on social media using the hashtag #estevirusloparamosunidos (that means "we will stop this virus together") massive applause to recognize the contribution and courage of medical staff. international media harshly criticized the spanish government for their management of the health crisis. 10/04 the daily death toll is estimated to be around 700 deceased. slight increase of daily death toll. the social media coverage of isolation was extensive, and a broad array of topics were addressed, as shown in figure 3 . however, there are four main topic groups: firstly, those that are specifically focused on the covid-19 illness, mainly regarding deaths, treatments and infection rates. secondly, those concerning lockdown, including self-isolation, confinement, home, family and going out. thirdly, there are topics that show society's concerns due to the uncertainty of the situation and its consequences, such as money, work, hunger, help and world. lastly, there were other topics that could not be classified within the first three groups, such as gratitude, donations, personal protection equipment and solidarity. moreover, it should be noted that, when considering daily usage of twitter hashtags during the pandemic, some of the most widely used during the study period were #yomequedoencasa (i am staying at home) and #quedatencasa (stay at home) with the intention of urging people to stay at home. the effect of these kinds of conversations in social media can also be appreciated in figure 3 , as the frequency of words such as "cuarentena" (quarantine) and "casa" (home) are very high. furthermore, this also explains the prevalence of words such as "salir" (go out) "termine" (finish), since people were also discussing their desire for this situation to end. it should be noted that the emotional response timelines displayed in figure 2 suggest a pattern of polarization on the topic of isolation. many communications expressed personal experiences, sentiments and proposals to stay at home, even initiatives to support medical staff and other front-line professionals; especially during the first half of the study period, in other words, near the end of stage 2. on the other hand, during stage 3 the focus of the citizens shifted towards the effects of the confinement measures, and the possible negative consequences of the new normality. regarding the coexistence of feelings, it should be noted that there are some events that clearly show the synergies of feelings. for example, march 27 marks the beginning of widespread temporary employment regulations in spain, designed to mitigate the economic consequences of the covid-19 pandemic. the peaks of joy and sadness reflect the mixed feelings on this issue (figure 2 ). another example of synergism between joy and fear happened on april 26. on this date the government allowed children under 14 years old to play outside. this was an expected measure, but a large portion of the population was worried about a possible new peak in infections. moreover, during the first days of stage 1, both anger and fear displayed a slight peak in the second hierarchical level of analysis, in other words, the dotted lines in figure 2 . the death toll seems to be the main cause of this peak; nevertheless, this behavior shifted towards the end of stage 3, where people expressed their concerns about the new normality. the analysis of the emotional content in the context of isolation due to covid-19 provides valuable insights into how sentiments are affected by confinement measures and how they are expressed and spread on social media. previous literature has addressed this issue by focusing on economic and financial crisis impacts [6] and how media content studies have been applied in health crisis management, which have been observed more from the communication point of view and more specifically through a public relations lens [1, 4] . although some authors have already pointed out that feelings expressed in online conversations can be contagious both in a positive [9, 15] and a negative way [11] [12] [13] , this work covers the gap by analyzing the public's sentiments in digital ecosystems as a health issue. the emotional reactions detected were in line with the general sentiment captured by the analysis of thelwall et al. [8] and neubaum and krämer [10] . the commentaries featured in online conversations highlight the societal impact and health implications of the pandemic as well as their implications in the global health crisis. additionally, it coincides with thelwall et al. [8] that sentiment detection in social media is challenging and can provide an interesting insight into facing the crisis, especially for those institutions with competences in this field. in any event, there are a few literature works focused on monitoring sentiments in social media [9, [11] [12] [13] 15] but not many through a health lens [5, 7] while taking into account the usefulness of analysis in health crisis management by considering all the responsible actors. this research is limited to the analysis of communications freely available in digital ecosystems; therefore, we consider that further studies using public opinion surveys, which could deepen the understanding of the emotional responses of the population, are needed. furthermore, this research focused solely on the hardest stages of covid-19 isolation in spain; thus, we recommend this study be replicated for other countries. the social distancing, self-isolation and lockdown measures in spain significantly affected the emotions of the population. furthermore, the driver of these emotions evolved and shifted during the stages of the confinement. the results of this study provide a snapshot of the emotional response of the spanish population during the covid-19 isolation. likewise, a repository of emotional content of an unprecedented outbreak is provided. furthermore, it reveals that social media can be a form of "social therapy" and a suitable approach for health crisis communication. this research responds to the lack of research at the intersection of emotional responses during crisis situations and, particularly to those related to public health and social media. moreover, the findings of this study provide valuable insights based on the repository of emotional content of a traumatic event such as the covid-19. the findings of this research are useful for encouraging health institutions to improve the management of social media and digital ecosystems during a health crisis; and to polish 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type? an international cross-sectional survey of emotions associated with alcohol consumption and influence on drink choice in different settings negative emotions and emotional eating: the mediating role of experiential avoidance emotion regulation as a moderator between anxiety symptoms and insomnia symptom severity rumor acceptance during public health crises: testing the emotional congruence hypothesis an internet-based intervention to alleviate stress during social isolation with guided relaxation and meditation: protocol for a randomized controlled trial population figures (cp) as of automating visualization, descriptive, and predictive statistics decision making in social media with consistent data. knowl.-based syst estimating the importance of consumer purchasing criteria in digital ecosystems non-parametric estimation of a multivariate probability density. theory probab. its appl natural language processing with python this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord-342415-j3fv7u2d authors: dietler, dominik; lewinski, ruth; azevedo, sophie; engebretsen, rebecca; brugger, fritz; utzinger, jürg; winkler, mirko s. title: inclusion of health in impact assessment: a review of current practice in sub-saharan africa date: 2020-06-10 journal: int j environ res public health doi: 10.3390/ijerph17114155 sha: doc_id: 342415 cord_uid: j3fv7u2d natural resource extraction projects, including those in the mining sector, have various effects on human health and wellbeing, with communities in resource-rich areas in sub-saharan africa (ssa) being particularly vulnerable. while impact assessments (ia) can predict and mitigate negative effects, it is unclear whether and to what extent health aspects are included in current ia practice in ssa. for collecting ia reports, we contacted 569 mining projects and 35 ministries regulating the mining sector. the reports obtained were complemented by reports identified in prior research. the examination of the final sample of 44 ia reports revealed a heavy focus on environmental health determinants and included health outcomes were often limited to a few aspects, such as hiv, malaria and injuries. the miniscule yield of reports (1.6% of contacted projects) and the low response rate by the contacted mining companies (18%) might indicate a lack of transparency in the ia process of the mining sector in ssa. to address the shortcomings identified, policies regulating ia practice should strengthen the requirements for public disclosure of ia reports and promote a more comprehensive inclusion of health in ia, be it through stand-alone health impact assessment or more rigorous integration of health in other forms of ia. impact assessment (ia) is an established approach to minimize adverse environmental, social and health impacts of projects, policies and programs, while fostering opportunities for equitable and sustainable development [1] [2] [3] . the first legislation promoting ia dates back more than 50 years, when legislation on environmental impact assessment (eia) was introduced in the united states [3] . passed in 1969, this legislation required human health to be included as part of the assessment. since then, the field of ia has evolved and diversified. during the 1970s, the social impact assessment (sia) approach was established, placing particular emphasis on the interrelations between the environmental and social impacts, including health [1, 3] . with the aim to more specifically address potential impacts of projects, programs, plans and policies on human health as a stand-alone process, health impact assessment (hia) was introduced in the late 1980s/early 1990s [2, [4] [5] [6] . over the past 30 years, the methodology and approach for assessing health impacts has been further developed [7] . at present, for member countries of the extractive industries transparency initiative (eiti), a request to their contact person was sent. all messages were sent either through a contact form on the company/ministry web page or directly by e-mail. a maximum of two reminders at an interval of at least 2 weeks were sent if the contacts did not respond to the initial message. the messages to the companies were sent between november 2018 and may 2019, those to the ministries and eiti representatives between may and july 2019. publicly available reports were searched online through google and company web pages. in the google search engine, a systematic online search was conducted using boolean operators. separately for each country in ssa, the term "impact assessment" and terms representing an activity of natural resource extraction projects ("natural resource or mine or mining or dam or drilling or gas or hydrocarbon or oil or petrol or hydroelectricity or hydropower or biofuel or electricity or exploration or exploitation or extraction") were combined with the different spellings for the respective country (e.g., "côte d'ivoire" or "ivory coast"). initial piloting of the search methodology revealed that most of the relevant documents were found among the first 50 hits. of note, this search terminology also served another research component that systematically searched contents of ia reports of a broader spectrum of large natural resource extraction projects [37] . for the current analysis, the full sample of reports retrieved was reduced to include mining projects only. the search was carried out in october and november 2018 in switzerland. additionally, the web pages of the contacted companies were visited to check the public availability of ia reports. if no direct link to the company was available in the mining database, the project and the company operating or owning the project were searched on google. all web pages were visited in may 2019. an ongoing research initiative, the "health impact assessment for sustainable development" (hia4sd) project [38, 39] aims at generating a deeper understanding of health impacts of natural resource extraction projects in burkina faso, ghana, mozambique and tanzania. as part of the research activities, in-country project partners established contacts with mining companies and ministry representatives and obtained reports between march 2018 and january 2019. as a result, ia reports were made available either directly by the companies or by the national environmental authorities. request to their contact person was sent. all messages were sent either through a contact form on the company/ministry web page or directly by e-mail. a maximum of two reminders at an interval of at least 2 weeks were sent if the contacts did not respond to the initial message. the messages to the companies were sent between november 2018 and may 2019, those to the ministries and eiti representatives between may and july 2019. publicly available reports were searched online through google and company web pages. in the google search engine, a systematic online search was conducted using boolean operators. separately for each country in ssa, the term "impact assessment" and terms representing an activity of natural resource extraction projects ("natural resource or mine or mining or dam or drilling or gas or hydrocarbon or oil or petrol or hydroelectricity or hydropower or biofuel or electricity or exploration or exploitation or extraction") were combined with the different spellings for the respective country (e.g., "côte d'ivoire" or "ivory coast"). initial piloting of the search methodology revealed that most of the relevant documents were found among the first 50 hits. of note, this search terminology also served another research component that systematically searched contents of ia reports of a broader spectrum of large natural resource extraction projects [37] . for the current analysis, the full sample of reports retrieved was reduced to include mining projects only. the search was carried out in october and november 2018 in switzerland. additionally, the web pages of the contacted companies were visited to check the public availability of ia reports. if no direct link to the company was available in the mining database, the project and the company operating or owning the project were searched on google. all web pages were visited in may 2019. an ongoing research initiative, the "health impact assessment for sustainable development" (hia4sd) project [38, 39] aims at generating a deeper understanding of health impacts of natural resource extraction projects in burkina faso, ghana, mozambique and tanzania. as part of the research activities, in-country project partners established contacts with mining companies and ministry representatives and obtained reports between march 2018 and january 2019. as a result, ia reports were made available either directly by the companies or by the national environmental authorities. in a first step, the eligibility of the reports was assessed. reports were excluded if (i) not all ia reports were available for projects for which multiple assessments were conducted (e.g., only sia was available that was conducted in connection with an eia); (ii) it represented only a summary of the assessment (e.g., environmental impact statement); or (iii) the project was not rated as a category a project according to the international finance corporation (ifc)'s environmental and social categorization, so that the sample includes only projects "with potential significant adverse environmental or social risks and/or impacts that are diverse, irreversible, or unprecedented" [40, 41] . category a projects, such as most large-scale mining projects, are required to conduct a comprehensive ia, including a thorough assessment and data collection for informing potential health impacts [40, 42] . more specifically, in contexts where availability and quality of health-related data are limited, the collection of primary data in affected communities is indicated for ensuring a robust evidence-base for the ia and enabling monitoring of health impacts over time [43] . the second step comprised of examining the full ia reports for their consideration of different health factors. additionally, to assess the completeness of the executive summaries, the summaries of the ia reports found through the google search were screened separately. the screening followed the same methodology for both, the full ia reports and the sample of executive summaries. for each report section (e.g., baseline, impact assessment, mitigation measures and monitoring plan), information on the inclusion of different health aspects was extracted. an adapted analysis framework from quigley et al. [44] , the ifc hia guidelines [43] and winkler et al. [20] was used, which comprised 4 health determinant categories (table a1 ) and 10 health outcome groups (table a2 ). in total, 23 specific health determinants and 35 health outcomes were identified. furthermore, the data sources that the ias used for the health baseline assessment were categorized into different primary and secondary data source categories. the primary data sources consisted of key informant interviews (kiis), focus group discussions (fgds), household surveys (hhs) and biological or environmental samples, including field observations. the options for the secondary data sources included routine health surveillance data (e.g., health facility data, district health information system 2 (dhis 2) data), national and regional surveys (e.g., demographic and health surveys (dhs) and multiple indicator cluster surveys (mics)), official government statistics (national or local), peer-reviewed articles and grey literature. other data sources that might be relevant were classified as "other primary data source" and "other secondary data source". full reports that were electronically available were screened by two authors (d.d. and r.l.), while executive summaries were examined by a third author (s.a.). case study reports that were only available in printed form were examined by the hia4sd project research associates in the respective countries. parallel screening of the reports and validation of the results ensured the consistent application of the methodology across all assessors. to facilitate data entry during the screening stage, the assessors used an online survey tool (www.surveymonkey.com). the survey data were extracted and summary statistics generated using r version 3.5.1 (r foundation for statistical computing, vienna, austria) [45] . the unit of analysis were the projects. hence, if more than one ia report was available for a specific project (e.g., a hia was conducted together with an eia), the health aspects included in the different reports were combined. the statistics are presented for different aspects for each health determinant and outcome. comparisons were made between the different report sections and report types (health-specific ia (hia and eshia) vs. non-health-specific ia (eia, sia or esia)). as shown in figure 1 , a total of 54 ia reports were obtained. reaching out to contacts of 569 mining projects and representatives from ministries in 35 countries of ssa yielded only 9 and 4 reports, respectively. through the systematic google search, 14 reports were found. additionally, the ia reports of 9 companies were readily available on company web pages. the sample was completed by 18 reports obtained from case studies in the hia4sd project. among the case study reports, 2 were also found on the company web pages and 2 were made available by company contacts. furthermore, 1 report was shared directly by a company contact and publicly on the web page. two reports were excluded from the analysis because only part of the ia documents were available. additionally, 3 reports considered only the expansion of existing projects and, thus, did not necessarily require a full ia (i.e., not category a projects). our final sample included 44 ia reports. panel a in figure 2 shows the geographic distribution of the 44 included ia reports as well as the location of the 569 contacted mining projects in ssa. reports from 18 different countries were obtained. most reports stemmed from the hia4sd project countries, namely ghana (n = 8), burkina faso (n = 4), mozambique (n = 4) and tanzania (n = 3). furthermore, a sizable number of reports of projects in malawi (n = 5) and the democratic republic of the congo (n = 4) were shared. of note, despite hosting the vast majority of mines listed in the s&p mining database (n = 263) very few reports (n = 3) could be retrieved from south africa. a broad variety of ia report types were collected (see figure 2 , panel b). for some projects, more than one type of ia report was available. most of the reports were eias (n = 28), which were often conducted alongside sia, hia and esia. only 8 reports were obtained that addressed health by design (i.e., hia and eshia). a temporal pattern is visible in the publication year of the ia reports (see figure 2 , panel c). most of the reports were published in 2010 or later (n = 28). only 3 of the reports were published before 2000. figure 3 provides an overview of the percentage of ia reports considering the screened health determinants. large differences were observed between the health determinants. while the environmental determinants were considered in most ia reports, the social determinants and institutional factors were less often included. some particular aspects received little attention, including the capacity of maternal and child health services, as well as access and capacity of traditional health services. the impacts on individual health risk factors, such as alcohol consumption, tobacco or drug use, were least frequently assessed. overall, the number of health determinants considered decreased with later sections of the ia reports (i.e., mitigation and monitoring plan). the average percentages of health determinant items included were 65.4%, 61.2%, 54.7% and 39.3% in the baseline description, impact assessment section, mitigation plan and monitoring plan, respectively (see table a3 ). health outcomes were less frequently included in the ia reports than health determinants ( figure 3 and table a4 ). overall, a third (35.9%) of health outcomes were considered across the report sections, compared to 76.8% for the health determinants. in the ia chapters, only 19.4% of health outcomes were included. figure 3 provides an overview of the percentage of ia reports considering the screened health determinants. large differences were observed between the health determinants. while the environmental determinants were considered in most ia reports, the social determinants and institutional factors were less often included. some particular aspects received little attention, including the capacity of maternal and child health services, as well as access and capacity of traditional health services. the impacts on individual health risk factors, such as alcohol consumption, tobacco or drug use, were least frequently assessed. overall, the number of health determinants considered decreased with later sections of the ia reports (i.e., mitigation and monitoring plan). the average percentages of health determinant items included were 65.4%, 61.2%, 54.7% and 39.3% in the baseline description, impact assessment section, mitigation plan and monitoring plan, respectively (see table a3 ). health outcomes were less frequently included in the ia reports than health determinants ( figure 3 and table a4 ). overall, a third (35.9%) of health outcomes were considered across the report sections, compared to 76.8% for the health determinants. in the ia chapters, only 19.4% of health outcomes were included. colors represent the percentage of reports or report sections considering the specific health aspect. red shading indicates percentages below 50%, blue shadings above 50%. acc. = access; cap. = capacity; cd = communicable disease; mch = maternal and child health; resp. = respiratory; trad. = traditional. in impact assessment reports. colors represent the percentage of reports or report sections considering the specific health aspect. red shading indicates percentages below 50%, blue shadings above 50%. acc. = access; cap. = capacity; cd = communicable disease; mch = maternal and child health; resp. = respiratory; trad. = traditional. only 8 health outcomes were included in more than 50% of the reports. among them were, in decreasing order, hiv/aids, traffic-related injuries, work-related injuries, malaria, diarrhea, acute respiratory infections, tuberculosis and undernutrition. zoonoses, mental health, non-communicable diseases and vector-borne diseases other than malaria received less attention. similarly to the health determinants, health outcomes were more often considered in the baseline and impact assessment chapters than in the mitigation and monitoring plans. mitigation measures for specific health outcomes were proposed in few of the ia reports. figure 4 shows the percentages of different data sources used as baseline indicators among the ia reports considering the respective health determinants or outcomes. overall, primary data were collected predominantly for the health determinants. for measuring health outcome indicators, primarily secondary data sources were used. collection of primary data pertaining on baseline conditions among the potentially affected communities through participatory approaches, such as kiis, fgds or hhs, was rare (see also table a5 ). for all health-related aspects, peer-reviewed literature was consulted in only a few instances. for the assessment of environmental determinants (e.g., air quality, water quality and quantity or noise) a comprehensive sample collection was often conducted. in some cases, these aspects were even assessed in separate specialist reports. in contrast, qualitative information from kiis and fgds were more often used to assess the social determinants of health. for some aspects related to access and capacity of public services (e.g., health and education), secondary data, such as official statistics, were also used. in most cases, secondary information for the baseline of specific health outcome indicators stemmed from health facility data or official statistics. if primary data were used, it was mostly qualitative data obtained from kiis or fgds. . data sources used for assessing health aspects in impact assessment reports. the height of the bars indicate the percentage of reports using any primary (blue bars) and any secondary (red bars) data source for the different health aspects. bar widths indicate the number of reports considering the specific health aspect (used as denominator for determining the bar height of the respective aspect). acc. = access; cap. = capacity; mch = maternal and child health; resp. = respiratory; trad. = traditional the differences in the percentages of ia reports addressing the various health aspects in health-specific ia (i.e., hia and eshia; n = 8) and non-specific ia (i.e., eia, esia and sia; n = 36) are shown in figure 5 . almost all health determinants and outcomes were more prominently featured in the ia reports addressing health by design. among the health determinants, aspects related to access and capacity of traditional health services were included more frequently in health-specific ia reports. the differences were less pronounced for the environmental determinants of health. with regards to the health outcomes, 32 of 35 studied items were more often considered in projects for which a health-specific ia was conducted. differences of at least 50 percentage points were observed for tuberculosis, arboviral diseases (e.g., chikungunya, dengue and yellow fever), the non-communicable diseases diabetes and chronic respiratory diseases, anemia and tuberculosis. on the other hand, work-related injuries were featured more often in projects for which no health-specific ia was conducted. figure 5 . difference in percentages of impact assessment (ia) reports including the different health determinants and health outcomes between health-specific ia reports and non-health-specific ia reports. blue bars indicate more frequent consideration of the respective health determinant/health outcome in health-specific ia reports; red bars indicate more frequent consideration in non-health-specific ia reports. missing bars indicate a difference of 0%. acc. = access; cap. = capacity; eshia = environmental, social and health impact assessment; hia = health impact assessment; mch = maternal and child health; resp. = respiratory; trad. = traditional. the representation of health aspects in the executive summaries of the ia reports was analyzed and compared to their corresponding full reports ( figure 6 ). the executive summaries frequently omitted information on the different health determinants and health outcomes, although they were included in the full texts. similar to the full texts, the executive summaries mainly featured information on environmental determinants of health. some health outcome categories, such as soil-, water-and waste-related diseases, non-communicable diseases, food-and nutrition-related diseases, maternal and child health or mental health, were not included in the executive summaries despite some full reports having considered these aspects (indicated as missing bars in figure 6 ). leishmaniasis, hepatitis a/e, food-borne diseases and self-harm/suicide were excluded from this analysis because they were not considered in any of the full texts. overall, 44 ia reports from 18 countries in ssa were obtained from various sources and analyzed for the inclusion of health. we reached out to as many as 569 mining projects and 35 ministries. however, only 13 reports were obtained from these contacts and sources. public access to ia reports on the internet was also limited; only 21 ia reports were readily accessible online. screening of the reports revealed a heavy focus on environmental determinants of health. health outcomes were considered to a lesser extent than the health determinants. still, some health outcomes, such as malaria, hiv, diarrheal diseases or injuries, were more frequently included. furthermore, other health aspects, such as zoonoses, mental health issues, non-communicable diseases and food-and nutrition-related issues, received little attention. reports that had a specific focus on health (i.e., hia and eshia) addressed substantially more health aspects than other reports. primary data were frequently collected along with secondary data as indicators for the health determinants, particularly for environmental factors. for health outcomes, primary data collection was the exception rather than the norm. participatory data collection approaches with affected communities through kiis, fgds or hhs were rarely conducted. the ifc's sustainability framework through its performance standards on environmental and social sustainability sets out the requirements for the management of environmental and social risks of industrial investment projects [42] . the ifc performance standards have been adopted by the equator principles financial institutions (epfi), a consortium that currently embraces more than 100 banks and financial institutions [46, 47] . since the ifc's sustainability framework is considered an international benchmark for identifying and managing environmental, social and health risks [48, 49] , this standard is also applied in this discussion chapter for reflecting on our findings stemming from a comprehensive review of the available ia reports. the ifc performance standards require projects to publicly disclose information on project-related risks and impacts to affected communities [42] . the scope of this information can range from full ia reports to short summaries of findings, depending on the project size and magnitude of anticipated impacts [42] . for ifc-funded projects, the bank itself publishes a summary of the main findings of the ia [50] . in our study, only a miniscule 1.6% of the 569 contacted large-scale mining projects shared their report, while more than 80% did not respond at all to our data inquest, despite an offer of strict confidentiality. the extremely low yield of ia reports indicates that there is a lack of transparency in current ia practice in the mining sector of ssa. research on public disclosure in ia practice from low-human development index (hdi) countries is scarce. in myanmar, a lack of public disclosure of eia reports conducted for the oil and gas sector was described, although improvement has been seen in recent years [51] . instead of disclosing the full ia reports, often, only the executive summaries are published, thereby fulfilling the minimum requirements set out in the ifc performance standards. however, our results indicate that these summaries do not offer sufficient insights to inform the public about the potentially broad set of impacts on health. hence, more stringent requirements for public disclosure of the full ia reports would contribute to increase the accountability of large industrial mining companies and other large-scale infrastructure projects [51] . hence, in addition to legal texts regulating ia practice, the need for public disclosure of full ia reports for projects should also be more explicitly demanded in policies and guidelines of international financing institutions (e.g., ifc), industry peak bodies (e.g., international council on mining and metals) and private companies. for large-scale projects (i.e., category a) the ifc performance standards [42] and the world bank's operational policies [40] further require a comprehensive assessment of the project impacts, including aspects of human health and safety. furthermore, different guidance and scientific documents promote a comprehensive approach to health in hia, covering the full spectrum of aspects determining human health, especially in complex social-ecological contexts of ssa [44, 52, 53] . in our sample of ia reports, on average only about a third of investigated health outcomes were included and among the health determinants there was a strong focus on the physical environment. moreover, when health was integrated in other types or ias (i.e., eia, esia and sia), a more narrow range of health aspects were covered. this pattern has been seen in other parts of the world. for example, a lack of inclusion of health aspects was found in eia reports from the united states [11] , australia [12, 15, 16] and vietnam [54] . furthermore, the assessment of health impacts within eias from australia was mainly limited to risks related to the physical environment [12] . consistently, in hias from low-and middle-income countries, a lack of consideration of the social determinants of health was seen [55] . this may be linked to the limited technical expertise to conduct hia in many parts of the world [7] . in order to address this constraint, hia capacity building efforts are needed that do not only aim to build up technical capacity among ia practitioners but also provide trainings to regulators in governments and international financing institutions to appraise ia reports from a health perspective [7, 53] . the strengthening of regulatory frameworks that specify under what circumstances hia is required, and to what extent, could be an important initial step for triggering the demand in hia capacity building in resource-rich countries of ssa [7, 18] . finally, in light of the health aspects currently not included in ia practice, it should be reflected whether national and international ia guidance documents provide sufficient details on the scope of health to be considered in the ia process. a comprehensive assessment of health impacts, as required by the ifc performance standards, comprises data collection on health aspects in affected communities [42, 43] . particularly in mining areas in low-hdi countries, the demographic, social-economic, environmental and epidemiological characteristics further warrant the collection of additional local-level data [56] . however, in the ia reports obtained and scrutinized in the present study, primary data were predominantly collected for aspects related to the physical environment. for health outcomes, the assessments often relied on secondary data sources, such as coarse national and regional-level statistics or local health facility data. although these data sources hold considerable potential for monitoring health indicators, they are prone to low data quality [55, 57] . the collection of local-level data by means of kiis, fgds and hhs is an additional means to engage affected groups in the ia process and can help identify and address local health impacts among vulnerable and marginalized populations [58] [59] [60] [61] [62] [63] . comprehensive baseline health data collection requires broad public health expertise among practitioners conducting the ia [26, 64, 65] . however, health specialists in countries of ssa are rarely engaged in ia and often have limited awareness and knowledge about the ia process [19] . for the health sector to be more actively engaged in hia, capacity building efforts should reach out beyond the public health sector (e.g., actors in overseeing ministries) to increase the understanding of the skill set required for conducting a thorough assessment of health impacts [19, 53] . for this study, we attempted to pursue the different options that affected community members have at their disposal for accessing ia reports. physical contacts with project proponents or local authorities within the countries may potentially have increased the yield of reports. however, given that only 18% of companies responded to our data inquiry indicates that project representatives are difficult to approach. the resulting small and geographically clustered sample of ia reports limits the representativeness of our sample from which we derive our conclusions. furthermore, the analysis only assessed whether and to what extent health issues were addressed. an analysis of the interrelationships between the different health aspects or of the quality of the assessment itself (e.g., the necessity of primary data collection) was beyond the scope of our study. for conclusively judging the appropriate use of different data sources, a more in-depth study is needed, taking into account local characteristics and the quality of alternative data sources. this comprehensive review of ia reports of mining projects in ssa points at three main shortfalls of current ia practice: (i) lack of transparency; (ii) narrow scope of considered health aspects, with a strong focus on the physical environment; and (iii) lack of local-level primary data collection on health outcomes. there are different potential approaches to address these shortcomings at the national and international level. at the national level, ministries overseeing ia should reconsider how health is addressed in regulatory frameworks and policies regulating ia practice. this should include critical reflections on whether there is sufficient specificity provided in terms of methodological guidance on how to assess health impacts (i.e., the width (range of potential impacts) and depth (quality of the evidence-base) of the assessment) either in hia as a stand-alone approach or integrated in other forms of ia. furthermore, there is a need to understand whether existing frameworks provide sufficient guidance as to which expertise is needed for leading the assessment of health impacts. in addition, regulatory frameworks should be revised if they do not sufficiently promote disclosure of ia findings, with particular considerations for health-related information. at the international level, financing institutions, such as the ifc and the members of the epfi, can play a crucial role in closing the identified gaps. this can be done by setting and enforcing more stringent requirements for public disclosure of full ia reports along with strengthening guidance on how health needs to be included in different forms of ia in order to achieve consistency in quality. finally, any efforts in promoting more rigorous inclusion of health in ia must be coupled with hia capacity building, which appears particularly salient in the currently environment-dominated impact assessment practice in ssa. improving international standards for hia lays a foundation to improve global relationships; health outcomes for local communities need to be prioritized in order to create long-term, sustainable economic investment opportunities. we encourage other groups who pursue ia in the mining and other sectors in ssa and elsewhere to specifically address health, which cannot be emphasized enough in the current covid-19 pandemic. acknowledgments: the authors would like to thank our partners in burkina faso, ghana, mozambique and tanzania that were engaged in the collection and screening of the ia reports for the hia4sd case study. further, we want to thank all of the people within the ministries and mining companies that have taken their time to accommodate our request. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. table a1 . health determinant categories. factors related to the individual's biology and behavior. these comprise for example gender, age, ethnicity, dietary intake, level of physical activity, tobacco use, alcohol intake, personal safety, sense of control over own life, employment status, educational attainment, self-esteem, life skills, stress levels, resilience and risk behavior. conditions in which people are born, grow, live, work and age. these include access to services and community (health, education, nutrition, institutional and social support, social and health insurance); income/unemployment rate; distribution of wealth; empowerment of women; sexual customs and tolerance; racism; attitudes to disability; trust; sites of cultural and spiritual significance. environmental determinants of health physical, chemical, and biological factors external to a person, and all the related factors impacting behaviors, such as exposure to heavy metals, pesticides and other compounds, solvents or spills and releases from road traffic; air pollution (indoor and outdoor); noise pollution and exposure to malodors. it also includes factors, such as inadequate housing, water and sanitation services, and the mixing of population groups with different levels of communicable diseases which can be associated with in-migration. availability of services, including (traditional) health services, transport and communication networks; educational and employment; environmental and public health legislation; environmental and health monitoring systems; laboratory facilities; social and health insurance schemes. cds = communicable diseases; env. = environmental; mch = maternal and child health; mnch = maternal, neonatal and child health; n.a = not applicable; trad. = traditional. percentages are illustrated on a color scale from red to blue. red shading indicates percentages below 50%, blue shadings above 50%. social impact assessment: the state of the art. impact assess proj health impact assessment: the state of the art. impact assess proj environmental impact assessment: the state of the art health impact assessment in relation to other forms of impact assessment differing forms, differing purposes: a typology of health impact assessment. environ. 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implications, and lessons for public policy making. environ. impact asses drawing from the well of community participation: an evaluation of the utility of local knowledge in the health impact assessment process community participation in health impact assessment. a scoping review of the literature. environ. impact asses towards environmental health equity in health impact assessment: innovations and opportunities health impact assessment and health equity in sub-saharan africa: a scoping review changing patterns of health in communities impacted by a bioenergy project in northern sierra leone experience and lessons from health impact assessment guiding prevention and control of hiv/aids in a copper mine project, northwestern zambia this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-301264-lkfhtb1w authors: davahli, mohammad reza; karwowski, waldemar; sonmez, sevil; apostolopoulos, yorghos title: the hospitality industry in the face of the covid-19 pandemic: current topics and research methods date: 2020-10-09 journal: int j environ res public health doi: 10.3390/ijerph17207366 sha: doc_id: 301264 cord_uid: lkfhtb1w this study reports on a systematic review of the published literature used to reveal the current research investigating the hospitality industry in the face of the covid-19 pandemic. the presented review identified relevant papers using google scholar, web of science, and science direct databases. of the 175 articles found, 50 papers met the predefined inclusion criteria. the included papers were classified concerning the following dimensions: the source of publication, hospitality industry domain, and methodology. the reviewed articles focused on different aspects of the hospitality industry, including hospitality workers’ issues, loss of jobs, revenue impact, the covid-19 spreading patterns in the industry, market demand, prospects for recovery of the hospitality industry, safety and health, travel behavior, and preference of customers. the results revealed a variety of research approaches that have been used to investigate the hospitality industry at the time of the pandemic. the reported approaches include simulation and scenario modeling for discovering the covid-19 spreading patterns, field surveys, secondary data analysis, discussing the resumption of activities during and after the pandemic, comparing the covid-19 pandemic with previous public health crises, and measuring the impact of the pandemic in terms of economics. on december 8, 2019, the government of wuhan, china, announced that health authorities were treating dozens of new virus cases, identified as coronavirus disease 2019 (covid-19) [1] . since then, covid-19, a new strain of sars (sars-cov-2), has grown into a global pandemic and spreading across many countries. a highly transmissible respiratory disease, covid-19 spreads through contact with other infected individuals, with symptoms such as fever, cough, and breathing problems [2] . transmission can also occur from asymptomatic individuals, with up to 40% of infected persons remaining asymptomatic [3] . other factors that facilitate infection include (1) speed and efficiency of covid-19 transmission; (2) airborne transmission [4] ; (3) close contact between infected and non-infected individuals; (4) vulnerability of immunocompromised individuals with specific underlying health conditions (e.g., hypertension, diabetes, cardiovascular disease, respiratory problems); (5) susceptibility of persons over 65; and (7) contact with persons who have traveled to locations with a high number of cases [5] . rq1 . what aspects of the hospitality industry at the time of the covid-19 pandemic have been studied? rq2. what research methodologies have been used to investigate the impact of covid-19 on the hospitality industry? in order to address the above questions, a search strategy was developed to list and review all relevant scientific papers by (a) defining keywords and identifying all relevant materials, (b) filtering the identified records, and (c) addressing the risk of any bias [13] . one of the main steps in a systematic review is developing specific keywords. herein, our objective was to target all critical segments of the hospitality industry (e.g., hotels, restaurants) and the broadly defined tourism industry. the defined keywords are shown in table 1 . web of science, science direct, and google scholar were used as database search tools. keywords were used to discover relevant articles and identify 175 articles with relevant content. because this topic is rapidly evolving, it is important to mention that article discovery was finished at the end of august 2020. after developing the main database and identifying all relevant papers, a formal screening process based on specific exclusion and inclusion criteria was followed. because of the very timely issue of the covid-19 pandemic, we included documents in the forms of peer-reviewed academic publications, grey literature, and pre-print articles. however, we excluded secondary sources that were not free or open access, letters, newspaper articles, viewpoints, presentations, anecdotes, and posters. the screening of the titles, abstracts, conclusions, and keywords in the identified records after removing duplication (n = 168) resulted in excluding articles (n = 115) because of not enough relating to the topic. the remaining articles (n = 53) were read in full against the eligibility principle, and three articles were excluded for not addressing the research questions. selection bias in a systematic review can occur by the erroneous application of inclusion/exclusion criteria and/or the specification of included papers' dimensions. to address the first type of bias, two researchers (md and wk) independently reviewed the title, abstract, and conclusions of the identified records to select articles for the full-text review. subsequently, the two researchers compared their selected articles to reach a consensus. after reading the full text of the selected papers, the authors decided whether to include the article-which was considered and included upon reaching an agreement. disagreements were resolved by the input of the other two authors (s.s. and y.a.). to address the second type of bias, two researchers (md and wk) independently specified the included papers' classifications and subsequently compared the results, resolving disagreements by consultation with the other authors (s.s. and y.a.). the selection strategy, as per prisma guidelines, is illustrated in figure 1 all included articles were categorized and stored in the main database according to year, source of publication, the industry segment, geographic location, research approach, aspect of the hospitality industry, and methodology. the characteristics of the included papers are shown in table 2 . table 2 . characteristics of the included papers. title segment of industry geographic location approach [21] pandemics, tourism and global change: a rapid assessment of covid-19 airlines, accommodation, sports events, restaurants, cruises comparing covid-19 with previous public health crises [22] hedging feasibility perspectives against the covid-19 for the international tourism sector tourism expenditure, inbound and outbound tourism, conference tourism, pilgrimage tourism, virtual reality tourism comparing covid-19 with previous public health crises [23] how all included articles were categorized and stored in the main database according to year, source of publication, the industry segment, geographic location, research approach, aspect of the hospitality industry, and methodology. the characteristics of the included papers are shown in table 2 . table 2 . characteristics of the included papers. title segment of industry geographic location approach [21] pandemics, tourism and global change: a rapid assessment of covid-19 airlines, accommodation, sports events, restaurants, cruises global comparing covid-19 with previous public health crises [22] hedging feasibility perspectives against the covid-19 for the international tourism sector the publication sources of the included papers are illustrated in figure 2 . the most popular publication sources include tourism geographies, international journal of infection diseases, and journal of tourism and hospitality education. discussing resumption of activities during and after the pandemic [68] navigating hotel operations in times of covid-19 discussing resumption of activities during and after the pandemic the publication sources of the included papers are illustrated in figure 2 . the most popular publication sources include tourism geographies, international journal of infection diseases, and journal of tourism and hospitality education. to generate a better picture of the included papers, the map of the co-occurrence of terms in the title and abstract is shown in figure 3 . the colorful nodes are associated with specific terms, and their to generate a better picture of the included papers, the map of the co-occurrence of terms in the title and abstract is shown in figure 3 . the colorful nodes are associated with specific terms, and their sizes represent the frequency of term occurrence, and links between two nodes indicate the co-occurrence of the terms. in this figure, frequently co-occurring terms create clusters and appear closer with the same color. a first glance at figure sizes represent the frequency of term occurrence, and links between two nodes indicate the cooccurrence of the terms. in this figure, frequently co-occurring terms create clusters and appear closer with the same color. a first glance at figure 3 reveals the central cluster (blue color) with terms including covid-19, health, travel, effect, and global tourism. sizes represent the frequency of term occurrence, and links between two nodes indicate the cooccurrence of the terms. in this figure, frequently co-occurring terms create clusters and appear closer with the same color. a first glance at figure 3 reveals the central cluster (blue color) with terms including covid-19, health, travel, effect, and global tourism. the included papers used different research approaches to investigate the impact of covid-19 on the hospitality industry (see figure 5 ). each approach is explained in the following section. the included papers used different research approaches to investigate the impact of covid-19 on the hospitality industry (see figure 5 ). each approach is explained in the following section. the reviewed papers used different research approaches and focused on various subjects related to the hospitality industry during the covid-19 pandemic. however, all papers have been classified into six groups as follows: (1) developing simulation and scenario modeling, (2) reporting impacts of the covid-19 pandemic, (3) comparing the covid-19 pandemic with previous public health crises, (4) measuring impacts of the covid-19 pandemic in terms of economics, (5) discussing the resumption of activities during and after the pandemic, and (6) conducting surveys. since some of the reviewed papers belong to more than one group, these have been assigned to the dominant group. eight included papers in this review applied simulation & scenario modeling to estimate aspects of tourism demand and the covid-19 spreading pattern. the studies used different models and analyses, including a dynamic stochastic general equilibrium (dsge) model, supply and demand curve, agent-based model, epidemiological model, and susceptible exposed infected recovered (seir) model. yang et al. [2] applied dsge, a macroeconomics technique that depicts economic phenomena based on the general equilibrium framework, to investigate the impacts of increasing health disaster risk (the pandemic) and its persistence on the model parameters such as tourism demand. he incorporated two indicators (health status, and health disaster) and three categories of decisionmakers (the government, households, and producers) into the dsge model concerning the tourism sector. the findings are not surprising and point out that the longer pandemic will have a more devastating effect on the hospitality industry. bakar and rosbi [1] utilized a supply and demand curve to analyze the economic impact of covid-19 on the hospitality industry. in order to develop the supply and demand curve, the demand function was created by using factors of price setting of selected goods, tastes and preferences of customers, customers' expectations, the average income of certain countries, and the number of buyers. the reviewed papers used different research approaches and focused on various subjects related to the hospitality industry during the covid-19 pandemic. however, all papers have been classified into six groups as follows: (1) developing simulation and scenario modeling, (2) reporting impacts of the covid-19 pandemic, (3) comparing the covid-19 pandemic with previous public health crises, (4) measuring impacts of the covid-19 pandemic in terms of economics, (5) discussing the resumption of activities during and after the pandemic, and (6) conducting surveys. since some of the reviewed papers belong to more than one group, these have been assigned to the dominant group. eight included papers in this review applied simulation & scenario modeling to estimate aspects of tourism demand and the covid-19 spreading pattern. the studies used different models and analyses, including a dynamic stochastic general equilibrium (dsge) model, supply and demand curve, agent-based model, epidemiological model, and susceptible exposed infected recovered (seir) model. yang et al. [2] applied dsge, a macroeconomics technique that depicts economic phenomena based on the general equilibrium framework, to investigate the impacts of increasing health disaster risk (the pandemic) and its persistence on the model parameters such as tourism demand. he incorporated two indicators (health status, and health disaster) and three categories of decision-makers (the government, households, and producers) into the dsge model concerning the tourism sector. the findings are not surprising and point out that the longer pandemic will have a more devastating effect on the hospitality industry. bakar and rosbi [1] utilized a supply and demand curve to analyze the economic impact of covid-19 on the hospitality industry. in order to develop the supply and demand curve, the demand function was created by using factors of price setting of selected goods, tastes and preferences of customers, customers' expectations, the average income of certain countries, and the number of buyers. meantime, the supply function is developed by using elements of production techniques, resource price, price expectations, price of related goods, supply stocks, and numbers of sellers. the supply and demand curve was then developed in the market equilibrium condition where the demand in the market is equal to the supply in the market. finally, changes in market equilibrium as the result of the covid-19 outbreak were investigated. the results indicate that the pandemic created some "panic" level among people and consequently decreased overall demand in the tourism and hospitality industry [1] . the study urged governments to discover a vaccine as quickly as possible and identify policies to prevent the further decrease in demand for tourism and hospitality services during the post-pandemic period [1] . d'orazio et al. [38] used an agent-based model to determine the virus spreading in tourist-oriented cities and, consequently, discover sustainable and resilient strategies [38] . the model represented simulated individuals' movement and the contagion virus spreading approach (the epidemic rules based on previous studies) in a touristic urban area. the model calculated the probability that an infector: (i) could infect a susceptible individual j based on a linear combination of the current incubation time of (i), the exposure time, and the mask filter adopted by both i and j. the model evaluated the number of infectors within the touristic urban area over time and the number of visitors who return home being infected over time. after analyzing different scenarios, such as "social distancing-based measures" and "facial mask implementation", the results reveal that "social distancing-based measures" were related to significant economic losses [38] . this phenomenon appears to be an effective policy in locations with the highest infection rates [38] . however, "social distancing-based measures" lose their advantage in areas of low infection rates and a high degree of "facial mask implementation" [38] . five studies investigated covid-19 cases and spreading patterns on the diamond princess cruise ship. on february 1, 2020, a disembarked passenger from the ship tested positive for covid-19 [69] , after which the 3711 passengers were quarantined [69] . by the end of the quarantine, more than 700 passengers were infected with covid-19 [69] . fang et al. [33] developed the flow of passengers (crowd flow simulation model) on the diamond princess cruise ship, and then created the virus transmission rule between individuals to simulate the spread of the covid-19 caused by the close contact during passengers' activities. mizumoto and chowell [34] and mizumoto et al. [35] developed an epidemiological model based on discrete-time integral equations and daily incidence series. rocklöv et al. [36] collected data on confirmed cases on the diamond princess cruise ship. they used the seir model (compartmental technique estimating the number of susceptible (s), exposed (e), infected (i), and recovered (r) individuals) to calculate the primary reproduction number. the basic reproduction number is the expected number of cases directly generated by one case in a population where all individuals are susceptible to infection [70] . zhang et al. [37] collected data of daily incidence for covid-19 on the diamond princess cruise ship, data of a serial interval distribution (the time between successive cases in a chain of transmission [71] ), and applied "projections" package in r to calculate the basic reproduction number. the studies concluded that the cruise company's immediate response in following recommended safety guidelines and early evacuation of all passengers could prevent mass transmission of covid-19 [33] [34] [35] [36] [37] . seventeen papers applied secondary data analysis to report covid-19 pandemic's impacts on the hospitality industry. because of the ongoing pandemic and publication time of included papers, secondary data sources have been invaluable for most studies in this review. the studies reported impacts of the pandemic on different aspects of the hospitality industry, including job loss, revenue losses, access to loans, market demand, emerging new markets, hostile behaviors towards foreigners, and issues of hospitality workers and hotel cleaners. nicola et al. [49] summarized the pandemic's impact on the global economy by reviewing news distributed by mass-media, government reports, and published papers. to better understand the impacts of the pandemic, the study divided the world economy into three sectors of primary (including agriculture, and petroleum & oil), secondary (including manufacturing industry), and tertiary (including education, finance industry, healthcare, hospitality tourism and aviation, real estate, sports industry, information technology, and food sector). they reported job loss, revenue losses, and decreasing market demand in the hospitality, tourism, and aviation sectors [49] . ozili and arun [51] provided a list of covid-19 statistics, including confirmed cases, confirmed deaths, recovered cases in several countries and continents, and discussed the global impact of covid-19 on the travel and restaurant industries. the study reviewed different policy measures implemented by different countries around the world to deal with covid-19. ozili and arun [51] categorized these into four groups of (1) human control measures; (2) public health measures; (3) fiscal measures; and (4) monetary measures. in the human control policies measures, different actions including foreign travel restrictions, internal travel restrictions, state of emergency declarations, limiting mass gathering, closing down of schools, and restricting shops and restaurants, have also been identified [51] . several studies reported the effect of covid-19 on specific critical domains of the hospitality industry, such as undocumented workers and hotel cleaners. williams and kayaoglu argued that the most vulnerable workers in the industry need governmental financial support but cannot receive assistance, most likely because they are undocumented immigrants [55] . furthermore, rosemberg [50] highlighted the issues of job insecurity, risk of exposure to covid-19, lack of health insurance, added pressure due to increased workload, and extra time required for ensuring complete disinfection during the pandemic [50] . other studies focused on the pandemic's impacts on specific countries, including china, malaysia, nepal, and india. wen et al. [54] reviewed literature and news on chinese tourist behavior, tourism marketing, and tourism management; they concluded the growing popularity of luxury trips, free and independent travel, and medical and wellness tourism post-covid-19 period [54] . they indicated that new forms of tourism would be more prevalent in post-covid-19, including (1) slow tourism, which emphasizes local destinations and longer lengths of stay, and (2) smart tourism, which uses data analytics to improve tourists' experiences [54] . another study used automated content analysis to investigate newspaper articles and identified nine key themes among 499 newspaper articles, including, "covid-19's impact on tourism, public sentiment, the role of the hospitality industry, control of tourism activities and cultural venues, tourism disputes and solutions, national command and local response, government assistance, corporate self-improvement strategies, and post-crisis tourism product" [42] . two papers compared the covid-19 pandemic with previous public health crises. in the first study, lessons learned from previous crises and pandemics are discussed, including malaria, yellow fever, ebola, zika virus, middle east respiratory syndrome (mers-cov), avian influenza (h5n1), creutzfeldt-jakob disease (mad cow disease), swine flu (h1n1), and severe acute respiratory syndrome (sars) [22] . this paper concluded that the impacts of covid-19 on the global economy and china's tourism and hospitality industry, in particular, are likely to differ from previous pandemics, from which the tourism and hospitality industry recovered relatively quickly [22] . gössling et al. [21] reviewed the impact of previous crises on global tourism, including the middle east respiratory syndrome (mers) outbreak (2015), the global economic crisis (2008-2009), the sars outbreak (2003), and the september 11 terrorist attacks (2001) [21] . the authors indicated that previous crises did not have long-term impacts on global tourism. the authors also warned about increasing pandemic threats for several reasons, including the fast-growing world population, rapidly developing global public transportation systems, and increasing consumption of processed/low-nutrition foods [21] . gössling et al. [21] also discussed the impact of covid-19 on different hospitality industry sectors. the authors distinguished the impact of covid-19 in view of two different aspects of (1) observed impacts (e.g., declines in hotel occupancy rates, liquidity problems in the restaurant industry); and (2) projected impacts (e.g., revenue forecasts in the accommodations sector, estimation of revenues) [21] . the still-evolving understanding of the coronavirus's behavior makes it difficult to predict the industry's recovery in the near future. however, suggestions have already been made for post-covid-19 management of the tourism and hospitality industry. these include: (1) focusing primarily on domestic tourism; (2) ending mass tourism and pilgrimage tourism; (3) focusing more on conference tourism, virtual reality tourism, and medical tourism; and (4) building a more sustainable tourism and hospitality industry rather than a return to "business as usual" [21, 22] . five papers measured the impacts of the pandemic on the hospitality industry in terms of economics. these studies used different models and analyses, including seasonal autoregressive integrated moving average model, scenario analysis, and trend analysis. the economic impact of covid-19 on the tourism and hospitality industry has been examined in terms of lost earnings or jobs. centeno and marquez [29] developed seasonal autoregressive integrated moving average models for the philippines' tourism and hospitality industry, forecasting the total earnings loss of around 170.5 billion php (philippine peso)-equivalent to $3.37 billion-from covid-19 just until the end of july 2020. to ease the pandemic's effects on the hospitality industry, the authors propose dividing the country into two regions according to the level of infection risk (high-risk and low-risk of to allow domestic travel into low-risk regions or areas [29] . günay et al. [30] applied a scenario analysis technique to calculate the impact of covid-19 on turkey's tourism and hospitality industry. their model predicts the total loss of revenues in the best and the worst scenarios as $1.5 billion and $15.2 billion, respectively, for 2020 [30] . the worst-case scenario involves the closing of borders for four months without any economic recovery [30] . the authors indicated that this would be one of turkey's worst tourism crises under the worst-case scenario, exceeding the losses from public health crises due to swine flu, avian flu, and sars [30] . mehta [31] estimated the effect of covid-19 on india's economy at an earnings loss of about $28 billion in 2020, along with 70% job losses for tourism and hospitality workers, and mass bankruptcies [31] . trend analysis was also used to examine the impact of covid-19 on the global tourism and hospitality industry and global gdp [32] . according to priyadarshini [32] , the real global gdp growth will drop from 2.9% in 2019 to 2.4% by the end of 2020, while global revenues for the tourism and hospitality industry will drop by 17% compared to 2019. the study also predicts that north america, europe, and asia will experience the most massive losses in global revenues. the tourism and hospitality revenues will fall in the u.s., germany, italy, and china by 10%, 10%, 24%, and 40%, respectively [32] . cajner et al. [28] analyzed the covid-19 pandemic impact on the u.s. labor market. the study calculated that about 13 million paid jobs were lost between march 14 to 28, 2020. to better understand this number's significance, the authors pointed out that only nine million private payroll employment jobs were lost during the great recession of the 1930s (less than 70% of the pandemic job loss) [28] . the study also highlighted that the leisure and hospitality industry was the hardest hit and most affected industrial sector [28] . thirteen papers recommended various remedial and management actions for the resumption of activities during and after the pandemic. the consequences of covid-19 on the hospitality industry, such as empty hotels and loss of jobs, are discussed in one paper that offers a positive outlook that the industry will receive a significant flow of guests upon the easing of travel bans and restrictions [63] . the author stressed the importance of support for the hospitality industry during the pandemic and the need for proper guidance to ensure successful reopening during the post-pandemic period. taking a different perspective, another study suggests that the hospitality industry may not do well after the lifting of travel bans and mobility restrictions [58] . the study refers to a survey that found more than half of the participants would not order food even after the pandemic ends. the author also recommends a series of actions for restaurants to attract customers in the post-covid-19 period, such as including island-sitting arrangements to assure maximum physical distances between people, live cooking counters to allow customers to watch their food being prepared to instill confidence in its safety, and having appropriate hygiene and cleaning procedures throughout [58] . bagnera et al [68] investigated the impact of covid-19 on hotel operations and recommended a series of actions for hotel owners and managers, including using fewer rooms (reducing hotel capacity); emphasizing take-out or delivery options to reduce public dining, implementing intensified cleaning/sanitizing protocols; committing to the use of personal protective equipment (ppe) for workers and increasing attention to personal hygiene; communicating new covid-19 policies to guests and employees; implementing physical distancing practices in public areas, and implementing protocols for guests exposed to or infected by covid-19 [68] . it should be noted that the world health organization (who) produced a guide titled "operational considerations for covid-19 management in the accommodations sector" to provide practical assistance to the hospitality sector in particular [64] . the report is divided into sections for the management team, reception and concierge, technical and maintenance services, restaurants and dining rooms and bars, recreational areas for children, and cleaning and housekeeping with a list of responsibilities to help manage the threat of covid-19 [64] . furthermore, jain discussed different hotel industry strategies to bring back customers, including disposable utensils in rooms, emphasizing staff health and hygiene, and using uv light to disinfect [59] . specific steps for an exit strategy and the reopening of activities in different business sectors are presented by peterson et al. [62] . primary steps include implementing widespread covid-19 testing, having enough ppe supply, lifting social distancing and mobility restrictions, using electronic surveillance, and implementing strategies to decrease workplace transmission [62] . emphasis was placed on the daily screening of hospitality sector staff for covid-19 by using real-time reverse transcription-polymerase chain reaction or serology tests [62] . in this aspect, another study used primary and secondary data and applied the descriptive analysis method to explore revitalization strategies for small and medium-sized businesses, especially in the tourism industry, after covid-19 in yogyakarta [56] . the study recommended several policies, such as implementing banks' credit policies with simpler processes and lower interest [56] . several papers discussed redesigning and transforming the tourism and hospitality industry after covid_19 pandemic. the proposed ideas include increasing resilience and security of the tourism and hospitality workforce in post-covid-19 by cross-training and teaching different skills to workers [61] ; exploiting the unique opportunity presented by covid-19 to transform and refocus the tourism and hospitality industry towards local attractions rather than global destinations, and redesigning spaces to assure a 6-foot distance between tourists [57, 60, 67] . hao et al. [65] developed a covid-19 management framework as a result of reviewing the overall impacts of the covid-19 pandemic on china's hotel industry. the framework contains three main elements of an anti-pandemic process, principles, and anti-pandemic strategies. the anti-pandemic process adopted the six phases of disaster management, including the pre-event phase (taking prerequisite actions), the prodromal phase (observing the warning signs), the emergency phase (taking urgent actions), the intermediate phase (bringing back essential community services), the recovery phase (taking self-healing measures), the resolution phase (restoring the routine). hao et al. [65] recommended four principles for the different phases of disaster management, including disaster assessment, ensuring employees' safety, customer & property, self-saving, and activating & revitalizing business. finally, the study discussed the main anti-pandemic strategies in the categories of leadership & communication, human resource, service provision, corporate social responsibility, finance, and standard operating procedure. recently, sönmez et al [66] reviewed the impacts of the covid-19 pandemic on immigrant hospitality workers' health and safety. the study indicated that while a significant rise in occupational stress has been observed in immigrant hospitality workers over the past 15-20 years, the covid-19 pandemic can add more pressure on workers and potentially deteriorate their mental and physical health condition. the authors recommended different actions in aspects of public and corporate policy, workplace policy, and future research areas. five papers conducted survey studies to investigate different hospitality industry aspects, including social costs, customer preference, expected chance of survival, and travel behavior. qiu et al. [25] developed the contingent valuation method to estimate costs borne by residents of tourist destinations (social costs) due to the covid-19 pandemic. contingent valuation is a survey-based economic technique for the valuation of non-market resources [72] . the survey asks questions about how much money residents would be willing to pay to keep a specific resource. the study attempted to investigate how residents perceive the risk of tourism during the covid-19 pandemic. by considering three chinese urban destinations, qiu et al. [25] quantified tourism's social costs during the pandemic. the results indicate that most residents were willing to pay for risk reduction, but this payment differs based on respondents' age and income. alonso et al. [27] focused on the theory of resilience and conducted a survey from a sample of 45 small hospitality businesses to answer questions about participants' main concerns regarding the covid-19 pandemic. how small hospitality businesses are handling this disruption. furthermore, what are the impacts of the pandemic on day-to-day activities. alonso et al. [27] analyzed the qualitative responses through content analysis. the study highlighted nine theoretical dimensions about owners-managers' actions and alternatives when confronted with the covid-19 pandemic. kim and lee [26] studied the impacts of the perceived threat of the covid-19 pandemic on customers' preference for private dining facilities. the study conducted a survey and concluded that the salience of the covid-19 increases customers' preference for private dining facilities. bartik et al. [23] discussed the impact of covid-19 on the u.s. small businesses, especially restaurants and tourism attractions, and highlighted their fragile nature in the face of a prolonged crisis. such companies typically have low cash flow, and in the face of this pandemic, they will either have to declare bankruptcy, take out loans, or significantly cut expenses [23] . their restaurant owners' survey found that the expected chance of survival during a crisis lasting one month is 72%, for a crisis that lasts four months is 30%, and for a crisis that lasts six months is 15%. the result also indicated that more than 70% of u.s. small businesses want to take up the cares act paycheck protection program (ppp) loans, even though most of them believe it would be challenging to establish eligibility for receiving such loans [23] . finally, a survey study by nazneen et al. [24] investigated the pandemic's impact on travel behavior and reported that it had significant impacts on tourists' decisions to travel for the next 12 months. the authors also concluded that respondents are concerned about hotels' safety and hygiene, recreational sites, and public transports [24] . it has also been postulated that hygiene and safety perception will play a significant role in travel decisions in post-covid-19 times [24] . even though included papers studied different aspects of the hospitality industry during the covid-19 pandemic (see figure 6 ), the main topics relate to recovery of the industry (19% of papers), market demand (18% of papers), revenue losses (16% of papers), the covid-19 spreading patterns in the industry (14% of papers), job losses (10% of papers), safety and health aspects (8% of papers), issues related to the employment of hospitality workforce (7% of papers), travel behaviors (4% of papers), preferences of customers (2% of papers), and social costs of pandemic (2% of papers). actions for the resumption of activities during and after the pandemic. travel behaviors, preferences of customers, and social costs were mainly analyzed in the "conducting surveys" approach. the reviewed papers used a variety of research models and analyses to study the hospitality industry in the face of covid-19 (see figure 7) . secondary data analysis was utilized to study almost all aspects of the hospitality industry. covid-19 spreading patterns were investigated by using several quantitative models, including the seir models, epidemiological models, agent-based models, and crowd flow simulation models. the seasonal autoregressive integrated moving average model was used to calculate job loss and revenue losses. the contingent valuation method, content analysis, and analyzing questionnaire data were parts of the "conducting surveys" approach and were used to analyze social and behavioral aspects of the hospitality industry response to the covid-19 epidemic. the employment issues of hospitality workers have been mentioned by 7% of papers in the categories of "reporting the impacts of the covid-19 pandemic" and "discussing the resumption of activities". these papers discussed job insecurity, financial, and health issues among documented and undocumented workers. ten percent of included papers reported or measured job losses in the hospitality industry as the result of the covid-19 pandemic. revenue losses, market demand, and recovery of the industry were the most popular aspects of the hospitality industry, and 16%, 18%, and 19% of the included papers, respectively, discussed these topics. it should be noted that these aspects were mainly discussed in the framework of "reporting the impacts of the covid-19". the aspect of covid-19 spreading patterns was the most popular topic in the approach of "developing simulation & scenario modeling." eight percent of included papers recommended different safety actions for the resumption of activities during and after the pandemic. travel behaviors, preferences of customers, and social costs were mainly analyzed in the "conducting surveys" approach. the reviewed papers used a variety of research models and analyses to study the hospitality industry in the face of covid-19 (see figure 7 ). secondary data analysis was utilized to study almost all aspects of the hospitality industry. covid-19 spreading patterns were investigated by using several quantitative models, including the seir models, epidemiological models, agent-based models, and crowd flow simulation models. the seasonal autoregressive integrated moving average model was used to calculate job loss and revenue losses. the contingent valuation method, content analysis, and analyzing questionnaire data were parts of the "conducting surveys" approach and were used to analyze social and behavioral aspects of the hospitality industry response to the covid-19 epidemic. all aspects of the hospitality industry. covid-19 spreading patterns were investigated by using several quantitative models, including the seir models, epidemiological models, agent-based models, and crowd flow simulation models. the seasonal autoregressive integrated moving average model was used to calculate job loss and revenue losses. the contingent valuation method, content analysis, and analyzing questionnaire data were parts of the "conducting surveys" approach and were used to analyze social and behavioral aspects of the hospitality industry response to the covid-19 epidemic. this paper provides a systematic review of the published research topics relevant to the understanding of the hospitality industry in the time of covid-19 pandemic. by selecting keywords and following prisma guidelines, we explored two main research questions related to the objective. a total of 50 papers that met the predefined inclusion criteria were included in the review. the following two research questions have been explored: rq1. what aspects of the hospitality industry at the time of the covid-19 pandemic have been studied? rq2. what research methodologies have been used to investigate the impact of covid-19 on the hospitality industry? the included papers were classified into six thematic groups, including: (1) developing simulation and scenario modeling, (2) conducting surveys, (3) reporting impacts of the covid-19 pandemic, (4) comparing the covid-19 pandemic with the previous public health crises, (5) measuring impacts of the covid-19 pandemic, and (6) proposing different remedial and management actions (discussing resumption of activities). these papers focused on different aspects of the hospitality industry, including the recovery of the industry after the pandemic, market demands, revenue losses, the covid-19 spreading patterns in the industry, job losses, safety and health, employment issues of hospitality workers, travel behavior, preference of customers and social costs. the reviewed papers used a variety of research methodologies, such as the seir model, epidemiological model, agent-based model, supply and demand curve, dsge model, crowd flow simulation model, secondary data analysis, seasonal autoregressive integrated moving average model, scenario analysis, trend analysis, descriptive analysis, contingent valuation model, content analysis, and analyzing questionnaire data. in general, conducting a systematic literature review has several limitations. the first limitation is identifying and analyzing papers published in a specific time frame. the second limitation is the inability to discover individual relevant papers arising from a limited number of keywords. the third limitation is using a limited number of search databases for article discovery. although we defined several search keywords and followed prisma guidelines, it is possible that some papers that met the inclusion criteria were not considered in our review. we did not include the papers published after august 2020 as several papers on the topic have just started to emerge. second, we selected papers only from web of science, science direct, and google scholar databases. third, we could not include articles where authors investigated the hospitality industry at the time of the covid-19 pandemic without mentioning the hospitality industry, tourism industry, event industry, hotel industry, and restaurant industry. fourth, one of the main challenges of this review was defining inclusion criteria. because of the very timely issue of the covid-19 pandemic, we defined broad inclusion criteria. therefore, we could not include several studies that met inclusion criteria but generated by institutions outside of the traditional academic publishing and distribution channels. despite the above limitations, we identified the hospitality industry's main aspects in the face of the covid-19 pandemic. these include the recovery of the hospitality industry (discussed by 19% of included papers), market demand (18% of papers), revenue losses (16% of papers), the covid-19 spreading patterns in the industry (14% of papers), job losses (10% of included papers), safety and health aspects (8% of papers), issues related to the employment of hospitality workforce (7% of papers), travel behaviors (4% of papers), preferences of customers (2% of papers), and social costs of pandemic discussed by 2% of included papers. it should be noted that there are numerous other fertile research areas and methodologies that can be applied by multidisciplinary research teams to study the effects of the covid-19 pandemic on the hospitality industry. such approaches and methods include (1) using complex system science frameworks such as syndemics, (2) developing simulation modeling in different types of system dynamics, discrete event simulation, agent-based modeling, and monte carlo/risk analysis simulation, (3) investigating the application of new technologies such as educational technology, information technology, and robotics in response to the pandemic, (4) using artificial intelligence in different types of machine learning, deep learning and neural networks, and (5) developing the best practices concerning the pandemic (see figure 8 ). these research approaches can be used to analyze the main aspects of the hospitality industry at the time of the covid-19 pandemic, such as developing sustainable industry, recovery and resilience of the hospitality industry, the safety of customers, issues of undocumented workers, market demand, and emerging the new market, hostile behavior toward customers, and the risks of resumption of activities during the pandemic. information technology, and robotics in response to the pandemic, (4) using artificial intelligence in different types of machine learning, deep learning and neural networks, and (5) developing the best practices concerning the pandemic (see figure 8 ). these research approaches can be used to analyze the main aspects of the hospitality industry at the time of the covid-19 pandemic, such as developing sustainable industry, recovery and resilience of the hospitality industry, the safety of customers, issues of undocumented workers, market demand, and emerging the new market, hostile behavior toward customers, and the risks of resumption of activities during the pandemic. for example, due to the complex and dynamic nature of the current pandemic, the use of a wide array of complex systems science frameworks and simulation modeling can make an important contribution by examining how the synergistic effects of work and living conditions, as well as covid-19 government and corporate responses, can influence the long-term health and safety of tourism and hospitality workers. along these lines, the development and application of new technologies and equipment in the hospitality industry should protect guests and workers alike. finally, other potential areas of research include the use of machine learning and artificial intelligence in building a more sustainable tourism and hospitality industry and developing the best practices in improving the industry's resilience in the future. for example, due to the complex and dynamic nature of the current pandemic, the use of a wide array of complex systems science frameworks and simulation modeling can make an important contribution by examining how the synergistic effects of work and living conditions, as well as covid-19 government and corporate responses, can influence the long-term health and safety of tourism and hospitality workers. along these lines, the development and application of new technologies and equipment in the hospitality industry should protect guests and workers alike. finally, other potential areas of research include the use of machine learning and artificial intelligence in building a more sustainable tourism and hospitality industry and developing the best practices in improving the industry's resilience in the future. author 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socarxiv/4quga covid-19-we urgently need to start developing an exit strategy coronavirus and tourism operational considerations for covid-19 management in the accommodation sector interim guidance; world health organization covid-19 and china's hotel industry: impacts, a disaster management framework, and post-pandemic agenda understanding the effects of covid-19 on the health and safety of immigrant hospitality workers in the united states possible evolutionary pathways towards the transformation of tourism in a covid-19 world. tour what the cruise-ship outbreaks reveal about covid-19 basic reproduction number a dictionary of epidemiology contingent valuation funding: this research received no external funding. the authors declare no conflict of interest. key: cord-295513-q5f8d0ig authors: zhao, pengcheng; zhang, nan; li, yuguo title: a comparison of infection venues of covid-19 case clusters in northeast china date: 2020-06-03 journal: int j environ res public health doi: 10.3390/ijerph17113955 sha: doc_id: 295513 cord_uid: q5f8d0ig the world has been suffering from the covid-19 pandemic since late 2019. in this study, we compared various types of infection locations in which covid-19 cases clustered, based on the data from three adjacent provinces in northeast china. the collected data include all officially reported cases in this area until 8 march 2020. we explored the associations between the cases and the frequency of infection locations. the covid-19 epidemic situation was worse in heilongjiang province than in liaoning and jilin provinces. most clustered cases occurred in individual families and/or between relatives. the transmission in public venues served as a hub for transmitting the disease to other families and results in new clusters. the public transport spread the infection over long distances by transporting infected individuals, and most infections did not seem to occur within vehicles. this field study shows the effect of indoor environments on sars-cov-2 transmission and our data may be useful in developing guidance for future disease prevention and control. a novel coronavirus pneumonia (covid-19) emerged in wuhan, hubei province, china in late 2019, and has swept around the world [1] [2] [3] . its transmissibility between people has been reported to exceed that of sars-cov-1 [4] [5] [6] and mers-cov [7, 8] . several studies have investigated sars-cov-2 transmission by the statistical analysis of outbreaks on large scales, such as entire countries [3, [9] [10] [11] or by case studies of a family [12] [13] [14] [15] [16] [17] or a specific group of people, such as the elderly [18] and healthcare workers [19] . however, few studies have focused on the characteristics of sars-cov-2 transmission for a regional epidemic situation in a medium-scale area, with an analysis accounting for local policy and government actions. thus, we propose choosing a region with a sufficient number of covid-19 cases and their detailed case reports to illustrate the role of different types of location in person-to-person transmission of this disease. in the covid-19 outbreak, the chinese health authorities made their case investigation data publicly available [8, 20] . these data present a good opportunity to investigate the roles of various infection locations in sars-cov-2 transmission. previous viral outbreaks have reportedly involved transmission in various types of location, such as sars-cov-1 in a residential estate [21] , mers-cov in a hospital [7] , norovirus on mass transport [22] and influenza virus a in a market [23] , with various transmission routes, including the fomite [24] , large droplet [25] and airborne [26] routes. sars-cov-2, as a novel coronavirus, has also been reported to be transmitted in various locations, such as a shopping mall [27] , a cruise ship [28] , healthcare settings [19] and homes [15, 16] , with various possible transmission routes [29] . however, direct determination of the exact infection location is difficult in most situations when there is no complete and detailed record of a newly infected patient's itinerary before the case was confirmed [30] . only when we know the details of a patient's movement can we effectively determine the infection source [31] . for some cases, the infection source cannot be identified during initial tracking of the case's activities, unless trajectories of all individuals are tracked in public places, such as buses, restaurants and shops. in this study, we analysed the reported cases in liaoning, jilin and heilongjiang, which are three adjacent provinces in northeast china. the travel records of all confirmed patients in these three provinces have been posted online by local health authorities via official websites, social media or newspapers. for details, please refer to table s1 . this provides an opportunity to analyse the reported cases within a city or over provinces. the population inflow from southern china before the 2020 lunar new year (25 january) is known to have mainly come to these three provinces [32] , which helps in identifying the imported cases into the studied area. we first summarised all 712 covid-19 cases in the three provinces before 8 march 2020, and identified the relationships among the reported cases based on case reports. we also clustered the cases according to meeting locations of the involved individuals. based on the collected and deduced information, we compared the epidemic situations between cities and/or provinces and enumerated the cases for the various location clusters. we collected personal information (surname, age, sex, infection source) and itinerary reports of all cases confirmed before 8 march 2020 in the three provinces of northeast china. these cases were reported daily by the local health authorities of 37 cities via their websites, with a few cases published via social media or online newspapers, as listed in table s1 . the cases in each city (large city or prefecture regionalised by the state council [33] ; the administrative region containing counties, cities, municipal districts and townships) were sequentially numbered according to the timing of notification (or the original order in the city's report, usually according to the date of confirmation). a total of 712 cases were collected in the three provinces (liaoning, 126 cases; jilin, 92 cases; heilongjiang, 494 cases). we determined any related cases, including family members, relatives, friends and strangers in close contact [34] . note that the total number of cases in this study was based on the governments' daily reports. in some cities, we observed that the final reported number of confirmed cases was less than the sum of the daily reported cases. this occurred as some of the cases were later identified to belong to other regions outside the three provinces. in other situations, a few asymptomatic cases had been originally counted in the daily report, but were finally excluded from the statistics. when determining the potential relationships among cases, we noted that some cases had the same address and detailed itinerary, but their potential relationships were not directly noted in their case reports. we identified those cases as possible clusters in families. for any case pairs with a relationship (directly collected from case reports or identified by searching the report details) to the existing cases, the relationship is specified in table s1 . we also listed the locations where each case stayed and was likely to meet an infection source (in table s1 ). we summarised the frequently visited locations and categorised them according to the involved activities between people from an estimated high infection probability to an estimated low infection probability, as shown in table 1 , by assuming that dining activities and long-term or repeated close contact between people can increase the probability of the disease transmission [22, 34] . we summarise each of the cases and identify their relationships in figure 1 , based on the information summarised in table s1 . icons of the 712 cases are located in the three provinces in figure 1 , differentiated by colour according to their reported cities with their serial numbers in the cities. the cases were categorized into four groups: (i) imported from hubei province (black solid edge); (ii) imported from anywhere outside the three provinces other than hubei, including other countries (dashed edge); (iii) locally infected cases who had contact with an unknown covid-19 source (thin-dot edge); and (iv) locally infected cases with no report of contact with any covid-19 sources (no edge). in addition, the cases were clustered and connected by five types of line corresponding to the five categories of clustering location in table 1 . figure 1 specifies all locations outside the home where case clustering occurred, and all train or flight numbers are marked along with the cases' travel date. note that clusters solely within families in public locations (i.e., the locations of the last four categories in table 1 ) are not marked on figure 1 , because the potential infection within families was more likely to occur at home, so family itineraries outside the home may be assumed to play an insignificant role in investigating the location of infection clusters. further statistical operations were performed according to the information in figure 1 . to further understand the characteristics of the cases in the three provinces, a series of parameters were defined and counted as follows. first, the daily increase in the number of cases was searched for each province during the period between 18 january 2020 and 8 march 2020. these statistical data were obtained from each provincial health commission (websites are listed in table s1 ), as not all collected case reports had the confirmation date. second, to compare epidemic prevention and control between administrative regions, the case density (number of cases per million people) and the imported ratio (ratio of the number of imported cases to the total number of cases) were calculated for each city and province [35] . the population in each city and province was obtained from the household registered population [36] . to compare the frequency of case clustering between locations, the clustering cases were counted for each of the 15 specific types of infection location listed in the third column in table 1 . the number of cases connected in figure 1 was determined for each type of location. note that the cases that connect multiple clusters were counted for each type of location. as a reference, the total exposure time of all reported cases for each type of location were also quantified. on traditional trains, electric multiple units (emus; a series of high-speed trains) or aeroplanes, the case's total exposure time was calculated by searching for and summing all travel durations. for each of the other 12 location types, the total exposure time was estimated by the product of the total number of visits to the location and the average duration of stay per visit. in the 12 types of location, the average duration of stay per visit was assumed to be 12, 1 and 1 h for home, bus/metro and taxi/private car, respectively [37] ; and those for the other nine types of location were estimated by averaging the durations of stay per visit in the corresponding type of location mentioned in the case reports. we compared the clustering frequency of cases of different distances, i.e., contacts between cases whose home locations were separated as follows: inter-province contacts (connections between cases from different provinces in figure 1 ), inter-city contacts (connections between cases from different cities in the same province in figure 1 ) and intra-city contacts (connections between cases from the same city in figure 1 ). however, a case could be clustered with cases from the same and other cities simultaneously. for this reason, we cannot associate every case with merely a single contact event. thus, we assumed a series of rules, set out below, to enumerate the contacts between cases as a parameter to quantify the clustering frequency of cases of different distances. we introduced a definition, named effective contact, as the minimum number of contacts required for one source case to infect all the others in a cluster. for a cluster of n people that includes one infection source, the number of effective contacts equals n −1. the contacts counted in this study refer only to effective contacts, because extra contacts do not contribute to infection. we first set a case as the initial infection source of covid-19 for each cluster following the principles below. for a case in a cluster, if a case is imported from hubei, it is considered to be the infection source of the first order. ii. if no cases are imported from hubei but one is imported from outside the three provinces of northeast china, it is considered to be the infection source of the second order. iii. if no cases are imported from outside the three provinces of northeast china, but a case is imported that has been in close contact with some cases confirmed in other provinces, it is considered to be the infection source of the third order. iv. if there are multiple possible infection sources of the same order, or if there are no possible transmission sources, the first reported case (usually the case with the lowest serial number) among the cases of the highest order is considered to be the infection source. in addition, we set the priority order of contact between cases. for each infected case in the clusters in figure 1 (i.e., for all cases except the assumed source cases), we selected an upstream case as its most likely contacted case following the principles below: the disease spreads from the source case to the other cases step by step. ii. the case upstream from an infected case is only selected from direct-connected cases (without an intermediate case). iii. for an infected case with connected cases from different cities or provinces, the infection is first found from the cases of the same city, then from different cities in the same province, and then from different provinces. iv. for any two cases with more than one type of contact, we assume that the infection occurs in the category of contact with a smaller order in table 1 . thus, for each cluster in figure 1 , we assumed one case to be the initial source of infection and determined an upstream contacted case for each of the other cases. the number of contacts was then counted respectively for each category of location (in table 1 ) based on the rules introduced above. the contacts were further sub-categorised into inter-province contacts, inter-city contacts and intra-city contacts. the number of contacts in each sub-category was also counted. note that the assumed contact network in each cluster can be considered as a possible transmission chain for each case cluster. however, the number of contacts, as our target parameter, is related only to the set priority order of effective contact, but independent of the choice of source cases and the consequent possible transmission chains. the assumption of a source case is made only for the convenience of counting the number of contacts. table s1 . the locations for the clusters outside the home and the flight and train numbers along with the cases' travelling dates are specified on the diagram. in general, figure 1 shows that the epidemic situation varies by province and by city. the total number of cases, the number of clusters and the average scale of the clusters in heilongjiang are generally greater than those in the other two provinces. in all three provinces, most cases had recorded contacts with other cases and were therefore grouped into case clusters. inter-city and inter-province contact events occurred frequently. five hundred and twenty-six of the 712 cases were clustered due to family gatherings at home. most clusters have a simple structure with a single location of occurrence, but there are also some clusters in which multiple clustering events are connected to each other via several case nodes to form a larger cluster in which the exact infection sources are difficult to identify. the regional epidemic situations for all cities are shown in figure 2 . figure 2a depicts the daily increase in cases in each province. the first case was reported on 22 january 2020 in each of the three provinces. the peak of the daily increase in cases occurred later in heilongjiang than in the other two provinces, but the peak was significantly higher than in the other two provinces. in terms of the absolute number of cases, harbin became the worst affected city, with the darkest red area in figure 2b , and its cases comprised 38.5% of all cases in heilongjiang and 26.7% in the three provinces. figure 2c shows obvious differences in epidemic severity among cities and provinces. cities on the horizontal axis (y = 0) received no imported cases and thus had a light epidemic burden, and cities on the line of y = 1 had no locally infected cases and thus showed good performance in disease prevention and control. the epidemic situation in some cities in heilongjiang (red areas), such as shuangyashan, jixi and harbin, is significantly more serious than in the other regions. the situations of liaoning and jilin were relatively better. furthermore, a higher imported ratio was found in liaoning than in jilin (imported cases/total cases: liaoning, 76/126; jilin, 35/92; heilongjiang, 102/494), which indicates a lower ratio of local community infection in liaoning and thus a better effect of covid-19 prevention and control. the risk of infection in various locations is compared by counting the number of clustered cases in each type of location (in figure 3a ) and the contacts between cases of different distances (in figure 3b ). as shown in figure 3a , 69.2% of total cases were clustered in a home, apartment or residential estate. considering the lack of detailed information in the case reports, it is believed that some cases in the same apartment or residential estate could be from the same family. some clusters also occurred in restaurants (3.2%) and public buildings (9.2%), such as hospitals, shops and malls. the risk of infection in various locations is compared by counting the number of clustered cases in each type of location (in figure 3a ) and the contacts between cases of different distances (in figure 3b ). as shown in figure 3a , 69.2% of total cases were clustered in a home, apartment or residential estate. considering the lack of detailed information in the case reports, it is believed that some cases in the same apartment or residential estate could be from the same family. some clusters also occurred in restaurants (3.2%) and public buildings (9.2%), such as hospitals, shops and malls. however, a high frequency of infection in a type of location could be due to long exposure times in such locations, rather than the infection being particularly efficient. in figure 3a , the total exposure time of the 712 cases in each type of location is also displayed as a reference to compare with the number of cases clustered in the location. apart from the location of home/apartment/residential estate, the cases also exposed themselves for a long time in hospitals, hotels, offices and the coaches of traditional trains. figure 3b , the number of contacts also varies by province. the number of contacts between cases in public buildings in heilongjiang was significantly higher than those in the other two provinces (1, 2 and 77 events in liaoning, jilin and heilongjiang, respectively). table 1 . each bar is a stack of cases from all three provinces. as a reference, the cases' total exposure time (×100 h, grey bars) and unit exposure time (hours) are listed for each type of location. three important types of public vehicle are underlined. the unit exposure times estimated from experience are marked with an asterisk. (b) number of contacts between cases in five types of location. the contact events in each category were subcategorised into the provinces in which the contact occurred, and each bar is a stack of inter-province, inter-city and intra-city contacts. table 1 . each bar is a stack of cases from all three provinces. as a reference, the cases' total exposure time (×100 h, grey bars) and unit exposure time (hours) are listed for each type of location. three important types of public vehicle are underlined. the unit exposure times estimated from experience are marked with an asterisk. (b) number of contacts between cases in five types of location. the contact events in each category were subcategorised into the provinces in which the contact occurred, and each bar is a stack of inter-province, inter-city and intra-city contacts. figure 3b , the number of contacts between cases of different distances (i.e., inter-province, inter-city and intra-city) varied by location category. in general, 89.8% of the contacts occurred between cases from the same city. the inter-city and inter-province contacts occurred mostly on public vehicles (68.5%). however, a few inter-province and inter-city contacts still occurred at home or in public buildings, as cases received friends or family from other cities or provinces. in each category of location in figure 3b , the number of contacts also varies by province. the number of contacts between cases in public buildings in heilongjiang was significantly higher than those in the other two provinces (1, 2 and 77 events in liaoning, jilin and heilongjiang, respectively). figure 4 lists all 35 public vehicles, including 12 traditional trains, 14 emus and 9 flights, that were taken by cases from different families. the trains g1278 and t182, both of which departed from wuhan, suffered from the most severe epidemic situation and transported a number of cases to all three provinces. on the 35 public vehicles, contact occurred frequently between cases of each category of distance (inter-province, inter-city and intra-city contacts). however, only eight groups of cases were observed in the same coach of a train or on the same flight, as enclosed by dashed lines in figure 4 , and three groups of cases involved train staff. overall, most cases had a history of residence in hubei but travelled in different coaches or on different dates. of distance (inter-province, inter-city and intra-city contacts). however, only eight groups of cases were observed in the same coach of a train or on the same flight, as enclosed by dashed lines in figure 4 , and three groups of cases involved train staff. overall, most cases had a history of residence in hubei but travelled in different coaches or on different dates. during the period up to 8 march, the daily increase in cases in all three provinces reached its lowest point, and no new cases were confirmed from 5 to 9 march. the daily increase in cases rose again after 9 march, due to imported cases from overseas. we mainly analysed the effect of intervention in various regions and focused on the frequency of case clusters in various locations. the epidemic situation significantly varied by city and province. the case density and the imported ratio were calculated for comparing the regional epidemic situations, as shown in figure figure 4 . diagram of cases clustering on trains (black, traditional trains; purple, emus) and aeroplanes (orange), in reference to the train and flight numbers and the travel date. each ribbon with one or multiple colours shows the provinces of the cases source. the case cluster corresponding to each train or aeroplane can be found in figure 1 . the characteristics and the numbering of the icons are also consistent with those in figure 1 . the cases on the same coach/flight are enclosed by a dashed line. grey shadows represent trains/flights that should have departed from wuhan that were cancelled on that day (or the previous day for overnight trains). during the period up to 8 march, the daily increase in cases in all three provinces reached its lowest point, and no new cases were confirmed from 5 to 9 march. the daily increase in cases rose again after 9 march, due to imported cases from overseas. we mainly analysed the effect of intervention in various regions and focused on the frequency of case clusters in various locations. the epidemic situation significantly varied by city and province. the case density and the imported ratio were calculated for comparing the regional epidemic situations, as shown in figure 2c , in which the cities and provinces to the upper left of the graph have lower case densities and local infection rates (i.e., a high imported ratio among the cases), which means that these cities are considered least affected; in contrast, the cities to the lower right of the graph encountered a heavier epidemic burden due to the higher case density and local infection rate. we mark all areas with a population of more than 5 million in figure 2c , including six cities (shenyang, dalian, changchun, harbin, qiqihar and suihua) and the three provinces. most of these cities' positions in figure 2c are very close to their provinces (except for dalian, in which some cases did not have specified itineraries and were thus not counted as imported cases), which means that the epidemic situation in each province was highly related to that in these metropolises. we believe that this relationship was due not only to the cities' large percentage of their provinces' population, but also to their status as the transport hubs for the surrounding areas. the differences in the epidemic situation between cities and provinces may be due to differences in government actions and in public awareness of epidemic prevention and control. all three provinces initiated a level i emergency response to the public health emergency on 25 january 2020. however, several clustering events occurred in public buildings in heilongjiang after that date ( figure 1 ). considering the similar natural environment, culture and economic development level in the three adjacent provinces, it may be hypothesized that local government actions and the efficiency in intervention played a major role in the epidemic among regions [38] and that the early implementation of social distancing, testing and diagnostics can have a significant impact on epidemics [3, 9, 39 ]. in addition, as shown in figure 1 , significantly more large-family clusters (involving relatives from different estates) were found in heilongjiang, which means that people continued visiting relatives during this severe epidemic, indicating an absence of public awareness of epidemic prevention relative to the other two provinces. case clusters mostly occurred at home between families or relatives. in general, infection events on vehicles and in families were difficult to avoid at the beginning of the covid-19 outbreak. the outbreak overlapped with the 2020 lunar new year holidays (24 january to 2 february), for which people travelled home to reunite with their families [40] . some imported cases were quarantining themselves at home with their families before their diagnosis. however, the high prevalence of cases in some cities in figure 2c was mainly due to the occurrence of several local outbreaks in public buildings, as cases who had been newly infected in public buildings could then act as a source to infect their families. infection in public buildings usually occurred between non-associated individuals or friends from different families. once infection occurred, it could further lead to an outbreak in new families via the newly infected cases [41, 42] . some cities had a significantly large case density, such as harbin, jixi, suihua, shuangyashan and changchun (figure 2c) . we have observed large scale of clusters in public buildings in all these cities. for instance, seven cases from harbin and suihua, in heilongjiang, were staff or shoppers from toulong mall (a heilongjiang cluster with red and blue icons in figure 1 ); some were also members of family clusters, which indicates that the cases from toulong mall could be the second-generation infection sources of their family clustering infections; similar local outbreaks were also found in qiqihar first hospital (a heilongjiang cluster with grey icons in figure 1 ), the easyhome company's annual party (a jilin cluster with red icons in figure 1 ) and three fruit markets in shuangyashan (a heilongjiang cluster with green icons in figure 1 ). thus, public buildings showed a great effect on the spread of covid-19. in some cases, the patients went to the same hotels or pharmacies or took the same buses or cars, but very few cases were confirmed from those categories of locations because the summarised case clustering in those locations all occurred between families or relatives, so we believe that their infection is more likely to have occurred at home. clustering occurred far less often in clinics than in hospitals, possibly due to the shorter average unit exposure time (shown in figure 3a) , as clinics usually have no long-term inpatients. in addition, no cases were found to have been infected in offices, except for staff working in hospitals and clinics. some cases were clustered in public transport (17.5%). as shown in figure 3b , contacts on public transport led to more connections between cases from different cities or provinces than contacts in public buildings or at home. this means that contact between people as they travel by (or queue for) public transport could result in infection, spreading the disease to a new area. passengers on vehicles have a high risk of infection, but the risk still varies by the vehicle type. a higher infection rate was seen on traditional trains than on emus and aeroplanes. the case reports included 104 trips on traditional trains, and we found 56 clustering cases; the ratio of the number of clustering cases to the total number of reported trips was thus 53.8%. this ratio was 39.5% on emus and 28.6% on aeroplanes, possibly due to the long average unit exposure time on traditional trains (15.56 h; shown in figure 3a ) compared with emus (4.32 h) and aeroplanes (4.00 h). in addition, the direction of seats (and beds) may also influence the infection risk. passengers in aeroplane cabins and most emu coaches face forward, whilst the seats and beds on traditional trains face each other [43] . although figures 1 and 3 show a significant number of clusters on public vehicles, the number of actual infection events on trains and aeroplanes may have been far lower than the number of contacts quantified in figure 3b . figure 1 shows that a significant proportion of cases on the clustering trains and aeroplanes had a residence history in hubei (icons with black solid edge), the site of the initial outbreak. figure 4 further summarises the trains and aeroplanes in which cases from different families clustered. eleven of the 35 trains or flights had cases from different provinces. the two trains, g1278 and t182, departing from wuhan included patients from all three provinces. some cases on the two trains travelled on the same day (enclosed with thin-dot line in figure 4 ), which means that the infection could have occurred in the train coaches or in the trains' waiting rooms. however, we found only eight groups of cases in figure 4 (enclosed with dashed line), each as a cluster with cases from different families clustering in the same coach of a train or the cabin of the same flight. there was a high probability of close contact between the cases in each group. in contrast, most cases had a residence history in hubei province and travelled on different dates, which means that the cases that departed from hubei may have been infected before they boarded the trains or aeroplanes. thus, we still believe that public vehicles are risky locations where cases tend to cluster, but not all cases were infected during their trips. public vehicles play two roles, as the locations in which infection occurs and as the agents that transport cases to a new area. some cases were truly infected during the trips, whilst most cases were purely clustered by the trains or aeroplanes with no infection occurring during transportation to a new area [44] . in addition, 76 cases or case clusters in figure 1 had no connection to any imported cases or contact with any known covid-19 sources. in addition to the incomplete nature of the itinerary report, we believe that the absence of a possible infection source for a locally infected case (or case cluster) is due to the presence of asymptomatic cases [17, 30] . for example, the case fuxin-6 in liaoning province was reported to have had contact with a relative who took the train g1274, one of whose on-board staff became a covid-19 confirmed case (shenyang-11), but the relative of fuxin-6 was not reported as a confirmed case. if we assume that each case (or case cluster) with no connection to any imported sources was infected via an asymptomatic case [14] , then there should be about 76 asymptomatic cases, which yields an estimated ratio of asymptomatic cases to all cases of 76/(76 + 712) = 9.6%. this ratio is higher than the corresponding ratio of 5.0% in beijing [45] , which indicates that potential asymptomatic cases in the crowd might have not been detected and confirmed. furthermore, some cases had family members who were not named as infection sources in the case reports but may have been asymptomatic carriers, despite being officially excluded as confirmed cases. thus, we suspect that the ratio of the number of asymptomatic cases to symptomatic cases might be actually much higher than 9.6%, which is also evidenced by some recent reports [28, 46, 47] . this study analysed the epidemic situations in various areas in the three provinces of northeast china and the effects of various types of infection location on identified covid-19 clusters. in general, the epidemic situations varied significantly by city and province. most infections occurred between family members and relatives at home, and their contacts usually involved dining activities. case clustering in public buildings might play a hub role in regional epidemic, such as in heilongjiang, because clustering events could cause infection between different families, which could cause further clusters of infection in more families. some case clusters occurred on trains and aeroplanes, which transported the cases to new areas, and this situation also increased the risk of infection during the trip. the timely closure of public buildings and efforts to raise public awareness may help to significantly relieve regional epidemics in the future. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/11/3955/s1, table s1 : statistic result of 712 cases. author contributions: p.z. collected the data, drew the figures, conducted analyses and drafted the manuscript. n.z. and y.l. provided critical comments during the conceptualization and revision of the manuscript. all authors have read and agreed to the published version of the manuscript. virology, epidemiology, pathogenesis, and control of covid-19 the covid-19 epidemic characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72 314 cases from the chinese center for disease control and prevention the reproductive number of covid-19 is higher compared to sars coronavirus can we 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at regional level for covid-19 emergency in italy date: 2020-05-12 journal: int j environ res public health doi: 10.3390/ijerph17103344 sha: doc_id: 353890 cord_uid: dzauzjm7 covid-19 is a worldwide emergency since it has rapidly spread from china to almost all the countries worldwide. italy has been one of the most affected countries after china. north italian regions, such as lombardia and veneto, had an abnormally large number of cases. covid-19 patients management requires availability of sufficiently large number of intensive care units (icus) beds. resources shortening is a critical issue when the number of covid-19 severe cases are higher than the available resources. this is also the case at a regional scale. we analysed italian data at regional level with the aim to: (i) support health and government decision-makers in gathering rapid and efficient decisions on increasing health structures capacities (in terms of icu slots) and (ii) define a geographic model to plan emergency and future covid-19 patients management using reallocating them among health structures. finally, we retain that the here proposed model can be also used in other countries. covid-19 [1] is caused by the sars-cov-2 virus and belongs to the coronaviridae family, which contains many other viruses. only seven of which are known to be responsible for human diseases, e.g., 229e, nl63, oc43, hku1, mers-cov, sars-cov, and sars-cov-2 [2, 3] . the virus diffused with a surprisingly fast pace, and in one month putting under stress the healthcare resources worldwide, starting from china. italy was the first european country affected by the virus. the high spreading rate and the absence of tailored therapies and vaccines determine a relatively high mortality rate that has been controlled by blocking the virus spreading with severe mobility restrictions to the people of the infected regions [3] . by the end of march, while the situation in china seems to be under control, the virus is rapidly growing in other countries [4, 5] . with different time scales, other countries such as the usa, france, spain and north europe reacted by implementing containment measures. the virus has an initial exponential diffusion which requires: (i) home quarantine for low symptoms, (ii) hospitalisation for part of them and, (iii) hospitalisation in icus requiring respiratory support for severe ones. in some cases, covid-19 causes severe pneumonia, especially in the presence of co-morbidities [6] , thus patients need hospitalization in icu where respiratory support (such as mechanical ventilators) are required to keep them alive [7] . we focus on a disease diffusion model which helps predicting icu resources, for the italian emergency. the model is general enough to foresee its adoption also in other countries. it also scales well at a regional or sub-regional level. data. all data used in this work are provided by italian government on a publicly available web site https://github.com/pcm-dpc/covid-19 under licence cc-by-4.0. we start from the analysis of epidemiological data from wuhan city (china, hubey region). as reported in [8, 9] about a third of infected patients required icu admission. icu departments need to be well organised to be able to host covid-19 patients. there is also the need to avoid mixing covid-19 with other patients in icus [10] . in italy on 15 march, official data reported 24,747 total cases, 20,603 people currently infected, 1809 deaths and 2335 recovered patients. among these: 9268 were reported as being treated at home (i.e., not severe illness), 9663 hospitalised, and 1672 admitted to icus. to react to the exponential growth of infected patients requiring hospitalisation, the chinese government decided to build a large emergency hospital dedicated to covid-19 patients in a few days. in italy, the plan was to improve existing structures by extending the number of icu resources and beds, as well as using dedicated health structures. for instance, the study reported in [11] focuses the necessity of acquiring icu resources such as ventilators or breathing support devices. italy has approximately 5200 beds in icus, which, by law, are designed to be occupied by patients for the 80% at any given time. also, these are allocated at a regional level proportionally to its population and are usually managed locally (see table 1 ). many of such icu slots were yet occupied by non-covid-19 patients while as of 15 march 1672 beds are occupied by covid-19 patients. considering the infection trend, it is reasonable to predict that the number of icus patients will increase. since icu resources are limited, there is the need to know in advance how many will be used. such a decision may regard, for instance, the institution of new icu beds or the movement of people from one region to another. so, it is crucial to correctly estimate the number of patients that will need icu treatment [11] . we focus on decision strategy to increase number and structures able to treat covid-19 patients in intensive units, and thus increasing the number of icus. we propose a model able to manage in geographic scale the incoming patients and the icus available places. we cover the a need for the development of a predictive model for helping healthcare administrators in managing structure requirements to improve hospitals and patients managements. we extend a compartmental model for epidemiology, and we derive from italian public data the experimental parameters for simulating the model. literature contains many mathematical epidemiological models for studying the dynamics of infectious diseases [12] . these models fall in two main classes: deterministic models that are based on differential equations and stochastic models that are based on markov processes. we used a discrete-time markov chain model [13] and we derived the parameters of the model starting from publicly available data, the same described in section 3. we use as reference a compartmental model which we adapted from the literature [14] (see figure 1 ). in figure 2 the covid-19 diffusion is reported both for italy and china red zones (a "red zone" is a geographical area (e.g., city, region, state) of maximal infection for which the government implements special social rules in order to deal with the emergency: typically restriction of citizens' movements and prohibition to leave or enter the area). we can make the hypothesis of similar trends for different countries (including italy). initial exponential growth of the disease is first identified followed by a logistic regression trend as disease spread slows down. in the last phases of the infection, where the curve becomes logistic, diseases have to be treated, continue managing the fraction of patients that require icus. showing that the initial trend of the infection follows an exponential growth, even though the chinese government rapidly adopted stringent confinement measures. we can thus expect to observe the same initial infection evolution, before arriving to the logistic portion of the curve. the italian national health service is organised on a national and regional scale. the central government controls the distribution of resources and services are arranged at a regional scale. there are 19 regions and two autonomous provinces (21 total administrative units). therefore the icus is availability is organised at a regional scale, established by each region. table 1 summarise current icu beds availability per administrative units. patients are admitted into the icus of its region, without considering other criteria, such as free beds into icus of other regions that may be geographically closer. the access is freely guaranteed costs are mapped to citizen with respect to their regions of residence. consequently, some regions may have many available beds while other regions may not. this situation happened in northern italian regions. figure 3 shows the distribution of total icu beds versus occupied icu beds (i.e., in hospitals) for each region in italy whereas figure 4 shows the infected cases for each region. we compare through our model the management of beds in single regions as compartment and the management of places on a nationwide scale (admitting transfers among regions). our findings suggest that the management of icus beds as a whole across regions may improve the overall availability of free beds for covid-19 patients. figure 3 shows the distribution of total icu beds versus occupied icu beds (i.e., in hospitals) for each region in italy. figure 4 shows the infected cases for each region. we associated the number covid-19 infections with icu beds occupancy. in particular, the target is to predict the number of icu beds required for a certain amount of infections in a given region, using covid-19 trend. this is used to relate infections and icus beds (see figure 5b for lombardia region). we fitted the datapoints from current covid-19 infection with an exponential function. by using such a fitting we are able to predict infections (y axis of figure 5a ) for future days (x axis of figure 5a ). then, we can use such a number (x axis of figure 5b ) in order to predict the number of icus required in the future (y axis of figure 5b ). these predictions may be used to plan decision about covid-19 patients and also to reallocate them in different structures. predicting icu for non-saturated regions. we applied our predicting model to southern italian regions, when the infection trend was at the beginning (i.e., delayed curve and low numbers) with respect to northern ones. during this phase the icu beds capacity was under saturation (see figure 3) . we used the predicting model for these regions to early predict saturation phases. in figure 6a ,b a diffusion of disease and relative connections with icus requirements are reported and refer to a central italian region, i.e., lazio. by using infections vs icu beds trend, we were able to calculate the number of infections for some time point in the future and derive the number of predicted icu beds which will be occupied. similarly, in figure 6c we report campania region situation at 30 march as south of italy representation. in such case note that the government restrictions rapidly adopted allow a slower diffusion of infectious. note that in a similar way we map all data for all the 21 italian regions. the emergency of covid-19 is related to an aggressive virus that diffuses rapidly and strongly stresses the resistance of health structures. since the covid-19 related disease require different non-standard protocols, such as the use of respiratory devices, patients treatment is strictly intertwined with the availability of hospital structure resources (e.g., icu beds). we think that, by using a scalable predictive model, (at regional or district level) may support governments in a better management of the emergency. finally, the presented model is valid during the exponential growth of the infection. furthermore, since the swab tests are not available in sufficient numbers to guarantee a wide screening of the population, they are performed only to hubs (i.e., police officers, healthcare personnel) and people dyeing by covid who were previously hospitalized in icus. hence infection numbers are highly underestimated. we claim that such a model could be used in countries where diffusion is still at the beginning, such as us, france, spain and other european countries (see [15] where virus diffusion trajectories are reported for different countries). author contributions: g.t. was responsible for data analysis and statistics, and writing of the manuscript. p.h.g. was responsible for data analysis and writing of the manuscript. p.v. was responsible for data analysis and writing of the manuscript. all authors have read and agreed to the published version of the manuscript. funding: this work has been partially funded by project sistabene: sistema di tracciabilità avanzata per il benessere alimentare por calabria fesr-fse 2014-2020. the coronavirus 2019-ncov epidemic: is hindsight 20/20? eclinicalmedicine 2020 genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding nowcasting and forecasting the potential domestic and international spread of the 2019-ncov outbreak originating in wuhan, china: a modelling study covid-19: a new virus as a potential rapidly spreading in the worldwide the effect of travel restrictions on the spread of the 2019 novel coronavirus (covid-19) outbreak covid-19: italy confirms 11 deaths as cases spread from north critical care management of adults with community-acquired severe respiratory viral infection clinical features of patients infected with 2019 novel coronavirus in clinical characteristics of coronavirus disease 2019 in china preparing for covid-19: early experience from an intensive care unit in singapore covid-19 and italy: what next? modeling infectious diseases in humans and animals generalized markov models of infectious disease spread: a novel framework for developing dynamic health policies covid-19: epidemiology, evolution, and cross-disciplinary perspectives this article is an open access article distributed under the terms and conditions of the creative commons attribution acknowledgments: we thank italian protezione civile for freely providing online data thus allowing studies on covid-19. we thank tamer kahveci from university of florida for useful suggestions. the authors declare no conflict of interest. the following abbreviations are used in this manuscript: icu intensive care unit key: cord-351651-6dbt99h0 authors: sun, zhong; thilakavathy, karuppiah; kumar, s. suresh; he, guozhong; liu, shi v. title: potential factors influencing repeated sars outbreaks in china date: 2020-03-03 journal: int j environ res public health doi: 10.3390/ijerph17051633 sha: doc_id: 351651 cord_uid: 6dbt99h0 within last 17 years two widespread epidemics of severe acute respiratory syndrome (sars) occurred in china, which were caused by related coronaviruses (covs): sars-cov and sars-cov-2. although the origin(s) of these viruses are still unknown and their occurrences in nature are mysterious, some general patterns of their pathogenesis and epidemics are noticeable. both viruses utilize the same receptor—angiotensin-converting enzyme 2 (ace2)—for invading human bodies. both epidemics occurred in cold dry winter seasons celebrated with major holidays, and started in regions where dietary consumption of wildlife is a fashion. thus, if bats were the natural hosts of sars-covs, cold temperature and low humidity in these times might provide conducive environmental conditions for prolonged viral survival in these regions concentrated with bats. the widespread existence of these bat-carried or -released viruses might have an easier time in breaking through human defenses when harsh winter makes human bodies more vulnerable. once succeeding in making some initial human infections, spreading of the disease was made convenient with increased social gathering and holiday travel. these natural and social factors influenced the general progression and trajectory of the sars epidemiology. however, some unique factors might also contribute to the origination of sars in wuhan. these factors are discussed in different scenarios in order to promote more research for achieving final validation. since 2002, two epidemics of severe acute respiratory syndrome (sars) have originated from china, one in late 2002 and the other in late 2019. the etiological agents of these epidemics have been confirmed as a new subset of coronaviruses (covs), namely, sars-cov and sars-cov-2 ( figure 1 ), respectively, for the 2002 and the 2019 sars epidemics [1] . covs are named for their crown-like spikes on the viral surface. they are classified into four main sub-groupings known as alpha, beta, gamma, and delta. before the emergence of sars-cov, four covs were known as human coronaviruses (hcovs), i.e., covs capable of infecting human beings. these four hcovs cause a "common cold" and include hcov-229e and hcov-nl63 of the alpha group and hcov-oc43 and hcov-hku1 of the beta group [2] . since the discovery of sars-cov causing sars in china in 2002 [2] , another hcov was identified in 2012 as mers-cov, causing middle east respiratory syndrome (mers) [3] . figure 1 . phylogenetic analysis of virus isolated from severe acute respiratory syndrome (sars)-2 patients. sequence of wuhan seafood market pneumonia virus isolate wuhan-hu-1 was used for comparing with whole genome sequence database from national center for biotechnology information (ncbi) by using basic local alignment search tool (blast). maff (aist) was used to align the first 100 matching sequences. phylogenetic trees were constructed by using mega x through neighbor-joining (nj) methods. according to the phylogenetic tree, sars-2, bat sars-like coronavirus isolate bat-sars-like coronavirus (sl-cov) zc45, and bat sars-like coronavirus isolate bat-sl-covzxc21 share a common ancestor. sars-cov differs from mers-cov because it uses angiotensin-converting enzyme 2 (ace2) as a receptor for binding to human cells [4] . in contrast, mers-cov uses dipeptidyl peptidase 4 (dpp4) as a receptor for infecting human cells [5] . phylogenetically, sars-cov and mers-cov are distinct and both are distant from other covs, including hcovs. the recent outbreak of "wuhan pneumonia" in late 2019 in central china has been linked with a new cov formally identified as sars-cov-2. sars-cov-2 is not only phylogenetically closely related with sars-cov, an etiological agent of sars, but also uses a same receptor, ace2, as sars-cov does. thus, even though "wuhan pneumonia" has been called with various other disease names such as "new coronavirus pneumonia (ncp)" and now as "coronavirus disease 2019 (covid-19)", we feel that it may be more appropriate to refer to "wuhan pneumonia" as "sars-2" and the previous sars as "sars-1" if necessary. the etiological agent for "wuhan pneumonia" has been changed from "2019-ncov" to "sars-cov-2". a further change of "covid-19" into "sars-2" is logical and reasonable for streamlining taxonomy between disease agent and disease. in this minireview, we evaluate natural and social factors influencing both 2002 and 2019 sarss in order to understand some common epidemiological features that may be beneficial for controlling the ongoing epidemic and also for preventing future outbreak. this comprehensive knowledge is also helpful for searching the origin(s) of the viruses and for elucidating their initial occurrence(s). patients. sequence of wuhan seafood market pneumonia virus isolate wuhan-hu-1 was used for comparing with whole genome sequence database from national center for biotechnology information (ncbi) by using basic local alignment search tool (blast). maff (aist) was used to align the first 100 matching sequences. phylogenetic trees were constructed by using mega x through neighbor-joining (nj) methods. according to the phylogenetic tree, sars-2, bat sars-like coronavirus isolate bat-sars-like coronavirus (sl-cov) zc45, and bat sars-like coronavirus isolate bat-sl-covzxc21 share a common ancestor. sars-cov differs from mers-cov because it uses angiotensin-converting enzyme 2 (ace2) as a receptor for binding to human cells [4] . in contrast, mers-cov uses dipeptidyl peptidase 4 (dpp4) as a receptor for infecting human cells [5] . phylogenetically, sars-cov and mers-cov are distinct and both are distant from other covs, including hcovs. the recent outbreak of "wuhan pneumonia" in late 2019 in central china has been linked with a new cov formally identified as sars-cov-2. sars-cov-2 is not only phylogenetically closely related with sars-cov, an etiological agent of sars, but also uses a same receptor, ace2, as sars-cov does. thus, even though "wuhan pneumonia" has been called with various other disease names such as "new coronavirus pneumonia (ncp)" and now as "coronavirus disease 2019 (covid-19)", we feel that it may be more appropriate to refer to "wuhan pneumonia" as "sars-2" and the previous sars as "sars-1" if necessary. the etiological agent for "wuhan pneumonia" has been changed from "2019-ncov" to "sars-cov-2". a further change of "covid-19" into "sars-2" is logical and reasonable for streamlining taxonomy between disease agent and disease. in this mini-review, we evaluate natural and social factors influencing both 2002 and 2019 sarss in order to understand some common epidemiological features that may be beneficial for controlling the ongoing epidemic and also for preventing future outbreak. this comprehensive knowledge is also helpful for searching the origin(s) of the viruses and for elucidating their initial occurrence(s). it is amazing that, within a short time span of less than 17 years, two similar epidemic outbreaks occurred in china: sars-1 in 2002 and sars-2 in 2019. although identification of viral origin(s) is very critical for understanding these epidemics, a study comparing a wide variety of natural and social factors potentially influencing the progression and the trajectory of these epidemics is also important. through a comparative analysis of environmental factors and human activities in these two serious public health events, we wish to find some common ground for the occurrence of sars-1 and sars-2. sars-1 broke out in foshan, guangdong province, in november 2002 [6] . sars-2 started in wuhan in hubei province no later than early december 2019 [7] . in china, november and december are winter months, and are the coldest months of the year in these two locations [8, 9] . cold temperature usually provides a conducive environmental condition for virus survival. in addition to this, we also noticed that severe drought occurred in both locations at the times of the outbreaks. the annual rainfall in foshan in december 2002 nearly reached 0 mm [10] . in fact, drought occurred in the whole of guangdong province that year, causing more than 1300 reservoirs drying up and 286,000 hectares of farmland suffering drought [11] . coincidentally, wuhan also suffered its worst drought in nearly 40 years, with precipitation of only 5.5 mm in december 2019 [12, 13] . these drought conditions were rare for both locations as their average annual precipitations are greater than 1100 mm [8, 9] , which are higher than the global average annual rainfall of 990 mm, of which 715 mm is over land [14] . cold, dry conditions are more conducive than cold conditions alone for virus survival [15, 16] . during the cold winter, air-dried virus particles are a dangerous form of virus, which survives for a long period of time in airflows [17] . besides providing conducive conditions for virus survival and spreading, winter cold conditions also damper humans' innate immunity. cold temperatures cause reduced blood supply and thus the decreased provision of immune cells to the nasal mucosa. low humidity can reduce the capacity of cilia cells in the airway to remove virus particles and secrete mucus as well as repair airway cells. in addition, human cells release signal proteins after viral infection to alert neighboring cells to consider the danger of virus invasion. however, in low-humidity environments, this innate immune defense system is impaired [18] . more seriously, low humidity can cause nasal mucus to become dry; nasal cavity lining to become fragile, or even ruptured; and make the entire upper respiratory tract vulnerable to virus invasion [19] . the environmental situation of another coronavirus outbreak also seems to support the above-mentioned theory. mers-cov was first detected in a patient living in jeddah, saudi arabia, in june of 2012 [20] . the annual rainfall in jeddah is low at 61mm, and there was no rain at all in june of that year in jeddah [21] . therefore, relative to temperature, low humidity seems to be a more critical environmental factor influencing outbreak of human coronavirus disease. for both sars outbreaks, bat was suspected as a natural host for sars-covs. it was claimed that sars-cov virus originated from horseshoe bats in a cave of yunnan province [22] . in 2005, sars-like covs (sl-covs) were found in wild chinese horseshoe bats (rhinolophus sinicus) collected from a cave in yunnan province of china [22] . in 2013, live sl-cov was isolated from vero e6 cells incubated in bat feces [23] . the isolated virus showed more than 95% genome sequence identity with human and civet sars-covs. sl-cov possesses the ability to infiltrate cells using its s protein to combine with ace2 receptors [24] . this observation indicated that sars-cov originated from chinese horseshoe bats and that sl-cov isolated from bats poses a potential threat to humans without the involvement of any intermediate hosts. between 2015 and 2017, 334 bats were collected from zhoushan city, zhejiang province, china. a total of 26.65% of those bats were detected as having a conserved coronaviral protein rna-dependent rna polymerase (rdrp). full genomic analyses of two sl-covs (bat-sl-cov zc45 and bat-sl-cov zxc21) showed 81% nucleotide identity with human/civet sars covs. these viruses reproduced and caused disease in suckling rats, with virus-like particles being observed in the brains of suckling rats by electron microscopy [25] . thus, prior to 2018, bats collected in some areas of china have been shown to carry covs capable of directly infecting humans. a recent study showed that sars-cov-2 has 96% homology at the whole genome level with bat coronavirus. pairwise protein sequence analysis of seven conserved non-structural proteins showed that this virus belongs to the species of sars-cov [26] . in phylogenetic analysis, sars-cov and sars-cov-2 not only share a common ancestor, but also have an amino acid identity of 82.3% [27] [28] [29] . viruses often require intermediate hosts before transmitting from bats to humans. for example, the intermediate host of nipah virus is pig, and the intermediate host of mers-cov is camel [30, 31] . during sars-1 outbreak, civet was initially considered as a natural host for sars-cov [31] . later it was redefined as an intermediate host after bats were claimed as the natural hosts for sars-cov. in addition to civet, researchers also found sars-cov from domestic cat, red fox, lesser rice field rat, goose, chinese ferret-badger, and wild boar in guangdong's seafood market. it was believed that the virus was transmitted to civet from yunnan horseshoe bats, and civet cats carrying the virus were transported to guangdong, which led to sars-cov infection on humans and sars outbreak in guangdong [32] . currently, some intermediate hosts have been suspected for sars-cov-2. a study showed that sars-cov-2 has the same codon usage bias as shown for snakes. therefore, snake may be the intermediate host for sars-cov-2 [33] . however, david robertson, a virologist from the university of glasgow, united kingdom, stated, "nothing supports the invasion of snakes." at the same time, paulo eduardo brandão, a virologist from the university of st. paul, also said, "there is no evidence that snakes can be infected by this new coronavirus and act as hosts" [34] . a study on the genome sequence of diseased pangolins smuggled from malaysia to china found that pangolins carry coronavirus, suggesting that pangolins may be intermediate hosts for sars-cov-2 [35] . pangolins seized in anti-smuggling operations in guangxi and guangdong of southern china were detected with multiple cov linages with 85.5-92.4% genome sequence similarity to those of sars-cov-2 [36] . more interestingly, covs collected from caged pangolin obtained from an unspecified research organization showed over 99% genome sequence identity to those of sars-cov-2 [37] . meanwhile, nanshan zhong, the leader of the sars-cov-2 virus treatment expert group, predicted the intermediate host of sars-cov-2 to be bamboo rat [38] on the basis of the animal distribution in zhoushan, which is not only the natural habitat of bat-sl-covzc45-carrying bats, but also the natural habitat of cobra, bamboo rat, and pangolin [39] [40] [41] . before viruses in wildlife make a jump to infect human beings, they usually accumulate a series of mutations in their viral genomes [42] and invade human beings as a result of human occupation of their normal ecosystem, as exemplified with a story of initial human infection by hiv carried by chimpanzees in rainforests of west africa [43, 44] . at the outset, sars-covs might have a species barrier before it can be transmitted to humans. however, due to human activities, the virus has expanded its host of infection. it was found that the sars-cov responsible for sars-1 in 2002 existed in civet [32] . viruses phylogenetically similar to sars-cov-2 in genome sequence have now being detected in wild bats [26] , snakes [33] , and pangolins [35] [36] [37] 45] . thus, humans might become unfortunate hosts for sars-covs as a result of some inappropriate interactions with wildlife and thus exposure to unfriendly viruses ( figure 2 having identified some relevant natural and social factors common for affecting both sars epidemics, it is also necessary to discuss if variations in these factors contributed to the unique outbreak of sars-2 in wuhan. because many factors confounding the sars-2 epidemic are still unknown, we herein discuss sars-2 outbreak in wuhan (figure 3 ) under different scenarios. having identified some relevant natural and social factors common for affecting both sars epidemics, it is also necessary to discuss if variations in these factors contributed to the unique outbreak of sars-2 in wuhan. because many factors confounding the sars-2 epidemic are still unknown, we herein discuss sars-2 outbreak in wuhan (figure 3 ) under different scenarios. an early guess and also a dominant view expressed in published reports assumes that sars-2 outbreak started from a single site in wuhan, namely, huanan seafood market [46] . however, the only source of bats that have been publicly identified as carrying virus phylogenetically close to sars-cov-2 is far away from wuhan in zhoushan, zhejiang. zhoushan is also one of the largest breeding bases in zhejiang for bamboo rat, which is suspected as one of the intermediate hosts for sars-cov [38, 47] . thus, in order for these bats and/or rats to pass the virus to humans, they must have first been able to migrate or be moved to wuhan and also must have carried viruses that actually achieved mutations for affording the capability of infecting human beings. bats have an ability to migrate more than 1000 kilometers and tend to fly to insect-rich areas [48] . abundant insects are often found in wildlife market areas due to their selling of various animals. animal carcasses also make these places suitable habitats for bats. bats are also attracted to artificial green lights and tend to gather around green light areas [49] . in agreement with these natural characteristics, bats have been found to inhabit locations near yangtze river bridge, which has rows of green lights that are tuned on for all of the night-time. incidentally, huanan seafood market is only 20 minutes away from this bridge. bats gathered near the yangtze river bridge might have released the virus and even infected intermediate hosts for some time. the cold and dry winter helped viruses to survive in the environment and eventually found some ways to cross the species barrier, a phenomenon known as "viral chatter" [50] . the increased vulnerability of human beings in winter time and the increased human exposure to wild animals during holidays made infection to sars-cov-2 more likely. at present, there is no evidence to prove the source of bamboo rats in huanan seafood market. therefore, there are two possible places for bamboo rat be infected with sars-cov-2. the first site might be the bat habitat in zhoushan. due to the promotion of bamboo rat breeding by huanong brothers in 2018, the amount of bamboo rat breeding and market demand increased significantly [51] . since the market demand increases, the new bamboo rat breeding base may not be far from the local habitat of sars-cov-2-carrying bats. the model of sars-cov-2 transmission, similar to nipah virus, is that farms are built around bat habitats, causing bats to pass the virus to animals through saliva, urine, and feces [30] . at the same time, because zhejiang is a natural habitat for bamboo rats, it is possible that some farms directly introduced wild bamboo rats, which were already infected with sars-cov-2 virus. for the above reasons, the bamboo rats carrying sars-cov-2 virus were transported from the infected place to the incident site in the same way that civets spread sars-cov [32] . the second site is wuhan, the place of the sars-cov-2 outbreak, and it is also the end point for some bat migration. zhengli shi's team from wuhan institute of virology, chinese academy of sciences, isolated a live sars-like strain in the feces of horseshoe bats [23] . this suggests that the way the bats spread the virus is not only via direct contact, but also through feces. therefore, when bats carrying sars-cov-2 virus forage at huanan seafood market, they may pass the virus directly or indirectly to intermediate hosts. however, to confirm this scenario, it is necessary to find wild bats in wuhan and its neighboring areas that carry covs identical to those isolated from various sars-2 patients. it is also necessary to find a mechanism for the very quick outbreak in such a wide area by a natural source of sars-cov-2. epidemiological investigations showed that 13 of the first 41 patients diagnosed with sars-cov-2 had nothing to do with huanan seafood market [45] . another survey of sars-2 found that no bats were on sale in huanan seafood market [52] . with so many bats concentrated into a local area, the spreading of viruses by bats might be much wider than just being restricted to one wildlife trading place such as the huanan seafood market. the viruses might have lived in this big "incubation bed" for some time and achieved some mutations before jumping on to the final hosts-human beings. a study on horseshoe bats in hong kong and guangdong showed that the viruses carried by horseshoe bats in these two places are different. however, some horseshoe bats were found to carry two viruses after mating and foraging activity. this indicates that horseshoe bats not only have the ability to migrate, but also the ability to promote the spread of virus within the same roost and from roost to roost. in addition, sequencing the entire genome of virus carried by bats in multiple regions revealed frequent recombination among different strains. for example, civet sarsr-cov sz3 recombination was detected between sarsr-rh-batcov rp3 from guangxi, china, and rf1 from hubei, china [53] . therefore, there is a possibility that sars-cov-2 spread from zhoushan to wuhan due to bat migration. it turned out that bats are not only attracted by green lights but also red lights [54] . along the yangtze river there are also huge bridges decorated with a massive number of red lights. thus, bats migrating along the yangtze river might be attracted by these red lights and be relocated nearby. wuhan might be a new habitation site for a massive number of bats. these bats, coming from different locations, might carry different virus strains. the separate evolution and the recombination of these viruses might lead to the creation of various sars-covs capable of cross-species transmission and ultimate infection of human beings. many observations have shown the outbreak of sars-2 actually started from multiple sites, instead of just a single site, as originally reported [27, 52, 53, 55] . in evaluating the epidemiological patterns of sars-2 within wuhan, surrounding wuhan, and remote from wuhan, it appears that the incidences of sars-2 have some distinct patterns. although the remotely occurring sars-2 usually have a human-human linkage and can be traced to a single source of infection, some wuhan cases and the surrounding cases in hubei province still lack reliable sources of infection. amazingly, most of the sars-2 patients can be traced to a single unique etiological agent, sars-cov-2. how could this likely single source of virus quickly infect so many people in such large geographic area? this is a question that is difficult to answer now, but must be answered in future. although the origins and the occurrences of sars-cov-2 are both unclear, the control measures for the current epidemic should focus on immediate cut-off of transmission of the disease and through disinfection of infected locations. quarantine of patients (both confirmed and suspected), isolation of susceptible population, and protection of high-risk professions are necessary measures for reducing exposure to the viruses and eliminating the risk of getting infected by the viruses. at the same time, infected locations must be adequately disinfected. areas that will be open to the public should be carefully surveilled for the existence of sars-cov-2 and be cleaned of the virus if it is found. modern communication methods should be effectively used for passing reliable information on the epidemic status, the treatment measures, and the self-protection skills, among others. as a matter of fact, if fine-tuned and highly-effective internet control for "public opinions" can be turned into beneficial use of monitoring the "epidemic situation", fighting against an even larger outbreak of any infection would be much easier and cost-effective. sars-cov-2 has entered human communities, and eliminating virus from human bodies does not means its eradication in nature. the risk of sars-cov-2 infection will remain for a long time. thus, adequate cautions must be taken for safe-guarding against future outbreaks of sars. the prevention can be achieved by implementing a multi-facet system that considers both natural and social aspects of the sars epidemiology discussed earlier. for example, regular surveillance of viral status in nature should be carried out to monitor the variation/evolution and abundance/localization of the virus. this information may be served as an early warning and used for preparation of potential vaccines. the government should issue laws and policies to tighten protection of wildlife and prohibit consumption of wild animals. a grass-roots and transparent reporting system should be established and put into public use for reporting any case of confirmed or suspected human infection. the disease-reporting system should be organically synchronized with the meteorological system so that adverse environmental conditions conducive for viral infection on human beings can be forecasted and macro-scale preparations can be made in case an emergency occurs. finally, but not lastly, in developing human society including building massive constructions for residence and transportation, potential ecological impact on wildlife and possible consequences of breaking natural balance of the ecosystems should be carefully evaluated. this mini-review evaluated the common epidemiological patterns of both sars epidemics in china and identified cold, dry winter as a common environmental condition conducive for sars virus infection to human beings. thus, meteorological information should be integrated into future forecast of potential outbreak of new sars. the identification of bats as very likely natural hosts for sars-covs and consideration of some other wild animals as potential intermediate hosts leads to a prevention requirement of protecting natural ecosystem and prohibiting consumption of wildlife. the presentation of different scenarios of sars outbreaks points to some urgency in identifying the true origin(s) of sars-covs and establishing more comprehensive anti-infection measures that will resist any kind of viral assault. author contributions: all authors have made a contribution to this manuscript. z.s. designed, drafted, and edited the initial manuscript. k.t. reviewed and edited the initial manuscript. s.s.k. edited the initial manuscript. g.h. conceptualized and designed the framework of the manuscript. s.v.l. wrote the revision of the manuscript and brought many of his independently originated ideas into the revised manuscript. all authors have read and agreed to the published version of the manuscript. funding: this work is supported in part by the national natural science foundation of china under grant no. 71964020. the proximal origin of sars-cov-2. artic network an overview of their replication and pathogenesis angiotensin-converting enzyme 2 is a functional receptor for the sars coronavirus host species restriction of middle east 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of globalization origins of hiv and the aids pandemic. cold spring harb clinical features of patients infected with 2019 novel coronavirus in a novel coronavirus genome identified in a cluster of pneumonia cases-wuhan the largest bamboo rat chinese silver star bamboo rat breeding base in zhoushan. shanghang.net determinants of spring migration departure decision in a bat migratory bats respond to artificial green light with positive phototaxis mapping disease transmission risk of nipah virus in south and southeast asia adventures of huanong brothers: shooting bamboo rat videos became popular, fans exceeded 5 million and annual income exceeded 300,000. tencent us from coronavirus: live updates on covid-19. live science ecoepidemiology and complete genome comparison of different strains of severe acute respiratory syndrome-related rhinolophus bat coronavirus in china reveal bats as a reservoir for acute, self-limiting infection that allows recombination events migratory bats are attracted by red light but not by warm-white light: implications for the protection of nocturnal migrants evolution and variation of 2019-novel coronavirus acknowledgments: thanks to the alumni of tongji medical college, huazhong university of science and technology for their selfless help and miss tao's suggestions for manuscript. the authors declare no conflict of interest. key: cord-345991-d26y5291 authors: jing, jane lee jia; pei yi, thong; bose, rajendran j. c.; mccarthy, jason r.; tharmalingam, nagendran; madheswaran, thiagarajan title: hand sanitizers: a review on formulation aspects, adverse effects, and regulations date: 2020-05-11 journal: int j environ res public health doi: 10.3390/ijerph17093326 sha: doc_id: 345991 cord_uid: d26y5291 hand hygiene is of utmost importance as it may be contaminated easily from direct contact with airborne microorganism droplets from coughs and sneezes. particularly in situations like pandemic outbreak, it is crucial to interrupt the transmission chain of the virus by the practice of proper hand sanitization. it can be achieved with contact isolation and strict infection control tool like maintaining good hand hygiene in hospital settings and in public. the success of the hand sanitization solely depends on the use of effective hand disinfecting agents formulated in various types and forms such as antimicrobial soaps, water-based or alcohol-based hand sanitizer, with the latter being widely used in hospital settings. to date, most of the effective hand sanitizer products are alcohol-based formulations containing 62%–95% of alcohol as it can denature the proteins of microbes and the ability to inactivate viruses. this systematic review correlated with the data available in pubmed, and it will investigate the range of available hand sanitizers and their effectiveness as well as the formulation aspects, adverse effects, and recommendations to enhance the formulation efficiency and safety. further, this article highlights the efficacy of alcohol-based hand sanitizer against the coronavirus. the emergence of the covid-19 (coronavirus disease-2019) pandemic has risen to be a significant global public health concern and led to extensive use of hand disinfectants given its contagious nature. there was a total of 3.8 million reported cases affecting over 200 countries worldwide as of 7 may 2020 [1, 2] . covid-19 is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), which can persist and remain infectious on surfaces for up to 9 days [3, 4] . the recent study reveals that transmission of sars-cov-2 is possible in the form of aerosol and fomite, and the virus can remain viable and infectious in aerosols for hours and on surfaces up to days, depending on the inoculum shed [5] . hence, it is crucial to interrupt the transmission chain of the virus through contact isolation and strict infection control tools [6] . following face masks, appropriate hand hygiene is of utmost importance as hands may be contaminated from direct contact with patients' contaminated from direct contact with patients' respiratory droplets from coughs and sneezes or indirect contact via surfaces, which may then facilitate the transmission and spreading of the disease [7] [8] [9] . the 2003 severe acute respiratory syndrome (sars) outbreak was caused by a novel human coronavirus (cov) (sars-cov) that could survive on surfaces for 24 to 72 h [10] . the studies on sars-cov outbreak settings showed that providing efficient handwashing facilities reduced transmission [11] . given the dangers imposed by this disease, the centre for disease control and prevention (cdc), the united states has promoted and encouraged hand hygiene through handwashing or use of hand sanitizer [12] . hand disinfectants are commercially available in various types and forms such as anti-microbial soaps, water-based or alcohol-based hand sanitizers, most often used in hospital settings. different types of delivery systems are also formulated-for instance, rubs, foams, or wipes ( figure 1 ). the world health organisation (who) recommends alcohol-based hand sanitizer (abhs) in line with the proven advantages of their rapid action and a broad spectrum of microbicidal activity offering protection against bacteria and viruses. however, the effectiveness against nonenveloped viruses is still debatable and questionable [7, [13] [14] [15] [16] [17] [18] . to date, most effective hand sanitizer products are alcohol-based formulations containing 62%-95% of alcohol as it is capable of denaturing the proteins of microbes and inactivating viruses [19, 20] . there are a few challenges and concerns with regard to this formulation in terms of fire hazards and skin toxicity due to high alcohol content [21] . this systemic review aims to investigate the range of available hand sanitizers and their effectiveness against the human coronavirus as well as the formulation aspects, adverse effects, and recommendations to improve the formulation of current hand sanitizers. this study was conducted according to the prisma recommendations [22] . we systematically reviewed the available literature in pubmed and google scholar, up to 2020. the search terms we used are hand sanitizers and alcohol and treatment and handwashing and virucide and bactericide and (cure or failure or mortality). a manual search was also performed. we set no year limit, and english is the only language we limit. the study selection based on effective treatment resulted in a potential eradication of pathogens. the data extracted from each study comprised the main characteristics of the study, such as the first author's name, year, study design, and country. out of many reports, we selected articles based on the hand disinfectant agents and their potential outcome suitable for the present viral pandemic. data were extracted by two authors based on the to date, most effective hand sanitizer products are alcohol-based formulations containing 62%-95% of alcohol as it is capable of denaturing the proteins of microbes and inactivating viruses [19, 20] . there are a few challenges and concerns with regard to this formulation in terms of fire hazards and skin toxicity due to high alcohol content [21] . this systemic review aims to investigate the range of available hand sanitizers and their effectiveness against the human coronavirus as well as the formulation aspects, adverse effects, and recommendations to improve the formulation of current hand sanitizers. this study was conducted according to the prisma recommendations [22] . we systematically reviewed the available literature in pubmed and google scholar, up to 2020. the search terms we used are hand sanitizers and alcohol and treatment and handwashing and virucide and bactericide and (cure or failure or mortality). a manual search was also performed. we set no year limit, and english is the only language we limit. the study selection based on effective treatment resulted in a potential eradication of pathogens. the data extracted from each study comprised the main characteristics of the study, such as the first author's name, year, study design, and country. out of many reports, we selected articles based on the hand disinfectant agents and their potential outcome suitable for the present viral pandemic. data were extracted by two authors based on the screening of the titles and abstracts obtained from the pubmed and google scholar database. the other authors have checked the materials to fulfil the criteria for the work. hand sanitizer can generally be categorized into two groups: alcohol-based or alcohol-free ( figure 2 ). an abhs may contain one or more types of alcohol, with or without other excipients and humectants, to be applied on the hands to destroy microbes and temporarily suppress their growth [23] . abhs can effectively and quickly reduce microbes covering a broad germicidal spectrum without the need for water or drying with towels. nevertheless, there are a few shortcomings with the effectiveness of abhs, such as its short-lived antimicrobial effect and weak activity against protozoa, some non-enveloped (non-lipophilic) viruses and bacterial spores [23] . screening of the titles and abstracts obtained from the pubmed and google scholar database. the other authors have checked the materials to fulfil the criteria for the work. hand sanitizer can generally be categorized into two groups: alcohol-based or alcohol-free ( figure 2 ). an abhs may contain one or more types of alcohol, with or without other excipients and humectants, to be applied on the hands to destroy microbes and temporarily suppress their growth [23] . abhs can effectively and quickly reduce microbes covering a broad germicidal spectrum without the need for water or drying with towels. nevertheless, there are a few shortcomings with the effectiveness of abhs, such as its short-lived antimicrobial effect and weak activity against protozoa, some non-enveloped (non-lipophilic) viruses and bacterial spores [23] . on the other hand, the alcohol-free sanitizer makes use of chemicals with antiseptic properties to exert the antimicrobial effects. these chemicals have a different mode of action and function according to their chemical functional groups (table 1 ) [24] [25] [26] . as they are non-flammable and often used at low concentrations, they are relatively safer to use among children as compared to abhs. abhs is available in different dosage forms, namely gel, liquid and foam. as each type has its own characteristics, a study was conducted to understand the impact on sensory attributes that may affect user's acceptance of the product and ultimately influence usage leading to hand hygiene compliance [27] [28] [29] . the overall result showed that gels and foams are more widely accepted compared to liquid, especially in terms of handleability, though the latter left a high clean feeling and took a shorter time to dry [30] . united states food and drug administration (usfda) has given the list of eligible antiseptic agents used in the non-prescription (also known as over-the-counter or otc) and listed in table 2 . this list is highly useful in selecting appropriate antiseptic active ingredients intended for use by health care professionals in a hospital setting or other health care situations outside the hospital [31] . recently, the united states pharmacopeia (usp) compounding expert committee (cmp ec) recommends the three formulations for compounding alcohol-based hand sanitizers for use during shortages associated with the covid-19 pandemic and listed in table 3 [32] . on the other hand, the alcohol-free sanitizer makes use of chemicals with antiseptic properties to exert the antimicrobial effects. these chemicals have a different mode of action and function according to their chemical functional groups (table 1 ) [24] [25] [26] . as they are non-flammable and often used at low concentrations, they are relatively safer to use among children as compared to abhs. abhs is available in different dosage forms, namely gel, liquid and foam. as each type has its own characteristics, a study was conducted to understand the impact on sensory attributes that may affect user's acceptance of the product and ultimately influence usage leading to hand hygiene compliance [27] [28] [29] . the overall result showed that gels and foams are more widely accepted compared to liquid, especially in terms of handleability, though the latter left a high clean feeling and took a shorter time to dry [30] . united states food and drug administration (usfda) has given the list of eligible antiseptic agents used in the non-prescription (also known as over-the-counter or otc) and listed in table 2 . this list is highly useful in selecting appropriate antiseptic active ingredients intended for use by health care professionals in a hospital setting or other health care situations outside the hospital [31] . recently, the united states pharmacopeia (usp) compounding expert committee (cmp ec) recommends the three formulations for compounding alcohol-based hand sanitizers for use during shortages associated with the covid-19 pandemic and listed in table 3 [32] . table 1 . chemical classification of commonly used disinfectants in hand sanitizer and their mechanism of antimicrobial action. examples mechanism of action denaturation of proteins in the plasma membrane chlorine compounds halogenation/oxidation of cellular proteins table 2 . list of hand antiseptic ingredients approved by the food and drug administration (fda) used in healthcare and over the counter (otc) [30] . healthcare personal hand rub abhs in the form of a spray which trigger stream aerosol solution allows direct contact of the alcohol solution with the target surface. however, there are several limitations associated with the sprays, including overspray, breathed by patients and flammability. ready-to-use alcohol "hand sanitizing wipes (hsw)" is a pre-wetted towelette containing disinfectants, antiseptics, surfactants, etc. in a sealed package ready for use in topical disinfection. the advantage of hsw is eliminating the possible contaminations and transfer of pathogen due to towelettes reuse. however, the longer storage time could increase the probability of losing antimicrobial/viricidal activity due to the possible binding of active ingredients onto the towelettes or by the degradation of the active ingredient [33] . alcohol 60%-95% y n y n y benzalkonium chloride y y y y n benzethonium chloride y y n y n chlorhexidine gluconate n n n n n chloroxylenol y y n y n cloflucarban y y n y n fluorosalan y y n y n hexylresorcinol y y n y n iodine complex (ammonium ether sulfate and polyoxyethylene sorbitan monolaurate) n y n y n iodine complex (phosphate ester of alkylaryloxy polyethylene glycol) y y n y n iodine tincture united states pharmacopeia (usp) y n n n n iodine topical solution usp y n n n n nonylphenoxypoly (ethyleneoxy) ethanoliodine y y n y n poloxamer-iodine complex y y n y n povidone-iodine 5%-10% y y n y n undecoylium chloride iodine complex y y n y n isopropyl alcohol 70%-91.3% y n y n y mercufenol chloride y n n n n methylbenzethonium chloride y y n y n phenol (equal to or less than 1.5%) y y n y n phenol (greater than 1.5%) y y n y n secondary amyltricresols y y n y n sodium oxychlorosene y y n y n triclocarban y y n y n triclosan y y n y n combinations: calomel, keeping hands clean is a fundamental and essential step to avoid getting sick while limiting the transmission of germs to others. cdc recommends handwashing with soap and water whenever possible as it remarkably reduces the amount of all types of microbes and dirt on the skin surface [15, 34] . both the soaps and alcohol-based sanitizers work by dissolving the lipid membranes of microbes, thereby inactivating them ( figure 3) . thus, the sanitizer serves as an alternative when the soap and water are not readily available. the suggested minimum alcohol content of 60% is needed for it to exert the microbicidal effect. as compared to soap, alcohol-based sanitizers do not eliminate all types of germs, including norovirus and clostridium difficile, the common pathogens that can cause diarrhoea [35, 36] . while most people prefer to use sanitizers as they come in handy, and assume that the sanitizers may not be as effective as the soap at killing germs, this is because people may not use a sufficient amount of sanitizers to clean the hands [37, 38] . the liquid may evaporate before it is evenly rubbed all over the hands, therefore compromising the efficacy of the sanitizers [37, 39] . also, the sanitizer may not work well when the hands are grossly dirty or contaminated with harmful chemicals [40] . diarrhoea [35, 36] . while most people prefer to use sanitizers as they come in handy, and assume that the sanitizers may not be as effective as the soap at killing germs, this is because people may not use a sufficient amount of sanitizers to clean the hands [37, 38] . the liquid may evaporate before it is evenly rubbed all over the hands, therefore compromising the efficacy of the sanitizers [37, 39] . also, the sanitizer may not work well when the hands are grossly dirty or contaminated with harmful chemicals [40] . although hand sanitizers may be less effective than soaps in some situations, it is undeniable that they are the preferred form of hand hygiene in healthcare settings. the use of alcohol-based sanitizer may improve the compliance of healthcare workers to hand hygiene practices as they are easily accessible and take less time to use. around 2.5-3 ml of liquid (equivalent to two pumps from a dispenser) is deposited on the palm and rubbed all over the surfaces of both hands for 25-30 s to maximize the efficacy of the sanitizer [41] . abhs contains either ethanol, isopropanol, or n-propanol. a concentration of 60%-95% of alcohol by volume is said to exhibit optimum bactericidal activity [42, 43] . the antimicrobial effect of alcohols is attributed to their ability to dissolve the lipid membranes and denature the proteins of microbes. alcohols have broad-spectrum antimicrobial activity against most vegetative forms of bacteria (including mycobacterium tuberculosis), fungi, and enveloped viruses (human although hand sanitizers may be less effective than soaps in some situations, it is undeniable that they are the preferred form of hand hygiene in healthcare settings. the use of alcohol-based sanitizer may improve the compliance of healthcare workers to hand hygiene practices as they are easily accessible and take less time to use. around 2.5-3 ml of liquid (equivalent to two pumps from a dispenser) is deposited on the palm and rubbed all over the surfaces of both hands for 25-30 s to maximize the efficacy of the sanitizer [41] . abhs contains either ethanol, isopropanol, or n-propanol. a concentration of 60%-95% of alcohol by volume is said to exhibit optimum bactericidal activity [42, 43] . the antimicrobial effect of alcohols is attributed to their ability to dissolve the lipid membranes and denature the proteins of microbes. alcohols have broad-spectrum antimicrobial activity against most vegetative forms of bacteria (including mycobacterium tuberculosis), fungi, and enveloped viruses (human immunodeficiency virus [hiv] and herpes simplex virus). however, they are ineffective against bacterial spores that are found most commonly in raw materials. the addition of hydrogen peroxide (3%) may be a solution to this issue, but handling with caution during production is required due to its corrosive nature [41] . for alcohol-free products, various antiseptics have substituted alcohol as the main active ingredient. the mechanism of action of alcohols and non-alcohol compounds have been summarized in table 4 . table 4 . mechanism of action of alcohols and non-alcohol compounds. alcohol denatures protein and lipid membrane of microorganisms. optimum concentration 60%-95%. hydrogen peroxide inactivates contaminating spores in the bulk solutions or excipients. • concentration is as low as 3%. similar to alcohol, chlorhexidine works by disrupting the arrangement of cytoplasmic membranes, thereby leading to precipitation of cell contents [44] . it is most effective against gram-positive bacteria and has modest activity against a gram-negative bacteria, as well as enveloped viruses [44, 45] . as chlorhexidine is cationic, it is advisable to avoid using chlorhexidine-containing products with natural soaps and hand creams that contain anionic emulsifying agents as they may cause inactivation or precipitation of chlorhexidine, thus reducing its efficacy [44] [45] [46] . chlorhexidine gluconate 0.12% is likely to have antiviral activity against the coronavirus as it does against other enveloped viruses [47] . chloroxylenol is a common agent as a preservative in cosmetics or as an antimicrobial agent in soap. the antimicrobial effect of chloroxylenol is attributable to its ability to deactivate enzyme systems and alter cell wall synthesis in microbes. it is good at killing bacteria and enveloped viruses but less active against pseudomonas aeruginosa [48, 49] . iodine was once an effective antiseptic used for skin disinfection. it can penetrate the microbial cell wall and form complexes with amino acids or unsaturated fatty acids to impair the synthesis of cellular components. nonetheless, due to its potential to cause skin irritation and discoloration, iodophors have come into play to replace iodine as the active ingredient in antiseptics. the fda has not cleared any liquid chemical sterilant or high-level disinfectants with iodophors as the main active ingredient [50] . iodophors are a combination of either iodine, iodide or triiodide, and a high molecular weight polymer carrier such as polyvinyl pyrrolidone. this carrier is responsible for improving the solubility of iodine, enhancing the sustained release of iodine, and minimizing skin irritation [51] . the degree of antimicrobial activity determined based on the amount of free iodine present in the structure. having said so, formulations with lower iodophor concentration may have significant antimicrobial activity as well because the amount of free iodine tends to increase after dilution [52] . both iodine and iodophors exhibit germicidal activity against a gram-positive, gram-negative, and spore-forming bacteria, as well as various fungi and viruses [53] [54] [55] . however, the concentration of iodophors used in antiseptics (e.g., povidone-iodine 5%-10%) is usually insufficient to achieve sporicidal action. furthermore, the nasal povidone-iodine formulation has shown acceptable tolerability and favorable risk/benefit profile to help mitigate the perioperative spread of covid-19 in patient decolonization [56] . quaternary ammonium compounds are composed of four alkyl groups connected to a nitrogen atom in the centre. the typical examples include benzalkonium chloride, benzethonium chloride, and cetyl peridium chloride. they act by adsorbing to the cytoplasmic membrane, thus causing leakage of the constituents. they are more active against gram-positive bacteria and lipophilic viruses. the activity against fungi, mycobacteria, and gram-negative bacilli is comparatively weak [15] . at low concentration, triclosan is bacteriostatic due to its harmful effects to bacterial enzymes responsible for the composition of fatty acid from cells wall and membranes. at high concentrations, triclosan disrupts the bacteria membrane, leading it to death [8, 57, 58] . it has good activity against gram-positive bacteria, including methicillin-resistant staphylococcus aureus, candida spp. and mycobacteria. the efficacy of triclosan may be affected by ph, use of emollients, and the ionic nature of certain skin formulations [58] . a lot of sanitizers also include humectant, for instance, glycerine, in the formulation to reduce the incidence of dry skin associated with the use of alcohol-based products as the alcohol can strip away sebum that helps to keep the skin moist. though fragrance and colorant added to improve the aesthetics, it is generally not recommended to do so due to the risk of allergic reactions [41, 43] . the skin is composed of three main layers: a superficial epidermis (50-100 µm), a middle dermis (≈2 mm), and an innermost hypodermis (1-2 mm). it constitutes the first line of defence against invading microorganisms while providing protection against mechanical impacts and preventing excessive loss of water from the body. the vital barrier function of the skin resides primarily in the uppermost epidermal layer, the stratum corneum (sc). the sc contains layers of corneocytes that are terminally differentiated from keratinocytes that make up the basal layer of epidermis [15, 59] . the adjacent corneocytes are interconnected by membrane junctions called corneodesmosomes to enhance the cohesion of the sc [60] . the lipids that are derived from the exocytosis of lamellar bodies during terminal differentiation of keratinocytes will fill up the intercellular spaces between the corneocytes, and they play a role in maintaining the cutaneous barrier function [61] . the layer underneath the sc is known as the keratinized stratified epidermis. it consists of melanocytes that produce melanin, a skin pigment that provides skin with its color and protects the skin from ultraviolet radiation. apart from that, langerhan's cells, which are involved in the immune response and merkel cells that are responsible for light touch sensation, can also be found within this layer [62, 63] . though the skin serves as a barrier that protects one against harmful microorganisms, it hosts a wide array of beneficial bacteria such as staphylococcus epidermis, staphylococcus aureus, micrococcus spp., propionibacterium spp. and corynebacterium spp. [64, 65] . these bacteria may help to prevent the colonization of pathogenic microbes by either competing with them for nutrients or stimulating the skin's defence system. under normal circumstances, they exhibit low pathogenicity. however, when the skin flora distribution is disrupted, for example, due to the long-term use of topical antibiotics or frequent hand washing, they may become virulent [66, 67] . to reduce the incidence of infection, the microbiota balance is restored and maintained through constant skin regeneration. the whole process takes about 28 days, starting from the mitotic division of basal epithelium to desquamation. when the dead keratinocytes in the sc are sloughed off, it takes away the microbes that colonized the skin surface. this continuous process significantly limits the invasion of bacteria while achieving a balanced growth among the microbial populations. the virus sars-cov-2 is termed due to of its genome sequence similarity to sars coronavirus (sars-cov) [68, 69] . the covs belong to the same genus beta coronavirus, sharing similar morphology in the form of enveloped, positive single-stranded rna viruses [70, 71] . these viruses can be deactivated by certain lipid solvents such as ethanol, ether (75%), chlorine-containing disinfectants, and chloroform, except chlorhexidine [70] . ethyl alcohol, at concentrations of 60%-80%, is a potent viricidal agent inactivating all the lipophilic viruses (e.g., influenza, herpes and vaccinia virus) and many hydrophilic viruses (e.g., adenovirus, enterovirus, rhinovirus, and rotaviruses but not hepatitis a virus (hav) or poliovirus) [32] . the 2015 who model list of essential recommended ethanol at 80% (v/v) and isopropyl alcohol at 75% (v/v) under the category 'disinfectant: alcohol-based hand rub' [72] . ethanol (60%-85%) appears to be the most effective against viruses compared to isopropanol (60%-80%) and n-propanol (60%-80%) [23] . the study conducted with who-recommended alcohol-based formulations demonstrated a strong virucidal effect against emerging pathogens, including zikv, ebov, sars-cov, and mers-cov [73] . another study conducted in germany found that the ethanol in the concentration of 42.6% (w/w) was able to destroy sars coronavirus and mers coronavirus within 30 s [74] . the efficacy of various alcohol-based sanitizers at different concentrations was also investigated in several studies, as shown in table 5 . rf: reduction factor (calculated as the difference in the quotient of control titration and after incubation of the virus with the disinfectant). higher rf value indicates higher virus reduction potential. log 10 value of ≤1 is not significant or ineffective, log 10 value of 1-2 is indicative/contributable effective, log 10 value of 2-4 is moderately effective, and log 10 value of ≥4 is highly effective. undetectable level indicates a higher potential than is demonstrated. the most commonly reported skin reactions with the use of abhs are irritant contact dermatitis (icd) and allergic contact dermatitis (acd) [76, 77] . the symptoms of icd can range from mild to debilitating with manifestations like dryness, pruritus, erythema and bleeding, if severe. as for acd, the symptoms can either be mild and localized or severe and generalized, with most severe forms of acd being manifested as respiratory distress or other anaphylactic symptoms [78, 79] . sometimes, it may be difficult to distinguish between icd and acd due to the overlap and similarities of symptoms. hand hygiene products such as sanitizer and soaps can be damaging to the skin through several mechanisms: denaturation of the stratum corneum proteins, alteration of intercellular lipids, decrease in corneocyte cohesion and reduction of stratum corneum water-binding capacity [80, 81] . the biggest concern is the depletion of the lipid barrier, especially with repeated exposure to lipid-emulsifying detergents and lipid-dissolving alcohols as it may penetrate deeper into the skin layers and change the skin flora, resulting in more frequent colonization by bacteria [82] [83] [84] . in order of decreasing frequency of icd including handwashing soaps are iodophors, chlorhexidine, chloroxylenol, triclosan and alcohol-based products. among the alcohol-based formulations, ethanol has the least skin-irritant property compared to n-propanol and isopropanol [21] . there are, however, other contributing factors that increase the risk of icds such as lack of use of supplementary emollients, friction due to wearing and removal of gloves and low relative humidity [85] [86] [87] . abhs also has a drying effect on hands which can further cause the skin to crack or peel [88] [89] [90] . on the other hand, acd is caused by allergic reactions towards certain agents in the formulations such as iodophors, chlorhexidine, triclosan, chloroxylenol and alcohols [91] . individuals with allergic reactions to alcohol-based preparations may have true allergy to alcohol or allergy to impurity, aldehyde metabolite or other excipients like fragrances, benzyl alcohol, parabens or benzalkonium chloride [29, 92, 93] . the adverse effects caused by sanitizer or handwashing soaps can be easily prevented by identifying the trigger and countered with appropriate measures using one or a combination of following methods: selecting products with a less irritating agent, moisturizing skin after hand sanitation and avoiding habits that may cause or aggravate skin irritation [29, 41, 93, 94] . when frequent hand cleansing is expected, for instance, among healthcare workers, it is preferable to select products that have a good balance between effectiveness, safety and compatibility with all skin types. the concerns about drying and irritant effects of alcohol or certain antiseptic soaps may hinder the acceptance and ultimate use of these preparations [52] . hence, to reduce this problem, abhs containing humectants or emollients can be used instead [95] . in recent years, novel water-based antiseptic lotions are also being studied such as that using benzethonium chloride, which not only addresses the issue regarding cutaneous adverse effects but also broadens the efficacy against viruses and tackles concerns about flammability associated with conventional abhs [76] . temperature and humidity are considered as significant contributors to the risk factors of dermatitis. the retention of skin moisture is longer in tropical countries and places with higher relative humidity compared to cold, dry environments [96] . this aspect calls for a varying need of emollients concerning respective environmental conditions and climates according to geographical locations. some individuals, such as the elderly and healthcare workers who often wear occlusive gloves, are more prone to dry skin. therefore, it is a good practice for these high-risk individuals to use moisturizers containing humectants, fats or oils to enhance skin moisture and improve skin barrier function [96] . proper hand hygiene by washing hands or using alcohol-based sanitizer is one of the most critical measures to prevent direct or indirect transmission of the covid-19 as it reduces the number of the viable sars-cov-2 virus on contaminated hands. there are five instances that call for hand hygiene: before and after having direct contact with patients, before handling invasive devices for patient care, after exposure to body fluids or excretions, after contact with objects including medical appliances within proximity of the patient, and before starting any aseptic task [96] . the cdc recommends washing hands with soap and water whenever possible because handwashing reduces the amounts of all types of germs and chemicals on hands [97] . if soap and water are not available, using a hand sanitizer with a final concentration of at least 60% ethanol or 70% isopropyl alcohol inactivates viruses that are genetically related to, and with similar physical properties as, the covid-19. the action of handwashing can mechanically remove the microorganisms, but the removal of resident pathogens is more effective when hands are washed with preparations containing anti-microbial agents [96] . according to the policies and procedures on cdc, who and the infection control by ministry of health malaysia, the recommended duration for the entire handwash procedure spans between 40 to 60 s using the standard 7-step technique. comparatively, sanitizer containing at least 60% alcohol is more effective in destroying the microorganisms than handwashing with anti-microbial soaps due to their ability to inactivate and destroy the microbes [96] . however, it should be noted that the abhs may not be as effective if the hands are visibly soiled, dirty or greasy, so handwashing with soap and water is preferred under these circumstances. the duration to rub sanitizer all over the hand surfaces is approximately 20 to 30 s [96] . proper hand hygiene is one of the essential infection control strategies as it can undeniably lower the likelihood of direct or indirect transmissions of microorganisms. the use of abhs is becoming more common because of their rapid action and efficiency in killing microorganisms, mainly when handwashing using soap and water is not practical or convenient. there are, however, some situations in which handwashing is preferred as abhs are less effective when the hands are visibly dirty or stained and cannot cover certain kinds of pathogens. it is vital to select abhs with the appropriate amount of alcohol and practice the correct hand hygiene technique when cleaning hands to ensure all the microorganisms are effectively killed. author contributions: t.m. and r.j.c.b. conceptualized the purpose of the review. j.l.j.j. and t.p.y. jointly extracted the articles and involved in the initial preparation of manuscript. j.r.m. and n.t. cross-checked the extracted data which was further reviewed and edited by t.m. all authors have read and agreed to the published version of the manuscript. covid-19 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funding: this research received no external funding. the authors declare that they have no conflict of interest. key: cord-346258-xlyi0cnl authors: radic, aleksandar; ariza-montes, antonio; hernández-perlines, felipe; giorgi, gabriele title: connected at sea: the influence of the internet and online communication on the well-being and life satisfaction of cruise ship employees date: 2020-04-20 journal: int j environ res public health doi: 10.3390/ijerph17082840 sha: doc_id: 346258 cord_uid: xlyi0cnl this study aims to elucidate the idiosyncratic effects of the internet and online communication on the well-being and life satisfaction of cruise ship employees. cross-sectional surveys and covariance-based structural equation modelling tools were used. in addition, univariate variance analysis was used to address the effects of socio-demographic variables (years of service on a cruise ship, working department on a cruise ship, gender, age, educational level and place of residency) on latent variables of the conceptual model. the conceptual model draws on existing theory and previous research and was empirically tested on a sample of cruise ship employee internet users. result show that while being onboard a cruise ship, employees experience strong social pressure to be constantly available and they fear of missing out on important information and life events. thus, relatedness to friends and family needs satisfaction is of paramount importance for cruise ship employees because they are fully aware that they are dispensable and replaceable to cruise ship companies, however to their friends and family, they are indispensable and unique. moreover, employees who engage in other tasks/activities while taking part in online communication with friends and family exhibit reduced performance, which leads to poor interaction and social dissatisfaction. lastly, employees experiencing under-reciprocating exchanges show significant negative effects on their well-being. overall, the results provided several important theoretical and practical implications relevant to cruise tourism and human resource management. cruise tourism growth for 2020 predicted by [1] will not be achieved due to the recent cruise tourism crisis caused by the covid 19 pandemic. on 14 march 2020, all cruise lines suspended their cruise operations for at least 30 days [2] . however, none of the cruise companies have filed for bankruptcy or cancelled their new builds. therefore, the prediction of the addition of 80,000 new crew members and officers each year until 2027 remains an achievable possibility [3] . a recent study by [4] revealed that cruise ship employees are exposed to long working hours and detachment from friends and family, which leads to poor social interactions and feelings of loneliness. however, advances in information and communication technologies have led to their widespread and increased usage by employees. internet access has become a basic necessity, a more essential element of their mundane ship life with paramount importance on their well-being and life satisfaction. enhanced connectivity is instrumental for bolstering morale and reinforcing job satisfaction, which ultimately strengthens the capability for communication between employees and their significant others back home and hence, reduces the feeling of loneliness [5] . moreover, maritime labour convention [6] recommended rational access to the internet with reasonable charges for services. from november 2019 to february 2020, only a handful of cruise companies (disney cruise line, holland america, azamara, and princess cruises) have provided free-of-charge specialized cross-platform messaging internet applications for their employees. interestingly, the seafarers happiness index, which covers 10 aspects of job quality, including mental and physical health and relationships at home and onboard, showed significant increases in happiness for cruise ship employees from 5.3 to 7 out of 10 [7, 8] . given the unique work and life conditions on cruise ships, whereby employees are set apart from their loved ones [9] , free internet access should be a universal entitlement [10] because of its ability to enhance seafarer morale, engagement, well-being and life satisfaction [11] . although significant amounts of research have been done on the positive effects of internet and online communication on social pressure [12] , fear of missing out [13] , relatedness to friends and family need satisfaction [14] , perceived social support [15] , well-being [16] and life satisfaction [17] , these effects were never studied in the peculiar environment of a cruise ship where life and work contexts are so intertwined such that the distinction between one and the other is blurred [18] . this study aimed to elucidate the idiosyncratic effects of the internet and online communication on the well-being and life satisfaction of cruise ship employees. we reviewed existing theory and previous studies on the effects of the internet and online communication on social pressure, fear of missing out, internet multitasking and relatedness to friends and family need satisfaction. we investigated the influence of social pressure and fear of missing out on relatedness to friends and family need satisfaction and internet multitasking. finally, we proposed relatedness to friends and family need satisfaction and internet multitasking as possible catalyst influencers of perceived social support which, in the end, are the impetus towards the well-being and life satisfaction of employees. the conceptual model draws on existing theory and previous research and was empirically tested on a sample of employee internet users. finally, we addressed the effects of socio-demographic variables (years of service on a cruise ship, working department on a cruise ship, gender, age, educational level and place of residency) on latent variables of the conceptual model. this study is exploratory in nature and presents work addressing a major research gap, given that the effects of internet and online communication on the well-being and life satisfaction of cruise ship employees have never been empirically tested. the results of this study will contribute towards the further development of cruise tourism theory and strengthen existing theories, such as theory of belongingness [19] , self-determination theory [20] , uses and gratification theory [21] , conservation of resources theory [22] and the paradigm of positive psychology [23] . while working and living on cruise ships, employees are detached from their family and friends [9] . primary communication instruments include internet and online communications [5] , which play significant roles in integrating work and family domains [28] . these communication instruments provide social capital, information and wider perspectives [25] . in recent survey conduct by [8] , the authors concluded that onboard crew members experience strong social pressure for being constantly available to their family and friends. today, almost every cruise ship employee has a mobile device [11] . although mobile devices allow users to be constantly available, they also create an environment that increases social pressure [29] . moreover, the social pressure to be constantly available is strongly related to communication load [13] , with a suppressing effect on well-being via social overload [30] . based on the social norm of reciprocity in friendship and family ties, psychological tensions and social pressures may arise [16] . thus, based on the literature review and empirical findings, the following hypothesis is proposed: there is a positive relationship between the internet and online communication and social pressure. in their theory of belongingness, baumeister et al. [19] argue how human beings have an irresistible need to be a part of a group. the hardest part for cruise ship employees is being away from home and missing so many important life events and quality time with family and friends [18] . similar results have been reported by [5] who demonstrated in their comprehensive report how due to being uncontactable at sea, seafarers miss key life events. cruise ship employees are fully aware that work-life on a cruise ship comes with a great burden [31] . however, they are not willing to tolerate any lack of connectivity [8] . internet and online communication are closely linked to fear of missing out [32] . fear of missing out is defined as "a pervasive apprehension that others might be having rewarding experiences from which one is absent" [33] . thus, we can conclude based on compensatory internet use theory [34] that individuals who feel that their life needs are not fulfilled and that they are missing important life events and social motivation will experience strong stimulation to use online communication and social networking sites. based on the theoretical background, literature review and empirical findings, the following hypothesis was derived: hypothesis 2 (h2). there is a positive relationship between the internet and online communication and fear of missing out. the internet, social networking sites and online communication have become our liaisons, special amusers, cerberus of our memories and, in times of need, even our counsellors [27] . based on self-determination theory [20] , relatedness to friends and family need satisfaction is one of three basic psychological needs that foster healthy self-regulation and promote mental and physical health. opportunities to experience positive feelings of proximity and affection with family and friends at home through the use of online communications benefits seafarers and their friends and family [5] . interestingly, in the latest survey conducted by [11] , although provisions of internet access for personal use had positively affected seafarer mental health and morale, home-related anxieties have remained the same, despite speculation that increased communications with family might generate more anxieties. the effects of the internet and online communication and relatedness to friends and family need satisfaction remain unclear [35] . previous studies have shown that internet and online communication are mainly linked to positive outcomes of relatedness to friends and family need satisfaction [36, 37] . few studies have demonstrated the opposite [25, 38] . thus, based on literature review, theory and empirical findings, we put forward the following hypothesis: there is a positive relationship between the internet and online communication and relatedness to friends and family need satisfaction. social pressure is conformist behaviour with multiple determinations when an individual or group craves specific social attention; this leads them to behave in certain ways unconcerned of any prestige advantage [39] . a recent study conducted by [13] showed how computer-meditated communication is portrayed and influenced by robust rules of conduct, where communication arrangements are under constant social pressure. interestingly, within seafarers, social pressure has shown a strong influence on their work-life at sea due to their social isolation, imbalanced family life, separation from home, family and friends, and lack of free onboard communication facilities [40] . moreover, relatedness proposes that cruise ship employees need to feel connected with their family and friends at home [5, 9, 18] : when employees feel satisfied with this need, they experience higher levels of work engagement and well-being. most employees own smartphones and experience social pressure to make themselves available to friends and family at home, thereby satisfying needs for relatedness. online communications induced by social pressure and relatedness to friends and family needs satisfaction has been directly linked with significant effects on user life satisfaction [41] . thus, based on the literature review, theoretical background and empirical findings, we put forward the following hypothesis: there is a positive relationship between social pressure and relatedness to friends and family need satisfaction. the constant occupation with smartphones has created a peculiar mindset in users with specific feelings of being permanently online and connected [42] . interestingly, online communication and social media are closely linked to fear of missing out [13] ; 56% of u.s. social media users suffer from fear of missing out [43] . thus, tensions related to social relationships may be the prevailing cause for the fear of missing out [44] . the uses and gratifications theory provides us with pragmatic theoretical lenses instrumental in understanding underlying motives and multitasking behaviours [45] . the theory proposes that hidden roots of social and psychological needs create certain expectations from various media, which guides users towards specific models of media exposure, culminating in need gratification [46] . looking at the advantages of online communications to those living and working at sea, fear of missing out has a significant impact; 75% of crew members need to be connected with the outside world, and 63% would leave their current company to join some other that would provide better onboard connectivity [5] . previous research also showed that higher levels of fear of missing out had an impact on a higher tendency to internet multitask [33] . cruise ship employees have long working hours and rarely go ashore; the tendency to internet multitask leads to some occupational injuries [4] . consequently, based on theory, literature review and empirical findings, the following hypothesis is derived: there is a positive relationship between fear of missing out and internet multitasking. widespread adoption of the internet, online communication, and social network sites have empowered people across the globe to grow their social network [47] . however, such a gift comes with responsibility because various social network sites compete for our attention by streaming content based on well-programmed algorithms founded on our likes, fears, and needs [27] . the digital world is doused with ever-growing social network sites that are changing the online behaviour of digital technology users but also how human beings interact with one another in real life [48] . moreover, human beings are social animals [49] in need of relatedness to friends and family, regardless of recent technological advancements. relatedness comes in the form of affective needs, which tend to intensify delightful and affecting experiences, and social needs that tend to bolster existing connections with family and friends [50] . thus, the need for relatedness is a feeling of satisfaction that comes from being a connected part of a community where individuals manifest a willingness to care about each other [51] . being away from their homes in an isolated environment [52] , cruise ship employees are constantly looking for social support [53] . interestingly, perceived social support, characterized as the tangible or intangible support received from an individuals' social circle, is associated with superior life satisfaction [54] . consequently, based on theory, literature review and empirical findings, the following hypothesis is derived: hypothesis 6 (h6). there is a positive relationship between relatedness to friends and family need satisfaction and perceived social support. the term internet multitasking refers to "any combination of internet use with other media or non-media activities" [13] p. 94. the main reasons for multitasking are social interactions with friends and family and information seeking [45] . cruise ship employees are most often in different time zones than their friends and family. this leaves them with a limited time frame for online communication and significantly lowers the opportunities for giving and receiving much needed social support. moreover, cruise ship employees are under extreme time pressure due to long working hours [4] ; this is when individuals perceive that if they engage in internet multitasking, they would be efficient [45] . however, the effects of internet multitasking on retention of information during online messaging and cognitive load, showed significant retention loss among simultaneous multitasks [55] . similarly, internet multitasking has been associated with lower gratification and perception memory achievement and sensitivity and moderate standard bias [56] . moreover, different types of multitasking have robust effects on task performance. task performance significantly decreased when the given task was a secondary task, when a neurological obstruction was high, and when the behavioural reaction was present [57] . thus, based on literature review and taking in consideration the conflicting empirical results of internet multitasking effect on perceived social support, and bearing in mind the importance of perceived social support for cruise ship employees, the following hypothesis is derived: there is a positive relationship between internet multitasking and perceived social support. the social relationship is flexible and essential for individual vitality because human beings exist within larger social contexts where friends and family play important roles [58] . moreover, if a persons' social context is supportive of significant relationships, then these individuals encounter elevated feelings towards psychological needs, which can be satisfied through social synergy [41] . social support has four dominant aspects in the creation of well-being and life satisfaction: main effect (adding particular supplementary function to mental health), mediating effect (intervening in relations between its precursors and health results), indirect effect (preventing disorders by framing mental health) and moderating effect (lowering the risk of any mental health-related components) [59] . previous studies have shown that the internet and online communication have a positive effect on social capital [60] where social capital is an antecedent of social support [59] . internet and online communication are bonding and bridging social capital [38] , which are of paramount importance for satisfying the social support need of cruise ship employees who tend to use online communication to contact geographically dispersed close friends and family [5] . thus, social support plays multiple roles in individuals' well-being and life satisfaction [59] . considering the importance of well-being and life satisfaction of employees, based on literature review and empirical findings, we put forward the following hypotheses: there is a positive relationship between perceived social support and well-being. people should focus on how to be happy, satisfied and filled with positivity [23] . thus, psychological well-being is an essential part of positive psychology. psychological well-being is related to ones' feelings and evaluations about their life [61] . moreover, well-being is seen as a psychological well-being that develops based on the eudaimonic dimension of well-being [62] and as happiness that is built around life satisfaction based on the hedonic dimension of well-being [63] . in the context of cruise ship employees, well-being is a fusion of eudaimonic (efficiency) and hedonic (thrill) dimensions. interestingly, gibson et al. [64] argues how due to work-life time constraints, task assignments and job anxiety, employees experience poor well-being. moreover, radić [18] questions the life satisfaction and well-being of employees who are economic gladiators in pursuit of an unobtainable economic freedom. thus, moore [65] calls cruise ships "misery machines" where in recent years, as walker [66, 67] point out, there has been a substantial increase in suicide rates due to the poor well-being of employees. interestingly, perceived social support from online communication has had a positive effect on well-being [5, 8] . social network sites have provided ambient awareness that increases the well-being of its users [68] . life satisfaction is related to a subjective, comprehensive evaluation of one's quality of life [69] . moreover, life satisfaction draws from the individual's psychological aspects and is related to one's hedonic satisfaction [62] , where at the same time, perceived social support from an individual's social networks has the potential to strengthen a person's life satisfaction [24] . in the q4/2019 report, seafarers happiness index [8] showed how free online communications have a significant impact on employee life satisfaction; as ang et al. [41] argue, computer-mediated communications can enhance life satisfaction. online communication and social network sites can drive a person towards achieving superior life satisfaction and better quality social relationships [38] . interestingly, although employees use online communication and social network sites to strengthen their close interpersonal connections and enhance their life satisfaction [18, 70] argue that weak ties are also valuable due to their potential to positively influence life satisfaction. figure 1 illustrates the research model and hypotheses of this study. freedom. thus, [65] calls cruise ships "misery machines" where in recent years, as [66, 67] point out, there has been a substantial increase in suicide rates due to the poor well-being of employees. interestingly, perceived social support from online communication has had a positive effect on wellbeing [5, 8] . social network sites have provided ambient awareness that increases the well-being of its users [68] . life satisfaction is related to a subjective, comprehensive evaluation of one's quality of life [69] . moreover, life satisfaction draws from the individual's psychological aspects and is related to one's hedonic satisfaction [62] , where at the same time, perceived social support from an individual's social networks has the potential to strengthen a person's life satisfaction [24] . in the q4/2019 report, [8] showed how free online communications have a significant impact on employee life satisfaction; as [41] argue, computer-mediated communications can enhance life satisfaction. online communication and social network sites can drive a person towards achieving superior life satisfaction and better quality social relationships [38] . interestingly, although employees use online communication and social network sites to strengthen their close interpersonal connections and enhance their life satisfaction [18, 70] argue that weak ties are also valuable due to their potential to positively influence life satisfaction. figure 1 illustrates the research model and hypotheses of this study. the theoretical framework of this study was based on a literature review; the conceptual model and hypotheses were tested based on a convenience sample. the post-positivistic paradigm was adopted in this study because as [71] argues, the post-positivistic paradigm takes into consideration the fact that in human behaviour studies, observations are imperfect with potential inaccuracies; thus, all theories could be amended. action research strategy allows the research to use different models of contemporary knowledge in solving genuine industry issues and applying obtained results outside the boundaries of the study [72] . thus, action research strategy was used. the research model was evaluated using a cross-sectional survey and covariance-based structural equation modelling the theoretical framework of this study was based on a literature review; the conceptual model and hypotheses were tested based on a convenience sample. the post-positivistic paradigm was adopted in this study because as [71] argues, the post-positivistic paradigm takes into consideration the fact that in human behaviour studies, observations are imperfect with potential inaccuracies; thus, all theories could be amended. action research strategy allows the research to use different models of contemporary knowledge in solving genuine industry issues and applying obtained results outside the boundaries of the study [72] . thus, action research strategy was used. the research model was evaluated using a cross-sectional survey and covariance-based structural equation modelling (cb-sem). cb-sem allows testing and validation of current theories and comparisons of different theories [73] . in summary, this study used a deductive approach followed by a cross-sectional time horizon and quantitative techniques for data collection. a comprehensive self-reported online survey in english was designed at surveymonkey®. possible participants were invited to take part in the survey via facebook group "crew center". the main criteria was that participants had to be onboard and employed by a cruise company. the survey was online from 24 august to 1 december 2019, and the final sample consisted of 532 cruise ship employees (see table 1 ). the sample comprised 328 males and 195 females from different geographical areas (43.8% from europe, 20.3% from north america, 16.4% from southeast asia, 7.3% from south america, 4.6% from central america, 4.2% from africa, and 3.4% from australia). most respondents were between 31-40 years old (50.9%) followed by respondents 21-30 years old (27.7%) and 41-50 years old (11.9%). among the participants, 49.5% were employed in the hotel department, 32.9% were from the deck and technical department, and 17.6% were from the entertainment department. most (45.9%) had worked in the industry for over six years. a large share of respondents had a bachelor's degree (57.7%). this extreme unrepresentative value was related to the convenience sampling method. overall, the sample was a very good representation of employee demographics [74] . internet and online communication were assessed using a five item scale designed to asses internet and online communication usage (all the measures are included in the appendix a). participants indicated on a five point scale from 1 (once per week) to 5 (several times per week) how often they use the internet for communication; from 1 (less than an hour) to 5 (more than 4 hours per day) how many hours per day (on average) they spend on internet communication; from 1 (once a week) to 5 (several times per day) how often they use a) instant messenger, b) social networking sites, and c) chat rooms. internal consistency in the present sample was acceptable (cronbach's α = 0.790). social pressure to be permanently available was assessed with an adapted perceived norm scale [13] that had four items (e.g., "people from my private social environment think that it is important that i'm constantly available") and is rated on a five point scale ranging from 1 (does not apply at all) to 5 (fully applies). internal consistency in the present sample was acceptable (cronbach's α = 0.794). fear of missing out on important life events and information was assessed with a three item scale (e.g., "if i would use the internet less frequently, i would be missing out on important things") developed by [13] . participants rated the items on a five point scale ranging from 1 (does not apply at all) to 5 (fully applies). internal consistency in the present sample was good (cronbach's α = 0.845). relatedness to friends and family need satisfaction was assessed with three item scale (e.g., "i feel that my friends and/or family sincerely care about me") developed by [75] . participants rated the items on a five point scale ranging from 1 (strongly disagree) to 5 (strongly agree). internal consistency in the present sample was good (cronbach's α = 0.905). internet multitasking was assessed with a five item scale (e.g., "how often do you use the internet while you simultaneously are in a conversation with another person") developed by [13] . participants rated the items on a five point scale ranging from 0 (never) to 4 (very frequently). internal consistency in the present sample was acceptable (cronbach's α = 0.747). perceived social support was assessed by the multidimensional scale of perceived social support [76] , which consisted of six items (e.g., "there is a special person who is around when i am in need") and was rated by participants on a seven point scale ranging from 1 (strongly disagree) to 7 (strongly agree). internal consistency in the present sample was acceptable (cronbach's α = 0.784). well-being was assessed by the world health organization well-being index [77] . it comprises five items (e.g., "i have felt cheerful and in good spirits") and was rated by participants on a six point scale ranging from 1 (all the time) to 6 (at no time). internal consistency in the present sample was good (cronbach's α = 0.875). life satisfaction was assessed by satisfaction with life scale [78] . it consists of five items (e.g., "in most ways my life is close to my ideal") and it was rated by participants on a seven point scale ranging from 1 (strongly disagree) to 7 (strongly agree). internal consistency in the present sample was good (cronbach's α = 0.869). structural equation modelling (sem) was computed using the amos 21 software packet (ibm, chicago, illinois), and the maximum likelihood method was used to estimate the parameters from the conceptual model (see figure 1 ). the kolmogorov-smirnov and shapiro-wilks test showed that none of the variables were normally distributed. thus, a maximum likelihood (ml) estimator with enough resistance capabilities to none-extreme deviations from the normal distribution [79] was used. model fit was tested based on the χ2 and cmin/df statistics, the comparative fit index (cfi) and the root mean square error of approximation (rmsea) as recommended by [80] . the univariate analysis of variances (anova) was used in search of differences among employee demographics and conceptual model variables. the model showed an acceptable fit to the data with the following values: χ2(483) = 1517,145, p = 0.000; rmsea = 0.064, lo 90 = 0.060, hi 90 = 0.068; cmin/df = 3.141 and cfi = 0.887. although the general indicator χ2 was significant, with such a large number of degrees of freedom, χ2 is not reliable; it is better to rely on other indicators. rmsea was close to the limit that indicates an excellent model (0.06), cmin/df was within the limits that represent a good model, whereas the cfi was close to the lower limit of acceptability of the model [80] [81] [82] . table 2 shows the hypothesized paths of the conceptual model. the zero-order correlations between social pressure and fear of missing out, demonstrate that these two variables are strongly interrelated. social pressure and fear of missing out show very high correlations (r = 0.79, p < 0.01). this significant relationship is reasonable: social pressure as a concept is closely connected to the concept of fear of missing out as these social processes on the internet and social network sites are synthesized. because social interaction through the internet and online communication are of paramount importance for cruise ship employees [5] , accomplishing this pursuit is a way towards well-being and life satisfaction. this conception is supported by results from [7, 8] , who reported that a recently developed free-of-charge specialized cross-platform messaging internet application (by a handful of cruise companies) had an immediate impact on the happiness index of employees by increasing to 32% from q2/2019 to q4/2019. except for hypotheses 3, 7 and 8, all other hypothesized relationships were supported in the final model ( figure 2 ). hypotheses 1 and 2 were supported showing how the internet and online communication had positive effects on social pressure (β = 0.169) and fear of missing out (β = 0.237). interestingly, hypothesis 3 was not supported, demonstrating that the internet and online communication did not have a positive effect on relatedness to friends and family need satisfaction (β = 0.075). as predicted in hypothesis 4, social pressure had a positive effect on relatedness to friends and family need satisfaction (β = 0.358), and fear of missing out has a positive effect on internet multitasking (β = 0.248) as predicted in and hypothesis 5. hypothesis 6 predicted that relatedness to friends and family need satisfaction had a positive effect on perceived social support; this hypothesis was supported (β = 0.148). hypothesis 7 predicted that internet multitasking had a positive effect on perceived social support; however, this hypothesis was not supported (β = −0.008). hypothesis 8 predicted that perceived social support had a positive effect on well-being; however, this hypothesis was not supported (β = −0.127). lastly, hypothesis 8 predicted that perceived social support had a positive effect on life satisfaction; this hypothesis was supported (β = 0.522). in pursuit of elucidating the peculiar socio-demographics characteristics of cruise ship employees and unrevealing significant differences on sample and research model variables, anova was used. the results disclosed the following pivotal differences. the hypotheses 1 and 2 were supported showing how the internet and online communication had positive effects on social pressure (β = 0.169) and fear of missing out (β = 0.237). interestingly, hypothesis 3 was not supported, demonstrating that the internet and online communication did not have a positive effect on relatedness to friends and family need satisfaction (β = 0.075). as predicted in hypothesis 4, social pressure had a positive effect on relatedness to friends and family need satisfaction (β = 0.358), and fear of missing out has a positive effect on internet multitasking (β = 0.248) as predicted in and hypothesis 5. hypothesis 6 predicted that relatedness to friends and family need satisfaction had a positive effect on perceived social support; this hypothesis was supported (β = 0.148). hypothesis 7 predicted that internet multitasking had a positive effect on perceived social support; however, this hypothesis was not supported (β = −0.008). hypothesis 8 predicted that perceived social support had a positive effect on well-being; however, this hypothesis was not supported (β = −0.127). lastly, hypothesis 8 predicted that perceived social support had a positive effect on life satisfaction; this hypothesis was supported (β = 0.522). in pursuit of elucidating the peculiar socio-demographics characteristics of cruise ship employees and unrevealing significant differences on sample and research model variables, anova was used. the results disclosed the following pivotal differences. the cruise ship employees come from various countries around the globe. thus, it is important to determine whether any fundamental differences were present based on country of residence and the research model variables. employee place of residence had prominent effects on internet and online communication (f(6, 516) = 3.47, p = 0.00), fear of missing out (f(6, 516) = 2.91, p = 0.01), social pressure (f(6, 516) = 3.44, p = 0.00), relatedness to friends and family need satisfaction (f(6, 94.46) = 8.12, p = 0.00), internet multitasking (f(6, 92.36) = 4.34, p = 0.00), perceived social support (f(6, 87.66) = 3.95, p = 0.00) and well-being (f(6, 91.14) = 3.03, p = 0.01). differences between place of residence and fear of missing out (η2 = 0.03) were low. differences among place of residence and internet and online communication (η2 = 0.04), social pressure (η2 = 0.04), relatedness to friends and family need satisfaction (η2 = 0.04), internet multitasking (η2 = 0.04), well-being (η2 = 0.02) and perceived social support (η2 = 0.06) were moderate. student's t-test revealed that employees from africa showed significant differences the goal of the current study was to investigate and model complex mutual interactions the internet and online communication had on social pressure, fear of missing out, internet multitasking and relatedness to friends and family need satisfaction, perceived social support, well-being and life satisfaction of cruise ship employees. the results revealed that the internet and online communication have positive effects on social pressure and fear of missing out, whereas social pressure and fear of missing out have positive effects on relatedness to friends and family need satisfaction and internet multitasking. moreover, internet multitasking had a positive effect on perceived social support, which in turn had a positive effect on life satisfaction. while onboard a cruise ship, employees are detached from their family, significant others and friends. thus, employees experience strong social pressure to be constantly available and fear of missing out on important information and life events. due to their rigorous schedule, i.e., working 10 to 13 hours every day of the week in an isolated environment, the internet and online communications are wonderful instruments that can meet the demands of social pressure and reduce the fear of missing out experienced by cruise ship employees. the internet and online communication are essential to employees from collectivistic cultures where friend and family ties are strong. thus, providing these employees instruments to maintain close contacts with friends and family at home will reduce their social pressure and fear of missing out, which in turn will create harmony among employee social groups. moreover, the provision of online communication creates an interactive platform for validation through communication acceptance; validation boosts employee sense of belonging and strengthens their relationships with friends and family at home. these results are supported by the theory of belongingness by [19] and are in line with previous studies conducted by [5, 8, 53, 83] . free time is the single most precious commodity for cruise ship employees. tight work schedules, ship itineraries, in-port safety duties, and daily job demands leave employees with very narrow time windows for engagement in social networking sites and online communication. thus, social pressure and fear of missing out effects on relatedness to friends and family need satisfaction force employees to engage in internet multitasking. within the minimal and confined space of a cruise ship, employees lose almost all points of reference to the outside world and friends and family at home; thus, social pressure and fear of missing out fuels the need for relatedness to friends and family and internet multitasking. employees spend on average between four and six months onboard in small shared cabins while working long hours every day of their full contract length and are in desperate need of the support of family and friends. thus, if cruise ship companies provide ad libitum internet access to online social networks and communication, employees will enjoy a strong network of supportive family and friends that can help them enhance life satisfaction. interestingly, employees with bachelor's degrees exhibited high levels of internet multitasking, which correlated positively with their working memory and ability to divert their attention among different tasks. these results are supported by self-determination theory of [20] as well as uses and gratification theory [21] . moreover, these findings are in line with previous studies conducted by [11, 13, 18, 33] . cruise ship employees understand they are dispensable and replaceable to cruise ship companies [9] . thus, relatedness to friends and family needs satisfaction is of paramount importance for employees because they know that to their friends and family, they are indispensable and unique. moreover, living and working onboard a cruise ship is a lifestyle; while this particular lifestyle may seem to disregard certain employee rights, it does not dehumanize the employee. when employees feel their needs towards relatedness are satisfied, they experience elevated social support through strengthened connections with friends and family. although cruise ship employees work and live on the high seas, they do not thrive alone: donne [84] pointed out that each man relies on others. however, there are slight differences between employees and their relatedness to friends and family who need satisfaction. experienced employees with 6+ years exhibited stronger needs towards relatedness because they feel lonely and isolated for a significant period of their life. employees working in the entertainment department and employees coming from south america expressed greater needs because they have a wide circle of close ties at home. lastly, the youngest cruise ship employees between 21-30 years exhibited greater needs towards relatedness because at their age, friendships are highly complex and offer significant self-disclosure and support. these results are also supported by self-determination theory of [20] and are in line with previous studies conducted by [5, 18] . onboard cruise ship operations are in constant flux, and employees come and go frequently. for many employees these crew changes become the only point of reference. during long contracts, tiredness of employees builds up as physical pain, exhaustion and psychic fatigue. however, cruise ship employees are required to continuously work until the completion of their contracts. experiences like these build highly intense relationships where employees need social support. in such an environment, employees lean on their friends and family at home for support, which comes in many forms most often as empathy, compassion and providing care. social support is the foundation of healthy relationships that improves employee life satisfaction. employees who spent 6+ years living and working on cruise ships are exposed to prolonged periods of loneliness and isolation, which affects them in ways that would require social support to achieve happiness and life satisfaction. male employees look for social support to feel happy and satisfied, whereas female employees engage in social support to pursue increased well-being. employees with master/doctoral degrees enjoy social support from their close ties because they understand the benefits of happiness that comes from such relationships. finally, employees from north america consider deep relationships to have significance in enhancing social support because larger social networks improve life satisfaction. these results are supported by the positive psychology paradigm by [23] . moreover, these findings are in line with previous studies conducted by [5, 8, 11] . although keeping in touch with family and friends at home is essential for cruise ship employees, the majority of cruise companies charge significant prices for internet and online communication services. thus, due to limitations of internet and online communication use because of high service prices, poor coverage and slow data connection, employees are prevented from satisfying their needs through their friends and family at home. moreover, due to in-port manning duties, employees cannot use free internet services off ship, which leads to chronic emotional distress, frustration, anger, despair, and anxiety. this finding is in line with [25] who argued that people heavily dependent on social networking sites to satisfy their needs towards relatedness to friends and family may experience a lack of social capital outcomes; this can trigger detrimental impacts on their well-being. employment on cruise ships carries many occupational safety hazards [4] . to compensate, employees engage in internet multitasking; however, doing so exposes employees to added distractions and prevents them from safely or effectively completing their tasks. moreover, employees who engage in other tasks/activities while taking part in online communication with friends and family exhibit reduced performance, which leads to poor interaction and social dissatisfaction. this finding was in line with [56] who argued that multitasking is related to reduced enjoyment in messages and reduced recognition memory performance. similarly, örün et al. [55] argue that retention of communication content during online messaging is significantly worse while multitasking. lastly, the perceived social support from internet and online communications and social networking sites with family and friends at home is dependent on reciprocity. employees experiencing under-reciprocating exchanges show significant negative effects on their well-being. these results are supported by the conservation of resources theory [22] and the reciprocity norm [85] . perceived social support is a multi-dimensional construct highly dependent on personality traits. personality can affect perceived social support relationship with well-being to the point of being non-significant [86] . overall, our results provided several important theoretical and practical implications relevant to cruise tourism and human resource management. this study contributes to academic literature in several ways. first, working and living on a cruise ship, carries a heavy burden where cruise ship employees are detached from their family and friends at home [9] and their main communication instruments are the internet, social networking sites and online communications [5] . thus, although this study is of an exploratory and pioneering nature regarding the effects of internet communication on employee well-being and life satisfaction, this study was founded on well-known theories. overall, the results are consistent with the theory of belongingness [19] , the self-determination theory [20] , the uses and gratification theory [21] and the conservation of resources theory [22] and confirmed previous studies that reported positive effects of the internet and online communication on social pressure on fear of missing out [5, 11] ; relatedness to friends and family needs satisfaction [18] ; fear of missing out on internet multitasking [13] ; relatedness to friends and family needs satisfaction and perceived social support [8] ; and life satisfaction [5] . intriguingly, the results did not confirm positive effects of internet and online communication on relatedness to friends and family needs satisfaction, internet multitasking on perceived social support, and perceived social support on well-being. however, these findings are supported by previous studies, such as [25, 55, 56, 86] . a second contribution to the literature is the final model's broad scope and applicability towards achieving life satisfaction of employees who work and live in a specific workplace, as described by [87] . comprehensive measurement scales (based on previously confirmed scales by [13, [75] [76] [77] [78] for measuring internet and online communication effects on well-being and life satisfaction of cruise ship employees showed strong reliability and validity. these tools can be used in future studies as instruments for measuring internet and online communication effects on the well-being and life satisfaction of various employees. this study offers valuable practical recommendations for cruise ship companies. unhappy, detached and dissatisfied employees can become unproductive and disengaged, which can lead to high employee turnover, absenteeism, and increased expenses due to health care costs and insurance premium fees [3] ; this can harm the profitability of cruise ship companies. companies that provide free-of-charge internet and access to social networking sites and online communication, will satisfy employee needs for belongingness. this will allow employees to enjoy a strong network of family and friends to achieve and maintain life satisfaction. moreover, companies who understand and appreciate the value of employees who flourish in life satisfaction should reinforce their core values by setting their "true north" towards providing employees instruments to maintain close contacts with their friends and family at home. such provisions by companies would suppress employee social pressure and fear of missing out. this would create harmony among their close ties and social groups, ultimately leading to life satisfaction of cruise ship employees. this study has several limitations. first, this study utilized a cross-sectional time horizon; there is space for potential causality and reciprocal relationships among components [88] . future studies should use a longitudinal time horizon to investigate the effects of the internet and online communication on well-being and life satisfaction during various stages of cruise ship employee contracts. second, common method bias is expected in this study due to self-reported answers collected from employees who agreed to participate in the survey. to lessen this challenge, a cautiously composed and validated survey was used following the suggestion of [89] . as such, participant anxiety related to giving right or wrong answers was at least reduced to its lowest possible level, if not completely avoided. nevertheless, components that were used in this study could only be measured by particular, authentic impressions of employees. third, participants in this study were recruited via the facebook group "crew center". thus, the sample is not representative of the general population of all cruise ship employees who use the internet and online communications because many cruise ship employees are not members of the aforementioned group and as such are underrepresented. the fourth limitation is related to the sampling method, i.e., the convenience sample method. this method could have limited the generalizability of the overall findings. the fifth limitation is related to the research model. even though components showed satisfactory levels of validity and reliability, component constituents should be tested in future work on wider populations of employees. the sixth limitation is the quantitative analyses that were used to evaluate research data. future studies could mix qualitative and quantitative techniques to obtain comprehensive knowledge about the effects of 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factor analysis for applied research bentler department of psychology university of california los angeles cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives principles and practice of structural equation modeling dimensionalizing cultures: the hofstede model in context. online readings psychol devotions upon emergent occasions, and severall steps in my sicknes the norm of reciprocity: a preliminary statement the relationship between social support and subjective well-being across age an investigation into hospitality cruise ship work through the exploration of metaphors games researchers play -extreme-groups analysis and mediation analysis in longitudinal occupational health research common method biases in behavioral research: a critical review of the literature and the recommended remedies key: cord-351785-d35kqobp authors: dewitt, emily; gillespie, rachel; norman-burgdolf, heather; cardarelli, kathryn m.; slone, stacey; gustafson, alison title: rural snap participants and food insecurity: how can communities leverage resources to meet the growing food insecurity status of rural and low-income residents? date: 2020-08-19 journal: int j environ res public health doi: 10.3390/ijerph17176037 sha: doc_id: 351785 cord_uid: d35kqobp the burden of obesity disproportionately influences poor health outcomes in rural communities in the united states. various social and environmental factors contribute to inadequate food access and availability in rural areas, influencing dietary intakes and food insecurity rates. this study aims to identify patterns related to food insecurity and fruit and vegetable consumption within a snap-eligible and low-income, highly obese rural appalachian community. a prospective cohort was implemented to identify gaps in resources addressing obesity and food insecurity challenges. sas 9.4 software was used to examine differences in dietary intakes and shopping practices among snap participants. among participants (n = 152), most reported an annual household income less than usd 20,000 (n = 90, 60.4%), 29.1% reported food insecurity, and 39.5% reported receiving snap benefits within the last month. the overall mean fv intake was 3.46 daily servings (95% ci: 3.06–3.91) among all participants. snap participation was associated with food insecurity (p = 0.007) and those participating in snap were two times more likely to report being food insecure (or = 2.707, 95% ci: 1.317, 5.563), relative to non-participants. these findings further depict the need for intervention, as the burden of food insecurity persists. tailoring health-promoting initiatives to consider rurality and snap participation is vital for sustainable success among these populations. the burden of obesity and related chronic diseases disproportionately affects rural communities in the united states (u.s.) more so than their urban counterparts [1] . theories of social disorganization suggest that the intersection between community structure, such as poverty, socioeconomic status (ses), and residential instability, can result in a void of health promoting culture, infrastructure, and efficacy [2, 3] . previous insights have shown disparaging differences between urban and rural areas on mortality, chronic disease, and screening rates [3, 4] . residents' limited knowledge of health promoting behaviors may lead to poor health literacy and unhealthy lifestyle behaviors, including poor dietary intakes and sedentary physical activity levels [5] [6] [7] . thus, the degree of rurality among geographic areas throughout the u.s. influences the numerous barriers rural communities face and, consequently, their morbidity and mortality rates. among rural populations, myriad factors affect obesity rates, though fruit and vegetable (fv) intakes are of great influence and few u.s. adults are meeting recommended amounts [8] . this is particularly true in rural communities, where adults exhibit higher obesity prevalence and are less likely to meet daily fv recommendations due to various social and environmental factors [1, 9] relative to their urban counterparts. in addition to individual level factors associated with poor dietary intake, rural residents also face greater rates of food insecurity [10] . a depleted or limited food landscape can predispose residents' dietary consumption and shopping patterns thereby further influencing their health status, as diet is a contributing factor in several chronic illnesses [11] . while agriculture and food production are prominent in many rural landscapes across the u.s., it is not the case for all rural communities. rurality does not equate to farmland or local food production, which many would think support food security within these communities. further, the 2017 census of agriculture revealed a decline in number of farms and farmers and in acres of farmland and farmland production [12] . at the local level, there are numerous factors that dictate food production, including geography, terrain, and inadequate resources such as economic hardship or lack of farmers. those who do operate small farms rely on additional off-farm sources for household income [13] . these factors can also influence the household food environment in rural areas. among low income rural populations, the household food environment, including food security and income concerns, are key factors controlling food choice [14] . rural communities continue to face higher rates of food insecurity, compared with their urban counterparts [10] , and food insecurity has been associated with obesity and greater cardiometabolic risk [15] . the supplemental nutrition assistance program (snap) is the largest federally funded nutrition program in the u.s., serving as a household-supporting infrastructure for individuals facing food insecurity. snap assists eligible, low-income individuals and families in need throughout the u.s. [16] . while eligibility varies by state, those whose income and resources fall below certain thresholds are able to supplement their food budgets using snap benefits [16] . thus, snap is often considered a vital resource for those living in rural communities, as the perpetual ses divide continues between rural and urban settings [17] . at the national level, approximately 16% of those living in rural communities live below the federal poverty line, compared with 12% in urban areas [18] . due to these income gaps, snap participation is higher in rural areas, with 16% of households participating, compared with 13% in urban areas [19] . additionally, most recent federal data from 2017 indicate that of those eligible for snap, participation is higher in rural areas (90%) compared to urban areas (82%), and this participation gap continues to climb [20] . rural areas account for 63% of counties in the u.s., and 87% of counties with the highest rates of food insecurity [21] . furthermore, a report from 2018 indicates that 13.3% of those living in rural areas faced food insecurity, compared with 11.5% in urban areas [10] . resources, such as snap benefits, and other programs for those of low ses, are imperative for those in rural communities, as many in these areas are at risk of being food insecure. thus, initiatives like snap can aid in alleviating food insecurity among vulnerable households and improve dietary intakes, when adequate access to nutritious choices are available [22] . community-based efforts have emphasized the importance of looking at social and physical environments when striving to improve food access [23] [24] [25] . therefore, community-based efforts focused on addressing the local food system are necessary to alleviate the barriers related to the procurement of nutritious foods in rural areas. prioritizing engagement with key stakeholders and community members is vital to consider how to best approach food access initiatives in rural communities. conceptually, community-based efforts can be successful in rural communities, as the multifaceted community setting plays a vital role in influencing the food environment and, ultimately, diet choice in these communities. improving health outcomes pose unique challenges, as resources are sparse and healthcare infrastructure is limited; however, modifying or improving the existing food environment encourages nutritious food choices and shopping behaviors. nonetheless, environmental triggers and product availability affect the dietary choices individuals make, influencing overall health and obesity status [26] . given the unique limitations rural communities face, exploring frequented destinations to assess availability can be beneficial to mitigating the barriers that exist [27] . knowing one's food environment, snap participation, and food insecurity status can influence diet quality, an understanding of the interrelationship among these factors can provide guidance for intervention. this study aims to identify patterns related to fv consumption and food access within a snap-eligible and low-income, highly obese rural appalachian county in kentucky. these findings will serve as a baseline to provide context for addressing food insecurity in a remote rural region of the u.s. baseline findings will guide points of intercept, design future programming to explore the impact rurality has on obesity status, and address the barriers related to accessing nutritious foods within this community and those similar. the present study is part of a multi-year high obesity program (hop) project through the centers for disease control and prevention (cdc) to reduce rural obesity prevalence and decrease the risk of chronic disease and preventable mortality. this paper describes one component of the hop project aimed at providing increased geographic or financial access to nutritious foods. efforts to improve food access will address food insecurity. this work was completed by leveraging existing cooperative extension (ces) infrastructure, with an emphasis placed on community partnership and empowerment, thus enforcing action via established community infrastructure. the cdc funding announcement identified eligible counties across the u.s. based on their obesity prevalence. the setting for this funded project was one eligible appalachian county in kentucky with an adult obesity prevalence greater than 40% per the cdc. the appalachian region of the u.s. has continued to experience significant decline in life expectancy [28] , lack of economic development, and stark out-migration, leaving once fervent and thriving communities destitute, impoverished, and struggling to prosper [29] . this community is reflective of the region, experiencing a persistently high rate of poverty and unemployment, low educational attainment, and food insecurity. the cdc's social vulnerability index, comprised of social and economic indicators, designates the county as "highly vulnerable." [30] the county population is approximately 11,200, and declining, with a median household income of usd $35,000 and an estimated 39% of the population living in poverty [31] . the estimated food insecurity rate is 21%, and approximately 31% of households participate in snap [32, 33] . in order to assure broad community input into all program activities, a health coalition was formed, comprised of key stakeholders including local officials (mayor, magistrates), school representatives (food service director, family resource coordinators), library director, concerned citizens, health department representatives, faith-based organization representatives, and community advocates. the health coalition has been pivotal in establishing partnerships to improve health outcomes within the community. it continues to provide input and direction for all aspects of the current project to identify and implement nutrition-related strategies to address the issue of obesity in the county. the current study aims to identify gaps in community resources to establish new partnerships that address obesity and food insecurity challenges. therefore, a formative food system assessment was conducted at baseline to identify potential areas for intervention to enhance healthier food procurement options. figure 1 outlines the community's primary food access points identified through the food systems assessment. findings from the assessment were shared with the coalition to identify potential programmatic efforts to reduce food insecurity within the community. in alignment with the aim of this study, and to complement community efforts, a prospective cohort was enrolled at baseline for a longitudinal study. the prospective cohort study included a face-to-face survey that occurred in year 1 and will again at years 2 and 3. the university of kentucky institutional review board (irb) approved the research, promotional materials, consent forms, and survey instrument. in summer 2019, messages on the county's ces facebook page recruited community residents interested in participating in the cohort study. the ces office, a local food pantry, several faith-based organizations, and grocery stores in the county distributed recruitment materials. furthermore, recruitment occurred through current community programs offered at the ces office. recruitment messaging continued until enough individuals enrolled to meet the required sample size, which allowed for attrition. participants were excluded if they were under 21 years of age, lived outside the county, were non-english speaking, reported plans to move within the next three years, had lived in the county for less than one year, or if they had been diagnosed with cancer. invited study participants completed the survey via a face-to-face meeting. prior to survey administration, interviewers verbally reviewed key points of the consent form with participants, who then reviewed the full consent form independently, and provided an opportunity to ask questions or to decline participation. once deemed eligible, and agreeable to participation, the participant signed the informed consent form and enrolled in the study. a statistical power analysis was performed for sample size estimation and a proposed sample size of 150 adults were recruited to allow for expected attrition. the prospective cohort study surveys were administered at three locations in the county on various days in fall 2019: the ces office, a local food pantry, and the senior citizens center. the initial date of administration had greater turnout than anticipated by study personnel; several surveys were self-administered as a result (n = 24). moving forward, study personnel modified recruitment processes to schedule appointments for each eligible participant to partake in a verbally administered survey. those interested contacted study personnel or the county's ces office to schedule a day and time to participate. this resulted in fewer ineligible participants and complete survey responses. the in alignment with the aim of this study, and to complement community efforts, a prospective cohort was enrolled at baseline for a longitudinal study. the prospective cohort study included a face-to-face survey that occurred in year 1 and will again at years 2 and 3. the university of kentucky institutional review board (irb) approved the research, promotional materials, consent forms, and survey instrument. in summer 2019, messages on the county's ces facebook page recruited community residents interested in participating in the cohort study. the ces office, a local food pantry, several faith-based organizations, and grocery stores in the county distributed recruitment materials. furthermore, recruitment occurred through current community programs offered at the ces office. recruitment messaging continued until enough individuals enrolled to meet the required sample size, which allowed for attrition. participants were excluded if they were under 21 years of age, lived outside the county, were non-english speaking, reported plans to move within the next three years, had lived in the county for less than one year, or if they had been diagnosed with cancer. invited study participants completed the survey via a face-to-face meeting. prior to survey administration, interviewers verbally reviewed key points of the consent form with participants, who then reviewed the full consent form independently, and provided an opportunity to ask questions or to decline participation. once deemed eligible, and agreeable to participation, the participant signed the informed consent form and enrolled in the study. a statistical power analysis was performed for sample size estimation and a proposed sample size of 150 adults were recruited to allow for expected attrition. the prospective cohort study surveys were administered at three locations in the county on various days in fall 2019: the ces office, a local food pantry, and the senior citizens center. the initial date of administration had greater turnout than anticipated by study personnel; several surveys were self-administered as a result (n = 24). moving forward, study personnel modified recruitment processes to schedule appointments for each eligible participant to partake in a verbally administered survey. those interested contacted study personnel or the county's ces office to schedule a day and time to participate. this resulted in fewer ineligible participants and complete survey responses. the administered survey took approximately 45-60 min to complete. participants received a usd $25 incentive to be used a local grocery store as compensation for completing the survey. the survey instrument utilized for this cohort comprised a variety of items to measure fv intake, household environmental measures, food purchasing practices, and demographic characteristics. demographic items in this analysis included age (in years), gender, preferred language, residential status, highest attained education level, race, and annual household income. snap participation was assessed by asking: "in the past month, did you or any member of your household receive snap benefits or food stamps?" response options included 'yes' or 'no'. questions from the national cancer institute (nci) fruit and vegetable intake screener [34, 35] assessed fv intake. the nci screener asks respondents about usual intake of various fv, ranging from never to ≥5 times per day, and portion sizes for every item (e.g., "over the last month, how many times per month, week, or day did you eat fruit?" and "each time you ate fruit, how much did you usually eat?"). items include 100% fruit juice, fruit, lettuce salad, french fries or fried potatoes, other white potatoes, cooked dried beans, other vegetables, tomato sauce, vegetable soup, and the survey instrument utilized for this cohort comprised a variety of items to measure fv intake, household environmental measures, food purchasing practices, and demographic characteristics. demographic items in this analysis included age (in years), gender, preferred language, residential status, highest attained education level, race, and annual household income. snap participation was assessed by asking: "in the past month, did you or any member of your household receive snap benefits or food stamps?" response options included 'yes' or 'no'. questions from the national cancer institute (nci) fruit and vegetable intake screener [34, 35] assessed fv intake. the nci screener asks respondents about usual intake of various fv, ranging from never to ≥5 times per day, and portion sizes for every item (e.g., "over the last month, how many times per month, week, or day did you eat fruit?" and "each time you ate fruit, how much did you usually eat?"). items include 100% fruit juice, fruit, lettuce salad, french fries or fried potatoes, other white potatoes, cooked dried beans, other vegetables, tomato sauce, vegetable soup, and mixtures that included vegetables. summed items created an overall measure of fv intakes among the sample. this measure served as the primary dependent variable for analysis because increased fv intake is a primary goal of the cdc hop project. the secondary dependent variable, food insecurity, was assessed by asking "which of the following statements best describes the amount of food eaten in your household in the last 30 days?"-enough food to eat, sometimes not enough to eat, or often not enough to eat [36] . "sometimes not enough to eat" and "often not enough to eat" were collapsed into "not enough food to eat" to create a dichotomous assessment of food insecurity. potential covariates of interest included gender, income, education, and years of residency. to minimize skewedness, income, education level, and residential status categories were collapsed: income was dichotomized as <usd $20,000/year or ≥usd $20,000/year; education categorized as less than high school degree or high school degree or more; and years of residency was dichotomized into <20 years or ≥20 years. data were entered into redcap (vanderbilt university, nashville, tn, usa) by trained study personnel and were double-checked to minimize data entry errors. data were then exported, and analyses were conducted using sas 9.4 (sas institute, cary, nc, usa). for all analyses, significance was set at p < 0.05. descriptive statistics, including frequencies and medians, were used to characterize survey responses. the nci food frequency scores were calculated using the published algorithms [34] . to test comparisons across groups, wilcoxon rank sum tests were used for continuous measures (age, fv consumption patterns) and chi-square and fishers exact were utilized, as appropriate, for categorical measures. logistic regression models were fit to assess the predictors of food insecurity. since fv servings per day were skewed, the data were log transformed and fit with a generalized linear model. models were adjusted for age, gender, snap participation, residency, and income. table 1 details the characteristics of the cohort study population and those of the martin county population. of those who registered, there were 152 participants consented and enrolled in the baseline cohort. participants (n = 152) had a mean age of 56 years, with the majority (n = 99, 65.1%) identifying as female. most participants reported an annual household income less than usd $20,000 (n = 90, 59.2%) and 39.5% report receiving snap benefits within the last month. table 2 outlines household shopping practices. respondents shop at grocery stores (80%) or supercenters (20%) and primarily shop there due to price (42%) and location (41%). these practices were not significant when stratified by snap participation. participation in snap was associated with an awareness of the farmers' market (p = 0.04), yet not with regularly shopping at this venue (p = 0.31). findings from the regression analyses are in table 3 . among all participants, the overall mean fv intake was 3.46 daily servings (95% ci: 3.06-3.91). males not participating in snap (4.45 servings; 95% ci: 3.43-5.76) and females participating in snap (3.94 servings; 95% ci: 3.12-4.99) reported highest fv intakes within the sample. there is no significant effect for daily fv intake by residency or education. among all participants, 29.1% reported food insecurity, with a greater percentage of snap participants reporting being food insecure (41.7%) than non-participants (20.9%). logistic regression models indicate that snap participation was associated with food insecurity (p = 0.007) compared to those not participating in snap. those participating in snap were two times more likely to report being food insecure relative to non-participants (or = 2.707, 95% ci: 1.317, 5.563). when examining food insecurity and dietary intake by snap participation stratified by gender (table 4 ), the effect of snap participation on food insecurity was stronger for females (or = 3.136, 95% ci: 1.288-7.636), but not significant for males. it is clear among the literature that numerous factors contribute to high obesity prevalence, including poor nutrition, absence or lack of physical activity practices, and the environment [1, 8, 9] . residents of rural communities experience greater obesity prevalence and limited access to healthy choices related to the environments in which they live [9] . these factors shape rural residents' behaviors, and are well understood as influencing obesity prevalence. additionally, attention to the food environment is imperative in order to increase consumption of healthier foods within rural communities. access to healthy foods, such as fv, must be a grounding consideration of obesity prevention efforts within disadvantaged communities such as those found in rural appalachia. rural communities typically face greater financial burden compared with urban communities, particularly in the south, [18] and low household income augments obesity prevalence [37, 38] . we did not specifically investigate income within this sample because of collinearity between income and snap participation. therefore, we used snap participation as our independent variable to measure ses, given that nearly two-thirds of the current population report an annual income less than usd $20,000 and nearly half receives snap assistance. our findings illuminate a growing trend between rural residency, snap participation and food insecurity. it is interesting to note that snap participants were more likely to report being food insecure, suggesting immediate intervention is necessary within this population living in an impoverished community. previous studies have found snap participation to improve food security [22] ; however, our data suggest that those in snap are currently experiencing high rates of food insecurity. this paradox reveals high rates of reported food insecurity despite snap participation, leading to questions of adequate parameters or potential pitfalls. perhaps snap alone is not sufficient to reduce food insecurity, yet is a necessary factor to help prevent higher rates among those who are eligible for snap participation. some suggest that snap participants have lower fv intakes due to unobserved preferences [39] while others have found snap participants would be more food insecure if benefits were not available [40] . thus, improving diet quality while simultaneously combating food insecurity requires nuance. although snap participation provides an avenue to food security, it is clear that when compounded by additional factors, such as the economic disparities this rural appalachian community experiences, it does not equate to consistent nutritional nourishment for these areas. furthermore, rurality and geographic location are important factors to consider when it comes to food security and snap participation. previous studies have even shown that rural geography contributes to differences in food perceptions and purchasing patterns, due to differences in access and availability [41] [42] [43] . this could explain, at least in part, the barriers in the appalachian region. the appalachian region includes all or parts of 13 states where 42% of the population is rural, compared with only 20% throughout the u.s. [44] . appalachian communities experience a high propensity for food insecurity and poverty. across the appalachian region, the median household income is approximately usd $48,000, compared to usd $58,000 across the u.s. [45] . further, the central appalachian region, which includes all of the appalachian counties in kentucky, maintains an annual household income of usd $36,000 [45] , which may mean these communities are more disadvantaged than other rural and appalachian communities across the u.s. our findings further identify martin county as representative of a geographically isolated and persistently impoverished area in central appalachia with exacerbated food insecurity. snap participation could be a mitigating factor to improve diet quality and food security among food insecure individuals [17, 40, 46] . thus, food access initiatives must also consider affordability and snap participation with obesity prevention efforts focused on improving diet quality. our study also reveals that gender may influence food insecurity and would be valuable to examine in future investigations. gender was the only covariate that had a significant effect within our sample, suggesting it may be more salient in terms of food insecurity among rural residents. the effect being stronger for females could have occurred for various reasons, including differences in other constraints for food insecurity between men and women, though we did not explore this relationship in the present study. examining the relationship between gender and food insecurity will aid in understanding why individuals in rural communities are able or unable to access healthy foods. although increasing access to nutritious foods, including fv, may be challenging in a community with limited income, it is possible [47] [48] [49] . rural communities continue to struggle with food accessibility within the retail food landscape, and in a particularly impoverished community, such as the one of this study, addressing the mechanisms and avenues that support food access is imperative. recently, covid-19 incidence has shed light on the disparities that exist between low-income and higher income households [50] . rates of food insecurity have risen dramatically in the u.s., given a host of factors related to covid-19 virus [51] . thus, current programmatic and intervention efforts are critical to assist communities in dire need. further, as figure 1 depicts, much of the existing food system is heavily reliant on food assistance programs such as food pantries, usda subsidized commodity foods, and small-scale church assistance [52] . therefore, a mode of improving health status and dietary consumption would be to target these outlets and enhance offerings to individuals that utilize this network of need-based food assistance. while environmental modifications are pivotal for sustained change, so too are policy considerations. the implications of these baseline findings align with the opportunities laid out for federal nutrition research within the u.s. [53] . this work allows us to grasp the influence of the food environment and other environmental determinants on health disparities, as well as potential relevant solutions. it is evident that policies that dictate federal nutrition program funding and allocation must consider social determinants of health within vulnerable populations. these findings also illuminate the broader systemic issues that underpin the growing rates of food insecurity within these regions exacerbated by the covid-19 pandemic. currently, snap is the only federal nutrition support offered during covid-19, in the form of emergency allotments, adjusted verification requirements, and expanded benefits to children [54, 55] . while these policy changes are temporary, they highlight larger issues and provide a platform to build upon for future research and policy development. our findings demonstrate that providing snap benefits alone is not sufficient to eliminate food insecurity in rural populations. thus, we need stronger policies that improve how we reach all vulnerable populations with improved food access. collectively, these findings elucidate the need for intervention, as the burden of obesity and food insecurity are major public health concerns that frequently coexist within rural communities. however, tailoring interventions to rural appalachian communities, and other communities with unique needs such as these, is vital to implement sustainable solutions successfully. thus, these factors should be considered together in order to construct an understanding of the intricate interrelationship between them. in rural appalachian communities with fewer resources, using existing assets and infrastructure are critical for community-based efforts related to food system enhancements [56] . while we are not directly influencing individual behavior with future interventions, traditional ces programing encompasses direct education focused on food procurement, preparation, preservation, and nutrition. researchers cannot neglect these concepts when implementing community-level systems or environmental changes. obesity prevention efforts must be multifaceted to address all levels of the socio-ecological model. these data create a critical baseline for a prospective cohort study that will allow us to measure the ongoing work of the cdc hop project in martin county. since the time of survey administration, several strategies have been implemented, or will be considered for implementation, to encourage healthy eating and active living as a well-rounded approach for obesity reduction and prevention. these strategies include nutrition and environmental audits of gas stations and grocery stores [57, 58] , a community garden [59] , an in-store marketing initiative [60, 61] , a community-wide walking challenge [62, 63] , and enhancements to existing walking trails in partnership with the public library [64] . these approaches have led to the formation of additional partnerships within the community emphasizing healthy lifestyle behaviors. collectively, these projects and partnerships further augment healthy eating and active living initiatives aimed at reducing obesity in this highly obese community. the generalization of the study findings is limited due to the study's sample of participants from one rural appalachian county in kentucky, which may not be representative of all rural communities in kentucky, or in other states. while verbally administered by a trained interviewer, self-reported survey responses may include social desirability or recall bias and other errors. we aimed to minimize bias by including validated survey instruments. furthermore, researchers verbally administered the survey to reduce concerns of participants with low literacy and to reduce the likelihood of missing data due to skipping questions or not following question instructions. this format also aided in reducing survey fatigue, as the survey was 13 pages long. a portion of surveys were self-administered; however, sensitivity analyses conducted between self-administered and verbally administered surveys revealed no significant differences in findings. results of the analyses are available upon request. because our survey was cross-sectional, we are unable to determine causality with these results. moreover, these are baseline data used to understand the priority population. thus, we are not powered on interactions and results should be interpreted with caution. however, these data represent the baseline findings of a longitudinal study, which will eventually allow us to estimate causal relationships. the findings of this study support continued collaboration with community networks to identify and implement strategies to address accessibility of nutritious foods. while obesity prevention efforts continue in rural areas, this community's high obesity prevalence, coupled with low fv intakes and high food insecurity, suggests community-based efforts aimed at improving healthy food access would prove beneficial. furthermore, tailored health-promoting initiatives that consider rurality and snap participation may have the greatest impact. therefore, important next steps include leveraging existing relationships with local food providers to encourage healthier choices via food pricing and marketing strategies at their venues. additional collaboration with local partners, such as a community health coalition and the ces, is vital to appropriately design and implement programs that consider these specific identifiers and enhance access to venues offering healthy foods. prevalence of obesity among adults from rural and urban areas of the united states: findings from nhanes the relationship between rural status, individual characteristics, and self-rated health in the behavioral risk factor surveillance system rural/urban differences in self-rated health: examining the roles of county size and metropolitan adjacency spatial patterns of rural 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walkable neighborhoods this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we gratefully acknowledge the contributions to this study by jennifer hunter and would like to acknowledge the martin county cooperative extension office and the martin county health coalition for their ongoing support of this project. we would like to thank grace anderson (uk undergraduate student), haley copeland, caroline blincoe, and cora teets (uk graduate students) for their assistance with data collection and data entry. this research utilized the center for clinical and translational science redcap tool, supported by the nih national center for advancing translational sciences through grant number ul1tr001998. the content is solely the responsibility of the authors and does not necessarily represent the official views of the nih. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-339835-ze9ay2rm authors: daphna-tekoah, shir; megadasi brikman, talia; scheier, eric; balla, uri title: listening to hospital personnel’s narratives during the covid-19 outbreak date: 2020-09-03 journal: int j environ res public health doi: 10.3390/ijerph17176413 sha: doc_id: 339835 cord_uid: ze9ay2rm healthcare workers (hcws) facing the covid-19 pandemic are required to deal with unexpectedly traumatic situations, concern about contamination, and mounting patient deaths. as a means to address the changing needs of our hospital’s hcws, we conducted a narrative analysis study in the early stages of the covid-19 outbreak. a focus group of medical experts, conducted as the initial step, recommended that a bottom-up research tool be used for exploring hcws’ traumatic experiences and needs. we therefore conducted 450 semi-structured in-depth interviews with hospital personnel. the interviews were based on maslow’s pyramid of needs model, and the narratives were analyzed by applying the listening guide methodology. the interviewees expressed a need for physical and psychological security in the battle against covid-19, in addition to the need for attachment and meaning. importantly, we also found that the interview itself may serve as a therapeutic tool. in light of our findings, we recommended changes in hospital practices, which were subsequently implemented. further research on hcws’ traumatic experiences and needs will provide evidence-based knowledge and may enable novel approaches in the battle against covid-19. to conclude, the knowledge generated by listening to hcws’ narratives may provide suitable support programs for professionals. the moment that i was informed that we had become a covid-19 department, i was devastated. this coronavirus is so frightening, and i knew that i could die from it. i am a person who needs to be in control, and i had lost control, i was so frightened. this entire new situation was scary-a situation of life or death. moreover, i was in it. at the level of the team, we did not know what to expect, personally and collectively, as a department. i did not know what was expected from me as a social worker and what were the guidelines; everything was new. we created everything from the beginning, and i was scared. studies on outbreaks of infectious diseases reveal the profound and broad-spectrum psychological impacts that disease outbreaks can inflict on healthcare professionals [1, 2] . experience with the sars and ebola virus outbreaks suggests that healthcare professionals are subject to extremely high levels of stress and emotional turbulence [3] [4] [5] . in dealing with the sars virus, which is similar in some respects to the 2019 novel coronavirus (sars-cov-2), healthcare professionals were troubled by intrusive thoughts and images associated with sars and exhibited symptoms of ptsd and substantial psychological distress [6] , if not mental illness [7] . in addition, healthcare professionals feared that they would fall ill from sars but were equally or more worried about infecting family members and other people [8] . nonetheless, prior experience with pandemics, disasters, and major traumatic events has indicated that enhanced support for healthcare professionals enabled them to remain efficient and focused during these stressful events [9] . the on-the-job stress and burnout of healthcare workers (hcws) employed in hospitals [10] [11] [12] is one of the key themes in studies of the trauma of these professionals in the corpus of literature on the cost of caring [13] . this recurring motif is not surprising, since the hospital environment is challenging in that it frequently demands holistic treatment of patients that integrates psychological elements with physical treatment: in the course of their routine hospital work, hcws are required to deal with patients and their families who have experienced traumatic events and life-threatening episodes [14] . it was against this background that hospital hcws the world over first encountered the global covid-19 pandemic in december 2019 [15] . facing this global public health event situated hcws in an unbearable situation, with them being required to function under extreme physical and psychological pressure on both the professional and personal levels [16] . in parallel, they were often required to make impossible decisions, including how to deal with limited equipment, how to balance their own physical and mental welfare needs with those of their patients, and how to bring into line their responsibility to their patients with their responsibility to their family and friends. in addition, their wish to provide optimal care for severely ill patients was often constrained by inadequate resources. thus, in the covid-19 pandemic, frontline hcws had to work under particularly intense stress levels in unprecedentedly difficult situations [17] -situations that may indeed cause stress, moral injury, and physical and mental health problems [4, 17] . the unfolding pandemic has been compared to war, as described in "'the art of war' in the era of coronavirus disease 2019 (covid-19)" by maxwell et al. [18] , who claim that the image of war is often used in the field of infectious diseases. indeed, from the beginning of the pandemic, hcws in the hospital setting have been faced with caring for patients with an incredibly contagious and life-threatening disease about which nothing was known and for which there was no known lifesaving treatment-a situation similar to a war. they were-and still are-handling life-and-death situations while simultaneously putting their own lives at risk. this factor has contributed to a real sense of danger among hospital staff, who have found themselves in the forefront of defense against the pandemic [19] . in parallel, hcws are being required to deal with emerging challenges [20] . they are often required to develop, in an extremely short time, novel concepts and new interventions for unpredictable situations. the need for hcws to be proactive results from the fast-growing numbers of critically ill patients, the lack of treatment modalities, and shortages of critical medical resources and staff. like the general population, the hospital staff is struggling with the emotional stressors imposed by the pandemic. however, they are also faced with additional stressors and a rapidly evolving work environment that differs significantly from their pre-covid routines [21, 22] . marchand-senécal et al. [23] point out that specialized, dedicated covid-19 teams could quickly be overwhelmed as numbers of cases increase markedly. they also hold that longer shifts and increased work intensity may lead to hcw fatigue and lapses in the use of the correct techniques for handling personal protective equipment (ppe). they illustrate this conclusion by citing initial reports indicating that about 4% of chinese hcws caring for covid-19 patients were infected, with 15% of those hcws being classified as severe or critical cases. it is thus not surprising that a survey of 1257 frontline nurses, physicians, and other hcws who treated covid-19 patients in hospitals in china found that the participants carried a psychological burden, with symptoms related to depression, anxiety, and distress [1] . earlier studies on epidemic outbreaks have indeed revealed that medical personnel, particularly first responders, including physicians, nurses, ambulance personnel, and other hcws, become emotionally affected and traumatized and display heightened stress and higher levels of depression and anxiety [24, 25] . these findings are to be expected, since anxiety and the fear of being infected are aggravated as the risk of exposure is elevated. this heightened anxiety is exacerbated even further by the fear of transmission of the infection to loved ones. the need to maintain a sense of balance between professional duty, altruism, and personal fear for oneself and others thus often causes a mental conflict for hcws [1] . in the guidelines published on 19 march 2020 by the world health organization, it was declared that, by virtue of their caring for and close contact with covid-19 patients, the people most at risk of acquiring the disease are hcws and that protecting hcws is of paramount importance. in light of the above, at the beginning of the covid-19 outbreak in israel, we arranged a meeting in our hospital of an ad-hoc group of experts from different disciplines in healthcare and with different types of expertise. the recommendations of this focus group and the results of the interviews that were constructed and conducted as an outcome of these recommendations are described below. the theory of how humans usually function in daily life, as embodied in the ideas of abraham maslow, appear to be remarkably relevant to massive crises, especially to the present global crisis resulting from the covid-19 pandemic [26] . maslow's theory establishes a hierarchy of human needs [27] and, as such, provides a framework to describe the needs of hospital personnel [28, 29] . maslow's theory divides human needs into five categories. the first category, forming the base of a pyramid of needs, comprises physiological needs, such as air, water, food, shelter, sleep, and clothing. for medical personnel, hale and his colleges [28] extend this level to include the basic determinants of good physical and mental health and safety. the first category is followed, in order, by four more layers: safety needs, such as personal security, employment, resources, health, and property; love and belonging, which includes friendship, intimacy, family, and a sense of connection; esteem and respect, which includes self-esteem, status, recognition, strength, and freedom; and, finally, at the top of the pyramid, the desire to become the best that one can be, relates to personal growth [30, 31] . maslow described each level as a separate need that relies on the previous need. however, modern-day theorists have modified this conceptualization into an overall concept in which each need coexists with the others [28] . we used semi-structured interviews based on maslow's pyramid to survey hcws in our hospital. we then analyzed the interviews by choosing, from the umbrella of narrative analysis, the listening guide methodology to analyze the recorded interviews and their transcripts [32, 33] . this qualitative research methodology was developed as an alternative analysis to conventional coding schemes used to analyze qualitative data [33] . it differs from other means of analysis in that it places emphasis on the psychological complexities of people through attention to voice as a manifestation of the psyche. the listening guide in its attention to voice-and silence-thus provides a way of exploring the interplay of inner and outer worlds and of bringing the inner world out into the open [33] [34] [35] . by focusing on different voices, on the dynamics and interplay of these voices within the interview transcript, and on the socio-cultural setting of the research, the guide establishes a contextual framework for understanding and/or interpreting the narratives of the interviewees and thereby facilitates psychological discovery. the details of methodology are described in the materials and methods section [36] . although every analytical process has its advantages and drawbacks, we chose the listening guide, since its intent is to capture the layers of perception and experiences of trauma and stress [37, 38] that might otherwise remain unnoticed, thereby broadening the understanding of traumatic situations. by applying this methodology, we aimed to expand knowledge-and to generate new knowledge-regarding the mechanisms and the strategies used by hospital workers to cope with the covid-19 pandemic. specifically, we sought to reveal the overt and covert voices [39] emerging from the experiences of front-line workers and to examine how these workers describe and experience their traumas in their struggle to treat patients with covid-19. as mentioned above, being aware of the necessity to address the needs of the hospital's hcws, we conducted a study aimed to expand the knowledge of these needs during the first phase of the covid-19 outbreak. specifically, the goal of the study was to enable the contrapuntal voices emerging from the hospital staff's experiences to be "heard" and thereby to provide recommendations as to how to meet their changing needs as the crisis unfolded. by paying close attention the narratives of the hospital staff, we were able to address an additional aim, namely, to initiate the establishment of a data-based foundation for both immediate and future interventions, thereby expanding knowledge regarding the psychological mechanisms and strategies that front-line personnel use to cope with exposure to traumatic situations. the first step of the research comprised the establishment of a focus group of hcws, all trauma experts, in the hospital. on 18 march 2020, the focus group met to exchange thoughts about the evolving crisis conditions in the hospital and to find the means to evaluate-and indeed alleviate-the situation. the focus group comprised an emergency department physician and five medical-social workers with specializations in mental health and trauma. the decision to constitute a focus group of experts as the opening stage for this research project derived from the perspective that the novel coronavirus poses an unmet challenge to medical treatment and hence challenges hcws in many unknown ways. the focus group was charged with delineating the new situation in the hospital and with deciding on the exact research methodology and research tool(s) that could be applied in a research project and possibly later as adjunct practical tools for dealing with the evolving crisis. the final question put to the focus group was: what is the next step in the research project?" the participants pointed out the need to conduct bottom-up interviews at all levels and sectors in the hospital as a means of understanding the emerging needs of the hospital personnel [40] . the focus group suggested conducting a survey based on semi-structured in-depth interview based on maslow's pyramid of needs' model. the survey and results are described below. the interview protocol involved questions designed to capture the hcws' ways of describing their unique experiences. to this end, the interview protocol comprised a standard set of questions, beginning with a request to share with the interviewer thoughts on what it meant to be an hcw in a hospital at the time of the corona crisis. this opening question was followed by encouragement to share thoughts on personal needs. more specific questions were used to clarify the stories as the interviews proceeded, such as: what do you need-physically or anything else? what distresses you at work? what would make you feel safer? what helps you to feel better? what helps you to know that you are appreciated? what motivates you to get up every morning for work? in a year from now, what do you think will have changed in your family, at the hospital, within yourself? do you have something that you think important to add to the body of knowledge specifically about coronavirus or about trauma situations in general? four hundred and fifty semi-structured interviews were conducted in three waves: the first in the middle of march 2020, before recognition of covid-19 as a global pandemic (163 staff members; 36.2% of the interviewees); the second, two weeks later (157; 34.9%); and the third in the middle of may 2020, at the end of israel's national lockdown (130; 28.9%). interviews were conducted with personnel [87 (20.2%) men and 344 (79.8%) women] serving a variety of functions in the hospital: physicians, nurses, pharmacists, respiratory therapists, department supervisors, laboratory technicians, social workers, and administrative workers from various sectors and with different levels of seniority (average 16.6 years; median 15 years, range:0-50) the breakdown of sectors and departments is given in table 1 . the interviews each lasted approximately 20 min to 1 h and were conducted under conditions of assured confidentiality. as we indicated above, the interview narratives (in audio form and as transcripts) were analyzed by applying gilligan's listening guide methodology [41] , which is comprised of four stages, as follows [37, 42] . in the first stage, "listening to the plot," attention is paid to the whole story of the interviewee. the researchers' goal in this stage is to analyze the story in its context, similar to the analysis of an unfolding plot of a novel. the researchers identify recurring images and words, key metaphors, and dominant themes. the guide also requires that the researchers document their own reflexive emotional and intellectual responses, thoughts, and feelings, as a means to better recognizing how their responses to the interviewee might affect their understanding of the narrative and the subsequent analysis. this stage is similar to the analysis modes in several of the qualitative thematic methods described in the literature [43] . the second stage, "i poems," is unique to the listening guide method. the second-stage listening and transcript analysis follows the use of the first-person pronoun "i." within a passage in the transcript, scholars underline every use of "i" together with the attendant verb and any seemingly important accompanying words and then paste these "i voice" phrases together to compose an "i poem." this composite traces how the interviewee views herself/himself and the most prominent themes that preoccupy her/him. 3. the third step, "listening for contrapuntal voices," concentrates on how the interviewee talks about her/his or relationships with others. in this phase, scholars identify the multiple aspects of the story being told, often in multiple voices, with each voice (e.g., "you voice," "the voice of trauma and stress"; see below) being underlined in a different color. the transcript thus provides a visual way of examining how the different voices change in relation to one another. 4. in the fourth and final step, "composing an analysis," an interpretation of the interviews is developed that synthesizes what has been learned during the entire process by assembling the evidence drawn from the different instances of listening as the basis for composing the analysis. a summary analysis is then constructed [42, 43] . the reported study conformed to internationally accepted ethical guidelines and relevant professional ethical guidelines and was approved by the institutional review board (irb) of kaplan medical center, rehovot, israel. to assure confidentiality, each participant was identified by a pseudonym. step: "listening to the plot" the narratives of the healthcare professionals covered a description of their experiences, explaining in detail their engagement with corona patients and their families and their relationships with members of the hospital staff. two main themes emerged from the analysis of listening to the plot, the first of which was preparing for war in that the participants compared the situation in the hospital to the experience of preparing for war. sara, for example, said: "in our country, we know what a war is, and in the healthcare system we know how to function in the hospital during times of war, but still, this is a new war, a war that we have never handled, an invisible enemy, and it is frightening all of us." in similar vein, doron said: "to be significant, to be at the front is important. before it was the army that was at the front, now it is the turn of the healthcare system to be at the front." the second theme to emerge was that of security and insecurity, which related to two main aspects of the situation-fear of contamination and uncertainties derived from the assignment of hcws to new teams and departments whose purpose and essence were unfamiliar. the idea of working in new and unfamiliar teams distressed the personnel, and their narratives reflected their feelings of insecurity. the changing reality was reflected by dikla a nurse: "in the internal medicine department, i have been working for the past 18 years with my team, physicians, nurses, secretary-we have a common language. i felt especially secure in those days. how i will be able to use, in an efficient way, a new situation and new staff? this is ridiculous." similarly, tania, a social worker, said: "this will increase the feeling of insecurity . . . think that the entire situation is new and scary; so, what will i do without my friends who i have been working with for years?" in particular, the need to be protected during shifts was pronounced. as sara told us: "in order to continue to come here, i need to feel that someone is taking care of me. i do not care who in charge of that in the hospital, but i need to feel safe; it is essential for me." according to the listening guide protocol, at this stage of the analysis, the interviewer should document his/her own reflexive emotional responses. we found that listening to the interviewees and reading the transcripts induced emotional concern for and feelings of empathy with our colleagues who were struggling with unbearable situations and ethical dilemmas. we were full of tears when we heard about the burdens of caring for patients and the cost of that caring. the interviews and the transcript readings thus gave rise to a range of emotions, including sadness, anger, compassion, and frustration, but also to pride in the devoted teams and to an appreciation of their devotion. step: the "i poem" the second phase of the listening guide involves composing the "i poem," which is a core feature of the approach that serves to identify the active self. the process of composing the "i poem" [44] can best be understood by examining some examples. let us start by examining the transcript of the interview with julie, a nurse in the icu: "i cannot believe it . . . because of the workload . . . it is only because of the workload . . . i have to tell you that i haven't eaten for whole days . . . i grab something. it is not that there isn't any food, but we don't have the time and the needs of the staff draw you and you can't ignore them; you need to respond to each one. at other times its different, of course. here you can't say anything to them. it's the mask; it creates wounds on their noses, so i brought them cream. this kind of mask or any other; so, i saw masks in the grocery store and i bought them pink surgical masks so they would feel joy. every day i am bringing something to make them happy. all the time. yes, the protective equipment is a problematic issue by itself . . . i understand since i am involved in that; it depends on the equipment that comes to israel, but it is not always suitable . . . this equipment is insane." in her "i voice," julie demonstrated her personal difficulties in the corona icu and her difficulties in taking care of herself, even with regard to basic needs, such as food. however, as a manager in the icu, her "i voice," expressed her competency in taking care of her icu staff, as reflected in her "i poem": one can see that, in general, the "i poems" reflect a layer of self-confidence and feeling of empowerment. this voice stands in contrast to other voices in the narratives that describe difficulties, stressors, and chaos, as described below. irrespective of the contrapuntal voices embodied in the narratives, all the hcws who worked in the hospital's corona department stated that the daily routine in the corona department was more complicated than that in the rest of the hospital. the corona team concurred that the reasons for the differences were both physical and emotional and that acknowledgment should be given to the unique characteristics of the department. sharon, a nurse, summed up this opinion very succinctly as: "corona-it is not extra work, it is completely different work." against the background of this commonly held perspective, the third stage of the listening guide analytic technique nonetheless enabled us, the interviewers, to identify multiple voices that revealed different aspects of hcws' experiences and needs, including their attitudes towards the coronavirus pandemic, the staff and the hospital, and their own needs. the listening guide analysis of the focus group and the interviews identified five different contrapuntal voices-trauma and stress, security, knowledge, attachment, and meaningfulness-intertwined not only with one another but also with the "i voice" and the "you voice" (see below). the contrapuntal voices and examples of quotes from the transcripts that represent these voices are described below. the hospital workers' narratives reflected their direct exposure to traumatic events and the pervading presence of death in the hospital, as particularly manifested in the agony of seeing people dying without their families beside them and in the procedures for preparing the deceased for burial by special, double wrapping of the dead body as a precaution against contagion. for example, in response to the interviewer's question "but you are accustomed to the death of patients, what is the difference?" golda, a nurse, shared her feelings about traumatic moments after a patient's death: a deceased is a deceased but the separation from the family is extremely difficult, the wrapping process is a different from what you normally do in the internal ward. in addition to the regular wrap we put them in a nylon wrap and that is horrifying. a really unpleasant sight. it is like you put your patients in a plastic bag and you close it with a zipper. and then you cover with another bag but from the opposite side. an unpleasant wrapping of a patient since it is supposed to be isolated. similarly, marina, a senior physician in the icu, shared her difficulties in dealing with professional uncertainty and the absence of definitive information in the medical literature: look, the coronavirus is something completely new. a whole new disease that we do not have a clue how to treat, how to behave with it . . . and the craziest thing [is] that no-one in the world has the knowledge how to treat this disease, no knowledge-based expertise, no medical literature. so, you are constantly calling your colleagues in the country and around the world. then, you are planning how you will cope with your first coronavirus patient. in discussing the traumatic nature of their work in the icu and the coronavirus department, marina and golda used the personal pronoun "you" in the masculine form when they spoke about taking decisions about life-and-death issues. we note here that in hebrew, this usage of "you" in the masculine form is a generic usage that does not refer to the gender of the user. according to the listening guide methodology, the use of the masculine "you" hints at marina's and golda's difficulties in connecting emotionally to their traumatic experience of treating corona patients in the icu [12, 45] . harel-shalev and daphna-tekoah [45] have defined this voice as the "you voice," a voice that enabled the hcw's to distance themselves from recurring exposure to traumatic and painful experiences. it might represent a symptom of dissociation from traumatic events, not as a dissociative disorder, but rather as a coping mechanism allowing them to keep functioning as professionals. experiences such as these during routine work in unfamiliar situations were balanced by feelings of competency and an ambition to fight and succeed in the mission to conquer the novel coronavirus. these two voices-security and knowledge-are presented together since they are intimately intertwined. at the beginning of the crisis, the hcws expressed their need for security and safety, primarily physical safety, and their need for crucial information and knowledge as a means to help them to feel more secure. with the progression of the pandemic, the hcws became less anxious about physical safety and medical protection, as the hospital management met these basic needs and as the hcws acquired the knowledge about how to protect themselves against contracting the disease. however, they still expressed the fear that, in the future, there could be a lack of equipment. according to maslow, the most fundamental human needs are physiological, namely, air, water, food, shelter, and sleep. for medical personnel, hale and his colleges [28] extended this level to include the basic determinants of good physical and mental health and safety. orr, a nurse in the corona department, shared the following thoughts with us: at the beginning of the corona outbreak, there was a lack of food, protective gear, and clothes and shielding eyeglasses to protect ourselves. we had to shower between the shifts, and there was a shortage of showers in the hospital, and we had to fight for the basic needs to be protected, especially during the weekends. the fear of being infected and of infecting others inside and outside the hospital, especially family and friends, was expressed vividly by the hcws, mainly those working in the corona department. dorit, a nurse, said: there was constant anxiety and fear that we would infect others; we [at the corona department] felt like lepers . . . and then the isolation from my family since i was so afraid that i would infect them. i was isolated like a leper. my children could not go out to play with other children because i was terrified that i would infect my children and that they would infect their friends with coronavirus. at the beginning of the coronavirus, my daughter was so stressed out from this crazy situation. the interviewees tied knowledge to the feeling of security and protection. dan shared his feelings with us: "the head of the department is constantly updating us . . . i do not feel detached . . . i feel secure, knowing where i stand." in contrast, avi, an administrator, shared with us that: " . . . a lack of communication and information about what is happening at the hospital at the general level and not at the sector level bothers me. i am worried." in answer to the question, what helps you feel better? yoav responded: "uncertainty concerns me-assessments of the situation and updates by my immediate supervisor would help me." and ruth stated: "i feel like i'm in the dark and don't know what's going on." as could be predicted from maslow's hierarchy of needs, the dominant needs for security and knowledge were replaced by the needs for belonging, love, recognition, and respect from supervisors and the hospital management as the pandemic progressed. the hcws stated that a sense of family in the departments and the departments and friendship within their teams provided the much-needed sense of support during the pandemic. moreover, the hcws stated that without friendship, comradery, and a sense of belonging to a larger family, they would not have been able to work under such difficult conditions. for example, sisi, a secretary at the hospital, said: we were all a big family helping each other. i felt so close to all my peers; working together in such a tough time was different from what i had known in the last 26 years that i have been working in the hospital. as a team, we have become closer to each other, and i have discovered additional angels in my team . . . . in our department there is a sense of "togetherness" and comradery. professionally, there will be changes; there are thoughts about modifying procedures in light of the current pandemic . . . . relating to each other, currently feeling that we are a united and cohesive group. tova, a nurse in the icu, said: this period is a mixture of emotions. the reality is that everything is so new and unfamiliar. nevertheless, the staff are so devoted to each other and struggling to do their best to help each other and changing shifts due to the lack of nurses. sometimes they asked about treatment and i did not have an adequate answer. how i will say it? this is the period that we are re-inventing the protocols and rules of treatment. i am telling them that i am so sorry but there are no guidelines yet. in addition, the interviewees expressed a need for recognition-appreciation and reinforcementfrom their direct supervisors. for example, tomer said: "a good word, a compliment, and a positive attitude made me feel valued and . . . reassured." orna said: "a kind word makes my day . . . . it is essential for me to get feedback on my work and to know that i am doing my job well." another narrative relating to attachment was the need for a managerial presence, manifested as "managing by walking around." this practice is considered one of the most important ways to build good manners and performance in the workplace and emphasizes the importance of interpersonal contact, open appreciation, and recognition [46] . the hcws did indeed voice their desire for appreciation in the form of the need to meet management representatives in the various departments. alma, for example, said: "the presence of management in all departments and during all shifts made the staff aware that there was someone with them." she added: "personal appreciation by the management increases motivation and reduces concern . . . .i would like to see more direct communication with management . . . in my team, i feel appreciated. i don't feel i'm getting feedback from management." lili said that when management came into the corona department to visit the staff and the patients, they asked her personally how she felt, and this was what helped her to feel valued. the hcws were in agreement in their approval of the actions taken by the hospital management, judging the management's conduct during the crisis to be appropriate and effective. opinions of the following type were expressed: management worked well during the crisis; i want to thank the management for the adaptions that were made by mobilization of staff and change of policies and for taking the time to listen; and in my opinion, the hospital and management are doing well. the importance of feeling meaningful was verbalized by hanna: "patients with coronavirus helped me to feel valued and meaningful, [especially] the conversations with the patients and the phone conversations with their families out there in their homes, so worried about their loved ones. i was there for the patients and their families, and it allowed me to feel meaningful and to want to continue treating patients." the global covid-19 pandemic has challenged scholars and practitioners to find the means to alleviate stress and to treat the trauma experienced by members of the healthcare professions. our study was designed to examine the experiences of hcws during the first weeks of the covid-19 pandemic, which may be considered as a massive traumatic event. the hcws in this study, like other medical professionals caring for covid-19 patients [40] , have found themselves in a battle on two fronts: as hospital-based professionals fighting for their patients' lives, giving rise to their perspective of themselves as combatants fighting on the frontline of a war, and as family members fighting to protect their families from exposure to the virus and paying the price for fighting the "new war." as mentioned in the introduction and results sections, the image of war has become a common motif in discussions about the covid-19 pandemic. medical experts have even suggested that military strategies to be applied to outbreak management and have highlighted the importance of prioritizing healthcare staff capacity, as is done in military scenarios [18] . by documenting knowledge about hcws, we thus contribute to a scholarly assessment and understanding of various elements of the new war-that against covid-19. by seeking a dialogue with hcws and, particularly, by engaging hospital staff in a genuine dialogue that deepens our understanding of the new battlefield and the "new health combatants," we are now in a position to raise questions about "conventional wisdom" in the health system and to expand the knowledge about understudied topics in the new war [12, 46] . we believe that to produce a deeper understanding of the experiences of frontline workers, whoever they may be, we should listen to them attentively [47] . thus, the listening guide methodology provides a tool that can capture subconscious expressions through investigation of voices that are not usually otherwise revealed. by implementing the listening guide method in this study, we were able to explore more deeply the ways in which the hcw's represent themselves and others-the ways in which they tell their story of the situation. in addition, we suggest that this methodology be integrated into the methods utilized in the healthcare arena and should be further explored in additional healthcare contexts. during the interviews, the hcws emphasized the high level of emotional intensity associated with long hospital shifts, the constant fear of death and of exposure to new and unfamiliar traumatic events, and the constant feeling of insecurity. the hcws indicated that to cope with these emotional facets of their working environment, they needed a secure base. issues of security and insecurity were revealed in different ways at different stages of the evolving crisis: at the beginning of the interviews, a clear majority of the staff emphasized the need for physical protection and the need to fulfill basic requirements, such as adequate food, a place to rest between long shifts, protective equipment, and showers in the corona department for use after their shifts. another level of insecurity was emphasized by the need for personal recognition from direct supervisors and from hospital management. we found, however, that these needs changed as the pandemic progressed. at the beginning of the pandemic, when work environments were subject to change and scheduling remained uncertain, basic needs and physical safety were emphasized. in particular, respondents noted a shortage of protective equipment. the rapidly changing situation and the lack of supplies at the beginning of the pandemic crisis increased feelings of insecurity and intensified the importance of basic needs. however, as the crisis evolved, the need for security at the physical level was supplanted by a basic craving for security at the psychological and spiritual levels: the respondents focused on interpersonal relationships with their peers and their supervisors and their need for appreciation from their colleagues within their departments and beyond and from management. the focus thus transitioned from personal health and well-being to a sense of social belonging, a need for respect and appreciation, and even a sense of personal and professional self-fulfillment as predicted by maslow's theory of needs [27] . horesh and brown [48] have encouraged trauma researchers "in the age of covid-19" to employ all methods of scientific practice, including unique study designs and creative collaborations between disciplines with the aim to deepen the understanding of the health implications of the global coronavirus crisis. in particular, they indicated the need to develop novel methods for empowering and supporting medical personnel, as was done in the current study. our status as researchers in the field of trauma and health and our particular, and perhaps unique, insider/outsider status as hospital personnel may raise questions about our specific situation and positionalities with regard to this study [46] . in response to such questions, we note that fieldwork, by its very nature, situates researchers among the community that they are researching, either as active participants or as observers or as a combination of the two [49] . as "researchers from within" [48] , who are also hcws, we felt obliged to study the experiences of hcws in this unpredictable crisis. we were surprised by the high volume and the intensity of the traumatic experiences reported by the hospital personnel. we did not anticipate that hcws who are accustomed to treating patients in the healthcare system would experience such insecurity and vulnerability. importantly in this regard, we found that the anonymous qualitative interview-being conducted by skilled social workers-also served as a therapeutic tool and as a proactive means of communication with staff about their needs. the interviews enabled the hcws to express their vulnerability and to acquire a sense of visibility and value. brown [49] claims that vulnerability is the source of resilience and that vulnerability allows us to feel the emotions that we really crave-the need for human connection and the ability to belong and to "be seen" is something that every human being wants and needs. brown holds that for us to be seen, we need to let others see us in a vulnerable state. thus, the study framework-by enabling hcws to express their concerns about "not been seen by friends or management" during the battle against the coronavirus-instilled a sense of confidence in the personnel with regard to their ability to communicate their vulnerability, needs, and concerns, particularly the need for personal and psychological security [49] . bowlby [50] , in his influential book "a secure base," expands on the need for psychological security when he states that a basic component of human nature is the need for intimate emotional bonds and attachment. by enabling the hospital personnel to give voice to their needs and their insecurities, the interview itself became an intimate and emotional tool and a route of communication that ultimately allowed management to tailor various interventions to the needs of the employees and to increase the feeling of security in an extremely nonsecure situation. following the analysis of the data, the following practical interventions were developed by the hospital's social work department: 1. ad-hoc meetings aimed at strengthening and supporting staff in transition (in that their departments had changed location and/or function to corona-related locations/functions) were arranged. covid-19-dedicated teams were approached immediately before or after transition, and a focused, short intervention was conducted with all available staff members. telephone support for teams put in isolation after exposure to the coronavirus was established. 140 calls were made to support employees who were in isolation following exposure to patients infected with coronavirus. 3. targeted short interventions were initiated for hcws experiencing anxiety symptoms, and various relaxation techniques, such as eye movement desensitization and reprocessing (emdr) treatment, were offered for trauma treatment. basic information was made available to employees exposed to patients hospitalized for covid-19. using the current research results, we created a brochure, in question and answer format, designed to provide information on employee health and rights, workplace guidelines, and the procedure that should be followed after an unwitting exposure to a patient with covid-19. a 24/7 hotline was opened for consultations and questions concerning mental or emotional distress. the rationale for these interventions is embodied in the ideas of santarone, mckenney and elkbuli [51] that "maintaining the mental resilience of frontline workers involves offering solutions that allow them to perform their duties." the study showed that the interventions reinforced the concept of the hospital as a protective organization, learning from the knowledge and experience of its staff rather than making assumptions to define these needs. we note that the interventions were not the main intention of the research but evolved from the needs of the hcws, as expressed in the interviews. the need to generate immediate solutions to an acute crisis informed our decision to conduct a qualitative narrative analysis study. nonetheless, as a "side-benefit" we have accumulated rich data, which we are now analyzing in greater depth in a mixed-methods study. in light of the findings of this study, we recommend that leaders in the health care system should identify hospital hcws as first responders (similar to combatants in the traditional military environment). listening to hospital staff and exposing the price of the battle against the novel coronavirus may provide knowledge about new and understudied topics. this knowledge generated by narrative research, such as the current study, may, in turn, assist in providing suitable support programs for professionals fighting the new war in the health battlefield. moreover, this new knowledge may be invaluable information and contribute to organizational resilience and coping strategies. to conclude, in this era, health care management should exhibit leadership by listening to hcw's needs and adapting suitable interventions aimed to meet those needs. mental health strategies to combat the psychological impact of coronavirus disease 2019 (covid-19) beyond paranoia and panic severe acute respiratory syndrome (sars) in hong kong in 2003: stress and psychological impact among frontline healthcare workers mental health in emergency response: lessons from ebola responding to the 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processes in improving the quality of health care delivery: a contingency perspective listening as a path to psychological discovery: an introduction to the listening guide on the listening guide: a voice-centered relational method managing by walking around bringing women's voices back in: conducting narrative analysis in ir beyond binaries: analysing violent state actors in critical studies focus groups and the collective construction of meaning: listening to minority women. women's stud traumatic stress in the age of covid-19: a call to close critical gaps and adapt to new realities breaking the binaries in security studies a secure base. parent-child attachment and healthy human development preserving mental health and resilience in frontline healthcare workers during covid-19 this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors would like to thank sarit avishai-eliner, eitan lavon and lion poles for the productive discussions and their immense efforts in supporting the hospital's staff in the battle during the coronavirus. a special appreciation to inez mureinik for her inspiring remarks and careful editing. the authors declare no conflict of interest. key: cord-332496-xxz6qd3i authors: jiménez, óliver; sánchez-sánchez, laura c.; garcía-montes, josé m. title: psychological impact of covid-19 confinement and its relationship with meditation date: 2020-09-11 journal: int j environ res public health doi: 10.3390/ijerph17186642 sha: doc_id: 332496 cord_uid: xxz6qd3i the objective of this study was to evaluate the psychological impact of confinement due to the covid-19 pandemic, considering any protective factors, such as the practice of meditation or self-compassion, and their relationship with different lifestyles and circumstances of adults residing in spain. a cross-sectional study was done using an anonymous online survey in which 412 participants filled out the depression, anxiety and stress scale-2; the impact of events scale; and the self-compassion scale-short form, reporting severe symptomatology of posttraumatic stress and mild anxiety and depression. quality of cohabitation and age were found to be key variables in the psychological impact of confinement. the impact of confinement was more negative for those who reported very poor cohabitation as opposed to very good (f (3, 405) = 30.75, p ≤ 0.001, d = 2.44, r = 0.054) or for those under 35 years of age compared to those over 46 (f (2, 409) = 5.14, p = 0.006, d = 0.36). practicing meditation was not revealed as a protective factor, but self-compassion was related to better cohabitation during confinement (f (3, 403) = 11.83, p ≤ 0.001, d = 1.05). these results could be relevant in designing psychological interventions to improve coping and mental health in other situations similar to confinement. in december 2019, an outbreak of pneumonia with an unknown etiology was announced in wuhan (china), soon becoming a global pandemic and surpassing the severe acute respiratory syndrome (sars) of 2003 [1] . the world health organization (who) identified this new pneumonia as a new coronavirus called sars-cov-2 or as it is commonly called, covid-19. since the first cases were recorded in december 2019, the number has increased exponentially throughout the world and a public health emergency of international interest was declared on 30 january 2020 [2] . by march 11th, covid-19 had already been declared a worldwide pandemic with 118,000 cases in 114 countries, although 90% of them were concentrated in china and the republic of korea [3] . at the time of writing, 28 june 2020, global coronavirus cases surpassed 10 million, with over half a million deaths. in europe, over 2.5 million people have been infected, with almost 200,000 deaths, and spain has had the third most cases in europe, with 248,770, and the sixth most deaths, with 28,343 [4] . this rapid expansion of the virus is partly due to its high transmissivity, which has an estimated basic reproduction number of 2.24 to 3.58, meaning that an individual who is a transmitter of the virus could infect from two to four others [5] , even though they do not show any symptomatology [6] , and its incubation period varies from two to 14 days, with an average of seven days [7] . the symptomatology of those infected is fever, dry cough, sore throat, difficulties breathing, fatigue, nausea, vomiting, and diarrhea. the most commonly reported comorbidities are hypertension, diabetes, headache, dizziness, fatigue, myalgia, hypo/anosmia, and gustatory dysfunction [8] . regarding psychiatric and neuropsychiatric presentations, it seems that in its acute stage, sars-cov-2 might cause delirium in a significant proportion of patients. it might also cause depression, anxiety, fatigue, posttraumatic stress disorder, and more rarely, in the long-term, neuropsychiatric syndromes [9] . covid-19 can infect people of all ages, but men over 70 with preexisting conditions, such as asthma, diabetes, or heart disease, are the most susceptible, reporting an >8% mortality rate [5] . women are less susceptible to infection and because of their distinctive immune system, severity and mortality are much lower in children than in adults [5] . in view of all of the above and especially because of the rapid expansion of the epidemic, many countries have decreed a state of emergency with mass quarantine of their citizens. in the particular case of spain, this state of emergency has imposed a closure of establishments, ceasing of all except essential activity, and home confinement of the population during a period of time depending mainly on the evolution of the number of people infected and the expansion of the virus. in this respect, recent studies [10, 11] have mentioned that understanding the effect this quarantine has on the population is of great importance, especially in countries as severely affected as spain. quarantine could be understood as an important source of stress as it is unpredictable and uncontrollable, which are core features of the psychobiological construct of stress [12] . a recent review [10] on the psychological impact of quarantining for sars, h1n1 flue, and other causes reported fear in over 20% of the population, 18% sadness and 10% blame, and a high prevalence of distress, stress, depression, or bad mood. some of the factors generating stress during the sars quarantine were duration and fear of infection. some studies showed a positive association between length of quarantine and increase in posttraumatic stress symptoms, avoidance behaviors, or anger [10] . in recent studies on the impact of covid-19, women have manifested a greater psychological impact and worse mental health [13] . young people and students are also more vulnerable because of schools and universities closing, as well as social isolation, altering the normal development of their education [14] . in such a situation, systematic psychological self-care should have a high priority in coping with the detrimental impacts of covid-19 and social distancing. thus, acknowledging one's own limitations with compassion as a part of the shared human experience could have a positive impact on mental health. in this respect, possible protective factors could be mindfulness or self-compassion, since, as mentioned in a recent review [15] , it seems that mindfulness-based treatments are effective in reducing posttraumatic stress disorder (ptsd) symptoms and the mindfulness-based stress reduction program was the one that provided the most evidence [16] . in this vein, another review [17] emphasized the promising results associating an increase in self-compassion with reduction in ptsd symptoms, reducing the impact of exposure to trauma. therefore, and since to date there are few studies reporting on the emotional impact the pandemic is having on the psychological health of those confined, the objective of this study was to explore the impact of confinement due to covid-19 on the mental and emotional health of adult spanish-speaking residents of spain. in particular, we intended to inquire into the possible impact of confinement on anxiety, depression, and posttraumatic stress and whether practice of some type of meditation or self-compassion could be a protective factor against this impact. then, any between-group differences in these variables would be analyzed by sample sociodemographic variables (age, cohabitation, etc.) and finally, the relationships between the abovementioned variables (anxiety, depression, stress, self-compassion) and the sociodemographic variables selected (e.g., age or treatment of those confined) would be explored. a total of 412 adults from 63 spanish provinces, with a mean age of 40.48 (sd = 10.79) participated in the survey out of a total of 420 (finalization rate: 98.09%). most of the participants were spanish (91%), women (84.5%), aged 18 to 73, with no changes in their employment because of covid-19 (73.8%), a university education (42%), and did not practice any type of meditation (69.9%). the rest of the sociodemographic variables recorded are presented in table 1 . data collected for the study were sociodemographic (gender, age, nationality, marital status, occupation, employment, education); health (whether under treatment or not and if so, what); quality of cohabitation during the pandemic; cohabitation with a case of covid-19; whether religious or not and if so, practicing or not; and whether they practiced mediation and if so, what type. mental health was evaluated using the following scales: depression, anxiety and stress scale-21 (dass-21). the dass-21 consists of 21 items evaluating the frequency and severity of emotional symptoms experienced during the previous week, using a self-report scale with four choices from 0 (never) to 3 (almost always). it is made up of three subscales, depression, anxiety, and stress, with seven items each. a high score on each subscale means stronger symptomatology ( [18, 19] spanish adaptation). internal consistency of the spanish adaptation has an α = 0.93 for the depression scale, α = 0.86 for anxiety, α = 0.91 for stress, and α = 0.96 for the total scale [19] . impact of events scale (ies). the ies consists of 15 items evaluating subjective stress from stressful and or traumatic experiences in the previous week, with two subscales, intrusion and avoidance, with seven and eight items, respectively ( [20, 21] spanish adaptation). it is a four-choice self-report scale varying from 0 (never) to 4 (often). based on the sum of all the items, the cutoff points are 8.6 to 19 for mild symptoms and 19 or over for severe symptoms. the internal consistency of the spanish adaptation has an α =.86 for the total scale, α = 0.76 for intrusion and α = 0.82 for avoidance [21] . self-compassion scale-short form (scs-sf). the short form of the scale is made up of 12 items that evaluate self-compassion ( [22, 23] spanish adaptation). it consists of three main subscales (mindfulness, self-kindness, and common humanity) and their opposites (over-identification, self-judgment, and isolation). the scale has five answer choices from 1 (almost never) to 5 (almost always). a higher score is interpreted as more self-compassion. the internal consistency of the spanish adaptation is α = 0.71 for self-judgment, α = 0.75 for common humanity, α = 0.77 for isolation, α = 0.74 for mindfulness, α = 0.76 for over-identification, α = 0.73 for self-kindness, and α = 0.85 for the total scale [23] . a cross-sectional study was conducted from 4 april 2020 to 1 may 2020. the sample was recruited by non-probabilistic snowball sampling, since it was an exploratory study in which rapid access to data was needed. first, contacts of the research team were invited to participate and then, these contacts were asked to forward the invitation to their contact networks. an online survey form was prepared using google forms, which included information on the study; telling the participants that they would not receive any compensation for taking part in it; a series of sociodemographic and additional variables of interest; and the dass-21, ies, and scs scales. the study protocol was approved by the university of almería bioethics committee (no. ualbio2020/032) and the participants signed their consent after being informed of the implications of their participation and the confidentiality of the data provided, according to the helsinki declaration and the organic law on data protection 15/1999 of december 13th. all the analyses were performed with spss version 26.0 (ibm corp., armonk, ny, usa) and the descriptive results of the quantitative variables were reported with mean and standard deviation. an anova was done to evaluate the between-group differences in the sociodemographic variables and then, a student's t-test was applied for comparisons between each pair of groups. further, the effect size was calculated for those that were statistically significant. finally, the bivariate correlation was calculated to evaluate the relationship of the different sociodemographic ordinal variables and subscales. in all the analyses, p < 0.05 was considered statistically significant. the general mean on the dass-21 scale for participant stress was 6.67 (sd = 5.25), 3.88 (sd = 4.51) for anxiety and 4.51 (sd = 4.54) for depression, which reflects mild depression and anxiety, and the stress score was not symptomatic. on the ies scale, the mean for intrusion was 12.61 (s = 7.39), 13 .66 (sd = 7.62) for avoidance, and on the total scale, it was 26.22 (sd = 13.78), which shows severe symptomatology. finally, on the scs scale, mean self-kindness was 6.46 (s = 1.67) and for common humanity, it was 6.44 (sd = 1.60) and in mindfulness, it was 6.69 (sd = 1.69). an anova was done with the most significant variables to test for differences between the sociodemographic variables and psychological scales. this section only shows the data for those sociodemographic variables that were statistically significant. to be able to compare the groups by age, a new variable was created a posteriori by grouping participants by age into three groups of equivalent size by the quartiles found from the cutoff points. this new variable, "age group", was divided into young adults (18 to 35), adults (36 to 45), and middle aged (over 46). in addition, and since one of the objectives of this study was to test the importance of meditation on the psychological impact of confinement, this variable was also included for testing. after the anova and meeting the assumptions of normality and homogeneity of variance, statistically significant differences were found between psychological variables and sociodemographic variables. in stress, significant differences were found between age groups [f (2, 409) = 5.14, p =0 the results show that the total ies scores were lower in the groups with the best cohabitation, with a large effect size, except between very good and good, which was small, and between good and poor, which was moderate. differences were found with regard to occupation [f from the comparison between groups, it may be seen that the scores on common humanity were higher in those groups where cohabitation was better, with a large effect size. finally, statistically significant between-group differences were also found between groups by type of meditation [f (4, 396) = 6.10, p ≤ 0.001], especially between none and mindfulness (m = 6.23, sd = 1.54 vs. m = 7.02, sd = 1.64, d = 0.50, r = 0.001) and between none and transcendental (m = 6.23, sd = 1.54 vs. m = 8.00, sd = 1.58, d = 1.14, r = 0.004). in both cases, the participants who showed more common humanity were those who practiced some type of meditation compared to those who did not, with a moderate effect size between those who did not and those who did practice mindfulness and a large effect size between those who did not practice and those who practiced transcendental meditation. concerning the last subscale, mindfulness, statistically significant differences were observed between age groups [f ( in general, in those groups that practiced meditation, the score on the mindfulness scale was higher than in those who did not practice any, with a large effect size, except between none and mindfulness, which was small. lastly, by type of occupation, statistically significant between-group differences [f (6, 398) = 2.96, p < 0.05] were also found between unemployed and housewife/husband the rest of the sociodemographic variables with their mean and standard deviation are shown in table 2 . after the correlation analysis, older age was observed to be related to higher frequency in practicing meditation, better cohabitation, more common humanity, and more mindfulness. on the contrary, less stress, anxiety, and depression were related with older age. higher education was significantly related to more frequent practice of meditation and an increase in the variables in the scs scale. on the contrary, greater anxiety, intrusion, and avoidance were related to a lower education. more frequent meditation practice was significantly related to less depression and an increase in scs scale variables. better cohabitation quality was significantly related to higher scores on scs variables and a lower score on the rest of the scales. finally, as expected, the psychological scales were significantly correlated with each other (see table 3 ). after analyzing the survey results with regard to the objectives originally set, the participants showed mild depression and anxiety, not reporting symptoms of stress. however, they did report severe symptomatology on the ies scale as in previous studies, which related high scores in posttraumatic stress symptoms or avoidance behaviors after 10 days of quarantine [8] . this difference may be, in part, because the ies scale evaluates the psychological impact of an event after the fact and the participants could have understood that the event referred to covid-19, but not on the dass-21 scale. another of the objectives of the study proposed self-compassion and mindfulness as protective factors against the impact of confinement. it is worth mentioning that the participant scores on the various self-compassion scale subscales (mindfulness, self-kindness, and common humanity) were negatively related in both the ies and the dass-21, suggesting that self-compassion might be an important protective factor, fostering emotional resilience [24] . the results show that higher scores of self-kindness, common humanity, and mindfulness were related to not being under treatment and in turn, higher scores of self-kindness and common humanity were related to higher cohabitation quality. there was no significant relationship of mindfulness practice with lower scores on the ies or dass-21 scales, but there was an increase in the self-compassion scale, as was to be expected, given the relationship of mindfulness with self-compassion [25] . the sociodemographic variables that had the strongest relationship with psychological impact were being under treatment or not, age, and quality of cohabitation during the quarantine, indicating that not being under any treatment implied lower scores of intrusion and avoidance. being young was related to higher scores of stress and depression, in agreement with recent studies on the psychological impact, relating age and being a student with higher vulnerability and psychological impact from confinement [14, 26] . furthermore, an improvement in quality of cohabitation was related to a lower total ies score. on the contrary, worse cohabitation is related to greater intrusion and avoidance. these results would suggest that young people under some type of treatment and who report that the quality of their cohabitation is not good, would experience a negative psychological impact of confinement. specifically, young people show more posttraumatic stress symptomatology, so it would be of interest for authorities to develop psychological interventions, providing a support network during quarantine as previous studies have related an increase in ptss after similar events, such as middle east respiratory syndrome [27] . it was also observed that cohabitation with a person who was covid-19 positive implied more intrusive thoughts and avoidance, as well as a higher score on the total ies, which would be related to experiencing more fear of becoming infected with the virus and in turn, infecting others [10, 28, 29] . being retired was also related to more intrusion and a higher total score on the ies scale and on the contrary, being a student was related to less intrusion and a lower score on the total ies scale. this study has some limitations, especially due to the limited resources available and the urgency in its implementation during the state of emergency. we cannot establish any causal relationships between the variables studied. the sample was mostly comprised of women and only an adult population, so it is not a true representation of the entire population. future studies should have a larger and more homogeneous sample and use a more complex sampling strategy or perform a prospective study that would enable a more specific result to support the need for health initiatives focused on improving the mental health of the participants, promoting attitudes or behaviors for coping with confinement. in spite of these limitations, the results of this study provide important information on the psychological and social impact of the first three weeks of a covid-19 quarantine period, including that self-compassion might be an important protective factor, and may be used as a reference in future epidemics or outbreaks of the virus that provoke similar short or long-term situations to generate hypotheses for improvement of prevention and intervention. the results could also provide a baseline for evaluating the psychological and social consequences during the rest of the covid-19 epidemic, which was still underway at the time of writing. during this first stage of confinement due to the covid-19 outbreak, the participants reported mild anxiety and depression symptomatology, as well as severe posttraumatic stress symptomatology. the quality of cohabitation was shown to be a key variable in the psychological impact of the participants, since its poorer quality was related to higher scores of intrusion and avoidance, which were lower the better the quality of cohabitation was. being young and being under treatment were also related to a greater psychological impact. finally, self-compassion was related to better cohabitation during confinement. the findings shown in this study could be used for psychological interventions to improve mental health and coping with confinement during the covid-19 epidemic. sars control and psychological effects of 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health survey" (cuestionario de salud sf-36): un instrumento para la medida de los resultados clínicos the development and validation of a scale to measure self-compassion validation of the spanish versions of the long (26 items) and short (12 items) forms of the self-compassion scale (scs). health qual self-compassion: an alternative conceptualization of a healthy attitude toward oneself immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china mindfulness estado, habilidades mindfulness y auto-compasión en el aprendizaje de mindfulness: un estudio piloto impacto psicológico de la pandemia de covid-19: efectos negativos y positivos en población española asociados al periodo de confinamiento nacional mental health status of people isolated due to middle east respiratory syndrome the emotional impact of covid-19: from medical staff to common people this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. the authors would like to thank all the participants and the university of almeria's third generation behaviour therapy training program for their suggestions about the content of this article. key: cord-348717-qgny6f6y authors: shumba, constance; maina, rose; mbuthia, gladys; kimani, rachel; mbugua, stella; shah, sweta; abubakar, amina; luchters, stanley; shaibu, sheila; ndirangu, eunice title: reorienting nurturing care for early childhood development during the covid-19 pandemic in kenya: a review date: 2020-09-25 journal: int j environ res public health doi: 10.3390/ijerph17197028 sha: doc_id: 348717 cord_uid: qgny6f6y in kenya, millions of children have limited access to nurturing care. with the coronavirus disease 2019 (covid-19) pandemic, it is anticipated that vulnerable children will bear the biggest brunt of the direct and indirect impacts of the pandemic. this review aimed to deepen understanding of the effects of covid-19 on nurturing care from conception to four years of age, a period where the care of children is often delivered through caregivers or other informal platforms. the review has drawn upon the empirical evidence from previous pandemics and epidemics, and anecdotal and emerging evidence from the ongoing covid-19 crisis. multifactorial impacts fall into five key domains: direct health; health and nutrition systems; economic protection; social and child protection; and child development and early learning. the review proposes program and policy strategies to guide the reorientation of nurturing care, prevent the detrimental effects associated with deteriorating nurturing care environments, and support the optimal development of the youngest and most vulnerable children. these include the provision of cash transfers and essential supplies for vulnerable households and strengthening of community-based platforms for nurturing care. further research on covid-19 and the ability of children’s ecology to provide nurturing care is needed, as is further testing of new ideas. the coronavirus disease 2019 (covid19) pandemic is spreading in unprecedented ways and has a significant impact on nurturing care and early childhood development outcomes. currently, there are over eighteen million covid-19 confirmed cases globally, kenya recording over 20,000 cases as of 3 of 19 therefore, there is a need to mitigate the impact of covid-19 by prioritizing programs and policies that support the continuum of ecd [10] . anecdotal evidence in kenya shows that the covid-19 pandemic is contributing to deteriorating optimal environments that threaten children's early development and has direct health impacts on caregivers and children [11] [12] [13] . strategies are required to prioritize a range of ecd interventions during the covid-19 pandemic to support caregivers so that they can meet the needs of their young children. ecd goes beyond improving child survival to enabling children to reach their full potential through cognitive, socio-emotional and physical development. failure to prioritize ncfecd will lead to a future pandemic where children who are presently most vulnerable, will have significant deficits on their health, wellbeing and productivity. previous pandemics have had long-term negative impacts over multiple generations. the development of children who were exposed to the asian influenza pandemic in 1957, while in utero, was hampered with evidence of poor cognitive development [14] . the 1918 spanish flu was reported to lower educational attainment for those individuals whose mothers had potential in utero exposure [15] . in japan, primary school children born between 1919 to 1929 were shorter than those in surrounding cohorts [16] . the timing of the prenatal exposure to influenza was also reported to have had worse consequences in those who were exposed in early gestational 0 to 8 weeks, as it was associated with delayed psychomotor development at 6 months of age [17] . in fact, it has been established that the spanish flu had negative outcomes in later life for those who were exposed in utero in several countries such as the usa [18] , brazil [19] , switzerland [20] , and taiwan [21] . in a narrative review of infants and children with congenital zika virus, epilepsy and motor abnormalities were noted [22] . wearing masks to prevent the transmission of sars also negatively impacted communication between children and adults, and was also threatening to children who had been sexually abused [23] . the hiv pandemic had a negative impact on child growth and development. globally and in sub-saharan africa including in kenya, young children affected by hiv particularly those who are hiv-infected, have a high risk of mental health problems, neurocognitive deficiencies, developmental delay, and poor nutrition outcomes [24] [25] [26] [27] [28] . the hiv pandemic generated a lot of lessons related to ecd. however, for a very long time, ecd was associated with child survival only, without a strong focus on promoting thriving and transforming [29] . ecd-related outcomes such as cognitive impairment and developmental delays as well as long-term impacts across the life course have not been tracked widely. even where there are attempts to focus on thriving and transforming, during epidemics and pandemics, the focus reverts to child survival. despite the frequency of epidemics, there is a scarcity of research on holistic ecd outcomes in the sub-saharan africa context. where research in sub-saharan africa exists, it has focused on other types of emergencies such as conflict and refugee crises [30] . there are several far-reaching, interlinked direct and indirect impacts of the covid-19 pandemic and associated control measures on nurturing care and related ecd outcomes including children's cognitive, physical, language, motor, and social and emotional development (figure 1 ). these include direct physical and mental health impacts resulting in illness and/or death from covid-19 infection, and severe stress leading to deterioration of mental health and well-being. with deaths increasing, many children are becoming orphaned or experiencing greater adversity. covid-19 has also affected access to health and nutrition systems including routine immunizations. social impacts include increased teenage pregnancies and a rise in gender based violence, all with a bearing on ecd outcomes. they also include lack of social and child protection services to support parents and primary caregivers. furthermore, child development and learning impacts including lack of access to institutional-based childcare services and critical nurturing environments have become more severe during this period, affecting the learning that children need during the most critical period of brain development. finally, the economic impacts have a direct interplay with all other impacts, and have contributed to increased stress among caregivers and children. in some places, it has resulted in food insecurity, thereby also influencing children's physical health. all these impacts have short-term consequences that will translate into long-term changes in children's life trajectories. deaths increasing, many children are becoming orphaned or experiencing greater adversity. covid-19 has also affected access to health and nutrition systems including routine immunizations. social impacts include increased teenage pregnancies and a rise in gender based violence, all with a bearing on ecd outcomes. they also include lack of social and child protection services to support parents and primary caregivers. furthermore, child development and learning impacts including lack of access to institutional-based childcare services and critical nurturing environments have become more severe during this period, affecting the learning that children need during the most critical period of brain development. finally, the economic impacts have a direct interplay with all other impacts, and have contributed to increased stress among caregivers and children. in some places, it has resulted in food insecurity, thereby also influencing children's physical health. all these impacts have short-term consequences that will translate into long-term changes in children's life trajectories. 5.2.1. impacts on children's health covid-19 is an evolving pandemic, and despite the worldwide spread, the effects of covid-19 on pregnancy, childbirth in addition to newborns and toddlers are not well-established, and the evidence is mixed. recent experience suggests there is a low risk of intrauterine infection by vertical transmission in women with covid-19 disease [31] [32] [33] , although the first case of vertical transmission was recorded in july 2020 in india [34] . a systematic review by zimmermann and curtis (2020) [35] on covid-19 in children, pregnancy and neonates reported fetal distress in 30% of pregnancies, with 37% of women having preterm deliveries. neonatal complications including respiratory distress or pneumonia (18%), disseminated intravascular coagulation (3%), asphyxia (2%) and two perinatal deaths were also reported. 5.2.1. impacts on children's health covid-19 is an evolving pandemic, and despite the worldwide spread, the effects of covid-19 on pregnancy, childbirth in addition to newborns and toddlers are not well-established, and the evidence is mixed. recent experience suggests there is a low risk of intrauterine infection by vertical transmission in women with covid-19 disease [31] [32] [33] , although the first case of vertical transmission was recorded in july 2020 in india [34] . a systematic review by zimmermann and curtis (2020) [35] on covid-19 in children, pregnancy and neonates reported fetal distress in 30% of pregnancies, with 37% of women having preterm deliveries. neonatal complications including respiratory distress or pneumonia (18%), disseminated intravascular coagulation (3%), asphyxia (2%) and two perinatal deaths were also reported. the epidemiological and pathophysiology of covid-19 in children remains unclear. evidence from china [36] , italy [37] , netherlands and the uk [38] indicate that children represent less than 5% of diagnosed covid-19 cases. however, children under one year and those with comorbidities such as asthma are more likely to be hospitalized [39] . although covid-19 in children seems to have mild symptoms, there is a high prevalence of pneumonia associated with covid-19 in children at 53% [40] . the majority of children have less severe symptoms, and thus are less likely to be tested, leading to an underestimate of child infections. indeed, studies confirm that severe illness and mortality from covid-19 is rare in children [41] . however, there are emerging concerns of a novel severe kawasaki-like disease in children related to covid-19 that may represent a post-covid infectious syndrome [38] . in a systematic review, children were found less likely to be the main drivers of the pandemic compared to adults who get severe disease [41] . in kenya, the reported cases of young children testing positive for covid-19 are low; 9% of reported cases as of 27th july were children aged 0-9 years with a 2% case fatality rate [42] . although children do not account for the majority of cases, they are likely to face the most substantial impact of the covid-19 pandemic [43] . consequently, a focus on children, and especially the youngest, is vital not only due to the impact that they may face during the current crisis, but also because the negative impact has the potential of persisting across their lives in many years to come. there is also heightened stress and psychosocial difficulties among parents and caregivers that threaten the provision of optimal nurturing care environments which children need to achieve their potential [12] . worry, stress, and being anxious have been reported among 75% of kenyans due to covid-19 [44] . school and daycare closure, job losses, economic uncertainty, inability to afford food and lack of access to essential services have resulted in increased stress and anxiety among caregivers. some level of stress is normal and can even be beneficial when it is positive, but when it is elevated, constant and adds to existing adverse conditions, it can become toxic [45] . toxic stress can have long-term impacts on a person's hormones, thereby affecting a child's brain architecture, physiological and chemical makeup, and overall development over a lifetime that may never be fully reversed [45] . the ministry of health in kenya developed a comprehensive guide for health workers on mental health and psychosocial support during the covid-19 pandemic to cover the needs of the population and people on treatment for covid19 [46] . however, it is not clear if this has been widely disseminated, and the extent to which various population segments are benefitting from the guidance is also unclear. access to material and psychosocial support, caregivers' and families' ability to cope with the pandemic and its consequences may be limited, and they may not be able to provide effective nurturing care [10, 47] . when children experience trauma, experience adversity and lose secure attachment and bonding due to deficiencies in responsive caregiving, they experience stress, which has negative impacts on their health, wellbeing and lifelong learning, including a higher risk for developing a variety of cognitive, behavioral and emotional difficulties later in life [45] . aside from the direct health impacts on the physical and mental health and wellbeing of children, caregivers and families, covid-19 has also affected health systems and disrupted access to routine nurturing care services. covid-19 has placed a strain on the overstretched healthcare systems, a key entry point for nurturing care, and disrupted the delivery of vaccination of children under five years due to supply chain and human resource constraints [48] . the weak health systems in lmics such as kenya are vulnerable to the spread and impact of covid-19, having witnessed service disruptions and lack of preparedness in the face of the crisis. the basic tenets of the right to health are being tested. public health expenditure as a percentage to gdp is deficient in the region, and kenya stands at 5.7%, far below the recommended 15% per the abuja declaration [49] . the country already had a shortage and maldistribution of health workers, but with covid-19, the disparities in access to healthcare between the rich and the poor in urban areas, as well as between the rural and urban divide, are widening. though most nurturing care interventions in kenya begin at birth, maternal preconception health and wellbeing influences child development. intrauterine growth restriction has been linked to adverse outcomes including prematurity, low birth weight, stunting, anemia, neurodevelopmental conditions, stillbirths and child mortality [50, 51] . evidence from lmics shows that reproductive, maternal, newborn and child health interventions including iodine, iron and folate supplementation during preconception have had a significant impact on children's cognitive, physical and socio-emotional wellbeing [52] . the uptake of preconception care in kenya is very low since over 40% of the pregnancies in the country are unintended [53] . notably, the majority of the unintended pregnancies occur in young girls who take time to acknowledge their pregnancies. this leads to delay of the first antenatal visit and, in some instances, non-uptake of antenatal services throughout the pregnancy [54] . in a context where covid-19 has led to an increase in the number of teenage pregnancies as well as a disruption in routine care, the net effect will be delays and low uptake of antenatal services. consequently, there may be an increased risk of infant and maternal morbidity and mortality. the covid-19 pandemic has disrupted maternal and child health and nutrition, including antenatal, skilled delivery and postnatal services, as well as immunizations, health education and promotion, all resulting in a reversal of the previous gains made in reducing maternal and neonatal mortality [55] . the reduced accessibility of essential maternal and child health and nutrition services is worsening ecd outcomes and further exacerbating disparities among vulnerable households such as those living in informal urban settlements. the pandemic threatens the continuity of critical and essential services for expectant women, newborns, and children under five years including those with disabilities and developmental delays. the reluctance of parents to visit clinics due to fear of infection with covid-19 may also interrupt immunization and other child health programs [56] . the social distancing, lockdown and curfew measures have led to decreased utilization of maternal health services. pregnant women experience challenges in accessing health and nutrition services, which has been worsened by the covid-19 crisis. for example, lack of transport during lockdown and curfews, and fear of visiting health facilities due to concerns regarding covid-19 infection have been observed [57] . maternal and child malnutrition, including micronutrient deficiencies and child stunting are expected to increase [58] . mothers and children need access to key essential nutrition actions and services so that they are well-nourished pre-conceptually, intrapartum and during lactation. furthermore, they also need services to diagnose and address micronutrient deficiencies through iron and folic acid (ifa) supplementation to prevent neuro-developmental disabilities in children [59] . however, anecdotal reports confirm reduced utilization of maternal and child health services in kenya, worsened by infection of some health workers leading to the suspension of maternal services [60] . likewise, in sierra leone and liberia, the ebola crisis exacerbated the poor health outcomes within weak health systems [61, 62] . liberia and guinea experienced a sharp decline of more than 25% in the monthly number of children vaccinated against measles in 2014 and 2015 due to the ebola outbreak as compared to the previous years [63] . the indirect effects of ebola on maternal and child health were believed to be greater than the direct consequences [62] . antenatal care, family planning, facility delivery and postnatal care were adversely affected, leading to an increase in maternal neonatal and stillbirth deaths in 2014-2015 [61] . the economic well-being of a family affects a child's ecd outcomes because it affects the child's ability to be in a safe and protective home and access health services and programs and nutritious foods, all of which cost money. children growing up in vulnerable households face even greater challenges to thrive given the pandemic and existing adversities [64] . the directives to reduce transmission through social distancing, hand-washing, self-isolation and self-quarantine for 14 days for those exposed to the virus may be unattainable for informal settlement residents who have space limitations and limited access to water, sanitizers and masks. families who were already vulnerable prior to the pandemic have been pushed to dire circumstances with losses in income and are unable to afford basic necessities, while others juggle work and childcare among other responsibilities. stay at home orders and lockdowns are unlikely to be followed through as quest for food and basic commodities is necessary [65] . the economic impacts of the pandemic are anticipated to have far-reaching consequences on long-term health and wellbeing of the population compared to the direct health impacts [66] . there is a downward trend in the kenyan economy marked by job losses, inconsistent food supply and an increase in stress levels among adults and children [67] . the pandemic has caused a severe unemployment crisis in kenya, with at least one million people having lost their jobs or been placed on indefinite unpaid as of june in both the formal and informal sectors [68] . there was a marked decline in labor force participation from 75% in 2019 to 57% in april 2020, and women are the most affected with a participation rate of 49% compared to men at 65.3% [69] . the government has introduced various fiscal policy and income support measures such as tax waivers, reduction in taxes for all micro, small and medium enterprises, as well as covid-19 emergency funds and earmarked funds for social protection in the form of cash transfers [66] . however, the number of vulnerable families continues to increase as the pandemic persists. families living in informal settlements live in overcrowded areas and lack basic housing, water and sanitation, which make them vulnerable to disease outbreaks despite having the knowledge of covid-19 measures [65, 70] . contact tracing has shown local transmission of covid-19 to rise as community transmission becomes a significant driver, especially with people living in a big families leading to an increase in deaths [71] . this can be related to the respiratory viral transmission of covid-19 through direct contact in the households where space is inadequate and social distancing impossible. families also continue to experience other non-covid-19-related health challenges coupled with movement restrictions, placing caregivers of children at greater risk of morbidity and mortality. as the situation continues to unfold and countries adopt this 'new normal', the potential negative impact of the prevailing situation on unborn and young children cannot be ignored [57] . holistic child development requires a stimulating, safe environment, social interaction, education opportunities and adequate nutrition, all of which have been affected in one way or another [57] . the resultant economic impacts of covid-19 have been felt at household level with a ripple of negative impacts on nurturing care. there has also been increased risk of abuse, neglect and violence against children of all ages [72] and domestic violence in kenya [73, 74] . children with developmental delays and disabilities are very vulnerable and are often subjected to stigma and various forms of neglect and abuse [75] . stress and anxiety among children are also likely due to disrupted routines. routines are critical to enabling children to thrive in supportive environments in the home, childcare and early learning centers. all these circumstances mean that children in lmics such as kenya are at risk of faltering outcomes, as caregivers find it challenging to provide their children with the nurturing care they need during this pandemic. children need a safe, secure and loving environment, yet these stressful experiences in early life increase the risk of developmental delays and non-communicable disease in later life [3, 10] . therefore, to promote safety and security, families and children need to live in safe environments, where children experience supportive discipline and do not experience neglect or violence. responsive caregiving ensures sensitivity to children's cues, thus promoting play and stimulation for early learning through day-to-day activities as well as caregiver-child interactions that are enjoyable [76, 77] . it is plausible that with the lockdown and restrictions on movement, caregivers and families may have limited access to child protection services and programs. where the services are present, they may experience difficulties reaching and providing care to vulnerable children. the closure of "babycares" may have implications for child protection, as the children are not being looked after by caregivers who offer an environment with some level of safety and security. due to the ongoing crisis, children may also be locked up and restricted from exploring their environments or playing with other children due to fear of infection. without access to social protection, caregivers facing heightened vulnerability due to loss of income may lack the safety nets to provide for and protect children. in cases where caregivers succumb to direct covid-19 infection or due to the indirect health impacts of covid-19, children are orphaned. this affects children's access to basic needs and nurturing care [78] . the experience of bereavement itself is a form of adversity, and could lead to emotional and psychological trauma, and induce fear and a sense of helplessness in children without positive coping mechanisms [79] . orphaned and vulnerable children have an increased risk of being neglected, harmed, exploited, and they may experience gender-based violence, including early marriage. they also miss out on opportunities for play, a crucial aspect of child development and early learning. in kenya, there is weak oversight of services to support orphaned and vulnerable children. traditionally children would live with other relatives, and, in general, family-based care is preferred to institutional care where there are reports of abuse, neglect and exploitation [80] . however, with covid-19 putting increasing food insecurity and economic hardships of families, orphaned and vulnerable children may not be supported in these families without the provision of safety nets. high teenage pregnancy is not new in kenya. data from the demographic and health surveys show that almost 2 out of 10 girls between the ages of 15 and 19 are reported to be pregnant or already had a child [81, 82] . this trend has been fairly consistent for more than two decades with little change in prevalence between 1993 and 2014. nevertheless, in light of the covid-19 pandemic, the trend of teenage pregnancy is already showing signs of being more severe as a result of prolonged school closure, sexual violence and the declining economic situation in kenya [83] . this trend is dire, as girls from poor families across the country are engaging in transactional sex to acquire money to buy sanitary pads and food [83, 84] . globally, it is predicted that due to the harsh economic times, the number of girls involved in survival sex will increase [85] . previously, girls were able to access free sanitary towels through their schools; however, this is no longer the case since schools were closed following the covid-19 crisis [86] . teenage pregnancy presents significant health consequences to both mothers and newborns. complications in pregnancy and childbirth are the leading cause of death among girls aged 15-19 years globally [87] . the risks are even higher for girls below the age of 16 years. pregnant adolescents face a higher risk of eclampsia, endometritis and puerperal infections than women aged 20-24 years [88] . in addition, adolescent births are more likely to result in preterm births, low birth weight and newborns with severe congenital conditions. furthermore, teenage pregnancy is a major contributor to a never ending cycle of ill-health and poverty [87] . the impact of teenage pregnancy includes loss of education opportunities, early marriages, and economic disempowerment [83, 89] . studies have shown that most teenage pregnancies occur among teenagers from deprived backgrounds [81, 90] . therefore, all these factors result in the intergenerational transmission of poverty from the teen mothers to their children with poor ecd outcomes. the situation is bound to get worse with the covid-19 pandemic. furthermore, cases of gender-based violence, in particular, child and early marriages are also on the rise [83, 91, 92] . it is well understood that children of teenage mothers tend to have poor ecd outcomes. the children have lower iqs and academic achievement, and are at a greater risk of repeating a grade. they are also at a greater risk of perinatal death and having a fatal accident before turning one year old [93, 94] . the ministry of education announced that all schools within the territory of the republic of kenya shall remain closed until january 2021 [95] . this announcement is worrisome given the increasing cases of teenage pregnancy during the extended period of schools' closure [96] . the closure of daycares and pre-primary classes, which includes children up to four years, has affected children's access to early learning, that is, building their brains in a safe and stimulating environment and developing their social and emotional skills while their parents work. children learn best through play and interaction with peers; with daycares and other early learning centers closed, many children are not able to receive these critical inputs. these centers are also important sites for immunizations, meals and psychosocial support, all of which are being disrupted due to covid-19 [97] . prior to the covid-19 pandemic in kenya, along with the rising urban population and the need for parents to find informal work, there was a growing demand for childcare and early learning services. high unemployment and literacy rates of parents, and the absence of extended family support and public amenities and the prohibitive cost of quality childcare services led families relying on informal childcare centers as they sought employment. there was a proliferation of relatively low-cost, non-regulated and informal privately owned childcare centers for children aged three years and below, commonly referred to as 'babycares' with at least 2700 of them in nairobi [98] . these informal babycares are often home-based or faith-based and lack the minimum standards, expertise and infrastructure required to support children to attain their developmental potentials. some of these have poor lighting, are crowded with children that sleep most of the time, lacking play and stimulation and being served nutrient-poor or deficient foods. this large number is exacerbated by the lack of policy and legal framework to guide the services they provide for children below four years and their families. the 2006 national ecd policy framework of 2006 was not implemented due to operational issues [99] . numerous conversations among stakeholders continue on the state of ecd for children below the age of four. with the nurturing care framework adopted in kenya, the focus on children below four years is taking center stage alongside the prioritization of programs and services to meet their needs. while nascent, at the beginning of covid-19, there had been considerable traction. with the pandemic, these gains are threatened, as policy makers' focus and funds have been diverted to physical health, which includes preventing and treating those with covid-19, rather than considering all aspects of child development. for middle-and upper-class families, they can hire childcare or early learning support, but this is out of reach for poor families. during the covid-19 pandemic and beyond, the kenyan government and other ecd stakeholders interested in ensuring that the youngest of children in the country are able to survive, thrive and continue on a positive life trajectory can reorient nurturing care. this is possible through utilizing the lens of direct health; health and nutrition systems; economic and social protection; and child development and early learning. children's needs are inter-related and holistic and so support must also possess these qualities. kenya has a number of policies and systems in place to bolster nurturing care during the covid-19 pandemic, but as is the case with many countries around the world, they are not fully financed and operational. actions to mitigate the negative impact on maternal, newborn, child and adolescent health need to be addressed by borrowing, developing, and implementing strategies utilized in previous epidemics and pandemics. this will guarantee continuity of care and avoid a rise in maternal and newborn morbidity and mortality. support to caregivers and families would enable them to nurture their young through a multi-sectoral approach that builds on existing programs [100] . it is crucial to examine existing evidence on the direct effects of covid-19 on maternal and newborn care and develop programs that target easy access to maternal and newborn health services, warranting safety for mothers, children and health professionals following the guidelines. this could include increased bottom-up community health education and promotion strategies on the current covid-19 guidelines, utilizing a multi-sectoral approach through establishment of partnerships with community gatekeepers to teach mothers and caregivers. these strategies should be designed to be evidence-based and culturally appropriate, leading to holistic well-being for caregivers. particularly, families and caregivers of children with developmental delays and disabilities require targeted support that meets their needs during the ongoing crisis, enabling them to practice responsive caregiving through ensuring child safety and security [47] . these children and those who are orphaned should be prioritized for social protection interventions implemented by both the government and development agencies. this support could include some or a combination of the following: cash transfers, food packs, mobile health and nutrition services, as well as regular support and monitoring by child protection teams. children with disabilities may experience stress, have underlying health conditions that increase their risk of complications from covid-19, and may also be unable to access therapy during this period. similarly, their caregivers may have heightened stress. therefore, it is important to take care of their physical and mental health by improving access to community and home-based play spaces, therapy, health and psychosocial services, as well as other service navigation support. creatively delivering parenting education focused on enhancing caregiver capacities to become more responsive, promote maternal and child health and wellbeing, as well as adequate nutrition services will be at the core of driving nurturing care, and hence improving ecd outcomes. critical and essential health and nutrition, as well as other social services, can be delivered and sustained during the pandemic period with adherence to adequate infection prevention and control measures. furthermore, health education and promotion in addition to continuous engagement and referrals of caregivers and families through community health structures is crucial. innovative culturally acceptable strategies that transcend the existing pandemic barriers with a strong emphasis on strengthening community-based reproductive, maternal, newborn, child and adolescent health services are required. these services include family planning services; maternal nutrition such as promoting the uptake of iron and folic acid supplements; antenatal care; seeking skilled delivery and post-natal services; as well as essential nutrition services to support infant and young child feeding, routine growth monitoring and counselling through baby-friendly community initiatives. these should be further complemented with adequate transport to a health facility during curfew or lockdown situations. in some settings, health services are being taken to families in remote locations, especially those through mobile vans or clinics, thereby enabling greater and equitable nurturing care support for the youngest of children during the covid-19 crisis [101, 102] . essential new-born care should be an area of sustained focus: early initiation and assessment for exclusive breastfeeding, addressing danger signs for referrals and timely linkages to health services. mothers and caregivers also need timely referrals and access to services for treatment of maternal and child undernutrition. integrated community case management of common childhood diseases, in particular malaria, diarrhea, pneumonia and malnutrition, should not be neglected. mental health, often overlooked, has risen to the consciousness of policy makers and donors. this pandemic provides an opportunity to take the innovations and expand mental health/psycho-social services throughout kenya. all people, young and old, are facing mental and emotional difficulties. caregivers juggling full-time jobs, caring for others such as the elderly and children at home, are feeling especially overwhelmed. development agencies are supporting families' mental health and psycho-social wellbeing where possible by establishing phone helplines to increase access to free professional mental health support. referral systems are also being established through these helplines, and this needs to be expanded and accessible. simple tips and exercises, relevant to both the young and old, are being broadcast on tv, radio, social media (facebook (facebook, inc., san francisco, ca, usa) or whatsapp (whatsapp inc., san francisco, ca, usa)) and through short videos. the design and utilization of mhealth can lead to improved ecd outcomes. in particular, the use of telehealth consultations where possible, with health professionals, can also help to minimize hospital visits. efforts should be made to scale up provision of nurturing care through integration into their health systems by adopting the mnurturingcare app in clinical encounters and at the community level [103] . in addition, partnerships with the local communities are important to increase engagement and dialogue on the measures for supporting nurturing through heightened communication with health professionals who can offer prompt identification of complications and provide appropriate referrals. as covid-19 is negatively affecting the economic situation of many families in kenya, especially those who work in the informal sector and/or were already in precarious economic situations prior to the outbreak, innovative approaches such as cash transfers are necessary. in various emergencies around the world and in kenya, conditional and unconditional cash transfer programs have provided an economic safety net and positively impacted health during difficult periods such as the one we face [104] [105] [106] . although the government has instituted social protection schemes in the form of cash transfers to cushion vulnerable families, the need is greater. more investments are required, particularly programs that support those who were previously working in the informal sector and have lost incomes. this can be achieved through reallocation of funds to social protection to increase the resources available for cash transfers and food supplies in order to mitigate socio-economic impacts, including addressing food insecurity [58, 66] . these measures should be accompanied with the introduction of functional community mechanisms for identifying vulnerable households and children who lack access to basics such as food, water, shelter and healthcare, and provide targeted support. social safety nets for vulnerable families during this pandemic enable them to provide nurturing care to promote resilience among children, despite the stressors surrounding them. it is clear that many social and child protection services targeted at children and adolescents in kenya, such as meals and sanitary pads among others, have largely been delivered through childcare and school platforms; with school closures, this avenue is not viable. there is a need to build and leverage community level programs and policy support, targeting children at risk of abuse and neglect, and adolescents at risk of early pregnancy, to ameliorate the negative effects of the pandemic, such as poor nurturing care environments and transactional sex for food and pads among adolescent girls, all of which subsequently leading to poor child development outcomes. mitigation strategies should focus on safety nets for poor families in addition to identifying and supporting vulnerable children and adolescents within these families. urgent strategies are required to protect young children and girls from the increased gender-based violence during the pandemic period. these strategies include improved access to psychosocial support services through community agents or call-in centers to reduce caregiver stress, expansion of social and child protection services such as family tracing and reunification of separated or orphaned children, and increased delivery of reproductive health services through mobile reproductive health services and telemedicine in remote communities. for orphaned children, evidence indicates that family-based care is better for young children than institutional care [80] . the landmark longitudinal study of romania's orphans led by the bucharest early intervention project showed that brain development can be severely affected when orphaned children are in institutional care without nurturing care [107] . the study indicates that this effect can last over a person's lifetime. key stakeholders therefore should find safe and protective homes for orphaned children with other relatives and ensure they benefit from social and child protection services. this could also include conditional and unconditional cash transfers to help relatives of orphaned children that want to take care of them in supportive family environments. other critical community outreach strategies are also required to address poor nurturing care environments and rising transactional sex in partnership with nurses and community workers. these include expanding community outreach for nurturing care skills among caregivers and increasing access to sexual and reproductive health and rights education, as well as distribution of sanitary pads and contraceptives among adolescent girls. these strategies must be accompanied by facility and community-based youth-friendly reproductive health services. special attention needs to be given to the children of young teen mothers through social protection schemes to ensure that their children can achieve the highest developmental potential during this period. children and their primary caregivers/parents need social and educational support to ensure socio-emotional well-being, safety and security from violence and harm and opportunities to boost young children's brain development. children are separated from peers and extended family members such as grandparents, and are unable to attend early learning centers, daycares, and crowded areas. some children, just by being home, are exposed to domestic violence; early evidence points to an increase in such cases as stress levels of families' increase [72] . concerted efforts including awareness raising are necessary to reduce violence against children. some innovations are being tested in this area by development agencies. for instance, the use of tv, radio, pre-made videos and social media to support early childhood educators, teachers, and family members with simple ways to support young children's learning and development at home has been observed. parents and caregivers are the most important support structure for young children, and their ability to nurture adequately while remaining physically and mentally healthy is critical. parents and caregivers should therefore become a critical target audience for ecd stakeholders in kenya and the region, ensuring that nurturing care becomes a family-centered with a whole-society approach. with the additional burdens being placed on parents and caregivers, they need to prioritize their physical and mental health. the strategies suggested above in the section on health and health systems support can be crucial. additionally, parents and caregivers also need practical tools and guidance to enable them to provide early nurturing care in the home environment, particularly providing opportunities for early learning as well as increasing community-led sanitation and nutrition programs. this includes strategies on how to regularly interact and communicate with children and provide them with age-appropriate play and learning resources at home, using locally available, low-cost or household materials easily found in their surrounding environment. the care for child development package is a useful intervention that can be cascaded widely, leveraging multi-sectoral community counselling platforms to encourage greater parental or caregiver responsiveness through communication and play [108] . this will contribute to the healthy development and growth of children by supporting caregivers to build stronger relationships with their children and solve challenges in providing nurturing care. for those children who may have been attending babycares that have been closed due to the crisis, the caregivers need practical support to provide quality early learning in the home environment. linkages with child and social protection actors should be strengthened to promote nurturing care, as parents have now taken over childcare and schooling in the home while balancing dual roles of work and managing the household. in the critical early years, young children need at least one loving and trusted adult to feel secure, grow and develop holistically. in this period of adversity, children need nurturing relationships with caregivers and families to provide a buffer to counterbalance the hardships [10] . covid-19 is still ravaging kenya and most of the world. there is still a lot to learn about what can work and what cannot. little research is currently published on how to support nurturing care for children under 4 years in the wake of such a pandemic, especially in africa. while the impacts of the pandemic on the lives of young kenyan children and their families have been severe, and evidence around further impacts is coming to light, there are opportunities to learn and "build back better". interventions need to address five critical areas: direct health impacts, health and nutrition systems impacts, economic impacts, social and child protection impacts and child development learning impacts. there is need to leverage technology and use a community-based approach to support continuity of nurturing care services with timely referral and follow-up to a wide range of cross-sectoral services including psychosocial support. kenya has an opportunity to learn from other countries about how to develop practical and feasible guidance to reopen childcare centers and early learning spaces, given the low incidence of covid-19 in younger children. tailored plans are required for children with unique needs, and consideration should be given to provide holistic and inclusive support. the government and development actors need to consider increasing their investments to scale-up nurturing care through the development of policies and coordinated intervention programs during this pandemic period. this paper took stock of what we currently know about the impacts of covid-19 on nurturing care for the youngest kenyans, but this is just the tip of the iceberg. although our review paper has provided useful insights and made an important contribution to the body of knowledge, the key limitation is that it is mainly based on secondary sources including grey literature, and it did not rely on primary data. further primary research and investigation on the youngest children and the ability of children's ecology to provide nurturing care is needed, as is the further testing of new ideas. primary research is required particularly to explore the mental health impacts on caregivers and children; understand how domestic violence has impacted nurturing care; and shed more light on the experiences and support available to teenage mothers and caregivers of children living with disabilities. 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responsive caregiving and early child development. child care health dev key: cord-349313-2gupfqnl authors: martinez-perez, clara; alvarez-peregrina, cristina; villa-collar, cesar; sánchez-tena, miguel ángel title: citation network analysis of the novel coronavirus disease 2019 (covid-19) date: 2020-10-21 journal: int j environ res public health doi: 10.3390/ijerph17207690 sha: doc_id: 349313 cord_uid: 2gupfqnl background: the first outbreaks of the new coronavirus disease, named covid-19, occurred at the end of december 2019. this disease spread quickly around the world, with the united states, brazil and mexico being the countries the most severely affected. this study aims to analyze the relationship between different publications and their authors through citation networks, as well as to identify the research areas and determine which publication has been the most cited. methods: the search for publications was carried out through the web of science database using terms such as “covid-19” and “sars-cov-2” for the period between january and july 2020. the citation network explorer software was used for publication analysis. results: a total of 14,335 publications were found with 42,374 citations generated in the network, with june being the month with the largest number of publications. the most cited publication was “clinical characteristics of coronavirus disease 2019 in china” by guan et al., published in april 2020. nine groups comprising different research areas in this field, including clinical course, psychology, treatment and epidemiology, were found using the clustering functionality. conclusions: the citation network offers an objective and comprehensive analysis of the main papers on covid-19 and sars-cov-2. coronaviruses (coronaviridae) are a family of viruses that cause infections in humans and animals. it is a zoonotic disease, i.e., it can be transmitted from animals to humans through direct contact with infected animals or their secretions [1, 2] . in 2003, sars-cov-1 caused almost 8000 cases in 27 countries and had a 10% mortality rate. between that year and december 2019, no further cases were detected in humans [3] . then, a group of pneumonia cases with an unknown origin was reported in wuhan, in the chinese province of hubei, on 8 december 2019 [4] . on 7 january 2020, the chinese authorities identified a new outbreak of the coronaviridae family after analyzing several samples from the respiratory tract, which was subsequently named sars-cov-2 [4, 5] . on 11 february, the general director of the who (world health organization) announced "covid-19" as the name of the disease caused by sars-cov-2. a month later, the who declared the pandemic status following an increase in the number of cases, which had reached 118,000 infections and more than 4000 deaths in 114 countries [6] . in europe, the first case was detected in france on 24 january, and the virus then spread to nine other countries in just one month (belgium, finland, france, germany, italy, russia, spain, sweden and the united kingdom). by march, the number of positive cases in europe had increased to 195,511 [7] . meanwhile, between 21 january and 28 february, 33 positive cases were reported in the americas in the search of publications was carried out using the web of science (wos) database with the following search terms: "covid-19", "sars-cov-2", "the coronavirus disease 2019" and "corona virus disease 2019". these terms were selected bearing in mind the study objective; additionally, these are the most common terms in all research fields. since the results of the search comprised some articles shared by several fields, the boolean operator not was used in the second search ("sars-cov-2" not "covid-19"), the third search ("the coronavirus disease 2019" not "sars-cov-2" not "covid-19") and the fourth search ("corona virus disease 2019" not "the coronavirus disease 2019" not "sars-cov-2" not "covid-19"). additionally, the search was carried out by selecting "subject" as the search field, and it was limited by abstract, title and keywords. in this way, we covered all articles that included other terms, such as "2019 novel coronavirus", "2019 novel coronavirus diseases" or "2019-ncov". the period selected was from january 2020 to july 2020. furthermore, web of science makes it possible for users to add references to their library when conducting bibliographic searches directly in external databases or library' catalogs. with regards to the citation indexes, social sciences citation index, science citation index expanded and emerging sources citation index were used. on the other hand, given that the way in which authors and institutions cite works may vary, the citespace software was used to standardize the data. the date on which the publications were searched and downloaded was 28 july 2020. the publications were analyzed using the citation network explorer software, which allows the researcher to analyze and visualize citation networks of scientific publications. furthermore, it is possible to download citation networks directly from web of science and manage citation networks that include millions of publications and related citations. therefore, a citation network composed of several millions of publications can be the starting point from where a deeper analysis can be conducted to obtain a small subnetwork with 100 publications on the same subject. a quantitative analysis of the most mentioned publications in a period was carried out using the attribute citation score. therefore, not only the internal connections within the web of science database but also any external connections were quantified, meaning that other databases were considered [21] . citnetexplorer provides several techniques for the analysis of publication citation networks. the clustering functionality is achieved using the formula developed by van eck in 2012 (equation (1)) [21] . then, to assign a group to each publication, the clustering functionality was applied. as a result, the most related publications are usually found in the same group based on citation networks [21] . finally, the core publications were analyzed using the identifying core publications functionality, which consists of identifying the publications that are considered the core of a citation network; that is, they have a minimum number of connections with other core publications, so those that are irrelevant may be eliminated. the number of connections is established by the researchers, so the higher the value of this parameter, the lower the number of core publications [21] . in this study, the publications that have four or more citations in the citation network were considered. additionally, the drilling down functionality, which allows for a deeper analysis of each of the groups at different levels, was also used. the vosviewer software (centre for science and technology studies (cwts), leiden, the netherlands) was used to create and visualize bibliometric networks (journals, researchers, individual publications, bibliographic relationships, etc.) through graphs. the first articles on covid-19 were published at the beginning of 2020, so the period of time selected was from january 2020 to july 2020. a total of 14,409 publications and 42,377 citation networks were found in the search in wos. among all the publications, 39.90% were articles, 26.42% were editorial material, 18.73% were letters, 9.93% were reviews, 4.3% were news items and 0.8% were edits, book reviews, retractions or meeting abstracts. figure 1 shows the publications with greater weights and the group to which they belong. the color of an article represents its group, and the lines that connect the elements represent links. the number of publications on covid-19 has increased since april 2020 (january-march 2020: 2.21% of the publications; april-december 2020: 97.79% of the publications). june was the month with the largest number of publications, with 4212 publications and 1990 citation networks ( figure 2 ). table 1 shows the 20 most cited publications in this citation network. the most cited article is that of guan et al. [22] , published in april 2020, with a citation index of 1150. in this publication, 1099 patients were included from 19 december 2019 (when the disease first broke out) to 29 january 2020. the patients were from 552 hospitals in 30 different regions of mainland china, out of which 67 were excluded because they had been admitted to the icu (intensive care unit), were on invasive mechanical ventilation or had died. the most common symptoms were fever (43.8% when admitted to hospital and 88.7% during hospital stay), cough (67.8%) and diarrhea (3.8%). in addition, ground-glass opacity of the lung was the most common radiological finding in thorax computed tomography (ct) scans (56.4%), and 83.2% of patients presented lymphocytopenia upon admission. the average hospitalization time was 4 days. during the first two months of the outbreak, covid-19 spread quickly throughout china. the disease often presented with different degrees of severity, as patients frequently showed no signs of fever or unusual radiological findings. when analyzing the 20 most cited articles, 17 can be found on the symptoms, viral transmission and experimental treatment methods [22] [23] [24] [25] [27] [28] [29] [31] [32] [33] [34] [36] [37] [38] [39] [40] [41] . there are two that address unusual clinical symptoms and findings [26, 35] , and there is one that compares how covid-19 affects patients with cancer and those without cancer [30] . the research on covid-19 is multidisciplinary. the fields of internal medicine (16.37%) and public environmental occupational health (7.82%) are worth mentioning ( figure 3 ). medicine is the main area of publication in the field of health, as it is one of the oldest research fields [42] . similarly, public environmental occupational health has been studied for centuries. however, this research field has significantly increased in the past few years [43] . the quartile according to the scimago journal rank (sjr) is included in the table to show the importance and relevance of the main journals that have published the most articles, a dimension selected based on its quality and the fact that its use is widespread among the international scientific community. quartiles are based on the rank of each journal within its topic and are measured by assessing the distribution of the impact factor of a given journal for that topic category. scimago journal rank is a website of scientometric and informetric values, which allow researchers to monitor the behavior and impact of their contributions on an international scale; that is, it measures the scientific influence of the journals according to the number of citations. the citations are weighted depending on their field and prestige [44] . table 2 shows the 10 journals with the largest number of publications. after comparing our results with the first bibliometric publications on covid-19, we could observe that the journals with the largest number of publications were as follows: journal of medical virology, which has the most publications (n = 25), followed by chinese journal of tuberculosis and respiratory diseases (n = 9), journal of travel medicine (n = 8), journal of clinical medicine (n = 8), lancet (n = 7), radiology (n = 6) and jama (n = 5) [45] . as shown in table 3 , the authors with the largest number of publications on covid-19 were wang y (0.55%), mahase e (0.47%) and li y (0.43%). the united states (26.75%), china (14.55%) and italy (12.32%) were the countries with the highest publication rates (figure 4) . similarly, the study by fan et al. [46] analyzed the countries with the highest rates of publication and found that the authors with a large number of publications on covid-19 in english-language journals were as follows: li y had the highest number of published papers (7, 4.9%), followed by benvenuto d, eurosurveillance editorial team and leung gm (5, 3.5%) and angeletti s, gao gf, ran j, wei y, wu jt and yang g (4, 2.8%). as regards chinese journals, the authors with the largest numbers of publications were as follows: wang yg and yang fw published the highest number of papers (6, 0.8%), followed by wang yj (5, 6.9%). similarly, the study by belli et al. [47] analyzed the first 12 weeks after the outbreak and found that china represented 32.5% of the publications, followed by the us with 29.44%. the most frequently used keywords were "covid-19" (4089 publications), "coronavirus" (1618 publications) and "sars-cov-2" (1488 publications). figure 5 shows the 30 most used keywords from the most relevant publications. this is consistent with the study conducted by fan et al. [46] , in which the 10 most common keywords in english-language publications were "sars-cov-2", "covid-19", "china", "sars", "epidemic", "adult", "psychological", "nucleic acids", "plague" and "infection". moreover, the most common keywords used in chinese journals were "covid-19", "sars-cov-2", "prevention and control", "traditional chinese medicine", "computed tomography", "epidemic", "public health", "mers", "pneumonia" and "male". by using the clustering function, each publication in the citation network is assigned to a group, which means that publications that are close in the citation network must belong to the same group. consequently, each of these groups consists of publications that are strongly connected through their citations. in this way, it could be interpreted that every group represents a different topic in the scientific literature. in order to differentiate the groups, each of them has been assigned a specific color. additionally, the links between groups have been marked using colored lines. the clustering function identified 16 groups, 9 of which have a significant number of articles; however, the remaining groups only account for 1.10% ( figure 6 ). table 4 shows the information of the citation networks for the nine main groups, listed from the largest to the smallest according to their size. in group 1, 4121 publications and 15544 citations were found throughout the network. the most cited publication is that of guan et al. [22] , published in april 2020 in the new england journal of medicine, which is also at the top of the 20 most cited publications. in this group, the different articles analyze the viral transmission of sars-cov-2, the most frequent symptoms (fever, cough, diarrhea, etc.) and experimental treatment methods such as chloroquine phosphate (figure 7 ). for group 2, 2481 publications and 6424 citations were found throughout the network. the most cited publication is that of liang et al. [30] , published in march 2020 in lancet oncology. in this paper, the authors discuss how cancer patients are more vulnerable to covid-19 than people without cancer. this is due to their immunosuppressive status resulting from malignant neoplasm or cancer treatments such as chemotherapy. furthermore, these patients have a worse prognosis. therefore, three control strategies were established for cancer patients during the covid-19 crisis: • postpone surgery and chemotherapy treatment in patients diagnosed with cancer in a stable state. • improve staff protection. increase surveillance or provide more intensive treatment when cancer patients are infected with sars-cov-2, especially in elderly patients or those with comorbidities. by analyzing the articles belonging to group 2, it can be noticed that they address how covid-19 can affect patients with cancer and how they should be treated. additionally, they discuss the different methods of transmission, namely, through droplets, aerosols or contact with elements such as metal. consequently, an analysis of protection methods against covid-19 is offered, both for health professionals and other members of staff, with the final recommendation being to opt for telemedicine. additionally, the procedure for performing tracheotomies in the icu and in the operating room is also explained (figure 8 ). in group 3, 960 publications and 1990 citations were found throughout the network. the most cited publication is that of chen et al. [48] , published in april 2020 in lancet psychiatry. this article analyzed the physical and psychological pressures to which health professionals were exposed. to this end, a psychological response plan was developed, covering three main areas: • development of a medical/psychological intervention team, which provided online courses in order to guide medical staff to deal with common psychological issues. • a psychological hotline team, which provided guidance and supervision on solving psychological issues. psychological interventions, providing group activities aimed at relieving stress. moreover, health professionals presented diverse concerns, namely, infecting their relatives, poor knowledge of the disease, lack of protective equipment, inability to treat patients and poor rest. therefore, hospitals were forced to improve their resting areas, food supply and safety measures. they concluded in this study that preserving the mental health of employees is essential to improving the management of infectious diseases; however, it is still uncertain which approach would be the best. therefore, the articles belonging to group 3 address the psychological problems of health professionals, medical students and patients (anxiety, stress or depression). furthermore, they show methods of treatment aimed at reducing mental health issues, such as support supervisors or online mental health services (questionnaires, books, communication programs, psychological guidance or cognitive therapy) (figure 9 ). in group 4, 835 publications and 1220 citations were found throughout the network. the most cited publication is that of shi et al. [35] , published in april 2020 in lancet infectious diseases. the authors described findings from thorax computed tomography (ct) scans over the course of the disease. patients were grouped depending on the onset of the symptoms and the results of their first ct scan. as a result, the authors found that covid-19 pneumonia causes abnormalities that can be found in ct images of the thorax, even in asymptomatic patients, as well as the quick development of ground-glass focal opacities, which evolve from unilateral to bilateral diffuse lesions and advance or coexist with pulmonary consolidations over 1-3 weeks. therefore, they concluded that combining ct assessment and clinical and laboratory findings could help in providing an early diagnosis of covid-19 pneumonia. articles from this group focus on clinical findings in computerized tomography images from the lungs due to covid-19 pneumonia ( figure 10) . in group 5, 524 publications and 1454 citations were found throughout the network. the most cited publication is that of mao et al. [49] , published in april 2020 in jama neurology. in this article, the authors analyze neurological disturbances in patients infected with covid-19. they examined 214 hospitalized patients, and the neurological disturbances were categorized as follows: • central nervous system manifestations: dizziness, headache, altered states of consciousness, acute cerebrovascular disease, ataxia and seizures. • peripheral nervous system manifestations: taste, sight, smell and nervous alterations. manifestations of muscular-skeletal lesions. the study showed that 36.4% of the patients presented neurological alterations. they advised that, upon detecting any neurological disturbance, doctors should consider covid-19 as a differential diagnosis in order to avoid late or erroneous diagnosis. when analyzing the total number of articles in this group, it is clear that their main aim is to analyze neurological alterations related to covid-19 ( figure 11 ). in group 6, 519 publications and 1206 citations were found throughout the network. the most cited publication is that of emanuel et al. [50] , published in may 2020 in the new england journal of medicine. this article analyzes the lack of healthcare resources in us hospitals during the covid-19 crisis, namely, icu beds, respiratory ventilators, qualified healthcare personnel for critical care units, personal protective equipment and medication. in this sense, they presented recommendations to maximize the benefits (saving the largest number of lives or saving the largest number of years of life by giving priority to patients who will survive longer after treatment), to treat all patients in an equal manner, to encourage and reward instrumental value (the instrumental value could be fostered by giving priority to those who can save others, or rewarding those who have saved others in the past) and to give priority to the most disadvantaged (those who are sick or the youngest people). articles in this group analyzed how to take advantage of and distribute limited critical care resources during a pandemic. furthermore, in order to avoid further outbreaks, these authors determined that social distancing could be necessary until 2022 and that continuous surveillance of covid-19 should be conducted, given that a resurgence of contagion could be possible until 2024 (figure 12 ). in group 7, 369 publications and 933 citations were found throughout the network. the most cited publication is that of dong et al. [51] , published in march 2020 in jama: journal of the american medical association. this article analyzed whether sars-cov-2 could be transmitted in the uterus from the infected mother to her baby before birth. to this end, both the mother and baby underwent a thorax ct scan; furthermore, rt-pcr (reverse transcription-polymerase chain reaction) was conducted for sars-cov-2 nucleic acid through a nasopharyngeal swab, and igm (immunoglobulin m) and igg (immunoglobulin g) antibodies, cytokines and other biochemical markers in the blood were analyzed. additionally, vaginal secretions of the mother during labor were tested with rt-pcr. the results of the analysis showed that newborns born from a mother with covid-19 had high antibody levels and unusual cytosine test results two hours after birth. high igm antibody levels suggest that the newborn was infected in the uterus since these antibodies are not transferred to the fetus from the mother. although the possibility of infection at birth cannot be dismissed, igm antibodies do not usually appear until 3-7 days after the infection. conversely, igg antibodies may be transmitted to the fetus through the placenta and may appear at a later time than igm antibodies, so high igg levels could be a symptom of maternal or infant infection. the articles in this group address coronavirus infection in children and babies ( figure 13 ). in group 8, 149 publications and 167 citations were found throughout the network. the most cited publication is that of luo et al. [52] , published in february 2020 in the chinese journal of integrative medicine. this study consisted of an analysis of chinese medicine and its potential use for preventing covid-19. to this end, 23 provinces in china were treated with "chinese medicine" to strengthen qi and protect it from external pathogens by dispersing wind, dissipating heat and reducing humidity. they found that the chinese herbal formula could be an alternative treatment approach to prevent covid-19 in a population at high risk. nevertheless, further studies are necessary to confirm this theory. in this group, the articles analyze the use of traditional medicine to protect patients from covid-19. in addition, they also establish that environmental pollution can be a trigger for enhanced transmission of covid-19 ( figure 14) . in group 9, 140 publications and 199 citations were found throughout the network. the most cited publication is that of fang et al. [38] , published in april 2020 in lancet respiratory medicine. this article shows the importance of half-face masks for preventing the spread of respiratory infections. evidence shows that covid-19 can be transmitted even before the carrier shows any symptoms, and, thus, the transmission rate could be reduced if everyone, including those who are already infected but asymptomatic and yet contagious, wore masks. these articles emphasize that authorities should optimize the distribution of masks, prioritizing frontline health workers and the needs of the most vulnerable population, as the latter is more susceptible to infection and mortality, including older adults and people with other underlying medical conditions. this group analyzes the different methods for individual protection, such as half masks, safety spectacles, gloves, facial shields, respirators, air purifiers and robes ( figure 15 ). after analyzing the relationships among the nine main groups using the drilling down functionality, a connection between groups 1 and 5 ( figure 16 ) was found. furthermore, it was found that publications by the authors an p, baud d and chen cj appear in both groups. thirteen sub-clusters were found (figure 17) , five of which have a significant number of publications ( table 5 ). the rest of the groups are relatively small, with fewer than 650 publications and 1072 citation networks. sixteen sub-clusters were found (figure 18 ), only four of which have a significant number of publications ( table 6 ). the rest of the groups are relatively small, with fewer than 800 publications and 1857 citation networks. alterations in the digestive system as a result of covid-19 blood clotting alterations in covid-19 patients. clinical findings can help not only to identify the cause of death but also to provide new ideas on the pneumonia's pathogenesis related to sars-cov-2. this may help doctors to give an appropriate response or to provide a therapeutic strategy for critical patients and thus reduce the mortality rate. sars-cov-2 uses sars-cov's ace2 receptor for the input and the tmprss2 serine protease for the priming of protein s. treatment using cytokines and/or tocilizumab is likely to become one of the effective approaches for critically ill covid-19 patients. it has been shown that digestive symptoms are common in covid-19 patients. furthermore, these patients showed longer blood clotting time and increased hepatic enzyme levels. however, more sample studies are needed to confirm these findings. covid-19 patients show signs of venous thromboembolism. it has been proven that an anticoagulant therapy, mainly low molecular weight heparin, seems effective. however, more studies are necessary to establish the type of medication, the dose and the optimal duration of the prophylaxis. evaluate the incubation period of covid-19 and its effects on public health. evaluate the efficiency of the contention methods for reducing covid-19 outbreaks. the presence of sars-cov-2 on different surfaces is very similar to that of sars-cov-1. the epidemiological differences between these viruses may be due to the high viral loads in the respiratory tract and the possibility that sars-cov-2-infected people could transmit the virus while being asymptomatic. the mean period of incubation is of 5 days, and in most of the people, the symptoms appear within 11 days. however, these numbers vary between mild cases and severe cases. containment methods, such as social distancing or the use of masks, have proven to be effective in limiting virus transmission. therefore, the general public must be aware of the recommendations regarding covid-19 contention. public health authorities must keep tracking the situation to obtain new information about the virus and its outbreaks in order to estimate the risk of further outbreaks with greater precision. the main databases, such as web of science or scopus, make it possible to create citation networks. however, their usefulness is limited when conducting a systematic review of all of the existing literature on a subject, as they do not offer a general overview of the connections among the citations of a group of publications. for this reason, the citnetexplorer software was selected, as it allows the researcher to visualize, analyze and explore citation networks of scientific publications. hence, citnetexplorer offers a more detailed analysis through the creation of citation networks when compared to other databases, such as web of science or scopus [21] . the main goal of this study was to analyze the existing literature on covid-19. it should be taken into consideration that the search was carried out before the existence of an effective vaccine against sars-cov-2 in humans. in order to identify relevant publications, the web of science database was used, which is one of the most comprehensive databases, as its searching range goes back to the year 1900. nevertheless, it must be taken into consideration that web of science only accepts international journals once they have undergone a rigorous selection process. thus, once the existing bibliography had been downloaded from wos, the citnetexplorer software allowed us to collect and analyze every available piece of literature on covid-19 to date. furthermore, the connections between fields of study and the different research groups were obtained through the analysis of citation networks. the function called "clustering" was used to collect the results, and the publications were then grouped according to the relationships among the citations. the drilling down function was used to examine the existing bibliography for each group, and the core publication function was used to show the main publications, that is, to show the publications with a minimum number of citations. therefore, these functions make it possible to conduct a complete study and analysis of the research on the field of study. the first publication on covid-19 was published by bogoch et al. [56] on 14 january 2020 in the travel medicine journal. when this article was published, there was news about a pneumonia outbreak in wuhan, china. consequently, the authors analyzed the potential for the international dissemination of this disease through air travel. subsequently, numerous research pieces followed the same idea, including studies on epidemic processes, as well as measures and strategies for prevention and control. in doing so, they analyzed the source of infection, mode of transmission, the population's susceptibility and other influencing factors. when comparing these articles to previous studies on other viruses, such as sars-cov or mers cov, they found that the most frequent transmission routes, like respiratory droplets and direct contact, were the same as those for covid-19 [57, 58] . furthermore, it was found that, even though covid-19 does not seem as severe as sars-cov and mers-cov, the sudden increase in the number of cases and growing evidence of human transmission suggest that this virus is more infectious [59, 60] . the countries with the largest number of publications are china, the us and italy. at the beginning of the pandemic, as expected, most of the research works published in international journals were written by chinese researchers. however, this has been a cause of major concern among frontline health workers and politicians due to the language barrier. currently, publications mainly cover the symptomatology and focus on finding an effective vaccine against covid-19. this explains why research is being carried out in this field in countries with higher income and thus better infrastructures, which leads to an increasing number of publications. we suppose that countries with lower income focus on other research fields, such as transmission or epidemiology, although with fewer publications [61, 62] . similarly, the upward trend in numbers of publications in countries such as the us or the uk has been linked to a combination of factors, such as the fact that they are english-speaking countries or the possible connections between different research groups within the scientific community [63, 64] . other bibliometric studies on covid-19 and sars-cov-2, such as those conducted by lou et al. [65] and tran et al. [66] , have found a significant increase in the number of publications over the last few months. comparing our bibliographical research to theirs, we found that june was the month in which the number of publications was significantly larger when compared to other months. as more publications become available in the upcoming months, we foresee that these numbers will grow significantly. the reason for this might be that our research scope was wider and comprised more types of documents and a longer period. furthermore, of the studies in june, the research by mcgonagle et al. [67] should be highlighted, as they found that patients with severe pneumonia related to covid-19 might show signs of systemic hyperinflammation (macrophage activation syndrome) or cytokine storm (secondary hemophagocytic lymphohistiocytosis). in this sense, the clinical features of covid-19 are diverse, from the asymptomatic state to acute respiratory distress syndrome and multiple organ dysfunction. the study conducted by chen et al. [68] showed that the progression of the disease was linked to increased inflammatory cytokines, namely, il2, il7, il10, gcsf, ip10, mcp1, mip1a and tnfα. additionally, the study conducted by casey et al. [69] found that, in some patients, covid-19 was related to a hypercoagulable state and to an increased risk of venous thromboembolism. in addition, they found that, unlike patients with pulmonary embolism, positive covid-19 cases rarely showed hemoptysis. on the other hand, the study conducted by yang et al. [70] suggested that the gastrointestinal tract and the liver could also be infected by the sars-cov-2. this is due to the gastrointestinal epithelial cells and hepatic cells expressing ace2 enzymes (main receptor of sars-cov-2). these findings prove that, even when sars-cov-2 has been eliminated from the respiratory tract in some patients, the virus continues replicating through the gastrointestinal tract and could be excreted in the feces. the study by xu et al. [71] analyzed the characteristics of 10 pediatric patients with covid-19 and found that 80% of them recurrently tested positive in rectal swabs, even after the nasopharyngeal tests had come back negative. in turn, the study by ellul et al. [72] showed a broad range of neurological manifestations in covid-19 patients. sixteen out of the 214 patients in chinese hospitals and 40 out of the 58 patients in french hospitals showed signs of encephalopathy. moreover, guillain-barré syndrome was found in 19 of the patients. on the other hand, anosmia and ageusia were frequent and could occur in the absence of other clinical features, while 2-6% of hospitalized patients showed apoplexy. regarding the treatment, various antiviral medications have been tested, such as ribavirin and lopinavir/ritonavir, which are commonly used in the treatment and prevention of aids. thus, the study showed that a patient treated with lopinavir/ritonavir together with ribavirin had better results when compared to those to whom only ribavirin was administered [68] . chloroquine has also been used as a form of treatment and has shown antiviral effects on the cells of primates infected by sars-cov. similarly, in the research by vincent et al. [73] , a favorable inhibition of the virus spread was observed when the cells were treated with chloroquine before or after sars-cov infection. it should be noted that the use of remdesivir was authorized on 3 july as the first conditionally marketable treatment. this facilitates early access to medication in emergency public health situations. this antiviral is a treatment against covid-19 for adults and teenagers aged 12 or over who suffer from pneumonia and who require supplementary oxygen [74] . on the other hand, there are currently 110 possible vaccines from different laboratories, of which 102 are in a preclinical phase and 8 are in the clinical phase [3] . research conducted by gao et al. [75] was published recently, and it reports a pilot-scale production of picovacc, a possible vaccine that would inactivate the sars-cov-2 virus. this vaccine has created antibodies in mice, rats and non-human primates. they also neutralized 10 strains representative of sars-cov-2, which might suggest a greater possible neutralizing capacity against other strains. this leads us to believe that there is a strong probability of developing an effective vaccine for humans shortly. additionally, upon development/availability and approval of a vaccine or a new effective treatment against sars-cov-2, we believe it necessary to carry out a new search and citation analysis. the future of covid-19 is still uncertain. this is due to the lack of knowledge of the clinical progression of this illness. in particular, many patients experience a recurrence of symptoms after periods of showing no signs, or they show symptoms such as febricula, asthenia or headaches for a longer period. moreover, some patients test positive again in the pcr test after testing negative. this might be due to the sensitivity of this test, especially when the viral charge is lower and/or when the viral rna is on the threshold of the detection rate of the test [76] . on the other hand, whether covid-19 can also have after-effects is still to be determined. the research by zhang et al. [77] found that 4.6% of survivors showed signs of pulmonary fibrosis. we recognize that there is still further research to be conducted in order to confirm whether covid-19 can have after-effects or whether it varies depending on the severity of the condition. consequently, the number of studies on covid-19 is constantly on the increase since more research is needed in order to fight this illness. citation network studies are becoming more numerous, as this is the only analysis method that provides a global overview of the different research fields within a specific topic. furthermore, citnetexplorer software facilitates the analysis of all existing research on a specific topic through detailed studies. this could change how studies in different research areas are conducted. in conclusion, this research offers a specific and objective analysis of the main articles on covid-19 and sars-cov-2. in addition, it was possible to visualize, analyze and explore the most cited articles and citation networks existing to date using the web of science database and the citation network explorer database. by doing so, we have obtained information regarding the epidemiology, clinical features, diagnosis and treatment of covid-19. the importance of neurological and gastrointestinal alterations in a high percentage of positive cases of covid-19 is also worth mentioning. in addition to the great progress made towards effective treatment, the research conducted by gao et al. must be highlighted, as it shows the first results regarding the creation of the first vaccine for humans. therefore, covid-19 disease is a relevant field for researchers, with the number of publications continuously on the increase. consequently, the clinical progression of the disease will be understood in the upcoming months, and a new vaccine and an effective treatment will be discovered soon. in this way, this paper contributes to a better understanding of the information structure by identifying, in 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infection and potential evidence for persistent fecal viral shedding neurological associations of covid-19 chloroquine is a potent inhibitor of sars coronavirus infection and spread european commission secures eu access to remdesivir for treatment of covid-19 rapid development of an inactivated vaccine candidate for sars-cov-2 epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore long-term bone and lung consequences associated with hospital-acquired severe acute respiratory syndrome: a 15-year follow-up from a prospective cohort study key: cord-332977-884z6qrq authors: ehrlich, rodney; spiegel, jerry m.; adu, prince; yassi, annalee title: current guidelines for protecting health workers from occupational tuberculosis are necessary, but not sufficient: towards a comprehensive occupational health approach date: 2020-06-03 journal: int j environ res public health doi: 10.3390/ijerph17113957 sha: doc_id: 332977 cord_uid: 884z6qrq health workers globally are at elevated occupational risk of tuberculosis infection and disease. while a raft of guidelines have been published over the past 25 years on infection prevention and control (ipc) in healthcare, studies in different settings continue to show inadequate implementation and persistence of risk. the aim of this commentary is to argue, based on the literature and our own research, that a comprehensive occupational health approach is an essential complement to ipc guidelines. such an approach includes a health system framework focusing on upstream or mediating components, such as a statutory regulation, leadership, an information system, and staff trained in protective disciplines. within the classical prevention framework, primary prevention needs to be complemented by occupational health services (secondary prevention) and worker’s compensation (tertiary prevention). a worker-centric approach recognises the ethical implications of screening health workers, as well as the stigma perceived by those diagnosed with tuberculosis. it also provides for the voiced experience of health workers and their participation in decision-making. we argue that such a comprehensive approach will contribute to both the prevention of occupational tuberculosis and to the ability of a health system to withstand other crises of infectious hazards to its workforce. high rates of tuberculosis (tb) in the populations of low-and middle-income countries (lmics) are associated with high rates of latent tb infection (ltbi) and tb disease in health workers [1] [2] [3] . the most recent systematic review reports a pooled incidence rate ratio for active tb disease among health workers of 2.94, and a pooled odds ratio for ltbi of 2.27, relative to control populations [3] . in high-hiv-burden countries, hiv infection among health workers [4] sharply increases their risk of tb, while the rise in drug-resistant tb has further intensified the threat associated with the disease [5, 6] . there is no shortage of prevention guidelines directed at healthcare settings where a tb hazard to staff and patients exists. international popularisation of the tb infection prevention and control (ipc) triad of administrative, environmental, and respiratory protection controls can be dated to the publication of guidelines in 1994 by the u.s. centers for disease control and prevention (cdc) [7] . the guidelines, updated in 2005, constituted a response to a resurgence of tb in the united states and nosocomial transmission in u.s. hospitals in the wake of the hiv epidemic [8] [9] [10] . in parallel, the world health organization (who) has published a series of guidelines for low-resource settings [11] [12] [13] , as well as several supporting documents on the implementation of ipc [14, 15] and provision of healthcare and related services for affected health workers [16] . ipc in healthcare settings has featured in other international responses. after considerable advocacy effort, including a statement by the international commission for occupational health (icoh) [17] , the united nations (un) general assembly political declaration of 2018 recognised healthcare workers as an occupational group at risk from tb, and called for ipc and tb screening and surveillance for this population [18] . while the core ipc guidelines were based on public health "first principles", systematic reviews have concluded that evidence of the effectiveness of various protective measures is limited and/or of "low quality" [2, 13, 19] . the inability to provide data conforming to that produced, for example, in drug trials, arises from the practical and ethical difficulty of undertaking randomised controlled trials for prevention in this context. however, as argued in this commentary, successful preventive practices require an enabling system. an omnibus approach to the ipc package has emerged, reflecting the complex nature of such interventions [2, 13, 19] . usefully, recent guidelines, have employed the grading of recommendations, assessment, development and evaluation (grade) rating framework for public health and clinical recommendations which includes other sources of information and judgements-specifically, a balance of benefits and disadvantages, values and preferences, and resource requirements [13, 20] . this enables "low quality" evidence on effect size to contribute to a "moderate" or "strong" recommendation if the other criteria are favourable. this approach thus incorporates contextual factors and uses an optimisation approach to applying evidence. however, the need for an approach that goes beyond ipc guidelines is suggested by the growing number of studies across the world that consistently reveal poor or inadequate implementation of tb ipc [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] . barriers to ipc implementation vary with the study design and questions asked, but cover the whole gamut: lack of a national regulatory framework and associated budget; lack of management support; unfamiliarity of staff with ipc guidelines; failure to triage or screen patients; insufficient infrastructure and equipment, such as isolation spaces and personal protective equipment (ppe); deficient ventilation; inadequate staffing and training; poor functioning of infection control committees; and neglect of exposed non-clinical staff. qualitative studies, which have a greater capacity to probe health workers' experience, reveal a perception among health workers of a disproportionate focus on individual-level personal protections, particularly n95 respirators [24] ; an experience of powerlessness [29] ; habituation to tb risk or a sense of fatalism [26] ; and difficulty in understanding patients and securing patient cooperation with ipc [21, 28, 31] . the objectives of this piece are to argue for a comprehensive occupational health approach to the problem of tb in health workers, and to reflect on what such an approach adds to the prospects for improved prevention and practice. we draw on research carried out by our group as occupational health professionals and researchers in recent years [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] , plus the experience of two of the authors (r.e. and a.y.) as clinicians and policy advisors to healthcare facilities, as well as provincial and national public sector health departments in south africa and canada, respectively. we argue that a comprehensive approach should conceive of the problem of protecting health workers within the widest possible framework, including legal and ethical considerations, should be multilevel and cross-disciplinary, and should be informed by the experiences of health workers themselves. a schema for making this argument is given in table 1 . each domain is dealt with in the sections that follow. table 1 . components of a comprehensive occupational health approach to the protection of health workers from occupational tuberculosis (tb). primary (control of tb transmission in healthcare settings), secondary (tb screening, early diagnosis of health workers, and effective treatment), and tertiary (rehabilitation, jobs, and social security). health systems framework assessing and strengthening the capacity of the health system to deliver quality healthcare to the whole population, including its own workforce, across all medical conditions, and to respond to crises. 3 law and ethics understanding and use of statutory legal instruments, as well as the management of ethical implications of practices to protect health workers from tb. health worker voice and advocacy extent to which opportunities are provided for the views and experiences of health workers to be raised to influence the organisation of healthcare. figure 1 applies the framework of primary, secondary, and tertiary prevention to consider opportunities for protecting health workers from occupational tb. it directs attention to the number of ways in which health workers can be at risk and protected from tb, and is an antidote to exclusive focus on any one level. a strong health system is both an enabler and a consequence of prevention activities, as discussed further in the next section. table 1 . components of a comprehensive occupational health approach to the protection of health workers from occupational tuberculosis (tb). primary (control of tb transmission in healthcare settings), secondary (tb screening, early diagnosis of health workers, and effective treatment), and tertiary (rehabilitation, jobs, and social security). assessing and strengthening the capacity of the health system to deliver quality healthcare to the whole population, including its own workforce, across all medical conditions, and to respond to crises. understanding and use of statutory legal instruments, as well as the management of ethical implications of practices to protect health workers from tb. extent to which opportunities are provided for the views and experiences of health workers to be raised to influence the organisation of healthcare. figure 1 applies the framework of primary, secondary, and tertiary prevention to consider opportunities for protecting health workers from occupational tb. it directs attention to the number of ways in which health workers can be at risk and protected from tb, and is an antidote to exclusive focus on any one level. a strong health system is both an enabler and a consequence of prevention activities, as discussed further in the next section. primary prevention in the form of ipc receives the lion's share of attention in guidelines, and remains the foundation for protection. however, secondary prevention contributes to primary prevention by aiming to keep health workers unimpaired and non-infectious in their daily work. this includes occupational health services to provide screening for active tb and the management of affected health workers [16] . an occupational health platform would also be needed for any programme to screen for and treat ltbi. ltbi screening has long been recommended in low-tbincidence countries, such as the united states [7, 10] , and appears in the latest who guideline as a (conditional) recommendation for low-tb-incidence countries only [43] . consensus on what is required and feasible in high-tb-incidence, lmic settings is elusive. while there are many studies of primary prevention in the form of ipc receives the lion's share of attention in guidelines, and remains the foundation for protection. however, secondary prevention contributes to primary prevention by aiming to keep health workers unimpaired and non-infectious in their daily work. this includes occupational health services to provide screening for active tb and the management of affected health workers [16] . an occupational health platform would also be needed for any programme to screen for and treat ltbi. ltbi screening has long been recommended in low-tb-incidence countries, such as the united states [7, 10] , and appears in the latest who guideline as a (conditional) recommendation for low-tb-incidence countries only [43] . consensus on what is required and feasible in high-tb-incidence, lmic settings is elusive. while there are many studies of ltbi prevalence in these settings, programme implementation research in this area is scarce and is a pressing need. tertiary prevention, by ensuring that health workers with an occupational disease have access to medical care and special sick leave, and to rehabilitation or to supported retirement, should be regarded as a basic labour right and is discussed further in section 5. although not explicitly presented in figure 1 , hiv-infected health workers need to be considered within this framework as a particularly vulnerable sub-population needing protection. in south africa, estimates of the proportion of health workers infected with hiv are of the order of 16% [4] . hiv infection dramatically increases the risk of progression from tb infection to disease [44] . a programme of voluntary hiv testing, followed by treatment and counselling on job placement, should thus be regarded as part of primary prevention of tb in affected settings. vaccination of health workers against tb also falls into the category of primary prevention. bacille calmette-guerin (bcg) vaccination or revaccination of health workers is not currently a recommendation by either the cdc [10] or who, and variation in health worker bcg vaccination practice across europe reflects the lack of consensus as to its efficacy [45] . however, vaccination should remain on the agenda of a comprehensive occupational health approach-for example, revaccination of ltbi-negative health workers or testing and rollout among health workers of one of the new vaccines on the horizon [46, 47] . using a health system framework involves a shift in perspective towards one that is cross-cutting and systemic, political as well as technical. it draws attention to the governance and organisation of healthcare that enable disease control and clinical programmes and practices, and which are geared to achieving greater equitability and sustainability in health outcomes. health system assessment and strengthening are conceptualized by who as focused on the performance of six inter-related building blocks: governance and leadership, information, health financing, health workforce, services, and technology [48] . this is a two-way interaction. adequate performance in respect of all the building blocks is required if ipc and workplace tb prevention programmes are to work, as discussed further below. conversely, investment in protecting health workers from occupational infectious disease has the potential to yield system-wide benefits. these include tb surveillance as an indicator of respiratory disease risk in healthcare settings; "cross-silo" cooperation in the healthcare system; reduced absenteeism and improved staff retention and morale; and greater patient safety, quality of care, and trust in the health system [32] [33] [34] 49, 50] . at their most upstream, structural health system barriers encompass international and national political economy. an example particularly relevant to africa is the imposition on governments of structural adjustment programmes by international lenders that require reducing the size of the public sector, thereby decreasing healthcare expenditures-including on the control of tb [51] . zelnick [52] studied the struggles among south african nurses to provide care and protect themselves against bloodborne exposure in the early days of the hiv/aids epidemic. among the causes of this situation, the author identifies the failure of the new south african government, under the pressure of neoliberal macroeconomic policies, to devote sufficient resources to district health facilities, resulting in staff shortages and a hazardous work environment over which nurses felt they had no control. more recently, lispel and fonn have illuminated the relatively unexplored subject of corruption in the health sector, particularly the diversion of health funding through rigged tendering and supply activities, combined with the enabling factor of poor governance [53] . a little more downstream, we recently used the who health systems framework from an occupational health perspective to explore the perceptions of key informants within the south african health system of barriers to protection of health workers from tb [38] . such barriers include, inter alia, lack of an information system to produce the necessary intelligence on health and safety; fragmentation of governance across different organisational units within jurisdictions and health facilities; difficulty in maintaining technological components, such as germicidal ultraviolet light air disinfection; and lack of occupational health services trusted by staff. remedying the deficits outlined above involves costs in the form of organisational management, staffing, clinical practice, ancillary services, and procurement. cost within fixed administrative budgets is, however, a major cross-cutting barrier [38, 40] . this creates hesitancy among senior health service managers to commit significant resources to occupational health and safety amidst competing priorities, even if the actions are legally mandated, and especially if they believe tb in their staff is not an occupational disease [38, 40] . this suggests that a useful starting point for collaboration between occupational health and ipc is an information system able to track and investigate active tb in health workers for the purposes of risk assessment and targeted ipc. an example is the occupational health and safety information system (ohasis), developed through a collaboration of occupational health and ipc professionals at the university of british columbia with the national institute for occupational health in south africa, and applied in the national health laboratory service of south africa [54, 55] . those applying generic guidelines need to consider the legal and related institutional environment of their jurisdictions, and whether this environment is sufficiently enabling. in many and perhaps most countries, occupational health and safety is governed by statutory regulation, which provides a framework of requirements and standards, as well as an enforcement mechanism to prevent occupational injuries and disease [56] . a review across botswana, zambia, and south africa of laws relevant to reduction of tb transmission adopted a systems view by focusing on regulations governing national legal and policy frameworks; facility design, construction, and use; patients' and health workers' rights; and research, as well as the monitoring of infection control measures and tb surveillance among health workers. the authors concluded that the laws and regulations provided a "strong foundation" for these activities [57] . however, in high-tb-burden countries, particularly in public sector facilities, the competing demands on the healthcare budget may be used as an alibi for the failure to provide sufficient resources to protect staff from tb [38, 40] . there may also be resistance to the application of an "industrial" model of regulation, inspection, and enforcement to the healthcare sector. the notion of voluntary acceptance of risk, an old common law defence by employers against liability for occupational injury or disease, and one that has long formed part of the vocational ethos of healthcare, contributes to this resistance [9, 36] . legislation by itself is thus no guarantee of adequate preventive practice in healthcare-as indicated, for example, by the number of studies on poor implementation of tb ipc in south africa [23, 24, 28, 29, 31] . worker's compensation or broader social security are components of tertiary prevention of occupational tb. as with preventive legislation, practice varies. in south africa, tb suffered by a health worker who has had contact with tb patients is presumed to be occupational. in contrast, in mozambique, tb is not recognised by statute as an occupational disease, an omission identified by local health workers as a major barrier to comprehensive management of occupational tb [40] . worker's compensation does not cover students unless they are regarded as employee trainees. students, however, are also at risk of workplace tb [58] . high annual tb infection rates (i.e., new infections) of 23/100 person years have been recorded in medical students in johannesburg using the tuberculin skin test (tst) [59] , and 19.3/100 person years in nursing students in zimbabwe [60] . community health workers are another category of health worker who may be vulnerable to weak benefits or protections in their employer-employee relationship and thus lack proper social protection [36, 61] . outside of statutory protection, there are ethical considerations applicable to secondary prevention and occupational health generally. two areas of impact are stigma and screening. there is now a large body of literature confirming that stigma looms large in health worker attitudes to tb preventive practices, including unwillingness to self-disclose tb disease or participate in employer provided services where confidentiality is of concern [23, [37] [38] [39] [62] [63] [64] [65] [66] . the reduction of stigma requires an understanding of its context-specific nature and cultural content, e.g., in south africa, where tuberculosis has a strong association with hiv infection [62] . however, the need for protection of the privacy of affected workers is in tension with the social need for self-disclosure to serve accurate risk assessment and to protect and educate co-workers. a contrasting strategy used in south africa by a network of health workers affected by tb has been to publicise their status and share their personal experiences as an educational and a mobilising strategy [50, 66] . screening programmes, particularly in low-resource settings, need to pay attention to the ethical implications of medically examining workers who have not presented themselves to healthcare professionals. such considerations have long been part of medical surveillance in occupational health practice, and a body of ethical and legally sensitive guidelines have been developed [67] . these address issues of informed consent and refusal of consent, the reliability of the test, confidentiality, and third-party reporting of results to employers, all of which require an agreed protocol in advance of screening. historically in some countries, labour unions have played an important role in securing recognition of the tb risk to health workers and related action [68] . this has included efforts to include a labour perspective in early cdc deliberations on preventive guidelines [69] . however, it is difficult to make a general statement about the current state of labour union involvement globally in the protection of health workers against tb. in south africa, advocacy by health workers themselves has emerged as a prominent voice for health worker rights in the form of tb proof, a voluntary group that includes a number of members who have suffered from tb [66] . their work is augmented by a network of concerned health workers internationally [63, 64] . tb proof activities have a several elements that we believe should be emulated elsewhere. these include engagement with national policy-making on tb; maintaining a website with educative and activist materials; a strong focus on destigmatising tb; the targeting of students and junior healthcare staff to protect themselves, but also to assert their right to be protected; and the effective use of personal narratives and media [66] . the voice of health workers has found a place in the large number of publications using qualitative research-typically key informant but also arts-based methods-and covering all aspects of occupational tb risk and management [21, 23, 25, 26, 28, 35, [37] [38] [39] 61] . some of this work throws light on unrecognised deficiencies in health care practice, such as the exposure of community health workers to infective risk [61] or the failure of patients to accept or understand ipc owing to cultural or language barriers [28] . guidelines aimed at standardising operational practice to prevent occupational tb are essential. however, implementation takes place in a local setting, characterised by its own legal framework and employee rights regimen, resourcing, co-morbidity (such as hiv), and cultural attitudes. as greenhalgh and papoutsi have argued, the complexity lies in the interaction between an intervention and the pre-existing organisation of health care, and not necessarily in the intervention on its own [70] . for example, barriers to implementation can be lowered by intensified training of health workers [71, 72] , but the argument here is that such training is insufficient for sustainability if the necessary systemic scaffolding is not in place. the experience of two of the authors (a.y. and j.s.) in an occupational health/ipc programme, developed over almost 10 years in one of south africa's poorer provinces, illustrates the value of customized interventions, including new policies and staffing, at the individual, facility, and provincial and national government levels [34, 42] . a common approach to improving implementation is auditing, using operational checklists as a basis for expected quality improvement [41, 73] . however, what we propose here is that the concept of a checklist be expanded to include the widest perspective possible. it should cover questions such as whether the system includes primary, secondary, and tertiary levels of protection, as well as embracing a health system framework such as the ones we have described here; whether there is explicit commitment of senior leadership to health system strengthening via ipc and occupational health and safety; whether the legal and ethical implications in relation to screening, coverage, and other thorny aspects referred to earlier are being dealt with; and whether channels for worker voice and agency exist and are used. while not easy to achieve, particularly in high-tb-burden, low-resource settings, policies and practices that incorporate this approach are more likely to provide for long-term sustainable protection of the essential human resources needed to fight tb and indeed other infectious hazards at work. this commentary was prepared before the covid-19 crisis. while there are many differences between tuberculosis and covid, the approach outlined provided a guide in the early phases of the local covid epidemic in south africa. over and above the urgent pressures of ipc, a systems approach has enabled recognition of the need for collaboration across disciplines and organisational units, occupational health coverage of all levels of the health system, a rapid-response 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co-epidemic alters tb stigma and its management among healthcare workers #unmaskstigma initiative 2017. tb proof, cape town. available online international code of ethics for occupational health professionals germs at work: establishing tuberculosis as an occupational disease in britain, c.1900-1951 tuberculosis in the workplace: a labour perspective studying complexity in health services research: desperately seeking an overdue paradigm shift preventing tuberculosis among health workers in malawi evaluation of a tb infection control implementation initiative in out-patient hiv clinics in zambia and botswana periodic checklist for periodic evaluation of tb infection control in health-care facilities this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-340128-qxkopvot authors: schreibauer, elena christina; hippler, melina; burgess, stephanie; rieger, monika a.; rind, esther title: work-related psychosocial stress in small and medium-sized enterprises: an integrative review date: 2020-10-13 journal: int j environ res public health doi: 10.3390/ijerph17207446 sha: doc_id: 340128 cord_uid: qxkopvot background: work-related psychosocial stress can cause mental and physical illnesses resulting in high costs for the individual, the economy and society. small and medium-sized enterprises (smes) employ the majority of the world’s workforce and often have fewer financial and human resources compared to larger businesses. the aim of this review is to summarize current knowledge on work-related stress in smes according to well-established guidelines categorizing psychosocial factors at work. methods: a systematic database search was carried out in pubmed, psycinfo, psyndex and business source premiere from march to june 2019, updated in january 2020. data of included studies were analyzed and mapped into five themes: “work content and task”, “organization of work”, “social relations”, “working environment” and “new forms of work”. results: after full-text screening, 45 out of 116 studies were included for data extraction. studies were very heterogeneous and of varying quality, mostly applying a cross-sectional study design. psychosocial factors in smes have been researched with a focus on the work patterns “work organization” and “work content and task”. conclusions: this review underlines the need for more and better quality research of psychosocial factors in smes, particularly in relation to ongoing and new challenges in the workplace, including stressors related to the process of digitalization or the development of safe working conditions during the emerge of new infectious diseases. according to the international labour organization (ilo), 2.8 million workers die from work-related diseases each year and there are about 374 million non-fatal work-related injuries annually [1] . this results in human and economic costs of about 4% of the annual global gross domestic product [1] . additionally, work-related psychosocial risks, comprising issues such as work-related stress, have been identified as significant risks in the field of occupational health and safety over the last two decades [2, 3] . however, as of yet only a few countries have drafted specific regulations on psychosocial risks (e.g., the 2014 belgian royal decree on the prevention of psychosocial risks at work or the colombian resolution 2646 on risk assessment and management of psychosocial hazards from 2008) or have implemented existing policies in their national occupational safety and health legislation [4, 5] . furthermore, there is little evidence whether and how these recommendations and policies can be implemented in a working environment with limited human and financial in order to support enterprises with the development of instruments and interventions to reduce psychosocial risks, knowledge on relevant work-related psychosocial factors is essential. between 2014-2017, the german federal institute for occupational safety and health (baua) conducted several literature reviews to describe the scientific evidence regarding mental health in the working world [35] . based on well-established theoretical models including the job-demand-control-model [36] , the effort-reward-imbalance-model (eri) [37] or the organizational justice (oj) model [38] , a framework was developed to categorize the results into four subject areas: "working task", "leadership and organization", "working time" and "technical factors". the reviews did, however, not specifically focus on the situation of employers and employees working in smes. furthermore, the joint german occupational safety and health strategy (gda) published recommendations for implementing psychosocial risk assessments listing five work patterns (i.e., work characteristics) that have been identified as primary stress factors in the workplace [39] : • work content and task (e.g., job autonomy, completeness of tasks, emotional demands); • organization of work (e.g., working time and processes); • social relations (e.g., aspects of hierarchy, leadership and managerial abilities); • working environment (e.g., physical factors, working equipment); • new forms of work (e.g., spatial and temporal mobility). to organize the results of this review, we used this classification because it comprises all of the psychosocial factors published by the baua [35] and integrates factors published by other well-established international frameworks (eu-osha (the european agency for safety and health at work) [12] , who (world health organization) [40] and ilo [5] ). furthermore, the gda-classification includes a systematic table and detailed examples of work-related psychosocial demands which provided a useful framework for a clear assignment of the studies identified in this review. to the best of our knowledge, this review is the first to summarize and categorize the current evidence on work-related psychosocial demands with a specific focus on small and medium sized enterprises to identify gaps in current knowledge and provide a systematic overview of which psychosocial factors, outcomes and economic sectors have been considered to date. the subsequent research questions guided our review: (1) what is the current state of knowledge on psychosocial demands in smes? (2) which outcomes and economic sectors have been examined? we conducted an integrative review according to the five-stage method described by whittemore et al. [41] . to select relevant studies, we used the peo criteria (population, exposure, outcome) which are applied frequently in evidence-based health research [42, 43] . for our study, we defined the criteria as follows: p = workforce in smes (with smes defined according to the eu definition: number of employees < 250 [44] ) and e = psychosocial demands as defined by the gda [39] . we did not predefine any outcomes for the literature search because we did not want to limit our review to certain health or health-related outcomes. the literature search was carried out between march and june 2019 and updated in january 2020 with individually adapted search strings in medical (pubmed), psychological (psycinfo, psyndex) and economic (business source premiere) databases. additionally, we performed a hand search of the reference lists of the studies included. the search terms followed this general scheme: terms related to "workforce in smes" and terms related to "psychosocial demands". we also considered relevant medical subject headings (mesh)-terms and search terms previously published [45] . terms including "family business(es)" were excluded because this resulted in a considerable number of articles not relevant in our context. for example, many articles dealt with the financing of micro-enterprises or the family income situation in developing countries. the complete search strategy for pubmed and the applied search string is presented in supplementary table s1 . we included all types of peer-reviewed quantitative and qualitative studies as well as literature reviews relevant to the sme setting considering at least one of the psychosocial demands listed by the gda [39] . articles that did not report employment figures, but whose surveyed enterprises were designated as smes, were included if their sme definition complied with the european definition [44] . if multiple publications were based on the same dataset, all papers meeting the inclusion criteria were selected. we limited our search to articles published in german or english from january 2000 onwards, the beginning of the fourth industrial revolution promoting digital processes in the working environment [46, 47] introducing new stressors to the workforce such as digitized performance monitoring or information overload [47, 48] . furthermore, we excluded study protocols as well as publications which tested and/or validated questionnaires on psychological demands or work-related stress. we also excluded reviews because we considered the original research and did not consider any kind of "grey literature". after the removal of duplicates, all studies were transferred to rayyan [49] , a free web application for systematic review screening. two raters (e.c.s. and s.b.) screened titles and abstracts independently, according to the predefined inclusion and exclusion criteria. articles that could not be judged by title and abstract were included in the full text screening, also independently executed by two raters (e.c.s. and m.h.). lack of agreement was solved in consensus discussions with a third reviewer (e.r.). a tabular scheme for data extraction (author, year, country, year of data collection, topic, study design, data collection methods, type of enterprise, sample size, industrial classification of the business, investigated psychosocial demands, outcomes, and data collection instruments) was compiled and used for data extraction. we used the agency for healthcare research and quality ahrq study design algorithms [50] to classify the study design if it was not reported. the allocation of the studies to economic sectors was carried out according to the international standard industrial classification of all economic activities (isic) [51] . we amended the classification of the baua-project [35] to categorize the outcome variables of the studies into these subcategories: general (work-related) stress outcomes, health, well-being, factors affecting cardiovascular health, mental health, musculoskeletal system, social relations, and business-related outcomes. different tools were used for critical appraisal: the special unit for review evidence (sure) checklist for cross-sectional studies [52] the sure-checklist of randomized controlled trials and other experimental studies [53] , the sure-checklist for qualitative studies [54] , and the joanna briggs insitute (jbi)-critical appraisal tool [55] for text and opinion articles to assess the quality of narrative reviews. we identified 3658 studies through electronic data base searching (see prisma-flowchart [56] figure 1 ). after the removal of duplicates, 3460 studies remained for title and abstract screening, including eleven articles detected by hand search. for the full-text-screening, 116 articles were eligible, of which 45 were included in the full text analysis (figure 1 ). the first article suitable for this review was published in 2004. since then, the annual number of publications was relatively low (<5/year) with a peak in 2018, when nine articles were published. due to our main database search in the first half of 2019 (hand search update march 2020), it can be assumed that studies published in 2019 were not completely indexed at that time. the first half of 2019 (hand search update march 2020), it can be assumed that studies published in 2019 were not completely indexed at that time. the samples of the studies were very heterogeneous. the number of participants varied between seven and 23,000. five studies included only sme-managers and enterprise owners [57] [58] [59] [60] [61] . some studies used data from nationwide surveys that provided a large sample size and included a range of economic sectors and branches [29, 30, [62] [63] [64] [65] [66] [67] . other studies included only participants of a single enterprise [68] [69] [70] [71] . a complete summary of the study characteristics can be found in supplementary table s2 . most of the studies included were carried out in europe (n = 24) and in asian countries (n = 13). other studies were conducted in australia [57, 72] , the united states [73] and new zealand [74] . four studies from japan [62, [64] [65] [66] seemed to use data from the same survey but examined different outcomes. no studies from africa or south america met our inclusion criteria, and four studies were transnational [61, [75] [76] [77] . the majority of studies were cross-sectional (n = 37), analyzing a variety of psychosocial factors in the sme-setting, mainly using data from nationwide surveys or specifically designed questionnaires for particular companies or settings. we also identified qualitative studies (n = 2), narrative reviews (n = 3), and intervention studies (n = 3). one qualitative study [69] looked at the samples of the studies were very heterogeneous. the number of participants varied between seven and 23,000. five studies included only sme-managers and enterprise owners [57] [58] [59] [60] [61] . some studies used data from nationwide surveys that provided a large sample size and included a range of economic sectors and branches [29, 30, [62] [63] [64] [65] [66] [67] . other studies included only participants of a single enterprise [68] [69] [70] [71] . a complete summary of the study characteristics can be found in supplementary table s2 . most of the studies included were carried out in europe (n = 24) and in asian countries (n = 13). other studies were conducted in australia [57, 72] , the united states [73] and new zealand [74] . four studies from japan [62, [64] [65] [66] seemed to use data from the same survey but examined different outcomes. no studies from africa or south america met our inclusion criteria, and four studies were transnational [61, [75] [76] [77] . the majority of studies were cross-sectional (n = 37), analyzing a variety of psychosocial factors in the sme-setting, mainly using data from nationwide surveys or specifically designed questionnaires for particular companies or settings. we also identified qualitative studies (n = 2), narrative reviews (n = 3), and intervention studies (n = 3). one qualitative study [69] looked at psychosocial resources instead of focusing on psychosocial risks like most other studies. however, as a single-case study, there are issues with the transferability of the results. the other qualitative study [78] aimed to identify challenges faced by novice community pharmacists at transition to independent practitioners. the three narrative reviews [79] [80] [81] focused on changing work characteristics in smes during the first years of the 21th century. cooper [80] analyzed the changing world of work and its impact on employees and their families in that period. he focused on new forms of work, affecting most of all employees in smes, as well as self-employed and workers outsourced in virtual organizations. allan et al. [79] investigated challenges of online learning in smes. yuhshy [81] discussed work-and family-related stress as significant problems of smes. we identified only three intervention studies [71, 73, 82] : casteel et al. [73] evaluated an intervention to reduce violent crimes in smes. magnavita [71] reported an intervention to reduce psychosocial risks at the workplace in smes. he described a cost-effective participatory model and emphasized the usefulness of regular health examinations as they can be used to identify problems in the workplace climate and work organization. in a controlled intervention study, torp [82] reported results of a 2-year training program for managers of small and medium-sized enterprises. he examined the program's impact on the companies' health and safety management systems and on the mental and physical health of employees. applying the sure-criteria [53] , the internal validity of these studies was rated as medium quality, because of some methodological limitations and limited representativeness. furthermore, we identified four studies investigating the differences of job stress in smes compared to large firms [30, 31, 63, 67] . whereas tsai et al. [31] found higher levels of job stress and "higher favorable attitudes toward managers" in smes, lai et al. [63] obtained no firm size effect on overall job stress after adjusting for covariates including individual and organizational characteristics (information on job tenure, contractual status, gender, age, marital status, number of children, caring responsibility, long-term illness, academic qualification, weekly pay, work condition changes, organizational support) in an european (u.k.) sample. yeh et al. [67] reported higher job demands, higher job insecurity, lower job autonomy and lower career prospect in smes, compared to those of large private enterprises and the public sector. encrenaz et al. [30] investigated the influence of the size of enterprises on mental health and the mediating role of perceived working conditions in this relationship by measuring the outcome "anxious/depressive episodes" in employees. between micro-enterprises compared to the others, there were differences in perceived working conditions: taking working conditions into account, the risk of "depressive/anxious episodes" was larger in micro-enterprises. as summarized in table 1 , most studies investigated several work characteristics with a focus on factors related to 'work content and task' (n = 33) and 'organization of work' (n = 31), followed by factors related to 'social relations' (n = 30), 'new forms of work' (n = 8) and the 'working environment' (n = 7). only one study considered all five work characteristics to measure work quality in smes [29] . a relatively high number of studies assessing the work characteristics 'work content and task' included the factors 'freedom of action' (n = 15), 'responsibility' (n = 10) and 'emotional demands' (n = 9). multiple studies also investigated factors related to 'organization of work', mostly looking at 'work time' (n = 16), 'work process' (n = 20), and 'communication/cooperation' (n = 13). however, the correlations of these factors with the outcomes were not always reported. many studies also investigated the work characteristics 'social relations'. for example, berthelsen et al. [85] measured perceived social support in the workplace among danish dentists, and agervold et al. [68] measured social contact, social climate and management style in a danish manufacturing company. intragroup conflict and social support were assessed by three japanese studies [62, 65, 66] . the work characteristics 'social relations' in general were measured by four studies [57, 60, 70, 82] and one study referred to siegrist's effort-reward-imbalance model (eri) [71] , in which the eri questionnaire was used to asses occupational stress with items on esteem and job promotion. the work characteristics 'working environment' and 'new forms of work' have received less attention. only three studies measured physiochemical factors: 'lighting' was measured by two studies [29, 75] , 'climate' was measured only by isahak et al. [75] . rhee et al. [76] assessed the variables "hazardous work condition" and "handling of hazardous materials". three studies investigated physical factors: "physical occupational activity" [84] , "poor physical working conditions" [90] and "heavy physical work, repetitive activities, forced postures and risks of falls" [75] . the factor 'workplace and information structure' was only studied by díaz-chao et al. [29] ("workspace"). the factor 'work equipment' was taken into account by sonnentag et al. [89] looking at "situational constraints associated with malfunctioning, missing, incomplete, or outdated equipment, tools, or information". myers et al. [83] investigated "staff and technical problems", including 'equipment breakdown and defective materials'. the characteristics 'new forms of work' was taken into account by eight studies. job insecurity was measured by five studies [29, 63, 67, 75, 91] . flexible work hours and work-life-balance was taken into account by three studies [29, 59, 92 ]. cooper's [80] theoretical exploration focused on several aspects of new forms of work, including free-lancers, flexible working hours, and work-family-conflicts related to new forms of work. there was only one study [98] focusing on accessibility and expected availability of workers due to new communication methods. another study investigated the work-home interference and well-being of self-employed entrepreneurs [59] . mental health risks and resources were the most commonly studied outcomes. as shown in table 2 , many studies examined mental health outcomes (n = 19), with general (work-related) stress outcomes being the second most studied (n = 15), followed by outcomes representing business-related outcomes. coping self-efficacy [77, 95] seven-item coping self-efficacy scale (cse-7) depressive symptoms [62] japanese version of the center for epidemiologic studies depressive symptoms scale (ces-d) depressive episodes [30] hospital anxiety and depression scale (hads-d) training needs [90] unspecified questionnaire (probably self-developed) importance of work [59] mow's question on the centrality of work general stress and mental health outcomes were assessed more often as risks, business outcomes were assessed almost equally as risks and resources and social relations were examined more often as resources. the only non-self-reported outcomes were blood pressure and the observed rate of violent crimes; all other outcomes were assessed as self-reported outcomes, mostly via questionnaires. several studies (n = 17) examined manufacturing enterprises (please see supplementary table s3 ). each of the other economic sectors was considered by less than six studies. eight studies [30, 57, 59, 63, 67, 92, 93, 98] included several sectors; for example; lai et al. [63] used data of a nationwide survey with participants of all industrial sectors, godin et al. [59] and cocker et al. [57] examined entrepreneurs of several sectors. seven studies [58, [79] [80] [81] 86, 88, 90] did not provide information on particular economic sectors. in this review, we evaluated the current evidence on work-related psychological stress in smes, also summarizing the type of outcomes investigated as well as the economic sectors considered. the majority of the 45 studies were cross-sectional (n = 37). we also identified qualitative studies (n = 2), narrative reviews (n = 3), and intervention studies (n = 3). as most studies applied a cross-sectional design investigating relationships between various outcomes and psychosocial factors in the workplace, the number of studies investigating causal relationships was relatively low. only one study conducted an intervention specifically developed for the sme setting [71] indicating a lack of studies applying a high quality research design (e.g., randomized controlled trials) with a focus on psychosocial stress in the smes. all studies were published from 2004 to 2019 considering very heterogeneous populations of smes. we did not find suitable studies from 2000 to 2004. as the definition of smes was inconsistent at the beginning of the century, articles from this period may not have met the inclusion criteria of the european definition of smes. since smaller enterprises have become a focus for researchers and policy makers in recent years, this may have resulted in an increased number of publications from 2017 onwards. only one study [29] investigated all five dimensions of work-related psychosocial demands as defined in the gda recommendations [39] . although these recommendations are based on the european council directive [21] and have great similarities with other international classifications (e.g., [12] , p. 14), we appreciate that the gda recommendations have been developed with a focus on the german context and may not be transferable entirely to other settings. nevertheless, since the job-demand-control model [36, 99] and the extended job-demand-control-support-(jdcs-) model [100] have been used for decades, work characteristics based on these models, have found their way into many study-designs and work-stress questionnaires. this resulted in a frequent examination of the work pattern 'work content and task' although some of the subcategories were hardly considered ('variability) or not mentioned at all ('completeness of task'). the work patterns 'organization of work' and 'social relations' have also been considered frequently. although the psychosocial health effects of the working environment have been studied as a cause for work-related illness for decades e.g., [101] , this work characteristics including 'physicochemical factors' or 'physical factors' have received little attention from the psychosocial perspective in the studies we identified in this review. in terms of advancing digitalization, topics such as 'workplace and information structure' are important fields of research as they involve the risk of information and stimulus satiation [47] . their psychosocial impact on employees in small and medium-sized enterprises appears to have been poorly researched to date. this may be related to the slow pace of digitization in smes requiring financial and human resources, frequently exceeding the means of small enterprises [102] . the european agency for safety and health at work (eu-osha) recognized job insecurity, precarious work, intensification of work and higher requirements for flexibility and mobility from workers as emerging risk for health and safety [2] ; nevertheless, 'new forms of work' also have received little attention in the setting of smes [103] . we also classified the outcomes considered according as defined by the baua-project [35] including these subcategories: general (work-related) stress outcomes, health, well-being, factors affecting cardiovascular health, mental health, musculoskeletal system, social relations, and business-related outcomes. most outcomes were related to the fields of general stress, mental health and business. there appears to be a gap in the investigation of outcomes on physical health, particularly those representing cardiovascular health, even though the link between work-related stress and physical illness is well established [18, 19] . promoting and maintaining the health of employees is the fundamental purpose of occupational medicine. prevention is therefore particularly important. work-related resources were, however, less frequently studied than risks, and most outcomes considering resource were related to the fields of 'social relations' and 'business-related outcomes'. factors considering the prevention of work-related stress and the promotion of a healthy working environment should therefore be considered more frequently in sme-research. finally, we categorized the studies identified to the international standard industrial classification of all economic activities (isic) [51] . with few exceptions, the number of studies allocated to economic sectors corresponded to the frequency with which smes in europe and asian countries are represented in these sectors [27, 104] . in the eu-28, for example, employment was highest in smes active in the sectors 'construction' (13,9%) and 'wholesale and retail trade; repair of motor vehicles and motorcycles' (13,6%) between 2016 and 2018 [105] . although we identified a number of studies (n = 9) investigating psychosocial demands in these sectors, the highest number of studies looked at smes active in 'manufacturing' (n = 17) where the percentage of employment was considerably lower (6.7%). this may be related to differences in lobbying activities which have been shown to be relatively high in the manufacturing sector compared to other sectors including 'wholesale trade' [106] . the other economic sectors were partly more typical for large enterprises (e.g., electricity suppliers, oil companies, insurance companies) or public and civil-service institutions (hospitals, schools, public offices) and, as expected, fewer studies were identified here. within the sector 'human health and social work activities' four studies were identified looking at psychosocial factors in the setting of general dentists' practices, pharmacies and a welfare and assistance agency for professionals. although the setting of myers et al. [83] and magola [78] was not clearly in the sme area (myers et al. examined dental practices that were also partly funded by the british national health service (nhs), magola included pharmacists who also worked for larger chains), the studies were included in this review because they represented the sector of healthcare and the organizations under review (dental practices and pharmacies) which ultimately had the structure of an sme. we also expected family or medical practices to be characterized as small businesses, but no corresponding study was identified also indicating that these "enterprises" were unlikely to be categorized as a typical sme [107] . this review also has some limitations. our broad research objective was very useful to give an overview of the current state of research and to detect gaps in knowledge. however, it was not suitable for a "classic" systematic review design and resulted in a heterogeneous sample of included studies and a high number of irrelevant hits, particularly in the database "business source premiere" which identified numerous entries on "financial stress" not related to our research objective. the bias risk has been minimized by a strict application of review methods like systematic literature search and reviewing by independent reviewers. the broad question and the application of the peo scheme could also be the reason for finding only three intervention studies. it may be appropriate to search particularly for intervention studies in smes; however, a recent review from 2019 examined health interventions in smes and only one of the included studies met our inclusion criteria [82] . the reasons for this may be related to applying different sme definitions, the inclusion of public institutions or the exclusion of work-related psychological factors as most of the interventions considered in the review [108] dealt with physical fitness or work-safety-interventions. to provide a more manageable and specific set of results, we have refrained from using 'family business terms' in our search string. apart from using a european definition of smes, this could also be a reason why we did not identify studies from south america and africa. to study psychosocial factors in the family business setting, a new search with a more specific search term would be required. the same may be true for micro-enterprises which may not be covered by our search string in all databases. furthermore, the consideration of "grey literature" (e.g., governmental reports) may provide further evidence in this context. finally, we aimed to categorize all studies identified in this review according to well-established frameworks [35, 39, 50, 51] . nevertheless, the process of systematization was partly subjective since psychosocial factors are mostly interdependent or interrelated; hence, we could have also chosen different categorizations for some of the studies identified. psychosocial risks differ between large companies and smes [30, 31, 67] . since smes represent the majority of all companies worldwide, it is important to conduct research specifically focused on smaller enterprises, also including micro-enterprises. as early as 1997, cooper et al. [109] called for further studies to investigate the long-term effectiveness of stress intervention strategies. with the findings of this review we can renew this demand for the sme setting. in order to offer smes effective interventions for the primary prevention of psychosocial risks, the long-term effects of the interventions should be examined applying high-quality study designs. for the development of interventions, it would be desirable to measure all dimensions in which psychosocial risks may occur and resources can be established and consolidated, rather than limiting the assessment of psychosocial stress to single factors. hereby, the dimensions of psychosocial risks defined by the gda [39] proofed to be a good framework for the classification of the studies identified. furthermore, we would like to point out that about one third of the outcomes identified were measured using self-developed items, scales or questionnaire, or by using adapted preexisting questionnaires. on the one hand this complicates the comparison of results with prior research and may impact the validity and reliability of previously established measures. on the other hand, it may be necessary to develop new instruments suitable for a particular research question or setting. previous research has provided valuable context for the development of new research instruments, also emphasizing the necessity to carefully discuss the pro and cons of using preexisting or newly developed measures e.g., [110] . working conditions do not only influence the physical but increasingly impact the mental wellbeing of employees [111] . the process of transforming to industry 4.0 with the resulting digitization and emergence of new forms of work (e.g., platform work, remote work, freelancers, home office) has been researched for the last decade and provided valuable insight in central issues or smes adapting to the accelerating change of the working environment (e.g., lack of operational capacity for systematic reorganization) [102, 112] . moreover, the trajectory of climate change and the current covid-19 pandemic have accelerated these processes [113, 114] . particularly the necessity of infection control has resulted in an even greater necessity of work-related mobility and flexibility and is expected to impact the working environment in the long term. as a result, employers and employees are facing new psychosocial risks, e.g., social isolation, increasing technical and social challenges related to electronic communication [115] which has been related to the development of depression, anxiety, self-reported stress, and sleeping disorders [116] . especially in smes, where frequently fewer (financial) resources are available compared to larger companies, the redesign and adaption of a continuously changing working environment is particularly challenging. new evidence of the effectiveness of workplace enhancements in the sme setting could facilitate necessary changes. the results of this review highlight that the various psychosocial factors in smes have been researched with varying intensity. as chirico [103] pointed out in 2017, the new work-related risks have not received sufficient attention from the scientific community. this can be recognized here by a lack of studies for the work characteristics "new forms of work" and "working environment". within the context of the current covid-19 pandemic, the relevance of these aspects becomes even more evident. smes from the economic sectors "professional, scientific and technical activities" and "wholesale and retail trade, repair of motor vehicles and motorcycles" should also be subject to more research, as they appeared to be underrepresented. due to the lower financial and human resources available in smes and a lower awareness of the resulting costs of inadequate health and safety management [12] , research for cost-efficient and effective interventions to improve mental health in smes is of high relevance to 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in small-and medium-sized enterprises: a meta-analytic review an intervention strategy for workplace stress measurement instruments and data collection: a consideration of constructs and biases in ergonomics research institute of world health organization. health impact of psychosocial hazards at work: an overview; world health organization back to the future: policy pointers from platform work scenarios new forms of employment series, new forms of employment series; publications office of the european union living, working and covid-19 data european agency for safety and health at work. covid-19: back to the workplace the work is associated with, but not funded by a project funded by the federal ministry of education and research of the federal republic of germany (bmbf 01gl1751a improvejob). many thanks to the four reviewers for their constructive and valuable suggestions during the review process of this manuscript. many thanks to anke wagner for her advice regarding the development of the search strategy and quality assessment of the papers. we would also like to thank the members of the seminar "health services research" (coordination centre for health services research, university hospital tuebingen) for their constructive feedback during the development of the research questions and the search string, and benjamin lee for his linguistic advice on the manuscript. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-348012-idflfwpb authors: alcover, carlos-maría; rodríguez, fernando; pastor, yolanda; thomas, helena; rey, mayelin; del barrio, josé luis title: group membership and social and personal identities as psychosocial coping resources to psychological consequences of the covid-19 confinement date: 2020-10-12 journal: int j environ res public health doi: 10.3390/ijerph17207413 sha: doc_id: 348012 cord_uid: idflfwpb the confinement imposed by measures to deal with the covid-19 pandemic may in the short and medium term have psychological and psychosocial consequences affecting the well-being and mental health of individuals. this study aims to explore the role played by group membership and social and personal identities as coping resources to face the experience of the covid-19 confinement and radical disruption of social, work, family and personal life in a sample of 421 people who have experienced a month of strict confinement in the region of madrid. our results show that identity-resources (membership continuity/new group memberships, and personal identity strength) are positively related to process-resources (social support and perceived personal control), and that both are related to better perceived mental health, lower levels of anxiety and depression, and higher well-being (life satisfaction and resilience) during confinement. these results, in addition to providing relevant information about the psychological consequences of this experience, constitute a solid basis for the design of psychosocial interventions based on group memberships and social identity as coping resources. the accelerated expansion of covid-19 in the early months of 2020 forced governments to enact extraordinary and emergency measures of social distancing to deal with the pandemic. as a consequence, millions of people were suddenly isolated and confined to their households. in march 2020, in just one week large cities such as milan, madrid or new york underwent rigid limitations on mobility and going out on the street, attending non-essential work and normal activities of daily life were forbidden. in the following days, the number of people infected and dead from covid-19 increased in fairly fast progression. overflowing hospitals, intensive care units at risk of collapse, overwhelmed health authorities and shortages of health resources to protect health professionals and citizens, generated a state of alarm unknown to current generations in developed countries. investigating and understanding how people dealt with a situation without referents is essential to identify resources that can be useful in an emergent and global crisis. there are antecedents of pandemic situations related to contagious diseases (i.e., the epidemics of sars 2002-2003, the pandemic 2009 h1n1, or the ebola virus disease epidemic 2013-2016) [1] , natural disasters and humanitarian crises caused by war conflicts. however, the scopes, large-scale and sudden nature of the covid-19 pandemic in a globalized world, make it an unprecedented experience for most of humanity. consequently, we need data that sheds light on the mechanisms and processes that people mobilize and develop to coping experiences that, directly and vicariously, dramatically affect their lives and, eventually, their physical and mental health. disaster research pointed out the importance of going beyond psychological coping approaches. thus, a perspective that considers coping as a social process includes a collective dimension, an experience-based dimension, and a local dimension, highlighting resources such as social capital and community resilience [2] . social identity theory (sit) [3] argues that in any social context people define themselves from their group membership, which means define their self in terms of social identity. if the multiple groups that define the self "provide a person with stability, meaning, purpose, and direction, then this will typically have positive implications for that individual's mental health" ( [4] , p. 5). extensive research from the social cure approach [5] has provided robust evidence on the importance of social factors, specifically of the curative role played by social integration and social support, for mental and physical health [5] . based on these approaches, this study aims first, to explore the possible existence of significant differences in relation to several socio-demographic and occupational variables regarding group memberships, social and personal identities, social support and health and well-being factors during the covid-19 pandemic. and second, to explore the role played by group membership, social and personal identities and social support as coping resources to face the experience of the covid-19 confinement and radical disruption of social, work, family and personal life. to do this, it uses a sample of 421 people who have experienced a month of strict confinement in the region of madrid. in mid-july, spain had the third most deaths proportionally to their covid-19 cases for population in the world (60.80 deaths for 100,000 population, behind belgium, 85.69, and united kingdom, 67.76) [6] ; and madrid was one of the european cities with the highest incidence of contagion (1071 per 100,000 population) and deaths (126 per 100,000 population; 8418 people have died (29.7% of deaths in spain), suffered between march and june 2020. the rapid global expansion since the end of 2019 in wuhan, in the chinese province of huabei, of the coronavirus named covid-19, led to the majority of the european governments decreeing confinement, quarantine and isolation measures in their own homes or in public dependencies (hospitals, hotels, ocean liners, etc.). these measures affected millions of people on a scale never previously known. confinement is considered a public health preventive measure to reduce the risk of disease transmission, and affects not only sick people, but also healthy or asymptomatic individuals. quarantine involves separating and restricting the movement of people who have potentially been exposed to the contagious disease to determine if they are ill or have symptoms; their goal is to reduce the risk that they could infect other people in their close or public social context. and isolation refers to the social separation of people who have already been diagnosed with the contagious disease, so that they are not in contact with non-sick people [7, 8] . despite these differences between public health measures, the terms are often used interchangeably, and in practice people subjected to them by the authorities experience diverse thoughts and emotions due to the limitation or loss of freedom of movement, doubts or fear of being infected (themselves or their loved ones and acquaintances), the loss or reduction of interpersonal and social contact, the disruption of daily habits both at work and leisure, boredom, stigma, and uncertainty about the future [7, 9, 10] . there is scientific evidence of the psychological and psychosocial consequences of the confinement, quarantine and isolation measures studied in recent infectious diseases, such as sars, n1h1, or ebola [7, 8, [11] [12] [13] [14] , and the current covid-19 in china [15] . these consequences are usually related to problems of anxiety, negative affectivity, irritability, fear, frustration, panic, depression and other negative emotional reactions, leading to infected people experiencing stigma and suicidal ideation or intentions. in turn, these consequences can lead to other health problems, both physical and mental, and a reduction in the quantity and quality of sleep. overall, literature review suggests [7, 10] that the psychological impact of quarantine and confinement is wide-ranging, substantial, detrimental, and can be long lasting, depending on how long it lasts; evidence shows that a longer quarantine is associated with poorer psychological outcomes. however, this evidence has been obtained basically from an individual perspective, or a clinical approach, and as far as we are aware, the role played by collective and social factors in the psychological consequences of confinement and quarantine has not been sufficiently investigated. the social world is the canvas where human lives are painted. given the social nature of human beings, group membership and high-quality social relationships are vital for health and well-being. social contact and belonging to many groups are fundamental and pervasive human motivations [16] and shape the roots of personal and social identity. for decades, research has accumulated data and solid arguments that show an association between social relationships and health [17] . social factors play a central role in shaping health outcomes, and its effects are similar and often larger than that of poor health habits [5] . less socially isolated or more socially included people had better psychological and physical health and less likely to die, at least prematurely [17] . large meta-analytic data across 308,849 individuals, followed for an average of 7.5 years, was conclusive [18] . individuals with adequate levels in two social factors associated with interpersonal relationships (social inclusion and social support) have a 50% greater likelihood of survival compared to those with poor or sparse social relationships. in an additional meta-analysis across 70 independent studies in which several possible confounders were statistically controlled for, the weighted average effect sizes corresponded to an average of increased likelihood of mortality by 29% for social isolation, 26% for loneliness, and 32% for living alone [19] . social inclusion occurs primarily through group membership. being a member of multiple groups satisfies the need to belong and, especially, provides identities [16] . sit theory has demonstrated the central role of groups in building the social self. furthermore, individual self-concept includes both personal identity and group memberships, since people need others to validate their attitudes and behaviors [20] . as tajfel [21] has pointed out, social identity is the part of self-concept that derives from their awareness of belonging to social groups, as well as from the emotional and evaluative meaning associated with these multiple memberships. in sum, sit [5, 22] has stressed that social behavior depends largely on the degree to which people see others sharing their social identities with them. internalized group memberships provide shared social identities. in turn, important psychological resources with implications for health are derived from shared social identities [5] . these psychological resources primarily refer to perceptions of social connection and positive orientation to other people; a sense of meaning, purpose, self-worth through social connectedness and group life; social support exchange with people who define themselves in terms of shared social identity; and the development of a sense of control, efficacy and power [5, 23] . extensive research has shown that one of the key resources that flow from shared social identities and group memberships are social support exchange opportunities, that is, interaction contexts for receiving, giving, and benefit from both social actions [5, 24, 25] . empirical evidence in different contexts revealed that receiving social support was generally beneficial for psychosocial health [26] [27] [28] [29] [30] , although there were some inconsistent results [17] , and also that providing it might be even more beneficial than receiving it [31, 32] . finally, although from the sit perspective traditionally personal and social identities are considered as the end points of a continuum [33] , identity theory research has also analyzed the relationships of social identity with personal identity strength e.g., [34] . from this perspective [35] , people have different components of self-linked to each of the group role behavioral sets that they perform. the self, or personal identity, can be seen as a collection of identities that reflects the multiple roles that a person occupies in groups to which he/she belongs [35, 36] . even if personal and social identity can be theorized and measured as separate, the fact of being strongly intertwined structures allows for the permeability of personal and social identities [37] . furthermore, it has been suggested [5, 38] "that a strong sense of 'me' flows from a strong sense of 'us'" ( [5] , p. 32). consistent with this idea, and in accordance with sit, research has shown [5, 38] that a sense of shared social identity-as a result of group membership-has the ability to make group members feel capable and with personal control over their lives, through the development of a sense of agency, self-efficacy and power [5] , with positive consequences for their health and well-being. in sum, these results show that social group memberships generate personal benefits through greater perceived personal control [38] . the social cure approach proposed by [5, 39] posits a three component model: social identity and identification factors (e.g., multiples identities, multiple group membership, social identity continuity, personal identity strength, and so on), process factors (e.g., group norms, social support, perceived discrimination, perceived personal control, and so on), and health and well-being factors (such as depression, anxiety, stress, resilience, affect, personal self-esteem, life satisfaction or general health) related with both antecedent factors (social identity and process) ( [5] , see p. 347 for an overview of the model). based on this model, our study explores whether: (1) group memberships (specifically, membership continuity and new memberships) and personal identity strength, considered as identity-resources derived from group social identities, and (2) social support (received and provided) and perceived personal control, considered as process-resources derived from the identity-resources, are related to well-being and psychological health in the confinement experience during the covid-19 pandemic. figure 1 summarizes the proposed model. identity can be theorized and measured as separate, the fact of being strongly intertwined structures allows for the permeability of personal and social identities [37] . furthermore, it has been suggested [5, 38] "that a strong sense of 'me' flows from a strong sense of 'us'" ( [5] , p. 32). consistent with this idea, and in accordance with sit, research has shown [5, 38] that a sense of shared social identity-as a result of group membership-has the ability to make group members feel capable and with personal control over their lives, through the development of a sense of agency, self-efficacy and power [5] , with positive consequences for their health and well-being. in sum, these results show that social group memberships generate personal benefits through greater perceived personal control [38] . the social cure approach proposed by [5, 39] posits a three component model: social identity and identification factors (e.g., multiples identities, multiple group membership, social identity continuity, personal identity strength, and so on), process factors (e.g., group norms, social support, perceived discrimination, perceived personal control, and so on), and health and well-being factors (such as depression, anxiety, stress, resilience, affect, personal self-esteem, life satisfaction or general health) related with both antecedent factors (social identity and process) ( [5] , see p. 347 for an overview of the model). based on this model, our study explores whether: (1) group memberships (specifically, membership continuity and new memberships) and personal identity strength, considered as identity-resources derived from group social identities, and (2) social support (received and provided) and perceived personal control, considered as process-resources derived from the identity-resources, are related to well-being and psychological health in the confinement experience during the covid-19 pandemic. figure 1 summarizes the proposed model. in the absence of previous studies from this theoretical perspective on the effects of confinement, and based on the propositions of the sit and the social cure model on the specified relationships between these constructs, as well as on the available empirical evidence on their combined effects on health, we formulated the following research questions: rq1: how will group memberships be related to psychological health and well-being during the confinement experience? rq2: how will the strength of personal identity be related to psychological health and wellbeing during the confinement experience? in the absence of previous studies from this theoretical perspective on the effects of confinement, and based on the propositions of the sit and the social cure model on the specified relationships between these constructs, as well as on the available empirical evidence on their combined effects on health, we formulated the following research questions: rq1: how will group memberships be related to psychological health and well-being during the confinement experience? rq2: how will the strength of personal identity be related to psychological health and well-being during the confinement experience? rq3: how will social support received and social support provided be related to psychological health and well-being during the confinement experience? rq4: how will perceived personal control be related to psychological health and well-being during the confinement experience? this study has been approved by the research ethics committee of universidad rey juan carlos (madrid, spain), record number 0604202009320, dated 08-04-2020, and meets all ethical and legal standards applicable to research of this survey modality. the participants were 421 inhabitants from the region of madrid, 289 women (68.6%) and 128 men (30.4%), mean age 45.38 years (sq = 15.40, range = 17-89). the most frequent level of studies completed was a bachelor's degree (32.1%), followed by a master's degree (18.1%) and a high school diploma (17.6%). participants completed a questionnaire via the qualtrics platform, that included socio-demographical data and self-report measures related to the study variables. the socio-demographic and occupational variables were evaluated by means of ad hoc items, related to age, gender, current occupational status, educational level, maintaining or not a couple relationship during confinement, having or not having children, belonging to a covid-19 risk group, type of work during confinement, and being or not a health professional. this variable was measured with the exeter identity transition scales (exits) [40] . the scale has two dimensions: membership (or social identity) continuity and new membership. membership continuity: four items, scored on a 7-point likert response format ranging from 1 (completely disagree) to 7 (completely agree). the time frame is before confinement. an example item is: "before the confinement start: . . . i belonged to many different groups". new memberships: four items, with the same 7-point likert response format. "during the period of confinement: . . . i've joined one or more new groups" is an example item. the internal consistency was adequate for both dimensions (α = 0.94 and α = 0.81, respectively). higher scores indicated higher levels of group membership. this scale [41] consisted of five items scored on a 7-point likert response format (1 = completely disagree, 7 = completely agree). item example, "i know what i want in life", and the reliability was good. the internal consistency was α = 0.76. this is a short version of a 10-item measure originally developed by [24] . the measure incorporates items designed two subscales, received social support (e.g., "i know what i want in life") and provided social support (e.g., "get the emotional support you need from others"), with 4-items each one and with 7-point likert format, from 1 (completely disagree) to 7 (completely agree). both subscales showed high reliability (α = 0.89 and α = 0.88, respectively). this is measured with the scale developed by [38] ; 3 items scored on a 7-point likert response format (1 = completely disagree, 7 = completely agree). the alpha coefficient was α = 0.81. an example item is: "i feel in control of my life". the instrument used was the generalized anxiety disorder-7 (gad-7) [42] in its spanish adaptation [43] . this widely used test consists of seven items, in which the subject must respond according to his agreement with one of the four possible alternatives, thinking about what happened during the last week, 0 = never; 1 = several days; 2 = more than half the days; 3 = almost every day. an example item statement is: "feeling nervous, anxious or on edge". higher scores indicated higher levels of anxiety symptoms. the reliability was α = 0.91. we used the patient health questionnaire-depression scale (phq-9) [44] adapted to spanish [45] . nine items scored on a 4-point likert response format (0 = never; 1 = several days; 2 = more than half the days; 3 = almost every day) to answer about the personal situation in the last week. an example item statement is: "little interest or pleasure in doing things". higher scores indicated higher levels of depressive symptoms. cronbach's alpha was α = 0.88. brief resilience scale (brs) [46] : six items with a likert scale scored on a 7-point likert response format (1 = completely disagree to 7 = completely agree) to answers for items such as "i tend to bounce back quickly after hard times". the internal consistency was α = 0.80. this parameter was measured by the satisfaction with the life scale (swls) [47] , in its spanish version [48] . this scale consisted of five items that were scored on a 7-point likert-type scale (1 = completely disagree, 7 = completely agree). an item example is: "the kind of life i lead is similar to the kind of life i always dreamed of leading". cronbach's alpha was α = 0.85. two measures developed by [49] were used. the mental health one has four items, with a dichotomous response (yes/no) and people should think about what happened last week to answer questions like: "have you enjoyed life most of the time?" cronbach's alpha was α = 0.76. the questions of the perceived physical health scale have a different answer format for each of the three items, and score was calculated as an index. an example item is "do you often have pain problems?" in spain, population lockdown took effect at 00:00 on sunday, 15 march 2020. due to the isolation circumstances in which the research team conducted this study, a virtual snowball sampling was used. for the sampling to produce significant monitoring data, access to subjects was ensured from six personal and two professional networks. participants completed a self-report questionnaire on a qualtrics online platform which they accessed via a web link, after being informed of the study and giving their consent to be included in it. the data collection was carried out from 13 to 20 april 2020, after one month of confinement. for statistical procedures, statistical package for social sciences (spss) v. 26 (ibm corp., armonk, ny, usa) was used. the kolmogorov-smirnov normality test was used to verify data distribution. results for normality test failed, and therefore nonparametric contrast tests were conducted. to verify the relation between identity, social support and well-being measures, spearman's rank correlation coefficient test was used. to assess differences on these non-normally distributed continuous variables among socio-demographic characteristic groups, analyses of covariate were conducted using mann-whitney u test for 2 independently sampled groups and kruskal-wallis h test for 3 or more groups using post-hoc dunn test with bonferroni adjustment. mann-whitney u tests and kruskal-wallis tests results are expressed as median (range). the socio-demographic characteristics of our study sample are described in table 1 . firstly, we offer the most significant differences in relation to gender ( table 2) , age (table 3) , educational level (table 4) , working and occupational status (table 5) , people who were (or not) in a relationship in confinement (table 6) , and membership of a covid-19 risk group. table 3 . descriptives (md (iqr)) and post-hoc differences by age group. regarding gender differences (table 2) , the mann-whitney test indicated that the provided social support was greater for females than for males, although females also showed higher values for anxiety and depression. males scored higher in resilience and physical health. with regard to age group differences, the kruskal-wallis h test performed showed a significant difference in new memberships (χ 2 (6, n = 421) = 14.35, p = 0.026). the most significant post hoc results showed (table 3) worse results for the younger age groups (less than 39 years). notably, group 2 (20-29 years old) presented worse general indicators, with higher levels of anxiety and depression and lower levels of mental health than participants over 40, and lower levels of perceived physical health, resilience and life satisfaction than those in group 6 (60-69 years). similarly, group 3 (30-39 years) presented greater anxiety and worse mental health than the participants over 60 years old, the latter result also obtained by those of 18-19 years old. 1 dunn-bonferroni post hoc test. only significant differences between groups appear (p < 0.05). table 6 . descriptives (md (iqr)) of the variables with significant differences for "having or not a relationship during confinement" and "having or not children". in reference to the educational level, the kruskal-wallis h test reported significant differences between groups in continuity in membership (χ 2 (7, n = 421) = 18.56, p = 0.010) and new memberships (χ 2 (7, n = 421) = 21-68, p = 0.003). as can be seen in table 4 , participants with higher levels of education showed better general indicators. specifically, those with doctoral degrees expressed lower levels of anxiety and depression than high school graduates, and higher levels of mental health and resilience than those with primary education. while those with a master's degree reported greater group membership continuity than high school graduates, and more new group memberships than those with a bachelor's degree. as shown in table 5 , people who were working during the period of confinement (teleworking or face-to-face) presented greater membership continuity, life satisfaction, resilience and mental health than people who didn't work (temporary suspension of contract, sick leave, erte or inactivity due to confinement). moreover, people who didn't work expressed higher levels of depression that people who were in working in confinement. regarding occupational status, the most significant results showed that retirees experienced lower levels of anxiety and depression than part-time workers and students, better mental health than part-time workers, the unemployed, covid-19 unemployed, and students, and also less depression than the latter three groups. in addition, students showed less resilience than retirees, worse mental health and greater depression than self-employed and full-time workers, and greater anxiety than the latter. the results shown by the students are consistent with those already mentioned for the younger age groups (table 3 ). compared to other professionals (o), health professionals (hp) reported that they developed more new group memberships, showed greater personal identity strength, provided more social support, and had more perceived personal control. the results in table 6 show that people who were in a relationship in confinement showed lower levels of depression and better mental health. in turn, people with children showed less anxiety and depression, and also displayed higher personal identity strength, life satisfaction, resilience, mental health and physical health. finally, people who belonged to a covid-19 risk group only reported worse perceived physical health (mdn = 7.29, iqr = 8.29-5.78) than those who did not belonged (mdn = 7.86, iqr = 8.86-6.29), u = 14481.50, p = 0.021). as shown in table 7 , maintenance of memberships before quarantine was correlated with the building of new ones during quarantine (ρ = 0.34, p < 0.01). membership continuity was associated with identity strength (ρ = 0.20, p < 0.01), but new memberships were not correlated with it. meanwhile, received social support correlated with membership continuity (ρ = 0.22, p < 0.01) and with personal identity strength (ρ = 0.30, p < 0.01). and provided social support was positively associated with membership continuity (ρ = 0.29, p < 0.01), new memberships (ρ = 0.12, p < 0.05) and highly with personal identity strength (ρ = 0.41, p < 0.01). moreover, perceptions of received and provided social support were strongly correlated (ρ = 0.56, p < 0.01). spearman's rank correlation coefficients related to perceived control are also presented in table 2 . personal identity strength showed a significant association (ρ = 0.28, p < 0.01), and also received social support (ρ = 0.24, p < 0.01) and provided social support (ρ = 0.31, p < 0.01). correlations regarding relationships group and identity-resources measures and health and well-being perceptions are also shown in table 2 . membership continuity was correlated with resilience (ρ = 0.15, p < 0.01). personal identity strength was positively associated with resilience (ρ = 0.30, p < 0.01), life satisfaction (ρ = 0.30, p < 0.01), mental health (ρ = 0.21, p < 0.01) and perceived physical health (ρ = 0.17, p < 0.01) and negatively with anxiety (ρ = −0.11, p < 0.05) and depression (ρ = −0.18, p < 0.01). new identities showed no associations with well-being. meanwhile, received social support was positively associated with resilience (ρ = 0.18, p < 0.01), life satisfaction (ρ = 0.31, p < 0.01), mental health (ρ = 0.22, p < 0.01) and perceived physical health (ρ = 0.21, p < 0.01) and negatively with anxiety (ρ = −0.12, p < 0.05) and depression (ρ = −0.17, p < 0.01). whereas provided social support was positively associated with resilience (ρ = 0.21, p < 0.01), life satisfaction (ρ = 0.27, p < 0.01), mental health (ρ = 0.16, p < 0.01) and perceived physical health (ρ = 0.16, p < 0.01) and negatively with anxiety (ρ = −0.10, p < 0.05). lastly, perceived control was positively associated with resilience (ρ = 0.29, p < 0.01), strongly with life satisfaction (ρ = 0.57, p < 0.01), mental health (ρ = 0.35, p < 0.01) and perceived physical health (ρ = 0.43, p < 0.01) and negatively with anxiety (ρ = −0.34, p < 0.01) and depression (ρ = −0.36, p < 0.01). we conducted additional analysis in order to delve deeper into the relationships between received and provided social support during the pandemic, perceived personal control and personal identity strength and the different health and well-being factors. to this end, these variables were recoded in three clusters or groups as follows: level 1 or low (equal to or below the 25th percentile), level 2 or medium (above the 25th and below the 75th percentile), and level 3 or high (equal to or above the 75th percentile). to study the differences between the three clusters of each variable, the kruskal-wallis h test and the dunn-bonferroni post hoc test were performed. with respect to differences between levels of received social support, the kruskal-wallis h test showed significant differences in life satisfaction (χ 2 (2, n = 421) = 35.03, p < 0.001), depression (χ 2 (2, n = 421) = 9.01, p = 0.011), mental health (χ 2 (2, n = 421) = 15.55, p < 0.001), resilience (χ 2 (2, n = 421) = 10.02, p = 0.007) and physical health (χ 2 (2, n = 421) = 17.65, p < 0.001). the results of the dunn-bonferroni post hoc test pointed out that people who experienced a high level of received social support had greater mental health (p < 0.05), and physical health (p < 0.01) than those who had a low or medium level. they also expressed greater resilience (p < 0.01) and lower depression (p < 0.05) than the low-level group. in addition, the medium group had greater life satisfaction (p < 0.01) than those with low level. as for the differences in the levels of provided social support, our data reported significant differences in life satisfaction (χ 2 (2, n = 421) = 25.15, p < 0.001), mental health (χ 2 (2, n = 421) = 8.08, p = 0.018), resilience (χ 2 (2, n = 421) = 15.57, p < 0.001) and physical health (χ 2 (2, n = 421) = 8.69, p = 0.013). the dunn-bonferroni post hoc test showed that those with a high level of provided social support had greater life satisfaction (p < 0.001), mental health (p < 0.05), resilience (p < 0.001) and physical health (p < 0.05) than the group of low level. medium level group presented greater life satisfaction (p < 0.01) and resilience (p < 0.05) than low level group. with regard to the differences between the three groups of perceived personal control, the performed test reported significant differences in life satisfaction (χ 2 (2, n = 421) = 115.56, p < 0.001), anxiety (χ 2 (2, n = 415) = 43.87, p < 0.001), depression (χ 2 (2, n = 410) = 52.04, p < 0.001), mental health (χ 2 (2, n = 417) = 45.60, p < 0.001), resilience (χ 2 (2, n = 418) = 31.97, p < 0.001), and physical health (χ 2 (2, n = 421) = 72.42, p < 0.001). the dunn-bonferroni post hoc test showed that those with a high level of perceived personal control had greater life satisfaction (p < 0.001), mental health (p < 0.001), resilience (p < 0.001) and physical health (p < 0.001), and lower levels of anxiety (p < 0.001) and depression (p < 0.001) than the group of low level. moreover, presented greater life satisfaction (p < 0.001), mental (p < 0.05) and physical (p < 0.001) health and lower depression (p < 0.05) than the group of medium level. in addition, the group of medium level showed greater life satisfaction (p < 0.001), mental health (p < 0.001), resilience (p < 0.001) and physical health (p < 0.001) and lower anxiety (p < 0.001) and depression (p < 0.001) levels than the group of low level. finally, attending to the differences between the levels of personal identity strength, the results indicated the existence of significant differences in life satisfaction (χ 2 (2, n = 421) = 38.39, p < 0.001), depression (χ 2 (2, n = 410) = 12.69, p = 0.002), mental health (χ 2 (2, n = 417) = 18.44, p < 0.001), resilience (χ 2 (2, n = 418) = 31.43, p < 0.001) and physical health (χ 2 (2, n = 421) = 10.64, p = 0.005). the post hoc tests reported than those with high level of personal identity strength had greater life satisfaction (p < 0.001), resilience (p < 0.001), mental (p < 0.001) and physical health (p < 0.01) and lower depression (p = 0.001) than those belonging to the low group. also presented greater resilience (p = 0.001) than the medium level group. moreover, the medium level group had greater life satisfaction (p < 0.001) and mental health (p < 05) than the low-level group. in relation to the first objective of our study, our preliminary results showed that women had poorer mental health (anxiety and depression) than men, who showed better physical health and greater resilience. prior evidence on gender differences in relation to the psychological consequences of quarantine was inconclusive, with some studies [50] showing a greater negative psychological impact on women, while others [11, 51] found no difference. our results did show a higher incidence in women, although it would be necessary to know the history of psychiatric illness in order to conclude that these worse mental health indicators were related to the experience of confinement. meanwhile, our data showed that women were providers of social support to a greater extent than men. this result was consistent with the evidence for women's greater ability to provide social support-as gender (femininity) not as sex [52] ; however, by showing higher levels of depression than men, it appears that the social support exchanged between women, and that received from men, was not sufficient to buffer the negative effect of confinement stressors. this interpretation is consistent with the evidence suggesting [53] that women are better providers of social support to men than men are to women. however, this result does not confirm the prediction [54] that the modalities of social support (empathy, active coping assistance, and role modeling) provided by experientially similar others-i.e., women-be efficacious in alleviating the psychological impacts of stressors. regarding age groups, the worst mental health (anxiety and depression) and the lowest well-being (life satisfaction) of the 20-29 year-old group and the students can be highlighted. this result is also consistent with prior evidence; for instance [50] found that the [16] [17] [18] [19] [20] [21] [22] [23] [24] year age group suffered the most negative psychological impact in a quarantine situation, and [51] , in a study conducted in china in the context of covid-19, have found that the younger population perceived more impacts of the epidemic outbreak (changes over living situations or emotional control), negative coping style and had higher level of psychological distress. the poorer mental health and lower life satisfaction of young people, as well as of students, can be explained by the disruption of their lifestyle by confinement, at an age where relationships and social contact are high valued. in addition, the economic effects of covid-19 on employment may further affect young people's precarious employment and career opportunities, increasing their frustration. regarding educational level, people with doctoral degree show greater continuity of membership and more new memberships than people with close educational levels (high school and bachelor's degrees), as well as better mental health, lower anxiety and depression, and greater resilience than those with primary education and elementary school degree. consistent with these results, there is broad evidence (e.g., [5, 24, 55] ) that people with high (perceived) socio-economic status (assessed in terms of level of education) or with high (perceived) group status have more social capital and it is beneficial for their well-being and health. people who had a relationship and cared for children during confinement manifest better mental health and higher strength of identity, life satisfaction, resilience and physical health. data from china's population in the early stages of the covid-19 quarantine [51] showed that unmarried people were more aware of the impacts of the epidemic outbreak and had a higher level of psychological distress. these data seem to indicate that affective and family relationships can play a buffering role of confinement stressors. the results also indicated that continuing to work (face-to-face or teleworking) was associated with better indicators of social identity and mental health compared with those who did not work for any reason. in this case, it appears that the potential stress from working under the conditions imposed by the pandemic was not experienced or added to the confinement stressors. rather, it can be interpreted that group membership continuity (i.e., identity continuity) facilitated by work activity is related to a perception of less life disruption, and consequently, to better mental health and greater resilience and vital satisfaction [6] . it is also possible that downward social comparisons of people in working with those who lost their jobs or were infected by covid-19, may have facilitated their perception of psychological well-being [56] . regarding retirees, the results also seem to underline the importance of identity, as is the case for working people. in this regard, although they no longer worked, their mental health indicators were better (along with those of full-time employees) than those of most occupational groups. this interpretation is consistent with previous data [5, 57] indicating that new group memberships and identification as a retiree play a protective role and has positive effects on well-being and mental health. as for our second objective and the four research questions that we asked, our results allow us to give a preliminary answer to all of them. identity-resources showed a significant relationship between them, so that membership continuity was associated with new memberships during confinement. this result may be relevant, as it indicates that in such a life disruptive experience the identities associated with group memberships were maintained and could facilitate new identities through memberships that were necessarily largely adopted without face-to-face contact. this result is consistent with sit's postulates [5, 21] and self-categorization theory (sct) [22] that the (cognitive) perception of group membership is sufficient to create a group identity. as sct posit [22, 58] , group membership and social category-based self-conceptualization are motivated by uncertainty reduction [59] . thus, contextual uncertainty created by confinement and the covid-19 pandemic could be reduced entering new groups, adopting new identities and by group action, although within the limits imposed by social distancing and quarantine measures. a significant relationship was also found between membership continuity and personal identity strength, which coincides with sit's approaches that defend the links between social identity and personal identity [35, 36] and permeability of both [37] . the correlation between the new memberships and personal identity strength was not significant, but this may be due to the relatively short time that has passed since the adoption of new group identities (less than a month), so it will be relevant to analyze whether this relationship is reinforced over time. in sum, our results show that participants had both identity-resources during the confinement, and it is important to check, as our model based on the social cure approach [5] proposes, if they are related to process-resources and, especially, to well-being and health perceptions. with regards to social support, a significant relationship was found between support received and support provided. this result is relevant, because prior evidence indicates [60] that both occur when the size of social network is large, which again is associated with group membership, since a positive relationship was found between continuity and social support received and given, and new membership and social support provided during confinement. our results are coincident with prior research founding that shared social identities and group memberships are social support exchange opportunities for receiving, giving, and benefit from both social actions [5, 24, 25] . in addition, personal identity strength was positively related to received and provided social support and perceived personal control. in turn, both types of social support were significantly related to perceived personal control, which is consistent with the previous literature [61] [62] [63] . thus, it can be concluded that social support exchange with people who define themselves in terms of shared social identity are related with the development of a sense of control, which constitute important psychological resources for people [5, 23] . our model based on the social cure approach [5] suggested that both types of social and personal resources (identity-resources and process-resources) would be related to perceived well-being and health. correlational analyses and, especially, additional analyses conducted clustering in low, medium and high levels of identity and process resources, confirm the relationships between strength of personal identity, social support received and provided, and perceived personal control and health and psychological well-being consequences experienced during the covid-19 pandemic. the clearest indicator of these relationships is resilience, since all resource variables, except for new memberships, are positively and significantly related to it. these results are reinforced by the significant differences found in the greater resilience of groups with high levels of social support received and provided, perceived personal control, and strength of personal identity in relation to groups with medium and low levels of these three resources. these results are consistent with previous evidence that identifies multiple group memberships [64] , strength of personal identity [65] , social support received [66] , especially in people exposed to trauma [67] , and perceptions of personal control [68] as antecedents to resilience. overall, our results are aligned with the perspective that postulates social identity as a basis for resilience, both individual [5] and collective resilience [69] , and have important implications for the design of psychosocial interventions that foster group membership and participation, specially to coping with potential future confinement experiences in cases of new outbreaks of the covid-19. for their part, anxiety experienced during confinement was less, perceived mental health was greater, and life satisfaction was higher for people who felt personal identity strength, received and provided social support, and perceived personal control. these results are also consistent with extensive prior evidence [5, [17] [18] [19] , and are relevant for future interventions, as discussed below. similar results were found for depression, although in this case the social support provided was not significantly related. finally, people who pertained to the cluster of high levels of provided and received social support, personal identity strength, and perceived personal control experienced in general greater mental health and life satisfaction and better overall physical health than groups of medium and low level, which is also consistent with prior evidence [5, 38, 41] . the main implications of our study concern the design of psychosocial interventions. for instance, the team of haslam et al. [5] has successfully implemented a social intervention program labeled groups 4 health that develops the social identity model of identity change (simic) [39] , applied to life transitions as retirement. in a similar vein, our model proposal and the results obtained can be useful for the design of strategies and psychosocial interventions in the sense of strengthening social networks and the potential social support derived from them. given the strong link between social relations, support and mental health [17, 63] , actions aimed at strengthening interpersonal relations and social networks through, for example, support groups, community initiatives or networks of people who share similar characteristics (of studies, profession, interests, etc.) [70] , can be very effective in providing social coping and resilience resources that increase the personal resources of those who experience, for example, post-traumatic stress following confinement. interventions designed with the groups 4 health model to address problems of social isolation or loneliness, stress, anxiety and depression have proven effective [71] , so that its adaptation to address the potential psychological consequences of confinement appears promising. this proposal for group-based interventions is even more relevant if we take into account the warnings of health authorities regarding potential outbreaks of covid-19 in the coming months. this study was conducted with a non-probabilistic sample and using a measure of the study variables one month after the start of the confinement. consequently, only relationships between variables can be established, so our aim is for future studies to include a greater number of temporary measures with subsequent follow-ups in order to identify causal relationships between variables. in this sense, longitudinal studies may allow to test the potential mediating role of process-resources in the relationship between identity-processes and factors related to health and well-being [5] . likewise, the participants were residents of the region of madrid and the sample size is relatively small, so the results cannot be generalized to the spanish population. however, given that madrid was one of the european regions where the covid-19 was most virulent, our results are relevant for understanding the experiences of citizens and their perceived levels of well-being and health in a situation of extreme alarm. future research, as well as potential interventions, should test whether resources based on social and personal identity and group membership, as well as the process resources provided by them (social support and perceived control), can play a protective (buffering) role for well-being and health in disruptive situations such as that triggered by the covid-19 pandemic. if future threats of virus outbreaks or similar health crises occur, this knowledge can be of great value and use in helping people to cope and overcome them with as little harm to their well-being and health as possible. in short: our results provide a first overall answer to our research questions: identity-resources and process-resources associated with them have positive relationships with the levels of well-being and health experienced during confinement. furthermore, as far as we know, this is the first time that the social cure model [5, 38] is used in a sample of the spanish population, and our results may complement those obtained by other studies carried out in spain during the covid-19 pandemic (i.e., [72] [73] [74] ). finally, our study may also contribute to the design of interventions based on this model, as we discussed in the prior section. infectious disease pandemic planning and response: incorporating decision analysis understandings of coping: a critical review of coping theories for disaster contexts the social identity theory of intergroup behavior social identity, health and well-being: an emerging agenda for applied psychology the new psychology 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linkage, self-concept, and well-being after severe traumatic brain injury social support and resilience to stress: from neurobiology to clinical practice how does social support enhance resilience in the trauma-exposed individual? risk and resilience factors in coping with daily stress in adulthood: the role of age, self-concept incoherence, and personal control collective resilience in mass emergencies and disasters social relationships and health. in social support measurement and intervention: a guide for health and social scientists groups 4 health: evidence that a social-identity intervention that builds and strengthens social group membership improves mental health related health factors of psychological distress during the covid-19 pandemic in spain idoiaga-mondragon, n. stress, anxiety, and depression levels in the initial stage of the covid-19 outbreak in a population sample in the northern spain covid-19: factores asociados al malestar emocional y morbilidad psíquica en población española [covid-19: factors associated with emotional distress and psychic morbidity in spanish population funding: this research received no external funding. the authors declare no conflict of interest. key: cord-341616-ts98sfxx authors: yang, yang; su, yingying title: public voice via social media: role in cooperative governance during public health emergency date: 2020-09-18 journal: int j environ res public health doi: 10.3390/ijerph17186840 sha: doc_id: 341616 cord_uid: ts98sfxx with the development of the internet, social networking sites have empowered the public to directly express their views about social issues and hence contribute to social change. as a new type of voice behavior, public voice on social media has aroused wide concern among scholars. however, why public voice is expressed and how it influences social development and betterment in times of public health emergencies remains unstudied. a key point is whether governments can take effective countermeasures when faced with public health emergencies. in such situation, public voice is of great significance in the formulation and implementation of coping policies. this qualitive study uses china’s health code policy under covid-19 to explore why the public performs voice behavior on social media and how this influences policy evolution and product innovation through cooperative governance. a stimulus-cognition-emotion-behavior model is established to explain public voice, indicating that it is influenced by cognitive processes and public emotions under policy stimulus. what is more, as a form of public participation in cooperative governance, public voice plays a significant role in promoting policy evolution and product innovation, and represents a useful form of cooperation with governments and enterprises to jointly maintain social stability under public health emergencies as a positive extra-role behavior, voice has attracted extensive interests from scholars and gained substantial attention in the organizational behavior literature [1] [2] [3] . public voice is a new type of voice behavior that refers to the behavior of citizens who share opinions on social media to improve the social status quo or prevent harmful practices [4] . as a pro-social behavior, public voice is vital for advancement and betterment of society [4] , and it is believed that public voice plays an important role in the cooperative governance of government and other organizations (e.g., enterprises, non-profit organizations) under a public health emergency. considering that public participation in public administration and policy formulation is beneficial to government performance, governments attach much importance to the public's role in policy-making, especially in the areas of environmental governance, public health, and sustainable development [5] [6] [7] [8] . in the face of extraordinary development problems, such as economic recession, public opinion in policy-making is extremely important [9] . thus, to ensure the timeliness and efficiency of policy in the case of public health emergencies, the value of public voice, along with technical support from enterprise, should not be underestimated. in the covid-19 epidemic, many governments have begun to cooperate with high-tech enterprises to formulate epidemic prevention and control policies such as the health code in china, covidwise in virginia, and corona-warn in germany [10] [11] [12] [13] . public voice on social media has effectively promoted the evolution of epidemic control policy and tracking applications developed by enterprises, making an outstanding contribution to social stability. thus, it is necessary to study public voice in public health emergencies in relation to the implementation of government policies and the promotion of enterprises' product innovation. public voice is also of great significance in further realizing cooperative governance. voice behavior refers to the extra-role interpersonal communication behavior in which organizational members actively make constructive suggestions to the organization for the purpose of improving work or organization status quo [14] . previous studies on voice behavior have mainly focused on employee voice and customer voice within organizations; public voice in a broader context has received little attention. the importance of employee voice and customer voice for the sustainable development of enterprises suggests that the role of public voice in social improvement should not be underestimated, and is worthy of in-depth discussion [4] . given that public voice can have wide ranging influence in terms of social change, this research focuses on its effect on the evolution of policy implemented under public health emergencies. public voice in public health emergencies has several important characteristics: first, the target of public voice is more extensive. the targets of employee voice and customer voice are employees inside the enterprise and customers who have cooperative relationships with the enterprise, respectively. they often offer advice to the enterprise as a single identity. however, for public voice, the target is the general public, who have dual identities as policy participants and enterprise customers. second, under cooperative governance, multiple subjects participate in policy-making, so the targets and content of public voice are also diverse. for example, voice to a government may relate to the implementation of policy, while that to an enterprise may focus on product improvement. third, the channels for public voice are more diverse. employees mainly voice to supervisors face-to-face or make suggestions through the internal social networks of an enterprise, and most customer voice occurs through the virtual community created by the enterprise. as social networking sites provide a more convenient platform for people to voice their concerns and make their voices heard, the public can voice through a variety of social networking sites [4] . finally, the effect of public voice is more significant. public health emergencies prompt the public to respond to the policy more actively and provide timely feedback [15] , which forces the governments and enterprises to absorb public opinion as soon as possible to improve policies and products. overall, research on public voice behavior is still in its infancy. the factors driving public voice and the mechanism of its action on government policies and enterprise product innovation are unclear. the purpose of this study is to address this gap and further explore the role of public voice in promoting cooperative governance under public health emergencies. the main contributions of this paper are threefold. first, it extends the literature on voice behavior. most studies on voice behavior have focused on employee voice and customer voice. under cooperative governance, the public is a participant in government policy as well as a customer of enterprises, yet the mechanisms for the influence of public voice on policy and product are not clear. this paper focuses on the dynamic role of public voice in policy-making and evolution and product innovation. second, it constructs a dynamic model of public voice to promote policy implementation under public health emergency. studies of public participation have mainly focused on its effect on environmental projects and decision, as public participation is seen as highly valuable and necessary to achieve the goal of environmental pollution control [8, 16, 17] . however, the voice behavior of the public in the formulation and evolution of policies in public health emergencies is unknown. finally, this paper extends the literature on cooperative governance in a public health emergency and attaches more importance to the role of public voice in the process of collaborative. this research uses china's health code policy under covid-19 as an example. this is an epidemic prevention policy whose implementation relies on a health rating system developed by alibaba, tencent, and other firms. the system uses opaque algorithms and individuals' data, such as physical condition and contact with an infected person, to make judgments about the infection risk of system users [18] . the system then generates a qr code corresponding to this risk level that is used as a passport. based on the evolution process of health code policy, this paper downloads comments about the health code policy to do research. this study uses the qualitative research method of grounded theory to explore the factors driving public voice and reveals the dynamic mechanism of its influence on policy formulation and product innovation. further, this research provides support for cooperative governance involving government, enterprises, and the public under public health emergencies. the concept of voice was first proposed by hirchman in the field of economics. it has been further developed in the field of organizational behavior [19] . currently, voice behavior is divided into employee voice, customer voice, and public voice. most research on voice behavior has been in the field of organizational behavior and mainly aimed to explain employee voice within organizations. van dyne and lepine define employee voice behavior as a positive extra-role behavior focused on improving existing working methods and procedures through constructive suggestions; they emphasize the 'promoting' role of employee voice for the organization [14] . van dyne et al. further expand the concept, pointing out that voice includes not only suggestions for improvement, but also concerns about the organization [20] . on this basis, liang et al. clearly divide voice behavior into promotive voice and prohibitive voice [21] . promotive voice refers to innovative ideas or suggestions put forward by employees to improve the overall operation of the organization, while prohibitive voice refers to employees' attention to work practices, and events and employee behaviors that are not conducive to the development of the organization [21] . employee voice is widely considered a valuable and positive extra-role interpersonal communication behavior, a kind of organizational citizenship behavior that plays an important role in the team and organization. scholars have conducted in-depth research on the influential factors and outcome variables of employee voice. previous studies indicate that personal characteristics, leadership, and organizational climate can influence employee voice, which will be beneficial to organizational betterment [2, 3, [22] [23] [24] [25] [26] [27] [28] [29] . additionally, the approaches of employee voice are also optimized due to the development of the internet [30] . with the aggravation of market competition, customer participation becomes crucial for the product and service innovation of enterprises, and enterprises have created brand virtual communities to gather customers' ideas and opinions. research on voice behavior has also expanded from the internal voice of the organization to the field of consumer behavior. on the connotation level, griffin and hauser regard customer requirements as customer voice, holding the view that customers would sort their needs according to importance and convey them to enterprises [31] . enterprises can then develop new products based on customer requirements. lee et al. expand the connotation of customer voice and define it as a description of customers' needs and expectations or preferences and dislikes, including the pursuit of rights and interests, suggestions for new products and services, and complaints about previous use experience. earlier definitions of customer voice are based on customer needs, but with advances in research on employee voice within organizations, scholars have begun to redefine customer voice from the perspective of role orientation. ran and zhou clearly define customer voice as the extra-role communication behavior in which customers actively make suggestions or express opinions to improve the status of enterprises; this kind of behavior belongs to the category of customer citizenship behavior [32] . at the dimension level, most previous studies on customer voice divide it into two categories: customer satisfaction and customer complaint [33] . with the deepening of research, scholars find that customers not only express dissatisfaction regarding product and service providers, but also express satisfaction and praise, and make their own suggestions. therefore, with reference to the classification of employee voice by liang et al., customer voice can be divided into promotive voice and prohibitive voice [21] . promotive voice refers to the innovative ideas and suggestions of customers regarding improvements to the efficiency of enterprises, while prohibitive voice refers to the expression of opinions on actual and potential problems within the products, services, or management of an enterprise that are harmful to the enterprise or its customers. as the input behavior of customers to enterprises, customer voice can urge enterprises to innovate products and services to meet the needs of customers, thus improving customer satisfaction and maintaining customer loyalty. it can also help enterprises correct errors, provide solutions to problems, and improve enterprise performance [33, 34] . with the rapid development of social media, people can express their views on social issues more directly and conveniently, and research on voice behavior has been further extended to a broader social life context. public voice behavior refers to citizens sharing opinions on social media to improve their social status quo or prevent harmful practices. it is essentially a pro-social behavior [4] . public voice channels have begun to focus on social media, because in the modern world, social media presents extensive information; people express their concern about education, security, the environment, work-life balance, and many other issues online. moreover, the diversity and openness of social media provides a broad platform for public expression. the public can conduct online voice behavior through third-party social media and public participation is increasing. however, research on public voice based on social media is still in its infancy and is uncommon. bhatti et al. explore the mechanism of the effect of individual moral identity and proactive personality on public promotive voice and prohibitive voice based on self-consistency theory [4] . research on voice behavior as discussed above has several characteristics. first, the research field has shifted from intra-organization to a broader social background. second, the voice subjects present a change trend of 'employee-customer-public'. third, the targets of voice behavior change from organizational practice to general social phenomena. fourth, the form of voice presents the evolution trend of "face-to-face-virtual community-social media". citizen participation in the formulation and consultation of public policies is an important way to strengthen and support modern democracy [35] . regarding the influence of public participation on policy, most research reveals extensive interest in environmental protection and pollution control, as public participation can help decision makers recognize public concern and demands, and handle environmental conflict in a more flexible manner [36, 37] . fu and geng explore the influence of public participation and regulation compliance on 'green development' with panel data from 30 provinces in china from 2004 to 2014, finding that public participation can lead enterprises to improve compliance and thus promote green development [8] . regional environmental quality (req) is a comprehensive indicator of emissions of waste gas, waste water, and waste solids, and its improvement requires coordination between governance and public participation. public participation can be coordinated with governance to effectively improve req effectively, and further promote the optimization of environmental governance system [38] . the arrival of the internet era has changed the method of public participation. as a branch of e-government, e-participation has been widely examined by scholars. considering that public participation is a voluntary activity, whether the public is willing to participate is the decisive factor affecting the success of e-government platforms. scholars consider that in addition to demographic differences, willingness to use an e-participation system is affected by system technical factors, personal incentive factors, and social capital factors. based on the unified theory of acceptance and use of technology, planned behavior theory, social capital theory, and other information system theories, previous studies have explored the willingness of the public to use the e-community to participate in policy-making and provide strategic suggestions for governments to improve e-government platform [39, 40] . product innovation is an important focus in the innovation research field and is key for enterprises to obtain sustainable competitive advantage. at present, there is no unified definition of product innovation in academia. katila and ahuja define it as change in design attributes-such as technology, appearance, quality, and structure-relative to the existing products of an enterprise. this is also known as technological innovation or design innovation [41] . the organization for economic co-operation and development defines product innovation as the process leading to a new or significantly improved product or service [42] . various scholars' definitions of product innovation, identify two aspects: entity product innovation and service-related innovation. according to the different degree of innovation, product innovation can be divided into radical innovation and incremental innovation [43] . rapid change in the external environment drives enterprise innovation; enterprises can only achieve long-term development by constantly producing more competitive products according to the needs of users. as an external innovation resource, customer voice can be regarded as a gift given by users to enterprises to help them carry out product innovation based on the collective wisdom [44] [45] [46] . customer voice provides valuable information for enterprises, which can help product designers and engineers to understand customers' needs and preferences, and turn them into key objectives of product improvement by making targeted adjustments to products and services to meet the needs of users [47] . further, customer voice can help enterprises identify the product attributes to which customers pay most attention and focus on product improvement and new product development [48] . governance refers to processes and structures in public decision making and may involve the participation of multiple agents, such as governments, corporations, and the public, with the aim of carrying out a public purpose that cannot be accomplished by single force [49] . cooperative governance is not limited to formal government-initiated arrangements, but involves diverse kinds of multi-partner governance related to a wide range of fields [49] . for example, because of the production of pollution, enterprises take the greatest responsibility for environment contamination control. however, as it is difficult for governance goals to be achieved through the actions of a single enterprise, so governance among enterprises is indispensable [50] . with regard to cooperative governance among governments, zhang et al. find that superior government should supervise heterogeneous local governments and increase penalties for non-cooperative parties to improve the efficiency of haze pollution control [51] . further, cooperative governance can provide guidance for participatory governance by the public [4] . studies of cooperative governance involving public participation have focused on environmental governance and sustainable development. when making local energy decisions, local governments should be given more autonomy and sufficient capacity to strengthen public participation. what is more, public opinion ought to be taken into consideration when developing policy [52] . studies show that policy-making style presents convergence to the cooperation among government, public and non-profit organizations. as the government may lack the necessary resources to deal with issues, they rely on other subjects to provide support to ensure policy utility [53] . to summarize, there are several problems needing to be solved: first, research on public voice is not mature and more studies are needed to clarify its antecedents as well as its effects on policy implementation and social development. second, it is undeniable that the public plays a crucial role in environmental governance, but the role of public voice behavior in policy-making and implementation under public health emergencies is still unclear. third, the role played by public voice in cooperative governance and how this happens deserve exploration. at the beginning of 2020, the outbreak of covid-19 brought great impact on people's life and work. in order to contain the spread of novel coronavirus and speed up the normalization of production and life, on 7 february 2020, yuhang first launched the yuhang health code. and on 11 february 2020, hangzhou launched the hangzhou health code to implement "green code, red code, yellow code" three-color code dynamic management [18] . the implementation of this policy has aroused widespread concern of the people all over the country, and local governments have followed up and implemented a local version of code in few weeks [18] . the implementation of health code policy is assisted by the qr rating health code system developed by alibaba, tencent, or other firms. when registering, individuals should provide their names, id numbers, phone numbers, and answer a series questions about physical health conditions and travel trajectory to get the initial rating [54] . in addition, the rating changes according to individual real-time data, which consists of individuals' travel history, directly related health information, overall medical test results, and overall risk assessment from individuals' reports, information from gps (global positioning system), telecommunications supplier, consumption record, qr code usage record, etc. the system assesses individual's infection risk and generates green, yellow, or red codes according to individual's data [55] . people with green codes have a very low probability to be infected and can move around freely, while people with yellow codes have a risk to be infected to some extent and should be quarantined for a week. people with red codes are at great risk of infection and need to be quarantined for 2 weeks. during the quarantine, if people with yellow or red codes check in on the app every day, the codes will turn green at the end of quarantine periods. and if the real-time information shows that people with green codes have gone to a high-risk area or been in contact with an infected person, the code will turn yellow or red as well [10] . up to august 2020, the tencent health code covers a population of 9 hundred million people, more than 400 cities and counties, and more than 5100 villages in china, with a cumulative total of 42 billion visits [56] . with the evolution of the health code policy, the effective circulation of personnel from all over the country has met the needs of residents' normal life and enterprises' resumption of work and production. at present, residents only need to provide a real-time qr code generated in a mini-app embedded in alipay (alibaba, hangzhou, china) or wechat (tencent, shenzhen, china) to the guard, they can move around [54] . in the health code policy implementation process, the high-tech enterprises not only provide technical support to develop the health code system, but also participate in the formulation of policy standards and establishment of policy platforms. for example, alibaba and tencent have been fully involved in the formulation of national standards for the personal health information code series [57, 58] . besides, during this process, the public is actively voicing on the implementation and evolution of the health code policy as well as improvements of health code application on social media. in the official weibo of people's daily, tweets about the health code policy get plenty of comments and followers, most of which are advice for policy implementation and system improvement. for example, the tweet about the hangzhou health code has 7227 comments and 79,547 followers. the government press conference and reports about enterprises confirm the public voice does play an important role in the evolution and promotion of health code policy and the voice is fully considered and adopted by government and enterprises when making decisions. on the joint prevention and control conferences of covid-19, the government spokespersons provided response to public concern and the governments also instructed local government and related enterprises to take measures to meet public voice. in addition, the enterprises responded to public voice as well. in the government affairs strategy conference, yuepeng qiu, vice president of tencent, said that they had updated the system more than 50 times. this study adopts a dynamic research perspective, and takes the dynamic evolution of health codes policy as an example, focusing on exploring how public voice promoted the improvement of products by enterprises and the implementation of policies by the government under a public health emergency. the core of grounded theory emphasizes the process of collecting and analyzing original data. in the data collection stage, the researcher takes the evolution process of the health code policy as the time axis, and collects public comments under the official microblog of the people's daily as the research object. data analysis included the following stages: firstly, open coding is used to identify phenomena, define concepts, and discover categories from the original data. secondly, axial coding is carried out to further analyze to get the main category. thirdly, selective coding is used to find the core category, and systematically connect it with other categories to construct a logical relationship. in the whole coding process, researchers keep supplementing the material. finally, the selective coding is analyzed and theoretical construction is carried out, and the density, variation, and high integration of theoretical concepts are adjusted to form a theoretical framework. the qualitative analysis software nvivo 11.0 (qsr international, melbourne, australia) was used for the analysis of this study. open coding is to analyze the original data word by word, so as to summarize the initial concepts and categories in the original data. following the process of "tagging-conceptualizationcategorization", the researchers analyzed the collected data word by word and refined the semantics of the data to obtain the corresponding concepts and categories. examples are shown in table 1 . it's much more convenient than running around to apply material this is not only efficient to reduce the burden of screening personnel, but also can record personal travel the purpose of axial coding is to explore the potential logical relationship between categories and develop main categories. this study classifies different categories according to their relationship at the conceptual level, and concludes eight main categories, which are divided into three classifications. the main categories and their corresponding classifications and relations are shown in table 2 . there is a risk of information leakage when the product collects too much user information there is a risk of abuse of rights when enterprises assume part of government responsibilities on the basis of axial coding, selective coding excavates the core category from main categories and analyzes the connection relationship among them. as shown in figure 1 , the dynamic mechanism of public voice behavior to promote policy implementation and evolution in public health emergencies is as follows: first, under the guidance of the government, enterprises participate in the development of policy and design products to assist policy implementation with advanced technologies. second, in response to the government policy, the public will use enterprise products in their daily life and work. and through judging whether the policy can effectively solve the current problems and guide the future development of the society to form the policy effectiveness perception. third, public's perception of the effectiveness of policies will trigger public emotions. different perceptions of policy effectiveness can lead to positive or negative emotions. then, emotions can induce public voice behavior, including voice for government policies and for enterprise products. finally, the government and enterprises will give feedback to the public voice and improve the policies and products accordingly. as a new external stimulus, the improved policies and products also have an impact on the public's perception of policy effectiveness, forming a dynamic mechanism of public suggestions to promote policy evolution and product innovation, as shown in figure 1 . induce public voice behavior, including voice for government policies and for enterprise products. finally, the government and enterprises will give feedback to the public voice and improve the policies and products accordingly. as a new external stimulus, the improved policies and products also have an impact on the public's perception of policy effectiveness, forming a dynamic mechanism of public suggestions to promote policy evolution and product innovation, as shown in figure 1 . based on the results of grounded theory and cognitive appraisal theory of emotion, this paper constructs a driving mechanism of public voice behavior: "stimulus-cognition-emotion-behavior" model. the model shows that there are causal relationships among cognition, emotion, and behavior. according to the cognitive appraisal theory of emotion, under the stimulation of external events, the external information obtained by individuals first enters the perceptual system for compilation and processing, forming specific cognitions. cognitions trigger the individual's emotional response, and finally produces specific behavioral tendency [59] . based on the results of grounded theory and cognitive appraisal theory of emotion, this paper constructs a driving mechanism of public voice behavior: "stimulus-cognition-emotion-behavior" model. the model shows that there are causal relationships among cognition, emotion, and behavior. according to the cognitive appraisal theory of emotion, under the stimulation of external events, the external information obtained by individuals first enters the perceptual system for compilation and processing, forming specific cognitions. cognitions trigger the individual's emotional response, and finally produces specific behavioral tendency [59] . public policy is the political and technical approach to solve problems, fundamentally, it is pragmatic [60] . under the cooperative governance, the government is no longer the only decision-maker, but the main participant plays a guiding role [49] . with the advent of the new internet era, the impact of big data, cloud computing, and other technologies on policy formulation and implementation cannot be ignored. first of all, the internet can optimize the link of policy-making, and the process of it can be completed with the help of the internet, thus making policy-making more efficient. secondly, big data can provide a wider range of data sources for policy evolution. through data mining and analysis, it can provide big data support for policy evolution, making policy formulation and implementation more reasonable. finally, the open data system can further broaden the channels for the public to participate in policy discussions and make policy-making more democratic. due to the immature application of big data by the government and lack of professional talents, enterprises are required to provide technical support. the technical support of enterprises is more important for the formulation of policies under public health emergencies. as public health emergencies tend to be urgent, destructive, and uncertain, putting forward higher requirements for the timeliness, scientificity, and effectiveness of policies. in this case, it is very necessary for the government to cooperate with enterprises to formulate policies. the government is responsible for policy formulation and implementation, while enterprises take technological advantages to provide products or services to assist policy implementation. according to the cognitive appraisal theory of emotion, when individuals encounter the external stimuli, they will experience two-stage cognitive appraisal processes: primary appraisal and secondary appraisal. in addition, through the appraisal, people can assess the relevance of external stimuli to themselves and whether the resources they have can cope with the situation [61] . in public health emergencies, the policy launched by government-enterprise cooperation is an external stimulus for the public. additionally, public appraisal mainly focuses on whether the policy can achieve policy purpose and effectively solve specific public problems, that is, perceived policy effectiveness. under the policy stimulation, the public will use the cognitive system to make evolution of it [62] . the perception of policy effectiveness reflects the individual's judgment of the correlation between the policy and himself and is an important way for policy to act on public behavior. a high level of perceived policy effectiveness indicates that the public believes the policy is beneficial to their daily life, while on the contrary, they consider that the policy has no significant positive impact or may pose a threat. policy is the action route or method to guide the current and future decision-making, and its role should not be limited to solving the current problems, but also should be instructive for future development of society [63] . according to the results of analysis, the policy effectiveness in public health emergency includes crisis resolution and social normalization. in the case of public health emergencies, the first problem to be solved by policies is to reduce the adverse impact of emergencies, that is crisis resolution. on the premise that the crisis is under control, policies should also have effects of accelerating the social normalization and promoting economic recovery, that is, the social normalization function. taking the health code policy as an example, if the public thinks that the health code policy cannot effectively control the spread of covid-19, or cannot speed up work resumption, the public's perceived effectiveness of health code policy will be low. otherwise, the perception will be high. emotions are the products of an individual's appraisal of the person-environment relationship and of great diagnostic value to help an individual identify what is important under a specific situation. additionally, emotions vary with the change of appraisals [61] . the public's emotional response to policy is formed on the basis of perceived policy effectiveness. according to the cognitive appraisal theory of emotion, emotion intuitively shows the public's evolution of external stimulus perception, and its core is evaluative cognition. almost everything will stimulate people to produce emotion, no matter if it happens or not [62] . however, emotion cannot be aroused by external stimulus directly; the appraisal process of relationship between person-environment is necessary to evoke emotion. when individuals are in a certain situation, they will evaluate it, be satisfied or dissatisfied, beneficial or harmful, and make corresponding emotional reactions [59] . if perceived policy effectiveness is high, the public will have a positive emotion, or vice versa. taking the health code policy as an example, different perceptions of public policy effectiveness will stimulate different emotions. when the public perceive that the health code policy can effectively control the spread of covid-19 or accelerate economic recovery, they will generate positive emotions. otherwise, they will hold negative emotions. examples of comments about health code policy are as follows. comment 1: as i am from hubei province, i didn't go back to my hometown, so i couldn't enter the market for 20 days. after having the health code, i entered the market for the first time without being stopped. it is easy to use and it's really convenient, give it a thumb up! comment 2: i'm in fuyang, and i'm not even allowed to go to my husband's hometown in the countryside. i haven't left fuyang for nearly a month. i haven't even gone to downtown or move around fuyang. what the hell is this code? i don't understand. i'm so angry! according to the cognitive appraisal theory of emotion, the cognition and appraisal of external environment will stimulate special emotions. then, the emotion will motivate coping behaviors to prevent harm or to improve the prospects for benefit [64] . public voice behavior is generated under the influence of public emotions. according to cognitive appraisal theory of emotion, emotional response will lead to an individual's specific behavior tendency to regulate the emotion (emotion-focused coping) or change for the better the problem (problem-focused coping) [61] . on the basis of the public perceived policy effectiveness, the emotional reaction is finally transformed into the driving force to improve the effectiveness of the policy, which urges the public to put forward a constructive voice or point out the problems existing in the policies and products. when the public believe the policy can effectively defuse the current crisis and benefit future development, they will hold positive emotions and employ behaviors that can maximize the policy benefits. however, when the public think that there are some defects in the process of policy implementation undermining the policy effectiveness, they will generate negative emotions and take actions to reduce potential harm. after analysis, it is found that public voice can be divided into two dimensions: policy voice and product voice. according to the content of voice, policy voice can be divided into policy evolution and policy implementation. policy evolution voice is promotive voice and usually occurs when the public is in positive emotion, referring to the public's suggestions on the promotion and unification of policies across the nation. policy implementation voice refers to the voice made by the public for the actual implementation process of policies. in a public health emergency, policy implementation voice is mainly in the form of pointing out defects in the process of policy implementation, and it usually happens when the public is in negative emotion. public voice on products can be divided into product utility and potential risk. product utility voice refers to the public's suggestions on improving product efficiency and it includes both promotive voice as well as prohibitive voice. while potential risk voice is prohibitive voice, referring to the public's concern about the negative effects caused by enterprise's products. the examples of the health code policy are shown below. comment 3: now in many provinces, the biggest problem is that people are not allowed to enter the community! not even people with health codes! this is too unreasonable! if a policy is made, it is to be implemented. what good is policy if the implementation problem at the grassroots level is not solved? comment 4: the health code really gives me a great convenience in my life. it's easy to go out with it. i hope it can be promoted nationwide. in conclusion, the formation process of public voice behavior conforms to the "stimulus-cognition-emotion-behavior" model of cognitive appraisal theory of emotion. policy stimulus leads to the public's cognition of the effectiveness of policy, which arouses public emotion response and further leads to public voice behavior. the formation and evolution of policy is a dynamic and continuous process. previous studies have paid more attention to the impact of public participation in the policy-making stage [65, 66] . however, this study finds that after policies are made, public voice also has a great impact on the evolution and implementation of policies. based on the results of grounded analysis, this paper divides the process of policy evolution into three stages: policy formation, policy promotion, and policy optimization, and constructs a dynamic mechanism of public voice to promote policy evolution and product innovation, as shown in figure 2 . the policy is formed in accordance with the rigorous policy-making process in order to solve specific public problems. as the output of the political system, the main function of policy is to solve social public problems effectively. as public health emergencies often pose a major threat to social security and public order, as well as the safety of citizens' lives and property, the policy under public health emergencies aims to resolve the crisis state timely and effectively and restore the normal life order as soon as possible [15] . as an external stimulus, the formation of policies will lead to the public's perceived policy effectiveness. at this stage, citizens' cognition of policy effectiveness mainly focuses on crisis resolution. whether the policy can effectively alleviate the adverse impact of public health emergencies is an important factor affecting public emotion. when policy is implemented, the public will form the perception of whether the policy can resolve the crisis effectively. when perceived policy effectiveness is high, the public will have positive emotion and tend to conduct promotive voice. as the construction of national emergency management system follows the basic principles of "ability-standard" and "center of gravity down", the local government is in the front line when dealing with public health emergencies and bears the main responsibility. therefore, the policies under public health emergencies are often formulated by the local government, and the superior government selectively promotes the policies according to the evolution of the applicability. so the public will suggest to promote policy across the country if they think the policy is effective enough. besides, the public will provide promotive voice to improve product utility in a state of positive emotion. when the public perceive the policy is not effective enough, they will have negative emotion and tend to conduct a prohibitive voice. public health emergencies prevent policy-making from following a strictly procedural process. the government needs to complete the implementation of the policy in a limited time, and it is difficult to guarantee the implementation of the grassroots administrative staff in a short time [15] . therefore, the prohibitive voice mainly focuses on pointing out the problems existing in the implementation of the policy at the grassroots level. in the policy formation stage, as the implementation of enterprise's product auxiliary policy, the public's requirements for its effectiveness are more stringent. therefore, the public will be more active in pointing out problems in the use of products. through the evolution and adoption of public voice, the government improves the policy and the policy is formed in accordance with the rigorous policy-making process in order to solve specific public problems. as the output of the political system, the main function of policy is to solve social public problems effectively. as public health emergencies often pose a major threat to social security and public order, as well as the safety of citizens' lives and property, the policy under public health emergencies aims to resolve the crisis state timely and effectively and restore the normal life order as soon as possible [15] . as an external stimulus, the formation of policies will lead to the public's perceived policy effectiveness. at this stage, citizens' cognition of policy effectiveness mainly focuses on crisis resolution. whether the policy can effectively alleviate the adverse impact of public health emergencies is an important factor affecting public emotion. when policy is implemented, the public will form the perception of whether the policy can resolve the crisis effectively. when perceived policy effectiveness is high, the public will have positive emotion and tend to conduct promotive voice. as the construction of national emergency management system follows the basic principles of "ability-standard" and "center of gravity down", the local government is in the front line when dealing with public health emergencies and bears the main responsibility. therefore, the policies under public health emergencies are often formulated by the local government, and the superior government selectively promotes the policies according to the evolution of the applicability. so the public will suggest to promote policy across the country if they think the policy is effective enough. besides, the public will provide promotive voice to improve product utility in a state of positive emotion. when the public perceive the policy is not effective enough, they will have negative emotion and tend to conduct a prohibitive voice. public health emergencies prevent policy-making from following a strictly procedural process. the government needs to complete the implementation of the policy in a limited time, and it is difficult to guarantee the implementation of the grassroots administrative staff in a short time [15] . therefore, the prohibitive voice mainly focuses on pointing out the problems existing in the implementation of the policy at the grassroots level. in the policy formation stage, as the implementation of enterprise's product auxiliary policy, the public's requirements for its effectiveness are more stringent. therefore, the public will be more active in pointing out problems in the use of products. through the evolution and adoption of public voice, the government improves the policy and policy evolution enters the policy promotion stage. as a new external stimulus, the improved policy continues to act on public cognition. more than that, the focus of perceived policy effectiveness begins to shift from crisis resolution to social normalization. under the control of the government, the grassroots implementation has been further improved, and the effectiveness of policies to solve current problems (i.e., crisis resolution effectiveness) has been effectively played. however, the effects of policies cannot limit to provide methods to solve the current problems, but also play a guiding role in the future development of society [63] . public health emergencies make society change from normal state to emergency state, which has a great impact on public life and work [15] . therefore, on the basis of effective resolution of the crisis, whether the policy can further promote the recovery of social normality has been widely concerned by the public. under the influence of public emotion caused by the cognition of policy utility, voice behavior emerges. in the stage of policy promotion, public promotive voice is policy unification. government policy-making under public health emergencies emphasizes the local government's ability of 'territorial management'. however, with the promotion of local policies across the country, the problem of compatibility between policies begins to emerge. the inconsistency of policies in different regions will bring many inconveniences to the public. therefore, in order to improve the effectiveness of policies, the public suggests that policies should be unified across the country. at this stage, with policy promotion, the audience range of the product is constantly expanding, the public's attention to the product utility is also increased. improvement suggestions to enhance the effectiveness are still the focus of voice. however, in addition to the utility of the product, the public also began to pay attention to the use experience of the product, pointing out the problems of the system in the use process. under the influence of public voice, the government and enterprises constantly improve the policies and products, and the policy evolution enters the optimization stage. at this time, with the public health emergency in the rehabilitation stage, the effectiveness of the policy has been played out to a greater extent; the public urgently need to return to normal life and work state, so the focus of perceived policy effectiveness is social normalization. public voice is still affected by the emotional response based on cognition, and the content of public voice has changed further. considering the adverse impact of public health emergencies, with the purpose of preventing the recurrence of the public health emergency, the public suggest that the policy should be normalized. policy normalization can predict the occurrence of public health emergencies in the early stage and minimize the loss. in addition, the public begin to pay attention to the coverage of the policy, pointing out that the omission of the population covered by the policy may have a negative impact on the fairness. with regards to the products of enterprises, the public voice focuses on the risks of long-term use of products. products are tools for enterprises to participate in cooperative governance and used to supply policy implementation. with the help of products, enterprises take part of the responsibilities originally belonging to the government, which will cause public concern. to sum up, public voice plays an important role in the evolution of policies. first, public opinion provides the widest source of information for policy feedback. public health emergencies require the government to formulate effective policies in the shortest time based on the least information and resources, and the effectiveness of the policies is uncertain [15] . the public voice gives quick feedback to the policy, which provides the basis for the government to evaluate the effectiveness of the policy. second, the public voice expresses the public interest demands and promotes the policy to be more democratic and efficient [67] . in order to gain more and more public support in the process of policy-making, public voice is an important consideration for the government in the process of formulating and implementing policies. finally, public voice behavior also plays an important role in product improvement and innovation. it can be seen from the analysis, that in the policy of government enterprise cooperation, due to the particularity of the product, the public's requirements are more stringent. voice for product improvement aims at making it more suitable to assist policy implementation, and it will provide an important reference for enterprise product innovation. this study reveals the driving mechanism of public voice behavior and enriches the literature on voice behavior. first, based on the results of qualitative research, this paper employs the cognitive appraisal theory of emotion to explain the process of formation of public voice behavior under public health emergencies, via the stimulus-cognition-emotion-behavior model. unlike voice within an organization, public voice on social media is a kind of self-motivated behavior free from the pressure of peers and organizational climate [4] . what is more, as the purpose of public voice is to improve social status quo, the cognitive appraisal theory of emotion is eminently suitable for explaining the formation of public voice behavior. as an external stimulus, a policy will have an impact on the public's cognitive processes, and prompt them to evaluate whether the policy can resolve a current issue and play a guiding role in the future development of society. when the public perceives the policy to be highly effective, they will have positive emotions; otherwise, they will have negative emotions. take the health code policy as an example, if the public think that the policy can effectively contain the spread of the novel coronavirus and speed up the resumption of the normal activities, they will experience positive emotions, and vice versa. in accordance with the cognitive appraisal theory of emotion, emotional response will stimulate behavioral tendencies. the public's positive emotions will lead them to employ a promotive voice to expand the effectiveness and coverage of the policy, whereas the public has the tendency to use prohibitive voice to reduce the possible negative effects of a policy when they are not satisfied with its effectiveness. this result is consistent with previous studies that make a clear distinction between promotive voice and prohibitive voice, where the former is positive in tone and the later negative [68] . in this study, members of the public feeling positive emotions will voice to promote a policy and establish uniform standards throughout the nation, whereas those experiencing negative emotions will identify deficiencies such as implementation at the grassroots level. second, this study clarifies the objects and types of public voice. compared with employee voice and customer voice, the coverage of public voice is more extensive. thus, for different problems, the objects of public voice are also different, which require separate analysis in each situation. under this circumstance, the objects of public voice include two main bodies involved in policy-making: governments and enterprises. for the health code policy, the objects of public voice are the government, alibaba, and tencent. with regard to voice type, there is some similarity with the other two kinds of voice-public voice can also be divided into promotive voice and prohibitive voice. finally, through qualitative research, this paper has attempted to reveal the role of public voice in policy evolution and product innovation, clarifying the promoting effect of public voice on societal improvement. the study emphasizes the importance of public voice via social media, suggesting that both government and enterprises ought to attach more significance to public voice when making decisions. taking china's health code policy under covid-19 as an example, this paper has constructed a dynamic mechanism for the effects of public voice on policy evolution. the study focused on the promotion of public voice for policy improvement and evolution in the late stages of policy-making. public opinion contains information about demands and aspirations which is very valuable for decision makers. to absorb more public opinions and take into account public aspirations or priorities before policy formulation, previous research has paid much attention to the impact of public opinions at the pre-policy-making stage [65, 66] . no studies have examined the impact of public voice on policy after its implementation. the development of social media not only provides a wider source of information for the public, but also builds a more convenient platform for the public to voice their opinions at any stage of policy formulation or implementation, thus having effect on policy. this study shows that after a policy is implemented, public voice is still of great value for policy evolution. however, this study divides policy evolution into three stages: policy formation, policy promotion, and policy optimization. it introduces changes in public policy utility perception and public voice content at different stages, and constructs the dynamic mechanism of the effect of public advice on policy improvement based on the government's adoption of public advice to promote policy evolution and implementation. to some extent, this study provides support for cooperative governance research. cooperative governance has different connotations in different situations, and there are also some differences among participants. the formulation and evolution of policies under public health emergencies is an important practice of cooperative governance. faced with a public health emergency, the government, enterprises, and citizens should form an open overall system to jointly govern social public affairs. the government, enterprises, and individuals play their own roles, participate and cooperate with each other to effectively reduce the negative impacts of a crisis and maintain the stable development of society. in this process, governments, enterprises, and the public are in a more equal position, and multi-agent participation is truly realized. faced with covid-19, yaowen wang, deputy director of shenzhen municipal government service data management bureau, said the epidemic situation was a great challenge to the government's governance ability and level. in addition, the fundamental problem was laid in whether the whole society could be quickly mobilized and organized to participate in the prevention and control in a short period of time. as an organ of power, the government is responsible for the formulation and implementation of policies. enterprises participate in the formulation of policies, and provide products and services with technical advantages to assist with policy implementation. as for the public, in addition to regulating their own behaviors under the guidance of policies, they also provide feedback and voice on policies and enterprises' products and services. take china's health code policy as an example, the government is responsible for the formulation and implementation of the policy. alibaba and tencent are committed to the development and updating of the health code system and participate in the formulation of the policy standards. the public need to move around in strict accordance with the policy guidelines and actively provide voice. under a public health emergency, public voice is an important way for public to participate in cooperative governance. it provides real-time feedback for policy, helping government and enterprises to make decisions as quickly as possible and set aside more time to fight against emergencies. further, public voice can facilitate the promotion of effective policy, improving prevention efficiency. as a universal way of participating in cooperative governance, public voice via social media deserves more attention in the future. although this research makes several contributions, there are still some limitations. first, we studied the influence of public voice only on policy evolution and specific product innovation. as public voice is social-oriented, it will affect almost all social affairs and phenomena. future research can explore the influence of public voice behavior in other respects. second, this study revealed the generative mechanism of public voice behavior from the perspective of emotional cognition. as a self-oriented behavior, public voice may be triggered by other internal processes. future research could explore the antecedents of public voice from different perspectives. third, this study was conducted under a public health emergency, covid-19. as public emergencies take several forms, the results differ in different situations. future research might examine public voice in other contexts. fourth, although many countries and regions have formulated corresponding policies in the context of public health emergencies, results from the study of china's health code policy under covid-19 may not be fully applicable to other nations, and future research should be conducted in different cultural contexts. author contributions: y.y. conceived the idea of this study, y.s. collected and analyzed data and wrote this paper. all authors have read and agreed to the published version of the manuscript. speaking up when water is murky: an uncertainty-based model linking perceived organizational politics to employee voice leadership behavior and employee voice: is the door really open? acad leader personality traits and employee voice behavior: mediating roles of ethical leadership and work group psychological safety constructive voice behavior for social change on social networking sites: a reflection of moral identity does performance management relate to good 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of governance: problems of democratic accountability in complex environments hangzhou proposes more expansive health code system we read the technical standards for china's 'health code has launched for 100 days, covering 1 billion users the national health code standard, which tencent participated in developing, was officially released the national standard of personal health code was released, and alibaba participated in the formulation introduction: understanding public policy through its instruments-from the nature of instruments to the sociology of public policy instrumentation if it changes it must be a process: study of emotion and coping during three stages of a college examination emotion and adaptation how governmental policy is made dynamics of a stressful encounter: cognitive appraisal, coping, and encounter outcomes sacred land, mineral wealth, and biodiversity at coronation hill, northern australia: indigenous knowledge and sia. impact assess. proj democratisation versus engagement? social and economic impact assessment and community participation in the coal mining industry of the bowen basin public deliberation in an age of direct citizen participation servant leadership and follower voice: the roles of follower felt responsibility for constructive change and avoidance-approach motivation this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord-340882-why0t9ld authors: carneiro, lara; afonso, josé; ramirez-campillo, rodrigo; murawska-ciałowciz, eugenia; marques, adilson; clemente, filipe manuel title: the effects of exclusively resistance training-based supervised programs in people with depression: a systematic review and meta-analysis of randomized controlled trials date: 2020-09-15 journal: int j environ res public health doi: 10.3390/ijerph17186715 sha: doc_id: 340882 cord_uid: why0t9ld the purpose of this study was to systematically review the effects of supervised resistance training (rt) programs in people diagnosed with depression or depressive symptoms. the following databases were used to search and retrieve the articles: cochrane library, ebsco, pedro, pubmed, scopus and web of science. the search was conducted in late june 2020. search protocol required the title to contain the words depression or depressive or dysthymia. furthermore, the title, abstract or keywords had to contain the words or expressions: “randomized controlled trial”; and “strength training” or “resistance training” or “resisted training” or “weight training”. the screening provided 136 results. after the removal of duplicates, 70 records remained. further screening of titles and abstracts resulted in the elimination of 57 papers. therefore, 13 records were eligible for further scrutiny. of the 13 records, nine were excluded, and the final sample consisted of four articles. results were highly heterogeneous, with half of the studies showing positive effects of resistance training and half showing no effects. in two of the four combinations, the meta-analysis revealed significant benefits of rt in improving depressive symptoms (p ≤ 0.05). however, considering significant differences with moderate (effect size = 0.62) and small (es = 0.53) effects, the heterogeneity was above 50%, thus suggesting a substantial level. to draw meaningful conclusions, future well-designed randomized controlled trials (rcts) are needed that focus on understudied rt as a treatment for depression. data from 2016 has revealed that depression is the leading cause of mental health-related disease burden globally, affecting an estimated 300 million people worldwide [1] . the who declared the sars-cov-2 (covid-19) outbreak a global pandemic in march 2020, which has affected the lives of 71,429 people globally [2] , and may potentially generate an increase in depressive states as a result of psychosocial stressors like life disruption, fear of illness, or fear of negative economic effects [3, 4] . therefore, it is important to understand how to approach depression and depressive symptoms in order to better prepare for an expected increase of people affected by it. the conventional treatment to treat depression is antidepressant medication. besides pharmacotherapy, clinicians recommend cognitive behavior therapy and mindfulness-based therapy [5] , as well as physical exercise [6] . thus, treatment guidelines for mental illnesses from leading international organizations now recommend the integration of physical activity-based interventions as part of routine psychiatric care [7] . exercise promises to be an efficacious treatment for people with depression. indeed, several systematic reviews and meta-analyses have positively assessed the effects of exercise on depression [8] [9] [10] [11] [12] [13] [14] . furthermore, persons with depression are at an increased risk of sedentary behavior [15] , and exercise contributes to physical health in addition to mental health [6] . specifically, evidence-based recommendations for the prescription of exercise for patients with major depressive disorders (mdds) propose interventions of 2-3 sessions of supervised aerobic and/or aerobic and resistance training exercise of 45-60 min duration with moderate intensity per week [7] , although it has been suggested that the volume of training may be more relevant than frequency [16] . to achieve optimal outcomes and decrease dropouts, the evidence also indicates that physiotherapists and qualified exercise professionals should lead and supervise physical exercise programs [17] . even home-based programs, which may occur due to a plethora of reasons (e.g., distance, difficulties with transportation, costs), could benefit from being supervised through the utilization of new technological tools [18] . this could become more relevant if future scenarios similar to the covid-19 situation are to be repeated and, therefore, force people to stay at home for prolonged periods of time. the benefits of aerobic exercise (ae) for depression have been well documented; namely, it has been recognized that it promotes neurophysiological effects of which results may be similar to those observed after antidepressant drug treatments [19] . a meta-analysis of seven randomized controlled trials [20] showed that there was also good evidence that aerobic exercise over roughly 12 weeks improved cardiorespiratory fitness in people with depression. however, the effects of resistance training (rt) are less investigated, and the literature regarding rt as a stand-alone therapeutic intervention for mdd is limited [7] . earlier studies that focused on rt for people with depression reported positive effects. however, these must be interpreted with caution due to the heterogeneity of the interventions and poor methodology by reporting several confounding variables that could interfere and introduce the potential for bias. as an example, kim et al. [21] aimed to investigate the effects of 24 weeks of the rt program on depression in older women and their neurotransmitters. however, the rt intervention was composed of a 10 min warm-up consisting of walking and dynamic stretching, and then a 10 min cool-down with static stretching. therefore, 20 min of the program, 40% of the session in part i, 33 .3% in part ii and 28.5% to 25% in part iii, were devoted to activities that were not resistance training, and this may have contaminated the data. to date, only one meta-analysis examined the efficacy of rt on depressive symptoms. gordon and colleagues [22] analyzed 33 papers meeting their inclusion criteria. their review concluded that rt significantly reduced depressive symptoms in adults regardless of health status, the total prescribed volume of rt, or significant improvements in strength. however, in the present systematic review and meta-analysis, which differs from the previous, more strict inclusion and exclusion criteria were defined. namely, we excluded other comorbidities (e.g., parkinson's, alzheimer's, cancer and dementia) and only supervised exclusively resistance training-based interventions, with minimal warm-up activities outside the scope of the main exercise mode. therefore, this systematic review and meta-analysis allows for a more comprehensive assessment of the potential benefits of rt for depression pathology. hence, this systematic review with meta-analysis (srma) addresses one question: how effective is a stand-alone supervised intervention with rt at improving depression? this systematic review and meta-analysis followed the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines and the cochrane collaboration guidelines for the evaluation of risk of bias in randomized studies. the protocol was published in the international platform of registered systematic review and meta-analysis protocols with the number inplasy202070004 and doi 10.37766/inplasy2020.7.0004. articles were eligible if they were published or in press in a peer-reviewed journal, with full text in the english language. no limitations were placed regarding publication date, and articles in press were considered. the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines were adopted [23] . p.i.c.o.s. was established as follows: (i) participants were humans explicitly diagnosed with any form of depression according to established criteria (e.g., the american psychiatric association's [24] diagnostic and statistical manual of mental disorders-dsm-5 ® or previous versions, or the world health organization's [25] international classification of diseases-icd-11 or previous versions) or those with depressive symptoms above clinical threshold (cutoff values) determined by a validated screening measure (e.g., beck depression inventory-bdi or bdi-ii-by beck et al. [26] , the hamilton rating scale for depression-ham-d-by hamilton [27] , the geriatric depression scale-gds-of yesavage [28] ), but without other major disease (e.g., parkinson's, alzheimer's, cancer, dementia); (ii) only supervised exclusively resistance training-based interventions were considered, with minimal warm-up activities outside the scope of the main exercise mode; comparators were control groups not performing any training protocol and/or supervised contrast groups also performing an alternative exercise program (i.e., yoga, stretching, aerobic exercise); outcomes were any effects on performance, health and quality of life; study design was limited to randomized controlled trials (rcts). the following databases were used to search and retrieve the articles: cochrane library, ebsco, pedro, pubmed, scopus and web of science. the search was conducted in late june 2020. search protocol required the title to contain the words depression or depressive or dysthymia. furthermore, the title, abstract or keywords had to contain the words or expressions: (i) "randomized controlled trial"; and (ii) "strength training" or "resistance training" or "resisted training" or "weight training". no limitations were established for publication date, and in press articles were considered. for cochrane library, only trials were considered. for ebsco, the title and abstract had to be searched separately, and, therefore, we chose to search (i) "randomized controlled trial"; and (ii) "strength training" or "resistance training" or "resisted training" or "weight training" without any limitations in the field. for pubmed, combined search only afforded the selection of title/abstract, not keywords. the same was valid for pedro, besides only affording one field at a time. therefore, multiple searches were needed in pedro. in addition, the criterion of "clinical trial" was selected, therefore automatically excluding practice guidelines and systematic reviews. in web of science, the combination of title, abstract and keywords was termed "topic". the initial screening provided 136 results. after the removal of duplicates, 70 records remained. screening of titles and abstracts resulted in the elimination of 57 papers. this was due to the following reasons: (i) non-scientific production (e.g., protocol registrations without actual research; book chapters, letters, replies); (ii) reviews (e.g., narrative or systematic reviews, meta-analyses); (iii) abstract-only records; (iv) original research where the exercise intervention did not apply resistance training; (v) original research where there was no group exclusively using resistance training; (vi) participants with other major health problems (e.g., cancer, parkinson's disease, dementia, end-stage renal disease); (vii) single group experiments; and (viii) papers unrelated to our topic. therefore, 13 records were considered eligible for further scrutiny, and all were written in the english language. of the 13 records eligible for full-text analysis, nine were excluded. the paper by kim, o'sullivan and shin [21] was excluded because the warm-up consisted of 10 min of walking and dynamic stretching, and the training session was followed by a 10 min warm-down consisting of static stretching. therefore, 20 min of the program (representing 40% of the training in part i of the program, 33.3% in part ii and 28.5% to 25% in part iii) was devoted to activities that were not resistance training, and this may have contaminated the results. similarly, the paper by pereira et al. [29] included a 20 min warm-up consisting of walking and stretching, thereby meaning that 40% of the training session duration was not composed of resistance training. in a similar vein, sims et al. [30] stated that there were warm-up and warm-downs besides resistance training, but there was no reporting of the duration and type of activities performed in these two stages. the paper of teychenne et al. [31] was excluded because the strength and conditioning group had a mixture of resistance training and aerobic training. the papers of ansai and rebelatto [32] , chin et al. [33] , kekäläinen et al. [34] , lecheminant et al. [35] , and levinger et al. [36] were excluded because there was no diagnostic of depression and the average values of the utilized scales for evaluation of depression or depressive symptoms did not reach the cut-off value indicative of depressive symptoms. the final sample consisted of four articles: krogh et al. [37] , moraes et al. [38] , sims et al. [39] and singh et al. [40] . the process is synthesized in figure 1 . two of the four articles included had more than one main outcome, resulting in the need to perform more than one meta-analysis ( figure 1 ). ja and fmc conducted the initial search and the screening and exclusion process independently. lc later reviewed the entire process. after this stage, the entire process was compared step by step, and disagreements were discussed with all the authors of this manuscript until consensus was achieved. study characteristics: (i) sample size and general characteristics (e.g., age, sex/gender, physical activity habits); (ii) duration and characteristics of the intervention; (iii) adherence rates to the training protocol. primary outcomes: mean change in depressive symptoms in the exercise group assessed by any validated scale, from baseline to post-intervention, in comparison with the mean change of the control and/or comparison groups. if an author reported the results of two outcome measures meeting our criteria (i.e., mean change/pre and post-test change in depressive symptoms according to two different measures), we used the primary outcome chosen by the author. if this was not clear, we used the ham-d or the bdi to increase homogeneity in our results. these outcome measures were also prioritized since they were commonly used in the exercise and depression literature [9] . secondary outcomes: (i) physical (e.g., performance tests, body composition, perceived exertion); (ii) psychosocial (e.g., body image and appearance, reporting of positive or negative feelings, self-esteem, cognitive evaluations, memory and concentration tasks). the revised cochrane risk-of-bias tool for randomized trials (rob 2) was applied to evaluate the individual studies, considering its five dimensions: bias arising from the randomization process, bias due to deviations from intended interventions, bias due to missing outcome data, bias in the measurement of the outcome and bias in the selection of the reported results. ja and fmc completed the risk-of-bias evaluation independently. after completion of the first coding, the figures were compared, and all disagreements were discussed with all authors of the manuscript and reanalyzed until consensus was achieved. the analysis and interpretation of results in this srma were only conducted if at least three study groups provided baseline and follow-up data for the same measure [41] . means and standard deviations for a measure of pre-post rt interventions were converted to hedges' g effect size (es). the inverse-variance random-effects model for meta-analyses was used because it allocated a proportionate weight to trials based on the size of their standard errors [42] and enabled analysis while accounting for heterogeneity across studies [43] . the ess were presented alongside 95% confidence intervals (cis) and interpreted using the following thresholds [44] : <0.2, trivial; 0.2-0.6, small; >0.6-1.2, moderate; >1.2-2.0, large; >2.0-4.0, very large; >4.0, extremely large. the analyses were carried out using the comprehensive meta-analysis program (version 2; biostat, englewood, nj, usa). to estimate the degree of heterogeneity between the included studies, the percentage of total variation across the studies due to heterogeneity was used to calculate the i 2 statistic [45] . low, moderate and high levels of heterogeneity corresponded to i 2 values of <25%, 25-75% and >75%, respectively [45] . finally, the extended egger's test [46] was used to assess the risk of bias across the studies. in case of bias, a sensitivity analysis was conducted. as described in the methods, the initial search provided 136 articles, of which 70 remained after the removal of duplicates. screening delivered 13 articles eligible for full-text analysis, after which nine papers were excluded with reasons that were previously explained. four articles were included in the qualitative synthesis and meta-analysis. table 1 presents the general data items for the individual studies. the article by krogh, saltin, gluud and nordentoft [37] was an rct with patients diagnosed with unipolar depression according to the icd 10th revision. the sample of 165 patients (73.9% of which were women) was by far the largest among the included articles, potentially affording greater confidence in terms of the generalizability of the results. furthermore, it was the longest trial, with 16 weeks of intervention. three randomized groups of 55 patients each were formed: (i) rt; (ii) aerobic training; and (iii) relaxation, which had characteristics that approximated it to a true control group. primary outcomes were assessed with the hamilton scale, and there were no changes after the 16-week intervention. there were also no changes in secondary outcomes, such as quality of life and cognitive abilities. however, the resistance training group improved in 1 repetition maximum (1rm) testing, while the aerobic group improved in maximal oxygen uptake. most importantly, there were reduced percentages of days absent from work in the rt group. the lack of broader and better results may, however, be due to very poor adherence rates to the training programs, with the top value of 56.2% being attributed to the rt group. table 2 synthesizes the details concerning the rt protocols, table 3 synthesizes the parallel group protocols, while table 4 synthesizes the results for primary outcomes. exercise did not change primary outcomes, but rt reduced absences to work. rt group improved in 1rm chest press, while at group improved in maximal oxygen uptake. no effect on cognitive abilities. moraes et al. [38] randomized trial with three exercise groups as adjunct treatments to pharmacotherapy (antidepressants and anxiolytics) for 25 persons diagnosed with major depressive disorder (mdd) according to dsm-iv, not engaged in physical exercise outside of the treatment setting. patients were over 60 years old and sedentary for more than 3 months. exclusion criteria: psychiatric comorbidities, score >18 points in ham-d, score <24 on the mini-mental state examination, cerebrovascular infarction, neurodegenerative disease, severe cardiovascular disease, illiteracy, poor mobility, balance disorders, and severe deficits in visual and/or auditory function. a 12-week intervention. resistance training (n = 9). aerobic training (n = 9). low intensity exercise control (n = 7). all patients had a minimum of 75% attendance rate. none. rt and at groups showed significant reductions in depressive symptoms in both scales compared to controls, therefore improving upon the efficacy of pharmacological treatment only. authors report the rt group had lower depression scores after the intervention, but not at the 6-month follow-up. however, the rt group already had much lower depression scores at baseline. rt group improved significantly in strength, but ultimately there were no significant changes in ces-d from pre-to post or at follow-up. singh et al. [40] randomized controlled trial with 60 adults (33 women and 27 men, >60 years old) with major or minor depression or dysthymia, determined through dsm-iv, and who also had gds score ≥14. exclusion criteria: dementia, folstein mini-mental state examination score ≤23, medical contraindications for exercise, bipolar disorder, active psychosis, perceived suicidal tendencies, currently seeing a psychiatrist, prescribed antidepressant drugs in the previous 3 months, or participating in any exercise training more than twice a week.an 8-week intervention. high intensity rt (n = 20). eighteen completed the study. low intensity rt (n = 20). seventeen completed the study. controls (n = 20). nineteen completed the study. there were six drop-outs. of those who completed the study, adherence rates were >95%. ham-d 17 . gds. physical outcomes: 1rm chest press, upright row, shoulder press, leg press, knee extension and knee flexion. moraes, silveira, oliveira, matta mello portugal, araújo, vasques, bergland, santos, engedal, coutinho, schuch, laks and deslandes [38] performed a 12-week, three-armed randomized intervention with 25 patients diagnosed with mdd according to dsm-4, and all taking medication, with the three groups (i) rt; (ii) aerobic training; and (iii) low-intensity exercise control. the small sample, especially the small number of patients per group, advises caution when generalizing the results. the adherence to the intervention was solid, with all patients engaging in ≥75% of the training sessions. after the intervention, both exercise groups outperformed the controls, showing significant reductions in both the hamilton scale and the beck depression inventory, suggesting that exercise improves the efficacy of exclusively pharmacological interventions. no secondary outcomes were assessed. in their investigation, sims, galea, taylor, dodd, jespersen, joubert and joubert [39] investigated 45 stroke survivor patients (stroke > 6 months before the investigation) diagnosed with depressive symptoms, but that were otherwise healthy at the beginning of the intervention, including in cardiovascular terms (see exclusion criteria in table 1 ). the 10-week program compared an rt group with a non-exercise control group. adherence was solid, with an average of 75% attendance rate to training sessions. the authors reported lower depression scores in the rt group after the 10-week intervention, but not after the 6-month follow-up. this should be interpreted as a normal detraining effect; after all, the patients exercised for 10 weeks, but later went through a detraining process lasting 14 weeks. however, even the short-term comparisons after the 10-week intervention should be taken with a grain of salt, as the differences in the centre for epidemiologic studies for depression scale (ces-d) were already significant in baseline testing, with the exercise group presenting lower scores even before the intervention had started. there were no changes in secondary outcomes, such as quality of life, social support, self-esteem and other psychosocial assessments. unsurprisingly, the rt group improved in 1rm strength testing. finally, singh, stavrinos, scarbek, galambos, liber and singh [40] selected 60 adults with some form of depression or depressive symptoms and randomized them into a high-intensity rt group, a low-intensity rt group and a control group. adherence rates to the 8-week program were excellent, with over 95% average attendance rate to the training sessions. primary outcomes were assessed using the hamilton scale and gds, and showed improvements in depressive symptoms for both experimental groups. interestingly, this was the only study analyzing a dose-response relationship, and the improvements observed in the high-intensity group were much superior to those registered in the low-intensity group. however, the differences between the two experimental groups may have been exaggerated due to an excessive dissimilarity in exercise intensities. firstly, one group worked with 80% 1rm, while the other was limited to 20% 1rm, which was already a very significant difference. most importantly, though, while the 80% 1rm group was regularly re-tested to keep the loads adjusted at 80%, the 20% 1rm group kept the initial loads. therefore, with adaptation to training, it is possible that by the later weeks, the low-intensity group was actually working with 10-15% 1rm. additionally, this study showed that strength gains were associated with a decrease in depressive symptoms. the high-intensity group also experienced greater increases in quality of life. risk of bias was assessed using cochrane's rob 2 (see table 5 ). risk of bias arising from the randomization process was low for the articles by krogh, saltin, gluud and nordentoft [37] and singh, stavrinos, scarbek, galambos, liber and singh [40] , but there were concerns with the other two papers [38, 39] . risk of bias due to deviations from intended interventions (effect of assignment to intervention) was low for all articles. risk of bias in the effect of adhering to intervention was high in the paper of krogh, saltin, gluud and nordentoft [37] , but low for the remaining articles. all articles had a low risk of bias due to missing outcome data. risk of bias in measurement of the outcome was low for the paper of krogh, saltin, gluud and nordentoft [37] , but there were some concerns with the other three papers. finally, risk of bias was uniformly low for the selection of the reported results. out of six dimensions, the article by krogh, saltin, gluud and nordentoft [37] had a high risk of bias in one dimension and low risk of bias in the remaining dimensions. the article by singh, stavrinos, scarbek, galambos, liber and singh [40] presented some concerns in one dimension, but low risk for the others. finally, the articles by moraes, silveira, oliveira, matta mello portugal, araújo, vasques, bergland, santos, engedal, coutinho, schuch, laks and deslandes [38] and sims, galea, taylor, dodd, jespersen, joubert and joubert [39] raised some concerns in two dimensions, but had a low risk of bias in the others. two of the articles [38, 40] had two primary outcomes, which required different combinations resulting in four separate meta-analyses (figures 2-5) . the relaxation group in the article by krogh, saltin, gluud and nordentoft [37] was considered a control group for practical purposes. first, the exercises were relaxation-based and with extremely low intensity, and therefore did not fit into recognizable categories of training programs. furthermore, adherence rates to the sessions was <35%, meaning that this experimental group behaved very similarly to a true control group. the following results represent the possible combinations for detecting the effects of rt in primary outcomes related to depressive symptoms. in the first combination, four randomized-controlled studies provided data for depressive symptoms, involving five experimental and four control groups (pooled n = 198). there was no significant effect of resistance training on depressive symptoms (es = 0.39; 95% ci = −0.05 to 0.84; p = 0.082; i 2 = 53.2%; egger's test p = 0.310; figure 2 ). the relative weight of each study in the analysis ranged from 12.2% to 28.6%. in the second combination, four randomized-controlled studies provided data for depressive symptoms involving five experimental and four control groups (pooled n = 198). there was a significant effect of resistance training on depressive symptoms (es = 0.62; 95% ci = 0.03 to 1.20; p = 0.040; i 2 = 71.9%; egger's test p = 0.155; figure 3 ). the relative weight of each study in the analysis ranged from 13.7% to 25.3%. in the third combination, four randomized-controlled studies provided data for depressive symptoms, involving five experimental and four control groups (pooled n = 198). there was no significant effect of resistance training on depressive symptoms (es = 0.48; 95% ci = −0.06 to 1.02; p = 0.081; i 2 = 67.2%; egger's test p = 0.235; figure 4 ). the relative weight of each study in the analysis ranged from 12.9% to 26.1%. in the fourth combination, four randomized-controlled studies provided data for depressive symptoms, involving five experimental and four control groups (pooled n = 198). there was a significant effect of resistance training on depressive symptoms (es = 0.53; 95% ci = 0.02 to 1.03; p = 0.040; i 2 = 62.7%; egger's test p = 0.206; figure 5 ). the relative weight of each study in the analysis ranged from 13.6% to 26.9%. this meta-analysis is, to the best of our knowledge, the first to examine rcts aimed at measuring the efficacy of exclusively rt supervised programs in people having depression. although multimodal interventions are usually advised, understanding the role of each exercise modality is paramount to understanding the effects and necessity of such a training component. this is highly relevant health-wise, but also to assess whether time should be invested in a given training modality, or if better investments would be applied elsewhere. therefore, the purpose of this study was to systematically review the effects of supervised resistance training programs in people diagnosed with depression or depressive symptoms. upon retrieval of 136 papers (70 after the removal of duplicates), only four papers fulfilled the inclusion criteria, meaning the effects of resistance training on depressive symptoms is still not widely studied, against our expectations. the risk of bias was assessed with cochrane's rob 2, with only a few selected concerns having arisen, but overall the four analyzed studies had a low risk of bias, and so we believe the reported results are trustworthy. primary outcomes focused on depressive symptoms. here, results were highly heterogeneous, with half of the studies showing positive effects of resistance training and half showing no effects. in two of the four combinations (figures 3-5) , the meta-analysis revealed significant benefits of rt in improving depressive symptoms (p < 0.05). although considering significant differences with moderate (es = 0.62) and small (es = 0.53) effects, shown respectively in figures 3 and 5 , the heterogeneity was above 50%, thus suggesting a substantial level [42] . in fact, in combinations 2 and 4 ( figures 3 and 5) , the experiment of sims, galea, taylor, dodd, jespersen, joubert and joubert [39] was favorable to the control group, and the experiment of moraes, silveira, oliveira, matta mello portugal, araújo, vasques, bergland, santos, engedal, coutinho, schuch, laks and deslandes [38] largely benefited the rt group. however, no experimental group experienced a worsening of symptoms as a result of resistance training. the reason different combinations lead to different results appears to be a factor of analysis. it is important to note that several rating scales were used to assess the severity of depression in research and clinical settings. these measures were categorized as clinician-rated, such as the ham-d, montgomery åsberg depression rating scale (madrs) [47] or quick inventory of depression symptomatology clinician rating [48] , and self-reported scales, such as bdi and its revised version bdi-ii, and patient health questionnaire-9 [49] . in this study, as a primary outcome, ham-d (17-item version), bdi, ces-d and gds were used. nevertheless, other studies utilized different assessment measures for their different interests. choosing appropriate outcome measures is a fundamental component of any assessment. therefore, selecting outcome measures could be considered as a compromise between factors. for example, depression measures should be selected based on the patient population. indeed, depression occurs in children, adolescents, adults and the elderly. as a matter of example, gds was specifically designed to screen and measure depression in geriatric patients. it contains 30 forced-choice "yes" or "no" questions, a format that is helpful for individuals with cognitive dysfunction [28] . although various scales for rating depression severity have been developed to date, the ham-d (17-item version) is the most regularly used clinician-rated scale in research and clinical settings. originally published by max hamilton in 1960, the first version of the ham-d, the ham-d21, comprised 21 items [27] . hamilton recommended, nonetheless, to use only the first 17 items of the ham-d21 since the last four symptoms (i.e., diurnal variation, depersonalization, derealization, paranoid and obsessional/compulsive symptoms) were either not considered part of the illness, or they were relatively infrequent or not considered features related to depression severity [50] . on the other hand, the bdi is one of the most widely used self-rating scales. thus, both the ham-d and the bdi/bdi-ii are frequently adopted as the primary outcome to assess depression severity in this scope [9] . in this line, it should be important to know what a given total score or a change score from baseline on one scale means in relation to the other scale. this notion is supported by a review carried out by furukawa et al. [51] , these results can help clinicians interpret the ham-d or bdi scores of their patients in a more versatile way and also help clinicians and researchers assess such scores reported in the literature when scores on only one of these scales are provided. these dates were obtained from the rcts of psychological and pharmacological treatments for major depressive disorders. however, despite being extensively used, the clinician-administered ham-d [50] has been identified to present various psychometric problems, including lack of unidimensionality and poor ability to detect changes among persons with mild to moderate depressive symptoms [52] . these problems may be particularly relevant to studies investigating the antidepressant effects of exercise because exercise is a treatment that is particularly recommended for individuals with mild to moderate symptom severity. consequently, the use of the ham-d scale may not accurately reflect the magnitude of the antidepressant effect of exercise [53] . another key point to address is related to a clear definition in the rcts, which is the scale, aimed at measuring the main outcome. therefore, it is crucial to provide clear information about it. frequent omissions of key details, namely on the primary outcome and the scale used to measure the main outcome, may impair interpretability, replicability and synthesis of rcts that could interfere with decision-making. in the first meta-analysis [22] , which examined the efficacy of rt on depressive symptoms, there was wide variability in the scales used to measure depression, including beck depression inventory another important topic is how to better frame the primary outcomes. it is very important to analyze adherence rates (i.e., compliance with training sessions). these were excellent in three of the four papers, but were very low in the study of krogh, saltin, gluud and nordentoft [37] . therefore, despite being the longest study and having the greatest sample size, the very low adherence rates may have compromised the results of the interventions. dropouts from exercise treatment represent a huge barrier that impedes individual benefit from an intervention, and appear to be a particular problem in persons with depression [54] . in this line, stubbs, vancampfort, rosenbaum, ward, richards, soundy, veronese, solmi and schuch [17] conducted the first systematic review and meta-analysis which explored the incidence and predictors of dropout rates among adults with depression participating in exercise rcts. these authors found that in mdd patients, higher baseline depressive symptoms predicted an increased dropout. some strategies may serve as facilitators to reduce the impact of dropouts in those with mdd, namely sessions supervised by physiotherapists and exercise physiologists. moreover, schuch, vancampfort, richards, rosenbaum, ward and stubbs [14] identified that, in people with depression who have higher social support, the likelihood of having symptom improvements in response to exercising increases. additionally, incorporating a motivational component into exercise interventions for depression may be needed to decrease dropouts. vancampfort et al. [55] found that autonomous motivation (i.e., acting out of choice and pleasure) was the key to adopting and maintaining physical activity behavior in patients with severe mental disorders defined as schizophrenia, bipolar disorder or mdd. additionally, understanding that exercise is not a "one size fits all" intervention leading to immediate results is a key step to achieving progress [56] . at a certain point, [37] state that the american college of sports medicine's guidelines suggest three weekly sessions, and lament the fact that their study could only provide two weekly sessions. however, as became apparent, even those two sessions had very low compliance rates. the classic study of dunn, trivedi, kampert, clark and chambliss [16] assessed the dose-response relationship between frequency of activity (three or five times per week) and the amount of exercise based on energy expenditure (7 or 17.5 kcal/kg/week). the results demonstrated that the most important factor for decreasing depressive symptoms in people with mild to moderate depression seems to be the amount/dose of activity instead of frequency. with these populations, a home-based supervised protocol could help. indeed, home-based exercise programs may be an effective method to overcome barriers to exercise and increase exercise adherence. as a matter of example, blumenthal, babyak, doraiswamy, watkins, hoffman, barbour, herman, craighead, brosse, waugh, hinderliter and sherwood [19] randomized 202 individuals into four groups for 16 weeks of either home-based aerobic exercise, supervised group exercise, taking a placebo pill or taking sertraline. the authors concluded that individuals receiving active treatments tended to achieve higher remission rates than the placebo group: supervised exercise = 45%; home-based exercise = 40%; medication = 47%; placebo = 31% (p = 0.057). however, further research with larger sample sizes is needed to confirm adherence and efficacy for improving depressive symptoms. in any case, home-based exercise may be a good alternative to practicing physical activity, in particular for vulnerable people. even in the other three studies, which had very good adherence to the programs, no study had more than two weekly training sessions. this may be a manifestly low frequency, perhaps insufficient to promote more expressive gains. it should also be highlighted that the study of singh, stavrinos, scarbek, galambos, liber and singh [40] presented the greater improvements in primary outcomes, despite being the shortest trial of only 8 weeks. the adherence rate of >95% presence in each training session can potentially explain this success. therefore, training programs should be designed in a motivating manner to ensure high adherence rates, especially if only two weekly training sessions are performed. motivation is a crucial predictor of success and a critical factor in supporting sustained exercise. concerning secondary outcomes, only one study failed to assess physical outcomes [38] . this is unfortunate because the other three studies showed that even when depressive symptoms do not ameliorate, there are still benefits in terms of strength and cardiovascular response, which is positive in itself. several reviews and studies have shown that people with severe mental illness, including people with mdd, have an excess mortality, being two or three times as high as those within the general population, and this excess mortality is mainly due to physical disease [57] . in this sense, and as an example, the rate of type ii diabetes mellitus in individuals with mdd is around 8%, representing an increase of around 50% in comparison to the rate achieved for people without mdd [58, 59] . a meta-analysis [20] revealed that individuals with depression could achieve clinically relevant improvements in cardiorespiratory fitness levels in response to exercise interventions. furthermore, previous studies have found that exercise can improve physical and psychological domains of quality of life in individuals with severe mental illness [60] , and specifically in people with depression [61] . thus, exercise may act in these two directions, not only by improving symptoms of depression but also by improving the cardiovascular health and wellbeing of this vulnerable population. additionally, none of the four articles reported the rest times between exercises, although this a highly important and well-recognized variable to consider when prescribing rt. indeed, when prescribed appropriately with other key prescriptive variables (i.e., volume and intensity), the amount of rest between sets could influence the efficiency, safety and effectiveness of an rt intervention [62] . even if rest times were self-regulated in the studies, that should have been reported. relatively to psychosocial variables, effects on cognitive abilities and quality of life were scarce and heterogeneous. moreover, only one study tested for a dose-response effect [40] , with the high-intensity group having experienced not only the greatest improvements in depressive symptoms, but also in the quality of life. this raises the necessity of designing training programs that avoid excessively low intensities. however, despite the evidence which supports a dose-response relationship, people with depression typically have low cardiorespiratory fitness, so it seems to be idealistic to start with high volumes or intensities of exercise. literature within this scope has shown that intensity is not critically significant for symptom management, and that exercise of even a light intensity can lead to short-term improvements in mood in this specific population [63] . for example, people with severe mental illness may face additional challenges towards exercise such as inexperience with intense physical efforts, associated fatigue and discomfort, increased risk of physical injuries, limited availability of physical activity facilities and specialized equipment, and costs associated with access to facilities or training [56] . moreover, other barriers may include psychiatric medication side effects (e.g., sedation, fatigue, weight gain), lack of motivation and low self-confidence [64] . lastly, recommendations for the prescription of exercise for patients with mdd should not be discarded. small, incremental improvements can be obtained through real-life interventions aimed at improving the health of people with severe mental illness [7, 65] . the existence of only four articles fulfilling inclusion criteria is daunting and reveals that this field has potentially not been adequately investigated. moreover, the considerable heterogeneity of the studies (i.e., sample size and characteristics, experimental protocols, evaluated parameters, and so on) makes comparisons difficult and conclusions tentative. also, only one study evaluated a dose-response effect [40] . furthermore, it should be underlined that the four studies referred to samples from brazil, denmark and australia. therefore, out of the entire american continent, only south america is represented (and only by one country), while europe also has a single representative. no data on the topic is available from asia and africa. this is troublesome, as the prevalence of depression may vary depending on a country's human development index [66] . patel et al. [67] carried out a systematic review and meta-analysis, which included 26 studies on developed countries. approximately two-thirds of all studies and five out of six longitudinal studies showed a statistically significant positive relationship between income inequality and the risk of depression. moreover, because societal context is paramount for understanding access, motivation and engagement with structured physical activity [68, 69] , cultural specificities may be important in understanding why, how and how often people have access to and engage with supervised exercise programs [70, 71] . in the case of depression, country of origin, ethnicity and cultural differences are suspected of playing a major role in the patients' symptoms and on the behaviors of their family aggregates [72] . in summary, the majority of interventions in this specific scope have been focused on aerobic exercise, and it is perhaps time to change the paradigm and invest in more research to assess the effects 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activity structural and cultural factors influencing physical activity in switzerland socio-cultural determinants of physical activity across the life course: a 'determinants of diet and physical activity' (dedipac) umbrella systematic literature review cultural differences in the development and characteristics of depression designing resistance training programmes to enhance muscular fitness: a review of the acute programme variables this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord-332387-rmmmhrjy authors: ma, chang-jin; kang, gong-unn title: air quality variation in wuhan, daegu, and tokyo during the explosive outbreak of covid-19 and its health effects date: 2020-06-09 journal: int j environ res public health doi: 10.3390/ijerph17114119 sha: doc_id: 332387 cord_uid: rmmmhrjy this study was designed to assess the variation of the air quality actually measured from the air pollution monitoring stations (aqms) in three cities (wuhan, daegu, and tokyo), in asian countries experiencing the explosive outbreak of covid-19, in a short period of time. in addition, we made a new attempt to calculate the reduced dose(pm)(2.5) (μg) at the bronchiolar (br.) and alveolar-interstitial (ai) regions of the 10-year-old children after the city lockdown/self-reflection of each city. a comparison of the average pm(2.5) of a month before and after the lockdown (wuhan) and self-reflection (daegu and tokyo) clearly shows that the pm(2.5) concentration was decreased by 29.9, 20.9, and 3.6% in wuhan, daegu and tokyo, respectively. wuhan, daegu and tokyo also recorded 53.2, 19.0, and 10.4% falls of no(2) concentration, respectively. wuhan, which had the largest decrease of pm(2.5) concentration due to covid-19, also marked the largest reduced dose(pm)(2.5 10-year-old children) (μg) (3660 μg at br. and 6222 μg at ai), followed by daegu (445 μg at br. and 1287 μg at ai), and tokyo (18 μg at br. and 52 μg at ai), over two months after the city lockdown/self-reflection. our results suggest that the city lockdown/self-reflection had the effect of lowering the concentration of pm(2.5), resulting in an extension of the period it took to the acute allergic airway inflammation (aai) for the 10-year-old children. since the initial report of cases in wuhan (see figure 1 ), china, on 31 december 2019, the coronavirus disease 2019 (covid-19) spread worldwide in a short period of time and is still in progress [1] . during the pandemic, 4,445,920 confirmed cases were reported in 213 countries and 298,440 people have died so far from the covid-19 outbreak, as of 14 may 2020 [2] . in response to the rapid increase in the covid-19 case, the chinese administrative authorities have sealed off the entire city of wuhan. as a concrete city blockade, they blocked traffic and banned people from moving out of town. to prevent the spread of covid-19, they also closed various educational institutions and established numerous quarantines [3] . as shown in figure 2 , in the case of daegu metropolitan city, south korea, the number of cases sharply increased at the time when the number of confirmed cases of wuhan was on the decline. in daegu, just 17 days after the first case was reported on 18 february, an explosive outbreak of covid-19 occurred. the authorities of daegu also implemented various administrative regulations to prevent the outbreak of covid-19, and the number of newly confirmed cases decreased to 5 cases per day on 5 april (see figure 3 ). the authorities of daegu also implemented various administrative regulations to prevent the outbreak of covid-19, and the number of newly confirmed cases decreased to 5 cases per day on 5 april (see figure 3 ). the authorities of daegu also implemented various administrative regulations to prevent the outbreak of covid-19, and the number of newly confirmed cases decreased to 5 cases per day on 5 april (see figure 3 ). meanwhile, the number of confirmed cases increased in tokyo following the sharp drop in daegu, reaching 197 daily confirmed cases on 11 april (see figure 2 drawn from the data of toyo keizai online [4] ). as covid-19 spread rapidly, tokyo also issued executive orders, such as temporary closure request for public schools (3 march) , request for self-reflection at home (25 march) , and declaration of the state of emergency (7 april) (see figure 3 ). as mentioned above, on 23 january 2020, the central government of china imposed a lockdown in wuhan (see figure 3 ) and other cities in hubei, when the cumulative confirmed cases reached 1410. daegu and tokyo have requested self-reflection on 23 february and 25 march, when the cumulative confirmed cases were 319 and 212, respectively. until the official city lockdown was lifted by 8 april, all vehicles and people in wuhan were not allowed to move. there was no compulsion like wuhan, but the number of vehicles and floating population dropped sharply after the request for self-reflection in daegu and tokyo, too. meanwhile, while people were facing covid-19 worldwide, the unexpected positive effects of environmental pollution decreasing have been reported. among them, the satellite imagery of nasa [5] has shown how no 2 has improved drastically in big cities across china during the covid-19 pandemic. according to a report from the world health organization (who) [6] , the exposure to toxic air, both indoors and outdoors, kills some 600,000 children under the age of 15 each year. brauer [7] also suggested that air pollution kills seven million people, especially for infants and the elderly, worldwide every year, and more than 90% of people around the world breathe polluted air. even in european countries, 193,000 people died in 2012 because of airborne particulate matter [8] . meanwhile, the number of confirmed cases increased in tokyo following the sharp drop in daegu, reaching 197 daily confirmed cases on 11 april (see figure 2 drawn from the data of toyo keizai online [4] ). as covid-19 spread rapidly, tokyo also issued executive orders, such as temporary closure request for public schools (3 march), request for self-reflection at home (25 march) , and declaration of the state of emergency (7 april) (see figure 3 ). as mentioned above, on 23 january 2020, the central government of china imposed a lockdown in wuhan (see figure 3 ) and other cities in hubei, when the cumulative confirmed cases reached 1,410. daegu and tokyo have requested self-reflection on 23 february and 25 march, when the cumulative confirmed cases were 319 and 212, respectively. until the official city lockdown was lifted by 8 april, all vehicles and people in wuhan were not allowed to move. there was no compulsion like wuhan, but the number of vehicles and floating population dropped sharply after the request for self-reflection in daegu and tokyo, too. meanwhile, while people were facing covid-19 worldwide, the unexpected positive effects of environmental pollution decreasing have been reported. among them, the satellite imagery of nasa [5] has shown how no2 has improved drastically in big cities across china during the covid-19 pandemic. according to a report from the world health organization (who) [6] , the exposure to toxic air, both indoors and outdoors, kills some 600,000 children under the age of 15 each year. brauer [7] also suggested that air pollution kills seven million people, especially for infants and the elderly, worldwide every year, and more than 90% of people around the world breathe polluted air. even in european countries, 193,000 people died in 2012 because of airborne particulate matter [8] . it is well known that the exposure to particulate matter with a diameter of less than 2.5 µm (pm 2.5 ) has been related to both acute and chronic respiratory diseases. many epidemiologic studies have suggested that children are more vulnerable to pm 2.5 [9, 10] . according to the results of several previous studies, it can be said that air pollution causes far more human deaths than covid-19 from a long-term perspective. it is quite meaningful to assess the improvement of air quality during the covid-19 pandemic through actual measurement data and to evaluate the health effects of the improved amount, especially on children. in this study, the air quality variation with the trend of covid-19 at wuhan in china, daegu in south korea, and tokyo in japan experienced explosive outbreaks in a short period of time, which was estimated based on the actual measured data from air pollution monitoring stations (aqms). the health effect of the reduced pm 2.5 dose due to covid-19 on 10-year-old children in each city was also quantitatively assessed. wuhan is the capital city of hubei province in china, with a population of over 11.08 million. it covers an area of around 8,494 km 2 and has a humid subtropical climate, with abundant rainfall in summer and four distinctive seasons [11] . by the end of 2018, the total number of registered motor vehicles in wuhan was 2.97 million, accompanied by increasing urban traffic pressure [12] . daegu metropolitan city, south korea is the fourth-largest after seoul, busan, and incheon. its major industries are the textile industry, metals and machinery, the automobile component industry, mobile development, and medical care. as of may 2019, the population and area of this city are 2.49 million and 883.54 km 2 , respectively. the total number of cars registered was 1,190,154, of which gasoline, diesel, lpg, cng and hybrid were 561,643, 470,569, 114,533, 2617, and 26,026, respectively [13] . tokyo, the capital of japan, is located at the head of tokyo bay on the pacific coast of the central honshu. this metropolitan area is the largest industrial, commercial, and financial center in japan. the area and population of tokyo are approximately 2188 km 2 and 13.95 million, as of 1 january 2020 [14] . in 2019, a total of 3.95 million motor vehicles were registered in tokyo. total motor vehicles include cars, trucks and buses, as well as special purpose vehicles [15] . in this study, the data of pm 2.5 and no 2 measured continuously at one-hour intervals at the air quality monitoring stations (aqmss) of three cities were studied. the data monitored at the aqmss of three cities from 9 january to 29 april 2020 became the subjects of this study. the data of wuhan were monitored at the hankoujiangtan urban aqms (30.59 n, 114 .30 e) and published on the website of the ministry of environmental protection (mep) in china [16] . the average monthly temperature in wuhan ranged between 5.1 and 17.3 • c from january to april, 2020. those of relative humidity and wind speed during the same period are 58.8-78.4% and 2.38-2.97 m/s, respectively. the atmospheric environment standards of pm 2.5 and no 2 in china are below 35 µg/m 3 and 40 ppb, respectively, on annual average concentration. the data of daegu were monitored at the suchang-dong aqms (35.52 n, 128.36 e), installed in an urban area. the average monthly temperature ( • c), relative humidity (%), wind speed (m/s) in daegu during the measurement period ranged from 3.8-13.5 • c, 52-61%, and 2.1-2.4 m/s, respectively. the environmental quality standards in south korea for the 24-h average and annual average of pm 2.5 are <35 and <15 µg/m 3 , respectively. in the case of no 2 , the daily average for hourly values shall be within the 40-60 ppb or below this zone. the selected aqms in tokyo was shinjuku (35.69 n, 139.70 e), a major commercial and administrative center for the government of tokyo. wind speed (m/s), temperature ( • c), and relative humidity (%) at the monitoring sites of shinjuku ranged from 0-2.9 m/s, 0.9-22.1 • c, and 21.8-97.7%, respectively. the environmental quality standards are the same as those of korea. to better represent the time series trend of pm 2.5 concentration over the whole measurement period, all data were treated with the 5-day simple moving average (sma) c d sma by the following equations: where c d is the daily average of measured data every hour, and n is the number of days in an interval of daily average data (5-day in this study). the c d sma can help us distinguish between typical measurement noise and actual trends. typical measurement noise and actual trends. figure 4 shows the time series variation of the concentration of pm2.5 in wuhan, daegu, and tokyo, with their cumulative confirmed cases of covid-19. unlike tokyo, where the concentration was not high before the self-restraint regulation, there was a clear reduction in the pm2.5 concentration in wuhan and daegu. although it was not a continuous reduction, the concentration of pm2.5 in wuhan showed a significant decrease. it is necessary to assess whether this is a simple seasonal variation or a change due to the city lockdown. the results of our study are compared with those of gong et al. [17] , which investigated the monthly concentration of pm2.5 in wuhan in 2015. in their study, the monthly average of pm2.5 from january to april was 146, 82, 87, and 72 μg/m 3 . meanwhile, in this study, the concentrations of pm2.5 in each month during the same period were 80.8, 51.7, 52.0, and 48.8 μg/m 3 . although our results are like the seasonal trends in 2015, the pm2.5 concentrations for each month from january to april were greatly reduced by 44.7, 37.0, 40.3, and 32.3%, compared to those of 2015. in february, when the number of the confirmed covid-19 cases was at its peak, pm2.5 concentration was 57.3% lower than that in february 2017 (121.2 μg/m 3 ) [18] . therefore, it can be said clearly that the city lockdown has resulted in a great reduction in pm2. 5 . in daegu, the concentration of pm2.5 shows a temporary increase or decrease, but the trend of decline was evident in the overall period. the overall decline of the pm2.5 in tokyo is not seen, but it is clearly decreasing after request for self-reflection on 25 march. apart from the overall pattern of decline, several short reduction intervals due to rainfall were also clearly found in all three cities. figure 5 shows the result of comparing the average pm2.5 of a month before and after the lockdown (wuhan) and self-reflection (daegu and tokyo) in each city. the decreasing rate of pm2.5 concentration in each city was 29.9, 20.9 and 3.6% in wuhan, daegu and tokyo, respectively. unlike tokyo, where the concentration was not high before the self-restraint regulation, there was a clear reduction in the pm 2.5 concentration in wuhan and daegu. although it was not a continuous reduction, the concentration of pm 2.5 in wuhan showed a significant decrease. it is necessary to assess whether this is a simple seasonal variation or a change due to the city lockdown. the results of our study are compared with those of gong et al. [17] , which investigated the monthly concentration of pm 2.5 in wuhan in 2015. in their study, the monthly average of pm 2.5 from january to april was 146, 82, 87, and 72 µg/m 3 . meanwhile, in this study, the concentrations of pm 2.5 in each month during the same period were 80.8, 51.7, 52.0, and 48.8 µg/m 3 . although our results are like the seasonal trends in 2015, the pm 2.5 concentrations for each month from january to april were greatly reduced by 44.7, 37.0, 40.3, and 32.3%, compared to those of 2015. in february, when the number of the confirmed covid-19 cases was at its peak, pm 2.5 concentration was 57.3% lower than that in february 2017 (121.2 µg/m 3 ) [18] . therefore, it can be said clearly that the city lockdown has resulted in a great reduction in pm 2.5 . in daegu, the concentration of pm 2.5 shows a temporary increase or decrease, but the trend of decline was evident in the overall period. the overall decline of the pm 2.5 in tokyo is not seen, but it is clearly decreasing after request for self-reflection on 25 march. apart from the overall pattern of decline, several short reduction intervals due to rainfall were also clearly found in all three cities. figure 5 shows the result of comparing the average pm 2.5 of a month before and after the lockdown (wuhan) and self-reflection (daegu and tokyo) in each city. the decreasing rate of pm 2.5 concentration in each city was 29.9, 20.9 and 3.6% in wuhan, daegu and tokyo, respectively. xu et al. [19] reported that, during the defined 3-week lockdown period, wuhan's pm2.5 level went down 44% from 2019. in the case of tokyo, the decreasing rate was significantly lower compared to the two cities, probably because of usual low pm2.5 concentration. figure 6 shows the daily variations of the concentration of no2 in wuhan, daegu, and tokyo, with the cumulative confirmed cases of covid-19. the concentration of no2 in wuhan significantly decreased while the city was in lockdown from 23 january to 8 april. no2 is generally emitted from traffic and factories and is therefore a good indicator of human activity outside the home. a large peak appeared around 8 april, when the wuhan lockdown officially ended, may be because of the comeback of a floating population and traffic amount. although smaller than this, the peak also appeared in the distribution of pm2.5 (see figure 4 ). in the cases of daegu and tokyo, the continuous reduction in no2 concentration was more evident than that of pm2.5. although there were occasional temporary reductions in no2 because of the wash-out, the overall decline might also be due to people's efforts, such as the reduction of traffic volume and the partial shutdown of industrial facilities under autonomous self-reflection. xu et al. [19] reported that, during the defined 3-week lockdown period, wuhan's pm 2.5 level went down 44% from 2019. in the case of tokyo, the decreasing rate was significantly lower compared to the two cities, probably because of usual low pm 2.5 concentration. figure 6 shows the daily variations of the concentration of no 2 in wuhan, daegu, and tokyo, with the cumulative confirmed cases of covid-19. xu et al. [19] reported that, during the defined 3-week lockdown period, wuhan's pm2.5 level went down 44% from 2019. in the case of tokyo, the decreasing rate was significantly lower compared to the two cities, probably because of usual low pm2.5 concentration. figure 6 shows the daily variations of the concentration of no2 in wuhan, daegu, and tokyo, with the cumulative confirmed cases of covid-19. the concentration of no2 in wuhan significantly decreased while the city was in lockdown from 23 january to 8 april. no2 is generally emitted from traffic and factories and is therefore a good indicator of human activity outside the home. a large peak appeared around 8 april, when the wuhan lockdown officially ended, may be because of the comeback of a floating population and traffic amount. although smaller than this, the peak also appeared in the distribution of pm2.5 (see figure 4 ). in the cases of daegu and tokyo, the continuous reduction in no2 concentration was more evident than that of pm2.5. although there were occasional temporary reductions in no2 because of the wash-out, the overall decline might also be due to people's efforts, such as the reduction of traffic volume and the partial shutdown of industrial facilities under autonomous self-reflection. the concentration of no 2 in wuhan significantly decreased while the city was in lockdown from 23 january to 8 april. no 2 is generally emitted from traffic and factories and is therefore a good indicator of human activity outside the home. a large peak appeared around 8 april, when the wuhan lockdown officially ended, may be because of the comeback of a floating population and traffic amount. although smaller than this, the peak also appeared in the distribution of pm 2.5 (see figure 4 ). in the cases of daegu and tokyo, the continuous reduction in no 2 concentration was more evident than that of pm 2.5 . although there were occasional temporary reductions in no 2 because of the wash-out, the overall decline might also be due to people's efforts, such as the reduction of traffic volume and the partial shutdown of industrial facilities under autonomous self-reflection. figure 7 shows the result of comparing the average no 2 of a month before and after the city lockdown (wuhan) and self-reflection (daegu and tokyo) in each city. wuhan, daegu, and tokyo recorded 53.2, 19.0, and 10.4% fall of no 2 , respectively. although it is a short-term decline, it can be said that this result is very meaningful for the citizens' health of three cities, especially wuhan citizens. the model calculation by dutheil et al. [20] suggested that the reduction of no 2 in china due to covid-19 epidemic during a time period of two months saved around 100,000 lives in china. wuhan, daegu, and tokyo recorded 53.2, 19.0, and 10.4% fall of no2, respectively. although it is a short-term decline, it can be said that this result is very meaningful for the citizens' health of three cities, especially wuhan citizens. the model calculation by dutheil et al. [20] suggested that the reduction of no2 in china due to covid-19 epidemic during a time period of two months saved around 100,000 lives in china. exposure to pm2.5 can cause lung function abnormalities including increased airflow obstruction and airway hyper responsiveness [21] . according to research done by gauderman et al. [22] , the short-term exposure of pm2.5 on chronic obstructive pulmonary disease demonstrated the impact of pm2.5 on years of life lost. li et al. [23] suggested that the deficits in the growth of the expiratory volume in one second for the ages between 10 and 18 years old were associated with exposure to pm2.5. airborne allergens usually develop by 10 years of age, and this reaches its peak in the teens or early twenties [24] . as mentioned above, the difference in the average concentration of pm2.5 in the month before and after self-reflection were 18.0, 5.3, and 0.36 μg/m 3 in wuhan, daegu, and tokyo, respectively. to find out what the reduced pm2.5 concentration in each city means for health, we calculated the exposure dose of pm2.5 (dosepm2.5) amount, namely, how much pm2.5 penetrates our respiratory system. first, we tried to calculate the reduced dosepm2.5 (μg) for the 10-year-old children (dosepm2.5 10-yearold children) per day and over two months after the city lockdown/self-reflection of each city. the calculation of the reduced dosepm2.5 10-year-old children was made by modifying the formula proposed by löndahl et al. [25] reduced dosepm2.5 10-year-old children (μg) = reduced cpm2. where the reduced cpm2.5 are 18.0, 5.3, and 0.36 μg/m 3 in wuhan, daegu, and tokyo, respectively, i/o ratio is the average indoor/outdoor (i/o) ratio of pm2.5 concentration at three different cities [26] [27] [28] . fdep. is the maximum deposition fraction at bronchiolar (br.) additionally, alveolar-interstitial (ai) regions suggested by yamada et al. [29] , texp. is the exposure time (1-day or 60-day), and rbre. is breathing rate (m 3 /h). the fdep. and rbre. are decided by the activity patterns of 10-year-old children. in this study, their daily activity patterns were classified into sleep, sitting or rest, light activities (exercise or movement), and heavy activities. the time allocated for each activity of the day is 9, 4, 10, and 1-h, respectively (see table 1 ). four kinds of their daily activity patterns were set up, assuming that they would have spent most of their time at home due to requests for self-reflection. the variables and the calculated reduced dosepm2.5 (μg) for the 10-year-old children per day and over two months after the self-reflection of each city are summarized in table 1 . exposure to pm 2.5 can cause lung function abnormalities including increased airflow obstruction and airway hyper responsiveness [21] . according to research done by gauderman et al. [22] , the short-term exposure of pm 2.5 on chronic obstructive pulmonary disease demonstrated the impact of pm 2.5 on years of life lost. li et al. [23] suggested that the deficits in the growth of the expiratory volume in one second for the ages between 10 and 18 years old were associated with exposure to pm 2.5 . airborne allergens usually develop by 10 years of age, and this reaches its peak in the teens or early twenties [24] . as mentioned above, the difference in the average concentration of pm 2.5 in the month before and after self-reflection were 18.0, 5.3, and 0.36 µg/m 3 in wuhan, daegu, and tokyo, respectively. to find out what the reduced pm 2.5 concentration in each city means for health, we calculated the exposure dose of pm 2.5 (dose pm2.5 ) amount, namely, how much pm 2.5 penetrates our respiratory system. first, we tried to calculate the reduced dose pm2.5 (µg) for the 10-year-old children (dose pm2. 5 10-year-old children ) per day and over two months after the city lockdown/self-reflection of each city. the calculation of the reduced dose pm2. 5 10-year-old children was made by modifying the formula proposed by löndahl et al. [25] reduced dose pm2. 5 10-year-old children (µg) = reduced c pm2.5 × i/o ratio × f dep. × t exp. × r bre. (2) where the reduced c pm2.5 are 18.0, 5.3, and 0.36 µg/m 3 in wuhan, daegu, and tokyo, respectively, i/o ratio is the average indoor/outdoor (i/o) ratio of pm 2.5 concentration at three different cities [26] [27] [28] . f dep. is the maximum deposition fraction at bronchiolar (br.) additionally, alveolar-interstitial (ai) regions suggested by yamada et al. [29] , t exp. is the exposure time (1-day or 60-day), and r bre. is breathing rate (m 3 /h). the f dep. and r bre. are decided by the activity patterns of 10-year-old children. in this study, their daily activity patterns were classified into sleep, sitting or rest, light activities (exercise or movement), and heavy activities. the time allocated for each activity of the day is 9, 4, 10, and 1-h, respectively (see table 1 ). four kinds of their daily activity patterns were set up, assuming that they would have spent most of their time at home due to requests for self-reflection. the variables and the calculated reduced dose pm2.5 (µg) for the 10-year-old children per day and over two months after the self-reflection of each city are summarized in table 1 . in table 1 figure 8 shows the reduced dose pm2. 5 10-year-old children (µg) at br. and ai regions over two months after the city lockdown/self-reflection of each city. (2014), respectively. figure 8 shows the reduced dosepm2.5 10-year-old children (μg) at br. and ai regions over two months after the city lockdown/self-reflection of each city. wuhan, which had the largest decrease of pm2.5 concentration (18 μg/m 3 ), also showed the largest reduced dosepm2.5 10-year-old children (3,660 μg at br. and 6,222 μg at ai), followed by daegu (445 μg at br. and 1,287 μg at ai) and tokyo (18 μg at br. and 52 μg at ai) additionally, the reduced dosepm2.5 10-year-old children (μg) varied greatly depending on the children's behavior patterns. in all three cities, the reduced dosepm2.5 10-year-old children (μg) was high, in order of light activity > heavy activity > sleep > sitting/rest. the reason why the light activity was assessed to be a higher dose than heavy activity is because the activity time was set to be ten times higher. it is also clear that much more pm2.5 deposits at ai, a deeper part of the lungs, than in the bronchiolar. through the thymic stromal lymphopoietin activation in mice, liu et al. [30] suggested that the exposure to concentrations of pm2.5 equivalent to moderate pollution (31.6 μg of pm2.5) and severe pollution (100 μg of pm2.5) has been linked to the allergic airway inflammation (aai) in mice. it is very meaningful to calculate the amount of the exposure dose that can cause inflammation in humans (dosehuman (mg/kg)) indirectly through the experimental results with mice. therefore, we tried to calculate the dose for 10-year-old children (dosepm2.5 10-year-old children (mg/kg)) through the following equation, for the dose conversion from mouse to human introduced by balakrishnan and jacob [31] . dosepm2.5 10-year-old children (mg/kg) = dosemouse(mg/kg) × km ratio where km ratio = . each km i.e., km mouse and km 10-year-old children can be calculated with the following equation: the km 10-year-old children for the chinese, korean, and japanese were calculated by the average weight and body surface area (bsa) of boys and girls in each country. their bsa were also wuhan, which had the largest decrease of pm 2.5 concentration (18 µg/m 3 ), also showed the largest reduced dose pm2. 5 10-year-old children (3,660 µg at br. and 6,222 µg at ai), followed by daegu (445 µg at br. and 1,287 µg at ai) and tokyo (18 µg at br. and 52 µg at ai) additionally, the reduced dose pm2. 5 10-year-old children (µg) varied greatly depending on the children's behavior patterns. in all three cities, the reduced dose pm2. 5 10-year-old children (µg) was high, in order of light activity > heavy activity > sleep > sitting/rest. the reason why the light activity was assessed to be a higher dose than heavy activity is because the activity time was set to be ten times higher. it is also clear that much more pm 2.5 deposits at ai, a deeper part of the lungs, than in the bronchiolar. through the thymic stromal lymphopoietin activation in mice, liu et al. [30] suggested that the exposure to concentrations of pm 2.5 equivalent to moderate pollution (31.6 µg of pm 2.5 ) and severe pollution (100 µg of pm 2.5 ) has been linked to the allergic airway inflammation (aai) in mice. it is very meaningful to calculate the amount of the exposure dose that can cause inflammation in humans (dose human (mg/kg)) indirectly through the experimental results with mice. therefore, we tried to calculate the dose for 10-year-old children (dose pm2. 5 10-year-old children (mg/kg)) through the following equation, for the dose conversion from mouse to human introduced by balakrishnan and jacob [31] . dose pm2. 5 10-year-old children (mg/kg) = dose mouse (mg/kg) × k m ratio (3) where k m ratio = k m mouse k m 10−year−old children the k m 10-year-old children for the chinese, korean, and japanese were calculated by the average weight and body surface area (bsa) of boys and girls in each country. their bsa were also calculated from following [32] [33] [34] : then, the dose pm2.5 for the aai of 10-year-old children, i.e., the aai dose pm2. 5 10-year-old children (mg), can be calculated by following: aai dose pm2. 5 10-year-old children (mg) = dose pm2. 5 10-year-old children (mg/kg) × weight 10-year-old children (kg) (6) in this study, the aai dose pm2. 5 10-year-old children (mg) was calculated by the dose mouse (mg/kg), with 1.58 mg/kg (31.6 µg per mouse), on the assumption of medium air quality [30] . additionally, the time (day) to reaching the aai dose pm2. 5 10-year-old children can be calculated by the following: day to reaching aai dose pm2. 5 where the daily dose pm2. 5 10-year-old children is the reduced dose pm2.5 (µg) at the bronchiolar of the 10-year-old children per day during the city lockdown/self-reflection and is specified in table 2 . figure 9 , the number of days it takes to cause allergic airway inflammation (aai) by pm2.5 exposure, before and after the city lockdown/self-reflection at each city. in the case of wuhan, it took 25 days before the city lockdown, but 35 days after the city lockdown. meanwhile, it was calculated that it took 130 to 164 days in daegu and 570 to 587 days in tokyo. while it is easy to predict that inhaling clean air is good for children's health, this study was able to quantitatively evaluate that the temporarily reduced pm 2.5 concentration due to covid-19 was effective for the delaying the aai in three cities of asia. meanwhile, there is still a possibility that much more harmful household air pollutants may have been exposed by staying indoors during the city lockdown/self-reflection periods. figure 9 . the number of days it takes to cause allergic airway inflammation (aai) by pm2.5 exposure, before and after the city lockdown/self-reflection at each city. figure 9 . the number of days it takes to cause aai by pm2.5 exposure, before and after the city lockdown/self-reflection at each city. in the case of wuhan, it took 25 days before the city lockdown, but 35 days after the city lockdown. meanwhile, it was calculated that it took 130 to 164 days in daegu and 570 to 587 days in tokyo. while it is easy to predict that inhaling clean air is good for children's health, this study was able to quantitatively evaluate that the temporarily reduced pm2.5 concentration due to covid-19 was effective for the delaying the aai in three cities of asia. meanwhile, there is still a possibility that much more harmful household air pollutants may have been exposed by staying indoors during the city lockdown/self-reflection periods. in this study, the air quality variation was estimated in three cities in asian countries experiencing the explosive outbreak of covid-19, in a short period of time. the data assessment based on the actual measurements from the air pollution monitoring stations of each city clearly showed a quantitative reduction of pm2.5 and no2. the health effect of the pm2.5 dose (reduced due to covid-19) on 10-year-old children in each city was also quantitatively assessed. especially, this study was able to quantitatively evaluate that the temporarily reduced pm2.5 concentration due to covid-19 was effective for the delaying the aai in three cities of asia. there are many unmeasured factors other than pm2.5 level responsible for making the delay on aai. therefore, the delay effect of aai estimated in the present study may be limited only by the effects of the reduced pm2.5. according to the study of cohen et al. [10] , 4.6 million people are dying annually because of the diseases and illnesses directly related to poor air quality. therefore, the delay effect of aai estimated in this study is limited only by the effects of the reduced pm2.5. according to the study of cohen et al. [10] , 4.6 million people are dying annually because of the diseases and illnesses directly related to poor air quality. therefore, in terms of long-term human health hazards, the threat of air pollution can be much greater than that of covid-19. therefore, we should not only try to overcome the current situation of the covid-19 pandemic, but at the same time seriously consider the new eco-lifestyle that we have to pursue after the end of covid-19 pandemic. in this study, the air quality variation was estimated in three cities in asian countries experiencing the explosive outbreak of covid-19, in a short period of time. the data assessment based on the actual measurements from the air pollution monitoring stations of each city clearly showed a quantitative reduction of pm 2.5 and no 2 . the health effect of the pm 2.5 dose (reduced due to covid-19) on 10-year-old children in each city was also quantitatively assessed. especially, this study was able to quantitatively evaluate that the temporarily reduced pm 2.5 concentration due to covid-19 was effective for the delaying the aai in three cities of asia. there are many unmeasured factors other than pm 2.5 level responsible for making the delay on aai. therefore, the delay effect of aai estimated in the present study may be limited only by the effects of the reduced pm 2.5 . according to the study of cohen et al. [10] , 4.6 million people are dying annually because of the diseases and illnesses directly related to poor air quality. therefore, the delay effect of aai estimated in this study is limited only by the effects of the reduced pm 2.5 . according to the study of cohen et al. [10] , 4.6 million people are dying annually because of the diseases and illnesses directly related to poor air quality. therefore, in terms of long-term human health hazards, the threat of air pollution can be much greater than that of covid-19. therefore, we should not only try to overcome the current situation of the covid-19 pandemic, but at the same time seriously consider the new eco-lifestyle that we have to pursue after the end of covid-19 pandemic. clinical features of patients infected with 2019 novel coronavirus in covid-19 coronavirus/death toll: national health commission (nhc) of the people's republic of china isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-ncov) outbreak coronavirus disease (covid-19) situation report in japan nasa: airborne nitrogen dioxide plummets over china air pollution kills 600,000 children each year according to who how long, what, and where: air pollution exposure assessment for epidemiologic studies of respiratory disease evaluation of short-term mortality attributable to particulate matter pollution in spain in-cabin air quality during driving and engine idling in air-conditioned private vehicles in hong kong estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the global burden of diseases study assessment of air quality status in wuhan exploring the weekly travel patterns of private vehicles using automatic vehicle identification data: a case study of wuhan report on the results of air quality analysis in ministry of internal affairs and communications automobiles registered: automobile inspection & registration information association ministry of environmental protection (mep) in china characteristics of pm1.0, pm2.5, and pm10, and their relation to clack carbon in wuhan, central china pm2.5/pm10 ratio prediction based on a long short-term memory neural network in wuhan impact of the covid-19 event on air quality in central china covid-19 as a factor influencing air pollution? environ. pollut. 2020, 263, 114466 divergent effects of urban particulate air pollution on allergic airway responses in experimental asthma: a comparison of field exposure studies the effect of air pollution on lung development from 10 to 18 years of age the short term burden of ambient fine particulate matter on chronic obstructive pulmonary disease in ningbo all about allergies, kidshealth size-resolved respiratory-tract deposition of fine and ultrafine hydrophobic and hygroscopic aerosol particles during rest and exercise indoor/outdoor relationships of airborne particles under controlled pressure difference across the building envelope in field investigation of pm 2.5 in schoolchildren's houses and classrooms in changsha situations and countermeasure for indoor pm2 influences of biometrical parameters on aerosol deposition in the icrp 66 human respiratory tract model: japanese and caucasians fine particulate matter aggravates allergic airway inflammation through thymic stromal lymphopoietin activation in mice a simple practice guide for dose conversion between animals and human standardization of the body surface area (bsa) formula to calculate the dose of anticancer agents in japan determination of hand surface area by sex and body shape using alginate human body surface area database and estimation formula this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the data of aqmss were published online by the environmental authorities of each city. these data were the basis of this paper and provided a great reference of data discussion. the authors observe the rules of the use of open data, and also express their deep appreciation for the provision of data. the authors declare no conflict of interest. key: cord-339324-ab0ecwvw authors: moret-tatay, carmen; baixauli-fortea, inmaculada; grau-sevilla, m. dolores title: profiles on the orientation discrimination processing of human faces date: 2020-08-10 journal: int j environ res public health doi: 10.3390/ijerph17165772 sha: doc_id: 339324 cord_uid: ab0ecwvw face recognition is a crucial subject for public health, as socialization is one of the main characteristics for full citizenship. however, good recognizers would be distinguished, not only by the number of faces they discriminate but also by the number of rejected stimuli as unfamiliar. when it comes to face recognition, it is important to remember that position, to some extent, would not entail a high cognitive cost, unlike other processes in similar areas of the brain. the aim of this paper was to examine participant’s recognition profiles according to face position. for this reason, a recognition task was carried out by employing the karolinska directed emotional faces. reaction times and accuracy were employed as dependent variables and a cluster analysis was carried out. a total of two profiles were identified in participants’ performance, which differ in position in terms of reaction times but not accuracy. the results can be described as follows: first, it is possible to identify performance profiles in visual recognition of faces that differ in position in terms of reaction times, not accuracy; secondly, results suggest a bias towards the left. at the applied level, this could be of interest with a view to conducting training programs in face recognition. faces represent a fundamental characteristic of our identity. not surprisingly, it is the first part we would hide to avoid being recognized. we all have witnessed advances in facial biometrics in our environment for many fields, from security and health care systems to social networks. even if this issue has become crucial in smart cities, many challenges still remain [1] . among these, one should bear in mind that some face-recognition technology is able to do this process under not the most optimal conditions, e.g., even for people wearing masks to combat the spread of covid-19 [2] . current approaches have focused their attention on predictions through artificial intelligence. in this way, computer vision performance often employs algorithms as depicted in approaches such as the convolutional neural network [3] . however, is this effect transferable to the cognitive abilities of human beings? in other words, are we able to recognize a face in complex situations? the human brain is able to process a great number of characteristics belonging to a familiar face in a matter of milliseconds and without apparent cognitive cost [4] . this type of processing seems to be inherent to the human being and fundamental for multiple areas; among them, one of the most crucial ones would be socialization [5] [6] [7] . of interest, this process occurs in the area intended for human face recognition, named as ffa (face form area), which has been described as one of the most specialized regions for facial recognition in the human visual system [8] . more precisely, the ffa is located in the fusiform gyrus, brodmann area 37, and has also been related to other tasks: word recognition [9] and objects [10] , among other processes. however, even if all these processes might be sharing the same brain areas [11] , their nature is different, as, e.g., words have to be learned in comparison to face recognition [12] . visual processing, as described in the literature, begins with the coding of the orientation of the local border in the primary visual cortex named v 1 [13] . the responses of the neurons belonging to the v 1 area oversee the preferred orientation, producing a maximum level of response. some of the most relevant models in face recognition have focused on neural components [7, 14, 15] . through anatomic-functional evidence, it is stipulated that the human brain would make use of different but connected cognitive processes related to aspects of the stimulus in terms of variance and invariance. thus, the most consistent and least variant stimuli would be supported in areas such as the intraparietal groove (related to spatial attention) and the auditory cortex (such as prelexical perception for associated names, among others) [7, 8, 16] . on the other hand, the more abstract and variant aspects would make use of the amygdala and the limbic system to address aspects of emotional processing, and the anterior temporal zone for aspects of identity recognition [7, 14, 17] . there is undeniable consensus on some inherent aspects of face recognition in neurotypical patients across the life span. newborns show a preference for the upper, as opposed to the lower, part of a face [18] , suggesting that not only sensory properties but also structural characteristics are of interest. on the other hand, evidence has shed light on how facial recognition can be affected in older adults, for both detection [19] and identification proposes [20] . although studies with clinical samples are of interest, at a more basal level, other studies seem to indicate that the maturation of specialized processing throughout the life span also depends on previous experiences [21] . in this way, several factors can interfere, such as the number of expositions and even the way that a stimulus is presented [22, 23] . the aging process seems to be related to qualitative changes as well as quantitative changes in the perception of the face, which would be reflected in aspects such as processing components or reaction time [24] . some progress has been made in understanding the molecular mechanism of face recognition. however, there is no single or simple answer for the rehabilitation approach in behavioral terms. some research points to the role of cognitive strategies [25, 26] . in this way, it has been described that good recognizers would be distinguished not only by the number of faces they recognize but also by the number of these stimuli that they can reject as unfamiliar [27] . when it comes to the role of stimulus on face recognition, it is important to remember that position, to some extent, would not entail a high cost, unlike other stimuli, such as written words [26] . moreover, in our daily routine, it is common to constantly face different positions for a face in our environment. hence, the identification of a human face may imply the recognition of the invariant structure of aspects in dynamic environments of our daily life [13] . the most ecological environments will be related to low viewing conditions [28] , in terms of lighting [29] or distance [30] , among others. one of the most interesting variants that can include all the variables described above is the movement or the position of presentation and a face. however, the scientific literature supports the effects of cultural configuration on visuospatial skills [31] . habits such as reading have a strong influence on the cognitive system and can introduce spatial biases at both the perceptual and representational levels of a wide range of stimuli. specifically, biases towards the left have been found in readers of french origin [32] and towards the right in readers of hebrew [33] . this might be related to attentional issues, but different strategies might also be expected in a participant profile. therefore, an analysis of the participants' performance in face recognition is proposed. the starting point for evaluating the best participants, as marked by the literature, would be the ability to discard new and unfamiliar faces by choosing different position levels. a total of 26 spanish university students participated in this study. therefore, a total of 13 men and 13 women volunteered to participate in the study, ranging from 18 to 23 years old. in order to participate, all participants gave written informed consent as described by the university ethics committee (ucv/2017-2018/31). g*power 3 [34] was employed to examine effect size, f 2 = 0.15, probability of error, α = 0.05, and sample size under a repeated measures design. the karolinska directed emotional faces (kdef) from the karolinska institutet [35] was used. this consists of a total of 4900 images of facial expressions with different emotions and a total of 5 different positions: central, partial right, right profile, partial left and left profile (see figure 1 for an exemplification). a sample of 28 stimuli was chosen in order to exclusively select neutral expressions under these positions. each stimulus was repeated several times under a repeated measures design. therefore, for the present study, a total of 28 pictures (14 men and 14 women) matched in physical characteristics were selected. the total number of stimuli was 140. after a presentation block, participants were instructed to identify the previous stimuli and discard the novel ones. a windows operating system computer was used with the free experimental dmdx software [36] . participate, all participants gave written informed consent as described by the university ethics committee (ucv/2017-2018/31). g*power 3 [34] was employed to examine effect size, f 2 = 0.15, probability of error, α = 0.05, and sample size under a repeated measures design. the karolinska directed emotional faces (kdef) from the karolinska institutet [35] was used. this consists of a total of 4900 images of facial expressions with different emotions and a total of 5 different positions: central, partial right, right profile, partial left and left profile (see figure 1 for an exemplification). a sample of 28 stimuli was chosen in order to exclusively select neutral expressions under these positions. each stimulus was repeated several times under a repeated measures design. therefore, for the present study, a total of 28 pictures (14 men and 14 women) matched in physical characteristics were selected. the total number of stimuli was 140. after a presentation block, participants were instructed to identify the previous stimuli and discard the novel ones. a windows operating system computer was used with the free experimental dmdx software [36] . the experiment consisted of two phases, a first called "presentation" with 24 photographs that appeared at random. after 5 min, the participants passed the second phase called "recognition", where the previous stimuli appeared plus another 24 (48 in total). in this phase, the participants had to press the green key (m) if they recognized the image of the previous block and press the letter z, or red, if they considered the image novel. each session lasted approximately 15 min. as mentioned before, this was an experimental design under repeated measures. this approach was selected as it reduces the variance of estimates in comparison with other designs, such as between subjects' ones. moreover, all participants came across all conditions, allowing statistical inference to be made with fewer subjects in comparison with other designs. in order to know the response profiles in the discarding of new information, a cluster analysis was performed, which, as a multivariate technique, seeks to group elements (or variables) to achieve maximum homogeneity in each group, as well as the greatest differences between them. one should bear in mind that cluster analysis has enabled the formation of homogeneous groups within multiple fields of cognitive science and public health [37, 38] . for example, studies have developed dendrograms from the hierarchy clustering analysis based on the strength of functional connectivity among the face-selective specified regions of interest (or roi's) when the participants performed a face recognition task [39] . this procedure was similar to the previous literature for small samples [38, 40] . data were analyzed using spss ibm statistical software for windows version 23.0 (ibm corp., armonk, ny,usa). data were checked for multicollinearity and multivariate outliers. in addition, the kolmogorov-smirnov test was used to verify that the scores on the variables had a normal distribution. cluster analysis was performed under the registration probability test based on the schwarz bayesian inference criterion (bic). the proposed two-stage cluster analysis was replicated with a hierarchical cluster. the experiment consisted of two phases, a first called "presentation" with 24 photographs that appeared at random. after 5 min, the participants passed the second phase called "recognition", where the previous stimuli appeared plus another 24 (48 in total) . in this phase, the participants had to press the green key (m) if they recognized the image of the previous block and press the letter z, or red, if they considered the image novel. each session lasted approximately 15 min. as mentioned before, this was an experimental design under repeated measures. this approach was selected as it reduces the variance of estimates in comparison with other designs, such as between subjects' ones. moreover, all participants came across all conditions, allowing statistical inference to be made with fewer subjects in comparison with other designs. in order to know the response profiles in the discarding of new information, a cluster analysis was performed, which, as a multivariate technique, seeks to group elements (or variables) to achieve maximum homogeneity in each group, as well as the greatest differences between them. one should bear in mind that cluster analysis has enabled the formation of homogeneous groups within multiple fields of cognitive science and public health [37, 38] . for example, studies have developed dendrograms from the hierarchy clustering analysis based on the strength of functional connectivity among the face-selective specified regions of interest (or roi's) when the participants performed a face recognition task [39] . this procedure was similar to the previous literature for small samples [38, 40] . data were analyzed using spss ibm statistical software for windows version 23.0 (ibm corp., armonk, ny, usa). data were checked for multicollinearity and multivariate outliers. in addition, the kolmogorov-smirnov test was used to verify that the scores on the variables had a normal distribution. cluster analysis was performed under the registration probability test based on the schwarz bayesian inference criterion (bic). the proposed two-stage cluster analysis was replicated with a hierarchical cluster. first, face recognition was analyzed based on reaction time on the position stimuli. we were interested in the participants' profile when discarding new information. in this way, a descriptive analysis was carried out. after examining the assumptions of interest, a cluster analysis was carried out. descriptive statistics (response latencies and correct answers) were included in table 1 , as well as the increase in latencies (∆) between the target and distractor stimuli. the dependent variable of interest is the reaction time, as this is considered to reflect the cognitive architecture, and not surprisingly, is a star variable in the literature [41] . however, the rts (reaction times) are drawn from positively skewed distributions; for this reason, extreme data were trimmed, as in previous literature [42] . moreover, different assumptions were checked in terms of outliers and multicollinearity, and no more than 2% of the data were trimmed. the kolmogorov-smirnov test was used to examine whether the variables were normally distributed, p > 0.05. this was the same case for the shapiro-wilks normality test. levene's test indicated equal variances (all p > 0.05). the anova on the distractor rts showed that the target images were processed faster than the distractor images: f (1.24) = 10.56; mse = 36,479.79; p < 0.001 η 2 = 0.30. no position effect was found for response latencies, and no difference in efficacy across the hit rate (all p > 0.05). secondly, an exploratory two-stage cluster analysis was performed to identify the number of clusters in the participants on the distracting stimuli. likewise, the schwarz-bayesian inference criterion (bic) is shown in table 2 . we used it to select the lowest bic value in the different estimated models, in this case for two clusters. after the analysis, 100% of the cases were included, the size ratio was optimal, with a value of 1.17. two groups were formed with 46.2% and 53.8% of cases respectively. these two profiles were described as follows (see table 2 ): a profile named g1 with slower and more conservative processing (n = 14) and a g2 profile with faster and more efficient processing (n = 12). in addition, depending on the values ∆, different response patterns can be described (see table 3 ). the participants' sex was not related to the distribution of the new groups; moreover, it seemed to be distributed in a proportionate way, as the g1 was composed of seven men and seven women, while the g2 by six men and six women. as expected, the test χ 2 did not depict sex differences for new clusters. in the analysis of these new groups, a non-parametric approach was chosen, as shown in table 3 . as depicted in table 4 , the mann-whitney u test showed statistically significant differences for all conditions by cluster group. in addition to the mann-whitney u-test, jointly, the vovk-sellke indicators are offered to examine the maximum possible probability in favor of h 1 over h 0 [43] . this information was included to complement traditional p-value-based analyses, as suggested in the previous literature, through the use of probability [44] . all conditions were statistically significant for differences between groups. also included was the hodges-lehmann's estimate, with its confidence intervals, which would indicate the difference in the median between the two groups, and the bias-range correlation coefficient, which can be considered an effect size and is interpreted as the same as pearson's correlation coefficient [45] . as depicted in table 5 , the increments were addressed (∆) following the previous procedure. this analysis attempts to shed light on differences in patterns by estimating the distance between target and distracting condition latencies. as well as the central position, considered more ecological, not presenting changes in the group increments, the differences between groups seem to mark a bias towards the left side, and the right side was the one that distinguishes the participants with better execution in the task. finally, the proposed two-stage cluster analysis was replicated with a hierarchical cluster. the objective was to replicate the exploratory structure of the previous analysis. in relation to the new hierarchical cluster, a representation of the suggested dendrogram is included, which replicates the previous structure. in figure 2 , this structure is presented in a tree diagram format that tries to illustrate the groupings of the participants. two large groups are presented, consistent with the previous analysis, except for two subjects, who, although they are not within this subgroup, are closely linked. in relation to the new hierarchical cluster, a representation of the suggested dendrogram is included, which replicates the previous structure. in figure 2 , this structure is presented in a tree diagram format that tries to illustrate the groupings of the participants. two large groups are presented, consistent with the previous analysis, except for two subjects, who, although they are not within this subgroup, are closely linked. lastly, the box and whiskers diagrams for all experimental conditions by cluster group are shown in figure 3 . this representation allows us, in a very visual way, to know not only the central tendency statistics but also their relationship with the variability, which was markedly lower for group 2. lastly, the box and whiskers diagrams for all experimental conditions by cluster group are shown in figure 3 . this representation allows us, in a very visual way, to know not only the central tendency statistics but also their relationship with the variability, which was markedly lower for group 2. familiar versus unfamiliar recognition is of interest in the field of face processing, and its expert role in the visual system [22, 46, 47] . the holistic and features segmentation approaches have been familiar versus unfamiliar recognition is of interest in the field of face processing, and its expert role in the visual system [22, 46, 47] . the holistic and features segmentation approaches have been described for both face and word recognition, suggesting the need for more research in terms of holistic versus feature perspective in the visual process as a continuum (and not only in isolated steps such as the perceptual, attentional or decisional one). the current results' differences according to internal and external characteristics emphasize the role of participants' strategies. in this way, the scientific literature supports the effects of cultural configuration on visuospatial skills [31] . it has been found that habits such as reading have a strong influence on the cognitive system and can introduce spatial biases at both the perceptual and representational levels of a wide range of stimuli. this aspect is of special interest when we must recognize a face, since, as a stimulus, unlike, for example, written words, it can appear in multiple positions and be processed, apparently without effort. as mentioned before, a total of two profiles were found regarding their capacity to discard new information. the literature has described profiles of good recognizers, which would be distinguished not only by the number of faces they recognize but also by the number of these stimuli they are able to reject as unfamiliar [27] . the patterns between the two suggested groups showed differences between latencies or response times, so a more conservative pattern will be found for one of the profiles. from a qualitative approach, these results could support sensitivity to oblique information in the near horizontal range or biases [48, 49] or preferences towards one of the orientations [32, 33] . there are different limitations in this study. first, the sample of men and women is too small to examine possible gender differences. in addition, aspects such as the city of origin and its density have not been considered, which is stipulated to possibly moderate the recognition process. future lines of research should conduct both direct and systematic replications over these issues and are expected to address these limitations. these should involve controlling the sex of participants and the density of their home populations. moreover, the chosen stimuli were neutral, and therefore, future lines of research should include aspects such as the emotional valence of a face. as a first approach, a simpler manipulation has been proposed, and in this way, we hope it will serve for future manipulations that contemplate a greater variability gradient of the stimulus. thus, the type of battery of stimuli used in this study, the karolinska directed emotional faces, is ideal for such a purpose as it was designed for emotional manipulations. in sum, we consider these results of interests for training programs, where profiles can be of interest to understand participants' strategies. at a theoretical level, this information is of interest to multiple fields, such as psychology or forensic medicine, by reducing errors within the psychology of testimony, and obviously, whether it is possible to determine face recognizer profiles would be of great interest for its social and personal consequences. at the applied level, this could be of interest not only with a view to conducting training programs in face recognition but also to better understand cognitive strategies. in this way, the literature has demonstrated the plastic capacity of the process, even in some clinical profiles [50] [51] [52] . although the sample used is not a clinical one, we hope that future replications of the study can reach this level. the aim of this paper was to examine recognition profiles, according to face position. this might shed light on differences in terms of strategies to deal with familiar versus unfamiliar stimuli. therefore, a cluster analysis was carried out. the results can be described as follows: first, it is possible to identify performance profiles in visual recognition of faces that differ in position in terms of reaction times, not accuracy; secondly, results suggest a bias towards the left. in sum, the main contributions and implications of the current work are listed as follows: first, to develop recognition profiles and encoding of facial stimuli in relation to the ability to discard new information. secondly, to examine the role of facial stimulus invariance according to its orientation on human recognition, as described above. this type of contribution could offer a starting point in strategies based on the two points described in non-clinical participants. face recognition systems: a survey assessment of the wearability of facemasks against air pollution in primary school-aged children in london deep convolutional neural network-based approaches for face recognition the cognitive neuroscience of person identification the encyclopedia of child and adolescent development conspec and conlern: a two-process theory of infant face recognition human neural systems for face recognition and social communication the fusiform face area: a module in human extrastriate cortex specialized for face perception the unique role of the visual word form area in reading defining face perception areas in the human brain: a large-scale factorial fmri face localizer analysis the "visual word form area" is involved in successful memory encoding of both words and faces early development of letter 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without visual expertise problems in dyslexic readers editorial: aging in the digital era neurobiological aspects of face recognition: the role of oxytocin can you identify these celebrities? a network analysis on differences between word and face recognition. mathematics 2020 new insights on real-world human face recognition low-resolution face recognition with single sample per person. signal process acquiring linear subspaces for face recognition under variable lighting distance measures for pca-based face recognition reading direction shifts visuospatial attention: an interactive account of attentional biases bisections in two languages: when number processing, spatial representation, and habitual reading direction interact influence of reading habits on line bisection power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences facial expressions of emotion (kdef): identification under different display-duration conditions dmdx: a windows display program with millisecond accuracy ontology with hybrid clustering approach for improving the retrieval relevancy in social event detection profile changes in male partner abuser after an intervention program in gender-based violence the hierarchical brain network for face recognition cluster analysis in family psychology research age slowing down in detection and visual discrimination under varying presentation times the mediational role of distracting stimuli in emotional word recognition calibration of ρ values for testing precise null hypotheses scientific method: statistical errors rank-biserial correlation uncovering phonological and orthographic selectivity across the reading network using fmri-ra let's face it: reading acquisition, face and word processing the orientation selectivity of face identification faces are "spatial"-holistic face perception is supported by low spatial frequencies perception of musical pitch in developmental prosopagnosia use of a correlative training method in the rehabilitation of acquired prosopagnosia this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we would like to thank the participants involved in the study and the universidad católica de valencia, san vicente mártir. the authors declare no conflict of interest. key: cord-323372-770sos8m authors: glenn, jeffrey; bluth, madeline; christianson, mannon; pressley, jaymie; taylor, austin; macfarlane, gregory s.; chaney, robert a. title: considering the potential health impacts of electric scooters: an analysis of user reported behaviors in provo, utah date: 2020-08-31 journal: int j environ res public health doi: 10.3390/ijerph17176344 sha: doc_id: 323372 cord_uid: 770sos8m electric scooters (e-scooters) are an increasingly popular form of transportation in urban areas. while research on this topic has focused primarily on injuries, there are multiple mechanisms by which e-scooter share programs may impact health. the aim of this study is to explore the health-related behaviors of e-scooter users and to discuss their implications for public health. data were collected using an online survey emailed to registered e-scooter users. a total of 1070 users completed the survey. descriptive variable statistics and chi-squared analysis were performed to determine variable dependent relationships and equality of proportions. the most common destinations reported were “just riding around for fun”, home, and dining/shopping. the two most common modes of transportation that would have been used if e-scooters were not available were walking (43.5%) and using a personal vehicle (28.5%). riding behavior was equally mixed between on the street, on the sidewalk, and equal amounts of both. e-scooters in provo are likely having both positive (e.g., air pollution) and negative impacts on health (e.g., injuries, physical inactivity). future research should further explore patterns of e-scooter use and explicitly examine the linkages between e-scooters and areas of health beyond just injuries. there is growing awareness in academic and policy circles of the close linkages between health and urban transportation practices [1] . stand-up electric scooters (e-scooters), two-wheeled vehicles with a small electric motor and a thin deck on which a single rider stands, are a relatively new micro-mobility option for urban areas and have the potential for both positive and negative health impacts [2] [3] [4] . although research on the health impacts of e-scooters is sparse, the topic merits further exploration given the rapid increase in e-scooter popularity over the past three years in the united states and around the world [5] [6] [7] [8] . gaining a better understanding of the true positive and negative health impacts of e-scooters must start with more fully understanding e-scooter users and patterns of use [9] . the potential health impacts of e-scooters depend on answers to questions related to user behaviors-e.g., substituting other forms of transit, commuting vs. recreational use, compliance with safety regulations. while some information exists to help answer these and other key questions, important knowledge gaps remain. the aim of this study is to explore the health-related behaviors of e-scooter users in provo, utah four months after an e-scooter share program was introduced. among the many evidence gaps that remain, this study focuses on four primary research questions: (1) what motivations do users have for riding e-scooters?; (2) what are the primary destinations of e-scooter users?; (3) what alternative travel mode would riders be using if not riding an e-scooter?; (4) to what degree are e-scooter users aware of and complying with safety regulations? (5) what program or policy changes do e-scooter users believe would improve provo's e-scooter share program? based on this research, we identify opportunities for policy change that will facilitate positive health impacts of e-scooter use in provo and other cities. we also hope to encourage researchers and policymakers to seek a deeper understanding of patterns of use in diverse contexts as they consider the broad range of potential health impacts of e-scooters. [5, [10] [11] [12] [13] . in 2018, users took 38.5 million trips on shared e-scooters in the united states [14] . two of the largest e-scooter companies, bird and lime, were recently valued at over $2 billion each [6, [15] [16] [17] . multiple other companies, including ride share giants uber and lyft, have entered the competitive e-scooter market, which is predicted to become a $42 billion industry by 2030, although there is some evidence that the covid-19 pandemic has contributed to reduced ridership numbers in recent months [18] [19] [20] . while there are variations between programs, in a typical e-scooter share arrangement a private company enters an agreement with local government officials to place e-scooters on city streets and make them available to rent for short periods of time [2, [21] [22] [23] . potential users download a mobile phone application that allows them to view the locations of available e-scooters in real time and to begin, end, and pay for their rides. users are typically charged a flat fee for the rental plus an additional fee for each minute the e-scooter is used. users leave their e-scooters at their final destinations where the e-scooters then become available to other users. within municipal share programs, e-scooters typically have a range between 15 and 20 miles, and speeds are usually capped at 15 miles per hour [10] . e-scooters are appealing for a variety of reasons. for users, e-scooters offer a convenient, affordable, fun transportation option that serves as an alternative to motor vehicles, biking, and walking [3, 11] . e-scooters are frequently used for both commuting and recreational purposes [6] . for local governments, e-scooters represent a new form of transportation that can help bridge the "last mile" gap, a common obstacle for transit use, by connecting people with public transit nodes [9, 22, 24, 25] . e-scooters are also seen as an environmentally friendly means for reducing traffic congestion in urban areas [26, 27] . moreover, e-scooter programs may be appealing to local officials because government funds are not usually required to start or maintain them; rather, e-scooter companies pay fees that allow government agencies to make infrastructure improvements for e-scooter riders [14] . e-scooters may even be a contributing factor to economic development because they facilitate easier access to businesses located in urban centers where parking is scarce and motor vehicle travel is more difficult. e-scooters have been warmly welcomed by some municipalities and shunned by others as state and local governments have struggled to enact appropriate regulations to manage the rapid expansion of e-scooter share programs [5, 21, [28] [29] [30] . significant variation in e-scooter laws exists between states and cities-e.g., helmet use, sidewalk riding, hours of operation. [6, 10, 21, 28, 31, 32] . since many state legislatures have not specifically addressed e-scooter usage, local governments have taken on the brunt of regulatory responsibility by attempting to manage e-scooter use with city ordinances [21] . e-scooters create complicated liability issues in which municipalities may become liable for e-scooter injuries [10, 21, 31] . there is a range of mechanisms through which e-scooters may affect health. in a recent evidence review, khreis et al. found multiple linkages between urban transport exposures or practices and adverse health impacts [1] . while the research on e-scooters and health is limited, many of these linkages have been shown or theorized to apply to e-scooters discussed below. figure 1 highlights these linkages and illustrates that they are shaped by available transport options and features of the built environment. there is a range of mechanisms through which e-scooters may affect health. in a recent evidence review, khreis et al. found multiple linkages between urban transport exposures or practices and adverse health impacts [1] . while the research on e-scooters and health is limited, many of these linkages have been shown or theorized to apply to e-scooters discussed below. figure 1 highlights these linkages and illustrates that they are shaped by available transport options and features of the built environment. a primary public health concern, and the focus of the vast majority of academic research on escooters to date, is e-scooter-related injuries [10] . several studies in the united states and elsewhere have found a high incidence of injuries related to scooter usage, particularly head and limb trauma, after the introduction of e-scooter share programs [5, 12, 24, 28, [33] [34] [35] . there is even some evidence that the injury rate for e-scooters may be higher than that of motorcycles and personal vehicles [27, 36] . most injuries are due to falls or collisions with objects (not with motor vehicles) that occur due to poor road conditions or excessive speeds [5, 23, 33, 35, 37] . there have also been reports of burns resulting from explosions of batteries [35, 38] . in the united states at least nine known deaths have been linked with e-scooter use [10] . various factors contribute to the prevalence of e-scooter injuries: incompatible infrastructure (e.g., lack of bike lanes), lack of directional tools on e-scooters (e.g., turn signals, headlights), rider inexperience and noncompliance with age restrictions, failure of users to obey traffic rules, alcohol use, and reluctance to wear helmets [5, 7, 24, 28, 33] . recent studies have found helmet use among injured e-scooter riders to be extremely low, ranging from 0% and 8% in most studies [5, 6, 23, 24, 28, 34, 35, 39] . additionally, despite regulations prohibiting them from doing so, e-scooter users commonly ride and park on sidewalks, which can lead to injuries to users as well as to pedestrians [40, 41] . one study found that 44% of collisions occurred on sidewalks where riding was prohibited, and others have found that approximately 10% of all e-scooter related injuries involve pedestrians [5, 7, 10, 23, 26, 31, 33, 42] . vulnerable populations such as the elderly, hearing impaired, and young children have an increased risk for sidewalk-related injuries [31] . a sizeable proportion of escooter injuries among users involve children under 18, despite most rental company agreements prohibiting ridership for minors [5] . many of these hazards relate to cultural norms and limited regulation that may minimize users' perception of potential dangers and therefore lead to unsafe behaviors [28] . a primary public health concern, and the focus of the vast majority of academic research on e-scooters to date, is e-scooter-related injuries [10] . several studies in the united states and elsewhere have found a high incidence of injuries related to scooter usage, particularly head and limb trauma, after the introduction of e-scooter share programs [5, 12, 24, 28, [33] [34] [35] . there is even some evidence that the injury rate for e-scooters may be higher than that of motorcycles and personal vehicles [27, 36] . most injuries are due to falls or collisions with objects (not with motor vehicles) that occur due to poor road conditions or excessive speeds [5, 23, 33, 35, 37] . there have also been reports of burns resulting from explosions of batteries [35, 38] . in the united states at least nine known deaths have been linked with e-scooter use [10] . various factors contribute to the prevalence of e-scooter injuries: incompatible infrastructure (e.g., lack of bike lanes), lack of directional tools on e-scooters (e.g., turn signals, headlights), rider inexperience and noncompliance with age restrictions, failure of users to obey traffic rules, alcohol use, and reluctance to wear helmets [5, 7, 24, 28, 33] . recent studies have found helmet use among injured e-scooter riders to be extremely low, ranging from 0% and 8% in most studies [5, 6, 23, 24, 28, 34, 35, 39] . additionally, despite regulations prohibiting them from doing so, e-scooter users commonly ride and park on sidewalks, which can lead to injuries to users as well as to pedestrians [40, 41] . one study found that 44% of collisions occurred on sidewalks where riding was prohibited, and others have found that approximately 10% of all e-scooter related injuries involve pedestrians [5, 7, 10, 23, 26, 31, 33, 42] . vulnerable populations such as the elderly, hearing impaired, and young children have an increased risk for sidewalk-related injuries [31] . a sizeable proportion of e-scooter injuries among users involve children under 18, despite most rental company agreements prohibiting ridership for minors [5] . many of these hazards relate to cultural norms and limited regulation that may minimize users' perception of potential dangers and therefore lead to unsafe behaviors [28] . in providing an electric alternative to motor vehicles, e-scooters are typically perceived as an environmentally friendly form of transportation that could lead to lower vehicle emissions and cleaner air in cities where they are being used [3] . since air pollution is responsible for premature morbidity and mortality from a number of diseases-including, for example, respiratory infections, cardiovascular disease, and premature birth-the potential positive impact of e-scooter use on health is significant [1, 43] . exposure to noise from motor vehicle engines, which has been linked to increased incidence of ischemic heart disease, cognitive impairment among children, and sleep disturbance, is also inversely correlated with e-scooter use since the battery-operated engines are essentially silent [1, 10] . although e-scooters are commonly seen as a green alternative to gasoline-powered motor vehicles, they present a number of environmental concerns-including greenhouse gas emissions, particulate matter formation, and use of mineral and fossil resources-that often go overlooked [44] [45] [46] [47] . findings from recent studies suggest that, overall, e-scooters have a more negative life cycle impact on the environment than the transportation modes they are replacing [2, 47] . one study found that e-scooters' impact on climate change is better than that of personal automobiles but worse than that of buses with higher ridership or electric bicycles [2] . with an average lifespan of about 2 years before often ending up in landfills, e-scooters' high level of disposability is a key driver of negative environmental impacts, which means that this impact will likely lessen as technology improves, a goal e-scooter companies are actively workings towards [2, 47, 48] . another major issue is the vehicles used to collect e-scooters each day for charging and relocating. one study found that the 43% of the emissions attributable to e-scooters stem from collection vehicles [2] . more sparsely populated areas likely necessitate higher collection miles driven and thus the e-scooters will likely lead to more air pollution than in densely populated urban areas. another environmental concern is the greenhouse gas emissions required to manufacture and assemble e-scooters [2] . this process includes the extraction of raw materials, including aluminum and lithium, for the e-scooter frames and batteries. very little research exists on the linkage between e-scooters and physical activity. insufficient physical activity is responsible for over 2 million deaths each year as a key risk factor for multiple chronic diseases [49] . because the act of riding e-scooters in itself likely offers few physical activity benefits, some health researchers have expressed concerns that e-scooters will replace active forms of transportation such as walking and cycling [50] [51] [52] . on the other hand, some advocates have observed a positive association between the increase in e-scooters and more active transportation as cities seeking to accommodate e-scooters have improved infrastructure that indirectly creates an environment and culture more conducive to cycling and walking [53, 54] . some e-scooter companies have argued that e-scooters offer a low-intensity workout that can help users increase core strength and exercise their legs, in addition to acting as a "gateway activity" to further exercise [55] . while these specific claims have yet to be confirmed through research, some preliminary conclusions that e-scooters offer the potential for at least minor physical activity benefits may be drawn from the literature about the positive health benefits of standing compared to sitting [56] [57] [58] . critical questions remain regarding the effects of e-scooters share programs on social life in communities in which they operate. community health and social interaction, which are influenced by neighborhood design and transport infrastructure, have a significant impact on mental health and well-being of community members [1, 59, 60] . community severance occurs where transportation acts as a physical or psychological barrier that separates built-up areas or open spaces [1] . there are reasons to believe e-scooters may increase community connectedness by improving access to transit, recreation facilities, and other public spaces where social interaction occurs. on the other hand, e-scooters may also contribute to community severance, for example by increasing risks of pedestrian injuries or by acting as a visual symbol of disorder in urban neighborhoods due to erratic placement of e-scooters after use [50, 61] . there are reports of frustrated city residents vandalizing e-scooters and even celebrating their actions by posting evidence of that vandalism on social media [62] . even if e-scooters do not represent a new barrier to community connectedness, the benefits of e-scooter access may not be available equitably to people of lower socioeconomic statuses while any negative health impacts may disproportionately affect these same people, which could exacerbate existing inequalities [51] . this study looked at e-scooter rider behavior in provo, ut, a city of 116,000 people [63] located approximately 40 miles south of salt lake city, ut. the close proximity of two large universities within or near provo city limits has contributed to a high concentration of residents and traffic. provo's mayor was primarily interested in the e-scooter program to improve the air quality of the city by providing zero emission alternatives to driving [64] . in partnership with the company zagster, an e-scooter share program was introduced in provo in august 2019. the geographic area principally targeted in the e-scooter program lies between downtown provo and brigham young university (byu), where there is a high concentration of college-aged residents, relatively dense commercial and educational land use, and a new bus rapid transit (brt) line. byu does not permit e-scooters on campus. figure 2 shows the geospatial distribution of e-scooter rides observed in october 2019. at the time of the survey, 500 total e-scooters were available on city streets. between august 19 and december 31, over 85,000 rides were taken on provo's e-scooters [65] . provo city code 9.15.200 prohibits e-scooter use on sidewalks [66] helmet use is not required but is strongly encouraged. while utah state law prohibits people under eight years old from riding an e-scooter, zagster policy requires users to be eighteen or older to rent an e-scooter. even celebrating their actions by posting evidence of that vandalism on social media [62] . even if escooters do not represent a new barrier to community connectedness, the benefits of e-scooter access may not be available equitably to people of lower socioeconomic statuses while any negative health impacts may disproportionately affect these same people, which could exacerbate existing inequalities [51] . this study looked at e-scooter rider behavior in provo, ut, a city of 116,000 people [63] located approximately 40 miles south of salt lake city, ut. the close proximity of two large universities within or near provo city limits has contributed to a high concentration of residents and traffic. provo's mayor was primarily interested in the e-scooter program to improve the air quality of the city by providing zero emission alternatives to driving [64] . in partnership with the company zagster, an e-scooter share program was introduced in provo in august 2019. the geographic area principally targeted in the e-scooter program lies between downtown provo and brigham young university (byu), where there is a high concentration of college-aged residents, relatively dense commercial and educational land use, and a new bus rapid transit (brt) line. byu does not permit e-scooters on campus. figure 2 shows the geospatial distribution of e-scooter rides observed in october 2019. at the time of the survey, 500 total e-scooters were available on city streets. between august 19 and december 31, over 85,000 rides were taken on provo's e-scooters [65] . provo city code 9.15.200 prohibits e-scooter use on sidewalks [66] helmet use is not required but is strongly encouraged. while utah state law prohibits people under eight years old from riding an escooter, zagster policy requires users to be eighteen or older to rent an e-scooter. this study was a cross sectional study designed to address the primary research questions. data were collected using a 13-item online questionnaire; three were demographic questions and 8 questions were about riding history, behavior, and knowledge (see appendix a for full question list). demographics included city residence, age, and gender. riding behavior questions included trip origin, trip destination, trip motivation, and street versus sidewalk riding on users' most recent e-scooter trip. open-ended responses were solicited related to changes that would enable street versus sidewalk riding and to e-scooter staging. the survey was emailed the week of 24 september 2019 to all registered zagster users (~15,000) in provo city. a total of 1070 users completed the survey, for a response rate of 7.1%. all research procedures were performed in compliance with relevant laws and institutional guidelines. participant demographic characteristics (age, gender, and place of residence) were first calculated, and descriptive variable statistics were then conducted for each item in the questionnaire. after verifying statistical assumptions, chi-squared analyses were performed to determine variable dependent relationships and equality of proportions between demographic characteristics and motivations for riding, destinations, travel mode alternatives, and safety behaviors. quantitative analysis was performed using the r statistical software (r foundation for statistical computing, vienna, austria) [67] . two researchers used nvivo qualitative data analysis software to thematically code responses to the open-ended survey questions [68] . these coded responses were then analyzed collectively by the full research team to identify the most prominent emergent themes. the majority of respondents were 18-24 years old (56.2%), and 5% were under 18 years old. more men than women completed the survey (63% vs. 37%). roughly 95% of participants were residents of utah county (provo city-85.0%, utah county-11.9%) ( table 1) . the most frequently mentioned reason for riding e-scooters was "to have fun" (42.2%) followed by "to save time" (32.3%) (see table 2 ). though "having fun" was the top reason for riding e-scooters for both men and women, significantly more women (48.3%) reported riding for this reason compared to men (39.1%) (χ 2 = 12.3, df = 1, p < 0.001). similarly, men were more likely to ride "to avoid parking hassles" (14.8%) compared to women (9.0%) (χ 2 = 10.3, df = 1, p = 0.001). college-aged (ca) persons aged 18-24 years old comprise the largest portion of e-scooter ridership in provo city (56.2%). while more non-ca persons (49.4%) than ca persons (37.6%) reported a motivation for riding e-scooters was to have fun (χ 2 = 21.35, df = 1, p < 0.001), more ca than non-ca persons reported a motivation was to save time (39.2% compared to 22.4%; χ 2 = 48.73, df=1, p < 0.001). the most common destinations to which e-scooters are reportedly being ridden are "just riding around for fun" (25.3%), home (20.0%), and dinning/shopping locations (17.1%) (see table 3 , a full table is presented in appendix a). there were no statistical gender differences with respect to destination with the exception of school; men tended to ride to school more (13.2%) than women (8.2%) (χ 2 = 5.64, df = 1, p = 0.02). the destinations of ca persons were different in many instances compared with non-college-aged persons. ca persons were less likely to use the e-scooter when dining out/shopping (χ 2 = 2.67, df = 1, p = 0.10; ca = 15% vs. non-ca = 24%); to just ride around for fun (χ 2 = 24.67, df = 1, p < 0.001; ca = 19.4% vs. ca = 32.9%); and, to work (χ 2 = 9.99, df = 1, p = 0.002; ca = 5.51% vs. non-ca = 10.97%). conversely, they were more likely to ride home (χ 2 = 10.11, df = 1, p = 0.001; ca = 24% vs. non-ca = 18%); to school (χ 2 = 42.23, df = 1, p < 0.001; ca = 17.03% vs. non-ca = 4.09%); and to social gatherings (χ 2 = 1.73, df = 1, p = 0.19; ca = 17.4% vs. non-ca = 14.2%). the two most common modes of transportation that would have been used if e-scooters were not available were walking (43.5%) and using a personal vehicle (28.5%) (see table 4 ). the only statistical difference by gender was for bicycling, where men were more likely to use a bicycle if an e-scooter were unavailable (5.2% vs. 1.9%) (χ 2 = 6.16, df = 1, p = 0.01). similar to trip destination, there were significant differences between the 18-24-year-old ca and non-ca group. as an alternative to e-scooters, ca persons were less likely to have used a bicycle (χ 2 = 4. riding behavior was equally mixed between on the street (n = 369, 34.6%), on the sidewalk (n = 357, 33.4%), and equal amounts of both (n = 342, 32.0%). sidewalk and street riding was associated with gender in that men were more likely to ride on the street (χ 2 = 11.01, df = 1, p < 0.001) and women were more likely to ride on the sidewalk (χ 2 = 3.01, df = 1, p = 0.08). there was no difference between genders who reported to ride equally on the street and sidewalk. likewise, ca persons were less likely to ride on the street (30.2% vs. 40.2%; χ 2 = 11.20, df = 1, p < 0.001) and more likely to ride on the sidewalk (38.3% vs. 27.0%; χ 2 = 14.6, df = 1, p < 0.001). there was no difference by age for those who equally rode between sidewalk and street. the majority of respondents did not know that it is illegal, according to provo city code, to ride e-scooters on the sidewalk (n = 691, 64.7%). there were no differences between genders but there were by age. college-aged persons were less likely to know about the sidewalk riding code (31.6% vs. 40.6%; χ 2 = 9.06, df = 1, p = 0.002). when asked what program changes would make them ride on the street rather than the sidewalk, some participants (12%) reported that they would have ridden in the street if they had known that it was acceptable to do so and/or they could be sure drivers were aware that they were allowed to do so. overwhelmingly, most of the respondents (74%) asked for the addition of bike lanes and/or better constructed bike lanes throughout provo. there were very few mentions of where the bike lanes should be added. most respondents use the adjectives "good", "wider", "improved", "clearly marked", and "painted" when describing what was meant by better bike lanes. the next highest response called for better roads; 16% of respondents said that provo streets had potholes, narrow roads, bumpy streets, and a lack of lane divisions. reckless drivers and curbside parking-which blocks bike lanes, takes up room on the shoulders, and pushes scooter riders further into the center of the road-were cited as deterrents to riding off the sidewalk. when asked if there was anything else users wanted to mention about the scooters, many of them (15%) simply stated that they enjoyed having scooters in the area. this study sought to consider the relationship between e-scooters and health by gaining a better understanding of e-scooter users and their behaviors in provo, ut. while e-scooters may affect health in the various ways, whether they have a net positive or negative impact on health depends largely on why and how people are riding them. two-thirds of users who responded to the survey were men, and over half were 18-24 years old. this age range is similar to what we would expect given the age demographics of provo where the median age is 23.6 and 44% of the population is between ages 20-29 [63] . while injury data from provo has not yet been reported, previous studies in other cities found that the majority of e-scooter injuries were among male millennials, the same demographic group who make up the majority of e-scooter users in provo [6, 12, 37, 69] . user compliance with safety regulations is another important health-related factor addressed by these data. despite the zagster policy requiring renters to be at least 18 years of age, 5% of all respondents were under 18, which raises concerns about user safety and the ability of zagster (and other private e-scooter companies) to enforce its rider policies. additionally, only 34.6% of users reported complying with local law and riding exclusively on the street while the rest reported riding at least partially on the sidewalk. while data from other cities is limited, a pilot e-scooter program in portland, or found that the proportion of sidewalk riders varied greatly depending on street design-18% rode on sidewalks with a 20 mph speed limit compared to 66% with a 35 mph speed limit, and 8% rode on sidewalks if a protected bike lane existed compared to 39% where there were no bike facilities [42] . riding on sidewalks is overall more dangerous for users and much more likely to lead to pedestrian injuries as have been found in previous studies [3, 10, 31] . the finding that women were more likely than men to avoid on-street riding is consistent with research on gender differences in cycling behavior that finds safety perception is a major factor [70, 71] . the majority of users (64.7%) reported being unaware that e-scooters were not permitted on sidewalks, which represents a higher proportion of riders compared to the 43% of users in rosslyn, va who were not familiar with e-scooter laws concerning sidewalk riding [40] . while the difference between cities likely reflects that the e-scooter program in rosslyn had been active for a longer period of time, the lack of knowledge around laws suggests that better educating users may be a first step in reducing unsafe riding behavior. nearly 75% of users in provo mentioned in their open-ended responses that additional and improved bike lanes would make it easier for them to ride on the street, which highlights another opportunity, albeit one requiring a greater financial investment from the city, to create a safer environment for e-scooter users. the data show that e-scooter users in provo choose to ride for a variety of reasons. the top reason given was to have fun (42.2%) and the top destination reported by users was "just riding around for fun" (25.3%). however, a sizeable number of users also report riding e-scooters to commute to work (7.9%) or school (11.4%) and for other purposes such as dining/shopping (17.1%) and traveling to social gatherings (16%). these numbers are similar to those in portland, or where 28.6% of riders used e-scooters for recreation or exercise while 71% used them to get to a destination [42] . convenience appears to be an important motivator as the second and third top reasons given for riding e-scooters in provo were to save time (32.3%) and to avoid parking hassles (12.9%). interestingly, ca users were more likely to rent e-scooters to save time than to have fun whereas non-ca users reported the opposite. ca users were also more likely to ride to school and social gatherings while non-ca users were more likely to ride to dine out/shop or commute to work. our findings suggest that age is more influential on trip destination as opposed to gender. a very small percentage of riders (2.3%) reported their destination as a public transit stop, which may indicate that e-scooters in provo are not necessarily delivering on the promise of solving the "last mile" problem, although because the questionnaire asked specifically about the most recent trip it is likely that some of the other riders were connecting from public transit. this is key question that should be addressed through a different survey design in future research. given the variety of motivations cited for riding e-scooters, a critical question in terms of health implications is: for which alternative modes of travel are e-scooters being substituted? the most common response, given by 43.5% of users, was that they would have walked if an e-scooter had not been available; among ca riders this percentage increased to 50.4%. additionally, 4% of users reported riding e-scooters instead of bicycling. similarly, in portland, or 37% and 5% of e-scooter riders, respectively, would have walked or biked instead of using an e-scooter, and in raleigh, nc 49% of riders would have walked or biked [2, 42] . the most likely impact of these findings is an overall reduction in physical activity levels because e-scooters are replacing more active forms of transportation. while this may be cause for concern in terms of health, on the other hand, 29.4% of e-scooter users reported that they would have used a personal vehicle or rideshare service (i.e., uber, taxi) if an e-scooter had not been available. this number is comparable to data from rosslyn, va (39%), raleigh, nc (34%), and portland, or (34%) [2, 40, 42] . (in portland, 6% of users even reported getting rid of a personal vehicle due to e-scooter availability [42] .) these rides represent fewer cars on the road and, in all likelihood, an overall reduction in local air pollution and associated poor health. additionally, the survey does not capture the possibility that the respondent would have chosen a different destination entirely were an e-scooter not available. given that e-scooters are best designed for short trips in urban areas, it is possible that the avoided motor vehicle trips would have been longer than their e-scooter substitutes. this finding is particularly relevant for provo city, a place with problematic winter air pollution and whose primary motivation for introducing e-scooters was to provide a green alternative to motor vehicles; yet, considering disposability issues and emissions due to collecting and placement of e-scooters, important questions remain about the full environmental impact and its implications for health. based on the findings of this study, there are several policy change strategies that could help optimize the heath impacts of e-scooter share programs in provo and in other cities. first, to reduce the probability of injuries, more training and strategically placed educational information (e.g., signs posted in high traffic areas) should be provided to increase users' knowledge about safety precautions (e.g., avoiding sidewalks, safe parking) and users' e-scooter operating skills. considering the shared road space, information should also be provided to help drivers, cyclists, and pedestrians be more aware of e-scooter riders. second, as evidenced by ridership among children, there is an enforcement gap in zagster's ability to enforce safety policies. similarly, although this study did not explicitly explore helmet use, informal observation on the streets of provo suggest that helmet use is extremely rare among e-scooter users, which is consistent with other studies [7, 10, 33] . to improve safety, cities should work with private e-scooter companies to identify ways, which may include the passing of additional local ordinances, to identify violations and enforce policies. third, for e-scooters to experience long term success it is clear that bike lines and other infrastructure must continue to improve. when asked about possible improvements that would encourage them to ride on the street, the vast majority stated designated lanes would be most helpful (n = 787). enhanced education and training alone will likely be ineffective without a more conducive riding environment, which should be a priority for city decision makers concerned with improving safety fourth, while a sizeable proportion of users are substituting e-scooters for personal vehicles, there are still negative environmental impacts that should be considered and minimized. zagster recently introduced a new, more durable model of e-scooter to provo city streets, and city policymakers should continue to push for e-scooters that have longer durability. they should also work with zagster to ensure low-emissions vehicles are used for collecting and placing e-scooters, and that the routes driven for these tasks are as short as possible. finally, cities should consult regularly with community members-those who use e-scooters and those who do not-to understand the impacts of e-scooters on community severance and social interactions, particularly among marginalized populations. this study makes a significant contribution to the literature by applying an existing health impact framework and proposing a range of linkages between health and e-scooters, a rapidly emerging public health issue for which previous studies have focused almost exclusively on injuries. the study also reports data from a relatively large sample of e-scooter users on their self-reported behavior, which is scarce in the academic literature, that serve as starting point for understanding how population health may be impacted by e-scooters. these data led to concrete, valuable recommendations for policymakers in provo and other places, especially mid-sized cities, which are currently grappling with instituting appropriate policy responses for the variety of issues that come with e-scooter programs. some critical limitations should be noted. first and foremost, while this study considered linkages between e-scooters and health, its findings do not directly address the health impact of e-scooters on provo residents. even where it adds value in terms of providing a clearer picture of why and how e-scooters are being used, it omits key demographic variables (e.g., race/ethnicity, income, etc.) that are essential for understanding some of the connections between e-scooters and health (e.g., community severance). finally, the survey used is potentially problematic because it represents a single point in time shortly after e-scooters were introduced in provo. it also asks only about users' most recent trip and it relies on responses from a small, non-representative sample of registered zagster users, which may be a source of bias if those who elected to respond to the survey have different patterns of behavior than those who did not respond. the use of an online survey may also lead to bias by selecting for younger, internet-using adults; however, this is not a major concern because these respondents are also the most likely to be e-scooter users. e-scooters are a nascent public health issue that positively and negatively affect health in a number of ways, including through injuries, air pollution levels, physical activity levels, and community severance. to understand the full impact of e-scooters on health we need to gain a thorough understanding of e-scooter users and their patterns of use. this study found that in provo, ut e-scooter users are predominantly male, college-aged individuals who ride e-scooters for a variety of reasons, the top being for recreational purposes. most users were unaware of laws prohibiting e-scooters from sidewalk riding, which led to two-thirds of users riding at least part of the time on sidewalks. about half of users would be walking or riding bicycles if e-scooters were not an option, while about one-third would be driving a personal vehicle. thus, e-scooters in provo are likely having both positive and negative impacts on health. future research, perhaps in the form of a health impact assessment, should be designed explicitly to examine the linkages between e-scooters and areas of health beyond just injuries, e.g., by focusing on community severance among marginalized communities or on users' physical activity levels. research is also needed to evaluate the impact of policies and interventions designed to reduce e-scooter related injuries. thoughtful, evidence-based implementation of e-scooter programs is critical to ensuring a future net positive benefit to public and community health. the authors declare no conflict of interest. on your last trip, why did you choose to ride a scooter? 2. on your last trip, what mode of transportation would you have taken had a scooter not been available? 3. on your last trip, where did you ride to? 4. on your last trip, where did you ride from? 5. on your last trip, where did you primarily ride? 6. if you rode on sidewalks, why did you choose to do so? 7. did you know that provo city code 9.15.200 prohibits riding on sidewalks? (don't worry, we won't tell on you.) 8. what changes would make you want to ride in the street instead of the sidewalk? 9. where should scooters be staged in the morning that they aren't currently? 10. anything else you'd like to tell us? 11. what city do you live in? 12. what is your age? 13. what is your gender? health impacts of urban transport policy measures: a guidance note for practice are e-scooters polluters? the environmental impacts of shared dockless electric scooters understanding spatio-temporal heterogeneity of bike-sharing and scooter-sharing mobility electric scooters: batteries in the battle against ambient air pollution? lancet planet injuries associated with standing electric scooter use the e-merging e-pidemic of e-scooters. trauma surg behavior of electric scooter operators in naturalistic environments electric scooters: why bird, lime, skip, and spin are taking over cities. vox analysis of e-scooter trips and their temporal usage patterns electric scooters: case reports indicate a growing public health concern the integration of electric scooters: useful technology or public health problem? the electric scooter: a surging new mode of transportation that comes with risk to riders electric scooters are going worldwide are shared electric scooters going extinct? lime's valuation reportedly tanks bird raises $275 million at a $2.5 billion valuation lime vp on company's meteoric rise to $1 billion valuation; venturebeat electric scooter-sharing grinds to a halt in response to the covid-19 pandemic. the verge trends in e-scooter litigation: an update on the still-evolving body of law. bench bar minn are electric scooters promoted on social media with safety in mind? a case study on bird's instagram injury from electric scooters in copenhagen: a retrospective cohort study craniofacial injuries seen with the introduction of bicycle-share electric scooters in an urban setting can e-scooters solve the 'last mile' problem? they'll need to avoid the fate of dockless bikes. conversat israel trauma group. the casualties from electric bike and motorized scooter road accidents early experience with electric scooter injuries requiring neurosurgical evaluation in district of columbia: a case series craniofacial injuries related to motorized scooter use: a rising epidemic the case for electric scooters invasion of the electric scooter: can our cities cope? guard sharing the sidewalk: a case of e-scooter related pedestrian injury shared micromoblity policy toolkit: docked and dockless bike and scooter sharing emergency department visits for electric scooter-related injuries after introduction of an urban rental program impact of electric scooters to a tertiary emergency department: 8-week review after implementation of a scooter share scheme new peril on our roads: a retrospective study of electric scooter-related injuries electric scooters were to blame for at least 1500 injuries and deaths in the us last year 262 epidemiology of dockless electric rental scooter injuries received 40 cases of e-scooter fires in 2017 ntd control and health system strengthening pedestrians and e-scooters: an initial look at e-scooter parking and perceptions by riders and non-riders where do riders park dockless, shared electric scooters? findings from e-scooter findings report transport for health: the global burden of disease from motorized road transport lessons from the streets of paris. conversat electric scooters aren't quite as climate-friendly as we thought. the verge it's dockless scooters! but can these electric-powered mobility options be considered sustainable using life-cycle analysis? dockless e-scooter: a green solution for mobility? comparative case study between dockless e-scooters, displaced transport, and personal e-scooters global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the global burden of disease study electric scooters on collision course with pedestrians and lawmakers. conversat our position on e-scooters local bike advocates: e-scooters are game-changing. streets blog usa the nexus does an electric scooter keep you fit? replacing sitting time with standing or stepping: associations with cardio-metabolic risk biomarkers continuous dose-response association between sedentary time and risk for cardiovascular disease a meta-analysis sitting less and moving more: improved glycaemic control for type 2 diabetes prevention and management the social and distributional impacts of transport: a literature review rethinking the links between social exclusion and transport disadvantage through the lens of social capital as electric scooters proliferate, so do minor injuries and blocked sidewalks. npr fed-up locals are setting electric scooters on fire and burying them at sea provo launches new motorized scooter program. dly. her ready to roll: shareable electric scooters return to utah county frequently asked questions regarding scooters r: a language and environment for statistical computing nvivo (version 12) motorized scooter injuries in the era of scooter-shares: a review of the national electronic surveillance system gender differences in recreational and transport cycling: a cross-sectional mixed-methods comparison of cycling patterns, motivators, and constraints explaining gender difference in bicycling behavior this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-336614-u6alc6rs authors: pérez-belmonte, luis m.; lópez-carmona, maría d.; quevedo-marín, juan l.; ricci, michele; martín-carmona, jesica; sanz-cánovas, jaime; lópez-sampalo, almudena; martín-escalante, maría d.; bernal-lópez, m. rosa.; gómez-huelgas, ricardo title: differences between clinical protocols for the treatment of coronavirus disease 2019 (covid-19) in andalusia, spain date: 2020-09-19 journal: int j environ res public health doi: 10.3390/ijerph17186845 sha: doc_id: 336614 cord_uid: u6alc6rs our objective was to compare clinical protocols for the treatment of the novel coronavirus disease 2019 (covid-19) among different hospitals in andalusia, spain. we reviewed the current covid-19 protocols of the 15 largest hospitals in andalusia. antiviral treatment, empirical antibacterial agents, adjunctive therapies, anticoagulant treatment, supportive care, hospital organization, and discharge recommendations were analyzed. all protocols included were the latest updates as of july 2020. hydroxychloroquine in monotherapy was the most frequent antiviral drug recommended for mild respiratory illness with clinical risk factors (33.3%). combined hydroxychloroquine with azithromycin or lopinavir/ritonavir was found in 40% of protocols. the recommended treatment for patients with mild and moderate pneumonias was different antiviral combinations including hydroxychloroquine plus azithromycin (93.3%) or hydroxychloroquine plus lopinavir/ritonavir (79.9%). different combinations of hydroxychloroquine and lopinavir/ritonavir (46.7%) and triple therapy with hydroxychloroquine, azithromycin, and lopinavir/ritonavir (40%) were the most recommended treatments for patients with severe pneumonia. there were five corticosteroid regimens, which used dexamethasone, methylprednisolone, or prednisone, with different doses and treatment durations. anakinra was included in seven protocols with six different regimens. all protocols included prophylactic heparin and therapeutic doses for thromboembolism. higher prophylactic doses of heparin for high-risk patients and therapeutic doses for patients in critical condition were included in 53.3% and 33.3% of protocols, respectively. this study showed that covid-19 protocols varied widely in several aspects (antiviral treatment, corticosteroids, anakinra, and anticoagulation for high risk of thrombosis or critical situation). rigorous randomized clinical trials on the proposed treatments are needed to provide consistent evidence. the global pandemic of the novel coronavirus disease 2019 (covid-19) caused by a newly emergent severe acute respiratory syndrome coronavirus 2 (sars-cov-2) was firstly recognized in wuhan (china) in december 2019. it quickly became a global pandemic, spreading worldwide [1] . spain is one of the most affected countries, with more than 593,000 confirmed cases and more than 29,700 deaths. andalusia-one of the 17 autonomous communities of spain and the most populous of them, with a total population of over eight million-has officially registered around 42,640 cases (7.2% of total confirmed cases nationwide) and 1552 deaths (5.2% of total deaths nationwide) [2] . currently, efficacy has not been fully established for any drug therapy for sars-cov-2. several agents are being used in clinical trials and compassionate-use protocols based on in vitro activity against sars-cov-2 or related viruses, and on limited clinical experience [3] . early detection and optimized supportive care to relieve symptoms and support organ function in more severe presentations are the mainstay of management. where possible, moderate to severely ill patients should be managed in a hospital setting [4] . there are hundreds of clinical protocols around the world adapted locally to patient characteristics, prevention measures, diagnostic tests, availability of potential therapy options, and possibility of follow-up. the use of clinical protocols in health care aims to provide practitioners with locally agreed information about what is currently the recommended approach for a specific practice. such protocols should be systematically developed and based on an evaluation of the current best evidence. thus, they also have the potential advantage of reducing unnecessary variations in care and contributing to evidence-based health care [5] . based on this premise, we conducted this study, whose main objective was to compare updated clinical protocols for treatment of covid-19 among the largest university hospitals in andalusia, spain. we hypothesized that clinical protocols could vary in several aspects among andalusian hospitals, regardless of whether they belong to the same local health system administration and have similar resources. in this study, we used the clinical information provided in the covid-19 protocols of the largest university hospitals in andalusia. in andalusia, hospitals are stratified into 4 categories according to service area and number of medical and surgical specialties [6] : (1) regional university hospitals (referral hospital in the whole autonomous community with all specialties available); (2) specialized university hospitals (referral hospital in a province and with wide number of specialties available); (3) basic general hospitals (referral hospital in a region and with all basic specialties available); (4) highly-specialized hospitals (referral hospital in a local area and with all basic specialties available). we included 6 regional university hospitals and 9 specialized university hospitals: hospital universitario reina sofía (córdoba), hospital universitario juan ramón jiménez (huelva), hospital universitario virgen del rocío (sevilla), hospital universitario virgen macarena (sevilla), hospital virgen de valme (sevilla), complejo hospitalario torrecárdenas (almería), hospital universitario de jerez de la frontera (jerez de la frontera), hospital universitario puerta del mar (cádiz), hospital de puerto real (puerto real), hospital universitario virgen de las nieves (granada), hospital universitario san cecilio (granada), complejo hospitalario de jaén (jaén), hospital universitario virgen de la victoria (málaga), hospital costa del sol (marbella), and hospital regional universitario de málaga (málaga). this study was approved by the institutional research ethics committee of málaga on 1 may 2020 (ethical code: pi-prot-0520) we excluded 19 basic general hospitals and 15 highly-specialized hospitals. normally, the treatment recommendations adopted in the reference hospital indicate how their area of influence proceeds. antiviral treatment, empirical antibacterial agents, adjunctive therapies, anticoagulant treatment, supportive care (oxygen, intravenous fluids, monitoring, high-flow nasal oxygen/noninvasive ventilation, and mechanical ventilation, among others), dosage, method of administration and duration of treatment, drug side effects and interactions, nonrecommended treatment or recommendation for other drugs, hospital circuits, ward organization and care planning, and discharge recommendations were collected from all clinical protocols for covid-19. covid-19 protocols contained patient groups according to the patient's clinical condition: mild upper respiratory illness with and without clinical risk factors (aged ≥60 years old and comorbidities), mild pneumonia (defined as curb-65 severity score [7] ≤1 or pneumonia severity index [8] i or ii, basal oxygen saturation >95%, respiration rate at rest <22, unilateral opacity, d-dimer <1000 ng/ml (normal range: 220-500 ng/ml), ferritin <1000 mcg/l (normal range: 8-252 mcg/l), interleukin-6 <40 pg/ml (normal range: <4.4 pg/ml)), moderate pneumonia (defined as curb-65 severity score ≥2 or pneumonia severity index ≥iii, basal oxygen saturation >92-95%, respiration rate at rest 22-30, bilateral opacities, d-dimer >1000 ng/ml, ferritin >1000 mcg/l, interleukin-6 <40 pg/ml), and severe pneumonia (defined as sepsis or shock with acute respiratory distress syndrome (ards), basal oxygen saturation <92%, respiration rate at rest >30, bilateral opacities, d-dimer >3000 ng/ml, ferritin >1000 mcg/l, interleukin-6 >40 pg/ml, elevated troponin i). prophylaxis in suspected cases was not taken into consideration. all protocols included were obtained from covid-19 teams of each hospital and were the latest updates as of july 2020. protocols are only available for healthcare providers on previous request to covid-19 teams of each hospital. the update of protocols was routinely made by covid-19 teams when they considered necessary. all variables analyzed were categorical and are shown as the absolute value and percentage, respectively. statistical analyses were performed using spss statistics for windows, version 15.0(ibm, armonk, ny, usa). symptomatic treatment, recommendations for infection prevention and control, and recommendations for early identification of covid-19 alarm symptoms were adopted for patients with mild upper respiratory illness without clinical risk factors and confirmed cases without symptoms. antiviral treatment was recommended for patients with mild upper respiratory illness with clinical risk factors and patients with mild, moderate, and severe pneumonia. patients could be treated with monotherapy using hydroxychloroquine or lopinavir/ritonavir; dual therapy with hydroxychloroquine plus azithromycin or lopinavir/ritonavir; or triple therapy with hydroxychloroquine, azithromycin, and lopinavir/ritonavir. hydroxychloroquine could be used in four different regimens, and lopinavir/ritonavir could be used in two different regimens, with varied dosages and duration of treatment-either a short (5-day) regimen or long (10-day) regimen. azithromycin was recommended at the same dosage and duration of treatment. protocols included the combination of all four hydroxychloroquine regimens with azithromycin. regimens 1 and 3 of hydroxychloroquine were combined in dual therapy with the two regimens of lopinavir/ritonavir, which in turn were combined with azithromycin in triple therapy. chloroquine 500 mg twice per day was recommended as an alternative when hydroxychloroquine was not available. in patients with three antiviral agents, lopinavir/ritonavir could be replaced with once-daily remdesivir if the patient was enrolled in a clinical trial. the dosage and durations of antiviral treatments are shown in table 1 . for treating mild respiratory illness in patients with clinical risk factors, up to six antiviral options were found. monotherapy with regimen 1 of hydroxychloroquine was the most frequent antiviral treatment recommended (5/15 protocols, 33.3%), followed by hydroxychloroquine regimen 1 plus azithromycin (3/15, 20%). dual antiviral treatment using hydroxychloroquine with azithromycin or lopinavir/ritonavir in combination was found in 40% of protocols. no treatment was recommended in two protocols. in regard to mild pneumonia, 14 protocols recommended dual therapy: seven recommended hydroxychloroquine plus azithromycin, and seven recommended hydroxychloroquine plus lopinavir/ritonavir. only one protocol did not recommend any antiviral treatment. for moderate pneumonia, hydroxychloroquine regimen 1 in combination with lopinavir/ritonavir regimen 2 was the most recommended treatment (5/15, 33.3%). different combinations of hydroxychloroquine and lopinavir/ritonavir (7/15, 46.7%) and triple therapy with hydroxychloroquine regimen 3, and azithromycin and lopinavir/ritonavir regimen 2 (6/15, 40%) were the most recommended treatments for patients with severe pneumonia. most protocols showed a preference for dual or triple antiviral therapy for patients with pneumonia. further details about recommended antiviral treatment of covid-19 are summarized in table 2 . all protocols recommended initiating empirical antibacterial treatment when secondary bacterial infection was suspected, according to local antibacterial therapy guidelines. empirical antibiotics were also indicated when pneumonia was diagnosed in seven protocols regardless of suspected bacterial infection. amoxicillin plus clavulanic acid or ceftriaxone were the main antibiotics recommended for use. all protocol considered the management of ards with signs of cytokine release syndrome, which included elevation of interleukin-6, fibrinogen, d-dimer, and c-reactive protein levels [9] . the therapies (corticosteroids, anticytokine or immunomodulatory agents, and immunoglobulin therapy) were recommended once these syndromes were observed. the choice of which therapy to use was made by physicians according to their own clinical judgment. corticosteroids were widely included in all protocols; indeed, only 2 out of 15 hospitals did not include any corticosteroid regimen. there was a total of five corticosteroid regimens, which used dexamethasone, methylprednisolone, or prednisone. dexamethasone was recommended in eight protocols with two different regimens: 20 mg (5/8, 62.5%) or 40 mg (3/8, 37.5%) daily. methylprednisolone was included in 13 protocols with 2 different regimens: 125-250 mg (8/13, 61.5%) or 1 mg/kg (5/13, 38.5%) daily. only one protocol included prednisone with a single regimen of 40 mg daily. the duration of treatment varied from 3 to 10 days, depending on the patient's clinical condition. tocilizumab was recommended in all protocols with the same dosage (400 or 600 mg) according to body weight. anakinra was included in seven protocols with six different regimens. immunoglobulins were included as possible therapy in three protocols. in six protocols, other optional therapies were included, such as sarilumab, baricitinib, colchicine, ciclosporin a, sirolimus, tacrolimus, and vitamin d, according to clinical trials. dosage and durations of corticosteroids, anticytokine or immunomodulatory agents, and immunoglobulin therapy are shown in table 3 . all protocols included anticoagulant treatment (low-molecular-weight heparin as the first option and unfractionated heparin as an alternative) and recommended prophylactic heparin during hospitalization. in 8 of the 15 covid-19 protocols (53.3%), the dose of prophylactic low-molecular-weight heparin was increased if there was a high risk of thrombosis (severe covid-19 with evidence of cytokine release syndrome, previous venous thromboembolism or acute ischemic artery disease, or d-dimer >3000 ng/ml). in five protocols (33.3%), heparin was increased to therapeutic doses if the condition was critical or if there was a progressive increase in d-dimer levels. all protocols included therapeutic heparin if there was evidence of venous thromboembolism. at discharge, prophylactic heparin was recommended if d-dimer >1500-3000 ng/dl for 7 days or during the time of the expected severe immobilization in seven protocols (46.6%). adjustments of heparin doses were indicated in the respective protocols. supportive care, hospital circuits, ward organization, and care planning were included in all protocols. drug side effects (including follow-up electrocardiogram for qt prolongation), interactions, nonrecommended treatment, or recommendation for other drugs were included in 11 protocols (73,3%), and discharge recommendations in 12 (80%). this study showed that the covid-19 protocols of the largest hospitals in andalusia (spain) varied widely in several aspects, including antiviral treatment: they used different dosages, durations, and combinations of treatment for the same clinical condition. corticosteroid and anakinra regimens varied among hospitals, whereas tocilizumab was uniform across all protocols. although anticoagulant treatment was recommended in all protocols, including prophylactic heparin during hospitalization for all patients and therapeutic heparin for patients with evidence of venous thromboembolism, only a few protocols included higher prophylactic doses for patients at high risk of thrombosis and therapeutic doses for patients in critical condition or who experience a progressive increase in d-dimer levels. on the other hand, all treatment protocols included the same patient groups, defined according to the clinical situation, symptomatic treatment and recommendations for infection prevention and control, supportive care and hospital organization, equivalent empirical antibacterial agents, drug warnings and interactions, and discharge recommendations. the clinical presentation of the novel covid-19 may vary from mild cases with fever, fatigue, and cough to moderate-severe cases involving pneumonia and multiorgan failure [10] , and several factors may predispose covid-19 patients to adverse outcomes. the older age, critical disease, and high levels of inflammatory markers have been associated with increased risk of death [11] . patients with moderate to severe forms of covid-19 normally require hospitalizations and pharmacological treatments. however, currently, there is no solid evidence that any potential drug improves outcomes in patients with suspected or confirmed covid-19 [12, 13] . only clinical experience and treatment guidance based on repurposed and experimental treatments are available. several antiviral agents have been proposed for use in combatting covid-19 based on apparent in vitro activity [3] . one of the most widely used agents has been hydroxychloroquine and chloroquine. although studies from china [14] and france [15] have reported improved radiologic findings, improved viral clearance, and reduced disease progression with the use of chloroquine and hydroxychloroquine compared to standard supportive care, their efficacy remains inconclusive, and further studies are warranted. in addition, it seems that hydroxychloroquine may act synergistically in combination with azithromycin [3, 15] . recently, in a large observational study from italy, hydroxychloroquine was associated with a 30% lower risk of death in covid-19 hospitalized patients [16] . despite these results, these studies had severe methodological limitations, such as lack of randomization, lack of covariate-adjusted analysis, and potential selection bias. recovery trial-the largest randomized controlled study on hydroxychloroquine-has suggested that hydroxychloroquine might not reduce deaths and might increase length of hospital stay [17] . chloroquine dosage has been 500 mg orally once or twice daily. however, hydroxychloroquine dosage recommendations have varied from a total daily dose of 400 mg (with a loading dose of 400 mg twice daily for 1 day) to 600 mg orally, based on safety and clinical experience for other diseases [3] . with this limited evidence, international guidelines with consensus statements on the treatment of covid-19 have not included any recommendation about using hydroxychloroquine/chloroquine as a potential treatment [4, [18] [19] [20] , but rather have only suggested its use in the context of a clinical trial [21, 22] . in our study, monotherapy with 400 mg hydroxychloroquine twice daily the first day followed by 200 mg twice daily from day 2 to day 5, alone and in combination with azithromycin, were the preferred recommended regimens among protocols in andalusia for treating mild respiratory illness with clinical risk factors. for mild pneumonia, dual therapies consisting of hydroxychloroquine-azithromycin or hydroxychloroquine-lopinavir/ritonavir were the most frequent treatments recommended, with regimens that included different dosages and durations of treatment. for moderate pneumonia, a shorter regimen of hydroxychloroquine in combination with a longer regimen of lopinavir/ritonavir was the most recommended treatment among all protocols. for the most severe form of pneumonia, the triple therapy with a longer regimen of hydroxychloroquine and lopinavir/ritonavir in combination with azithromycin was the most commonly indicated treatment. thus, more complex and longer antiviral therapies were recommended according to the severity of covid-19 in our protocols. lopinavir/ritonavir has had the same limitations of use as hydroxychloroquine/chloroquine, with no clear benefits beyond standard care [3, 23] . considering the uncertainty and the likely increase in gastrointestinal side effects, principal guidelines around the world have not contemplated its use in patients with covid-19 [4, [18] [19] [20] or have only considered it in the context of a clinical trial [21, 22] . remdesivir was only considered when patients were enrolled in a clinical trial. randomized controlled trials have reported that remdesivir reduces the duration of mechanical ventilation and time to symptom resolution, but its effect on mortality and other adverse outcomes remains uncertain [24] . other antivirals were not routinely included in our protocols. antiviral agents such as oseltamivir, umifenovir, favipiravir, or ribavirin as well as miscellaneous agents such as interferon-α or interferon-β are being studied for use as possible treatments for covid-19 [3] . currently, principal guidelines have either not reported any recommendation for their use [4, [18] [19] [20] [21] or have suggested not using them in patients with covid-19 [22] . in regard to management of ards with evidence of cytokine release syndrome, several adjunctive therapies have been proposed. the rationale for the use of corticosteroids is to reduce host inflammatory responses in the lungs. the potential harm, such as delayed viral clearance, increased risk of secondary infection, and hyperglycemia episodes, have led to caution in their routine use in covid-19 patients unless the patient had other conditions for which these are indicated [3, 4, [18] [19] [20] [21] . however, in observational and randomized studies focused on hospitalized patients with covid-19 pneumonia, the administration of corticosteroids reduced the risk of mortality [25] [26] [27] . based on this fact, a recently published guideline suggested using 40 mg methylprednisolone intravenously for 10 days in patients with severe covid-19 and ards [22] . in our study, corticosteroids were included in 87.7% of the protocols. methylprednisolone was the most frequently included corticosteroid in the protocols (13/15 protocols) with high-dose regimens (≥1 mg/kg/day) and a variable duration of treatment (between 3 and 10 days). high-dose dexamethasone (20 or 40 mg) was included in 53.3% of the protocols and prednisone in just one protocol (40 mg per day for 5 days). monoclonal antibodies targeting key inflammatory citokines or other aspects of the innate immune response are another potential treatment for covid-19 [28] . tocilizumab, an anti-interleukin 6 receptor antibody, has been used in small studies with early reports of success. a dose of 400 mg was associated with clinical improvements and successful discharge, with most patients only receiving a single dose [29, 30] . several randomized clinical trials on tocilizumab, either alone or in combination, in patients with covid-19 with severe pneumonia are underway, and its use was included in the chinese national treatment guidelines [30, 31] . likewise, tocilizumab was recommended in all protocols in andalusian hospitals; the protocols indicate a single dose of 400 mg or 600 mg, according to body weight, and a second dose 12-24 h later, if required. although tocilizumab is a promising therapy, the data currently available are still too limited to draw any conclusion about its viability. anakinra, an interleukin 1 receptor antagonist, has also been proposed in order to reduce hyperinflammation and respiratory distress in patients with sars-cov-2 infection, but here, too, limited evidence has been published [32] . in this study, less than half of the protocols included anakinra in their recommendations, and six different regimens were described with significant differences in dosage (ranging from 100 to 400 mg per day) and duration of treatment (between 3 and 10 days). other monoclonal antibodies, immunomodulatory agents, and immunoglobulin therapy are in clinical trials for the treatment of covid-19-associated cytokine release syndrome [3] . as recent studies have found, severe covid-19 is commonly complicated with coagulopathy, including disseminated intravascular coagulation and venous thromboembolism [33, 34] . for this reason, the administration of heparin has been recommended for covid-19 patients according to expert consensus [4, 31] , although its efficacy remains to be validated. in a study of 449 patients with severe covid-19 and sepsis-induced coagulopathy criteria or with markedly elevated d-dimer levels (higher than sixfold of upper limit of normal), anticoagulant therapy, mainly with low-molecular-weight heparin, was associated with better prognosis [34] . beyond severe coagulopathy, special attention to venous thromboembolism prophylaxis is necessary in the management of covid-19 [35] . low-molecular-weight heparin is preferred over unfractionated heparin in order to reduce patient contact (depending on the patient's bleeding risk and creatinine clearance) [36] . we found that all protocols analyzed included anticoagulant treatment, with low-molecular-weight heparin as the first option. it was recommended that all hospitalized covid-19 patients receive prophylactic heparin. this recommendation was extended to after discharge if necessitated by the patient's clinical condition in 46.6% of protocols. an increase in prophylactic heparin doses was recommended in 53.3% of the protocols for patients at high risk of thrombosis. in five protocols (33.3%), heparin was increased to therapeutic doses if the condition was critical or if there was a progressive increase in d-dimer levels. all protocol included therapeutic heparin if there was evidence of venous thromboembolism. our findings show significant differences among local protocols throughout andalusia (spain) regarding the management of covid-19 patients. there are some possible explanations for these disparities, including a lack of strong evidence about medical therapies that have been definitively reported to be effective at this time, the local availability of therapies, and administrative decisions about organization and care planning. although consensus statements in some international guidelines recommend against routine use of most antiviral agents, the eagerness to help our patients leads healthcare providers to explore different therapeutic strategies, balancing benefits and detriments. the same issue occurs with adjunctive therapies that are only suggested for treating ards with evidence of cytokine release syndrome as well as with anticoagulation in patients at high risk of thrombosis. there is greater consensus on the routine use of thromboembolism prophylaxis or anticoagulation for established venous thromboembolism. all protocols analyzed, in accordance with other guidelines, emphasize the prompt implementation of recommended infection prevention and supportive care for complications. these results are important because they show significant differences among the recommended treatments for covid-19, according to the treatment protocols of large university hospitals in a region of spain. they reveal a need for specifically designed randomized clinical trials to determine the most appropriate evidence-based treatment regimen. covid-19 is having a strong impact in several countries, including spain, in several aspects, especially health, economic, and social. there is a quickly growing body of evidence on this topic trying to find the best practice for the treatment of symptomatic patients with covid-19 [37] . this study has several limitations. first, we only analyzed the data provided in the hospitals' treatment protocols, and no information on treated actually provided to patients was obtained. furthermore, we did not know the degree of protocol implementation in the hospital or its coverage area. second, only the protocols of the largest hospitals of andalusia were analyzed in this study, even though there are many smaller hospitals and healthcare centers. normally, the treatment recommendations adopted in reference hospitals indicate how their area of influence proceeds, but this cannot be definitively assured. third, our study focused only on adult patients, and the recommendations were not applicable to pediatric populations. finally, the recommendations provided in the protocols are based on local expert opinions, clinical experience in managing covid-19 patients, and current international evidence regarding major proposed treatments, whether repurposed or experimental, for covid-19. therefore, no strong therapeutic recommendations could be drawn from the protocols analyzed in this study. in conclusion, this study showed that the covid-19 protocols of the largest hospitals in andalusia, spain, varied widely in several aspects, including antiviral treatment; corticosteroids; anakinra; prophylactic heparin for patients at high risk of thrombosis; therapeutic doses of heparin for patients in critical condition or with a progressive increase in d-dimer levels; and different dosage, duration, and combinations of treatment for patients in the same clinical condition. the use of tocilizumab for selected patients, prophylactic heparin for all patients, therapeutic heparin for evidence of venous thromboembolism, general symptomatic and supportive care, and hospital organization were recommended in all protocols. rigorous randomized clinical trials on the proposed interventions are needed in order to provide solid evidence. funding: this work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. china novel coronavirus investigating and research team. a novel coronavirus from patients with pneumonia in china pharmacologic treatments for coronavirus disease 2019 (covid-19): a review clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected: interim guidance clinical guidelines and care protocols consejería de salud y familias defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study a prediction rule to identify low-risk patients with community-acquired pneumonia cytokine storms in infectious diseases clinical features of patients infected with 2019 novel coronavirus in covid-19 risk and treatments (corist) collaboration. common cardiovascular risk factors and in-hospital mortality in 3894 patients with covid-19: survival analysis and machine learning-based findings from the multicentre italian corist study therapeutic strategies in an outbreak scenario to treat the novel coronavirus originating in wuhan, china drug treatments for covid-19: living systematic review and network meta-analysis breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of covid-19 associated pneumonia in clinical studies hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial use of hydroxychloroquine in hospitalised covid-19 patients is associated with reduced mortality: findings from the observational multicentre italian corist study effect of hydroxychloroquine in hospitalized patients with covid-19: preliminary results from a multicentre, randomized, controlled trial. medrxiv 2020 surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) covid-19 guidelines version 1. camberwell (au): the australian and new zealand intensive care society (anzics). 2020. available online: www.anzics.com.au/coronavirus-guidelines london (uk): national institute for health and care excellence. 2020. available online: www.nice.org.uk/ guidance/ng165 infectious diseases society of america guidelines on the treatment and management of patients with covid-19 treatment of patients with nonsevere and severe coronavirus disease 2019: an evidence-based guideline factors associated with prolonged viral shedding and impact of lopinavir/ritonavir treatment in hospitalized non-critically ill patients with sars-cov-2 infection remdesivir in adults with severe covid-19: a randomised, double-blind, placebo-controlled, multicentre trial risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease dexamethasone in hospitalized patients with covid-19: preliminary report glucocovid: a controlled trial of methylprednisolone in adults hospitalized with covid-19 pneumonia hlh across speciality collaboration, uk. covid-19: consider cytokine storm syndromes and immunosuppression effective treatment of severe covid-19 patients with tocilizumab current pharmacological treatments for covid-19: what's next? national health commission and state administration of traditional chinese medicine. diagnosis and treatment protocol for novel coronavirus pneumonia continuous intravenous anakinra infusion to calm the cytokine storm in macrophage activation syndrome abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy attention should be paid to venous thromboembolism prophylaxis in the management of covid-19 covid-19 and vte/anticoagulation: frequently asked questions coronavirus diseases (covid-19) current status and future perspectives: a narrative review we thank all hospital covid-19 teams for the protocol developments and updates, sociedad andaluza de medicina interna for the coordination, and claire conrad for her help with the final english-language version. the authors declare no conflict of interest. key: cord-356156-jjdkwalk authors: moretti, antimo; menna, fabrizio; aulicino, milena; paoletta, marco; liguori, sara; iolascon, giovanni title: characterization of home working population during covid-19 emergency: a cross-sectional analysis date: 2020-08-28 journal: int j environ res public health doi: 10.3390/ijerph17176284 sha: doc_id: 356156 cord_uid: jjdkwalk evidence about the characterization of home workers in terms of both work-related outcomes and health issues is lacking. the purpose of this cross-sectional study was to examine the impact of home working on perceived job productivity and satisfaction, work-related stress, and musculoskeletal (msk) issues. we included 51 mobile workers, collecting data about demographic characteristics, working experience, job productivity, and stress. job satisfaction was assessed through the utrecht work engagement scale (uwes), while msk pain was investigated by the brief pain inventory (bpi) and fear avoidance beliefs questionnaire (fabq). moreover, a home workplace analysis had to be carried out according to current italian regulations. participants declared that they were less productive (39.2%) but less stressed (39.2%) and equally satisfied (51%) compared to the time of office working. regarding msk disorders, low back pain (lbp) was referred by 41.2% of home workers and neck pain by 23.5% of them. neck pain worsened in 50% of home workers, while lbp did not exacerbate in 47.6% of cases. home workers with msk pain reported a lower job satisfaction. depending on our data, the home environment seems to be not adequate in the mobile worker population, with an increased risk for mental health and msk problems, particularly affecting the spine. addressing these issues can significantly reduce risks for health, thus, improving job productivity and satisfaction and reducing cost. the covid-19 health emergency has profoundly changed working life. to minimize physical contact among individuals and prevent new infections, many companies implemented "mobile working" or "home working" or "remote working", a form of carrying out a job without specific place of work restrictions, with the possible use of technological tools [1] . in 2017, italy had the lowest percentage of remote workers across all europe [1] , and this percentage amounted to about 8% of total employment at the end of april 2020. during the covid-19 pandemic, the number of remote workers increased by 69% in italy, while it has been estimated that about 81% of the worldwide workforce has been affected by workplace changes [2] . for most remote employees, it has probably been the first experience. among advantages, there are reduced commuting time, possible productivity gains, increased staff motivation, better work-life balance, and better control over time schedule, while among disadvantages there are difficulties monitoring performance, cost of working from home, communication problems, no clear separation between home and work tasks, and unsuitability with all works [3, 4] . the home environment is likely to be faulty in many aspects in comparison to the workplace. in particular, the absence of ergonomic office furniture at home may impede the adoption of a healthy posture and may promote the onset of musculoskeletal (msk) disorders [5, 6] . working in a sedentary position for prolonged periods increases the risk of neck pain and/or low back pain (lbp) [7, 8] . home working may cause also stress, anxiety, and isolation, which influences job effectiveness, well-being, and work-life balance [9, 10] . even if the effects of home working on various aspects (e.g., quality of life, health and safety, and productivity) have been also investigated, this research area is still developing. whilst the psychological benefits of home working-e.g., higher work engagement, work-related flow, and connectivity among staff-can attract many organizations to consider its implementation, the negative impacts such as blurred work-home boundary, fatigue, and mental demands should be addressed when/if home working is implemented [11] . for many workers, the opportunity to work from a home office makes everyday life easier. among positive effects the most expected are higher efficiency at work, better concentration, reduction of psychological stress, and a better family life [12] . working at home permits a better work-life balance, and this is important for workers caring for sick family members or children, but this results in little time for personal leisure activities [13, 14] . on the other side, there are negative effects associated with remote working. for example, it has been found that home workers experience overlaps between work and home lives [15] . moreover, they often experienced increased irritability and negative emotions, which were attributed to social isolation and being unable to share the troubles at work and find possible solutions with colleagues [16] . however, studies concerning the characterization of the mobile worker population in terms of both work-related outcomes and health issues are lacking. the aim of this study is to investigate the role of home working on job satisfaction, occupational stress, perceived productivity, and msk issues. a population of mobile workers was included in the present cross-sectional study. participants were contacted by phone; they received a full explanation of the study and signed an informed consent about privacy regulations regarding their personal data. all individuals were employed as administrative officers that moved to work remotely since the beginning of covid-19 health emergency. office work lasted for 8 h a day, with a 1 h lunch break. this study was conducted in accordance with the declaration of helsinki and its later amendments. we prepared a questionnaire consisting of 12 items. we investigated employees' subjective data such as age, gender, weight, height, education, job levels, and cohabitants, in particular children. subsequently, we asked participants about their previous remote working experience, focusing on the kind of job and its differences from traditional work (tasks, schedule, and salary). we also included questions about productivity, work-related stress, and job satisfaction. in particular, we asked about factors that might improve productivity (saved travel time to go to the office, time flexibility, autonomy, reconciliation of work life with personal and family life, enhanced attention) or might decrease it (distractions in the domestic environment such as children to look after, planning difficulties, impaired interaction with colleagues, technical failures). for questions about advantages and disadvantages of working at home on job productivity, it was possible to choose multiple answers. finally, the workers were asked whether they would continue working remotely after the end of the covid-19 emergency. low back pain was assessed by the brief pain inventory (bpi) [17] . the pain intensity section of the bpi is composed by four items that are scored from 0 (no pain) to 10 (worst pain), while the functional interference section is composed by seven items that are scored from 1 (no interference with activities of daily living, adls) to 10 (total interference). the severity index is calculated on the basis of the mean of the four pain intensity items, and interference index is calculated from the mean of the seven pain interference items. workers' beliefs about how physical activity and work affect lbp and neck pain were rated using the fear avoidance belief questionnaire (fabq), which consists of 16 items investigating how physical activity and work affect employees' pain [18] . the fabq physical activity (fabq-pa) evaluates atti tudes and beliefs related to general physical activities (five items, range 0-30), and the fabq work (fabq-w) assesses attitudes and beliefs related to occupational activities (eleven items, range 0-66). each item is scored from 0 ("do not agree at all") to 6 ("completely agree"). the overall score is calculated by adding fabq-pa and fabq-w scores (range 0-96). job satisfaction was assessed by the utrecht work engagement scale (uwes) [19] . this tool includes 17 items divided into three dimensions (i.e., vigor, dedication, and absorption). items were measured on a 7-point rating scale, from 0 (never) to 6 (always). participants were asked about structural aspects of their workplace at home: chair (adjustable seat height, back height, back inclination), table (type, height), type of computer (desktop/laptop), monitor (adjustable in inclination, height, rotation), eye distance from the monitor, presence of external keyboard and its distance from the edge of the table, presence of a footstool. presence of breaks and periods with increasing amount of work were also investigated. for the general health risk assessment, we referred to current regulations and the italian organization for standardization (uni) standards (uni en 1335-1-"office work chairs-dimensions-determination of dimensions"; uni en 527-1 "office furniture-work tables and desks-dimensions"; uni 10380-a1 "indoor lighting with artificial light") ( figure 1 ). descriptive statistical analy sis was performed using the spss v. 25.0 software (spss inc.; chicago, il, usa). continuous variables are expressed as means ± standard deviations, while categorical ones are reported as absolute values and percentages, whereas the ordinal data are represented as medians. we performed the shapiro-wilk normality test for all the continuous data. if data followed a normal distribution, the student's t test was used to compare data across groups; if not, the two-sample wilcoxon rank-sum (mann-whitney) test was used when appropriate. statistical tests were carried out on a two-sided significance level of 0.05. a total of 51 home workers were included. the mean age was 46.67 ± 11.26 years, and the percentage of women was 56.9%. most of the participants had three or more cohabitants (56.9%), but only 29.4% had children to look after. fifty-five percent of workers had a second level degree. the main population characteristics are reported in table 1 . in 53% of cases, no differences were recorded between home and office working in terms of tasks, schedule, and salary. thirty-nine percent of the subjects self-perceived to be less productive but less stressed, while 51% were equally satisfied. among mobile working advantages, the most appreciated was saved travel time (82.4%) and the least appreciated was greater autonomy (9.8%). impaired interaction with colleagues (41.2%) and distractions in the domestic environment (40.6%) were judged to be the worst disadvantages. thirty-nine percent of employees stated that they would like to continue working at home only occasionally. characteristics and quality of remote work are showed in table 2 . note: values are expressed as counts (percentages). * for these items, more than one answer was possible. concerning health problems, 70.5% of participants reported msk pain, most frequently at the low back (41.2%) or neck (23.5%), and 23.5% in multiple sites (table 3) . pain severity and pain interference during everyday activities have been found slightly higher for neck pain compared to lbp (table 4 ). in the fabq subscales, the mean score was higher in the work component than in the physical activity component for subjects affected by lbp or neck pain. moreover, workers with neck pain reported a higher mean score on the fabq work component than those with lbp (table 5) . worsening of previous neck pain was reported by 50% of participants, while in 8.3% an improvement of neck pain occurred. in 47.6% of subjects, there was no exacerbation of lbp since they work remotely, whereas 38.1% reported an increase of lbp severity, and only 14.3% showed pain improvement (table 6 ). home workers without pain reported a significantly higher job satisfaction assessed by uwes than those with pain (p = 0.009) ( table 7) . regarding structural aspects of the home workplace (tables 8 and 9 ), most of the participants reported using a conventional four-leg kitchen chair (56.9%), and that the seat was not adjustable in height (54.9%). in most cases, the back was concave (54.9%), not adjustable in height (70.6%) or inclination (68.6%). although most workers used a worktable with height 72 ± 1.5 cm (home table) the number of home workers who used a desktop computer was higher (58.8%), with monitor adjustable in height only for 29.4%. in two-thirds of cases, eye distance from the monitor was 50-70 cm. external keyboard was used by 62.7% of individuals, and in almost all workers (92.2%) there was enough space for the upper limbs as the keyboard was positioned 15 cm away from the table edge. nobody used a footstool. forty-one percent used a laptop. finally, all participants reported taking self-managed breaks. periods with increasing amount of work were reported by 51% of home workers. to the best of our knowledge, this is the first study investigating how home workers set up their home workplace and the impact of existing equipment on msk health. moreover, no previous study had ever measured mobile working-related job satisfaction on a specific scale. we characterized a population of mobile workers in terms of work-related outcomes, such as perceived productivity and job satisfaction, and onset or changes of previous msk disorders, particularly lbp and neck pain. over 80% of workers reported no difference in tasks, although 29.4% had a different schedule, with 51% of the population declaring, surprisingly, less than 36 working hours per week, according to regular hours of employment for office workers in italy. in our population, working at home resulted in relevant productivity changes (a decrease in 39.2% and an increase in 29.4% of participants). these data are in contradiction with results publicized by flexjobs' 7th annual survey, where about 65% of workers assessed their productivity as higher at home than in a traditional office [20] . the reduction of productivity in our study could be explained by the presence of distractions in the domestic environment and impaired interaction with colleagues, whereas in participants reporting increasing productivity, a main role may be played by reduced stress and/or commuting time. in our population, about half of the participants did not report any variation in job satisfaction between remote and office work. this finding might likely be due to unchanged job type and amount during the home working period. our data are consistent with that of other studies [21, 22] demonstrating a negative correlation between job satisfaction and the increased amount of home working. forced social isolation coupled with a marked reduction in physical activity could negatively impact both physical and mental health [23] [24] [25] . therefore, remote working seems to also be associated with an increased risk of mental and physical health issues. regarding occupational stress, no significant change occurred in mobile workers, considering that 39.2% of participants declared a reduced stress level since they work remotely, 27.5% reported an unchanged level, and one-third of subjects experienced increased stress. on the contrary, in the research conducted by the international labour organization and eurofound, about 41% of home workers declared that they felt stressed compared with 25% of their colleagues who work in the office [1] . the stress reduction reported in our study could be due to saved travel time to go to the office, higher time flexibility, and better family life. concerning physical health issues related to remote working, increased sedentariness and poor posture due to the use of non-ergonomic equipment in our population seemed to promote the onset of msk disorders, particularly lbp and neck pain. this finding is not surprising, considering that spine pain is one of the most frequent health problems in the working-age population worldwide. according to a recent study, the prevalence and incidence of lbp ranged from 1.4% to 20% and from 0.024% to 7%, respectively, in workers [26] . the overall mean prevalence of neck pain in the general population is 3.6% [27] , with a higher incidence in office and computer workers [28] . italian estimated lifetime prevalence is 9% for lbp and 5% for neck pain [29] . literature offers controversial evidence about the relationship between lbp and sedentary jobs. it has been argued that the risk of lbp seems to increase when office workers stay seated for more than 7 h per day. however, no significant association between sitting itself and the risk of lbp has been demonstrated [30] . this finding could be explained by the multifactorial nature of lbp [31] . the incidence of this condition is significantly associated with anthropometric, ergonomic, and psychosocial factors, in particular age, gender, body mass index, body distance from computer screen, adjustable back support, body position while sitting, job satisfaction, and repetitive work [32] . as stated by burdorf et al., a sustained sedentary job in a forced non-neutral trunk posture is a risk factor for lbp [33] . due to low-grade activation of lumbar muscles while sitting, the load is conducted by passive structures such as ligaments and intervertebral discs. because of the viscoelasticity of these structures and deactivation of lumbar muscles, the lumbar spine may be predisposed to deconditioning and lbp [34] . similarly, while an association between the increased use of computers and work-related neck pain has been observed, it is unclear whether this is a causal relationship, considering the complex etiology of neck pain that comprises physical, psychological, and environmental factors [35] . office workers with neck pain usually show limited range of motion of the cervical spine and enhanced activity of the cervical flexors and cervical extensors muscles [36] , which might prolong neck pain. a comfortable workplace may help in preventing msk disorders. some experts recommend [37] that the worktable and chair must be adjustable in height so that the feet are supported to be always well placed on the ground. in the absence of a height-adjustable chair, the use of a footrest is recommended. moreover, the monitor must be at the appropriate eye level so as not to force a persistent head tilt. in our study, we found that most of the participants used a common kitchen chair, not adjustable in height, and nobody used a footrest during working hours. therefore, these factors may contribute to lbp, although no relevant changes in the onset and/or worsening of this condition were reported in our population. on the other side, both frequency (23.5%) and worsening (50%) of neck pain were stepped up in workers who used laptops without any height-adjustable support. however, pain intensity and interference with adl (bpi scores) seemed to be negligible in home workers with lbp or neck pain. furthermore, the work component of fabq in people reporting low back and neck pain was mild. these data testify that remote working seems to not significantly affect spine pain, probably because subjects were practicing this job type since about 3 months, a too brief period to produce the putative adverse effects of prolonged use of non-ergonomic equipment. according to a national survey [38] , lbp and neck pain got worse during the lockdown, and 21% of individuals attributed this worsening to home working. our results are consistent with these data only for neck pain, while the participants have not declared a worsening of lbp during home working period. furthermore, participants with pain were less satisfied with working at home. however, 62.7% of participants expressed the wish to continue remote working in the future, at least occasionally. the first limitation of our study is the small sample size, which can lead to unpersuasive findings. second, our results refer to italian workers from the campania region, so they may be not generalizable across different regions or countries. third, the cross-sectional design is not able to establish a cause-effect relationship because exposure and outcome are simultaneously assessed. finally, productivity, satisfaction, and msk issues in workers often have a variety of simultaneous influences that need to be accounted for. in the face of increasing use of home working, we did not find an adequate home environment, with a higher risk for health issues, particularly affecting the spine. our study suggests solutions for adapting the home environment, such as adjustable seating and worktable, which in our opinion can significantly reduce risks for health. this would lead to better productivity, lower costs, and enhanced job satisfaction. our results show reduced remote workers' perception about productivity. effective organization of the working day at home may improve job performance. it could be nice to make a list of daily goals, to create a space specifically reserved for work, and to reduce sources of distraction (i.e., by family members). in our perspective, management strategies should be provided to enhance productivity, particularly by adapting the home environment to allow comfortable working posture (height-adjustable chairs, tables, and monitors). these adjustments might lead to improving overall health and job performance. the covid-19 outbreak and social distancing have radically changed the work organization. current research investigated the impact of mobile working on work-related outcomes, mental health, and msk issues. in this survey, we have investigated for the first time how remote workers set up their home workplace and the impact of existing equipment on lbp and neck pain. in our study, home workers perceived themselves to be less productive, less stressed, and equally satisfied compared to their office working period. remote workers appreciated particularly saved travel time to go to work and were not pleased to be isolated from colleagues. the use of non-ergonomic equipment (conventional four-leg kitchen chair not adjustable in height, not height-adjustable monitor, the absence of a footstool) may increase msk disorders. most participants complained of worsening of neck pain, but no exacerbation of lbp was reported, probably due to the short duration of the study. moreover, our results suggest that msk disorders related to remote working might reduce job satisfaction. data provided by this survey would be useful to improve the home working environment and time organization in order to promote the mental and physical health of remote workers. further studies with a greater sample size are needed to examine, in a longer time span, the risks for msk well-being and the health-related burden of home working. funding: the authors would like to acknowledge the vanvitelli per la ricerca (valere) program for the allocation of funding that aims to publish university of campania "luigi vanvitelli" research products. the authors declare no conflict of interest regarding this study. eurofound and the international labour office. working anytime, anywhere: the effects on the world of work european union: luxembourg; the international labour office covid-19 and work from home: digital transformation of the workforce the balance careers. the pros and cons of a flexible work 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the creative commons attribution (cc by) license key: cord-338578-e0aiknb6 authors: patel, kajal; straudi, sofia; yee sien, ng; fayed, nora; melvin, john l.; sivan, manoj title: applying the who icf framework to the outcome measures used in the evaluation of long-term clinical outcomes in coronavirus outbreaks date: 2020-09-05 journal: int j environ res public health doi: 10.3390/ijerph17186476 sha: doc_id: 338578 cord_uid: e0aiknb6 (1) objective: the world health organization’s (who) international classification of functioning, disability and health (icf) classification is a unified framework for the description of health and health-related states. this study aimed to use the icf framework to classify outcome measures used in follow-up studies of coronavirus outbreaks and make recommendations for future studies. (2) methods: embase, medline, cinahl and psycinfo were systematically searched for original studies assessing clinical outcomes in adult survivors of severe acute respiratory distress syndrome (sars), middle east respiratory syndrome (mers) and coronavirus disease-19 (covid-19) after hospital discharge. individual items of the identified outcome measures were linked to icf second-level and third-level categories using icf linking rules and categorized according to an icf component. (3) results: in total, 33 outcome measures were identified from 36 studies. commonly used (a) icf body function measures were pulmonary function tests (pft), impact of event scale (ies-r) and hospital anxiety and depression scale (hads); (b) icf activity was 6-minute walking distance (6mwd); (c) icf participation measures included short form-36 (sf-36) and st george’s respiratory questionnaire (sgrq). icf environmental factors and personal factors were rarely measured. (4) conclusions: we recommend future covid-19 follow-up studies to use the icf framework to select a combination of outcome measures that capture all the components for a better understanding of the impact on survivors and planning interventions to maximize functional return. coronavirus disease 2019 (covid-19) has posed a major challenge to healthcare systems worldwide, with over 6 million confirmed cases and 350,000 deaths reported as of may 2020 [1] . whilst current efforts have been duly focused on reducing mortality, issues regarding potential long-term complications in covid-19 survivors are starting to emerge [2] [3] [4] . in the previous coronavirus outbreaks of severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers), such long-term sequelae spanned across the physical, psychological and social domains of health [5, 6] . early reports of covid-19 follow-up studies are suggestive of prevalence of similar health problems in covid-19 survivors as those reported in previous outbreaks of sars and mers [7, 8] . considering the multi-systemic impact of covid-19, follow-up studies across all these domains of health are required in order to truly understand these individuals' experiences and support their return to societal roles. post-acute early rehabilitation of coronavirus survivors would foremost involve recovery of body structure and function. impairment of respiratory function [9] [10] [11] , exercise tolerance [12] and neuromuscular functions [13] have been reported to be present in coronavirus survivors beyond 3 months post-infection, with improvement to some degree in many of these individuals. however, improvement in these impairments of body structure and function may not necessarily translate into recovery from disability and role limitation [14, 15] . for instance, during the sars outbreak in 2002, even though most patients had good recovery from their physical illness, their quality of life was still lower than healthy individuals and as many as 17% of coronavirus survivors had not returned to work 1-year post-discharge [11] . furthermore, evaluation of impairment without the knowledge of personal factors and help available to them in their environments can be futile as barriers in these contextual factors need to be overcome to facilitate participation of the individual in society. in order to assess survivors' long-term health comprehensively and provide rehabilitation, all aspects of health that influence recovery, including organ impairments, functional limitations and personal circumstances, should be assessed. the world health organization's international classification of functioning, disability and health (who icf) model put forward in 2001 provides a coherent view of different aspects of health from biological, individual and social perspectives [16, 17] . this framework has been extensively researched and validated for describing health state [17] , epidemiology [18] and public health [18] , classifying outcome measures [15, 19] and planning interventions [16, 20] . the interplay between these factors in covid-19 survivors is important to recognize in order to characterize their multi-systemic problems and disability and improve "functioning" by targeted interventions. the aim of this systematic review is to identify outcome measures which have been used in follow-up studies in the coronavirus outbreaks, including sars in 2002 and mers in 2012 [21] , and to classify them using the icf model. this will allow an understanding of whether all aspects of the health condition have been captured by these studies and highlight any gaps that need to be considered when selecting outcome measures for future studies. this systematic review was conducted in two stages. the searches were first screened using the abstract and then using the full text by two independent authors based on the inclusion and exclusion criteria below. original studies involving adults with confirmed diagnosis of coronavirus infection who were followed up for any period post-discharge were included. further inclusion was limited to studies that used at least one clinical outcome measure during the follow-up (e.g., studies investigating mortality only were excluded). reviews, case reports and editorial reports were excluded. information regarding the authors, study year and outcome measures used in all the included studies was extracted into standardized tables. extraction was undertaken by kp and ms independently and then compared for accuracy. icf linking rules were used in this study. these rules have been developed specifically to link the content of each outcome measure to the icf framework [22] . the rules suggest that meaningful concepts within the items of outcome measures should be identified and then linked to the most precise icf category. meaningful "concepts" are those that describe health condition, person, functional activity or any of the environmental factors. for example, the measure ies-r scale (impact of event scale-revised) has two items, "i had trouble staying asleep" and "i felt angry", the concepts extracted from these items were sleep and anger. sleep was linked to the second level icf category, "b134-sleep function", and anger was linked to the third level icf category, "b1522-anger". meaningful concepts referring to "quality of life" are assigned to the "not definable-quality of life" category. if a meaningful concept is not contained in the icf and is clearly a personal factor, it is assigned "personal factor". if a meaningful concept is not contained in icf and is not a personal factor, it is assigned "not covered". if the meaningful concept refers to a diagnosis or a health condition, it is assigned "health condition" [22] . based on the above rules, meaningful concepts were extracted from the items of the identified measures and linked to relevant icf categories. finally, each outcome measure was then classified to belong to the icf component that covered the majority of its constituent questions. for example, the items of ghq-12 were linked to the two icf components, "body function and structures" and "activities", with the majority of questions linking to the icf "body function and structures" component. hence, this outcome measure was classified as belonging to (or representing) icf "body function and structures". this stage was undertaken by authors kp and ms and cross-checked for consensus by nys and nf. based on the spread of the these meaningful concepts, each outcome measure was classified into one of the main individual icf components [22] , defined as follows: • body structure and body function: refers to anatomical structure or physiological function such as those required for cognition, cardiovascular function, motor functions, pain or emotion. personal factors: refers to characteristics that are unique to each individual such as age, gender, ethnicity, personality, resilience or experiences. this stage was undertaken independently by all authors and cross-checked for consensus. the search of four databases yielded 1528 studies. out of these, 36 studies were finally included in this review. the reasons for exclusion of studies at each stage are reported in figure 1 . tables 1 and 2 the mapping of meaningful concepts to the icf categories is shown in table 3 . based on how the units mapped, the authors decided on which icf component each outcome measure ultimately represents. figure 2 portrays the classification of outcome measures based on icf components. in total, 19 outcome measures measured icf body structure and function, three outcome measures measured activity, four outcome measures measured participation, one outcome measure measured environmental factors and seven outcome measures measured personal factors (see table 1 ). the mapping of meaningful concepts to the icf categories is shown in table 3 . based on how the units mapped, the authors decided on which icf component each outcome measure ultimately represents. figure 2 portrays the classification of outcome measures based on icf components. in total, 19 outcome measures measured icf body structure and function, three outcome measures measured activity, four outcome measures measured participation, one outcome measure measured environmental factors and seven outcome measures measured personal factors (see table 1 ). friends + * personal factors do not have second-level or third-level categories yet, "+" means that these icf concepts were assessed by the item of the respective outcome measure [17] . considering the widespread prevalence of covid-19, the long-term complications of coronavirus infection in survivors will increase healthcare utilization significantly in the coming months. previous outbreaks have shown that there is a broad spectrum of long-term complications of coronavirus infection which spans across all of the icf components, with prevalence of respiratory compromise, exercise intolerance, psychological distress and reduced quality of life being considerably high several months following infection [5] . deficits in different components do not necessarily translate into each other and there is no causal relationship between them [15] . the return of covid-19 survivors to pre-infection levels of activity and participation in society are influenced not only by the degree of recovery from impairments in body structure and function but also by their personal and environmental factors, which hinder or facilitate their return to previous societal roles [54] . therefore, it is essential that all future follow-up studies looking at covid-19 survivors measure all aspects of the icf framework. this review assimilates the outcome measures used in all the follow-up studies conducted during the present and past coronavirus outbreaks and classifies them according the icf categories in order to provide a conceptual framework for the selection of outcome measures for future covid-19 follow-up studies. all studies included in this review reported outcomes in terms of body structure and function. the most commonly reported impairment in coronavirus survivors was respiratory compromise [9] [10] [11] [12] [34] [35] [36] 39, [42] [43] [44] 48, 55] , with mainly restrictive patterns of lung function abnormality on pulmonary function testing. neuromuscular impairment of muscle power and sensory function, particularly in those admitted to intensive care units, have also been reported based on neurological examination, mrc muscle power and grip strength measurements [13] . long-term fatigue has also been measured using fss and cfq and found to be prevalent at 6 months post-discharge [24, 27] . alongside physical impairment, psychological impairments have also been widely elaborated by several studies. prevalence of ptsd [23, 24, 26, 27, 29, 38] , depression [23, 24, 26, 27] and anxiety [23, 26] have been found to be particularly high in this cohort of patients. these mental health outcomes have been measured using a variety of scales. outcome measures which were particularly useful in measuring impairment in these individuals were ies-r, phq-9 and ghq-12 as these were able to capture the impact of psychological issues on a range of functions such as sleep, concentration, appetite and energy. we believe that at least two outcome measures should be used to assess impairment in body structure and function to address the physical and psychological impairment separately, such as a combination of lung function test and a ptsd outcome measure. limitations in activity have been measured through 6-min walking distance [9, 12, 31, 45] and cardiopulmonary testing in the included studies [34] . most of the studies report these to be reduced following discharge, with gradual improvement at 6 months post-discharge. participation has been measured using sf-36, sgrq and sdss. these reflect several domains of self-care, domestic life, interpersonal relationships, mobility, work and social life. quality of life has been reported to be considerably reduced in coronavirus survivors [11, 29, 31, 42, 56] . despite having extensive impact on the overall wellbeing of an individual, these tools have been measured by only a minority of studies and should be measured consistently across all future follow-up studies in covid-19 survivors. we recommend at least one functional measure of activity, such as walking distance, and one to capture participation and quality of life, such as sf-36, for future studies. environmental factors have not been explored adequately by the included studies. only one study measured these through the perceived social support scale [28] . none of the studies provided or reported information regarding pulmonary rehabilitation, pharmacological interventions or psychological support. as these interventions are also considered as environmental factors which could facilitate the recovery of these impairments in survivors, reporting of such factors in covid-19 patients is also important. attitudes of family and society members have also not been explored. some of the measures which have been used to measure environmental factors in other areas of health have been the craig hospital inventory of environmental factors (chief), environmental factors item bank (efib), facilitators and barrier's survey/mobility (fabs/m) and home and community environment instrument (hace). future studies must aim to capture these factors along with family and carer support available in their chosen environments. funding for rehabilitation will also play an important role in recovery for covid-19 patients [57] . personal factors which may play a role in recovery, such as coping styles, self-esteem, social stigma and personality, have been measured using self-constructed scales by some studies [24] . some of the validated tools which have been used to measure such personal factors in other areas of health are the connor davidson resilience scale [58] and kessler 6 psychological distress scale [59] . inclusion of these measures could enable us to explore this domain further. through the use of the icf framework, it is evident that, whilst impairments in body structure and function and restrictions in activity and participation have been measured extensively using standardized outcome measures, personal and environmental factors have only been measured in a small number of studies. the measurement of these contextual factors using standardized measures is essential as they have a major role to play in these individuals' health and return to function. [60] . we propose that at least five different outcome measures spanning across all five icf components need to be used in future follow-up studies. it might be useful wherever possible for researchers to try to use the same outcome measures that were used in previous studies as this allows comparability and pooling of results. we however acknowledge that this might not be possible when there is a compelling case to use a measure that serves the purpose of the study better. for example, eq5d is better suited to capture the health economics of the impact of the covid-19 outbreak and researchers might opt to choose this over sf-36, which was predominantly used as the quality of life measure in previous studies. the aim of this review was merely to categorize the currently available outcome measures into the icf domains so that future researchers could pick an outcome measure corresponding to each category in order to capture the entire breadth of the health condition. we do not intend to make recommendations regarding specific outcome measures under each icf domain that the reader should use. this would require further exploration of the psychometric properties of each measure, which is outside the scope of this paper. we only aim to provide a framework that one should keep in mind when choosing the measures rather than providing recommendations on which specific measure to use. in the 36 studies included in this review, there were 33 different outcome measures used at follow-up. this makes comparison of results from studies using different measures difficult. in order to be able to do so, these diverse measures need to be converted into a common framework. this would most logically be done using the icf, as it is the most commonly recognized international language of functioning. thus, categorizing the measures into such a framework would be useful for researchers as it would identify the icf categories that these authors found useful for their studies and inform their choice for future studies. the main limitation of this review is that we have only described the outcome measures which have been used in the follow-up studies so far. this does not mean that outcome measures not used in these included studies are not suitable for use in future studies. moreover, our search strategy was not designed to look for rehabilitation studies in coronavirus survivors. if these had been included in the review, then the set of outcome measures included in this review might have been slightly different. however, the aim of this review was to provide an icf-based framework for the selection of outcome measures which researchers and clinicians are recommended to use. they need not necessarily use the same outcome measures as previous studies. for example, some researchers might prefer to use eq5d instead of sf-36 for capturing quality of life. the rehabilitation community will be working hard in the next few years to help covid-19 survivors achieve the best possible outcomes. the selection of outcome measures must be an essential first step rather than an afterthought in this process. in conclusion, we are proposing an icf-based framework to assist researchers in selecting outcome measures for future follow-up studies of covid-19 survivors. this review highlighted that most studies so far placed greater emphasis on measuring body function impairments, limitations in activities and restrictions in participation. icf personal and environmental factors were not as comprehensively covered and need to be included in covid-19 follow-up studies. the individual icf components are not linearly related and therefore a combination of outcome measures that capture all the components is recommended for a better understanding of the impact on survivors and planning interventions to maximize functional return. coronavirus disease (covid-19) pandemic. 2020 we need a nightingale model for rehab after covid-19 the role of physical and rehabilitation 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medicine and rehabilitation funding: this research received no external funding. the authors declare no conflict of interest. key: cord-355095-4sxuppmo authors: kimhi, shaul; eshel, yohanan; marciano, hadas; adini, bruria title: distress and resilience in the days of covid-19: comparing two ethnicities date: 2020-06-03 journal: int j environ res public health doi: 10.3390/ijerph17113956 sha: doc_id: 355095 cord_uid: 4sxuppmo the covid-19 pandemic is an ongoing epidemic of coronavirus disease, caused by severe acute respiratory syndrome, which has spread recently worldwide. efforts to prevent the virus from spreading include travel restrictions, lockdowns as well as national or regional quarantines throughout the international community. the major negative psychological outcome of the covid-19 pandemic is the anxiety caused by it. the aim of the present study was to examine the level of concern and the contributions of modes of resilience, well-being and demographic attributes towards decreasing or enhancing anxiety and depression among two samples: israeli jews (majority group) and israeli arabs (minority group). these random samples included 605 jews and 156 arabs who participated in an internet survey. a previous study, which has been conducted in the context of terror attacks, has shown that compared to israeli jews, israeli arabs expressed a higher level of fear of war and lower levels of resilience supporting personality attributes. the results of the current study indicated a similar pattern that emerged in the context of the covid-19 pandemic: the israeli arabs reported a higher level of distress and a lower level of resilience and well-being. the coronavirus disease (covid19) which has erupted in china in 2019 is an infectious disease caused by a newly discovered strain of coronavirus. this pandemic is rapidly spreading worldwide, with constantly growing numbers of morbidity and mortality [1, 2] . it has led to severe global disruptions, such as closing schools and universities, partial or total closure on the population enforced by governments, reduced travel and ensuing unemployment and economic difficulties, world-wide stock markets decline, and panic buying due to widespread fears of supply shortages [3] . the covid-19 illness is very risky for older people who have additional health problems, but statistics show that the percentage of infected people in the population is relatively small, in countries that maintain proper health systems [4] . the vast majority of the general public is not expected to become sick and suffer directly from the covid-19 symptoms. however, people are liable to be concerned by this pandemic and suffer from it psychologically. they are likely to experience fear, anxiety, and uncertainty, worrying whether they or their dear ones may be susceptible to the virus, become sick and risk death. furthermore, many individuals may wonder whether they are already affected by this virus although they do not show the typical symptoms caused by it [5] . although the limitations of social contact which have been introduced and enforced in various countries may slow this pandemic from spreading, they are likely to intensify people's concerns and apprehension concerning the dangers of this pandemic. for the vast majority of people who do not regard themselves as sick yet, the covid-19 epidemic may constitute a major psychological issue which is expressed by increased tension, concerns, and anxiety. these psychological effects are strengthened by a lack of an effective vaccine that may prevent the disease's contagion or medicine which can cure it and are also influenced by the ambiguity concerning how long it will continue to disrupt individual and public life [6] . the ongoing intensive discussion of this pandemic by the mass media as well as politicians, and grim forecasts concerning its potential disastrous future outcomes, further enhance these negative emotions [7] . the impact of the covid-19 pandemic on the general public will be assessed, therefore, by the individual level of concerns and anxiety which is raised by it among the general public. the present study investigated psychological and demographic variables that affected the level of concern among individuals who, as far as we know, have not been affected by the covid-19. these impacts were examined separately for two populations: a sample of the israeli jewish majority, and a sample of its israeli arab minority. in characterizing the israeli arab culture, it has been claimed that western cultures encourage individualism and self-actualization through attributes such as goals, dreams, abilities, personality traits, and talents, whereas the arab society in israel generally centers on a collectivist culture [8] . this culture enhances the importance of intergroup relationships which help each member to fit in this society. it is based on the belief that all problems and issues should be solved within the extended family, without looking outward for help or advice. its members are expected to turn to their families for assistance, in any social, economic, or health-related difficulty. despite changes in the structure of the arab family due to the modernization process, there has been some continuity in the extended relationships between family members, which has retained the three main family units of this society: the hamula (kinship group), the extended family, and the nuclear family. the extended family is still the basic social unit responsible for caring for aged family members and for supporting all its members during distressing times (haj yahia-abu ahmad, 2006, unpublished doctoral dissertation). we assume that this family structure would also support members of this ethnic group during the current covid-19 pandemic. a previous comparison of reactions of jewish and arab israelis to threats of war and acts of terror [9, 10] have indicated a similarity between jews and arabs in their previous exposure to terror. however, the arab sample expressed a significantly higher level of fear of war and significantly lower levels of community and national resilience. we assumed, therefore, that israeli arabs would also show a higher level of covid-19 psychological symptoms. moreover, disastrous events are likely to enhance a continuous sense of danger that strongly and negatively influences the reaction to these adversities [11] . a high sense of danger is positively correlated with distress symptoms [12] , and negatively correlated with a sense of coherence [13] and individual resilience [14] . a previous study of responses to war threats had indicated that while a sense of danger increases distress feelings, feeling safe at home decreases anxieties raised by a potential calamity [15] . accordingly, we assumed that israeli arabs would show a higher level of sense of danger and a lower level of feeling safe at home, compared with israeli jews. furthermore, earlier studies indicated that highly threatening and painful events, such as the covid-19 pandemic, undermine people's basic sense of security and increase distress symptoms. these symptoms include continuous emotional and behavioral reactions [16] such as depression, anxiety, and grief. previous studies have indicated that well-being and individual, community and national resilience contribute to countering distress. individual resilience theory concentrates on understanding the process through which people overcome traumatic events and calamities experienced by them [17] . researchers have claimed that resilience combines protective factors that modify, ameliorate, or alter a person's response to environmental hazards that predispose to a maladaptive outcome [18, 19] . for example, a previous study [15, 18] has shown that individual resilience positively and significantly predicts better coping with stressful situations. in a different context, individual resilience was found to be negatively associated with fear of war among israelis [14, 15] . community resilience expresses an identification of individuals with their social system, and their belief that their societal networks will succeed in providing for their needs in times of adversities [19] . community resilience is defined as the network's "capability to anticipate risk, limit impact, and bounce back rapidly through survival, adaptability, evolution, and growth in the face of turbulent change" [20] (p. 10). a review of the research presents that community resilience is associated with increased local capacity, social support, and resources, as well as decreased risks, miscommunication, and trauma [21] . national resilience represents the society's ability to withstand an adversity with its values and institutions remaining intact, as well as the society's ability to cope with a changing, and sometimes hostile, environment by adapting and readjusting in new and innovative ways [22] . it has been claimed that national resilience is composed of four attributes: patriotism, optimism, social integration, and trust in political and public institutions [23] . national resilience has been positively predicted by a sense of coherence, well-being, and economic conditions [24] . well-being represents individuals' perceptions of their quality of life [9] . the present study aimed to examine the level of sense of danger and distress symptoms, the contributions of modes of resilience, well-being and demographic attributes towards decreasing or enhancing anxiety and depression among two samples: israeli jews (majority group, n = 605) and israeli arabs (minority group, n = 156). overall, we expected in the current study to find negative correlations between the distress symptoms and a sense of danger, individual, community, and national resilience, and the well-being, across the two groups. we also expected that arab israelis would demonstrate a higher level of distress and a lower level of resilience, compared with israeli jewish. in line with the above discussion, we hypothesized the following: 1. the arab sample would score higher than the jewish sample on the level of covid-19 pandemic distress and the level of sense of danger perceived by its members and would score lower than the jewish sample on individual and public (community and national) resilience as well as on feeling safe at home. 2. the covid-19 pandemic concerns expressed by both groups would be positively predicted by their sense of danger, and negatively predicted by their individual resilience. demographic variables associated with greater life experience would negatively predict this anxiety, whereas a higher level of education, which indicates a better understanding of the complex implications of this disease, will positively predict this anxiety. the present study was based on a random internet sample of 605 jews (299 females) and 156 arab adults (78 women) who have agreed to participate in the research. they are characterized by a wide range of demographic attributes (see demographic characteristics detailed in table 1 ). the data have been collected by the internet panel company that consists of the largest internet panel in israel (over 100,000 panelists). all data was gathered anonymously, following approval of the irb of the tel aviv university for the reliability and validity of the on-line questionnaire, see [25] . all participants signed informed consent forms before filling out the questionnaires. the participants were randomly sampled from the large internet panel and accessed the questionnaire that was distributed to their e-mail address. at the beginning of the questionnaire, a brief explanation was presented, informing them that the participation in the study is voluntary and the completion of the questionnaire constitutes an agreement to participate in the study. the explanation included the email address of two researchers, inviting the respondents to approach them should the questionnaire cause them any discomfort. the collected data was uploaded to spss (version 23) and analyzed to identify differences between groups based on matt whitney u test and multiple regressions, conducted separately for each ethnic group. individual resilience was measured by a 10-item connor-davidson scale [26] portraying individual feelings of ability and power in the face of difficulties. this scale was rated by a 5-point response scale ranging from 1 = not true at all, to 5 = generally true. significant correlations were found between this scale and emotional intelligence, life satisfaction, self-esteem, and positive affect; and a negative significant correlation was found with negative affect [27] . cronbach's alpha reliabilities of this scale were α = 0.87 and α = 0.91, for the investigated jewish and arab samples, respectively. community resilience was assessed by a short version of 10 items of the ccram scale [28] . for this study, we changed the scale each time the word 'security crisis' emerged for the 'coronavirus crisis'. this tool covered five main issues: social trust, social support, leadership, emergency preparedness and attachment to place (e.g., "i trust the decision-makers in my community"). items of this scale were rated by a 5-point scale ranging from 1 (does not agree at all) to 5 (totally agree). the cronbach alpha reliabilities of this scale were α = 0.92 and α = 0.91 for the jewish and arab samples, respectively. national resilience was measured by the nr-13 instrument [29] that pertains to trust in national leadership, patriotism, coping with national crises, and belief in social justice. the 13 items have been rated by a scale ranging from 1 = does not agree at all, to 6 = very highly agree. cronbach's alpha reliability of this resilience in the present study was α = 0.88. a seven-item sense of danger scale, which is based on solomon and prager [30] scale, referred to as a lingering sense of danger in the context of security threats, was used to assess the sense of danger. in the current study we modified the threat from security to the covid-19 pandemic threat (e.g., "to what extent are you worried about the increase of the covid-19 global crisis?"). also, we added the item "to what extent are you worried that we will not be able to overcome the covid-19 crisis before many citizens in our country die from this disease?" responses were rated on a likert-like scale ranging from 1 (not at all) to 5 (very much). the cronbach alpha reliabilities of this scale were α = 0.83 for both arab jewish samples. the level of individual distress symptoms, in the context of the covid-19 pandemic, was determined by nine items about anxiety and depression out of the brief symptom inventory [31] . this inventory was scored by a likert scale ranging from 1 (not suffering at all) to 5 (suffering very much). (e.g., "how much do you suffer from feelings of a sudden fear with no reason?"). due to ethical considerations, we did not include the item concerning suicidal thoughts. cronbach's alpha for both samples was α = 0.86. this issue was examined by a single item: "to what extent do you feel safe at your home?" the response scale ranged from 1 = not safe at all, to 5 = very safe. kimhi and shamai [32] have assessed post-war strength by an individual level of recovery from war. in more peaceful times, this strength has been assessed by 'my life today' or well-being scale in which people rate their current health, work, social contacts, and their achievements. the sense of coherence, social support, and community resilience has consistently predicted this variable over time [33] . the scale consists of 9 items ranged from 1 = not good at all, to 6 = very good. cronbach's alpha for both samples was α = 82. six demographic attributes were examined (table 1) due to the inequality of the participants' characteristics, mann-whitney u tests were used to compare the two participating groups-jews versus arabs. the demographic characteristics of the two participating groups (table 1) indicated that the israeli arab participants scored significantly lower than the israeli jewish participants on two demographic characteristics: age (p < 0.0001) and income (p < 0.0001), and scored significantly higher on level of religiosity (p < 0.04). concerning political attitudes, arabs presented more left-wing political attitudes compared to the jewish group (p < 0.0001). no significant difference was found between these groups according to their educational level. in agreement with the first hypothesis on the mean differences between the two investigated groups, mann-whitney u tests indicated that the arab respondents expressed a significantly higher the second hypothesis on the predictors of covid-19 distress of the participants was examined by two multiple regression analyses, conducted separately for the jewish and the arab samples ( table 2) . as expected, a higher sense of danger contributed to increasing the covid-19 distress in both samples, whereas individual resilience contributed to decreasing this anguish in both groups. feeling safe at home negatively predicted covid-19 anxiety in the jewish sample and had no significant effect on the arab sample. two additional variables, age and the number of children, negatively predicted this anxiety in the jewish group, but not in the arab group. the educational level of the participants significantly predicted covid-19 anxiety in both groups. however, higher educational levels predicted a higher level of such anxiety among jewish participants and negatively predicted it among arab respondents. the present study aimed to examine the level of concern and the contributions of modes of resilience, well-being, and demographic attributes towards decreasing or enhancing anxiety and depression in two samples: israeli jews and israeli arabs. the most prominent result of the current study is the differences we found between the jewish majority and arab minority samples. the differences between the two samples refer both to different levels of distress and resilience, and their predictors. members of the current arab sample expressed higher levels of distress and perceived danger of the present pandemic. this is interesting to note as theoretically, the covid-19 pandemic does not pose a greater risk to the minority group compared to the majority population. the covid-19 endangered most of israel's citizens to about the same extent, and the percentage of jews who were affected by it, so far, was higher than the percentage of sick arabs. the present results seem to indicate that the higher level of anxiety expressed by the arab sample, more likely portrays permanent concerns of this minority and perceived inequality, which preceded the covid-19 [34] . examining the variables that predicted covid-19 pandemic anxiety in each of the investigated samples indicated, as expected, that a higher sense of danger, raised by this pandemic, tended to enhance anxiety levels, whereas a stronger individual resilience was inclined to decrease the rate of this apprehension. these effects were replicated in both samples. these results strengthen previous findings that presented a negative relationship between individual resilience and anxiety [35] . the rest of the predictors differentiated between the two groups. feeling safe at home negatively predicted pandemic anxiety. arab participants felt less secured at their homes compared to jewish individuals, and their sense of safety at home was not strong enough to negatively affect their anxiety. these perceptions were most likely derived from the ongoing variability that exists between israeli arab and jewish populations concerning safety perceptions in the different settings, including in their homes as was identified in previous studies [1, 17] . these differences were likely to impact their perceived well-being and levels of stress [36] . these results partly correlate with the previous finding of the lower resilience of minorities under stressful conditions [37] . two additional unlikely characteristics contributed to decreasing the investigated anxiety, but in the jewish sample only: age of participants and number of children. regarding the first one, it may be reasoned that in the present context this variable is relevant to the extent to which it represents life experience. more mature individuals had probably more than one opportunity to experience different highly distressing events, which affected their lives and the lives of their children, and an opportunity to learn that in most cases these adversities sooner or later disappear. furthermore, they are more adept at self-regulating their psychological well-being [3] . these findings are aligned with other reported results indicating that older individuals showed lower levels of concern and anxiety, despite their belonging to a much higher-risk group for contracting covid-19 [38] . it was expected that the potentially disastrous impacts of the covid-19 pestilence and the difficulties in finding means for treating it, as well as efficient immunization for it, will be appreciated more readily by individuals with higher education. the present findings indicated that the level of education played the opposite role in predicting this distress in the two investigated groups. more advanced education levels contributed to increased anxiety in the jewish sample, and at the same time was a significant factor in decreasing this anxiety among arabs. wang et al. [3] also found during the current pandemic, that higher education was related to higher levels of depression and anxiety. the assumption was that highly educated professionals are accustomed to a busy lifestyle and the current isolation from routine colleagues, activities, and occupations, contributed to elevated frustrations and anxiety [3, 39, 40] . the lower national resilience of the arab participants most probably did not reflect solely the way they perceive the government's management of the covid-19 crisis. it is more likely that it represented a permanent struggle concerning their national identity and their identification with the state of israel. it was argued that israeli arabs were expected to determine the extent to which they identified themselves as mainly palestinians or israelis, and this awkward choice was likely to lead them to a sense of identity threat [41] . these contrary identities were based on different, and opposing national aspirations, and seemed to disagree on the history of the israeli-arab conflict, its root causes, and the role played by each group in initiating and maintaining it [42] . furthermore, the israeli arabs tend to regard themselves as a deprived but non-assimilating minority [43] , and we submit that responses of minority groups to all kinds of calamities could serve as indicators for their actual or perceived relative social position. beyond these specific group differences, we suggest that different socio-cultural groups are likely to respond differently to ambiguous and complicated situations. the regression analyses indicated which individual characteristic predicted covid-19 anxiety, and there was no reason to believe that members of either group were aware of the prediction pattern that characterized them. however, it appeared that members of the jewish community raised inadvertently several potential predictors for their emotional response to this pandemic, whereas members of the arab public tended to restrict their responses unintentionally and seemed to be satisfied with a smaller number of such predictors. this conclusion was supported by a previous comparison between israeli arabs and jews in predicting individual resilience in light of their experienced security situation at that time [9] . this study indicated that the degree of fear of war, and the level of exposure to terror acts negatively predicted individual resilience in both groups. however, while no additional individual characteristic predicted this resilience in the arab sample, it was significantly predicted as well by age, level of religiosity, political attitudes, family income, and sense of coherence of the jewish participants. in both studies, the total impact of the predictors on the predicted variable was quite higher in the jewish sample compared with the arab sample. our results indicated similarities as well as differences between the characteristics of the present sample and those obtained in previous comparisons conducted between israeli jews and arabs in a security context [1, 10] : the arab respondents of the previous research scored significantly lower than the jews on individual, community and national resilience scales. furthermore, the arab respondent was significantly more religious and held more left-wing political attitudes compared to the jewish sample. both samples reported a higher level of sense of danger and distress symptoms, a lower level of individual resilience and higher level of community resilience, compared with the results obtained in previous studies. however, there were no differences between the two studies, regarding national resilience [9] . the first limitation of this study concerns the internet sample on which this study was based, as we cannot guarantee that it is a representative sample of the israeli population, even though the sample is large and includes a broad distribution of demographic variables. the second limitation is the fact that our study is a correlational study and does not allow causality inference. our results replicate earlier studies indicating that a minority group is more susceptible to disasters and threats, and less resilient, compared with the majority group. it seems that perceived inequalities that existed before the adversity, increased during an emergency. an additional possible conclusion is that the high degree of uncertainty that characterizes the current covid-19 crisis greatly increases anxiety and distress symptoms. based on the current research and further studies we strongly recommend continuous measurement of stress and resilience over time. how will country-based mitigation measures influence the course of the covid-19 epidemic? response to covid-19 in taiwan: big data analytics, new technology, and proactive testing assessing the impact of reduced travel on exportation dynamics of novel coronavirus infection (covid-19) supporting vulnerable health systems improve infection prevention and 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psychological dynamics of intractable ethnonational conflicts renegotiating israeli identities, collective victimhood and social exclusion of arab israelis in a changing social reality this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research has received no external funding. the authors declare no conflict of interest. key: cord-353867-617f90wq authors: ory, marcia g.; lee, shinduk; towne, samuel d.; flores, starr; gabriel, olga; smith, matthew lee title: implementing a diabetes education program to reduce health disparities in south texas: application of the re-aim framework for planning and evaluation date: 2020-08-30 journal: int j environ res public health doi: 10.3390/ijerph17176312 sha: doc_id: 353867 cord_uid: 617f90wq health disparities in diabetes management and control are well-documented. the objective of this study is to describe one diabetes education program delivered in the united states in terms of the re-aim (reach, effectiveness, adoption, implementation, and maintenance) planning and evaluation framework. questionnaires, clinical data, and administrative records were analyzed from 8664 adults with diabetes living in south texas, an area characterized by high health disparities. the diabetes education program delivered was a professionally led 12-month program involving 8 h of in-person workshop education followed by quarterly follow-up sessions. changes in average blood glucose levels over the past 3 months (e.g., a1c levels) were the primary clinical outcome. descriptive and multiple generalized linear mixed models were performed. this community-based initiative reached a large and diverse population, and statistically significant reductions in a1c levels (p < 0.01) were observed among participants with type 2 diabetes at 3 months. these reductions in a1c levels were sustained at 6-, 9-, and 12-month follow-up assessments (p < 0.01). however, considerable attrition over time at follow-up sessions indicate the need for more robust strategies to keep participants engaged. for this diabetes education program, the re-aim model was a useful framework to present study processes and outcomes. health disparities are often geographically bound and occur more frequently in impoverished populations characterized by low socio-economic status and a dearth of available healthcare resources [1] [2] [3] [4] . the u.s.-mexico border is impacted by extremely high disparities in income, education, and healthcare access, and these social determinants of health make this region among the nation's figure 1 illustrated the 27 counties formally included in the healthy south texas initiative [30] , and the counties in which the diabetes education program was offered were marked with a red dot. counties along the us-mexico border were included, as well as areas adjacent to border counties, which were all referred to as south texas. including urban, small town, and rural areas, the overall estimated population in these counties in 2015 was approximately 2.8 million, and these areas were among the most impoverished in the nation in terms of socioeconomic status and lack of healthcare services [31, 32] . as a community-driven initiative, inclusionary criteria were broad with the intent of serving those both directly and indirectly involved in a person's diabetes prevention and management. while the focus was on adults with type 2 diabetes, persons with pre-diabetes and type 1 diabetes were invited, as well as family members or friends providing care for persons with diabetes. as indicated in figure 1 , the formal diabetes education program was offered in 14 of the 27 south texas counties in two primary hubs clustered around nueces and hidalgo counties. given the community-based nature of this initiative and the desire to reach as many participants as possible to show widespread program penetration, participants were recruited from a variety of sources including screenings at health fairs, referrals from healthcare facilities, outreach to community partnerships with flyers and other social media, and self-referrals. although there was no attempt to standardize referral sources, which differed by organizational sponsorship and location, promotional materials (e.g., flyers) were standardized with a uniform healthy south texas brand. the diabetes education program was a recognized american diabetes association (ada) program that was professionally led but also included community health workers for outreach and programming assistance [27] . all ada-recognized programs provided quality education for people with diabetes and followed the national standards for diabetes self-management education and support (dsmes) guidelines [33] . ada-recognized diabetes education programs were eligible for reimbursement through many federal and private u.s. insurers [34] . offered in both spanish and english, the program consisted of 8 hours of face-to-face educational workshop sessions led by at least one trained health professional (e.g., registered nurse (rn), registered dietician (rd), pharmacist, or certified diabetes educator). workshop sessions were followed with brief (e.g., 15-30 min) in-person individualized follow-up educational and support sessions offered on a quarterly basis for a year. focal workshop topics included a discussion of, as well as hands-on experiential learning about what diabetes is, blood glucose monitoring, given the community-based nature of this initiative and the desire to reach as many participants as possible to show widespread program penetration, participants were recruited from a variety of sources including screenings at health fairs, referrals from healthcare facilities, outreach to community partnerships with flyers and other social media, and self-referrals. although there was no attempt to standardize referral sources, which differed by organizational sponsorship and location, promotional materials (e.g., flyers) were standardized with a uniform healthy south texas brand. the diabetes education program was a recognized american diabetes association (ada) program that was professionally led but also included community health workers for outreach and programming assistance [27] . all ada-recognized programs provided quality education for people with diabetes and followed the national standards for diabetes self-management education and support (dsmes) guidelines [33] . ada-recognized diabetes education programs were eligible for reimbursement through many federal and private u.s. insurers [34] . offered in both spanish and english, the program consisted of 8 h of face-to-face educational workshop sessions led by at least one trained health professional (e.g., registered nurse (rn), registered dietician (rd), pharmacist, or certified diabetes educator). workshop sessions were followed with brief (e.g., 15-30 min) in-person individualized follow-up educational and support sessions offered on a quarterly basis for a year. focal workshop topics included a discussion of, as well as hands-on descriptive statistics (mean and standard deviation or frequency and percentage) were used to describe the characteristics of participants. not all implementation sites collected the exact same set of variables; thereby, the descriptive statistics reflected available data (i.e., not all variables had the same number of missing cases). bivariate analyses (e.g., independent t-tests or chi-square tests) were performed to compare the characteristics of participants recruited during the first biennium and second biennium. next, retention rates were estimated for each follow-up session. as a part of retention analysis, characteristics of participants who attended and did not attend each follow-up session were described and were then compared using bivariate analyses. this study used data collected between september 2015 and december 2019. although having four additional data collection months after the second biennium ended in august 2019 allowed for more follow-ups, not all participants had an opportunity to complete all their follow-up sessions. intervention delivery dates were used to identify and exclude participants from the retention analyses based on their eligibility to participate in the follow-up. for example, participants who participated in the workshop after june 2019 were excluded from the retention analyses for the 6-month follow-up. similarly, participants who participated in the workshop after march 2019 were excluded from the retention analyses for the 9-month follow-up; and those who participated in the workshop after december 2018 were excluded from the retention analyses for the 12-month follow-up. multiple generalized linear mixed models with participant-level random intercepts were fitted to examine changes in a1c level over time among participants with pre-diabetes or type 2 diabetes. persons with type 1 diabetes (n = 221) or gestational diabetes (n = 12) were not included in the regression models due to small sample sizes. separate models were performed for the first and second biennia. the first set of models examined changes in a1c levels over time in participants with type 2 diabetes (n = 1922 in the first biennium and n = 2733 in the second biennium). the second set of models examined changes in a1c level over time in participants with pre-diabetes (n = 380 in the first biennium and n = 482 in the second biennium). the third set of models examined any differences in the changes in a1c levels over time based on diabetes type (pre-diabetes or type 2 diabetes) (n = 2302 in the first biennium and n = 3215 in the second biennium). the next set of models examined changes in a1c level among participants with type 2 diabetes by their baseline a1c level (i.e., 4.0-5.6%, 5.7-6.4%, 6.5-7.9%, 8.0-8.9%, 9.0-9.9%, 10.0-11.9%, and 12.0% or higher) (n = 1912 in the first biennium and n = 2722 in the second biennium). in addition, a separate regression model was used to examine any racial/ethnic differences in changes in a1c level (n = 2302 in the first biennium and n = 3215 in the second biennium). all regression models controlled for covariates including age, sex, race/ethnicity, education, language, and baseline bmi category. given that there were only 5 participants reported speaking "other" as their primary language, they were excluded from the regression analyses. a significance level of 0.01 was used. this study involved retrospective reviews and analyses of limited data, and this study was reviewed and approved by the institutional review board at texas a&m university (irb2019-0225d). results were presented based on the five re-aim elements to provide a case study of this applied research about diabetes self-management education [29] . reach was defined as "the absolute number, proportion, and representativeness of individuals who are willing to participate in a given initiative, intervention, or program, and reasons why or why not" [36] . the number of persons who participated in the program and their general characteristics were tracked (table 1 ). the majority of program participants were aged between 45 and 64 years (55.3%), female (61.6%), hispanic (68.6%), and had high school or less education (72.2%). most participants reported english as their primary language (89.5%) ( table 1 ). the intervention could be attended by individuals with pre-diabetes or diabetes as well as their family and friends. among the program participants with a recorded diabetes type, nearly 15% had pre-diabetes and more than 80% had type 2 diabetes. the mean a1c level was 6.2% among those with pre-diabetes, 8.7% among those with type 1 diabetes, and 8.6% among those with type 2 diabetes. * p < 0.01; ** p < 0.001; a . p-values from bivariate analyses (e.g., independent t-tests or chi-square tests) comparing the characteristics of participants recruited during the first biennium and second biennium; b . chi-square comparison was performed after excluding "other" language (n = 8650); c . in total, 21.7% of diabetes type records were missing, and frequency and percentage were calculated based on available data (n = 6788); d . mean and standard deviation of baseline a1c percentage measures were estimated among those with pre-diabetes and type 1 and type 2 diabetes. bmi, body mass index. a1c, average blood glucose level over the past 3 months. there were statistically significant differences in characteristics of the participants recruited during the first and second biennium (table 1) , indicating changes in program participant profiles and expanded program reach. compared to participants recruited during the first biennium, those recruited during the second biennium tended to be younger (22.0% vs. 17.1% aged 18-44 years), normal or overweight (32.4% vs. 29.6%), and not knowing their diabetes type (2.0% vs. 0.4%) ( table 1) . in addition to considering initial recruitment, it was important to assess population representativeness over time. the program consisted of an educational session and four quarterly follow-ups to track behavioral goals and clinical outcomes. however, less than 50% of participants attended the first scheduled quarterly follow-up session at 3 months, and the attendance rate for the subsequent follow-up sessions further decreased to 30.5% at 6 months, 23.0% at 9 months, and 18.4% at 12 months. the attendance rates at 9 and 12-month follow-up sessions were higher during the second biennium than during the first biennium (24.8% vs. 21.0% at 9 months and 21.1% vs. 15.9% at 12 months). table 2 shows the number and characteristics of overall program participants who attended and did not attend at each follow-up assessment. for all four follow-ups, retention rates were higher among those in the older age group, females, non-hispanic individuals, those with more than a high school education, and those whose primary language was spanish ( table 2) . retention rates tended to be lowest for those with bmis classified as being underweight (table 2) . among participants with type 2 diabetes, those not attending a follow-up session at any given time point had significantly higher baseline a1c levels than those who attended the follow-up session ( table 2) . among participants with pre-diabetes or type 1 diabetes, no statistically significant differences were observed based on baseline a1c level attending a follow-up session at any given time point (table 2 ). at the 3-month follow-up, the retention rate was significantly different based on participants' diabetes type ( table 2 ). the retention rate was highest among those with pre-diabetes (54.9% at 3 months) and type 2 diabetes (51.3%), followed by those with type 1 diabetes (44.3%) and those who were unaware of their diabetes type (35.5%) ( table 2 ). however, the association between retention rates and diabetes type was not statistically significant at subsequent follow-ups (table 2) . effectiveness was defined as "the impact of an intervention on important individual outcomes, including potential negative effects, and broader impact including quality of life and economic outcomes; and variability across subgroups (generalizability or heterogeneity of effect)" [36] . this study evaluated changes in a1c level among participants from baseline to each follow-up time point. in both the first and second biennium, a statistically significant reduction in a1c level was observed among participants with type 2 diabetes at the 3-month follow-up (b = −0.97, p < 0.001 in the first biennium and b = −1.13, p < 0.001 in the second biennium), and this a1c level reduction was sustained at the 6-month (b = −0.98, p < 0.001 and b = −1.20, p < 0.001), 9-month (b = −1.10, p < 0.001 and b = −1.19, p < 0.001), and 12-month (b = −0.95, p < 0.001 and b = −1.32, p < 0.001) follow-up. for example, for participants with type 2 diabetes who joined during the second biennium, the average a1c level dropped from 8.6% at baseline to 7.5% at 3 months, and this a1c level reduction was sustained at subsequent follow-ups (7.4% at 6 months, 7.3% at 9 months, and 7.3% at 12 months). on average, participants with pre-diabetes had a1c levels that remained controlled (<6.5%) from baseline to the subsequent follow-ups. for example, in the first biennium, a statistically non-significant reduction in a1c level was observed among participants with pre-diabetes at all follow-ups (b = −0.12 and p = 0.06 at 3 months; b = −0.13 and p = 0.07 at 6 months; b = −0.12 and p = 0.13 at 9 months; and b = −0.12 and p = 0.19 at 12 months). participants who had type 2 diabetes showed significantly greater reductions in a1c level than those with pre-diabetes (p < 0.001 for the interaction term between time and diabetes type in both the first and second biennia) ( figure 2 ). table 2 . characteristics of the program participants who attended and did not attend 3-, 6-, 9-, and 12-month follow-up assessments. p-values from bivariate analyses (e.g., independent t-tests or chi-square tests) comparing the characteristics of participants who attended and did not attend the follow-up session; e . excluded 5 participants who reported "other" primary language to prevent possibility of identifying the individuals; f . excluded 12 participants who reported having gestational diabetes to prevent possibility of identifying the individuals; g . high missing response rates and frequency and percentage were calculated based on available data (n = 6776 at 3 months, 6400 at 6 months, 5834 at 9 months, and 5288 at 12 months); h . mean and standard deviation of baseline a1c percentage measures were estimated among those with pre-diabetes, type 1 diabetes, or type 2 diabetes. bmi, body mass index. a1c, average blood glucose level over the past 3 months. significant reduction in a1c level was observed among participants with pre-diabetes at all followups (b = −0.12 and p = 0.06 at 3 months; b = −0.13 and p = 0.07 at 6 months; b = −0.12 and p = 0.13 at 9 months; and b = −0.12 and p = 0.19 at 12 months). participants who had type 2 diabetes showed significantly greater reductions in a1c level than those with pre-diabetes (p < 0.001 for the interaction term between time and diabetes type in both the first and second biennia) (figure 2 ). (a) (b) figure 2 . estimated changes in a1c from baseline to 3, 6, 9, and 12-month follow-up after adjusting for age, gender, ethnicity, education, language, and baseline bmi category, by diabetes type and biennia: (a) first biennium; (b) second biennium. a1c, average blood glucose level over the past 3 months. bmi, body mass index. changes in a1c values over time among participants with type 2 diabetes were also examined based on baseline a1c values. estimated changes in a1c by baseline a1c values show similar trends over time among the participants enrolled during the first biennium ( figure 3a ) and second biennium (figure 3b ). for both biennia, there was a statistically significant modification effect of the baseline a1c level on changes in a1c values over time (p < 0.001 for the interaction term between time and the baseline a1c level in both the first and second biennia). participants with high baseline a1c values (e.g., 8% or higher) achieved a decline in their a1c values at the 3-month follow-up assessments and maintained during the subsequent follow-ups. the estimated a1c level decline was most pronounced for those with highest baseline a1c values (e.g., 12% or higher). on average, participants with controlled diabetes at the baseline remained in control during the subsequent follow-ups. level on changes in a1c values over time (p < 0.001 for the interaction term between time and the baseline a1c level in both the first and second biennia). participants with high baseline a1c values (e.g., 8% or higher) achieved a decline in their a1c values at the 3-month follow-up assessments and maintained during the subsequent follow-ups. the estimated a1c level decline was most pronounced for those with highest baseline a1c values (e.g., 12% or higher). on average, participants with controlled diabetes at the baseline remained in control during the subsequent follow-ups. in a separate regression model, which included the interaction term between time and race/ethnicity, there was no statistically significant differences in changes in a1c values over time among participants with pre-diabetes or type 2 diabetes (p = 0.11 in the first biennium and p = 0.25 in the second biennium). adoption was defined as "the absolute number, proportion, and representativeness of settings and intervention agents (people who deliver the program) who are willing to initiate a program, and why" [36] . in lieu of being able to quantify adoption, the general adoption approach was described. the coastal bend health education center (cbhec) in corpus christi served as the healthy south texas regional headquarters. the texas a&m south texas center, mcallen campus, served as a second regional hub. while planning the intervention roll-out, a hub-and-spoke model was determined to be the most effective strategy in which a central "hub" supports multiple "spokes" in communities to provide a range of services. with this approach, cbhec and the mcallen campus identified other regional partners to help recruit and deliver the program. due to the staffing requirements (e.g., needing a health professional to lead the educational workshops and sessions), the program was not delivered in all counties; rather, it was more selectively offered around the two hubs-with the spokes representing adjacent service areas. in accordance with ongoing collaborative health promotion activities in their respective local communities, both cbhec and the mcallen campus were able to call upon their extended healthcare and public health networks for program delivery assistance. regional partners that helped deliver the program represented diverse community and clinical entities including community-based organizations, federally qualified health centers, hospitals, clinics, pharmacies, school districts, academic institutions of higher education, state agencies and not-for-profit social service organizations, behavioral health organizations, and city and county government offices. partnerships varied with some organizations assuming a fuller responsibility for delivering courses on their own, some helping with overall recruitment, and some solely offering physical space for classes. implementation was defined as "the intervention agents' fidelity to the various elements of an intervention's key functions or components, including consistency of delivery as intended and the time and cost of the intervention. adaptations are also included in this re-aim element" [36] . as an ada-recognized program, there was a need to demonstrate that ada principles of diabetes education were being followed. this involved an annual review by a designated quality control coordinator to review delivery processes, certify them as compliant, or note aspects to be corrected. program standardization across sites was facilitated by having a centralized hub for training and data reporting, in coordination with the scientific-administrative oversight functions provided by healthy south texas leadership. cbhec trained staff in program delivery using a standardized program manual and holding periodic problem-solving feedback sessions with regional program managers and implementers. adaptations to the program were discussed with the evaluation team to enhance program reach and retention. for example, program staff reported that many participants found it difficult to attend a single-day, 8-h workshop. therefore, other options were offered such as spreading the workshop over multiple days in two 4-h sessions or four 2-h sessions. program costs were not tracked in the first biennium, but efforts were made to retrospectively estimate actual program costs based on personnel, supply and space costs toward the end of the second biennium. the program was estimated to cost between usd 800 and 1200 per participant, albeit with substantial variation based on how established the program was delivered at different sites, methods of recruitment, and the number of participants in each class. a major indicator of program implementation was how many participants engaged in all program activities (e.g., the initial educational workshop plus four quarterly follow-up sessions to track behavioral goals and clinical outcomes over time). as seen in table 2 , only about 50% of participants attended the first quarterly follow-up session at 3 months, and attendance rates decreased for the subsequent follow-up sessions. given that process evaluation activities were initially built into the program evaluation, program staff were made aware of this issue concerning attendance. subsequent action was taken in an attempt to bolster follow-up rates. retention rates at 9 and 12-month follow-up sessions during the second biennium were significantly higher than the rates during the first biennium (i.e., 24.8% vs. 21.0% at 9 months and 21.1% vs. 15.9% at 12 months). maintenance was defined at the individual level as "the long-term effects of a program on outcomes after a program is completed" and at the setting level as "the extent to which a program or policy becomes institutionalized" [36] . at the individual level, the trajectory of a1c level change over time during the 12-month intervention period has already been reported in the effectiveness section (figures 2 and 3) . at the setting level, programs included within the healthy south texas initiative were intentionally designed to be housed within and delivered by established community partners who could draw upon their existing networks to facilitate programmatic spread and sustainability. for legislative feedback purposes, the amount of actual and in-kind dollars the health science center leveraged during the first two biennia was calculated. from private and public sources, over usd 15,000,000 was identified in direct support and in-kind dollars for the healthy south texas initiative (including delivery of the diabetes education program, as well as other disease prevention and health promotion activities) by governmental and nongovernmental entities. the program is still ongoing with a legislative commitment for a third biennium (september 2019-august 2021), and program delivery remains a core function of the two regional hubs. the healthy south texas diabetes education program reached and benefitted large numbers of participants in a region with documented health inequities that have perpetuated health disparities [13] . utilizing the re-aim framework for both planning and evaluation enabled the study team to describe this diabetes program in terms of its reach, adoption, implementation, effectiveness and maintenance [37] , and explore the unique challenges faced when applying and assessing re-aim elements in community settings [38, 39] . this community-based initiative reached a large and diverse population in this region, thus supporting the external validity of the positive results observed. the hispanic population accounted for over two-thirds of the total population in the service region [40]; hence, the ability to provide the program in spanish was a critical element that enabled the program to reach this population. an estimated 65,000 persons were served in the first two biennia across a broader range of diabetes outreach and education activities implemented by the texas a&m health science center healthy south texas initiative, in which the diabetes education program was a single component. this initiative capitalized on its understanding of the local community and organizational context, which has been deemed critical for the implementation and dissemination of other health promotion programs [41] . this enabled the implementation sites to draw upon highly visible stakeholders and their diverse relationships with community and clinical organizations for outreach and delivery. culture, language, and access to resources are known barriers to access to care in the hispanic population with type 2 diabetes [42] , and collaboration with diverse local community and clinical entities enabled recruitment of culturally competent staff and facilitators to reach the hispanic population, who are likely to be an underserved population in the region. this study has generated several general take-home messages to be considered before implementing future health promotion initiatives. foremost, program planners should conduct community needs assessments and/or engage stakeholders from the communities they wish to target during initial planning, when assessing feasibility, and when deciding which components to include (e.g., considering potential cultural competency considerations and the need to tailor materials). while research studies typically need to offer incentives for participant recruitment [43] , the healthy south texas initiative promoted program adoption by providing sites with necessary materials and/or subcontracted for services, which allowed programs to be offered free to participants who may have otherwise lacked resources to pay for such services. this was a critical component that helped alleviate or limit the participants' financial burden as a major barrier to participation, particularly among the socioeconomically disadvantaged population. when considering the generalizability of this evaluation in future settings and populations, program implementers and other key stakeholders should consider this option, where possible, as it may determine whether or not participants can access similar services in other initiatives. balancing fidelity to program implementation with the need for adaptation remains challenging in translational research [44] . over the past two biennia, many of the recommended re-aim strategies for improving the implementation processes were implicitly followed and should serve as explicit guideposts in future studies [29, 37] . for example, some sites adapted intervention delivery modes and routinized follow-up reminder contacts. other sites switched the health professional type needed to lead workshops to accommodate local needs and preferences. for example, one hub determined that in their setting a registered dietician was preferable to a registered nurse, and the ada offered some latitude when selecting the specific type of health professional used to lead workshops without jeopardizing the ada-recognized status or program fidelity. of particular note, the high attrition rates for follow-up visits raises issues about the feasibility and appropriateness of the current diabetes education program structure. the first biennium was a learning curve for the problem facilitators and implementation sites, and additional activities (e.g., reminder calls) were considered and conducted to enhance follow-up rates in the second biennium. reviewing other successful chronic disease self-management programs [45] , the difficulties of expecting the targeted population to consistently engage in intervention sessions over a 12-month period were recognized. hence, one major adaptation for future programming is to consider modifications of the current diabetes education program and/or the development of a new iteration of such a program with a shorter active intervention period. long-term supports are still valuable for participant success and should still be incorporated in some capacity (e.g., by their healthcare provider, virtually, telephonically). the effectiveness of the diabetes education program demonstrated significant decreases in a1c levels over time which were clinically meaningful [46] . however, a closer look provides guidance for future targeting, which is a major concern in intervention research [47] . while reducing a1c levels is a clinical goal for persons with elevated a1c levels, targeting those with a1c values of 8 and above has greater potential to be most cost effective, given these a1c levels are associated with the most diabetes complications and need for costly medical care [19] . findings from our study indicate that self-management programs adhering to ada best practices can achieve large decreases in a1c levels among this population. maintenance of individual and system-level outcomes is often the most challenging re-aim element to achieve [36, 48, 49] . it is critical to be aware of how context can influence outcomes at both levels. the practical robust implementation and sustainability model (prism) framework, which is now an integral part of the re-aim framework [50] , helps us understand the contributory role of recipients, implementation and sustainability, infrastructure, and the external environment. one successful maintenance strategy at the individual maintenance level was to pair the diabetes education program with opportunities for class-based exercise programming throughout the year. based on feedback from program managers, participants seemed to enjoy these sessions and kept them engaged in the diabetes education program. additionally, the diabetes education program was seen as a core component of the two healthy south texas regional hubs, and organizational efforts are underway to build capacity and support for continued delivery through a network of concerned partners. in the current third biennium of state funding (september 2019-august 2021), program staff are fully aware of the importance of context during these unprecedented times. thus, different options for long-term sustainability are being explored, noting that the current covid-19 crisis may make future state support less likely due to budgetary considerations [51] . toward this end, strategies for defining and promoting the value proposition of this and other health education programs are being formulated. for example, fee-for-service options, seeking insurance reimbursement for recognized diabetes management programs, and/or providing the program for a modest charge to community or healthcare organizations as a community benefit are being investigated. to assist in making a value proposition based on the potential return on investments made, economic evaluation studies that can demonstrate objective value in multiple ways (e.g., monetary outcomes, measures of gains in quality of life, reductions in years of potential life lost, reductions in potentially preventable hospitalizations) are recommended. such studies are important to inform local, state, and national stakeholders about the potential return on investment for these and similar studies and should complement other evaluation activities of similar initiatives to reach a broader audience. while there were many strengths in this community-based study, there were some limitations that must be acknowledged. this is a case study of a single diabetes education program in a geographic area. hence, the findings, while promising, may not be generalizable to all community diabetes prevention and control programs or to other areas with differing population characteristics, settings, or varying levels of baseline risk (e.g., a1c level). additionally, in contrast to academic-based research studies, service delivery often has priority in community-driven programs relative to data collection and management processes, which can limit the types and quality of data collected. for example, although there was a record of engagement by partnering organizations, there was no record of the extent to which organizations agreed to participate when asked. furthermore, while a large sample size was used, lack of randomization in community settings could be impacted by selection bias. the re-aim model provided a general framework for reporting the planning and evaluation of this initiative. as such, full measures on all re-aim dimensions were not collected. while this is a potential shortcoming, it is also aligned with the recognition that applying the re-aim model in "real-world" studies does not depend on the assessment of all five dimensions [39] . despite the relatively large numbers of community residents served by the diabetes education program, the proportion reached relative to people with diabetes residing in these south texas counties was still minimal, given the high rates of adults with diabetes in the south texas region [52] . further, the large attrition rate for follow-up sessions was considerable, which may highlight recruitment or fidelity issues and introduce self-selection and/or a healthful bias (i.e., participants with type 2 diabetes with lower a1c levels had better retention rates at all follow-up sessions). finally, data were not collected longer than 12 months following the diabetes education program workshop; therefore, an assessment of long-term clinical control and management among participants was not possible. similarly, as the healthy south texas initiative is still ongoing, long-term program delivery and institutionalization post external funding could not be assessed. however, lessons can be learned from this initiative that advance knowledge about research translation. in line with guidelines for implementing evidence-based diabetes prevention and control programs [53] , two successful strategies were employed to enhance reach with the ultimate goal of reducing health disparities in underserved populations. first, community health workers were integral to participant recruitment because they were seen as trusted members in the community [54] . another successful strategy was establishing and using diabetes health champions [55] (i.e., persons in the program who had successfully lowered their own a1c levels) to serve as program promoters who could engage populations typically characterized as "hard to reach" and who were unaware of, or previously uninterested in, participating in health promotion programs [56] . the diabetes education program provided an example of dedicated effort to meet the overall public health goal of diabetes prevention and management for all americans, especially among those experiencing a multitude of social determinants of health inequities [57] . offering the diabetes education program through two regional hubs was a major advantage for program reach and adoption as well as launching the initiative quickly. overall, the diabetes education program, as part of the healthy south texas initiative, made a substantial impact on the target area reaching diverse and potentially at-risk populations with measured benefits as evidenced in the current study. for long-term programmatic sustainability, such programs will need to be viewed as essential to routine diabetes regional risk: mapping single and multiple chronic conditions in the united states regional differences in rural and urban mortality trends; nc rural health research program: chapel hill trends in socioeconomic status-related differences in mortality among people with chronic obstructive pulmonary disease understanding associations among race, socioeconomic status, and health: patterns and prospects healthy border 2020: a prevention & health 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health champions approaches to recruiting 'hard-to-reach' populations into re-search: a review of the literature this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors would like to thank the healthy south texas team within the texas a&m health science center for their work to deliver and evaluate this program. a special thanks is given to the diabetes education program trainers, educators, and staff in corpus christi and mcallen who are continually dedicated to improving lives in south texas. additionally, the authors would like to thank carrie l. byington, former senior vice president of the texas a&m university health science center and vice chancellor for health services of the texas a&m university system (currently executive vice president and head of uc health at the university of california) and susan ballabina, deputy vice chancellor for texas a&m agrilife for their leadership role in the healthy south texas initiative during the study period. the authors declare no conflict of interest. key: cord-350031-2c9x55hx authors: zhao, sheng zhi; wong, janet yuen ha; wu, yongda; choi, edmond pui hang; wang, man ping; lam, tai hing title: social distancing compliance under covid-19 pandemic and mental health impacts: a population-based study date: 2020-09-14 journal: int j environ res public health doi: 10.3390/ijerph17186692 sha: doc_id: 350031 cord_uid: 2c9x55hx the success of public health measures for controlling the coronavirus disease 2019 (covid-19) pandemic relies on population compliance. we analyzed compliance with social distancing and its associations with mental health. the hong kong covid-19 health information survey was conducted from 9–23 april 2020 on 1501 adults randomly sampled for landline telephone interviews (n = 500) and online surveys (n = 1001). compliance with social distancing and staying-at-home, stress (perceived stress scale-4), anxiety (general anxiety disorders-2), and depressive symptoms (patient health questionnaire-2) were collected. the associations between mental health symptoms and compliance were examined by multivariable regression models. of the 1501 respondents (52.5% female, 72.3% aged 18–59 years), 74.2%, 72.7%, and 59.7% reported avoiding going out, going to crowded places, and attending social gatherings of more than four people, respectively. most respondents had stayed-at-home for at least four of the past seven days (58.4%; mean 4.12, standard deviation 2.05). adoption, perceived effectiveness, and perceived compliance with social distancing were associated with lower stress levels and less anxiety and depressive symptoms (all p < 0.01). however, more days stayed-at-home were associated with more depressive symptoms (adjusted odds ratio 1.09; 95%confidence interval 1.00, 1.18). the long-term psychological impact in relation to social distancing and staying-at-home requires further investigation. the coronavirus pandemic 2019 (covid-19) has caused millions of confirmed cases and thousands of deaths since early 2020. driven by the increasingly frequent worldwide transportation of those with asymptomatic patients, the infection is spreading more rapidly and widely than ever [1] . public health measures such as border restrictions, bans on public gatherings, closures of schools and nonessential businesses, stay-at-home and social distancing have been enforced in many countries. at the early stage of the epidemic, hong kong responded quickly with precautionary behaviors including mask wearing and hand hygiene [2] [3] [4] . solidarity and altruism were aroused for collective community protection [5] . isolation, quarantine, contact tracing and social distancing were the main measures to prevent community outbreak and were effective in that the transmission of covid-19 remained low (daily effective reproduction number r 1 approximately equal to 1) by early march without lock the hong kong covid-19 health information survey (covhins) was a population-based dual sampling landline and online survey conducted from 9-23 april 2020. the target population was general hong kong residents aged 18 or above. social policy research limited, a reputable local survey agency, was commissioned to conduct the survey. we adopted two-stage random sampling in the landline survey using the web-based computer-assisted telephone interview system (web-cati). residential telephone directories that covered approximately 76% of hong kong residents [21, 22] were used to generate a random list of telephone numbers for interview. invalid numbers (e.g., fax line, non-residence line and non-working line), nonresponses, and ineligible households were excluded. after telephone contact had been successfully established with a target household, one eligible person was selected using the "next birthday" rule (i.e., the household member whose birthday was nearest to the interview date was selected). all telephone interviewers completed a half-day training related to covid-19 knowledge, contents of the questionnaire, sampling procedures and interviewing techniques. briefing and de-briefing sessions were arranged during data collection, and rigorous quality checks were adopted (17.2% were checked) to ensure research fidelity. each interview took approximately 25 min. among the 816 valid telephone number sampled (305 refused, 11 dropout), 500 respondents completed the interview yielding a response rate of 61.3%. the online survey was conducted on a representative panel of hong kong residents. this panel was previously formed by inviting local mobile phone users to join. all mobile phone numbers (prefix starting with 5, 6 or 9), which covered over 90% of hong kong residents, received an invitation message. these numbers were generated using the numbering plan for telecommunication services in hong kong provided by the office of the communications authority (ofca). a total of 100,079 residents covering diverse socio-economic backgrounds joined the panel. stratified random sampling by sex and age was adopted to select a random list of panel participants, who were then invited to join the online survey by an invitation text message. participants self-administered the questionnaire via web-cati. the response rate was 61.7% (1001 of 1623 eligible panel participants). ethics approval was granted by the institutional review board (irb) of the university of hong kong/hospital authority hong kong west cluster (uw 20-238). informed consent was obtained from all respondents before answering the questions. the adoption of social distancing measures (yes/no) since the first case confirmed in hong kong included: (i) avoid going out, (ii) avoid going to crowded places, (iii) avoid going to high-risk places (e.g., bar, wet market, hospital), (iv) avoid social gatherings of more than four people (government regulation, with penalty, issued on 29th march), (v) avoid greetings with physical contact such as handshaking, hugging and kissing, and (vi) keep 1.5 meters from others in public. the total number of social distancing measures was calculated (ranged 0-6). perceived overall effectiveness of and perceived compliance with the above social distancing measures were measured on a scale ranging from 0-10 with higher scores indicating higher perceived effectiveness and compliance. stay-at-home, which was voluntary, was measured by the number of days at home except for essential tasks in the past seven days. personal protection measures including: (i) wearing surgical mask, (ii) washing hands with alcohol-based sanitizers, (iii) using alcohol to clean daily necessities, and (iv) adding water to household drainage system in the past seven days were recorded. stress level in the preceding month (from early-march to mid-april 2020) was assessed by the four-item perceived stress scale (pss-4) [23] . pss-4 consists of four items measuring the degree of ability to cope with existing stressors (positive elements, two items, cronbach's α = 0.68) and the degree of lack of control and affective reactions (negative elements, two items, cronbach's α = 0.69). each item is rated on a likert-like scale ranged from 0 (never) to 4 (very often). higher total scores on the four items (0-16) indicate a higher perceived stress level. the chinese version of pss-4 has been validated in our previous study with satisfactory internal consistency (cronbach's α = 0.67) [24] . anxiety and depressive symptoms in the past two weeks (from late-march to mid-april 2020) were assessed using the four-item patient health questionnaire (phq-4). phq-4 consists of the two-item general anxiety disorder (gad-2) and the two-item patient health questionnaire (phq-2) [25, 26] . gad-2 covered two core criteria for generalized anxiety that screen for social panic and anxiety disorders. phq-2 measured depressive symptoms, depressed mood and loss of interest, two core diagnostic criteria for major depression disorder [26] . each item scores on a likert-like scale ranging from 0 (not at all) to 3 (nearly every day). subscales of the gad-2 and phq-2 scores range from 0-6 with a score of ≥3 indicating anxiety and depression symptoms [27, 28] . we have previously validated the chinese version of the phq-2 in the hong kong population [29] . the internal consistency of gad-2 (cronbach's α = 0.81) and phq-2 (cronbach's α = 0.81) were positive in this study. sex, age, marital status (never married, married or cohabited, divorced or separated, or widowed), current living arrangement (living alone, co-living with family members, or co-living with other people), and socioeconomic status (ses) including educational attainment (primary or below, secondary, or tertiary), employment status (full-time work, part-time work, student, housemaker, unemployed or retired) and monthly personal income (hk$ ≤ 10,000; 10,001-20,000; 20,001-30,000, 30,001-40,000, or ≥40,001; us$1 = hk$7.8) of the respondents were recorded. we used chi-squared test and t-test to compare sociodemographic characteristics and mental health symptoms between the landline telephone and online self-administrated samples. to improve the representativeness of the sample, all data were weighted according to provisional figures obtained from the census and statistics department on the sex, age, and education attainment distributions of hong kong's general adult population in 2016. multivariable linear regression was used to examine the associations with sociodemographic characteristics of number of social distancing measures adopted, number of days stayed-at-home and perceived compliance with social distancing measures. the association of mental health symptoms including stress, anxiety and depression with the number of measures adopted, number of days stayed-at-home and perceived effectiveness and compliance were calculated by multivariable linear (for stress) and logistic (for anxiety and depression) regressions. in regression model 1, potential sociodemographic confounders including sex, age, educational attainment, current employment status, and monthly income were adjusted. we additionally adjusted for the four personal protection measures in regression model 2. the association between personal protection measures and mental health symptoms were analyzed by multivariable regression models adjusted for sociodemographic factors and social distancing. effect modifications by age (18-59, 65+ years) and education attainment (primary or below, secondary, and tertiary) on the associations between mental health symptoms, stay-at-home and compliance with social distancing were assessed using the interaction terms. analyses were performed using stata version/mp 15.1 (statacorp lp, college station, tx, usa). there were no significant differences in the sociodemographic characteristics of the landline telephone sample (n = 500) and the online self-administrated sample (n = 1001) (all p > 0.05; table 1 ). in the combined weighted sample, 52.5% were female, 72.3% aged 18-59 years, 66.1% were married or cohabitated, and 92.9% were co-living with family members. three quarter (76.8%) of respondents had a secondary or higher education, 62.9% were employed and 68.2% had a monthly household income of hk$20,000 or lower. the average stress score was 7.20 (standard deviation, sd: 2.12), and 15.8% and 14.8% of the respondents had experienced anxiety and depressive symptoms, respectively. table 2 shows that most respondents adopted the social distancing measures including avoid going out (74.2%), avoid going to crowded places (72.7%), avoid social gatherings of more than four people (59.7%), avoid going to high-risk places (54.8%), and avoid handshaking, hugging and kissing (50.7%), but only 42.9% kept 1.5 meters away from others. respondents adopted on average 3.55 (sd 1.76) social distancing measures and most had stayed-at-home for at least four days in the past seven (58.4%; mean 4.12, sd 2.05). respondents perceived the social distancing measures to be effective in containing the infection (mean 7.34, sd 1.88) and perceived a moderate level of compliance (mean 6.68, sd 1.98). table 3 shows that older age and higher education attainment were significantly associated with the adoption of more social distancing measures, more days stayed-at-home and perceived higher level of compliance with social distancing (all p for trend <0.01). being female was associated with more days stayed-at-home (adjusted β 0.49; 95%ci 0.30, 0.68) and perceived compliance with social distancing (adjusted β 0.27; 95%ci 0.07, 0.46). compared with respondents in full-time work, those who were economically inactive spent more days at home and reported higher compliance with social distancing (all p for trend <0.001). having higher income was associated with increased perceived compliance with social distancing (p for trend <0.001). table 4 shows that adopting more social distancing measures was significantly associated with lower stress level (adjusted β −0.12; 95%ci −0.18, −0.06) and lower risk for anxiety symptoms (adjusted or 0.87; 95%ci 0.79, 0.95) after the models were adjusted for sociodemographic and personal protection measures (model 2). perceived effectiveness and compliance with social distancing measures were associated with lower stress levels and risks for anxiety and depressive symptoms (all p < 0.001). consistently, personal protection measures, including mask wearing, use of alcohol to clean daily necessities and adding water to the household drainage system were associated with lower stress levels and lower risks for anxiety and depressive symptoms (all p < 0.01) (supplementary table s1 ). nevertheless, more days stayed-at-home was significantly associated with increased risk for depressive symptoms (adjusted odd ratio (or) 1.09; 95%ci 1.00, 1.18). supplementary table s2 shows that more days stayed-at-home was associated with anxiety (p for interaction = 0.005) and depressive (p for interaction = 0.008) symptoms especially among respondents with older age (60+ years). more days stayed-at-home was associated with a higher stress level especially among respondents with primary or lower education attainment (p for interaction = 0.014). we have provided the first evidence on compliance with non-pharmaceutical community containment strategies including stay-at-home and social distancing and their associations with mental health symptoms during the covid-19 pandemic. random samples from landline and mobile phone increased the representativeness of the study. the effectiveness of public health interventions depends on the degree of population engagement and compliance in practice. avoiding going out and avoiding social gatherings were mostly practiced, which may have resulted in the achievement of suppressing the first wave of community outbreak in february and march (first eight weeks) and in mitigating the second wave, due to imported cases, in april and may [2] . most respondents have voluntarily stayed at home for at least four days in a week except for essential tasks (e.g., shopping for daily necessaries). perceived overall compliance was satisfactory considering no lockdown has been implemented and some must maintain a normal working life. keeping a physical distance of 1.5 meters, especially in public transportation, workspaces and restaurants, is demanding in crowded metropolitan districts such as hong kong. flexible working schedules to avoid crowded transportation, home office working, and closure of unessential businesses may supplement these distancing measures [16] . being female, older age, and having higher ses were associated with higher levels of perceived compliance with social distancing measures. without the need for work-related essential tasks, the practice of stay-at-home and social distancing is easier for economically inactive people (e.g., students with class suspensions, homemakers, or retirees). the early reported higher mortality rate among older adults (aged 60+) [30] might have raised alarm, leading to higher compliance with home-confinement in the elderly. females and people with higher ses were more vigilant in recognizing and practicing public health measures. one possible explanation is that women and people with a higher ses are more health conscious [31] . in contrast, males with lower ses may have more essential job requirements and less flexible working schedules, which may lead to lower compliance. knowledge of infectious disease, social norms and perceived effectiveness of the measurements were reported to be decisive regarding level of compliance [32] . timely epidemiological reports, combined with minute-by-minute case reports and open contact tracing, may have strengthened health communication and population-wide adoption of precautionary measures during this pandemic [3, 33] . the perceived effectiveness of and compliance with social distancing were associated with lower risks of mental distress. consistently, personal protection measures including mask wearing and household disinfection were associated with less stress and depressive symptoms, adjusted for social distancing. the association between social distancing and mental health remained robust after additional adjustment for personal protective measures. perceived effectiveness and compliance with public health measures in preventing the infection for oneself and family members, and contributing to the safety and health of the community and country may strengthen feelings of security and alleviate mental distress related to the pandemic. a repeated cross-sectional study conducted in january, february and march 2020 has reported that perceived susceptibility to worries about being infected was decreasing, while confidence in protecting oneself was increasing in hong kong [2, 3] . personal protective measures such as mask wearing have become a social norm, and this perceived protection and solidarity may further enhance individual compliance [9] . dynamic fluctuation in mental well-being is possible following different stages of the pandemic and the effectiveness of control measures. areas experiencing severe outbreaks and with poor community control may encounter shortages in preventive supplies, more worries about being infected, less confidence in self-protection, less compliance with social directives and more serious mental health crises. in contrast, staying at home for a longer time was associated with increased risks of depressive symptoms. reverse causation is possible in which respondents with depressive symptoms might have tended to stayed-at-home. however, a crowded living environment, restricted face-to-face social interactions and restricted outside activities have led to a physically inactive and sedentary lifestyle for months, which may contribute to boredom, low mood, or mental distress. the elderly and less educated population might be more vulnerable regarding the processing of health information and sudden changes in social rules, especially in the digital world where public communication is mostly performed online [33, 34] . we found in our subgroup analysis that older and less educated adults were more vulnerable to mental health symptoms if they stayed for more days at home. increasing knowledge and promoting the use of preventive measures for the most vulnerable individuals is urgently needed in order to increase compliance with social distancing and maintain mental well-being. health care providers have an important role in addressing mental distress as part of the pandemic response, improving compliance with social distancing and helping reduce the impact of covid-19 on mental health. decline in virus transmission and ease of public health restrictions are yet to come in this worsening pandemic. social distancing is in need of collective effort for a long period of time in most affected countries and areas [18] . the long-term psychological impact in relation to the pandemic and social distancing measures requires further nation-and world-wide investigation. some limitations of the study should be noted. causal relations could not be inferred in this cross-sectional study, where respondents with psychological distress were less likely to comply with public health measures. pre-existing psychological problems were not collected, and residual confounders were not able to be excluded. recall bias may exist in self-reporting measurements. the reasons for non-compliance with social distancing need further investigation for further public directives to be put into practice. the pss-4 has a satisfactory construct validity [23] but a somewhat lower reliability (cronbach's α < 0.7). however, the reliability coefficient of 0.67 should not seriously attenuate validity [35] and the scale was consistent with pss-14 and pss-10 in correlations with other health-related variables, which provides a concurrent validity of the scale [24] . simple measurements of mental health symptoms have restricted the clinical implications and more rigorous measurements are warranted. however, diagnostic instruments could be hard to implement in such a population-based survey. respondents identified with higher stress level and having anxiety or depressive symptoms could benefit from further psychological assessment and support. we measured immediate mental health symptoms during the epidemic, and long term psychosocial responses such as social inactivity, post-traumatic stress disorder, and subthreshold or clinical anxiety and depression disorder will need further investigation. compliance with social distancing and stay-at-home is higher among female, older and educated respondents. compliance with and perceived effectiveness of social distancing were associated with lower levels of stress, anxiety and depressive symptoms. more days stayed-at-home, however, may increase the risk of depressive symptoms, especially in older adults. public health interventions are needed to protect the "new normal" in a future with or without covid-19. the long-term psychological impact in relation to social distancing and stay-at-home requires further investigation. social support and targeted interventions for the psychological well-being of the most underprivileged community members are urgently needed. presumed asymptomatic carrier transmission of covid-19 impact assessment of non-pharmaceutical interventions against coronavirus disease 2019 and influenza in hong kong: an observational study community responses during early phase of covid-19 epidemic mass masking in the covid-19 epidemic: people need guidance wearing face masks in the community during the covid-19 pandemic: altruism and solidarity the incubation period of coronavirus disease 2019 (covid-19) from publicly reported confirmed cases: estimation and application temporal dynamics in viral shedding and transmissibility of covid-19 depression and anxiety in hong kong during covid-19 multidisciplinary research priorities for the covid-19 pandemic: a call for action for mental health science the psychology of pandemics: preparing for the next global outbreak of infectious disease the psychological impact of quarantine and how to reduce it: rapid review of the evidence an overview of systematic reviews on the public health consequences of social isolation and loneliness 2019-ncov epidemic: address mental health care to empower society public mental health crisis during covid-19 pandemic factors influencing compliance with quarantine in toronto during the 2003 sars outbreak the covid-19 pandemic calls for spatial distancing and social closeness: not for social distancing! public health interventions for covid-19: emerging evidence and implications for an evolving public health crisis scientific and ethical basis for social-distancing interventions against covid-19 from a sprint to a marathon in hong kong effective containment explains subexponential growth in recent confirmed covid-19 cases in china using information and communication technologies for family communication and its association with family well-being in hong kong: family project the association of problematic smartphone use with family well-being mediated by family communication in chinese adults: a population-based study a global measure of perceived stress three versions of perceived stress scale: validation in a sample of chinese cardiac patients who smoke an ultra-brief screening scale for anxiety and depression: the phq-4 a 4-item measure of depression and anxiety: validation and standardization of the patient health questionnaire-4 (phq-4) in the general population screening for anxiety disorders with the gad-7 and gad-2: a systematic review and diagnostic metaanalysis detecting and monitoring depression with a two-item questionnaire (phq-2) screening for depression with the patient health questionnaire-2 (phq-2) among the general population in hong kong clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study the gender gap in mortality: how much is explained by behavior? j. health econ how to improve adherence with quarantine: rapid review of the evidence health information exposure from information and communication technologies and its associations with health behaviors: population-based survey protecting older adults during social distancing uses and abuses of coefficient alpha we thank the respondents for their participation in the survey. the authors declare no conflict of interest. key: cord-341661-sokoghh1 authors: ahmed, muhammad adeel; jouhar, rizwan; ahmed, naseer; adnan, samira; aftab, marziya; zafar, muhammad sohail; khurshid, zohaib title: fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak date: 2020-04-19 journal: int j environ res public health doi: 10.3390/ijerph17082821 sha: doc_id: 341661 cord_uid: sokoghh1 an outbreak of novel coronavirus disease (covid-19) in china has influenced every aspect of life. healthcare professionals, especially dentists, are exposed to a higher risk of getting infected due to close contact with infected patients. the current study was conducted to assess anxiety and fear of getting infected among dentists while working during the current novel coronavirus diseases (covid-19) outbreak. in addition, dentists’ knowledge about various practice modifications to combat covid-19 has been evaluated. a cross-sectional study was conducted using an online survey from 10th to 17th march 2020. the well-constructed questionnaire was designed and registered at online website (kwiksurveys) and validated. a total of 669 participants from 30 different countries across the world responded. after scrutiny, completed questionnaires (n = 650) were included in the study. statistical analysis was performed using spss version 25. chi-square and spearman correlation tests were applied to control confounders and assess the relation of dentists’ response with respect to gender and educational level. more than two-thirds of the general dental practitioners (78%) from 30 countries questioned were anxious and scared by the devastating effects of covid-19. a large number of dentists (90%) were aware of recent changes in the treatment protocols. however, execution of amended treatment protocol was recorded as 61%. the majority of the dentists (76%) were working in the hospital setting out of which 74% were from private, and 20% were from government setups. individually we received a large number of responses from pakistan and saudi arabia, but collectively more than 50% of the responses were from other parts of the world. despite having a high standard of knowledge and practice, dental practitioners around the globe are in a state of anxiety and fear while working in their respective fields due to the covid-19 pandemic impact on humanity. a number of dental practices have either modified their services according to the recommended guidelines to emergency treatment only or closed down practices for an uncertain period. an outbreak of novel coronavirus disease in china has influenced every aspect of life [1] . within a few months, covid-19 has spread globally and on 11th march 2020, the world health organization (who) declared it as a controllable pandemic disease [2, 3] . the latest strain of coronavirus is believed to have originated in a seafood market in wuhan, china [1] . on 11th february 2020, who used the term covid-19 to describe the latest strain of coronavirus [4] . structurally, covid-19 is an ss-rna, enveloped virus with a size of~350 kilobase-pair (kbp) [5] . covid-19 has the potential to cause severe acute respiratory tract infection among infected humans and is commonly transmitted from person to person via hands, saliva, nasal droplets, and surface contacts [3, 6] . the average incubation period ranges of covid-19 from 4 to 14 days [7] . the infected person usually presents with upper respiratory tract infection (rti) and complaints of high-grade fever, a dry cough, and dyspnea [8] . it is highly recommended to keep any suspected individuals in quarantine (isolation) and under observation until further investigation by the real-time polymerase chain reaction (rt-pcr) can take place [9] . unfortunately, there is no antiviral vaccine available on the market, but on 16th march 2020 the first clinical trial was initiated by the national health institute (nhi), usa [3] . therefore, patients have to rely on supportive therapy such as vitamins a, c and d; chloroquine phosphate; and general healthcare until the body's immune system can eradicate the infection [10] . considering the vital role of the body's immune system, elderly patients with chronic debilitating diseases have a higher risk of getting infected compared to young, healthy individuals with a strong immune system [11] . to date, three quarter of a million cases have been reported, and more than thirty-three thousand patients have died around the world (source who situation report-70). although the mortality associated with covid-19 is low, it has a high spreading potential [12] . since the covid-19 outbreak is so fast and devastating, many countries have shut down teaching institutions, social gatherings, sports activities, events, airports, and even banks in an attempt to control the spread of the infection. besides this, several individuals went into self-quarantine in order to play their part in society by limiting the spread of disease. on the other hand, healthcare facilities are necessarily required for any society and are rarely closed under such pandemic conditions. healthcare professionals are exposed to a higher risk of getting infected due to their close contact with infected patients [13] . in particular, dentists perform their duties not only in close contact with patients but also while exposed to aerosol and droplets splashing out of patients' oral cavity [13, 14] . therefore, dentists have a high risk of getting infected from patients and potentially spreading it to their peers, families, and other patients. under these circumstances, it may be natural for dentists to develop a fear of being infected by their patients. fear and anxiety are powerful emotions that may be associated with the overwhelming reports on the covid-19 pandemic by social, electronic, and print media. mild anxiety is natural and fosters preventive and safeguarding behavior [15] . at the current juncture, people with persistent anxiety may panic and are more likely to make mistakes leading to irrational decisions and behavior. being on the list of high-risk professions, dentists are very much expected to develop severe anxiety about the current pandemic situation [16] . considering the current rapid spread of infection, the american dental association (ada) highlighted key steps to be taken by dentists in addition to the standard universal precautions such as taking patients' recent travel history; assessing signs and symptoms of rti; recording patients' body temperature; mouth rinsing with 1% hydrogen peroxide prior to commencement of any procedure; using a rubber dam and high volume suction during procedures; and frequently cleaning and disinfecting public contact areas including door handles, chairs and, washrooms [13] . although the ada has published preventive guidelines, the majority of dentists are still reluctant and feel fearful of treating patients in such a situation (source ada-covid-19 resources for dentists). in fact, most dentists may not be aware of the recent guidelines. therefore, we have conducted a questionnaire-based study to evaluate dentist response globally. the present study aimed to assess anxiety and fear of getting infected among dentists working during the current viral outbreak. in addition, dentist knowledge about various practice modifications to combat the novel coronavirus disease (covid-19) outbreak has been evaluated. the present cross-sectional study was conducted using an online survey questionnaire from 10th to 17th march 2020. for this purpose, a well-constructed questionnaire was designed at www. kwiksurveys.com and validated through intra-class correlation with a strong relation of 0.74. the online survey link was circulated through social media and an e-mail to dental professionals and received a response through an online survey submission. any paramedical staff and dental students were not included in this survey. the questionnaire was comprised of a total of 22 closed-ended questions, which were divided into two sections. the first section focused on the fear among dentists about getting infected with covid-19 and the second section was designed to gather information about their practice modifications to combat covid-19 outbreak in accordance with the centers for disease control and prevention (cdc) and ada practice guidelines. a total of 669 participants from 30 different countries across the world participated and submitted the questionnaire, excluding 19 unfilled or partially filled forms ( figure 1 ). an ethical review board approved the study (aidm/ec/03/2020/20) and statistical analysis was done on spss version 25. a chi-square and spearman correlation test were used to control confounders and assess the relation of dentist response with respect to concerning gender and education level. we have conducted a questionnaire-based study to evaluate dentist response globally. the present study aimed to assess anxiety and fear of getting infected among dentists working during the current viral outbreak. in addition, dentist knowledge about various practice modifications to combat the novel coronavirus disease (covid-19) outbreak has been evaluated. the present cross-sectional study was conducted using an online survey questionnaire from 10th to 17th march 2020. for this purpose, a well-constructed questionnaire was designed at www.kwiksurveys.com and validated through intra-class correlation with a strong relation of 0.74. the online survey link was circulated through social media and an e-mail to dental professionals and received a response through an online survey submission. any paramedical staff and dental students were not included in this survey. the questionnaire was comprised of a total of 22 closed-ended questions, which were divided into two sections. the first section focused on the fear among dentists about getting infected with covid-19 and the second section was designed to gather information about their practice modifications to combat covid-19 outbreak in accordance with the centers for disease control and prevention (cdc) and ada practice guidelines. a total of 669 participants from 30 different countries across the world participated and submitted the questionnaire, excluding 19 unfilled or partially filled forms ( figure 1 ). an ethical review board approved the study (aidm/ec/03/2020/20) and statistical analysis was done on spss version 25. a chi-square and spearman correlation test were used to control confounders and assess the relation of dentist response with respect to concerning gender and education level. a total of 650 participants from 30 countries worldwide submitted the completed questionnaire with a total of 22 questions comprising of two sections about fear or anxiety level and practice modification due to covid-19. the responses were recorded from various countries as follows: saudi arabia (80) the demographic information of the participants is presented in table 1 . out of a total of 650 participants, 160 were male and 490 female, with a common age bracket between 20 and 40 years (92.84%). by designation, 511 were general dentists, 97 specialists, and only 42 were from the consultant category. similarly, 511 were graduates and 139 postgraduates by qualification while 482 dentists were from a private setup, 37 were semiprivate and 131 from a government work setting. the majority of participants (495) were working in a hospital while 155 were working in clinics ( table 1 ). the present study reported no significant relationship (rho-0.2), (p 0.06) between dental care professionals' responses with gender and their education level. (20) in table 2 there is a description of the fear and anxiety levels of dental care professionals towards covid-19; 87% of participants were afraid of getting infected with covid-19 from either a patient or a co-worker. while treating a coughing or a patient suspected to be infected with covid-19, 90% were anxious. more than 72% of participants felt nervous when talking to patients in close vicinity, 92% were afraid of carrying the infection from dental practice to their families, and 77% were afraid of getting quarantined if they got infected. the anxiety rate concerning the cost of treatment if they the demographic information of the participants is presented in table 1 . out of a total of 650 participants, 160 were male and 490 female, with a common age bracket between 20 and 40 years (92.84%). by designation, 511 were general dentists, 97 specialists, and only 42 were from the consultant category. similarly, 511 were graduates and 139 postgraduates by qualification while 482 dentists were from a private setup, 37 were semiprivate and 131 from a government work setting. the majority of participants (495) were working in a hospital while 155 were working in clinics ( table 1 ). the present study reported no significant relationship (rho-0.2), (p 0.06) between dental care professionals' responses with gender and their education level. (20) in table 2 there is a description of the fear and anxiety levels of dental care professionals towards covid-19; 87% of participants were afraid of getting infected with covid-19 from either a patient or a co-worker. while treating a coughing or a patient suspected to be infected with covid-19, 90% were anxious. more than 72% of participants felt nervous when talking to patients in close vicinity, 92% were afraid of carrying the infection from dental practice to their families, and 77% were afraid of getting quarantined if they got infected. the anxiety rate concerning the cost of treatment if they got infected was 73%, while 86% felt afraid while they learnt about mortalities because of covid-19. a considerable number of dentists (66%) wanted to close their dental practices until the number of covid-19 cases start to decline. in table 3 there is a description of the knowledge of dental care professionals about covid-19; 97% were aware of its mode of transmission, and 90% were updated with the current cdc or who guidelines for cross-infection control. accordingly, 82% preferred asking about the patient's travel history, 81% recorded every patient's body temperature before performing dental treatments, and 78% deferred dental treatment of patients who disclosed suspicious symptoms. in terms of using personal protection, 85% believed that a surgical mask is not enough to prevent cross-infection of covid-19. in comparison, 84% favored the use of n-95 masks for routine dental procedures during the current outbreak. on the contrary, 90% reported not wearing an n-95 mask while treating a patient. although the majority (89%) recommended routine universal precautions of infection control, 84% did not use rubber dam isolation for every patient. seventy-six percent of participants used high-volume suction for every patient. however, 74% did not ask patients to rinse the mouth with antibacterial mouthwash before dental treatment. ninety-four percent of participants practiced washing hands with soap and water or sanitizer before and after treatment of patients, while 80% of participants were aware of the proper authority to contact if they came across a patient with a suspected covid-19 infection. table 3 . knowledge and practice of dentists about covid 19 n = 650. the present cross-sectional study reported the anxiety and fear of getting infected among dentists while working during the current viral outbreak. for this purpose, a questionnaire focusing on closed-ended questions was used to gather information about dentist's fear and any practice modifications to combat the covid-19 outbreak epidemic. questionnaire-based studies are proven for gathering information regarding preferences, attitudes, opinions, and experiences of participants; however, careful data collection and interpretation is required [17] . the questionnaire used in the present study collected information objectively and validated through intra-class correlation with a strong relation of 0.74. any incomplete questionnaires were excluded. psychological implications such as fear and anxiety are natural in pandemics, especially when the number of infected individual and mortality rates are increasing sharply. studies on previous outbreaks of similar infectious diseases such as severe acute respiratory syndrome (sars) demonstrated various factors leading to psychological trauma in healthcare workers including the fear of getting infected while treating an infected patient, or infecting a family member [18, 19] . the repercussions of the current rapid spread of covid-19, which has affected millions of people worldwide, ranging from being isolated and quarantined to fatality has resulted in considerable psychological stress and fear. with the prolonged incubation period of the coronavirus (as long as 14 days), it is virtually impossible to pinpoint an individual's exposure to the virus [20] . in addition, there is no vaccine or approved treatment, which further enhances anxiety upon the thought of getting infected. healthcare workers dealing with sick patients continuously are at a higher risk of acquiring infectious diseases, adding a tremendous psychological toll [21] . since it has been established that the primary route for transmission of coronavirus is through droplets and aerosols [22] , this enhances the likelihood of dentists and dental healthcare workers of getting infected and further spreading the virus. the current study found that a large number of dentists fear getting infected by their patients or co-workers. the response is similar to the perception of rest of the population where people are terrified of getting infected from other individuals in the community in the presence of a rapidly developing epidemic [23] . the majority of the dentists are fearful of providing treatment to any patient reporting suspicious symptoms. since covid-19 has rapidly infected such a large number of individuals in almost every country, the fear of getting infected by a patient is justified. the high level of anxiety was reflected as a large proportion of dentists wanted to close down their practices which may have significant economic implications for dentists and dental healthcare workers. in addition, patients suffering from dental pain and/or undergoing a multi-visit treatment plan may have to experience delays in dental care in such circumstances. the current guidelines on the covid-19 outbreak have recommended deferring all non-essential dental treatment, and only patients suffering from pain, swelling, bleeding, and trauma are advised to undergo treatment [14, 24] . in the current scenario, all elective or non-essential dental treatment for all patients should be deferred until the situation is regressing or under control [14] . there is a study conducted at a dental emergency department in beijing, china [25] , where they have observed an impact of the covid-19 pandemic on the reporting of dental treatments, which has declined in the emergency department as compared to reporting pre-covid-19. due to the covid-19 pandemic, less dental trauma has been reported and the proportion of dental and oral infection has increased while those of dental trauma and non-urgency have decreased [25] . another genuine fear that dentists have is of carrying infections from their dental practices to their families. the coronavirus can last on various surfaces for a few hours to a few days [26] . this, combined with its prolonged incubation period before symptoms develop, are factors that make it particularly difficult to limit its transmission. the trepidation of getting quarantined as a result of suspected disease or actual infection is also a legitimate fear when one thinks about how the rest of the family members are likely to suffer due to various aspects. the burden on the healthcare system and cost incurred during treatment also puts one's mind at stress. health facilities may not be state-sponsored globally and hence can result in a significant financial burden. the screening and testing for covid-19 have been greatly subsidized by the government bodies in many countries worldwide, which is encouraging residents to get tested for covid-19 in cases of suspected infection. a positive aspect reposted by the present study was that the majority of the participants were aware of the covid-19 mode of spread and transmission. as a part of infection control measures, such information is essential during dental practice. it is crucial in the face of this pandemic to further follow the procedures and guidelines focusing on reducing the amount of aerosol generated and deal with it effectively. similarly, it was encouraging that a large number of dentists were aware of the current guidelines issued by the center for disease control (cdc) and who for cross-infection control in the dental practice including asking patients' travel history and recording patients' body temperature [8] . understandably, both these facts may provide a fair idea of potentially infected patients and their precautionary management in dental practice. of course, the routine universal precautions already recommended and endorsed by various regulatory and infectious control authorities worldwide for the prevention of cross-infection in dental practice should be rigorously adhered to in the current circumstances. although the majority of dentists agreed that these precautions should be practiced for every patient, unfortunately, a large number of participants reported not using basic cross-infection measures like the rubber dam for every patient. use of a rubber dam is an effective way to control cross-infection by limiting the spread of aerosols with good patient acceptance for dental procedures [24] . considering the benefits, there is no excuse for not using rubber dam during dental procedures, especially while using rotary instruments that generate a large quantity of aerosols and droplets. the use of high-volume suction is also considered an essential means to control aerosols evacuation during dental procedures and should be used for the majority of patients [22] . at the start of any dental procedure, rinsing with an antimicrobial mouthwash also significantly reduces the microbial load [27, 28] . this practice is recommended in the current pandemic, however the majority of dentists reported ignoring it. at present there is no available evidence addressing the effects of commonly used antimicrobial mouth rinses on covid 19. hence, this recommendation could be based on the fact that gargling has been reported to decrease the viral load and spread by removing oropharyngeal protease and associated viral replication [29] . in addition, mouthwashes containing agents with anti-viral activity such as povidone-iodine have exhibited effectiveness against various respiratory viruses [30, 31] . during the outbreak of covid-19, the importance of hand hygiene has been emphasized repeatedly and this is even more important in the case of dental practitioners. studies have shown that proper hand hygiene, including handwashing with soap and water and cleaning using alcohol-based sanitizers, is an essential measure in controlling the spread of respiratory illness including sars [32, 33] . therefore, who recommends frequent hand washing or using an alcohol-based hand sanitizer in the dental practice. the use of a particulate respirator such as the n-95 mask has been recommended for treating patients suspected of covid-19. otherwise, at least a surgical mask must be used while treating all patients when the distance between the dental healthcare worker and the patient is less than 1 m [22] . currently, recommendations are based on experiences and pertinent guidelines in addition to universal precautions applied to all dental patients. additionally, the intra-oral radiographs may be replaced by extra-oral radiographs such as orthopantomogram, and cone beam computed tomography where possible. periodontal procedures utilizing ultrasonic scalers should be substituted with hand scalers aiming to reduce the production and spread of aerosol and splatter. besides the regular use of a rubber dam, high-volume suction helps to keep aerosols in check and prevent droplets originating in the patient's oral cavity and respiratory tract from spreading and potentially transmitting infection. currently, around the world, dental regulatory authorities such as the ada are urging dentists to conduct only emergency dental treatments. further recommendations for dental treatment can be found elsewhere in relevant documents [6] . it is crucial in the face of the fear and anxiety shown by the dental community towards covid-19 that psychological coping mechanisms and strategies are practiced in order to remain calm and function efficiently. the fear that dentists have regarding getting infected from covid 19 could be greatly curtailed if dentists and dental healthcare workers meticulously follow the relevant recommendations issued by the regulatory authorities. these include the universal cross-infection control protocols along with some additional precautions in cases where patients present with any suspicious symptoms. some of the limitations of this study is data was collected in a concise duration of time, keeping in mind the rapid effect this outbreak was having on the psychology and practices of dental health practitioners. it may be argued that the attitudes and knowledge of dentists may alter with the emerging research and possible treatment of covid-19. furthermore, we did not receive responses from all countries that have been affected by the outbreak. hence, the generalizability of the study is limited. although the present study included participants from various countries across the globe, every country may have variable information, policies, and guidelines regarding covid-19 that may directly influence participant responses. similarly, some countries are more affected than others which may affect administrative, precautionary, and healthcare measures taken by a specific country that can also influence the outcome of a survey. therefore, the findings of the present study should be interpreted carefully and not be globalized. even though the questionnaire was sent to dentists almost all over the world, there was a lack of response mainly from european and african countries and resultant small sample size. the reason for this could be that the current panic may have diverted the attention of potential respondents towards other priorities, possibly related to the continuing or imminent lockdown conditions in many countries. due to the cross-sectional nature of the study plan, we couldn't conclude a cause-effect relationship. despite having high standards of knowledge and practices, dental practitioners around the globe are in a state of anxiety and fear while working in their respective fields due to the covid-19 pandemic impact on humanity. currently, the effects of covid-19 around the globe are worsening day by day. several dental practices have either modified their services according to recommended guidelines to emergency treatment only, or closed down practices for an uncertain period. it is essential that in the present scenario, priority is given to dental procedures labeled as emergencies by the who and that all dental treatments are deferred until a time when the outbreak goes into recession. this would be an appropriate step in attempts to curtail the further spread of covid-19. return of the coronavirus: 2019-ncov. viruses potential impact of seasonal forcing on a sars-cov-2 pandemic al human saliva: non-invasive fluid for detecting novel coronavirus (2019-ncov) covid-19): a perspective from china emerging coronaviruses: genome structure, replication, and pathogenesis transmission routes of 2019-ncov and controls in dental practice incubation period of 2019 novel coronavirus (2019-ncov) 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workers active quarantine measures are the primary means to reduce the fatality rate of covid-19 factors associated with mental health outcomes among health care workers exposed to coronavirus disease possible aerosol transmission of covid-19 and special precautions in dentistry fear and stigma: the epidemic within the sars outbreak dental-dam for infection control and patient safety during clinical endodontic treatment: preferences of dental patients the impact of the covid-19 epidemic on the utilization of emergency dental services aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 efficacy of preprocedural mouthrinses in the reduction of microorganisms in aerosol: a systematic review antimicrobial effects of chlorhexidine, matrica drop mouthwash (chamomile extract), and normal saline on hospitalized patients with endotracheal tubes in vitro bactericidal and virucidal efficacy of povidone-iodine gargle/mouthwash against respiratory and oral tract pathogens great cold investigators-i. can we prevent influenza-like illnesses by gargling? the action of three antiseptics/disinfectants against enveloped and non-enveloped viruses effectiveness of handwashing in preventing sars: a review interventions for the interruption or reduction of the spread of respiratory viruses this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord-352501-5c78kq0w authors: lin, paohui; tsai, hsientang; ho, tzuya title: food safety gaps between consumers’ expectations and perceptions: development and verification of a gap-assessment tool date: 2020-08-31 journal: int j environ res public health doi: 10.3390/ijerph17176328 sha: doc_id: 352501 cord_uid: 5c78kq0w in recent decades, food safety has become a major concern due to frequent food safety incidents in many countries. this may lead to increased health risks associated with low quality food consumption, thereby reducing consumer trust in food safety. a better understanding of consumer perceptions of food safety can improve indicators that do not meet consumer expectations. we propose a food safety gap model with four gap-construct based on consumer expectations and perceptions. the model was empirically tested through a survey of 25 items, and then assessed for gaps through the importance–performance analysis (ipa). from a sample of 697 taiwanese consumers, we found a huge gap between consumer expectations and perceptions related to food safety. more importantly, the results of the ipa indicate that most items must be immediately improved, which is vital in order to mitigate the risk of food safety. food safety has become an important public health concern, so it is controlled and regulated by the government. governments have taken measures to manage issues, and many previous studies have also explored these mechanisms, including governmental policies and regulations on organic farming [1] , the impact of foodborne poisoning caused by food contamination [2] , a novel coronavirus caused by microbial contaminants in game meat [3] , concerning the risk of animal diseases such as avian flu, swine flu, mad cow virus [4, 5] , safety assessment of meat products [6] , and food inspection standards, such as instrumental detection methods based on the nuclear magnet resonance [7] or low field nuclear magnetic resonance [8] to assess the adulteration of oils and fats. it is hoped that these approaches can be used to ensure a baseline level of food safety. in academia, various researchers have studied complex food safety issues, each with its own terminology and classification, for example, wu and hsiao [9] used a failure mode and effect analysis (fmea) method to evaluate risk in food cold chains for chilled or frozen food companies in taiwan; lai et al. [10] estimated on disease burden from foodborne illnesses in taiwan from 2012 to 2015; wu, lin, and chen [11] investigated food safety risks in china; whitworth, druckman, and woodward [12] proposed the categorization of food scares; jespersen, maclaurin, and vlerick [13] developed the food safety desirability response scale; park, kim, and bahk [14] analyzed south korean food safety incidents between 1998 and 2016; nayak and waterson [15] studied the food safety culture of a group of industry stakeholders in the uk; wongprawmas and canavari [16] provided food safety label categories that are indicators of thailand consumers' willingness to pay. despite the increased academic interest in food safety issues in recent years, food safety incidents remain problematic and have not declined significantly over the past decade. food safety incidents cause economic losses, social disruption, and also have environmental impact, so manufacturers involved in the food supply chain and associated governmental departments are striving to reduce both the frequency and severity of their occurrence. however, many of these incidents can be traced back to food manufacturers and their non-compliance with food hygiene and/or food safety procedures. for example, sun et al. [17] pointed out that street food vending in the night markets presents public health challenges, with evidence of diarrheal diseases. park et al. [14] found that between 1998 and 2016, south korea had an average of 4.3 food safety incidents per month, which had both local and international impacts. according to peng et al. [18] , taiwan has also faced food safety incidents in recent years, with adulteration involving illegal additives being the most common: black tea with coumarin, emulsifiers with plasticizer, edible oils with cu-chlorophyll, lard with recycled cooking oil, and antibiotics (tetracycline) in honey. it is worth noting that the taiwan food and drug administration (tfda) has established official regulations and analytical methods to assess food quality and determine whether food is adulterated. however, many food safety incidents still occur, although the cause of each event may vary by product, time, and geographic distribution, but a pattern can be seen between certain events. therefore, it is useful to classify consumers' similar perception gaps when developing strategies to reduce food safety scares. parasuraman, zeithaml, and berry [19] noted that the consumer expectations will be influenced by past experiences, personal needs, and word-of-mouth. indeed, there are various attributes of safety food. with the improvement of food safety awareness, more consumers are willing to pay higher prices to buy safe foods. for example, products with food traceability, food certification mark, and labeling of product ingredients. parasuraman, zeithaml, and berry [19] studied consumer perception models (called pzb model), which is the most cited literature on service quality gaps. the original pzb model proposed five gaps to describe the service quality model by conducting in-depth interviews with fourteen executives from four service companies and service users. the pzb model is very attractive because it can reasonably explain the gap between perception and expectation. however, the model concerned the perceived discrepancy between management and customer. the gap is strongly managers-oriented and not particularly applicable in the context of food safety. thus, we propose a food safety gap model that uses the concept of the pzb to describe the food safety gap between consumer perceptions and expectations, and develops a multiple-item instrument to measure these gaps. prior research focused on consumer perceptions of food safety risks [11] , food-related hazards [20] , trust of food [21, 22] , and consumer acceptance of food safety incidents [23, 24] . recent studies have developed several instruments to measure perceptions of food safety in food-related organizations, such as food safety climate [25] , and food safety culture [26] . nonetheless, based on the consumer-oriented context, the concepts of food safety gaps are still ambiguous and no unanimous definition has been found. drawing on food safety related literature and expert views, we have developed a conceptual model of psychological activity of food consumers to explicate the key determinants of food safety gaps, and define the main concepts which are present in this study. the psychological activity of food safety perceptions includes three stages: evaluation, confirmation, and action. we called this the eca model and depicted this conceptually in figure 1 . the evaluation stage is subdivided into four gaps between consumers' expectations and perceptions. this process is derived from the gap concept of the pzb model [19] . confirmation and action stages can be divided into the expectation of confirmation or not as the antecedent of subsequent perceptions. the upper part of the framework refers to related concepts of the expectation confirmation theory (ect; [27, 28] ). this explains how consumers evaluate their food safety experience and how this evaluation affects their decision to continue purchasing (e.g., expectation confirmation → satisfaction → continuance trust). the lower part depicts the psychological contract breach [29] . reneging and incongruence are two root causes of perceived psychological contract breach. for example, an obligation exists but knowingly fails to meet that obligation, or made an explicit promise and then failed to uphold that promise. however, the perception of contract breach will not necessarily lead to intense emotional reactions. whether this cognitive perception of breach will lead to an emotional response, and the intensity of this reaction, depends on the interpretation and persuasion process of the defaulter, whereby the consumers attaches meaning to the perceived breach (e.g., expectation disconfirmation → expectation trust breach → emotion regulation ← interpretation/persuasion). the definition of the eca model in our study includes the gap of expected and perceived, which then affects cognition attitude and subsequent behavior intention. after experiencing the first-stage of the evaluation and finding a perceived gap, if consumers' perceptions of food safety are much lower than expected, consumers are exposed to food safety gaps and vulnerabilities. that is, the importance of food safety and gaps are the main reasons for this study. study the expectations versus the actual perceived disparities at the consumer's level and unravelling human perceptions in the context of food safety is important as both might affect the validity of the evaluation stage. this study emphasizes a consumers' perspective on food safety being subjective and experiential. this approach aims to explore gaps on how consumers actually perceive food safety in terms of an evaluation of its expected trust. therefore, we will not only give a brief overview of prior research on food safety but also discuss the food safety gap model, and assessment tool. food safety is defined as a necessary condition to guarantee the health of consumers [30] , which is considered as the basic rights of consumers. food safety specifications and laws are among the instruments used from manufacturers and governments to discuss safety issues in the food supply chain [31] . governments often set food-related regulations or standards to figure out the baseline level in food safety, which can protect consumers from food safety issues [32] , this includes a number of routines that should be followed to avoid potential health hazards. nelson [33] argued the food has credence-attributes in the consumption market and may face the asymmetry of product information because consumers cannot see or verify, either before or after purchase. if this is not a priority, this can cause serious damage in food safety. however, giving credence-attributes can be costly, and firms can also incur fixed costs associated with providing accurate information [34] , so reducing credence-attributes can be one of the means to improve performance. the tracks within this line of thought are safety between the government and industry, and then between industry and the market, and then between the market and the consumer. specifically, a lack of food safety can be the main reason for the gaps in perceptions that consumers have. therefore, gap 1 to gap 4 illustrates the difference between consumers' actual perceptions and expectations concerning food safety in the first-stage of the eca model. the gap model further constitutes a theoretical explanation for the mentality of food safety, which is the main focus of this study. among these four gaps of food safety trust, 'gap' stands for the expected difference between consumers, manufacturers, and government. gap 1 shows the difference between consumers' actual perceived and expected trust towards manufacturers. before selling food, a company's management essential to understand the characteristic of food safety to fill consumers' needs, due to the affected consumers' evaluation of food safety. gap 2 describes the consistency of trust between consumers and the government in food safety, which in turn forms food safety regulations to protect consumers. it is because the commitment and policies communications by government can affect consumers' perceptions regarding food safety. gap 3 is the discrepancy between food manufacturers and what is promised via external regulations put in place by the government. various situations, such as legal conditions and regulatory constraints, may lead to differences between expected trust from manufacturers and governments by consumers and what they perceive these established regulations for food safety. gap 4 is the difference between consumers' perceptions and expectations of food safety. the gap is concept-oriented, especially for food safety. gap 4 may also be affected by gaps 1, 2, and 3. the means that the direction and size of each gap will have an influence on food safety. the reasons for the gap include (a) unrealistic food information, (b) public anxiety over food safety incidents, and (c) poor enforcement of food safety regulations. hence, further research is needed to help consumers understand their gaps of food safety. in order to develop the food safety gap scale (fsgs) to measure the gap between consumer expectations and food safety-related concepts, we collected 40 items related to the basic attributes of food quality from previous studies. we divided these 40 measurement items into four dimensions, which include assurance, commitment, regulation, and assessment. the explanation of each dimension is as follows. assurance-this is related to measuring the objectivity or clear evidence of food, such as food label information, appearances being kept intact, food certification marks, labeling of product ingredients, and food traceability [35] . these items which were classified as "food manufacturers have the control, honest, and sufficiently open about the safety of food" (a1-3) are based on the consumers for confidence-in-food manufacturers questionnaire [36] . for consumers, manufacturers must prove that food safety and hygiene are more important than productivity and cost savings. although this notion already is ingrained in the consumers' perception, food safety goals often are in conflict with the financial performance of a manufacturer [37] . therefore, if the manufacturers' ethical beliefs and values of food safety align with consumers, they will be more motivated and exceed expectations. this will then decrease negative perceptions of food safety for consumers such as item a9 "absence of a code of ethics in enterprises makes you suspect the safety of the food with additives." [38] , and item a10 "alert and attentive to potential problems and risks related to hygiene and food safety" [39] . in addition, according to taylor's survey items, where framed in the context of food safety: "the food product is labelled with all necessary information" (a4) as well as " the food producer (a5)/shop or retailer (a6) maintains control over the hygiene" [40] , these items were adopted. another indicator that manufacturers face with food safety issues is the assurance of trust. as argued by morgan and hunt [41] , trust and confidence plays an important role in the business/consumer relationship, yet this trust appears only when the supplier satisfies the needs of the consumer [42] . this sense can bring about increased motivation on the part of the consumer, and it also means that people "trust taiwanese food manufacturers to produce safe foods" (a7) and "trust processors to honestly convey the country of origin and the product's ingredients" (a8) [21] . as described above, items of the food safety gap between consumers and manufacturers are integrated into the first version of the self-assessment scale in table 1 . the food product is labelled with all necessary information. the food producer maintains control over the hygiene. a6 the shop or retailer maintains control over the hygiene. a7 i trust taiwanese food manufacturers to produce safe foods. i trust processors to honestly convey the country of origin and the product's ingredients. absence of a code of ethics in enterprises makes you suspect the safety of the food with additives. wu et al. [38] a10 my acquaintances (e.g., family, friends, or colleagues) are alert and attentive to potential problems and risks related to hygiene and food safety. griffith et al. [39] 3. the commitment to food safety through government is a measure which consumers consider regarding their own values and beliefs about food safety, and if they are aligned with those of their own government. previous research has identified the relationships between the positive and negative effects of organizational commitment across a wide range of different contexts [43, 44] . nevertheless, the extent of the changes brought upon by the commitment of government is yet to be explored. in this case, the component commitment of this study is to identify the impact of government commitment on consumers, and to assess the expectation gap between consumers and government. based on the leader-member exchange (lmx), the commitment in an environment of food safety is affected by the government-consumer exchange (gcx). this notion is inferred from the quality of the social exchanges between government and consumers. regarding gcx, a high gcx can result in better engagement in commitment concerning regulation and policies. the term "commitment" is used to describe food safety, the purpose is to reduce the social panic that may be caused by contaminated food, and how to effectively promote policies to attract consumers [45] . for example, item c1 "government's regulation on additives is a lack of effectiveness" [38] , item c2 "government set clear objectives", and item c3 "government strive for continuous improvement" [25] . every time the government participates in critical food issues, it must prove the significance of their regulations and how they impact food safety. therefore, we introduced item c4 "government clearly considers food safety and hygiene to be of great importance" and item c5 "government acts quickly to correct problems/issues" [46] . we argued that a high gcx also means that communication from government to consumers is a major factor. generally, consumers expect that food will not harm their health or the environment. consumers' trust in regulators is vital in building and maintaining confidence in food safety [47] . therefore, griffith et al. [39] conceptualized that consumers' confidence in food safety is influenced by their trust in government, food safety risks and food risk controls, such as items c6, c7, and c8. when consumers cannot maintain the control of food quality they are consuming, the trustworthy relationship with government is considered a good deputy for controllability [48] . the choices associated with the assessments of food risks result in a very time-consuming process. so, people need to delegate control with certain situations and let other trusted characters act on their behalf [49] . in this sense, the level of food safety control handing as a determinant of food quality is based on government regulations, specifically, the safety controls required by law for public hygiene, risks related to manufacturers' food production, and certifying bodies' indirect controllability. for these reasons, it is important to know how much trust the public has in the government's food regulations to cope with food risks, such as development items c9 [50] , c10 [51] , c11 and c12 [52] (see table 2 ). the government strives for continuous improvement of food safety and hygiene. the government clearly considers food safety and hygiene to be of great importance. hall et al. [46] c5 the government acts quickly to correct problems/issues that affect food safety and hygiene. c6 the government sets a good example concerning food safety and hygiene. in our government, the risks related to food safety and hygiene are known. in our government, the risks related to food safety and hygiene are under control. in our government, good policies and procedures concerning food safety and hygiene are in place. yiannas [50] c10 i think that the food safety level of market product is very poor/very good. berry the government should design regulations and standards related to hygiene and food safety, and ensure that manufacturers know their roles and responsibilities. at the regulatory level, taiwanese laws abide with the strict regulatory framework established by the united states and the european union (e.g., hazard analysis and critical control points (haccp), genetically modified organisms (gmos), and regulation (ec) no. 178/2002) to trace food safety. for this reason, item r1 "taiwanese authorities enforce strict hygienic standards for food" [40] was retained. in addition, the nature of trust is very complex [53] , such as the recognized qualities of taiwanese local gastronomic products, but taiwanese may also have doubts regarding the safety of food. specifically, over the various food safety incidents which may have led to lower consumer confidence and an increase in food scares. on the one hand, food scares can be interpreted with more and more people having anxiety over food safety incidents, and this anxiety is closely correlated with media attention given to such events [54] . on the other hand, media information about the relationship between food safety and consumers is often highly distrustful compared to other sources, but it is also a primary source of information for many consumers [49] . in general, if government authorities appear willing to disseminate relevant regulatory information regarding food safety, consumers will be have more "trust in imported food, and feel it is safe" (r2), "trust the food inspection schemes adopted" (r3), and "trust the food safety standards adopted" (r4) [21] . if "governments communicate regularly with the public (r5) and food manufacturers (r6) about hygiene and food safety" [50] , this process creates a short-term positive impact upon consumer consumption behavior. additionally, whether these violations of public health will be corrected immediately have also caused significant consumers concern. therefore, guchait, neal, and simons [37] proposed a causal sequence illustrating the importance of serious (r7) and substantial (r8) food safety violations. each of the above these items are included in table 3 . i trust the food inspection schemes adopted by the taiwan government. r4 i trust the food safety standards adopted in taiwan. the government communicates regularly with the public about hygiene and food safety. yiannas [50] r6 the government communicates in a clear way with the food manufacturers about food safety and hygiene. if health violations have a direct impact on public health and must be corrected immediately. serious items may, as a group, lead to the closure of a food establishment if not corrected (e.g., food additive, filthy food contact surfaces, temperature problems, food from unapproved sources, adulterated food). guchait et al. [37] r8 these are violations of such a direct and substantial impact to public health that the violation must be immediately corrected or the health officer will require the closure of the food establishment (i.e., no water; no hot water; no ability to sanitize; sewage back up; power outage; pest infestation; no/expired food dealer's permit). expectation-disconfirmation theory (edt) [27] has been utilized by researchers to understand consumer satisfaction, intention to purchase again in the future, and complaining behaviors, and is an extension of cognitive dissonance theory (cdt) [55] . cdt explains how discrepancies between one's cognition and reality change the individual's later cognition and behavior. in the context of food safety, cognition refers to one's food risk opinions [56] , food consumption values [57] , affective attitudes of food [58] , and food safety knowledge [59] , while behavior refers to actions started in response to this cognition or individual's evaluation of such behavior [55] . food safety is a social risk associated with human factors, therefore, the relationship between expectations and actual perception is complex. using edt to depict a psychological process of individual behavior whereby consumers generate initial expectations about a food product, experience its usage over time, and then form actual perceptions of the food product itself. although earlier research explained the gap between food safety attitudes and behavior [60, 61] , it did not measure the consumers' observed expectations of change in terms of cognitive dissonance. the gap between consumers' original expectations and actual perceived existed in the disconfirmation construct. cognitive dissonance may be positive or negative depending on whether the actual perception is above or below initial expectations, and is viewed as a deviation of initial expectations. indeed, some contend that the gap is ambiguous, and the effect appears to be mixed, or inconclusive. both the actual perceptions and expectations play a factor in determining consumer satisfaction or dissatisfaction with food safety, and explain the continued intention among food purchases. in line with this conception, among these food safety incidents in taiwan, adulterations involving illegal food additives were the most frequent [18] . items e2 to e7 explain the observed expectation changes in terms of food additives [38] . food safety and any possible risks related to it, should be known by the consumers, so they can take this information into account in their purchase decisions. consumers may be aware of the "attention given to the risks of consuming certain foods in taiwan" (e1) [62] , "responsible for food safety after purchase" (e8) [63] , or "know where the food originates from" (e9) [40] . in line with these conceptions, consumers may not just blindly trust the system, item e10 "as a result of the occurrence of food safety incidents, i am suspicious about certain food products" is measured for the over-confidence of consumers concerning food safety and public health issues [36] . each of the above these items are included in table 4 . table 4 . indicators of food safety gap between consumers' expectation and actual perceived. i usually put attention on risks of food in taiwan. sparks and shepherd [62] e2 influence from information regarding the presence or absence of quality and safety certification of food with additives. wu et al. [38] e3 doubt about the food safety of domestic food market. e4 influence from information regarding additives on the package labels. e5 unwilling to buy food with additives due to the experience of family. e6 abuse of food additive became a major potential food risk. e7 lose confidence in the domestic food market. e8 consumer is responsible for food safety after purchase. drawing upon the aforementioned literature regarding food safety, previous research has centralized on improving food safety quality to promote the consumer trust. however, this did not significantly increase consumer confidence in buying foods, mainly because many foods on the market still do not satisfy the consumers' expectations. three experts interviewed during this elicitation stage consisted of a member from food manufacturer administration, a senior staff of the government's health department, and a professor in the field of food safety. next, a pretest for 30 food consumers to evaluate the comprehension of this closed questionnaire. the participants were recruited from a range of food markets for supermarket, organic stores, and traditional taiwanese markets. after conducting this pretest, we revised the tested fsgs into the first version for this study. the first version of the fsgs was distributed during a preliminary and test stage which lasted from december 2017 to january 2018. a total of 215 questionnaires were returned, and only 200 were used for data analysis to evaluate the reliability and validity of each dimension, and we apply confirmatory factor analysis (cfa) to purify the structure of fsgs. the number of indicators were confirmed using the factor loading values greater than 0.7 criterion. items that did not meet this criterion were removed one at a time to ensure utmost accuracy. after iterative rounds of cfa, we excluded 15 items to constitute the final version. the final version of the fsg self-assessment questionnaire is divided into four parts, including subjective perceptions of food safety, the importance and performance of food safety, along with basic demographic information of the respondent. all items were scored by using 7-point likert scale, ranging from 1 = "strong disagree" to 7 = "strong agree", except for personal information. the data collected were over a period of approximately three months (february 2018-may 2018). a total of 697 valid responses were collected and then included in reliability and validity, and importance-performance analysis (ipa) to understand the food safety gaps of consumers. the profiles of participants were shown in table 5 . note. cfa = confirmatory factor analysis, ipa = importance-performance analysis. using the data of subjective perception for reliability and validity analysis. among the participants in the final version of fsgs (n = 697), the convergent validity was assessed by determining the significance of item to factor loadings [64] , and further the internal consistency. the calculated cronbach's alpha values ranged from 0.86 to 0.94 (cutoff value >0.70), and displayed in table 6 . convergent validity was measured by composite reliability (cr), which should be greater than average variance extracted (ave), which in turn should be greater than 0.5 [65] . the cr values of this study range from 0.90 to 0.95, and ave value range from 0.59 to 0.76. thus, good internal consistency among the attributes within each dimension was confirmed. in addition, these thresholds also tested the discriminate validity of the assumption that the ave square root of each variable exceeds the related coefficients of these variables [65] . additionally, a pairwise correlation less than 0.85 indicates discriminant validity between two factors [66] . in summary, the 25-item measurement fsg exhibited a considerable construct which was deemed valid and reliable (see tables 6 and 7) . note. items on the diagonal in boldface represent the ave square root; ** p < 0.01. importance-performance analysis (ipa) developed by martilla and james [67] , and marketing research techniques helped provide insights to management in order to identify the strengths and weaknesses of service attributes [68] . more importantly, ipa is able to determine the most important attributes that have the highest impact on consumer satisfaction, and understanding that the lowest performance attributes that need to be improved immediately [69] . therefore, to date, the application of ipa extends to a wide range of fields, including manufacturing [70] , tourism [71, 72] , hospitality [73] , food [74] , health care [75] , transportation [76] and other industries. in this study, ipa involves two dimensions and four quadrants that measure the performance/perceived (x-axis) and importance/expectation (y-axis) of food safety attributes. according to their position on the matrix, the following improvement gap of food safety can be recommended. quadrant i: "keep up the good work", are viewed as the opportunities to achieve or maintain competitiveness; quadrant ii: "concentrate here", high importance, but low performance is considered as a major weakness for food safety gaps. therefore, immediate improvement is required; quadrant iii: "low priority", the attributes in this quadrant are not considered crucial and do not require additional efforts; quadrant iv: "possible overkill", low importance but high performance, customers do not particularly value these attributes in this quadrant, which indicated that the resources committed are excessive. table 8 shows the mean importance (i), mean performance (p), gaps score, paired t-value between importance and performance, and quadrants of each item gained through the analysis of data. the paired sample t-test shows that significant differences exist between the respective expectation mean and perception mean for all 25 items. moreover, these gap scores between the importance/expectation and performance/actual perceptions are negative which indicates that the quality of food safety is generally less than what consumers think it actually is. from a gap analysis perspective, all items must be improved, as well as the order of their improvement priorities based on the results of the ipa. looking at the different aspects among score gaps, the items a6 (1.91), a7 (1.96), and e9 (1.97) have a smaller gap score, while items a4 (3.15) and e10 (3.09) have a larger gap score. specifically, these items mostly belong to the "assurance" and "assessment" constructs in the fsf-scale. as revealed in the above results, the data were then transferred to the ipa matrix presentation in figure 2 . the practical implication based on the result diagram of expectation and perception is that food safety should pay more attention to these items to decrease the gap. note. i = importance, p = performance, quad. = quadrant, no item in quadrant iv, *** p < 0.001 significance levels. our findings have revealed that gaps in food safety have highest importance and performance in quadrant i, such as items a3, a5, e1, and e2. therefore, at least the performance level should be continued and then narrow the gap. in quadrant ii, where 'performance/actual' perception is lower than 'importance/expectation', there are many items that fall into the "concentrate here" quadrant (a4, a9, c3, c5, c9, c12, r1, r2, r5, r6, r7, r8, e7, e8, e10) . in short, government and manufacturers must focus on improving these attributes. it is worth noting that all items related to the "regulation" construct fall within this quadrant. the gap analysis results illustrate that these items with a gap less than 2.33 fall into the "low priority" quadrant (iii) in the ipa matrix, implying low importance and low performance. therefore, these items may not be prioritized when government or manufacturers make improvement plans. in quadrant iv, the consumers are satisfied with the performance but they assess less important food safety attributes. however, not any particular item falls into this quadrant. the above results indicate that the gap scores were able to successfully evaluate the magnitude of the gap between consumers' expectations and actual perceptions of food safety. the evaluation of all items based on expectations and actual perceptions of consumers' food safety has generated a conflicted consequent with a lower perception and rather higher expectation. this overwhelmingly verifies that a gap exists between consumers' expectations and actual perceptions of food safety in all indicators, and that the improvement of these indicators needs to be promoted because they fail to satisfy customers' expectations [77] . previous studies have argued the gap exists between food safety attitudes and behaviors of respective food vendors [60, 61, 78] . our results indicate a gap between consumer expectations and actual perception of food safety, which is one of the enduring challenges for dealing with food safety. figure 3 represent the magnitude of the gaps within each indicator ranging within the four constructs. from the magnitude in each gap, we found that there is a wide gap existing between expectations and actual perceptions of food safety. despite most food vendors complying with governmental regulations and standards, it is likely that they cannot truly satisfy the expectations of the consumer. moreover, in order to increase the sales within the food economy, the government has inadvertently ignored the actual perception of food safety by consumers and has not yet provided any approach to address consumers' perceptions of food safety after recurring incidents of food safety. though recognizing that incident of food safety was an extremely important issue for the future at the consumer level, if manufacturers and governments were unwilling to expand any additional effort in the environment of food, these problems threaten to permanently diminish their quality of food safety. while food production is becoming increasingly more complex, no matter how different in terms of risk characteristics and the degree of threat to public health, successive food scares may lower consumer confidence. as a result, consumers tend to rely heavily on government and manufacturers to ensure the quality of the products they consume. however, less research has focused on the level of importance consumers place upon aspects of expectation and gap concerns regarding food safety perceptions. the eca model is viewed as a three-stage model where first-stage "evaluation" is caused by the gaps between expectations and actual perceptions of food safety, and to confirm the size of the gap. given this background, the purpose of this paper is to describe the application of a gap model and how it affects and relates to food safety. more specifically, this study was undertaken in order to understand consumers' gap of food safety, and to suggest some theoretical as well as practical implications of this process. the results show that taiwanese consumers have large gaps in the food safety environment. a larger gap between expectations and perceptions means that consumers are less confident about food safety in the market, or their lack of confidence in mandatory regulation has led to the current level of food safety that may not meet the need or expectation of consumers. for instance, ipa suggests the "regulation" performs poorly with all indicators that fall into quadrant ii. therefore, we argue that the government should still be a key actor. although the taiwanese food and drug administration (tfda) ensures food safety and the quality of food, developed official regulations and analytical methods to assess food quality are used to determine whether food has been adulterated. even in situations where tfda affects practice, these influences appear not to be more valid over time. that is, the weak enforcement of food safety regulations, which at best create a favorable attitude. in addition, the consumers from our survey are generally concerned about food safety, they are considered with one of the most important sources, 'the food labelled with full product information', since this indicator (a4) has the highest importance score (5.96) and the largest gap score (3.15) . the possible reason is that in the initial period of purchasing food, this information can only be obtained through labels seen on the packaging. therefore, we argue that manufacturers should clearly label food information to reduce potential issues of transparency between consumers and manufacturers. even though taiwan is presently improving its food safety standards, consumer concerns about food safety are also increasing. indeed, there is a public demand for improving food quality by food providers, the food safety environment is a much more significant factor affecting their decision-making process when they decide to purchase food. in conclusion, food safety has become a priority for many countries, citizens, and the food industry. as food manufacturers place more concern on the strategic importance of food safety, consumers will have a positive view of the governmental regulations, and this is important for consumers. additionally, consumers are seeking added reassurance and are willing to pay a higher price for a safer food environment. the findings of this research should lead to a food safety gap taxonomy which will allow us to study the psychological mechanisms involved when a food safety message is expressed in a consumer environment, versus what is actually communicated from the manufacturer themselves. they could also be applied to improve the importance-performance analysis in food safety, as well as consumer behavior. in general, they will be useful for improving evaluative indicators and in particular, to unify evaluation criteria among the consumer of the food and safety hazards. furthermore, since food manufacturers are ubiquitous figures in the food market worldwide and are one of the main causes of food safety incidents outbreak, identifying the potential gaps in consumers' expectations and perceptions is imperative to building upon interventional strategies to promote food safety. the fsg scale allows quantification of this tendency by evaluating the extent of consumers' expectations themselves by asserting how they are actually perceived. this research is significant as a new validated scale can now be applied to the measurement of food safety gaps. however, whether this will also apply to food safety contexts in other parts of the world cannot be determined based on this study. further research is therefore warranted in different cultural and geographical contexts. finally, this study has some potential limitations. due to its convenience sampling in taiwan, the data presented here may not be representative of other regions worldwide. in addition, since this is a cross-sectional survey, we recommend a longitudinal study to obtain more contextual relationships between food 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research was supported by ministry of science and technology, taiwan, roc under the grant most 106-2410-h-110-077-to national sun yat-sen university. the authors declare no conflict of interest. key: cord-344075-ucd6ooob authors: bartoszek, adrian; walkowiak, dariusz; bartoszek, agnieszka; kardas, grzegorz title: mental well-being (depression, loneliness, insomnia, daily life fatigue) during covid-19 related home-confinement—a study from poland date: 2020-10-12 journal: int j environ res public health doi: 10.3390/ijerph17207417 sha: doc_id: 344075 cord_uid: ucd6ooob the covid-19 pandemic is a great threat to both physical and mental health as it may lead to psychological stress connected with an economic crisis, threat of unemployment, or fear of losing family members. emerging data shows that the general public may be vulnerable to the pandemic-related stress and experience frequently prevalent anxiety. a study involving 471 subjects (85.6% female) was conducted online during the covid-19 pandemic. we used the following scales: insomnia severity index (isi), beck depression inventory (bdi), revised university of california, los angeles (r-ucla) loneliness scale, and daily life fatigue scale (dlf). women had higher mean scores of depression, loneliness, and daily life fatigue and more often than males started exercising. among people professionally active before the pandemic, there were more cases of increased alcohol consumption than among students. no differences in alcohol consumption patterns were found between genders. people living alone had higher scores of loneliness and daily life fatigue compared to those living with someone. respondents who started taking any new drugs during covid-19 home confinement had higher outcomes in all questionnaires. during home confinement, high scores of depression, insomnia, loneliness, and everyday fatigue were observed. the outbreak of the global covid-19 pandemic revealed that the world had been completely unprepared for it. as of 25 may 2020, the global number of reported cases has reached 5.2 million and is still rising [1] . so far, there is no specific anti-covid-19 treatment, nor targeted prevention. fortunately, currently over 50 vaccine candidates are in pre-clinical studies with some in phase i [2] . hopefully, an effective vaccine is expected to be available in early 2021. the first confirmed covid-19 case in poland was announced on 4 march 2020. on 24 march, the polish government announced strict restrictions, which forced the vast majority of polish citizens to obey home confinement. this meant that people were obliged to spend most of their day at home-schools, universities, public institutions operated remotely (online), most of the workers were asked to work from home. the restrictions included: mandatory covering of mouth and nose in public spaces, keeping a minimum two-meter distance between pedestrians, the cancellation of public events, limited number of customers in shops, closed shopping centers, international travel ban, and closed airports. on 20 april the polish government started to gradually abolish the restrictions. the global health crisis of the covid-19 pandemic is a great threat not only in terms of physical health. as multiple countries worldwide have decided to apply the technique of social distancing, this creates a huge challenge in terms of mental health, greatly reinforced by other factors that may lead to psychological and psychiatric disturbances, such as economic crisis, the threat of unemployment, or fear of losing family members. emerging data show that the general public may be vulnerable to pandemic-related stress and frequently experience prevalent anxiety [3] . psychological and psychiatric disorders are complex in terms of pathogenesis with multiple causative factors including genetics, physical state, socioeconomic status, etc. however, in general, psychological and social factors may play a role in triggering some of these disorders (e.g., anxiety or depression). in light of that, social distancing and home confinement regulations are important factors that shall be considered in managing social and psychological well-being [4] [5] [6] [7] [8] . since the beginning of the covid-19 pandemic at the end of 2019, some research on mental health has been published. the issues covered include mostly depression and anxiety, with some preliminary reports also on insomnia. however, these reports are mostly from china and other asian countries, where the pandemic first started and lessons on the issue were learned first [9] [10] [11] . some reports from other regions confirm a declining tendency in peoples well-being and mental condition during the covid-19 pandemic [12] [13] [14] . moreover, many of these studies are focused on the mental health of healthcare workers [15] , who are on the frontline of the pandemic, yet fewer studies are focused on those not involved in healthcare [16] . to date, very limited data is available on the issue of the impact of the covid-19 pandemic on mental health in european countries [17] . only one study covered some aspects of this topic in poland, whose authors studied the effects of mandatory face mask restrictions on anxiety, depression, insomnia, and social dysfunction questionnaire scores [18] . as described above, certain areas of research on mental health during home confinement were not covered, particularly, especially regarding the geographic distribution of the studies. moreover, in june 2020 a position paper was published in the lancet with a call-for-action for studies on mental health effects of the covid-19 pandemic across population and vulnerable groups [19] . this is particularly important as not only is the pandemic still active, but the world may also face its second wave. in fact, some countries already re-implemented social distancing requirements and home confinement regulations. to extend the scope of the research on the topic, we decided to include some further factors that may be associated with varying mental health outcomes during covid-19 home confinement. these factors included: alcohol consumption, taking psychiatric drugs (antidepressants, anxiolytics, sedatives or others), and living alone or with others during home confinement. the aim of the study was to measure indicators of mental well-being in a polish sample with regard to selected sociodemographic and health behavior data during home confinement related to covid-19 pandemic. we suspected that selected sociodemographic and health behavior data could differentiate mental well-being during home confinement related to covid-19 pandemic. this was an online study involving polish adult citizens, conducted during the covid-19 pandemic. current/recovered covid-19 patients were excluded from participation in the study. study participants were invited to complete a self-administered online questionnaire (google forms) 1.5 weeks after home confinement restrictions were introduced in poland (3 april 2020) and the questionnaire was available for the following two weeks. participation in the study was generally requested through the researchers' university emails and their official websites. a request for participation was also sent via the researchers' institution social media profile (facebook). the survey was created on the basis of a literature review on mental well-being and with the use of standardized research tools examining symptoms of depression, loneliness, insomnia, and fatigue. sociodemographic questions concerning age, gender, professional status, number of household members, and the questions related to alcohol consumption, physical activity, and administration of new drugs at the time of questionnaire filling (that is during current covid-19-related home confinement) were collected. we also asked about the date at which an individual began his/her home confinement. the insomnia severity index (isi) was used to measure the potential severity of insomnia. each item of that tool is rated on a 0-4 scale, and its total score ranges from 0 to 28. a higher score suggests more severe insomnia symptoms [20] . the scale is widely used in polish population [21] . internal consistency of isi, assessed with cronbach's α and mcdonald's ω, was found to be sufficient for the study (α = 0.898, ω = 0.901). the beck depression inventory (bdi), developed by aaron t. beck, is a self-administered questionnaire consisting of 21 multiple-choice questions. it is one of the most commonly used instruments for measuring the severity of depression. the global score of bdi is an arithmetic summation of the ratings of all 21 symptoms scored on a final scale ranging from 0 to 63. the higher the global score, the greater the depression level [22] . the scale has been validated in poland [23] . internal consistency of bdi was found to be sufficient for the study (α = 0.904, ω = 0.909). revised university of california, los angeles (r-ucla) loneliness scale is a 20-item scale designed to measure one's subjective feelings of loneliness as well as feelings of social isolation. participants rate each item on a scale from 1 (never) to 4 (often) [24] . the scale has been validated to polish conditions [25] . internal consistency of r-ucla was found to be sufficient for the study (α = 0.791, ω = 0.801). the daily life fatigue scale (dlf) is a polish questionnaire which consists of three subscales: physical fatigue (pf), associated with daily physical activity; mental fatigue (mf), associated with the mental activity (e.g., calculations in memory or remembering a phone number); and social fatigue (sf), regarding social activities, e.g., planning time with loved ones. the result of the scale is a measure of general everyday fatigue, which is the sum of points obtained in all 24 positions of the three subscales in the range from 0 to 24. the higher the score, the higher the level of general everyday fatigue felt [26] . internal consistency of dlf was found to be sufficient for the study (α = 0.826, ω = 0.829). participation in the study was fully voluntary. all participants were familiarized with the study conditions and gave informed consent to participate. confidentiality and anonymity were maintained as no data that potentially identified a responder was collected. bioethics committee confirmed that according to polish law and good clinical practice regulations this research does not require an approval of a bioethics committee (kb nr 542/20). the data collected in the questionnaires were verified and checked for completeness, quality, and consistency. then it was coded and exported into statistical packages: jasp (version 0.12.2; university of amsterdam, amsterdam, the netherlands) and statistica 13.1 (tibco, palo alto, santa clara, ca, usa). for all scales, the mean, median, and standard deviation (sd) values were calculated. welch's unequal variances t-test was used to compare differences between sub-groups (gender, age, activities, and others). effect size is given by cohen's d. we used kendall's tau b to measure the strength of the relationships between variables. a 5% level of significance was used for all hypothesis tests. sociodemographic characteristics and other personal data are presented in table 1 . generally, most of the respondents were women, students. standard deviation (sd) the average dlf result was 7.541, with results ranging from 0 to 24 ( table 2 ). the results of bdi ranged from 0 to 54, with a mean score of 14.161. the average r-ucla result was 42.041, ranging from 20 to 74. the mean isi result was 15.781, with results in a range of 7-35. in our group, 86% participants scored above the cut-off point of isi questionnaire for acute/chronic insomnia (>7 points). the average isolation period of our respondents was 20 days (range 3.5-24). we did not observe the impact of isolation time on bdi, r-ucla, and isi results. for dlf, an effect of isolation time on results was observed (kendall's tau b = 0.064, p = 0.043). the results of all scales were analyzed in terms of age, activities, solitude, employee vs. student status, traditional work vs. telework, and gender. statistically significant differences in the reaction to the new social experience of isolation and social distancing were only observed between genders (table 3 ). women had significantly higher mean scores in dlf, bdi, and r-ucla, but not in isi, where the difference was borderline, but higher than the assumed level of statistical significance. among the other factors examined in connection with the social isolation period were also issues related to physical activity. while individual groups (female /male, working/not working) did not differ in the declared frequency of leaving the house, it turned out that there were some differences regarding lifestyle choices. no statically significant differences in physical activity among genders was shown (see table 4a ). in the group of people professionally active before the pandemic, there were more cases of drinking alcohol more or more often than in the case of students (table 4b ). no differences in alcohol consumption patterns, however, were found between genders. we also studied the impact of living alone on the well-being of people during pandemic-enforced isolation. table 5a presents the results of the scales broken down into two groups, one where the respondents were in home confinement with a partner or family and the second group in which people were living alone. differences for individual scales between people who started taking new drugs during a pandemic and those who did not were also investigated (table 5b) . as for depression, measured with bdi, the mean score in the group that declared increased alcohol consumption was 17.82 compared to 13.67 in the group that declared not consuming more alcohol (bdi cut-off for mild depression is >13). research on mental health during the covid-19 pandemic is an important study area that possibly concerns many individuals, considering that the government announced strict restrictions, which forced the vast majority of polish citizens to obey home confinement, to study and work remotely, and to adjust to the new situation. for this reason, our study aimed to measure mental well-being (levels of depression, insomnia, daily life fatigue, and loneliness) in a sample of the polish population during covid-19 related home confinement. we focused on differences between genders, physical activity, alcohol consumption, drugs, and living alone. in a review of studies on depression among healthcare workers (over 33,000 cases) the depression prevalence was estimated to be 23%. moreover, another review on depression, which was focused on the general population, showed a 33.7% depression prevalence. this clearly shows the scale of psychological and psychiatric problems related to the pandemic, both among healthcare workers-who in their previous work have already dealt with numerous stressful situations related to other peoples' health-and the general public, for whom this situation may be a kind of a reminder of value and fragility of humans' health [10, 27] . a very recent study from china, where the authors used similar methodology as we did in studying insomnia (online isi questionnaire, pre-and during the pandemic) found a significant increase of insomnia (isi > 7) from 26.2% to 33.7%. the authors of that study conclude that their findings suggest that insomnia is associated with the covid-19 outbreak-related psychological reactions and poor sleep hygiene [28] . another recent report from greece found that 37% of respondents scored above the cut-off score for insomnia. in our study, this percentage was 86%. both of these values are above the generally reported worldwide insomnia (acute and chronic) prevalence, estimated before the pandemic to be between 3.9% and 22% [29] . these findings may be an indication that some exacerbations of sleep disturbances happen during the covid-19 pandemic. moreover, differences in insomnia scores between genders were confirmed in the cited study from greece, contrary to our results [17] . some explanation of these findings may be that during home confinement, people experience less physical fatigue and sun exposure, as well as possibly tend to more prominently use electronic devices that altogether may influence sleep homeostasis [30] [31] [32] . also, without a doubt, the psychological stress caused by this unprecedented situation greatly contributes to this phenomenon. a study similar to ours was carried out in italy online on 2291 respondents during march and april 2020. the results have clearly shown that the pandemic and associated psychological stress are risk factors for sleep disorders and psychological diseases, e.g., the authors have shown that all of the elements of the psychological well-being (pgwb) questionnaire (anxiety, depressed mood, positive well-being, self-control, general health, vitality) were significantly worse among study respondents than in previous general population data [33] . in a very recent meta-analysis of studies on depression, anxiety, and insomnia among healthcare workers during the covid-19 pandemic the authors analyzed the results of 13 articles on these subjects, all of which were 2020 reports from asia (china predominantly). insomnia was found in five out of these 13 studies. the conclusion of this meta-analysis was that insomnia prevalence during the covid-19 pandemic was 34.32%. the authors did not perform gender sub-group analysis due to limited data available [10] . although the issue of insomnia is complicated and little is known on the impact of covid-19-related stress on it, we may find some practical recommendations addressing this issue. in april 2020 the european cognitive behavioral therapy for insomnia (cbt-i) task force published their recommendations on dealing with sleep problems during this pandemic [34] . existing reports show positive correlations between home confinement during covid-19 pandemic and perceived loneliness. tull et al. have shown this using the ucla questionnaire in 500 u.s. adults. surprisingly, in the same study, the perceived impact of covid-19 itself was negatively associated with loneliness and additionally positively associated with social support [35] . studies suggest that loneliness during covid-19 home confinement is more strongly felt by younger people [36] . however, interventions addressing loneliness during covid-19 home confinement, which are discussed in literature, are proposed to be particularly important among the elderly [37, 38] . these include, for example, telehealth and online group interventions targeting these psychological needs [39] . although societies have-in a way-become used to the fact that loneliness concerns the elderly, in these difficult times it has affected almost every age group. in fact, regardless of the age group, the possibility of psychological support and maintaining social life, e.g., online, should provide an opportunity to improve individual's well-being. a specific type of psychological fatigue is the daily life fatigue (dlf). the author of the questionnaire (urbańska) defines dlf as subjective overall fatigue, which is expressed by the reluctance to undertake daily physical, mental, and social activities [26] . similar to the other scales used in the study, women had significantly higher mean scores in dlf, comparing to men. living alone and taking new drugs during covid-19 home confinement, were both variables associated with higher scores of dlf. of importance in the perceived dlf is the self-interpretation of an individual's situation; one may subjectively feel considerably tired while having objectively few everyday activities and vice versa. to the best of the authors' knowledge, there has not yet been a study that addressed the issue of dlf during covid-19 home confinement. this may be caused by the fact that the dlf scale is a relatively novel tool, developed in polish and has no english translation and validation yet. however, a study that covers the topic of 'psychological fatigue' in turkey has recently been published by morgul et al. the authors concluded that although knowledge, attitudes, and behavior concerning covid-19 preventive measures are important to prevent transmission of the disease, they are also associated with participants' fatigue. this, in turn, might lead to a psychological outcome e.g., pandemic-related fear and anxiety [40] . we found that, compared to pre-pandemic times, higher declared alcohol consumption is associated with higher beck depression inventory scores. this outcome implies that some specific caution regarding addiction and mental health should be addressed to those people-both by healthcare professionals and, most importantly, by family members that are together during home confinement. this is particularly important as alcohol misuse during the covid-19 pandemic may be considered one of the potential public health crises [41] , since rising alcohol sales and consumption have been reported in european countries [42] . with social isolation and home confinement, there are also a number of social consequences related to mental health. among them, it is worth mentioning the risk of intensification or exacerbation of domestic violence, which has been highlighted in the literature [43] . this and other themes, combined with the observations on mental health, should particularly lead to interventions aimed at improving people's well-being. this is one of the very first studies on the impact of covid-19 pandemic on mental health in europe. in particular, it is only the second covering this topic in poland. to date of article submission, one report from poland has shown that face mask restrictions, apart from preventing the spread of covid-19, may in a way increase the level of perceived self-protection and social solidarity, which may improve the general mental health well-being [18] . certain limitations apply to the results of our study. first of all, it is important to acknowledge this was an online only study which was performed via sharing the link to the survey. this implies that the results are limited to those with access to the internet only. moreover, we acknowledge that our study group is predominantly female, yet we believe that the statistical analysis we provided still allows an objective analysis of the results obtained. moreover, gender differences in r-ucla, bdi, and dlf have strong statistical significance. due to the study design (social media) we are unable to provide the response rate to the survey. with time and downturn of the epidemic in poland, the home confinement regulations were (and at the time of article submission constantly are) being loosened, thus further data collection would possibly result in biased results. the final limitation of our research is that it is a survey from which a nation-wide scale should not be directly extrapolated. this would have been possible only with nationally representative study. however, we believe that our results may still provide useful information on the impact of covid-19 pandemic on the peoples' mental health. we have shown some general tendencies across genders that imply that further studies in the area may be needed. the other issue is the 18-30 age predominance in our study group. however, we found that studies with a similar approach to ours (web-based questionnaire studies during covid-19 in europe) faced similar problems of female and 18-30 sample predominance [17] . self-selection bias for interest in psychological themes next to bias due to the online administration system is possible. what we report are results on depression, insomnia, loneliness, and fatigue across covid-19 free individuals. however, it should be remembered that the above-mentioned problems also apply to patients diagnosed with covid-19, as reported in the literature [44] . the outbreak of any infectious disease is associated with panic among people. people's response to a pandemic determines not only the rate of the spread of the disease but also psychosocial disorders both during and after the pandemic. despite this, there are not enough tools that could help maintain the social well-being of the population. this is understandable at the beginning of the spread of the disease where all funds are directed directly to fighting the disease. as the pandemic progressed, severe restrictions were imposed in many countries to keep people at home. this can lead to further disorders related to social isolation. during homestay, people have higher scores of depression, insomnia, loneliness, and everyday fatigue. an important role in the development or deepening of mental disorders can be caused by new drugs that inadequately administrated can cause an increase in the number of hospitalizations, which is 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loneliness and social isolation in older adults during the covid-19 pandemic: implications for gerontological social work using telehealth groups to combat loneliness in older adults through covid-19 covid-19 pandemic and psychological fatigue in turkey alcohol use and misuse during the covid-19 pandemic: a potential public health crisis? lancet public health 2020, 5, e259 covid-19 and alcohol-a dangerous cocktail danger in danger: interpersonal violence during covid-19 quarantine anxiety and suicidality in a hospitalized patient with covid-19 infection this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord-351880-iqr419fp authors: fan, changyu; liu, linping; guo, wei; yang, anuo; ye, chenchen; jilili, maitixirepu; ren, meina; xu, peng; long, hexing; wang, yufan title: prediction of epidemic spread of the 2019 novel coronavirus driven by spring festival transportation in china: a population-based study date: 2020-03-04 journal: int j environ res public health doi: 10.3390/ijerph17051679 sha: doc_id: 351880 cord_uid: iqr419fp after the 2019 novel coronavirus (2019-ncov) outbreak, we estimated the distribution and scale of more than 5 million migrants residing in wuhan after they returned to their hometown communities in hubei province or other provinces at the end of 2019 by using the data from the 2013–2018 china migrants dynamic survey (cmds). we found that the distribution of wuhan’s migrants is centred in hubei province (approximately 75%) at a provincial level, gradually decreasing in the surrounding provinces in layers, with obvious spatial characteristics of circle layers and echelons. the scale of wuhan’s migrants, whose origins in hubei province give rise to a gradient reduction from east to west within the province, and account for 66% of wuhan’s total migrants, are from the surrounding prefectural-level cities of wuhan. the distribution comprises 94 districts and counties in hubei province, and the cumulative percentage of the top 30 districts and counties exceeds 80%. wuhan’s migrants have a large proportion of middle-aged and high-risk individuals. their social characteristics include nuclear family migration (84%), migration with families of 3–4 members (71%), a rural household registration (85%), and working or doing business (84%) as the main reason for migration. using a quasi-experimental analysis framework, we found that the size of wuhan’s migrants was highly correlated with the daily number of confirmed cases. furthermore, we compared the epidemic situation in different regions and found that the number of confirmed cases in some provinces and cities in hubei province may be underestimated, while the epidemic situation in some regions has increased rapidly. the results are conducive to monitoring the epidemic prevention and control in various regions. the outbreak of a new coronavirus (2019-ncov) has spread internationally since the initial report of cases by wuhan municipal health commission, china on 31 december 2019 [1] [2] [3] [4] . on 26 january 2020, who announced that there is a high risk of a 2019-ncov epidemic in china and at a global level [5] . the analysis object of this study was the floating population who have lived in wuhan for more than one month. short-term migrants and students were not included. distinct from other models of the dynamics of this epidemic, we used the information of the respondents from the cmds and their family members to further explore the origins of wuhan's migrant population, such as their returning destination, population characteristics, family structures and other metrics. this approach can provide practical solutions to prepare prevention strategies, and approaches to assess resources for treatment and containment of the epidemic. the national health commission of china released a report on 27 january 2020 that stated that 2019-ncov could be transmitted not only via respiratory droplets, but also via direct contact. 2019-ncov has now spread nationally and worldwide, and due to the lack of data on the size and origins of the floating population of wuhan, it has been difficult for the chinese government to arrange real-time medical resources and implement effective public health interventions. we used data from the wuhan floating population monitoring survey to estimate the size and origins of the migrant population in wuhan. we also described the socio-demographic characteristics of this population, and compared confirmed cases from different regions to estimate the epidemic with modelling techniques. we found that three-quarters of wuhan's floating population are from hubei province, and that nearly 85% migrated with nuclear families. the number of members per family is 3 to 4, and most individuals are migrant workers from rural areas with low education levels. by comparing the predicted and actual values obtained from the model, we analysed the profile of the epidemic in various regions since january 25, and found that the spread of the 2019-ncov has varied greatly between regions, and that the epidemic in some regions may be underestimated. there may also be unknowns, such as structural factors in some regions, that deserve further attention. the majority of the floating population left wuhan before the city was "closed off" by authorities, so our analysis will be useful for estimating the key geographic areas for prevention and control. the results indicate that the floating population of wuhan is centred in hubei province and the surrounding provinces, so local government must quickly and effectively take steps to prevent further spread of 2019-ncov. higher-level governments must also strengthen the assistance they are providing, such as sending medical workers and medical supplies to these areas to avoid 2019-ncov becoming a new pandemic. at the same time, it is important to increase surveillance in areas where the epidemic may be underestimated, and promptly identify prevention and control loopholes to reduce the burden of a new round of transmission. china has been deeply involved in the globalisation process, and even china's central and western regions have become important links in the global production and trade chain. therefore, while our research is aimed at china in the current era of migration, this research has practical implications for global public health and disease control, as floating populations are increasing in size all over the world and relationships between countries are becoming increasingly close. thus, other countries should pay attention to the epidemic situation in specific geographic areas of china to prevent secondary and international transmission of the 2019-ncov. the data used in this study are based on the 2013-2018 china migrants dynamic survey (cmds), and the tabulated data of 5 million migrants in wuhan recently released by the wuhan municipal government. this survey was carried out via a multi-stage stratified sampling method, and collected data with structured questionnaires. as survey data is limited to the mainland provinces, municipalities, autonomous regions, and hainan province, the population analysed in this study excluded the populations of hong kong and macao. a total of 11,999 samples of the resident floating population in wuhan from 2013 to 2018 were extracted from the survey dataset. according to the survey design, wuhan's floating population was defined as the population from other cities and districts, aged 15 and over, residing for more than one month in wuhan, and not registered in wuhan. in table 1 , the sample distribution of the resident population in wuhan over time is presented. the sample size was 1999 in the year 2013, and 2000 for other years. the outbreak is considered to have originated in the huanan seafood market, near hankou railway station in the jianghan district, wuhan, china. a severely infected area was concentrated in the urban areas of hankou. from the sample distribution in table 1 , the floating population of wuhan is seen to be concentrated in the urban area of hankou. the results indicate that the sample proportion of jianghan district and nearby jiang'an district, tongkou district, and dongxihu district is approximately 51.6%. therefore, the samples used in this study are suitably representative and thus acceptable for assessing the spread of the 2019-ncov outbreak among the floating population. total 1999 2000 2000 2000 2000 2000 11,999 hankou zone jiang'an 400 360 360 320 400 -1840 qiaokou 240 240 240 200 240 -1160 jianghan 280 240 200 200 160 -1080 dongxihu 200 160 200 320 200 -1080 huangpi 120 120 120 120 160 -640 xinzhou 0 0 40 40 0 -80 wuchang zone hongshan 239 240 240 240 200 -1159 wuchang 200 160 200 200 240 -1000 qingshan 80 160 120 80 40 -480 jiangxia 40 0 40 40 40 -160 hanyang zone hanyang 120 160 160 160 200 -800 hannan 40 120 80 80 80 -400 caidian 40 40 0 0 40 -120 all three zones -----2000 2000 we obtained data from the "dingxiangyuan" national real-time epidemic website on confirmed cases from 25 january to 31 january 2020 [6] . these data are compiled from open data released by authorities such as the national health commission, and the provincial and municipal health commissions. to ensure data comparability, we collected the data daily from 12:00 to 14:00 every day. using the information of the floating population and their family members in wuhan, we analysed their return destinations and their structural characteristics by descriptive statistical methods. in table 2 , the distribution of the origins of wuhan's floating population is presented, at the provincial level, over the past several years. the sample size is quite stable for each province over time. the province of origin for 75% of the floating population was hubei province, which contains the city of wuhan, and approximately 25% of the population originated in other provinces. the location information published in other historical survey data is limited to the province where household registration is located, due to a lack of data for 2019. the data provided by the hubei provincial health commission in 2017 includes more detailed information of prefectures, cities, districts and counties. the analysis was therefore divided into two parts; the first part comprised an analysis of the origin of wuhan's floating population at the provincial level using historical data. the second part comprised an analysis of the floating population within hubei province based on 2017 data. when analysing the floating population at the provincial level, we used all samples from the previous years-i.e., the mean of 6 years of data collection-to ensure the robustness of the results, in view of the stability of sample distributions in each province over time. total 1999 2000 2000 2000 2000 2000 11,999 hubei 1514 1508 1487 1465 1477 1547 8998 henan 113 134 109 159 170 125 810 anhui 59 58 55 53 56 46 327 hunan 57 46 68 54 41 36 302 jiangxi 58 40 53 57 49 34 291 chongqing 34 29 34 33 33 35 198 zhejiang 22 29 25 33 25 33 167 sichuan 22 30 45 21 22 27 167 fujian 14 17 16 15 39 19 120 jiangsu 38 13 16 19 13 11 110 shandong 12 18 11 13 8 12 74 guangdong 7 8 18 18 14 8 73 hebei 0 1 5 tianjin 1 0 0 1 0 1 3 shanghai 0 1 0 1 0 1 3 inner mongolia 1 0 0 0 1 0 2 xizang 0 0 1 0 0 1 2 ningxia 0 0 1 0 0 0 1 according to the current infectious features of 2019-ncov, which are that middle-aged and elderly people have a high risk of infection, and transmission can occur between individuals, families and communities, we assessed several main variables. these comprised age group, educational level, pattern of migration, number of migrating family members per household, type of household registration, and reasons for migration. we defined these variables in the following ways: (1) age group was classified as under 20, 21-30, 31-40, 41-50, 51-60, and over 60; (2) educational level was divided into junior high school and below, high school/secondary school, and college and above; (3) pattern of migration was divided into independent migration, nuclear family migration, and extended family migration; (4) number of migrating family members per household was classified as 1, 2, 3, 4, and 5 or more; (5) types of household registration were divided into rural and urban household registration; (6) reasons for migration were working and doing business, family relocation, or other reasons. the analyses assume a theoretical model of 2019-ncov transmission. we considered a floating population of 5 million in wuhan, who returned to their hometowns from 23 january 2020, as potential infected persons. moreover, we added factors of demographic characteristics, the situation of medical diagnosis, government prevention and control, the number of confirmed cases, and undisclosed data to our statistical model to estimate the dynamics of the epidemic. after controlling for certain factors, we analysed the factors that were not controlled, such as government intervention and the number of statistical reports. specifically, we first analysed the correlation between the size of the floating population in wuhan and the number of confirmed cases per day. then, we examined the differences among regions and proposed a transmission rate as a reference to compare the differences in regions. in the comparative analysis, we focused on the probably underestimated number of cases and the virus transmission rate to determine the likelihood of epidemics existing in different regions. finally, we predicted the floating population of wuhan using statistical methods and compared it with the number of 2019-ncov confirmed cases in each region, to identify regional differences of 2019-ncov infection. furthermore, we predicted the forthcoming epidemic trend at the prefectureand province-level based on the proportion of wuhan's floating population represented by people from these areas. human-to-human transmission of the 2019-ncov has been confirmed. four sets of factors that may influence regional differences appear to be involved: (1) demographic factors, such as short-term business travellers between wuhan and other regions, college students in wuhan returning to their homes in other regions, spring festival tourists from wuhan to other regions, and trans-regional floating populations for spring festival family reunions from or across wuhan; (2) intervention factors, such as medical treatments and governmental preventative measures; (3) information disclosure and the information release system; and (4) other unknown factors. we considered all these factors, and hypothesised the social environment of 2019-ncov transmission. first, although the government had taken the unprecedented measure of sealing off wuhan city on 23 january 2020, we assumed that, at that time, the entire floating population of wuhan, all short-term business travellers to wuhan and all college students in wuhan had returned to their hometowns throughout china, because 24 january 2020 was the spring festival's eve (normally, the 2020 spring festival holiday from january 24 to 30). moreover, this spring festival vacation period started at least a week before this date time, leaving plenty of time for these people to leave the city. however, the number of people in wuhan that travelled to reunite with their families in other cities during the spring festival vacation may be negligible, for the sealing-off of the city and other preventive measures taken across the country may have prevented their travelling. second, the influence of the college students in wuhan was an invariant factor, as college students are young and healthy, have fixed travelling routes, come from different regions evenly scattered across the country, and travelled to return home on or around january 10; we would assume their influence on virus transmission to different regions to be the same. third, the medical treatment ability of regional medical centres of hubei province would also be the same, as the breakout emerged so fast that these regional medical centres would have had the same level of emergency-preparedness. finally, the above factors will not change dramatically until the mass return of wuhan's floating population after the conclusion of the spring festival vacation. to estimate the floating population in the cities of hubei province and across the country, we must determine the floating population residing in wuhan in 2019. as the statistics compiled by the wuhan city government from 2019 have not been released, the data from previous years was used for this prediction. the prediction of floating population in wuhan based on the statistics from previous years is presented in table 3 , demonstrating that there were approximately 2.43 million migrants living in wuhan for more than six months in 2019. however, if the predictions of the statistical data were combined with survey data, which was used in this study to estimate the origin of wuhan's floating population that return to their hometowns, there would have been a problem with inconsistent statistical strength. this would have resulted from the fact that the floating population measured by the government statistics department reflects those who have lived in wuhan for more than 6 months, but the respondents in the survey have lived in wuhan for over one month. a shorter defined residence time would have therefore produced a larger estimate of the population, and thus the total floating population in wuhan, as determined from the cmds data, was larger than the population as determined by the government statistics department. on 22 january 2020, xinhua news agency (an official government media source) interviewed the mayor of wuhan and reported that more than 5 million members of the floating population had returned to their hometowns before the spring festival holiday. this number stated (over 5 million) was more than twice the predicted value in this study (2.43 million), indicating that the statistical strength of the news report was based on a shorter period of residence, and this was consistent with the data we used to determine the floating population residing in wuhan for over one month. thus, in the absence of more rigorous and authoritative total data, we used 5 million people as wuhan's floating population, from which to estimate the scale and distribution of those members of this population who returned to their hometown during the festival. based on sample survey data, in table 4 , the proportional estimation of the origins of wuhan's floating population at a provincial level is presented, as well as the results of statistical analysis based on a floating population of 5 million. estimation of population size is based on the total number of floating population in wuhan (about 5 million); ci = confidence interval. the national distribution of the migrants presents obvious spatial characteristics of circle layers and echelons at provincial level (table 4 and figure 1 ). (1) hubei province is the central area of origin of wuhan's floating population, accounting for 75% of the population, with a 95% confidence interval of (74.21, 75.76). based on a total population of 5 million people, wuhan's floating population with household registration in hubei province is approximately 3.75 million, with a 95% confidence interval of (3,710,227 to 3,788,125). (2) henan, anhui, jiangxi and hunan provinces belong to the first circle layer. henan province, home to a floating population of 337,000, had the highest proportion with respect to its total population, equating to approximately 6.7% and a 95% confidence interval of (315,401 to 360,712). based on the analysis of city data in 2017, xinyang, zhumadian, shangqiu, and nanyang cities in henan province accounted for 38.82%, 20.59%, 12.94%, and 10.59% respectively, of the floating population from henan living in wuhan, accounting for approximately 83% of the total. the floating population proportions of anhui, hunan, and jiangxi provinces were 2.7%, 2.5%, and 2.4%, respectively, with corresponding floating populations in wuhan of 136,000, 126,000, and 121,000 respectively. (3) chongqing, zhejiang, sichuan, fujian and jiangsu provinces are at the second circle layer, with 1.65%, 1.39%, 1.39%, 1.00% and 0.92% floating populations, respectively, with corresponding populations of approximately 83,000, 70,000, 70,000, 50,000 and 46,000 respectively. (4) shandong, guangdong, hebei, gansu, guangxi, heilongjiang, shaanxi, shanxi and guizhou provinces are at the third circle layer, with a proportion of 0.19% to 0.62% and a corresponding population of 10,000 to 30,000. (5) some provinces and municipalities, including qinghai, liaoning, yunnan, jilin and beijing, are located in the fourth circle layer, accounting for 0.08-0.16% of the floating population, equating to 4000-8000 people. (6) the remaining provinces and municipalities, such as hainan, xinjiang, tianjin, shanghai, inner mongolia, tibet and ningxia, are at the fifth circle layer, with a floating population proportion of less than 0.04%, corresponding to ≤2000 people. as presented in the table above, this population is mainly 21-40 years old, but the scale of the susceptible, high-risk and over 40 years old population is also very large. the distribution is as follows: (1) the susceptible and high-risk population is concentrated in hubei province. the size of the 41-50 age group is more than 800,000, that of the age group of 51-60 is 180,000, and the number of people over 60 is 40,000. (2) henan and anhui provinces have larger susceptible and high-risk populations, of more than 100,000 and nearly 40,000, respectively. (3) six provinces and municipalities, namely hunan, jiangxi, chongqing, zhejiang, sichuan and jiangsu, have a high-risk population of 41 to 50 years old, comprising 14,000-30,000 people. (4) in 10 provinces, namely fujian, shandong, guangdong, hebei, gansu, guangxi, shanxi, guizhou, qinghai and xinjiang, the susceptible and high-risk populations are also concentrated in the 41-50 age group, with a population of approximately 1500-6550. (5) the three provinces of northeast china, namely heilongjiang, jilin and liaoning, have large susceptible and high-risk populations, equating to approximately 7000 in heilongjiang and approximately 3000 in jilin and liaoning. infection of family members is a main means of transmission, and the distribution of the characteristics of floating population family migration at the provincial level are detailed in table 5 . the vast majority of the floating population migrates to wuhan in the form of nuclear families (84.42%), and most families comprise 3-4 members (71.44%). the distribution is as follows: (1) the number of nuclear family households in the wuhan floating population that originates from hubei province is 3.425 million, accounting for 62.85% of the total floating population of wuhan, and households with 3-4 family members number 2,693,500, accounting for 53.87% of the total. the high risk of 2019-ncov transmission within and by this population is self-evident. (2) families from henan, anhui, hunan and jiangxi provinces comprise a large proportion of those in the floating population of wuhan. those from henan total nearly 300,000 households, and the number of these households with 3-4 family members is more than 240,000. approximately 110,000 families from the remaining provinces are part of the floating population of wuhan, including nearly 100,000 3-4 family-member households from anhui and more than 80,000 from hunan and jiangxi. (3) the number of families in the floating population of wuhan from chongqing, zhejiang, sichuan, fujian and jiangsu municipalities and provinces is 40,000-80,000, and the number of households with 3-4 family members is 30,000-60,000. (4) the number of families in the floating population of wuhan that originate from 7 other provinces, namely shandong, guangdong, hebei, gansu, guangxi, heilongjiang and shaanxi, is 10,000-30,000 households, and the number of households with 3-4 family members is approximately 20,000. the remaining provinces comprise fewer than 10,000 households jiangxi. certain factors can easily spread the virus from homes to communities in rural areas, such as a lack of medical resources and investment, weak health prevention and control, low awareness of health, and insufficient awareness of infectious diseases. in table 5 , the floating population in wuhan is dominated by rural households (85.14%), and working or doing business is the main reason for their having travelled to wuhan (84.29%). therefore, epidemic prevention and control in rural areas is of critical importance. the distribution is as follows: (1) the joint distribution of the origins of wuhan's floating population within hubei province is 63.73%, equating to a population of 3,186,500, and 62.71% of these are migrant workers, equating to 3,135,500 people. (2) henan, anhui, hunan, and jiangxi province both have more than 100,000 households with rural household registers and migrant workers in wuhan, and the population of those from henan in wuhan's floating population is approximately 300,000. (3) chongqing, zhejiang, sichuan, fujian, jiangsu, shandong, guangdong, hebei, gansu, and guangxi provinces together have a population of 10,000-80,000 households with rural household registers in wuhan and less than 10,000 in the remaining provinces of china. notably, guangdong, gansu, heilongjiang and liaoning have a larger proportion of the population with urban household registers, and this is greater than the number of rural household registers in guangdong province. 0 0 1667 9167 1250 1667 1250 4167 4584 417 9584 2500 10,834 833 10,834 6251 2917 2917 guizhou 9584 417 5000 2500 1667 0 0 833 8751 0 833 1250 5417 2084 0 7501 2084 7084 2500 7084 5417 2084 2084 qinghai 7917 417 3750 2084 1667 0 0 0 7501 417 0 1667 3750 2084 417 7917 0 7084 833 7084 7501 417 0 liaoning 7084 0 1667 2917 1250 1250 0 1667 5000 417 1667 1667 3334 417 0 2500 4584 6251 417 6251 1667 1667 3750 yunnan 4584 833 2917 833 0 0 0 417 3750 417 417 833 2084 833 417 4167 417 3334 1250 3334 2917 417 1250 beijing 4167 0 417 833 2917 0 0 833 3334 0 833 1667 1250 417 0 1250 2917 4167 0 4167 1250 1667 1250 jilin 3750 417 1250 1250 833 0 0 1667 2084 0 1667 0 2084 0 0 833 2917 3334 417 3334 1250 0 2500 hainan 2084 0 1250 417 0 417 0 833 1250 0 833 0 1250 0 0 833 1250 1667 417 1667 417 833 833 xinjiang 2084 0 833 0 1250 0 0 417 1667 0 417 0 417 1250 0 2084 0 1667 417 1667 1250 417 417 tianjin 1250 417 417 417 0 0 0 417 833 0 417 417 0 417 0 833 417 833 417 833 417 0 833 shanghai 1250 0 833 0 0 0 417 417 833 0 417 833 0 0 0 0 1250 1250 0 1250 0 417 833 inner mongolia 833 0 417 417 0 0 0 0 833 0 0 0 833 0 0 417 417 417 417 417 0 417 417 xizang 833 0 0 417 0 0 417 0 833 0 0 417 417 0 0 417 417 417 0 417 417 417 0 ningxia 417 0 417 0 0 0 0 0 417 0 0 0 417 0 0 417 0 417 0 417 417 0 0 virus transmission is related to individual health awareness, which is affected by an individual's educational level, so we also examined the educational level of the floating population in wuhan. in table 5 , 60% of the population was educated to junior middle school and below, 26% had senior high school or technical secondary school education, and 14% had college education and above, indicating that the overall education level of this population was low. specifically: (1) in the provinces of qinghai, chongqing, jiangxi, anhui, henan, yunnan, guangxi and xinjiang, 60% or more of the population was educated to junior high school level or below. (2) approximately 50-60 % of the population of the provinces of hubei, sichuan, hebei, fujian, jiangsu, hunan, guizhou, shandong, shanxi, tibet and gansu was educated to junior high school level or below. (3) the population in three municipalities, including beijing, tianjin and shanghai, have a high level of education, with over 66% receiving tertiary education. the population of the remaining provinces had a medium-to-high educational level. above all, these data indicated that there is a large middle-aged and older high-risk floating population in wuhan. their social characteristics include having travelled to wuhan in a nuclear family of 3-4 members, being on a rural household register, and often having a lower educational level. these characteristics are consistent with conditions favouring the wide spread of 2019-ncov. according to the foregoing analysis, 75% of wuhan's floating population have registered households in hubei province, equating to approximately 3.75 million people. that such a large proportion of the floating population of wuhan originate from elsewhere in hubei province has reduced the possibility of the epidemic spreading across the country, but all regions in hubei province are facing tremendous pressure from the spread of the epidemic. therefore, we used the 2017 cmds data to analyse the distribution of the floating population in regions within hubei province. table 6 and figure 2 present the distribution of the origins of wuhan's floating population within hubei province. the proportion of the floating population gradually decreases from east to west across hubei province, and there are great differences between cities. the distribution is as follows: (1) xiaogan, wuhan, and huanggang are in the first echelon. the proportion of the floating population who originate from these cities is high, accounting for 23.4%, 19.6%, and 14% of the total, respectively. they are a cross-regional floating population of 734,000 and a 95% confidence interval of (65.89, 81.30). the analysis of districts and counties indicates that the members the floating population who originate from the outskirts of huangpi district and xinzhou district flow into the main urban area of hankou, so the epidemic situation in the outskirts of huangpi district and xinzhou district needs special attention. secondly, the members of wuhan's floating population who originate from xiaogan comprise the largest proportion, equating to approximately 788,000 people and a 95% confidence interval of (79.81, 96.25). members of wuhan's floating population who originate from huanggang comprise the third proportion, equating to approximately 52,549 people and a 95% confidence interval of (46.06, 59.58). (2) the three directly managed by province (dmp) cities (xiantao, qianjiang, and tianmen) and jingzhou belong to the second echelon, each comprising approximately 330,000 people, and each accounting for approximately 9% of the floating population of wuhan, with a 95% confidence interval of (28,39). (3) jingmen, suizhou, xianning, and huangshi belong to the third echelon, accounting for 3-5% of the floating population of wuhan, equating to 130,000-170,000 people. (4) xiangyang, ezhou, yichang, enshi, and shiyan belong to the fourth echelon, accounting for less than 3% of the floating population of wuhan, equating to fewer than 100,000 people. overall, the suburbs of wuhan surrounding xiaogan, huanggang, and the three dmp cities are the origins of the largest proportion (66%) of the floating population of wuhan, equating to approximately 2.475 million people. we used district-and county-level variables to estimate the floating population within hubei province, and the results are presented in table 7 . the survey covered 94 districts and counties, including huangpi, xinzhou, jiangxia, caidian, and hannan in wuhan, as well as cross-region active migrants in some major urban areas. the top 10 districts and counties of hubei province in terms of floating population are huangpi, hanchuan, xiantao, xinzhou, hong'an, yunmeng, honghu, macheng, xiaonan, and xiaochang. that is, ≥100,000 people from each of these districts and counties are part of the floating population of wuhan, with the top 3 districts and counties, huangpi, hanchuan and xiantao, having ≥200,000 people in wuhan's floating population. these top 10 district and counties of hubei province are followed by jingshan, yingcheng, dawu, guangshui, tianmen, lishui, jianli, anlu, jiangxia and caidian, which each have 60,000-100,000 people in wuhan's floating population. the third tier is huangmei, yangxin, daye, gongan, tongshan, jiayu, zhongxiang, qianjiang, songzi, huarong, zengdu, enshi, liangzihu, zaoyang, dongxihu, wuxue, huangzhou, hannan, xian'an, xiangzhou, zhijiang, echeng, luotian, badong, chibi, chongyang, hongshan, shayang, shishou, suixian, tuanfeng, gucheng and xiangcheng. these districts and counties each have 10,000-50,000 people in wuhan's floating population. the remaining districts and counties have fewer than 10,000 people in wuhan's floating population. in general, these members of wuhan's floating population originate from certain districts and counties of hubei province. the cumulative percentage of the top 30 districts and counties exceeds 80% of these areas' total population, showing a clear exponential distribution trend. we then analysed the social characteristics of the migrants in hubei province by age, type of migration, number of migrants, type of household registration, and reasons for traveling to wuhan to become part of its floating population. from table 8 (please see the last page), we observe that in terms of susceptible and high-risk groups over 40 years old, there are approximately 300,000 people in xiaogan, approximately 180,000 people in wuhan (cross-region migration), and approximately 150,000 people in huanggang. there are also approximately 100,000 people in the dmp cities and jingzhou respectively, and 30,000-50,000 people in jingmen, suizhou, xianning, and huangshi. fewer than 30,000 people from each of xiangyang, ezhou, yichang, enshi and shiyan have travelled to wuhan. the migration characteristics of the floating population of wuhan from hubei province are detailed in table 8 . migration with a nuclear family is the main pattern, accounting for nearly 80% of the total, or 2.985 million households. the proportion of households with 3-4 family members (i.e., nuclear families) is approximately 67%, or 2.53 million households. specifically, 740,000 nuclear families originate from xiaogan, 400,000-600,000 nuclear families originate from the inner suburbs of wuhan and huanggang, and approximately 260,000 nuclear families originate from the dmp cities and jingzhou. more than 100,000 nuclear families originate from jingmen, suizhou, xianning, and huangshi, while fewer than 100,000 nuclear families originate from xiangyang, ezhou, yichang, enshi and shiyan. the distribution of households with 3-4 members is similar to that of nuclear families. it also presents the distribution of the origins of wuhan's floating population who originate from within hubei province. according to the statistical results, rural household registers account for 83%, equating to a population of approximately 3.12 million. the proportion of the group who was working and doing business in urban areas is 77%, and the population is 2.89 million. the size of the population distribution in each city is similar to the aforementioned migration types and other variables, and is not reported here. in table 8 , the overall educational level of those members of wuhan's floating population who originate from hubei province is higher than the national level, with approximately 52% having been educated to junior high school level and below, approximately 29% to high school/secondary school level and below, and approximately 19% to college and above. however, in those members of wuhan's floating population who originate from the surrounding cities of wuhan, which contribute a large number of people to the floating population of wuhan, namely xiaogan, huanggang, huangshi, suizhou, dmp cities, xianning, and ezhou, >50% of people have an educational level of junior high school and below, with this being >60% in xiaogan. this means that the awareness of health protection and timely treatment may be low in this section of the floating population of wuhan, which will heighten the risk of large-scale transmission of 2019-ncov. the floating population in wuhan will serve as a sound predictor for the trend of the 2019-ncov outbreak. the pearson's correlation coefficient between the proportion of the floating population in wuhan who originate from a certain region of hubei and the number of confirmed 2019-ncov cases in each region increased from 0.65 on 25 january 2020 to 0.84 on 31 january 2020 (table 9 ). this indicates that when a region contributes a higher number of people to the floating residential population of wuhan, more confirmed cases will emerge in this region. table 6 ); 3 ratio = confirmed cases (on 2020/1/31)/floating population from wuhan (unit: 10,000 people); 4 dmp (directly managed by the province) cities includes xiantao, qianjiang and tianmen; 5 the pearson's correlation coefficient is calculated from the number of floating populations in wuhan and the number of confirmed cases per day. we assumed that the effect of the floating population on the transmission of the 2019-ncov is consistent across hubei province, and selected three prefectures that contribute the greatest number of people to the floating population of wuhan (xiaogan, huanggang and jingmeng) as the reference prefectures to predict the epidemic trend of the 2019-ncov at prefecture level. those prefectures can be divided into three groups since 28 january 2020 ( the floating population of wuhan originated from outside hubei province may have promoted the spread of 2019-ncov. table 10 compares the number of individuals travelling from wuhan to other provinces and the daily number of confirmed cases for those other provinces. analysis revealed that the correlation coefficient at the provincial level was lower than at the prefecture level within hubei province, but the correlation coefficient increased from 0.4 on 25 january 2020 to 0.63 on 31 january 2020. table 10 also shows the ratio of confirmed cases in each province to the proportion of people in the floating population in wuhan who originate from each of these provinces, on 28 january 2020. we divide provinces into two categories based on their short-term travel populations in wuhan, and wuhan's travelling population to other provinces during the spring festival holiday. the first category comprises those provinces that have large-scale short-term business trips or tourist populations in wuhan during the spring festival holiday, namely beijing, shanghai, tianjin, and hainan. obviously, such a high level of inter-provincial population mobility may exacerbate the spread of 2019-ncov. for example, the high ratio of confirmed cases in guangdong province may be due to the large short-term travel populations visiting shenzhen and guangzhou and wuhan, while the high ratio of confirmed cases in hainan province may result from the outbound tourist population from wuhan to hainan during the spring festival holiday. in table 10 , the results are divided into two parts: the correlation coefficient of the first category of provinces, which reaches a maximum of 0.96, and the correlation coefficient of the second category of provinces, which increased from 0.56 to 0.7. this abovementioned second category comprise the other 25 provinces that have small short-term business trip groups or tourist populations in wuhan during the spring festival holiday. we assumed that the effect of the floating population on the spread of 2019-ncov was consistent across the country. the other 25 provinces are divided into three groups since 25 january 2020 ( figure 4) : (1) provinces with a rapid increase in the number of confirmed cases, namely zhejiang, shandong, guangxi, shaanxi, liaoning, and yunnan; (2) provinces with a moderate increase in the number of confirmed cases, namely hunan, chongqing, sichuan, fujian, jiangsu, hebei, gansu, heilongjiang, shaanxi, guizhou, qinghai, jilin, xinjiang, inner mongolia, tibet, and ningxia; and (3) provinces with a small increase in the number of confirmed cases, namely henan, anhui, and jiangxi. in table 10 , if we exclude the data of henan province and zhejiang province from the second category, we find that the correlation coefficient on 31 january 2020 is 0.93. we selected four provinces (henan, hunan, sichuan, and zhejiang) as the reference provinces to predict the epidemic trend of 2019-ncov in each province. we found that: (1) the epidemic growth model of henan province does not fit the situation in most other provinces. that is, except in anhui and jiangxi, the actual number of outbreaks in other provinces was higher than that predicted by the henan model. as these provinces have large floating populations in wuhan, the rapid increase in the number of confirmed cases in henan, anhui and jiangxi may result from effective measures that have been taken to control the spread of 2019-ncov, or the lack of sufficient diagnostic capabilities to detect suspected cases. (2) the epidemic growth model for hunan and sichuan province predicts a rapid increase in the number of confirmed cases in henan, anhui and jiangxi provinces. thus, if the epidemic pattern in hunan and sichuan follows a typical evolutionary pattern, the current numbers of confirmed cases in the three provinces of henan, anhui, and jiangxi are greatly underestimated. for example, the number of confirmed cases in henan on 31 january 2020 would be between 860 and 889, but the number in official announcements was only 168. in contrast, the number of confirmed cases in zhejiang, shandong, guangxi, shaanxi, liaoning, and yunnan provinces were higher than the predicted number, which may be affected by uncontrollable local factors that need further investigation. (3) the epidemic growth model for zhejiang province predicts a rapid increase in the number of confirmed cases in most provinces, especially jiangsu and fujian provinces that are adjacent to zhejiang. it is important to investigate why there were so many confirmed cases in zhejiang, and whether the outbreak in jiangsu and fujian province was not detected in a timely manner, or whether all possible cases have not yet occurred. overall, the predicted epidemic pattern for hunan and sichuan provinces fits best to the actual epidemic trend of the 2019-ncov outbreak. however, the current number of confirmed cases in henan, anhui, and jiangxi provinces is likely to be underestimated, especially given that these contain extensive rural areas with large populations and limited medical resources. the higher actual number of confirmed cases in zhejiang, shandong, guangxi, shaanxi, liaoning, and yunnan provinces may be affected by other unknown factors or uncontrollable random factors that need further investigation. to prevent or mitigate the spread of an emerging infectious disease and its negative effects, public health interventions mainly aim at three types of population, namely the population in the source area, the floating population leaving the source area, and the population travelling from the infected area to other areas. the spring festival in 2020 is much earlier than in previous years. at this time, the possibility of human-to-human transmission of a new coronavirus had just been discovered. when the wuhan municipal government decided on 23 january 2020 to "close the city" to control the outflow of population, more than 5 million people had already left wuhan on the spring festival holiday, and it was too late to control the entire potentially infected population in the epidemic area. at present, china's high-speed railway and expressway transportation network has experienced great development. this fast and convenient transportation has led to a floating population that can leave the source area to quickly reach every part of the country, which makes it very difficult to quarantine the floating population leaving the source area through transportation stations. in addition, there is an incubation period after human infection, further increasing the difficulty of quarantine at traffic stations, which is also an important reason for the implementation of "city closure" control policies in many cities across the country. after 2019-ncov was confirmed as being capable of transmitting from human to human, the chinese government implemented top to bottom national mobilisation. it fully investigated and isolated the population of wuhan, and also publicised the severity of the epidemic, and also increased awareness of the prevention of infectious diseases and raised people's vigilance through messages on television, mobile communications and the internet. in addition, according to the latest epidemic surveillance, the incubation period of the coronavirus is 3 to 7 days, with an upper limit of 14 days. for this reason, the central government has issued an executive order to extend the spring festival holiday from 30 january to 2 february 2020. many provinces are even requiring firms to not restart work until 9 february, except those necessary for social operations related to the national economy and people's livelihood. extending the holiday is needed to avoid the returning people leaving home early and returning to work, so as to minimise the risk of the epidemic spreading again due to population fluctuations. there are limitations to this study. first, our analysis did not include other large-scale populations. for example, some are college students, because wuhan is the city with the largest number (>1 million) of college students in china and the world. the other parts include short-term business travellers, transit passengers and tourists. official media reported that the size of the populations during the spring festival holiday would reach more than 30 million. this can be confirmed from the daily-confirmed cases of 2019-ncov infection. although there is a small permanent population in wuhan whose household register belongs to provinces and cities such as beijing, shanghai, tianjin, hainan, and guangdong (in fact, shenzhen and guangzhou are two megacities), these provinces and cities still have large-scale temporary floating populations from and to wuhan because of the large population and well-developed economy. therefore, the number of confirmed cases of 2019-ncov infection in these areas is far ahead of that in most other provinces that have a large floating population in wuhan. second, our sample has a certain deviation. the data on the origin of wuhan's floating population does not include hong kong, macao, or international migrants, which makes our research unable to estimate the population size of these regions. at present, some cases have been confirmed in surrounding asian countries, europe, north america and australia. third, limited to interdisciplinary research capabilities, our model does not include infectious disease analysis models such as sir to further analyse the potential and scale of 2019-ncov spread, which may reduce the value of this research in the prevention and control of 2019-ncov infections. finally, the results of the study are mainly applicable to the end of the spring festival holiday, and after the large-scale population comes back to work or study, the spread of the epidemic will be more complicated. we believe that the abovementioned limitations can be overcome. using big data such as location information of transportation and mobile internet, short-term floating populations can be included in the study to maximise the estimated population flotation and scale in wuhan. unfortunately, thus far we have not seen a rigorous study using big data to analyse the outflow of populations in the epicentre of an epidemic. this means that there is still a long way to go for the research and application of big data in the field of national and global public health. at the time of writing this paper (29 january 2020), all provinces in china have reported confirmed or suspected cases of 2019-ncov, every prefecture and city in hubei province has confirmed cases of 2019-ncov, and transmission of 2019-ncov has spread from imported to inter-regional. due to the fact that 5 million migrants had left wuhan before the "closure of the city", our research reveals a high correlation between the number of wuhan's floating population and the number of confirmed cases. fortunately, the origin of wuhan's floating population is highly concentrated in hubei province and its surrounding provinces, of which the migrants with hubei household registers account for 75%, and more than 80% of the population is concentrated in the top 30 districts and counties. this means that some areas will face a very high risk of epidemic outbreaks, but it is also conducive to centralised resources enabling prevention and control of the epidemic to avoid large-scale spread in other regions. more than 5 million of wuhan's floating population have returned to their hometowns as potential carriers of the virus and may become carriers of the virus's re-transmission. due to china's urban and rural dualistic structure, most of these people are rural migrant workers with low levels of education. the results find that 85% of the migrants have rural household registers. these people, who frequently work outdoors or work overtime are more likely to be susceptible because of their poor diet and nutrition. at the same time, most of these people travel with 3-4 family members, and the susceptible and high-risk population over 40 years old accounts for a large proportion of this floating population, which provides ideal conditions for the transmission of 2019-ncov within families. to make matters worse, the rural areas where these people return to have very limited medical and public health services, and gatherings during the spring festival aggravate the risk of virus transmission in the community. so far, confirmed cases of 2019-ncov continue to increase every day across china. the results of our model analysis indicate that, on the one hand, the correlation between the size of the floating population and the number of confirmed cases in wuhan has continued to increase over time, and by 28 january, the correlation coefficient of these factors in hubei province had reached 0.78, which means that the size of the floating population in wuhan is an important parameter for predicting the epidemic. on the other hand, we also found that the effect of the size of the floating population in wuhan is heterogeneous across regions. some areas have a large floating population in wuhan, including henan, anhui, and jiangxi provinces, and xiaogan city, jingzhou city, and the three county-level cities directly under the provincial government, and yet the number of confirmed cases of 2019-ncov is apparently relatively small. however, we believe that the epidemic situation in these areas may be underestimated. considering the serious consequences of delays in diagnosis and loopholes in infection control in suspected or confirmed cases of sars in the sars epidemic in 2003, it is necessary to strengthen surveillance in these areas to determine the causes of the fewer confirmed cases of 2019-ncov in these areas. author contributions: l.l. conceived and proposed research ideas, c.f. and c.y. collected the data, c.f. undertook the main research work such as research methods, data analysis, and manuscript writing. c.f., l.l., w.g., a.y., c.y., m.j., m.r., p.x., h.l. and y.w. participated in draft review, contributed to data interpretation, and approved final manuscript. all authors have read and agreed to the published version of the manuscript. data sharing and outbreaks: best practice exemplified china coronavirus: what do we know so far? bmj 2020 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sars-cov to wuhan 2019-ncov outbreak: similarity of early epidemic and prediction of future trends a novel coronavirus emerging in china-key questions for impact assessment another decade, another coronavirus report 1: estimating the potential total number of novel coronavirus cases in wuhan city report 2: estimating the potential total number of novel coronavirus cases in wuhan city modelling the epidemic trend of the 2019 novel coronavirus outbreak in china clinical features of patients infected with 2019 novel coronavirus in epidemic situation of the novel coronavirus in guangdong province published on 23 xinhua news agency. 15 chinese medical workers confirmed infected with coronavirus the chinese new year travel rush-the world's largest annual human migration wuhan municipal people's government. wuhan implements restriction to curb the spread of the epidemic real-time update on coronavirus outbreak internal migration and health in china the new york times. china grapples with mystery pneumonia-like illness health status and access to health care of migrant workers in china. public health rep acknowledgments: thanks to the national health committee for the migrant population data; the youth project of national social science foundation and the youth teacher project of central china normal university 2019 for support on previous construction of floating population database; binbin tang and junyue qian for their selfless help in the process of thesis writing. the authors declare no conflict of interest. key: cord-352152-d3owtd98 authors: wang, cuiyan; pan, riyu; wan, xiaoyang; tan, yilin; xu, linkang; ho, cyrus s.; ho, roger c. title: immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (covid-19) epidemic among the general population in china date: 2020-03-06 journal: int j environ res public health doi: 10.3390/ijerph17051729 sha: doc_id: 352152 cord_uid: d3owtd98 background: the 2019 coronavirus disease (covid-19) epidemic is a public health emergency of international concern and poses a challenge to psychological resilience. research data are needed to develop evidence-driven strategies to reduce adverse psychological impacts and psychiatric symptoms during the epidemic. the aim of this study was to survey the general public in china to better understand their levels of psychological impact, anxiety, depression, and stress during the initial stage of the covid-19 outbreak. the data will be used for future reference. methods: from 31 january to 2 february 2020, we conducted an online survey using snowball sampling techniques. the online survey collected information on demographic data, physical symptoms in the past 14 days, contact history with covid-19, knowledge and concerns about covid-19, precautionary measures against covid-19, and additional information required with respect to covid-19. psychological impact was assessed by the impact of event scale-revised (ies-r), and mental health status was assessed by the depression, anxiety and stress scale (dass-21). results: this study included 1210 respondents from 194 cities in china. in total, 53.8% of respondents rated the psychological impact of the outbreak as moderate or severe; 16.5% reported moderate to severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels. most respondents spent 20–24 h per day at home (84.7%); were worried about their family members contracting covid-19 (75.2%); and were satisfied with the amount of health information available (75.1%). female gender, student status, specific physical symptoms (e.g., myalgia, dizziness, coryza), and poor self-rated health status were significantly associated with a greater psychological impact of the outbreak and higher levels of stress, anxiety, and depression (p < 0.05). specific up-to-date and accurate health information (e.g., treatment, local outbreak situation) and particular precautionary measures (e.g., hand hygiene, wearing a mask) were associated with a lower psychological impact of the outbreak and lower levels of stress, anxiety, and depression (p < 0.05). conclusions: during the initial phase of the covid-19 outbreak in china, more than half of the respondents rated the psychological impact as moderate-to-severe, and about one-third reported moderate-to-severe anxiety. our findings identify factors associated with a lower level of psychological impact and better mental health status that can be used to formulate psychological interventions to improve the mental health of vulnerable groups during the covid-19 epidemic. the 2019 coronavirus disease (covid-19) epidemic in china is a global health threat [1] , and is by far the largest outbreak of atypical pneumonia since the severe acute respiratory syndrome (sars) outbreak in 2003. within weeks of the initial outbreak the total number of cases and deaths exceeded those of sars [2] . the outbreak was first revealed in late december 2019 when clusters of pneumonia cases of unknown etiology were found to be associated with epidemiologically linked exposure to a seafood market and untraced exposures in the city of wuhan of hubei province [3] . since then, the number of cases has continued to escalate exponentially within and beyond wuhan, spreading to all 34 regions of china by 30 january 2020. on the same day, the world health organization (who) declared the covid-19 outbreak a public health emergency of international concern [4] . covid-19, similarly to sars, is a beta-coronavirus that can be spread to humans through intermediate hosts such as bats [5] , though the actual route of transmission is still debatable. human-to-human transmission has been observed via virus-laden respiratory droplets, as a growing number of patients reportedly did not have animal market exposure, and cases have also occurred in healthcare workers [6] . transmissibility of covid-19 as indicated by its reproductive number has been estimated at 4.08 [7] , suggesting that on average, every case of covid-19 will create up to 4 new cases. the reporting rate after 17 january 2020 has been considered to have increased 21-fold in comparison to the situation in the first half of january 2020 [8] . the average incubation period is estimated to be 5.2 days, with significant variation among patients [9] , and it may be capable of asymptomatic spread [10, 11] . symptoms of infection include fever, chills, cough, coryza, sore throat, breathing difficulty, myalgia, nausea, vomiting, and diarrhea [12] . older men with medical comorbidities are more likely to get infected, with worse outcomes [12] . severe cases can lead to cardiac injury, respiratory failure, acute respiratory distress syndrome, and death [13] . the provisional case fatality rate by who is around 2%, but some researchers estimate the rate to range from 0.3% to 0.6% [14] . since the outbreak, response efforts by the china government have been swift, and three weeks into the epidemic, in an unprecedented move to retard the spread of the virus, a lockdown was imposed on wuhan on 23 january, with travel restrictions. within days, the quarantine was extended to additional provinces and cities, affecting more than 50 million people in total. many stayed at home and socially isolated themselves to prevent being infected, leading to a "desperate plea" [15] . there have also been accounts of shortages of masks and health equipment. the ongoing covid-19 epidemic is inducing fear, and a timely understanding of mental health status is urgently needed for society [16] . previous research has revealed a profound and wide range of psychosocial impacts on people at the individual, community, and international levels during outbreaks of infection. on an individual level, people are likely to experience fear of falling sick or dying themselves, feelings of helplessness, and stigma [17] . during one influenza outbreak, around 10% to 30% of general public were very or fairly worried about the possibility of contracting the virus [18] . with the closure of schools and business, negative emotions experienced by individuals are compounded [19] . during the sars outbreak, many studies investigated the psychological impact on the non-infected community, revealing significant psychiatric morbidities which were found to be associated with younger age and increased self-blame [20] . those who were older, of female gender, more highly educated, with higher risk perceptions of sars, a moderate anxiety level, a positive contact history, and those with sars-like symptoms were more likely to take precautionary measures against the infection [21] . currently, there is no known information on the psychological impact and mental health of the general public during the peak of the covid-19 epidemic. this is especially pertinent with the uncertainty surrounding an outbreak of such unparalleled magnitude. based on our understanding, most of the research related to this outbreak focuses on identifying the epidemiology and clinical characteristics of infected patients [6, 12] , the genomic characterization of the virus [22] , and challenges for global health governance [23] . however, there are no research articles examining the psychological impact on covid-19 on the general population in china. therefore, this present study represents the first psychological impact and mental health survey conducted in the general population in china within the first two weeks of the covid-19 outbreak. this study aims to establish the prevalence of psychiatric symptoms and identify risk and protective factors contributing to psychological stress. this may assist government agencies and healthcare professionals in safeguarding the psychological wellbeing of the community in the face of covid-19 outbreak expansion in china and different parts of the world. we adopted a cross-sectional survey design to assess the public's immediate psychological response during the epidemic of covid-19 by using an anonymous online questionnaire. a snowball sampling strategy, focused on recruiting the general public living in mainland china during the epidemic of covid-19, was utilized. the online survey was first disseminated to university students and they were encouraged to pass it on to others. as the chinese government recommended the public to minimize face-to-face interaction and isolate themselves at home, potential respondents were electronically invited by existing study respondents. they completed the questionnaires in chinese through an online survey platform ('surveystar', changsha ranxing science and technology, shanghai, china). expedited ethics approval was obtained from the institutional review board of the huaibei normal university (hbu-irb-2020-001), which conformed to the principles embodied in the declaration of helsinki. information about this study was posted on a dedicated university website. all respondents provided informed consent. data collection took place over three days (31 january-2 february 2020) after the who declared the covid-19 outbreak as a public health emergency of international concern. previous surveys on the psychological impacts of sars and influenza outbreaks were reviewed [18, 21, 24] . authors included additional questions related to the covid-19 outbreak. the structured questionnaire consisted of questions that covered several areas: (1) demographic data; (2) physical symptoms in the past 14 days; (3) contact history with covid-19 in the past 14 days; (4) knowledge and concerns about covid-19; (5) precautionary measures against covid-19 in the past 14 days; (6) additional information required with respect to covid-19; (7) the psychological impact of the covid-19 outbreak; and (8) mental health status. sociodemographic data were collected on gender, age, education, residential location in the past 14 days, marital status, employment status, monthly income, parental status, and household size. physical symptom variables in the past 14 days included fever, chills, headache, myalgia, cough, difficulty in breathing, dizziness, coryza, sore throat, and persistent fever, as well as persistent fever and cough or difficulty breathing. respondents were asked to rate their physical health status and state any history of chronic medical illness. health service utilization variables in the past 14 days included consultation with a doctor in the clinic, admission to the hospital, being quarantined by a health authority, and being tested for covid-19. contact history variables included close contact with an individual with confirmed covid-19, indirect contact with an individual with confirmed covid-19, and contact with an individual with suspected covid-19 or infected materials. knowledge about covid-19 variables included knowledge about the routes of transmission, level of confidence in diagnosis, level of satisfaction of health information about covid-19, the trend of new cases and death, and potential treatment for covid-19 infection. respondents were asked to indicate their source of information. the actual number of confirmed cases of covid-19 and deaths in the city on the day of the survey were collected. concern about covid-19 variables included self and other family members contracting covid-19 and the chance of surviving if infected. precautionary measures against covid-19 variables included avoidance of sharing of utensils (e.g., chopsticks) during meals, covering mouth when coughing and sneezing, washing hands with soap, washing hands immediately after coughing, sneezing, or rubbing the nose, washing hands after touching contaminated objects, and wearing a mask regardless of the presence or absence of symptoms. the respondents were asked the average number of hours staying at home per day to avoid covid-19. respondents were also asked whether they felt too much -unnecessary worry had been made about the covid-19 epidemic. additional health information about covid-19 needed by respondents included more information about symptoms after contraction of covid-19, routes of transmission, treatment, prevention of the spread of covid-19, local outbreaks, travel advice, and other measures imposed by other countries. the psychological impact of covid-19 was measured using the impact of event scale-revised (ies-r). the ies-r is a self-administered questionnaire that has been well-validated in the chinese population for determining the extent of psychological impact after exposure to a public health crisis within one week of exposure [25] . this 22-item questionnaire is composed of three subscales and aims to measure the mean avoidance, intrusion, and hyperarousal [26] . the total ies-r score was divided into 0-23 (normal), 24-32 (mild psychological impact), 33-36 (moderate psychological impact), and >37 (severe psychological impact) [27] . mental health status was measured using the depression, anxiety and stress scale (dass-21) and calculations of scores were based on the previous study [28] . questions 3, 5, 10, 13, 16, 17 and 21formed the depression subscale. the total depression subscale score was divided into normal (0-9), mild depression (10) (11) (12) , moderate depression (13) (14) (15) (16) (17) (18) (19) (20) , severe depression (21) (22) (23) (24) (25) (26) (27) , and extremely severe depression (28) (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) . questions 2, 4, 7, 9, 15, 19 , and 20 formed the anxiety subscale. the total anxiety subscale score was divided into normal (0-6), mild anxiety (7-9), moderate anxiety (10) (11) (12) (13) (14) , severe anxiety (15) (16) (17) (18) (19) , and extremely severe anxiety . questions 1, 6, 8, 11, 12, 14, and 18 formed the stress subscale. the total stress subscale score was divided into normal (0-10), mild stress (11) (12) (13) (14) (15) (16) (17) (18) , moderate stress (19) (20) (21) (22) (23) (24) (25) (26) , severe stress (27) (28) (29) (30) (31) (32) (33) (34) , and extremely severe stress (35) (36) (37) (38) (39) (40) (41) (42) . the dass has been demonstrated to be a reliable and valid measure in assessing mental health in the chinese population [29, 30] . the dass was previously used in research related to sars [31] . descriptive statistics were calculated for sociodemographic characteristics, physical symptoms and health service utilization variables, contact history variables, knowledge and concern-related variables, precautionary measure variables, and additional health information variables. percentages of response were calculated according to the number of respondents per response with respect to the number of total responses of a question. the scores of the ies-r and dass subscales were expressed as mean and standard deviation. we used linear regressions to calculate the univariate associations between sociodemographic characteristics, physical symptom and health service utilization variables, contact history variables, knowledge and concern variables, precautionary measure variables, additional health information variables, and the ies-s score as well as the subscales of the dass. all tests were two-tailed, with a significance level of p < 0.05. statistical analysis was performed using spss statistic 21.0 (ibm spss statistics, new york, united states). epidemic from january 7 to february 2 2020 figure 1 shows the development trend of the covid-19 epidemic in china in january and february 2020. since china first announced the national epidemic data on 20 january 2020, the number of confirmed cases, suspected cases, recovered individuals, and deaths related to covid-19 infection have continued to escalate, with a sharp increase in the number of suspected cases after 26 january 2020. both children and the elderly have been particularly vulnerable to the virus, with the youngest confirmed case being that of a 9-month-old infant. we received responses from 1304 respondents, and 102 respondents did not complete the questionnaires. eventually, we included 1210 respondents from 194 cities in china who had completed the questionnaires (completion rate: 92.79%). overall, 1120 respondents submitted the questionnaires on the first day (31 january), 86 respondents submitted the questionnaires on the second day (1 february), and only 4 respondents submitted the questionnaires on the third day (2 february). the psychological impact of covid-19 outbreak, measured using the ies-r scale, revealed a sample mean score of 32.98 (sd = 15.42). of all respondents, 296 (24.5%) reported minimal psychological impact (score < 23); 263 (21.7%) rated mild psychological impact (scores 24-32); and 651 (53.8%) reported a moderate or severe psychological impact (score > 33). respondents' depression, anxiety and stress levels, measured using the dass 21-item scale, revealed a sample mean score of 20.16 (sd = 20.42). for the depression subscale, 843 (69.7%) were considered to have a normal score (score: 0-9); 167 (13.8%) were considered to suffer from mild depression (score: 10-12); 148 (12.2%) were considered to suffer from moderate depression (score: [13] [14] [15] [16] [17] [18] [19] [20] ; and 52 (4.3%) were considered to suffer from severe and extremely severe depression (score: . for the anxiety subscale, 770 (63.6%) were considered to have a normal score (score: 0-6); 91 (7.5%) were considered to suffer from mild anxiety (score: 7-9); 247 (20.4%) were considered to suffer from moderate anxiety (score: [10] [11] [12] [13] [14] ; and 102 (8.4%) were considered to suffer from severe and extremely severe anxiety (score: . for the stress subscale, 821 (67.9%) were considered to have a normal score (score: 0-10); 292 (24.1%) were considered to suffer from mild stress (score: 11-18); 66 (5.5%) were considered to suffer from moderate stress (score: [19] [20] [21] [22] [23] [24] [25] [26] ; and 31 (2.6%) were considered to suffer from severe and extremely severe stress (score: 27-42). sociodemographic characteristics are presented in table 1 for physical symptoms, table 2 shows that 0.5% of the sample reported a fever of 38 • c for at least one day within the previous two weeks. some respondents reported a range of physical symptoms, most frequently coryza (16.9%), cough (13.9%), sore throat (11.5%), headache (9.7%), myalgia (7.9%), dizziness (7.3%), chills (3.5%), fever (0.5%), and breathing difficulty (0.4%). around 0.3% of respondents reported a dyad of symptoms such as fever with cough or fever with breathing difficulty. overall, 793 respondents reported no symptoms (60.81%); 182 respondents reported one symptom (15.04%); 114 respondents reported two symptoms (9.42%); and 68 respondents reported three symptoms (5.62%). linear regression showed that chills, myalgia, cough, dizziness, coryza, and sore throat were significantly associated with higher ies-r, dass stress subscale, dass anxiety subscale, and dass depression subscale scores, while breathing difficulty was associated with only dass anxiety and depression subscale scores. in contrast, the presence of a dyad of symptoms such as fever with cough or breathing difficulty was not associated with ies-r, dass stress subscale, dass anxiety subscale, and dass depression subscale scores. in the prior two weeks, 3.5% of respondents had consulted a doctor in the clinic; 0.3% had been admitted to the hospital; 0.9% had been tested for covid-19; 2.1% had been under quarantine by a health authority; and 68.3% reported good or very good health status. around 93.6% of respondents did not suffer from any chronic illness, and 92.4% were covered by medical insurance. clinic consultations (b = 0.38, 95% ci: 0.02 to 0.73) and hospitalizations (b = 1.23, 95 % ci: 0.09 to 2.36) were significantly associated with higher dass anxiety subscale score. poor or very poor self-rated health status was significantly associated with a greater psychological impact of the outbreak (b = 0.76, 95% ci: 0.02 to 1.49), and higher dass stress subscale (b = 0.45, 95% ci: 0.02 to 0.88), dass anxiety subscale (b = 0.90, 95% ci: 0.22 to 1.58), and dass depression subscale (b = 0.65, 95% ci: 0.10 to 1.20) scores as compared to those with very good or good self-rated health status. history of chronic illness was significantly associated with higher ies-r, dass stress subscale, dass anxiety subscale, and dass depression subscale scores. table 3 shows the contact history of confirmed and suspected cases of covid-19. overall, 1% of respondents had been in contact with an individual with suspected covid-19 or infected materials; 0.5% reported indirect contact with an individual with confirmed covid-19; and 0.3% reported close contact with an individual with confirmed covid-19. variables in the contact history were not associated with ies-r and dass scores, with the exception of contact with an individual with suspected covid-19 or infected materials, which were significantly associated with anxiety (b = 0.98, 95% ci: 0.32 to 1.64). regarding knowledge about covid-19, table 4 also shows that the most common perceived route of transmission was through droplets (92.1%), followed by contaminated objects (73.7%), and airborne transmission (60.5%). nearly all respondents had heard that the number of infected individuals had increased (98.8%), the number of deaths had increased (97.8%), and the number of recovered individuals had increased (93.3%). the most common source of health information about covid-19 was from the internet (93.5%). the majority of respondents (75.1%) were very satisfied or fairly satisfied with the amount of health information available. dissatisfaction with the amount of health information available about covid-19 was significantly associated with higher ies-r score (b = 0.63, 95% ci: 0.11 to 1.14) and dass stress subscale score (b = 0.32, 95% ci: 0.02 to 0.62). the information on the increase in the number of recovered individuals was significantly associated with a low dass stress subscale score (b =−0.24, 95% ci: −0.40 to −0.07). regarding concerns about covid-19, about 75.2% of respondents were very worried or somewhat worried about other family members getting covid-19. in contrast, 50.9% of respondents were very worried or somewhat worried about a child younger than 16 years getting covid-19. about 46.5% of the respondents expressed a high level of confidence in their doctor's ability to diagnose or recognize covid-19; and 46.1% believed the risk of contracting covid-19 during the current outbreak was unlikely or not likely at all. the majority of respondents (69.2%) believed that they would be very likely or somewhat likely to survive covid-19 if infected. those who had no confidence in their own doctor's ability to diagnose or recognize covid-19 were significantly more likely to have higher scores in the dass stress subscale (b = 1. high levels of concern about other family members getting covid-19 were significantly associated with higher dass stress subscale scores (b = 0.50, 95% ci: 0.04 to 0.96). similarly, high levels of concern about a child younger than 16 years getting covid-19 were significantly associated with higher ies-r scores (b = 0.25, 95% ci: 0.05 to 0.44) and dass anxiety subscale scores (b = 0.24, 95% ci: 0.07 to 0.42). table 5 shows the precautionary measures adopted by the respondents in the past 14 days, which were most frequently always washing hands after touching contaminated objects (66.6%), always wearing a mask regardless of the presence or absence of symptoms (59.8%), always covering mouth when coughing and sneezing (57.4%), always washing hands with soap (56.5%), always washing hands immediately after coughing, sneezing, or rubbing nose (41%), and always avoiding sharing utensils (e.g., chopsticks) during meals (40.5%). linear regression analysis showed that avoiding the sharing of utensils (e.g., chopsticks) during meals was significantly associated with lower scores in the ies-r [20] [21] [22] [23] [24] 1025 (84.7) reference reference reference reference * p < 0.05; ** p < 0.01; *** p < 0.001. table 6 shows additional health information required by respondents. nearly all respondents desired additional information about covid-19, most frequently with respect to the route of transmission (96.9%), the availability and effectiveness of medicines/vaccines (96.8%), travel advice (95.9%), overseas experience in handling covid-19 (94.5%), the number of infected cases and locations (94.1%), advice on prevention of the covid-19(93.7%), more tailored information (e.g., for people with chronic illnesses) (93.6%), outbreaks in the local area (92.7%), and details on symptoms of covid-19 infection (91.6%). about 96.9% of respondents preferred regular updates for the latest information and these were found to be significantly associated with lower dass anxiety subscale scores ( our findings suggest that with respect to the initial psychological responses of the general public from 31 january to 2 february 2020, just two weeks into the country's outbreak of covid-19 and one day after who declared public health emergency of international concern, 53.8% of respondents rated the psychological impact of outbreak as moderate or severe; 16.5% of respondents reported moderate to severe depressive symptoms; 28.8% of respondents reported moderate to severe anxiety symptoms; and 8.1% reported moderate to severe stress levels. the prevalence of moderate or severe psychological impact as measured by ies-r was higher than the prevalence of depression, anxiety, and stress as measured by the dass-21. the difference between ies-r and dass-21 is due to the fact that the ies-r assesses the psychological impact after an event. in this study, respondents might refer the covid-19 outbreak as the event while the dass-21 did not specify any such event. in this study, the majority of respondents spent 20-24 h per day at home (84.7%), did not report any physical symptoms (60.81%), and presented with good self-rated health status (68.3%). in this study, very few respondents had a direct or indirect contact history with individuals with confirmed or suspected covid-19, or had undergone medical consultations related to covid-19 (≤1%). the majority of respondents (>70%) were worried about their family members contracting covid-19, but they believed that they would survive if infected. overall, the internet (93.5%) was the primary health information channel for the general public during the initial stage of covid-19 epidemic in china. nearly all respondents (>90%) requested regular updates on the latest information on the route of transmission, availability and effectiveness of medicines/vaccines, travel advice, overseas experience in handling covid-19, number of cases and location, advice on prevention, more tailored information (e.g., for people with chronic illnesses), information on outbreaks in the local area, and details on symptoms. the majority of respondents (>70%) were satisfied with the amount of health information available. more than half of the respondents washed their hands with soaps after touching contaminated objects, covered their mouth when coughing or sneezing, and wore masks regardless of the presence or absence of symptoms as precaution strategies. as the covid-19 epidemic continues to spread, our findings will provide vital guidance for the development of a psychological support strategy and areas to prioritize in china and other places which are affected by the epidemic. as the epidemic is ongoing, it is important to prepare health care systems and the general public to be medically and psychologically ready if widespread transmission occurs outside china [32] . our findings have clinical and policy implications. first, health authorities need to identify high-risk groups based on sociodemographic information for early psychological interventions. our sociodemographic data suggest that females suffered a greater psychological impact of the outbreak as well as higher levels of stress, anxiety, and depression. this finding corresponds to previously extensive epidemiological studies which found that women were at higher risk of depression [33] . students were also found to experience a psychological impact of the outbreak and higher levels of stress, anxiety, and depression. as the total number of people infected by covid-19 currently surpasses those stricken by the 2003 sars-cov epidemic, major cities in china have shut down schools at all levels indefinitely. the uncertainty and potential negative impact on academic progression could have an adverse effect on the mental health of students. during the epidemic, education authorities need to develop online portals and web-based applications to deliver lectures or other teaching activities [34] . as young people are more receptive towards smartphone applications [35] , health authorities could consider providing online or smartphone-based psychoeducation and psychological interventions (e.g., cognitive behavior therapy, cbt) to reduce risk of virus transmission by face-to-face therapy. online platforms could also provide a support network for those people spending most of their time at home during the epidemic. we found that the general public with no formal education had a greater likelihood of depression during the epidemic. local agencies need to provide information in a diagrammatic or audio format in simple languages to support those with no educational background during the epidemic. second, health authorities need to identify the immediate psychological needs of the general population presenting with physical symptoms during the epidemic. our results revealed that the general population presenting with specific symptoms including chills, coryza, cough, dizziness, myalgia, and sore throat, as well as those with poor self-rated health status and history of chronic illnesses, experienced a psychological impact of the outbreak and higher levels of stress, anxiety, and depression. after presentation to the clinic or hospital with the above physical symptoms, patients may be sent home, quarantined, or admitted for further investigation. health professionals should take the opportunity to provide resources for psychological support and interventions for those who present with the above symptoms, especially during hospitalization. taking a family history is essential, and health professionals should enquire about the level of concern for other family members, especially children, of contracting covid-19, as these concerns are associated with stress and anxiety, respectively. third, government and health authorities need to provide accurate health information during the epidemic to reduce the impact of rumors [23] . higher satisfaction with the health information received was associated with a lower psychological impact of the outbreak and lower levels of stress, anxiety, and depression. the content of health information provided during the epidemic needs to be based on evidence to avoid adverse psychological reactions. our results showed that up-to-date and accurate health information, especially on the number of recovered individuals, was associated with lower stress levels. additional information on medicines or vaccines, routes of transmission, and updates on the number of infected cases and location (e.g., real-time, online tracking map) were associated with lower levels of anxiety. fourth, the content of psychological interventions (for example cbt) needs to be modified to suit the needs of the general population during the epidemic. cbt should preferably be delivered online or via telephone to avoid the spread of infection. as online cbt does not require the presence of mental health professionals (e.g., psychologists), this will be helpful to the general public in china as there is a shortage of psychologists. based on our findings, cognitive therapy can provide information or evidence to enhance confidence in the doctor's ability to diagnose covid-19. cognitive therapy can challenge cognitive bias when recipients overestimate the risk of contracting and dying from covid-19. as the majority of the general population in this study was homebound for 20-24 h per day during the epidemic, behavior therapy could focus on relaxation exercises to counteract anxiety and activity scheduling (e.g., home-based exercise and entertainment) to counteract depression in the home environment. self-administered acupressure and emotional freedom techniques derived from key principles within traditional chinese medicine are potential interventions which may benefit the mental health of general public during the covid-19 outbreak. further research is required to evaluate the effectiveness of these interventions. fifth, our findings suggest that the precautionary measures adopted to prevent the spread of covid-19 could have had protective psychological effects during the early stage of the epidemic. during the 2003 sars-cov epidemic, researchers found that moderate levels of anxiety were associated with higher uptake of preventive measures by respondents [21] . our findings showed the opposite trend. specific precautionary measures including avoidance of sharing utensils (e.g., chopsticks), hand hygiene, and wearing masks regardless of the presence or absence of symptoms were associated with lower levels of psychological impact, depression, anxiety, and stress. the experiences of the 2003 sars-cov epidemic could have changed the perception of the general public towards precautionary measures and have led to a positive effect on the initial psychological responses to the covid-19 epidemic by giving respondents confidence and sense of control in prevention. as the chinese prefer to use chopsticks to pick up food commonly shared on a plate during mealtime as part of their culture, it is not unexpected that avoidance of sharing utensils (e.g., chopsticks) during meals is significantly associated with less psychological impact and lower levels of anxiety, depression, and stress. during the initial stage of the covid-19 epidemic, health authorities outside china had different recommendations for mask usage due to a global shortage of masks. while some health authorities urged citizens not to wear masks if they were well (e.g., singapore), other health authorities urged their citizens to always have masks and hand sanitizers ready (e.g., malaysia, vietnam) [36] . the official guidance from the world health organization (who) advises that healthy people should only wear masks if they are taking care of a person with suspected covid-19 infection or if people are coughing and sneezing [37] . our study found that wearing masks, regardless of the presence or absence of symptoms, was associated with lower levels of anxiety and depression. although the who emphasizes that masks are effective only when used in combination with frequent hand-cleaning with alcohol-based hand rub or soap and water, wearing a mask regardless of the presence or absence of symptoms could offer potential psychological benefits by offering a sense of security. this finding was anticipated because wearing face masks is a common practice when people are sick or to counter urban pollution or haze in parts of asia, including china [38] . governments and health authorities should ensure there are infrastructures to produce and provide an adequate supply of masks, soaps, alcohol-based hand rubs, and other personal hygiene products during the covid-19 epidemic. this study has several limitations. given the limited resources available and time-sensitivity of the covid-19 outbreak, we adopted the snowball sampling strategy. the snowballing sampling strategy was not based on a random selection of the sample, and the study population did not reflect the actual pattern of the general population. furthermore, it would be ideal to conduct a prospective study on the same group of participants after a period. due to ethical requirements on anonymity and confidentiality, we were not allowed to collect contact details and personal information from the respondents. as a result, we could not conduct a prospective study that would provide a concrete finding to support the need for a focused public health initiative. there was an oversampling of a particular network of peers (e.g., students), leading to selection bias. as a result, the conclusion was less generalizable to the entire population, particularly less educated people. another limitation is that self-reported levels of psychological impact, anxiety, depression and stress may not always be aligned with assessment by mental health professionals. similarly, respondents might have provided socially desirable responses in terms of the satisfaction with the health information received and precautionary measures. lastly, the number of respondents with contact history and who had sought medical consultations was very small. our findings could not be generalized to confirmed or suspected cases of covid-19. notwithstanding the above limitations, this study provides invaluable information on the initial psychological responses 2 weeks after the outbreak of covid-19 from respondents across 194 cities in china. our results could be used as a historical reference. most importantly, our findings directly inform the development of psychological interventions that can minimize psychological impact, anxiety, depression, and stress during the outbreak of covid-19 and provide a baseline for evaluating prevention, control, and treatment efforts throughout the remainder of the covid-19 epidemic, which is still ongoing at the time of preparing this manuscript. during the initial phase of covid-19 outbreak in china, more than half of the respondents rated their psychological impact as moderate-to-severe, and about one-third reported moderate-to-severe anxiety. female gender, student status, and specific physical symptoms were associated with a greater psychological impact of the outbreak and higher levels of stress, anxiety, and depression. specific up-to-date and accurate health information and certain precautionary measures were associated with a lower psychological impact of the outbreak and lower levels of stress, anxiety, and depression. our findings can be used to formulate psychological interventions to improve mental health and psychological resilience during the covid-19 epidemic. author contributions: conceptualization, c.w., r.p., and r.h.; methodology, c.w., r.p., and r.h.; validation, c.w., r.p., and l.x.; resources, c.w.; data curation, x.w., y.t., and l.x.; formal analysis, c.w., r.p., x.w., y.t., and l.x.; writing-original draft preparation, c.w., r.p., c.s.h., and r.c.h.; writing-review and editing, c.w., c.s.h., and r.c.h.; visualization, x.w., 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perceived dangerousness of pollution level the authors declare no conflict of interest. key: cord-353482-dz343h7t authors: ellis, matthew; pant, puspa raj title: global community child health date: 2020-05-11 journal: int j environ res public health doi: 10.3390/ijerph17093331 sha: doc_id: 353482 cord_uid: dz343h7t this special issue of ijerph has published a range of studies in this developing field of global community child health research. a number of manuscripts submitted in response to our invitation describing ‘community-based interventions which impact on child health and wellbeing around the globe. in addition to rural community-based initiatives given that most children now live in cities we are also interested to hear about urban initiatives….’ we hope this issue will of great interest to the researchers and practitioners as well as academia from the fields of global health as well as global child health because it comprised of 14 articles representing all five continents. physical activity appears a key component of the scientific community’s current conception of child well-being judging from the four papers published addressing this area. this issue also has papers on childhood obesity to rubella vaccination. despite of the journal’s strive for reaching out to a wider global child health community, this issue missed contributions relating to child safeguarding and social determinants of urban health. global community child health focusses on the health and development of children in a community context across the globe. whilst some threats to the well-being of children may be globally determined (e.g., climate change) many others are more local (e.g., a busy trunk road). whatever the level of the threat it is the mobilisation of community and household level interventions to protect and enable children which lies at the heart of global community child health [1] . community health workers facilitate these interventions working with parents and carers [2] whilst schools, children's centres, nurseries and creches provide enabling environments for interventions to reach children directly. although we know that investment in early child development remains a top priority for all communities [3] , it is becoming clearer that exclusive attention to the early years misses important opportunities both in middle childhood and the adolescent period [4] . this edition of ijerph was conceived of as an opportunity to sample a range of studies in this developing field of research. we invited studies describing community-based interventions which impact on child health and wellbeing around the globe. in addition to rural community-based initiatives, given that most children now live in cities we are also interested to hear about urban initiatives. although sustainable development goal (sdg) three was our primary focus, we were keen to hear about multi-sectoral interventions with synergistic impact across the sdgs. the 14 accepted articles are global in their reach, with papers from all five inhabited continents. physical activity appears to be a key component of the scientific community's current conception of child well-being judging from the four papers published addressing this area [5] [6] [7] [8] . of course, given the global obesity epidemic, this will remain an important issue for community child health, though given the obesogenic environment we all face following societal nutrition transition we suspect the answers to this lie further upstream in the food industry's regulatory framework [9] . infectious disease, despite the epidemiological transition, remains a major threat in childhood everywhere and several aspects come up in this special issue-not least the awareness of a disease (rubella) amongst health care workers in tanzania for which there is an available vaccine [10] . this reminds us that for vaccination, its understanding and promotion are key tasks for community health workers around the globe, even more so in this age of vaccine hesitancy. if there may be one benevolent side effect of covid-19 going forward it may be the greater appreciation of the value of vaccines! we also publish a paper presenting evidence in support of a role for a bacterial lysate to stimulate immunity in childhood [11] and an interesting exploration of traditional healers' knowledge of noma [12] , the disfiguring facial erosion encountered in children in africa, which almost certainly relates to the continuing wide spectrum of infectious disease in childhood. this paper reminds us that community health workers take many forms and a functional health system finds ways of connecting all members of the health care community. community mobilisation through groups is an important vehicle for community child health initiatives and where some of the best evidence of impact lies [13] . in this edition fathers' roles in parent groups supporting families affected by zika virus [14] links well with our review of early intervention for infants at high risk of developmental disability [15] . a team working in fiji also make use of group-based interventions in their description of what a community child health initiative looks like in an island community [16] . the social determinants of health are central to the concept of community child health [17] . these determinants operate at household, local population ("community"), national and supranational levels. we were sorry not to see any contributions relating to child safeguarding-always a sensitive and difficult research area-but one which therefore needs to be illuminated by an especially powerful light! this would be especially timely as we move globally towards legislation outlawing the corporal punishment of children (https://endcorporalpunishment.org/countdown). of course, the physical environment in which children play, go to school and all too often work also has a major impact on their health. given that environmental health is a primary concern of this journal it was good to be able to accept two papers focussing on children, the first investigating the role of toys in the transmission of diarrhoeal disease at children's centres in south africa [18] and the second an exploratory study assessing pesticide levels in children's urine in mexico [19] . strikingly, we did not receive a community-based study from an urban slum where far too many of the world's children are growing up. if we are to promote "health for all" at all ages then we must ensure that, as "a future for the world's children" [20] puts it, "children grow up in safe and healthy environments, with clean water and air and safe spaces to play". research assessing the impact of community led initiatives into road traffic injury reduction, child safeguarding and the social determinants of health in urban slums should be a focus of community child health researchers going forward. community participation: lessons for maternal, newborn, and child health integrated management of childhood illness global survey report; world health organisation early child development-a winning combination disease control priorities, c.; adolescent, h.; development authors, g. investment in child and adolescent health and development: key messages from disease control priorities international comparison of the levels and potential correlates of objectively measured sedentary time and physical activity among three-to-four-year-old children physical activity and quality of life of healthy children and patients with hematological cancers effect of a multidimensional physical activity intervention on body mass index, skinfolds and fitness in south african children: results from a cluster-randomised controlled trial goal-framing and temporal-framing: effects on the acceptance of childhood simple obesity prevention messages among preschool children's caregivers in china beyond food promotion: a systematic review on the influence of the food industry on obesity-related dietary behaviour among children stray-pedersen, a. awareness and factors associated with health care worker's knowledge on rubella infection: a study after the introduction of rubella vaccine in tanzania impact of om-85 given during two consecutive years to children with a history of recurrent respiratory tract infections: a retrospective study sociodemographic characteristics of traditional healers and their knowledge of noma: a descriptive survey in three regions of mali women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis engagement of fathers in parent group interventions for children with congenital zika syndrome: a qualitative study early intervention for children at high risk of developmental disability in low-and middle-income countries: a narrative review tuibeqa, i. strengthening health systems to support children with neurodevelopmental disabilities in fiji-a commentary commission on social determinants of, h. achieving health equity: from root causes to fair outcomes bacterial contamination of children's toys in rural day care centres and households in south africa urinary pesticide levels in children and adolescents residing in two agricultural communities in mexico a future for the world's children? a who-unicef-lancet commission key: cord-318944-13zk6cco authors: bizzoca, maria eleonora; campisi, giuseppina; lo muzio, lorenzo title: covid-19 pandemic: what changes for dentists and oral medicine experts? a narrative review and novel approaches to infection containment date: 2020-05-27 journal: int j environ res public health doi: 10.3390/ijerph17113793 sha: doc_id: 318944 cord_uid: 13zk6cco the authors performed a narrative review on severe acute respiratory syndromecoronavirus-2 ( sars-cov-2) and all infectious agents with the primary endpoints to illustrate the most accepted models of safety protocols in dentistry and oral medicine, and to propose an easy view of the problem and a comparison (prevs post-covid19) for the most common dental procedures. the outcome is forecast to help dentists to individuate for a given procedure the differences in terms of safety protocols to avoid infectious contagion (by sars-cov-2 and others dangerous agents). an investigation was performed on the online databases pubmed and scopus using a combination of free words and medical subject headings (mesh) terms: “dentist” or “oral health” and “covid-19” or “sars-cov-2” or “coronavirus-19”. after a brief excursus on all infectious agents transmittable at the dental chair, the authors described all the personal protective equipment (ppe) actually on the market and their indications, and on the basis of the literature, they compared (before and after covid-19 onset) the correct safety procedures for each dental practice studied, underlining the danger of underestimating, in general, dental cross-infections. the authors have highlighted the importance of knowing exactly the risk of infections in the dental practice, and to modulate correctly the use of ppe, in order to invest adequate financial resources and to avoid exposing both the dental team and patients to preventable risks. the era of corona-virus-disease-19 is an important historical period from various points of view, from the world health to the huge cascade of socio-economic implications. everyday habits have been turned upside down, and the way of life of people all over the globe, engaged in all activities, especially in the health sector, will be involved in this necessary change. dentists, being in close contact with the patient's droplets and aerosols generated, have to revise the operating protocols to protect the team and the patients from the risk of infectious diseases. unfortunately, the pandemic covid-19 will not stop immediately and everyone will have to face each other very long working and social recovery times of the population. in this time, a large part of the population will avoid dental treatment other than those imposed by pain or urgency, both due to money issues and, principally, for a psychological reason: it will not be easy to overcome the fear of infection. for many, the dental practice is a source of possible infections, considering that the first person at risk is the dentist himself. the scenario in dental practices is very complex and several problems can arise which are dangerous for the dental practice [1] [2] [3] [4] [5] [6] [7] [8] [9] . for an infection to emerge, it is necessary that an adequate number of specific microorganisms can infect a person or groups. the classic contamination paths clearly incorporate all the dental unit (team and patient): body fluids in direct contact with the wound site during operation, injuries of the skin and the mucosa with sharp objects, body fluids and contaminated material contact with eyes, aerosols arising during the operation with air produced by turbine and ultrasonic devices, contamination via droplet, and surgical smoke formed during electro-cautery or laser applications [10, 11] . the first problem raised with respect to covid-19, is related to the easy spread of viral agents in the air during dental procedures [12] [13] [14] [15] . hence, aerosol is the most aggressive source of covid-19 as well as other viral infections, placing dentists and their collaborators at the first line of the exposure to risk scale within the context of healthy personnel [10, 16] . the second problem is related to the persistence of the biological agent in operating rooms. the aerosol produced by high rotation instruments and ultrasound could remain for several hours in the air and on the surfaces [17, 18] . although it can save the operator, if well protected, during the therapeutic acts, it means that the air will be contaminated, thus presenting a risk for operators after removing the ppe (personal protective equipment) and for the next patients. this covid-19 pandemic has shown that several people can be positive and spread the viral agents around without any symptoms or signs of biological agents. so, the dental team, a part performing the double triage [1] , should consider each patient as sars-cov-2 positive until proven otherwise and use protective equipment in order to preserve their own health and the health of all patients as attending the dental office. for these reasons, it is necessary to use rigid and precise operating protocols capable of classifying dental procedures based on risks for the team as well as for the patients. this study was born from the awareness of a necessary change in decision making processes. it involves a rereading of relevant literature in order to build protocols addressed to dentists, to assess and modulate the risks of contagion in the dental practice. moreover, it proposes, on the basis of information from literature, a classification of dental procedures based on the risk of contagion of infectious agents, showing what will change for the dentist and the oral medicine expert. an investigation was performed on the online databases pubmed and scopus using a combination of free words and mesh terms: "dentist" and "covid-19" or "sars-cov-2" or "coronavirus-19", and "oral health" and "covid-19" or "sars-cov-2" or "coronavirus-19". only studies fulfilling the following inclusion criteria were considered eligible for inclusion in this study: (i) performed on human subjects, (ii) written in the english language, and (iii) published in 2019-2020. the manuscript titles list was highlighted to exclude irrelevant publications and search errors. the final selection was performed by reading the full texts of the papers in order to approve each study's eligibility based on sars-cov-2 and other infective agents involved in dentistry. data selection and revision was performed by two independent reviewers (meb, university of foggia and gc, university of palermo). they singularly analysed the papers, and in agreement, included 142 papers in this narrative review. the authors, in consideration of the importance of the emerging topic, decided to include also guidelines, online documents, reviews, experts' opinions, renouncing the prisma-related design of regular systematic reviews ( figure 1 ). after a brief excursus on all possible infectious agents, the authors described, on the basis of the literature selected, all personal protective equipment (ppe) actually on the market and their indications. then, they compared (before vs after covid-19 era) the correct safety procedures for each dental practice selected, underlining the danger of underestimating, in general, dental cross infections, if focused only on the newest sars-cov-2. results are summarised in tables 1-8. different classes of bacteria, viruses, and fungi can cause human infections. three factors are important for the transmission of these infectious agents: an infectious agent, a receptive subject and a transmission mode. the pathogens involved in infections during health care mainly derive from staff, from patients (and possible careers), but also from inanimate environmental sources ( figure 2 ). these human sources can: 1) have active infections, 2) be asymptomatic or in an incubation period, or 3) be colonized transiently or chronically with pathogen microorganisms. the infection is the consequence of the contact between a contagious agent and a potential host. moreover, the same characteristics of the host can influence the onset and the severity of the infectious disease. however, several other factors can modify the virulence and behavior of infectious disease such as the number of infectious agents, the transmission way and the pathogenicity [19] . predictors of the disease evolution in a specific subject could be: immune status at exposition time, age, comorbidity, and virulence of the agent [20] . there are two main ways of infective transmission, namely vertical (from mother to fetus: transplacental, during vaginal birth or breast feeding) and horizontal (sexual and non-sexual). in a dental setting, infectious agents are transmitted in the horizontal, non-sexual route [21] . in the non-sexual horizontal transmission, direct or indirect contact (e.g., herpes simplex virus, respiratory syncytial virus, s. aureus), droplets (e.g., influenza virus, b. pertussis) or airways (e.g., m. tuberculosis) are possible routes. other viruses can be transmitted by the blood (e.g., hepatitis b and c viruses and hiv) via percutaneous or mucous membrane exposure [3, 4, 14, 22] . in synthesis, the three main routes of the transmission are [23] : contact transmission: contact transmission can be through direct contact and indirect contact. during direct contact transmission, pathogens are transmitted from an infected person to another subject without an intermediate object or person (for example, mucous membrane or breaks contact blood or other blood-containing body fluids infected, or contact hsv lesion without gloves) [3, 4, 14, 15, 18, 22, 24, 25] . during indirect contact transmission, pathogens are transmitted to the host through objects or human body carrying those pathogens [17, 18, 22, [26] [27] [28] [29] [30] . moreover, all the personal protective equipment (ppe), such as uniforms or isolation gowns, can be contaminated by infectious agents during the treatment of a patient colonized or infected. • droplet transmission: some infectious agents can reach the host through the direct and indirect contact routes or through droplets [3, 15, [31] [32] [33] . droplets can carry infectious pathogens travelling for short distances directly from the respiratory tract of the infectious subjects to host reaching susceptible mucosal surfaces [3, 15, [31] [32] [33] . respiratory droplets are produced during coughs, sneezes, or talks [34] or by airway health procedures. the nasal mucosa, conjunctivae, and mouth are good portals for respiratory viruses [35] . to date, the maximum distance that a droplet can reach is not known, even if pathogens transmitted by a droplet do not run across long distances [19] . the size of droplets has traditionally been defined as being >5 µm [19] . several types of droplets, including those with diameters of 30 µm or greater, can remain suspended in the air [36] . the sizes of the droplets can determine the maximum distance reached: largest droplets, between 60 and 100 microns, totally evaporate before spontaneously falling 2 m away [37] . for respiratory exhalation flows, the critical factor is the exhalation air velocity: these droplets are carried more than 6 m away by exhaled air at a velocity of 50 m/s (sneezing), more than 2 m away at a velocity of 10 m/s (coughing), and less than 1 m away at a velocity of 1 m/s (breathing) [37] . airborne transmission: this means of transmission consists of dissemination of airborne droplet or small particles containing infectious pathogens that remain infective over time and distance (e.g., spores of aspergillus spp., and m. tuberculosis) [31, 33, [38] [39] [40] [41] [42] . several infectious agents can involve dentist and his team [10] (table 1) . • sars-cov-2 determines covid-19 (coronavirus disease 2019), an infectious disease characterized by several important systemic problems such as coronavirus associated pneumonia. the principal symptoms are fever, cough, and breathing difficulties; the most patients have mild symptoms, some progress to severe pneumonia [43] . the diagnosis is performed with the identification of the virus in swabs of patient throat and nose. covid-19 can involve the respiratory tract determining a mild or highly acute respiratory syndrome due to the production of pro-inflammatory cytokines, such as interleukin (il)-1beta and il-6 [44] . one mechanism that can make the coronavirus lethal is the induction of interstitial pneumonia linked to an over-production of il-6 [44, 45] . based on this principle, several researchers have started to use an anti-arthritis drug, tocilizumab, for its anti-il-6 action [46] [47] [48] [49] . herpes simplex virus (hsv) can determine a primary infection with minor, ulcerative lymphadenopathy gingivostomatitis [50] and a recurrent infection with cold sores. herpetic whitlow, an hsv infection of the fingers is usually caused by direct contact of the same fingers with infected saliva or a herpetic lesion [51] [52] [53] . skin, mucosal lesions, and secretions such as saliva can determine the transmission [54, 55] . lesions are usually characterized by vesicles and sequent crusting. acyclovir can be used for the treatment of the diseases. it is sufficient to wear gloves in order to avoid the herpetic whitlow when the clinician treats patients with hsv lesions [10, 56] . • varicella zoster virus (vzv) can determine chickenpox (primary disease), usually in children, and shingles, which is very painful (secondary disease), for the reactivation of a virus residing in sensory ganglia during the latency period [57] [58] [59] . chickenpox disease is highly contagious and spreads via-airborne routes [60] [61] [62] . the virus can infect nonimmune dental team via inhalation of aerosols from a patient incubating the disease. masks and gloves can be not sufficient for complete protection of the healthcare workers [10] . [77] . it is present in saliva and could infect susceptible subjects via direct contact or aerosols [78] . human t-lymphotropic virus is involved in adult t cell leukaemia and spastic paraparesis. this virus can be transmitted through blood [79] [80] [81] [82] and, in a dental setting, it can infect via sharp instruments injuries [10] . hepatitis b virus (hbv) causes acute hepatitis and it is an important risk-agent for the health care staff [83, 84] . the possible ways of transmission are sexual intercourse, through blood, contaminated material injuries, and perinatal way [85] [86] [87] [88] . so, all operators of the dental team should be vaccinated [10, 89] . hepatitis c virus (hcv) causes "non-a" and "non-b" hepatitis and it is transmitted like hbv [85] [86] [87] 90] . the primary infection is often asymptomatic and the most of infected subjects become carriers of the virus with risk of development of chronic liver disease that could evolve in hepatocellular carcinoma [10] . human immunodeficiency virus (hiv) infects the immune system of susceptible subjects, t-helper cells particularly. it can be transmitted like hbv (sexual intercourse, blood borne and perinatal ways) [91, 92] . moreover, this infection have oral manifestations that can help in diagnosis: e.g., oral candidiasis, oral hairy leukoplakia, oral necrotising ulcerative gingivitis and oral kaposi's sarcoma [10, [93] [94] [95] [96] . • cytomegalovirus (cmv) is part of the herpes virus family and can cause diseases with several manifestations [97] . mumps virus is part of the paramyxoviridae group. this pathogen often affects the parotid glands, and the consequently characteristic symptom is swelling of these salivary glands [98] . moreover, this virus can cause inflammation of the ovaries, testis, pancreas or meninges with several complications. after the introduction of the vaccine against measles, mumps, and rubella (mmr), mumps incidence has decreased, even if several mumps cases have recently been reported [99] . • mycobacterium tuberculosis causes tuberculosis and is a bacterium transmitted by inhalation, ingestion and inoculation. the main symptoms are cervical lymphadenitis and lung infections. in order to prevent infection, the dental team should be adequately vaccinated and wear ppe [100] [101] [102] [103] [104] [105] . this bacterium is resistant to chemicals and, for this reason, sterilization and disinfection protocols must be rigorously performed [10] . • legionella spp. is a gram-negative bacterium that causes legionellosis and generally it resides in water tanks. legionellosis occurs with pneumonia, sometimes lethal in older people. since this pathogen lives in water, it can be easily transmitted during dental procedures through aerosols from incorrectly disinfected water circuits [106, 107] . in fact, water circuits that remain unused for long periods of time should be checked regularly to prevent legionella bacteria from residing [106, 107] . • treponema pallidum causes syphilis and dental team must wear gloves in order to adequate protect themselves [10, 108] . meningococcal spp. are gram-negative bacteria. they are located on the nasopharyngeal mucosa and their presence is generally asymptomatic. the bacterium is easily transmitted, especially during adolescence, when people get together. as already mentioned, colonization of the nasopharynx is common, and while the resulting disease is rare, at times, it can cause death or permanent disability [109, 110] . staphylococcus aureus is an important agent involved in nosocomial infections. this bacterium causes a wide range of diseases that can be mild or life-threatening (e.g., bacteraemia, pneumonia, and surgical site infection [111] ). in addition, s. aureus can easily have antimicrobial resistance. this bacterium principally resides on the epithelium of the anterior nares in human beings [112] . group a streptococcus (gas) is a gram-positive, beta-haemolytic bacterium. this pathogen is responsible for several diseases in human beings, such as acute pharyngitis, impetigo and cellulitis. it can also cause serious invasive diseases such as necrotizing fasciitis and toxic shock syndrome (tss) [113] [114] [115] . the bacterium mainly resides in human nose, throat and on skin and it is often transmitted without symptoms [116] [117] [118] . obviously, asymptomatic subjects are less contagious than the symptomatic carriers of this bacterium. gas is transmitted through respiratory droplets spread in the air, for example during coughing, sneezing and nasal secretions [117, 118] . in addition, this bacterium can spread through close interpersonal contact during a kiss, using the same dishes and sharing the same cigarette. streptococci mutans mainly colonize dental surfaces after tooth eruption and is associated to the development of caries [119] . this bacterium may be transmitted horizontally between children during the initial phases of the s. mutans colonization in nursery environments [120] . there is scientific evidence of vertical transmission of s. mutans from mother to child [121] . • some periodontal bacteria (e.g., a. actinomycetemcomitans, p. gingivalis) are considered person-to-person transmitted, but it is still unclear if transmission is governed only by domestic pathways, without definitive implications for the dental office. vertical transmission of a. actinomycetemcomitans is between 30% and 60%, while that of p. gingivalis is rarely observed. horizontal transmission ranges from 14% to 60% for a. actinomycetemcomitans and between 30% and 75% for p. gingivalis [122] . certainly, by understanding the spread mechanisms of these bacteria, it would also be possible to prevent a number of systemic diseases [123] . the dental team must adapt several precautions to avoid these infections; an adequate training and information of the personnel is mandatory in order to control infections in the dental office. the individual protection methods include a series of enforcement with the aim to reduce the risks of contamination, unfortunately without being able to eliminate them. the basic principle of infection control is to approach to each patient as if he was an infected patient (by one of the main microbes listed above) and to correctly carry out the protection methods [124] . adequate personal protective equipment (ppe) must be selected based on a risk assessment and the procedure to be performed. the precautions for infection control require wearing gloves, aprons, as well as eye and mouth protection (goggles and mask, such as medical masks and filtering face piece or fpp) for each procedure involving direct contact with the patient body fluids. whenever possible "single use" or "disposable" equipment should be used [10] (table 2) . if the necessary precautions are not taken, it is inevitable that operators can become infected through contact of the mucous membranes with blood, saliva, and aerosols from a potentially infective patient [10] . in healthcare setting, masks are used in order to: protect personnel from contact with patient infectious material; 2. protect patients from infectious agents carried by healthcare workers; 3. limit the potential spread of infectious respiratory aerosol between patients [19] . masks can be worn with goggles in order to protect mouth, nose and eyes, or with a face shield to provide more complete face protection. we must distinguish masks from particle respirators that are used to prevent inhalation of small particles which may contain infectious agents transmitted through the respiratory tract. the mouth, nose, and eyes are sensitive portals to the entry of infective pathogens, such as skin cuts. medical masks: • could be flat or pleated (some are like cups) and fixed to the head with straps or elastic bands; • does not offer complete protection against small particle aerosols (droplet nuclei) and should not be used during contact with patients with diseases caused by airborne pathogens; • they are not designed to isolate the face and therefore cannot prevent inhalation by the health personnel wearing them; • they must be replaced if wet or dirty. there are no standards that evaluate the efficiency of the medical mask filter. aorn (association of peri-operative registered nurses) recommends that medical (surgical) masks filter at least 0.3 µ particles or have a bacterial filtration efficiency of 90%-95% [126] . surgical masks (sm) are used to prevent that large particles (such as droplets, sprays or splashes), containing pathogens, could reach nose and mouth [127] . although their purpose is to protect patients from healthcare professionals (and healthcare team from patients) by minimizing exposure to saliva and respiratory secretions, they do not create a seal against the skin of the face and therefore are not indicated to protect people from airborne infectious diseases. masks are available in several shapes (modeled and unprinted), dimensions, filtration efficiency and attachment method (ribbons, elastic through the ear). masks are disposable and must be changed for each patient. instead, during the treatment of patients with respiratory infections, particulate respiratory masks must be worn. particulate respirators (with filtering percentage) in use in various countries include: [126] . ffp2 european respirators are comparable to n95, and they are indicated for prevention of infectious airborne diseases. however, ffp3 respirators offer the highest level of protection against infectious agents and are the only ffp class accepted by the health and safety executive (hse) as regards the protection in the healthcare environment in the united kingdom [126] . the powered air purifying respirator is also considered a standard part of ppe in certain situations, including aerosol generation procedures in high risk environments. in the event of a pandemic infection, any aerosol generation procedure on infected patients should only be carried out with an ffp3 respirator. non-urgent procedures should be postponed until the infection resolves. in the us, the national institute for occupational safety and health (niosh) defined the following particulate filter categories in 2011, in title 42 code of federal regulations, section 84 (table 3) . there are several models of ffp2 and ffp3 respirators, both with valves and without valves. however, this is not a filter but a valve that regulates the flow of air at the outlet and therefore makes it easier to exhale. therefore, these masks are designed to be able to filter very well the air that comes in the mouth, nose, and lungs of those who wear them. instead, these masks are not designed specifically to prevent the wearer from infecting someone else with their own breathing. in practice, if a mask has a valve, it can let out particles, even if it manages to block almost all the inlet ones. and therefore, a healthy person can use it effectively so as not to get infected. for a sick person or one who could be contagious, however, using it could infect others by letting germs pass from their breath outwards. it is important to say that there is no specific test that has been done to verify the possibility that the virus spreads from an infected person passing through a mask equipped with a valve [128] . surgical masks, on the other hand, are similar in both directions. they have been designed to prevent healthcare workers and surgeons in particular from infecting their own breath with patients, who may have open wounds on the operating table, but also work to protect the healthcare staff themselves against a potentially contagious person. their effectiveness, however, is much lower also because they do not prevent the breath from spreading and allow a lot of air to pass through and to the mouth and nose [128] . the choice of individual eye protection devices (such as goggles or face mask) varies according to the exposure circumstances, other ppe worn. and the need for personal vision [10] . in order to protect the eyes, eyeglasses and contact lenses are not considered suitable [129] . eye protection must be effective but at the same time comfortable and allow sufficient peripheral vision. there are different measures that improve the comfort of the glasses, for example anti-fog coating, different sizes, the possibility of wearing them on prescription glasses. although they provide adequate eye protection, glasses do not protect from splash or spray the other parts of the face. disposable or sterilizable face shields can be used in alternative to glasses. face shield protects the other areas of the face besides the eyes (glasses only protect the eyes). the face shields that extend from the chin to the forehead offer better protection of the face and eyes from spray and splashes [83] . the removal of a facemask, goggles, and mask can be safely performed after removing dirty gloves and after performing hand hygiene. gowns and coveralls are additional personal protective equipment in the health sector [83] . operator hygiene, including wearing appropriate clothing and ppe, has a dual purpose: on the one hand, to defend the operator himself in an environment where the infectious risk is high, and on the other hand to prevent the operator from becoming responsible transmission of infections. to increase the protective function of the uniform or to carry out those procedures in which high contamination is expected, additional disposable clothing can be worn [83] . these clothes can be ppe certified for biological risk and for this recognition must comply with the requirements of the technical standards, namely european standards are en 14126 and iso 16604 (dpi) and en 24920 (dm). the material constituent is mainly tnt (texture not texture), which is suitable for "disposable" use in this specific area. to offer greater protection of the part front of the body, the most exposed to risk, it is required that such lab coats have standard features within the heterogeneity of the models, for example: back closure, covered or heat-sealed seams, long sleeves with cuffs tight and high collar. obviously, for these devices, comfort and practicality are also required, so the operator must be able to move freely and perceive good perspiration [83] . different types of gowns and overalls are available with varying levels of protection. the level of protection depends on various factors including the type of tissue, the shape and size of microorganisms, the characteristics of the conveyor, and various external factors [130] . in high-risk environments, it is recommended to use waterproof and fluid-resistant gowns or overalls. during minor oral surgery, surgical gowns must be worn with tight cuffs that must be inserted under the gloves. fabric work uniforms must be washed daily on a hot 60 • c cycle. fabric uniforms are not considered ppe since the material they are made of is absorbent and therefore offer little protection against infectious pathogens. during all dental procedures, it is impossible to avoid contact of the hands with blood and saliva [10] . that is why all operators must wear protective gloves before performing any type of procedure on patients [10] . gloves must be changed with each patient and at every contact with contaminated surfaces to prevent cross-infection [10] . not only the dentist, but also other dental team members must wear gloves during dental procedures [10, 131] . gloves used in dental clinic can be distinguished basically in two categories: those for purely use clinical and those for instrumentation reordering procedures and of the operational area. when cleaning dental appliances and instruments, more durable gloves should be worn than normal non-sterile gloves to prevent injury [10] . regarding clinical gloves, a clear distinction must be made between them procedures that require invasive action on the patient, or however at clear biological risk, and the procedures that do not require them, or in any case present a negligible biological risk for the operator. the two types of gloves resulting from this distinction are found in the words "inspection gloves" and "surgical gloves" one commonly used nomenclature [83] . both disposable products, from a macroscopic point of view usually have some obvious differences: • surgical gloves in general always distinguish the right side from the left, they are long enough to be worn over the cuffs of the gowns and always packaged in sterile pairs, • the inspection glove is usually an ambidextrous device, shorter and thinner than the previous one and rarely sterile [132] . in general, clinical gloves are made of latex, nitrile or vinyl. latex and nitrile have proven to be more resistant than and therefore are generally preferred. gloves contain powder to make them easier to wear, but which can cause skin irritation [10] . powder-free gloves exist on the market and they should be used when such reactions occur [10] . some people may experience allergies and contact dermatitis due to latex [10] . latex-free gloves for allergy sufferers are also available [10] . also, the weather of use is an absolutely relevant parameter in terms of protection. the use of the glove, especially if in latex, involves development not perceived of microperforations which become particularly significant from a numerical point of view after 60 min and which induce an increase in biological risk [133] . the simultaneous use of two pairs of gloves considerably reduces the passage of blood through microperforations [134] . there are no significant reductions in manual skills and the sensitivity of the operator wearing the double glove [132] . it was confirmed that the formation of microperforations can be also induced by washing gloves with soap, chlorhexidine, or alcohol. moreover, particular attention should be paid also while waiting for the total drying of the alcoholic substances applied on the hands, which has also proven to be potentially harmful to the integrity of the device, before wearing gloves [132] . other personal protective equipment include the disposable cap (headgear) and shoe covers. a disposable cap device is recommended for clear hygienic reasons, such as containment operator contamination and prevention of dispersion of dandruff in the environment, and even more generic protective functions for the worker, such as: interlocking with subsequent tearing of hair and possibly scalp from a part of moving and/or rotating organs, the burning of the hair due to flames or incandescent bodies, and hair fouling due to various agents, including powders and drops of blood-salivary material [83] . dentist personal hygiene is an absolute necessity for infection prevention [23] . the image that the doctor presents of himself and his study is related to the trust that the patient will show towards the doctor and the treatment itself, in an era in which there is increasing information and awareness of the risk. specific notes of hygiene include: • hair, if a doctor hair can touch the patient or dental equipment, should be attached to the back of the head or a surgical cap should be worn [23] ; • facial hair should be covered with a mask or shield [23] ; • jewels should be removed from the hands, arms, or facial area during the patient treatment [23] ; • nails should be kept clean and short to prevent the perforation of the gloves and the accumulation of debris [23] ; • full forearm and hand washing are mandatory before and after treatment [23] . it is very important to maintain an excellent level of hand hygiene in protection techniques that affects all members of the dental team [10] . "hand hygiene" includes several procedures that remove or kill microorganism on the hands [83] : • during handwashing, water and soap should be used in order to generate lather that is distributed on all surface of the hands and after rinsed off; • hand antisepsis, to physically remove microorganisms by antimicrobial soap or to kill microorganisms with an alcohol-based hand rub; • surgical hand rub procedure that kills transient organisms and reduces resident flora for the duration of a surgical procedure with antimicrobial soap or an alcohol-based hand rub [135] . there are different types of soap: • plain soap, that have no antimicrobial properties and works physically removing dirt ad microorganism; • alcohol-based hand rub, used without water, kills microorganism but does not remove soil or organic material physically; antimicrobial soap kills microorganism and removes physically soil and organic material [135] . in 1975 and in 1985, the cdc published a guideline on how to wash the hands, stating that the hands should be washed with antimicrobial soaps before and after procedures performed on patients [10] . the use of gloves is not an alternative to hand washing [10] . hand washing is different if it is a routine procedure or a surgical procedure: in the first case, normal or antibacterial soaps are sufficient [89] . alcohol-containing agents are preferable [10] . cold water must be of choice when washing hands because the repeatedly use of hot water can cause dermatitis [10] . it is recommended to wash hands using liquid soap for a minimum duration of 60 s. it is very important to reduce the number of microorganisms before each surgical procedure; that is why applying antibacterial soaps and acts a detailed cleaning followed by liquids containing alcohol is recommended [10] . despite the fact that the antibacterial effects of alcohol containing cleansers arise quickly, such antiseptics including compounds of triclosan, quaternary ammonium, chlorhexidine, and octenidine must be included [10] . before surgical hand washing, rings, watches, and other accessories must be taken off and no nail polishes or other artificial must be present [11, 89] . the use of disposable paper towels is preferable for drying hands. after every procedure and after taking off the gloves, it is highly recommended to wash hands once again with regular soaps. if soap and water are not readily available, it can be used an alcohol-based hand sanitizer that contains at least 60% alcohol [10] . • must consider all sharp objects contaminated with the patient blood and saliva as potentially infectious; • do not hood the used needles in order to avoid an accidental injection [83] ; • put all used sharp objects in suitable puncture resistant bins [83] . it is necessary to clean all instruments with detergent and water before sterilization [10] . during washing, it is advisable to avoid splashes of water a wear gloves and face protection. the instruments that penetrate the tissues must be sterilized in an autoclave [83] . it is advisable to heat sterilize items that touch the mucosa or to at least disinfect them, for example, with the immersion in a 2% glutaraldehyde solution in a closed bid, naturally following the instructions of the producer [83] . anything that cannot be autoclaved must be disinfected. the handpieces should be able to drain the water for two minutes at the start of the day. not autoclavable handpieces can be disinfected using viricidal agent. after sterilization, all instruments must be kept safely in order to avoid recontamination for a maximum of 30 days, 60 days if closed in double bags [83] . sterilization completely kills all vital agents and spores too. the classic sterilization procedure expects the use autoclave, with cycles at 121 • c for 15-30 min, or at 134 • c for 3-4 min [23, 83] . it is necessary to thoroughly wash and dry all items before sterilizing them as dirt and water can interfere with sterilization [83] . steam sterilization cannot be used for all facilities and a possible alternative can be the use of chemical sterilization using ethylene oxide gas, formaldehyde gas, hydrogen peroxide gas, liquid peracetic acid, or ozone [83] . the disinfection processes do not destroy the bacterial load, rather reducing it to acceptable levels. commonly used disinfectants are described below (table 4 ). the action of cleaning and disinfection can be manual or automatized. for example, it is possible to use ultrasonic baths in order to clean complex, articulated, or notched stainless-steel instruments such as cutters. the washer-disinfectors provide a high temperature passage (generally 90 • c for one minute), which drastically reduces the microbial contamination of the items. the final rinse must be carried out with high quality water (table 5 ). it is necessary to have always a perfect protection of operative room with disinfected surfaces [10] . there are two ways to make a surface aseptic [23] : • clean and disinfect contaminated surfaces [23] and • prevent surfaces from being contaminated by using surface covers [23] . a combination of both can also be used [23] . the following chemicals are suitable for surface and equipment asepsis: • chlorine, e.g., sodium hypochlorite • phenolic compounds • water-based, water with ortho-phenylphenol, tertiary amylphenol, or o-benzyl-p-chlorophenol • alcohol-based ethyl or isopropyl alcohol with ortho-phenylphenol or tertiary amylphenol • iodophor-butoxy polypropoxy polyethoxy ethanol iodine complex [23] . in the literature there are still little information on 2019-ncov. similar genetic features between 2019-ncov and sars-cov indicate that covid-19 could be susceptible to disinfectants such as 0.1% sodium hypochlorite, 0.5% hydrogen peroxide, 62%-71% ethanol, and phenolic and quaternary ammonium compounds [4] . it is important to pay attention to the duration of use, dilution rate, and especially the expiration time following the preparation of the solution [4] . a recent paper pointed out that surface disinfection could be performed with 0.1% sodium hypochlorite or 62%-71% ethanol for one minute in order to eliminate sas-cov-2 [139] . after each treatment, work surfaces should be adequately cleaned and decontaminated with ethyl alcohol (70%). if blood or pus is visible on a surface, it is necessary to clean and disinfect that surface with sodium hypochlorite (0.5%). it is necessary to wear protective gloves and care taken to minimize direct skin, mucosal or eye contact with these disinfectants. in addition to disinfection with chemicals, a ultraviolet-c (uv-c) irradiation lamp can be used [140] . the uv light system for disinfection has several advantages, including: does not require room ventilation, does not leave residues after use and have a wide action spectrum in a very short time [140] . the uv-c lamp must be activated only when the room is empty, without staff and without patient. in the literature, there are no cases of damage to the materials present in the room; despite this, the acrylic material can be degraded if subjected to repeated exposure to uv-c light and for this reason it is recommended to cover it during disinfection with uv-c [141] . ultraviolet light has a wavelength between 10 and 400 nm, while ultraviolet-c (uv-c) light has a wavelength between 100 and 280 nm, and the greatest germicidal power is obtained with a wavelength of 265 nm [142] . the germicidal effect of uv-c light causes cell damage thus blocking cell replication [141] . in descending order of inactivation by uv-c light, there are bacteria, viruses, fungi, and spores [143] . uv-c rays can be generated by low pressure mercury lamps and pulsed xenon lamps which emit high intensity pulsed light with a higher germicidal action [141] . uv-c rays are equipped with high energy which decreases exponentially with the increase of distance from the light source: objects or surfaces closer to the uv-c source will have a greater exposure and therefore will have to be disinfected for less time than distant objects [142] . depending on the nature of the object affected by uv-c light, it can block the light rays or allow itself to be passed through allowing the irradiation of the objects placed behind it. for example, the organic material completely absorbs the uv-c light and blocks its diffusion. for this reason, the surfaces must be manually cleaned to remove the organic substances before decontamination with ultraviolet light [142] . the extent of inactivation of the microorganisms is directly proportional to the uv-c dose received and this, in turn, is the result of the intensity and duration of exposure [142] . therefore, according to the data in the literature, the use of uv-c rays for disinfection has proven effective in reducing the overall bacterial count and significantly more effective than just manual disinfection on surfaces [141] . in addition, to encourage the exchange of air, it is recommended to ventilate the rooms between one patient and another. if it is not possible to allow the exchange of natural air (at least 20-30 min), forced ventilation systems with high efficiency particulate air (hepa) filters must be used, paying attention to the periodic replacement of the filters. recommendations for environmental infection prevention and control in dental settings [136] : • establish a protocol for cleaning and disinfection of surfaces and environments of which health personnel must be informed; • cover with disposable films all the surfaces that are touched during the procedures (for example switches, it equipment) and change these protections between each patient; • surfaces that are not protected by a barrier should be cleaned and disinfected with a disinfectant after each patient; • use a medium level disinfectant (i.e., tuberculocidal indication) if a surface is visibly contaminated with blood; • for each disinfectant, follow the manufacturer's instructions (e.g., quantity, dilution, contact time, safe use, disposal) [136] (table 6 ). if proper maintenance is not carried out, microbial pathogens (e.g., pseudomonas or legionella spp.) can multiply in duwls. these organisms grow in the biofilm on the internal surfaces of the tubes, where they cannot be attacked with chemicals. to prevent the formation of this biofilm, the systems should be drained at the end of each day [144] . in dental unit water lines (duwl), water must flow and they must be washed regularly: it is recommended to rinse for two minutes at the beginning and end of each day and for 20-30 s between patients [144] . different agents for disinfection of duwl are available. all handpieces and ultrasonic meters must be equipped with backstop valves and must undergo periodic maintenance and inspection. the filters used in the duwl must be checked periodically or, if they are disposable, they must be changed daily. recommendations for dental unit water quality in dental settings: • use water compliant with environmental protection agency (epa) standards for drinking water (i.e., ≤ 500 cfu/ml of heterotrophic water bacteria), • follow the recommendations for water quality monitoring given by the manufacturer of the unit or waterline treatment product, • use sterile water or sterile saline for the irrigation during surgical procedures [136] . any waste containing human or animal tissue, blood or other body fluids, drugs, swabs, dressings or other infective material is defined as "clinical waste" and it must be separated from non-clinical waste [144] . used disposable syringes, needles, or other pointed instruments must be disposed of in a special rigid container, in order to avoid injury to operators and operators in charge of waste disposal. the waste must be kept in a dedicated area before it is collected, away from public access, and excessive accumulation of waste must be avoided [4, 144] . the whole dental team must be vaccinated against hepatitis b in order to increase personal protection [83] . individuals who have already been vaccinated should monitor their levels of immunity against hbv over time and make booster shots [145] . all dental health care professionals should also receive the following other vaccinations: flu, mumps (live-virus), measles (live-virus), rubella (live-virus), and varicella-zoster (live-virus) [10] . in addition, the rubella vaccine is strongly recommended especially for women who have pregnancy uncertainty [131] . the influenza vaccine is very useful for dental health professionals as they are at risk for respiratory droplets infections by working in close proximity to the patients [10] . when the covid-19 vaccine is ready, healthcare professionals should take it. as additional infection prevention and health care worker measures, rapid tests can be used in dental practices to diagnose covid-19 before each treatment. this is because, as mentioned above, a patient without symptoms is not necessarily a healthy patient. from all these data, it is evident that the dentist and his team need to use rigid and precise operating protocols in order to avoid infectious contagion [23] . several authors proposed some right procedures in the operative dentistry [2] [3] [4] 10, 23, 83, 139, [146] [147] [148] [149] . for this reason, we reassume them in a precise operative protocol organized for all the patients and characterized by some defined steps: prevention of infections must be a priority in any healthcare setting and therefore also in any dental clinic. to do this, staff training and information, adequate management of resources, and use of well-defined operating protocols is necessary. adequate management of the protection for operators (and therefore also for patients) begins with the roles of the secretariat. in order to better organize the workflow, the secretariat must provide a telephone triage. it would be advisable to phone each patient to make sure he is healthy on the day of the appointment. patients with acute symptoms of any infectious disease should be referred at the time of symptom resolution. the medical history of patients may not reveal asymptomatic infectious disease of which they are affected. this means the operator must adopt the same infection control rules for all patients, as if they were all infective. in addition, the secretariat must organize appointments in order to avoid crowding in the waiting room. it would be advisable for the patient to present himself alone, without companions (only minors, the elderly and patients with psycho-physical conditions can be accompanied). in some urgent and non-deferrable cases, it is necessary to treat the patient despite being in the acute phase of infection with any virus. examples of urgent treatments are: pulpitis, tooth fracture, and avulsion [2] . in these cases, the operator must implement the maximum individual protection measures. in the waiting room all material (e.g., magazines, newspapers, information posters) that can represent a source of contamination must be eliminated so that the room is easy to disinfect. patients are requested to go to the appointment without any superfluous objects. at the entrance of the dental structure, the patient must wear shoe covers, disinfect the hands with hydroalcoholic solution according to the following indications, affix any jacket on a special hanger and disinfect the hands again with hydroalcoholic solution. if there are several patients in the waiting room, they must be at least two meters away from each other. the correct hand disinfection procedure with hydroalcoholic solution is as follows: a) apply a squirt of sanitizer in the palm of hand, b) rub hands palm against each other, c) rub the back of each hands with the palm of the other hand, d) rub palms together with your finger interlaced, e) rub the back of fingers with the opposite palms, f) rotate thumbs in the other hand, g) do a circle on palm with finger clasped, h) once dry, hands are safe. the same procedure is performed for washing hands with soap and water. the operators must be adequately dressed in the correct ppe. healthcare professionals will need to remove any jewel before starting dressing procedures. all the necessary ppe must already be positioned clearly visible and intact, in a room that will be distinct from the one where the undressing phase will take place. in both areas, hydroalcoholic solution and/or items necessary for washing hands with soap and water should be available. in the dressing room there must be trays for the collection and subsequent disinfection of the non-disposable ppe and special containers for the collection of waste where to dispose of the disposable ppe. a dressing and undressing procedure is described below, imagining that the dentist has to operate under a high risk of infection. dressing and undressing procedures must be particularly considered. dressing procedure: a) eliminate jewels and personal items from the pockets of the uniform; b) long hair must be tied and inserted into a cap not mandatory for single use (no tufts of hair must come out of the cap); c) wear shoe covers; d) perform social hand washing or disinfection with antiseptic gel; e) wear the first pair of gloves of the right size; f) wear the water repellent gown by tying it on the back without double knots (first the upper part and then the lower part, the latter must be tied on the front) being careful not to leave parts of the uniform exposed; g) wear the mask (ffp2-ffp3) which must adhere well to both the nose and the mind; h) put on the disposable water-repellent cap and be tied under the chin, the excess ribbons must be inserted inside the gown; i) wear glasses/protective screen; j) wear a second pair of gloves for direct patient assistance. these gloves must cover the cuffs of the disposable gown. undressing procedure: a) remove the second pair of (dirty) gloves being careful not to contaminate the underlying gloves; b) gloves still worn with a hydroalcoholic solution are disinfected and a new pair of gloves is worn on them; c) the face shield is removed: if it is disposable it should be trashed, and if it is not disposable, it should be placed in a container with disinfectant; d) the second pair of gloves is removed without contaminating the underlying gloves; e) the gloves are rubbed with hydroalcoholic solution and a new pair of gloves is worn; f) disposable gown removal starting from the top, then the bottom, rolling it up to touch the inside, clean; g) throw disposable shirts and second pair of gloves; h) the gloves are rubbed with hydroalcoholic solution and a new pair of gloves is worn; i) remove the water-repellent cap; j) the gloves are rubbed with hydroalcoholic solution and a new pair of gloves is worn; k) remove mask taking it by the elastics with the head bent forward and down; l) both the first pair and the second pair of gloves are removed; m) hands are disinfected with hydroalcoholic solution. before entering the surgical room, the patient must be dressed in a disposable gown and headgear worn in order to avoid any contagion on clothing and hair. 7. before dental session patient should rinse and gargle with a specific mouthwash. chlorhexidine is commonly used for pre-procedural oral rinses in dental offices, but its capacity of 2019-ncov destruction has not yet been demonstrated [4] . instead, pre-procedural oral rinses with oxidizing such as 1% hydrogen peroxide or 0.2% povidone-iodine are recommended [4] . so, the pre-procedural use of mouthwash, especially in cases of inability to use a rubber dam, can significantly reduce the microbial load of oral cavity fluids [3] . in fact, even if oral rinses seem to "limit" the viral load, virus can spread through the complete respiratory tract and it is not scientifically possible to guarantee that this reduction is constant during the operative manoeuvre (e.g., cough, sneezing, runny nose). then the following pre-operative procedure is recommended to the patient: a) 1% hydrogen peroxide 15" gargle followed by 30" rinse, b) do not rinse with water at the end of the rinse and continue with chlorhexidine 0.20% 60" rinse with final gargle of 15" [146] . at the end of the procedure, the patient must be appropriately undressed, and have another oral rinse performed before washing hands and face thoroughly. 8. after every patient, carefully clean all surfaces, starting from the least contaminated to the most potentially infected, taking care not to overlook the handles of the doors and the various drawers, worktops and all the devices used during the treatment and which are not disposable or autoclavable. cover switches, mice, computer keyboards, and anything else that may be more difficult to clean with disposable film. the worktops must be free from anything that is not strictly necessary to perform the service. an accurate disinfection of the surfaces includes a preventive cleaning of the same in order to eliminate the soil which otherwise would not allow the disinfectant to inactivate the microorganisms [29] . in the same way, if you want to use disinfectant wipes, you must use one to cleanse and after another to disinfect. as regards spray disinfectants, the percentage of dilution and the time of application vary from product to product: you must follow the instructions provided by the company. moreover, alcohol-based disinfectants (75%), 0.5% hydrogen peroxide, 0.1% sodium hypochlorite are recommended to be left to act on the surfaces for 1 min. disinfect the circuits of the treatment center at each patient change. between patients, the tubing of high-volume aspirators and saliva ejectors should be regularly flushed with water and disinfectant such as 0.1% sodium hypochlorite. always air the rooms after each patient (at least 20-30 min) or use germicidal lamps. clean floors with bleach at least two times a day. 9. during every procedure minimize the use of an air/water syringe: dry the site with cotton rollers when possible; use suction at maximum power (it might be an idea to use autoclavable plastic suction cannulas that have a greater suction capacity than normal disposable pvc cannulas) or use two saliva ejectors; in the case of exposed carious dentine, try to remove it as manually as possible using excavators; be sure to first mount the rubber dam, disinfect the crown with pellets soaked in 75% alcohol and recommend with the second operator to position the aspirator as correctly as possible to avoid excessive spraying and/or splashing; do not use air-polishing; avoid intraoral x-rays as they stimulate salivation, coughing and/or vomiting; prefer exams like opt (orthopantomography) or cbct (cone beam computed tomography). in case of extractions, it is preferable to use resorbable sutures to seal the post-extraction site. in the case of patients who are definitely positive for any infectious agent or on which there are greater possibilities of positivity highlighted by the medical history, it is necessary to plan their treatment at the end of the day. do not touch patient card and pens with dirty gloves. it is good practice to cough or sneeze into the elbow. the operator must avoid touching his eyes, nose and mouth with dirty gloves or hands. 10. isolation with rubber dam [4] . isolating the oral cavity with the use of rubber dams greatly reduces (about 70%) the spread of respiratory droplets and aerosols containing saliva or blood coming from the patient and aimed to the operator area of action [4] . after positioning the dam, the operator must provide an efficient high-volume intraoral aspiration in order to prevent the spread of aerosol and spray as much as possible [148] . if rubber dams cannot be used for any reason, the operator should prefer to use manual tools such as hand scalers [4] . 11. anti-retraction handpiece [4] . during the covid-19 pandemic, operators should avoid using dental mechanical handpieces that do not have an anti-retraction function [4] . mechanical handpieces with the anti-retraction system have valves (anti-retraction) that are very important in order to prevent the spread and dispersion of droplets and aerosol [148, 149] . 12. all instruments which have been used for the treatment of a patient or which have only been touched by operators during a session and which cannot be sterilized according to standard protocols, must be disinfected (e.g., immersed in a container with phenol) [23] . this tools bagged in disinfection solution must remain in solution for about 10 min [23] . some materials, such as polysulphide, polyvinylsiloxane, impression compound, and zoe impressing materials, after being in the patient mouth, are rinsed with water and immersed in a 5.25% sodium hypochlorite solution for about 10 min [23] . the alginate or polyether impressions are also rinsed with water, sprayed with a 5.25% sodium hypochlorite solution and placed in a container for about 10 min [23] . wax, resin centric relation records, and zoe are rinsed with water and sprayed with a 5.25% sodium hypochlorite solution and placed in a plastic bag for about 10 min [23] . provisional restorations and complete dentures removed from the patient mouth are immersed in a 5.25% sodium hypochlorite solution for 10 min [23] . otherwise, removable partial prostheses with metal bases are treated with 2% glutaraldehyde solution and placed in a plastic bag for 10 min [23] . a novel and useful indication is that of classifying each common dental procedure according to the likelihood of a contagion by one or more infective agents (via saliva, blood, droplets or aerosol) for the team and for the patient (under the cure or the subsequent), nevertheless its type and intrinsic operative difficulty (table 7) . according to this paradigm, all dental procedures involving the use of the air-water syringe and/or rotating/ultrasound/piezo tools are able to produce high levels of aerosols and droplets and for this reason the dentist must consider them dangerous for himself, the dental team, and the subsequent patients. meanwhile, procedures, even if refined (e.g., soft tissues biopsy for oral cancer suspicion) but characterized by a low/absent production of aerosol and droplets, must be considered not particularly threatening. for all these considerations, the dental team must reconsider its operative protocols and modulate the ppe use according to level of risk of common dental procedures of generating droplets or aerosols. table 8 presents the use of different ppes for each common dental procedure in pre-covid vs post-covid era. it is definitively clear that the use of air-water syringe and/or rotating/ultrasound/piezo tools able to produce high levels of aerosols and droplets need the use of the safest ppe in order to reduce/eliminate viral or other infectious agent diffusion within the dental setting. table 8 . proposal of modulation of personal protective equipment (ppe) according to level of risk or common dental procedures both in pre-covid and post-covid era (bold style means the introduction of the new ppe due the transition from a risk category to a higher one). in the face of the covid-19 pandemic, new biosafety measures are necessary to reduce contagion. dentistry is a profession that works directly with the oral cavity and is therefore very exposed to this virus or other infectious agents. because of this, some measures need to be taken to minimize contagion. in fact, dentists can play an important role in stopping the transmission chain, assuming correct procedures in order to reduce the viral agent diffusion, or in promoting undesirable infectious disease diffusion, if operating in adherence to adequate safety protocols. dental-care professionals must be fully aware of 2019-ncov and other viral agent spreading modalities, how to identify patients with active infections and, most importantly, to prioritize self and patient protection. 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efficacy of rubber dam isolation in reducing atmospheric bacterial contamination severe acute respiratory syndrome and dentistry approaches to the management of patients in oral and maxillofacial surgery during covid-19 pandemic interim guidance for management of emergency and urgent dental care; ada: niagara falls plan estratégico de acción para el periodo posterior a la crisis creada por el covid-19 key: cord-318061-xe8lljz0 authors: overgaauw, paul a.m.; vinke, claudia m.; van hagen, marjan a.e.; lipman, len j.a. title: a one health perspective on the human–companion animal relationship with emphasis on zoonotic aspects date: 2020-05-27 journal: int j environ res public health doi: 10.3390/ijerph17113789 sha: doc_id: 318061 cord_uid: xe8lljz0 over time the human–animal bond has been changed. for instance, the role of pets has changed from work animals (protecting houses, catching mice) to animals with a social function, giving companionship. pets can be important for the physical and mental health of their owners but may also transmit zoonotic infections. the one health initiative is a worldwide strategy for expanding collaborations in all aspects of health care for humans, animals, and the environment. however, in one health communications the role of particularly dogs and cats is often underestimated. objective: evaluation of positive and negative one health issues of the human–companion animal relationship with a focus on zoonotic aspects of cats and dogs in industrialized countries. method: literature review. results: pets undoubtedly have a positive effect on human health, while owners are increasing aware of pet’s health and welfare. the changing attitude of humans with regard to pets and their environment can also lead to negative effects such as changes in feeding practices, extreme breeding, and behavioral problems, and anthropozoonoses. for the human, there may be a higher risk of the transmission of zoonotic infections due to trends such as sleeping with pets, allowing pets to lick the face or wounds, bite accidents, keeping exotic animals, the importation of rescue dogs, and soil contact. conclusions: one health issues need frequently re-evaluated as the close human–animal relationship with pet animals can totally differ compared to decennia ago. because of the changed human–companion animal bond, recommendations regarding responsible pet-ownership, including normal hygienic practices, responsible breeding, feeding, housing, and mental and physical challenges conforming the biology of the animal are required. education can be performed by vets and physicians as part of the one health concept. the one health initiative or concept is a worldwide strategy that recognizes that public health is connected with animal health and the environment. it concerns multidisciplinary collaboration between physicians, veterinarians, environmental scientists, public health professionals, wildlife experts, and many others [1, 2] . with a multisectoral and transdisciplinary approach, public health threats can be better monitored and controlled. the resulting synergism enhances the knowledge of how diseases, known as zoonotic diseases, can be shared between animals and people with the goal of this article is based on an existing post-graduate course for veterinarians, vet technicians, family doctors, midwifes, and specialists such as pediatricians which explores healthy human-animal relationships. the existing evidence-based knowledge contained in this course has been actualized by performing a literature search to add new relevant publications. a literature search was conducted through 2 march 2020, using the national library of medicine's pubmed for the terms "one health" and "companion animals"; "pet ownership"; "households" and "pets"; "dogs" or "cats" or "pets" and "mental" or "physical health" or "children"; "animal assisted therapy"; "dogs" or "cats" and "nutritional problems" or "overweight" or "obesity" or "homemade" or "raw meat diets"; "dogs" or "cats" and "behavior problems" or "aggression" or "fear" or "anxiety" or "abnormal repetitive behavior"; "dogs" or "cats" and "breeding" or "genetic problems"; "dogs" or "cats" and "zooanthroponoses"; "pets" and "anthropomorphism"; "dogs" or "cats" or "exotic animals" or "rescue dogs" or "soil" and zoonoses. for some topics the internet was accessed and used as reference if additional information was not available as scientific publication. the authors selected articles that described pivotal and novel insights in the different topics. all searches were carried out without filters. the titles of all found articles were screened for relevance to the topic, and appropriate titles were assessed and selected based on their abstracts. if a selected article was a review, it was read and relevant citations were used to find primary literature on the subject. additional studies were found using the bibliographies of selected articles. occasionally, reviews were directly used as sources, mostly to convey background information that is not in the core focus of this article. original articles in english and different national languages (dutch, german, french, spanish, if available) were included. specific searches were made for citations dated after the year 2000 to ensure more recent literature on the topic had not been missed. a pet or companion animal is an animal that lives in or around the house and is fed and cared for by humans. until the 1960s, pets were mainly kept as utility animals, for example as draft dogs or watch dogs or for pest control when it comes to cats. due to major changes that have taken place in society since the second world war, such as increased leisure time and prosperity, but also individualization of humans, animals are nowadays kept as pets and are regarded by many owners as valued family members, e.g., over 90% in the united kingdom [13] . pet ownership is still increasing in many industrialized countries and these animals are more often considered a member of the family [5] . even in china, a country where pets were banned in urban areas until 1992, pet ownership has grown quite rapidly in the major cities. the rate of pet ownership of all usa households increased from 57.6% to 59% in 2018. dogs continue to dominate in popularity among american households. approximately 38% of households nationwide owned a dog, bringing the population of pet dogs to nearly 77 million, while 25% of households owned cats, with a total population of 58 million [14] . in 2018, an estimated 80 million european households owned at least one pet animal; 24% of households owned dogs and 25% owned cats [15] . there are 85 million pet dogs and 104 million pet cats in europe which is a 15% increase of dogs within 8 years (74 million dogs in 2010) and a 22% increase of cats (85 million in 2010) [16] . pet cats in europe thereby are more popular than dogs. an explanation of the higher popularity of cats may be the number of single-person households in the eu that rose on average by 2.0% per annum between 2006 and 2016 to 32.5%, and the growth of two-family households grew by 1% to 31% in this period [17] . also, dual-earner families are widespread as a result of quite a steep growth in female employment over the past two decades [18] . when animals live with humans, they too benefit from human interaction. over the past decades, animal welfare has evolved to recognize that animals are sentient beings capable of experiencing positive and negative emotions. the social and ethical dimensions of animal welfare, which are concerned with how human society morally regards and treats non-human animals, are also increasingly being recognized [19] . in dutch law, the intrinsic value of kept animals is expressly incorporated and used as a guiding ethical principle that forms the basis of any further legislation. the intrinsic value is thereby defined that animals are sentient beings that can feel pain and discomfort. therefore, they should be kept free of stress, pain, disease, hunger, thirst, and should be able to show natural behavior known as the five freedoms of r. brambell 1965 [20] . in industrialized countries animal keepers, their owners, are legally required to provide such circumstances and can be prosecuted if they infringe the law. of course, in the field there is animal abuse, negative animal welfare conditions, and animal diseases. however, in general, caretaking for companion animals is nowadays performed at a high level. new insights into animal behavior has had its influence on the general public. for example, owners are aware or are told by vets and pet shops that rabbits should not be kept alone but at least in pairs due to their need for social contact [21] . there are various reasons to keep pets, such as love, warmth, and companionship. companion animals have an important emotional value, and promote the socialization of the lonely elderly because they facilitate additional contact with people. pets form a goal in life, reduce stress, and ensure that the owner keeps physically active. around 95% of dog owners and 93% of cat owners expressed that owning their pet makes them happy and 44% of owners selected this as one of the reasons they got their pet in the first place [22] . however, the function of companion animals consists of more than just providing a socializing being. studies show other benefits of having a pet, such as the positive effect on individuals' mental and physiological health status. most research addressing the health benefits of pet ownership show reductions in distress and anxiety, decreases in loneliness and depression, and increases in physical condition [23] . the positive benefits to human health from interacting with animals, focusing on the companion animal, have also be described with the term "zooeyia" [24] . in fact, 63% of owners agreed that having a pet makes them physically healthier, with dog owners more likely to agree, most probably because dog owners exercise more (85% agreeing, compared to 41% of cat owners). besides, 84% of owners agreed that having a pet makes them mentally healthier. expressed reasons are the non-judgmental nature of their pets, their playfulness, or physical contact [22] . another demonstrated positive influence is the blood pressure and heart rate lowering effects that occurs when stroking a friendly-looking dog or even being in the presence of a friendly animal, while it is not necessary to own a pet to obtain these stress-moderating benefits [23] . many studies have demonstrated the association between pet ownership and cardiovascular health and dog owners appear to have a significantly greater chance of survival after a heart attack compared to people without pets [25] [26] [27] . pets can therefore play an important role in reducing absenteeism and visits to family doctors or the hospital [28] . it has been estimated that pet ownership saved australia $1 billion in 1994 [29] , while it may reduce the use of the national health service (nhs) in the uk to the value of £2.45 billion per year [30] . dogs also play an increasing role as co-therapist or as supporter for people with psychological or physical disabilities. the benefits of these animal-assisted activities are improved mood, decreased physiological distress, depression, dementia, and loneliness [31, 32] . examples include resident or visiting dogs in prisons, nursing homes [33] , mental institutions, and hospitals where they can reduce patient anxiety in a hospital emergency department [34] , reduce pain perceptions in children after surgery [35] , or calm young patients at a pediatric dental clinic [36] . since dogs have extremely sensitive noses, they are used for several purposes such as tracking, bomb detection, and search and rescue. in recent years, canine olfaction has also been more recognized as a diagnostic tool for identifying pre-clinical disease status, such as diabetes (ketones), different forms of cancer, and infections from biological media samples [37] . animal-assisted therapies can act as co-therapies to facilitate psychotherapy or to provide specific types of therapeutic interventions such as improving motor skills or behavior [23] . such interventions were effective in improving the state of children or adults with or at risk of developing mental disorders such as attention deficit hyperactivity disorder (adhd), post-traumatic stress disorder (ptsd), or autism spectrum disorder (asd) [38] [39] [40] , and for the treatment of ptsd in military veterans [41, 42] . assistance or service animals are trained to perform tasks for the benefit of individuals who have disabilities such as hearing loss, physical disabilities, emotional disabilities, seizure disorders, or diabetes [23] . finally, a wide range of emotional health benefits from childhood pet ownership has been identified, particularly for those suffering from low self-esteem and loneliness. there is evidence of an association between pet ownership and educational and cognitive benefits, increased social competence, social networks, social interaction, and social play behavior [43, 44] . significantly less absenteeism from school through sickness among children who live with pets has also been reported [13] . having a dog or cat in the house during the first year of life may protect against childhood asthma and allergy [45, 46] . it can therefore be concluded that companion animals contribute significantly toward the public health, but also increasingly, the health of individually challenged persons through animal-assisted interventions [47] . providing companion animals with feed by humans, has been considered an advantage for companion animals in their relationship with humans. however, the feeding practices can also have a negative impact on companion animals [48, 49] . obesity in cats and dogs is a disease which is rapidly increasing with significant and lifelong implications for animal welfare. although no universally accepted definition of canine and feline obesity exists, the american veterinary medical association defined obesity being more than 30% above the ideal weight of an animal. overweight is defined as 10%-20% above the ideal weight. using body condition scores, it has been estimated that in the united states, 54% of dogs and 59% of cats are obese or overweight. a study in the united kingdom reported 65% of adult dogs and 37% of juvenile dogs as being obese or overweight [50, 51] . overweight dogs are more likely to be diagnosed with, e.g., urinary tract diseases. obese and overweight dogs are at risk developing orthopedic disorders and hypothyroidism [52, 53] . obese cats are at higher risk for developing urinary tract disease, diabetes mellitus, and neoplasia [54, 55] . other diet-related problems in companion animals can be caused by the changed feeding behavior of humans, e.g., by providing companion animals with bone and raw feed (barf) or vegan diets. risks for companion animals associated with barf or vegan diets are the presence of microbial hazards, insufficient nutrition, and in raw meat diets the presence of risk materials like thyroid tissue. through contact with their animals, it is possible that risks could even develop for owners. there could be an increased risk of human salmonellosis because of the presence of salmonella spp. in the diet which can spread to humans through diet leftovers or by contact with animal feces. recently a review was published on the risks of barf feeding [56] . the authors concluded that the data for the nutritional, medical, and public health risks of raw feeding are fragmentary, but they are increasingly forming a compelling body of formal scientific evidence. publications were found reporting the presence of escherichia coli o157, salmonella typhimurium, campylobacter spp., and antibiotic resistant bacteria in the feed. nutritional problems, such as calcium/phosphorous imbalances and specific vitamin deficiencies [57] are also reported. moreover, homemade diets are inherently susceptible to nutritional imbalances and deficiencies [58] . awareness about climate change, public health and animal welfare has incited a major change in dietary choices among many individuals. the number of vegans in the world keeps growing, even quadrupling from 150,000 to 600,000 individuals between 2014 and 2019 in affluent countries such as the uk [59] . the popularity of veganism goes beyond the scope of the human diet, as more people are interested in the possibility of feeding their companion animal a vegan diet than ever before. to create animal-free complete cat food requires replacing nutrients in animal-based materials with plant-based materials. different sources are used such as corn, rice, peas, soy, potato, and different oils and seeds. any further nutrients that are missing from plant-based materials, such as taurine and carnitine, are replaced with synthetically produced versions [60, 61] . feeding trials using vegan animal food are either not performed due to testing costs or kept private due to the highly competitive vegan pet food market [62] . additionally, they reported testing 24 vegetarian diets for cats and dogs and found that one was lacking protein and six did not meet all amino acid concentration requirements. vegan animal food may not contain meat, but it does contain grains, soy, and corn. plant-based products, such as grains, can be a source of health problems because of the presence of mycotoxins, for example [63] . warm, humid storage conditions can lead to the formation of mycotoxins such as aflatoxins, produced by the fungi aspergillus flavus and aspergillus parasiticus. many regular animal feeds also contain plant-based products, therefore the negative impact of feeding vegan diets to companion animals, especially obligate carnivores such as the cat or the ferret, seems therefore more related to diet insufficiency than to microbial health risks. additionally, addressing behavioral problems, the "free" provision of food might fulfil the consumptive part of feeding behavior of our companion animals but does not fulfil the appetitive phase. especially this phase of feeding patterns can have consequences for the companion animals' mental health and may result in behavioral problems if appetitive physical and mental challenges remain chronically absent in the human-animal relationship. in the human-companion animal bond, pets may develop abnormal behavior, including excessive aggression, fear and anxiety, or even abnormal repetitive behavior. abnormal repetitive behavior (arbs) were first noticed in zoo-, shelter-, and laboratory animals: all animals housed under stimulus-poor conditions and with limited space. however, companion animals can develop arbs as well, if the individual's adaptive capacity is exceeded due to, e.g., a lack of social contact, physical exercise, mental challenges, and in uncontrollable and unpredictable environments (e.g., separation, mistreatment, or inadequate application of cages). arbs can either be classified in stereotypies or compulsive disorders [64] with stereotypies generally defined as unvarying repetitive behavior patterns with no obvious goal or function [65] . the terminology of compulsive disorders is preferably chosen for repetitive behavior patterns that are goal-directed and show variability in the repetitive (motor) patterns [66, 67] . under chronic conditions without possibilities to adapt (cope), companion animals may develop stereotypies or compulsive disorders like, e.g., tail chasing, polyphagia, compulsively self-directed licking and/or biting the coat [68] , or feather pecking in parrots [69] . self-directed patterns can result in serious degrees of alopecia, lick granuloma, or even self-inflicted injuries (auto-mutilation) with a risk of infection. two main reasons underlie the development of arbs in our companion animals. first of all, a lot of companion animals are social species eager for social contact. in the human-companion animal bond, the need for social contact with either conspecifics and/or humans [70, 71] can remain unfulfilled if owners work from nine to five, five days a week with the pet staying alone at home on a daily basis. on the other hand, a cat which is originally a solitary hunter with a complex dynamic social structure may start overgrooming or house soiling in the presence of another cat in the territory. such situations might occur in multi-cat households, in the presence of neighboring cats, and in in-stable grouped housing conditions in shelters [72, 73] . secondly, most companion animals are species that are eager for mental and physical challenges on a daily basis. the lack of foraging opportunities, the appetitive phase of feeding behavior [74] might be another reason for the possible development of arbs in companion animals. foraging is often regarded as a high priority behavior [75, 76] , i.e., an internally motivated behavioral pattern that should be performed, or otherwise may induce a state of chronic stress, which may result in behavioral pathology like arbs as described in many other animal species [77] [78] [79] . foraging patterns may include walking, running, jumping, nose pushing, digging, and overseeing the area, all active patterns that imply the daily need for physical exercise and mental challenges in most of our companion animals. nonetheless, our pets mostly, if not always, get their food for free with minimal foraging challenges, except for going out 3-5 times a day. for some individuals (and especially some dog breeds, e.g., malinois, border collies, and pit bull terriers) [80, 81] , situations and contexts with limited challenges can make them more vulnerable to the development of arbs. as well as arbs, other problematic behavior may develop in our companion animals, and the prevalence of some of this behavior is even higher than that of arbs, for example excessive interspecific and/or intraspecific aggression, fear, and anxiety. at what moment, and which type of problem behavior may develop, depends on the intermingled factors of, e.g., genetics, early life experiences (maternal-child bonding, weaning, socialization [82] ), daily environment, and multiple factors in and around the human-companion animal bond. the history of breeding animals goes back to a time when humans and animals shared each other's habitat. dogs originally have been selectively bred to support human needs, such as hunting, herding, obedience, guarding, rescuing, and for companionship. this artificial selection has generated a large number of dog breeds, displaying a large variation of behavior, size, head shape, coat color, and coat texture [83, 84] . unfortunately, in the last 100 years, intensive selection for extreme looks and a narrow gene pool of many breeds has interfered in the genetic make-up of dogs, leading to unfavorable anatomy (extreme large, or extreme "teacup" small), and genetic predisposition to numerous health, welfare, and behavioral problems [85] . over 700 inherited disorders and traits have already been described in the domestic dog [86] . one type of dog with a distinct dysmorphology is the brachycephalic dog. brachycephalic dogs are characterized by a large head and round face due to a shortened muzzle, a high and protruding forehead, and widely spaced large eyes. these facial features fit the concept of baby schema ("kindchenschema") proposed by konrad lorenz [87] . infantile (cute) faces are biologically relevant stimuli for rapidly and unconsciously capturing attention and eliciting positive or affectionate behavior, including the willingness to care [88] . the appeal of brachycephalic animals has led to specimens that are the so-called "over-typed" dogs and cats with a too short nose, excessively protruding eyes, too straight angulations, etc. breeding animals with this type of severe skull and muzzle abnormalities leads to physical and physiological hardship and limits their natural behavior [89, 90] . this violates their integrity and is a big risk for their welfare. selectively breeding animals in order to express specific traits does not only alter existing animals, but also creates new ones, turning animals into an instrument for human use [91] . the bambino sphynx cat is an example of so called "mutant breeding", where breeders deliberately stack in two steps the recessive inheriting mutations, which leads to hairlessness in sphynx cats, on the dominant inheriting (lethal) mutation responsible for the shortened legs of the munchkin cat. the lack of hair in combination with short legs interferes with the normal physiology of the cat with regard to the manner of movement, thermoregulation, and skin health. one may argue that artificial selection in exchange for money, status, or aesthetic reasons violates the animal's dignity and integrity [92] . conclusively, artificial selection for excessive traits can have direct consequences for individual health and welfare, may obstruct and prevent a pet from fulfilling its behavioral needs, and conflicts with the current moral way of thinking on animal dignity and integrity. pet animals are not only perceived in 80%-90% as family members or partners but are almost treated like humans. in one study, up to 62% of owners agreed with the statement "my dog is more important to me than any human being" [93] . this kind of behavior is the result of the attribution of human cognitive processes and emotional states to animals, such as feelings of happiness, love, or guilt. people believe that animals have awareness, thoughts, and feelings. this behavior is called anthropomorphism, personification, or humanization and can also be applied to plants, gods, or objects. anthropomorphism appears to be caused by the perceived similarity between humans and animals and the extent to which people have developed an affectionate bond with their dogs and cats [94] . human empathy provides the basis for the attribution of empathy to other animals, as well as attributions of the communicative ability of other animals [95] . anthropomorphistic behavior can be harmless, such as talking to pets, which many owners do and one of the reasons for this may be the unique ability of humans to recognize facial expressions. talking to pets is also found to be linked to social intelligence [94] . however, it can lead to animal welfare problems when the feelings of owners no longer match the needs and the intrinsic values of their animal. examples of this are designer dog clothes, animal perfumes, and jewelry, thought the use of protective coats in colder climates for small, short-haired breeds, e.g., chihuahuas, is considered useful. the large number of obese pets can also be partly attributed to anthropomorphism. studies from north america, europe, and australia to determine what proportion of animals, mainly dogs, are overweight or obese reported prevalences of between 22%-44% [96] . in 2018, an estimated 60% of cats and 56% of dogs in the usa were overweight or obese [50] . when the owner takes a treat with coffee, it is believed that the dog should also get it. even chocolate treats are given, when these are potentially fatal for dogs and cats. this also applies to a good meal that is shared with the pet. dog owners who did not consider obesity to be a disease, maybe because the facial features of their pets fit the concept of baby schema [87] , were more likely to have obese dogs [97] . an often-unrecognized risk for pets is reverse zoonotic disease transmission, the so-called zooanthroponosis. a review on this subject reported 56 articles dealing with human to animal disease transmission [98] . most of the articles dealt with bacterial pathogens but also viral, parasitical, and fungal pathogens were studied in these publications. animals reported to have been infected or inoculated with human diseases included wildlife, livestock, companion animals, and other animals or animals not explicitly mentioned. the majority of the studies focused on human to wildlife transmission with an emphasis on mycobacterium spp. for companion animals, mrsa-infection was especially reported but m. tuberculosis, influenza a, and candida albicans were also discussed. for all groups of animals, microsporum spp. and trichophyton spp. were identified as infectious agents originating from humans [99] . recent publications report a different kind of zooanthroponosis: the transmission of high-risk, multidrug-resistant pathogens from humans to animals [100] . a major issue mentioned is the transmission of high-risk clones of extended-spectrum beta-lactamase (esbl) producing bacteria including escherichia coli, enterobacter cloacae, and klebsiella pneumonia [100, 101] . the transmission of carbapenem-resistant ndm-5 producing e. coli from previously hospitalized humans to dogs has also been suggested [102] . transmission of hospital acquired antibiotic resistant bacteria from human patients to their pets has been confirmed, such as the vim-2 producing pseudomonas aeruginosa st233 strain in brazil [103] . this increased transmission of high-risk multidrug-resistant pathogens from humans to animals was related to the closer relationships between humans and companion animals. some authors doubt the generalized pet-effect on human mental and physical health because of conflicting results that are prevalent in this area of science and the lack of publication of negative results [13, [104] [105] [106] . the majority of research evidence was also considered inconclusive due to methodological limitations such as reliance on self-reports, small sample sizes that may not be representative of the general population, homogeneous populations, varying research designs, narrow range of outcome variables that were examined, and the use of cross-sectional designs that do not consider long-term health outcomes [107] [108] [109] . other studies found for example that pet ownership was associated with a higher incidence of heart attacks and readmissions in heart attack patients instead of a lower incidence [110] or that pet owners had higher diastolic blood pressure than those without pets [111] . müllersdorf (2010) showed that pet owners had better general health but suffered more from mental problems such as anxiety, insomnia, and depression, than those who did not own pets [112] . other studies failed to support earlier findings that pet ownership is associated with a reduced use of general practitioner services [113] or psychological or physical benefits on health for community dwelling older people [114] . negative effects of pet ownership include dog and cat bites or scratches, the spreading of disease (zoonoses), and fall injuries, caused by falling or tripping over dogs and cats [115] . allergic reactions may be a consequence of animal contact and affect 15%-30% of individuals (often genetically) predisposed [116] . allergies relating to more uncommon pets such as fish, birds, and amphibians seem to be increasing in prevalence [117] . other studies prove that pet ownership in early life did not appear to either increase or reduce the risk of asthma or allergic rhinitis symptoms in children aged 6-10 years. therefore, advice to avoid or to specifically acquire pets for primary prevention of asthma or allergic rhinitis in children should not be given [118] . there are also less-positive effects that pets can have on health. more excessive forms of anthropomorphism became clear in our study for the presence of zoonotic parasites in healthy dogs and cats. fifty percent of owners allow pets to lick their faces. sixty percent of the pets visit the bedroom; 45-60% (dogs-cats) are allowed on the bed, and 18-30% (dogs-cats) sleep with their owner in bed. six percent of pets always sleep in the bedroom. of the cats, 45% are allowed to jump onto the kitchen sink [119] . this means that in addition to the detected zoonotic parasites (the hazard), there was a significant potential exposure to these pathogens. in addition to parasites, other pathogens such as bacteria, viruses, and fungi can also be transmitted by animals by direct contact through biting, licking, scratching, sneezing or coughing, handling pets or their body fluids or secretions and by indirect contact through contaminated bedding, food, water, or bites from an arthropod vector [120] . not every individual will develop symptoms after being infected with a zoonosis. this is the result of various factors such as the causative pet species, housing, the degree of contact and contamination, the ability of a micro-organism to cause disease in humans and animals, but especially due to the degree of immunity of the recipient. in order to assess the risk of disease transmission from pets it is important that the nature and frequency of contacts between pets and their owners or other people are evaluated [120] . we traditionally know that young children (age < 5 years), the elderly (age ≥ 65 years), patients with an impaired immunity, and pregnant women that carry a fragile fetus are at more than average risk of becoming ill after an infection. moreover, they may have more severe disease, have symptoms for a longer duration, or develop more severe complications compared to other patients. young children (notably those aged 3-5 years) and some people with developmental disabilities often have suboptimal hygiene practices or higher risk contact with animals which further increases risk [121] . in children, hand-to-mouth behavior is part of their natural development and they mouth their fingers and other objects. in a meta-analysis, the average indoor hand-to-mouth frequency ranged from 6.7 to 28.0 contacts/hour and the average outdoor frequency ranged from 2.9 to 14.5 contacts/hour. the lowest value was attributed to the 6-to 11-year-olds and the highest to the 3-to < 6-month-olds [122] . fifteen percent of dog owners and 8% of cat owners always wash their hands after contact with the animals [119] . in addition, due to improved healthcare in recent decades, the group of immunocompromised patients has increased sharply. this includes, for example, patients with diabetes, post-splenectomy, after placement of implants and patients being treated with chemotherapy or immunosuppressants. the risk groups are also referred to as yopis (young, old, pregnant, and immune suppressed). patient surveys and epidemiological studies suggest that the occurrence of pet-associated zoonotic disease is low overall [121] . many of these pathogens are not reportable and presumably underdiagnosed or not recognized by family doctors due to the general, mostly flu-like, symptoms. therefore, any reported frequency of such infections is likely underestimated. to get a better picture of zoonotic risks, a risk analysis is required where a risk score can be calculated using exposure, contagiousness of the infection, and its consequences in the human. in addition, the disease burden of an infection for the population can be calculated and expressed in disability adjusted life years (dalys). this quantifies the health loss based on two components: the life years lost due to premature death and secondly the proportional loss of quality of life as a result of the disease. there is a trend towards closer physical contact between owners and their pets or their environment which poses an increased risk of transmission of zoonotic pathogens. these trends (a general direction in which something is developing or changing) will be explained. our publication [119] showed that a high percentage of pets were allowed in the bedroom and in bed, with 6% always sleeping in bed with their owner. is that a problem? already from a hygienic point of view, it is not advisable to sleep with animals or take them into bed. they do not pay attention to where they are walking outside and do not wipe their feet after arriving home. dogs like to roll in carcasses and both dogs and cats regularly lick the anus and thereafter the fur. in a pilot study with 28 healthy dogs and 22 healthy cats that slept with their owners, we tested 68% of the dogs (19) and 32% of the cats (7) positive for enterobacteriaceae on the fur or footpads. fleas and flea larvae were found on 14% of pets [123] . as a result of our publication, chomel investigated in 2011 whether transmission of infections by sleeping with pets and licking the face could be found in literature. he reported that also in the usa, france and the uk, a relatively large number of pets slept in bed with their owner (14%-33% of dogs and 45%-60% of cats) [124] . similar results of sleeping with pets were also reported from canada (26% of pets slept with children), the czech republic (45%), and qatar (63.3%) [125] [126] [127] . chomel found bacterial infections such as yersinia pestis (plague), bartonella henselae (cat scratch disease), methicillin-resistant staphylococcus aureus, and sometimes fatal bite wound infections such as capnocytophaga canimorsus and pasteurella multocida. furthermore, parasite infections such as cheyletiella spp. were reported. feline cowpox is a rare viral infection, but it can be transferred to the human after direct contact. both animals and humans reveal local exanthema on arms and legs or on the face. in most cases the disease is self-limiting, but immunosuppressed patients can develop a lethal systemic disease resembling smallpox [128] . it can be concluded that, although uncommon with healthy pets, the risk of transmission of zoonotic agents by close contact between pets and their owners through bed sharing is real and has even been documented for life threatening infections such as plague [129, 130] . although pets do not transmit arthropod-borne diseases to people (e.g., lyme borreliosis, ehrlichiosis, anaplasmosis), they do bring zoonotic disease vectors such as ticks and fleas, in close proximity to people, e.g., when they are sleeping with their animals [121] . while fleas are considered a vector of bartonella henselae (the causative agent of cat scratch disease) tickborne diseases are reported as increasing as ticks expand their ranges [131, 132] . with an estimated 65,000 cases a year, lyme borreliosis is responsible for the largest disease burden of any vector-borne disease in the european union [133] . another increased risk associated with close contact with fur is when it is contaminated with zoonotic parasite eggs. especially with echinococcus multilocularis (fox tapeworm) or e. granulosus (hydatid worm, or dog tapeworm). these eggs are immediately infective and may cause serious health problems in the human, many years post infection [134, 135] . despite a low prevalence of infectious (embryonated) eggs of toxocara spp. on dog's fur, the potential zoonotic risk should not be disregarded [136] . the same risk is applicable for the persistence of sporulated toxoplasma gondii oocysts in dogs' fur [137] . in relation to this, it is noteworthy that many publications report striking increases of ringworm, a common zoonotic fungal skin infection in mainly children caused by microsporum spp., trichophyton spp. or arthroderma spp., where the presence of pets is always mentioned [94] . however, nowhere has it been suggested that close contact with infected pets in bed increases the infection risk [138, 139] . rodents or rabbits are mainly infected with t. mentagrophytes, while m. canis is primarily found in dogs and cats. infection occurs by direct or indirect contact with infected hair, scales, or materials. infected animals may be asymptomatic carriers without clinical signs. examples are 16% m. canis carriage in a study of european cats [140] , 27% in suspected brazilian cats [141] , and the isolation of t. mentagrophytes dermatophytes from 4% of clinically healthy rabbits and 17% of guinea pigs in dutch pet shops [142] . licking the face of humans by mainly dogs is an expression of their naturally submissive, positive social behavior. the owner is recognized by the dog as the dominant superior in the ranking. in a pack of dogs, submissive dogs lick their dominant counterparts at the corners of the mouth from a typical submissive attitude [143, 144] . owners apparently allow this as a token of affection from their pet. such behavior is more common in young animals and has been considered as attention-seeking or care-soliciting gestures. it indicates to the owner the strength of the social bond between dogs and people [120] . licking or nudging of veterans by service dogs may help take their mind off any negative thoughts, emotions, or memories that they might be experiencing [145] . on the internet, many images can be found of mainly dogs, but also cats and even rats licking their owner's face. various studies show that around 40%-50% of owners allow this [119, 120] . the question is whether this is harmful due to the potential transmission of infections. the review by chomel (2011) shows in the literature that infections, especially pasteurella spp. and capnocytophaga canimorsus, were reported to have transmitted to humans by dogs, cats, kittens, and rabbits [124] . pasteurella multocida meningitis has been reported in 36 infants where 87% had been exposed directly or indirectly to the oropharyngeal secretions of household dogs or cats through licking or sniffing [146] . zoonotic transmission via this route is also assumed for various other pathogens such as gastric helicobacter spp. [147] , periodontal pathogens [148] , and bartonella henselae the etiological agent in cat scratch disease. the b. henselae bacteria may cause ocular complications, including parinaud oculoglandular syndrome, a severe eye infection. the route of infection is unknown, although direct conjunctival inoculation, most likely with infected flea feces, seems to be most plausible [149] . knowing, however, that b. henselae is present in up to 40% of cat saliva [150] , it is more plausible that salivary fluid could be rubbed directly into the eye from the skin after been licked by a cat. there are several anecdotal reports of infections in mainly young children that were transmitted by being licked. one recent example is an 8-month-old baby that presented with fever and preseptal cellulitis with purulent discharge. the causative agent was surprisingly corynebacterium bovis, a bacterium that is normally found in bovine mastitis. it became clear that the dog was frequently allowed to lick the baby's face and was fed on raw meat [151] . there is an ineradicable belief among a large part of the public that the licking of human wounds by dogs can disinfect them and that the saliva thereby has healing properties [152] . in addition, it is regularly reported that a dog's tongue is believed to be sterile. this is of course not the case and the oral flora of a dog comprises hundreds of species (including pathogenic) bacteria, fungi, and viruses [153, 154] . various wound healing saliva components have indeed been demonstrated in human and animal studies [155, 156] . the bactericidal effects of male and female dog saliva facilitate the hygienic function of maternal licking of the mammary and anogenital areas by protecting newborns from fatal coliform enteritis caused by e. coli and neonatal septicemia caused by streptococcus canis. however, the saliva is only slightly, and non-significantly, bactericidal against wound bacteria such as coagulase positive staphylococci and pseudomonas aeruginosa [157] . capnocytophaga canimorsus and pasteurella multocida are common commensals in the oral cavity of dogs, cats, and other species [158, 159] . transmission has been reported after the licking of mucous membranes or open wounds [160] [161] [162] . in patients at high risk, severe wound infections, sepsis, disseminated intravascular coagulation, or death can occur. patients with immunodeficiency, splenectomy, or alcohol dependence are at a particularly increased risk of infection with c. canimorsus [159] . even immunocompetent persons who have been licked by a dog can develop fatal sepsis [163] . a further negative effect of companion animal ownership is, of course, accidents inflicted on humans by these animals. these accidents can involve tripping over a cat or being dragged by an enthusiastic dog, but in literature, most evidence points towards biting and scratching incidents. dog biting and cat scratching incidents can cause physical health problems both at the time of infliction but also afterwards by triggering trauma-related secondary infections. dog biting incident reports are numerous, and numbers vary from country to country. in the uk, 18.7 dog bites per 1000 population per year were reported [164] , while a commission in the netherlands reported in 2008, 150,000 bite accidents per year in a population of 16 million (9 events per 1000 inhabitants) [165] . children are especially vulnerable to dog bites. the majority of dog bites occurred in children 5 years of age or younger (68.0%) and almost all (89.8%) of the dogs were known to the children [166] . recently, a systematic review has been published that analyzed more than 26,000 bites from the literature of the past 30 years about the risk of bites relative to specific breeds of dogs, combining bite incidence with bite severity [167] . the analysis by breed revealed that pit bulls were responsible for the highest percentage of reported bites across all studies (22.5%), followed by mixed breed (21.2%), and german shepherds (17.8%). dog bite incidents can result in medical treatment, hospitalization and even death. in the netherlands it was calculated that from the 150,000 dog bite victims per year, around 50,000 seek medical attention and 230 are hospitalized [165] . between 3% and 30% of dog bites become infected and complications become more severe when infection occurs. more than 100 species of bacteria have been isolated from bacterial infections of dog bites, suggesting that most oral flora of dogs have the potential to be pathogenic [168] . the top 3 pathogens found are pasteurella, staphylococcus, and streptococcus. in literature, specific attention is given to wound infections caused by capnocytophaga canimorsus, because this bacterium is seen as the relatively deadliest pathogen. it was suggested that only 2% of dog bite wounds contained capnocytophaga spp. [154] while others reported infection percentages of 4.2% [169] . wound infection with this bacterium can lead to severe complications like septicaemia, meningitis, osteomyelitis, peritonitis, endocarditis, pneumonia, purulent arthritis, and disseminated intravascular coagulation. c. canimorsus septicaemia has been associated with 30% mortality. the true number of c. canimorsus infections is probably largely underestimated due to the fastidious growth of the organism. however, infected dog bites in predisposed persons should be taken seriously especially after splenectomy [170] . cat bite incidents occur less frequently. in only 5%-10% of reported bite incidents in australia, cats are to blame. the long incisor teeth inflict less severe superficial wounds but because of the penetrating effect, joint and tendon infections more easily occur. in a review it is reported that 28%-80% of cat bites become infected mostly by pasteurella multocida [169] . the bacterium bartonella henselae can also be transmitted by cats through biting incidents but the transmission of this bacterium is much more related to a cat scratch accident. even less frequently reported animal biting incidents are those inflicted by rodents (2% of cases in australia). these bites have an infection rate of approximately 10%. this could result in rat bite fever in humans, an infection with streptobacillus monoliformis or spirillum minus, characterized by the triad of fever, rash, and arthritis [169] . cat scratch disease (csd) was first described in a french boy in 1931 and is a common, often self-limited, disease that usually presents as tender lymphadenopathy caused by bartonella henselae [171] . the cat is considered the primary reservoir for this bacterium, with infected fleas and ticks serving as vectors and humans and dogs as accidental hosts. vector transmission of this bacterium occurs via two primary routes: inoculation of bartonella contaminated arthropod feces via animal scratches, most often cat scratches, or by self-inflicted contamination of wounds induced by the host scratching arthropod bites [172] . immunocompromised human hosts (kidney transplant patients or patients with hiv) are especially susceptible to infection. in these individuals, the disease may be present as a more disseminated form with hepatosplenomegaly, meningoencephalitis, or angiomatosis [173] . an increasing number of pocket pets and exotic pets are kept by humans. numbers of ornamental birds in europe are estimated as 50 million, fish tanks 15.5 million (300 million ornamental fish), small mammals 27 million, and reptiles 8 million [15] . these animal species can also be a source of many zoonotic diseases, especially in young children and immunocompromised individuals. most cases of these conditions are not serious, and deaths are very rare but some of these diseases can be life threatening, such as rabies, rat bite fever infections, and plague [174] . however, there is also a trend to keep more unusual exotic animals, legally or illegally. these are "wild" animals that are kept in the home such as bats, foxes, skunks, raccoons, meerkats, prairie dogs, kinkajous, sloths, monkeys, apes, prosimians (mammals), parrots, mynah birds, finches (birds), crocodiles, turtles, tortoises, lizards, snakes (reptiles), frogs, toads, newts, salamanders (amphibians), fish, eels, rays (fish), crabs, crayfish, snails, insects, spiders, and millipedes (invertebrates) [175] . even fruit bats are kept as pets [176] and it is known that bats harbor a higher proportion of zoonoses than all other mammalian orders, including rabies-like viruses that are highly pathogenic for people. [177] . another example of a zoonosis is monkeypox following the importation of prairie dogs in the usa [178] . most reptiles and amphibians such as turtles, lizards, and frogs carry salmonella bacteria in their gut, in most cases without visible signs of infection. the infection may cause symptoms of sickness, diarrhea and fever in humans [179] . zoonotic transmission of salmonella infections causes an estimated 11% of salmonellosis annually in the united states. in cases involving pet turtles, almost half (45%) of infections occurred in children younger than 5 years [180] . salmonella infections are often transferred by feeder rodents [181] and outbreaks highlight the importance of improving public awareness and education in countries who receive imported reptiles [182] . it is advised to exclude reptiles, amphibians, rodents, exotic species, baby poultry, and raw animal-based pet food items from the households of patients at high risk. in lower risk households, an understanding of the risk of salmonellosis and other pet-associated zoonoses and preventive hygiene measures is needed. the pet trade in general, with its high turnover and diversity of available species, creates a reservoir for pathogens originating from all over the globe. reptiles account for approximately 10% of live animal shipments imported to the united states [182] . importation of live reptiles and amphibians for commercial purposes is for a great part unregulated at eu level except cites and customs regulations [176] . in a risk assessment study, the five pathogens with the highest public health risk caused by the import of exotic animals were salmonella spp., crimean-congo hemorrhagic fever virus, west nile virus, yersinia pestis, and arenaviruses. the risk via legally imported animals was considered low, but substantial for illegally imported animals due to the unknown health status of the animals [183] . avoiding exposure to exotic pet pathogens in the home is difficult and best achieved by not keeping them in the first place. otherwise, it is advised to always wash the hands immediately and thoroughly after contact with exotic pets and after handling raw (including frozen or defrosted) mice, rats and chicks. children should be supervised so that they do not put their mouths close to or kiss exotic animals. reptiles and other animals should be kept out of rooms in which food is prepared and eaten. the number of abandoned and homeless dogs and cats in europe is estimated to be over 100 million. countries with more than 1 million abandoned animals are italy, romania, russia, and ukraine [184] . there is an increasing trend to rescue and import dogs from countries with stray animal problems, in europe often from southern or eastern europe and in the us from puerto rico, the dominican republic, mexico, the middle east, turkey, china, and korea [185] . many charities and independent groups are involved to rescue dogs and seek adoption in more animal-friendly countries [186] . new owners primarily choose to adopt from abroad based on a desire for a particular dog they had seen advertised and on concern for its situation, while some were motivated by previously having been refused dogs from local rescues [187] . in the usa 85% of all household dogs were neutered and today there are no longer enough dogs being born in the usa annually to replace the approximately 8 million dogs that die each year. developing countries have hundreds of millions of street dogs available for export, for example egypt has an estimated 15 million, india, 30 million, and afghanistan, 100 million [188] . in 2006, more than a decade ago, the centers for disease control (cdc) estimated annual dog imports at around 287,000. today the number of imported dogs is estimated to be more than a million a year [189] . imported dogs are reintroducing diseases and parasites that were previously eliminated in the usa [190] . in the usa new and lethal strains of distemper and canine influenza as a result of imported rescue dogs were reported as well as canine brucellosis, rabies, and vector-borne diseases like ehrlichiosis, heartworm, babesiosis, and leishmaniasis [188, 191] . in many southern european countries, there is also a risk of exposure to diseases not encountered in the northern, importing, countries. animals could be infected with anaplasma phagocytophilum, babesia canis, brucella canis, borrelia burgdorferi, dirofilaria immitis (heartworm), dirofilaria repens (subcutaneous worm), echinococcus multilocularis (fox tapeworm), echinococcus granulosus (hydatid or dog tapeworm), ehrlichia canis, hepatozoon canis, leishmania infantum, linguatula serrata (tongue worm), onchocerca lupi, rabies, rickettsia conorii, strongyloides stercoralis, and thelazia callipeda. except b. canis, e. canis, and h. canis, the infections are zoonotic and regularly reported [192] [193] [194] [195] [196] [197] [198] [199] [200] [201] [202] . most of these are transmitted by ticks, sand flies, or mosquitoes that are non-endemic in the receiving countries, but a reservoir of infections has been created and the risk is that vectors will become present as result of climate change. [203] . animals that are infected with rabies or echinococcus spp. may infect people directly. the importation of dogs from endemic, predominantly mediterranean, regions to northern europe, as well as travelling with dogs to these regions carries a significant risk of acquiring an infection. pet owners are therefore advised not to travel with dogs and to seek the advice of their veterinarian prior to importing a dog from an endemic area or travelling to such areas [193] . for this reason, esccap developed maps on their website featuring european countries and regions with advice on endemic parasites, diseases and recommended treatments when travelling with dogs [204] . a three-year european union funded project entitled callisto (companion animal multisectorial interprofessional and interdisciplinary strategic think tank on zoonoses), has investigated zoonotic infectious diseases transmitted between companion animals and humans and food producing animals [176] . the committee advised that special attention should be given to stray cats and dogs. stray dogs, in particular, may pose serious health and welfare problems for humans and animals [81] , including the transmission of zoonotic diseases such as rabies. consideration should be given to controlling companion animal movement between areas of the eu endemic for particular zoonoses and areas that are not currently endemic for that disease. reliable figures are not available, probably because of the fact that many voluntary organizations are responsible for saving and transporting these rescue animals. such data are essential in order to be able to quantify the actual risks of zoonotic diseases attributable to companion animals and to develop sustainable interventions to prevent transmission to humans and livestock [176] . as long as there are no official guidelines, to prevent the spread of (zoonotic) diseases to new countries, the time, expense, disease risk, and the implications of adopting a dog from abroad should all be carefully considered before importation. as an alternative, the conditions for native dogs could be improved by supporting local charities to organize neutering campaigns and rehoming programs, to build local animal shelters and to improve attitudes towards dogs and their living conditions [205] . cats and dogs harbor the enteric nematodes toxocara canis and toxocara cati, and cats are the final host for the protozoal parasite toxoplasma gondii. these parasites can be transmitted to humans because they have an oral-fecal transmission cycle. humans can be infected by ingestion of infective toxocara spp. eggs or toxoplasma oocysts from contaminated soil (gardens, sandpits, and playgrounds) [206, 207] . a recent meta-analysis of data from published records indicates that public places are often heavily contaminated with a pooled global prevalence of toxocara eggs of 21% [208] . both parasites are considered by cdc as part of five neglected parasitic infections. these infections are considered neglected because relatively little attention has been devoted to their surveillance, prevention, and/or treatment. the diseases that they cause have been targeted as priorities for public health action based on the number of people infected, the severity of the illnesses and the ability to prevent and treat them [209] . tens of millions of people worldwide are estimated to be exposed to, or infected with, toxocara spp. and recent findings suggest that the effect of toxocarosis on human health is increasing in some countries. almost one fifth (19%; 1.4 billion individuals) of the world's human population is seropositive to toxocara. the highest seroprevalence rates were found in africa (mean: 37.7%) and the lowest in the eastern mediterranean region (mean: 8.2%) [210] . toxocara larvae migrate into the body of the human to several organ systems with a preference for the central nervous system (brain, eyes). human toxocarosis can manifest itself as syndromes known as visceral larva migrans, ocular larva migrans, neurotoxocarosis, and covert or common toxocarosis [211] . asthma is one of the most common chronic respiratory diseases worldwide, with a negative impact on the quality of life and socio-economic status of patients. two decades ago, the first evidence was published that suggested that toxocara infection is a neglected risk factor for childhood asthma [212] . the finding that children infected with toxocara spp. are more likely to have asthma compared to non-infected children was recently confirmed in a systematic review and meta-analysis [213] . cognitive or developmental delays in children or young adults who become infected is of particular concern. toxocarosis appears to be associated with decreased cognitive function [214, 215] . the annual toxoplasma oocyst burden measured in community surveys has been reported as up to 434 oocysts per square foot (4670 per square meter) and is greater in areas with loose soil, that cats like to use to cover their feces in gardens, children's play areas, and especially sandboxes, also called sandpits and sand piles [207] . because a single oocyst can possibly cause infection, this oocyst burden represents a major potential public health problem. an estimated one third of the world's population harbor anti-toxoplasma antibodies. due to keeping pigs indoors, more education and awareness, the prevalence of the disease in the usa and europe declined by 50% over the last decades [216] . during an acute invasion of toxoplasma parasites there is mild to major tissue damage without clinical symptoms (latent toxoplasmosis). the most important form is congenital toxoplasmosis when a woman receives her first exposure to toxoplasma during pregnancy. in early pregnancy, this can lead to abortion or to malformations that are not compatible with life shortly after birth. congenital infections may also be characterized by mental retardation and ocular defects. acquired infection after birth may result in clinical symptoms such as lymphadenitis, fever, and malaise and probably leads to a clinically symptomatic disease state more frequently than the congenital condition, with an estimated incidence of 30% of all ocular toxoplasmosis cases [216] . playing in a sandbox is also found to be a predominant risk factor for s. typhimurium salmonellosis in children aged 4-12 years [217] . this can be the result of fecal contamination of the sand by dogs and cats that have been fed raw meat (see section 5.1.1.). young children are especially at risk as they put their hands or other objects in their mouths every 2-3 min [208] . it has also been reported that children ingest a median of 40 mg of soil per day and that one child consumed 5-8 g of soil per day on average [218] . it is therefore advisable not to let children play in public places or on playgrounds with loose sand, but only in sandboxes that can be covered. furthermore, washing hands after playing outside is important and fingernails must be trimmed to prevent sand being left behind. in this context, a strange trend can be observed as young children play in mud baths on 29 june "as a way to connect and celebrate the natural joys of playing in the mud". this international mud day originated in 2008 and was initiated by an australian pedagogue who had observed this phenomenon during a visit to nepal [219] . if the origin of the soil needed for producing the mud is unknown, there is of course an infection risk for the above discussed parasites. to prevent the transmission of zoonotic diseases from pets, risk analysis is of great value. this starts with an assessment of the potential zoonoses in an area, depending on the endemicity (the hazard, h). hazard characterization also includes prevalence in animals (the reservoir), virulence for man, transmission routes, and survival of the agent in the environment. the second step is exposure assessment (e). who is exposed to the potential hazard and for how long or how often? how much of the potential pathogen is needed to become a health risk? this inevitably is directly related to human behavior in relation to their pets. the third step is to assess the impact of getting infected (i). how serious is the disease, what is the chance of complications, and what economic consequences may be expected (e.g., labor hours lost)? each of the parameters can be ranked in classes from negligible to the most serious possibility. ranking is based on literature data, own observations (measuring), or experts' opinions. the final risk assessment can be achieved by multiplying the outcome of hazard characterization, exposure assessment and impact (h × e × i = a number). the outcome can be compared with other zoonotic agents and a ranking of significance can be made [220] . there is one important parameter to reduce the risk of contracting a zoonotic infection that can directly be influenced, which is exposure. recommendations are particularly targeted to households with very young children, the elderly, pregnant women, or immunocompromised patients. they are based on reducing exposure to hazards and involve four categories of advice (table 1) . table 1 . recommendations to prevent the transmission of zoonotic pathogens from pets [121, 221] . • washing the hands thoroughly -after animal contact, at least before eating and drinking and before preparing food or drinks -after handling raw pet food -after handling pet habitats or equipment -after cleaning up feces -after removing soiled clothes or shoes reflecting on the changed human-companion animal bond, it can be concluded that pets undoubtedly have a positive effect on human health. conversely, the human-pet bond seen nowadays is facing many challenges, putting pet welfare under more pressure due to issues such as anthropomorphism, which mainly results in obesity, breeding on extreme appearance rather than health, behavioral problems connected to unfulfilled species specific mental and physical needs, and the provision of inadequate food because owners mistakenly think they feed more naturally. with regard to the negative effects of pets this article attempts to give an impression of increasing trends in the human-companion relationship that can be observed in society, which appears to increase the risk of transmission of infection between pets and humans. it is mainly a consequence of the increasing contacts between humans and pets and with pathogens secreted by animals in the shared environment. more than 6 out of every 10 known infectious diseases in people can be spread from animals, and 3 out of every 4 new or emerging infectious diseases in people come from animals [222] . the recent pandemic of the covid19 coronavirus (sars-cov-2), that may be originated from bats, is a good example of a recent emerging zoonotic infectious disease. a few cats and dogs have tested positive but are not considered as a source of infection for people. the proportion of zoonotic human disease that is attributable to pets is largely unknown. reports about the frequency of such infections are likely underestimated [120] ; however, the risk of infection is relatively small for many zoonoses and the severity of the disease is often limited. a person's age and health status may affect their immune system, and thereby increase his or her chances of getting a disease from animals. pregnant women should avoid contact with pet rodents, reptiles, cat feces, and raw meat to prevent infection of the unborn child, abortion, or birth defects. if symptoms occur in immunocompetent, non-pregnant persons between 5 and 64 years of age, these are mainly of a general nature such as diarrhea or flu-like symptoms. physicians do not regularly ask about the presence of pets or pet contact, nor do they discuss the risks of zoonotic diseases with patients, regardless of the patient's immune status, which means that many cases of zoonotic diseases go undiagnosed. the general public and people at high risk of pet-associated disease are not aware of the risks associated with high risk pet practices or recommendations to reduce them. since unfamiliarity with hazards reinforces fear, communication plays an important role in this. veterinarians play a key role in education regarding risk reduction by giving advice about responsible pet ownership and the required preventive hygiene. healthcare providers such as family doctors, school doctors, and pediatricians can also provide information about safe pet ownership. physicians should ask as part of the medical history about eventual contact with pets, particularly with patients at high risk [120] . the "one health" initiative aims to reduce this professional gap between vets and physicians [2] . when giving recommendations to prevent zoonotic transmission, one of the often-made remarks is that people nowadays are already too hygienic. it is assumed that there is a protective influence of postnatal infection and that it might be lost in the presence of modern hygiene. this belief is based on the hygiene hypothesis that was formulated in 1989 [223] . it was observed that hay fever in young adults was inversely related to the number of siblings in their family. this hypothesis focused exclusively on allergic conditions as a result of the modern way of life and the assumption that modern hygiene was reducing contact with bacteria. another view is that some chronic inflammatory disorders have increased over the last decades as a result of decreased frequency of infections due to pathogenic organisms [224] . another related theory is the "old friends" mechanism that is based on the positive influence of gut parasites, non-pathogenic environmental bacteria (saprophytes, pseudocommensals), and gut commensals or microbiota. however, decreased exposure to these microorganisms is not the only reason for the increasing frequency of allergies and chronic inflammatory disorders in industrialized countries. nowadays there is more information about the immunological roles of skin, oral mucosa, and gut microbiota as well as helminths and the influence these have on the immune system [225] . gut flora may be modified due to diet, obesity, hygiene, antibiotics, but also to psychological stress, vitamin d deficiency, and pollution [225] [226] [227] . pollution also has a significant effect on the development of several respiratory problems and diseases. not only due to outdoor pollution such as fine dust, harmful solids, liquids, or gases [228] , but also due to indoor molds as result of insufficient ventilation in energy efficient homes [229] . finally, there is a clear increase in the allergen production of house dust mites and pollen leading to more exposure and sensitization in susceptible individuals [230] . all together it must be clear that there is much more known about other causes of increasing allergies worldwide than simply excessive cleanliness as suggested in the hygiene hypothesis. regarding field infections with helminths such as trichuris trichiura in early life, these are associated with a reduced prevalence of allergies later in life and infants of helminth-infected mothers have a reduced prevalence of eczema. hookworm infections in developing countries are associated with a reduced prevalence of asthma [231] . the rate of eczema in such countries was found to be about five times higher in infants whose mothers had never had helminths compared with persistent helminth-infected mothers [232, 233] . helminths are nowadays even used under controlled conditions to stimulate immunity. examples are trichuris suis therapy for crohn's disease and necator americanus larvae to treat crohn's disease and other autoimmune disorders [234] . there are no clinically apparent childhood infections found to be associated with protection from allergic disorders [235] . it can even result in an opposite effect in the case of toxocara infection by children after soil contact. a recent meta-analysis showed that children infected with toxocara spp. are more likely to have asthma compared to non-infected children [213] . this parasite and asthma both have elevated immunoglobulin e (ige) levels and eosinophilia in common. that means that precautions should be taken in children to prevent soil contact not only to prevent toxocara infection, but also to prevent acquired ocular toxoplasmosis. there is no need, therefore, to stimulate the contraction of pathogenic bacteria or helminths to achieve a healthy gut microbiota and to reduce allergic conditions. recommendations based on the hygiene hypothesis should preferably be based on results from controlled studies to prevent unintentional negative effects. it is both humans and companion animals who experience negative effects of a changed human-companion animal bond. the education given by vets to their clients should therefore also focus on preventing these negative health and behavioral effects. for instance, by giving science-based advice on feeding practices. in general, regulating authorities should encourage the development of enforcement criteria for breeding dogs and cats to reduce health and welfare risks. pets undoubtedly have a positive effect on human health and well-being, while owners are increasingly aware of pet health, welfare, and well-being. anthropomorphism, also resulting in behavioral problems and breeding on appearance rather than health, and trends such as keeping exotic animals and importing rescue dogs may result in an increased risk of contracting zoonotic infections. recommendations regarding responsible pet ownership, including normal hygienic practices, responsible breeding, feeding, housing, and mental and physical challenges conform the biology of the animal, are key in preventing such negative aspects of the human-animal bond. there is no need to stimulate unhygienic practices following the hygiene hypothesis. education can be performed by vets and physicians as 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friends' hypothesis metabolic and metagenomic outcomes from early-life pulsed antibiotic treatment current understanding of the human microbiome environmental and health impacts of air pollution: a review. front. public health 2020, 8, 14 abridged version of the awmf guideline for the medical clinical diagnostics of indoor mould exposure house dust mite allergy under changing environments interactions between helminth parasites and allergy the impact of helminths on the response to immunization and on the incidence of infection and disease in childhood in uganda: design of a randomized, double-blind, placebo-controlled, factorial trial of deworming interventions delivered in pregnancy and early childhood immunologic profiles of persons recruited for a randomized, placebo-controlled clinical trial of hookworm infection an update on the use of helminths to treat crohn's and other autoimmune diseases infections presenting for clinical care in early life and later risk of hay fever in two uk birth cohorts this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord-339401-jv0rse14 authors: beeston, clare; robinson, mark; giles, lucie; dickie, elinor; ford, jane; macpherson, megan; mcadams, rachel; mellor, ruth; shipton, deborah; craig, neil title: evaluation of minimum unit pricing of alcohol: a mixed method natural experiment in scotland date: 2020-05-13 journal: int j environ res public health doi: 10.3390/ijerph17103394 sha: doc_id: 339401 cord_uid: jv0rse14 in may 2018, scotland became the first country in the world to implement minimum unit pricing (mup) for all alcoholic drinks sold in licensed premises in scotland. the use of a sunset clause in the mup legislation was a factor in successfully resisting legal challenges by indicating that the final decision on a novel policy would depend on its impact. an overarching evaluation has been designed and the results will provide important evidence to inform the parliamentary vote on the future of mup in scotland. the evaluation uses a mixed methods portfolio of in-house, commissioned, and separately funded studies to assess the impact of mup across multiple intended and unintended outcomes related to compliance, the alcoholic drinks industry, consumption, and health and social harms. quantitative studies to measure impact use a suitable control where feasible. qualitative studies assess impact and provide an understanding of the lived experience and mechanism of change for key sub-groups. as well as providing important evidence to inform the parliamentary vote, adding to the international evidence on impact and experience of alcohol pricing policy across a broad range of outcomes, this approach to evaluating novel policy interventions may provide guidance for future policy innovations. following a period of high and increasing rates of alcohol-related harm in scotland [1] , in 2009 the scottish government proposed a comprehensive strategy that aimed to reduce population levels of alcohol consumption and, in turn, levels of associated health and social harms [2] . the introduction of minimum unit pricing (mup) for alcohol was a central part of this strategic approach and, following an initial unsuccessful attempt, the necessary primary legislation was passed by the scottish parliament in 2012. a legal challenge followed, ending when the uk supreme court ruled in favour of the scottish government in late 2017. the initial level was set at 50 pence per unit (ppu), estimated to affect 47% of all alcohol sold through the off-trade in scotland in 2017 [3] . the policy was implemented on 1 may, 2018, when scotland became the first country to set a strength-based floor price which applied to all alcohol sold in or through licensed premises. the rationale for mup is based on strong and consistent systematic review evidence on the relationship between alcohol price, consumption, and related-harm. alcohol consumption is associated with a substantially increased risk of all-cause mortality and, while the size of the effect may vary, there is evidence from a number of studies that increases in price result in a decrease in consumption and associated harms [4, 5] . there is some evidence that pricing interventions may in particular target young people (aged under 18 years), young adult 'binge' drinkers, and heavy drinkers [4] . estimates of alcohol price elasticity suggest that a 10% rise in price might be expected to reduce demand for alcohol by about 5% [6, 7] . price elasticity varies by levels of consumption, with drinkers becoming proportionally less responsive to price as consumption increases [8] , although in absolute terms the reduction in units of alcohol consumed is greatest in heavier drinkers [9] . using existing evidence on the relationship between alcohol price, consumption, and harm, in 2016 it was estimated that a 50 ppu minimum unit price would reduce population alcohol consumption in scotland by 3.5% per year, leading to over 120 fewer alcohol-attributable deaths and over 2000 fewer alcohol-attributable hospital admissions per year when the policy reached its full effect (at 20 years), with effects most pronounced among those drinking at harmful levels, particularly those on lower incomes [10] . empirical evidence on the impacts of minimum pricing for alcohol is available from canada, where a form of minimum pricing applies in each of the 10 provinces. there is variation in the extent and frequency to which different drink types and outlets are affected by different forms of minimum pricing in these provinces [11] . retrospective analysis using population level administrative data from british columbia has shown that as minimum alcohol prices increase, there is an associated decrease in population consumption [12] , hospital admissions [13] , deaths [14] , and crimes [15] related to alcohol. similar results have been observed in saskatchewan, which has the form of minimum pricing most similar to scotland. here, a 10% increase in minimum price reduced consumption of all alcohol by 8% [16] . a limited form of mup was introduced in the russian federation in 2010 as part of a comprehensive set of alcohol control policies introduced at various points from 2000 onwards. efforts initially focused on restricting the production of alcohol, with increases in alcohol excise taxes, substantial reductions in the availability of alcohol and mup for vodka and other spirits introduced in 2011. since 2004, there has been a fluctuating downward trend in both alcohol consumption and related mortality, with a slowdown in the decline between 2014 and 2018, when there was a loosening of some policy measures, including a decrease in the mup [17] . the impact in population subgroups is likely to vary. heavier drinkers are more likely to mitigate the effects of price increases by consuming lower quality products, although the setting of a floor price may limit the opportunities for 'trading down' in this way [8] . a study with homeless drinkers found the most common strategies employed when alcohol became less affordable (due to changes in individual income or price) included re-budgeting (e.g., foregoing essentials such as food so as to afford alcohol), waiting for money, and going without alcohol. other consequences reported by at least a third of the sample included illicit drug use, drinking non-beverage alcohol, stealing alcohol, and seeking help or treatment [18] . however, in a study of dependent drinkers in edinburgh during a period when alcohol became less affordable, there was little evidence of acquisitive crime or substituting other harmful substances (such as non-beverage alcohol or illicit drugs) for alcohol. however, it was noted that the study took place before the introduction of mup and participants reported switching to cheaper products still available at the time [19] . alcohol-related harms have shown to be socially patterned, disproportionately affecting the most disadvantaged at a given level of alcohol consumption [20] . as such, the introduction of minimum pricing may reduce inequalities in alcohol-related harms. mup in the form it takes in scotland has not been implemented elsewhere and it is important to add to the evidence base on the impact and experience on alcohol pricing policies across a range of outcomes. furthermore, the scottish legislation includes a sunset clause requiring a positive parliamentary vote if mp is to continue beyond an initial six year period, and a review clause requiring that the scottish parliament must be provided with a report on the operation of mup and its impacts before this vote [21] . the review report is to cover the impact on: alcoholic drink producers and licence holders; • the five licensing objectives (covering crime and disorder, public safety, public nuisance, public health, and protecting children and young persons from harm); • different groups (defined by age, gender, social and economic deprivation, and levels of alcohol consumption), where possible. in their ruling, the supreme court recognised the experimental nature of mup and judged the inclusion of the sunset and review clauses to be important in reaching their decision [22] . the scottish government has tasked nhs health scotland (now part of public health scotland) with delivering an evaluation of mup that will form the basis of the review report. the aim is to provide robust and comprehensive evidence on the impact of mup in scotland for to generate knowledge and inform the parliamentary vote on the future of mup. the evaluation takes a theory-based approach to answer the evaluation questions: to what extent has mup contributed to reducing alcohol-related health and social harms in scotland? 2. are some people and businesses affected (positively and negatively) more than others? having a clear theoretical understanding of how a social or public health policy intervention is expected to achieve its effect is useful in a natural experiment design when it is difficult or impossible to use other experimental methods to control exposure [23] and where there are many potential interacting outcomes across a range of domains [24] . a theory of change ( figure 1 ) that shows the main chain of outcomes that may result from mup implementation has been developed, taking account of the existing evidence, legislative requirements, and stakeholder concerns. the theory of change shows the main expected chain of outcomes whereby compliance with mup results in an increase in the price of low cost, high strength alcohol, reducing alcohol purchasing and consumption and in turn reducing alcohol-related health and social harms. mup may stimulate the alcoholic drinks industry to make changes in product range, alcoholic strength, pack size, price of alcohol already >50 ppu, and/or marketing strategies. mup may also lead to changes in attitudes to mup and alcohol more broadly. there may be other changes, such as substitution to non-beverage alcohol or other drugs; displacement of spending previously used for other goods or services; an increase or decrease in demand for services; and a variable economic impact on organisations that are part of the alcoholic beverage production, distribution and retail chain. the effects of mup will be influenced by its interaction with factors external to mup, such as factors that influence the price of alcohol and/or disposable income, other alcohol policy, or changes in the broader social and economic determinants of health. finally, the effects of mup may change over time. for example, any immediate impact of reduced availability of strong, low cost alcohol, particularly among those drinking at harmful levels, may differ from longer term effects of any change in the amount or pattern of drinking. furthermore, the mup in scotland is not index linked and the real value will diminish over time. the theory of change shows the main expected chain of outcomes whereby compliance with mup results in an increase in the price of low cost, high strength alcohol, reducing alcohol purchasing and consumption and in turn reducing alcohol-related health and social harms. mup may stimulate the alcoholic drinks industry to make changes in product range, alcoholic strength, pack size, price of alcohol already >50 ppu, and/or marketing strategies. mup may also lead to changes in attitudes to mup and alcohol more broadly. there may be other changes, such as substitution to non-beverage alcohol or other drugs; displacement of spending previously used for other goods or services; an increase or decrease in demand for services; and a variable economic impact on organisations that are part of the alcoholic beverage production, distribution and retail chain. the effects of mup will be influenced by its interaction with factors external to mup, such as factors that influence the price of alcohol and/or disposable income, other alcohol policy, or changes in the broader social and economic determinants of health. finally, the effects of mup may change over time. for example, any immediate impact of reduced availability of strong, low cost alcohol, particularly among those drinking at harmful levels, may differ from longer term effects of any change in the amount or pattern of drinking. furthermore, the mup in scotland is not index linked and the real value will diminish over time. for ease of communication, the theory of change has been simplified into four main outcome areas:  compliance, implementation, and attitudes-covering compliance and availability of alcohol <50 ppu. it also includes changes in social norms and attitudes to alcohol and mup, although these may occur later in response to changes in other outcomes.  alcoholic drinks industry-covering price change, change in price distribution, reduced purchasing, product and marketing changes, and economic impact on the alcohol industry.  consumption-covering reduced individual and population consumption, and safer patterns of drinking.  health and social harms-covering reduced health and social harms, displacement of spending, substitution to non-beverage alcohol or drugs, and the impact on services. for ease of communication, the theory of change has been simplified into four main outcome areas: • compliance, implementation, and attitudes-covering compliance and availability of alcohol <50 ppu. it also includes changes in social norms and attitudes to alcohol and mup, although these may occur later in response to changes in other outcomes. alcoholic drinks industry-covering price change, change in price distribution, reduced purchasing, product and marketing changes, and economic impact on the alcohol industry. • consumption-covering reduced individual and population consumption, and safer patterns of drinking. health and social harms-covering reduced health and social harms, displacement of spending, substitution to non-beverage alcohol or drugs, and the impact on services. the evaluation uses a mixed method portfolio of studies to generate robust evidence on the outcomes in the theory of change. each outcome area will be evidenced by a number of studies from the portfolio, and many studies will contribute evidence on more than one outcome area. the portfolio includes quantitative studies designed to provide measurable quantitative estimates of change. where robust and consistent data on exposures and outcomes are available, we will compare outcomes in scotland with those in a control area. where possible, statistical analysis will be undertaken to evidence the scale of change in outcomes in scotland compared to the control area and to assess whether any differences are causally related to mup. other studies will quantify the extent to which outcomes have changed in scotland after mup even if comparison with a control area is not possible. the portfolio includes qualitative studies to assess impact and provide an understanding of mechanisms that underpin estimates of change, how people and organisations have responded to mup, and peoples' lived experience of mup in scotland. sub-groups of interest include those drinking at harmful levels, including those who are homeless and those under 18 years of age. this qualitative understanding is essential to improve interpretation of quantitative findings. taken together, these will provide a robust and comprehensive assessment of the impact of mup. the evaluation portfolio currently consists of 12 studies funded and managed through the monitoring and evaluating scotland's alcohol strategy (mesas) programme of work, and a further seven separately-funded studies. table 1 lists these studies, with more detail in appendix a. protocols for the mesas funded studies can be found on the mup evaluation webpages [25] and the academic literature for some of the separately funded studies [26] . the setting for the study is scotland, where mup applies, and, where possible, comparisons are made with outcomes in areas where mup does not apply (england or england & wales). mup was introduced in wales on 2 march 2020 and where appropriate the control will be adjusted accordingly. the evaluation also seeks to understand how impacts and mechanisms vary geographically within scotland, for example, in areas close to the border with england, where possible. findings from across the portfolio of studies, and other appropriately critically appraised studies, will be synthesised to generate conclusions about the impact of mup in scotland. the effectiveness of mup will be judged on its success in achieving the policy rationale (to reduce alcohol-related harms) via the main pathway in the theory of change (i.e., by reducing consumption, in particular in those drinking at harmful levels as a result of a price change). the other outcomes measured (e.g., economic impact on the alcoholic drinks industry) will help enhance interpretation and meet the legislative requirements. a transparent approach to synthesising findings across studies, using established and innovative methods, will be developed in preparation for the development of the final report, due in 2023. this is likely to draw on techniques including methods for synthesising qualitative evidence [27] , the decision theory approach [28] and cost consequence analysis [29] . mup applies to all alcohol sold through licensed premises in scotland. scotland was the first country to introduce mup and the evaluation will add to the international evidence on impact and experience of alcohol pricing policy across a broad range of outcomes. furthermore, the use of a sunset clause in the mup legislation was a factor in successfully resisting legal challenges by indicating that the final decision on a novel policy would depend on its impact. an overarching evaluation has been designed and to provide robust evidence to inform the parliamentary vote on the future of mup in scotland. public health scotland is leading this evaluation, working with in-house, commissioned, and separately funded research teams to deliver a mixed methods portfolio of studies designed to evidence the impact of mup on important outcomes, to understand the lived experience of key groups exposed to mup and to explore the mechanisms by which changes occur. we will draw on systematic review of other critically appraised studies to deliver a final report that will inform the future of mup in scotland. this approach to evaluating novel policy interventions may provide guidance for future policy innovations. using a theory-based approach to design the evaluation framework strengthens causal inference in policy evaluation based on a natural experiment [23] . by collecting evidence on the expected outcomes, intermediate links in the causal chain, and on external factors that might affect the same outcomes, we can be more confident in drawing conclusions on the contribution of mup to changes in outcomes. to gather the evidence required, this evaluation will use the most appropriate, feasible and proportionate study designs to meet the aims of each of the component studies. for example, to isolate the specific impacts of mup on health outcomes, we plan to use a natural experiment design, comparing health outcomes in scotland, where mup applies, to england or parts of england, where it does not. such a design is based on the assumption that the main difference between the two populations is the presence or not of mup. while another part of the uk (such as england or part of england) offers the most similar comparator population, in practice, other factors affecting outcomes, such as other alcohol policies or disposable incomes, may change in different ways in different countries at the same time as mup. furthermore, mup may stimulate changes in the comparator population-for example, a mup-driven product or price change may be rolled out in other countries of the uk. by taking a theory-based approach, with a portfolio of studies using mixed methods to gather evidence on a number of outcomes and other factors thought to influence those outcomes, in scotland and other parts of the uk, the evaluation will help to understand whether the intended outcomes have occurred, and whether this is likely to be due to mup rather than other confounding factors. the mup legislation requires that the evaluation assesses the impact of mup across a number of domains and, where possible, across different population groups. the evaluation needs to take account of the fact that mup is taking place within a complex system and there will be a wide range of potential outcomes (positive and negative). the whole population effects of mup, and the effects in different sub-groups will be influenced by interactions with other elements of the system, adaptations by individuals or organisations and feedback loops. theory-based evaluation aims to identify and measure the most important effects. evidence from across the portfolio will be synthesised transparently and using established and innovative methods. all studies in the portfolio are now underway. to date, deviations from protocol have been minor and limited to the compliance study, where data protection legislation and competing priorities in local authorities meant sufficient, suitable, quantitative data were not publicly available for use in the study. more recently, the current covid-19 pandemic and the resulting social distances measures have affected delivery of some studies, including the cessation of face-to-face data collection and no access to safe haven facilities. studies using administrative or market research data from 2020 and beyond are considering the best approach to dealing with the pandemic as a major factor affecting the outcomes of interest [30] . this will be a particular issue for those studies without a concurrent control and some of these have already shortened their post-mup data period (see appendix a). the final implications of the changes necessarily made to the evaluation will be detailed in individual study and final reports. the primary purpose of this evaluation is to inform a parliamentary process for reviewing and deciding whether to continue with mup. it is therefore important to consider both scientific and accountability processes, to ensure that the evaluation is transparent and recognised to be robust, impartial, and credible. the process and findings need to be trusted by stakeholders, including parliamentary decision makers, researchers, the public health community, service delivery partners, the alcoholic drinks industry organisations and the public. in time, it will be important to assess the impact of the evaluation and the parliamentary review on the policy process. the development and delivery of the mesas-funded evaluation is overseen by a multi-agency governance structure. this consists of a governance board that provides advice on study importance, the feasibility of robust design proportionate to the value of information, and the overall allocation of funding. evaluation advisory groups provide advice to and oversee the delivery of individual or groups of mesas-funded studies. members of the governance groups bring research, strategic delivery, and/or contextual expertise, and there is broad representation on appropriate groups from across stakeholder groups including, but not limited to, public services, nationally commissioned organisations, the alcoholic drinks industry, scottish government, and academia. scotland was the first country to implement a strength-based minimum price applying to all products sold through licensed premises, and the world is watching. this important multi-component evaluation will inform the future of minimum unit pricing in scotland. reports from individual studies will be published as they are completed, and the final report drawing together all the studies will be published in late 2023. the authors would like to thank the principal investigators for the commissioned and separately funded studies who, with their teams, designed their respective studies and commented on this paper. listed in the order of the studies in table 1 table a1 . brief description of mesas-funded studies, data period, research team and funder. research team brief description data period study funder compliance final report [31] nhs health scotland qualitative study. interviews with licensing and enforcement to provide an understanding of their experience of compliance with minimum unit pricing (mup) in licensed premises, and related issues in the first six months of implementation. descriptive analysis of any quantitative data on non-compliance published. aug.-oct. 2018 scottish government economic impact on the alcoholic drinks industry in scotland interim report [32] frontier economics mixed methods study. quantitative analysis of existing industry survey data to provide an assessment of impact on number of businesses; headcount; turnover; gross value added and value of output, with england and wales as a control. post implementation case studies with eight organisations across the industry to provide a qualitative understanding of industry behaviour and impacts. post implementation interviews with retailers on either side of the scotland-england border to provide a qualitative understanding of experiences of cross border purchase. interim reports [34, 35] public health scotland quantitative study. descriptive analysis of retail sales data (overall, by trade sector, by drink type). interrupted time series methods to assess whether the introduction of mup was associated with a change in the volume of pure alcohol sold in scotland (overall, by trade sector, and by drink category), with england and wales as the primary control. jan. 2013-april 2021 scottish government drinking at harmful levels university of sheffield, university of newcastle (australia) and figure 8 consultancy mixed methods study with four work packages survey and in-depth interviews with participants drinking at harmful levels recruited through treatment services to explore the lived experience of mup and changes in drinking behaviour, substitution to other sources and/or substances, their experience of crime, and the impact on their families. similar data collected in northern england for comparison. in-depth interviews with participants drinking at harmful levels recruited through the community to explore the lived experience of mup and changes in drinking behaviour, substitution to other sources and/or substances, their experience of crime. interviews with family members of those drinking at harmful levels to understand the lived experience of mup in families. quantitative analysis of market research data to assess the impact of mup on drinking behaviour in the general population in scotland, with england as a control. quantitative analysis using linked primary care and hospitalisation/death data to explore the impact of mup on patients drinking harmfully. it will assess whether there has been a significant change in health outcomes between pre-and post-mup implementation periods for these patients, looking at all alcohol specific causes (chronic and acute), all alcohol related causes (chronic and acute), and all causes of both hospitalisation and mortality. several different analytical approaches will be taken, including uncontrolled analyses, analyses using moderate drinkers as a control group and analyses using harmful drinkers in england as a control group. mixed methods study with three work packages: statistical analysis of survey data collected with repeated cross-sectional samples in emergency departments to assess the impact of mup on the emergency department attendance and prevalence of hazardous and harmful drinking, with data collected in england as a control. statistical analysis of survey data collected with repeated cross-sectional samples in sexual health clinics to assess the impact of mup on the other drug use and, source of alcohol and prevalence of hazardous and harmful drinking, with data collected in england as a control. qualitative longitudinal focus groups with at-risk drinkers and key informant interviews in three communities in scotland to explore implementation of mup, responses and attitudes. quantitative study. analysis of national population survey data, corrected for non-participation bias, to assess the impact of mup on self-reported consumption. medial research council/chief scientist office daily survey (n of 1) university of glasgow mixed methods study. using n of 1 methodology, daily data collection using a smartphone survey and qualitative interviews conducted by peer researchers to assess the impact of mup on drinkers recruited through addiction services. feb. 2018-sept. 2019 alcohol change uk qualitative study. interviews with homeless drinkers and service providers to explore the impact and lived experiences of mup among homeless drinkers and street drinkers, and implications for those providing services to these groups. quantitative study statistical analysis of household purchasing data 1 year before and after mup to assess the impact on household expenditure on food, and nutritional quality of family diets, with england as a control. april 2020-2022 chief scientist office (cso) liver cirrhosis mortality rates in britain from 1950-2002: an analysis of routine data changing scotland's relationship with alcohol: a framework for action monitoring and evaluating scotland's alcohol strategy: monitoring the public health burden of alcohol and the effectiveness and cost-effectiveness of alcohol control policies. an evidence review the demand for alcohol: a meta-analysis of elasticities effects of beverage alcohol price and tax levels on drinking: a meta-analysis of 1003 estimates from 112 studies alcohol quantity and quality price elasticities: quantile regression estimates protocol for the evaluation of alcohol minimum unit pricing in scotland model-based appraisal of the comparative impact of minimum unit pricing and taxation policies in scotland is alcohol too cheap in the uk? the case for setting a minimum unit price for alcohol does minimum pricing reduce alcohol consumption? the experience of a canadian province minimum alcohol prices and outlet densities in british columbia, canada: estimated impacts on alcohol-attributable hospital admissions the relationship between minimum alcohol prices, outlet densities and alcohol-attributable deaths in british columbia relationships between minimum alcohol pricing and crime during the partial privatization of a canadian government alcohol monopoly the raising of minimum alcohol prices in saskatchewan, canada: impacts on consumption and implications for public health alcohol policy impact case study. the effects of alcohol control measures on mortality and life expectancy in the russian federation. who how do people with homelessness and alcohol dependence cope when alcohol is unaffordable? a comparison of residents of canadian-managed alcohol programs and locally recruited controls the price of a drink: levels of consumption and price paid per unit of alcohol by edinburgh's ill drinkers with a comparison to wider alcohol sales in scotland socioeconomic status as an effect modifier of alcohol consumption and harm: analysis of linked cohort data scotch whisky association and others (appellants) v the lord advocate and another (respondents) (scotland) natural experiments: an overview of methods, approaches and contributions to public health research developing and evaluating complex interventions: the new medial research council guidance the evaluation of minimum unit pricing evaluating possible intended and unintended consequences of the implementation of alcohol minimum unit pricing (mup) in scotland: a natural experiment protocol methods for the synthesis of qualitative research: a critical review the appraisal of public health interventions: the use of theory cost-consequences analysis: an underused method of economic evaluation mitigating the wider health effects of covid-19 pandemic responses minimum unit pricing (mup) evaluation: compliance (licensing) study; nhs health scotland minimum unit alcohol pricing: evaluating the impacts on the alcoholic drinks industry in scotland: baseline evidence and initial impacts evaluating the impact of alcohol minimum unit pricing in scotland: observational study of small retailers minimum unit pricing (mup) evaluation. in sales-based consumption: a descriptive analysis of one year post-mup off-trade alcohol sales data evaluating the impact of minimum unit pricing (mup) on sales-based consumption in scotland: controlled interrupted time series analysis minimum unit pricing in scotland a qualitative study of children and young people's own drinking and related behaviour the impact of mup on protecting children and young people from parents' and carers' harmful alcohol consumption: a study of practitioners' views key: cord-353592-gsvobusu authors: luceño-moreno, lourdes; talavera-velasco, beatriz; garcía-albuerne, yolanda; martín-garcía, jesús title: symptoms of posttraumatic stress, anxiety, depression, levels of resilience and burnout in spanish health personnel during the covid-19 pandemic date: 2020-07-30 journal: int j environ res public health doi: 10.3390/ijerph17155514 sha: doc_id: 353592 cord_uid: gsvobusu the number of health workers infected with covid-19 in spain is one of the highest in the world. the aim of this study is to analyse posttraumatic stress, anxiety and depression during the covid-19 pandemic. associations between burnout, resilience, demographic, work and covid-19 variables are analysed. cross-sectional data on 1422 health workers were analysed. a total of 56.6% of health workers present symptoms of posttraumatic stress disorder, 58.6% anxiety disorder, 46% depressive disorder and 41.1% feel emotionally drained. the profile of a health worker with greater posttraumatic stress symptoms would be a person who works in the autonomous community of madrid, in a hospital, is a woman, is concerned that a person he/she lives with may be infected, and thinks that he/she is very likely to be infected. the risk variables for anxiety and depression would be a person that is a woman, working 12or 24-h shifts, and being worried that a family member could be infected. high scores on emotional exhaustion and depersonalization are risk factors for mental health, with resilience and personal fulfilment being protective variables. data are provided to improve preventive measures for occupational health workers. the world health organization declared the covid-19 outbreak as a pandemic on march 11, 2020 . in europe, italy and spain were the first to report a high number of deaths, as well as a rapid increase in admissions to intensive care units (icu) of patients with symptoms associated with the disease. in may 2020, spain is one of the top five countries with the highest number of people infected, registering over 242,707 cases as of 12 june 2020, and more than 27,136 deaths [1] . in critical pandemic-related situations, research indicates that individuals experience a stress response associated with their fear of contracting the virus from contact with other people or objects. they also have symptoms of posttraumatic stress, such as intrusive thoughts, insomnia or nightmares [2] . during the epidemic of severe acute respiratory syndrome (hereinafter, sars), a high prevalence of symptoms of posttraumatic stress, anxiety and depression was identified in emergency service professionals including hyperarousal, anger, loss of motivation at work, difficulty concentrating or trouble falling asleep [3] . however, not all individuals exposed to high negative impacts or crisis situations develop such symptoms, with resilience being relevant as a protective factor [4, 5] . resilience, the individual's ability to deal with adversities as challenges, has been shown to reduce the impact of traumatic events, decreasing the likelihood of developing posttraumatic stress disorders [6] . resilience can be understood as a process of positive adaptation to a stressful situation, in which an interaction between personal resources and the environment is established [7] . resilience varies from person to person and depends on several factors, such as personality or interpersonal and social backgrounds. the strategies to cope with the current pandemic that have been identified are optimism, social support, staying actualized, avoiding information overload and maintaining online communication [8] . in healthcare personnel, a key factor for promoting resilience is to increase the sense of control over the adverse situation. for example, perceiving that disease prevention measures can be managed or controlling the possibility of protecting oneself with the resources that health care providers have around them to care for infected patients are some of the strategies that have been adopted in this pandemic [9] . in similar critical situations, such as the severe acute respiratory syndrome (sars) epidemic, nurses who have shown higher levels of confidence in infection protection and control equipment have shown lower levels of anxiety, negative mood and emotional fatigue [10] . individuals with high levels of resilience have less irritability, less concern for environmental stimuli, better interpersonal relationships, fewer headaches and musculoskeletal pains, and lower levels of depression [11] . if these symptoms persist over time, the feeling of a lack of control and uncertainty at work may increase, leading to burnout. this syndrome is related to work. it is characterized by high emotional exhaustion, high levels of depersonalization and low personal accomplishment [12] . the person may experience dysphoric symptoms, such as tiredness or emotional exhaustion. the symptoms appear in relation to work situations in individuals who previously did not show psychosocial alterations. in addition, burnout is associated with a decrease in work performance due to negative behaviors towards work [13] . in particular, in health workers exposed to traumatic situations during this pandemic, the presence of burnout has been detected, as well as a reduction in the ability to apply coping strategies or negative attitudes towards work. in addition to the symptoms of exhaustion, related to anxiety, depression or other symptoms related to physical pathologies (e.g., cardiovascular problems), burnout can lead to intention to leave the post, which would cause high costs [14] . the speed with which the disease has spread, as well as the state of confinement, has led some researchers to analyse psychological variables resulting from the situation. for example, in a recent study of the general spanish population, in which 3480 people participated, more than 20% were found to suffer from anxiety, 18.7% revealed symptoms associated with depression, and approximately 16% suffered from posttraumatic stress. in addition, female gender was associated with greater symptomatology in anxiety, depression and posttraumatic stress, while being in the older age group was related to fewer symptoms [15] . this data are similar to those obtained in a survey carried out in the general population in china, in which 1210 people participated, of which 16.5% reported moderate to severe depressive symptoms and 28.8% moderate to severe anxiety [16] . in other european countries, such as italy, the general population has shown high levels of anxiety, depression and stress, highlighting a higher prevalence in women, people with negative affect and individuals who had family members infected or had to work away from home [17] . however, despite the state of confinement, certain professional groups, as in the case of health care personnel, have performed their jobs under great stress for weeks. these professionals, together with security forces, funeral staff and others, have been highly exposed to the virus and situations with high emotional impact. they are thus more likely to suffer mental problems, especially in the first three months in which symptoms of posttraumatic stress, affective disorders, burnout or others may increase [18] . spain leads the ranking of the number of health professionals infected with covid-19 during their work. more than 40,000 health workers have tested positive for covid-19 [19] . the critical situation requires the study of the psychological state of health professionals, and the potential harm to mental health caused by their exposure during the pandemic. a recent study on stress in 958 health workers from the city of wuhan indicates that more than half had symptoms related to anxiety and depression. specifically, 54% of the total sample experienced symptoms of anxiety, and 58% of depression, with the prevalence of stress being higher than that previously detected in health professionals who had to deal with the sars virus [20] . in a study involving 1257 health workers from china, of which 760 were from wuhan, 71.5% also showed symptoms of distress, 44.6% of anxiety, 50.4% of depression and 34% of insomnia. these symptoms were more severe in nursing staff, front-line professionals and those who worked at the epicentre of the covid-19 outbreak (wuhan) [21] . similar results have been found in other european countries such as germany, where health workers, specifically nurses, have reported high levels of stress, emotional fatigue and depressive symptoms [22] . the impact of the situation on health workers may even produce symptoms of psychotic disorder, even when this is not evident in their clinical history [23] . additionally, the stress generated by the possibility of being infected with the disease also adds to the rest of the stressful conditions of these professionals. during the influenza a (h1n1) pandemic, health workers were reported to be twice as likely to be infected through contact with patients [24] . working on the front line with infected people increases the likelihood of becoming infected, especially in this group [25] . health professionals must work in extreme conditions, in situations where resources can be scarce. for example, they must take care of a high number of patients in disaster or epidemic situations, often without sufficient beds or staff [26] . in addition to their jobs in hospitals, primary care or intensive care units, they also work in nursing homes, where the disease has had a major impact in spain. some authors indicate that risk factors for infection may include: (a) factors related to organization, such as the rapid development of new tasks and procedures, a shortage of protective material, frequent equipment changes or the high risk of increased demand for care by other different pathologies, in addition to covid-19; (b) watching patients die alone; (c) fear of infecting loved ones or having to practice social distancing for an indefinite period to protect them; and (d) prioritization of care for certain patients [27] . on the basis of the above, health professionals must deal with possible psychological, work-related consequences during the covid-19 crisis, such as posttraumatic stress, anxiety, depression or burnout [28] .the aim of this study is to assess the symptoms of posttraumatic stress, anxiety, depression, levels of burnout and resilience in the spanish health workers during the covid-19 pandemic. it also aims to evaluate the relationship between each of the variables (demographic, work, covid-19, burnout and resilience) and the symptoms of posttraumatic stress, depression and anxiety. it is equally intended to identify which variables have the most weight in each of the three categories (posttraumatic stress, anxiety and depression). the main hypotheses of this study would be the following: (a) health care workers evaluated will have high levels of post-traumatic stress, anxiety, depression and burnout; (b) resilience factor will be associated with lower burnout and with symptoms related to the above three categories; (c) the female gender will be associated with symptoms of the three categories; (d) older health care personnel would have fewer symptoms; (d) health care workers in contact with other infected patients, who are highly likely to become infected and have fewer resources or protective equipment, will have more symptoms of post-traumatic stress disorder, anxiety, depression and burnout. the sample includes 1539 subjects, recruited by non-probabilistic sampling. as criteria of exclusivity, the participants had to be in contact with patients of covid-19. finally, 117 were eliminated because they were not health personnel in contact with these patients. the sample of the study was made up of 1228 women (86.4%) and 194 men (13.6%). the mean age was 43.88 (sd = 10.82, ranging between 19 and 68). the following instruments were used: demographic, job-related and variables specific to covid-19. due to the importance of understanding how the disease affects these professionals, the researchers of this study collected information related to demographic variables, associated with the job, changes of residence, possible contact with people during work, covid-19 tests, hospitalization, isolation, protective equipment, concern over becoming infected, concern that a family member and/or someone with whom they are living may be infected. posttraumatic stress: the impact of event scale-revised (ies-r) was used [29] . this scale was used to assess the emotional distress that accompanies a stressful life event. it is made up of 22 items distributed in three scales: intrusion (7 items, an example of this scale would be "i thought about it even when i did not want to"); avoidance (8 items, an example is "i tried not to think about the event"); and hyperarousal (7 items, a sample item is "i was easily startled and scared"). in relation to posttraumatic stress, a score of 20 was considered as the cut-off point. a total score greater than or equal to 20 on the ies-r is associated with a diagnosis of psychiatric disorder and a mean score less than or equal to 14 is associated with a non-diagnosis of a psychiatric disorder [30] . it shows adequate psychometric properties in its spanish adaptation, confirming the solution of the three factors mentioned and a reliability greater than 0.70 in all subscales. anxiety and depression: the spanish adaptation of the hospital anxiety and depression scale (hads) instrument was used [31, 32] . consisting of 14 items that correspond to two subscales: anxiety and depression, with 7 items each, on a likert 0-3 response scale. an example of an item in the anxiety scale is "i feel tense and nervous" and "i feel slow and awkward" in the depression scale. it evaluates symptoms of anxiety and depression in patients and in the general population. the cut-off values are between 7 and 13 possible or probable presence of a mood disorder, and greater than 14-15 for severe disorder (the range ranges from 0 to 21) for both anxiety and depression scales. accordingly, to analyse the prevalence of symptoms in this study, the variables have been categorized as follows: < 6.99 no disorder, 7-13.99 possible or probable, > 14 severe disorder. the higher the score, the greater the prevalence of symptoms of anxiety and depression. in its spanish adaptation, it has shown adequate psychometric properties, confirming the validity of two factors and an internal consistency of 0.77 in anxiety and 0.71 in the depression subscale [32] . burnout: the spanish adaptation of the maslach burnout inventory-mbi-hss instrument was applied, which assesses burnout syndrome [33, 34] . it consists of 22 items of seven response options on a likert scale from 0 (never) to 6 (every day). the cut-off points for health personnel in the spanish sample were used to analyse the prevalence of the different components of burnout in this study: emotional fatigue (low < 22, medium 22-23, high > 31); depersonalization (low < 7, medium 7-13, high > 16); and personal accomplishment (low < 30, medium 30-35, high > 35). it presents adequate psychometric characteristics, showing an appropriate fit for the three-factor solution and an internal consistency greater than 0.71 in all subscales [35, 36] . an example of an item in the emotional exhaustion scale is "i feel emotionally drained for my work", "i think i treat some people like impersonal objects" in the depersonalization scale, and "i easily understand how people feel" in the personal accomplishment scale. resilience: the spanish adaptation of the brief resilience scale (brs) was used [37, 38] . it evaluates the resilience construct, understood as the subject's ability to deal with environmental obstacles and recover from stressful circumstances. it is made up of 6 items that are answered on a likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). the higher the score, the greater the degree of resilience the person shows to deal with adversities. an example of an item in this scale is "i tend to recover quickly after going through difficult times". the spanish adaptation presents adequate psychometric properties, corroborating the single-factor solution and an internal consistency of 0.83. the approval of the deontological committee of the faculty of psychology of the complutense university of madrid (ref. pr_2019_038; 01/04/2020) was obtained before beginning the study. researchers contacted both the coordinators and trade unions of health centres to inform them of this study. due to lockdown, data were collected by means of an online survey, from 1 to 30 of april 2020, which included the instruments described above. before starting the survey, participants had to give their informed consent in order to continue. informed consent included the purpose of the study, those responsible for it and information on the confidentiality of the data, anonymity and the legal clause on personal data protection. before completing the survey submission, participants were required to respond to all items. the completion time for all items was approximately 15 min. the analyses were carried out with the spss 26 statistical package. the proportion of cases with symptoms of the disorders mentioned above was analysed. descriptive analyses (frequencies, mean, standard deviation) were performed for symptoms associated with posttraumatic stress disorder, anxiety, depression, burnout and resilience. linear regression equations were used to evaluate the relationship between each of the variables (demographic, work, covid-19, burnout and resilience) irrespective of the symptoms (posttraumatic stress, anxiety and depression), using the r 2 value and the standardized β coefficient. the objective was to calculate the impact of posttraumatic stress, anxiety and depression on each of the variables. dummy variables were used for this. finally, linear regression models were used to see which variables (demographic, work, covid-19, burnout and resilience) were jointly related to symptoms of posttraumatic stress, anxiety and depression. the model was estimated by least squares, using the forward extraction method. analyses were carried out to evaluate the proportion of health care cases with symptoms associated with possible posttraumatic stress disorder, anxiety, depression and burnout at their different severity levels. the results of both genders are shown in table 1 . there are gender differences in symptoms of post-traumatic stress disorder, anxiety and depression. in addition, there are differences between men and women in depersonalization scale of burnout. the data of internal consistency and correlations between the factors evaluated with the instruments used are represented in table 2 . regarding gender and age, being a woman is positively and significantly associated with posttraumatic stress, anxiety and depression, while age is negatively and significantly associated with symptoms of posttraumatic stress and anxiety. working outside the autonomous community of madrid and in any centre other than primary care, hospital, nursing home or day centres (other category) is negatively and significantly related to posttraumatic stress. possessing doctoral and postgraduate studies is negatively and significantly associated with anxiety and posttraumatic stress, respectively. being a member of the non-supervisory staff is positively and significantly associated with posttraumatic stress, just as being a doctor is negatively and significantly associated with symptoms of all the evaluated categories. the caregiver position is negatively and significantly associated with anxiety and depression. working a fixed shift in the afternoon is positively and significantly associated with posttraumatic stress, anxiety and depression, while working a night shift is only positively and significantly associated with posttraumatic stress. with respect to rotating shifts, the late-night shift and on-call, or 12/24 h shifts are positively and significantly associated with posttraumatic stress and depression, respectively. working part-time is positively and significantly associated with all three categories (posttraumatic stress, anxiety, and depression). having a permanent statutory (civil servant) contract and having a training contract are negatively and significantly associated with posttraumatic stress and depression, respectively. finally, the number of hours worked per week is positively and significantly associated with depression, and the number of on-call hours performed per month is positively and significantly associated with posttraumatic stress and depression (see table 3 ). changing address or living with people who are at risk is positively related to symptoms of posttraumatic stress, anxiety or depression. on the other hand, having personal protective equipment and not being very concerned that family members are infected is negatively related to symptoms of posttraumatic stress, anxiety or depression. hospitalization for symptoms of covid-19 and isolation due to possible contagion of the disease is positively related to posttraumatic stress. thinking that becoming infected with covid-19 is highly unlikely is negatively related to symptoms of posttraumatic stress and anxiety. emotional fatigue and depersonalization are positively and significantly related to symptoms of posttraumatic stress, anxiety and depression, while personal accomplishment is negatively and significantly related to symptoms of anxiety and depression. finally, resilience is associated in a negative and significant way with symptoms from all the evaluated categories. on the other hand, these professionals present moderate levels of resilience, while the highest possible score on resilience is 6, the mean score for these individuals is 3.02 (sd = 0.39), therefore indicating moderate levels. all associations can be seen in table 4 . as shown in table 5 , the posttraumatic stress symptom model was significant, explaining 39.6% of the variance (f(17, 1405) = 54,022, p < 0.001). it was also significant for anxiety symptoms, explaining 40.2% of the variance (f(12, 1412) = 78.593, p < 0.001). in relation to the depression model, it was significant, explaining 39.3% of the variance (f(14, 1408) = 64.932, p < 0.001). the variables common to the three models were emotional fatigue, depersonalization, resilience, gender, and concern that someone with whom they live could be infected. the variables positively related to posttraumatic stress are emotional exhaustion, depersonalization, working in the autonomous community of madrid, having a primary education, working in a hospital, being very concerned that someone with whom they live may become infected and thinking that there is a high risk of also becoming infected with covid-19. on the other hand, the variables negatively related to posttraumatic stress are resilience, being a man, having a doctor's degree, living with an unmarried partner, being a doctor or having another profession (mainly pharmacist or psychologist, but not a nurse, nursing assistant or caregiver), having protective equipment at work, not being concerned that someone you live with can be infected with the disease and the number of people you live with. the variables positively and significantly related to anxiety would be emotional exhaustion, depersonalization, 12-or 24-h shifts or on-call hours and being very concerned that someone with whom they live could be infected. the variables negatively and significantly related to anxiety would be resilience, being a man, being separated, working in nursing homes or day centres, being a doctor, having a rotating morning-afternoon shift and not having been isolated due to covid-19. finally, having symptoms of depression is positively and significantly related to: emotional exhaustion, depersonalization, 12-or 24-h shifts or on-call hours, the number of guards per month, being very concerned that someone with whom you live may be infected, not having a family and thinking that it is very likely that you will be infected with covid-19. the variables negatively and significantly related to depression would be personal fulfilment, resilience, being a man and having a fixed or training contract. the gender-differentiated posttraumatic stress models were significant, in both men and women, explaining 35.2% of the variance in women (f(13, 1210) = 50,667, p < 0.001) and 53.7% in men (f(9, 183) = 23,548, p < 0.001). on the anxiety scale, the models were significant, explaining 36.3% of the variance in women (f(11, 1212) = 64,280, p < 0.001) and 62.7% in men (f(6,168) = 52,066, p < 0.001). for the depression scale, the models were significant, explaining 37.73% of the variance in women (f(14, 1223) = 52.310, p < 0.001). tables 6 and 7 show the regression models of post-traumatic stress, anxiety and depression, differentiated by gender. in relation to the gender-differenciated models, in women (see table 6 ): the symptoms of posttraumatic stress are positively and significantly related to emotional exhaustion, depersonalization, working in a hospital, being very concerned that someone with whom they live may become infected and thinking that becoming infected with covid-19 is very likely. on the other hand, the variables negatively related to posttraumatic stress are personal accomplishment, resilience, living with and unmarried partner, working in nursing homes, being a doctor or having another profession (mainly pharmacist or psychologist, but not a nurse, nursing assistant or caregiver) and thinking that is very unlikely to be infected with covid-19. the variables positively and significantly related to anxiety would be emotional exhaustion, depersonalization, being very concerned that someone you live with can be infected with the disease and change of residence through fear of infecting family members. the variables negatively and significantly related to anxiety would be resilience, being separated, working in nursing homes and not being at all concerned that someone you live with can be infected with the disease. having symptoms of depression is positively and significantly related to emotional exhaustion depersonalization, being a nurse, 12-or 24-h shifts or on-call hours, those who live with people who are at risk and being very concerned over a possible infection of a family member they do not live with. the variables negatively and significantly related to depression would be personal accomplishment, resilience, being a doctor, having a fixed or training contract. in relation to the gender-differentiated models, in men (see table 7 ): the symptoms of posttraumatic stress are positively and significantly related to emotional exhaustion, having a primary education and being very concerned that someone with whom they live may become infected. on the other hand, the variables negatively related to posttraumatic stress are resilience, having a doctor's degree, not having been isolated due to covid-19 and not being concerned that someone with whom you live with can be infected with the disease. the variables positively and significantly related to anxiety would be emotional exhaustion, being a nurse and having been isolated due to covid-19. the variables negatively and significantly related to anxiety would be resilience, having a training contract and having a statutory fixed-term employment. having symptoms of depression is positively and significantly related to emotional exhaustion depersonalization and being very concerned that someone with whom they live may become infected. the variables negatively and significantly related to depression would be personal accomplishment, resilience, having a doctor's degree, having a training contract, not having been isolated due to covid-19 and not having been hospitalized for symptoms compatible with those of coronavirus. table 6 . regression models for posttraumatic stress, anxiety and depression in women (n = 1228). table 7 . regression models for posttraumatic stress, anxiety and depression in men (n = 194). this research aimed to assess the symptoms of posttraumatic stress, anxiety, depression, burnout and resilience in spanish health workers during the covid-19 pandemic. it was also aimed at evaluating the relationship between each of the variables independently (demographic, work, covid-19, burnout and resilience) and the symptoms of posttraumatic stress, depression and anxiety, as well as the variables that (together) carry more weight in each of the three categories (posttraumatic stress disorders, anxiety and depression). the results show that 56.6% of health workers present symptoms of posttraumatic stress disorder. the number having a possible anxiety disorder is 58.6%, with 20.7% having a severe disorder. equally, a high percentage, specifically 46%, would have a possible depressive disorder and 41% feel emotionally drained. in this sense, the first hypothesis would be fulfilled, although it would be necessary to make a thorough evaluation to determine a clinical diagnosis. most workers present probability of developing a posttraumatic stress disorder, anxiety or depression. during the middle east respiratory syndrome (mers) or ebola crises, among others, health professionals reported a higher number of symptoms related to posttraumatic stress [39] , so it is necessary to pay attention to the increase in these symptoms, even more so in the situation of the covid-19 pandemic that has not yet subsided. the demographic variables show that having a doctoral or postgraduate degree represent protective variables of anxiety and posttraumatic stress, respectively. in addition, lower-level workers show more symptoms of posttraumatic stress. this result may be due to the fact that, in lower-level jobs, control over procedures and decision-making capacity is lower than in other higher-level positions. some authors have shown that the main differences among professions regarding the symptomatology evaluated during the covid-19 pandemic apply to nurses and other positions, such as doctors. nurses present more symptoms of anxiety and depression [40] . these differences may be associated with the contact of these professionals with infected patients. on the other hand, being a woman is associated with greater symptoms of posttraumatic stress, anxiety or depression in the sample of health workers evaluated. younger health workers show greater levels of posttraumatic stress and anxiety. this may be due to a lack of work experience in similar stressful situations. another possible reason is that, during the current pandemic, the lack of health care staff has required that senior students or people with fewer experience have had to deal with the demands of the covid-19 patients. the data obtained in this study on the gender and age variables coincide with the findings of other studies in health personnel from different countries [41, 42] . some authors suggest that, both in the current situation due to covid-19 and in similar previous situations, symptoms of stress, anxiety and depression generally increase in health professionals and also coincide in pointing out that women present more symptoms than men do. regarding gender differences, the data obtained in this study may be due to the high number of women in positions such as nurse or nursing assistant. on the other hand, in mood disorders, which have a high comorbidity with those of anxiety, there is a high prevalence of women compared to men. for example, women present more rumination and there are hormonal differences that can explain these results [43] . variables related to jobs show that those health workers who have part-time jobs have more symptoms of posttraumatic stress, anxiety and depression. the shifts most related to psychological problems are the night, afternoon and afternoon-night rotating shifts. in this regard, similar results have been identified with health personnel that indicate the association between working the night shift and having gastrointestinal problems, hormonal problems, and changes in mood and cognitive state, among others [44] . regarding the work shift, other authors specify that there is a greater risk of having symptoms of depression as the number of days worked in the night shift increases [45] . doctors have fewer symptoms of posttraumatic stress, anxiety, or depression, and caregivers have fewer symptoms of anxiety and depression. health workers with a lower job category have more symptoms of posttraumatic stress, while those who work more hours a week have more symptoms associated with depression. health workers who do more on-call hours a month have more symptoms of posttraumatic stress and depression. therefore, the hours of rest for these professionals must be respected. in relation to the information collected on covid-19, it should be noted that the health workers who have had to change their residence due to the pandemic have been isolated due to possible contagion, and those who live with people who are at risk or think they may infect other people have more symptoms of posttraumatic stress, anxiety or depression, although these differences were not statistically significant in depression for the two variables: being isolated due to possible contagion and the likelihood of becoming infected with covid-19. regarding the hypothesis related to these variables, it would be partially fulfilled, since the association between the possibility of infection and the symptoms of depression would not be significant. recent research indicates that one of the greatest concerns of health personnel is the possibility of infecting others, especially family members [46] . believing that they are very unlikely to be infected with covid-19 is related to fewer symptoms of posttraumatic stress and anxiety. on the other hand, as proposed in the study hypothesis, those health workers who have personal protective equipment to cope with the disease have fewer symptoms of posttraumatic stress, anxiety or depression. these results may be due to the fact that, on the one hand, contact with people who may be infected is a risk factor for imminent contagion among health workers, as a result of the high transmission of the disease [47] ; on the other hand, the use of personal protective equipment is essential to be able to work and treat patients with covid-19 [48] . the profile of a health worker with greater symptoms of posttraumatic stress would be a person who works in the autonomous community of madrid, in a hospital, is a woman, has primary studies, worries that their family members may become infected and thinks that they are very likely to be infected with covid-19. the protective variables of suffering posttraumatic stress symptoms are being a man, having a doctor's degree, living with a partner (not married), being a doctor or working in "another position" (a category made up mainly of pharmacists and psychologists), having protective equipment at work, not being concerned about infecting the people with whom they live and not living alone. the risk variables associated with anxiety symptoms are being a woman, having a 12-or 24-h on-call shift and being worried that a person he/she lives with could be infected. additionally, the following protective factors have been identified: being a man, being separated, working in nursing homes or day centres, being a doctor, having a rotating morning-afternoon shift and/or not being isolated by covid-19. the profile of the health worker with greater symptoms of depression is being a woman, working 12-or 24-h shifts or on-call hours, the number of on-call hours per month, thinking that they are very likely to become infected with covid-19, being worried about infecting someone with whom they live and having no family. the protective variables of depression are being a man, having a fixed-term or training contract, feeling professionally accomplished and not living with people who are at risk. presenting high scores in emotional exhaustion and depersonalization are risk factors for posttraumatic stress, anxiety and depression. however, resilience would be a protective variable that reduces symptoms in all three disorders, and personal accomplishment would be a protective variable against depressive symptoms. one study points out that, in 2003, during the sars epidemic, health personnel showed symptoms related to posttraumatic stress disorder and, in general, higher levels of psychological stress [49] . recent research has indicated that, during the influenza a (h1n1) outbreak, resilience levels had a direct influence on the psychological health of health personnel [50] . regarding the gender-differentiated models, being a nurse is associated with symptoms of mental disorder, specifically depression in women and anxiety in men. in men, depersonalization and personal accomplishment are only associated with depression (although this relationship is not significant), while in women it is associated with the three scales of burnout. that is to say, women who have high scores in depersonalization would have more symptoms of mental disorder than men. in men, personal accomplishment would not be a protective variable, while for women it would be a protective factor for posttraumatic stress, anxiety and depression. having a primary education would be a risk variable for posttraumatic stress and having doctoral studies would be a protective variable of posttraumatic stress and depression, but only in men. in relation to the type of contract, having a statutory fixed-term employment contract is negatively related to anxiety in men, not being a relevant variable for women. the type of shift is a relevant variable for women, but not for men. specifically, 12-or 24-h shifts are positively related to depression in women, but not in men. having a fixed contract is a more relevant variable for women than for men, since it is a protective variable of depression in women. with regard to the foregoing, one of the main results of this study is that the levels of resilience of the healthcare workers evaluated are moderate. taking into account that resilience is presented as a possible protective factor of symptoms of posttraumatic stress disorder, anxiety and depression, the need to promote resilience among health personnel is highlighted. different studies have pointed out various measures to promote resilience among these professionals during the covid-19 pandemic. these include the following: providing psychological training to healthcare workers so that they can help patients and encouraging support within the organization by the network of personnel and train communication [51] . the model of intervention in psychological resilience based on peer support (battle buddies) developed by the us military should be highlighted. this model requires a close support partner as well as a designated mental health consultant to facilitate training in stress inoculation methods and to coordinate referral to the outpatient psychological consultation [52] . it might be interesting to introduce the elements mentioned in the spanish health care system to establish measures to promote resilience in possible future waves of covid-19. in this sense, the hypothesis proposed at the beginning would be fulfilled, since resilience would be a protective factor for such symptoms. in relation to burnout, it should be noted that a large percentage of these professionals have high scores in emotional exhaustion, but low in depersonalization and very high in personal accomplishment. the first study hypothesis, therefore, would be partially fulfilled, since it was expected that the workers would have low levels of personal accomplishment. this could be explained by the fact that health professionals have been intensely involved with patients in this situation, have felt valued by patients and society, and have realized the great importance of their profession, which may have had a very positive influence on their personal fulfilment. the variable with the greatest weight in the regression models is emotional fatigue. hence, preventive measures to reduce this should be implemented for these workers. emotional fatigue is the dimension that has the greatest relevance compared to depersonalization and personal fulfilment, within the burnout construct [53] . other authors have also identified high levels of fatigue and negative emotions in health personnel from emergency teams in coping with the covid-19 situation [54] . the study does have some limitations. the data were obtained using an online tool and people not familiar with the web could not be included in this study. in addition, the survey was carried out at the peak of the pandemic in spain: the continuous exposure to negative stimuli and the constant information in the media about the state of health care workers and those infected and deceased by covid-19 may have had an influence in the perception of anxiety and depression levels, due to the feeling of fear experienced [55] . furthermore, there is a high proportion of women compared to men. other studies have shown the same limitation [56, 57] . in this case, one of the main reasons for this difference is that, in many positions, such as nurses and nursing assistants, the majority of the positions are occupied by women. another limitation has to do with the cross-sectional design of the study: the pandemic has not yet finished and its influence on mental health cannot be reflected in this research, so it would also be advisable to carry out a longitudinal study that evaluates the evolution over time of the symptoms assessed in this work. on the other hand, there has not been a previous situation in spain in which there has been a lockdown, and it is likely that after its ending, the levels of experienced symptomatology will be lower. however, during the sars crisis, other authors have found that the symptoms of psychological problems after the quarantine period of the disease have lasted up to three years later [3, 58] . in the long term, the effects of posttraumatic stress disorder, anxiety and depression will depend on the possible outbreaks of covid-19. the measures currently being taken in order to adapt the work place to the new situation (such as providing protective equipment or increasing the number of healthcare professionals) are relevant for mitigating these symptoms. if the appropriate actions to protect health care providers are not taken, they may make medical errors in the future, present higher burnout levels associated with depressive symptoms, anxiety, suicidal ideation, have poorer interpersonal relationships or develop substance abuse [59] . therefore, a follow-up study along the next few months becomes necessary. this research presents a detailed description of the association between different variables and symptoms of posttraumatic stress, anxiety and depression. previous studies for spanish health professionals to evaluate these characteristics, including resilience, and its associations with the described variables, have not been found. among the main uses for this study is the description of the profiles of spanish healthcare providers that present a greater risk of suffering from post-traumatic stress, anxiety and depression, so more specific intervention measures can be designed to reduce these symptoms. on the other hand, resilience is a protective factor of the mentioned symptoms, so it would be advisable to include the 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psychological impact of the sars quarantine experience burnout and posttraumatic stress disorder in the coronavirus disease 2019 (covid-19) pandemic: intersection, impact, and interventions resilience and emotional support in health care professionals during the covid-19 pandemic this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-355905-av03suua authors: romero starke, karla; petereit-haack, gabriela; schubert, melanie; kämpf, daniel; schliebner, alexandra; hegewald, janice; seidler, andreas title: the age-related risk of severe outcomes due to covid-19 infection: a rapid review, meta-analysis, and meta-regression date: 2020-08-17 journal: int j environ res public health doi: 10.3390/ijerph17165974 sha: doc_id: 355905 cord_uid: av03suua increased age appears to be a strong risk factor for covid-19 severe outcomes. however, studies do not sufficiently consider the age-dependency of other important factors influencing the course of disease. the aim of this review was to quantify the isolated effect of age on severe covid-19 outcomes. we searched pubmed to find relevant studies published in 2020. two independent reviewers evaluated them using predefined inclusion and exclusion criteria. we extracted the results and assessed seven domains of bias for each study. after adjusting for important age-related risk factors, the isolated effect of age was estimated using meta-regression. twelve studies met our inclusion criteria: four studies for covid-19 disease severity, seven for mortality, and one for admission to icu. the crude effect of age (5.2% and 13.4% higher risk of disease severity and death per age year, respectively) substantially decreased when adjusting for important age-dependent risk factors (diabetes, hypertension, coronary heart disease/cerebrovascular disease, compromised immunity, previous respiratory disease, renal disease). adjusting for all six comorbidities indicates a 2.7% risk increase for disease severity (two studies), and no additional risk of death per year of age (five studies). the indication of a rather weak influence of age on covid-19 disease severity after adjustment for important age-dependent risk factors should be taken in consideration when implementing age-related preventative measures (e.g., age-dependent work restrictions). the first cluster of cases of coronavirus disease 2019 (covid19) was reported in wuhan (huban province, china) in december 2019. only a little more than two months later, on 12 march 2020 the world health organization (who) announced the covid-19 outbreak to be pandemic. due to the high number of increasing cases and deaths, research identifying the risk factors for covid-19 disease severity is being published at a high rate. an increase in covid-19 disease severity with increased patient age has been widely noted [1] [2] [3] [4] . national health institutions such as the robert koch institute (rki) in germany and the centers for disease control (cdc) in the united states routinely report covid-19 cases and deaths stratified by age. they have described an increase in mortality with increasing age. in its covid-19 informational report, the rki states "the risk of severe diseases increases steadily from 50 to 60 years of age" [5] . due to these observations, several governments have recommended older workers, mostly starting at the age of 60, to abstain from going into the workplace during the pandemic because of the increased risk of complications due to covid-19. after the lockdown and in the course of the relaxation of restrictions, the federal state of lower saxony in germany stated that because teachers over the age of 60 (together with persons with chronic diseases) are considered a risk group, they may be able to work from home after the presentation of a medical certificate [6] . in general, the classification of people over 60 years of age as risk persons can significantly reduce the chances of older unemployed people finding a job or make them "targets" for layoffs. there is a major drawback in relying on the age-stratified data of disease severity for the individual assessment of the risk of a severe outcome of a disease: considering only the age-dependency of the disease course could result in a distorted picture. other risk factors, such as cardiovascular diseases, respiratory diseases, and conditions that result in a weakened immunity, also increase with increasing age, and must be taken into account to uncover the isolated effect of age. the largest report on risk factors for death due to covid-19 so far is based on 44,672 confirmed cases from the cdc in china [7] . along with a case fatality rate (cfr) of 2.6% in people older than 59 years, a 6% cfr was reported for patients with hypertension, 7.3% for patients with diabetes, 10.5% for patients with cardiovascular diseases, 6.3% for patients with chronic respiratory diseases, and 5.6% for cancer patients. in addition, there is increased evidence of an increased risk of negative covid-19 outcomes with obesity [8, 9] . a recent review names smoking as a likely risk factor for adverse covid-19 outcomes [10] . it is therefore of utmost importance to quantify the isolated effect of age in the risk for covid-19 disease severity. the aim of this study was to do exactly this. for this purpose, we performed a systematic rapid review of the studies investigating age and covid-19 adverse outcomes. on 15 may 2020, we searched pubmed using the search strings "covid-19" and "age". we applied no language, region, or time restrictions. articles in chinese were translated automatically with the help of google translate. following the population, exposure, comparator, outcome, study design (pecos) scheme for the eligibility criteria of the studies (table 1 ), we considered cross-sectional, case-control, and cohort studies on the general population infected with covid-19. we defined the outcome of interest, "disease severity due to covid-19", as hospitalization, admission to an intensive care unit (icu), intubation, or death due to covid-19. persons from the same study population with non-severe covid-19 could be used as a comparison group, and the definition of non-severity could depend on the definition of the outcome considered. we only considered studies which estimated the adjusted risk of age on disease severity, meaning that studies which only reported age-stratified results or univariate analysis were excluded. the resulting titles and abstracts were screened by two independent scientists to disqualify the studies which were unrelated to the defined research question. in case of disagreement on inclusion, a consensus decision was sought between the two scientists. if there was still no agreement, the decision was made by a third reviewer. the full texts of the remaining studies were again independently examined by two reviewers to determine if the inclusion criteria for this specific review were met. likewise, in case of disagreement, a consensus decision was sought between the two reviewers, and in case of no consensus, the decision was made by third reviewer. additionally, a manual search was performed to find additional relevant articles by screening the reference lists of key articles. the data extraction was done by one reviewer. we tried to obtain the missing or unclear information through personal communication with the authors. the data extraction form included information on the first author and publication year, country of origin, study population, outcome, confounding, and study results. for each included study, we evaluated the overall risk of bias as "low", "high", or "unclear". the overall risk of bias was based on seven domains of bias, following the example used by ijaz and colleagues [11] , and considering the criteria described by sign (scottish intercollegiate guidelines, 2012 [12] and casp (critical appraisal skills programme [13] ): a low-risk study should have avoided selection bias by ensuring an adequate recruitment method, such as randomized sampling. the response rate should be 50% or more, and if not achieved, a non-participation analysis should be performed. for cohort studies, if the loss to follow-up was below 20% and there was no substantial difference between the comparison groups, the risk of bias for this domain was rated as low. similarly, for a case-control study to be rated as having a low risk of bias for this section, both cases and control subjects should have had a response of 50% or more, and if this number was not achieved, the substantial differential selection of cases and controls should have been excluded by a non-participation analysis. if the exposure (age) was accurately measured and finely categorized (i.e., in per year categories), the domain for the study was considered to have a low risk of bias. if the age was measured in large categories, such as ≥65 years vs. <65 years, the domain was considered as having a high risk of bias. if the outcome was objectively measured to minimize bias, such as through hospital or medical records and the assessment was similar for the comparison groups, the domain was considered as having a low risk of bias. the following major age-dependent factors (which might at least partly mediate the influence of age on the course of disease) should have been considered for this domain to have a low risk of bias: (1) diabetes, (2) hypertension, (3) coronary heart disease/cerebrovascular disease, (4) compromised immunity/cancer, (5) previous respiratory disease, and (6) renal disease. other known risk factors of disease severity with no or little age-dependency (sex, obesity, smoking) were not considered as major age-dependent risk factors. if the adequate statistical models were used to reduce bias and control for confounding, this domain was considered as having a low risk of bias. if the risk factors were included in the model which reflected covid-19 infection (in other words, an over-adjustment on the model), this domain was regarded as having a high risk of bias. this was assessed in two areas: the sources of funding and the involvement of the funding body in the research. if a study was funded by non-profit organization(s) and it was not affected by sponsors, the domain was rated as having a low risk of bias. if the sponsoring organization participated in the data analysis or the study was probably affected by the sponsors, the domain was considered as having a high risk of bias. if the authors reported not having a conflict of interest, the domain was rated as having a low risk of bias. if one author had a conflict of interest, the domain was considered as having a high risk of bias. from the seven domains described, we considered the domains described in section 2.2.1-section 2.2.5 as major domains for a risk of bias, while sections 2.2.6 and 2.2.7 were minor domains. a "high risk" or "unclear risk" rating in any of the major domains would result in an overall "high risk of bias" assessment for each study. when studies used either the same population or a subset of another study's population and investigated the same outcomes, we chose the study with more precise age categories (i.e., per year of age) for the risk of bias assessment and for the subsequent meta-analysis. we used stata version 14.2 [14] for all statistical analyses. to obtain a precise pooled age-related risk, we decided a priori to conduct a meta-analysis if at least two studies were present with similar outcomes, exposures, and evaluating risk per year of age. we assessed statistical heterogeneity with the i 2 statistic and assessed publication bias by observing the funnel plot asymmetry and by performing egger's test (metabias). since we deem adjustment for age-dependent risk factors essential for determining the isolated risk of age on disease severity, we performed a meta-regression (metareg) to obtain the effect of the number of important age-dependent risk factors (0-6) used in the study models (diabetes, hypertension/cardiovascular disease, compromised immunity, respiratory disease) on the relative risk. in a sensitivity analysis, we included a bivariate factor (0 = no, 1 = yes) in the model, representing whether there was an over-adjustment in the model-meaning that the model included variables which already reflected a possible covid-19 infection (e.g., fever, dyspnea, neutrophil to lymphocyte ratio, c-reactive protein). through the database and manual search, 546 studies identified were screened, resulting in 57 full-text articles assessed for eligibility ( figure 1 ). from these, 45 articles were excluded for the following main reasons: the risk of age was not calculated, only the crude (unadjusted) risk of age was reported, irrelevant subject, unclear methodology, and unclear outcome definition. finally, twelve studies met our inclusion criteria. we assessed statistical heterogeneity with the i 2 statistic and assessed publication bias by observing the funnel plot asymmetry and by performing egger's test (metabias). since we deem adjustment for age-dependent risk factors essential for determining the isolated risk of age on disease severity, we performed a meta-regression (metareg) to obtain the effect of the number of important age-dependent risk factors (0-6) used in the study models (diabetes, hypertension/cardiovascular disease, compromised immunity, respiratory disease) on the relative risk. in a sensitivity analysis, we included a bivariate factor (0 = no, 1 = yes) in the model, representing whether there was an over-adjustment in the model-meaning that the model included variables which already reflected a possible covid-19 infection (e.g., fever, dyspnea, neutrophil to lymphocyte ratio, c-reactive protein). through the database and manual search, 546 studies identified were screened, resulting in 57 full-text articles assessed for eligibility ( figure 1 ). from these, 45 articles were excluded for the following main reasons: the risk of age was not calculated, only the crude (unadjusted) risk of age was reported, irrelevant subject, unclear methodology, and unclear outcome definition. finally, twelve studies met our inclusion criteria. the study characteristics are summarized in tables 2-5 and below. all studies originated in china and were retrospective cohort studies, using hospitalized patients as the study population. eight studies categorized and analyzed the patients' age by year [15] [16] [17] [18] [19] [20] [21] [22] , three studies constructed larger age categories for their analyses [23] [24] [25] , and one study did both [26] . the study characteristics are summarized in tables 2-5 and below. all studies originated in china and were retrospective cohort studies, using hospitalized patients as the study population. eight studies categorized and analyzed the patients' age by year [15] [16] [17] [18] [19] [20] [21] [22] , three studies constructed larger age categories for their analyses [23] [24] [25] , and one study did both [26] . seven studies evaluated the risk of patients' mortality [18] [19] [20] [21] [22] [23] [24] , four evaluated the covid-19 disease severity by building a composite index comprising of admission to the icu, invasive ventilation, or death [15, 17, 25, 26] , and one study evaluated the admission to icu [16] . there were studies that used the same study population or a subset of the other's study population. an example of this is the population from guan et al. 2020 [26] and chen, r et al. 2020 [23] , and liang, w. [17] et al., where all three studies used the same data from 1590 participants across 575 hospitals in mainland china. another example is that of zhou et al. 2020 [18] and du et al. 2020 [24] . in this case, both studies used data in a similar timeframe from a subset of hospitals included in the previous large study by guan and colleagues [26] , and therefore we considered these two studies [18, 24] to have used a subset of the guan et al. 2020 population [26] . a summary of the studies investigating disease severity by a composite index can be found in table 3 . the largest study in china was a retrospective cohort study from guan and colleagues [26] , which included the clinical data of 1590 laboratory-confirmed hospitalized covid-19 cases from 575 hospitals in china, representing almost a third of the certified hospitals in china for admitting patients with covid-19 between 11 december 2019 and 31 january 2020. after adjustment for malignancy, chronic obstructive pulmonary disease (copd), diabetes, hypertension, and smoking, every year of age increased the risk of severe outcome by 3.6% (hr = 1.036, 95% ci 1.022-1.050). because this study did not consider all the necessary risk factors into its analysis (coronary heart disease/cerebrovascular and renal disease missing), it was considered to have a high risk of bias (table 4 ). this study was included in our meta-analysis. liang et al. 2020 [17] investigated the above study's [26] same population and outcome and performed a similar analysis using somewhat different confounders, including biomarkers that were reflective of covid-19 infection. the study yielded similar results (per year of age hr = 1.03, 95% ci 1.01-1.05) as guan et al. 2020 [15] , but we preferred to use guan et al. 2020 in our meta-analysis, since liang et al. 2020 [17] used markers reflective of infection in their analysis. chen c. et al. 2020 [15] was a retrospective cohort made up of 150 patients admitted to the fever ward in tongji hospital. after adjustment for confounders, each year of age elevated the risk of severe disease by 1.9% (hr = 1.019; 95% ci 0.963-1.077), although the result was not statistically significant. this study did not consider all the necessary risk factors (diabetes, compromised immunity, respiratory disease missing). it also used several biomarkers reflective of covid-19 infection in its analysis, so it was evaluated as having a high risk of bias. this study was included in our meta-analysis. meng et al. 2020 [25] investigated chen c. and colleagues' [15] study population, but used large age categories (0-59, 60-79, ≥80 years) for the analysis. they found a higher risk of death in older patients than in those younger than 60 years. because of the broad age categories used, it was not used for the risk of bias or meta-analysis and chen c. et al.'s [15] analysis was instead preferred. the reasons for the exclusion of any study from our risk of bias assessment and meta-analysis are given in table 4 . again, we avoided having more than one study using the same population, and studies investigating the age effects per year of age were preferred to the studies using large age categories, such as <65 yrs. vs. ≥65 yrs. therefore, lian et al. 2020 [17] and meng et al. 2020 [25] were excluded, and guan et al. 2020 [26] and chen c et al. 2020 [15] were included in the risk of bias assessment and in the meta-analysis. figure 2 summarizes the risk of bias (rob) for composite endpoints of disease severity. because all important age-dependent risk factors were not considered, both included studies [15, 26] had a high risk of bias. in addition, chen c. et al. included all the factors indicating an infection and this study was further marked down. are given in table 4 . again, we avoided having more than one study using the same population, and studies investigating the age effects per year of age were preferred to the studies using large age categories, such as <65 yrs. vs. ≥65 yrs. therefore, lian et al. 2020 [17] and meng et al. 2020 [25] were excluded, and guan et al. 2020 [26] and chen c et al. 2020 [15] were included in the risk of bias assessment and in the meta-analysis. figure 2 summarizes the risk of bias (rob) for composite endpoints of disease severity. because all important age-dependent risk factors were not considered, both included studies [15, 26] had a high risk of bias. in addition, chen c. et al. included all the factors indicating an infection and this study was further marked down. the pooled effect of both studies [15, 26] indicates a 4% increase in the risk of severe disease per year of age (95% ci 2%-5%), figure 3 . the corresponding funnel plot indicates no evidence of publication bias (results not shown). the pooled effect of both studies [15, 26] indicates a 4% increase in the risk of severe disease per year of age (95% ci 2%-5%), figure 3 . the corresponding funnel plot indicates no evidence of publication bias (results not shown). the meta-regression from both studies [15, 26] indicated an intercept of 1.052 (95% ci 1.026-1.078) and a slope (ß) of 0.996 (95% ci 0.987-1.006). an estimate of the age-related relative risk by the number of important risk factors considered in the adjustment models can be found in table 6 . the unadjusted age effect was a 5.2% increase in disease severity per age year. the maximum number of important risk factors adjusted for by the studies was five, which resulted in a 3.5% increase in disease severity per age year. the meta-regression from both studies [15, 26] indicated an intercept of 1.052 (95% ci 1.026-1.078) and a slope (ß) of 0.996 (95% ci 0.987-1.006). an estimate of the age-related relative risk by the number of important risk factors considered in the adjustment models can be found in table 6 . the unadjusted age effect was a 5.2% increase in disease severity per age year. the maximum number of important risk factors adjusted for by the studies was five, which resulted in a 3.5% increase in disease severity per age year. because there were only two studies, a sensitivity analysis of the effect of both the important risk factors and the inclusion "over-adjustment" variables in the multivariate model could not be done. a summary of the studies investigating death due to covid-19 can be found in table 4 . chen r et al. [23] used the same study population as guan et al.'s (n = 1590) [26] , but studied mortality (table 4 ). they used broad age categories (<65, 65-74, and ≥75 years) for their analysis. after adjusting for coronary heart disease, cardiovascular disease, and for several biomarkers, there was an increased risk of mortality for older patients (≥75 years hr 7.86, 95% ci 2.44-25.35; 65-74 years because there were only two studies, a sensitivity analysis of the effect of both the important risk factors and the inclusion "over-adjustment" variables in the multivariate model could not be done. a summary of the studies investigating death due to covid-19 can be found in table 4 . chen r et al. [23] used the same study population as guan et al.'s (n = 1590) [26] , but studied mortality (table 4 ). they used broad age categories (<65, 65-74, and ≥75 years) for their analysis. after adjusting for coronary heart disease, cardiovascular disease, and for several biomarkers, there was an increased risk of mortality for older patients (≥75 years hr 7.86, 95% ci 2.44-25.35; 65-74 years hr 3.43, 95% ci 1.24-9.5). it was not included in the meta-analysis because no other study used comparable age categories. zhou et al. 2020 [18] investigated death in 191 covid-19 patients from two hospitals which were included as part of chen r et al. 2020 [23] and guan's study population and in similar timeframes. several of the risk factors of interest were missing from the analysis (diabetes, weakened immunity, and respiratory disease). after the adjustment for confounders, an increased risk of death was found for each year of age (or = 1.10; 95% 1.03-1.17). since "per year of age" analyses were done, the zhou et al. study was included in the risk of bias and meta-analysis for death as an outcome. we evaluated the study as having a high risk of bias because not all age-related risk factors were considered, and because biomarkers which were already reflective of covid-19 disease severity were used for the risk analysis. wang d. et al. 2020 [19] studied 107 patients hospitalized at zhongnan hospital of wuhan university and at xischui hospital. after adjusting for sex, hypertension, cardiovascular disease, and creatinine concentration, each increased year of age resulted in an 11% increased risk of mortality (or = 1.11; 95% ci 1.042-1.184). because not all important age-related risk factors were included in the analysis, and because they adjusted for biomarkers which were reflective of disease severity/covid-19 infection, the study was rated as having a high risk of bias. wang d. et al. 2020 [19] was included in our meta-analysis. in another retrospective study, wang k. et al. 2020 [20] studied 305 patients hospitalized in first people's hospital of the jiangxia district in wuhan from 7 january to 11 february 2020. after adjustment for hypertension and fever, there was a 9% increased mortality for every year of age (or = 1.09; 95% ci 1.054-1.14). due to the lack of age-related risk factors included in the analysis and the adjustment for fever, which is reflective of covid-19 infection/disease severity, this study was determined to have a high risk of bias. this study was included in our meta-analysis. shi et al. 2020 [21] studied the patients admitted to renmin hospital of wuhan university from 1 january to 23 february 2020, using a retrospective cohort design. they used two models: model 1 considered sex, hypertension, diabetes, coronary heart disease, chronic renal disease, cerebrovascular disease and several biomarkers as categorical variables. model 2 used sex and the same chronic diseases as model 1, but with the biomarkers as continuous variables. when model 1 was used, there was a 1% increased risk of death per year of life (or = 1.01; 95% ci 0.98-1.05) which was borderline statistically significant. model 2 resulted in a 4% increased risk of death per year of life (or = 1.04; 95% ci 1.00-1.07), also borderline statistically significant. we evaluated this study as having a high risk of bias, because not every important age-related risk factor was considered and because it used variables which may reflect covid-19 disease severity. shi et al. 2020 [21] was included in our meta-analysis. sun et al. 2020 [22] identified 244 patients over the age of 60 years of the sino-french new city branch of tongji hospital between 29 january to 5 march 2020. only patients who were 60 years or older were enrolled. after adjustment for sex, hypertension, previous respiratory diseases and other confounders, there was a 12% increase risk of death per year of life was observed (or = 1.12; 95% ci 1.01-1.25). this study received a high risk of bias rating because only patients older than 60 years of age were considered, because of missing risk factors, and because biomarkers were used that might indicate a covid-19 infection/disease severity. sun et al. 2020 [22] was included in our meta-analysis. the reasons for the exclusion of any study from our meta-analysis/risk of bias assessment for death are summarized in table 4 . in summary, five studies (zhou et al. 2020 [15] , wang d et al. 2020 [19] , wang k et al. 2020 [20] , shi et al. 2020 [21] , and sun et al. 2020 [22] ) were included in the risk of bias assessment and meta-analysis. all the studies included in the meta-analysis for mortality were rated as having a high risk of bias because not all age-dependent risk factors were considered and because the variables used in the analysis may have already indicated covid-19 disease severity. in addition, sun et al. 2020 [22] only investigated people over the age of 60, and therefore it received a high-risk in the recruitment procedure domain. the pooled effect of the five studies [18] [19] [20] [21] [22] indicates an 8% increase in the risk of death per year of age (95% ci 3-13%) when shi et al.'s [21] model with categorized values for the biomarkers was used (figure 4) . the effect remains similar with slightly narrower confidence intervals when model 2 was used with continuous values (rr = 1.08; 95% ci 1.06-1.11). the corresponding funnel plot indicates no evidence of publication bias (egger's test p = 0.21), see figure 5 for funnel plot). the pooled effect of the five studies [18] [19] [20] [21] [22] indicates an 8% increase in the risk of death per year of age (95% ci 3-13%) when shi et al.'s [21] model with categorized values for the biomarkers was used (figure 4) . the effect remains similar with slightly narrower confidence intervals when model 2 was used with continuous values (rr = 1.08; 95% ci 1.06-1.11). the corresponding funnel plot indicates no evidence of publication bias (egger's test p = 0.21), see figure 5 for funnel plot). the pooled effect of the five studies [18] [19] [20] [21] [22] indicates an 8% increase in the risk of death per year of age (95% ci 3-13%) when shi et al.'s [21] model with categorized values for the biomarkers was used (figure 4) . the effect remains similar with slightly narrower confidence intervals when model 2 was used with continuous values (rr = 1.08; 95% ci 1.06-1.11). the corresponding funnel plot indicates no evidence of publication bias (egger's test p = 0.21), see figure 5 for funnel plot). the meta-regression from five studies resulted in an intercept of 1.134 (95% ci 1.110-1.158) and a slope of β = 0.978 (95% ci 0.967-0.989). table 6 shows the estimates of the relative risk by the number of important risk factors adjusted for. the unadjusted age effect resulted in a 13.4% increase in mortality per age year. the maximum number of risk factors used by the studies was five, which would result in a 1.4% increase in death per age year. the sensitivity analysis shows a statistically non-significant decrease in the relative risk (0.979; 95% ci 0.923-1.039) with over-adjustment; meaning including variables which reflect a current infection (probably due to in the regression model will decrease the calculated relative risk by a factor of 0.979 (table 7 ). chen j. et al. 2020 [16] studied 249 patients at shanghai public health clinical center between 20 january and 25 february 2020 (table 5 ). after adjusting for sex, cardiovascular and cerebrovascular diseases, endocrine system diseases, digestive system diseases, respiratory system diseases, hepatitis b, malignant tumor, and several biomarkers, there was an increased, borderline statistically significant risk per year of age on the admission to the icu (or = 1.06; 95% ci 1.00-1.12). because the study [16] did not adjust for all the important risk factors and because it used biomarkers that may be indicative of a covid-19 infection or covid-19 severe disease, it was assessed as having a high risk of bias. no meta-analysis could be done for this outcome due to the lack of studies. according to the meta-regression of five studies, the effect estimate of age on mortality risk decreases with an increasing adjustment for important age-related risk factors. a maximum of five age-dependent risk factors were adjusted for in the included studies. after the adjustment for these five risk factors, the risk per age year decreases from 13.4% (unadjusted value) to 1.4% per year. this translates to about a 20% higher risk of death for a 60 year-old person compared to that of a 50 year-old person due to the (almost) isolated effect of age. nonetheless, no studies adjusted for all six important risk factors, which would further decrease the age-related risk. to illustrate our point more clearly, figure 6 shows how the effect estimate of disease severity and death decreases with the inclusion of the important age-dependent risk factors. looking at only disease severity (blue line) and death (orange line), the following is shown: the age-related risk decreases with adjustment for each age-related risk factor (i.e., age-related comorbidities). if we were to extrapolate to the scenario where all six age-dependent risk factors were adjusted for, there would be a 3.2% increased risk per age year for disease severity, and almost no age-related risk for death. figure 6 also depicts the effect of over-adjustment in the model, when the models use variables (usually biomarkers) that are already indicative of infection. in this case, the effect estimate is even lower than when just adjusting for the important age-dependent risk factors. such a scenario is also undesirable, since it leads to a considerable underestimation of the effect. our results show an increased age-related risk of covid-19 disease severity, admission to icu, and death. however, our risk of bias analysis show that these pooled results are biased: not one study adjusted for all the necessary age-dependent risk factors to obtain the isolated effect of age on covid-19 disease severity. further analysis attempting to correct for this bias shows that if important age-related risk factors are taken into account, there is a 2.7% increased risk per age year for disease severity (based on two studies), and almost no age-related risk for death (based on five studies). it appears that age-related comorbidities have a more important weight than age itself. to our knowledge, this is the first review to investigate the isolated age-associated risk for a covid-19 disease severity or death. the main strengths of our research methods were the systematic literature search, and the independent appraisal of titles, abstracts, and full text by two scientists. our formal risk of bias assessment for the included studies was integrated into the meta-analysis and interpretation of our results. we only included the studies published in peer-reviewed journals, although we included the studies available as a pre-print only due to the time criticality of the research question on hand. there was no indication of publication bias for the risk of severe outcomes or death. in our meta-regression, we assumed that the effect of each risk factor on the risk reduction was the same and that no interactions were present, which might not be the case. however, it was our wish to illustrate the general consequence of not adjusting for all (known) age-dependent risk factors when estimating the effect of age on covid-19 disease severity or death. future studies need to apply models that appropriately incorporate all relevant risk factors. in our risk of bias analysis, we assessed all the included studies to have biased results, mostly because none included all the important age-related risk factors necessary to estimate the isolated effect of age on disease severity. we therefore stress that future studies control for all of these factors in their analysis. the most common reason for study exclusion was that only the unadjusted risk of age was reported-meaning that only univariate analysis or age-stratified results were reported. the data might be indeed available already-but it has just not been adequately analyzed and published. in addition, studies might also have used different definitions of certain conditions, such as hypertension, or the collective terms such as "cardiovascular disease", or "renal disease". furthermore, most studies used biomarkers or disease markers reflective of an infection such as covid-19 in their analysis. our sensitivity analysis indicated that the use of those markers would lead to a (statistically not significant) decrease in the relative risk, underestimating the real age-related risk of death. further studies should restrain from including such variables in their models when studying covid-19 disease severity to avoid over-adjustment. all studies used hospitalized patients as the study population, which may not be reflective of the general population. therefore, the results of this study refer to the risk of covid-19 disease severity in hospitalized patients. in order to study the risk of disease severity in covid-19 infection, it is necessary to study the general population infected with covid-19 and to determine their outcomes with a prospective cohort study. it is necessary to accurately define and target risk groups for covid-19 disease severity for any prevention measures considered. taking the example of one of the included studies investigating disease severity [26] , the results show that the unadjusted risk of a 50 year old person is compared to that of a 60 year old person, the risk increase is comparable to the risk observed for diabetes, smoking or hypertension (or per 10 yrs. = 1.65). however, when a more isolated age effect is calculated by adjusting for other important age-related risk factors, the risk due to age decreases by almost a third, this time being lower than the risk caused by diabetes, smoking, hypertension, malignancy or copd. this way, one could make individualized risk profiles to set more transparent and logical recommendations in the case of a lockdown. one could for instance compare the risk of a 45 year-old person suffering from diabetes to the risk of a 60 year old person with no underlying illnesses and come to the conclusion that the younger person with diabetes would have a higher risk for covid-19 disease severity. thus, it is particularly important at this time that the general population is aware of their underlying conditions and to continue to attend health screenings and medical check-ups. policy makers should in turn promote screenings at this time. overall, it seems arbitrary to target persons over the age of 60 years as a high-risk group, solely based on age. there are estimates that up to 20-30% of people between the age of 60 and 65 have no underlying chronic disorders [27] . even if this estimate were lower, targeting solely by age group would bring potentially unnecessary and unjustified consequences. this undifferentiated classification may encourage the discrimination of older people in society at large, which has already been reported during the covid-19 pandemic [28] . serious negative repercussions can result for older people, including biographical constraints, psychological problems, and economic hardship [28] [29] [30] . in terms of the older worker, such undifferentiated classification would also be difficult to reconcile with the declaration of the council of the european union of july 2012, which, under the heading "prevention of age discrimination" [31] , cites "refraining from using age as a decisive criterion for assessing whether a worker is fit for a certain job or not". since age is an essential and inevitable characteristic of a person, particular caution seems necessary when defining age-specific exclusion criteria for certain jobs. in this respect, it should be pointed out that the social isolation often 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research, and medical education: a cross-sectional study an evaluation of tweets about older adults and covid-19 recovering from the covid-19 pandemic: a focus on older adults aging in times of the covid-19 pandemic: avoiding ageism and fostering intergenerational solidarity council declaration on the european year for active ageing and solidarity between psychosoziale folgen von quarantänemaßnahmen bei schwerwiegenden coronavirus-ausbrüchen: ein rapid review this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license funding: this research received no external funding. the authors declare no conflict of interest. key: cord-351413-3nfukrfl authors: al-ahmadi, khalid; alahmadi, sabah; al-zahrani, ali title: spatiotemporal clustering of middle east respiratory syndrome coronavirus (mers-cov) incidence in saudi arabia, 2012–2019 date: 2019-07-15 journal: int j environ res public health doi: 10.3390/ijerph16142520 sha: doc_id: 351413 cord_uid: 3nfukrfl middle east respiratory syndrome coronavirus (mers-cov) is a great public health concern globally. although 83% of the globally confirmed cases have emerged in saudi arabia, the spatiotemporal clustering of mers-cov incidence has not been investigated. this study analysed the spatiotemporal patterns and clusters of laboratory-confirmed mers-cov cases reported in saudi arabia between june 2012 and march 2019. temporal, seasonal, spatial and spatiotemporal cluster analyses were performed using kulldorff’s spatial scan statistics to determine the time period and geographical areas with the highest mers-cov infection risk. a strongly significant temporal cluster for mers-cov infection risk was identified between april 5 and may 24, 2014. most mers-cov infections occurred during the spring season (41.88%), with april and may showing significant seasonal clusters. wadi addawasir showed a high-risk spatial cluster for mers-cov infection. the most likely high-risk mers-cov annual spatiotemporal clusters were identified for a group of cities (n = 10) in riyadh province between 2014 and 2016. a monthly spatiotemporal cluster included jeddah, makkah and taif cities, with the most likely high-risk mers-cov infection cluster occurring between april and may 2014. significant spatiotemporal clusters of mers-cov incidence were identified in saudi arabia. the findings are relevant to control the spread of the disease. this study provides preliminary risk assessments for the further investigation of the environmental risk factors associated with mers-cov clusters. middle east respiratory syndrome coronavirus (mers-cov) is an emerging human viral respiratory infectious disease caused by a novel coronavirus. it was first reported in saudi arabia in 2012 [1] , and since then, it has spread to several other countries, resulting in global public health implications. from april 2012 through february 2019, a total of 2374 laboratory-confirmed mers-cov cases (with 823 deaths, 34.66%) were reported to the world health organization (who) by 27 countries, with the majority (1983 cases, 83.52%) being reported by saudi arabia (with 745 deaths, 37.56%) [2] . the risk assessment of mers-cov infection, transmission and severity is crucial in predicting and preventing further outbreaks of human infections and in enhancing control measures. recent studies have advised that dromedary camels (camelus dromedarius) serve as a reservoir host for mers-cov, and camel-to-human transmission can occur through sporadic zoonotic infections associated with exposure to infected dromedary camels and their products [3] [4] [5] . the risk factors were identified for primary mers-cov infection in persons with either direct or indirect exposure to camels. in particular, higher heterogeneity was more prominent in zoonotic than in human-to-human transmission in the middle east region; this result emphasizes the importance of the environmental component of the epidemic [32] . although approximately 83% of the globally reported mers-cov cases are found in saudi arabia, spatial patterns and clusters of the occurrence of this disease have not been addressed, leaving a wide gap in knowledge on this important issue. this study aimed to examine the spatiotemporal clustering of the mers-cov incidence in saudi arabia between 2012 and 2019 using spatial scan statistics and gis. all laboratory-confirmed mers-cov cases reported between june 13, 2012 and march 31, 2019 were compiled from the official websites of the saudi ministry of health (smoh) [33] and the who [34] . we undertook a detailed review of the mers-cov data and performed a range of checks for data consistency, completeness and fitness for the study purpose. we then developed a dataset with variables of interest for each individual with mers-cov. the dataset included the following: diagnosis date, gender, age, nationality, healthcare, employment status and source of infection, as well as the city, governorate and province of residence. a confirmed case is defined as a suspected case that has a laboratory confirmation of mers-cov infection. a suspected case is defined as either (i) an adult patient presenting with severe pneumonia or acute respiratory distress syndrome, based on clinical or radiological evidence, or (ii) an adult patient presenting with an unexplained deterioration of a chronic condition, such as congestive heart failure or chronic kidney disease being treated with hemodialysis, or (iii) a child or an adult patient exposed to a confirmed case of mers-cov or who has visited a healthcare facility where a mers-cov patient was recently identified, or has had a history of contact with dromedary camels or consumption of camel products within 14 days before symptoms and who presents with either (a) acute febrile illness (temperature ≥ 38 • c) with or without respiratory symptoms, or (b) gastrointestinal symptoms and leukopenia or thrombocytopenia. laboratory testing for mers-cov is performed at approved regional smoh and selected non-smoh governmental laboratories to confirm a clinically suspected case and to screen contacts by using validated, commercial, real-time, reverse-transcription polymerase chain reaction (rrt-pcr) assays. the laboratory confirmation of mers-cov infection requires either a positive rrt-pcr result for at least two specific genomic targets, or a region upstream and open reading frame1a (upe and orf1a) [35] . a primary case is defined as a person with a laboratory-confirmed mers-cov infection with no evidence of contact with infected individuals but is known or believed to have had direct or indirect exposure to camels or camel habitats. exposure to camels includes direct physical contact with camels or their surroundings (milking and handling excreta), drinking raw camel milk or other unpasteurized products derived from camel milk and handling raw camel meat. indirect contact includes casual contact with sites where camels have been (e.g., camel markets or farms) but without direct physical contact with camels, or living with a household member who has had direct contact with camels. by contrast, a secondary case is defined as a person who has shared the same enclosed space (e.g., a room or office) for frequent or extended periods with an individual with a symptomatic mers-cov infection. mers-cov is believed to spread between humans mainly through contact and respiratory droplets. however, transmission through small particle droplet nuclei (aerosols) may occur. environmental contamination during outbreaks in healthcare facilities can be extensive and might contribute to outbreak amplification, if adequate disinfection procedures are not followed [35] . the spatial database of the mers-cov incidence in saudi arabia was created in the format of an esri file geodatabase on the three spatial levels of city, governorate and province. saudi arabia consists of 13 administrative provinces, 136 governorates and more than 300 cities. mers-cov cases were grouped and aggregated to be represented by cities, governorates and provinces. the prevalence of intrinsic variance instability in estimating incidence rates as a result of the variation in populations across spatial units, which can possibly identify outliers, has received broad attention in the disease mapping field [36] . to address this issue, we used geoda [37] software for generating eb smoothed rate maps for mers-cov incidence. the number of mers-cov incidence cases for the governorates was used as an event variable, and the populations of governorates were estimated from the 2010 census [38] and used as base variables. we analyzed the spatiotemporal clustering of the mers-cov incidence in saudi arabia between 2012 and 2019 at the city level by using kulldorff's spatial scan statistics via satscan 9.6 [39] . we used purely temporal, seasonal, purely spatial and spatiotemporal retrospective analyses to scan, detect and evaluate the periods and geographical areas with the highest mers-cov risk incidence clusters. the purely spatial scan statistic is defined by a circular window on the map. the window is sequentially centered on each of several possible cities that are positioned throughout the study area. the spatiotemporal scan statistic imposes a cylindrical window with a circular geographic base and height corresponding to time. the temporal scan statistic uses a window that moves in one dimension, time, defined in the same way as the height of the cylinder used by the spatiotemporal scan statistic. the key feature that distinguishes the seasonal scan statistic from the purely temporal scan statistic is that the former ignores the year of the observation and retains only the day and month [40] . the number of mers-cov cases by city was used as the case file, the city population estimated from the 2010 census [38] was used as the population file and the latitude and longitude of each city were used in the coordinates file. in satscan, an analysis was conducted by progressively scanning a window across time and/or space through a comparison of the number of observed and expected cases of mers-cov incidence, assuming random distribution, inside the window at each city. the null hypothesis is that the incidence of mers-cov is randomly distributed, and the alternative hypothesis is that the incidence increases more inside the window than in areas outside it. the log likelihood ratio (llr) is the hypothesis-testing statistic estimated based on monte carlo randomization. the window with the maximum likelihood ratio is the most likely cluster; that is, it identifies the cluster that is least likely to occur by chance. in addition to the most likely cluster, satscan also designates secondary clusters for purely spatial and spatiotemporal analyses and ranks them in relation to their estimated llr statistic. satscan scans for clusters by using different criteria; the criterion recommended by satscan is the percentage of the population at risk, with a value of 50% [40] . we tested the percentage of the population at risk from 10% to 50%, and from the result, 30% performed best; that is, the value of 30% did not include neighboring cities that have a non-elevated risk. the four types of analyses (purely temporal, seasonal, purely spatial and spatiotemporal) were conducted using the poisson discrete-based model with 999 monte carlo permutations to test for statistical significance. only clusters with significance levels of 0.05 and only scans of cities with high rates were reported. for temporal analysis, values of 1 day, 1 month and 1 year were set as the time aggregation units for the daily, monthly and annual clusters, respectively, whereas for the seasonal cluster, 1 month was set. for spatiotemporal analysis, 1 month and 1 year were set for the monthly and annual spatiotemporal analyses, respectively. a total of 2008 laboratory-confirmed human mers-cov cases reported in saudi arabia during the period between june 2, 2012 and march 31, 2019 were included in this study. the primary cases accounted for 24.05% (n = 483) of the total number of confirmed cases; of these, 48.24% (n = 233) involved (direct and indirect) exposure to camels. secondary cases accounted for 40.90% (n = 821) of the total number of confirmed cases, whereas missing and unknown cases accounted for 18.02% (n = 362) and 17.03% (n = 342) of the total number of confirmed cases, respectively. on the incidence of mers-cov infection was mostly reported from riyadh (n = 722, 35.95%), jeddah (n = 276, 13.74%) and alahsa governorates (n = 129, 6.42%), figure 2 . the incidence in wadi addawasir, buraydah, taif, alkharj, najran, madinah and makkah governorates ranged from 51 to 81 cases. these were followed by five governorates in northern saudi arabia (hafr albatin, sakaka, hail, dumat aljundal and tabuk) and two governorates in eastern saudi arabia (alkhubar and dammam) with 20-26 cases. for the eb smoothed incidence rate of mers-cov infection, the wadi addawasir governorate showed the highest rate across the country, with 66.87 cases per 100,000 people ( figure 3 ). dumat aljundal and najran governorates followed with 33.46 and 20.02 cases per 100,000 people, respectively. alkharj, alhinakiyah and afif governorates exhibited an incidence rate in the range of 15.03-18.12 cases per 100,000 people. in riyadh, the capital of saudi arabia, the the incidence of mers-cov infection was mostly reported from riyadh (n = 722, 35.95%), jeddah (n = 276, 13.74%) and alahsa governorates (n = 129, 6.42%), figure 2 . the incidence in wadi addawasir, buraydah, taif, alkharj, najran, madinah and makkah governorates ranged from 51 to 81 cases. these were followed by five governorates in northern saudi arabia (hafr albatin, sakaka, hail, dumat aljundal and tabuk) and two governorates in eastern saudi arabia (alkhubar and dammam) with 20-26 cases. for the eb smoothed incidence rate of mers-cov infection, the wadi addawasir governorate showed the highest rate across the country, with 66.87 cases per 100,000 people ( figure 3 ). dumat aljundal and najran governorates followed with 33.46 and 20.02 cases per 100,000 people, respectively. alkharj, alhinakiyah and afif governorates exhibited an incidence rate in the range of 15.03-18.12 cases per 100,000 people. in riyadh, the capital of saudi arabia, the incidence rate of mers-cov infection was 13.92 cases per 100,000 people. in buraydah, alahsa and jeddah governorates, the incidence rates were 13.04, 12.06 and 7.98 cases per 100,000 people, respectively. temporal cluster analysis generated from the spatial scan test identified the years 2014, 2015 and 2016, the months of april and may of 2014, and the period from april 5 to may 24, 2014 as the strongly significant clusters of annual, monthly and daily mers-cov incidence, respectively (table 1) . seasonal cluster analysis revealed that april and may show strongly significant seasonal clusters of mers-cov incidence (table 1) . temporal cluster analysis generated from the spatial scan test identified the years 2014, 2015 and 2016, the months of april and may of 2014, and the period from april 5 to may 24, 2014 as the strongly significant clusters of annual, monthly and daily mers-cov incidence, respectively (table 1) . seasonal cluster analysis revealed that april and may show strongly significant seasonal clusters of mers-cov incidence (table 1) . the results of the purely spatial cluster analysis of mers-cov incidence from 2012 to 2019 revealed the most significant and secondary clusters at the city level (table 2 and figure 4 ). wadi addawasir in riyadh province had the most likely high-risk cluster, followed by a secondary significant cluster in alkharj and aldilm cities in the same province. spatial clusters in single cities were identified across the country; alhofuf (east), dumat aljundal (north), najran (south), alqunfidhah (southwest), alhinakiyah (west) and buraydah (center) represented the third, fourth, fifth, sixth, seventh and eighth secondary clusters, respectively. the results of the spatiotemporal cluster analysis of mers-cov infection, using years and months as the time aggregates from 2012 to 2019, showed significant most likely and secondary clusters in saudi arabia (table 3; table 4 and figure 5 ; figure 6 ). spatial variations existed between the annual and monthly spatiotemporal clusters. for the annual spatiotemporal clusters, a group of cities (n = 10) located in riyadh province was identified as the most likely high-risk cluster for mers-cov incidence between 2014 and 2016. this was followed by a secondary cluster that was found for three cities (jeddah, makkah and taif) in makkah province between 2014 and 2015. spatiotemporal clusters in single cities were also observed and varied in space and time across the country. wadi the results of the spatiotemporal cluster analysis of mers-cov infection, using years and months as the time aggregates from 2012 to 2019, showed significant most likely and secondary clusters in saudi arabia (table 3; table 4 and figure 5 ; figure 6 ). spatial variations existed between the annual and monthly spatiotemporal clusters. for the annual spatiotemporal clusters, a group of cities (n = 10) located in riyadh province was identified as the most likely high-risk cluster for mers-cov incidence between 2014 and 2016. this was followed by a secondary cluster that was found for three cities in this study, we examined the spatial pattern of mers-cov risk at the governorate level and the temporal, seasonal, spatial and spatiotemporal clustering of mers-cov incidence at the city level over a seven-year period. to the authors' knowledge, this is the first study that aims to analyze the spatiotemporal pattern and clustering of mers-cov in saudi arabia. a total of 2008 laboratory-confirmed mers-cov cases were reported in saudi arabia, representing approximately 83% of the global cases. overall, the majority of mers-cov cases were secondary infections (40.90%). this result indicates that secondary infections, either hospital or community acquired, remain a major challenge for the saudi healthcare system in the prevention and control of mers-cov outbreaks, despite the significant improvement in mers-cov surveillance. on the other hand, the primary cases accounted for only 24.05% of the total confirmed cases. although compared with the general population, people in close contact with dromedary camels have a higher risk of developing mers-cov infection via a primary source [3] [4] [5] , our results indicated that only 48.24% of the total primarily infected cases were associated with direct or indirect contact with camels. this result is consistent with previous findings [4] regarding the ambiguity of primary mers-cov infection transmission. in saudi arabia, camel milk and meat production has increased by 5.4% and 6.4% per year, respectively [41] . however, intensified animal production has epidemiological consequences, including increased risk of disease. recent trends in saudi arabia have indicated a tendency towards dromedary camel husbandry intensification since the 1960s, as evident in increased production in nearby cities by providing enhanced supplemental diets for the animals and improving camel health management [11, 42, 43] . these areas of intensified camel production are probable hotspots for the transmission and spread of mers-cov. in addition, dealing with camel products, consuming raw unpasteurized milk and conducting slaughter processes have been documented as risk factors for primary mers-cov transmission to humans [44] . the epidemic curve of mers-cov has varied significantly each year from 2012 to 2019, and it has exhibited variance in monthly peaks. a combination of sporadic and epidemic patterns as a result of animal-to-human, human-to-human and unknown exposure was observed. by contrast, the epidemic curve in south korea, where the largest outbreak outside of the arabian peninsula occurred, had a clear nosocomial epidemiological pattern [45] . purely temporal cluster analyses of mers-cov infection illustrated significant clusters in april and may of 2014. this finding is consistent with previous results [46] , which showed significant peaks in mers-cov incidence between march and may during a similar period. seasonal cluster analysis identified april and may as a strongly significant seasonal cluster of mers-cov infection. in accordance with our findings, it was reported in [47] that mers-cov infection occurred markedly in june, followed by may and april, and the lowest rates were seen in january. one possible reason for this trend is the seasonal variations in zoonotic infections in camels during the breeding season [48, 49] , when camel farms are considered an important potential source of mers-cov transmission [47] . moreover, a recent serological study in saudi arabia found a higher risk of mers-cov infection in camels in winter than in summer [50] . however, the low daily frequency and sporadic cases of mers-cov indicate a reduced likelihood of zoonotic-to-human transmission and increased possibility of human-to-human transmission, which is consistent with other findings [51] . the main mers-cov outbreaks in 2014 and 2015 were closely followed by human influenza a epidemics [52] . no coincidence was found between the peak of influenza occurrence and mers-cov occurrence, which suggests that the seasonal characteristics of mers-cov infections may vary from those of human influenza viral infections. in this study, no epidemics of mers-cov were observed during mass gatherings of pilgrims in the hajj season, which is consistent with previous findings [53] . this indicates another knowledge gap regarding the mode of transmission that needs further investigation. spatial clusters of mers-cov cases were mainly found in a group of cities in the provinces of riyadh, qassim, hail and najran located on the outskirts of larger deserts, which is the natural habitat for camels. however, significant spatial clusters of mers-cov cases were also reported from small general hospitals in single cities, such as wadi addawasir, dumat aljundal, alhinakiyah and alqunfidhah; in these settings, delays in the isolation of suspected patients, inadequate infection and control measures, and late case diagnosis and management are expected. the annual spatiotemporal high-risk mers-cov clusters occurred mainly in the early periods of the mers-cov epidemic (between 2014 and 2016) in major cities, such as riyadh, jeddah, taif, alhofuf and buraydah, whereas recent clusters (between 2017 and 2019) were observed in relatively small cities, such as dumat aljundal and wadi addawasir. this result can be explained by infection prevention and control practices, which were, to some extent, more effective in major cities than in small cities and remote areas. for the monthly spatiotemporal high-risk mers-cov clusters, the cities of jeddah, makkah and taif were identified as a part of the most likely high-risk mers-cov cluster for april and may of 2014, when the number of cases represented the largest accumulation of cases reported since the beginning of the mers-cov outbreak. the probable source of infection in the majority of the cases in this outbreak was secondary human-to-human transmission in jeddah that took place in healthcare facilities as a result of overcrowding and inadequate infection control measures, rather than a sudden increase in primary cases in the community [49] . the spatiotemporal cluster detected in riyadh between march 2014 and october 2015 could be attributed to several outbreaks, with the most prominent one occurring in a single healthcare setting in riyadh in august 2015 [54] . in addition, the most recent clusters of mers-cov incidence were identified in wadi addawasir in february 2019, in dumat aljundal in august 2017 and in buraydah in march 2016; according to [55] [56] [57] , the majority of the cases were associated with healthcare-acquired infections. this indicates persistent challenges related to nosocomial transmission, which require a thorough investigation of compliance to infection control measures by healthcare workers. mers-cov infection has global public health implications and has been labelled as an epidemic in saudi arabia. this study examined the spatial pattern and spatiotemporal clusters of mers-cov incidence in saudi arabia for the first time by using the latest publicly available mers-cov data. the results of this study provide initial risk assessments that can be used as the basis for the further investigation of the potential environmental risk factors that can explain the spatiotemporal clusters of mers-cov infection. the immediate isolation of suspected patients, adequate infection control measures and early case diagnosis and management remain the principal elements in controlling the spread of the 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is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors wish to express their gratitude to king abdulaziz city for science and technology and king faisal specialist hospital and research centre for supporting this study, as well as the smoh and the who for providing the data. the authors declare no conflict of interest. key: cord-337316-ialg7d7e authors: cori, liliana; donzelli, gabriele; gorini, francesca; bianchi, fabrizio; curzio, olivia title: risk perception of air pollution: a systematic review focused on particulate matter exposure date: 2020-09-03 journal: int j environ res public health doi: 10.3390/ijerph17176424 sha: doc_id: 337316 cord_uid: ialg7d7e the adverse health effects of exposure to air pollutants, notably to particulate matter (pm), are well-known, as well as the association with measured or estimated concentration levels. the role of perception can be relevant in exploring effects and pollution control actions. the purpose of this study was to explore studies that analyse people’s perception, together with the measurement of air pollution, in order to elucidate the relationship between them. we conducted a systematic review in accordance with the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines. in march 2020, pubmed, embase, and scopus databases were explored in an attempt to search for studies published from 2000 to 2020. the review included 38 studies, most of which were conducted in china (n = 13) and the united states (n = 11) and published over the last four years (n = 26). three studies were multicenter investigations, while five articles were based on a national-level survey. the air quality (aq) was assessed by monitoring stations (n = 24) or dispersion models (n = 7). many studies were population questionnaire-based, air monitoring and time-series studies, and web-based investigations. a direct association between exposure and perception emerged in 20 studies. this systematic review has shown that most of the studies establish a relationship between risk perception measurement. a broad spectrum of concepts and notions related to perception also emerged, which is undoubtedly an indicator of the wealth of available knowledge and is promising for future research. this systematic review is dedicated to clarifying the role of the perception of risk of air pollution, due to its relevance in the environmental and health field. the goal is to explore studies that analyse people's perception, together with the measurement of air pollution, in order to elucidate the relationship between them. the focus is on particulate matter (pm) as its negative health effects have been demonstrated and quantified. social, cultural, and contextual factors can influence people's perception and the impacts on behavior, agency, self-efficacy, and the relationship with measured pollution should be clarified. this knowledge could be crucial to complementing studies on the health to estimate the relative risk of mortality attributable to pm. in particular, long-term exposure to pm 2.5 was estimated to have caused 4.2 million deaths in 2015, corresponding to 7.6% of the total global mortality and making pm 2.5 the fifth-ranking mortality risk factor [25] . for pm 10 and pm 2.5 , concentration-response risk functions have been developed and proposed for health impact assessments. many studies have included recommendations for actions and explorations of policy implications and the economic impact of pm reductions. green energy policy in europe includes air pollutant emission reduction in the motivation for reduction. moreover, the international agreements addressing climate change consider pm in their reduction plans [32] . in several asian cities, outdoor pm air pollution is increasing. in india, outdoor air pollution was responsible for more than 670,000 deaths in 2016. to deal with these health effects, several countries have launched large-scale policies, such as china [33, 34] and india; in other countries like thailand, there is a growing demand for policies to address the issue of polluted air [35] . although in many countries there are no specific laws or protection rules, who guidelines are taken into consideration [28] . in china, to address the severe air pollution, the 2013 action plan on prevention and control of air pollution established a reduction of the pm 2.5 concentration in beijing, nanjing, and guangzhou cities by 25%, 20%, and 15%, respectively, between 2012 and 2017. after this, several plans and specific measures were implemented [36] . in the eu and us, air protection policies are similar and the reduction of air pollution is a central element. in the us, air quality (aq) is a federal matter and the relevant policies apply to the whole country. in the eu, aq policy is based on standards issued by the european commission and national implementations, where member states determine the best way to achieve them within each country. in addition, in the us, air pollution management is implemented through a combination of the aq standard and the emission standard strategies, whereas in the eu, emission standards, emission taxation, and cost-benefit analysis are used [37] . in 2013, the european commission adopted a clean air policy package for europe in order to set new objectives for eu air policy and reduce the negative health impacts of air pollution, such as respiratory diseases and premature death, by almost 50% by 2030 [38] . the present systematic review was developed according to the preferred reporting items for systematic reviews and meta-analyses (prisma) statement [39] . this systematic review was performed by searching three different electronic databases, embase, scopus, and pubmed. upon completing the search, a combination of medical subject headings (mesh) and non-mesh keywords was used. specifically, the keywords air pollution, particulate matter, pm 10 , pm 2.5 , risk perception, perception, and health were adopted in the following search query: (air and pollution or (particulate and matter) or pm 10 or pm 2.5 ) and (risk and perception or perception) and health. only studies written in english were included and reviews, letters to the editor, and abstracts were excluded. the first search of the three databases was conducted without any time limitations. few articles were published before 2000, so the search was limited to those published from january 2000 to march 2020. the following inclusion criteria were adopted: i. perception concerns, exclusively pm exposure; if exposure refers to several pollutants or environmental matrices, pm should be specifically mentioned; ii. pm levels are always measured, both directly and indirectly, and exposure refers to the specific population; iii. pm measurement is only conducted outdoors; iv. pm can also be included in an air quality index, aqi, while perception must always be measured, both directly and indirectly; v. perception can be evaluated via quantitative or qualitative methods. after removing duplicates, three researchers, who are the authors of the paper (l.c., g.d., and o.c.), independently evaluated titles and abstracts according to the eligibility criteria. the articles simultaneously selected by the three reviewers were employed in the next phase, i.e., the full text was read. the researchers thoroughly read the articles selected in the first phase in equal proportion. the reviewers individually decided to accept or reject the articles read. in cases of doubt among the three reviewers, the other two authors (f.g. and f.b.) examined the papers in order to achieve a final decision about their eligibility. all of the relevant data were extracted, including the author(s) name(s), publication date, title, study area, study design, age group(s) of participants, sample study, environmental exposure assessment methods, and main results. more specifically, the following information was taken into consideration: the methodology; the number and characteristics of the subjects involved in the research; how pm was measured; whether specific devices were tested; how risk perception was assessed; and which tools were used. these relevant data were included in table form to obtain a synthetic framework of all articles read in full by reviewers. this table format enabled the authors to complete a cursory overview of the materials selected in the first phase. to be able to analyse the perception, the main methodological issue is the extent of the concept. "perception" and "risk perception" were included in the search to be able to capture a wider variety of research in terms of methods, populations, and issues included. the perception linked to aq measurement is intended to gather information about understanding and knowledge of the issue, psychological reactions, the capacity or availability to act as a consequence of this knowledge, and the response to public policies. suggestions and recommendations for actions are generally presented as practical results of these studies. to systematically examine the articles selected, the explored dimensions of perception (understanding/sensorial perception; reactions/psychological consequences; reactions/physical consequences; behaviors) were categorized by 20 features (awareness; belief; knowledge; concern; risk perception; worry; fear; outrage; familiarity; trust; annoyance; anxiety; life quality change; self-reported health symptoms; avoidance of the problem; search for information; exposure reduction; proactivity; request for action; and acceptance). this means that in each article, one or more of those features are explicitly searched as a tool for the analysis or are assumed in the concept. the prisma flow diagram in figure 1 depicts the article selection process we followed for including studies in this review. we started by searching the three databases mentioned in the methods section and identifying 1830 articles. from these first records, we removed 353 duplicates, leaving 1457 for further review. we reduced the number of included studies to 121 after screening the titles and abstracts and applying the following exclusion criteria: studies where the main exposures referred to tobacco smoke, indoor settings, specific pollutants originating from industries, or other anthropogenic sources such as caves and mines; • studies evaluating health outcomes related to air pollution, but not to perception or risk perception; • generic studies, editorials, or abstracts in proceedings of conferences. • studies where the main exposures referred to tobacco smoke, indoor settings, specific pollutants originating from industries, or other anthropogenic sources such as caves and mines; • studies evaluating health outcomes related to air pollution, but not to perception or risk perception; • generic studies, editorials, or abstracts in proceedings of conferences. the remaining 121 articles underwent a full-text evaluation, bringing the total number down to 38 published articles that met our inclusion criteria. by the end of the identification process, we had removed about two-thirds of the reports from the amount we initially identified for this current study because it was impossible to know from the titles and abstracts alone whether or not they included the following criteria: presence of indoor air pollution; • presence of other pollutants. table 1 summarizes the main characteristics of the studies included in this review in reverse order of publication date. the remaining 121 articles underwent a full-text evaluation, bringing the total number down to 38 published articles that met our inclusion criteria. by the end of the identification process, we had removed about two-thirds of the reports from the amount we initially identified for this current study because it was impossible to know from the titles and abstracts alone whether or not they included the following criteria: presence of indoor air pollution; • presence of other pollutants. table 1 summarizes the main characteristics of the studies included in this review in reverse order of publication date. survey by a self-administered questionnaire used to collect data on socio-demographic, aq perception and respiratory health symptoms among university students. measurements of traffic-related air pollutants conducted at three sampling sites in university south campus. significant associations between each level of traffic-related air pollutants and aq perception and respiratory health symptoms (p < 0.05). d. dong, 2019 [47] china (nationwide) n/a web based time series study by the baidu index to explore the relationship between actual level of air pollution and residents' concern about air pollution. on the basis of daily data of 2068 days in shanghai, a vector autoregression (var) model was built for empirical analysis. aq measured by the aqi reported by environmental monitoring stations. daily aqi data to measure air pollution level in shanghai freely available from the website of the china aq online monitoring and analysis platform. local residents perceived deprivation of aq and expressed their concern on air pollution within the day the aq index rose. decline of aq in another towns, such as beijing, raised the concern of shanghai residents about local aq. rising concern in shanghai had a beneficial impact on aq improvement. no relationship between pollution perception and health concern, nor with air pollution exposure. pollution perception associated with age, sex, respiratory problems, aq alert knowledge. health concern associated with age, sex, aq alert knowledge, o 3 exposure and poverty. y. lu, 2018 [49] china (nationwide) n/a time series cross-correlation analysis. baidu search index to analyze the patterns of public concern about haze from 2013 to 2017, and the dynamic relationship between public concern and aq data. pm 2.5 concentration data before july 2017 from us embassy and from 1-7 to 7-12-2017 from a data integration platform (real-time data of pm2.5 from us embassy). public concern investigated via web. according to annual data, slight decrease of the weak correlation of public concern and aq. removing the annual trend component of time-series, the public concern resulted more sensitive to the short term fluctuation of aq (lag), even as pollution decreased. cross-sectional study by questionnaire to evaluate relationships between concern on health effects of air pollution and personal and environmental factors. participants recruited to fill an online questionnaire on travel and physical activity behaviour, perceptions, attitudes on active mobility and the environment, and socio-demographic factors. air pollution at the residence from europe-wide no 2 and pm 2.5 maps with a 100-m resolution and available for year 2010. the no 2 and pm 2.5 models explained 58.2% and 63.3% of spatial variation respectively. the european main road network was used to determine the distance of each residence to the nearest primary road. mean modelled air pollution and mean level of concern per city well correlated for no 2 (r 2 = 0.75), less for pm 2.5 (r 2 = 0.49). in regression model, sex, children in the household, physical activity and no 2 at the home address significantly correlated to individual concern over health effects of air pollution. no 2 but not pm 2.5 at the home address associated with concern over health effects of air pollution. great differences in health perception levels, average daily pm2.5 exposure (add), public acceptance levels, willingness to pay and to accept compensation for air pollution before, during, and after the yog. during the yog, public exposed to pm 2.5 lower concentrations most accepted risks posed by haze. after yog, residents more sensitive to haze and demanded higher aq. a greater willingness to pay for risk reduction and to accept compensation for health-related losses. f. gany, 2017 [56] new york city, usa 100 taxi drivers aged 18 and older survey by interview to assess taxi drivers' knowledge, attitudes, and beliefs (kab) about air pollution compared with direct measures of exposures. one hundred drivers completed an air pollution kab questionnaire, and seven taxicabs participated in preliminary in-cab air sampling. roadside and in-vehicle levels of pm2.5 and black carbon (bc) were continuously measured over a single shift on each subject, and exposures compared with central site monitoring. two aerosol monitors, a personal mie dataram 1000 and a microaethalometer, to measure fine pm and bc levels, respectively, inside new york city taxi cabs. even with general knowledge about the risks associated with occupational exposure to air pollution, taxi drivers did not consider their exposure and/or potential related risks to their health as priorities in the context of other health concerns. four non-urban regions of denmark: anholt, keldsnor, lindet, sundeved 1068 men and women aged 18 and older cross-sectional study to assess environmental conditions and health of residents living nearby agricultural land and animal production facilities. residents invited via mail by answering a printed questionnaire or an online version. exposure assessment to 14 atmospheric pollutants. the concentrations of all pollutants, except for ammonia, were calculated using the integrated multiscale air pollution model system (thor). annoyance is associated with air pollutants and noise. relationship between perceived smog intensity, risk perception and behaviour change (concern behaviours), enhanced in case of negative experience or harmful health experiences (preventive actions). higher level of awareness and risk perception for women. questionnaire survey, investigating how public perceptions of air pollution, risk beliefs and self reported actions limit personal exposure to air pollution across cities. analysis to quantify association between individual variables and self-protective and information-seeking actions due to bad aq. air pollution concentrations obtained from the local and regional environmental agencies. significant differences in subjective evaluation of local aq, according to annoyance, physical symptoms and distress due to air pollution. small differences in levels of self-reported attention to aq, perceived severity and controllability beliefs. self-reported attention to aq levels and worry about health effects of air pollution were the most associated variables with avoid polluted streets, information seeking, change leisure activities and use face-masks. z. tao message volume in sina weibo indicative of true particle pollution levels; the messages contain rich details including perceptions, behaviors, and self-reported health effects. social media data improve existing air pollution surveillance data, especially perception and health-related data that traditionally requires expensive surveys or interview. most informants perceived industrial pollution as posing considerable risk to themselves and the community. three occupational groups (industrial, commerce and service, farmers) perceived differently in relation to socio-economic factors. no consistent or significant correlations were found between annoyance and pm 2.5 exposure. large variations in levels of air pollution annoyance, with the highest in traffic; significant determinants: city, self-reported symptoms, downtown residence and gender. some associations with measured pollution emerged analysing specific correlation considering single cities, traffic, downtown living, work. the articles included in this systematic review concern studies carried out in china (n = 13), the usa (n = 11), greece (n = 3), south korea (n = 2), the uk (n = 3), italy (n = 2), spain (n = 2), switzerland (n = 2), austria (n = 1), bangladesh (n = 1), belgium (n = 1), brazil (n = 1), the czech republic (n = 1), denmark (n = 1), estonia (n = 1), finland (n = 1), germany (n = 1), india (n = 1), japan (n = 1), kenya (n = 1), malaysia (n = 1), pakistan (n = 1), sweden (n = 1), taiwan (n = 1) thailand (n = 1), and the netherlands (n = 1). figure 2 shows the geographical distribution of surveyed countries. the articles included in this systematic review concern studies carried out in china (n = 13), the usa (n = 11), greece (n = 3), south korea (n = 2), the uk (n = 3), italy (n = 2), spain (n = 2), switzerland (n = 2), austria (n = 1), bangladesh (n = 1), belgium (n = 1), brazil (n = 1), the czech republic (n = 1), denmark (n = 1), estonia (n = 1), finland (n = 1), germany (n = 1), india (n = 1), japan (n = 1), kenya (n = 1), malaysia (n = 1), pakistan (n = 1), sweden (n = 1), taiwan (n = 1) thailand (n = 1), and the netherlands (n = 1). figure 2 shows the geographical distribution of surveyed countries. three articles are multicenter studies, two are surveys performed in seven countries [35, 54] , and the remaining are surveys performed in six countries [74] . six studies were based on a national-level [41, 47, 49, 52, 60, 67] , three on multi-province [40, 45, 57] , and seven on multiple-city surveys [50, 51, 59, 63, 64, 71, 73] . looking at the timeline distribution of the articles, figure 3 shows that research has increased over the last four years, during which time over 85% of the studies were published. as indicated in the caption for figure 3 , the year 2020 includes only the first three months of the year. the red vertical line in figure 3 indicates the date iarc announced that pm is classified as a carcinogenic to humans (group 1) [30] . three articles are multicenter studies, two are surveys performed in seven countries [35, 54] , and the remaining are surveys performed in six countries [74] . six studies were based on a national-level [41, 47, 49, 52, 60, 67] , three on multi-province [40, 45, 57] , and seven on multiple-city surveys [50, 51, 59, 63, 64, 71, 73] . looking at the timeline distribution of the articles, figure 3 shows that research has increased over the last four years, during which time over 85% of the studies were published. as indicated in the caption for figure 3 , the year 2020 includes only the first three months of the year. the red vertical line in figure 3 indicates the date iarc announced that pm is classified as a carcinogenic to humans (group 1) [30] . not all studies considered the same type of pm and not all used the same methods for assessing exposure. specifically, 18 studies only considered pm2.5 as an indicator of exposure to pm; 7 studies only considered pm10; 1 study considered pm10, suspended particulate matter (spt), and total suspended particles (tsp); 2 studies considered particle number counters (pncs); and 10 studies considered pm2.5 and pm10. nine of the 10 studies that considered both pm2.5 and pm10 evaluated the association between pollution and survey responses using aqi, which is a six-category classification of ambient aq for six major pollutants: carbon monoxide, ground-level ozone, nitrogen dioxide, pm2.5 and pm10, and sulfur dioxide. regarding pm exposure assessment, the majority of studies (n = 24) used aq data from official monitoring stations, while seven studies used aq models such as the moderate resolution imaging spectroradiometer (modis) aerosol optical depth (aod). only seven studies directly measured pm air concentrations (see table 1 , column "exposure assessment"). two studies considered low pm level chronic exposure [52, 53] . the 38 studies selected presented multiple designs, populations involved, and procedures. many studies were questionnaire-based and air monitoring population studies, time series, and web-based studies. sample sizes in general population studies ranged from 40 adult participants in community-based interviews, focus group discussions, and a community forum in kenya [62] , to 28,303 respondents, to a standardized state-based telephone survey [70] , involving a total of 123,855 participants. six of the studies selected were not ad hoc studies, but part of major survey studies [27, 40, 41, 48, 53, 66] and most of them concerned the adult population. among the exceptions is the study of bergstra and colleagues [51] . in this research, a cross-sectional questionnaire study was conducted for both children (2 ± 18 years) and adults (19 years and above) living in the direct vicinity not all studies considered the same type of pm and not all used the same methods for assessing exposure. specifically, 18 studies only considered pm 2.5 as an indicator of exposure to pm; 7 studies only considered pm 10 ; 1 study considered pm 10 , suspended particulate matter (spt), and total suspended particles (tsp); 2 studies considered particle number counters (pncs); and 10 studies considered pm 2.5 and pm 10 . nine of the 10 studies that considered both pm 2.5 and pm 10 evaluated the association between pollution and survey responses using aqi, which is a six-category classification of ambient aq for six major pollutants: carbon monoxide, ground-level ozone, nitrogen dioxide, pm 2.5 and pm 10 , and sulfur dioxide. regarding pm exposure assessment, the majority of studies (n = 24) used aq data from official monitoring stations, while seven studies used aq models such as the moderate resolution imaging spectroradiometer (modis) aerosol optical depth (aod). only seven studies directly measured pm air concentrations (see table 1 , column "exposure assessment"). two studies considered low pm level chronic exposure [52, 53] . the 38 studies selected presented multiple designs, populations involved, and procedures. many studies were questionnaire-based and air monitoring population studies, time series, and web-based studies. sample sizes in general population studies ranged from 40 adult participants in community-based interviews, focus group discussions, and a community forum in kenya [62] , to 28,303 respondents, to a standardized state-based telephone survey [70] , involving a total of 123,855 participants. six of the studies selected were not ad hoc studies, but part of major survey studies [27, 40, 41, 48, 53, 66] and most of them concerned the adult population. among the exceptions is the study of bergstra and colleagues [51] . in this research, a cross-sectional questionnaire study was conducted for both children (2 ± 18 years) and adults (19 years and above) living in the direct vicinity of an area with heavy industry. parents were asked to answer questions about the health of their children, with a particular focus on respiratory symptoms. among the exceptions, a chinese survey performed on 1000 parents 18 years old or older with children between 1 and 12 years old can also be mentioned [65] . some research has focused on specific groups: gany and colleagues (2016) [56] recruited taxi drivers for an air-monitoring study in 2012-2013. another study in 2003 employed ethnographic field methods and semi-structured interviews to ask community members to identify salient risks from industrial pollution and examine whether and how perceptions differed across occupational groups (industrial workers, commercial and service sector workers, and farmers) in a futian community [72] . a study in malaysia included university students [46] and in a leipzig university study, a collective of cyclists wore a unique combination of sensors that measured the particle number counts (pnc), noise, humidity, temperature, and geolocation [43] . five studies investigated neighborhood vulnerability. in hong kong, a mixed-methods approach was applied to estimate neighborhood-based environmental vulnerability based on objective environmental measures and subjective environmental understanding from a local population [44] . in wisconsin, the associations between low-level chronic exposure pm 2.5 and cardiopulmonary health and the potential mediating or modifying effects of adverse neighborhood perceptions were examined [53] . in nairobi, the authors made a case for participatory approaches in aq studies, especially including those living in poor neighborhoods who may be particularly at risk from this trend [62] . in chicago, the community adult health study studied the impact of individual, social, and built environmental factors on health and disparities in health [66] . in seoul, korea, 16,041 subjects aged > 20 years rated the outdoor aq in the neighborhood [27] . studies using big data from the internet were typical of asian countries and we selected five of them: google trends for seven asian megacities [35] ; an internet search engine, baidu [47, 49] ; and posts analysed on weibo (a popular microblogging system) in china [64, 67] . as for the procedures of the studies included in the systematic review, field studies [50, 58, 69, 72] , telephone survey studies [42, 48, 68, 70, 71, 73] , on-line surveys [44, 54, 57, 61] , and mixed procedure studies [53] were found. in the context of field studies, face-to-face interviews were the fundamental, but sometimes not unique, method employed to collect the data of interest to be related to the objective levels of pollution [34, 42, 50, 55, [58] [59] [60] 66] . considering mixed procedures and methods, we can mention maleki's study (2018) [53] ; in this work, the protocol included in-person, audio-computer-assisted interviews; self-administered questionnaires; a physical examination; and biosample collection. to be able to systematically analyse the articles selected, the explored dimensions of perception were categorized by 20 features. the results of this analysis, presented in table 2 , showed that for "understanding" (44) , most of the articles focused on awareness (32); for "reactions/psychological" (48), more represented risk perception (23); for "reactions/physical" (44) , the declared symptoms were most represented (26); and for "behaviours" (38) , exposure reduction (13) and search for information (12) were the most represented. table 2 . recurrence of dimensions and features related to risk perception in the selected articles. understanding/sensorial perception (n = 44) awareness = acknowledgement of the existence of a problem 32 belief = opinion to be exposed 5 knowledge = capacity to understand the existence of a problem 7 reactions/psychological consequences (n = 48) concern = apprehension 9 risk perception = there is a risk for health (for me-for others) 23 worry = it is more that concern, linked to a depressive mood 5 the details are shown in table 2 , in lines of the table including each of the features. the studies examining understanding (44) included risk perception in 20 cases, symptoms in 23 cases, search for information in 12 cases, and exposure reduction in 13 cases. among the studies investigating psychological reactions (48) , awareness was included in 19, symptoms in 17, search for information in 10, and exposure reduction in 12 cases. the studies investigating physical reactions (44) also explored awareness in 24 cases, risk perception in 18 cases, search for information in 9 cases, and exposure reduction in 12 cases. the studies analysing behaviors (38) also explored awareness in 19 cases, risk perception was considered in 16 cases, and symptoms were considered in 14 cases. the results in terms of the association of perception, intended in the broad sense, included the 20 features examined, with measured pollution as the main outcome of this review. to examine the results in brief, see table 3 . table 3 . association between perception and measured air pollution. the number of articles for each kind of association is shown, with the references. further details for each article are in table 1 . association a direct association between air pollution and perception is established, with a specific role of symptoms, behavior, socioeconomic factors, and information/communication 20 in only two cases, the link with air pollution was not evaluated at all: in one case [63] , 14 features of perception, focusing on behaviors and socioeconomic analysis, were described and in the second case [50] , the pm level measured in hong kong was used to build the scenarios for the questionnaire, only focusing on public awareness [50] . in five articles, measured pollution was not correlated with perception [43, 48, 56, 71, 73] . in the study by ueberham et al. [43] , cyclists were not aware of a risk posed by air pollution. in the study of reames and bravo [48] , no association between pollution perception and air pollution exposure was observed and the findings supported the neighborhood stigma theory [66] . physical conditions are worse in minority communities, but a disadvantaged social composition seems to independently contribute to negative perceptions of these communities. perceptions of neighborhoods affect residents, also transcending the effects of objective conditions [72] . gany et al. [56] carried out air monitoring in new york city taxi cabs and at roadside taxi stands, combined with a survey of taxi drivers' knowledge related to air pollution and the associated health risks. semenza et al. [71] measured aq and meteorological conditions in portland, or and houston, tx and 1962 subjects were interviewed by telephone about their perception and response. in brody et al. [73] , the perception of local aq was different in dallas and houston and was not driven by actual readings from air monitoring stations. an indirect influence of air pollution on perception was reported by li et al. [40] , in favor of the relation between awareness and risk perception and symptoms, and by orru et al. [52] , for which the effect of perceived exposure on symptoms and the effect of perceived exposure on disease were mediated by health risk perception. in nine papers, aq had a scarce influence on perception. in huang et al. [55] , the main linkage was with behavioral changes as a pre-post survey of the youth olympics showed that awareness and concern grew over time. in huang et al. [59] , perception was boosted by previous negative experiences with pollution. experience was also crucial in chen et al. [60] and guo et al. [65] , where the influence of socio-economic factors was a relevant element for explaining differences in perception. in king et al. [66] , the stigma theory was utilized for explaining the linkages among awareness, risk perception, and socio-economic factors. socioeconomic factors were also relevant in kim et al. [27] , where the declared symptoms were not explicitly correlated with perception or pollution and in johnson et al. [68] and rotko et al. [74] , where symptoms were included and relevant. the study by pantavou et al. (2017 and [50, 58] established a direct link between symptoms and perception. the consideration of symptoms is crucial because their linkage with perception has been widely reported in the literature. let us consider this aspect in the following 20 articles, where a direct association between perception and measured pollution was identified, adding several further specific features. symptoms were a significant additional element in misra et al. [35] , where the circulation of information on the web was examined; in particular, the search for "cough" and "asthma", together with "air pollution", related to pollution measurement; zakaria et al. [46] used a self-administered questionnaire in selangor, malaysia and nikolopoulou et al. [69] employed a questionnaire-guide in san diego, california to interview university students; bergstra et al. [51] examined adults and children in an industrial area in the netherlands; malecki et al. [53] considered the linkage with low-level exposure in wisconsin, usa, selecting a number of questions within a wider survey; dons et al. [54] developed a cross-sectional questionnaire study in seven european cities; and pantavou et al. [58] undertook a field study in athens, associating citizen perception, behaviors, and symptoms with air pollution and dust. in mirabelli et al. [41] , symptoms and information were investigated as a distinctive explanation because the article examined the diffusion of air pollution alerts. there were several interesting observations-in particular, that the received information declared by interviewees is a central element in perception, but it frequently does not correspond to real circulating information (i.e., 44% of citizens living in an area without aq alerts reported being aware of the alerts). apart from this cue, the analysis strictly correlated referred symptoms with a high perception and pollution awareness. in ban et al. [34] , in nanjing, china and in wen et al. [70] , in six states in the usa, together with air pollution perception, symptoms and behaviors were considered to elucidate the consequences of individual behavioral change in terms of coping with smog pollution in the first article [34] and the consequences of alerts in the second [70] , several research papers have dealt with the issue of risk communication and alerts and their effects on the population's risk perception [41, 48, 69, 71, 73] . in mirabelli et al. [41] , knowledge of pollution and symptoms of related illnesses were more significant in areas where information about aqi was measured and disseminated. additionally, in reames et al. [48] , pollution perception and health concerns were associated with air quality alert knowledge. the study of wen et al. [70] showed that media alerts on air quality are a very important factor related to changes in outdoor activity. in brody et al. [73] , the authors sought to improve understanding of the major factors shaping public perceptions of air quality, concluding that perceptions appear to be influenced by the setting (urban vs. rural); state identification; and socioeconomic characteristics, such as age, race, political identification, and access to information. in the study of semenza et al. [71] , people changed behaviors when the air quality was worse, but this does not correspond with what is measured by control units. in dong et al. [47] , aq and perception were associated with information in the explanation because the analysis was conducted by baidu web information dissemination and people searched for information as a reaction to the growing level of pollution. in tilt et al. [72] , aq and perception were associated with socioeconomic factors in the elucidation of the relationship. the study was conducted in an industrial district in china, where the people expressed concern about air and water pollution; the analysis showed the differences among industrial workers, farmers, and workers in the commercial sectors, offering an interpretation of the different points of view of the local population. a direct association between perception and pollution has been established in a qualitative research study in a suburb in nairobi, kenya [62] and in a study using telephone questions and face-to-face interviews aimed at monitoring the evolution of perceived annoyance over time, related to pm in the environment [42] . furthermore, pu et al. [45] looked at the perceived risk and satisfaction of aq in 31 chinese provinces; lu et al. [49] , wang et al. [67] , and tao et al. [64] used big data; lu et al. (2018) [49] employed baidu to analyse the patterns of public concern about haze and the relationship between public concern and aq data provided by monitoring stations; wang et al. [67] and tao et al. [64] used weibo to examine the content and quantity of messages referred to aq and to construct an "air discussion index", respectively, to characterize the relationship between pm 2.5 and social media posts; cantuaria et al. [57] developed a cross-sectional study to assess the environmental conditions, annoyance, and health of rural residents in denmark; and cisneros et al. [61] studied california residents to understand their sources of aq information, perceptions of aq, and behaviors related to aq. the main finding of the present systematic review is that 31 articles out of 38 established a relationship between perception and measured pollution, even if indirect or moderate, showing a variety of methodologies and population samples (table 1) . regarding population samples, it must be underlined that the majority of the articles included in the systematic review did not consider the young population, when it is an integral part of the population, so this could be surveyed in the future. given children's vulnerability to the effects of air pollution [75] , it is vital to understand how children perceive their environment. if perception surveys are performed in schools and followed by environmental and health education interventions, we could also achieve the goal of raising awareness among younger generations [13, 76] . the distribution over time shows a substantial growth of publications on this topic in the last 4 years, with 26 publications between 2017 and 2020 ( figure 2 ); among them, the studies from china have acquired growing importance, with nine publications, while five studies were from the usa (figure 1 ). this is due to an increased concern for air pollution and the implementation of control policies to be monitored and reinforced with ancillary studies. two studies developed in china, at the national level [49] , and in four chinese megacities [64] used data collected by the usa embassy, mentioning the growing attention towards air pollution by the chinese population that apparently the usa was boosting, offering air quality data. as a whole, the results confirm the knowledge acquired on the relationship between air pollution and perception; in particular, that encompassed by the seminal article of karen bickerstaff [77] , which analyzes the developments in two main disciplinary directions. first, consolidation of the socio-cultural perspective, with the contribution of anthropology, geography, and sociology, and second, a convergence between the cultural and psychological approaches. most of the theories that maintain their validity and inform the research had already been presented [78] . bickerstaff concluded, in particular, that the perception of risk is multi-dimensional and influenced by complex social, political, and cultural processes and that to understand how people frame the risk, it is crucial to address behavioral changes and communication. this analysis is largely valid today, with some additional elements reflected in the articles examined in this systematic review. the diffusion of studies examining human bodies at a very sophisticated and intimate level, such as the human biomonitoring of blood, breast milk, and other specimens, or genetic tests, has led people to perceive pollution of the body and in the body in a more direct way, with relevant ethical implications [79] . the exploration of the perception of pollution in the body is a growing field of research that has developed from the experience gained and from the continuous attention to the issues of risk communication [13, [80] [81] [82] . the choice of 20 features to summarize the different components of perception was useful for observing the frequency in the recurrences of awareness, risk perception, self-reported symptoms, and search for information, which are representative of the main conceptual areas of interest of those studies. it is also interesting to highlight that some of them were scarcely considered, such as outrage and fear, widely examined in psychological and sociological studies, but included in only one study each [34, 63] ; anxiety was considered in two studies [53, 63] and request for actions from public authorities was considered in three cases [57, 62, 63 ]. an increasing number of studies are interpreting risk perception as a health modifier and it can be considered among the psychosocial determinants of health [83] [84] [85] . the term "social determinants" often evokes factors such as health-related features of neighborhoods, pointing to socioeconomic factors such as income, wealth, and education as the fundamental causes of a wide range of health outcomes [86] . most of the studies examined in this systematic review included health considerations as self-reported symptoms, subject to personal judgement, and the linkage between perception and health symptoms was documented. this is relevant to supporting the hypothesis that risk perception plays a role as a health determinant or health effect modifier. it is interesting to note that the measured pm pollution and the short-and long-term health effects were not relevant in the studies analysed in the present review. however, we wish to emphasize that in 2013, iarc released news about the identification of pm as a carcinogenic for humans [30] . this assessment defined a step forward for scientific knowledge and the weight of air pollution within the burden of diseases became clearer, as well as its role in the distal determinants of health [87] . in the same period, there was a turning point in china in terms of the implementation of policies to protect the health of citizens from air pollution and there was a significant improvement in studies on health and air pollution [33, 34] . the use of search engine data and social media is changing the ways in which researchers investigate public opinion. consequently, traditional survey research may play a less dominant role [88] . a recent review of the public's use of big data from web searches shows that the use of google trends has increased dramatically in the last decade. in the process, the focus of research has shifted to forecasting changes. in contrast, in the past, the focus was merely on describing and diagnosing research trends, such as surveillance and monitoring [89] . one of the most recent applications of big data for the social sciences focused on an investigation of the phenomenon of vaccine hesitancy. some studies have concluded that monitoring new media could be useful for detecting early signals of decreasing vaccine hesitancy and planning and targeting effective information campaigns [90, 91] . this systematic review identified only five articles that studied perceived pollution using big data in the past five years. three of them investigated perceived pollution using big data from web searches; namely, one of them used google trends [35] and the other two, the baidu index [47, 49] . although we found a correlation between the aq level and perceived pollution in these three articles, we noticed that each study used different search terms, namely, "air pollution", "cough", and "asthma" [35] ; "shanghai air quality" [47] ; and "haze" [49] . the other two articles collected messages from sina weibo, which is the most popular microblogging service in china. both studies show that social media may be a useful proxy for measuring pollution, mainly when traditional measurement stations are unavailable, censored, or misreported [40, 67] . although these studies show promising results, several limitations should be considered, suggesting that we cannot completely abandon the research method of a questionnaire survey. in this regard, one of the main limitations is that big data can only provide an active collective public response compared to questionnaire surveys, which directly indicate public concern based on individual responses. concerning chinese studies, we should consider the effect of government censorship on using social media for informatics in china. the disintermediation of communication, which has been growing exponentially in recent years, represents a relevant change in the circulation of information, with a potential relevant impact on risk perception and consequently, on health [92, 93] . it is reflected in the studies examined here, with growing attention being placed on big data utilization and the continuous attention given to the utilization of results, the role of citizens, and the importance to inform and involve people to foster prevention and reduce environmental pollution. in fact, it is clearly conceptualized by the scientific community and decision makers that the only way of managing complex problems in the environment and health domain is sharing responsibility and action to improve the quality and durability of decisions and actions. in particular, it is of utmost importance to gather information about risk perception to plan risk governance actions, including health literacy programs and communication and engagement activities, to be able to dialogue with different social actors and contribute to prevention and protection [3, 21] . to the best of our knowledge, this is the first systematic review investigating the relationship between ambient particulate matter levels and perceived pollution. in drafting this paper, we followed the prisma guidelines, which is one of the most appropriate tools for conducting systematic reviews. we searched three different databases to identify the highest possible number of studies and selected an extended timeframe, which allowed us to gather a significant proportion of the papers on this topic. all of the steps in the process, starting from the selection of abstracts to data extraction, were performed by three authors and not by the usual two, who have frequently consulted with each other when clarifying doubts. as for the scope of this systematic review, we are aware of the study's limitations, mainly regarding the capability to gather all published articles on this issue. specifically, two such limitations were the exclusion of some scientific databases and the selection of keywords. moreover, we are aware that our decision not to consider scientific papers from gray literature may represent a limit of completeness, although, on the other hand, we believe the higher qualitative reliability of the review is reasonable and not negligible [39, 94] . however, these types of limitations are inherent in all systematic reviews with similar objectives of producing new knowledge in an appropriate time period with only a few summarized articles. regardless of the stated limitations, we believe that our work will be of interest to readers and may provide useful information for developing future lines of research focused on the investigation of social media and web search engines as predictors of air pollution peak episodes. the results of this systematic review reinforce the hypothesis that aq has an important influence on risk perception, through both indirect and direct links. there is a tendency to consider a wide spectrum of concepts and factors connected with perception, for example, behavioural changes, boosted by previous negative experiences with pollution. experience is a key element of cognition and awareness, which can be influenced by socio-economic factors to explain differences in perception. in most articles, a direct association of perception with measured pollution was identified, with several specific features. unlike other types of environmental determinants, the impacts of air pollution, particularly pm, on the health of people and communities have been extensively studied, to the point of identifying a dose-response relationship. it is therefore possible to define the level of exposure of different populations and to take harm limitation measures. these measures will depend both on the actions taken by policy makers and on the willingness of people to contribute by changing personal and collective habits. from the point of view of epidemiological research, it is very interesting to understand whether and how much people are aware of the pollution that surrounds them and how it can affect their state of health. this is relevant for interpreting the existing data and for perspectives in terms of risk reduction, i.e., primary prevention. most of the studies examined in this systematic review include recommendations for actions and explorations of policy implications of air quality improvements. the public acceptance of mitigation policies constitutes a crucial factor for their success, necessitating ancillary actions such as health literacy programs, awareness raising campaigns, and public participation activities. the perception of people regarding exposure to air pollution and personal health is critical for evaluating the responses of communities and the acceptability of related policies. to conclude, this review may call for new studies that consider the younger segment of the population and that use big data as a source of knowledge, without renouncing the more classic methodologies of investigations. in addition, the analysis of the perception of risk as a determinant of health should be addressed. moreover, this topic should be examined in the context of the current covid-19 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authors: zhao, yu-feng; shou, ming-huan; wang, zheng-xin title: prediction of the number of patients infected with covid-19 based on rolling grey verhulst models date: 2020-06-25 journal: int j environ res public health doi: 10.3390/ijerph17124582 sha: doc_id: 343701 cord_uid: x5rghsbs the outbreak of a novel coronavirus (sars-cov-2) has caused a large number of residents in china to be infected with a highly contagious pneumonia recently. despite active control measures taken by the chinese government, the number of infected patients is still increasing day by day. at present, the changing trend of the epidemic is attracting the attention of everyone. based on data from 21 january to 20 february 2020, six rolling grey verhulst models were built using 7-, 8and 9-day data sequences to predict the daily growth trend of the number of patients confirmed with covid-19 infection in china. the results show that these six models consistently predict the s-shaped change characteristics of the cumulative number of confirmed patients, and the daily growth decreased day by day after 4 february. the predicted results obtained by different models are very approximate, with very high prediction accuracy. in the training stage, the maximum and minimum mean absolute percentage errors (mapes) are 4.74% and 1.80%, respectively; in the testing stage, the maximum and minimum mapes are 4.72% and 1.65%, respectively. this indicates that the predicted results show high robustness. if the number of clinically diagnosed cases in wuhan city, hubei province, china, where covid-19 was first detected, is not counted from 12 february, the cumulative number of confirmed covid-19 cases in china will reach a maximum of 60,364–61,327 during 17–22 march; otherwise, the cumulative number of confirmed cases in china will be 78,817–79,780. an epidemic of the novel coronavirus disease 2019 (covid-19) broke out in wuhan city, hubei province, china, in early 2020, and spread rapidly in china and across the world, causing tens of thousands of people to be infected with the virus. on 21 january, the prevention and control of the epidemic sprouted at the national level, and many provinces in china launched the first-level emergency response of epidemic prevention. by 30 january, more than 7000 covid-19 infection cases had been confirmed in china and more than 50 cases had been confirmed in countries and regions outside china, so the world health organization (who) had declared the outbreak of the novel coronavirus in china as a public health emergency of international concern (pheic). according to the latest data (http://www.nhc.gov.cn/) released by the national health commission of the people's republic of china, it can be seen from figure 1 that the number of confirmed cases increases in an s-shaped trend. although the cumulative number is rising, the number of newly confirmed cases reached an inflection point, reaching the peak on 4 february and then gradually decreasing. the number of newly confirmed cases rose excessively on 27 january due to the increase in the number of institutions with the capacity of pneumonia detection. figure 2 demonstrates that the number of suspected cases rose until 8 february and then decreased, while the number of deaths slowly increased and reached 2239 in total on 20 february. moreover, the number of cured patients significantly increased and reached 18 ,278 on the same day. on 11 february, the new coronavirus disease was officially named coronavirus disease 2019 (covid-19) by the who. the international committee on taxonomy of viruses (ictv) named the virus strain as severe acute respiratory syndrome coronavirus 2 (sars-cov-2). the accurate prediction of the number of patients infected with covid-19 in china is undoubtedly of great significance for implementing prevention and control measures and carrying out economic and social activities. considering the limited sample size since the outbreak of the epidemic and that a large sample size is needed to use the classical statistical prediction method, the present research used the grey system theory, which can be modeled with only four data points [1, 2] . on this basis, a rolling grey verhulst model and its derived models were established to predict the change trend of the number of cases of covid-19 infection in china. since the outbreak of the epidemic of covid-19, many scientists in the world have studied the causes and mechanisms of spread of the virus, along with relevant treatment programs. for example, based on the empirical analysis of a large amount of genomic data on a global scale, chen et al. [3] firstly tried to explain the reasons for rapid mutation, multiple hosts and strong host adaptability of betacoronavirus at the molecular level. xu et al. [4] found genetic evolutionary relationships of the novel coronavirus with the severe acute respiratory syndrome (sars) coronavirus and the middle east respiratory syndrome (mers) coronavirus. furthermore, lu et al. [5] found that this virus has specific nucleic acid sequences that are different from those of the known coronaviruses. zhang et al. [6] studied and summarized the new methods for detecting common respiratory viruses. koo et al. [7] found that a variety of interventions to maintain body distance are effective in reducing the number of sars-cov-2 cases. bi et al. [8] tracked covid-19-infected persons and their close contacts, showing that detection, isolation and tracking of cases can reduce the spread of the virus and help control the epidemic. archer et al. [9] used patients from 24 countries/regions, including europe and the united states, as data sources to investigate, for the first time, the impact of sars-cov-2 infection on pulmonary complications and mortality. to predict the number of people infected with the sars-cov-2 accurately, scholars have established a series of models, generally divided into three categories: the basic infectious disease models in the fields of mathematics and medicine [10] [11] [12] [13] , the economic models based on traditional statistical methods [14] [15] [16] and the algorithm models based on machine learning [17] [18] [19] . however, the above prediction models have some flaws. for example, the assumptions of the infectious disease model are strong, assuming that there is no super communicator, and are easily affected by factors such as geography; economic models or intelligent algorithms have strict requirements on data, requiring a large amount of data to be trained and tested to obtain relatively accurate prediction results. in response to such new viruses, with low data availability and incomplete cognition, the above models may not be applicable. for this reason, this research selected an innovative topic as the research object, namely the prediction of the final number of infected cases, which can provide a scientific basis for the government policies. grey system theory and grey prediction models have been widely used in many fields, such as economics [20] , demand prediction [21, 22] and environmental protection [23, 24] , since being proposed. the traditional gm(1,1) and the grey verhulst model are the core grey prediction models. bao et al. [25] predicted all factors of disability in middle-aged and old people and the probability of specific injuries through the grey gm(1,1) model and found that non-communicable diseases (ncds) are still the main threats to health for the elderly. in order to accurately predict the development of human echinococcosis in xinjiang uygur autonomous region, china, zhang et al. [26] made short-term predictions using three models, i.e., a traditional gm(1,1) model, a grey-periodic extensional combinatorial model (pecgm(1,1)) and a flamelet-generated manifold (fgm(1,1)) model optimized by fourier series. in the meanwhile, based on the transmission mechanism of echinococcosis, they established a prediction model for dynamic epidemics that can effectively predict the future development trend of epidemics. the traditional gm(1,1) model is mainly applicable to the sequences with strong exponential laws and can only describe the monotonic change process. however, the grey verhulst model has strong prediction capability for the non-monotonic swinging developmental sequences or the saturated s-shaped sequences due to the first-order accumulated generating operation (ago-1) of the original data. in recent years, some scholars have explored the optimization of initial conditions [27] and background values [28, 29] , the research of model properties [30, 31] and the accuracy improvement [32] of the grey verhulst model. for application scenarios of the grey verhulst model, some scholars have conducted research based on real socioeconomic systems, which to some extent reflects the effectiveness and superiority of the grey verhulst model in comparison with the traditional model. in order to improve the accurate prediction of short-term traffic speed and travel time, bezuglov and comert [33] utilized the gm(1,1) model, the gm(1,1) model modified by fourier error and the grey verhulst model modified by fourier error for prediction. the results demonstrate that the grey verhulst model modified by fourier error can better process sudden changes in the parameters of a traffic system sequence. wang and li [34] constructed a non-equal-interval grey verhulst model and its derived model and optimized parameters of the models by using particle swarm optimization. on this basis, they verified the environmental kuznets curve (ekc) of carbon dioxide emission in china by discussing the relationship between carbon dioxide emission and economic growth using a grey model. by building a grey verhulst model, wu et al. [35] predicted comprehensive air quality indexes in the chinese cities of beijing, tianjin and shijiazhuang, and the results show that the input of the government can promote improvement of air quality to some extent. zhang et al. [36] combined the verhulst model with the bp neural network to gain complementary advantages and improve prediction accuracy and stability. by utilizing the grey verhulst model, wang et al. [37] predicted the state of the iron and steel industry in 2025 based on the relationship between carbon emission of the industry and economic growth from 2001 to 2016; they also put forward relevant policy implications. in order to increase the predictive ability of the initial model, the model is changed appropriately to better adapt to the current needs. by introducing a new non-homogeneous exponential function, zeng et al. [38] constructed a grey n-verhulst model that overcame the defects of parameter dislocation and unreasonable initial value selection of the traditional verhulst model. in addition, some scholars have built grey models based on a rolling mechanism to explore the hidden useful information of the original data sequence and improve the modeling accuracy. akay and atak [39] proposed a grey prediction model based on a rolling mechanism to predict the total and industrial power consumption in turkey. the results demonstrate that the grey model based on a rolling mechanism shows greatly improved prediction accuracy. considering the complex randomness and nonlinearity of short-term traffic flow, xiao et al. [40] proposed a seasonal grey rolling prediction model based on the cycle truncation accumulated generation method and a rolling mechanism. xu et al. [41] established a br-agm(1,1) model based on the adaptive rolling mechanism to predict greenhouse gas emissions in china and discussed the policy significance of model overfitting and the modeling process.şahin [42] used a metabolism grey model, a nonlinear metabolism grey model and the optimized versions of the two to predict greenhouse gas emissions in turkey. the results demonstrate that prediction accuracy of the optimized nonlinear metabolism model based on a rolling mechanism is higher. the reminder of the research is arranged as follows: section 3 introduces the traditional grey verhulst model, the derived model of the grey verhulst model, the grey verhulst model based on a rolling mechanism and its derived models; section 4 shows the prediction and empirical results of pneumonia infection in china; and the conclusions are made in section 5. the grey verhulst model is an effective model to describe and predict a process with a saturation state (s-type) under the condition of small samples; it is commonly used in prediction of population, biological reproduction and product life. under strict anti-epizootic measures in china, it is assumed that covid-19 cannot spread indefinitely in china and the cumulative number of confirmed cases will not increase indefinitely and will eventually converge to the corresponding saturation value. therefore, the grey verhulst model is suitable for modeling growth and changes in the number of virus infection cases, especially for prediction of the final value and inflection point of the number of confirmed cases. the grey verhulst model selected in this study is proved to be able to predict non-linear data changes with small errors in multiple case studies [43] . furthermore, the rolling grey verhulst model established based on a rolling mechanism and its derived model can capture the dynamic characteristics of the future development trend of the system. to be clear, the model in this paper is only applicable to data with s-shaped growth, while the mortality rate and the number of deaths largely depend on the influence of a country's medical system, population parameters and various disease characteristics, which do not conform to the assumptions of the model and may lead to a large error. (1) represents the generated mean sequence of consecutive neighbors of x (1) definition 2. if x (0) , x (1) and z (1) are described as definition 1, the following formula is obtained. the above formula is the basic form of the gm(1,1) power model, and is the whitening equation of the gm(1,1) power model. (1) and z (1) are shown in definition 1, parameter listâ = [a, b] t can be calculated by using the least squares method and shown as follows: definition 3. particularly, when r = 2, then is the basic form of the grey verhulst model, and is the whitening equation of the grey verhulst model. the solution to the whitening equation of the grey verhulst model is shown as follows: by substituting the initial valuex (1) (1) = x (1) (1) into the above formula, the corresponding time response formula of the grey verhulst model is obtained as: finally, it needs to be reverted to get the predicted value of the original sequence x (0) (k). in the modeling process of the traditional grey verhulst model, a difference equation was firstly built and then converted into a differential equation, namely the whitening equation. moreover, the whitening time response function was derived through integral operation, and the prediction and simulation were finally conducted. the transformation process inevitably led to the inherent deviation of the grey verhulst model (see the work of wang et al. [30] ), so this study obtained a derived model of the grey verhulst model by referring to the traditional gm(1,1) derived model proposed by deng [44] and the method to derive the gm(1,1) power model by wang [45] . this derived model did not need further prediction by virtue of the whitening response formula, which was a function that the traditional gray verhulst model did not possess. in order to facilitate the deduction of the derived models of the grey verhulst model, the variable of the traditional gm(1,1) model is recorded as y and development coefficient is recorded as a . moreover, the grey action quantity is expressed as b . the derived model, namely the gm(1,1,y (1) ) model, is defined as follows: where α = a 1+0.5a and β = b 1+0.5a . according to this derived model, the derived model of the grey verhulst model can be obtained as follows: proof. based on the derived y (1) -type gm(1,1,y (1) ) model, the following formula can be derived. by adding the above k − 1 formulas up, by simultaneously adding y (0) (1) on both sides of the formula, the following formula is obtained: by substituting y (1) (k) = 1 into the above formula, the following equation can be obtained: when k = 2, when k = 3, 4, . . . , n, therefore, by substituting α = −a 1−0.5a , β = −b 1−0.5a into the above formula, the following formula is obtained: that is, the derived model of the grey verhulst model. where α = −a 1−0.5a and β = −b 1−0.5a . the flow chart of the derived grey verhulst model is shown in figure 3 . when using the grey verhulst model for modeling, the data before the real moment t = n are adopted. however, as time goes on, the development of any real socioeconomic system is accompanied by the constant access of some random disturbance factors, which affects the development of the system. a rolling mechanism can dynamically update the initial value of the data sequence and consider disturbance factors of the system, which has been proved to be able to greatly improve prediction accuracy [46] . therefore, this study introduced a rolling mechanism into the grey verhulst model and its derived model in order to reduce the influence of uncertain disturbance factors on the grey system in the future. the modeling process is presented as follows: the traditional grey verhulst model and its derived model established by the original data sequence x (0) = x (0) (1), x (0) (2), · · · , x (0) (n) are used to predict the next value x (0) (n + 1). by supplementing the value into the original sequence and removing the earliest data point x (0) (1), a new sequence, , is formed. this sequence is taken as the original sequence used to build the model, and the above steps are repeated for prediction and supplementation one by one. the models established according to the above steps are the grey rolling verhulst model and its derived model. the length of the rolling sequence is expressed as l. when l is 9, the rolling modeling process of the two models is shown in figure 4 . this model can make good use of new information and obtain more accurate predicted results. in order to compare accuracy and verify effectiveness and reliability of the models, absolute percentage error (ape) and mean absolute percentage error (mape) were used to calculate errors [47] : where e(i) = x (0) (i) −x (0) (i), in which x (0) (i) andx (0) (i) indicate actual value and predicted value, respectively. the levels of the accuracy of mape are shown in table 1 . relevant data of the numbers of confirmed cases, suspected cases, cured patients and deaths were acquired by referring the latest data released by national health commission (http://www.nhc.gov.cn/). by using the number of patients infected with covid-19 in china from 20 january to 20 february as the original data, empirical modeling and analysis were performed. firstly, the rolling grey verhulst model and its derived model were established, and the lengths of the rolling sequences were 7, 8 and 9. in accordance with the length of the rolling sequence, the original data were classified into a training set and a testing set, and the prediction accuracies of basic model and the derived model were compared. secondly, in view of different lengths of the rolling sequences, the model with the highest prediction accuracy was selected to predict the final value and inflection point of the number of confirmed cases. in accordance with the rolling mechanism described in section 3.3, the rolling grey verhulst model and its derived model were built. by replacing the earliest data with the latest ones, the prediction and supplementation were carried out successively. due to different analytic formulas of the general model and derived model, parameter estimation results are identical. by using the least squares method to estimate parameters of the two models, the parameter listsâ = [a, b] t are obtained when the rolling sequence lengths are 7, 8 and 9. the results are shown in table 2 . parameters of the rolling grey verhulst model and its derived model were obtained with different rolling sequence lengths, and predicted values were calculated based on recurrence prediction formula. by establishing the rolling grey verhulst model and its derived model with rolling sequence lengths of 7, 8 and 9, data from 20 january to 20 february 2020 were predicted, and the training and testing sets were established based on the length of the rolling sequence. on the basis of ensuring that the models could accurately simulate the number of confirmed patients in the training set, three models with high prediction accuracy in the testing set were selected to predict the maximum value and inflection point for different rolling sequence lengths. the results of the training and testing sets are presented in tables 3 and 4 . as displayed in table 3 , the prediction errors of the six models in the training set are less than 10%, indicating that the six models can accurately simulate changes of the number of confirmed cases in china. by observing prediction performance of the six models in the testing set, it can be seen that their prediction accuracies are all less than 10%, suggesting that the models can accurately predict changes of the number of confirmed cases in the future. as demonstrated in table 4 , in the testing set, prediction accuracy of the grey verhulst model with the rolling sequence length of 7 is higher than that of its derived model; the grey verhulst model and its derived model have mape values of 3.30% and 3.83%, respectively. when the rolling sequence lengths are 8 and 9, the grey verhulst models show lower prediction accuracy than their derived models. mapes of the grey verhulst model its derived model are 4.72% and 3.13%, respectively, when the rolling sequence length is 8. mapes of the grey verhulst model its derived model are 2.93% and 1.65%, respectively, when the rolling sequence length is 9. therefore, the grey verhulst model with the rolling sequence length of 7 and derived grey verhulst models with rolling sequence lengths of 8 and 9 were selected to predict the final value and inflection point of the number of confirmed cases in china. as shown in test results of models in section 4.2, the grey verhulst model with the rolling sequence length of 7 and derived grey verhulst models with the rolling sequence lengths of 8 and 9 were used to predict final value and inflection point of the number of confirmed cases in china. in order to ensure combination of the rolling mechanism and the derived grey verhulst models, for out-of-sample rolling prediction, the data from 12 to 20 february, 13 to 20 february and 14 to 20 february were used to predict the latest data, which served as the numbers of newly confirmed cases in the next period. then, by removing the data on 12, 13 and 14 february, new initial sequences were established to continue the rolling operation until the predicted result in the latest day no longer changes, allowing this result to be taken as the final value. on 13 february, hubei provincial health commission announced on its official website that, to be consistent with the case diagnosis and classification issued by other provinces in china, the province would release the number of clinically diagnosed cases and include this number in the confirmed cases. since then, due to the appearance of clinically diagnosed cases, the number of confirmed patients increased greatly every day. therefore, this study predicted changes of the number of confirmed patients with and without consideration of clinically diagnosed cases. this research further calculated out-of-sample prediction accuracies on 21 and 22 february to verify the predictive ability of the models. the results of final predicted values are demonstrated in table 5 . it was found that the three models could accurately predict out-of-sample data; the specific data are presented in table 6 . as illustrated in figures 5-7 , in the case of not considering clinically diagnosed cases, the maximum prediction values of the three models with rolling sequence lengths of 7, 8 and 9 are 60,364, 61,327 and 61,327, respectively. under the condition of considering clinically diagnosed cases, the final prediction values are 78,817, 79,780 and 79,780 on 17, 22 and 22 march, respectively. by analyzing changes in the number of confirmed patients, it is found that the number of confirmed patients does show an s-shaped trend. moreover, the current number of confirmed patients has been approximated to the final value, and the number of confirmed patients growing in a single day has decreased. in order to further calculate the inflection point, that is, the day with the maximum number of confirmed patients, this research plotted growth rate changes in single days using three models, as shown in figure 8 . as shown in figure 8 , the inflection point had appeared on 4 february, with the number of confirmed patients of 3892. in addition, the growth in single days declines rapidly, and the predicted results of the three models are basically the same, which proves that the results are robust. based on a rolling mechanism, the rolling grey verhulst model and its derived models for predicting the number of patients infected with covid-19 in china were constructed by adding the latest data and removing the earliest data. empirical modeling and analysis was conducted by using the number of infected cases from 20 january to 20 february. firstly, in order to ensure stability of prediction results, the rolling sequence lengths of 7, 8 and 9 were selected for the models. the original data were classified into the training and testing sets to compare prediction accuracies of the basic model and the derived models. secondly, considering the different rolling sequence lengths, the models with high precision accuracy were selected to predict the final value and inflection point of the number of confirmed patients. the results showed that the rolling grey verhulst model and its derived models could accurately predict the changes in the number of confirmed patients in china. the prediction accuracy of the rolling grey verhulst model with the rolling sequence length of 7 was higher than that of its derived model, while the prediction accuracies of the rolling grey verhulst models with rolling sequence lengths of 8 and 9 were lower than those of the derived models. therefore, this study used the rolling grey verhulst models with high accuracy to predict the final number of confirmed patients and the date of reaching the final number. by predicting the final number of confirmed patients in china using the rolling grey verhulst model, the maximum predicted numbers by the three models with rolling sequence lengths of 7, 8 and 9 were 60,364, 61,327 and 61,327, respectively, when clinically diagnosed cases were not considered. grey system theory and its application model comparison of gm (1, 1) and dgm (1, 1) based on monte-carlo 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chinese pig price index the basis of grey theory models derived from gm (1,1) power model forecasting u.s. shale gas monthly production using a hybrid arima and metabolic nonlinear grey model this article is an open access article distributed under the terms and conditions of the creative commons attribution the authors declare no conflict of interest. key: cord-350006-c4be9eii authors: martina, stefano; amato, alessandra; rongo, roberto; caggiano, mario; amato, massimo title: the perception of covid-19 among italian dentists: an orthodontic point of view date: 2020-06-18 journal: int j environ res public health doi: 10.3390/ijerph17124384 sha: doc_id: 350006 cord_uid: c4be9eii covid-19 has severely impacted dentists, who are at a great risk of infection. this study aimed to investigate if dentists are anxious about returning to their daily activities, and what the perception of the risk is for dentists and orthodontists regarding orthodontic procedures. an online questionnaire, including the patient health questionnaire-4 (phq-4), was sent to italian dentists during the final days of the lockdown with items about anxiety, fear, distress, perceived risk for operators, and concerns about orthodontic patients caused by working during the covid-19 outbreak. data were analyzed with a chi-square test and logistic regression analysis. the level of significance was set as p < 0.05. a total of 349 dentists completed the survey, including 183 orthodontists. returning to their daily work activity was a source of anxiety for 192 participants and this was associated with the level of distress (odds ratio (or) = 3.7; p < 0.001). most of the orthodontists (67.6%) thought that they would increase the number of working hours during the week (or = 1.8; p = 0.007). italian dentists were mostly scared to return to their daily activities because they considered their jobs a high risk to them and their families. dentists with an exclusive/prevailing orthodontic activity were forced to increase their working day during the week. in december 2019 a novel coronavirus (2019-ncov) was described in the chinese city of wuhan [1] . the 2019-ncov, afterwards renamed sars-cov-2 [2], caused a highly contagious disease (covid-19) [3] . covid-19 patients could have upper respiratory tract infection (rti), fever, dry cough, dyspnea and severe viral pneumonia with respiratory failure and even death, but there is a percentage of those infected that shows mild symptoms (pharyngodynia, nasal congestion, olfactory and gustative disorders) or no symptoms [4, 5] . covid-19 could directly cause cardiovascular injuries such as pericarditis, myocarditis, myocardial infarction, heart failure, arrhythmias or thromboembolic events [6] . in a few weeks, covid-19 had spread all over the world and on 11 march 2020, the world health organization (who) declared it a pandemic. the virus propagates between people through close contact and via respiratory droplets produced from coughs or sneezes [7] , but several uncertainties currently remain, particularly regarding the contribution of asymptomatic versus symptomatic patients to the transmission of the virus [8] . virus identification in human respiratory epithelial cells could be positive about 96 h from exposure and 24-48 h before the onset of symptoms [9] . the nasopharyngeal real-time polymerase chain reaction (rt-pcr) swab test was used to diagnose covid-19. however, this test has high costs and complex execution methods and, even though one of the epidemic fight strategies is the identification and isolation of the positive subject, the nasopharyngeal swabs on the whole population is still not sustainable. the available diagnostic accuracy data suggest that the test has very high specificity, but a moderate sensitivity (63-78%) [10] . in the absence of a vaccine or an effective treatment, many countries including italy have adopted quarantine measures and lockdowns to control the spread of covid-19, limiting mortality and maintaining healthcare demands within capacity. on 1 may in italy 207,428 cases of covid-19 were diagnosed out of 1,398,633 subjects tested, with 28,236 deaths [11] . in italy, during the lockdown (also known as phase-1), the dental assistance in private practices was not suspended by law to reduce the burden on the hospitals dealing with the covid-19 patients. however, the national medical and dental committee and the category unions strongly recommended rescheduling dental activities, limiting these to emergencies, such as pulpitis, abscesses and phlegmons. it can be assumed that stopping dental procedures may be due to several reasons: to avoid the movement of people, to reduce the consumption of personal protective equipment (ppe) and to reduce the risk of infection. indeed, aerosols formed during dental procedures, contact spread, and contaminated surface spread are possible routes of transmission for sars-cov-2 [12] . for these considerations, most of the treatments, including routine orthodontic appointments, were postponed. orthodontic patients were assisted virtually by means of photos, videos, or video calls, performing triage to select the real urgencies to be managed in person from remotely manageable situations [13] . the lockdown ended in italy on 4 may and the so-called phase-2 has started by imposing social distancing measures and the use of masks in everyday life. in a dental practice, it is obviously impossible to maintain these measures; therefore, dentists have a high risk of getting infected from patients and potentially spreading the virus. in light of this, it is not surprising for dentists to be afraid of being infected by their patients. on the other hand, orthodontics could be a less risky practice than other specialties of dentistry. orthodontic controls are usually quick, aerosol procedures are few and not very frequent during the same clinical day, and most patients are under 20 years of age, a category that seems to be less affected by covid-19 [14] . previous studies investigated the level of fear and psychological distress during the covid-19 pandemic [15, 16] , finding that elevated psychological distress was present among dentists who have a background illness, those who feared contracting covid-19 from a patient, and those who had higher subjective overload. none of these studies were performed in italy. the purpose of this study was to investigate how the return to their daily practice during phase-2 influences dentists and what their perception of risk is regarding orthodontic procedures. the present cross-sectional study was conducted by sending an online survey questionnaire to italian dentists, from 1 may to 6 may 2020. the survey was created on an online survey development cloud-based software called surveymonkey ® (svmk, san mateo, ca, usa). the participants were approached via facebook, whatsapp, and mailing lists. participants authorized the treatment of their data that were collected anonymously. the personal information of participants was protected and there were no inhumane questions or investigations. the questionnaire was comprised of 31 multiple-choice questions: 5 questions were about personal data (gender, age, region of residence); 4 were on symptoms of covid-19; 7 were about the perceived risk for operators during orthodontic procedures, anxiety and distress caused by working during the covid-19 outbreak; 6 were about the fears for an infection and the concerns regarding orthodontic and temporomandibular disorders (tmd) patients whose treatment has been suspended due to the epidemic; 5 were about emergencies and changes in clinical procedures and work organization as a result of the covid-19. the last 4 questions of the patient health questionnaire (phq-4) [17] were included in the questionnaire to assess whether the general state of anxiety and depression could influence the other answers. the phq-4 was composed of four questions with a 4-item likert scale. scores between 3 and 5 indicated a slight distress, between 6 and 8 indicated a moderate psychological distress, and higher than 10, a severe distress. in the survey, most of the questions had a dichotomous answer (yes/no). dentists were asked about the number of emergencies they faced during the lockdown period (less than 5, more than 5) and they had to classify what they feared most in the case of infection among the following: fear of dying, fear of the quarantine, fear of infecting family members, fear of economic loss, fear of interrupting treatments, or fear of discrimination. frequencies and percentages for categorical data were computed. a chi-square test was used to assess the association between gender (male vs. female), age (older than 70 years old vs. 60-69 vs. 50-59 vs. 40-49 vs. 30-39 vs. 20-29), region of residence (south vs. centre-north), level of distress (0-1 vs. 2-3), orthodontic activity (general practice vs. main/exclusively orthodontic activity) and questions about risk, anxiety and distress caused by working during the covid-19 outbreak. furthermore, the chi-square test was used to evaluate the association between the level of distress and the orthodontic activity with the 5 questions about emergencies and changes in clinical procedures and work organization as a result of the covid-19. in the case of a statistically significant association, logistic regression analyses to calculate the odds ratio (or) were performed. a standard statistical software package (spss, version 22.0; spss ibm, armonk, new york, usa) was used. the level of significance was set at p < 0.05. a total of 349 (175 m, 173 f, 1 not reported) dentists completed the survey. participants were asked to identify their age range and the most common were 30-39 years old (110) and 50-59 years old (76). most of the dentists lived with their families (289) or alone (51). a total of 226 were from the south of italy and 123 from the centre-north italy. among the 349 participants, 183 had a main (91) or exclusive (92) orthodontic practice, while 166 had a more general practice. none of the participants were diagnosed as covid-positive but only 35 were tested. the phq-4 reported 4 different levels of distress: 112 participants reported no distress, 160 slight distress, 58 moderate distress, and 19 severe distress. these data are shown in the table 1 . the level of distress was associated with 2 questions about anxiety and distress; indeed, 78% (60/77) of the dentists with higher distress levels were more anxious about starting their daily work activities again (odds ratio (or) = 3.7; p < 0.001) compared with 48.7% (132/271) of the dentists with less distress. furthermore, 31.2% (24/77) of dentists with higher distress levels were more inclined to close their activities (or = 3.9; p < 0.001) compared with 10.3% (28/271) of participants with less distress, for a total of 52 subjects out of 349 that were more inclined to stop their jobs (tables 2 and 3 ). only 27 out of 349 participants did not consider their work to be at a higher risk, and only 42 did not consider their work to be of higher risk also for their families. among these 42, 28% (12/42) were younger than 40 years old (or = 6.1; p = 0.002) and 66% (28/42) were from centre-north italy (or = 0.4; p = 0.004). returning to daily work activities was a source of anxiety for 192 participants, mostly women; indeed, 64% of women (110) replied yes against only 46.9% of men (82) (or = 2; p = 0.003). similarly, this was a source of anxiety more for those participants who were younger than 50 years old (141) than for those older (51), (or = 2.6; p = 0.026). regarding teamwork, 56 out of 349 dentists thought that their collaborators had less risk than dentists of being infected by covid-19. most of the participants (221) considered orthodontic procedures as a lower risk of contagion than general dental practices, even if adolescents and children were mostly considered a similar source of infection as adults (tables 2 and 3 ). the survey also asked about the number of emergencies faced during the lockdown period and 148 dentists had more than 5 patients during this lockdown period, but 79 dentists were extremely scared and 157 were moderately scared of dealing with emergencies. interestingly, there was an association between the number of dentists that dealt with fewer than 5 emergencies during this period and the level of fear facing the emergencies with 62.2% (147/236) of dentists that were strongly or moderately scared who faced less than 5 emergencies compared with 52.3% (59/112) of dentists that were slightly or not scared that faced more than 5 emergencies (or = 1.8; p = 0.035). finally, there was an association between the level of distress (phq-4) and the fear during emergencies. indeed, among the 77 dentists that had a high level of distress, 48% (37) were strongly scared and only 4% (3) were unafraid (or = 0.1; p < 0.001) ( tables 4 and 5) . furthermore, dentists thought that patients under fixed treatment who were not controlled for more than two months should be considered emergencies (209), while only 104 and 117 dentists considered emergencies those patients with removable appliances or with temporomandibular disorders that had not been controlled for 2 months (table 4) . finally, most of the dentists (342) thought that in this phase-2 they would reduce the number of patients during the day and 211 thought that they would increase their number of working hours during the week. interestingly, among these 211, the greater percentage (58.3%, 123/211) were dentists who had a main/exclusive orthodontic activity (or = 1.8; p = 0.007), and similarly among this group of dentists there was the greater percentage of participants that planned to postpone aerosol procedures (60.7%, 105/173, or = 1.9; p = 0.002). regarding the ranking of fears in case of contagion, most of the participants were afraid of infecting family members (indicated 160 times as their first fear), dying (indicated 82 times as their first fear), and being discriminated against (indicated 31 times as their first fear, table 6 ). this study was carried out during the final days of the lockdown in italy and just before dentists returned to their practices. the aim was to understand through a survey how dentists had approached phase-1 and how they were preparing for phase-2 and investigate whether these situations had created anxiety or distress. the sample was a good representation of different age ranges, different regions of residence, different levels of distress and different dental activities. none of the interviewed dentists were positive for covid-19 and almost 10% were tested. this percentage is higher than the total number of swabs done in italy (by 9 may, 4% of the population). in italy there was a considerable difference in the incidence of covid-19 between central-northern and southern italy, with nearly 90% of total cases from the centre-north [11] . therefore, the answers of dentists from the centre-north were compared with those from the south. despite the different number of cases, the perception of the problem by dentists between centre-north and south was similar. this could be due to the quarantine measures which were the same in all regions of italy and to the influence of the italian media which stressed the situation without any differences during phase-1. the phq-4 showed that 77 dentists out of 349 (22.1%) had moderate/severe psychological distress (score equal to or higher than 6) in the last 2 weeks. this percentage was greater compared with the data presented of the general population, where about 5% of the population presented these scores [18] . it could be argued that the tough situation due to the pandemic crisis and the possible italian economic crisis might influence the psychological status of the participants. moreover, it was interesting that people with higher distress levels were those with more anxiety about returning to work, more inclined to close their activities, more afraid of facing emergencies, and more fearful of infecting their families. this critical situation has highlighted the difficulties that italian dentists had to face during their activities, and as a vicious circle in which more psychological distress led to more fear and anxiety, that led to a decrease in psychological wellness [19] . most dentists interviewed considered themselves and their collaborators to be exposed to a high risk due to their jobs and they are afraid of infecting their relatives. these data are consistent with previous studies on the psychological impact in health care workers of similar infectious diseases, such as severe acute respiratory syndrome (sars), who were afraid of contracting an infection while treating an infected patient or infecting a family member [20, 21] . however, some associations were found between dentists that did not think they were a higher source of infection risk for their relatives due to their jobs regarding age and region of residence. this is probably due to the fact that, although with different means of contagion, dentists with more experience are used to managing in their practice several infective diseases, such as hepatitis b, hepatitis c, human immunodeficiency virus infection, tuberculosis, following strict protocols for infection control [22] . although many dentists treated less than 5 patients in phase-1, the management of these emergencies frightened them. the fear in dealing with emergencies was associated with the distress level of the dentists (the higher the distress, the higher the level of fear) but also with the number of emergencies seen during the lockdown period. indeed, the dentists that were more scared in facing the emergencies were those that treated fewer than 5 emergencies. two hypotheses might explain this association: first, dentists who were more fearful tried as much as possible to solve any potential emergency by using telemedicine to avoid meeting patients. second, those dentists who performed more than 5 emergencies understood that with adequate ppe the chance of contagion was low. however, due to the lack of ppe during phase 1 in italy, the fear of performing any emergency procedure may have also been due to the lack of availability of proper ppe. fifty-five percent of respondents were worried about the return to their dental practices in phase-2; 15% contemplated definitively ceasing their activity. it is obvious considering that, since there is no vaccine or approved treatment, anxiety about being infected is very high in the population. dentists and health professionals in general are at higher risk of contracting infectious diseases, with an additional psychological distress component [23] . moreover, dentists may be concerned about liability related to possible infection of workers or patients in their practices, and about the critical italian economic situation which could reduce the demand for dental treatment. women, dentists younger than 50 years old, and participants with higher distress levels were more concerned about coming back to work compared with other categories. as already mentioned, psychological distress and the fear of coming back to work with an increased patient load strongly influenced each other due to the concern about the contagion, and probably women and young people were more worried about their families. indeed, when asked to rank the situations that would be most frightening in case of infection, most dentists ranked the fear of infecting their relatives and the fear of dying as the top two. few have attributed importance to the possibilities of being discriminated against, economic loss and the suspension of ongoing treatments. surprisingly, dentists from the south said they were more concerned with infecting family members. in addition, most dentists believed that children and adolescents represent the same risk of infection compared with adults. a part of the questionnaire was focused on orthodontics and about 50% of the participants were orthodontists. most dentists thought that, with orthodontics, the risk of being infected is lower. the explanation for this could be that, unlike other branches of dentistry, in orthodontics there are procedures that do not require aerosols. aerosol procedures were indicated as more infective procedures in several articles [24, 25] . in fact, most orthodontists (57%) declared that they will postpone clinical procedures with aerosols as opposed to general practitioners, in which only 40% will postpone these procedures. sixty percent of participants believed that not examining a patient on fixed appliance treatment for more than 2 months is a serious problem, whereas they believed it is less critical to postpone exams for patients who have removable devices. some orthodontists may be worried about orthodontic activations of fixed appliances given before the lockdown, which hardly can be monitored with telemedicine. other orthodontists may believe that not checking patients for more than 2 months may have caused damage to the appliance, such as loose brackets and bands or worsened oral hygiene. these are all patient cooperation factors that could contribute significantly to increased treatment time [26] . removable appliances may suffer less from these issues and generally cause less discomfort to patients as compared with fixed appliances [27] . regarding rescheduling patients, compared with general practitioners a higher percentage of orthodontists declared that they would organize their weekly schedules to work more days during the week (53.0% vs. 67.2%). this is an important change in orthodontic practice because in italy most dentists that have a main/exclusive orthodontic activity work as consultants. due to the greater time needed to perform disinfection procedures, the chair time between two patients will increase and the number of patients that is possible to see in one day, obviously, will decrease forcing the dentists to work more days per week. regarding the management of tmd patients, most dentists thought that examining these patients is not an emergency; however, they believed that not controlling them for more than 2 months may have worsened the patient's psychological distress. this study presents some limitations. it is a survey-based study; hence information is self-reported, and the collection time was only one week. however, it also presents some strengths, such as the high number of participants, the good distribution of the factors, and the focus on the orthodontic practice. this survey-based study investigated the perception of italian dentists of the return to their daily practices and of their risk during orthodontic procedures. italian dentists were mostly afraid to return to their daily activities, and women, younger dentists and dentists with higher distress levels were more frequently scared by this aspect. the worst fears in case of contagion was infecting family members and the fear of dying. dentists considered their job a high risk to them and their families; however, orthodontic procedures were considered a lower risk compared with general dental procedures. dentists with an exclusive/main orthodontic activity were forced to increase their working day during the week. the species severe acute respiratory syndrome-related coronavirus: classifying 2019-ncov and naming it sars-cov-2 novel coronavirus (2019-ncov) situation report-22 clinical characteristics of covid-19 in china clinical presentation of covid-19: a systematic review focusing on upper airway symptoms. ear nose throat j. 2020, 0145561320920762 cardiovascular manifestation and treatment in covid-19 how covid-19 spreads estimating the asymptomatic proportion of coronavirus disease 2019 (covid-19) cases on board the diamond princess cruise ship incubation period of 2019 novel coronavirus (2019-ncov) infections among travellers from wuhan, china the appropriate use of testing for covid-19 dipartimento della protezione civile covid-19, i casi in italia il 1 • maggio ore 18 transmission routes of 2019-ncov and controls in dental practice management of orthodontic emergencies during 2019-ncov evolving epidemiology and transmission dynamics of coronavirus disease 2019 outside hubei province, china: a descriptive and modelling study covid-19 factors and psychological factors associated with elevated psychological distress among dentists and dental hygienists in israel fear and practice modifications among dentists to combat novel coronavirus disease (covid-19) outbreak an ultra-brief screening scale for anxiety and depression: the phq-4 a 4-item measure of depression and anxiety: validation and standardization of the patient health questionnaire-4 (phq-4) in the general population a nationwide survey of psychological distress among italian people during the covid-19 pandemic: immediate psychological responses and associated factors severe acute respiratory syndrome (sars) in hong kong in 2003: stress and psychological impact among frontline healthcare workers immediate and sustained psychological impact of an emerging infectious disease outbreak on health care workers health hazard evaluation in private dental practices: a survey in a province of northen italy factors associated with mental health outcomes among health care workers exposed to coronavirus disease covid-19 outbreak: an overview on dentistry covid-19): emerging and future challenges for dental and oral medicine an evaluation of factors affecting duration of orthodontic treatment pain and discomfort associated with labial multibracket appliances vs. clear aligners funding: this research received no external funding. the authors declare no conflict of interest. key: cord-346388-j6pajd68 authors: song, hwasung; park, chanyul; kim, miseong title: tourism destination management strategy for young children: willingness to pay for child-friendly tourism facilities and services at a heritage site date: 2020-09-28 journal: int j environ res public health doi: 10.3390/ijerph17197100 sha: doc_id: 346388 cord_uid: j6pajd68 the present study seeks to establish tourism destination management centered on young children for accessible tourism from a public perspective. preferences for services and facilities for young children were identified using a choice experiment (ce). the present study was conducted at hwaseong fortress, a unesco world heritage site, located in suwon city, which leads the clean restroom culture. overall, 1870 experiments were conducted with 374 participants to estimate their willingness to pay for child-friendly tourism facilities and services. as a result, willingness to pay was found in the order of specialized courses for young children, rest areas, restrooms, and rides. in conclusion, the importance of health/hygiene and amenities has implications for tourism destination management for young children. this study contributes to a better understanding of families with young children by evaluating preferences for levels of services and facilities for young children. have you ever experienced tourism with young children? in the republic of korea, under article 2 of the child care act, infants and young children refers to preschoolers under the age of six [1] . tourism with a child under 6 years of age brings many restrictions at tourist destinations. during tourism with young children, one faces the constraints of the basic needs for rest, eating, and toileting [2] [3] [4] . thus, it is expected that the contents that can be enjoyed at tourist destinations will change. the impact of children on tourism purchasing power is gradually increasing, and family vacations are expected to become more important for society in the future from the perspective of creating social benefits [5] . parents are gradually spending more money and energy to travel with their children [6] . additionally, travel experiences during one's childhood could affect travel behavior after becoming an adult [7] [8] [9] . therefore, not only is the scale of young children's tourism growing, but its importance in marketing is also increasing [9] . from these perspectives, research on travel time and cost for travel with young children [6] , preferred activities [4, 10, 11] , and facilities and services [2, 3, [12] [13] [14] has been steadily progressing. these studies have contributed to a better understanding of the tourism market for young children, but there is still a lack of answers as to which management strategy is needed from the view of providers. in particular, in terms of safety and hygiene, it is necessary to consider how to differentiate food, sleeping, facilities and services, and experiences. this is a more difficult aspect to deal with in the public domain. however, since tourism is a right that everyone should enjoy, not only an understanding of the economic importance of young children's tourism, but also the development of a tourism destination management strategy for young children's tourism in the public domain is needed. accessible tourism for all means "the ongoing endeavor to ensure tourist destinations, products, and services are accessible to all people, regardless of their physical limitations, disabilities, or age" [15] . young children, who have more restrictions than adults in terms of hygiene, safety, walking, and rest, are also the subject for accessible tourism. that is, the public sector should also improve facilities and services for young children. the tourism industry has been negatively impacted due to the covid-19 pandemic, and long-distance tourism such as overseas tourism has become very difficult [16, 17] . however, tourism and leisure are basic needs of humans [18] , and as covid-19 has become prolonged and new cases have significantly decreased, travel to nearby destinations such as parks is rapidly recovering in korea [19] . however, covid-19 makes tourism activities difficult for young children with weak immune systems. tourists with young children are very concerned about the fatigue of their children, so the younger the children are, the more they prefer short distances and try to reduce travel time as much as possible [4, 10] . in addition, the comfort and safety of the destination is an important determinant of the intention to visit, and the cleanliness of the destination is especially important [12] . this is the reason why covid-19 further reduces tourism activities, especially for tourists with young children. in the republic of korea, childcare facilities have been closed due to covid-19, and children spend most of their time at home. social exchanges and education provided by childcare facilities are on hold, tourism and outdoor activities are reduced, and people are suffering from increases in obesity due to mental stress and lack of exercise [20] . in particular, children belonging to the socially vulnerable class are more alienated, mentally stressed, and worsening in their physical health [21] . accordingly, it is necessary to look at young children's tourism from the perspective of accessible tourism in terms of public interest and to improve the conditions of young children's tourism to help heal the society after the covid-19 pandemic. under these circumstances, the importance of health/sanitation management for young children's tourism is growing [16] . therefore, the present study examines the preferences of tourists in order to establish a tourism destination management strategy for young children as a type of accessible tourism from a public perspective. choice experiments (ces) were used to estimate the willingness to pay (wtp) for facilities and services for young children at a tourist destination, in order to understand preferences. the ce method of estimating economic value based on stated preferences is widely used for estimating the wtp of tourists. the advantage of the ce is that you can check the wtp for the different levels of any attribute. for example, it is possible to check how much the wtp is based on the level of restrooms for young children. suwon hwaseong fortress, the target site of this study, was designated as a unesco cultural heritage site in 1997 and is a popular historical and cultural tourist destination in korea, even among young children, due to its educational aspects [22] . in particular, suwon city, in which hwaseong fortress is located, is the place where the "world restroom culture movement" began and is well known for its clean public restrooms [23] . yet, facilities and services for young children including restrooms at the tourist destination are insufficient. thus, this site was selected as the target site for establishing an optimal tourism destination management strategy for young children's tourism. the purpose of the present study was to establish a tourism destination management strategy centered on facilities and services for young children's tourism before the outbreak of covid-19. however, hygiene and amenities in young children's tourism and providing preferred facilities and services has become even more relevant in the era of covid-19, with implications for the tourism destination management for young children's tourism. young children are an important consumer group in the tourism industry. tourism has become one of the essential consumption elements for families with young children, and parents are spending more and more money and energy on travel with their children [6, 8] . children have a fair amount of influence on the tourism decision-making in the family. therkelsen revealed that the roles of mothers and children are equal in vacation planning [4] , and curtale found that parents are sensitive to their children's best and worst choices, and they make choices tailored to their preferences [9] . in addition, the satisfaction of children affects the satisfaction and behavior intention of parents [7, 9] . in particular, younger children have a greater influence on tourism decision-making [9, 10] . the size of the domestic children's industry in korea was 40 trillion in 2018, surpassing the 27 trillion from 2012, and new words such as vib (very important baby) and yucance (infant + hotel + vacation) were born [24] . in the tourism sector, in particular, various specialized programs are being provided for these vib customers. for example, worldwide resort club med provides various activities and facilities that are adapted to children of different age groups, ranging from 4 months to 17 years [25] . even in korea, midas hotel and resort [26] was designed for vacationing with children and operates premium children's clubs in line with this trend. therefore, in the tourism industry, it is necessary to establish marketing strategies for children in order to attract new customers, and it is important to provide tourism products that satisfy the preferences of children [9] . the private sector focuses on the market value of the children's industry, while the public sector focuses more on creating child-friendly tourism environments from an accessible tourism perspective [24] . since tourism is increasingly being conceived as a necessity, rather than a luxury [27] , accessible tourism is being considered both as a fundamental right as well as a new business opportunity [28] . accessible tourism for all means "the ongoing endeavor to ensure tourist destinations, products, and services are accessible to all people, regardless of their physical limitations, disabilities, or age" [15] . it could also be understood as the set of "facilities and services (including the physical environment, transportation, information, communication) which enable persons with special access needs, either permanent or temporary, to enjoy a holiday and leisure time with no particular barrier or problem" [29] . from this perspective, it has become important to consider the level of accessibility for young children when designing facilities and services of tourist destinations. in order to create child-friendly destinations, it is necessary to understand the characteristics of young children as tourists. first, young children need to have their primary needs for food, nap/bedtime, safety, and sanitary facilities met first [4] . families with young children will give positive reviews on tourism attraction if they are provided convenience facilities and food for their children [3] . nistoreanu and dragolea found that specialized facilities for children such as beds for children or rest areas are needed for providing comfort, and caring staff and hygienic conditions could improve safety [12] . in addition, khoo-lattimore and yang emphasized that a comprehensive approach should be taken when designing facilities and services for young children by considering accessibility, possibility of interaction with other children, safety, hygiene, room size, and staff size for child-friendly programs [14] . secondly, young children are usually satisfied with dynamic activities. nickerson and jurowski revealed that young children prefer dynamic activities such as gold mining more than static activities such as seeing an exhibition [11] . young children need engaging activities including various ecological experiences such as picking fruit, playing with animals, and fishing [12] . in addition, children prefer dramatic play opportunities such as horse riding and superheroes, and functional play opportunities such as swinging and rocking [30] . cosco found that children enjoy riding on wheeled toys on hard, curvy pathways [31] , and babara found that most observed play focused on standing, walking, running, and riding [32] . in sum, children need facilities that are comfortable and safe, and dynamic activities that are fun and entertaining. due to the characteristics of young children as previously discussed, facilities and services at tourist destinations must also be designed for young children. for families with young children, tourist attractions should provide customized facilities and services for children to minimize problems and to maximize their satisfaction during the tour [12, 13] . when comfort and safety are secured, families with young children are willing to visit tourist destinations. parents consider a safe and clean environment as the most important factor for choosing destinations while accompanied by young children [3, 13] . asians, in particular, regard clean restrooms as more important than hispanic or african americans [33] . furthermore, the worldwide pandemic situation due to covid-19 has highlighted cleanliness as the most important aspect which could make relieve visitors of anxiety and instead attract them [34] . as handwashing is recognized as an essential activity in maintaining cleanliness, children's handwashing has increased compared to before the outbreak of covid-19 [35] . therefore, it is necessary to prepare facilities (toilets, sinks) that can meet the needs of maintaining cleanliness including hand washing. restrooms are also an important facility from the perspective of accessible tourism destinations. various guidelines for accessible tourism destinations include the criteria of accessibility to public restrooms [15, 29, 36] . the guidelines of kto state the importance of the installation of convenience facilities such as nursing rooms and diaper changing stations, and designing these with consideration of children's characteristics, such as lowering the height of sinks [36] . regarding the design of restrooms and other convenience facilities, gender parity also needs to be considered. the increase in male participation and co-parenting in early childhood education and care [37] , including diaper-changing duties, helps to improve parent-child bonds and family relationships [38] . in this context, male restrooms should also include childcare facilities. in addition, rest areas such as benches and restroom are important facilities for young children. in order to make children feel safe and comfortable, it is necessary to provide areas for rest and some adequate protection from stressful natural elements such as wind, rain, and sun [12, 39] . even in the view of accessible tourism, having enough accessible rest points such as benches is a basic element [15] . children's vehicles should be an additional consideration as well. various guidelines for accessible tourism destinations regard the secure accessibility of public transportation and accessibility to any tourist spots without difficulties [15, 29, 36] . for example, a necessary consideration is that young children will usually take strollers into tourist destinations. as nyman and others revealed that an accessible setting with a universal design could be the reinforcement factor for choosing tourism destinations especially for families with wheelchair-bound children [40] , accessibility could be an important factor for travel decision-making for families with young children who should be carried in strollers. in addition, numerous tourist destinations, such as the representative theme park disney world, provide stroller rental services for families with young children [41] . for providing convenience, stroller or other vehicle rental services should be considered when designing tourist destinations. providing rides could also add a fun factor to destinations. various studies have revealed that children love to ride vehicles with wheels, so providing them with vehicles such as baby bicycles, strollers, and minicars could be a specialized option for tourist destinations [30] [31] [32] . lastly, specialized programs could strengthen the attractiveness of the destination. as we noted in the previous section, children prefer experiential activities [11, 12, [30] [31] [32] . various tourist destinations provide specialized programs for young children. numerous museums (e.g., guggenheim museum in the united states [42] , remai modern in canada [43]) offer stroller tours for families with young children, and some public parks offer playground associate programs for young children (e.g., 'kids in motion' in new york city parks [44] , 'playground program' in appleton parks [45] ). these specialized programs may have a positive effect especially during a pandemic era. specialized programs could broaden the recreation opportunity spectrum (ros), which is a frequently used management tool for protecting areas [46] . since it could manage the demand of visitors, it may be used to affect the number of visitors during a particular period in a specific area [47] . in this aspect, specialized programs with limits on time and number of participants, could disperse tourists and lower the density of visitors. this is also a good management plan for reducing the risk of infection by reducing exposure density [48] . suwon hwaseong fortress was recognized for its historical meaning and architectural excellence and designated as a unesco cultural heritage site in 1997 [49] . it is the representative historical and cultural legacy of beautiful asian fortresses, not confined to the joseon dynasty in korea. with various attractiveness, as shown in figure 1 , hwaseong fortress is known as one of the child-friendly places. according to the latest tourist survey of suwon in 2017, the rate of visitors in their 30 s and 40 s at suwon hwaseong was 41.7%, much higher than for other age groups. additionally, the primary type of companions of visitors in their 30 s and 40 s was family members (74.7%), so this group is comprised mainly of families with young children [50] . suwon has a large population of young children under the age of 6 [51] , and the city is recognized as a city with a child-friendly environment, as it received a child-friendly city (cfc) recognition from unicef [52] . in particular, suwon city, in which hwaseong fortress is located, is where the "world restroom culture movement" began and is well known for its clean public restrooms [23] . suwon is the only city which has a toilet museum (haewoojae) in korea and the world toilet association is located in suwon as well. as shown in figure 2 , the city is leading the world restroom culture as the birthplace of restroom culture and plays a pivotal role in the development of restroom culture through the operation of a toilet museum. therefore, it is the ideal place to evaluate and find the best options for restrooms, the representative convenience facility for tourists, especially in the era of covid-19 in which hygiene management has become more important. in this study, ce analysis was used for investigating preferences for child-friendly tourism facilities and services. the ce is a stated preference-based methodology to estimate the marginal willingness to pay (mwtp) using a multidimensional approach [53] . since this method can estimate the mwtp for each attribute, such as tourism facilities and services, it has been used in various tourism studies to evaluate the preference of tourists [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] . therefore, ce was selected as the analysis method for understanding tourists' preferences for child-friendly tourism facilities and services and developing a tourism destination management strategy for young children. for the experiments, the attributes and levels of child-friendly tourism facilities and services were employed based on previous studies as presented in section 2 above. the specific attributes of young children's tourism at suwon hwaseong fortress consist of rest areas, restrooms and facilities designed for young children, children's vehicles, and specialized courses, as shown in table 1 . an entrance fee was used as payment for the vehicles. each attribute was divided into three levels. level 1 for each attribute indicated the current state of the attribute or nothing. levels 2 and 3 indicated alternative facilities and services which require more investment. after collecting the choices of respondents, the indirect utility function was estimated by a conditional logit model (cl) designed by mcfadden [53] . using a maximum likelihood estimator for each attribute, mwtp was calculated. as all variables except the price variable (entrance fee) were binary variables, mwtp values for level 2 and level 3 of each attribute indicate additional wtp compared to level 1. the choice set for the experiment was composed of level-specific combinations of attributes from table 1 . since there are too many choice profiles in the full factorial design (3 4 ã� 4 = 324) to evaluate, a fractional factorial orthogonal design was used [60, 61] . in this study, 16 profiles were used as the choice set for the experiment which were derived by an orthogonal design using spss 23.0. for each round, survey respondents could randomly select 3 of these 16 profiles, as shown in table 2 , and choose the most preferred alternative for them, or nothing. the experiment was conducted by all respondents over 5 rounds. the number of valid responses to the questionnaire was 374, and the total number of experiments was 1870. the target population of this study was tourists in suwon hwaseong who were accompanied by young children under the age of 6. in order to increase the objectivity of the survey and to enhance the readability of the questionnaire items, a pretest with 35 responses was conducted in april 2019. after the questionnaire was revised, the main survey was conducted as an in-person 1:1 survey in korean from april to may 2019 (peak season of outdoor recreation) by skilled interviewers. sampling was performed using random sampling. a total of 500 questionnaires were distributed, and for a more accurate evaluation of facilities and services, the first visitor was excluded, and the final 374 samples were included in the analysis. the questionnaire also included items regarding general characteristics of tourism with young children, tourism characteristics of young children in suwon hwaseong, and demographic characteristics of respondents. the time required for the survey was about 20 min. the sample of 374 respondents with children included more women (n = 286, 76.5%) and mothers (n = 221, 59.1%). the average age of participants was 38.78 years (sd = 6.59) with more visitors in their 30 s (n = 237, 63.4%) than those in their 40 s (n = 100, 26.7%). college attendance/graduation was the most common educational level (n = 266, 71.1%) and household income was more than 4000 usd a month (n = 199, 53.2%), which indicated a high proportion of highly educated and high-income visitors. the results of the cl model estimation of the responses of the selection experiments are shown in table 3 . first, the coefficient estimate of the price variable is negative and statistically significant at the 1% significance level. it indicates that rational decision-making-larger payment, lower choice probability-occurred in the experiment. the coefficient estimates for each attribute and level were significantly positive. it means that ceteris paribus, the probability of choosing alternatives (level 2 or 3) was higher against the current state (level 1). table 4 summarizes the mwtp calculation results based on the coefficient estimates of cl for each attribute and level. first, we confirmed the mwtp of an additional entrance fee of about 6000-9000 krw for each attribute and level in general. despite the relatively low mwtp for child-friendly restrooms and children's vehicles, it is still more than 5000 krw (=4.22 usd), which is still more than five times the current admission fee of 1000 krw (=0.84 usd). second, among the suggested attributes, the highest mwtp was seen for a specialized course that young children can actively enjoy (level 1 â�� 3). however, the difference in mwtp for each attribute was not statistically significant. third, in general, the mwtp of the third level was higher than that of the second level, so the more investment in facilities and services is made, the higher the preference. again, there was no statistically significant difference between levels. in the case of the rest areas, it was found that among the attributes belonging to the third level, indoor rest areas had less mwtp than in the second level. the present study seeks to establish a tourism destination management strategy centered on young children for accessible tourism from a public perspective. preferences for facilities and services for young children were identified using ces. the study site was hwaseong fortress, a unesco world heritage site, located in suwon city, a leader in the clean restroom culture. the main implications of the study are as follows. first, the wtp for child-friendly tourism facilities and services was high. according to existing research, the weak immune systems of young children leads to increased concerns about environmental hygiene and health. in addition, young children's physical constraints lead to high demand for convenient mobility and comfortable rest [3, 4] . the results show that the wtp for each attribute and level was about 5-9 usd. considering that the admission fee for hwaseong fortress is about 1 usd, the high preference for facilities and services for young children was confirmed, as seen in previous studies [3, 4, 11, 12] . a small fee is required for rides, but restrooms and rest areas are generally free. nevertheless, the generally high wtp reflects the desire for improved facilities and services for young children. second, an examination of attributes indicated that the wtp was found in the decreasing order of specialized courses for young children, rest areas, restrooms, and vehicles. respondents showed the highest wtp for level 3 of a specialized course for young children, which aims to develop a special zone or course that young children can actively enjoy. a key characteristic of young children's tourism is to emphasize primary needs such as hygiene and safety [4] . in particular, it is necessary to engage young children who have difficulty understanding the historical value of hwaseong fortress in simple play activities and games that utilize amusing characters and colors, in order to stimulate their interests. third, wtp was higher for outdoor rest areas than indoor rest areas. the outdoor-oriented hwaseong fortress has rest areas in the form of unroofed benches that may not be appropriate as resting areas for young children since they do not shield out the sunlight and rain. level 2 is an outdoor rest area that adds shades to existing outdoor benches, and level 3 is an indoor rest area equipped with air conditioning and air purifiers. the results indicate that level 2, the supplementation of existing outdoor rest areas, was most preferred. this preference implies that visitors to the outdoor tourist destination of hwaseong fortress prefer to relax in outdoor areas rather than stay indoors for long periods of time. fourth, with regards to restroom facilities, wtp was high for child-friendly restrooms including hot water, diaper changing stations, and child-friendly toilets and sinks. although suwon is a leader in restroom culture, these results point to insufficiencies in tourism facilities and services for young children. for example, more careful management of the height of sinks as mentioned in kto's guide is needed [36] . interestingly, the preference for installation of young children's facilities and services in both male and female restrooms was higher than for in female restrooms only. the recognition of only mothers as the main caregivers of young children, and the provision of child-friendly facilities and services in female restrooms only, imply the need for improvement in gender parity in young children's care facilities. fifth, whereas mwtp for level 2 (convenience) and 3 (convenience and fun) for children's vehicles was smaller than for other attributes, wtp was still five times that of the current admission fee. nyman and others also cited accessibility as an important factor for travel decision-making for tourists with young children [40] . the difference between level 2 and level 3 was very small, and the preference for providing fun in addition to convenience was not large. the various linked resources within the open spaces of hwaseong fortress create long travel distances. as accompanying young children have limitations in walking long distances, as compared to adults, there is a large preference for rides that enhance convenience. the provision of ride services is particularly important at a destination such as hwaseong fortress, which has long travel distances and limited accessibility for young children. in addition, the hygienic management of these vehicles utilized by young children will be important, particularly in the era of covid-19. the present study has significant practical implications in that the preferences for facilities and services for young children at tourist destinations was estimated using ces, and tourists' priorities were identified from a public perspective. previous studies on young children's tourism focused mainly on the importance of tourism for young children, and key factors in tourist destination choices. in contrast, the present study examined more specifically preferences for levels of facilities and services as a key factor in choosing a tourist destination. this is useful in terms of tourism destination management for young children. due to the covid-19 pandemic, the importance of health/hygiene management strategies is growing. based on the results, the following suggestions for a tourism destination management strategy for young children can be provided. first, child-friendly restrooms have become a necessity, not just a preference, in a covid-19 tourism environment in which cleanliness is most important [35] . in particular, convenience facilities for children should be installed in both men's and women's restrooms, not in women's restrooms only. in addition, not only installation but also continuous cleanliness management is required. second, it is necessary to install rest areas suitable for outdoor tourist attractions. the existing resting space for children was mainly a private indoor space for baby feeding and diaper changing. however, in outdoor spaces, since the distance that children can move around is short and they have to take frequent breaks, the preference for basic rest areas with more benches and awnings was rather high. therefore, maintenance of outdoor rest areas with improved convenience is required. third, the effort to minimize crowding during the covid-19 era is emerging as a top priority at tourist destinations. minimizing contact is particularly relevant for young children with weak immune systems. the present study showed the highest preference for specialized courses for young children. not only can this lead to more attractive tourist destinations for young children, but also be a zoning strategy that separates adult tourists from young child tourists as a response to covid-19. in addition, convenience vehicles such as strollers and wagons can also serve to provide a private space by separating young children from other adults. the present study focused on child-friendly tourism facilities and services including restrooms, children's vehicles, rest areas, and specialized courses. there are other important factors in the dimension of tourism destination management such as programs and information provision that need study. for example, preferences for various levels of information provision can be analyzed. it is possible to consider an information map or app for caregivers of young children. this can be used as a congestion guidance system to avoid congestion during the covid-19 era. other information 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perceived place value and the willingness to pay in an urban lake park economic valuation of recreational attributes using a choice experiment approach: an application to the galapagos islands travellers' willingness to pay and perceived value of time in ride-sharing: an experiment on china non-market valuation of forest goods and services: good practice guidelines constructing efficient stated choice experimental designs on approximating the statistical properties of elasticities this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors declare no conflict of interest. key: cord-347126-hvrly37e authors: stanton, robert; to, quyen g.; khalesi, saman; williams, susan l.; alley, stephanie j.; thwaite, tanya l.; fenning, andrew s.; vandelanotte, corneel title: depression, anxiety and stress during covid-19: associations with changes in physical activity, sleep, tobacco and alcohol use in australian adults date: 2020-06-07 journal: int j environ res public health doi: 10.3390/ijerph17114065 sha: doc_id: 347126 cord_uid: hvrly37e the novel coronavirus (covid-19) has enforced dramatic changes to daily living including economic and health impacts. evidence for the impact of these changes on our physical and mental health and health behaviors is limited. we examined the associations between psychological distress and changes in selected health behaviors since the onset of covid-19 in australia. an online survey was distributed in april 2020 and included measures of depression, anxiety, stress, physical activity, sleep, alcohol intake and cigarette smoking. the survey was completed by 1491 adults (mean age 50.5 ± 14.9 years, 67% female). negative change was reported for physical activity (48.9%), sleep (40.7%), alcohol (26.6%) and smoking (6.9%) since the onset of the covid-19 pandemic. significantly higher scores in one or more psychological distress states were found for females, and those not in a relationship, in the lowest income category, aged 18–45 years, or with a chronic illness. negative changes in physical activity, sleep, smoking and alcohol intake were associated with higher depression, anxiety and stress symptoms. health-promotion strategies directed at adopting or maintaining positive health-related behaviors should be utilized to address increases in psychological distress during the pandemic. ongoing evaluation of the impact of lifestyle changes associated with the pandemic is needed. first reported in november 2019, the novel coronavirus (covid-19) has resulted in a global health emergency. as of 3 june 2020, the virus has claimed more than 375,000 lives globally and infected more than 6.2 million people. the scale of the pandemic has resulted in worldwide concern, not only for the loss of life but also the social and economic impacts. there is significant concern over how the changes in the ways that people normally engage in everyday activities impact their health and well-being. this is especially relevant for those in self-isolation or quarantine, where feelings of depression, fear, guilt, and anger may manifest [1] . in australia, similar to other countries, social distancing, travel bans, the cancellation of sporting and other mass participation events, and changes to work practices have dramatically affected daily life. the partial lockdown procedures implemented by the australian government to protect citizens and reduce the spread of the virus forced the closure of many businesses in late march 2020 saw unemployment levels rise to 16 .8%, more than three times higher than the pre-covid-19 predicted unemployment rate [2] . the impact of these changes likely comes at significant personal cost, including the onset, or worsening, of mental health issues. to address the psychological distress experienced by australians in the current pandemic, more than aud74 million has been committed to the development and delivery of mental health and well-being support services in australia. multiple calls to ensure the preparedness of psychological services have been presented [3] [4] [5] ; however, the uptake and immediate and long-term impacts of these services are unclear. the covid-19 pandemic may also lead to adverse changes in health behaviors, such as physical activity, smoking, alcohol use and sleep. with the enactment of social isolation and physical distancing restrictions in march 2020, the usual places to be physically active, such as gyms and outdoor recreation facilities, were no longer accessible. although some people may have sufficient autonomous regulation of physical activity to pursue alternate activities (e.g., online fitness classes, other home-based physical activities), others may reduce their physical activity due to the lack of social support available or concerns for contracting the virus in an outdoor environment. on the other hand, those forced to work from home may have spent less time commuting, and may have seized the opportunity to create new physical activity habits. alternatively, since exercise was one of few legitimate reasons for being able to leave the home some people may have developed a walking or cycling habit as a reason to escape being housebound. as many studies have demonstrated strong positive associations between physical activity and lower psychological distress [6, 7] , the commencement or continuation of physical activity during the pandemic will likely aid in reducing psychological distress. however, some concern has been expressed regarding increased risk of respiratory illness in those engaged in high-and very-high intensity exercise due to the potential for reduced immune response [8] . in contrast to health-promoting behavior such as physical activity, some people may manage social isolation and any pandemic-related psychological distress by commencing or increasing adverse health behaviors such as smoking or alcohol use. since covid-19 is an acute respiratory illness, commencement or continuation of tobacco use during the covid-19 pandemic may lead to the worsening of outcomes for those infected with the virus [9] . indeed, early indications suggest the proportion of current and former smokers is higher among those with severe disease and among those admitted to intensive care and requiring ventilation [10, 11] . harmful intake of alcohol leads to neuroadaptations that exacerbate alcohol cravings during times of stress [12] . hence, social isolation, coupled with changes in employment status or uncertainty about the future may trigger an increase in alcohol intake for susceptible individuals [13] . the combined effect of changes in lifestyle behaviors; confinement to the home through government restrictions in travel; and elevated depression, anxiety and stress associated with the current covid-19 pandemic, may have significant negative impacts on sleep [14] . this has been especially evident in healthcare workers, who may be required to work longer shifts in highly stressful environments [15, 16] . poorer sleep quality has been associated with higher levels of depression, stress, and anxiety [17] . maintaining sleep quality is important in strengthening immunity [18] , hence any sleep disturbances subsequent to covid-19-pandemic-induced stress, may increase susceptibility to infection, or compromise recovery in the case of infection [19] . there is currently limited research regarding psychological distress subsequent to the covid-19 pandemic. two recent studies from china reported high levels of psychological distress during the initial stages of the pandemic [20, 21] ; however, the association between psychological distress and health behaviors remains unclear. early evidence during the covid-19 outbreak suggests positive associations between increased physical activity and physical health and inverse associations between sedentary behavior and physical and mental health outcomes [22] . a more detailed exploration of health behaviors during stages of the covid-19 pandemic may help direct future public health messaging to promote positive behaviors and guard against uptake or the worsening of negative behaviors in order to maintain community well-being and mental health. therefore, the present study aims to examine associations between depression, anxiety and stress and changes in health behaviors, including physical activity, sleep, smoking and alcohol use subsequent to the onset of covid-19 and the implementation of social isolation rules in australia. an anonymous online survey was hosted on the survey platform qualtrics and distributed using social media sources (facebook and twitter) and via institutional sources including email and public marketing. eligible participants included all australian adults aged 18 years and over. ethical approval was granted by central queensland university's human research ethics committee (approval number 22332). data collection occurred between 9 and 19 april 2020. at the time of survey distribution, australia was in the midst of significant personal distancing, partial lockdown and travel restrictions. social distancing measures included keeping a minimum 1.5 meters between people, a ban on any public gatherings, a limit of no more than five people at personal gatherings such as weddings and funerals, and no person was allowed to meet with more than one other person outside of their own household. lockdown restrictions also included the closure of restaurants and bars, many retail stores, and restricted access to outdoor parks. most schools were closed, with students advised to study from home while being supported by online learning platforms and materials. university campuses limited or ceased face-to-face teaching and transitioned to online learning, with most clinical placements, residential schools, and simulations postponed. inter-and intra-state travel was banned, and travel within towns and cities was only permitted for essential work/workers, or to access essential services such as medical or health care, or to shop for groceries. existing covid-19 surveys from china, the united kingdom and germany were reviewed to inform development of the present survey. in addition to demographic information, the survey included questions examining chronic health conditions; depression, anxiety and stress; and physical and health behaviors such as physical activity, sleep, smoking and alcohol consumption. the current paper only reports on measures included in the survey associated with the study aim. demographic characteristics included age, gender, marital status, educational attainment, income and chronic disease status. psychological distress was assessed using the well-established 21-item depression, anxiety and stress scale (dass 21) [23] . seven items for each component were scored on a 4-point likert scale ranging from 0 (did not apply to me at all) to 3 (applied to me very much, or most of the time). scores for depression, anxiety and stress items were summed with valid scores ranging from 0-21 for each component. symptom severity was scored according standard cut-points [23] . physical activity was assessed using the active australia survey (aas) which comprises eight items assessing frequency and duration of walking, moderate and vigorous leisure physical activities, and vigorous gardening over the past seven days. total physical activity was calculated according to the aas guidelines, where total minutes of physical activity = minutes of walking + minutes of moderate activity + (minutes of vigorous activity × 2) [24] . a single item asked participants to report their change in physical activity since the onset of covid-19, with six response options ranging from 1 (i am much more physically active than usual) to 6 (i have ceased physical activity altogether). sleep was assessed using two items. first, participants were asked how many hours, on average, they slept per night prior to the onset of the covid-19 pandemic (sleep quantity). second, participants indicated the effect of the covid-19 pandemic on current sleep quality using the question, "since the onset of the covid-19 pandemic, i...". five response options ranged from "am sleeping much better than usual" to "am sleeping much worse than usual". smoking behavior was assessed by asking whether respondents consumed cigarettes or other tobacco products prior to the onset of covid-19. change in smoking behavior was examined using a single item with ten response options ranging from "since the onset of the covid-19 pandemic, i... smoke much more than usual", to "have not smoked (i am a non-smoker)". current alcohol use was examined using the first item of the alcohol use disorder identification test consumption (audit-c) [25] , which asks how often alcohol is consumed. response options were "never", "monthly or less", "2-4 times a month", "2-3 times a week", and "4 or more times a week". changes in alcohol consumption was assessed using a single self-report question: "since the onset of the covid-19 pandemic i . . . ", with the following response options: "drink much more than usual", "drink a little more than usual", "drink about the same as usual", "drink less than usual", "drink much less than usual", "intend to reduce my drinking", "intend to cease drinking", or "have ceased drinking altogether". sas v9.4 (sas institute inc., lane cove, australia) was used for the analysis. the descriptive statistics, including frequencies and percentages, were generated for categorical variables; means and standard deviations (sd) were generated for continuous variables. depression, anxiety and stress scores were compared based on participant's sociodemographic and health status using non-parametric analysis of wilcoxon rank-sum, the kruskal-wallis test and spearman's correlation. the responses for each behavior, i.e., physical activity, sleep, smoking and alcohol use, were recoded into negative change (−1), no change (0), or positive change (+1) for separate analyses of changes in each behavior. a multiple lifestyle behavior index [26] was created by summing the scores of the four behavior change items to reflect a composite health behavior change score, ranged from -4 to +4. the average composite health behavior change scores and sd were presented separately for each level of depression, anxiety and stress. linear regression was used to test associations between composite health behavior change score and depression, anxiety and stress. crude estimates and estimates adjusted for age, years of education, gender, marital status, household income and chronic disease status were reported with 95% confidence intervals (ci). logistic regression was used to test whether negative changes in individual behavior change items were associated with depression, anxiety and stress. crude odds ratios (or) (model 1) and ors adjusted for age, years of education, gender, marital status, household income and chronic disease status (model 2) with 95% ci were reported. all p-values were two-sided and considered significant if less than 0.05. the sociodemographic and health characteristics of the study sample are presented in table 1 . in total, 1491 people (mean age 50.5 ± 14.9 years, 999 female) completed the survey. most (n = 918, 62.8%) were married or in a relationship, and almost half (n = 693, 46.5%) reported having at least one chronic health condition. the average score for depression was 4.6 ± 5.0; anxiety, 2.2 ± 3.4; and stress, 5.2 ± 4.8. the average physical activity of participants was 312.5 minutes/week, but almost half (n = 729, 48.9%) reported a reduction in physical activity since the onset of the covid-19 pandemic. the average sleep duration reported prior to the onset of covid-19 was 7.1 ± 1.3 h per night, with half (n = 756, 50.7%) reporting no change in sleep quality since covid-19. most (n = 1319, 88.5%) were non-smokers, and the majority (n = 1228, 89.7%) reported no change in smoking since the onset of covid-19. almost one-quarter (n = 332, 22.3%) reported consuming alcohol on four or more occasions per week, and just over half (n = 825, 55.3%) reported no change in alcohol consumption. the depression, anxiety and stress scores in relation to different sociodemographic and health characteristics are presented in table 2 . no significant differences were found between males and females for depression and anxiety; however, females had significantly higher stress scores compared to males. younger individuals (18-45 years) had significantly higher depression, anxiety and stress scores compared to their older counterparts. similarly, those who were not in a relationship had significantly higher depression, anxiety and stress scores compared to other categories of relationship status. the spearman's correlation showed a significant negative association between years of education (recorded as a continuous variable) and scores for depression, but not for the anxiety or stress scores. those in the lowest income category had significantly higher depression scores compared to higher income categories; however, no difference was observed between different weekly household incomes and anxiety and stress. respondents who had been diagnosed with a chronic illness reported significantly higher depression, anxiety and stress scores, compared to those without chronic illness. diagnosed with a chronic disease the mean changes in composite health behavior score, stratified by depression, anxiety and stress severity, are presented in table 3 . for depression, anxiety and stress, the number of people in each symptom severity category decreased as the symptom severity increased, except for the categories of extremely severe depression and anxiety. for depression, anxiety and stress, the mean composite health behavior change score decreased as the symptom severity increased, except for the categories of extremely severe anxiety and stress. associations between depression, anxiety and stress severity and negative change in behavior are outlined in table 4 . since adjustment for age, years of education, gender, marital status, household income and chronic disease status did not impact associations, only adjusted or's are presented. participants who reported a negative change in physical activity were more likely to have higher depression (adjusted or = 1.08, 95% ci = 1.06, 1.11), anxiety (adjusted or = 1.09, 95% ci = 1.05, 1.13), and stress (adjusted or = 1.08, 95% ci=1.05, 1.11) symptoms. those who reported a negative change in sleep were more likely to have higher depression (adjusted or = 1.19, 95% ci = 1.15, 1.23), anxiety (adjusted or = 1.25, 95% ci = 1.19, 1.31), and stress (adjusted or = 1.30, 95% ci = 1.26, 1.35) symptoms. for those who reported a negative change in smoking, they were more likely to have higher depression (adjusted or = 1.09, 95% ci = 1.04, 1.13), anxiety (adjusted or = 1.12, 95% ci = 1.06, 1.18), and stress (adjusted or = 1.10, 95% ci = 1.05, 1.15) symptoms. similarly, those who reported a negative change in alcohol intake were more likely to have higher depression (adjusted or = 1.07, 95% ci = 1.04, 1.10), anxiety (adjusted or = 1.08, 95% ci = 1.04, 1.12), and stress (adjusted or = 1.10, 95% ci = 1.07, 1.13) symptoms. the results were consistent for composite change scores. there was a decrease of 0.09 (95% ci = −0.10, −0.07), 0.10 (95% ci = −0.12, −0.07), and 0.10 (95% ci = −0.12, −0.08) points in composite change score for every point increase in depression, anxiety and stress. the present study examined the association between depression, anxiety and stress and the change in health behaviors of physical activity, sleep, smoking and alcohol use subsequent to the onset of covid-19, as individual health behaviors and as a health behavior change index composite score. the main findings were that all aspects of psychological distress (depression, anxiety and stress) were significantly associated with changes in health behavior, both independently and as a composite score. numerous studies have examined the association between a range of health behaviors and psychological distress factors. for example, rebar and colleagues reported significant inverse associations between physical activity participation and depression and anxiety levels in their meta-analysis [27] . previous work has reported significant positive associations between smoking, and depression [28] , but not between smoking cessation and reductions in depression or anxiety [29] . large-scale studies also demonstrate a significant association between alcohol misuse and psychological distress [30] . taken together, the findings of previous work suggest variability in the associations between lifestyle behaviors and depression, anxiety and stress that appear to depend on the nature of the behavior under investigation. the present study also demonstrated that, as the severity of depression increased, the composite health behavior change score worsened. that is, those with normal levels of depression symptoms reported a small negative change (−0.42 points), while for those with extremely severe symptoms, the change in composite health behavior change score was more than three times greater (−1.45). for anxiety and stress, as symptom severity increased from normal to severe, so did negative changes in composite health behavior change score. linear regression showed a significant association between increased depression, anxiety and stress, and negative changes in composite health behavior change scores. logistic regression showed that, compared to no change or positive change, a negative change in all behaviors was associated with a significantly greater likelihood of increased depression, anxiety and stress. a number of reports suggest covid-19 is likely to have significant impacts on psychological distress [21, 31] ; however, the data from the present study suggest that the mean scores for depression, anxiety and stress are mostly within the normal to mild range. moreover, the mean scores for depression and stress were only slightly elevated when compared to normative data for australian adults, and anxiety the scores were marginally lower [32] . viewed another way, more than 60% of all respondents reported psychological distress within the normal range, and less than 13% reported severe to extremely severe scores. the mean scores for depression, anxiety and stress in the present study are all substantially lower than those reported in italy. mazza and colleagues [33] reported mean depression, anxiety and stress scores of 5.34, 2.89, and 7.43, respectively, compared to 4.6, 2.2, and 5.2, respectively, in the present study. these differences may be accounted for in the timing of data collection as data from italy were collected in mid-march, differences in government responses to the pandemic, and differences in the severity of impact on the population. the prevalence of moderate to severe depression in the present study (19.1%) is comparable to that reported in china (16.8%) [21] ; however, the prevalence of moderate to severe anxiety is markedly less in this study (8.3%) compared to that in china (28.8%). in contrast, the prevalence of moderate to severe stress reported in this study (15.1%) is almost double that reported in china (8.1%). the timing of data collection may account for some of these differences since the data from china were collected from residents in 194 cities during late january-early february, one day after the world health organization declared a public health emergency. in contrast, the data for the present study were collected in early to mid-april when significant travel and social distancing restrictions were already in place. it is possible that the low prevalence of depression may also be a result of government investment in mental health support services. the lower anxiety scores in the present study may be attributed to respondents being somewhat accustomed to changes in social contact, whereas the higher stress levels may be attributed to the uncertainly about the future, particularly regarding job losses and economic stress. the total average physical activity was 322.5 ± 36.5 min/week. this is similar to recent australian bureau of statistics data based on the active australia survey, showing that australians aged 15 and over reported 42 min of daily activity, or 294 min per week on average [34] , but substantially less than the peak of 541 min of activity per week reported by alley and colleagues using the same measure [35] . physical activity guidelines for australian adults suggest they should accumulate 150-300 min of moderate intensity physical activity, 75-150 min of vigorous intensity physical activity, or an equivalent combination of both, per week. however, here we report total physical activity, not moderate or moderate-to-vigorous activity. the aas is known to overreport physical activity participation, but actigraphy is not practical in large samples [36] . therefore, our data may be an over-representation of actual physical activity performed. almost half of our respondents (48.9%) reported a negative change (reduction) in physical activity since the onset of the covid-19 pandemic, but about 20% also reported a positive change. this is important to note, since there has been considerable emphasis in the media on the importance of maintaining physical activity for physical and mental health benefits [37, 38] . our data suggests these recommendations may have been ineffective for most people, but not all. these data are hard to interpret as there has been a visible increase in people using walking paths all over the country, as well as a strong increase in registrations to the 10,000 steps australia program [39] . it may be that the extra people who are walking are predominantly those who were already active (e.g., gym and sports club members) prior to the covid-19 onset, but had to undertake different activities at different locations due to the closure of exercise and sporting facilities. the reported overall decline in physical activity is likely a consequence of social distancing, travel restrictions, the closure of usual exercise venues, or unwillingness to change previous exercise habits. nonetheless, given the psychological distress responses to covid-19, [40] and the established benefits of physical activity on psychological distress [41, 42] , additional strategies to promote physical activity are needed. prior to the covid-19 pandemic, mean sleep duration was 7.1 ± 1.3 h, which meets the guidelines of 7-9 h for adults [43] and aligns with a recent national study of australian adults [44] . although half (50.7%) of all respondents reported no change in sleep quality since the onset of the covid-19 pandemic, 40.7% reported a negative change. this is unsurprising given the potential for psychological distress during a global pandemic, change in exercise behaviors, and employment and relationship concerns. a number of recommendations have been made to address poor sleep during covid-19, including maintaining a regular sleep routine, taking time for self-reflection, limiting exposure to covid-19-related news, and getting regular exercise during daylight hours [14] . apart from these covid-19-specific recommendations, most principles mirror those recommended for good sleep hygiene in usual circumstances. only 11% of survey respondents were smokers. this is less than the 15% prevalence of smoking recently reported among australian adults [45] . overwhelmingly, respondents have not changed their smoking behavior, with almost 93% reporting no change or a positive change (reduction) in smoking status since the onset of the covid-19 pandemic. among smokers, 16.3% (n = 28) report a positive change (reduction), 38.4% (n = 59) report no change, while 49.9% (n = 85) report a negative change (increase) in smoking behavior. since covid-19 is a respiratory illness, and smokers are more susceptible to respiratory tract infections, there is significant potential for adverse events in this population. early evidence from china suggests either a significant association, [46] or at least a trend [47] toward smoking being associated with poor prognosis in covid-19 cases. to date, there has been limited attention in the media to smoking cessation programs or adverse risk associated with smoking. although more research is needed, health promotion efforts directed at educating the population regarding the risks for smokers during the covid-19 pandemic are needed. these may include higher exposure to passive smoking during periods of lockdown or relapse-preventions strategies targeting those who have recently ceased smoking. almost three quarters of respondents reported no change or a positive change (reduction) in alcohol use since the onset of covid-19. a reduction in alcohol use might be driven by closures to licensed establishments such as bars and clubs and temporary restrictions on alcohol purchases. in contrast, around one quarter of respondents reported a negative change (increase) in alcohol consumption. this is consistent with research by australia's foundation for alcohol research and education [48] reporting that 20% of australians increased alcohol purchases since the onset of covid-19 and 70% were drinking more than usual. worryingly, this report suggests that almost 30% of adults are drinking more to cope with psychological distress [48] . concerns such as these have prompted the australian government to invest more than aud6 million into drug-and alcohol-related services to combat the risk of substance abuse and related harms, such as domestic violence, due to the pandemic. to the best of our knowledge, this is the first published study to report associations between health behaviors and psychological distress in australian adults during the covid-19 pandemic. one published study from europe reported that reductions in physical activity and increased sedentary behaviors during lockdown were associated with negative changes in physical and mental health [22] . moreover, a number of reports have highlighted the need for rapid and comprehensive responses to increasing mental health needs during covid-19 [3, 5] ; however, it is expected this support will need to be maintained for some years to come given the magnitude of the covid-19 pandemic. there are a number of strengths of the present study, including the inclusion of multiple health behaviors, a large sample size, and the timing of data collection relative to lockdown restrictions in australia. however, there are also some limitations to consider. firstly, all data are self-reported meaning responses are subject to recall bias. secondly, data are cross-sectional and therefore causality cannot be inferred. thirdly, participants in the present study are older compared to other studies examining health behaviors such as sleep [49] , and thus the generalizability to other populations needs to be confirmed. additionally, longitudinal data are needed to observe changes over time to assess the impact of changes in social restrictions. finally, our sample was recruited conveniently and therefore the results may not be generalizable to populations with different characteristics. in conclusion, our data suggests negative changes in health behaviors are associated with increased psychological distress in australian adults during the covid-19 pandemic. effective health promotion strategies directed at adopting or maintain positive health-related behaviors such as targeted social media messaging and balanced media reporting, should be used to reduce the acute and chronic increases in psychological distress during these unprecedented times. ongoing evaluation of the impact of lockdown rules and social distancing (associated with the pandemic) on health behaviors is necessary to inform these targeted health promotion strategies. the psychological impact of quarantine and how 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literature the role of exercise in preventing and treating depression physical activity protects from incident anxiety: a meta-analysis of prospective cohort studies sleep needs across the lifespan; sleep health foundation report to the sleep health foundation: 2016 sleep health survey of australian adults; the adelaide institute for sleep health australian institute of health and welfare alcohol, tobacco & other drugs in australia covid-19 and smoking: a systematic review of the evidence active smoking is not associated with severity of coronavirus disease 2019 (covid-19) foundation for alcohol research and education. alcohol sales and use during covid-19; foundation for the enemy who sealed the world: effects quarantine due to the covid-19 on sleep quality, anxiety, and psychological distress in the italian population this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the research received no external funding. the authors declare no conflict of interest. key: cord-355471-vt7qovf7 authors: ogojiaku, chinonso n.; allen, jc; anson-dwamena, rexford; barnett, kierra s.; adetona, olorunfemi; im, wansoo; hood, darryl b. title: the health opportunity index: understanding the input to disparate health outcomes in vulnerable and high-risk census tracts date: 2020-08-10 journal: int j environ res public health doi: 10.3390/ijerph17165767 sha: doc_id: 355471 cord_uid: vt7qovf7 the health opportunity index (hoi) is a multivariate tool that can be more efficiently used to identify and understand the interplay of complex social determinants of health (sdh) at the census tract level that influences the ability to achieve optimal health. the derivation of the hoi utilizes the data-reduction technique of principal component analysis to determine the impact of sdh on optimal health at lower census geographies. in the midst of persistent health disparities and the present covid-19 pandemic, we demonstrate the potential utility of using 13-input variables to derive a composite metric of health (hoi) score as a means to assist in the identification of the most vulnerable communities during the current pandemic. using gis mapping technology, health opportunity indices were layered by counties in ohio to highlight differences by census tract. collectively we demonstrate that our hoi framework, principal component analysis and convergence analysis methodology coalesce to provide results supporting the utility of this framework in the three largest counties in ohio: franklin (columbus), cuyahoga (cleveland), and hamilton (cincinnati). the results in this study identified census tracts that were also synonymous with communities that were at risk for disparate covid-19 related health outcomes. in this regard, convergence analyses facilitated identification of census tracts where different disparate health outcomes co-exist at the worst levels. our results suggest that effective use of the hoi composite score and subcomponent scores to identify specific sdh can guide mitigation/intervention practices, thus creating the potential for better targeting of mitigation and intervention strategies for vulnerable communities, such as during the current pandemic. 2 of 17 health, functioning, and quality-of-life outcomes and risks [1] . a shift in focus in the field of public health has caused additional attention to be paid to sdh. understanding the impact these determinants have on a community's health is a vital part of achieving health equity [2] . researchers estimate that approximately 40% of health can be attributed to social and economic factors and 10% are due to factors related to the physical environment [3] . these sdh vary both between and within communities based on variety of demographic characteristics. examples of sdh include access to healthcare services, neighborhood crime and violence levels, and food security and availability. due to the current coronavirus disease 2019 (covid-19) pandemic, the united states is currently experiencing a higher number in cases and deaths than what we are seeing globally [4] . the asymptomatic nature of the disease combined with pattern of transmission of covid-19, emphasizes the importance of community health. within the u.s., there are existing disparities of underlying health conditions that influences the way the pandemic is impacting marginalized groups and communities. the disparities in covid-19 related health outcomes can be linked to a number of factors. african american communities and other communities of color in new york for example, are experiencing higher rates of infection and death during the covid-19 pandemic than their white counterparts within the city [5] . various factors within these communities render them to being more vulnerable to disease. for example, residents are struggling to access healthcare resources in their neighborhoods, while multigenerational homes put older residents' home at risk. in addition, communities that have higher perveances of heart disease, diabetes, and other chronic diseases are seeing worse outcomes. furthermore, the composition of the essential worker population is predominantly black and brown, who do not have the luxury of staying at home. this results in these workers returning to their segregated community with the higher potential of spreading infectious diseases. public health practitioners, health systems, and community-based organizations often do not have tools to understand the complex interaction of social determinants linked to poor health outcomes. given that disparate health outcomes from chronic conditions or pandemics such as covid-19 are influenced by sdh and underlying health conditions, the ability to target these high-risk communities and provide interventions with a high degree of precision is critical to slowing the spread of the pandemic. health opportunity index (hoi) is a tool to understand the effect of sdh on health outcomes. tools such as the hoi can demonstrate how the sdh can shape a community's overall opportunity for optimal health. using tools for geospatial analysis with data from the hoi is an effective method of identifying health disparities as well as the sdh, which drive these disparities out of control [6] . a thematic map can overlay sdh over a community of interest, highlighting rates of a determinant or adverse health outcome in the area. while such an approach is functional-a more robust, informative method needs to be explored in order to develop a deeper understanding of a community's health. the hoi is a tool used to better identify the determinants in a community that drive poor health outcomes. the utilization of the hoi can assist in identifying communities with the lowest health outcomes and reduce health disparities. the hoi was developed by rexford anson-dwamena, an epidemiologist and gis/spatial analyst at virginia's public health department. the tool was later adopted by johnnie (chip) allen, director of health equity at the ohio department of health (odh). allen found that the hoi could become a useful asset in the state's effort to reduce health disparities and actively pursue true health equity. health equality calls for providing the same health interventions to all individuals, regardless of the level of health disparity they face. health equity, on the other hand, is achieved when every individual has the same opportunity to achieve their full health potential. achieving health equity requires the identification of communities that might need a variety of interventions to overcome social, economic, and structural barriers to reach their peak level of health. sdhs are multifaceted, complex and often operate at varying levels of severity from one neighborhood to the next. the dynamic nature of sdh makes it difficult to address them in a comprehensive manner. moreover, tools required for understanding the dynamic nature of sdh are needed now more than ever. one of odh's primary equity goals is to develop wide-spread capacity to identify and understand how specific sdhs operate at the local/neighborhood level. this understanding can empower local communities to comprehensively address these issues using targeted interventions with the help of broad-based coalitions. the hoi utilizes principal component analysis in order to create an individual score for each census tract. principal component analysis (pca) is a statistical procedure used in exploratory data analysis. pca is useful for data reduction and simplification, modeling, outlier detection, variable selection, classification, predictions, and unmixing. for the hoi, pca's data reduction functionality is critical. for example, literacy and educational determinants are both sdh and are strongly correlated. food accessibility and hunger behave similarly. for this reason, it can be useful to adopt clustering methodology approaches in an attempt to identify sdh within census tract profiles. common profiles include economic stability, education, health and built environment. while the hoi is a relatively new tool to the public health field, it shares similarities with another tool. the child opportunity index (coi) is a tool that measures the resources and conditions of a neighborhood that are critical to the development of a child [7] . its purpose is similar to the hoi, in that the tool aims to compare opportunity levels of different neighborhoods around the country under one metric. therefore, the goals of the present analyses are to; (1) educate environmental public health professionals and communities about the conditions children are exposed to in their neighborhoods, (2) inform the relevant policy makers who control the distribution of resources, and (3) improve equity and health outcomes in vulnerable populations. the index uses 29 indicators to measure neighborhood health for residents. some of these indicators include school poverty, access to healthy food, access to green space, home ownership rate as well as other related indicators. each indicator has an individual weight which correlates to the indicators ability to impact health. the indicators are all measured on different scales. for example, high school graduation rate and employment rate are expressed using percentages versus the hazardous waste site index, which is measured using a count. in order to combine these values, the raw data is standardized using z-score transformation. these indicators are then combined into one of three domains: education, health and environment, and social and economic. the scores are then weighted based on their health and economic impact and combined to a single score, scaled between 0 and 100. the coi contains information on over 72,000 census tracts that can be compared with other metro areas and across time periods. the coi 1.0 was released in 2014 and version 2.0 was released in january 2020. disparate health outcomes do not exist in a vacuum. moreover, it is important but difficult to understand how disparate health outcomes simultaneously exist at their worst levels and the social determinants which impact these disparities. to help understand how these issues are connected, j. chip allen also developed the convergence analysis (ca) to help contextualize the hoi. the ca is a technique that uses geographically referenced health data with gis mapping tools to visualize where various disparate health outcomes simultaneously exist at their worst levels. any dataset that is geographically referenced can be used with the ca. this paper reflects the ca which uses selected data sets from the cdc 2017 behavior risk factor surveillance survey (brfss) 500 cities project, 2013-2017, ohio department of health vital statistics data on prematurity and as well as 2017 data on lead exposure from the ohio department of health at the census tract level. specific datasets for the 2017 brfss 500 cities project data included crude prevalence rates of asthma, coronary heart disease, diabetes, high blood pressure, stroke, and poor mental health. the health opportunity index (hoi) is the primary outcome variable in this study and is comprised of 13 indices: affordability, income inequality, townsend deprivation, job participation, employment access, education, population churning, population-weighted density, segregation, food accessibility, walkability, access to care, and environmental quality index. these 13 indices are separated into profiles based on how they co-exist in the state of ohio. indices will fall into the environmental, consumer, mobility, or economic profile. hoi scores are calculated for each census tracts in order to highlight specific community needs. scores of census tracts were converted into shapefiles, then uploaded to arcgis to be displayed over a thematic map. hoi scores ranged from 0 to 1. the closer to zero the score is, the lower the probability residents in the census tract have the opportunity to achieve optimal health. a score closer to 1 signifies greater opportunity to achieve good health. the following section describes the methodology used to create the 13-index scores that make up the hoi within each of the four profiles. the environmental profile consists of six indices, which include affordability, health care access, walkability, employment, population density, and environmental quality. each index is described below. the affordability index measures the proportion of a neighborhood's income that is spent on housing and transportation. the equation used to derive the affordability index is as follows: the us census bureau has its own metric that it uses to measure poverty. however, this metric carries its own flaws as it assumes that the cost-of-living is uniform across the united states. this assumption is known to be false. to better account for this, the affordability index of the hoi identifies the most significant expenses a family incurs and weights the impact of that cost on disposable income [8] . the two major expenses factored into affordability are housing and transportation. the proportion of income spent on these two combined factors help account for the cost-of living variability and provide a better sense of affordability. the health care access index measures an area's access to healthcare. the is accomplished using a two-step process to assess physician availability [9] . first, within a predetermined travel radius from a healthcare provider, the total population that the supplier could reach is established. this is then converted to a provider-to population ratio, with the total number of providers in a healthcare setting being accounted for. next, once the area of interest (census tract) is established, the same predetermined travel radius is applied. every healthcare setting in the radius is captured and the provider-to-population ratios are summed to give part of the access to care index. the additional portion of the index comes from the percentage of uninsured population. the percentages come from the american community survey, which records uninsured levels at the census tract level. the walkability index is an epa tool used to differentiate census groups based on their walkability. the walkability of an area is based on the built environment that promotes or discourages walking as a mode of transportation. factors such as street connectivity, crime, and facilities for walking are examples of factors that can contribute to the walkability of an area [10] . the walkability index is derived from a four-variable formula from the international physical activity and the environment network (ipen). the equation is as follows: wai = (2 × con) + ent + far + hdens. ( the four variables represent what is known as the 4d's. design (2 × con), diversity (ent), distance (far), and density (hdens) make up the new walkability index. design refers to the design of the built environment and safety features of an area. a large number of street crossings that support safe pedestrian travel in a census block will increase this variable. diversity refers to the diversity of land use in the census block. it measures the variety of activities that are within a walkable distance. distance measures the distance to transit or how accessible it is for pedestrians to reach a transit stop. density refers to residential and employment density. these variables measure the density of activities within a walkable distance. the employment access index measures the accessibility of jobs in a particular area. poor job access can include barriers such as distance from residents and transportation availability. communities that experience poor employment access tend to have more employment instability [11] , which in turn leads to more socioeconomic disadvantages. the employment access index score is determined by utilizing a gravity model. the equation for the index is as follows: a i = job accessibility at location i, j j = the number jobs in location i, d = the travel time between them, β = the friction coefficient, n = the total number of job locations, v j = job location's proximity to all workers. this index is calculated by summing the total number of jobs in an area and dividing by the square of the distance to those jobs. this allows for further examination of the presence and proximity of jobs in an area. the gravity model makes it possible to observe what job opportunities are available in or around block group or census tract, which provides a better picture of job access. the population-weighted density index is critical to better understand the spatial differences between rural and urban populations [12] . the index captures the density at which the average individual lives. the index is calculated by dividing the total population-weighted by the square miles in the area. the higher the index score, the higher the concentration of people per square mile. the environmental quality index is calculated using the epa's national air toxics assessments (nata) environmental data. this assesses the level of air pollution by census tract. the nata has six indicators: neurological risk, cancer risk, respiration risk, on-road pollution, non-road pollution, and non-point pollution. the six indicators are combined into one indicator using principal component analysis. principal component analysis converts the individual variables into latent variables which are then standardized into hazard quotients. higher hazard quotients result in a higher possibility that the exposure to environmental conditions will result in a negative health outcome. the consumer profile consists of three indices which include education, food access, and material deprivation. these indices are described below. the education index measures the average education level achieved by the adult population in an area [13] . this is based on the average years of schooling in an area. higher educational attainment has been shown to have positive impacts on economic earning and positive health outcomes. the equation for this index is as follows: ays = average years of schooling, µ = average years of schooling for the concerned population, p i = proportion of population with certain level of schooling, y i = years of schooling at different education attainment levels. this index however does not take into account the quality of the education received, only average level of attainment. the food accessibility index measures low access to grocery stores, supermarket, and other suppliers of healthy foods. proximity to healthy food options plays a critical role in maintaining a well-balanced and healthy diet [14] . the index score is based on the proportion of the census tract population that fits into one of three usda criteria. the criteria on whether a significant portion of the population (500 individuals) or 33% of a low-income census tract live within a certain proximity to a grocery store or supermarket. the proximity to grocery store or supermarket depends on the population density of the census tract. residents who live further than 0.5 or 1 mile away from a grocery store or supermarket in an urban area are considered to have low food access. residents who live further than 10 or 20 miles away from a grocery store or supermarket in a rural area are considered to have low food access. the townsend deprivation index is used to measure material deprivation. material deprivation, according to sociologist peter townsend, encompasses the lack of goods, services, amenities, resources and physical environment that are typically found and approved by society [15] . the index is made up of four variables: unemployment, car ownership, home ownership, and overcrowding. the unemployment variable is derived by determining the percentage of active residents in a community between the ages of 16 to 64 who are unemployed. the car ownership variable is based on the percentage of private households who do not possess a car. home ownership is based off the percentage of private homes not currently occupied by the homeowner. the overcrowding variable is the percentage of private households with more than one person per room. each of these variables are equally weighed and combined together to determine the townsend deprivation index. in order to combine the variables, first the unemployment variable and the overcrowding variable must be log transformed. next, the z-score is calculated for each of the four variables and the scores are summed up for the composite score for the index. the higher the score, the more a particular area lacks access to the resources. the third profile in the hoi is the economic profile, which consists of three indices: job participation, segregation, and income inequality, which are described below: the job participation index is a measure of the percentage of working aged individuals (16-64 years of age) in the active labor force. the equation for the variable is as follows unlike the unemployment variable of the townsend deprivation index, the job participation index is supposed to identify the employment rate of the active working class of an area. this index is considered very sensitive to the attributes of the local community. attributes such as educational attainment, household composition, and car ownership can all influence an area's employment rates. this index is a strong indicator of economic growth and income, which are strong factors in individual and community health status [16] . the higher the index, the healthier the labor market. the segregation index, or the spatial dissimilarity index, measures how the racial composition of a population in a census tract compares to that of the rest of the state [17] . the mapping software tool arcgis (mapplerx, nashville, tn, usa) has a toolbox to assist in the calculation of this index. the equation to calculate spatial dissimilarity is noted below. the income inequality index within the hoi is measured using the gini coefficient. the gini coefficient (index) is a statistical measure typically used to measure economic inequality [18] . 7 of 17 the coefficient accomplishes this by measuring the diversity of actual earned income of a neighborhood. the equation is as follows: µ = the mean of the variable (income), n = total number of observations, y i and y j = dollar values of income of individuals. absolute neighborhood equality, or homogeneity, would result in a gini coefficient of 0. complete diversity in income for a neighborhood would result in a gini coefficient of 1. income inequality is a critical variable to account for due to its correlation with health outcomes. as the wage gap in the united states continues to increase, the disparities in health outcomes and life expectancy between high-income and low-income americans continue to increase [19] . the final profile in the hoi is the population mobility profile, which includes the population churning index and is described below. the churning index is used to capture the total migration of individuals into a community. population churning can bring both positive and negative aspects to a community. the in migration can bring an influx of social capital and opportunities. new community member can bring new business and employment opportunities. on the other hand, out migration can lead to the disruption of services that are critical to health and wellness [20] . the equation for the population churning index is as follows: population churning rate = in migration + out migration total population . population churning accounts for population movement in a manner that is different from net migration. rather than simply indicating the balance of movement as net migration does, population churning gives a standardized measure of the amount of movement in relation to the population at large. for the hoi, census mobility data was used to show 5-year mobility patterns. to provide assurance that the hoi was truly sensitive to major shifts in health status throughout the state, we used the most general definitions of good health, i.e., "life expectancy at birth" (le) and "years of potential life lost" (ypll) data to determine if the hoi demonstrated systematic public health differences between areas. figure 1 , above present's life expectancies at birth by hoi quintiles. the indicators (le and ypll) were chosen as the health outcomes of interest because they; (1) provide a global indication of health across a population and across the life span; and (2) summarize health in a manner that is easily understood by all-how long a life can i expect to live? our indicators also aligned with the notion that social determinants of health (sdh) are fundamental causes of disease. therefore, access or lack of access to sdh would be expected to influence the entire range of health outcomes, and not just those associated with the same behavior (for example, physical activity being associated with obesity and diabetes but not hiv). hoi was constructed to simplify a very complex social landscape important to the health of a community by specifying some very simple process-oriented indicators and determine how they interact within a local spatial context. of course, no traditional public health concern (e.g., infant mortality, asthma, or cardiovascular, stroke or hiv) is incorporated in the composite index. these are what we want to view in terms of the index. upon maximal refinement of the hoi, we can then explore how these health-based indicators relate to the broader community conditions. provide a global indication of health across a population and across the life span; and (2) summarize health in a manner that is easily understood by all-how long a life can i expect to live? our indicators also aligned with the notion that social determinants of health (sdh) are fundamental causes of disease. therefore, access or lack of access to sdh would be expected to influence the entire range of health outcomes, and not just those associated with the same behavior (for example, physical activity being associated with obesity and diabetes but not hiv). the state of virginia is our reference point for the maturation of the hoi and in virginia, the aforementioned independent variables were analyzed to determine which of these variables were associated with birth outcomes. as can be seen in figure 2 below, on a statewide level, infant mortality per 1000 live births increases with hoi quintile to demonstrate that hoi variables were in fact, associated with low birth weight infants and infant mortality. we can conclude that residents of very low hoi quintiles are more likely to experience infant deaths by a striking 48.9% as compared to residents of very high hoi quintiles. this striking disparity and trajectory by hoi quintile are also true for diabetes hospitalization. areas" on average is expected to live over four more years compared to the persons in "very low opportunity areas". hoi was constructed to simplify a very complex social landscape important to the health of a community by specifying some very simple process-oriented indicators and determine how they interact within a local spatial context. of course, no traditional public health concern (e.g., infant mortality, asthma, or cardiovascular, stroke or hiv) is incorporated in the composite index. these are what we want to view in terms of the index. upon maximal refinement of the hoi, we can then explore how these health-based indicators relate to the broader community conditions. the state of virginia is our reference point for the maturation of the hoi and in virginia, the aforementioned independent variables were analyzed to determine which of these variables were associated with birth outcomes. as can be seen in figure 2 below, on a statewide level, infant mortality per 1000 live births increases with hoi quintile to demonstrate that hoi variables were in fact, associated with low birth weight infants and infant mortality. we can conclude that residents of very low hoi quintiles are more likely to experience infant deaths by a striking 48.9% as compared to residents of very high hoi quintiles. this striking disparity and trajectory by hoi quintile are also true for diabetes hospitalization. post processing of data via principal component analysis (pca): as described above, the 13indicators for the hoi were carefully chosen as core variables to provide a broad aerial view of an "opportunity structure" that can be easily and intuitively recognized by most community residents. these indicators therefore circumscribe what residents in a particular area have to navigate to accomplish their normal daily life tasks. we chose to apply principal component analysis (pca) to reduce the noise and the dimension of the data structure, as recently discussed by kahlia et al., (2020) [21] . the 13-place based indicators were normalized (z scores), combined, and weighted using pca to discern local patterns in the data at the census tract level. the use of pca is greatest in scenarios where there are a large number of variables being considered in answering a question. in these post processing of data via principal component analysis (pca): as described above, the 13-indicators for the hoi were carefully chosen as core variables to provide a broad aerial view of an "opportunity structure" that can be easily and intuitively recognized by most community residents. these indicators therefore circumscribe what residents in a particular area have to navigate to accomplish their normal daily life tasks. we chose to apply principal component analysis (pca) to reduce the noise and the dimension of the data structure, as recently discussed by kahlia et al., (2020) [21] . the 13-place based indicators were normalized (z scores), combined, and weighted using pca to discern local patterns in the data at the census tract level. the use of pca is greatest in scenarios where there are a large number of variables being considered in answering a question. in these situations, it is difficult to partition and understand how each variable is interacting [22] . engaging in dimensional reduction reduces the amount of interactions between variables and pca achieves this through feature extraction by combining variables in specific ways. the methodology prioritizes critical parts of the variables while leaving out the less important aspects of the variables. therefore, pca was used in the present study to find the appropriate latent variables that might measure the landscape of an area. to maximize all indicators, the 13-indices were standardized into z-score and rotated using varimax with kaiser normalization method to retain four components based on an eigenvalue cut-off of 1 or more. this process means that, if the eigenvalue is greater than 1, it indicates that that component explains more variance than a single variable because the sum of the eigenvalues equals the number of variables in the model. each component was weighted using the proportion of their variance explained in the model as a percent of the cumulative variance and summed (weighted sum) to compute the composite index for each census tract. the hoi analysis results are presented in table 2 (below) using a census tract in cuyahoga county as an example. the analysis includes a number of data points which can be assessed. the primary data point is the hoi composite score. step 1: hoi composite score and profile scores range from 0 to 1. the closer the score is to zero, the lower the chances for residents in the census tract to experience opportunity for good health. conversely, the closer the score is to 1, the greater the chances that residents will experience high opportunities for good health. the public health professional can gauge health opportunity by looking at the quintile. quintile 1 reflects low health opportunity. quintile 5 reflects high health opportunity. life expectancy can also help gauge health opportunity. step 2: once overall health opportunity is determined; the public health professional can search for the social determinants that drive health opportunity. this requires an analysis of each of the profile scores (environmental, consumer, economic, and population mobility) to discern the profile with the lowest score. step 3: based on the profile with the lowest score, (in this case, consumer profile) the public health professional would select the social determinant(s) for that profile with the lowest score (in this case, food access). step 4: a public health professional might use other available data for the convergence analysis (see methodology section). the convergence analysis reveals that there are six (6) health outcomes that are simultaneously at the worst levels in this census tract. step 5: interpret/summarize findings (2016 data): census tract 39035118602 has overall low health opportunity for the residents to achieve good health. these sub-optimal outcomes include poor mental health, diabetes, stroke, coronary heart disease, asthma, and high blood pressure. the 2017 500 cities data also reflects that chronic obstructive pulmonary disease and kidney disease are at their worst levels. a deeper examination of the hoi data reveals that the social determinants of the consumer profile drive the observed poor health opportunity. a closer examination of the consumer profile reveals that food access is a major factor contributing factor to poor health opportunity in this census tract. as a result, the public health professional might recommend that interventions to improve overall health opportunity and disparate health conditions must take into account food access. as mentioned above, the composite index score serves to provide an overall indication for the health of a particular community. the relative profiles of a particular tract can then be examined to explain what variables are making the greatest contribution to a low (or high) composite score. by analyzing the various profile scores, the low numbers are indicative of the primary drivers of poor health opportunity in the community. by extrapolating further, the specific index within the profile can be identified as the primary driver of poor health opportunity in the community. the hoi analysis report in table 2 provides an example of the composite score for a census tract in cuyahoga county. the 0.041 score is reflective of a low health opportunity for the census tract. this is reinforced by the score's inclusion in the first quintile. by examining the four profiles, the consumer profile is shown to be the primary driver of low health opportunity with a score of 0.095. further, food access appears to be the index that is driving the consumer profile. table 2 . health opportunity index score card. see text for details. the score card displays the composite, profile and index score from the hoi the scores range from 0 to 1. the closer the number is to 0, the more responsible the score is for driving low health opportunity. the thematic mapping of hoi composite scores provides a visual breakdown of health opportunity disparities across census tracts in an area. figure 3 depicts an arcgis map with a shapefile containing composite scores from the cuyahoga county area. using the thematic map feature from arcgis, differing census tract composite scores can be highlighted by quintile. the closer the census tract is to yellow, the lower the health opportunity. census tracts highlighted in red provide higher health opportunity. the concentration of yellow census tracts aligns with the metropolitan area of downtown cleveland, ohio. figure 4 depicts the same hoi composite score but in the franklin county area. the concentration of the yellow census tracts aligns with the metropolitan area of downtown columbus, ohio. the thematic mapping of hoi composite scores provides a visual breakdown of health opportunity disparities across census tracts in an area. figure 3 depicts an arcgis map with a shapefile containing composite scores from the cuyahoga county area. using the thematic map feature from arcgis, differing census tract composite scores can be highlighted by quintile. the closer the census tract is to yellow, the lower the health opportunity. census tracts highlighted in red provide higher health opportunity. the concentration of yellow census tracts aligns with the metropolitan area of downtown cleveland, ohio. figure 4 depicts the same hoi composite score but in the franklin county area. the concentration of the yellow census tracts aligns with the metropolitan area of downtown columbus, ohio. to determine the validity of the health opportunity index's ability to predict high or low health opportunity, a disease convergence layer was added to the map. a disease convergent area is a census tract where multiple negative health outcomes simultaneously occur at their worst levels. using the 500 cities online database, crude prevalence rates for health outcomes such as coronary heart disease, copd, asthma, chronic kidney disease, and diabetes were analyzed at the census tract level. figure 5 shows a hoi composite score map for the hamilton county area. similar to the map from figure 3 the thematic mapping of hoi composite scores provides a visual breakdown of health opportunity disparities across census tracts in an area. figure 3 depicts an arcgis map with a shapefile containing composite scores from the cuyahoga county area. using the thematic map feature from arcgis, differing census tract composite scores can be highlighted by quintile. the closer the census tract is to yellow, the lower the health opportunity. census tracts highlighted in red provide higher health opportunity. the concentration of yellow census tracts aligns with the metropolitan area of downtown cleveland, ohio. figure 4 depicts the same hoi composite score but in the franklin county area. the concentration of the yellow census tracts aligns with the metropolitan area of downtown columbus, ohio. to determine the validity of the health opportunity index's ability to predict high or low health opportunity, a disease convergence layer was added to the map. a disease convergent area is a census tract where multiple negative health outcomes simultaneously occur at their worst levels. using the 500 cities online database, crude prevalence rates for health outcomes such as coronary heart disease, copd, asthma, chronic kidney disease, and diabetes were analyzed at the census tract level. figure 5 shows a hoi composite score map for the hamilton county area. similar to the map from figure 3 to determine the validity of the health opportunity index's ability to predict high or low health opportunity, a disease convergence layer was added to the map. a disease convergent area is a census tract where multiple negative health outcomes simultaneously occur at their worst levels. using the 500 cities online database, crude prevalence rates for health outcomes such as coronary heart disease, copd, asthma, chronic kidney disease, and diabetes were analyzed at the census tract level. figure 5 shows a hoi composite score map for the hamilton county area. similar to the map from figure 3 in cuyahoga county, the census tracts with the lowest opportunity scores are highlighted in yellow and concentrated around the metropolitan area around downtown cincinnati, ohio. the convergence analysis for census tract fips code 39035118602 revealed that there were six health conditions that simultaneously exist at their worst levels. they include poor mental health, diabetes, stroke, coronary heart disease, asthma, and high blood pressure. in figure 6 , the additional layer for disease convergence in hamilton county ohio has been added to the map as a cluster of outlined census tracts in the lowest scoring areas. in cuyahoga county, the census tracts with the lowest opportunity scores are highlighted in yellow and concentrated around the metropolitan area around downtown cincinnati, ohio. the convergence analysis for census tract fips code 39035118602 revealed that there were six health conditions that simultaneously exist at their worst levels. they include poor mental health, diabetes, stroke, coronary heart disease, asthma, and high blood pressure. in figure 6 , the additional layer for disease convergence in hamilton county ohio has been added to the map as a cluster of outlined census tracts in the lowest scoring areas. the hoi can function as an essential tool in advancing health equity. it is important to note that the hoi tool is not meant to assess health outcome. the purpose of this tool is to provide public health practitioners, policy makers, and local organizations with a tool to assess sdh at the census tract level. the hoi can then inform the actions of policy makers and local communities who embark in cuyahoga county, the census tracts with the lowest opportunity scores are highlighted in yellow and concentrated around the metropolitan area around downtown cincinnati, ohio. the convergence analysis for census tract fips code 39035118602 revealed that there were six health conditions that simultaneously exist at their worst levels. they include poor mental health, diabetes, stroke, coronary heart disease, asthma, and high blood pressure. in figure 6 , the additional layer for disease convergence in hamilton county ohio has been added to the map as a cluster of outlined census tracts in the lowest scoring areas. the hoi can function as an essential tool in advancing health equity. it is important to note that the hoi tool is not meant to assess health outcome. the purpose of this tool is to provide public health practitioners, policy makers, and local organizations with a tool to assess sdh at the census tract level. the hoi can then inform the actions of policy makers and local communities who embark the hoi can function as an essential tool in advancing health equity. it is important to note that the hoi tool is not meant to assess health outcome. the purpose of this tool is to provide public health practitioners, policy makers, and local organizations with a tool to assess sdh at the census tract level. the hoi can then inform the actions of policy makers and local communities who embark on the difficult work of improving the most serious health concerns of their communities by addressing the sdh that impacts health. first, the hoi provides a method of comparing overall health opportunities of surrounding areas using the composite score. it is important to note that the hoi does not function as a health ranking. while the composite hoi score can be used for comparison of health opportunity among counties, its great advantage is its ability to highlight challenges and opportunities within the county and its census tracts. when applying and allocating funds for health-related grants, it is critical that all parties use a tool that is standardized to provide a common understanding of sdh which drive health outcomes. the hoi also provides insight to similar challenges faced by different communities. the ability to highlight which census tracts have the lowest opportunities for optimal health can lead to specific policies, social, economic, environmental and structural changes to advance health equity. further, breaking down the hoi by examining its subcomponents makes it possible to highlight which aspects of a community need the most attention to increase overall health. for example, in table 2 , the consumer profile has a score of 0.095 which is identified as the primary driver of low health opportunity. the food access index score of 0.063 signifies that the census block in cuyahoga county suffers particularly from access to grocery stores, supermarkets and other suppliers of healthy food. with this information, the state's public health department or community supporters could implement healthy food interventions to improve food access. this detailed process offers a more accurate method of addressing health equity issues. the disease convergence layer is added over the hoi in order to provide better context of health. that is, to understand how different types of health disparities, at their worst levels, reflect low health opportunity and all of its complications. figure 6 highlights 10 census tracts that are highlighted as convergence areas in hamilton county. each of the convergence area census tracts highlighted are in low health opportunity census tracts. the occurrence of multiple chronic health conditions simultaneously present at their worst levels in a single census tract indicate the influence of challenging sdh on these disparities. one of the shortcomings in public health practice is the proliferation of programmatic silos, which often address a particular health issue at any given time. convergence analysis provides the opportunity for cross sector collaboration. in a census tract where diabetes, heart disease and hypertension all are occurring at their highest levels, health organizations with different programs can combine resources to address health conditions simultaneously. moreover, the hoi empowers collaborating organizations to be able to identify specific sdh to focus their collaborative interventions on. the hoi provides a large-scale image of an area's health opportunity. figure 3 highlights the census tracts that make up cuyahoga county. the thematic map presented displays the concentration of low health opportunity census tracts closer to proximity to downtown cleveland. urbanization provides a number of factors that can drive the health opportunity of an area down such as overcrowding, air pollution, and high unemployment rates [23] . these factors provide a potential explanation of the differences in health opportunity between downtown cleveland in figure 3 and columbus in figure 4 and their surrounding suburban census tracts. additionally, the thematic map allows stakeholders and policy makers to identify potential systematic issues that could be linked to low health opportunities. demographic information on the low health opportunity census tracts are publicly available. for figure 3 , the converging point for the cluster of low health opportunity census tracts is cleveland city, ohio. according to the united states census bureau, the cleveland city comprises approximately 25% of the cuyahoga county population and is predominately african american (49.6%) [24] . combining this knowledge with the hoi provides the potential for highly detailed and accommodating interventions in areas of the most need. our dashboard can be utilized by state and local health departments in municipalities across the us. microsoft access and arcgis online can be used to link the hoi with convergence analysis to create reports and thematic maps to better visualize and contextualize both datasets to target vulnerable communities. in the present study, the use of 500 cities data featuring the natural brakes classification method with seven (7) classes proved to be very useful, as was the 2013-2017 vital statistics data on prematurity, and the 2017 lead data using the equal ranges classification method with five classes (brfss 2017). each dataset was selected based on the highest two classes that reflected the highest burden of disease. all data were imported into a ms access database system. a query entitled "convergence" was created to create linking both dataset by the census tract fips code. a report was then created to identify census tracts that had at least four (4) of any of the conditions with a given census tract. additionally, to identify census tracts for the convergence of different health issues, a filter tool in arcgis online can be easily applied. by selecting the map layers with the appropriate data, it is possible to mimic the function of the ms access query by using the filter for the highest rates of disease based on the natural breaks or equal range classes of the original dataset. relevant to the public health emergency that we are currently experiencing, the hoi provides an opportunity for municipalities to address the capacity of health systems by identifying areas where the availability of physicians are low using a provider-to-population ratio. prior to the covid-19 pandemic, the hoi was able to identify communities where access to health care was limited. this access, or lack thereof, would be expected to be further exacerbated and strained during a pandemic such as the current covid-19 pandemic. as we have witnessed, as the pandemic has worsened across the united states, we continue to observe an increase in the population in need of health care as cases of covid-19 continue to rise. further, it is now apparent that these very low and low hoi areas are synonymous with the census tracts that are most disproportionately impacted in the covid-19 pandemic. therefore, we put forth the proposition that this novel tool will allow local, state, regional and national agencies to respond to covid-19 impacted areas and other chronic health concerns due to its ability to predict and identify communities were the need for a robust response is likely to be the greatest. the hoi utilizes data sets from a variety of sources. for urban areas, often times this information is more readily available and accessible. however, for rural areas, the inability to access these data could prove difficult to incorporate the hoi evenly across an entire state. the hoi is still in its early stages of implementation so, cleveland, columbus, and cincinnati are the initial major cities that have been hoi mapped across census tracts. additionally, the hoi is created on a state by state basis. the index is built according to available datasets at the census tract level for that particular state, including variables that stakeholders and health departments identify as important and actionable. if the variables can be linked to health outcomes through academic literature, then they will serve as the framework for that area's hoi. the hoi for the state of ohio does not contain the same indices as the hoi for the state of virginia. for this reason, cross state comparisons would prove to be difficult. hopefully, nationwide adoption of the hoi would facilitate the creation of a nationwide baseline hoi. finally, the hoi is a measure of access or availability of opportunity within a community. this tool does not measure utilization or individual level barriers but rather assesses opportunity at the community level. likewise, the hoi is not designed to address the sociocultural, organizational, geographic, and gender-related barriers in health care. again, the purpose of the hoi tool is to move beyond the health care setting and examine the social determinants of health that impact health outcomes. while health care is an important determinant, the tool is aimed at assessing access to healthcare based on the availability of physicians and that segment of the population that is uninsured. therefore, these issues are limitations of the hoi tool. the differences in opportunity to achieve optimal health among communities around the state of ohio further exasperate the disparities in health between these communities. the hoi is a novel tool capable of aiding public health officials and local stakeholders alike in identifying the differences in health opportunity. conditions that drive poor health are extremely complex, exemplified by the possibility of two adjacent census tracts having low hoi scores caused by different sdh. without having tools such as the hoi to understand which specific sdh drive poor health opportunity, it is highly likely that the wrong interventions will be applied, which will negatively impact efforts to advance health equity. it is not sufficient to just identify the differences, but understanding what factors are potentially driving down health are necessary for impactful health interventions. using geospatial mapping tools such as arcgis, it is possible to create interactive tools that facilitate collaborative efforts to address the sdh on many different levels to improve impact disparate chronic health outcomes in census tracts. as communities continue to diversify, so do their health concerns and troubles. addressing these growing concerns will require a more detailed intervention methodology by public health officials [25] . the implementation of the hoi presents a new tool to assist in this process. the fact that 12-of the 13 indices in the hoi are related to socioeconomic factors, its use in conjunction with the public health exposome framework presents an exciting future for environmental health science [26] . the recently described public health exposome framework can model the relationships between environmental and socio-demographic variables and health outcomes [27] . we have used the exposome framework to reveal latent associations between chemical stressors and low birth weights and pre-term births, both which have high prevalence rates in ohio. both the public health exposome and the hoi incorporate datasets from a variety of locations to present a geographical approach to combating health disparities. parallel use of these frameworks may prove to be beneficial to public health officials and local stakeholders alike. in combination with the public health exposome, the question as to how chemical stressors such as components of ambient pollution negatively impact vulnerable populations to result in premature death, including ischemic cardiovascular disease, stroke, respiratory infections, chronic obstructive pulmonary disease, and lung cancer might be more appropriately addressed [28] [29] [30] [31] [32] . using the public health exposome [33] [34] [35] and hoi analytics to integrate public health with exposure science and population-based epidemiological designs will likely provide novel and innovative theories and interventions to address disparate health outcomes. a recent study used data from the global burden of disease 2016 study to address the question: "how much does exposure to chemical stressor (as pm 2.5 air pollution) shorten human life expectancy around the world?" the study used a prior dataset that evaluated chemical stressor levels in 2000 and 2007 from 585 us counties and effects on life expectancy. the analysis revealed that in 2016, chemical stressor exposure reduced average global life expectancy at birth by ∼1 year with reductions of ∼1.2-1.9 years in polluted countries of asia and africa. a major conclusion from that study was; if exposure to chemical stressors in all countries met the world health organization air quality guideline (10 µg/m 3 ), the estimated life expectancy would increase by a population-weighted median of 0.6 year (interquartile range of 0.2-1.0 year), a benefit of a magnitude similar to that for eradicating lung and breast cancer [36] . this study and the many studies conducted prior to this most recent report serve to illustrate how mortality from exposure to airborne chemical stressors as environmental contaminants substantially reduces human longevity. funding: this research was funded in part, by a gra to co by us epa star award rd83927501 (dbh). support was also provided by an osu outreach and engagement grant #14848 (dbh): e 6 , enhancing environmental enterprises via e-equity, education and empowerment. office of disease prevention and health promotion, us department of health and human services, & office of disease prevention and health promotion healthy people 2020 who commission on sdh, & world health organization. closing the gap in a generation: health equity through action on the sdh: commission on sdh final report county health rankings: relationships between determinant factors and health outcomes severe outcomes among patients with coronavirus disease 2019 (covid-19)-united states covid-19 exacerbating inequalities in the us mapping the determinants of health inequalities in social space: can bourdieu help us? health place the child opportunity index: improving collaboration between community development and public health how sensitive is the spatial distribution of poverty to cost of living adjustments? measures of spatial accessibility to health care in a gis environment: synthesis and a case study in the chicago region measuring perceived neighborhood walkability in hong kong beyond neighborhood quality: the role of residential instability, employment access, and location affordability in shaping work outcomes for hope vi participants population density as an indirect indicator of urban and suburban land-surface modifications educational inequailty in the united states: methodology and historical estimates of education gini coefficients does opening a supermarket in a food desert change the food environment? health place an area-based material and social deprivation index for public health in québec and canada long-term trends in health, welfare, and economic growth in the united states. in health and welfare during industrialization measures of spatial segregation relative deprivation and the gini coefficient growing economic inequality sustains health disparities principal component analysis global urbanization and impact on health ohio quick facts adverse health effects of outdoor air pollutants the public health exposome: a population-based, exposure science approach to health disparities research the exposome: from concept to utility cardiovascular risk calculator and chart v3.0. available online prediction of coronary heart disease using risk factor categories estimation of cardiovascular risk in an individual patient without known cardiovascular disease global cardiovascular risk assessment in the primary prevention of cardiovascular disease in adults: systematic review of systematic reviews validation of the framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation predictive accuracy of the framingham coronary risk score in british men: prospective cohort study improving global vascular risk prediction with behavioral and anthropometric factors. the multiethnic nomas (northern manhattan cohort study) application of citizen science risk communication tools in a vulnerable urban community application of the public health exposome framework to estimate phenotypes of resilience in a model ohio african-american women s cohort the effects of social, personal, and behavioral risk factors and pm 2.5 on cardio-metabolic disparities in a cohort of effect of air pollution control on life expectancy in the united states: an analysis of 545 u.s. counties for the period from key: cord-341105-3uvbfp8c authors: li, dian-jeng; ko, nai-ying; chen, yi-lung; wang, peng-wei; chang, yu-ping; yen, cheng-fang; lu, wei-hsin title: covid-19-related factors associated with sleep disturbance and suicidal thoughts among the taiwanese public: a facebook survey date: 2020-06-22 journal: int j environ res public health doi: 10.3390/ijerph17124479 sha: doc_id: 341105 cord_uid: 3uvbfp8c coronavirus disease 2019 (covid-19) pandemic has impacted many aspects of people’s lives all over the world. this facebook survey study aimed to investigate the covid-19-related factors that were associated with sleep disturbance and suicidal thoughts among members of the public during the covid-19 pandemic in taiwan. the online survey recruited 1970 participants through a facebook advertisement. their self-reported experience of sleep disturbance and suicidal thoughts in the previous week were collected along with a number of covid-19-related factors, including level of worry, change in social interaction and daily lives, any academic/occupational interference, levels of social and specific support, and self-reported physical health. in total, 55.8% of the participants reported sleep disturbance, and 10.8% reported having suicidal thoughts in the previous week. multiple covid-19-related factors were associated with sleep disturbance and suicidal thoughts in the covid-19 pandemic. increased worry about covid-19, more severe impact of covid-19 on social interaction, lower perceived social support, more severe academic/occupational interference due to covid-19, lower covid-19-specified support, and poorer self-reported physical health were significantly associated with sleep disturbance. less handwashing, lower perceived social support, lower covid-19-specified support, poorer self-reported physical health, and younger age were significantly associated with suicidal thoughts. further investigation is needed to understand the changes in mental health among the public since the mitigation of the covid-19 pandemic. coronavirus disease 2019 (covid-19) is a novel infectious disease that emerged in wuhan, china at the end of 2019 and rapidly spread worldwide [1] . as the threat increased, the world health organization (who) declared the outbreak of covid-19 a global public health emergency on the 30 january 2020 and it was declared a pandemic on the 11 march 2020. the covid-19 pandemic is severely affecting people's daily lives all over the world, including their health, economic wellbeing and social interactions [2] . social distancing, self-isolation, and travel restrictions have resulted in a massive decrease in productivity across all economic sectors, which has had severe lockdown effects and placed a heavy burden on society, such as the decline in global stock markets and overload of healthcare services [3] . people in taiwan also suffered from threats of covid-19. the taiwan centers for disease control (taiwan cdc) identified the risk of the covid-19 pandemic and delivered necessary policy quickly at the end of january 2020. according to the situation report of taiwan cdc [4] , 443 cases were infected with covid-19 at june 12th. of the confirmed cases, there have been seven deaths, and 431 patients have been released from isolation. most of the morality was associated with elderly and chronic systemic disease. healthcare workers followed the order of authorities to increase the intensity of infection control, such as forced wearing of masks, taking body temperatures, and limitations for visitors in hospitals. due to limited cases of infection, the intense care facilities were sufficient. the relatively minimal proportion of less confident individuals may result from timely border control, application of big data analytics, and experienced teams of officials [5] . in addition to the socio-economic burden that covid-19 has caused, the pandemic may also have hazardous effects on the public's mental health. several studies had addressed the psychological impact of covid-19. a web-based survey reported that the overall prevalence of anxiety symptoms, depressive symptoms, and poor sleep quality were 35.1%, 20.1%, and 18.2%, respectively, among the public affected by the covid-19 outbreak in china [6] . another study recruited 1257 subjects reported that a considerable proportion of participants reported symptoms of depression (50.4%), anxiety (44.6%), insomnia (34.0%), and distress (71.5%) [7] . it is important to examine covid-19-related factors that affect mental health during the covid-19 pandemic. studies predicting factors associated with mental health problems will enhance understanding and help develop timely prevention and intervention strategies to enhance public mental health during covid-19 pandemics [8] . it was reported that nurses, women, frontline health care workers, and those working in wuhan, china were significantly associated with more severe degrees of depression and anxiety symptoms than other health care workers [7] . another covid-19 study indicated that female gender, student status, specific physical symptoms (e.g., myalgia or dizziness), and poor self-rated health status were significantly associated with higher levels of stress, anxiety, and depression [9] . in addition, individuals with frequent social media exposure were positively associated with higher odds of anxiety than lower exposed ones during the covid-19 pandemic [10]. although previous studies explored the high prevalence of psychological distress for the public during the covid-19 pandemic, it was still insufficient for investigations regarding the risk factors associated with mental health problems, such as social support. an egyptian population-based study demonstrated that only 24.2% of individuals had increased support from friends, while 40.6% of them reported increased support from family members during the covid-19 pandemic [11] . however, whether social support can buffer the negative effects of social isolation and changes in daily lives during the covid-19 pandemic warrants further study. in addition, seldom covid-19 related studies discussed suicide, which is an unneglectable issue due to elevated psychological distress [12] . therefore, the aim of the current study focused on the impact of covid-19 on daily lives and how varying levels of support may affects people's mental wellbeing, such as level of sleep disturbance and suicidal thoughts. participants were recruited through a facebook advertisement from april 10 to 23, 2020. facebook users were eligible for this study if they were ≥20 years old and living in taiwan. the facebook advertisement included a headline, main text, pop-up banner, and link to the research website and questionnaire. the advertisement was designed to appear in the facebook users' "news feeds," which is a continually updated list of posts from advertisers and the user's connections (such as friends and the facebook groups that they have joined). our advertisement only targeted users' news feeds, as opposed to other facebook advertising locations (e.g., the right column), because news feed advertisements are most effective in recruiting research participants [13] . the advertisement was targeted to facebook users by location (taiwan) and language (chinese), and facebook's advertising algorithm determined which users to show our advertisement to. to ensure that health care workers were recruited, the facebook advertisement was also posted link to line (a direct messaging app) and facebook groups joined by healthcare workers. this study was approved by the institutional review board (irb) of kaohsiung medical university hospital (approval no. kmuhirb-exempt (i) 20200011). as participation was voluntary and survey responses were anonymous, the irb ruled that this study did not require informed consent. the study participants were given no incentive or reward for their participation. the links were provided regarding the covid-19 information by the taiwan cdc, kaohsiung medical university hospital, and medical college of national cheng kung university so participants could learn more about covid-19. the sleep disturbance and suicidal thoughts of participants were assessed with the question on a 5-point likert scale, with scores ranging from 0 (never) to 4 (extremely severe). participants who rated the items of sleep disturbance and suicidal thoughts > 0 were classified as having sleep disturbance or suicidal thoughts, respectively [14] . the details of this and following questionnaires are provided as supplemental data (tables s1-s7). the participants' gender (female, male, or transgender), age, and education level (high school or below vs. college or above) were collected. moreover, whether the participants were healthcare workers was also identified. the five-item questionnaire developed by liao and colleagues to assess individuals' level of worry about h1n1 [15] was applied to assess the severity of participants current worry about covid-19. participants responded to them with four 5-point and one 10-point likert scale. cronbach's α was 0.71. a higher total score of the five questions indicated more severe worry about covid-19 (table s2 ). with reference to a previous study, seven questions were developed to evaluate the changes to participants daily lives due to covid-19 [15] . the responses were transformed into 0 ("no" or "yes, but not due to covid-19") and 1 ("yes, due to covid-19"). cronbach's α of the questionnaire was 0.57 (table s3 ). four questions were developed to assess the impact of covid-19 on social interaction. the responses were transformed into 0 ("no" or "yes, but not due to covid-19") and 1 ("yes, due to covid-19"). cronbach's α was 0.78. higher total scores for the four questions represented covid-19 having a more severe impact on the individual's social interactions (table s4 ). the academic/occupational interference was evaluated by the covid-19 pandemic with one question. participants responded to the question on a 5-point likert scale ranging from 0 (entirely no interference) to 4 (extreme interference) (table s5 ). three questions were used to measure the level of perceived social support. the responses to these three items were graded on a 5-point likert scale, with scores ranging from 0 (entirely disappointed) to 4 (extremely satisfied). cronbach's α was 0.81. a higher total score represented a higher level of perceived social support. the participants' level of covid-19-specified support was estimated with five questions. the responses to the questions were graded on a 3-point likert scale, ranging from 0 (entirely insufficient), 1 (mild insufficient), and 2 (sufficient). cronbach's α was 0.75. a higher total score represented higher satisfaction with the level of covid-19-specified support (table s6 ). two questions from the self-perceived health questionnaire developed by ko and colleagues [16] were used to assess the level of self-reported physical health. the level of self-reported physical health was a 5-likert scale rated from 1 (much worse) to 5 (much better). cronbach's α was 0.81. a higher total score indicated better self-reported physical health (table s7 ). descriptive analysis was used to summarize the variables. univariate logistic regression with crude odds ratios (cor) was used to identify potential covid-19-related factors associated with sleep disturbance and suicidal thoughts. furthermore, all potential predictive variables identified from the first step were eligible for inclusion in the forward stepwise logistic regression models with adjusted odds ratios (aor) to determine the independent predictors for sleep disturbance and suicidal thoughts. all tests were examined using a two-tailed test with the alpha level set at <0.05. all data were processed using spss version 23.0 for windows (spss inc., chicago, il, usa). initially, there were 2031 respondents who filled in the online questionnaire. after excluding those respondents with missing values (n = 31) and those aged below 20 years (n = 30), the data of 1970 participants (1305 females, 650 males, and 15 transgender) were entered for analysis. the mean age of the participants was 37.81 ± 11.00 years. a summary of the remaining characteristics for all participants are listed in tables 1 and 2. a total of 1099 (55.8%) participants reported sleep disturbance, and 212 (10.8%) reported having suicidal thoughts in the past week (table 3) . tables 1 and 2 show the results of the univariate logistic regression. the results demonstrated that current sleep disturbance was significantly associated with several factors, including younger age (cor = 0.99; p = 0.002), more severe worry about covid-19 (cor = 1.07; p < 0.001), more severe impact of covid-19 on social interaction (cor = 1.14; p = 0.001), lower perceived social support (cor = 0.87; p < 0.001), lower self-reported physical health (cor = 0.76; p < 0.001), higher academic/occupational interference (cor = 1.20; p < 0.001), lower covid-19-specified support (cor = 0.85; p < 0.001), and more household disinfection (cor = 1.23; p = 0.03). table 4 shows the results of the forward stepwise logistic regression. the results indicated that more severe worry about covid-19 (aor = 1.04; p = 0.001), more severe impact of covid-19 on social interaction (aor =1.07; p = 0.047), lower perceived social support (or = 0.91; p < 0.001), poorer self-reported physical health (aor = 0.80; p < 0.001), more severe impact of covid-19 on academic/occupational interference (aor = 1.12; p = 0.005), and lower covid-19-specified support (or = 0.92; p = 0.003) remained significant independent predictors associated with sleep disturbance. for suicidal thoughts, the univariate logistic regression indicated several potential factors that could predict suicidal thoughts, including a younger age (cor = 0.93; p < 0.001), being transgender (cor = 5.55; p = 0.001), being non-healthcare workers (cor = 0.41; p < 0.001), more severe worry about covid-19 (cor = 1.03; p = 0.032), lower perceived social support (cor = 0.73; p < 0.001), poorer self-reported physical health (cor = 0.72; p < 0.001), lower covid-19-specified support (cor = 0.76; p < 0.001), and less handwashing (cor = 0.48; p = 0.001) (tables 2 and 3 ). the results of the forward stepwise logistic regression demonstrated that younger age (aor = 0.93; p < 0.001), less handwashing (aor = 0.48; p = 0.002), lower perceived social support (aor = 0.79; p < 0.001), poorer self-reported physical health (aor = 0.81; p < 0.001), and lower covid-19-specified support (or = 0.81; p < 0.001) remained significant independent predictors of suicidal thoughts (table 4 ). the findings of the current study were discussed initially with the primary outcome, including sleep and suicidal thoughts. then several independent predictors associated with sleep disturbance and suicidal thoughts were discussed. the current study was conducted using an online survey, which has been reported to be a promising method for evaluating how the general public understand and perceive a fast-moving infectious disease outbreak [17] . in the current study, the rate of sleep disturbance in the previous week was 55.8%, which was much higher than the result of a population-based investigation in taiwan using the same question to assess sleep disturbance (up to 28.3%) [14] . the rate of suicidal thoughts reached 10.8% in the previous week, which was also higher than the findings of a previous survey in taiwan using the same question to assess suicidal thoughts (2.1%) [14] . in addition, increased worry about covid-19, more severe impact of covid-19 on social interaction, lower perceived social support, more severe academic/occupational interference due to covid-19, lower covid-19-specified support, and poorer self-reported physical health were significantly associated with sleep disturbance. less handwashing, lower perceived social support, lower covid-19-specified support, poorer self-reported physical health, and younger age were significantly associated with suicidal thoughts. the present study found that a high level of worry about covid-19 was significantly associated with sleep disturbance. previous study indicated that degree of worry was significantly associated with psychological distress measured by general health questionnaire-28 during 2009 a/h1n1 influenza [18] . another study regarding 2015 middle east respiratory syndrome (mers) reported that individuals with very high stress in daily life had higher levels of worry than those who reported having little stress [19] . people with significant psychological distress may suffer from sleep disturbance. in addition, it had been reported that misinformation about covid-19 has been proliferating on social media [20, 21] . owing to the significant association between worry about covid-19 and sleep disturbance, whether misinformation on social media may deepen people's worry about covid-19 warrants further investigation. social distancing is one of the main protective behaviors against contracting covid-19 [22] . moreover, previous studies have found that the severe acute respiratory syndrome (sars) outbreak changed social interaction because of the fear of contracting the disease among the public [23] and due to healthcare workers being stigmatized [24] . the present study found a significant association between changes in social interaction due to covid-19 and sleep disturbance, but not significant for suicidal thoughts. instead, the present study found that lower perceived social support and specific support against covid-19 were both independent predictors for sleep disturbance and suicidal thoughts. previous research has found that perceived support from a family member, friends, and medical staff were associated with mental health during the sars pandemic [25] , and also that insufficient social support was a risk factor for depression, anxiety, and sleep problems among healthcare workers in the covid-19 pandemic [26] . the results of this and previous studies demonstrate the importance of sufficient social support and specific support against infective respiratory diseases during a pandemic. social distancing may hamper physical, social interaction; however, social support can be offered by telecommunication. governments should provide support for those who are socially isolated before the pandemic and for those who are quarantined due to infection during the pandemic to help prevent mental health problems. to prevent the spread of covid-19, authorities all over the world announced stay-at-home and school-closure orders, which interfere with people's academic/occupational performance. the present study found that the higher the academic/occupational interference by covid-19 the higher the predicted sleep disturbance. although academic and occupational activities may be restored as the risk of covid-19 is mitigated, it takes time and consistent policies to restore economic prosperity. the unemployment rate increased because of the enormous impact of covid-19 on the global economy. research has found that the unemployment rate increased in parallel with the prevalence of depressive and anxiety disorders [27] . academic and occupational interference by the covid-19 pandemic and the negative effect this has on health should be monitored not only during but also after the pandemic. the daily lives of the public have changed due to the adoption of protective behaviors against contracting covid-19 and searching for information on covid-19. the present study found that less handwashing was significantly associated with suicidal thoughts in the multiple logistic regression. handwashing is the most recommended behavior by the who to protect individuals from contracting covid-19 [22] . however, people who had suicidal thoughts might not have the motivation to adopt the experts' recommendation of hand washing. this association may be influenced by level of depression. previous study revealed the association between depression prevalence rates and poor health habits [28] . in addition, people with mental illnesses have a greater vulnerability to serious complications from covid-19 due to cognitive impairment, little awareness of risk, and diminished efforts regarding personal protection [29] . early intervention for mentally ill individuals during the covid-19 pandemic is crucial for preventing a possible loophole for infection control. the present study found that poorer self-reported physical health was significantly associated with sleep disturbance and suicidal thoughts. several possible etiologies may account for this association. first, poorer physical health, such as chronic diseases or impaired physical function, may directly increase psychological distress [30] . second, people might stop seeing the doctors because they were worried about contracting covid-19 and the treatment for physical problems might be delayed. both anticipatory anxiety about and actual occurrence of exacerbated illnesses may result in sleep disturbance and suicidal thoughts. third, poorer physical health may result in reduced physical activities, which was reported to be associated with higher psychological distress [31] . fourth, sleep disturbance may worsen physical health [32] . moreover, people with suicidal thoughts were likely to have depressive disorders, which were significantly associated with physical health problems [33] . although the cross-sectional study design limited the ability to determine the causal relationship between self-reported physical health, sleep disturbance, and suicidal thoughts, health professionals should encourage the public to continuously enhance physical health in addition to detecting the symptoms of covid-19 infection. younger age was an independent predictor for suicidal thoughts as determined by multivariate logistic regression. it was also potentially associated with sleep disturbance. a recent study in china also demonstrated that younger subjects were at high risk of mental illnesses, such as general anxiety disorder during the covid-19 pandemic [6] . moreover, the present study found that non-healthcare workers and transgender people were potentially more likely to have suicidal thoughts than healthcare workers and females, respectively, as determined by univariate logistic regression. however, these associations became insignificant in the multiple logistic regression. the study in china found that healthcare workers were at high risk for poor sleep quality during the covid-19 pandemic [6] , whereas the present study did not find more severe sleep disturbance in healthcare workers compared with non-healthcare workers. given that the covid-19 epidemic in china was much more severe than in taiwan [4] , we suggest that varying healthcare burdens across the covid-19 pandemic may account for the discrepancy between the results of the present and other studies. transgender people were reported to have higher rates of depression, suicidal thoughts, and other mental illnesses compared with other genders [34] . the psychological impact of infectious disease pandemics on gender minorities should not be neglected. the present study has several limitations. first, although recruiting participants through the internet is a promising research method for targeting the general public, possible selection bias exists for those who are not netizens. hence, a paper-and-pencil test and advertisements posted on public area may recruit participants who rarely surf the internet. second, the cross-sectional design of this study during acute pandemic stage limited causal inference and the presence of sufficient information at follow-up. a prospective follow up study may further explore the causality between variables and change of measurements with time, especially during plateau or remission stage. third, this study was conducted during the period of covid-19 mitigation but not during period when covid-19 first emerged in taiwan. therefore, the initial impact of covid-19 cannot be identified. finally, sleep pattern and suicidal thoughts were only measured by a single question, which may limit the implication of the current study. formal questionnaires such as the pittsburgh sleep quality index may provide comprehensive assessment for sleep problems. the present study identified several covid-19-related predictors for sleep disturbance and suicidal thoughts among people during the covid-19 pandemic. this massively undesirable effect on mental health deserves more attention and support from authorities during the covid-19 pandemic. for instance, a lower support system was associated with higher risk of sleep disturbance and suicidal thoughts, indicating the importance of timely support during pandemics. in addition, the significant association between less handwashing and suicidal thoughts demonstrated the possibility that individuals with suicidal thoughts may have poor coping strategies of infection control. hence, intervention to those with mental health problems during the covid-19 outbreak is necessary to enhance their coping with the threats of infection, which may decrease the risk of poor infection control. the study provides information that could aid timely intervention in the mental health of the public. moreover, sleep disturbance and suicidal thoughts may occur not only during the covid-19 pandemic but also during the restoration period. further investigation is needed to fill the limitations of the current study. the prospective study with follow up at different stages of the pandemic can help us better understand the changes of association between mental health and multi-dimensional factors. moreover, studies with multiple recruiting sources and detailed questionnaires of mental health problems can further extend the application of the findings of the current study. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/12/4479/s1, table s1 : sleep disturbance and suicidal thoughts; table s2 : worry about covid-19; table s3 : impact of the covid-19 pandemic on participants' daily lives; table s4 : impact of the covid-19 pandemic on social interaction; table s5 : academic/occupational interference by the covid-19 pandemic; table s6 : perceived social support and covid-19-specified support; table s7 : self-reported physical health. the authors declare no conflict of interest. a novel coronavirus outbreak of global health concern covid-19 outbreak: migration, effects on society, global environment and prevention the socio-economic implications of the coronavirus and covid-19 pandemic: a review covid-19 press releases d-dimer and tat measurement in patients with deep 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meta-analysis of population data from 190 593 people across 43 low-and middle-income countries this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-355291-fq0h895i authors: yasir, ammar; hu, xiaojian; ahmad, munir; rauf, abdul; shi, jingwen; ali nasir, saba title: modeling impact of word of mouth and e-government on online social presence during covid-19 outbreak: a multi-mediation approach date: 2020-04-24 journal: int j environ res public health doi: 10.3390/ijerph17082954 sha: doc_id: 355291 cord_uid: fq0h895i although social presence plays an essential role under general conditions, its role becomes significant for societal protection during the quarantine period in epidemic outbreak. in this study, we attempted to identify the role of e-government and covid-19 word of mouth in terms of their direct impact on online social presence during the outbreak as well as their impacts mediated by epidemic protection and attitudes toward epidemic outbreaks. for this purpose, a unique multi-mediation model is proposed to provide a new direction for research in the field of epidemic outbreaks and their control. through random sampling, an online survey was conducted and data from 683participants were analyzed. partial least squares structural equation modeling was used to test the relationships between the variables of interest. the study results revealed that the roles of e-government and covid-19 word of mouth are positively related to online social presence during the outbreak. epidemic protection and attitude toward epidemic outbreak were found to positively moderate the impact of the role of e-government and covid-19 word of mouth on online social presence during the outbreak. the key findings of this study have both practical and academic implications. the flow of information in any matter is important and can considerably impact the situation during an epidemic outbreak. the role of e-government is also essential in any situation related to health protection, especially during an outbreak period. e-government (e-govt) is defined as "the use of information technologies that have the ability to transform relations with citizens, businesses, and other arms of government" [1] . keeping people calm and focused is necessary during an epidemic and its quarantine period. if people are quarantined, the roles of e-govt and word of mouth (wom), especially message sharing through social media, increase in importance. now, with the current covid-19 outbreak, people are under quarantine until further notice, with many countries experiencing epidemic outbreaks. people have more time to use social media, which could be a source of rumors, anxiety, and, most important, knowledge for with physicians' online statements [26] . this shows that women are more emotional about health conditions, especially during an epidemic outbreak. evidence was provided that rumors are spreading during the covid-19 outbreak in other countries, but in china, people were likely to improve their emotions in the fight against covid19 and stay strong during the outbreak period by sharing positive posts on social media. as of the date of writing, 9 march 2020, we have been in quarantine since20 january2020, having direct experience with both normal life and quarantine. on social media, the importance of being online, especially during an epidemic outbreak, and the role of e-govt in the quarantine period shown in previous research, urged us to explore this phenomenon on a broader basis. positive awareness through the effects of covid-19 word of mouth (2019-ncov-wom) and e-govt in the epidemic period has not been sufficiently explored. regardless of the important roles of 2019-ncov-wom and e-govt in the epidemic outbreak, quantity of research is lacking. although online social presence is important at this time, scholars have not explored it sufficiently. from the literature, questions were raised whether online social presence increased the ability to obtain information about the safety measures and, with 24 h of free time to use social media, if people might be more willing to spread safety information. on this basis, we tried to explore the direct effect of 2019-ncov-wom and e-govt on online social presence, and tried to fill this gap using a cohesive methodology to identify the mediating effect of attitude toward epidemic outbreak and epidemic protection on online social presence. we used five constructs (2019-ncov-wom, role of e-govt, attitude toward epidemic outbreak, epidemic protection, and online social presence in the outbreak) with a conceptual multi-mediation model. we explored a distinctive approach to answer two questions: is there any mediating effect of attitude toward epidemic outbreak and epidemic protection on online social presence? what is the best possible combination for the government to increase people's willingness to participate in quarantine with a psychological perspective? in the next section, we discuss our research model. based on the analysis, we discuss our study results in section 4. finally, consequences and practical implication of our research are given and future research is suggested in section 7. to fill these research gaps, we provide a new direction for research about epidemic outbreaks by discussing the role of e-govt and the effect of 2019-ncov-womin relation to the use of social media and their mediating effect on long-term outbreaks. our research questions (rqs) were: rq1: what is the association between social media, epidemic protection messages, and online social presence? rq2: is there any mediating association between 2019-ncov-wom and the role of e-govt in online social presence? people have perceptions about their government playing a role during an epidemic condition. perceptions are heightened during an outbreak period, as people are concerned about their protection, and their attitude toward an epidemic outbreak depends on this protection, to some extent. during a quarantine period, as people are isolated, the perceived role of e-govt may be increased and people might be motivated to play a role in epidemic protection after watching the involvement of e-govt. in our questionnaire, we asked about trust in e-govt, which might provide motivation to play an important role in epidemic protection. the literature shows that the role of government, especially governmental strategies and alertness messages, in any outbreak is progressively enhanced [27] . communication and interaction with the government has increased in last few years, as the government is interested in engaging its people through social media [28] . the abovementioned literature justifies that the government understands people's perceptions about the role of e-govt. people involved in policy-making are also inspired by social media [29] . factors involved in sharing information are not described in this literature [30] . attitudes and awareness is connected to the supposed efficiency of policy-making [31] . improvement and development in chinese e-waste has been seen in the last six years [32] .this might enhance the people perceptions about e-govt playing a role in an epidemic outbreak. in canada, social media was used as tool for facilitation of consumers by government officials [33] . in latin america, research on e-govt is increasing and conflicting with what is occurring in the world [34] . one reason we involved e-govt and online social presence in our research model is that a noteworthy difference was identified the in analysis of awareness about the use of mobile phones to seek health information during critical times [35] . awareness promotion plays an important role in burn cases [36] . universal and global research is needed in community health for the use of social media in e-govt [37] . our study variables included capability of isolation, quarantine compartment, and interaction methods, which are responsible for occupancy rate isolation [38] . to stop the transfer of infectious disease, isolating infected people from healthy ones is vital [39] . the biggest outbreak of coronavirus, the middle east respiratory syndrome (mers), occurred in south korea in 2015. the main spread of this virus occurred in south korea from and out of hospitals [40] . as an independent variable, we added role of e-government in our study, because studies were lacking on the emotional influence of mers outbreaks [41] . research showed that administration, media, and celebrities play important roles in health promotion on twitter [42] because people are more attracted to celebrities. recommendations that are logically expressed have a strong impact on public [43] . many governments are improving their use of social media in health departments and are trying to provide digital services to their people guidance; especially during outbreaks. to increase the theoretical literature on e-govt in the health sector, we aimed to fill this gap using a systematic review method to analytically evaluate, recognize, and create research evidence for the use of 2019-ncov-womin connection with the role of e-govt in protection from covid-19. we also tried to critically evaluate the role of social media and the willingness to undergo a long quarantine period for protection from this epidemic. here, per the literature, we take this variable of people's perception (perceived role) of the role of the chinese government, which was important because the government provided a plan to withstand the outbreak period. notably, this is the first critical review of the use of 2019-ncov-wom and the role of e-govt in the covid-19 epidemic (as independent variables). given the above literature, we expected that e-govt plays a considerable role in the perception of epidemic protection and online social presence and in changing public attitudes toward an epidemic outbreak. therefore, we hypothesized the following: hypothesis 1a (h1a): role of e-government considerably affects epidemic protection. role of e-government considerably affects online social presence during an outbreak. role of e-government considerably affects attitude toward an epidemic outbreak. wom provides new directions to people's thoughts and views about any condition, and especially during an epidemic outbreak. nowadays, the top trend is covid-19 epidemic conditions discussed in news and online social websites. many studies in the last 10 years proved that there has been a large increase in the number of people willing to find health information on the internet. an increase in the number of social profiles providing health information was also observed [44] . electroencephalography inter-subject correlation (eeg-isc) was improved by an increase in resilient health communication [45] . the people of wuhan felt great confidence in sharing their views during data collection during the covid-19 epidemic outbreak quarantine. health promotions broadcast by the media are used to promote awareness. for young italian people, the messages were mostly about health and the environment [46] . this is significant because health experts have been using it as a motivational tool during the treatment of patients [47] and because histories of patients with similar symptoms are important for predictions [48] . this may be helpful for the emotional treatment of patients in the future. conversely, the most important aspect of health promotions is increasing people's patience and keeping them calm during the quarantine period to avoid anxiety. the chinese government improved public endurance by their emotional awareness through message sharing, which encouraged people to share their views [26] . it is a common for people to first think that social media information is only rumors during an outbreak; as such, people were at risk of being ignorant of health information shared by the government or by individuals. to provide better and urgent cure, people should know the signs and symptoms of corona viruses. many symptoms of the novel covid-19-infected pneumonia (ncip) have been described by researchers; they include increased body temperature, dry cough, and body pain [49] . the chinese government promoted awareness among people through social media, so that individuals showing signs of covid-19would immediately understand and contact medical experts for treatment and minimize further spread of the virus. only online 2019-ncov-wom was used for the quarantine period in china, especially in wuhan and anhui; some other countries soon after implemented quarantine measures. this means the chinese government played a positive role in the safety of people. the above-mentioned research demonstrated the importance of online 2019-ncov-wom. so, we tried to explore the positive effect of 2019-ncov-wom on online social presence in our research using exclusive mediating variables. we expected that 2019-ncov-wom not only significantly affects perceptions of epidemic protection in terms of individuals' online social presence, but also influences changes in attitude toward the epidemic outbreak. so, we hypothesized the following: hypothesis 2c (h2c): covid-19 word of mouth considerably affects attitude toward the epidemic outbreak. everyone is concerned with their protection in any condition, but particularly during an epidemic outbreak. the protection factor might affect social presence, but as people are isolated during quarantine, this factor changes the effect on online social presence in other ways. individuals' attitudes toward fitness is boosted by viewing health information posted on facebook in video form [3] . people's responses to epidemic protection increase especially during quarantine because they are at home and have more free time. individuals with prolonged health problems acknowledged caretakers' guidance more than other adults in the u.s., but they did not obtain physical exercise guidance for good health [50] . the covid-19 epidemic protection urged people to increase their online social presence to enhance public emotions for epidemic protection. the empirical studies mentioned above encouraged us to relate epidemic protection as a dependent variable due to obtaining specific information to protect online users during the quarantine period. here, we took this variable as people's perception to ensure their safety. china is more conscious about health due to the one-child policy, free internet to obtain information, and the perception of being safe through obtaining safety measures. therefore, we hypothesized the following: the literature discussed above indicated that assuming the role of e-govt in online social presence of the public is mediated by epidemic protection and 2019-ncov-wom affects online social presence. however, we suspected that 2019-ncov-wom is boosted by the psychological perception of epidemic protection. so, we hypothesized the following: hypothesis 3c (h3c): epidemic protection mediates the association between covid-19 word of mouth and online social presence. hypothesis 4b (h4b): epidemic protection mediates the association between role of e-government and online social presence. a study showed that people's attitudes toward an epidemic outbreak are more influenced by information on social media compared with physical discussion because source reliability has no impact on the health information provided online [51] .people obtain information about the outbreak through social media and mobile health apps [26] .however, a risk of client secrecy exists because online services are substantially affected by the happiness of clients [52] .we took attitudes toward an epidemic outbreak as a mediating effect, meaning that attitudes toward an epidemic outbreak will promote or mediate the relationship of two independent variables and social online presence, as shown in figure 2 . presence. however, we suspected that 2019-ncov-wom is boosted by the psychological perception of epidemic protection. so, we hypothesized the following: hypothesis 3c (h3c): epidemic protection mediates the association between covid-19 word of mouth and online social presence. hypothesis 4b (h4b): epidemic protection mediates the association between role of e-government and online social presence. a study showed that people's attitudes toward an epidemic outbreak are more influenced by information on social media compared with physical discussion because source reliability has no impact on the health information provided online [51] .people obtain information about the outbreak through social media and mobile health apps [26] .however, a risk of client secrecy exists because online services are substantially affected by the happiness of clients [52] .we took attitudes toward an epidemic outbreak as a mediating effect, meaning that attitudes toward an epidemic outbreak will promote or mediate the relationship of two independent variables and social online presence, as shown in figure 2 . research showed that the availability of a vaccine for an epidemic affects people's attitudes toward the outbreak; for publicizing a vaccine, online sources are important. during epidemics, curiosity about a vaccine is more influenced by publicity, not by the epidemic conditions. however, vaccine uptake is also influenced by the epidemic condition when epidemic increases [53] .recommendations by doctors, friends, and relatives stimulate people [54] as they discuss their responses to epidemics. people who are isolated during an epidemic must recognize the importance of protection [55] .research in toronto, canada, proved the willingness of people to participate in studies and the stress experienced by medical experts due to wearing of caring apparatus and being infected by disease in canada. as these medical experts were involved in attempting to cure a disease about which they had little knowledge, they were worried that they would be next targets when they saw their coworkers becoming sick and dying due to the epidemic [56] . lack of trust in government was observed in the public in korea when attempting to control the mers epidemic [57] . however, our focus was on the effect of 2019-ncov-wom and the role of e-govt to protect the people during long-term outbreak, and to examine the response of people during the quarantine period. we supposed that public attitude toward epidemics affects their online social presence. in china, people are willing to share news and have positive attitudes when sharing the good news about protection. so, we hypothesized the following: research showed that the availability of a vaccine for an epidemic affects people's attitudes toward the outbreak; for publicizing a vaccine, online sources are important. during epidemics, curiosity about a vaccine is more influenced by publicity, not by the epidemic conditions. however, vaccine uptake is also influenced by the epidemic condition when epidemic increases [53] . recommendations by doctors, friends, and relatives stimulate people [54] as they discuss their responses to epidemics. people who are isolated during an epidemic must recognize the importance of protection [55] . research in toronto, canada, proved the willingness of people to participate in studies and the stress experienced by medical experts due to wearing of caring apparatus and being infected by disease in canada. as these medical experts were involved in attempting to cure a disease about which they had little knowledge, they were worried that they would be next targets when they saw their coworkers becoming sick and dying due to the epidemic [56] . lack of trust in government was observed in the public in korea when attempting to control the mers epidemic [57] . however, our focus was on the effect of 2019-ncov-wom and the role of e-govt to protect the people during long-term outbreak, and to examine the response of people during the quarantine period. we supposed that public attitude toward epidemics affects their online social presence. in china, people are willing to share news and have positive attitudes when sharing the good news about protection. so, we hypothesized the following: hypothesis 3b (h3b): attitude toward epidemic outbreak considerably affects online social presence. the attitude of the public toward a situation impacts their online social presence and affects the role of e-govt and 2019-ncov-wom on online social presence. this means that if the attitude of the public is positive, it mediates role of e-govt and online social presence. hence, we hypothesized that: hypothesis 4c (h4c): attitude toward epidemic outbreak mediates the association between covid-19 word of mouth and online social presence. hypothesis 5b (h5b): attitude toward epidemic outbreak mediates the association between the role of e-government and online social presence. according to social presence theory [58] , social presence is about intimacy, feeling of closeness, familiarity, immediacy, and urgency to exchange information and motives in society. online social presence is important during epidemic outbreak quarantine periods. it not only plays an important role in the coordination of society but also in the creation of motives. online social presence is predicted by online streaming, mediating communal television pleasure [26] . among the magnitudes of social presence (telepresence and social presence), online social presence indirectly plays a role in the mediating direction. findings encouraged innovative marketing policy through which participation can be optimistic by refining presence fundamentals [59] . people are more attracted toward celebrities, which strengthens online social presence [60] . so, if celebrities are active during outbreak periods, they can motivate people to increase their online social presence. in addition, human sympathy is apparent on online sites and especially social sites, representing their online social presence and recognizing their interactions and feelings [58, 61] . the capability of a platform to deliver personal indications and increase online social presence willingness [59] is interceded by useful commitments [62] . every website provides specific confidentiality, which is expressively affected by online social presence [63] . private platforms are facilitated by online social presence [64] , so we predicted that they also affect the online response of people in quarantine during epidemics. sociability, pleasure, and belief are emotive reactions that reconcile social presence [59] . these three responses were felt across the chinese nation during the covid-19 outbreak. people believe that we will overcome this deadly virus and people were seen to be more emotional and social during this pandemic. online social presence varies from their level of appointment, which reveals intellectual burden [65] . contribution by people is inspired by their social value [66] . addiction to social networking sites (sns) also improves online social presence and increases people's pleasure when interacting socially, also improving social communication and gratification [26] . online social presence influences online engagement [67] . we included two areas in our study: wuhan in hubei (all cities from this province) and anhui province. participants of our study were mostly from wuhan. anhui (hefei province) is the nearest city to wuhan, so we also considered anhui in our study. we were all in quarantine (except one doctor as a writer for medical terminology association but she is not living in china), directly experiencing the feelings of this situation. random sampling and snowball sampling techniques were used to collect the data. it was impossible for us to go to wuhan due to quarantine during the outbreak. we were quarantined by ourselves. to avoid this hindrance on data collection, we decided to collect data online. we sent our questionnaire to the people of wuhan and anhui provinces. data was collected during the covid-19 quarantine period, which has been in place for almost one month and continued during the research. most of the participants were chinese; however, we also included foreigners living in wuhan and anhui because of their presence. however, due to various countries' evacuation policies, we decided to exclude the foreigners' data. due to the mixed participants of our study, we used two versions of the questionnaire to overcome any language barrier. we used an english version for data collection from foreigners and a chinese version for the domestic population in wuhan and anhui. to increase interest and willingness of participants we sent them hongbao (lucky money) to the group owners of wechat through wechat (only owners, not the participants). we collected data from 704 people (still ongoing, the corresponding author is willing to help any researchers with future research). in total, the participants included 315 men and rest were women (we aimed to obtain participants equally from both sexes). due to online foreigners' evacuation during data collection, we excluded 21 records during analysis and used 683 valid samples for analysis. after the evacuation policy implementation, we decided to stop the collection from foreigners. the demographic characteristics of our research data are provided in table 1 . moreover, the itemized sources of constructs used in the research are given in table 2 . role of e-govt efforts of e-govt, trust in e-govt, support of e-govt [26] 2019-ncov-wom information,countries' status, 2019-ncov-plan [68] epidemic protection hand wash, mask, motivation to protect [69, 70] attitude toward epidemic outbreak willingness to quarantine, health psychology, doctors' advice [71] online social presence in outbreak more present in quarantine, present for social support, present to discuss covid-19 the steps in our methodology are reported in figure 3 . role of e-govt efforts of e-govt, trust in e-govt, support of e-govt [26] 2019-ncov-wom information,countries' status, 2019-ncov-plan [68] epidemic protection hand wash, mask, motivation to protect [69, 70] attitude toward epidemic outbreak willingness to quarantine, health psychology, doctors' advice [71] online social presence in outbreak more present in quarantine, present for social support, present to discuss covid-19 the steps in our methodology are reported in figure 3 . from 2013 onward, a noticeable increase in participation of partial least squares structural equation modeling has been reported [72] . if not familiar with the data type or if the data have a common factor or are composite-based, findings illustrate that use partial least squares (pls) is the best choice for analysis [73] . appraisal and review studies explained that in management research with multivariable analysis techniques, the application of partial least squares structural equation from 2013 onward, a noticeable increase in participation of partial least squares structural equation modeling has been reported [72] . if not familiar with the data type or if the data have a common factor or are composite-based, findings illustrate that use partial least squares (pls) is the best choice for analysis [73] . appraisal and review studies explained that in management research with multivariable analysis techniques, the application of partial least squares structural equation modeling (pls-sem) has been increased [74] . pls-sem is being increasingly used in investigative and theory-based research [75] . use of pls is increasing in different branches of management, especially research with one-variable-based techniques [76] . past studies showed that pls-sem in different branches of management research have used multivariate analysis. as research in online user psychology is in its infancy and is not as developed as management research, the existing psychological studies about patients during pandemics during a sensitive time period (isolation)does not adequately explain the behavioral psychology of online users. as such, we applied pls-sem (smart pls) in our research [74] . to assess our measurement model, we verified the concurrent validity, discriminate validity, and composite reliability (cr) [77] . in addition to the square root values of the average variance extracted (ave), we compared constructs to determine the discriminate validity [78] . factor loading values should be greater than 0.70 [79] . for data validity and measurement, the value of the ave should be greater than 0.5 [80] , cr > 0.7 [78] , and rho > 0.7 [81] . table 3 provides the reliability and validity of our measurement scales and table 4 provides the results of the fornell-larcker test used to check distinguished and divergent validity. to create intervals of confidence and t-values, we used bootstrapping (4000 re samples) to check for imagined associations between the concerned constructs of the planned structured model. streukens, s., et al. [82] stated that bootstrap replications can vary considerably from a minimum of 500 to a maximum of 5000.in other words, statistic inconsistency is checked using the inconsistency of data using bootstrapping, which is a nonparametric resampling method, instead of using parametric statements to check the accuracy of approximation [83] . efron, b., et al. [84] proposed using more than 1000 bootstrap samples. the mediation effect is absent if the direct effect is not significant. figure 1 illustrates the hypotheses testing of direct effects, which are also shown in table 3 . table 3 also provides the fit statistics. dependent variables indicate an important and positive precursor to their independent variables. particularly, the role of e-govt was a noteworthy predictor of epidemic protection. as can be seen from figure 4 and table 5 , all of the hypotheses were supported [85] for the direct effect hypothesis at this step. 500 to a maximum of 5000.in other words, statistic inconsistency is checked using the inconsistency of data using bootstrapping, which is a nonparametric resampling method, instead of using parametric statements to check the accuracy of approximation [83] .efron, b.et al. [84] proposed using more than 1000 bootstrap samples. the mediation effect is absent if the direct effect is not significant. figure 1illustrates the hypotheses testing of direct effects, which are also shown in table 3 . table 3 also provides the fit statistics. dependent variables indicate an important and positive precursor to their independent variables. particularly, the role of e-govt was a noteworthy predictor of epidemic protection. as can be seen from figure 4 and table 5 , all of the hypotheses were supported [85] for the direct effect hypothesis at this step. to check the importance of the structural path coefficients, we report the confidence interval [86] . these were supported because we did not add up zero values in any confidence interval [78] .at present, in standardized root mean square residual (srmr) pls path modeling, mostly model fit criteria are used. we checked the accuracy of the fit by using different tools like value of normed fit index (nfi), the non-normed fit index (nnfi), the comparative fit index (cfi), root mean square error of approximation (rmsea), and srmr. values equal to or higher than 0.95 in nfi, nnfi, and cfi indicate the best fit. sufficient adjustment was represented by rmsea and to check the importance of the structural path coefficients, we report the confidence interval [86] . these were supported because we did not add up zero values in any confidence interval [78] . at present, in standardized root mean square residual (srmr) pls path modeling, mostly model fit criteria are used. we checked the accuracy of the fit by using different tools like value of normed fit index (nfi), the non-normed fit index (nnfi), the comparative fit index (cfi), root mean square error of approximation (rmsea), and srmr. values equal to or higher than 0.95 in nfi, nnfi, and cfi indicate the best fit. sufficient adjustment was represented by rmsea and srmr with values less than 0.06 [87] . for comparatively good fit between the hypothesized model and observed data, a cut-off value near to 0.08 for srmr and near 0.06 is best for rmsea; hu, l.t. et al. [88] stated that a zero value for srmr indicates an ideal fit but if the value is smaller than 0.05,the fit is satisfactory fit [89] . we investigated the standards of the coefficient of determination (r 2 ) to verify the predictive strength of our structure model. collective consequences of exogenous contracts on endogenous constructs were indicated. the r 2 of the endogenous latent variables is the vital decisive factor for this evaluation. this marker is used, from the perspective of a statistical model, to forecast future results or can be used to check the hypothesis on behalf of other related information. r 2 also provides the results of the calculations and describes the practicality of the results [90] . researchers can also use pls procedure to check their model's out-of-sample predictive power [91] . in-sample predictive power, we also refer to the r 2 [92] . r 2 varies from 0 to 1 and greater values show better descriptive power. substantial, moderate, and weak descriptive powers are indicated by r 2 values of 0.75, 0.50, and 0.25, respectively [93] . pls-sem is less dependent on the model fit concept compared to cb-sem [79] . as recommended [74] rmsea cut-off values equal to or less than 0.08 using modification in r 2 report effect size (f 2 ) indicated that the effect of our dependent variables on independent variables was very satisfactory. the effect of the exogenous latent construct on the endogenous latent construct having three possible answers, i.e., substantial, moderate, and weak, was found using thef 2 effect size. the blindfold method was used to check the strength of the research model. cohen's f 2 is an identical measure of effect size that also permits checking the local effect size, which is the effect of one variable compared with the multivariate regression model [94] . if the cross-validated redundancy (q 2 ) is higher than 0,then the model is related to predicting that factor [95] . we focused on in-sample prediction more, compared to out-sample prediction, prognostic significance q 2 , and relative relevance q 2 , which are alternatives for evaluating a model's practical relevance, in addition to consulting r 2 outcomes as a gauge of a model's predictive capabilities [95] . r 2 , q 2 , path coefficients, and the effect size (f 2 ) are the decisive factors we use for evaluation. in addition to this evaluation, researchers are required to check the inner model for potential co linearity issues. if the constructs are interrelated, then results approximated by the inner model are considered biased [96] . a model's predictive accuracy is decided by the r 2 . the r 2 value also characterizes the combined consequence of exogenous variables on the endogenous variable(s). the effect ranges from 0 to 1. a value of 1 indicates complete predictive accuracy as can see in table 6 . table 6 . effect size and predictive relevance. cohen's f 2 was calculated to check the effect size of each path model. when a construct was removed from the model, we calculated f 2 while making no changes to r 2 . researchers have to approximate two pls path models for computing f 2 . the effect size of the omitted construct for a particular endogenous construct can be found by standard values: 0.02 for small, 0.15 for medium, and 0.35 for a large effect on the basis of the f 2 value [96] . this discussion supports the use of our mediators and variables in the model. in the pls path model, mediator variables absorb the effect of an exogenous construct on an endogenous construct; this absorption of effect is known as meditation [96] . the mediation effect can be investigated using many tools, including pls-sem. though researchers use an older method to determine the mediation effect in pls-sem, the procedure that identifies the effect of a precursor variable on the findings and results is judged by mediation; in other words, mediation considers transitional variables [97] . a mediating variable may have a transitional role in the association between dependent and independent variables, and engagement of this third variable is the important feature of the mediating effect [98] . clarification and elaboration are the main effects of mediation [81] . as such, we included multi-mediation concepts in the results of social presence theory and for psychological aspects during outbreaks (see table 7 ). table 7 . mediation analysis. table 7 . multiple mediation paths outcomes and potency (level) of mediation effects are demonstrated in figures 5 and 6 . precise indirect effects were investigated by bootstrapping techniques with the help of the bias correction technique. the two independent variables (role of e-govt and2019-ncov-wom) affected online social presence; these effects support h1b, h2b, and h3c in that order, as mentioned above. to determine whether h4b, h5b, h3c, and h4c are supported, we used the proposals by hair et al. [85] . to finalize conclusions about the mediation effect; we calculated the amount and magnitude of mediation. we incorporated the variance accounted for (vaf) method to calculate the strength of mediation (figures 5 and 6 ). if vaf is less than 0.2, there is no mediation; if vaf is less than or equal to 0.8, there is a partial mediation; if vaf is greater than 0.8, there is full mediation. the magnitude and strength of epidemic protection (h4b: a1b1) and attitude toward epidemic outbreak (h5b: a2b2) mediated the association between the role of e-govt and online social presence ( figure 5 ). we found via comparison that epidemic protection has a partial mediation effect on the role of e-govt and online social presence because the vaf value was more than 0.2, which indicated that there is a partial mediation effect. as such, h4b is supported. attitude toward epidemic outbreaks mediated the association between 2019-ncov-wom and online social presence; the vaf value was greater than 0.2, which indicated the presence of mediation. therefore, we hypothesized imaginary harmonizing partial mediation because the effects of 2019-ncov-womwere considerable both directly and indirectly and their products were positive [99] . hair et al. [85] concluded that complementary and competitive mediation can be differentiated if direct and indirect effects are more prominent. the condition in which direct and indirect effects work in the same direction is called complementary mediation. this means the outcome of the direct and indirect effect is positive. the magnitude and strength of the mediation effect of epidemic protection (h3c: a3b1) and attitude toward epidemic outbreak (h4c: a4b2) mediating the association of 2019-ncov-womand online social presence is shown in figure 6 . in comparison, the vaf value was higher than 0.2, which indicated the presence and effect of mediation. due to the prominent direct and indirect effects of 2019-ncov-wom, the complementary partial mediation was also positive. the comparison showed that the association between 2019-ncov-wom and online social presence was mediated by attitude toward epidemic outbreak. the vaf value was higher than 0.2, which indicated partial mediation, also supporting the multi-mediation hypothesis [99] . int. j. environ. res. public health 2020, 17, x for peer review 14 of 21 hair et al. [85] concluded that complementary and competitive mediation can be differentiated if direct and indirect effects are more prominent. the condition in which direct and indirect effects work in the same direction is called complementary mediation. this means the outcome of the direct and indirect effect is positive. the magnitude and strength of the mediation effect of epidemic hair et al. [85] concluded that complementary and competitive mediation can be differentiated if direct and indirect effects are more prominent. the condition in which direct and indirect effects work in the same direction is called complementary mediation. this means the outcome of the direct and indirect effect is positive. the magnitude and strength of the mediation effect of epidemic ipma, also called impact-performance map or priority map analysis, is a useful approach in pls-sem. ipma adds facets and measurements that consider the scores of latent variables reporting the path coefficient [99] . approaches to determining the role of precursor constructs and their significance for management actions are offered by the pls-sem studies based on ipma. ipma compares the significance and recital (performance of the variables) [99] . analysis dimensions are used to demonstrate the results of path coefficient approximation extended by ipma in figure 7 . the advantage of ipma is the validation of total effects and a representation of their significance in a construct with an average score that indicates their performance. our main purpose with the construct was to find the most significant component in the construct. presence was mediated by attitude toward epidemic outbreak. the vaf value was higher than 0.2, which indicated partial mediation, also supporting the multi-mediation hypothesis [99] . ipma, also called impact-performance map or priority map analysis, is a useful approach in pls-sem. ipma adds facets and measurements that consider the scores of latent variables reporting the path coefficient [99] . approaches to determining the role of precursor constructs and their significance for management actions are offered by the pls-sem studies based on ipma. ipma compares the significance and recital(performance of the variables) [99] .analysis dimensions are used to demonstrate the results of path coefficient approximation extended by ipma in figure7. the advantage of ipma is the validation of total effects and a representation of their significance in a construct with an average score that indicates their performance. our main purpose with the construct was to find the most significant component in the construct. online ratings are associated with higher enjoyment than negative reviews [100] . to the best of our knowledge, the broader tasks and household behaviors of the community and family members in social media and role of e-govt have been relatively under-examined. we used an online questionnaire and proposed a unique conceptual model and multi-mediation model to achieve the objectives of our study. we constructed eight hypotheses for the direct effects(h1a, h1b,h1c,h2a,h2b,h2c,h3a, and h3b) and four hypothesis (h4b,h5b,h3c, and h4c) for the mediation effect of our dual mediators, i.e., epidemic protection and attitude toward epidemic outbreak, with their indirect effect between the role of e-govt and2019-ncov-wom on online social presence during outbreaks. our results are supported by mmijail etal. [101] who concluded that local government affects the attitude and decision-making process of people with their e-government platforms. the results of our study showed that role of e-govt have a strong effect on the attitude of the public toward quarantine. our study results also showed that public relationship directly influences positive wom. our study results are supported by kim etal., who concluded that local government affects the social presence of community participants and the identified individuals' attitudes and community [102] . our study results online ratings are associated with higher enjoyment than negative reviews [100] . to the best of our knowledge, the broader tasks and household behaviors of the community and family members in social media and role of e-govt have been relatively under-examined. we used an online questionnaire and proposed a unique conceptual model and multi-mediation model to achieve the objectives of our study. we constructed eight hypotheses for the direct effects (h1a, h1b,h1c,h2a,h2b,h2c,h3a, and h3b) and four hypothesis (h4b,h5b,h3c, and h4c) for the mediation effect of our dual mediators, i.e., epidemic protection and attitude toward epidemic outbreak, with their indirect effect between the role of e-govt and2019-ncov-wom on online social presence during outbreaks. our results are supported by mmijail et al. [101] who concluded that local government affects the attitude and decision-making process of people with their e-government platforms. the results of our study showed that role of e-govt have a strong effect on the attitude of the public toward quarantine. our study results also showed that public relationship directly influences positive wom. our study results are supported by kim et al., who concluded that local government affects the social presence of community participants and the identified individuals' attitudes and community [102] . our study results revealed that attitude toward epidemic outbreak has a strong mediation effect between the role of e-govt and online social presence during outbreaks, indicating that other governments and organizations can follow china's safety model. the chinese government allowed full opportunity to be online and for online users to promote hand washing and mask wearing during the covid-19 outbreak. as for as effect of 2019-ncov-wom and online social presence is concerned, our study findings are supported a the previous study [102] in which human voice and wom were found to have a positive impact on social presence. our findings showed that 2019-ncov-wom has a positive effect on online social presence. online social presence is increasing worldwide. social media has become increasingly important, especially for covid-19 information. in this study, we determined the impact of the role of e-government and covid-19 word of mouth on online social presence. we estimated the mediation impact of epidemic protection and attitude toward epidemic outbreaks on online social presence. the key results showed that the role of e-government and covid-19 word of mouth positively impacted online social presence. similarly, epidemic protection and attitude toward epidemic outbreak showed positive mediation impact on online social presence. from estimated results, we outline some implications and policy suggestions: during quarantine, people have more free time to participate in social media, which increases their desire to be present online. for themselves and society, they want to participate in disease protection and to provide suggestions to perform positively during the difficult time caused by covid-19 quarantine. people can obtain basic information and protection measures from e-government and obtain specifics about the issue. for practical implementations during epidemic outbreaks, the results suggest that the health authorities and government should pay more attention to managing the attitude toward outbreaks and its relationship with the role of e-government. people's perceptions about the government will help build their willingness toward long-term pandemic control. some limitations were unavoidable in our study. we used two sampling techniques: random sampling and snowball sampling; future research can be improved using different kind of sampling and data collection techniques. the second major limitation was the use of single type of role of e-govt. the reason behind this limitation was the ongoing quarantine, so it was impossible to compare the relationship of 2019-ncov-wom in online social presence with offline discussion because personal meetings, face-to-face contact, physical interviews, etc. were prohibited. however, future research can be improved using different types of research variables, using web scraping and web mining of top trends complete protection analyses. however, our findings can be implemented to improve online social presence and increase emotive protection during epidemic quarantine periods. fourth, the data were collected online. therefore, we were unable to gauge the respondents' responses during data collection, although people were very motivated to share their answers to the questionnaire because of the involvement of the role of the government. more adequate research can be conducted by expanding the study area, e.g., people from other countries. our study was limited to two provinces because as of6 march, 2020, these two provinces were still under quarantine. the study could also be further improved by focusing on recovered patients and comparing different countries affected by covid-19 using the proposed research model. further research on special issues is highly encouraged in other countries that have different isolation facilities, e.g., free internet, quiz competitions for children, etc., on the basis of the theoretical background, web scraping, and trends. maturity assessment of local e-government websites in the philippines communication channels and word of mouth: how the medium shapes the message when audiences become advocates: self-induced behavior change through health message posting in social media advice reification, learning, and emergent collective intelligence in online health support communities product patriotism: how consumption practices make and maintain national identity quantifying health literacy and ehealth 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express sincere thanks to the anonymous reviewers for productive comments. we are also thankful to xiaojian hu and mengjiehu for the inspiration. the authors have no conflict of interest to declare. int. j. environ. res. public health 2020, 17, 2954 key: cord-341620-nmrkhx5t authors: chirico, francesco; sacco, angelo; bragazzi, nicola luigi; magnavita, nicola title: can air-conditioning systems contribute to the spread of sars/mers/covid-19 infection? insights from a rapid review of the literature date: 2020-08-20 journal: int j environ res public health doi: 10.3390/ijerph17176052 sha: doc_id: 341620 cord_uid: nmrkhx5t the airborne transmission of sars-cov-2 is still debated. the aim of this rapid review is to evaluate the covid-19 risk associated with the presence of air-conditioning systems. original studies (both observational and experimental researches) written in english and with no limit on time, on the airborne transmission of sars-cov, mers-cov, and sars-cov-2 coronaviruses that were associated with outbreaks, were included. searches were made on pubmed/medline, pubmed central (pmc), google scholar databases, and medrxiv. a snowball strategy was adopted to extend the search. fourteen studies reporting outbreaks of coronavirus infection associated with the air-conditioning systems were included. all studies were carried out in the far east. in six out the seven studies on sars, the role of heating, ventilation, and air conditioning (hvac) in the outbreak was indirectly proven by the spatial and temporal pattern of cases, or by airflow-dynamics models. in one report on mers, the contamination of hvac by viral particles was demonstrated. in four out of the six studies on sars-cov-2, the diffusion of viral particles through hvac was suspected or supported by computer simulation. in conclusion, there is sufficient evidence of the airborne transmission of coronaviruses in previous asian outbreaks, and this has been taken into account in the guidelines released by organizations and international agencies for controlling the spread of sars-cov-2 in indoor environments. however, the technological differences in hvac systems prevent the generalization of the results on a worldwide basis. the few covid-19 investigations available do not provide sufficient evidence that the sars-cov-2 virus can be transmitted by hvac systems. many countries have responded to the "coronavirus disease 2019" (covid-19) pandemic caused by the emerging infectious agent termed as "severe acute respiratory coronavirus type 2" (sars-cov-2) by adopting stringent containment measures, such as the so-called lockdown. while these behavioral, non-pharmacological interventions have been proven effective in curbing the spread of the virus [1, 2] , they are having, on the other hand, significant economic and social consequences [3, 4] and cannot, by their nature, be implemented and enforced indefinitely [5] . several governments have started gradually easing and relaxing restrictions, by reopening selected businesses and production activities. the resumption of daily activities is now taking place in some countries, during the summer season, when the use of air-conditioning systems in indoor environments is necessary to ensure comfortable working conditions. the question therefore arises whether the use of heating, ventilation, and air conditioning (hvac) systems can contribute to the further spread of the microorganisms in the workplace. being a novel virus, the precise mode and routes of transmission of sars-cov-2 are still debated. sars-cov-2 is thought to primarily spread from human to human, by close contact transmission, as well as through respiratory droplets of >5-10 µm in diameter, which are generated when an infected person coughs, sneezes, talks, or sings at short distances, generally <1-2 m [6, 7] . the "airborne" transmission of droplet nuclei ("aerosolized particles of <5 µm in diameter"), remaining infectious when suspended in the air over long distances and time, is still controversial [7] . indeed, it was found that some individuals behave as "speech super-emitters," releasing sars-cov-2 particles of ≤1 µm in diameter during normal breathing and speech [8] , coughing and talking [9, 10] . some airborne "superspreading" events have occurred in the past with other coronaviruses, e.g., in 2003, a sars-cov-1 outbreak initiated in hong kong and spread to other countries, and in 2012, a "middle eastern respiratory syndrome" (mers)-cov outbreak in the kingdom of saudi arabia and in 2015 in south korea [11] [12] [13] . moreover, the airborne transmission of sars-cov-2 can occur during medical procedures that generate aerosols ("aerosol-generating procedures") [14] . many aerosol-generating surgical procedures have been identified [15] [16] [17] [18] [19] [20] , and special preventive measures have been proposed [21, 22] . the transmission capacity, and therefore the infectious power of the aerosols, also depends on the presence of airborne particulates. one feature of all particulates is that they can convey and release toxic molecules, as well as microorganisms, including viruses [23] . some studies have associated the spread of covid-19 cases with pm2.5 microparticle pollution levels [24] [25] [26] . in italy and other european countries, technical guidelines have been released to limit the operation of hvac systems, such as the recirculation of exhausted air [27] [28] [29] . the different methods of air distribution have different limitations and solutions [30] . all safety measures, including those on the use of air-conditioning, have costs, which must be balanced by the benefits. the limitation of the use of air conditioners could create thermal discomfort, and negatively affect productivity and health outcomes in the workplace-where people spend one-third of their lifetime-and other indoor environments. the assessment of the risk of infection associated with the use of air-conditioning is essential for making correct decisions. therefore, to evaluate the covid-19 risk associated with the presence of air-conditioning systems, we conducted a rapid review of the literature concerning outbreaks of coronaviruses (sars-cov-1, mers-cov, and sars-cov-2) in indoor environments. due to time constraints related to the urgency of the ongoing pandemic, we carried out a rapid review [31] , thus streamlining the rules that characterize a systematic review. we utilized the participants-exposure-comparisons-outcome (pecos) criteria, and we defined them according to evidence-based practice [32] -p (participants) is human subjects residing in indoor environments, e (exposure) is exposed to air-conditioning systems (hvac), c (comparisons) is any comparison between the pathogens under study, and o (outcome) is respiratory infection outbreaks caused by sars-cov-1, mers-cov, or sars cov-2. only original studies (both observational and experimental researches) written in english were retrieved, with no limit on time. narrative reviews, opinions, and commentaries were excluded. we also excluded experimental studies on the airborne transmission of coronaviruses that were not associated with outbreaks. articles indexed in pubmed/medline, pubmed central (pmc), google scholar databases, and medrxiv (a pre-print server for health sciences), were retrieved on july 11, 2020. a snowball strategy was then adopted to extend the search, including extensive cross-referencing, and using subject headings or keywords to search for similar relevant articles. keyword checking was performed by the authors independently. the electronic search strategy used keywords related to the topic under investigation ("air-conditioning" or "hvac") in combination with "covid-19," "virus," "sars," "mers," "sars-cov-2," and "coronavirus," properly combined by boolean operators. after independently reviewing all titles/abstracts to identify potentially relevant articles, an author (fc) selected studies for full-text review [32] . data concerning the country of study, the study design, and the study setting, as well as the study's outcomes, were extracted. the results of the studies retained in the present rapid review were synthesized qualitatively. in our review, we found 14 studies reporting outbreaks of coronavirus infection in indoor environments (table 1) . seven studies concerned sars-cov-1, and six sars-cov-2, respectively, while only one regarded mers-cov. seven studies were carried out in hong kong, one in south korea, three in japan, and three in china. the studies were conceived as cross-sectional, in two cases with a retrospective collection of data, and in six cases complemented by an airflow modelling method or environmental sampling. in the sars-cov-1 epidemic, studies focused mainly on two outbreaks, which occurred in the prince of wales hospital, a regional and teaching government hospital, and in amoy gardens, a private housing estate in hong kong, which were the most seriously affected locations during the 2003 outbreak of severe acute respiratory syndrome (sars). both were served by air-conditioning systems. the episodes occurred in 2003. in the first one, in march 2003, 156 patients in the prince of wales hospital in hong kong were infected by a patient treated with a jet nebulizer [33] . in this episode, which affected healthcare workers, medical students, and patients, the proximity of the patients may have allowed the infection to spread through nuclei droplets, although the production of aerosols during treatment was evident. this outbreak was also studied by wong et al. [34] , with a retrospective observational study on 66 medical students who visited the index patient's ward. the authors showed that the flow rate was highest in the air supply diffuser in the index patient's cubicle, and lowest in the corresponding exhaust grille. this imbalance would have favored the spread of aerosols. the computed concentration contours of aerosols, in fact, matched epidemiologic data. a retrospective study of on outbreak involving 74 patients in the same hospital indicated that the rapid evaporation of the droplets produced by coughing in a relatively dry, air-conditioned environment, could also induce virus-laden aerosol, which was probably responsible for spreading the infection to patients who were not in the same room [35] . the ward, however, was air-conditioned by a fan coil system with a separate fresh air supply. the exhaust air from this ward was discharged to the outside and not recirculated to other wards. a modelling study conducted by chen et al. [36] on ward 8a of the same hospital in hong kong, where patients and staff were infected, demonstrated the direct responsibility of hvac systems in the diffusion of the disease. the air exchange owing to temperature difference played a significant role in sars transmission during the nosocomial outbreak in ward 8a, and the two-way airflow effect at the openings could have played an important role in bioaerosol transmission [36] . the sars outbreak that occurred in 2003 in the isolation ward of an infectious disease hospital in hong kong also had a spatial infection pattern compatible with airborne transmission. some design defects in the air-distribution system, with unbalanced flow rates in supply diffusers and exhaust grilles, could have played a role in infection spreading. computational fluid dynamics simulations confirmed this hypothesis [37] . in the same year, more than 300 residents of a private high-rise housing estate were infected with sars cov-1 within a short period, and 42 died. the case index was a tenant receiving haemodialysis. virus-containing aerosol could have escaped into the narrow lightwell between the buildings and spread in rising air currents. the association between the predicted bioaerosol concentration and the spatial infection pattern suggested an airborne transmission route, and the aerosol distribution patterns coincided with the spatial and temporal distribution of infections [38, 39] . unfortunately, none of the investigations were completed with the isolation of microorganisms in the environment. in 2015, the spread of mers was associated with aerosol transmission in three patients from two hospitals in south korea [40] . environmental sampling from the air exhaust damper revealed the presence of viral particles of mers-cov. the potential airborne transmission of mers was supported by the disclosure of viral particles in the hospital environment including air, fomites, and environmental surfaces. in summary, six of the seven sars studies suspected that the air-conditioning system had played a role in the spread of the infection. in the only study available on mers, contamination of hvac by viral particles was demonstrated. data concerning the new coronavirus sars-cov-2 are obviously scarce. the analysis of 318 outbreaks involving, in different settings, 1245 infected individuals in 120 cities in china from 29 december to 11 february 2020, prompted quian et al. to assert that long-range aerosol transmission had occurred in crowded spaces with poor ventilation. detection of infectious particles in the air and on inaccessible surfaces suggested that the virus might be transmitted via airborne routes, and not only from droplet exposure [41] . three studies were devoted to the outbreak that occurred in the diamond princess cruise ship, which affected 355 people in japan. according to zhang et al., the main route for transmission was from person to person, but other routes, including aerosol transmission via central air supply or drainage systems, could not be excluded [42] . the studies of xu et al. [43] and mizumoto and chowell [44] on the same outbreak, led to the opposite conclusion. most of the cases originated by passenger-to-passenger transmission through close contact and fomites. after the adoption of quarantine measures, new cases among passengers were limited to those who stayed in the same room with an infected passenger. therefore, the ship's central air-conditioning system would not have played a role, i.e., the long-range airborne route was not relevant in the outbreak. another outbreak occurred in a chinese restaurant from january 26 to february 10, 2020. ten persons from three families were infected with sars-cov-2. the restaurant had an air-conditioned, fifth-floor building without windows. each floor had its own air conditioner. according to lu et al. [45] , droplet transmission was likely prompted by air-conditioned ventilation. the key factor for the outbreak was the direction of the airflow. studying the same outbreak with computer simulations, li et al. [46] postulated that the infection distribution was consistent with a spread pattern representative of exhaled virus-laden aerosols. in summary, in four out of the six studies on sars-cov-2, the diffusion of viral particles through hvac was suspected or supported by computer simulation, while in the other two studies, it was excluded based on epidemiological considerations. the few covid-19 investigations available do not provide sufficient evidence that hvac systems can play an important role in the indoor outbreaks reported to date. demonstration of the contamination of hvac systems by sars-cov-2 viral particles is currently lacking. this evidence, in fact, was collected only during the mers epidemic, and it is still unknown if the sars-cov-2 virus has the same potential transmission and spreading diffusion as the previous one. furthermore, modelling studies on the distribution of viral particles for covid-19, which in the first sars epidemic strongly supported the possibility that sars-cov-1 aerosols could be captured and re-emitted by hvac, are not yet available. nevertheless, the findings obtained from the previous coronavirus epidemics, in which the hvac systems were often held responsible for the spreading of the virus, do not allow us to believe that they are now totally risk-free. furthermore, we know that certain medical procedures may produce aerosols, and that they have been responsible for the spread of coronavirus in healthcare settings [47] . environmental investigations have shown the presence of sars-cov-2 viral particles on surfaces that cannot be reached by droplets, and this is indirect evidence that the transmission of aerosols has taken place [48, 49] . recent covid-19 outbreaks reported during choir practice [50] , in a call-center [51] and in fitness classes [52] , have suggested the role of aerosol transmission in combination with droplet transmission, particularly in crowded and inadequately ventilated indoor spaces. experimental studies in a laboratory-controlled environment demonstrated that aerosolized sars-cov-2 particles (<5 µm) remained suspended in the air for at least 3 h, viable in air for at least 1 h, and on surfaces for up to days [53] [54] [55] . the half-life of viral particles could be different in relation to meteorological conditions-such as temperature, relative humidity, and ultraviolet radiation-that could degrade and weaken the virus [56] [57] [58] . ventilation systems have been already reported as a way of transmitting/spreading infectious diseases such as measles, chickenpox, flu, smallpox [59, 60] , and the 2009 influenza a (h1n1) pandemic [61] . the possibility that the sars-cov-2 virus remains suspended in the air, in free micro-drops or attached to particulates, and therefore can be picked up by the air-conditioning systems and put back into circulation, poses an evident safety problem for indoor environments [62, 63] . the characteristics of hvac systems, therefore, are very important for safety purposes. unfortunately, the available studies refer exclusively to outbreaks that occurred in the far east, in environmental and plant conditions that cannot be considered representative of other parts of the world. building types, air-conditioning systems, regulations, and maintenance requirements may differ between countries, so the available studies may not be generalizable. on the other hand, the accumulated knowledge about the novel sars-cov-2 indicates that it has higher aerosol and surface stability than sars-cov-1 and can remain viable and infectious in aerosol for hours [64] . patients affected by covid-19 could have a high viral load, which correlates with transmission risk and disease severity [65] . when dealing with a new disease, particular caution is required. the aerosol model of sars-cov-2 transmission has several practical implications, and this is confirmed by the analysis of the most important guidelines released by organizations and international agencies [27] [28] [29] , which should be based on the best available scientific evidence. most of the existing recommendations, which suggest deactivating air recirculation mode in all indoor environments, seem to be especially based on previous evidence of airborne transmission of sars-cov-1 and other airborne viruses, as research on sars-cov-2 is still limited. only future studies will clarify whether hvac implants played a role in favoring the spread of viruses in covid-19. in the meanwhile, occupational preventive measures should be based on the best possible scientific evidence by balancing costs and effectiveness, yet according to the principles of a precautionary approach. limiting recirculating air may not be technically possible in all workplaces, may give rise to additional costs, and could not balance cooling and heating functions in summer and winter, with appropriate levels of relative humidity and air velocity [66] . moreover, too high, or too low temperatures, and low ambient humidity, are known to enhance viral transmission [67, 68] , and thus could harm the elderly and workers with "fragilities." therefore, employers, assisted by their consultants, must conduct a careful assessment of the risks and benefits associated with the use of air-conditioning systems. the choice to keep the systems in operation, guaranteeing comfortable working conditions, must always be accompanied by a continuous and scrupulous maintenance of the systems, with the use, where possible, of high-efficiency total filters. the technical and engineering characteristics of hvac are of the utmost importance in the diffusion of pollutants. undoubtedly the most effective methods to reduce pollution are the increase in ventilation (increase in air flow rates) and the minimization of air recirculation, with the introduction and treatment of external air. however, these methods are very expensive, and often not very efficient. all air intake systems should be designed so as to avoid the presence of air currents in the respiratory area of workers or occupants; this undoubtedly contributes to avoiding the long-distance transport of droplets and aerosols. the efficiency of hvac systems filters could be increased by nanomaterials [69] . in healthcare settings, environmental engineering controls, consisting of physical engineering elements such as negative pressure rooms, dilution ventilation, high-efficiency particulate air filtration, ultraviolet lights, and scavenging devices, can reduce the aerosol diffusion [70] . in other types of environment, proposed alternatives to hvac include adopting natural ventilation and personalized ventilation-personalized exhaust systems (pv-pe) for microenvironments [61] . in the risk assessment process, it is of primary importance to estimate the probability that an infectious person is inside the premises. this probability can be inferred from the trend of the epidemic in the region where the building is located, and from the consideration that covid-19 can spread in many people in an entirely asymptomatic way, making screening at the entrance ineffective [71] . it was observed that oligosymptomatic patients with a sars-cov-2 infection can have a greater viral load than that of patients hospitalized with severe forms [72] , and therefore represent a real threat. therefore, the risk assessment and the decision to keep the air-conditioning system active must be dynamic and based on the epidemiological evolution of the pandemic, as well as on the verification of the characteristics of the system and its efficiency. this rapid review aimed to synthesize the available information for policy-makers, employers, technicians, and workers concerning the aerosol transmission of sars, mers and covid-19 infections in air-conditioned indoor environments, in order to give a guide to the best choices for workers' health protection. the weaknesses of our study are mainly in the data retrieved. studies included in this review were few, often anecdotal, and published in non-peer-reviewed journals. the lack of quantitative data did not allow us to extract meta-analytical information. the "rapid" nature of this review, and finally the type of studies included, prevented us from making an appropriate evaluation of their quality. in conclusion, this short review is a warning for health and safety consultants, and a stimulus for further studies on the relationship between sars-cov-2 and air-conditioning systems. the studies available to date are not sufficient to support the conclusion that air-conditioning systems favor the spread of the sars-cov-2 infection in office and indoor community environments. however, in previous coronavirus epidemics, hvac systems not specifically designed to accommodate infectious patients were suspected of facilitating the spread of sars-cov-1 and mers-cov in hospital and community settings. the guidelines released by organizations and international agencies for controlling the spread of sars-cov-2 in indoor environments are based on these studies. the formation of aerosols, which is possible in many medical activities, and the great variability in the viral load in patients, make it necessary to adapt the safety of the hvac systems to the specific control needs. prevention in workplaces must be personalized, with the adoption of more stringent measures when epidemiological circumstances (e.g., increase in the number of cases, increase in hospital admissions) require it. the precautionary principle requires the utmost attention in the design and management of air-conditioning systems, while waiting for further evidence on the effectiveness of safety measures proposed by international guidelines. only strict quarantine measures can curb the coronavirus disease (covid-19) outbreak in italy quarantine alone or in combination with other public health measures to control covid-19: a rapid review shielding from covid-19 should be stratified by risk covid-19: 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li, zhi; chen, weiming; zhao, yunpu; yue, hanxun; wu, zhenzhen title: path optimization of medical waste transport routes in the emergent public health event of covid-19: a hybrid optimization algorithm based on the immune–ant colony algorithm date: 2020-08-12 journal: int j environ res public health doi: 10.3390/ijerph17165831 sha: doc_id: 343767 cord_uid: nnx8adtl in response to the emergent public health event of covid-19, the efficiency of transport of medical waste from hospitals to disposal stations is a worthwhile issue to study. in this paper, based on the actual situation of covid-19 and environmental impact assessment guidelines, an immune algorithm is used to establish a location model of urban medical waste storage sites. in view of the selection of temporary storage stations and realistic transportation demand, an efficiency-of-transport model of medical waste between hospitals and temporary storage stations is established by using an ant colony–tabu hybrid algorithm. in order to specify such status, wuhan city in hubei province, china—considered the first city to suffer from covid-19—was chosen as an example of verification; the two-level model and the immune algorithm–ant colony optimization–tabu search (ia–aco–ts) algorithm were used for simulation and testing, which achieved good verification. to a certain extent, the model and the algorithm are proposed to solve the problem of medical waste disposal, based on transit temporary storage stations, which we are convinced will have far-reaching significance for china and other countries to dispatch medical waste in response to such public health emergencies. medical waste refers to wastes produced by medical and health institutions in the course of medical treatments, preventions, health care, and other related activities, which are directly or indirectly infectious, toxic, and have other hazardous characteristics. for large and medium-sized cities, how to set up an effective medical waste transport system has long been the focus of the world. the academic community has also put forward many ideas and solutions. for example, gerasimos mantzaras [1] developed an optimization model to minimize the cost of a collection, haul, transport, treatment and disposal system for infectious medical waste (imw). qiu cheng [2] believed that a bot (build-operate-transport) model could be used to solve the problem of medical waste treatment, and selected kunming city as an example for the research. liu xiaoli [3] analyzed the current situation of medical waste transport in primary hospitals with wuhan as an along with a novel decoding method to solve cvrp [30] ; mauro dell'amico proposed a new iterated local search metaheuristic method for cvrp that also includes a vital mechanism from the adaptive large neighborhood search combined with further intensification through local search [31] ; r. baldacci described a new integer programming formulation for cvrp based on a two-commodity network flow approach [32] ; fernando afonso santos introduced a branch-and-cut-and-price algorithm for two-echelon cvrp [33] ; jiafu tang developed a beam-mmax algorithm that combines a max-min ant system with beam search to solve cvrp [34] ; jacek mańdziuk proposed a solution to cvrp with traffic jams, which relies on application of the upper confidence bounds applied to the trees method [35] ; juan rivera presented a mixed integer linear program and a multistart iterated local search, calling a variable neighborhood descent to solve multitrip cumulative cvrp [36] ; vincent f. yu presented a symbiotic organism search heuristic method for solving cvrp [37] ; ehsan teymourian presented an enhanced intelligent water drop and cuckoo search algorithm for solving cvrp [38] . most of the research mentioned above only focused on the improvements of the cvrp solution and some preliminary applications of the theoretical model without considering practical applications such as the transport of medical waste. considering the particularity of the transport problem of medical waste, it is of paramount importance to establish a targeted model. in terms of the algorithm, the specific model discussed in this paper not only simplifies cvrp, but also involves location and its allocation; the algorithm above has its limitations, and we need to put forward a specific algorithm to solve this model. moreover, due to the emergency, urgency, and criticality of the pandemic, the establishment of an efficient transport system model of medical waste has become a priority in response to the emergent public health crash. in this paper, the immune algorithm, the q-value method, and the improved ant colony algorithm are applied to the model to solve the path planning problem of the transport of medical waste. finally, the strategy under the simulation parameters is given in the simulation experiment. the model could provide a valuable reference for emergency vehicle scheduling and transport of medical waste before and after such unprecedented public health events. the rest of this paper is organized as follows: in section 2, a complete mathematical description of the model is proposed. in section 3, the theory of the immune algorithm and the ant colony algorithm, which are used to lead to our improved algorithm, is explained, in addition to the initialization of some key parameters. in section 4, wuhan is taken as an example to verify the algorithm and to solve the model in the actual background. additionally, section 5 gives a review and conclusion of the whole work. the studies of this paper are to establish a number of transport stations and an efficient medical waste transport model between hospitals and transport stations and, eventually, optimize the transportation paths. this problem is a nonconvex and nonsmooth nonlinear programming problem with complex constraints. it is an np-hard problem, and it is difficult to solve in a traditional way. the problem can be divided into the following two subproblems: the first subproblem is to establish several waste transport stations for numerous existing hospitals. when establishing the model of the transport stations, factors including the environment and traffic need to be considered. the second subproblem is based on the first subproblem. after establishing the transport stations, we need to optimize the transportation paths between each of the hospitals and the corresponding transport stations. in path optimization, factors such as the load capacity of the transport vehicle and the amount of generated waste are taken into account. the second subproblem is similar to cvrp. in addition to the two problems above, considering the practical background of this problem, to reasonably initialize the amount of medical waste and the number of transport vehicles is also required. however, these problems are not major. as a result, their solutions are not presented as separate subproblems. to solve the problem of finding suitable transport stations, we have established the following mathematical description: explanation of the variables used in the model: n = 1, 2, . . . n is the serial number set of all hospitals; s is the upper limit of the distance between the transport station and the hospital we set; m i is the set of candidate transport stations, with a distance to hospital i less than s; ω i represents the amount of medical waste generated by hospital i every day; d ij represents the distance from hospital i to the nearest transport station j; z ij is a boolean variable, indicating whether there is a transshipment relationship between hospital i and transport station j. when z ij is 1, it means that the waste of hospital i will be transported to the transport station j; h j is a boolean variable. when h j is 1, it indicates that location j is selected as the relay station. p is the number of transport stations we set, which is a constant. explanation of the formula in the model: formula (1) is the goal of this model, which ensures a minimum transportation cost from the hospital to the transport station; formula (2) ensures that the waste of each hospital will only be transported to the only transport station corresponding to this hospital, which is convenient for management; formula (3) ensures that hospital waste can only be transported to the location set as a transport station; formula (4) ensures that the number of points selected as a transport station is p; formula (5) indicates that z and h are boolean variables; formula (6) indicates that all transport stations should be within the transportation range of the hospital. in addition to the establishment of these transport stations, we also need to consider their impact on ecological and human-activity areas. therefore, on the basis of the mathematical model, we also used the buffer analysis technology of arcgis software to exclude the areas where the environmental assessment indicators are unqualified. this exclusion belongs to the application of the model. thus, this exclusion is mentioned in section 3.4.1, later in the article. in the first problem, we established several transport stations, and each transport station is responsible for a certain number of hospitals. the waste of these hospitals only needs to be transported to their corresponding transport stations. hence, in path optimization, considering the transportation between each transport station and the corresponding hospital, as well as the transportation between the hospitals responsible for the same transport station, are needed. nothing else needs to be considered. for example, suppose there are two transport stations, a and b. a is responsible for two hospitals, c and d. then, we merely need to consider the transportation between a, c, and d, not the transportation between a and b, nor the transportation between b, c, and d. therefore, the problem has been simplified to a scheduling problem between one transport station and its corresponding hospitals. after understanding this simplification, we improved cvrp to make it suitable for our problem. then, we could get the following mathematical model: explanation of the variables used in the model: for one transport station, m is the number of transport vehicles we assign to it; d i is the amount of daily waste generated by hospital i; c ij is the distance of the transport vehicle from hospital i to hospital j; b k is the capacity of transport vehicle k; x k ij is a boolean variable used to indicate the vehicle's path. when x k ij is 1, it means that vehicle k visits hospital j immediately after visiting hospital i. explanation of the formula in the model: formula (7) is the goal of the model, which ensures that the transportation path between each transport station and its corresponding hospitals is the shortest; formula (8) indicates that the transport vehicles depart from the transport station and return to the transport station after completing the transportation task. each car's path forms a hamilton tour; formulas (9) and (10) indicate that the vehicle must serve all hospitals and they can only be served once; formula (11) indicates that when each vehicle serves the hospitals, its own load cannot be lower than the total amount of medical waste of the hospitals it passes through. evolutionary algorithms have strong robustness to solve complex optimization problems [39] . the immune algorithm (ia) is a new intelligent algorithm inspired by biological immune systems. it applies the diversity of the immune system to generate and maintain the diversity of the population, which overcomes the "premature" problems that are difficult to deal with in the general optimization process, especially in the multimodal function, and finally obtains the global optimal solution [40] . the ant colony optimization (aco) algorithm, as one of the modern heuristic algorithms, has received wide attention since it was proposed. it has the advantages of positive feedback, parallelism, and robustness, which show good performance in solving task allocation and path optimization. however, at the same time, the ant colony algorithm also has some defects, such as when solving large-scale problems, as problems such as long operation time, slow convergence speed, and ease of getting into the local optimal solution frequently happened. the tabu search (ts) algorithm constructs a tabu table to avoid getting into the global optimal solution and improves the optimization ability of the algorithm. in this paper, a hybrid intelligent algorithm of ia-aco-ts is proposed to solve the problem of the model in a realistic background. as an extension of the emerging intelligent algorithm and the genetic algorithm, the immune algorithm has good robustness and global search ability for the location of the transport station, the coordinates of the distribution of hospitals, and the transport station are selected. for the path optimization problem between the transport station and the hospitals, we used the ant colony optimization algorithm and the tabu search algorithm to solve it, which is a vehicle routing problem with load constraints (cvrp). considering that the ant colony algorithm can easily fall into local optimum and its stability is not good enough, we optimized the pheromone updating mechanism using the basic idea of the tabu search algorithm and set the tabu table and aspiration criterion in order to improve the effectiveness of the algorithm to solve the problem. the specific process of the immune algorithm is shown in the flowchart in figure 1 . we can find more specific information in [41] . if the memory library is not empty, then the antibody population is generated from the memory library. otherwise, the initial population would be generated in the feasible solution space randomly. simple coding is used here. each selection of the location can produce an antibody of length ( if the memory library is not empty, then the antibody population is generated from the memory library. otherwise, the initial population would be generated in the feasible solution space randomly. simple coding is used here. each selection of the location can produce an antibody of length p (p for the number of transport stations), while each antibody represents the sequence selected for the hospital to which the transport station belongs. for example, consider the problem containing 10 hospitals, with 1 to 10 being the sequence of hospitals. suppose you pick three of them, and antibody 1, 2, 3 represent a feasible solution, which means 1, 2, 3 have been chosen for the transport stations. (1) affinity between antibody and antigen antibody-antigen affinity indicates the recognition degree of antigen to antibody. according to this model, we set up affinity function a: the first term of the denominator is the objective function of the model, and the second term gives a penalty function to the solution violating the distance constraints. c is a large, positive number. we use the affinity between the antibody and antigen as a fitness function. (2) affinity between antibodies the antibody-antibody affinity reacts to the degree of similarity between antibodies. in this paper, we use the r-continuous bit matching rule proposed by forrest in 1994 to calculate the affinity. where k v,s is the number of the same bits between antibody v and s. l is the length of the antibody. ( the concentration of the antibody is the percentage of the antibody's population to the whole population. (4) expected reproductive probability in a population, the expected reproductive of each individual is determined in part by antibody-antigen affinity a and antibody concentration. 3.1.4. immune operation (1) selection. we used the roulette selection mechanism for select operation. the individual selection probability is expected to be the more reproductive probability. (2) the algorithm uses a single-point crossover for crossover operation. (3) mutation random selection of mutation bits is used for mutation operation. ant colony optimization (aco) is an optimization algorithm that simulates the foraging behaviors of ants. it was first proposed by italian scholar dorigo, m. and others in 1991 and used in solving tsp (the traveling salesman problem) for the first time. aco uses the concept of pheromones to simulate the communication mechanism between individuals, which endows the artificial ant with certain memory abilities, so the path chosen would be optimized gradually with the increase of the number of drops. the pheromone update formula for each path is presented as follows: the formula represents the updating of pheromone on path (i, j) at time (t + n); τ ij (t) represents the pheromone on path (i, j) at time t; ρ represents the information volatilization factor. when the ant colony algorithm is used to solve cvrp, ants produce pheromones on each path. the pheromones indicate the attraction degree of the next customer j to the vehicle k. when the vehicle's load meets the needs of customers, the vehicle will select customers according to the transport rules we set. after all the selected customers form loops, the pheromone of each path is updated, and then an iteration is operated. when the iteration reaches the maximum number of times, a pareto solution can be obtained. compared with other heuristic algorithms, aco has higher performance. when ant k is at node i, solve for the probability density function to the next node according to the following rules: in the expression, τ ij represents the concentration of pheromone on edge (i, j), η ij is the attraction of transporting from one node to another, and we could let η ij = 1 d ij , where d ij is the distance between the nodes. n k i (t) is the set of optional nodes. when the transport probability is worked out, a random number table is generated to determine the next transport station. according to the above description, aco is applied to solve the vehicle routing problem in a specific region. the steps of the algorithm are as follows: (1) parameters initialization. set the maximum number of iteration n c , the current optimal shortest path length shortest len , the customer demand load[j], and the current optimal path tabu table tabu min . calculate the pheromone's initial value τ 0 , transport attractiveness η ij (i, j = 1, 2, . . . .tabu and the optimal path is updated globally. the specific process of the whole algorithm is shown in the flowchart in figure 2 . replace with [ ]. and the optimal path is updated globally. the specific process of the whole algorithm is shown in the flowchart in figure 2 . according to "technical principles for environmental impact assessment of construction projects of hazardous waste and medical waste disposal facilities (for trial implementation)", the location of hazardous waste and medical waste disposal facilities must strictly abide by the relevant provisions of national laws, regulations, and standards. additionally, the site selection should be based on a comprehensive analysis of the social environment, natural environment, site environment, engineering geology, hydrogeology, climate, emergency rescue, and other factors. according to the assessment guidelines of the actual situation in wuhan, this paper summarizes the exclusion criteria that are not suitable for the construction of medical waste disposal facilities in the analysis process using arcgis, as shown in table 1 . under such epidemics, the distribution of limited carrying capacity is a common resource allocation problem, which is a typical case of the application of mathematics in the political field. the goal is to be as fair and reasonable as possible when a large group allocates certain resources to a small group. since carrier forces are quantized, the key to solving the problem is to propose a fairness measure that satisfies the following five principals: 1. an increase in population on one side would not result in the loss of a place on the other; 2. on an average basis throughout the period, each side will receive its own share; 3. increases in the total number of places would not result in a decrease in the number of places for one side; 4. neither side's places will deviate from its proportional places; 5. the absence of a place transport from one side to the other will bring both sides closed to their share. since there is no absolute fair distribution, people have devoted themselves to the study of relative fairness. the famous q − value method was developed in 1982 by d.n. burghes and i. huntley, which is a simple method that can overcome some contradictions of other methods, so it has been widely used in the problem of fair allocation of resources. for the specific problem in this paper, we have the following model: suppose that there are m vehicles participating in n distributable transport stations, where the resources of i are p i . the total resource of m is p = m i=1 p i , and the vehicles for i are n i . how do we find a set of integers n 1 n m that make m i=1 n i = n as fair as possible? the ideal fair distribution scheme is the distribution according to the proportion of resources; that is, the number that the i should distribute is n i = p i p n, which often is not an integer, and a "round-off" leads to unfairness, so the classical q − value method was put forward. the q − value method is used to derive a standard quantity q i for the allocation of seats, m) . according to it, we determine which side should be allocated the next seat, as follows: first, each side is assigned a seat based on the calculated value of qi. the larger side has priority to get the next seat. then, calculate the value again, and so on, until all seats are allocated. we applied the q − value method to solve the problems of assigning buses to each transport station in wuhan. in this paper, the total quantity of waste in each transport station is taken as the parameter p in the method, and it is known that wuhan has 50 vehicles that can transport waste at present. the p-value is substituted into the formula, and the total number of vehicles assigned to each transport station is solved circularly. the q − value method is used to allocate the vehicles, and the carrying capacity is reasonably distributed in each area of wuhan so that the existing manpower and material resources can be used more evenly and efficiently. based on the data we have, we initialize the amount of medical waste generated by hospitals of all levels. the result is shown in table 2 . for the amount of medical waste, the number is initialized by statistics. hospitals are divided into three levels according to the objective hospital grade, with the lowest level being 1 and the remaining two levels being 1.25 and 1.54, respectively. in this model, we consider the temporary shelter hospitals established during the special period of the pandemic. considering that the shelter hospitals only accept patients with coronavirus and their scale is limited, taking into account the fact that this part of the patients' household waste would be classified as medical waste, all the shelter hospitals in the second class are clarified. since the outbreak of covid-19 in wuhan in december 2019, the epidemic has escalated rapidly, with more than 400,000 confirmed cases worldwide and a total of 35 countries declaring a state of emergency. as another significant field of epidemic prevention and control, the treatment of highly infectious medical waste has also been attached with great importance by the chinese government. with the reference of the latest data from the ministry of ecology and environment of the people's republic of china, the average daily output of medical waste in wuhan before the outbreak was 400,000 tons, while after the epidemic developed at an unprecedented level, the topmost output of medical waste was 2.4 million tons, whose rate was much faster than its incineration at medical waste disposal centers. during the period of epidemic prevention and control, medical waste generated from the medical treatment of confirmed and suspected patients and their close associations, as well as people isolated at home, was highly contagious, and therefore territorial medical waste was completely cleaned every day, which burdened the medical waste disposal units heavily. since the disposal centers did not have excess disposal capacity, many designated treatment hospitals also needed to concentrate on sanitizing the excessive medical waste immediately. although wuhan's medical waste treatment capacity has greatly improved, it is still in a "tight balance", with a daily medical waste loading rate of 93.2 percent, as the director of the emergency response office of the chinese ministry of ecology and environment said at a press conference. he mentioned that we are now faced with many problems, such as the relative lag of the linkage efficiency of various positions, the inability to transport medical waste in a punctual way, and the high pressure on communities and medical institutions (including 48 designated hospitals and 16 shelter hospitals). the question of how to solve these problems of the existing medical waste management system in public health emergencies is considerable, for further reducing the risk of secondary transmission of the virus, reducing the transportation time cost of medical waste, and promoting the progress of epidemic prevention and control. based on the major public health event in wuhan, the transport efficiency of medical waste is not enough; this paper takes wuhan during the epidemic period as an example to verify our model. the data of wuhan is used for data visualization (dataset information, hospital/shelter hospital coordinates and relay station coordinate scatter points, ia-aco-ts parameter setting, result visualization) to verify the applicability and validity of the model. the research also provides the perspective of medical waste transport for the world to fight against the epidemic. the first step in setting up medical waste disposal sites is using the criteria of table 2 to exclude inappropriate areas based on gis software. as shown in figure 3 , the yellow areas are unsuitable and the pink areas are suitable for the construction of medical waste disposal facilities. given that most of the clinical waste is generated in urban areas, in order to minimize transportation costs, we needed to select a location that is closer to the city center, acting as the final disposal point, the coordinates of which are 30.491111, 114.182922. using the immune algorithm to optimize our calculation, we obtained the geographical coordinates of each relay station and then screened the stations according to the environmental evaluation criteria. the result is shown in figure 4 and table 3 . as shown in figure 5 , with the increase in the number of iterations, the results gradually converged and we obtained a relatively stable optimal solution. the first step in setting up medical waste disposal sites is using the criteria of table 2 to exclude inappropriate areas based on gis software. as shown in figure 3 , the yellow areas are unsuitable and the pink areas are suitable for the construction of medical waste disposal facilities. given that most of the clinical waste is generated in urban areas, in order to minimize transportation costs, we needed to select a location that is closer to the city center, acting as the final disposal point, the coordinates of which are 30.491111, 114.182922. using the immune algorithm to optimize our calculation, we obtained the geographical coordinates of each relay station and then screened the stations according to the environmental evaluation criteria. the result is shown in figure 4 and table 3 . the − value method is used to assign the corresponding vehicles to each transport station. the error function is defined as ℎ is the staging area, is the number of vehicles allocated, and is the proportion of waste to the total. after calculation, the vehicle allocation and the resulting error are shown in table 4 . the cumulative error is = 0.02897. this result is in line with the actual demand, which means the distribution effect is good. to demonstrate the effectiveness of our algorithm, we applied real data from wuhan, including its current capacity and the distribution of hospitals, as well as the shelter hospitals, to the model. the final road map is shown in figure 6 . the q − value method is used to assign the corresponding vehicles to each transport station. the error function is defined as where i is the staging area, n is the number of vehicles allocated, and p is the proportion of waste to the total. after calculation, the vehicle allocation and the resulting error are shown in table 4 . the cumulative error is ε = 0.02897. this result is in line with the actual demand, which means the distribution effect is good. to demonstrate the effectiveness of our algorithm, we applied real data from wuhan, including its current capacity and the distribution of hospitals, as well as the shelter hospitals, to the model. the final road map is shown in figure 6 . as it can be seen, there are eight relay stations in total in the diagram, which are color-coded. each transport station has its corresponding hospital. the green line is the result of path optimization by utilizing the ant colony-tabu hybrid algorithm. this result ensures the efficiency of medical waste dispatch in the area controlled by each transport station effectively. as it can be seen, there are eight relay stations in total in the diagram, which are color-coded. each transport station has its corresponding hospital. the green line is the result of path optimization by utilizing the ant colony-tabu hybrid algorithm. this result ensures the efficiency of medical waste dispatch in the area controlled by each transport station effectively. focusing on each of the transport stations, we get the information shown in figure 7 . with the increase in the number of iterations, the convergence of the algorithm is shown in figure 8 . as can be seen in figure 8 , with the increase of the number of iterations, the results gradually converge and obtain a relatively stable optimal solution. in view of this, we are certain that the model of this paper has a good fit and dispatching effect even for wuhan, which is a very complicated city. therefore, by giving different parameters to different cities, it is quite convenient to apply our strategy, which would provide an effective scheme to optimize the scheduling of the whole urban transport system of medical waste. in past studies, balvinder singh gill et al. studied the transmission of covid-19 in malaysia [42] , and carol i. blvd et al. made algorithmic scheduling for the delivery of medical forces [43] . compared to their approach, our approach is more comprehensive, practical, and provides a better picture of what delivery scheduling actually looks like when covid-19 outbreaks occur in cities. in figures 6 and 7 , the center point of each small area is the medical center of the area, and the green line segment indicates that if two points belong to the same subdivision area, they are connected by a line segment. the distribution of cars is obviously different at disparate transport stations. in the areas where the hospitals are more concentrated, the routes are more complex. with the increase in the number of iterations, the convergence of the algorithm is shown in figure 8 . the outbreak of covid-19 in wuhan has exposed the inefficiency of transporting medical waste and urges us to solve this impending problem. therefore, in this paper, several temporary storage points were discussed above, according to the environmental impacts and assessment criteria, utilizing the − value method to allocate medical waste transport vehicles, and applying the immune-based ant colony algorithm, together with the tabu search algorithm, to arrange the correct pathways of waste transportation. eventually, a complete "build-match-transport" system model for medical waste is established during these procedures. the application of this model to the epidemic situation of wuhan has achieved excellent results, which has practical significance and enlightenment to the emergency response and dispatch of wuhan and other major cities. as can be seen in figure 8 , with the increase of the number of iterations, the results gradually converge and obtain a relatively stable optimal solution. in view of this, we are certain that the model of this paper has a good fit and dispatching effect even for wuhan, which is a very complicated city. therefore, by giving different parameters to different cities, it is quite convenient to apply our strategy, which would provide an effective scheme to optimize the scheduling of the whole urban transport system of medical waste. in past studies, balvinder singh gill et al. studied the transmission of covid-19 in malaysia [42] , and carol i. blvd et al. made algorithmic scheduling for the delivery of medical forces [43] . compared to their approach, our approach is more comprehensive, practical, and provides a better picture of what delivery scheduling actually looks like when covid-19 outbreaks occur in cities. the outbreak of covid-19 in wuhan has exposed the inefficiency of transporting medical waste and urges us to solve this impending problem. therefore, in this paper, several temporary storage points were discussed above, according to the environmental impacts and assessment criteria, utilizing the q − value method to allocate medical waste transport vehicles, and applying the immune-based ant colony algorithm, together with the tabu search algorithm, to arrange the correct pathways of waste transportation. eventually, a complete "build-match-transport" system model for medical waste is established during these procedures. the application of this model to the epidemic situation of wuhan has achieved excellent results, which has practical significance and enlightenment to the emergency response and dispatch of wuhan and other major cities. an optimization model for collection, haul, transfer, treatment and disposal of infectious medical waste: application to a greek region. waste manag analysis on medical waste management and disposal in kunming city an optimization model for collection, haul, transfer, treatment and disposal of infectious medical waste: application to a greek region analysis on medical waste management and disposal in kunming city current situation and countermeasures of medical waste management in primary medical institutions of wuhan. chin medical waste management in jordan: a study at the king hussein medical center safe transportation of biomedical waste in a health care institution public opinion polarization by individual revenue from the social preference theory 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new efficient approach for solving the capacitated vehicle routing problem using the gravitational emulation local search algorithm an improved hybrid firefly algorithm for capacitated vehicle routing problem analytic centre stabilization of column generation algorithm for the capacitated vehicle routing problem bilayer local search enhanced particle swarm optimization for the capacitated vehicle routing problem an adaptive iterated local search for the mixed capacitated general routing problem an exact algorithm for the capacitated vehicle routing problem based on a two-commodity network flow formulation a branch-and-cut-and-price algorithm for the two-echelon capacitated vehicle routing problem beam search combined with max-min ant systems and benchmarking data tests for weighted vehicle routing problem uct in capacitated vehicle routing problem with traffic jams a multistart iterated local search for the multitrip cumulative capacitated vehicle routing problem symbiotic organisms search and two solution representations for solving the capacitated vehicle routing problem enhanced intelligent water drops and cuckoo search algorithms for solving the capacitated vehicle routing problem evolutionary algorithm based offline/online path planner for uav navigation artificial immune systems: theory and applications artificial immune system assessment of covid-19 waste flows during the emergency state in romania and related public health and environmental concerns modelling the effectiveness of epidemic control measures in preventing the transmission of covid-19 in malaysia the authors declare no conflict of interest. key: cord-348269-6z0kiapa authors: nguyen, quynh c.; huang, yuru; kumar, abhinav; duan, haoshu; keralis, jessica m.; dwivedi, pallavi; meng, hsien-wen; brunisholz, kimberly d.; jay, jonathan; javanmardi, mehran; tasdizen, tolga title: using 164 million google street view images to derive built environment predictors of covid-19 cases date: 2020-09-01 journal: int j environ res public health doi: 10.3390/ijerph17176359 sha: doc_id: 348269 cord_uid: 6z0kiapa the spread of covid-19 is not evenly distributed. neighborhood environments may structure risks and resources that produce covid-19 disparities. neighborhood built environments that allow greater flow of people into an area or impede social distancing practices may increase residents’ risk for contracting the virus. we leveraged google street view (gsv) images and computer vision to detect built environment features (presence of a crosswalk, non-single family home, single-lane roads, dilapidated building and visible wires). we utilized poisson regression models to determine associations of built environment characteristics with covid-19 cases. indicators of mixed land use (non-single family home), walkability (sidewalks), and physical disorder (dilapidated buildings and visible wires) were connected with higher covid-19 cases. indicators of lower urban development (single lane roads and green streets) were connected with fewer covid-19 cases. percent black and percent with less than a high school education were associated with more covid-19 cases. our findings suggest that built environment characteristics can help characterize community-level covid-19 risk. sociodemographic disparities also highlight differential covid-19 risk across groups of people. computer vision and big data image sources make national studies of built environment effects on covid-19 risk possible, to inform local area decision-making. the covid-19 pandemic has caused approximately 150,000 deaths in the united states as of 29 july 2020 [1], and has had unprecedented negative effects on the u.s. economy and households in numerous ways. the unemployment rate rose up to 14.9% in april and the gdp fell by 1.2% in the first quarter in 2020, which is the largest decline since the great recession [2, 3] . yet the negative impacts of covid-19 are not evenly distributed. about half of lower-income u.s. households lost employment income. about 62% of hispanics and 57% of black adults were in households that experienced employment income loss compared to 45% of whites [4] . moreover, the spread of covid-19 is not evenly distributed. racial/ethnic disparities in covid-19 infection and mortality are coming to light, with disproportionate numbers of covid-19 cases and deaths among racial/ethnic minorities compared to non-hispanic whites [5, 6] . some of these differences reflect the living and social conditions faced by racial/ethnic minorities. for instance, institutional racism that produced residential segregation may increase the likelihood that racial/ethnic minorities live in densely populated areas with substandard and crowded housing conditions impede social distancing [7, 8] . a recent analysis suggested that counties that are predominately black have three times the infection rate of covid-19 compared to white majority counties [9, 10] . covid-19 can spread through droplets that are released when people talk, cough or sneeze or when people touch a contaminated surface and then touch their nose or mouth [11] . research has identified a myriad of important factors that influence covid-19 transmission including anti-contagion governmental policies [12] , community adherence to preventative health behaviors (e.g., mask wearing, social distancing) [13] and other environment characteristics like air pollution. emerging research has found higher levels of air pollution may increase covid infection rates as well as covid-related mortality, possibly because particulate matter can act as a carrier of the virus and also compromise the baseline health of communities that have chronic exposure to air pollution [14] . in the current study, we focus on a neglected area of research, the potential relationship between built environment characteristics and covid-19 cases. to conduct this investigation, we utilized the largest collection of google street view images that has been leveraged for public health research to characterize neighborhood environments. in examining associations between built environment characteristics and covid cases, we controlled for demographic compositional characteristics of areas and population density, which has previously been utilized in econometric studies as a proxy for air pollution and other factors found with greater prevalence in urban areas [15, 16] . neighborhood environments may structure risks and resources [17] that produce covid-19 disparities through several pathways. firstly, neighborhood built environments that allow greater flow of people into an area or impede social distancing practices may increase residents' risk for contracting the virus. a recent study that used data from pregnant women in new york city revealed that overcrowding housing units have higher chances of contracting covid-19 [18] . neighborhoods with a mixture of residential and commercial uses (e.g., high prevalence of grocery stores and businesses), multiple lanes of traffic, and higher density of sidewalks, may allow more people to congregate in an area and more easily spread covid-19. additionally, previous studies found that physical disorder in the neighborhood environments is significantly associated with higher prevalence of chronic diseases [19] and poor self-rated health [20] , which also increases the chances of contracting covid-19 [21, 22] . physical disorder refers to features of the environment that signal decay, disrepair, and uncleanliness. examples of neighborhood indicators of physical disorder include vacant or abandoned housing, vandalized and run-down buildings, abandoned cars, graffiti, and litter [23] . physical disorder is often interpreted as an indicator of low neighborhood quality [24] . physical disorder is hypothesized to indicate a breakdown of social disorder and control, which reduces individual well-being and increases fear, mistrust, isolation, anger, anxiety, and demoralization [25] . mechanisms proposed include the daily stress imposed by environments that are deemed unsafe. previous research has connected physical disorder with an array of detrimental health outcomes including worse mental health, higher substance use, physical functioning and chronic conditions [26] . physical disorder might also indicate fewer resources for infrastructure maintenance and investment. communities with poor-quality housing stock may have less healthy indoor conditions, with consequences for baseline respiratory health. in this study, dilapidated buildings and visible utility wires overhead were utilized as indicators of disorder. visible utility wires hanging overhead are visually striking and may impact residents' aesthetic sense of their environment, altering perceptions of safety or pleasurability and influencing both mental health (by affecting stress levels) and physical health (by disincentivizing walking). other studies that have examined this indicator have been done outside the u.s., where they may also represent an unsightly presence and electrocution/electrical fire risk [27] . computer vision models have struggled with small objects, precluding us from labeling other indicators of physical disorder such as litter or trash [19] . investigations into neighborhood conditions are typically conducted on small scales for only certain cities or neighborhoods [28, 29] . when conducted, neighborhood data collection is expensive and time consuming, and then only available for certain time periods. currently, detailed neighborhood data come from neighborhood surveys, administrative data such as census data, and systematic inventories of neighborhood features. subjective assessments of neighborhoods from community residents can help identify factors that residents believe are most important to their health and increase understanding on how individuals differentially use and interact with their environment. however, self-reported neighborhood data can be influenced by participants' health status and cognitive function, resulting in "single source bias" [30] . the other neighborhood data we do have is mainly data on demographics (e.g., percent black). to our knowledge, our study is the largest to date using zip code level cases from 20 states to investigate associations between built environments and covid-19 cases. previous studies examining the distribution of covid-19 cases are only focused on one or two states [31] [32] [33] or larger geographies like counties [34] . google street view (gsv) images represent a massive, publicly available data resource that has high potential but is very underutilized for health research. it can be used to extract information on physical features of the environment at point locations all over the country. consistently constructed neighborhood quality indicators across large areas are severely lacking. while some studies have used human coders to classify environmental features seen in google street view images [35] this approach is not feasible on the massive scale necessary to compare thousands of u.s. neighborhoods. the development of data algorithms that can automatically analyze big data sources such as street view images will create a new national data resource for timely decision-making to mitigate the impact of covid-19 and future outbreaks on health and health disparities. the purpose of characterizing built environments that have higher covid-19 risk is to identify places where additional safeguards and resources are needed. study aims and hypotheses. in this study, we investigated how the built environments affect covid-19 cases at the zip code level. we utilized 170 million gsv images sampled at 50 meters apart and computer vision models to comprehensively characterize neighborhood conditions across the united states. from gsv images, we created indicators of urban development (non-single family home, single lane roads), walkability (crosswalks, sidewalks), and physical disorder (dilapidated building, visible utility wires). we hypothesize that built environments characterized by greater urban development, walkability, and physical disorder will have higher covid-19 infection rate. street view image data collection. we utilized google street view's application programming interface (api) to capture street view images of our search set. image resolution was 640 × 640 pixels. we surveyed all u.s. roads and obtained 4 images from each sample location with angle views at 0, 90, 180, and 270 degrees, thus permitting fuller capture of the surrounding area of a point location. in total, 164 million images were obtained in november 2019. image data processing. convolutional neural networks (convnets) [36] [37] [38] achieve state-of-the-art accuracy for several computer vision tasks including but not limited to object recognition, object detection, and scene labeling. for example, the state-of-the-art accuracy of imagenet [39] with 1000 categories and over one million image samples is improved every year using convnet-based methods. the imagenet dataset contains images from various categories (e.g., "moped", "granny smith apple") and corresponding category labels. models trained on this dataset use trial and error to learn combinations of colors, shapes, and textures that are relevant to a wide variety of image interpretation tasks, and therefore can be used as a starting point for creating computer vision models for tasks where labeled training data is scarce. a convnet model "pre-trained" on imagenet can be "fine-tuned" using a smaller amount of training data from the desired task, which delivers strong classification performance without requiring the vast training data and computational resources necessary to train the original convnet. neighborhood definitions. zip codes were utilized as neighborhood boundaries because various health departments across the country are releasing covid-19 cases by zip code. to arrive at the neighborhood indicators, we processed street imagery and then combined information on all street imagery within a zip code to arrive at zip code-level summaries (e.g., the percentage of images in a zip code that contain a sidewalk). built environment indicators. to create a training dataset for our computer vision models, from december 2016-february 2017, we manually annotated 18,700 images (from chicago, illinois; salt lake city, ut; charleston, west virginia; and a national sample). these locations were chosen to capture heterogeneity in neighborhood environments across geographically and visually distinct places with varying population densities, urban development, and demographics. labelers included the principal investigator and three graduate research assistants. inter-rater agreement was above 85% for all neighborhood indicators. each image received labels for these binary neighborhood characteristics: (1) street greenness (trees and landscaping comprised at least 30% of the image-yes/no), (2) presence of a crosswalk, (3) single lane road, (4) building type (single-family detached house vs. other), and (5) visible utility wires. green streets were utilized to indicate lower urban development. single lane/residential roads limit the number of cars and hence flow of people. non-single family home was utilized as an indicator of residential and commercial mixture. crosswalks were utilized as an indicator of walkability. visible utility wires were utilized as indicators of physical disorder. we randomly divided the dataset into a training set, a validation set, and a test set. the training and validation set contained 80% of total labeled images and the remaining 20% was used as a test set to evaluate the model's performance. once the hyper-parameters were chosen, each model architecture was trained multiple times. note that neural network training is stochastic even when starting from the same initialization and using the same training set, therefore, multiple training runs are used to assess the mean and standard deviation of the error. the testing set remained unobserved until the best models had been selected using the training set. we assessed the final quality of the model using the test set. we first resized all the images to the size 224 × 224 for processing. we then trained a standard deep convolutional neural network architecture-visual geometry group vgg-19 [36] in tensorflow [40] with sigmoid cross entropy with logits as the loss function. the weights of the network were initialized from imagenet weights. adam optimizer was used with batch size 20. training took 20 epochs and started with learning rate 10 −4 . we considered the model saved in the last epoch as our final model. accuracy of the recognition tasks (agreement between manually labeled images and computer vision predictions) were the following: street greenness (88.70%), presence of crosswalks (97.20%), non-single family home (82.35%), single lane roads (88.41%), and visible utility wires (83.00%). these figures were consistent with a separate, semi-supervised learning approach. below, we describe the model building process for two additional neighborhood indicators that utilized different training datasets. dilapidated building indicator. our training dataset consists of approximately 29,400 google street view images captured from baltimore and detroit based upon administrative lists from city governments on vacant buildings and buildings marked for demolition from 2014-2018. we randomly split this dataset in the ratio 80:20 for validation to obtain about 23,500 images for training and 5900 for validation. the dataset has an equal number of normal and dilapidated buildings. we then trained a standard deep convolutional neural network architecture-resnet-18 [38] in pytorch [41] with nll loss as the loss function. for the dilapidated building indicator, the resnet-18 model produced an accuracy of 89.1% and a f1 score of 89.1. sidewalk indicator. our training dataset consists of about 24,316 images captured from google street view from new jersey that had been manually labeled. we randomly split this dataset in the ratio 80:20 for validation to obtain 19,452 images for training and 4864 for validation. the minority label images were oversampled so that the dataset has an equal number of sidewalk present and absent cases. we then trained a standard deep convolutional neural network architecture-resnet-18 [38] in pytorch [41] with nll loss as the loss function. for the sidewalk indicator, the resnet-18 model produced an accuracy of 84.5% and a f1 score of 81.0. covid-19 cases. to our knowledge, there is no national data source for zip code covid-19 cases, with the centers of disease control and prevention and john hopkins covid-19 map only showing county level cases as the lowest level of geography. to obtain zip code covid-19 cases, we visited state and county health departments that had covid-19 information (31 websites in total; 12 websites utilize arcgis dashboards, and 19 utilized a mixture of pdfs, csv files, and tableau/powerbi embedded websites). data were obtained from official government websites and actively maintained github repositories using various methods. this collection process was automated using python packages including scrapy, selenium, beautifulsoup, and requests. specifically, for websites with arcgis map layer, we used arcgis query services to query the feature layer; for websites with csv data files to download, we automated the download process from the websites; for static website tables, we leveraged scrapy or beautifulsoup packages to harvest the web content; for websites with pdf files, we first downloaded the pdf files and utilized ocr technology to convert the data into the csv format. some states have report data for all zip codes, but others only report for certain cities or counties. zip code confirmed covid-19 cumulative cases as of 21 ) . covid-19 cases varied across zip codes with some zip codes reporting zero or few cases and others reporting hundreds of cases. about 50% of zip codes had 15 or fewer cases ("cold spots") and 10% had 250 or more cases ("hot spots"). in this study, we investigated whether zip code built environments can help explain some of the variation in covid-19 cases across 20 states. for each zip code, we calculated the percentage of total number of images that contained a given built environment indicator (e.g., number of images with a sidewalk/total number of images) *100 = percent with sidewalk. from there, we created tertiles and classified each zip code based on their percentage, with the lowest tertile as the reference group. we fit poisson regression models to estimate associations between gsv-derived built environment characteristics and covid-19 cases, controlling for potential confounding variables. log of total population at risk was used as the offset variable, to account for varying population sizes across zip codes. goodness-of-fit chi-square tests indicated the data fit with the poisson model form. all predictor variables were standardized with a mean of 0 and a standard deviation of 1. coefficients from poisson regression models were exponentiated to arrive at estimates of incidence rate ratios for a one-unit change in the predictor variable (i.e., one standard deviation change). separate regressions were run for each built environment indicator given moderate associations between the built environment indicators that varied from −0.23 for single lane roads and visible wires to −0.83 for green streets and non-single-family homes. models controlled for population density, household size, median age, household income, poverty rate, unemployment, percent with less than a high school education, percent asian, percent black, and percent hispanic. covariate information was obtained from the american community survey 2018 5-year estimates, with the exception of population density and household size which were obtained from the 2010 us census. we hypothesized that zip codes with more crosswalks and sidewalks (indicators of walkability), non-single family homes (an indicator of mixed commercial/residential uses), more visible wires and dilapidated buildings (indicators of physical disorder) would be associated with more covid-19 cases. we hypothesized that zip codes with more single lane roads (an indicator of lower urban development) would be associated with fewer covid-19 cases. stata ic15 (statacorp lp, college station, tx, usa) were used for all data analyses. this study was approved by the university of maryland institutional review board. figure 1 presents examples of processed google street view images. predictions were algorithm-derived labels for neighborhood features. "true" labels were manual annotations provided by the research team. our computer vision model was able to classify even winter scenes as "green streets" because the model was trained with manually annotated images to recognize tree branches as landscaping. station, tx, usa) were used for all data analyses. this study was approved by the university of maryland institutional review board. figure 1 presents examples of processed google street view images. predictions were algorithm-derived labels for neighborhood features. "true" labels were manual annotations provided by the research team. our computer vision model was able to classify even winter scenes as "green streets" because the model was trained with manually annotated images to recognize tree branches as landscaping. table 1 displays descriptive statistics at the zip code level. on average, approximately 25% of images in a zip code contained a building that was not a single family home, 20% of images had a sidewalk, 2% with a crosswalk, and 44% with visible utility wires. dilapidated buildings had a prevalence of 18%, while single lane roads (65%) and green streets were more prominent (87%) ( table 1) . we examined covid-19 cases in 8171 zip codes across 20 states in the united states with an average of around 546 cases per 100,000. table 2 presents the results of our poisson regression analyses examining the relationship between gsv-derived built environment characteristics and covid-19 cases. we found that zip codes with a standard deviation increase in sidewalks had 40% more cases (table 2) . a standard table 1 displays descriptive statistics at the zip code level. on average, approximately 25% of images in a zip code contained a building that was not a single family home, 20% of images had a sidewalk, 2% with a crosswalk, and 44% with visible utility wires. dilapidated buildings had a prevalence of 18%, while single lane roads (65%) and green streets were more prominent (87%) ( table 1) . we examined covid-19 cases in 8171 zip codes across 20 states in the united states with an average of around 546 cases per 100,000. table 2 presents the results of our poisson regression analyses examining the relationship between gsv-derived built environment characteristics and covid-19 cases. we found that zip codes with a standard deviation increase in sidewalks had 40% more cases (table 2) . a standard deviation increase in crosswalks and non-single family homes was associated with 14% and 21% more cases, respectively. we also found that indicators of physical disorder such as dilapidated buildings or visible utility wires were associated with more cases. alternatively, single lane/residential roads and green streets were associated with fewer cases. zip codes with a standard deviation increase in single lane roads and green landscaping had 10% and 4% relative fewer covid-19 cases, respectively. additionally, population characteristics associated with increased coronavirus cases included household size, percent with less than a high school education, percent racial/ethnic minorities (in particular percent black), and population density. estimates for covariates varied because the gsv-derived variable was different in each of the models. correlations between covariates and the particular gsv-derived characteristic differed and hence the coefficient estimates for covariates also differed. nonetheless, the variation in estimates for covariates was generally small/moderate. across models, a standard deviation increase in percent with less than a high school education was associated with 42-54% increase in covid-19 cases. across models, percent black was associated with 17-29% increases in coronavirus cases. a standard deviation in population density was associated with 1-4% more coronavirus cases. mobility changes during the covid-19 pandemic may have increased the importance of neighborhood environments. google's community mobility report [42] indicates that out of six categories of movement (retail and recreation, grocery and pharmacy, parks, transit stations, workplaces, and residential), movement volumes declined in all categories except residential and parks ( figure s1 ). consequently, the neighborhood environment is crucial for containing the spread of coronavirus, as more residents may have limited activities to their immediate neighborhood surroundings. our study finds that neighborhood built environment may influence the spread and containment of covid-19. leveraging google street view images, we found that single-lane/residential roads and green streets were associated with fewer cases, while non-single family homes, sidewalks, and physical disorder were associated with more cases in the neighborhood. in other words, covid-19 risk is highest in more built-up, more walkable, and more physically deteriorated zip codes, and lower in zip codes with smaller, greener streets. these associations persist after controlling for urbanicity and sociodemographic indicators, suggesting a meaningful role for the built environment in influencing covid-19 risk. the study is one of the first to investigate the effect of neighborhood built environment on the spread of coronavirus at the zip code level. single-lane/residential roads and green streets are indicators of lower urban development and lower social contacts. green streets are especially prevalent in rural areas and suburban areas. conversely, neighborhood environment indicators such as non-single family homes, sidewalk presence, and physical disorder may facilitate the spread of coronavirus. the ability to perform social distancing is not equally distributed across neighborhoods, and it is more difficult to achieve in highly developed urban areas. one study found that it is impossible to implement effective social distancing in urban areas with homes in close proximity to each other, such as cape town [43] . the same argument can also be applied to densely populated areas such as new york city, which was the epicenter of the covid-19 pandemic in the u.s. residential settings other than single-family homes-for instance, apartment complexes-are more likely to be the source of infectious disease outbreaks. in 2003, the sars outbreak started in a 33-floor apartment block in hong kong [44] . shared elevators and shared space are both risk factors for covid-19 infection. sidewalks, on the other hand, are likely associated with more walking, and the majority of neighborhood sidewalks do not allow pedestrians to maintain the cdc-recommended 6-foot distance. in this study, we find that indicators of physical disorder (dilapidated buildings and unsightly visible utility wires) were connected with more covid-19 cases, possibly due to worse health and higher comorbidities that increase in disorderly neighborhoods. our study is significant because it strives to identify and make available novel indicators of neighborhood quality by leveraging big data resources and furthering the application of computer vision. we utilized google street view images as a time-and cost-efficient data source for the characterization of built environments involving close to 170 million images sampled 50 m apart. the inclusion of 20 different states with varying built environments and covid-19 burden further strengthened our study. our study found that neighborhoods with greater urban development, higher walkability, and physical disorder had higher coronavirus cases. nonetheless, our study also has limitations. the cross-sectional study design inhibits causal inference. although we have observed strong associations between neighborhood built environment indicators and coronavirus prevalence, we cannot conclude that these characteristics cause higher covid-19 rates. additionally, we were not able to control for local covid-19 resources (e.g., testing availability). however, we controlled zip code sociodemographic characteristics such as racial/ethnic composition and median income that are correlated with greater resource access. fine particle air monitor data from the u.s. environmental protection agency (epa) are not available at the zip code level(https://www.epa.gov/outdoor-air-quality-data/pm25-continuous-monitor-comparabilityassessments) and hence, we were unable to account for this characteristic in our analyses. air pollution can vary between areas and has been related to a variety of acute and chronic conditions [45, 46] , which can compromise health and place individuals at greater risk for more severe covid-19 illness. lastly, the study was u.s.-based; built environments, demographics, health policies, and other considerations vary across international settings and thus our study results might not generalize to other countries. nonetheless, gsv images have been utilized in international settings to examine neighborhood features, and thus has the potential to enable other countries to examine the influence of built environment characteristics on health and other outcomes [47, 48] . like other modes of data collection, image data can only capture a subset of features of a community. images do not capture all of the features of the neighborhood environment that may impact health outcomes. for instance, we were unable to capture indicators of perceived safety that impact people's willingness to walk in an area. additionally, google street view api provides the most recent image available for a location. however, areas differ with regard to the rate at which their gsv image are updated. in our dataset, image dates ranged from 2007-2019 and the median year was 2015. thus, the neighborhood data for certain areas might not reflect current conditions. moreover, rural areas tend to have older gsv images than urban areas, which may lead to differential measurement bias. in addition, not all types of built environment characteristics lend themselves to easy extraction by computer vision algorithms. objects that are small (e.g., litter), vary in appearance (e.g., dilapidated buildings), or are very rare in the dataset (e.g., graffiti) are difficult for computer vision models to predict with high accuracy. subjective characteristics such as the aesthetics or the visual appeal of an area are also difficult to model with computer vision. for subjective characteristics, use of crowdsource techniques that incorporate ratings from residents and visitors might be an effective way to create area-level ratings that capture the variability in these perceptions. besides the type of neighborhood features that can easily lend themselves to automatic extraction via computer vision models, the depth of neighborhood features that can be extracted may be limited. well-known neighborhood audit instruments such as the irvine-minnesota inventory [49] and the pedestrian environment data scan [50] can involve hundreds of different features. building a computer vision model to accurately extract each of these hundreds of features would be a difficult task. additionally, computer vision models using supervised learning approaches often require large training datasets composed of potentially tens of thousands of manually labeled images to adequately train models and hence investigative teams need to build in time and resources to create these large training datasets. in our study, to create our training dataset, team members took two months to label over 18,000 images for neighborhood characteristics. we also utilized administrative datasets that contained the locations of vacant building and buildings marked for demolition to provide enough training examples for our dilapidated building indicator. the use of computer vision and gsv images enables large studies of neighborhood features across broad geographies. however, the use of these automated technologies might limit the type, variety, and level of detail in neighborhood features that can be examined. for investigators interested in neighborhood characteristics for small areas, manual neighborhood inventories might be the appropriate choice to provide the necessary data. while computer vision is not without its limitations, using computer vision and millions of gsv images was the only feasible way to examine fine area-level built environment characteristics across 20 different states. gsv is a growing new area of research that has immense potential to shed light on the potential influence of neighborhood environments on a variety of health outcomes. the contextual factors that influence the spread of the coronavirus risk are poorly understood. with recent advances in computer vision and the emergence of massive sources of image data, we developed a data collection strategy utilizing geographic information systems to assemble a national collection of google street view images of all road intersections and street segments in the united states. we utilized this data bank and leveraged computer vision algorithms to produce neighborhood summaries of conditions that are linked with covid-19 risk through increased opportunity for person-to-person transmission. we found that indicators like greater urban development (mixture of residential and commercial buildings, multiple lanes of traffic), walkability (which may increase contact), and greater physical disorder were related to more coronavirus cases. our study results can help inform population-based strategies to mitigate covid-19 risk. a higher level of caution can be recommended for the reopening 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informal dwelling outlines to identify high risk areas for covid-19 transmission from a social distancing perspective apartment complex holds clues to pandemic potential of sars particulate air pollution and acute health effects chronic disease prevalence in women and air pollution-a 30-year longitudinal cohort study validation of a google street view-based neighborhood disorder observational scale exploring places of street drug dealing in a downtown area in brazil: an analysis of the reliability of google street view in international criminological research the irvine-minnesota inventory to measure built environments: development © 2020 by the authors. licensee mdpi we thank dina huang for her research guidance. the authors declare no conflict of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-334711-58ygbyiz authors: hernández-sánchez, brizeida raquel; cardella, giuseppina maria; sánchez-garcía, josé carlos title: psychological factors that lessen the impact of covid-19 on the self-employment intention of business administration and economics’ students from latin america date: 2020-07-22 journal: int j environ res public health doi: 10.3390/ijerph17155293 sha: doc_id: 334711 cord_uid: 58ygbyiz background: the 2019 coronavirus disease epidemic (covid-19) is a public health emergency of international concern and poses a challenge to the labor market. the pandemic has a devastating and disproportionate effect on young workers, their interest in entrepreneurship, and their mental health. research is needed to develop evidence-based strategies to improve coping and reduce adverse psychological problems. the objective of this study was to analyze the impact that covid-19 pandemic perception and psychological need satisfaction have on university students and their self-employment intention. in addition, we also analyzed the role of moderation played by psychological aspects. these psychological factors (i.e., optimism and proactiveness) can also improve young people’s mental health and well-being. methods: an explorative study (online survey) was conducted in march 2020 934 university students from latin america. regression analysis models were built to examine the relationships between covid-19 pandemic perception, personality variables, and entrepreneurial intention. mediation models, through the bootstrapping method, were performed to analyze the mediating role of proactiveness and optimism. results: results indicate that students’ perception of covid-19 and psychological need satisfaction are associated with entrepreneurial intention. additionally, the present study argues that proactiveness and optimism mediate these relationships. conclusions: this study identifies psychological factors associated with a lower level of covid-19 impact and that can be used for psychological interventions that result in an improvement in the mental health of these vulnerable groups during and after the covid-19 pandemic. theoretical and practical implications are discussed. entrepreneurship is a determining factor for economic and social development [1, 2] , enhances the creation of wealth and value [3] , and improves the well-being in nations [4] . over the years, entrepreneurship has received a broad consensus in the academic and international communities on its importance, however, research on its relevance in uncertain and adverse situations is rather scarce [5] . covid-19 (coronavirus disease 2019) is a serious disease caused by a new type of coronavirus (sars-cov-2) first detected in wuhan, china in december 2019. the virus has spread rapidly throughout the world [6] , registering more than 5,000,000 cases and more than 300,000 deaths. on 11 march 2020, with 114 countries involved, the who officially decreed a state of pandemic [7] . not surprising that, due to their crucial role as a preliminary stage in the business creation process, researchers have focused their efforts on researching the factors that positively influence people's intention to start a business [28, 29] . despite the considerable contribution of the scientific literature on the processes that favor entrepreneurship, personality factors, and their relationship with the intention to start a business have not received enough attention in situations of uncertainty, catastrophes, pandemics, etc. [30] [31] [32] [33] . psychological need satisfaction, in previous researches, has been considered an interesting intrinsic motivational factor for understanding the business process [34] and that could act as a driver to face a crisis. the satisfaction of basic psychological needs has a positive effect on the well-being and growth of the individual, while the lack of satisfaction translates into low motivation and a feeling of discomfort that can even lead to the onset of mental illness. as many academics point out [35, 36] , the satisfaction (or lack thereof) of basic psychological needs depends on the environment in which the subject lives. in general, supportive environments promote well-being in a subject, while frustrating environments generate malfunction and discomfort [37] . studies have analyzed these relationships in safe situations. little or nothing is known of the effect they could have on situations perceived as dangerous. furthermore, the perception of the pandemic itself could influence individuals' entrepreneurial intentions through the subjective perception of danger, blocking the positive behaviors, and frustrating the basic psychological needs satisfaction. this is one of the main objectives of this work, which tries to fill this gap in the literature. in an environment perceived as uncertain and dangerous, the effect of covid-19 pandemic perception and psychological need satisfaction may depend on additional factors. one of them is proactiveness. only in recent years have some studies shown a positive association between proactive personality and entrepreneurial intentions [38, 39] . for example, in the study by hansen et al. [40] , proactiveness, which is related to the ability to find opportunities and possible solutions in uncertain situations, was considered one of the main factors that influence entrepreneurial intentions. ideologically connected with proactivity, optimism appears to also be considered (especially in adverse situations, such as the current pandemic) a particularly important factor for entrepreneurs to pursue their long-term goals [41, 42] . having a positive perspective on future results, focusing attention on positive stimuli, and avoiding those that are perceived as threatening leads to an increase in entrepreneurial intention and, consequently, predisposes the individual to implement a specific behavior [43] and generated well-being. a study by kleiman et al. , [44] demonstrated the multidimensional nature of optimism which appears to be related to fewer depressive episodes as a consequence of stressful and anxiety-provoking life events. given the historical period we are experiencing, characterized by the covid-19 pandemic, we conducted this study to increase our understanding of the factors that influence entrepreneurial intentions in situations of crisis and uncertainty, examining, in particular, the influence of covid-19 pandemic perception and psychological need satisfaction in entrepreneurial intentions, as well the possible mediating role of proactiveness and optimism. understanding the dynamics of these relationships is particularly important for the numerous governments and companies present in the area facing this economic shock. by understanding what drives entrepreneurial intentions in adverse conditions, we can design better programs to effectively improve business efforts. to meet these goals, we conducted an explorative study with a sample of college students to examine the effects of covid-19 pandemic perception, psychological need satisfaction, proactiveness, and optimism are in entrepreneurial intentions. in this work, we first develop the theoretical background of our research. based on this, we present the hypotheses, which are then empirically tested with the data from a survey carried out in 934 university students. the methods are described in the next section, after which we provide the results of our empirical study. we conclude with a discussion of the main results in relation to the previous literature, as well as suggest some recommendations for future policies and lines of research. theoretical models that analyze the entrepreneurial process [45, 46] emphasize the importance of personal, cognitive, and prescriptive factors to determine the probability that an individual would be willing to start a new business. among the main factors related to entrepreneurial intentions are personality traits associated with entrepreneurs [30, 31, 33] . the results of previous studies suggest that personality traits substantially influence how entrepreneurs think, the objectives they set, and, through their actions, what they achieve [22, 47] . in particular, previous studies have established that an entrepreneur generally has an optimistic orientation towards the future and seems more capable of finding opportunities and achieving the desired objectives [38, 48, 49] . this research will focus on four characteristics, namely proactiveness, optimism, the covid-19 pandemic perception, and psychological need satisfaction, to quantify the relationship between these four traits of the students and their entrepreneurial intention. in summary, this approach will allow this research to determine the relative importance of the four business characteristics to predict the ei of students in an adverse situation. despite literature supporting the link between psychological and personality factors and entrepreneurial intentions, these four characteristics have been ignored in the literature. the four dimensions are briefly described below. entrepreneurial intention has been considered the most important predictor of behavior [46, 50, 51] . by intention, we can understand "a state of mind directing a person's attention (and therefore experience and action) towards a specific object (goal) or a path to achieve something (means)" (bird [52] p. 442). intentions are related to a plurality of factors (beliefs, values, habits, needs) which also include cognitive factors, which can improve or decrease these intentions. over the years, different models of intentions have been developed in the field of entrepreneurship [45, [52] [53] [54] [55] . in general, scholars who have analyzed the gap between intentions and behaviors tend to consistently demonstrate this, as much as 39% of the variance in actual behavior can be explained by intentions [56] [57] [58] . therefore, more than half of the variance remains unexplained. several studies [52, 56, 58] have tried to remedy this lack, through the inclusion of some factors and moderators additional. some studies indicate that other predictors, on a personal or social level, may influence entrepreneurial intentions. for example, according to krueger et al., [54] the intentions are developed from the perceptions of desirability and viability of the entrepreneurial action. after this, a situation perceived as uncertain or dangerous can influence a person's intention to start a business. for example, considering the current pandemic situation, the perception of the lack of safety in travel, for commercial reasons, combined with the fact that many aspects of public and private life have become online [59] , could have a negative impact on the viability of behavior. krueger et al., [54] also argue that self-efficacy positively influences the viability of entrepreneurship and that the personal propensity to seek opportunities and act on these opportunities (proactiveness in this study) can facilitate the development of intentions. as proactivity is closely linked to identification opportunities, it plays an important role in encouraging new businesses. in other words, in the case of contexts perceived as dangerous or adverse, other variables associated with the individual's psychological, cognitive, and personality traits can still help develop entrepreneurial intentions. some studies on entrepreneurial intentions [60] [61] [62] [63] [64] have laid the foundations for a deeper examination of the intentions of people in situations of insecurity. specifically, the strength of the intention to become a self-employed person would depend on the tolerance that the subjects show for the risk and on their preference for independence. according to the approach of social-cognitive theory [65] , the surrounding environment influences the behavior of the individual through personal perceptions. not all people perceive the same situation with the same degree of severity. taking these differences into account and understanding them is important to analyze behavioral responses, especially in adverse situations. in the literature, few studies have focused on perceptions derived from an unsafe, dangerous, and risky environment, and the impact these perceptions can have on the intention of starting a business. for example, gaibulloev and sandler [66] suggest that terrorism and other violent events could hinder business growth by increasing business costs that reduce profits and returns, discouraging the creation of new businesses. among the few studies relating to dangerous situations, we find those related to the scenarios of war [67, 68] , terrorism [69] , and natural disasters [70, 71] . currently, there is no empirical evidence that has analyzed the psychological and cognitive factors that could influence entrepreneurial intention in relation to a pandemic situation. current studies have focused more on the general economic aspect [17, 72] . to describe the literature on the subject, we will refer explicitly to the more general concept of perception of danger. previous studies have shown the negative relationship between perception of danger and intention for business. bullough, renko, and myatt [67] examined the effects of perceived danger, self-efficacy, and resistance on business intentions under unfavorable conditions during the war in afghanistan. their results suggest that perceived danger was negatively related to an individual's entrepreneurial intentions but marginally less among highly resistant individuals. jahanshahi, zhang, and gholami [73] also in afghanistan, studied the antecedents of the persistence of companies run by female entrepreneurs. the results showed that female entrepreneurs with a high level of internal locus of control have higher levels of resilience. furthermore, the perceived danger and influence of supporting family businesses (the first negatively, the second positively) resulted in the persistence of female-led businesses. these studies highlight the importance of the interaction of psychological, social, and environmental factors in shaping the entrepreneurial capacity of people in uncertain situations. motivational factors have proven to be an important paradigm for the study of the determinants of an entrepreneurial career choice. on the one hand, personal motivational factors act to seek, through business, a possible form of self-realization and to escape the unemployment trap. on the other hand, there is a strong and profound interaction between family, social and institutional factors, within which the entrepreneurial career choice appears as a "response" linked to the satisfaction of basic psychological needs. according to self-determination theory (sdt) [74, 75] , motivation is a vital source that makes people persistent and active in implementing their behaviors [76] . specifically, sdt classifies motivation on a continuum, ranging from extrinsic motivation to intrinsic motivation. what leads to intrinsic motivation is the satisfaction of three basic psychological needs conceptualized by sdt: autonomy, competence, and relatedness. it is argued that these needs are necessary for the well-being and persistence of behavior [77] and that they play a role in defining aspirations and, therefore, in professional choices [78] . when these needs are not met, intrinsic motivation will be hampered, which is called psychological need frustration [76, 79] and, as a result, people could develop health problems and persist less in purposeful behaviors. conversely, if these needs are met, they are more likely to engage persistently in entrepreneurial behavior [76] . in this case, we speak of the psychological need satisfaction, which is the factor we will refer to in the present study. the perception of autonomy, of being competent, and of having a sense of closeness with others, is at the heart of entrepreneurial research, but, surprisingly, this has rarely been explored in previous studies on entrepreneurship, meaning the mechanisms behind motivations have been ignored [80] . however, the few studies carried out have highlighted its indisputable relevance. for example, baluku et al., [81] found that the need for autonomy satisfaction is positively related to entrepreneurial intention (ei) and that business mentoring is related to ei in individuals who show higher levels of autonomy. in an interesting study with university students in yemen, al-jubari [82] tested the influence of satisfying the basic psychological needs of sdt on business intention through the factors of the theory of planned behavior. the results of the study support the theoretical integration of the model, in which the satisfaction of basic psychological needs has a positive effect on the attitude towards entrepreneurship, subjective norms, and perceived behavioral control and these, in turn, have a positive effect in the entrepreneurial intention. bateman and crant [83] discussed the importance of proactiveness in organizational behavior, defining it as the ability to achieve significant change in the environment by identifying opportunities. in reality, it is not just about important attributes of flexibility and adaptability towards an uncertain future. being proactive is taking the initiative in improving business as well. for years, researchers have debated the nature of proactiveness. according to some scholars, it is a stable disposition of the individual [84] , others have considered it a model of general behavior [85] , and others, lastly, a specific attitude in the workplace [86] . in general, the proactive approach considers the possibility that individuals create their own environment, that behavior is controlled by factors internal and external to the individual, and that situations are a function of people and vice versa [87] . there are mutual causal links between the person, the environment, and the behavior [88] , therefore, individuals can intentionally and directly change their current circumstances and given situations. this proactive orientation has been discussed in the entrepreneurial process. much research has found a significant relationship between proactive personality and entrepreneurial behavior [89] [90] [91] , even during the economic crisis [92] . shapero and sokol [45] discussed a trend towards action and initiative to describe the social dimensions of business events. krueger and brazeal [93] included the concept of "propensity to act" in their study of business intentions and potential. furthermore, becherer and maurer [94] related proactiveness with the decision to start a business, as well as with the legacy of a company. proactive personality has been linked to professional success [95, 96] and as an employability asset [97, 98] . crant et al., [99] in the bibliographic review carried out on proactiveness in the organizational field, provide empirical evidence on a wide spectrum of favorable results linked to higher performance and innovation, emotional commitment, and job satisfaction. bell [100] in a study conducted with uk university students, showed that proactiveness, along with risk, are the key factors in positively influencing entrepreneurial intentions. kumar and shukla [101] have also achieved similar results. these studies confirm the importance that personality traits, such as proactiveness, have in the entrepreneurial intention. optimism has been studied little in relation to entrepreneurial intentions. the few studies in the literature have suggested that optimism may play an important role in the entrepreneurial process [41, 42, 102] . in a crisis, optimistic entrepreneurs believe more in the success of their actions and, therefore, may be more likely to establish a new business [103] . some have concluded that optimism is a key requirement for entrepreneurship [104, 105] . furthermore, as krueger & day [48] states: "some of the most promising recent models of entrepreneurship focus on cognitive processes, showing the importance of an opportunity-friendly cognitive infrastructure" (p. 324). for example, lee et al., [106] discovered that optimism is associated with self-confidence among students. overall, positive attitudes toward entrepreneurship, such as a possible career choice, and confidence in one's skills were found to be significantly related to entrepreneurial intentions. a few years earlier, giacomin, janssen, and shinnar [107] found that the students who most expected positive results in entrepreneurship showed higher levels of business intentions. furthermore, in general, employers have a greater tendency to be more optimistic than other workers [103, 108] . however, as far as we know, only the studies by bernoster et al. [109] and madar et al. [105] documented a positive relationship between optimism and entrepreneurial intention among students. in summary, despite the theoretically positive relationship suggested by the literature between optimism and entrepreneurial tendencies, little attention has been paid to the empirical investigation of the relationships between the two constructs [110] . as discussed in the previous sections, this study is the first attempt to analyze entrepreneurial intentions in a pandemic situation. first, through a representative sample of latin american university students, this study aims to analyze the relationships between proactiveness, optimism, covid-19 pandemic perception, psychological need satisfaction, and entrepreneurial intention in an adverse situation, as it is this current pandemic. second, the current study focuses primarily on how the covid-19 pandemic perception and need satisfaction mediate the predictive effects of student proactivity and optimism on entrepreneurial intention. consequently, this study raises the following hypotheses: hypothesis 1: the covid-19 pandemic perception are negatively associated with entrepreneurial intentions (h1a) and psychological need satisfaction are positively associated with entrepreneurial intentions (h1b). proactiveness is positively related to entrepreneurial intentions. optimism is positively related to entrepreneurial intentions. the relationship between covid-19 pandemic perception and entrepreneurial intentions is mediated by the proactiveness (h4a) and optimism (h4b). the relationship between psychological need satisfaction and entrepreneurial intentions is mediated by the proactiveness (h5a) and optimism (h5b). these hypotheses are represented in figure 1 . to recruit participants, we contacted several professors from various universities in latin america, to motivate their students and involve them in completing the questionnaire. our sample includes 934 university students from latin american countries (45.6% from ecuador, 45.3% from panama and 9% from other countries), of whom 67.5% are female, and 32.5% male. regarding the area of knowledge, most of the students are enrolled in the faculty of business and administration (55.4%) and the faculty of economic sciences (23.7%). the remaining 25% is enrolled in the faculty of social and health sciences. the age range is between 18 and 69 years, with an average of 23.6 (sd = 5.94). with previous permission and authorization from authorities, the students were informed about the purpose of the study. the questionnaires were administered online, participation was voluntary, and the data were processed anonymously and confidentially following the ethical criteria established by the a.p.a. (american psychological association). considering the data collection method (online questionnaire), the only possible method due to the pandemic, the researchers were unable to check the characteristics of the sample, therefore it is not representative of the population studied (latin america). self-report questionnaires were used to collect data on the study variables. the responses on all scales followed a 5-point likert format ranging from strongly disagree (1) to strongly agree (5) . to measure covid-19 pandemic perception, we created an ad hoc questionnaire. the scale consisted of 14 items: 7 items measure the impact of covid-19 in the country, and the other 7 items measure the impact of the pandemic on the person itself surveyed. the country's scale did not show good internal consistency, probably because many of the students interviewed live far from their homelands. for this reason, we decided to use only the personal subscale. examples of items were: "the covid-19 negatively affects my future" or "the covid-19 will decrease my job opportunities". the scale showed good validity with a cronbach's alpha value of 0.884. psychological need satisfaction was measured using the version developed and validated by chen et al. [35] . the scale has been translated into several languages, including spanish. the entire scale is made up of 24 items, 12 to measure need satisfaction, and another 12 to measure need frustration. for our study, we decided to use the 12 items corresponding to the need satisfaction. examples of some of these items are: "i feel free to choose the things i do", "i feel connected to the people who care for me and who are important to me". the scale has a cronbach alpha value of 0.797. entrepreneurial intention was measured with the six-item scale of the entrepreneurial orientation questionnaire (eoq; coe in spanish) [111] . some items on this scale are: "i will make any effort to start and develop my own firm"; "i have thought very seriously about creating a firm." the scale showed a cronbach alpha value of 0.926. to measure proactive personality, the corresponding scale of the entrepreneurial orientation questionnaire (eoq; coe in spanish) was used [112] . this scale is made up of 10 items and measures the tendency of the respondents to exhibit proactive behavior. the construction of this subscale was based on the work of seibert et al. [95, 113] . some items on this scale are: "i am constantly looking for new ways to improve my life", "if i believe in an idea, no obstacle will prevent me from making it come true". the cronbach alpha value for the scale was 0.874. finally, to measure optimism, we used the optimism scale of the proe questionnaire [113] . the scale consists of 9 likert-type items and measures the tendency of an individual to have positive expectations about the future. examples of the items that make up the scale are: "i see the positive aspects of things"; "i think i will achieve the main goals of my life." the scale showed good reliability (cronbach's alpha of 0.858). in line with previous studies on entrepreneurship [114] , data were collected on demographic variables such as age, sex, country, and faculty department. data were analyzed using spss version 23 (imb corp., armonk, ny, usa) and amos version 23 (ibm corp., armonk, ny, usa). first, descriptive statistics were produced using standard means and deviations for all variables. correlations between variables were evaluated using pearson's correlations. hierarchical regression analyzes were performed to analyze the impact of the variables on entrepreneurial intention. to examine the indirect effect of covid-19 pandemic perception and psychological need satisfaction on entrepreneurial intention through proactiveness and optimism, we used the bootstrap method. the key principle underlining the bootstrap procedure is that it allows the researcher to simulate repeated subsamples from an original database, allowing the stability of the parameter estimates to be evaluated and their values to be reported with a higher degree of precision. bootstrap evaluates the indirect effect in each data set and establishes confidence intervals for each indirect effect [115] . in this study, we used the following indices to evaluate model fit: the comparative fit index (cfi) and the bollen fit index (ifi), both with adequate values greater than 0.90 and the root mean square error of approximation (rmsea) which must have a value of less than 0.08 [116, 117] . the level of significance (p-value) will be 5%. the acceptability of the measurement model was assessed by the reliability of individual items, internal consistency between items, the model's convergent, and discriminant validity. the literature suggests 0.7 as the acceptable value for cronbach's alpha. average variance extracted (ave) is higher than 0.5 but we accepted 0.4. according to fornell and larcker (1981) [118] , if ave is less than 0.5, but composite reliability is higher than 0.6, the convergent validity of the construct is still adequate. for discriminant validity, the analysis can be performed by the square root of the ave value. when the square root of the mean variance extraction rate (ave value) of each measurement question is greater than the correlation coefficient between the variables, it indicates that there is a strong discriminant coefficient between the variables, that is, the difference between each measurement variable is better (see tables a1 and a2 ). before testing the hypotheses, the mean, standard deviations (sd), and correlations between the variables were calculated ( table 1 ). the average scores indicate that the students in our sample show medium to high levels of optimism, proactiveness, psychological need satisfaction, and entrepreneurial intention. the covid-19 pandemic perception variable obtained the lowest score (m = 3.05, sd = 0.904). the dependent variable, entrepreneurial intention, was significantly and negatively correlated with covid-19 pandemic perception (r = −0.24, p < 0.01), suggesting that high levels of pandemic perception negatively affect its career choice. psychological need satisfaction (r = 0.39, p < 0.01), proactiveness (r = 0.45, p < 0.01) and optimism (r = 0.44, p < 0.01) were positively and significantly related to entrepreneurial intentions. these results give us initial support of our hypotheses. asymmetry and kurtosis were calculated under the assumption of normal data distribution. all univariate asymmetry values varying between 0.367 and −2.04, while kurtosis values, which must vary between −0.063 y 4.70, thus, meeting with the univariate normality criterion [119] . in accordance with "for sample sizes greater than 300, depend on the absolute values of skewness and kurtosis without considering z-values". either an absolute skew value larger than 2 or an absolute kurtosis (proper) larger than 7 may be used as reference values for determining substantial non-normality" (hae-young [119] p. 53) . given that the variables of our study show significant correlations, variance inflation factors (vif) were calculated to investigate multicollinearity. all vif values were well below the threshold of 2.5 [120] . furthermore, none of the correlations exceeded 0.7 [121] . we can, therefore, conclude that multicollinearity is not an issue in this analysis. the next step of data analysis was to test the goodness-of-fit of the model, using the amos graphics 23.0 software. the fit indices for the proposed model were: χ 2 = 2,763,073, df = 806, p < 0.01, cfi = 0.90, ifi = 0.90, rmsea = 0.05. the confirmatory factorial analysis showed an adequate adaptation of the data to the model. although the chi-square was significant (χ 2 (806) = 2,763,073, p < 0.01), due to the large sample size, the other adaptation measurements made confirmed good compatibility. to examine whether the variables in our study predicted entrepreneurial intention in a statistically significant way, a hierarchical regression analysis was performed ( table 2 ). the first model includes the control variables: gender, age, country of origin, and faculty department. all variables had a significant effect on business intentions. in model 2, we added the independent variables. as the results show, covid-19 pandemic perception (β = -0.013, p < 0.01) is negatively related to entrepreneurial intentions and psychological need satisfaction, (β = 0.35, p < 0.01) is positively related to entrepreneurial intentions, which supports hypothesis 1. furthermore, the relation of intention with proactiveness (model 3) was positive (β = 0.29, p < 0.01), providing support for hypothesis 2. lastly, model 4 supported hypothesis 3. optimism was positively related to entrepreneurial intentions (β = 0.16, p < 0.01). to calculate the mediation effect by the proactiveness and optimism (h4 and h5) , the bootstrap method was used according to the recommendations of preacher and hayes [115] . during the mediation test, bootstrap was performed with 5000 iterations and the bias-corrected confidence interval was adjusted to 95%. if the 95% confidence interval does not include 0, then the mediation effect is considered statistically significant at the level = 0.05. table 3 understanding what factors contribute to support entrepreneurship as a career choice in a crisis seems to be of fundamental importance as it translates into the desire for growth and resilience that people can face when faced with an adverse situation. specifically, we hypothesized that proactiveness and optimism would mediate negative relationships between covid-19 pandemic perception and intention, and the positive relationship between psychological need satisfaction and entrepreneurial intention. our results support the mediation hypotheses and suggest that optimism and proactiveness are particularly important in the entrepreneurial process. furthermore, we found that psychological need satisfaction supports entrepreneurial intention, but also that the covid-19 pandemic perception hinders them. our model, and the results obtained, are a first attempt to close the gap in our knowledge of what drives entrepreneurship in highly adverse conditions (for example, in economies subject to pandemics). our suggested mediation model expands on previous literature, which is mainly focused on the direct relationship between personality and intentions [38] . in particular, the current study joins the few studies in the literature about possible mediation processes that influence the relationship between personality and entrepreneurial behavior [105, 122] in situations perceived as negative and high in uncertainty. in addition to its positive and direct effect on intentions, proactiveness, and optimism interact with the pandemic's perception and with psychological need satisfaction. furthermore, and this is an important contribution of this study, optimism and proactiveness attenuate the negative relationship between covid-19 perception and intentions. optimism and proactiveness significantly strengthen the positive relationships with entrepreneurial intention, indicating that both traits are important to understand entrepreneurship given dangerous situations such as a pandemic scenario. as such, according to this study, influencing the entrepreneurial intention of students (potential entrepreneurs), who are hampered by the pandemic situation, means analyzing the psychological and social factors that influence intentions and understanding how they relate to entrepreneurial behavior in the practice. previous studies have demonstrated a positive influence of proactive personality on entrepreneurial intentions [89] . therefore, it is highly important to appreciate proactive traits in students so that they can think of entrepreneurship as a possible career option. we have also shown that optimism is significantly and positively related to entrepreneurial intentions, specifically in difficult times. this importance of optimism for the development of entrepreneurial intentions complements previous studies in which entrepreneurs have been considered individuals who remain optimistic and persist even in adverse situations [123, 124] . however, it should be noted in this regard that studies have not always produced consistent results in the literature [108, 125] . while some studies have found a positive relationship between optimism and entrepreneurial orientation [108] , others have found a negative one [126] . these latest studies have concluded that excessive optimism may be a factor behind wrongful decisions with high levels of risk-taking. however, the conclusions of james and gudmundsson [127] , in line with our study, suggest that moderate levels of optimism have a positive impact on the entrepreneurial process and, consequently, increase the chances of success for a new company. furthermore, our results are in line with psychological theories that suggest having an optimistic orientation (positive psychology) and an ability to find alternative solutions are valuable psychological resources that can help deal with stress and facilitate coping strategies [128] , especially during crises. an environment that is perceived as highly dangerous and uncertain is negatively related to the intentions for starting a business of its people. however, the individual perception of a negative situation differs between individuals, with different consequences for their intentions [54] . certainly, beyond individual specificities, what must be taken into account is the role that the variables of our study have in entrepreneurial intentions. previous research has described proactiveness as a resource that people can mobilize in a time of stress or adversity, which allows them to overcome the barriers of various areas of life [129, 130] . it seems that having optimistic thoughts about the future is an important factor, especially in uncertain situations. it appears that these effects may have a similar role in the entrepreneurial spirit, allowing the development of entrepreneurial intention in environments of uncertainty. this study presents an innovative approach because it examines the psychological aspects of entrepreneurial intention in a pandemic situation. furthermore, our work confirms previous studies that also show the positive role of need satisfaction, which acts as an accelerator of an entrepreneurial initiative by increasing entrepreneurial intention. in this way, it joins the growing literature that explores how basic psychological needs act as motivational drives that positively influence one's future, including career choice [34] . our findings have shown that satisfaction of needs is positively related to entrepreneurial intentions in support of the consensus that, to be successful, an entrepreneur must express and use various skills, including those aimed at satisfying his needs and at achieving your own well-being in general [82, 131] . our results come from a sample of latin american students who are experiencing the consequences of the pandemic, and for whom decisions about ways to rethink their future, including work and entrepreneurship, are important. the entrepreneurial intention in our sample is high. this result is not entirely surprising, both, because of the specificity of the sample composed mainly of students from the business and management and economics fields, but also because of the high rates of youth unemployment that affect the areas of latin america, which stands at 14% [132] , and for which job opportunities seem limited and entrepreneurship represents a solution capable of generating higher economic returns than alternative job opportunities. according to the multilateral investment fund (a member of the inter-american development bank), small and medium-sized enterprises (smes) are responsible for 66% of jobs worldwide, on average [133] . in general, the stronger the ability to cope with adverse situations and the greater their optimistic orientation towards the future, their proactiveness and the satisfaction of their basic needs, the greater the probability that people will successfully face a negative event or moment of crisis as a learning experience [134] , with positive repercussions on their psychological health. as competent actors in their future, they can develop intentions to change the status quo of the communities in which they live by undertaking entrepreneurial initiatives. this study has some limitations. first, in this study, one limitation concerned how the sample was recruited. the fact that we contacted the professors for the recruitment of the participants did not allow us to monitor their characteristics, generating an unrepresentative sample. in addition, the use of self-report data and a single method of data collection raises questions about the variation of the method. however, multicollinearity was not a problem in our study, so we believe that according to siemsen et al. [135] should not inflate the meaning of the interaction effects. furthermore, data collection at a time like this has created certain problems for the research team. the online administration method dictated the use of scales with few items, focusing the research objectives on analyzing the variables considered more important for hypothesis purposes. this could probably be a limitation since longer scales could have led to more robust results [136] . this study could represent a limitation for those who are specifically interested in analyzing entrepreneurial behavior (not simply intention). however, the link between intention and behavior has been widely documented in the literature [21, 52, 137] . we believe that future research that also focuses on behavior could help improve our understanding of the intention-behavior relationship, even under critical conditions. our study offers important implications for all those who are called to promote entrepreneurship in notoriously difficult situations, such as in economic crises. all governments are making great efforts to face the economic crisis and help countries to overcome the challenges that the pandemic situation has imposed. institutional support seems important both to preserve the businesses present in the area and to launch new businesses that could work as a solution to the discouragement that the current pandemic is generating. therefore, the main objective of these adverse conditions should be based on creating a social and institutional environment that potential entrepreneurs can perceive as safe. economic growth has raised living standards worldwide. modern economies have often used the standard metric of economic growth, the gross domestic product (gdp), as a unit to indicate the development of a nation, combining its economy with the well-being of society. as a result, policies leading to economic growth are considered beneficial for society. furthermore, considering the close relationship between health and economic growth, this study represents a moment of reflection about the psychological factors that can influence people's lives and their well-being. when the environment is uncertain, people are likely to draw on their skills and develop entrepreneurial intentions when they believe they have the skills to find alternative solutions to overcome obstacles (to be proactive) by taking advantage of more positive aspects of the situation (to be optimistic). proactiveness helps people focus on long-term goals and productive activities, even when times are tough. of course, improving people's confidence about the future and their proactive behavior does not guarantee that they will be successful as entrepreneurs, it only increases the probability that they will consider an entrepreneurial path. for example, since both proactiveness and optimism can be encouraged, entrepreneurship study programs should be intensified within schools and universities [138] . for example, educators should work directly training students and promoting curriculum projects that foster the development of useful personal skills to develop an entrepreneurial mindset [139] . these activities are particularly important in developing high standards of personal performance and expectations for performance-based results [140] . entrepreneurship and education, if interconnected, have extraordinary potential because by developing the human capital necessary to build the society of the future, as they generate employment and economic growth [141] . in addition to the contribution of this study to the importance of the social and institutional sphere; and the acquisition of skills among young people, these results also have important implications at the organizational level. times of crisis can become an opportunity for enterprises to become more innovative. faced with outside pressures, the challenge for business leaders is to break out of their comfort zone and routine to become creative problem solvers and rediscover their entrepreneurial spirit. generating innovation in companies in a constantly changing market is essential for the survival and success of a company. as tellis [142] suggested, the key to innovation is human capital, therefore, understanding these elements of personality that drive innovation among employees will certainly contribute to the success of businesses. longitudinal research analyzing who has embarked on an entrepreneurial career in situations characterized by uncertainty and adversity is an important direction for future research, especially given the importance of entrepreneurship for the economic and sustainable development of a community. in this study, we analyze the perceived effects of the covid-19 pandemic in a specific context (latin america). naturally, the perception of the pandemic can be felt differently in many other parts of the world. an interesting path for future research could include analyzing several nations so that the results can be compared with countries with different economies, as well as with countries that are considered entrepreneurial-friendly. such research could address issues related to the importance of proactiveness and optimism based on the level of perceived adversity, and if whether the most proactive and optimistic entrepreneurs are the ones who are best able to overcome the challenges posed by the pandemic. this study is particularly important in the current moment of international economic crisis as a consequence of the covid-19 pandemic as it involves the production structures of many countries, which are at risk of an implosion in terms of economic growth, the most evident effects of which they can already be seen in the processes of a reduction in the labor market of numerous employees, and by the increasing phenomena of discouragement and/or resignation from job participation, especially in younger generations. our study found that the perception that university students have of the covid-19 pandemic is decreasing their intentions to start a business, with repercussions on their psychological needs. how can we solve this? in our study, we have considered two personality traits that manifest themselves as keys to enhancing the intention to undertake in this specific situation: proactiveness and optimism. these traits can dampen the effect of covid-19's negative perception on the intention to start a business, and also enhance the well-being and mental health of these young people to be able to self-employ. the authors declare no conflicts of interest. the funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. note. the bold number is the square root of ave. the bold numbers listed diagonally are the square root of the variance shared between the constructs and their measures. the off-diagonal elements are the 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science subjects: the latvian experience unlocking entrepreneurial capabilities to meet the global challenges of the 21st century; executive summary; global education initiative unrelenting innovation: how to create a culture for market dominance the authors would like to thank the students that participated in the study and the chair of entrepreneurs university of salamanca for administrative and technical support. key: cord-355513-vgs96w3b authors: ma, rongyang; deng, zhaohua; wu, manli title: effects of health information dissemination on user follows and likes during covid-19 outbreak in china: data and content analysis date: 2020-07-14 journal: int j environ res public health doi: 10.3390/ijerph17145081 sha: doc_id: 355513 cord_uid: vgs96w3b background: covid-19 has greatly attacked china, spreading in the whole world. articles were posted on many official wechat accounts to transmit health information about this pandemic. the public also sought related information via social media more frequently. however, little is known about what kinds of information satisfy them better. this study aimed to explore the characteristics of health information dissemination that affected users’ information behavior on wechat. methods: two-wave data were collected from the top 200 wechat official accounts on the xigua website. the data included the change in the number of followers and the total number of likes on each account in a 7-day period, as well as the number of each type of article and headlines about coronavirus. it was used to developed regression models and conduct content analysis to figure out information characteristics in quantity and content. results: for nonmedical institution accounts in the model, report and story types of articles had positive effects on users’ following behaviors. the number of headlines on coronavirus positively impacts liking behaviors. for medical institution accounts, report and science types had a positive effect, too. in the content analysis, several common characteristics were identified. conclusions: characteristics in terms of the quantity and content in health information dissemination contribute to users’ information behavior. in terms of the content in the headlines, via coding and word frequency analysis, organizational structure, multimedia applications, and instructions—the common dimension in different articles—composed the common features in information that impacted users’ liking behaviors. since the outbreak of the novel coronavirus (covid-19)-infected pneumonia (ncp) in december 2019, it has quickly spread across the world. the world health organization declared the outbreak of covid-19 as a global public health emergency. more than 7 million cases have been confirmed as of 9 june 2020 [1]. covid-19 has attracted attention worldwide, and information and discussions about it have been spreading on the internet, especially on social media. the ubiquity and ease of access make social media a powerful complement to traditional methods in information dissemination [2] . according to a report released by csm media research, 77.3% of chinese people purposefully seek pandemic information online, and approximately 78.7% use wechat more frequently during the outbreak than before it occurred [3] . social media is widely used for disseminating health information [4] . as one of the most popular social platforms in china, wechat has more than 1.1 billion monthly active users [5] and has become a frequently used information dissemination platform [6] . wechat contains a specific module called wechat official account [7] , which is a platform operated by institutions, communities, or individuals. wechat official accounts are widely used to share stories, report news, or disseminate various types of information. information on these accounts can be posted by anyone, including experts, novices, and even saboteurs [8] . wechat has changed channels of health information dissemination and manners of obtaining feedback [9] . for instance, evidence-based clinical practice guidelines in medical fields are traditionally spread by publishing in peer-reviewed journals, sending emails or paper notices to physicians, and advertising through news media outlets [10] . however, wechat official accounts now enable guidelines for covid-19 to be shared on this platform when they are simultaneously published by health authorities. in response to the pandemic, people prefer to receive real-time news and instructions on personal protection [3] . as such, many wechat official accounts have posted articles about ncp. however, different account operators tend to post various types of articles in different numbers. for example, some accounts have reported the number of infected cases every day to keep people informed about the pandemic state. some accounts have instructed the public to protect themselves. some accounts have refuted fake news to avoid confusion and inappropriate interventions. health information posted on these accounts can have a great impact on receivers' behavior because of its real-time nature and various forms [11] . they can express their appreciation and interest by liking an article or following an account [12] . we found that the number of followers on many official accounts changed dramatically within a week. meanwhile, the number of likes differs greatly among articles. in this work, we aimed to determine whether and how health information dissemination affected users' information behavior in terms of following an account and liking a post. researchers studied the influence of health information on information behaviors on different social media platforms, such as facebook and microblogging sites. the findings are shown in table 1 . zika, mers, and chikungunya messages motivate the public to search for related information frequently and to post actively. bragazzi et al. [13] mahroum et al. [14] jang et al. [15] mommy blog users with a personal connection to the health issue tend to post articles about it. burke-garcia et al. [16] adoption and sharing behavior pregnancy-related information influences expectant mothers to adopt and share from the perspective of perceived influence and prenatal attachment. zhu et al. [17] harpel. [18] lupton. [19] commenting behavior microblog information correlated with the vaccine event or environmental health in china can significantly influence users' comments. an et al. [20] wang et al. [21] prevention behavior instagram facebook intervention messages on breast cancer can effectively affect prevention behavior and lead to high exposure scores in consideration of the influence of leaders' opinion. wright et al. [22] however, we found that few researchers concentrated on wechat in china. the above did not study detailed characteristics in the information. these studies mainly focused on the effect of health information on information behavior. however, during the pandemic, users may concentrate on different types of information, and their reaction to a given information may vary. for example, more people have followed wechat official accounts to give continuous attention to the pandemic [23] , users' behavior on social networks is the inclination to use social network services and various activities [37] . researchers studied users' information behavior on some popular social media platforms. for example, bian et al. [38] found that the tendency to discuss promotional lynch syndrome-related health information on twitter shows users' prevention awareness. iftikhar et al. [39] clarified that health information on whatsapp, facebook, and twitter can urge users to verify it on google. meanwhile, gan [40] summarized three factors, namely, hedonic, social, and utilitarian gratifications, which affect the tendency of wechat users to like a post. users' information behavior is manifested everywhere on the internet [41] . their behavior on wechat official accounts includes acquiring information, liking a post [40] , and following an account. different behaviors may reflect different inclinations. for example, reading an article shows users' interest in a certain health theme [42] . liking a post reflects their preference and appreciation [12, 43] . after reading an article, users can like it to show their appreciation for the important message [23] , and following accounts may indicate that users want to know what is being posted and their willingness to pay continuous attention [44] . however, to the best of our knowledge, few studies have focused on analyzing the influence of information on users' information behavior to explore specific characteristics that satisfy wechat users. thus, this study aimed to address this issue. for this purpose, we developed multiple and simple linear regression models. we chose the number of different types of articles and the aggregated number of headlines on ncp posted on the selected accounts in a 7-day period as independent variables (a total of seven) to denote the health information source and reflect the dissemination state. we also chose the number of new followers and likes in this period as dependent variables to represent users' information behavior. then, we analyzed the relationship between information and behavior in quantity. we selected the number of related articles because it is a critical indicator in evaluating information dissemination [45] . besides, for the impact of content on liking behaviors, we chose all of the headlines on ncp which won more than 10,000 likes to conduct our content analysis. information can affect users' information behavior on other media [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] . we want to explore whether information conveyed in each type of articles posted on wechat can play the role, impacting users' following and liking behavior. thus, on wechat official accounts, we drew the following hypotheses-h1 to h3. these articles will be classified into different types in the later part of this paper. h3: the headlines with a great number of likes may possess common characteristics in content that can impact users' liking behavior. we collected data from the xigua website (data.xiguaji.com) in china. it is a big data platform that provides operational data on wechat official accounts. the data include the number of articles posted in the last 7 days, comments, the number of likes, and other information on each account. xigua is an open-access website for researchers, and official accounts on this website can be classified into different fields, such as economy, sports, and health. we focused on health and used data on monthly rankings. we used bazhuayu, a chinese web crawler software for data collection, to collect data within the top 200 accounts as shown in figure 1 . the outbreak of the disease in china occurred on 19 january 2020. since then, information regarding the pandemic has attracted considerable attention. at this time, the online reaction of the public may be greatly intense as they were faced with this severe condition suddenly. in a short period, their behaviors may be easier and more obvious to observe than before. thus, we selected 21 january 2020, and 27 january 2020, as two time nodes to collect and classify account information, including the name, rank, operator, and number of followers. these accounts can be classified into three types based on their operators: nonmedical institution, medical institution, and individual accounts. different types of accounts are operated by different stakeholders. nonmedical institution accounts are operated by companies and governments; medical institution accounts are administrated by hospitals, including maternal and child care service centers; and individual accounts are managed by individuals. table 2 presents the number of accounts. then, we calculated the change in followers in 21-27 january 2020. because we intended to study information on ncp, we filtered several accounts to identify the influence of information on the pandemic and deleted those who did not post any article related to ncp. for the 124 remaining accounts, 66.1% (82/124) were nonmedical institution accounts, 24.2% (30/124) were medical institution accounts, and 9.7% (12/124) were individual accounts. figures 2 and 3 show the screenshots of the rank list and data collection page, respectively. following an account and liking a post can represent users' activity. the change in the number of followers in the 7-day period and the aggregated number of likes in the headlines that are correlated with ncp can reflect users' information behavior. thus, we used them as two dependent variables. we recorded the state of articles on every account and counted the number of posts on ncp. we classified them into six types; namely, counter-rumor, report, science, story, instruction, and others. we classified articles that struck sensationalism or misinformation and clarified a fact as a counterrumor article. we classified articles on news about the state of the pandemic, several facts, or a press conference conducted by the national health commission or other governmental institutions as a report. we also grouped an interview with professionals as a report. we categorized posts on scientific outcomes about ncp, explanations of this new virus, or information about psychology under science. we identified shared self-or public-description articles about how physicians resisted the pandemic in hospitals as a story. we identified posts that instructed the public to protect themselves or published a diagnosis and treatment guideline as instruction. other posts, such as commentary, appealing for aid, advocating, and encouraging articles, were grouped under others. we classified posts that integrated more than one type of topic based on titles and main contents. this classification standard was approved by all the authors. we defined six independent variables for the six article types. following an account and liking a post can represent users' activity. the change in the number of followers in the 7-day period and the aggregated number of likes in the headlines that are correlated with ncp can reflect users' information behavior. thus, we used them as two dependent variables. we recorded the state of articles on every account and counted the number of posts on ncp. we classified them into six types; namely, counter-rumor, report, science, story, instruction, and others. we classified articles that struck sensationalism or misinformation and clarified a fact as a counter-rumor article. we classified articles on news about the state of the pandemic, several facts, or a press conference conducted by the national health commission or other governmental institutions as a report. we also grouped an interview with professionals as a report. we categorized posts on scientific outcomes about ncp, explanations of this new virus, or information about psychology under science. we identified shared self-or public-description articles about how physicians resisted the pandemic in hospitals as a story. we identified posts that instructed the public to protect themselves or published a diagnosis and treatment guideline as instruction. other posts, such as commentary, appealing for aid, advocating, and encouraging articles, were grouped under others. we classified posts that integrated more than one type of topic based on titles and main contents. this classification standard was approved by all the authors. we defined six independent variables for the six article types. moreover, we counted the number of headlines on ncp to explore its correlation with likes. each account will post many articles on ncp every day, and headline is the first one with a conspicuous title and illustration. we recorded and counted the total number of likes in each article in this period. we defined headlines as another independent variable. table 3 presents the collected and processed sample data. the scale of change in the number of followers was 10,000; for the number of likes, the scale was 1000. before estimating the models, we tested whether the variables were normal. we used a one-sample kolmogorov-smirnov test to examine the normality of variables. table 4 shows the results. the sample size was 124 (n = 124). all p values were below 0.001. therefore, all variables were normal and could be estimated in the linear regression models. we developed a multiple linear regression model to explore the relationship between the change in the number of followers and the six types of articles. meanwhile, we developed a simple linear regression model for the aggregated number of likes. we proved the normality of variables. models are shown in the following two equations. y i represents the change in the number of followers in the 7-day period. counter-rumor i , report i , science i , story i , instruction i , and others i denote the number of counter-rumor, report, science, story, instruction, and other types of articles, respectively. y i ' represents the aggregated number of likes in headlines in this period. headlines i indicates the total number of headlines related to the pandemic. where i = 1,2, . . . , n index all accounts; α 0 to α 6 are the parameters to be estimated; ε i is the corresponding residue. where i = 1,2, . . . , n index all accounts; β 0 and β 1 are the parameters to be estimated; ε i is the corresponding residue. we designed our research to figure out the effect of information quantity on users' information behaviors. we were also interested in the effect of content. we found an interesting phenomenon that among the accounts whose articles were usually unpopular, one article received a large number of likes. it did not correspond to the popularity of the account. for example, west china hospital lagged in the rank list, and most of its posted headlines were plain. nevertheless, on 22 january 2020, it posted a headline that received 60,225 likes, which might be a crucial factor that can affect our regression result. we can hardly find an article that received such an unexpected number of likes. we determined the reason why these articles were exceptional in terms of users' liking behavior. to further conduct our study, we browsed the selected headlines that received more than 10,000 likes in this period and explored their characteristics in terms of content that could affect the liking behavior. we examined a total of 13 headlines. we code them from 4 perspectives: the account group that an article comes from, original/non-original articles, the article type, and the length of articles. meanwhile, we recorded the form of multimedia applied in each article to show information (including the number of videos, pictures and graphics). the codebook is presented in tables a1-a4 in appendix a. the intercoder reliability was tested to be ideal. the coding results and some statistics are shown in table 5 . we used spss 25.0 to analyze the data. table 6 shows the estimation results based on the least squares method and stepwise regression. we developed model 1-3 to represent nonmedical institutions, medical institutions, and individual accounts, respectively. however, not all models could fit well. for nonmedical institution accounts in model 1, the variables of report and story types had a significant effect (b = 2.724, p = 0.007; b = 14.875, p = 0.003) and played a positive role. the remaining variables were insignificant. for the medical institution accounts in model 2, the variables of report and science types were significant (b = 4.381, p = 0.009; b = 31.564, p < 0.001) and positive. however, for individual accounts in model 3, we did not obtain any result. model 1 and 2 had adjusted r 2 of 0.355 and 0.452, respectively, denoting an acceptable fit. we were unable to obtain a satisfactory result for model 3. thus, we partially confirmed h1. this section explored h2. table 7 shows the simple linear regression result based on the least squares method and stepwise regression. among the three groups, only nonmedical institution accounts in model 1 showed significance. the variable of headlines played a positive role (b = 3.084, p< 0.001). the adjusted r 2 was 0.317, denoting an acceptable fit. we did not discover significance for medical institution and individual accounts. thus, h2 was partially confirmed. we found some impact factors of information dissemination on behavior, but we did not obtain a significant result in model 2 and 3 when we analyzed headlines and likes. it may because of some exceptional articles with a large number of likes recorded in table 5 that led to insignificance when we analyzed model 2. when we discarded this datum, the analysis result was significant. thus, this factor could remarkably affect our results. some findings in content analysis are as follows. of the 13 articles, 8 (62%) were posted by nonmedical institution accounts. of these 8 articles, 5 were posted by dingxiang doctor, which was the most active account. dingxiang doctor was also the second-most popular in the rank list. besides, one account named dingxiang yuan posted 1 article. these two accounts are affiliated with the same company called hangzhou lianke meixun biomedical technology corporation. in addition to these 8 articles, 1 (8%) was posted by medical institution accounts, and 4 (30%) were posted by personal accounts. however, the only article posted by west china hospital received the most number of likes and reached 60,225. the reason why articles from the medical institution group accounted for the least proportion may be that these accounts usually post affairs about their affiliated hospitals, which may be less interesting in the public opinion. compared with them, the public tend to prefer articles from nonmedical institution accounts. these accounts usually post various types of articles about common sense or short stories, which are easy for the public to understand and receive. this may be the reason why the public pay more attention to them and their articles. among the 13 articles, 7 (54%) were original, and 6 (46%) were not. we did not identify an evident preference for originality. in these headlines, instruction, story, others, and counter-rumor types accounted for 46% (6/13), 23% (3/13), 15% (2/13), and 8% (1/13), respectively. report articles had the same proportion, accounting for 8% (1/13). for the two others, one article presented a timeline since the pandemic broke out, whereas the other article revealed several latent dangers after the city was locked down. story-type articles were confirmed to be positive in regression analysis. an instruction-type article could provide suggestions during a public health emergency. this article type might be the most popular because it met users' demands to seek prevention. wu [46] believed that perceived usefulness is a precondition of users' overall satisfaction. perceived usefulness can affect users' attitude and determine the continuance of using an information system [47] . reading behavior can show the perceived usefulness from users [48] , and liking an article may denote their gratifications [40] . instruction articles will inspire users' perceived usefulness and promote an account's popularity. we studied the length of each article and the method of transmitting information in table 5 . the length varied among headlines; 8 articles in the 13 (62%) was coded as "2", possessing 2000-4000 characters. many articles limited the content length by using visual aids. for example, all articles applied infographics, including images and graphics. the post "can you go out without a mask? experts recommended the proper wearing of masks." by west china hospital had the most images (up to 28). infographics and other visual aids, such as videos, can promote health information communication [49] . using visuals based on conventional text gains an ideal outcome from the perspective of health information promotion [50] . infographics and videos can help users visualize information and facilitate the straightforward understanding of information. as a result, the content is concise and clear, and it may help account operators to improve their performance in dissemination, making it easier for the public to receive information. although the types of articles varied, most of them integrated different types. for example, the article "can you go out without a mask? experts recommended the proper wearing of masks." not only provided an instruction but also appended a report on the pandemic. the counter-rumor article "novel coronavirus fears alcohol and high temperature, but vinegar, saline, and smoke are useless: 11 rumors you need to know." also taught several prevention methods. none of the articles had only one type of content. our coders classified the articles on the titles and main content. diversity in types could simultaneously enhance the practicability of the content and meet users' different demands. however, the main part of the article should be specific to prevent it from being misinterpreted. we counted and recorded high-frequency words in these articles. they are shown in table 8 . words occurring more than five times were listed in it. all the articles introduced general features about covid-19, mentioning some same words, such as pandemic, doctor, infection, and so on. along with it, we found that different types of these articles all referred to one common dimension. that is the instruction. for example, words including mask, wash hands, and isolation indicated instructions on how to protect the public. they existed in most of these articles. besides, arbidol hydrochloride capsules is a drug used to relieve the state of infected cases. this noun also showed up in different articles, introducing an instruction on selecting drugs. most of them introduced instructions on prevention. it may because of the usefulness perceived by readers that helped these articles win a large number of likes. table 8 . high-frequency words in each article. a wuhan doctor was suspected of being infected. he recovered after 4 days' isolation at home! please spread his life-saving strategy to everyone! the usefulness of the article. the comments suggested that the article could facilitate the timely acquisition of knowledge about prevention during a health crisis. furthermore, a story about the heroic contributions of doctors and other people may inspire readers. a counter-rumor type of article may help users identify inaccurate information and prevent them from adopting inappropriate prevention methods. however, popularity is accompanied with limitations, and this issue should be considered. given the severity reported in these articles, information may lead to unnecessary public panic. some people even protect themselves excessively, as the disease is devastating if uncontrolled. however, with the contributions of physicians, we must be hopeful for the future situation. therefore, the aspect of reducing the negative effects of articles on readers should be considered by account operators. a prevention guideline against the new pneumonia. scientific prevention, we should not believe and transmit rumors. coronavirus, pneumonia, protection, prevention, infection, transmission 3.3.5. effects on readers are positive frequently but should consider the limitation these articles usually have positive effects on readers. for example, figure 10 shows the screenshot of reviews from readers of an article with the most likes. most of the readers admired and appreciated the usefulness of the article. the comments suggested that the article could facilitate the timely acquisition of knowledge about prevention during a health crisis. furthermore, a story about the heroic contributions of doctors and other people may inspire readers. a counter-rumor type of article may help users identify inaccurate information and prevent them from adopting inappropriate prevention methods. however, popularity is accompanied with limitations, and this issue should be considered. given the severity reported in these articles, information may lead to unnecessary public panic. some people even protect themselves excessively, as the disease is devastating if uncontrolled. however, with the contributions of physicians, we must be hopeful for the future situation. therefore, the aspect of reducing the negative effects of articles on readers should be considered by account operators. the organizational structure, location, and description of information on social media affect public attention [51] . multimedia applications, such as infographics and videos, make the structure clear and concise. certain types of articles can satisfy the public's demand for information and improve the popularity of articles. diversity in types can promote users' liking behavior and health the organizational structure, location, and description of information on social media affect public attention [51] . multimedia applications, such as infographics and videos, make the structure clear and concise. certain types of articles can satisfy the public's demand for information and improve the popularity of articles. diversity in types can promote users' liking behavior and health information dissemination because of the superior content of articles. besides, these articles always referred to a common dimension which introduced some instructions. h3 was proven to be true. this study aimed to explore the effects of health information dissemination on users' information behavior on wechat official accounts. our hypotheses were tested using two-wave data collected from the xigua website over a period of 7 days. meanwhile, we further explored the content characteristics based on the 13 headlines with an unexpected number of likes to answer our research question. first, our results suggested that not all types of articles significantly affected the users' tendency to follow an account. for nonmedical institution accounts, report and story types positively influenced the change in the number of followers. for medical institution accounts, report and science types exerted positive effects. however, we did not find significant relationships for individual accounts. second, the number of headlines on the pandemic contributed to likes for nonmedical institutions. however, we did not obtain the same result in medical institution and individual accounts. for medical institution accounts, we found an article with an unexpected number of likes of up to 60,225. when we rejected this information, the analysis result was significant. thus, several articles with an unexpected number of likes could determine the regression result to a great extent. third, we reviewed 13 headlines to further explore the characteristics of information from articles that could affect users' liking behavior. in the headlines, organizational structure, the manner of description, and the application of multimedia contributed to unexpected likes. users showed an inclination to instruction and story types, especially those from nonmedical institution accounts. health authorities should take advantage of these accounts to enhance health information dissemination and reduce public panic. meanwhile, paying attention to methods of delivering messages was crucial, for the application of multimedia such as graphics, videos or pictures may make it easier for the public to understand and receive information. besides, diversity in types was also crucial in encouraging likes, and the role of instructions should not be left out. these dimensions composed the common features of information that can impact users' likes. this study has theoretical implications. on facebook, twitter, and other social media, information dissemination can affect users' information behavior [31] . in the present study, we expanded the research scope to wechat in china, especially in the health field. we identified several factors that affected users' information behavior on this platform. for nonmedical institution accounts, report and story types of information should be emphasized. likewise, report and science types should be promoted for medical institution accounts. particular account groups, multiform transmission, and diversity in types, including instruction and story, are essential for promoting popularity. this study also has practical implications. first, on social media, account operators can promote information dissemination. analyzing users' information behavior may allow them to determine the kind of information that satisfies the public. they should fully utilize the superiority of headlines to enhance diffusion. second, the above conclusions could be explored further and in depth by analyzing twitter, facebook, or youtube trends in other countries, contributing to the worldwide campaign in the medical informatics and health dissemination domains. this strategy might help authorities determine what kind of information the public needs. if dissemination is efficient, the public will receive accurate information and useful prevention suggestions in a timely manner. this method can help health authorities successfully manage this public health emergency [52] . this research has several limitations. during the data analysis, we did not identify the significance of some variables because the sample size was small. for example, we only assessed 12 individual accounts among 124 accounts. for this reason, we could not ensure that such insignificant factors would not contribute to users' information behavior. in our future work, we will involve more comments from users on different groups of accounts and expand the sample size to conduct further analyses. we considered that likes mainly denote users' appreciation. however, some readers may like an article without a valid reason or for conformity [53] . other users can express their positive feelings by commenting. thus, in further studies, we will assess the implications of users' behavior, such as liking, following, commenting, and even sharing, based on quantitative methods. interviews that reflect users' actual feelings are also essential. we will also explore the effect of content on readers by analyzing their comments. the effects of information dissemination on users' information behavior during the covid-19 pandemic were examined. two models were developed to test our hypotheses that 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key: cord-339503-nutc1mvz authors: pan, wenyan; gulzar, muhammad awais; hassan, waseem title: synthetic evaluation of china’s regional low-carbon economy challenges by driver-pressure-state-impact-response model date: 2020-07-29 journal: int j environ res public health doi: 10.3390/ijerph17155463 sha: doc_id: 339503 cord_uid: nutc1mvz the “driver–pressure–state–impact–response” (dpsir) model has recently become a popular approach to deal with environmental problems. the combination of dpsir with analytic hierarchy process (ahp) is a useful method to study low-carbon evaluation because the ahp model has a special advantage in multi-indexes evaluation. this paper constructs the low-carbon economy evaluation system and comprehensively evaluates the numerical value of low-carbon economic development of china’s 30 regions from 2000 to 2015 by using the ahp method. it shows that the numerical value of low-carbon economy of china’s 30 regions varies in terms of growth rate. the numerical value of east regional low-carbon economy shows a pattern that is gradually higher than that of the west region. the numerical value of low carbon economic development in the south region is higher than that of the north region by degrees. in addition, based on the model of coordination degree in 2015, the result indicated that the four subsystems have primary coordination in the east area and bare coordination in the central and west areas. it is indicated that the four sub-indexes should be developed at the same pace and promoting the development of a low-carbon economy in the mid-west areas is the key in china. finally, we proposed that environmental regulations and policies should be formulated to improve coordination in various aspects and various departments. calculating the degree of low-carbon economic coupling coordination may be helpful for policy makers to formulate effective policies and take actions in the future. the 26th meeting of the conference of the parties (cop26) of the united nations framework convention on climate change (unfccc), originally scheduled for november in glasgow, united kingdom has been postponed until 2021 [1] . patricia espinosa (executive secretary of unfccc) said covid-19 is the most urgent threat facing humanity today, but we cannot forget that climate change is the biggest threat over the long term. it clarifies the content of anthropogenic climate change and the political statements of reducing greenhouse gas emissions of each country. an important contribution made by the paris agreement (cop21) was the nationally determined contributions (ndcs) [2] . this is the key to achieving long-term goals. the ndcs identified the efforts and commitments of each country to reduce greenhouse gas emissions, improving the impact of climate change. the aim is to work together to respond to the challenge of climate change and the greenhouse effect. the paris proposed a pressure-state-response (psr) frame model [18] . on that basis, the united nations proposed the driving force-state-response frame model. finally, the european environment agency and others combined the benefits of the previous two index systems and proposed a new conceptual frame model: driving force-pressure-state-impact-response (dpsir) [19, 20] . it can be seen that the dpsir model is the expansion and revision of psr model, which adds the "driving force" factor as the cause of the "pressure" factor and the "impact" force caused by the environment [21] . the scholars who use the model think that it is people's activities such as production and consumption that put the natural environment under pressure, consequently leading to change in the natural environment. however, we should respond to the effects that the climate change brings. the dpsir model is widely used for analyzing problems about resources, environment, economy, and society. for instance, maxim et al. supplemented the dpsir model by using the complex system theory, and then, the model was used to analyze the risk of biological diversity in the aspects of policy, society and economy [22] ; ness et al. think the dpsir model is quite up to the requirements of sustainable scientific outlook on development, and with the help of that, they can research the eutrophication in the baltic sea [23] . atkins et al. create a model which supports marine environment decision by integrating the dpsir model with features of ecosystem service and social welfare [24] . the dpsir model was selected due to its simplicity and because it is the most powerful communication tool between environment, economy and society [25, 26] . from these aforementioned examples, it is clear that the applicability of dspir model is very high and that's why it is used by many scholars for the analysis of all kinds of resources and in environmental as well as social and economic problems. dpsir model particularly focuses on economic operations, their effects on the environment and their interrelations. thus, it is a very systematic, comprehensive, widespread and flexible model. the "driving force" indicates the potential cause of the changes in environmental conditions, which mainly refers to the development trend of economic activities, social activities and changes in the industrial structure. the "pressure" is the influence of human activities on natural environment, energy and resources. the "state" refers to the situation of environment under the above-mentioned pressures and mainly considers regional resource consumption and environment degradation. the "impact" is the influence of system's status on environment and social economic structure. lastly, the "response" shows the methods and effective policies that people create when facing environmental impact. firstly, the analytical framework of a low-carbon economy system is constructed, in which the dpsir model is used considering human needs, social progress, economic development, energy demand, carbon emissions, resource status, low-carbon consumption and economic development. this progress reflects the features of a low-carbon economy, as a complex system relevant to the mutual effect of human activities and natural resources. showing the connotation of a scientific outlook on development, the low-carbon economic system should be human-oriented and development-coordinated. the analytical framework of the system based on dpsir model is shown in figure 1 . in order to construct a multi-dimensional and scientific evaluation index system that not only can conduct the horizontal comparison in all regions but also the vertical reflection of steady shift, the principles mentioned below must be followed. for the purpose of ensuring that the evaluation of the system completely and objectively reflects its comprehensiveness and shift result, plenty of work needs to be done. in addition to that, the overlap between indexes must be avoided. therefore, the index system must be made clear by level diversification and index classification according to system structure. the evaluation index should also scientifically and moderately reveal the properties and transitional characteristics of a low-carbon economy. besides, every evaluation with its calculation should be standardized, normalized and clearly defined; even those statistics that cannot be obtained from the existing statistical source can be brought into the index system if they have the ability to reflect the practicality and the embodiment of the low-carbon economy. in order to construct a multi-dimensional and scientific evaluation index system that not only can conduct the horizontal comparison in all regions but also the vertical reflection of steady shift, the principles mentioned below must be followed. for the purpose of ensuring that the evaluation of the system completely and objectively reflects its comprehensiveness and shift result, plenty of work needs to be done. in addition to that, the overlap between indexes must be avoided. therefore, the index system must be made clear by level diversification and index classification according to system structure. the evaluation index should also scientifically and moderately reveal the properties and transitional characteristics of a low-carbon economy. besides, every evaluation with its calculation should be standardized, normalized and clearly defined; even those statistics that cannot be obtained from the existing statistical source can be brought into the index system if they have the ability to reflect the practicality and the embodiment of the low-carbon economy. as a whole, the system should include various indexes that can affect the level of the low-carbon economy. although it is impossible to cover all the relevant indexes, the system must be capable of reflecting all aspects that can affect the level of the low-carbon economy in the current social economy. in addition, the selected indexes should reflect the main character and status of the evaluated system from different aspects. in order to make the index system easy to use, while choosing indexes, we must emphasize on their depiction and avoid redundancy. the worldwide recognized common index must be followed after altering it according to required standards, and concurrently, the internationally accepted names, concepts and calculations must be adopted. in addition to that, whatever the evaluation index, system construct is a global perspective oriented job. therefore, we must take full account of the dynamic change of the system when designing the index system and embrace innovation. in this paper, the system is established based on dpsir model, as shown in table 1 . the "impact" was removed from the dpsir model because indicators in "impact" overlap with those in "pressure" and "state". at the same time, the relevant statistics for economic losses and natural hazard caused by air pollution are hard to get. as a whole, the system should include various indexes that can affect the level of the low-carbon economy. although it is impossible to cover all the relevant indexes, the system must be capable of reflecting all aspects that can affect the level of the low-carbon economy in the current social economy. in addition, the selected indexes should reflect the main character and status of the evaluated system from different aspects. in order to make the index system easy to use, while choosing indexes, we must emphasize on their depiction and avoid redundancy. the worldwide recognized common index must be followed after altering it according to required standards, and concurrently, the internationally accepted names, concepts and calculations must be adopted. in addition to that, whatever the evaluation index, system construct is a global perspective oriented job. therefore, we must take full account of the dynamic change of the system when designing the index system and embrace innovation. in this paper, the system is established based on dpsir model, as shown in table 1 . the "impact" was removed from the dpsir model because indicators in "impact" overlap with those in "pressure" and "state". at the same time, the relevant statistics for economic losses and natural hazard caused by air pollution are hard to get. the connotation of "driver" is reflected by setting the "driver for social development" (d1) and "driver for economic development" (d2), completely representing the essence of people's needs and social development of scientific outlook on development. the connotation of "pressure" is reflected by setting the "resource pressure" (p1) and "environmental pressure" (p2), symbolizing the damages and losses that social progress and human development do to the environment and resources. the connotation of "state" is reflected by setting the "state of low-carbon consumption" (s1) and "state of low-carbon resources" (s2), describing the objective condition of resources and environment in the low-carbon economy system. the connotation of "response" is reflected by setting the "scientific response" (r1), "human response" (r2) and "policy response" (r3), embodying the positive response of countries towards environmental pollution, resources consumption and ecological destruction. at the same time, the frequently used indexes from the relevant studies about low-carbon economy are selected. this paper focuses on the coordination degree among four sub-indexes. degrees of interaction among the four sub-indexes are defined by their respective characteristics as the degree of coupling coordination. the equation is as follows: where t represents the development degree of the comprehensive evaluation index, which is the reflection of the development level of low-carbon economy. x , i represents the "driver" indexes. y , i represents "pressure" indexes. z , i represents "state" indexes. k , i represents "response" indexes. the weight values are µ, φ, ξ, θ, α i , β i , σ i . where c represents the coupling degree, which is a measure of coordinated development. c ranges from 0 to 1. the greater the coupling degree among the systems the closer the c is to 1. contrary to it, the smaller the coupling degree among the systems, the closer the c is to 0. besides, there is no need to develop it while the sub-indexes are irrelevant. d is coupling coordinated degree. t is development degree. it measures the situation as a whole of the development of coordination in the system [27] . the classification criterion of d is as in table 2 . in the current literature and research, the calculation caliber of regional carbon emissions data is difficult to unify. we use the methodology in the ipcc guidelines: where c represents total co 2 emissions from regional energy consumption; i is the type of energy; t i is the terminal consumption for i; f i is the coefficient of co 2 emissions for i: a i is the coefficient of carbon emissions for i (kgc/gj); b i is the oxidation rate in the combustion for i type energy; a i and b i are derived from ipcc (2006). in table 3 , c i is the coefficient of co 2 emissions for i (kgco 2 /tj); d i is the original coefficient for i type of energy (kg co 2 /kcal); e i is the calorific value of unit fuel in china. this paper calculates co 2 emissions in china's 30 regions . the data for these provinces are derived from china's statistical yearbook. the reason we removed the refinery gas and liquefied petroleum gas is because they are difficult to gather, and they are used less. we calculated the total co 2 emissions from 1995 to 2016, which show a tendency to increase year after year (table 4 ). we evaluate the level of the low-carbon economy development level in china's 30 regions from 2000 to 2015 as shown in table 1 . the demographic data are obtained from "china population statistic yearbook", the per capita gdp, the gdp growth and the average income of rural and urban families are obtained from the statistics in "china statistical yearbook". the energy data are obtained through the calculation of statistics in "china energy statistical yearbook" and china's 30 regions' statistical yearbooks. the scientific data are attained from "china statistical yearbook on science and technology". we can set the 6% and 75% as moderate indexes, which is the ideal value of natural population growth rate and urbanization rate. table 3 . coefficient of co 2 emissions in china. a b c = a × b × (44 / 12) × 1000 d = c × 4186.8 × 10−9 × 10−3 e f = d × urbanization rate (d12). urbanization rate refers to the percentage that the urban population accounts for the entire population, which witnesses city's history and development. since the current statistics do not cover all sub-provincial cities' statistical data of urbanization rate, this paper adopts the method that "non-agricultural population accounts for total population proportion" to calculate the urbanization rate, which is authorized by police departments. the method can be summarized as "the urbanization rate = non-agricultural population/total population. per capita carbon emissions (s11). from 1990s to the year 2000, the global average annual co 2 emission has increased from 22 billion tons to 264 billion tons. therefore, the primary goal of developing the low-carbon economy is to limit co 2 emissions. due to unavailability of authorized statistics on carbon emissions, this paper estimates the carbon emissions produced by fossil resources (coal, oil and natural gas) based on other existing statistics. the total carbon emissions = σ (each resource consumption × carbon emissions per unit of energy consumption), summarized as per capita carbon emissions = total carbon emissions/population. carbon emissions of residents' consumption (s12) and government's consumption (s13). they refer to the carbon emissions created by government's and residents' final consumption on goods and services over a period of time, which can reflect the influence of consumption level and structure on carbon emissions. the government's consumption on carbon emissions refers to the carbon emissions created by government's consumption on public services, which can reflect the impact of local government governance level on carbon emissions. we account these two indexes according to the proportion of residents' consumption in gdp (known as final consumption rate) and carbon intensity per unit of economy. that is, carbon emissions of residents' consumption = total carbon emissions/residents' consumption, carbon emissions of government's consumption = total carbon emissions/government's consumption. the efficiency of energy process and conversion (r12). the process of energy conversion is a production link of the energy process system, which is the important index for evaluating the advancement of the energy conversion device, the production technique and the quality of administration. the improvement of efficiency of energy process and conversion means that the low energy input can create high energy output. its formula is as follows: efficiency of energy process and conversion = energy output/energy input. carbon productivity (r13). it is considered as the core index of measuring low carbonization, which is the gdp per unit of carbon emitted. this index links the gdp output with the carbon emissions of energy consumption directly. therefore, it can visually reflect the carbon use efficiency of the whole social economy and measure the overall level of low-carbon technology. in addition, as a result of its relation with economic structure, the carbon productivity can have the potential of further reduction of carbon emissions intensity of unit consumption when the country's technology has accumulated to a certain extent. its formula is carbon productivity = gdp/carbon emissions. the collected original data must be dimensionless through range conversion as they cannot be compared directly. we set x ki as the value of the index k that has been normalized in the evaluated area i, and set the v ki as the value of the index k in the evaluated area i, the n as the quantity of the evaluated area. positive data was calculated: negative data was calculated: regarding, moderate interrelation for those factors, the closer it approached to ideal value, the better. in reference to a large number of previous literature, this paper sets the planning objective of the country's natural population growth rate in china (v1 = 6% ) as the ideal value of natural population growth rate (d11) and sets the average urbanization rate in developed countries (v2 = 75%) as the ideal value of the urbanization rate (d12). we set x ki as the value of the index k that has been normalized in the evaluated area i, set the v ki as the value of the index k in the evaluated area i, the v 0 ki as the ideal value and the n as the quantity of the evaluated area. moderate data was calculated: ahp model was developed by satty [28] ; it includes both qualitative and quantitative indicators, and ranks programs based on multiple criteria. it has been widely used in macro (complex and realistic) and human (management subjective) problems [29] [30] [31] . nowadays, it is used in many research fields [32] [33] [34] [35] . in this study, the low-carbon economy system includes four levels (table 1) . if a ij is the result of comparing i with j. the matrix is we employed the delphi method to analyze the relative importance of d, p, s and r. in this study, we provided a scoring table for 30 experts from the universities, scientific institutions and government decision-making departments. then we calculated the judgment matrix, obtained the indicator weighting and established pair-wise comparison matrix for a (table 5 ).finally, we found that "state" (s) was crucial to the low-carbon economy level, and it was the base for low-carbon economy, therefore, weight of s was the highest. a ij , (i = 1, 2, 3, 4) finally, we calculated the weight of d, p, s and r were 0.1186, 0.2162, 0.4141 and 0.2511. the eigenvalue λ max = 4.1576. then, we tested ci (the consistency index) = 0.0525. cr (the consistency ratio) = 0.059 ≤ 0.10. ri is used to modify the ci. in this paper, ri = 0.90. we calculated the indexes according to the aforesaid principles, then used a composite index that contains rule hierarchy composite index and comprehensive composite index (using the hundred percentage point system). in other words, the method of linear weighted sum is used to calculate index value in all rule hierarchies, and then from its result the low-carbon evaluation index (lcei) value is obtained. we use z j to express the numerical value of second grades in the comprehensive system; in order, there are d index, p index, s index and r index. then we set x k as the dimensionless index after normalization and the w k as the weight of the indexes (table 1) . we present the low-carbon economy level of china's 30 regions in table 6 . as mentioned above, the horizontal comparisons of the coordination degrees are shown in table 7 , the coordination degrees of the 30 regions in china were calculated and analyzed and were based on the model of coordination degree in 2015. the coupling degree (c) results show a pattern for that central area lower than the west area and the west area lower than the east area. the average degree of the whole country is 0.6723, which is higher than west and central areas but lower than the east area. the coordination degree (d) results show a pattern for the west area lower than the central area and the central area lower than the east area. the average degree of the whole country is 0.5840, which is higher than the west and central areas but lower than the east area. moreover, based on the model of coordination degree in 2015, the coordination degrees of the 30 regions in china were calculated and analyzed. the results indicated the four sub systems were primary coordination in the east area and bare coordination in the central and west areas in 2015. it indicated that four sub-indexes should be developed at the same pace and be improved based on stable development. the construction of low-carbon economy in mid-west areas is the key in china. in table 8 , the numerical value increases gradually; all provinces, municipalities and autonomous regions show varying increasing rates; the level of low-carbon economy varies by province. the index level shows a gradually decreasing trend from southeastern coastal areas to the north on spatial variation. the figure 2 reflects the distribution of development capability of regional low-carbon economy in china in 2015. it can be seen from figure 2 that in the spatial distribution, the numerical value of development capability shows a pattern that indicates the southeast is gradually higher than the north. while the clear winner would be the east, which overall stands on the top. this spatial distributive characteristic is closely related to china's industrial structure, economic development and resource distribution features. for example, shanxi and inner mongolia are important coal-producing bases where coal mines and resources are so crowded that they have weak low-carbon economy development. however, guangdong and fujian relatively have lack of natural resources so that their economy has reached a higher level, and the low-carbon economy develops well. although beijing is located in northern china and is very near the coal resource centers geographically, with coal making up such a large proportion in its energy structure, it has a well-developed economy; especially, the proportion of its tertiary industry is over 80%. its industry is mainly based on modern manufacturing and tech industry; therefore, beijing is under less pressure on low-carbon economy and it ranks 1st in low-carbon economy. however, industrial manufacturing still accounts for a definite proportion of the industrial structure in shanghai; as a result, shanghai is under more pressure on low-carbon economy than beijing even though its economy is better. the figure 2 reflects the distribution of development capability of regional low-carbon economy in china in 2015. it can be seen from figure 2 that in the spatial distribution, the numerical value of development capability shows a pattern that indicates the southeast is gradually higher than the north. while the clear winner would be the east, which overall stands on the top. this spatial distributive characteristic is closely related to china's industrial structure, economic development and resource distribution features. for example, shanxi and inner mongolia are important coalproducing bases where coal mines and resources are so crowded that they have weak low-carbon economy development. however, guangdong and fujian relatively have lack of natural resources so that their economy has reached a higher level, and the low-carbon economy develops well. although beijing is located in northern china and is very near the coal resource centers geographically, with coal making up such a large proportion in its energy structure, it has a well-developed economy; especially, the proportion of its tertiary industry is over 80%. its industry is mainly based on modern manufacturing and tech industry; therefore, beijing is under less pressure on low-carbon economy and it ranks 1st in low-carbon economy. however, industrial manufacturing still accounts for a definite proportion of the industrial structure in shanghai; as a result, shanghai is under more pressure on low-carbon economy than beijing even though its economy is better. table 8 . we found that the 30 regions can be divided into 4 categories. these 4 categories correspond in order to reveal the figures of low-carbon economy in different regions, we used ward's method to do cluster analysis on china's 30 regions based on spss statistical software. for instance, the results of 2015 were shown in table 8 . we found that the 30 regions can be divided into 4 categories. these 4 categories correspond respectively to the 4 statuses: leading status, good status, medium status and poor status. the evaluation results show that the numerical value varies greatly in different regions ( table 9 ). the leading status is almost all in the east area except jiangxi, guangxi and hunan, which are included in the central area. shanxi, inner mongolia and ningxia fall into poor status. figures 3 and 4 compare the difference of average low-carbon economy level in different regions. they show that the numerical value of east regional low-carbon economy shows a pattern that is gradually higher than the west region. the numerical value of low carbon economic development in the south region is higher than the north region by degrees. almost all parts of the west are low level. ningxia is considered to have very low level. we find that the average level has shown a downward trend since 2010. this is due to the decline in economic growth and gdp. growth rate was 10.3% in 2010 and 7.4% in 2015. they show that the numerical value of east regional low-carbon economy shows a pattern that is gradually higher than the west region. the numerical value of low carbon economic development in the south region is higher than the north region by degrees. almost all parts of the west are low level. ningxia is considered to have very low level. we find that the average level has shown a downward trend since 2010. this is due to the decline in economic growth and gdp. growth rate was 10.3% in 2010 and 7.4% in 2015. in view of the driving sub-index, state sub-index and pressure sub-index, there are some differences in all regions, and the leading status is significantly better than the poor status. as seen from the "response" sub-index, the resource consumption and degree of pollution vary from province to province, as well as pollution abatement and efforts for environmental protection. all these factors reflect that the more efforts the government, system, society and individual make to improve the status of resources, the better the low-carbon economy develops. the drive sub-index varies greatly from province to province. it shows a pattern with the indication of northeast gradually lower than southeast, which is determined by china's terrains and regional development policies. from figure 5 , we can see that the regions with high grades of drive sub-index value are all located in coastal areas. this is because these areas have significant regional advantages, which make the input cost of commerce activities and production activities much lower than in other regions. therefore, their input and output efficiency in economic activities is relatively high. in addition to that, in the earlier stage of reform and opening, china has given special importance to the economic development in coastal areas by providing support in policies. various regional preferential policies were introduced to form advantages for development; thus, their level of driving force on low-carbon economy is higher than the average level in china. in view of the driving sub-index, state sub-index and pressure sub-index, there are some differences in all regions, and the leading status is significantly better than the poor status. as seen from the "response" sub-index, the resource consumption and degree of pollution vary from province to province, as well as pollution abatement and efforts for environmental protection. all these factors reflect that the more efforts the government, system, society and individual make to improve the status of resources, the better the low-carbon economy develops. the drive sub-index varies greatly from province to province. it shows a pattern with the indication of northeast gradually lower than southeast, which is determined by china's terrains and regional development policies. from figure 5 , we can see that the regions with high grades of drive sub-index value are all located in coastal areas. this is because these areas have significant regional advantages, which make the input cost of commerce activities and production activities much lower than in other regions. therefore, their input and output efficiency in economic activities is relatively high. in addition to that, in the earlier stage of reform and opening, china has given special importance to the economic development in coastal areas by providing support in policies. various regional preferential policies were introduced to form advantages for development; thus, their level of driving force on low-carbon economy is higher than the average level in china. the situation of the pressure sub-index generally indicates the north being gradually lower than the south, the west gradually lower than the east, and hopping in some areas as shown in (figure 6 ), which is determined by various causes of development foundations, regional conditions and development policies in all regions. for quite a long time, the speed of economic development in china's eastern coastal areas was much faster than in central and western areas. in addition, the coming years offer a critical period for western areas to accelerate industrialization; thus, the low-carbon pressure in east is relatively lower than in the west. we can conclude that the index value in the rule hierarchy of pressure has gradually decreasing effects around the main energy supplement region and the surrounding areas, so shanxi, inner mongolia, ningxia and qinghai have the most pressure on low-carbon economy. china's eastern coastal areas was much faster than in central and western areas. in addition, the coming years offer a critical period for western areas to accelerate industrialization; thus, the lowcarbon pressure in east is relatively lower than in the west. we can conclude that the index value in the rule hierarchy of pressure has gradually decreasing effects around the main energy supplement region and the surrounding areas, so shanxi, inner mongolia, ningxia and qinghai have the most pressure on low-carbon economy. the situation of the state sub-index indicates the north being gradually lower than the south; therefore, the ranks of hainan, guangxi and fujian are relatively higher, while shaannxi, hunan and hubei are in the second tier ( figure 7 ). this is because southeastern coastal areas have good economic development with external supply of energy, oil and natural gas. hydroelectricity and nuclear electricity occupy a large proportion in the structure of energy consumption, so the low-carbon economy in these regions is in good status. however, although central and southern areas have certain coal resources, the consumption far outstrips the production. as a result, the external supply of energy is badly needed. at the same time, these areas that are rich in forest resources vigorously develop hydroelectricity and pursue rational use of energy, so the numerical value in these regions is better than it is in the north. the situation of the state sub-index indicates the north being gradually lower than the south; therefore, the ranks of hainan, guangxi and fujian are relatively higher, while shaannxi, hunan and hubei are in the second tier ( figure 7 ). this is because southeastern coastal areas have good economic development with external supply of energy, oil and natural gas. hydroelectricity and nuclear electricity occupy a large proportion in the structure of energy consumption, so the low-carbon economy in these regions is in good status. however, although central and southern areas have certain coal resources, the consumption far outstrips the production. as a result, the external supply of energy is badly needed. at the same time, these areas that are rich in forest resources vigorously develop hydroelectricity and pursue rational use of energy, so the numerical value in these regions is better than it is in the north. the situation of the response sub-index shows a pattern of hopping and overlapping in some areas. beijing, shanghai and guangdong rank the first three in 2015, while in the north, northwest and southeast, the index values are gradually low (figure 8 ). this is due to the combined impact of the economic and scientific development level, energy consumption efficiency and industrial structure. according to the statistical yearbook, major consumption of energy in west regions is from coal, and there are more coal resources without desulfurization, which combines with low economic development and inadequate input in environment protection. as a result, the efficiency of energy process and conversion is low, and the productivity of carbon falls behind. electricity occupy a large proportion in the structure of energy consumption, so the low-carbon economy in these regions is in good status. however, although central and southern areas have certain coal resources, the consumption far outstrips the production. as a result, the external supply of energy is badly needed. at the same time, these areas that are rich in forest resources vigorously develop hydroelectricity and pursue rational use of energy, so the numerical value in these regions is better than it is in the north. the situation of the response sub-index shows a pattern of hopping and overlapping in some areas. beijing, shanghai and guangdong rank the first three in 2015, while in the north, northwest and southeast, the index values are gradually low (figure 8 ). this is due to the combined impact of the economic and scientific development level, energy consumption efficiency and industrial structure. according to the statistical yearbook, major consumption of energy in west regions is from coal, and there are more coal resources without desulfurization, which combines with low economic development and inadequate input in environment protection. as a result, the efficiency of energy process and conversion is low, and the productivity of carbon falls behind. as mentioned above, the horizontal comparisons of the coordination degrees are shown in table 8 ; the coordination degrees of the 30 regions in china were calculated and analyzed and were based on the model of coordination degree in 2015. the coupling degree (c) results show a pattern for the central area lower than the west area and the west area lower than the east area. the average degree of the whole country is 0.6723, which is higher than the west and central areas but lower than the east area. the coordination degree (d) results show a pattern for the west area lower than the central area and the central area lower than the east area. the average degree of the whole country is 0.5840, which is higher than the west and central areas but lower than the east area. moreover, based on the model of coordination degree in 2015, the coordination degrees of the 30 regions in china were calculated and analyzed. the results indicated the four sub-systems were primary coordination in the east area and bare coordination in the central and west areas in 2015.in addition, four sub-indexes should be developed at the same pace and improved on the basis of stable development. it shows that promoting the development of a low-carbon economy in mid-west areas is the key in china. based on the above results, the following conclusions are drawn: all 30 regions show varying increasing rates. the regional distributions of the sub-indexes are the combined impacts of regional economic development level, resource endowment and policy support. the numerical values in china's 30 regions vary greatly; as a whole, they indicates the north is gradually lower than the southeastern coastal areas, and the east is higher than the west; the south is higher than the north, and there is overlapping in some areas. beijing and shanghai are far ahead while shanxi, inner mongolia and ningxia are backward. as compared to the developed countries that have already achieved industrialization, china focuses particularly on achieving sustainable development by combining industrialization with ecological civilization. it is worth noting that china has large regional differences. compared with the developed regions in the east, there are still a lot of heavy-duty industries in the central and as mentioned above, the horizontal comparisons of the coordination degrees are shown in table 8 ; the coordination degrees of the 30 regions in china were calculated and analyzed and were based on the model of coordination degree in 2015. the coupling degree (c) results show a pattern for the central area lower than the west area and the west area lower than the east area. the average degree of the whole country is 0.6723, which is higher than the west and central areas but lower than the east area. the coordination degree (d) results show a pattern for the west area lower than the central area and the central area lower than the east area. the average degree of the whole country is 0.5840, which is higher than the west and central areas but lower than the east area. moreover, based on the model of coordination degree in 2015, the coordination degrees of the 30 regions in china were calculated and analyzed. the results indicated the four sub-systems were primary coordination in the east area and bare coordination in the central and west areas in 2015.in addition, four sub-indexes should be developed at the same pace and improved on the basis of stable development. it shows that promoting the development of a low-carbon economy in mid-west areas is the key in china. based on the above results, the following conclusions are drawn: all 30 regions show varying increasing rates. the regional distributions of the sub-indexes are the combined impacts of regional economic development level, resource endowment and policy support. the numerical values in china's 30 regions vary greatly; as a whole, they indicates the north is gradually lower than the southeastern coastal areas, and the east is higher than the west; the south is higher than the north, and there is overlapping in some areas. beijing and shanghai are far ahead while shanxi, inner mongolia and ningxia are backward. as compared to the developed countries that have already achieved industrialization, china focuses particularly on achieving sustainable development by combining industrialization with ecological civilization. it is worth noting that china has large regional differences. compared with the developed regions in the east, there are still a lot of heavy-duty industries in the central and western regions. industrial structure transformation is more difficult. therefore, promoting the development of low-carbon economy in mid-west areas is the key in china. the improvement of people's living quality and social welfare can best embody the development of low-carbon economy. the result of this study may be helpful for policy makers to formulate effective policies and take actions in the future. we firmly believe that ecological civilization construction, industrialization and urbanization are not mutually exclusive at all. we must emphasize realizing sustainable development through the low-carbon system while people's material life has benefited a lot. therefore, we ought to change the bad social consumption mode, as well as wrong consuming concepts and patterns. besides, we must make great efforts to turn the low-carbon way of life into a conscious behavior while improving our quality of life and stick to it in concrete activities. challenges for pacific small island developing states in achieving their nationally determined contributions (ndc) adoption of the paris agreement in the wake of paris agreement, scientists must embrace new directions for climate change research transition towards a low carbon economy: a computable general equilibrium analysis for poland three-perspective view of greenhouse gas emission responsibilities in new zealand micropolitan areas and urbanization processes in the 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science to management a model for integrated assessment of sustainable development management of the marine environment: integrating ecosystem services and societal benefits with the dpsir framework in a systems approach an analysis of risks for biodiversity under the dpsir framework structuring problems in sustainability science: the multi-level dpsir framework investigating the impacts of urban densification on buried water infrastructure through dpsir framework interaction between urban land expansion and land use policy: an analysis using the dpsir framework coupling relationship between green production and green consumption: case of the yangtze river delta area a scaling method for priorities in hierarchical structures a review of applications of analytic hierarchy process in operations management combining ahp with gis in synthetic evaluation of eco-environment quality-a case study of hunan province the integrated eco-environment assessment of the red soil hilly region based on gis-a case study in changsha city environmental quality indexing of large industrial development alternatives using technological, economic and sustainability evaluation of power plants using the analytic hierarchy process methods, concepts & applications of the analytic hierarchy process an attempt at decision making in tissue engineering: reactor evaluation using the analytic hierarchy process (ahp) key: cord-353041-qmpatq8m authors: han, ruixia; cheng, yali title: the influence of norm perception on pro-environmental behavior: a comparison between the moderating roles of traditional media and social media date: 2020-09-30 journal: int j environ res public health doi: 10.3390/ijerph17197164 sha: doc_id: 353041 cord_uid: qmpatq8m the activation of norm perception can promote pro-environmental behavior. how does media, as important variables in activating norm perception, affect pro-environmental behavior? through an online survey of 550 randomly selected chinese citizens, this study examines the roles of traditional media and social media in influencing the relationship between norm perception and pro-environmental behavior. based on multi-level regression analysis of data, this study found that (1) compared with traditional media, social media play a more significant role in moderating the relationship between norm perception and pro-environmental behavior; (2) the promotion of the perception of injunctive norms by traditional media has a negative relationship with pro-environmental behaviors; (3) the activation of subjective norm perception by social media will promote pro-environmental behaviors. according to this research, in the current media environment, we should carefully release pro-environmental information on social media and encourage relevant discussions, and appropriately reduce environment-relevant injunctive normative information on traditional media. the study also discusses the role of media in regulating norm perception and pro-environmental behavior in different cultural contexts. the global spread of the covid-19 has brought issues of health-related risk prevention back to public attention, of which environmental protection is one. according to the data released by the environmental performance index (epi) in 2020, overall, china ranks 120th among 180 countries. regarding china's performance in individual indicators it ranks 96th in health, 96th in air quality, and 156th in ecosystem vitality. this indicates the importance of improving environmental quality in china. china proposed the "ecological civilization system reform" in the 2017 nineteenth report. however, the launch and implementation of any policy is inseparable from the cooperation and implementation by individual citizens. how to promote environmental protection on a personal level is very important to the success of various environmental protection movements. various studies have explored factors influencing personal pro-environmental behaviors. gifford and nilsson [1] summarize 18 major personal and social factors affecting pro-environmental behaviors. personal factors include knowledge experience, personality and self-construal, felt responsibility, cognitive biases, etc. social factors include urban-rural differences; religion, cultural and ethnic variations; norms, etc. these variables work together to influence pro-environmental behaviors, and it is important to discover the moderating and mediating mechanisms between these factors. through a meta-analysis of 57 articles, bamberg and möser [2] demonstrate that eight core psycho-social variables influence pro-environmental behaviors. they are perceived behavior control, feelings of guilt, problem awareness, social norms, internal contribution, attitude, ethics, and intention. they believe that pro-environmental behavioral intention interferences with other variables' effect on pro-environmental behaviors. these researchers prove that there are complex correlations between various influencing factors of pro-environmental behavior. it is very important to understand the relationship between different factors, as some of them play a more important role than others. then, what are these factors, and what are the mechanisms affecting their role in pro-environmental behavior? there are four theoretical paradigms to analyze factors influencing pro-environmental behavior: rational behavior theory [3] , planned behavior theory [4] , normative behavior theory [5] , and value-belief-norm theory (vbn) [6] , the last of which is based on the theory of normative activation. each theory has a different focus. for example, rational behavior theory emphasizes the importance of self-interest and believes that people conduct pro-environmental behaviors to reduce personal health risks. the theory of planned behavior emphasizes the importance of behavioral intention. it believes that behavioral intention is the key variable in affecting pro-environmental behaviors, while the influencing factors of individual behavioral intention may be multifaceted. the theory of normative activation focuses on activating internal norms, such as expectations, stress, and subjective perception. value-belief-normative theory incorporates the belief in ecological values into the theory of normative activation. generally speaking, rational behavior theory and planned behavior theory are often integrated, and various theoretical frameworks also attach great importance to the importance of norms. for example, in the theory of planned behavior, "norm" is considered to be an important variable affecting individual behavioral intention. in the normative activation theory, different types of "norm" become the core variables of discussion. recent scholarship tends to advocate the integration of these theoretical orientations to form integrated models [2, 7, 8] . "norm" occupies an important position in virtually all of these models. there are various types of norms. according to their source, they can be divided into descriptive norms and injunctive norms [9] . some scholars have proposed subjective norms. the different influences of each norm on various environmental behaviors have also become an important part of recent research. for example, park and smith [10] study the effect of subjective norms, personal descriptive norms and injunctive norms, social descriptive norms and injunctive norms on organ donation intentions and behaviors. however, we tend to neglect the fact that the formation of norms is also affected by external information and environment. social media play an increasingly significant role as one source of information that ultimately affects pro-environmental behaviors by influencing the formation of norms. for example, based on a survey of 173 households in hong kong, chan [11] finds that mass media can influence residents' pro-environmental behavior by affecting their subjective norms. the research by hynes and wilson [12] indicates that social media can effectively activate people's social comparison psychology and promote people's pro-environmental behavior by improving people's normative cognition. these studies indicate that media environment does affect people's social normative cognition and pro-environmental behaviors. in mainland china, the development of social media in recent years is very rapid. social media have infiltrated into the daily lives of ordinary people. take the most widely used wechat as an example. according to wechat's official report, the number of wechat users has exceeded 1.1 billion [13] . what is the impact of social media on pro-environmental behavior in comparison to traditional media? what is the difference between them in changing people's social norms? what is the specific logic of the use of media to influence social norms and then affect the occurrence of pro-environmental behavior? the theory of social norms derives from perkins and berkowitz's [14] study of adolescent alcohol abuse behavior. they discover that providing alcoholic adolescents with information about the attitudes of peer groups is far more effective than providing information about the negative consequences of alcoholism itself. therefore, they advocate that intervention should focus more on improving the health awareness and behaviors of the general public. they discover the existence and great influence of social norms and further develop it into an important theoretical path in the study of behavioral and attitude changes [15] [16] [17] [18] . in practice, social normative intervention has also become an important path of behavioral intervention, such as the use of seat belts [19] , prevention of drunk driving [20] , prevention of sexual assault [21] [22] [23] and other issues have achieved significant results. pro-environmental behavior is one of these behaviors. pro-environmental behavior refers to environmentally beneficial behaviors that people exhibit in their daily lives, that is, behaviors that tend to be pro-environmental [24] . in general, pro-environmental behavior is influenced by a variety of self-states and external perceptions, such as individual age, gender, knowledge and education, values, politics and worldview, goals, responsibility, childhood experiences, perceived environmental risk perception, environmental knowledge, etc. normative cognition actually involves the intrinsic specific path of pro-environmental behavior. in this regard, the normative focus theory provides theoretical support. social psychologists cialdini et al. [25] suggest that people do a lot of good behaviors not because they have a good sense, attitude or purpose, but because they are constrained by social norms, other people's behaviors, and typical practices. taking energy-saving behaviors as an example, they are conducted not so much due to the consideration of environmental protection, social benefit, and money saving than to the influence of the surrounding environment [26] . that is to say, social norms actually affect people's pro-environmental behavior. different social norms affect pro-environmental behavior differently. social norms are generally divided into two categories, namely descriptive norms and injunctive norms. descriptive norms refer to the popularity of a certain act, whereas injunctive norms refer to social approval of the act [9] . reno, cialdini, and kallgren [27] argue that injunctive norms can lead people to perform certain behaviors beyond specific socio-cultural contexts and have stronger behavioral guidance. many scholars have carried out empirical research on different aspects of garbage disposal behavior, energy conservation behavior, conservation and resource conservation behavior, by which they are able to demonstrate the impact of the two norms on various pro-environmental behaviors. however, social norms are not just descriptive norms and injunctive norms. park and smith [10] indicate that subjective norms, personal descriptive norms, personal injunctive norms, societal descriptive norms and societal injunctive norms all affect organ donation behavior. they pay special attention to the perceptibility of norms and distinguish the individual from the social aspects. the personal level mainly refers to the influence of family and friends who are in daily contact with people, while the social level mainly refers to the social-cultural environment. because this study focuses on groups in the same cultural context, it will focus on perceptual descriptive norms and perceptual injunctive norms at the individual level. in addition, park and smith [10] also point out that descriptive and injunctive norms are only derived from the division of normative theory. in fact, from the perspective of planned behavior theory, subjective norms should also be included. subjective norms are designed to capture descriptive norms, i.e., whether important others themselves perform the behavior [28] . we have reason to believe that the norm perception of these three aspects will affect the pro-environmental behavior. thus, we assume that: h1: social norm perception has a positive correlation with pro-environmental behavior; h1-1: subjective norm perception has a positive correlation with pro-environmental behavior; descriptive norm perception has a positive correlation with pro-environmental behavior; h1-3: injunctive norm perception has a positive correlation with pro-environmental behavior. the influence of media on pro-environmental behavior has been confirmed by many research institutes. the impact mechanism can be roughly divided into three categories: first, from the perspective of risk communication, media have an amplifying effect on public environmental risk perception, which affects people's pro-environmental behavior by affecting their attitudes. agha [29] indicates that the exposure to information about aids on mass media amplifies people's perception of risk and causes them to change behavior. mileti [30] finds that media communication plays a mediating role between risk perception and pro-environmental behavior. zeng [31] believes that new media have a greater amplifying effect on environmental risk perception. understanding of the role of media in affecting people's risk perception is multi-dimensional. for example, wahlberg and sjoberg [32] believe that media do have an impact on risk perception, but the impact is not as heavy as interpersonal communication, and their relationship with behavioral change is not certain. meanwhile, fischhoff [33] points out that the relationship between media and risk perception has undergone several stages. in sum, these studies all demonstrate the fact that media influence pro-environmental behavior by affecting people's risk perception. the second category is from the perspective of use satisfaction theory which points out that media can raise people's environmental concern, provide environmental-related knowledge, and then affect pro-environmental behavior. for example, huang [34] discovers that the global warming information obtained by taiwanese residents from television, newspapers, and the internet did influence them to behave in a more pro-environmental manner. the works of holbert et al. [35] and trivedi, patel and acharya [36] both examine the impact of media use on pro-environmental behavior from the perspective of promoting environmental concern. the third category is to analyze the role of media according to the framework of planned behavior theory, subjective norm theory, media dependence and other theories. among them, chan [11] combines the influence of mass media on subjective norms and the analysis model of planned behavior theory to analyze the pro-environmental behavior of hong kong residents. lee [37] integrates media exposure in an attitude-intention-behavior model of pro-environmental behavior, and ho [38] combines planned behavior theory and media dependence theory. liao et al. [39] test the mediating role of perceived media influence between perceived media exposure of others and perceived social norms. in these studies, the most typical and basic research is the ipmi (the influence of presumed media influence) model [40] . the above research informs us to propose the following hypotheses: h2: media usage of environmental information acquisition has a positive correlation with pro-environmental behavior. by further analyses, we find that the influence of media on pro-environmental behavior shows different characteristics at different stages in the history of media development. for example, in the early days, people mainly focused on the influence of such traditional media types as television, radio, and newspapers on pro-environmental behaviors. then internet gradually displayed its influence. in recent years, however, social media have become a new force that initiates their influence on pro-environmental behaviors. if the research of holbert [35] mainly focuses on tv, the research of huang [34] compare tv, newspapers and the internet, while the research of ho [38] further refers to other media as traditional media to be compared with the internet. in comparison, the impact of social media on pro-environmental behavior deserves further exploration. in fact, social media have multiple potentials to influence pro-environmental behavior. for example, oakley et al. [41] , mankoff et al. [42] have pointed out that the display function of social media reminds the public to follow and promote environmental behavior. at the same time, the recording function of social media also allows the public to have an intuitive feeling about the effects of their pro-environmental behaviors, thereby strengthening their engagement in this aspect of behavior. social media also function to stimulate social comparison, activate normative perception, and improve pro-environmental behavior [12] . the last advantage of social media is that the information they provide, in comparison to that from official media, attracts more public trust. this helps the construction of online communities and promotes participation in pro-environmental behaviors [43] . therefore, we argue that social media not only promote pro-environmental behaviors, but also combine the characteristics of media communication with interpersonal communication, and help us perform more than traditional media are capable to do. therefore, we assume the following: h2-1: traditional media have a positive correlation with pro-environmental behavior; h2-2: social media have a positive correlation with pro-environmental behavior; the degrees of the influence of social media and traditional media on pro-environmental behavior are different. previous studies have indicated that the perception of social norms can significantly affect pro-environmental behavior. normative activation theory provides one theoretical support. it is also supported by the focus theory of normative conduct. relevant behavioral studies have confirmed that regulating people's norm perception does affect people's pro-environmental behavior. for example, if the information of the average household electricity consumption in a community is told to those who consume more, they will reduce electricity consumption [44] . this discovery is more significant to the promotion of pro-environmental behavior in countries like china, where it is increasingly difficult to improve people's environmental awareness and environmental level [45, 46] . under the circumstance when the influencing factors discovered by the planned behavior theory become less influential, it is particularly important to effectively activate public norm perception. the study also finds that perceived descriptive norms and perceptual injunctive norms have different effects on people's pro-environmental behavior. taking "discarding garbage" and "zoo feeding" as examples, descriptive norms describe what most people do, whereas injunctive norms look at behaviors' social consequences in different contexts [27, 47] . it is, therefore, particularly important to discover how to arouse people's normative focus. subjective norms which develop from planned behaviors are also affecting people's pro-environmental behavior. our study pays particular attention to how the three social norms are related to pro-environmental behavior in the chinese environment. social norms can only affect individual behavior when they are perceived and activated. researchers have explored the connection between social norms and pro-environmental behaviors by examining the mechanism in which social norms are produced and activated. miller and prentice [48] conclude that there are three sources of normative beliefs: direct observation of the behavior of others; communication between people or media communication; and speculation of others' behavior based on personal knowledge. media, particularly social media, have become more and more important in our lives. social media combine the functions of traditional mass media with interpersonal communication. while affecting our lives, social media also help adjust our understanding of norms. existing research demonstrates that media composure does affect people's perception of social norms and affect people's pro-environmental behavior. for example, chan [11] argues that mass media influence pro-environmental behavior by affecting people's subjective norms. hynes [12] also indicates that social media indirectly enhance people's normative cognition by activating people's social comparative psychology. whether traditional media and social media activate the perception of social norms in the same way, and how the possible difference affects their influence on pro-environmental behavior are the focus of our research. therefore, we propose the following: h3: media exposure moderates the relationship between norm perception and pro-environmental behavior; h3-1: traditional media moderate the relationship between norm perception and pro-environmental behavior; h3-2: social media moderate the relationship between norm perception and pro-environmental behavior. previous studies demonstrate that different norm perceptions have different effects on pro-environmental behavior. for example, injunctive norm perception is more likely to make people jump out of specific situations and make the norm more effective than descriptive norm perception [27] . this finding is particularly important for the guidance of public behaviors in countries with a low level of pro-environmental behavior. at the same time, we also find that the mechanism of media exposure's impact on pro-environmental behavior is different. for example, ho [38] finds that traditional media attention and internet media attention have different effects on green buying behavior. chan [11] indicates that television, newspapers and magazines have different effects on subjective norms. the influence and mechanism of social media on norm perception are more likely to be different. for example, it has been found that social media play a role in pro-environmental behavior through social display, social comparison, and public environmental protection efficacy. because of their own production content, they have a higher influence than the official media. then, the impact of social media on different norm perceptions may also differ and ultimately affect the environmental behavior, so we assume the following: h3-1-1: traditional media moderate the relationship between subjective norm perception and pro-environmental behavior; h3-1-2: traditional media moderate the relationship between descriptive norm perception and pro-environmental behavior; h3-1-3: traditional media moderate the relationship between injunctive norm perception and pro-environmental behavior; h3-2-1: social media moderate the relationship between subjective norm perception and pro-environmental behavior; h3-2-2: social media moderate the relationship between descriptive norm perception and pro-environmental behavior; h3-2-3: social media moderate the relationship between injunctive norm perception and pro-environmental behavior. summarizing these research hypotheses, this study focuses on the following two levels of research questions: rq1. how do social norm perception and media exposure affect pro-environmental behavior? rq2. how does media exposure influence the relationship between social norm perception and pro-environmental behavior? if so, how do social media and traditional media moderate the relationship between different type of norm perceptions and pro-environmental behaviors in the chinese social context? this research is mainly based on 550 items of sample data collected through china's online questionnaire platform wenjuanxing (changsha ranxing information technology co., ltd, changsha, hunan province, china). the website's sample database is composed of 2.6 million people in 30 provincial units in china (excluding xinjiang). in this survey, by setting ip addresses, user restrictions, logic questions, etc., and by randomly rolling out questionnaire links, the minimum effective sample number set in this survey is 550. the survey was conducted between august 20 and 27 in 2019. the specific demographic distribution of the survey sample is as follows: 44.7% male and 55.3% female. taking into account the sex ratio 104.64 (female 100) of china's actual population, in the subsequent data processing, we carry out a weighted processing. the education distribution is 83.3% for universities and colleges, 11.8% for masters and above, and 2.8% for high schools and below. in terms of income distribution, the annual income of cny 50,000 to 100,000 accounts for 33.8%, cny 100,000 to 200,000 accounts for 30.5%, less than cny 50,000 accounts for 28.1%, more than cny 200,000 accounts for 7.5%. the average age of the entire sample is 30.5. the specific demographic distribution can be found in our other study [49] . in addition, 83.9% of the samples came from cities, 10.49% from counties and towns, and 5.61% from rural areas. public pro-environmental behavior is the core variable of this study. there are many measurement methods, such as those of bratt [50] , gatersleben et al. [51] , and dono et al. [52] . taking into account the specific social and cultural background of china, we adopt the question series used by hong et al. (2014) [53] in cgss (the china general social survey) of 2003, 2010, and 2015. this group of questions consists of 10 measurement items, including recycling and discussing environmental issues with relatives and friends [49] . the answers include four items of never, seldom, sometimes and always, to which we assigned 0, 1, 2 3, respectively. the value range of the entire scale is 0-30, and cronbach's alpha is 0.741. the mean is 13.51, and the standard deviation is 3.89. see table 1 . there are various measurement scales for the perception of social norms. this study uses the measurement of subjective norm perception, perceptual descriptive norm, and perceptual injunctive norm in park and smith [10] . the research theme has been transformed into specific operations. table 1 . considering the classification of media types in existing studies [38] and the actual use of media by chinese residents, the use of traditional media in this study mainly includes magazines, newspapers, television, radio, and the internet. in particular, based on the history of the internet, this study separates social media from the internet as a parallel category. the types of social media usage by chinese residents in this study mainly include weibo, wechat, tiktok, kuaishou, zhihu, qq, douban, baidutieba, facebook, twitter, and instagram. the specific measurement content includes whether people obtain the four aspects of information through the above media. the specific measurement items refer to our other research [54] . one point is scored for each item. the final score-weighted average value range is 0-4 points. the means of traditional media usage for environment information acquisition (tme) scale is 1.8, the standard deviation is 80, and cronbach's alpha is 0.777. the mean of social media usage for the environment information acquisition (sme) scale is 1.04, the standard deviation is 60, and cronbach's alpha is 0.807. see table 1 . other variables in this study include some demographic variables and important variables related with pro-environmental behavior: age, gender, community participation (cp), environmental knowledge (ek), and environmental risk perception (erp). for operational measurements of gender, age, and community participation, we measured the following: gender: 1 = male, female, and female as control. age: calculated using 2019 minus the year of birth. community participation includes: (1) churches, religious groups, (2) sports and fitness groups, (3) cultural and educational groups, (4) professional associations (such as educational associations, business associations), and (5) school-related groups (alumni association), (6) owners' committee, (7) clan association, family association, association, with 1 point for each participation, ranging from 0-7; the internal consistency coefficient of the scale is 0.754 (cronbach's alpha) [49] . the environmental knowledge level adopts the cgss2013 version, consisting of 10 measurement items. the internal consistency coefficient is 0.773, and the mean and standard deviation are 9.3 and 1.23, respectively. environmental risk perception also uses the cgss2013 version. the internal consistency coefficient of the scale composed of 12 items is 0.818, and the average and standard deviation are 3.74 and 0.93, respectively. for the measurement of the above control variables, please refer to our related research [54] . see table 1 . this study uses spss 19.0 to conduct research hypothesis testing by hierarchical regression. pro-environment behavior was specifically set as the dependent variable, and then five types of predictive variables were put into the regression model in turn. these five types of predictive variables include (1) demographic variables: gender, age, and community participation; (2) environment-related variables: environmental knowledge and environmental risk perception; (3) norm perception variables, and three types of secondary indicators include: subjective norm perception, descriptive norm perception, and injunctive norm perception; (4) traditional media usage for environment information acquisition and social media usage for environment information acquisition; and (5) interaction variables. we calculated interaction variables by multiplying the relevant variables of norm perception and media exposure. after pearson's test of the relevant variables involved in the study, it can be found that for those general variables that affect pro-environmental behaviors, in addition to age (r = 0.152, p < 0.01), environmental knowledge (r = −0.116, p < 0.01) and environmental risk perception (r = 0.152, p < 0.01) are significantly correlated with pro-environmental behavior. of particular note is that environmental knowledge and pro-environmental behavior show a significant negative correlation. regarding the correlation between norm perception and pro-environmental behavior, norm perception (r = 0.482, p < 0.01) and its three constituent variables, subjective norm perception (psn) (r = 0.431, p < 0.01), descriptive norm perception (pdn) (r = 0.401, p < 0.01), and injunctive norm perception (pin) (r = 0.381, p < 0.01), are significantly related to pro-environmental behaviors. in terms of the correlation between media exposure and pro-environmental behaviors, the influence of traditional media exposure (tme) was not significant, while the influence of social media exposure (tme) was significant (r = 0.235, p < 0.01). these research results provide an understanding basis for our follow-up regression analysis. it should be noted that because social norm perception is a synthetic variable composed of subject norm perception, descriptive norm perception and injunctive norm perception, its correlation coefficient with these three variables exceeds 0.8 (r > 0.8). see table 2 . table 3 shows the results of regression analysis using demographic variables, environment-related variables, norm perception, traditional media usage for environment information acquisition (tme) and social media usage for environment information acquisition (sme), and norm perception and their interaction terms to predict pro-environment behavior. we report the coefficients for the final model and the final r-squared value. from the reported results, it can be found that there is no significant correlation between gender and pro-environmental behavior, that is, there is no significant difference in the performance of pro-environmental behavior between men and women. there is a significant influence of age on pro-environmental behavior (b = 0.073, p = 0.000), with older people engaging in more pro-environmental behavior. there is a significant influence of community participation on pro-environmental behavior (b = 0.500, p = 0.000), that is, those who are more involved in various types of community organization activities are more engaged in pro-environmental behavior. the model can account for 1.84% of variance in pro-environment behavior. the relationship between environment-related variables and pro-environmental behavior can be found in m3-2. both of them have a significant relationship with pro-environmental behavior, but the impact of environmental risk perception on pro-environmental behavior is more significant (b = 1.466, p = 0.000).the impact of environmental knowledge on pro-environmental behavior is relatively insignificant (b = −0.288, p < 0.05), and in the current sample, environmental knowledge is negatively correlated with pro-environmental behavior. m3-3 examines the impact of integrating norm perception variables on pro-environmental behaviors. it can be found that norm perception has a significant effect on pro-environmental behaviors, and they are significantly positively correlated (β = 2.498, p = 0.000). this result supports h1. the explanatory power of the entire model has been significantly improved, and the adjusted r-squared value has reached 34.6%. m3-4 examines the impact of traditional media usage for environment information acquisition (tme) and social media usage for environment information acquisition (sme) on pro-environmental behavior. it can be found that the impact of traditional media usage for environment information acquisition (tme) on pro-environmental behavior is near a significant point (b = −0.379, p = 0.053), and the impact of social media on pro-environmental behavior is significant (b = 0.875, p = 0.001). this partially supports h2 and h2-1, and fully supports h2-2, h2-3. that is, media composure will positively affect pro-environment behavior; traditional media usage for environment information acquisition (tme) has a near-significant impact on pro-environment behavior, but it is negatively correlated; social media usage for environment information acquisition (sme) has a significant positive correlation with pro-environment behavior. the impact of social media on pro-environmental behavior is greater than that of traditional media. m3-5 examines the impact of norm perception and media exposure on pro-environmental behaviors. it is found that the interaction effects of norm perception and traditional media usage for environment information acquisition (tme) have no significant impact on pro-environmental behaviors (b = −0.358, p = 0.237), but the interaction effect of norm perception and social media usage for environment information acquisition (sme) has a close and significant positive correlation to pro-environmental behavior (b = 0.783, p = 0.055), which partially supports h3. h3-1 is not verified, while h3-2 is. table 3 . multiple regression analysis of the influence of norm perception on pro-environmental behavior. gender in order to further test the robustness of the results obtained by the above causal step regression method, we use the bootstrap method to test the main relationship with the help of the process plug-in in spss. the results show that without controlling other variables, the mediating effect of social media on norm perception and pro-environmental behavior is significant (r = 0.49, p = 0.00), and the llci and ulci are. 0053 and. 0386, respectively. this interval does not contain 0, which suggests that the result is robust. the mediating effect of traditional media on norm perception and pro-environmental behavior is also significant (r = 0.48, p = 0.00), but the result is not robust, with llci and ulci of −0.0146 and. 0064, respectively. with the pearson test results of the pairwise correlation in table 2 , this result suggests the rationality of the strong moderation effect of social media and the possibility of the marginal moderation effect of traditional media without controlling other influencing variables. in order to examine in more detail the moderating effect of media environmental information exposure on the relationship between different types of norm perception and pro-environmental behaviors, we conduct further regression analysis to form table 4 . m4-1 and m 4-2 mainly examine the relationship between demographic variables and environment-related variables and pro-environmental behaviors, and the results are consistent with m3-1 and m3-2. m 4-3 examines the relationship between three types of norm perception and pro-environmental behavior. the results show the following: subjective norm perception and pro-environmental behavior are significantly positively correlated (b = 1.197, p = 0.000); descriptive norm perception and pro-environmental behavior are significantly positively correlated (b = 0.744, p = 0.003); injunctive norm perception was significantly positive correlation with pro-environmental behavior (b = 0.586, p = 0.014). this result supports h1-1, h1-2, and h1-3. m4-4 examines traditional media usage for environment information acquisition (tme) and social media environmental information exposure on pro-environmental behaviors. the results show that traditional media have no significant effect on pro-environmental behaviors (b = 0.349, p = 0.076), and social media have a significant positive impact on pro-environmental behaviors b = 0.846, p = 0.002), once again negating h2-1, supporting h2-2 and h2-3. the results of m 4-5 indicate that the interaction between injunctive norm perception and traditional media environmental knowledge acquisition is significantly negatively correlated with pro-environmental behavior (b = −0.735, p = 0.027). the interaction effects (b = −0.040, p = 0.903) between subjective norm perception and traditional media (tme) and the interaction effects (b = 0.467, p = 0.217) between descriptive norm perception and traditional media (tme) have no significant correlation with pro-environment behavior. the interaction effect (b = 0.964, p = 0.048) between subjective norm perception and social media usage for environment information acquisition (sme) is significantly positively correlated with pro-environmental behavior, and the interaction effect (b = −0.168, p = 0.757) between descriptive norm perception and social media usage for environment information acquisition (sme) and the interaction (b = −0.192, p = 0.676) between injunctive norm perception and social media usage for environment information acquisition (sme) have no significant correlation with pro-environmental behavior. this result supports h3-1-3 and h3-2-1. h3-1-1, h3-1-2, h3-2-2, h3-2-3 are not verified. this means that traditional media play a moderating role between injunctive norm perception and pro-environment behavior, and social media play a moderating role between subjective norm perception and pro-environmental behavior. in other types of norm perception and pro-environmental behavior, neither traditional media nor social media have significant influence. this result more clearly shows the specific mode of traditional media usage for environment information acquisition (tme) and social media usage for environment information acquisition (sme) influencing pro-environmental behavior. table 4 . multiple regression analysis of the influence of different types of norm perception on pro-environmental behavior. gender this article aims to examine how norm perception and media composure influence pro-environmental behavior, and whether media composure plays a mediating role between norm perception and pro-environmental behavior. in order to better respond to research questions and report research results more clearly, we have summarized the hypothesis test results, as is shown in table 5 . the table demonstrates that: (1) norm perception does affect pro-environmental behavior. different types of norm perception have different effects on pro-environmental behavior. (2) the influence of media exposure on pro-environmental behavior has been confirmed again, although the effect of traditional media deserves further exploration. (3) the influence of media exposure on the relationship between norm perception and pro-environmental behavior is characterized by differentiation. specifically, traditional media play a negative role in moderating the relationship between injunctive norm perception and pro-environmental behavior, while social media have a positive influence in moderating the relationship between subjective norm perception and pro-environmental behavior. tests on the relationship between media exposure and pro-environmental behavior tests on the moderating effects of different types of information composure on the relationship between different types of norm perception and pro-environmental behavior this study mainly discusses the role of traditional media and social media in activating public norm perception and influencing pro-environmental behavior in the current media society. the research results show that traditional media usage for environment information acquisition (tme) activates norm perception and affects pro-environmental behaviors less than social media usage for environment information acquisition (sme). further detailed research discovers that the deepening of public perception of the injunctive norms through traditional media actually reduces people's pro-environmental behaviors, whereas social media are mainly helpful to activate people's subjective norm perceptions, thereby promoting pro-environmental behaviors. the influence of environmental knowledge acquisition through traditional media on subjective norm perception and descriptive norm perception has no significant correlation with pro-environmental behavior, and the influence of social media usage for environment information acquisition (sme) on descriptive norm perception and injunctive norm perception has no significant correlation with pro-environmental behavior. the results of this study are very instructive for the promotion of pro-environmental behavior in the age of social media. the influence of media on pro-environmental behavior has been confirmed by many studies, and its influence mechanism has also been confirmed by many studies. as mentioned in the literature review, media promote pro-environmental behaviors by amplifying environmental risks [29, 31] , by increasing people's environmental concerns and environmental knowledge [34] [35] [36] , and by enhancing people's value orientation or activating their norm perceptions [11] . in short, media can indirectly affect people's pro-environmental behaviors in various ways. relevant research has also found a basis in risk perception theory, use satisfaction theory, acculturation theory, planned behavior and normative activation theory, and has been centrally presented in media dependency theory. however, existing studies have mainly focused on the impact of traditional media, such as television, radio, newspapers, and the internet on pro-environmental behaviors. research about the impact of social media on pro-environmental behavior also focuses on the mining of influence mechanisms. for example, social media bring normative pressure through their own social comparison function [12] , while improving self-efficacy to promote pro-environmental behavior [41, 42] . however, there is no direct research focus on the influence of social media and traditional media on pro-environmental behavior. our research indicates that social media play a more significant role than traditional media in influencing pro-environmental behavior. in the current era of the media environment, the influence of social media on pro-environmental behavior has become the main way to exert media influence, while the influence of traditional media on pro-environmental behavior is declining. the influence of interpersonal communication on pro-environmental behavior has long been the focus of many studies. ho compares respective roles of traditional media and interpersonal communication in media dependence and green purchasing behavior [38] . with many other studies, ho proves that interpersonal communication plays a greater role than traditional media. nevertheless, few studies have compared between interpersonal communication and social media. social media blend characteristics of both interpersonal and mass communication. by interpreting interpersonal communication as interpersonal demonstration effect, our research indicates that social media influence pro-environmental behavior by strengthening interpersonal communication's demonstration effect. social media affect pro-environmental behaviors by displaying them publicly. oakley et al. [41] and mankoff et al. [42] indicate that social media put small behaviors in daily life under public scrutiny and encourage people's pro-environmental behaviors by improving public understanding of their own behavior and the behavior of others. social media also affect pro-environmental behaviors with the recording function, which helps form public awareness of their deeds and efficiency. social media also affect pro-environmental behaviors by stimulating people's psychology of social comparison and improving their recognition of social norms [12] . han et al. [43] points out that user-generated content (ugc) is more likely to gain public trust than official information, by activating pro-environmental norms, creating environmentally friendly online communities, and increasing public pro-environmental participation. compared to studies which focus exclusively on social media, this study makes a comparative analysis of the mechanism by which interpersonal communication and social media influence pro-environmental behaviors. our research shows that in the current era of social media, the influence of traditional media on pro-environmental behavior is weakening, while the influence of social media on pro-environmental behavior is increasing. taking normative perceptual activation as an example, the influence of traditional media on pro-environmental behavior is far less significant than that of social media. at the same time, in the specific types of normative activations, the activation of injunctive norms by traditional media negatively affects pro-environment behavior. excessively diffusing pro-environment information on traditional media may make people stressful and reduce pro-environmental behavior, which is very close to the negative correlation between the increase in environmental knowledge and the pro-environmental behavior found in this sample. in comparison, disseminating pro-environmental information on social media is helpful to improve people's supervisory cognition and promote pro-environmental behaviors. in other words, we should pay attention to the diffusion of pro-environmental information on social media, guide people to form discussions on pro-environmental behaviors in social media, and promote public pro-environment behaviors by stimulating social comparison, norm perception and self-efficacy. we should shift the focus of media information promotion for pro-environmental behavior from traditional media to social media. this study indicates that there is a complex correlation between normative perceptual activation and media usage. understanding this relationship is a prerequisite to effectively promote pro-environmental behavior. the research results show that the dissemination of the prescriptive normative information must be appropriately reduced in traditional media. this result is very similar to the effect of excessive "persuasion" in communication research, especially in countries with a strong collectivist cultural tradition. an overemphasis on prescriptive normative information, or the evaluation of others, is likely to cause people's rebellious psychology and reduce people's pro-environmental behavior. the activation effect of social media on subjective norms proves that people's sense of freedom on social media can stimulate their sense of self-efficacy and subjective norms, thereby promoting pro-environmental behavior. this demonstrates the flexible effects of social media on personal and social integration. in the current situation where the relationship between media and people is more and more interactive, paying attention to the activation of people's subjective norms by social media will be an effective way to improve pro-environmental behavior. the focus of this study is the moderating effect of traditional media and social media on norm perception and pro-environmental behaviors. therefore, we focus on demographic variables and environmental protection related variables that have significant relationships. there are many factors affecting pro-environmental behaviors. gifford and nilsson [1] have summarized the 18 major personal and social factors of pro-environmental behavior, but in order to study the core themes, we select only the variables that are considered most important to this study. regarding the conceptual configuration of norm perception, we divide it into subjective norm perception, descriptive norm perception, and injunctive norm perception. we mainly draw on the research division proposed by park and smith [28] . there are other more reliable and better ways of operation, which are worthy of further research. this study examines the relationship between media's activation of norm perception and its impact on pro-environmental behavior. in fact, the type of media contact, whether through traditional media or social media, is composed of multiple specific types of media. what are the differences in the activation of specific media types such as wechat and facebook? this will be very meaningful for studying the influence mechanism of specific social media in different cultural backgrounds, and it is worth further exploration in future research. in terms of research methods, this research uses traditional multi-level regression to compare different models, even though there are many types of media and norm perception. if the structural equation method is adopted, the complexity can be more clearly shown. in addition, this study is based on specific practical considerations, and some assumptions that have a significance level slightly higher than 0.05 are marked as significant, which requires special explanation. this study is based on a chinese sample. will the role of media contact between norm activation and pro-environmental behavior be different in different cultural contexts? if we find that the activation of injunctive norms by traditional media reduces pro-environmental behaviors, and the activation of subjective norms by social media is conducive to pro-environmental behaviors, then in non-collectivist cultures, will the activation of injunctive norms by traditional media be positive? the influence on pro-environmental behavior needs to be tested by comparative studies. to conclude, this study indicates that in the current media society, social media play a more important role than traditional media in regulating and promoting pro-environmental behavior. understanding this role of social media is of great significance for regulating people's cognition and behavior in an era of 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ly2fop7d despite the increased attention given to the health impact assessment of air pollution and to the strategies to control it in both scientific literature and concrete interventions, the results of the implementations, especially those involving traffic, have not always been satisfactory and there is still disagreement about the most appropriate interventions and the methods to assess their effectiveness. this state-of-the-art article reviews the recent interpretation of the concepts that concern the impact assessment, and compares old and new measurements of attributable risk and attributable fraction. it also summarizes the ongoing discussion about the designs and methods for assessing the air pollution impact with particular attention to improvements due to spatio-temporal analysis and other new approaches, such as studying short term effects in cohorts, and the still discussed methods of predicting the values of attributable risk (ar). finally, the study presents the more recent analytic perspectives and the methods for directly assessing the effects of not yet implemented interventions on air quality and health, in accordance with the suggestion in the strategic plan 2020−2025 from the health effect institute. the impact of exposure on public health is assessed by measuring its contribution to the total disease incidence or mortality [1] . the attributable risk and the attributable fraction are the most important measurements of this impact. the attributable risk (ar) is the rate (proportion) of a health outcome (disease or death) in exposed individuals, which can be attributed to the exposure [2] . ar assesses how much greater in absolute terms the frequency of an outcome is among the exposed compared with the non-exposed [3] . it is measured as the difference in the rates of an outcome among unexposed individuals (iu) from the rates among those who have been exposed (ie), according to the formula: ar = ie − iu. this estimate is based on the assumption that all other possible causes of the studied outcome have equal effects in exposed and non-exposed individuals. the concept of ar was first proposed by levin in 1953 [4] in the context of studies on cancer, which were mainly cohort studies where people were assembled on exposure and followed over a defined period of time. in the light of the discussion about the attributable measures by greenland and robins in 1988 [5] , steenland and armstrong in 2006 [6] , rothman [1] and greenland in 2015 [7] we underline that this ar is very similar to a difference of incidence proportions or average risks, since it uses as denominators the exposed and not-exposed individuals and not the time-persons. the attributable fraction (af) is the proportion of all cases (or overall incidence) that can be attributed to a specific exposure in a population since it combines relative risk and prevalence of exposure. it is measured as ar divided by the incidence risk in the exposed, according to the formula: af = ((ie − iu)/ie). thus giving an estimate of the proportion of cases that would not have occurred if exposure had been totally absent [1, 6] . the no-exposure hypothesis is usually defined as counterfactual-i.e., far from the experience-in a causal approach framework, since it postulates that the same population is followed in an identical situation where only the exposure level changes to the reference value of 0 [8] . this estimate as well as ar is based on the assumptions that (1) all other possible causes of the studied outcomes have equal effects in the exposed and nonexposed groups, (2) the studied association is causal. the af, like the ar, uses proportions or risk fractions, but divides the difference estimated in the ar by the proportion of cases among the exposed, thus giving an indication of the magnitude of excess risk from exposure as a proportion of total incidence, unlike ar. to extend this definition to the general population, ar should be theoretically estimated from a life-time follow-up of exposed and non-exposed cohorts in the studied population [6] . in general, using ar, af and ef similarly in those exposed and in the population as a whole, is not acceptable as it has been pointed out by rothman [1] and greenland [7] , essentially because populations are not closed cohorts and causality requires many assumptions relative to biological evidence. attributable fraction has been renamed excess fraction (ef) by greenland and robins [5] , to resolve the ambiguity introduced by the term "attributable" whose meaning might be either a case in which an exposure played an etiological role (etiological fraction) or a case that would not have occurred, had the exposure not occurred (excess fraction). the difference is important since all excess cases are etiological cases, but not all etiological cases contribute to the fraction attributable to a specific exposure. the authors then proposed three different meanings of attributable fraction: excess fraction, etiologic fraction and incidence-density fraction, that uses the rate per person-years per year. these definitions should be chosen and estimated according to the questions of the research and to their relevance to public health, as discussed below. if the essential question is "whether" the outcome occurs by time t due to an exposure, and if then the public health objective is to control the dangerous exposure overall, then the excess fraction is an adequate estimate of an attributable fraction. if the essential question is "when" the exposure occurs, and the public health objective is identifying the specific age and condition when preventing or reducing exposure, the excess fraction could adequately represent the af, on the condition that hypotheses about periods or conditions of vulnerability are made explicit. if the essential question is "whether the exposure caused the outcome", attributable fraction (af) by itself is not an appropriate estimate, because according to the traditional definition, the af measures only the excess cases that could in total be much fewer than the etiological cases, because they are related only to the studied exposure. we would like to point out here that excess fraction could be an etiological fraction (ef) and therefore, the proportion by which the incidence rate of the outcome in the population would be reduced on condition that the exposure was eliminated; in the above first and second cases, it is also required that (1) a causal (etiological) relationship between the studied exposure and the effect was assessed, and (2) the many biological assumptions about a causal relationship were respected. ar has been used in the literature to mean various concepts and measures. these other measures include the population attributable risk (par), the population excess rate (per), and the rate difference (rd), but none of them can be considered entirely equivalent to af. their definitions follow according to the last dictionary, 2001 [2] to lead to a better understanding in the literature, and to review briefly the possible pitfalls connected to the concept of causality [5, 7] . the population attributable risk (par) helps determine which exposures are most important in a specific community and is calculated as the incidence of a disease in the total population, minus the incidence in the group of those unexposed to a specific risk factor (it − iu), thus giving the risk attributable to that risk factor in the population. par is often used instead of af. it is measured as: par = ((it − iu)/(it × 100), where "it" is the incidence rate for the total population, iu is the incidence rate among the unexposed, or par = (((pe(ie − iu)/(pt × it) × 100), where pe is the number of people exposed, ie is the incidence rate among the exposed, iu is the incidence rate among the unesposed, pt is the number of people in the population, and it is the incidence rate in the population. the population excess rate (per) is very similar to par; it measures the disease associated with exposure to a putative cause in the population, but it is calculated merely as the difference between the rates of disease in the total population and in the nonexposed. per = pt − pu. the rate difference is used as a measurement that is equivalent to the population excess rate, but it is once again calculated as absolute difference between incidence rate in an exposed population group and a non exposed population group, according to the formula: rd = ie − iu. to complete this brief review of the concepts related to the definition of attributable risk we would also like to consider here the definitions of health impact assessment and accountability. the definition of health impact assessment (hia), as published in the gothenburg consensus paper by the who regional office for europe in 1999, is "a combination of procedures or methods by which a policy, program or project may be judged as to the effects it may have on the health of a population [9] ." impact assessment is an important step in public health epidemiology, and can be seen as related to risk characterization, the last step in risk assessment, as defined by epa [10] , together with hazard assessment, dose-response assessment and exposure assessment. risk characterization (1) reports the epidemiological results, including estimates of population exposed with harmful effects, (2) makes explicit assumptions and uncertainties, and (3) provides indications for public-health interventions to reduce exposure. the fields in which impact assessment has been applied include studies about the environment where people live, either natural [11] or man-made (through urban planning or house building [12] ), their health care systems [13] , their medical treatments [14] , but also the clinical prediction models [15] and the impact of reducing exposure through controlling sources and passing legislation to reduce exposure [16] . on the other hand, it has long been recognized that health and its determinants are strongly influenced by policies, programs, and projects outside of the health care sector. thus we have the obvious interface between the epidemiological results for the hia and the more complex policy impact assessments (pias), which define formally evidence-based procedures to assess the economic, social, and environmental effects of public policy [17] . these procedures are not analyzed here, nor are the possible interactions with various levels of pias. we would like just to touch upon the complexity of pias which require many different kinds of expertise. the pia procedures have been incorporated into policy making in the oecd countries and the european commission [18] . we would instead like to verify here how much of the prediction made many years ago by irvapicciottohas in fact come to pass. she wrote at the time: "a serious appraisal of current methods and practice suggests that much can be done to improve scientific rigor in risk assessment [19] . accountability which has been termed "evaluating the extent to which air quality regulations improve public health" is part of a broad effort to assess the performance of environmental regulatory policies. the methods for accountability research have been promoted by the health effect institute [20] . one of the strengths of this approach consists in analyzing the compliance to the most important steps of the chain of effectiveness to add or change regulatory actions. in the case of air pollution, the crucial steps involve emissions, ambient air quality, exposure/dose, human-health response. the health effects of air pollution have been well known to the scientific community since the early 20th century, when serious epidemics of mortality and respiratory diseases were linked to concurrent extraordinary peaks of air pollution in natural experimental or extraordinary scenarios such as london fog [21] ; fog in the meuse valley [22] ; still mill in utah valley [23] . toward the end of the 20th century, researchers started to focus their attention on the possible adverse health effects induced by "common" levels of outdoor air pollutants [24, 25] . clinicians have also acknowledged the causal role of air pollution on human health since 2000, when the american thoracic society (ats) first defined the concept of an "adverse respiratory effect of air pollution" (ats, 2000) as "medically significant physiologic or pathologic changes" [26] . all these scientific contributions provided a fundamental support for the definition of standardized legislation on air quality in the united states (u.s. epa, 1996) and in europe (european council, 1999; european parliament and council, 2008). today's research is exploring the possible effects of air pollution below the current limits of exposure both for short-term exposure-going from aphena in europe and the usa [27] up to the recent almost worldwide studies [28, 29] -and for long-term exposure (e.g., in the netherlands [30] in europe [31] , in the usa [32, 33] and in china [34] ). in the late 1990s, two important multicity studies-one in europe (aphea, 1996) and another in the usa (nmmaps, 2000)-were started with the aim of providing answers to the unresolved uncertainties which had emerged from previous studies about the short-term effects of air pollution which had been carried out mainly in single cities, apart from the milestone air pollution andmortality in six us cities [24] . we summarize below the essential points of these studies since they are the basis of many subsequent methodological developments right up to today. both aphea and nmmaps were multicity studies which benefited from the following advantages over single-city studies: they involve larger populations and can recruit a larger number of cases, thus increasing the power of association; 2. they can observe the same relationship under different circumstances, such as seasons, and in different populations thus making causality a more plausible interpretation of any possible association, providing that heterogeneity has been controlled for or assessed; 3. even a "weak" effect of air pollution on health will constitute an important public health problem, since a unique characteristic of air pollution exposure is its ubiquity for large populations. the most important problems with these studies were recognized by the researchers themselves, i.e., (1) not having studied other factors potentially responsible for the effects, including air pollutants other than particulate matter (pm), (2) not having individual measurements of exposure, which could prefigure exposure measurement errors, (3) having measured mortality that was premature only by a few days, which is an effect of limited public-health impact, (4) having used different methods to study this association in different cities. to respond to the above problems: 1. the researchers thereafter proposed a "measurement error model for time-series studies of air pollution and mortality" which was a combination of the berkson model; and the bayesian hierarchical generalized additive model (gam). the berkson model [35] deals with the relationship between ambient concentration and personal exposure by comparing the two measurements to estimate the error between them. although the berkson error-unlike the misclassification-causes little or no bias in the association, the difference between the average personal exposure and the true ambient level has been identified as an important source of bias in log-linear models [36] . the bayesian hierarchical generalized additive model was the tool for modeling variability across the studies of the relationship between personal and ambient exposure concentrations. two different approaches were available: a hierarchical multivariate regression with missing predictors for either continuous or categorical data [37] . 2. they included gaseous pollutants in subsequent studies on air pollution effects. this innovation was supported by using a hierarchical model to assess exposure-health outcome association which made it possible to estimate the independent effects of multiple pollutants in the presence of measurement error [38] . they adopted a longer scale of mortality linked to short-term exposure which overcame the mortality displacement [39] , and helped to introduce the long-term studies. 4. they took into account the temporal structure of the exposure-response relationship which led to including effects of up to 5 days after exposure peak or harvesting. the distributed lag models played the major role in assessing the new exposure-response relationship of short-term effects [40, 41] . later, the study by gasparrini and leone [42] extended the definition of attributable risk within the framework of distributed lag models. 5. they revised the frailty hypothesis-which restricted mortality to the frail people-by showing that larger effects occurred in frail people only at shorter time scales [43] . in parallel, a rich discussion developed about which was the better design, to assess the effects of long-term exposure between time-series and cohort study. the idea that cohort design might have been more appropriate for assessing effects related to long-term exposure was introduced in nmmaps in 2000 [44] . the discussion began with kunzli's observations [45] about the double action of air pollution on both the long-term underlying diseases and the short term risk of death: the author identified four different combinations: (a) air pollution increases the risks of both underlying diseases, leading to frailty, and of short-term mortality among the frail; (b) air pollution increases the risk of chronic diseases but is unrelated to the timing of death; (c) air pollution is unrelated to chronic diseases but short term exposure increases mortality among the frail; (d) neither underlying chronic disease nor death is related to air pollution exposure. the author concluded that the cohort design was more powerful for studying long-term exposure, as opposed to the time-series approach, because the later captures deaths in categories (a) and (c) only, whereas the cohort design assesses cases in categories a, b and c. hence the impact assessment of air pollution on mortality should be based on cohort studies. this position has been discussed claiming that "lifetime lost due to short air pollution peaks, may not be sufficiently captured in cohort studies because long-term mean concentrations are insensitive to such hidden peaks" [46] . although no available design could fully assess the contribution of air pollution to life experience, cohort studies might be more powerful for case attribution, if long-term exposure was used, since it also reflects past peak exposures. the spatio-temporal extension of short-term analysis [47] as well as the studies of the short term effects in cohorts [48, 49] contributed important developments in assessing the effects of this sort of cumulative exposure to both short-term and long term exposures: • the first approach overcame the limited capacity of the time-series so as to take account of spatial variation [47] and the introduction of cox proportional hazards models in spatio-temporal analysis introduced the possibility of estimating results for different geographic levels, such as cities and states; • the second approach included in the short-term assessment the effect due to the sensitivity of some population subgroups, which is itself due to long-term exposure [48, 49] . the current situation seems to promise further interesting developments in the methods of dealing with spatial-temporal analysis of short-term health effects. two recent studies show the potential of using the time-series approach in studying numerous areas [28, 29] , strengthened by the concentration-response function whose important role has been recognized as a metric for impact assessment in addition to the cause-effect metric [50] [51] [52] (see also below page 12, the role of dose-response curve). in the above-cited recent multi-area papers [28, 29] , the contribution of short-term exposure in increasing mortality emerged as independent of long-term exposure, and a no-threshold linear relationship has been confirmed for the pm-mortality function, with continuous increases starting even at concentrations below those of the current guidelines. it is also worth noting that the authors used the excess fraction to estimate the risk attributable to short-term exposure, thus highlighting the opportunity of regulatory interventions [28, 29] . daily increases of 10 µg of pm 10 have been associated, within 2 days, with an additional 0.44% (95% cis, 0.39−0.50) of daily mortality, 0.36% (95% ci, 0.30−0.43) of cardio-vascular mortality and 0.47% (95% ci, 0.35−0.58) of respiratory mortality. the studies of long-term (l-t) effects are characterized by prolonged exposures to air pollution, measured by annual average and by health effects in the exposed population. health effects are usually measured as all-cause and cause-specific mortality, and as diseases diagnosed in health services (hospitals, emergency rooms, medical offices). health effects are also estimated as decreased survival which is measured in terms of either life expectancy or years of life lost (yll). all of these measurements are appropriate for estimating attributable risks or excess fractions, both which are important metrics of risk assessment. the long-term approach led to important methodological improvements after the first studies on mortality [24, [53] [54] [55] , that facilitated estimating ars: 1. an increasingly accurate assessment of exposure (although not yet at the individual level) ranging from continuous monitoring of pm 10 and pm 2.5 components [56] to models for spatial analysis [47] up to the current, almost worldwide coverage [57] ; 2. a more comprehensive picture of the health effects of air pollution, which include cancer [58, 59] , metabolic diseases [60] , maternal and birth outcomes [61, 62] , developmental effects [63] , cognitive impairment [64] and central nervous system (cns) diseases [65] . all these additional diseases have a progression that is consistent with cumulative exposure and progressive mechanisms of damage, such as chronic or degenerative diseases; 3. an updated definition of "adverse health effects of air pollution" that includes asymptomatic signs of health deterioration, such as biological effects, altered biomarkers and reduced functions [66] the extension of exposure-lag-response models to allow for the health effects due to the protracted exposures to environmental factors [69] . the most frequently used approaches for assessing l-t effects were cohort studies and the studies that use functions to link exposure to health effects [11] . cohort studies had been focused on specific sources that were both noxious to human health and susceptible to reduction, such as traffic density [70] [71] [72] , industrial emissions [73] and home wood combustion [74] . or they used cohorts created for different reasons but appropriate for representing population and assuring long prospective follow-ups to assess exposure changes after interventions [30, 47, [75] [76] [77] . in addition, they also used populations that were resident in defined areas thanks to the availability of wide-ranging administrative and environmental data [78] [79] [80] [81] [82] . studies using functions to link long-term exposure to health effects were promoted by the global burden of disease (gbd) for estimating the burden of diseases attributable to ambient pm 2.5 in areas with extremely high concentrations of air pollution, but no direct epidemiological evidence [83] , such as india [84] . the integrated response function that these studies implemented uses satellite data to assess air pollution and makes deaths data and mortality rates comparable through the use of a standardized method [85] . this makes it possible to compare attributable risks across countries, where, briefly, the risk function to link exposure to health effects is estimated in each country for different exposures (ambient air pollution, second-hand smoke, active smoking and household solid cooking fuel), and the population attributable fractions (pafs) for each of them are calculated by using worldwide ambient pm 2.5 concentrations [86] . both short-term and long-term studies of air pollution effects contribute to health impact assessment, since both of them give estimates of damage due to increasing noxious exposures, by using population attributable fractions or excess fractions, as the metric of effects. an additional metric called "impact fraction" has also been proposed [87] for assessing "the potential efficacy, effectiveness, adequacy, and efficiency of planned intervention strategies", in studies that aim to estimate the health gains achievable by potential reductions of air pollutants levels [88] [89] [90] . this approach could contribute increasingly to supporting the political decision to cut back air pollution, but the methods used in estimating the potential benefits should be further enhanced, so that the hei indicates it as the first pointer for accountability in the strategic plan 2020−2025 for understanding the health effects of air pollution, 2nd mar,2020:1−3 [91] . the theoretical concept of these potential effect measures is that they are a special case of attributable fraction that compare the effect of an observed exposure with that of a counterfactual case in which exposure is completely absent. as a matter of fact, different potential conditions of exposure are usually chosen [92] (possibly on the basis of the knowledge about the available technologies). hence, a current choice of new limits to which air pollution concentrations should be decreased cannot rely on a counterfactual case that would posit zeroing air pollution, nor on a safe tested level, as we know that no threshold exists in the dose-response curve of air-pollution and health effects. finally, the definition of an "acceptable" damage not based on scientific evidences should involve larger social, economic and-political institutions. these studies have been and could be still useful also in revising the methods used to predict the possible beneficial effects of interventions, along the same lines as what the hei did by supporting, in the 2000s, intervention studies on air pollution to test whether the proposed methods were able (1) to assess the population exposure, (2) to identify an effective dose of exposure (3) to identify the best health outcomes (defined as those associated with several pollutants and detectable shortly after exposure change), (4) to identify the best populations as those which make it possible to assess differences between areas, and to study the effects related to intervention [93] . other studies help in choosing priorities for the intervention studies on the basis of the observed risk assessments for different exposures (behavioral, environmental, occupational), like those provided by the gbd studies [94] , or from different sources (industrial, residential, vehicular and multiple sources) with respect to their effects on mortality, morbidity and on changes in pollutant concentrations [95] . promoting an intervention to reduce air pollution with the purpose of reducing the health effects, requires evidence of a causal relationship between exposure to that pollution and those effects. it also requires estimates of excess fractions for the exposure so as to be able to evaluate to what extent the interventions have met expectations. a no-threshold linear concentration-response (c-r) curve has been assumed to exist by researchers on the basis of a linear relationship of the observed intermediate values in most of the initial studies on air pollution effects. likewise, a further assumption was that a linear relationship of not measured values there could be on both the left curve, i.e., at the lowest levels of pollutants, and the right one, at the highest levels. the assumptions about the lowest levels of pollutants were discussed from the point of view of public health, since the shape of the c-r curve is an important parameter for predicting the benefits of reducing high-level exposure [50, 51] . just a bit of evidence of a threshold was found, whereas the two methods of assessing regression linearity (penalized splines and model averaging) were equivalent. the possibility of predicting c-r curves at the highest levels at which to intervene first of all so as to reduce damages, has been discussed most recently by cox [96] . the author questions the possibility that the observed c-r relationship might be used to predict the effects of an intervention at the highest levels of pm 2.5 , because this would imply that the magnitude or the direction of the observed curve was similar to those of the predicted curve after intervention. this assumption could not be necessarily true, since the observed values are fixed, whereas the predicted values are based on changing pollutant levels. additionally, pope, even though he recognized that both the burden of disease attributable to pm 2.5 and the benefits of reducing pollution depend upon the observed c-r function, found that pollution abatement may yield greater benefits in relatively clean areas than in highly polluted ones. hence, he concluded that the shape of the c-r function should be further explored to better understand this relationship for more effective abatement of air pollutant effects in the future [97] . new types of evidence were proposed for estimating air pollutant regulatory strategies on the basis of direct experiments, rather than deriving predictions from observed situations [98] . the most important feature of this approach-that justifies the use of the term 'causal inference'-is that different areas are analyzed to allow for the assumption that the intervention to reduce exposure in certain areas is assessed at random, as in a hypothetical randomized experiment. thus the researchers "anchored" the exposure assessment to the estimates of the causal consequences of well-defined interventions, and could conclude that the observed health effects, observed after the intervention, had diminished due to a given reduction in concentrations. the new methods were applied by zigler and colleagues to two case studies: • the first one, the "causal" health impact on mortality-among medicare beneficiaries-in areas which exceeded the pm 10 limits, was compared with the mortality rates among medicare beneficiaries in areas where pm 10 limits were not reached. the members of the first group were assumed to be randomly assigned to "treatment", after testing their comparability with the second group (controls) for potential confounders by using the propensity-score method. in other words, this causal approach allows the consideration of mortality rates among controls as the mortality that might have occurred among cases had their area's exposure been below the pm 10 limit. the second case study examined the extent to which sulfur dioxide (so 2 ) affects emissions of so 2 , nitrogen oxides (no(x)), and carbon dioxide (co 2 ). the authors tested a range of scrubber technologies to reduce multiple gaseous pollutants (so 2 , no 2 and co 2 ) in emissions and outdoor pm 2.5 concentrations in areas where plants were either equipped with scrubbers or were not so equipped. the causal estimates were supported by applying principal stratification and causal mediation methods to assess the exposure, while a bayesian nonparametric method was used to evaluate whether the effect on pm 2.5 was really mediated by reducing gas emissions. scrubber systems (chemical or gas scrubbers) control air pollution by removing particulate matter and/or gases from industrial exhaust streams. propensity scores [99] , principal stratification [100] , causal mediation analysis [101] , spatial hierarchical models [102] , and bayesian estimation [103] are the methods that support and allow us to evaluate a causal relationship [98] . by grounding accountability research in a potential-outcome framework and applying these methods to national data sets, the authors provide additional evidence of the health effects of long-term, large-scale air quality regulations. the experiences briefly presented above remind us of the difficulties of this discussion. if, from a scientific point of view, it is always possible and appropriate to improve on the available knowledge, as was done in developing the first studies on air pollution effects (see above pp. 5-7), from a public heath point of view, taking a decision on the basis of the contemporaneously available knowledge (as it was done at the end of the 20th century in both europe and the usa) would be at times desirable or even necessary. epidemiologists have expressed doubts about policy indecision in the face of clear scientific evidences [104, 105] . on the other hand, the problems of uncertainty [92] , verification of hypothesis [89, 90] and heterogeneity still affect important studies. uncertainty is due to errors in estimating mean values in a population, especially when parts of it are commuters; uncertainty may have multiple explanatory factors and is currently quantified by montecarlo simulation, a statistical technique requiring many assumptions. interventions implemented to reduce traffic have not achieved the expected results, but the verification of this hypothesis could rely on many factors not considered in carrying out the interventions such as the spatial and temporal variability of a similar "preventive" intervention. heterogeneity, the first recognized in the multicity studies, has been partly explained by the different composition of particulate matter in different areas [106] , or controlled by using hierarchical bayesian models to combine the city-specific estimates [107] but the discussion about the assumptions of these models is still open [108, 109] . we can but wish for increasingly well-defined research questions, more accountability studies and further improvements in research methods so as to provide more solid answers to the scientific questions and the policy indecision. meanwhile we would like to go back here to what pope and dockery wrote in 2006 about the effects of fine particulate air pollution [53] . "despite important gaps in scientific knowledge and continued reasons for some skepticism, a comprehensive evaluation of the research findings provides persuasive evidence that exposure to fine particulate air pollution has adverse effects on cardiopulmonary health". the accountability studies, as we saw before, arose as an attempt to "evaluate the extent to which air quality regulations improve public health to assess the performance of all environmental regulatory policies" [20] . we return now to this first mission of accountability, to reconsider its strengths and weaknesses. three fundamental steps were identified in evaluating these regulatory policies, in logical sequence they are as follows: (1) reducing emissions, (2) improving ambient air quality, (3) reducing adverse health effects; we could summarize these steps as the impact of air quality improvement on public health. a few of the most important accountability studies which applied these criteria are reported as follows: 1. the ban of coal sales in dublin was followed by an important decrease in black smoke concentrations (70%); natural mortality decreased by 5.7%, respiratory mortality by 15.5% and cardiovascular mortality by 10.3% [110] . reducing the sulfur content in fuel in hong kong was followed by a substantial reduction in seasonal deaths during the first 12 months, followed by a peak death rate in the subsequent cool-season. it seemed that the intervention led to a significant decline in the annual trend of deaths from all causes (2.1%; p = 0.001), respiratory (3.9%; p = 0.0014) and cardiovascular (2.0%; p = 0.0214) diseases, but not from other causes. the average gain in life expectancy attendant upon the lower pollutant concentration was 20 to 41 days [111] . some measures to reduce traffic were implemented in more than one situation. the results in these cases are conclusive as regards neither exposures nor health effects. among the initial studies, those carried out in atlanta during the olympic games have produced contradictory results. the first [112] found promising evidence, as the decreased led to a prolonged reduction in ozone levels and lower rates of childhood asthma events. the other study [113] instead found that meteorological conditions contributed significantly to the reduction in ozone, emergency department visits did not decrease, and the strategy adopted for the occasion would not be sustainable beyond that exceptional event. in contrast, both the studies carried out in london to assess the impact of the congestion charging scheme (ccs) did not find conclusive results: the first, appearing five years after the introduction of the ccs, showed a modest benefit in air pollution levels and life expectancy. the explanation given was that the greater reductions in air pollution in deprived areas have had only a small impact in counteracting the socioeconomic inequalities in exposure and mortality rates [114] . the second study, published eight years after the introduction of the ccs, deals with the oxidative potential (op) of pm as a parameter of traffic exposure. it shows a remarkable variation of op between roadside and urban background locations, which was attributed to varying pm components. this result is consistent with the increased vehicle use throughout london in recent years and a decreased number of vehicles entering the ccs [115] . another well-conducted study evaluates, in several dutch cities, the air quality and health effects of local traffic policies including low emission zones; however, apart from one urban street in the hague where traffic flow and air pollution were drastically reduced, the study did not find that "reductions in air pollution related to abatement policies lead to actual improvements in respiratory function" [116] . the experience that the world is currently facing thanks to covid-19 reduces mobility-worldwide and simultaneously-as regards both long distance and local urban traffic, thus offering the framework for a "natural" experiment which the health effect institute also suggested to study [117] more specifically about the health effects of reducing traffic and long-distance transports. what has emerged until now are few points which, however, support the hypothesis of a natural experiment, such as the reduction of particulate matter in the atmosphere during the pandemic [118] , the association of air pollutants (pm, no 2 and o 3 ) with an increased risk of covid-19 infection [119] and a possible role in transmission of severe covid-19 infections by air pollutants [120] . some people would like causal accountability studies to support the more effective political interventions and thus replace traditional assessment which would be based on expensive studies about the exposure-response relationship in estimating the burden of diseases [93] . but the authors themselves of the causal accountability studies have concluded that their methods are "an important addition to the toolkit and should continue to be further explored, but cannot wholly substitute for accountability assessments that rely on evidence from other scientific methods, including more traditional epidemiology analyses." in general, the impact of the interventions on public health should be maintained both to verify the full achievement of the results and to identify the potential necessary corrections, since the process of accountability involves so many scientific, administrative and political institutions. in addition, it is possible that many interventions together, or in sequence, are needed to reduce pollutants or that they require more time to exert effects on total population health and so on. this is well evidenced in a not very recent paper which anticipated the importance of longer term, wide-ranging actions or events such as the complex changes associated with the reunification of germany [121] . this approach is also evocative of experiments that respect the natural times for changes. 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of air pollutants on the transmission and severity of respiratory viral infections the influence of improved air quality on mortality risks in erfurt this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license acknowledgments: i thank karen christenfeld for the accurate revision of the english text. neither financial nor other relationships might lead to a conflict of interests.note: manuscript has neither been published previously nor is under consideration for publication in another journal. key: cord-351529-30apdn73 authors: hamlin, matilda; steingrimsson, steinn; cohen, itzhak; bero, victor; bar-tl, avishay; adini, bruria title: attitudes of the public to receiving medical care during emergencies through remote physician–patient communications date: 2020-07-20 journal: int j environ res public health doi: 10.3390/ijerph17145236 sha: doc_id: 351529 cord_uid: 30apdn73 providing health services through remote communications for sub-acute health issues during emergencies may help reduce the burden of the health care system and increase availability of care. this study aimed to investigate the attitudes of the public towards receiving medical services and providing medical information through remote communication in times of emergencies. during the pandemic outbreak of the novel coronavirus (covid-19), pandemic outbreak, 507 participants answered a structured online survey, rating their mean willingness to receive medical care and provide medical information, on a four-point likert scale. furthermore, demographic characteristics, social media use, and trust in data protection was collected. the mean willingness to receive medical services was 3.1 ± 0.6 and the mean willingness to provide medical information was 3.0 ± 0.7, with a strong significant correlation between the two (r = 0.76). the multiple regression model identified higher trust in data protection, level of education, and social media use as statistically significant predictors for a higher willingness to receive medical information while the first two predicted willingness to provide information. the findings suggest an overall positive attitude to receive medical care through remote communications. major disasters and emergency events pose continual threats to the public health. the current ongoing pandemic outbreak of the novel coronavirus (covid-19) constitutes a grave risk to the health of the global community and presents complex challenges in striving to contain the spread of the virus and mobilizing responses to maintain public health [1, 2] . at the late end of december 2019, the first human cases of covid-19 were observed in wuhan, china [3] [4] [5] . the outbreak is currently ongoing, and as of the beginning of may 2020, over 3.4 million confirmed cases were identified globally [6] . to control a pandemic spread, strategies to minimize contact between infected and uninfected, must be utilized [1, 7] . for example, in south korea, during 2015, one single infected patient that visited a crowded emergency department (ed) caused 82 additional cases of the novel middle east respiratory syndrome coronavirus (mers-cov), with a 20% attack rate of those who were in close the study was conducted among a population insured by meuhedet health services (mhs), which is one of four health funds operating in israel, with over 1 million insured. this health fund was chosen for the study as it has advanced computerized systems for managing emergencies and was a leading actor in integrating telemedicine into the response plans for emergency scenarios. the sample size was calculated to 500 respondents, using the open source software for epidemiological statistics, openepi at openepi.com. to encompass the two main populations that characterize the israeli society, both hebrew-and arabic-speaking individuals were included. as the division of the two groups in the israeli population is 4:1, 405 responses from the hebrew-speaking population and 102 responses from the arabic-speaking population were collected. only individuals over 18 years of age were included in the study. a cross-sectional study was performed in the end of january through february 2020, in the midst of the covid-19 outbreak, following the publication that several israelis may have contracted the virus while visiting wuhan, china. the study was planned by the researchers prior to covid-19, resulting from the need to prepare for varied types of emergencies, including security scenarios and potential natural disasters. as covid-19 erupted prior to the dissemination of the questionnaire to the respondents, it is not possible to disregard the impact of the pandemic on the answers of the participants. a supplementary figure illustrates a timeline for the different study procedures (supplementary material figure s1 ). the research tool used to collect data was a quantitative questionnaire developed specifically for this study, checked for content validity by 8 content experts and pilot tested among 20 participants, prior to its distribution. the questionnaire was conceptualized in hebrew, and translated to arabic (and re-translated to ensure validity) to enable both the majority and minority groups of israel to partake in the study. the first part of the questionnaire charted attitudes of the respondents concerning receiving medical services through remote communications during emergencies. six statements focused on the attitudes towards receiving medical care from the health fund's providers through remote communication (for example, receiving information about available medical facilities, instructions concerning needed medical treatment, distant medical examination through video-conference, etc.). six other statements concentrated on attitudes towards providing the health fund with information or requesting medical/mental health services through remote communication (for example, updates concerning your current medical condition, transmit photos or video of your medical condition, request a home visit, etc.). a 4-point likert scale was used ranging from 1 = "not ready at all" to 4 = "very ready" for each of the 12 different statements. the second part of the questionnaire included demographic questions on gender, age, place of residence, marital status, number of children under the age of 18/adult offspring living with the respondents, education, religion, religiosity, and socioeconomic status. the third part of the questionnaire collected information on social media use, such as the frequency of activity and through which types of social media the respondents are willing to be contacted through in times of emergency. furthermore, the third part contained a question concerning the trust of the data protection in transferring medical information through remote communication. the questionnaire was distributed to members of mhs through an internet panel that employs a panel of over 100,000 individuals (http:www.ipanel.co.il). one of the exclusion criteria was members of other health funds, so that only members of this specific health fund were sampled. further, through the panel, a representation of all demographic and geographic components of the population was conducted using stratified sampling methodology, based on quotas of age, gender, and geographic classification. the representation was based on data from the central bureau of statistics. the likert scale for statements 1-12 was converted into two different indices, one index for the willingness to receive medical services from a health fund through remote communications during emergencies and another index for the willingness to provide information to a health fund through remote communications during emergencies. the reliability of the indices was tested by cronbach's alpha and found to be very high (0.84 for willingness to receive medical services and 0.89 for willingness to provide information through remote communication). to investigate differences in mean willingness between groups of characteristics, an independent samples t-test was calculated for dichotomous variables and an analysis of variance (one-way anova) was calculated for variables with more than two values. when statistically significant values in the one-way anova were presented, it was followed by bonferroni's post hoc test. the pearson's correlation coefficient (pearson's r) was calculated to examine a correlation between the willingness to receive medical services and the willingness to provide medical information through remote communication during emergencies. spearman's rank correlation coefficient (spearman's r s ) was calculated to examine monotonic correlations between the willingness to either receive medical services or provide medical information and the ordinal variables social media use and trust of the data protection in transferring medical information through remote communication. the correlation was considered weak when coefficients r or r s ranged between −0.3 and 0.3; moderate between >−0.3 and −0.6 or >0.3 to 0.6; and strong between >−0.6 and −1.0 or >0.6 and 1.0. finally, a prediction analysis was conducted using a multiple linear regression model. all statistical analysis was conducted using ibm spss statistics version 26 (ibm corp., armonk, ny, usa). p value below 0.05 was considered significant. the study protocol was approved by ethical committees at the tel aviv university (# 0000734-2) and at meuhedet health services (# p-01-29-01-20) according to local ethical guidelines. each participant gave an informed consent after receiving information of the study before any data was collected. furthermore, the study followed the declaration of helsinki principles in research ethics where participation was voluntary without a risk for breach of personal integrity. the characteristics and descriptive statistics of the 507 respondents to the questionnaire are presented in table 1 . the mean age was 38.4 (standard deviation (sd) = 14.2) years and ranged between 18 and 70 years. the majority of the respondents had an income level near or above the average monthly salary (58.2%) and more than one child (54%). self-reported frequency in use of social media was ≤1 a week (14.6%), several times a week (19.9%), and several times a day (65.5%). when rating the trust of data protection, 23.1% answered they "do not trust", 36.5% answered they "trust", and 40.4% "highly trust". the mean willingness to receive medical services from the health fund through remote communications, in times of emergencies, was 3.1 (sd = 0.6). the mean willingness of the respondents to provide medical information to the health fund through remote communications, in times of emergencies, was 3.0 (sd = 0.7). figure 1 shows the statistically significant differences that were found in mean willingness to receive medical services through remote communications during emergencies. according to age, the mean willingness to receive was significantly higher among those above 40 years of age compared to those under 40 years (t(505) = 2.1, p = 0.037). similarly, the mean willingness to provide medical information through remote communications was found to be numerically higher in the age group above 40 years (mean 3.2, sd = 0.6 and mean 3.1, sd = 0.6, respectively); however, this was not statistically significant (t(505) = 1.91, p = 0.056). figure 2 presents the statistically significant differences in the mean willingness to provide medical information through remote communications during emergencies. socioeconomic-related differences were statistically significant in the mean willingness to both receive medical services (f(2504) = 3.48, p = 0.032) and provide medical information through remote communication (f(2504) = 3.14, p = 0.044). post hoc analysis using bonferroni's multiple comparison showed higher levels of mean willingness to receive medical services among respondents with an above-average salary compared to respondents with a salary near average (p = 0.049); however, the multiple comparison was not statistically significant in willingness to provide. significant differences were seen between the respondents according to their level of trust of the data protection when transferring medical information through remote communications during emergencies, in both mean willingness to provide medical information (f(2504) = 54.36, p < 0.001) and to receive medical services (f(2504) = 44.11, p < 0.001). further post hoc analysis, using the bonferroni multiple comparison, showed that the mean willingness of both providing and receiving was higher between all groups that reported higher levels of trust of data protection (p < 0.001). there were no significant differences between different religions, which is equivalent to the two language categories, hebrew and arabic. furthermore, gender, living area, religiosity, marital status, education, and social media use were not associated with a higher mean willingness to receive or provide medical care/information. there was a significantly strong positive linear correlation between willingness to provide medical information and willingness to receive medical services through remote communication during emergencies (r = 0.763, p < 0.001). significant moderate positive monotonic correlations were found between trust in data protection in transferring medical information through remote communication and both the willingness to provide (rs = 0.43, p < 0.001) as well as the willingness to receive (rs = 0.38, p < 0.001), i.e., higher willingness was associated with higher trust. a linear regression model was conducted in order to examine which variables can predict the willingness of the respondent to receive medical services through remote communications. the anova test was significant (f(3368) = 20.02, p < 0.001) and showed a good fit of the model (r 2 = 0.14). there was a significantly strong positive linear correlation between willingness to provide medical information and willingness to receive medical services through remote communication during emergencies (r = 0.763, p < 0.001). significant moderate positive monotonic correlations were found between trust in data protection in transferring medical information through remote communication and both the willingness to provide (rs = 0.43, p < 0.001) as well as the willingness to receive (rs = 0.38, p < 0.001), i.e., higher willingness was associated with higher trust. a linear regression model was conducted in order to examine which variables can predict the willingness of the respondent to receive medical services through remote communications. the anova test was significant (f(3368) = 20.02, p < 0.001) and showed a good fit of the model (r 2 = 0.14). there was a significantly strong positive linear correlation between willingness to provide medical information and willingness to receive medical services through remote communication during emergencies (r = 0.763, p < 0.001). significant moderate positive monotonic correlations were found between trust in data protection in transferring medical information through remote communication and both the willingness to provide (r s = 0.43, p < 0.001) as well as the willingness to receive (r s = 0.38, p < 0.001), i.e., higher willingness was associated with higher trust. a linear regression model was conducted in order to examine which variables can predict the willingness of the respondent to receive medical services through remote communications. the anova test was significant (f(3368) = 20.02, p < 0.001) and showed a good fit of the model (r 2 = 0.14). this means that in total, 14% of the variance of a respondent's willingness to receive medical services through remote communications can be explained by using three variables: the respondent's level of trust in data protection (p < 0.001), respondent's level of education (p = 0.038), and respondent's level of activity on social media (p = 0.043). among these three variables, the trust of data protection has the highest effect on respondents' willingness to receive medical services (b-coefficient = 0.347). the linear regression model is presented in table 2 . gender, age, marital status, religion, religiosity, socio-economic status, number of children under the age of 18, or other dependent adults living with the respondents were not statistically significant in the multiple analysis and therefore were not included in the model. similarly, a linear regression model was conducted to examine the predicting variables in the willingness to provide medical information through remote communications. the anova test was significant (f(2369) = 35.8, p < 0.001), with r 2 = 0.16. in total, 16% of the variance of a respondent's willingness to provide medical information through remote communications can be explained by using two variables: the respondent's level of trust in data protection (p < 0.001) and the level of education (p = 0.015). among the two variables, the trust of data protection has the highest effect on respondents' willingness to provide medical information (b-coefficient = 0.389). the linear regression model is presented in table 3 . gender, age, marital status, religion, religiosity, socioeconomic status, number of children under the age of 18, or other dependent adults living with the respondents and level activity on social media were not statistically significant in the multiple analysis and therefore were not included in the model. this study, examining attitudes to receive health services through remote communications in times of emergency, was conducted during an emergency situation-the covid-19 crisis. though the actual cases that were infected in the israeli communities were only confirmed at a later date, the study was conducted during a period in which the population was notified of an evolving epidemic that though (at that time) it impacted other countries, it was expected to also impact the local society. therefore, it can be assumed that the results of this study realistically reflect the attitudes and perceptions of the public concerning consumption of services through remote communication, in a way which could not have been achieved otherwise [35] . in this situation, when mobility in society is restricted and medical facilities are primarily dedicated to treating the moderate and severe patients, it is more likely that respondents can relate and prefer health services through remote communications as an alternative way to receive needed medical care for sub-acute illnesses and monitoring of chronic illnesses [36] . furthermore, it may reflect their concern from being exposed to the risk, such as contracting the covid-19 if they were to physically go to the medical facilities [37] , and thus consent to utilizing the services through telemedical means. the willingness of the general public to provide medical information and to receive medical services from a health fund through remote communications in times of emergency was found to be high. by testing each factor's effect on patient's willingness to receive medical services and provide medical information, the factors associated with a higher willingness to receive medical services were age, salary in relation to average income, and trust of the data protection while for willingness to provide medical information, the latter two were statistically significant. the respondents scored very similar in willingness to receive medical services and provide medical information to a health fund through remote communications in times of emergency. not surprisingly, there was a significant strong positive correlation between the two variables. the predictors of willingness to receive medical services by using a multiple model were trust of data protection transferring medical information through remote communications, level of education, and level of activity on social media. similarly, the predictors of willingness to provide medical information were trust of data protection and level of education. the r 2 value represents the percent of the variance of the dependent variable that can be explained by using the regression model including the independent variables. the prediction values were relatively low, which could be explained as there was a low variance in the willingness reported by the participants. further, including other independent variables in order to predict the dependent variables could have increased the r 2 value. according to the conducted literature review, no previous studies concerning attitudes towards health services through remote communications in times of emergency were identified. however, the willingness to use telemedical means among patients with specific medical conditions, such as chronic diseases with increased risk of cardiovascular disease or depression, has been studied [38] [39] [40] . in one of them, an american study investigating attitude towards telemedical means when monitoring diabetic retinopathy, valikodath et al. reported (2017) that 97% of their respondents had never been in contact with the word telemedicine before [39] . this indicates that there are barriers to overcome when implementing telemedical means in general; however, patient satisfaction rates are reported as very high in the majority of studies when it is implemented [41] [42] [43] . the trust of data protection transferring medical information through remote communications is the one factor that remained statistically significantly associated with willingness to use remote communications in all our analyses. these results are in accordance with previous studies [44] [45] [46] . in a dutch study, trust of the data protection in transferring medical information through remote communications is shown to be the one sub-factor that affects the overall trust in using telemedicine the most, with a higher impact than both trust in health care providers, health care workers, and offered treatment [44] . furthermore, a german study showed how the trust of data protection is of great importance, especially among healthy respondents, when considering the use of health services through remote communications [46] . this study indicates that socioeconomic differences might affect the attitude towards medical services through remote communications. an american study [47] found that the level of education was associated with increased use of health services through remote communications. similarly, green and colleagues found that a lower education level was associated with a higher likelihood in refusing to participate in a trial to monitor and optimize blood pressure through remote communications [48] . level of activity on social media was a predictor in the willingness to receive medical services through remote communications. in a recent study, it was shown that in an ed-visiting population with a low socioeconomic status, 96% had access through a smart phone [40] , indicating that in high-income regions, the access to social media is high regardless of socioeconomic status. although age was not found to be an independent predictor, it is surprising that younger age was not a strong predictor. even though technological use is increasing in the older generation [49] , it is common that the younger generation uses technology to a greater extent. it is reasonable to believe that more frequent use and convenience in technology would correlate with a higher willingness towards telemedicine. in accordance with this consideration, a polish study examining the willingness to use telemedicine among those 60 years and older showed that 66% of the respondents were reluctant to conduct a video consultation with a physician [50] . one possible explanation to the counterintuitive age-related results found in our study can be that in times of emergency, the older generation are more likely to trust the authorities in emergency management compared to the younger generation. it may also reflect a higher degree of concern with health-related issues among older individuals compared to younger people, who tend to be generally healthier. more so, as the elderly were defined as highly vulnerable to covid-19, their willingness to access services through remote communication may signify their perceived concern of leaving their homes and thus a higher preference for maintaining their safety by not being potentially exposed to the virus. the younger populations, perceiving themselves as less vulnerable, were most probably less concerned with the need to strictly maintain social distancing [51] . the cross-sectional design cannot determine causality nor capture changes in attitudes over time. given this, it is difficult to assess the extent of the impact that covid-19 has had on the results. future research is needed to evaluate the differences in usage and patient satisfaction of telemedical means, actually implemented in clinical practice during the covid-19 pandemic outbreak. furthermore, a strength of the study is how the internet panel, with over 100,000 individuals, made it possible to stratify the sampling, based on quotas of age, gender, and geographic classification, enabling a comparison to the israeli population and also to collect the exact calculated sample size. however, distributing the questionnaire exclusively through an internet panel when the aim was to investigate willingness to access health services using electronic tools could exclude groups in the society who do not have access or are reluctant to use electronic devices. if the questionnaire were to be conducted also by post or phone-call, respondents with less access to electronic tools may have been more fully represented. in this cross-sectional study, conducted during an ongoing worldwide pandemic outbreak, the willingness to receive medical services and to provide medical information through remote communications in times of emergency was found to be high. there are factors associated with statistically significant differences in the attitude towards health services through remote communications, where the trust of data protection in transferring medical information through remote communications was the factor with the highest impact. the results are important in future implementation of these solutions in clinical practice. funding: this research received no external funding. steinn steingrimssons' research time was financed by grants from the swedish state under the agreement between the swedish government and the country councils, the alf-agreement (alfgbg-588611). will ebola change the game? ten essential reforms before the next pandemic. the report of the harvard-lshtm independent panel on the global response to ebola characteristics of and public health responses to the coronavirus disease 2019 outbreak in china three emerging 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general personnel during offshore emergency situations covid-19 pandemic: what consequences for cardiac rehabilitation? monaldi arch anxiety regarding contracting covid-19 related to interoceptive anxiety sensations: the moderating role of disgust propensity and sensitivity are people with chronic diseases interested in using telehealth? a cross-sectional postal survey patient attitudes toward telemedicine for diabetic retinopathy potential of mobile health technology to reduce health disparities in underserved communities patients' satisfaction with and preference for telehealth visits patterns of use and correlates of patient satisfaction with a large nationwide direct to consumer telemedicine service systematic review of patient and caregivers' satisfaction with telehealth videoconferencing as a mode of service delivery in managing patients' health measuring patient trust in telemedicine services: development of a survey instrument and its validation for an anticoagulation web-service trust in telemedicine portals for rehabilitation care: an exploratory focus group study with patients and healthcare professionals privacy and data security in e-health: requirements from the user's perspective. health inform predictors of ehealth usage: insights on the digital divide from the health information national trends survey 2012 patient ability and willingness to participate in a web-based intervention to improve hypertension control factors associated with change in internet usage of swedish older adults health in old age, and patients' approaches to telemedicine in poland awareness, attitudes, and actions related to covid-19 among adults with chronic conditions at the onset of the u.s. outbreak: a cross-sectional survey the authors would like to thank the respondents to the questionnaire. the authors declare no conflict of interest; funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. key: cord-353391-o0s2h0y0 authors: haj bloukh, samir; edis, zehra; shaikh, annis a.; pathan, habib m. title: a look behind the scenes at covid-19: national strategies of infection control and their impact on mortality date: 2020-08-04 journal: int j environ res public health doi: 10.3390/ijerph17155616 sha: doc_id: 353391 cord_uid: o0s2h0y0 (1) background: the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) began spreading across the globe in december and, as of 9 july 2020, had inflicted more than 550,000 deaths. public health measures implemented to control the outbreak caused socio-economic havoc in many countries. the pandemic highlighted the quality of health care systems, responses of policymakers in harmony with the population, and socio-economic resilience factors. we suggest that different national strategies had an impact on mortality and case count. (2) methods: we collected fatality data for 17 countries until 2 june 2020 from public data and associated these with implemented containment measures. (3) results: the outcomes present the effectiveness of control mechanisms in mitigating the virus for selected countries and the uae as a special case. pre-existing conditions defined the needed public health strategies and fatality numbers. other pre-existing conditions, such as temperature, humidity, median age, and low serum 25-hydroxyvitamin d (25(oh)d) concentrations played minor roles and may have had no direct impact on fatality rates. (4) conclusions: prevention, fast containment, adequate public health strategies, and importance of indoor environments were determining factors in mitigating the pandemic. development of public health strategies adapted to pre-existing conditions for each country and community compliance with implemented policies ensure the successful control of pandemics. a novel coronavirus (cov) was identified in december 2019 in wuhan, china. this highly contagious and previously unknown pathogen caused complications in the respiratory system and was named severe acute respiratory syndrome coronavirus 2 (sars-cov-2). who first declared the outbreak of coronavirus disease 2019 (covid-19) a six public-health emergency of international concern, before subsequently declaring it a pandemic [1] . human coronaviruses (hcovs) are enveloped, non-segmented, positive-sense, single-strand ribonucleic acid (rna) viruses [2] . hcovs can infect animals and humans, causing respiratory, hepatic, and neurologic diseases [3] . covs are divided into four genera: alpha-coronavirus (α), beta-coronavirus (β), gamma-coronavirus (γ), and delta-coronavirus (δ) [2] [3] [4] [5] . human coronaviruses were identified in late 1960 and are known to infect humans, france-spain are compared as examples of european countries. latin america is represented by analysis of data from brazil, peru, ecuador, and mexico. south korea and japan were chosen as examples of far eastern countries with previous experience of sars and efficient national strategies to combat covid-19. we depict the results of the controversially discussed factors of average serum (25(oh)d) concentrations and median age, in addition to geographical factors of temperature and humidity. the outcomes of the analysis underline the importance of pre-existing conditions (health care system preparedness, median age, population size, population density, geographical conditions) and adequate public health strategies within a suitable time-frame. we comment on the effectiveness and problems of the implemented control mechanisms, including the general lockdown-and postlockdown implications. finally, we conclude with recommendations for the covid-19 outbreak and future pandemics. progression of cov to severe pneumonia is directly related to advanced age, history of metabolic syndrome, smoking, and other chronic conditions such as cardiovascular disease [19] . countries with a high percentage of advanced age and high population density in urban areas need to impose swiftly efficient measurements to reduce fatalities [19] . primc et al. analyzed the public health measures of european countries during the pandemic [19] . they concluded that qualitative development of the health care system and improving protective health conditions such as serum (25(oh)d) concentrations may be important for the control of covid-19 [19] . to investigate the importance of serum vitamin d levels, median age, temperature, and humidity we compare infection control measures and their impact on covid-19-related fatalities in portugal, sweden, and switzerland ( figure 1 ). figure 1 shows the highest fatality numbers in sweden, followed by switzerland and then portugal. sweden is one of the few european countries refraining from nationwide closures and lockdown [19] . this, in combination with a lack of clear recommendations for the public in how to prevent viral spread, especially in indoor environments, may have aggravated sars-cov-2 spread in sweden. primc et al. reported a possible relationship between low 25-hydroxyvitamin d (25(oh)d) concentrations and susceptibility to covid-19 [19] . vitamin d deficiency is prevalent in the northern hemisphere due to reduced solar irradiation especially in the winter months [20] [21] [22] [23] . the infection figure 1 shows the highest fatality numbers in sweden, followed by switzerland and then portugal. sweden is one of the few european countries refraining from nationwide closures and lockdown [19] . this, in combination with a lack of clear recommendations for the public in how to prevent viral spread, especially in indoor environments, may have aggravated sars-cov-2 spread in sweden. primc et al. reported a possible relationship between low 25-hydroxyvitamin d (25(oh)d) concentrations and susceptibility to covid-19 [19] . vitamin d deficiency is prevalent in the northern hemisphere due to reduced solar irradiation especially in the winter months [20] [21] [22] [23] . the infection rates of covid-19, which started in the month of december 2019, are now showing exponential growth in northern hemisphere countries, [19, 24, 25] . according to a recent review by grant et al., 25 -hydroxyvitamin d (25(oh)d) concentrations may play a relevant role in the progression of covid-19 [20] . sufficient plasma (25(oh)d) concentrations around 75 nmol/l ensure cellular immunity, decrease the risk of infections caused by microorganisms, and protect against metabolic syndrome and other chronic illnesses [20] . severe vitamin d deficiency is defined as serum 25(oh) d levels lower than 30 nmol/l [21] . factors such as screen-based entertainment, sedentary lifestyle, and less outdoor physical activity are directly related to poor endogenous vitamin d synthesis [21] [22] [23] . higher susceptibility of advanced age individuals to covid-19 may confirm this hypothesis. commonly, serum 25-hydroxyvitamin d (25(oh)d) concentrations are less than 30 nmol/l in elderly individuals and geriatric patients due to indoor dwelling, physical inactivity, and increased pharmaceutical drugs intake, especially in the winter [20, 21, 26] . sufficient serum vitamin d levels above 70 nmol/l may have a positive impact on recovery rate and survival of patients during illness [20] [21] [22] [23] . ilie et al. associated mean serum vitamin d levels in elderly populations of european countries with covid-19 infection and mortality [27] . they compared the mean serum vitamin d levels for the populations in portugal (39 nmol/l), spain (42.5 nmol/l), switzerland (46 nmol/l), uk (47.4 nmol/l), italy (50 nmol/l), germany (50.1 nmol/l), turkey (51.8 nmol/l), france (60 nmol/l), sweden (73.5 nmol/l), and other countries [27] . portugal has the smallest, switzerland represents the average, and sweden the highest mean serum 25-hydroxyvitamin d (25(oh)d) levels and similar population sizes of 10,281,762, 8,516,543, and 10,183,175, respectively (figure 1) [18, 27] . the highest number of fatalities is in sweden, followed by switzerland, and then portugal, although the opposite trend was expected due to mean serum vitamin d levels and population number. we can conclude that mean plasma 25-hydroxyvitamin d (25(oh)d) levels have no direct impact on fatality rates and remain controversial in their relation to covid-19. the results of figure 1 show that the highest covid-19-related mortality was in sweden, followed by switzerland and portugal with median ages of 41.1, 42.7, and 44.6, respectively [24] . therefore, we also can conclude from our analysis that median age is not a sufficient variable to predict fatality. according to scafetta, temperature and relative humidity have an impact on viral transmission [24] . temperatures from 4 to 12 • c and relative humidity of 60-80% with gentle wind speeds increase the susceptibility to respiratory tract infections and the spread of sars-cov-2 [24] . our analysis reveals that temperature and relative humidity are not the only factors with direct impact on fatality rates. the first fatal cases were announced in each of the three countries in march, while the first confirmed covid-19 case was reported in portugal, switzerland, and sweden on 3 march, 26 february, and 1 february 2020, respectively [18, 24] . the average temperature in march 2020 was the highest in portugal at 12.4 • c, followed by switzerland with 2.2 • c, and the lowest was sweden with −3.3 • c [24] . the lowest relative humidity was recorded in portugal with 70%, switzerland's was 73%, and the highest was in sweden with 88% [24] . according to these numbers, the spread of covid-19 should be higher in portugal, but again it was sweden. an explanation for the higher fatality in sweden is the cold weather itself. the virus cannot survive for long outside in the cold, but spreads easily because people remain indoors [24] . indoor air is more suitable for the spread of sars-cov-2, especially due to close contact of people in unventilated, closed rooms without uv irradiation [24] . a coordinated effort to educate the population about the means of preventing transmission and infection in indoor and outdoor environments during a pandemic is crucial to avoid uncontrolled spread of the virus. indoor and outdoor climate are related to each other and aggravate viral transmission under given conditions. indoor environments can proliferate sars-cov-2 infection by raised viral loads through droplets and direct contact on infected surfaces more than an outdoor climate. this also confirms the spread of covid-19 in household contacts and the need for indoor social distancing. according to luo et al., pre-symptomatic cases within the household may transmit the virus rapidly [28] . especially vulnerable and high-risk individuals are at risk of being infected. luo et al. concluded in their prospective cohort study that the risk of transmitting covid-19 is highest in household contacts [28] . public health strategies need to include habitancy and dwelling patterns in relation to climate in measures to control outbreaks. including dwelling modes in virus containment and control is essential, especially if nationwide closure and lockdowns are not imposed. in addition, a mask wearing strategy needs to be enforced in indoor and outdoor settings, especially in countries with a high population density. wearing masks can reduce the airborne transmission by droplets and smaller particles, especially in indoor environments [16, 17] . a study compared community-wide mask compliance in relation to the number of confirmed sars-cov-2 cases/fatalities in hong kong, singapore, and other countries [29] . singapore has the second highest population density in the world, directly followed by hong kong [29] . due to their previous experience with the sars virus in 2003, 97% of the studied population in hong kong began using masks when the first covid-19 confirmed case emerged [29] . this mask-wearing strategy combined with social distancing, personal hygiene, cancellation of social gatherings, use of the home office, and school closures resulted in the effective control of the sars-cov-2 transmission compared to other neighboring countries [29] . the authors conclude that a mask-wearing strategy irrespective of covid-19 symptoms mitigates infection of susceptible individuals [29] . another study from cowling et al. analyzed data from 60 general outpatient clinics and three cross-sectional surveys in hong kong [30] . they findings indicate that rapidly implemented public health measures and the compliance of the population mitigated the sars-cov-2 outbreak in hong kong [30] . the population readily embraced the recommended prevention methods and social distancing, together with restrictions on the borders, while cases and their surrounding contacts were successfully tracked, isolated, and quarantined [30] . according to the authors, these measures controlled the sars-cov-2 outbreak more efficiently and reduced socio-economic tensions without strict nationwide closure and lockdown during the covid-19 outbreak compared to other countries [30] . the measures also reduced the transmission of influenza in the month of february 2020 [30] . high levels of fatality were recorded in advanced age patients with immune systems compromised by diabetes, hypertension, and cardiovascular disease during sars-cov, mers-cov, and covid-19 [31] . deng et al. compared the characteristics of the fatality group of patients with those of the recovered group [31] . advanced age, dyspnea, comorbidities, low oxygen saturation, high white blood cell (wbc) count, low lymphocytes, and high levels of c-reactive protein (crp) are significant indicators of mortality [31] . giang et al. directly related people aged 65 and above with death rates [32] . they found that the measures of social distancing, lockdown, quarantine, and a high-quality health care system with appropriate numbers of health care workers and emergency rooms helped to decrease fatality rates [33] . the quality and preparedness of the health care system in a country defines the thin line between survival and death. in most covid-19 confirmed cases, symptoms such as fever, dry cough, fatigue, runny nose, or other upper respiratory symptoms appeared in sars-cov and mers-cov [34] [35] [36] [37] [38] . distinguishing covid-19 from other known respiratory tract viruses clinically is a difficult task due to its non-specificity. a precise diagnosis can be carried out by reverse real-time quantitative polymerase chain reaction (rt-qpcr) testing and radiological study of the cases [35, [39] [40] [41] [42] . fast and reliable methods of covid-19 testing can be life-saving tools to eradicate the virus in far eastern countries. to validate this thesis, we compared the fatality numbers in south korea and japan during the sars-cov-2 pandemic (figure 2 ). the first confirmed covid-19 case in japan was announced on 15 january 2020, while south korea had a confirmed case five days later [18] . the first fatality in japan occurred on 13 february 2020, while south korea's first covid-19 fatality occurred on 21 february [18] . the total number of fatalities in japan on 2 june 2020 was 894 within a population of more than 126 million, and south korea's was 24 within more than 5 million [18] . the low fatality rate in both countries indicates excellent pandemic control. nonetheless, the factors relevant to this success should be discussed. the median age in japan of 48.6 years is the highest globally, and could have led to the highest global fatality rates because of the higher susceptibility of elderly [28] . the number of deaths is low compared to mexico with a similarly sized population (>126 million) and 10,167 fatalities until 2 june 2020 [18] . the median age in south korea is 43.2 [28] . both south korean and japan adopted early intervention strategies to control the viral spread with measures of social distancing and widespread covid-19 testing, combined with strict follow-up of clusters of infections [43] . both societies gained experience during the sars outbreak, whereby they developed the habit of wearing masks, which prepared them for this pandemic. south korea introduced a dynamic and quick response to the needs of the time. the measurements were implemented in harmony with the public through open information sharing and transparency, thus ensuring public support and collaboration [43] . these joint efforts orchestrated a supply of masks, their distribution, and smart use [43] . a drive-through screening system was used to support general widespread covid-19 testing and all individuals were followed up via personal tracking [44] . as a result, the pandemic was controlled without a complete lockdown in both countries mainly by widespread covid-19 testing, individual tracking, and follow-up of clusters. public support was essential through social distancing, wearing of masks, personal hygiene, transparency during the pandemic, collaboration to meet the needs of the market in mask production, and, most importantly, widespread covid-19 testing with strict follow up mechanisms for clusters. many countries responded with different control mechanisms compared to the experiences of china, south korea, japan, and hong kong [29, 30, 44, 45] . highly industrialized, european countries were expected to best cope with the pandemic due to their level of sustainable development. to verify this thesis, we analyzed the data of selected european countries and grouped them according to their population size and/or number of fatalities [18] . germany (population 2018: 82,927,922) and turkey (population 2018: 82,319,724) faced their first reported covid-19 case on 28 january 2020 and 12 march 2020, respectively [18] . until 2 june 2020, the number of confirmed cases in germany was 182,028, while turkey had 164,769 cases. germany had reported a total number of 8522 fatalities, while turkey recorded 4563 fatal cases ( figure 3 ) [18] . south korea japan the first confirmed covid-19 case in japan was announced on 15 january 2020, while south korea had a confirmed case five days later [18] . the first fatality in japan occurred on 13 february 2020, while south korea's first covid-19 fatality occurred on 21 february [18] . the total number of fatalities in japan on 2 june 2020 was 894 within a population of more than 126 million, and south korea's was 24 within more than 5 million [18] . the low fatality rate in both countries indicates excellent pandemic control. nonetheless, the factors relevant to this success should be discussed. the median age in japan of 48.6 years is the highest globally, and could have led to the highest global fatality rates because of the higher susceptibility of elderly [28] . the number of deaths is low compared to mexico with a similarly sized population (>126 million) and 10,167 fatalities until 2 june 2020 [18] . the median age in south korea is 43.2 [28] . both south korean and japan adopted early intervention strategies to control the viral spread with measures of social distancing and widespread covid-19 testing, combined with strict follow-up of clusters of infections [43] . both societies gained experience during the sars outbreak, whereby they developed the habit of wearing masks, which prepared them for this pandemic. south korea introduced a dynamic and quick response to the needs of the time. the measurements were implemented in harmony with the public through open information sharing and transparency, thus ensuring public support and collaboration [43] . these joint efforts orchestrated a supply of masks, their distribution, and smart use [43] . a drive-through screening system was used to support general widespread covid-19 testing and all individuals were followed up via personal tracking [44] . as a result, the pandemic was controlled without a complete lockdown in both countries mainly by widespread covid-19 testing, individual tracking, and follow-up of clusters. public support was essential through social distancing, wearing of masks, personal hygiene, transparency during the pandemic, collaboration to meet the needs of the market in mask production, and, most importantly, widespread covid-19 testing with strict follow up mechanisms for clusters. many countries responded with different control mechanisms compared to the experiences of china, south korea, japan, and hong kong [29, 30, 44, 45] . highly industrialized, european countries were expected to best cope with the pandemic due to their level of sustainable development. to verify this thesis, we analyzed the data of selected european countries and grouped them according to their population size and/or number of fatalities [18] . germany (population 2018: 82,927,922) and turkey (population 2018: 82,319,724) faced their first reported covid-19 case on 28 january 2020 and 12 march 2020, respectively [18] . until 2 june 2020, the number of confirmed cases in germany was 182,028, the covid-19 fatality numbers in germany are almost double the number of fatalities in turkey. the reason may be due to the higher median age in germany [24] . the median age of the german population is the second highest after japan [24] . the arrival of the pandemic in turkey was more than one month later than in germany. both countries reacted after the first covid-19 fatality with a partial lockdown and social distancing measures, and closure of workplaces, schools, and universities [19] . the borders were closed for non-essential travel [19] . citizens stranded in other countries were repatriated and quarantined for two weeks. all border crossings were controlled and checked. authorities started with widespread testing and followed-up on clusters and asymptomatic cases. turkey started producing masks, effective personal protection equipment (ppe), and respirators to cope with demand inside and outside the country. according to the curves in figure 4 , the peak of the pandemic is over for both countries. both countries were well prepared to handle the pandemic due to well-developed health care systems and by taking the needed measures to control the spread of the virus. italy and spain have younger populations compared with germany [24] . the median age in germany is 47.8, while in italy it is 46.6 and in spain it is 43.9 [24] . furthermore, the mean serum vitamin d levels for the populations in italy and spain are similar to those of germany [27] . these factors should have resulted in lower sars-cov-2 susceptibility and better control of the outbreak. however, italy and spain were confronted with a massive outbreak of covid-19 in 2020. italy reported the first confirmed case in 31 january 2020 and the first fatality on 23 february 2020 [18] . spain confirmed the first case on 1 february 2020 and the first fatality occurred almost one month later on 5 march 2020 [18] . spain had recorded 239,638 cases and 27,940 fatal cases with a population of approximately 46,723,749 [18] . the number of covid-19 cases in italy was 233,197 with a population size of 60,431,283 and 33,475 fatalities until 2 june of 2020 ( figure 4 ) [18] . the covid-19 fatality numbers in germany are almost double the number of fatalities in turkey. the reason may be due to the higher median age in germany [24] . the median age of the german population is the second highest after japan [24] . the arrival of the pandemic in turkey was more than one month later than in germany. both countries reacted after the first covid-19 fatality with a partial lockdown and social distancing measures, and closure of workplaces, schools, and universities [19] . the borders were closed for non-essential travel [19] . citizens stranded in other countries were repatriated and quarantined for two weeks. all border crossings were controlled and checked. authorities started with widespread testing and followed-up on clusters and asymptomatic cases. turkey started producing masks, effective personal protection equipment (ppe), and respirators to cope with demand inside and outside the country. according to the curves in figure 4 , the peak of the pandemic is over for both countries. both countries were well prepared to handle the pandemic due to well-developed health care systems and by taking the needed measures to control the spread of the virus. italy and spain have younger populations compared with germany [24] . the median age in germany is 47.8, while in italy it is 46.6 and in spain it is 43.9 [24] . furthermore, the mean serum vitamin d levels for the populations in italy and spain are similar to those of germany [27] . these factors should have resulted in lower sars-cov-2 susceptibility and better control of the outbreak. however, italy and spain were confronted with a massive outbreak of covid-19 in 2020. italy reported the first confirmed case in 31 january 2020 and the first fatality on 23 february 2020 [18] . spain confirmed the first case on 1 february 2020 and the first fatality occurred almost one month later on 5 march 2020 [18] . spain had recorded 239,638 cases and 27,940 fatal cases with a population of approximately 46,723,749 [18] . the highest fatalities were recorded towards the end of march in italy, while the number of confirmed cases started to decline 10 days earlier ( figure 4 ). widespread covid-19 testing was initiated in the beginning of march with a delay of one month after the first confirmed case. both curves descended slowly towards 2 june 2020 which indicates that the sars-cov-2 outbreak was under control prior to the summer months ( figure 4 ). the delay of widespread covid-19 testing for one month aggravated the pandemic in italy. due to this delay, the implemented state of emergency, nationwide closures, lockdown, and further measures did not effectively control the spread of the virus. in addition, lower median age and similar serum vitamin d levels compared to germany did not have any positive impact on the covid-19 disease course and did not reduce fatality numbers in italy. france and the united kingdom (uk) were also severely hit by the covid-19 pandemic. both countries have around 67 million inhabitants [18] . the total number of fatalities in france was 28,833 and in the uk 39,045 until 2 june 2020 ( figure 5 ) [18] . the highest fatalities were recorded towards the end of march in italy, while the number of confirmed cases started to decline 10 days earlier ( figure 4 ). widespread covid-19 testing was initiated in the beginning of march with a delay of one month after the first confirmed case. both curves descended slowly towards 2 june 2020 which indicates that the sars-cov-2 outbreak was under control prior to the summer months ( figure 4 ). the delay of widespread covid-19 testing for one month aggravated the pandemic in italy. due to this delay, the implemented state of emergency, nationwide closures, lockdown, and further measures did not effectively control the spread of the virus. in addition, lower median age and similar serum vitamin d levels compared to germany did not have any positive impact on the covid-19 disease course and did not reduce fatality numbers in italy. france and the united kingdom (uk) were also severely hit by the covid-19 pandemic. both countries have around 67 million inhabitants [18] . the total number of fatalities in france was 28,833 and in the uk 39,045 until 2 june 2020 ( figure 5 ) [18] . the highest fatalities were recorded towards the end of march in italy, while the number of confirmed cases started to decline 10 days earlier ( figure 4 ). widespread covid-19 testing was initiated in the beginning of march with a delay of one month after the first confirmed case. both curves descended slowly towards 2 june 2020 which indicates that the sars-cov-2 outbreak was under control prior to the summer months ( figure 4 ). the delay of widespread covid-19 testing for one month aggravated the pandemic in italy. due to this delay, the implemented state of emergency, nationwide closures, lockdown, and further measures did not effectively control the spread of the virus. in addition, lower median age and similar serum vitamin d levels compared to germany did not have any positive impact on the covid-19 disease course and did not reduce fatality numbers in italy. france and the united kingdom (uk) were also severely hit by the covid-19 pandemic. both countries have around 67 million inhabitants [18] . the total number of fatalities in france was 28,833 and in the uk 39,045 until 2 june 2020 ( figure 5 ) [18] . france recorded 152,091 and uk reported 276,332 covid-19 cases until the same date [18] . the highest number of fatalities were counted in france between 31 march and 20 april 2020. uk registered a steady decline of covid-19 related fatalities after 20 april 2020. according to ilie et al., the mean serum vitamin d level of the french population is 60 nmol/l, which is higher than that for the populations of portugal, spain, switzerland, uk, italy, germany, and turkey, with 39, 42.5, 46, 47.4, 50, 50 .1 and 51.8, respectively [27] . as a result, low serum vitamin d levels have no direct impact on covid-19 fatality rates. the covid-19 case and mortality counts on the european continent reveal mixed results that do not depend on temperature, mean age, or mean serum 25-hydroxyvitamin d (25(oh)d) levels, but on the preparedness of the health care system and suitable public health strategies. the next epicenter evolved on the american continent. the first confirmed case of sars-cov-2 infection in the united states of america (usa) was reported on 21 january 2020 one day after that of south korea [18] . the fatality rate on 10 april 2020 was 2% for south korea and 3.6% in the usa [46] . south korea, due to its previous sars experience, reacted swiftly with sophisticated, new measures including transparent, community-supported policies and widespread covid-19 testing with strict individual follow-up tracking mechanisms of clusters of transmission [43, 44] . the usa had recorded 105,147 total covid-19-related fatalities and 1,811,277 confirmed cases as at 2 june 2020 ( figure 6 ) [18] . figure 6a shows a sharp increase in the confirmed covid-19 cases after 17 march 2020. the next epicenter evolved on the american continent. the first confirmed case of sars-cov-2 infection in the united states of america (usa) was reported on 21 january 2020 one day after that of south korea [18] . the fatality rate on 10 april 2020 was 2% for south korea and 3.6% in the usa [46] . south korea, due to its previous sars experience, reacted swiftly with sophisticated, new measures including transparent, community-supported policies and widespread covid-19 testing with strict individual follow-up tracking mechanisms of clusters of transmission [43, 44] . the usa had recorded 105,147 total covid-19-related fatalities and 1,811,277 confirmed cases as at 2 june 2020 ( figure 6 ) [18] . figure 6a shows a sharp increase in the confirmed covid-19 cases after 17 march 2020. the fatality curve in figure 6b shows a peak on 15 april 2020. thereafter, a steady decline in fatality numbers was reported. this curve may indicate that the worst of the outbreak in the usa is over and the peak lasted for around one month after the first reported case of covid-19 on 17 march 2020. the us started to test for covid-19 one month after this first confirmed case [46] . this delay of testing caused a rapid viral spread through the population because the infected cases were not identified and followed-up [46] . the unexpected mass of severe cases strained the unprepared health care system. other compounding factors, such as a lack of drugs, treatment protocols, or vaccines resulted in a health disaster for the usa (105,147) (fatalities in usa due to covid-19 at the time of writing), in addition to countries such as the uk (39,045), italy (33, 475) , brazil (29,937), france (28, 833) , spain (27, 940) , and mexico (10,167), which had recorded mortalities in excess of 10,000 prior to 2 june 2020 [18] . asymptomatic cases are a leading cause of the viral outbreak [46] . widespread and random testing are effective methods to identify clusters of infections and mitigate the transmission patterns through follow-up and quarantine [46] . re-testing cases during the isolation and post-quarantine is essential [46] . the first covid-19 case in latin america was reported on 26 february 2020 [47] . subsequently, sars-cov-2 spread at a rapid rate across the continent. we analyzed the data for selected countries in latin america and compared their number of fatalities from the european centers for disease control and prevention (edcd) (figure 7) [18]. the fatality curve in figure 6b shows a peak on 15 april 2020. thereafter, a steady decline in fatality numbers was reported. this curve may indicate that the worst of the outbreak in the usa is over and the peak lasted for around one month after the first reported case of covid-19 on 17 march 2020. the us started to test for covid-19 one month after this first confirmed case [46] . this delay of testing caused a rapid viral spread through the population because the infected cases were not identified and followed-up [46] . the unexpected mass of severe cases strained the unprepared health care system. other compounding factors, such as a lack of drugs, treatment protocols, or vaccines resulted in a health disaster for the usa (105,147) (fatalities in usa due to covid-19 at the time of writing), in addition to countries such as the uk (39,045), italy (33,475), brazil (29,937), france (28,833), spain (27, 940) , and mexico (10,167), which had recorded mortalities in excess of 10,000 prior to 2 june 2020 [18] . asymptomatic cases are a leading cause of the viral outbreak [46] . widespread and random testing are effective methods to identify clusters of infections and mitigate the transmission patterns through follow-up and quarantine [46] . re-testing cases during the isolation and post-quarantine is essential [46] . the first covid-19 case in latin america was reported on 26 february 2020 [47] . subsequently, sars-cov-2 spread at a rapid rate across the continent. we analyzed the data for selected countries in latin america and compared their number of fatalities from the european centers for disease control and prevention (edcd) (figure 7 ) [18] . brazil has reported the highest number of fatalities with 29,937, followed by mexico with 10,167, peru with 4634, and ecuador with 3394 [18] . at the present time, it appears that brazil and mexico have reached the peak of the pandemic according to figure 4 , while ecuador and peru may still be in the initial phase of the pandemic if the curve continues to rise [18] . the covid-19 pandemic in ecuador may also overlap with further viral outbreaks of dengue and/or zika, when the country already lacks a suitable number of intensive care unit beds [47] . the arrival of further epidemics such as measles and malaria may exacerbate the burden on the already depleted health care system in latin america [47] . the situation in south america is far from resolved and could develop into the worst covid-19 outbreak this year. china, south korea, singapore, hong kong, and taiwan are among the countries that were able to control the covid-19 outbreak by reducing infection numbers [41, [48] [49] [50] [51] . nationwide closures, lockdowns, travel restrictions, personal hygiene, and social and workplace distancing may help to prevent infection. a modeling study from singapore investigated the impact of control measures implemented to reduce the spread of covid-19 [49] . the most effective method was a combination of isolating infected cases, strict quarantine, and closure of schools and workplaces [16, 49] . the lockdown of educational establishments and offices (workplace distancing) paved the way for online solutions, which helped to education and work to continue from home. after the outbreak in wuhan, china, the korean government activated a 24/7 emergency response system to screen all travelers entering the country from that city [49] . in taiwan, proactive and comprehensive health checks of passengers from hubei province were established quickly from the beginning of january 2020 [50] . the taiwanese centers of disease control (cdc) tested 2105 cases by february 28 using multiplex pcr analysis with filmarray tm respiratory panel and confirmed 34 covid-19 patients [50] [51] [52] . according to hsih et al., covid-19 is more contagious than seasonal respiratory pathogens but infected cases have common clinical and laboratory results [52] . therefore, each suspected case needs close follow-up through individual tracking, gathering of mobility and contact data, isolation, and quarantine [52] . hsih et al. underline the elevated pandemic level of sars-cov-2 manifested by prolonged viral shedding, and the large number of asymptomatic and mild illness cases that remain undiscovered and continue to spread covid-19 [52] . they also note that some recovered patients still had detectable virus levels for almost two further weeks [52] . furthermore, some patients showed negative covid-19 test results from their naso-oropharyngial system but positive results in their sputum or fecal specimens [52] . the authors are concerned about possible sars-cov-2 transmission through the fecal-oral route [52] . peru equador mexico brazil has reported the highest number of fatalities with 29,937, followed by mexico with 10,167, peru with 4634, and ecuador with 3394 [18] . at the present time, it appears that brazil and mexico have reached the peak of the pandemic according to figure 4 , while ecuador and peru may still be in the initial phase of the pandemic if the curve continues to rise [18] . the covid-19 pandemic in ecuador may also overlap with further viral outbreaks of dengue and/or zika, when the country already lacks a suitable number of intensive care unit beds [47] . the arrival of further epidemics such as measles and malaria may exacerbate the burden on the already depleted health care system in latin america [47] . the situation in south america is far from resolved and could develop into the worst covid-19 outbreak this year. china, south korea, singapore, hong kong, and taiwan are among the countries that were able to control the covid-19 outbreak by reducing infection numbers [41, [48] [49] [50] [51] . nationwide closures, lockdowns, travel restrictions, personal hygiene, and social and workplace distancing may help to prevent infection. a modeling study from singapore investigated the impact of control measures implemented to reduce the spread of covid-19 [49] . the most effective method was a combination of isolating infected cases, strict quarantine, and closure of schools and workplaces [16, 49] . the lockdown of educational establishments and offices (workplace distancing) paved the way for online solutions, which helped to education and work to continue from home. after the outbreak in wuhan, china, the korean government activated a 24/7 emergency response system to screen all travelers entering the country from that city [49] . in taiwan, proactive and comprehensive health checks of passengers from hubei province were established quickly from the beginning of january 2020 [50] . the taiwanese centers of disease control (cdc) tested 2105 cases by february 28 using multiplex pcr analysis with filmarray tm respiratory panel and confirmed 34 covid-19 patients [50] [51] [52] . according to hsih et al., covid-19 is more contagious than seasonal respiratory pathogens but infected cases have common clinical and laboratory results [52] . therefore, each suspected case needs close follow-up through individual tracking, gathering of mobility and contact data, isolation, and quarantine [52] . hsih et al. underline the elevated pandemic level of sars-cov-2 manifested by prolonged viral shedding, and the large number of asymptomatic and mild illness cases that remain undiscovered and continue to spread covid-19 [52] . they also note that some recovered patients still had detectable virus levels for almost two further weeks [52] . furthermore, some patients showed negative covid-19 test results from their naso-oropharyngial system but positive results in their sputum or fecal specimens [52] . the authors are concerned about possible sars-cov-2 transmission through the fecal-oral route [52] . we investigated the sars-cov-2 pandemic in the united arab emirates (uae) as an example of a highly populated, globally interconnected country with an equatorial hot climate and excellent control of the covid-19 outbreak. in this work, we present the level of public health responses and control of sars-cov-2 in the uae, and underline that publications about covid-19 in the uae are very rare. figure 8a shows the confirmed cases and figure 8b the fatalities in the uae. we investigated the sars-cov-2 pandemic in the united arab emirates (uae) as an example of a highly populated, globally interconnected country with an equatorial hot climate and excellent control of the covid-19 outbreak. in this work, we present the level of public health responses and control of sars-cov-2 in the uae, and underline that publications about covid-19 in the uae are very rare. figure 8a shows the confirmed cases and figure 8b the fatalities in the uae. the population in the uae totals around 7 million according to the 2018 census [18] . the total number of confirmed cases was 35, 192 and the number of fatalities was 266 on 2 june 2020 [18] . the first fatality occurred on 22 march, almost one month after the first reported case [18] . during the month of march, the median temperature was 23.6 °c and the relative humidity was 59%. this high temperature and low relative humidity were not conducive to sars-cov-2 proliferation [24] . similar climatic conditions also exist in hong kong, singapore, and other gulf countries [24] . all of these countries are characterized by warm temperatures and low humidity in winter months, dense populations in their capital cities, well-connected international airports, and low median age (with the exception of hong kong in the case of the latter) [24] . these countries can be counted as examples of excellent pandemic control. the uae authorities responded in a rapid, flexible, effective, and transparent way to curb the spread of sars-cov-2. rapidly implemented public health measures, closure of borders, nationwide closures of educational institutions, complete lockdowns for certain periods, and work-from-home schemes reduced mobility and helped to efficiently control the viral outbreak in the uae [53] . via stepwise measures, on 25 march 2020 the uae general civil aviation authority suspended all flights into and from the country [53] . the "national disinfection programme" was implemented by the ministry of health and prevention (mohap) and ministry of interior (moi) to disinfect public facilities, public transport, and roads [53] . the disinfection campaign was initiated on 26 march 2020 and performed every night from 8 pm to 6 am [53] . nationwide covid-19 testing was launched by the ministry of health and prevention, the ministry of interior, and the national emergency crisis and disasters management authority at the end of march 2020 [18] . drive-through covid-19 testing facilities were opened in many locations throughout the uae and continue to serve the population together with mobile laboratory units, home testing for people of disabled hospitals, and licensed medical centers [53] . recommendations for community-wide social distancing and a mask-wearing strategy complemented by gloves and personal hygiene measures were embraced by the population. the beginning of the fasting month of ramadan eased the closure of restaurants, shops, and other facilities for entertainment and leisure activities. prayers were suspended shortly before the month of ramadan, and this suspension was extended on 16 march 2020 by the national emergency crisis the population in the uae totals around 7 million according to the 2018 census [18] . the total number of confirmed cases was 35, 192 and the number of fatalities was 266 on 2 june 2020 [18] . the first fatality occurred on 22 march, almost one month after the first reported case [18] . during the month of march, the median temperature was 23.6 • c and the relative humidity was 59%. this high temperature and low relative humidity were not conducive to sars-cov-2 proliferation [24] . similar climatic conditions also exist in hong kong, singapore, and other gulf countries [24] . all of these countries are characterized by warm temperatures and low humidity in winter months, dense populations in their capital cities, well-connected international airports, and low median age (with the exception of hong kong in the case of the latter) [24] . these countries can be counted as examples of excellent pandemic control. the uae authorities responded in a rapid, flexible, effective, and transparent way to curb the spread of sars-cov-2. rapidly implemented public health measures, closure of borders, nationwide closures of educational institutions, complete lockdowns for certain periods, and work-from-home schemes reduced mobility and helped to efficiently control the viral outbreak in the uae [53] . via stepwise measures, on 25 march 2020 the uae general civil aviation authority suspended all flights into and from the country [53] . the "national disinfection programme" was implemented by the ministry of health and prevention (mohap) and ministry of interior (moi) to disinfect public facilities, public transport, and roads [53] . the disinfection campaign was initiated on 26 march 2020 and performed every night from 8 pm to 6 am [53] . nationwide covid-19 testing was launched by the ministry of health and prevention, the ministry of interior, and the national emergency crisis and disasters management authority at the end of march 2020 [18] . drive-through covid-19 testing facilities were opened in many locations throughout the uae and continue to serve the population together with mobile laboratory units, home testing for people of disabled hospitals, and licensed medical centers [53] . recommendations for community-wide social distancing and a mask-wearing strategy complemented by gloves and personal hygiene measures were embraced by the population. the beginning of the fasting month of ramadan eased the closure of restaurants, shops, and other facilities for entertainment and leisure activities. prayers were suspended shortly before the month of ramadan, and this suspension was extended on 16 march 2020 by the national emergency crisis and disaster management authority and the general authority of islamic affairs and endowments until further notice. the ministry of education announced school and university closures on 8 march 2020 coinciding with the spring break and implemented a distance learning initiative on 22 march 2020 [53] . education continued without disruption through online teaching after the spring break and is expected to remain distance-learning-based until the end of the educational year in summer 2020 [53] . remote working was adopted by most institutions of the federal and local governments in the uae to protect employees and customers. the pre-existing advanced technological infrastructure of the uae enabled remote working and online meetings throughout the educational and public sectors [53] . numerous apps, such as alhosn uae, were created to track cases and advise the population [53] . offices and malls briefly closed and reopened towards the end of may 2020 with strict control measures to prevent covid-19 spread. the closure of all shopping malls, with the exception of pharmacies, food retail outlets, cooperative societies, grocery stores, and supermarkets, was announced on 25 march 2020 [53] . children below 12 years and individuals above 60 years were not permitted to enter malls and outlets [53] . everyone entering any facility is required to wear surgical masks and gloves, and is screened for symptoms of fever. disinfectant dispensers are widely distributed in all buildings. most institutions, such as ajman university in ajman, uae, contributed unreservedly to the campaign by disseminating the recommendations and applying the necessary measures in a timely manner ( figure 9 ). [53] . education continued without disruption through online teaching after the spring break and is expected to remain distance-learning-based until the end of the educational year in summer 2020 [53] . remote working was adopted by most institutions of the federal and local governments in the uae to protect employees and customers. the pre-existing advanced technological infrastructure of the uae enabled remote working and online meetings throughout the educational and public sectors [53] . numerous apps, such as alhosn uae, were created to track cases and advise the population [53] . offices and malls briefly closed and reopened towards the end of may 2020 with strict control measures to prevent covid-19 spread. the closure of all shopping malls, with the exception of pharmacies, food retail outlets, cooperative societies, grocery stores, and supermarkets, was announced on 25 march 2020 [53] . children below 12 years and individuals above 60 years were not permitted to enter malls and outlets [53] . everyone entering any facility is required to wear surgical masks and gloves, and is screened for symptoms of fever. disinfectant dispensers are widely distributed in all buildings. most institutions, such as ajman university in ajman, uae, contributed unreservedly to the campaign by disseminating the recommendations and applying the necessary measures in a timely manner ( figure 9 ). the covid-19 outbreak is currently under control in the uae: the number fatalities is low and shows a downward trend (figure 8 ). the health care system was rapidly supported and prepared for the covid-19 outbreak is currently under control in the uae: the number fatalities is low and shows a downward trend (figure 8 ). the health care system was rapidly supported and prepared for a mass outbreak. steadily rising temperatures from april 2020 and high relative humidity did not prevent covid-19 from spreading. the curve in figure 8b peaks on 12 may 2020 in terms of the number of fatalities, while in figure 8a the peak for confirmed cases appears around 10 days later [18] . increasing uv irradiation, temperature, and relative humidity may have been supportive factors in controlling the sars-cov-2 outbreak in the uae. the influence of hot weather and increasing humidity in the coming months should be questioned. the virus cannot be inactivated solely by high temperatures, and can survive in the human body [24] . the outdoor climate is highly interconnected with the indoor climate and human dwelling patterns. with the steady rise of temperatures above 45 • c and high humidity, indoor environments should be included in thinking about the virus. when the pandemic began at the end of february, the temperature was suitable for outdoor activities. in very hot climates, people gather in indoor environments. the summer months are marked by indoor dwelling, and spending time in air-conditioned closed apartments, offices, buildings, and shopping malls. the indoor environment in summer may cause aggravated sars-cov-2 transmission patterns and an increase in covid-19 cases and fatalities. new waves of infection can only be prevented by continuing the community-wide, strict measures of social distancing, personal hygiene, wearing of surgical masks and gloves, nationwide testing, and individual tracking of clusters and their contacts. equatorial countries may witness an increase in cases and/or fatalities during the coming months. the spread of sars-cov-2 in the summer months can be prevented by adding new strategies to the existing measures. our recommendation for countries with hot climates in summer is to prevent an influx of cases from other countries and to control indoor environments. the latter can be achieved via sufficient ventilation several times a day, continued strict disinfection protocols using antimicrobial agents/disinfectants for surfaces, and use of humidifiers equipped with essential oils and/or antimicrobial plant extracts. split air conditioning systems may be better than central systems. these air conditioning systems need to be regularly cleaned and maintained. sterilization of indoor environments may be possible using uv lamps as an alternative. these measures may inactivate the virus and reduce the number of viral droplets in indoor air. the temperature in closed rooms may not reach 4-12 degrees celsius, but virus-loaded droplets can easily infect anyone in the vicinity by entering the naso-pharyngial tract or the eyes if the viral density in the air is high, or through contact transmission by fomites [16, 17, 24] . however, airborne transmission is a controversial issue, which depends on climatic pre-existing conditions (indoor/outdoor environments) and needs a case-by-case approach when public health measures are to be implemented. according to cheng et al., a community-wide mask-wearing strategy may decrease the shedding of respiratory droplets or saliva from symptomatic or asymptomatic covid-19 cases [29] . pecho-silva et al. indicate that airborne transmission can occur due to floating viral droplets suspended in the air [54] . they suggest that droplet nuclei may be only produced by specific medical treatment protocols such as intubation and nebulization [54] . stadnytskyi et al. reported that sars-cov-2-loaded droplet nuclei can be transmitted from an asymptomatic case while speaking in a closed room with stagnant air [55] . as a result, transmission by fomites and direct inhalation of droplets in indoor environments is a serious problem in closed, unventilated, and crowded rooms with very poor air exchange. although the issue remains controversial, strict guidelines should be followed to prevent viral infections until further research emerges. india implemented strict nationwide lockdowns to address the problem of viral transmission; however, by keeping the population indoors it may have created precisely these unventilated, crowded room scenarios that can lead to a high number of cases and fatalities. the indian government reacted rapidly with very strict nationwide closures and a complete lockdown, and prevented an uncontrolled sars-cov-2 outbreak from march to june 2020 [56] . the first fatality in india was recorded on 13 march 2020 ( figure 10 ) [18] . the first covid-19 case appeared with a delay of more than one month on 30 january 2020 [18] . the total number of confirmed cases for india was 198,706 within a population of around 1.4 billion [18] . a total of 5598 fatal cases were reported until 2 june 2020 [18] . the covid-19 outbreak was controlled firmly until beginning of april 2020, however, incidence thereafter began to increase. the curve currently shows an upward trend in fatalities and a peak is not yet visible in figure 10 . a lack of awareness and a relaxed attitude has resulted in an increase in covid-19 cases and fatalities [56] . the situation in india is far from over and strict regulations should continue, paired with maskwearing strategies, nationwide testing, and control of overcrowded indoor environments. we collected and analyzed the implemented public health measures during the sars-cov-2 pandemic. different countries implemented various measures and experienced differing results during the covid-19 pandemic (table 1) . the first covid-19 case appeared with a delay of more than one month on 30 january 2020 [18] . the total number of confirmed cases for india was 198,706 within a population of around 1.4 billion [18] . a total of 5598 fatal cases were reported until 2 june 2020 [18] . the covid-19 outbreak was controlled firmly until beginning of april 2020, however, incidence thereafter began to increase. the curve currently shows an upward trend in fatalities and a peak is not yet visible in figure 10 . a lack of awareness and a relaxed attitude has resulted in an increase in covid-19 cases and fatalities [56] . the situation in india is far from over and strict regulations should continue, paired with mask-wearing strategies, nationwide testing, and control of overcrowded indoor environments. we collected and analyzed the implemented public health measures during the sars-cov-2 pandemic. different countries implemented various measures and experienced differing results during the covid-19 pandemic (table 1) . hardly under control (figure 9) a lack of preparedness for the sudden onset of covid-19 by governments and health care systems, combined with inadequate public health strategies and deficiencies in diagnostic mechanisms, treatment options, and management protocols, aggravated the virulence of sars-cov-2 globally. there has been a direct impact of public health strategies on case count and mortality. far eastern countries with experience of the sars outbreak controlled the pandemic with the lowest number of covid-19 fatalities. covid-19 case and mortality counts in europe are not directly dependent on temperature, mean age, or mean serum 25-hydroxyvitamin d (25(oh)d) levels, but on preparedness of countries' health care systems and adequate public health strategies. infection control measures in indoor environments are essential in viral transmission prevention and need to be taken into consideration. indoor environments are interconnected with climatic conditions. indoor climates are crucial to the control of the sars-cov-2 outbreak. development of health care systems by increasing the number of hospitals, critical care units, and health care personnel are also key factors, and are particularly needed for the protection of the vulnerable and elderly population. the preparedness of the health care system includes stockpiles of appropriate and effective personal protection equipment (ppe), fast and reliable testing methods, and cluster and individual tracking of cases and their contacts. recommendations of social distancing, personal hygiene, avoiding of gatherings, and mask wearing must be strictly followed even in indoor environments and household settings, 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of cases in south korea, italy, and brazil featuring covid-19 cases via screening symptomatic patients with epidemiologic link during flu season in a medical center of central taiwan the united arab emirates' government portal airborne sars-cov-2: weighing the evidence for its role in community transmission the airborne lifetime of small speech droplets and their potential importance in sars-cov-2 transmission covid-19 (coronavirus): a global emergency outbreak and its implications in india we are thankful to the ajman university environmental health and safety (ehs) department, ajman uae, for providing us with the figure "follow safety measures on campus" and ms. fariyal s. shaikh from new vision university, tiblisi, georgia with her contributions to this paper by preparing the graphical abstracts. we also like to thank prof. dr. florian stadler and prof. dr. daniel tan for their advices related to personal hygiene. the authors declare no conflict of interest. key: cord-355055-7m8on8ct authors: xie, xiaoru; huang, liman; li, jun (justin); zhu, hong title: generational differences in perceptions of food health/risk and attitudes toward organic food and game meat: the case of the covid-19 crisis in china date: 2020-04-30 journal: int j environ res public health doi: 10.3390/ijerph17093148 sha: doc_id: 355055 cord_uid: 7m8on8ct in december 2019, a novel laboratory-confirmed coronavirus (2019-ncov) infection, which has caused clusters of severe illnesses, was first reported in wuhan, the capital of hubei province, china. this foodborne illness, which reportedly most likely originated in a seafood market where wild animals are sold illegally, has transmitted among humans through close contact, across the world. the aim of this study is to explore health/risk perceptions of and attitudes toward healthy/risky food in the immediate context of food crisis. more specifically, by using the data collected from 1008 respondents in january 2020, the time when china was hit hard by the “corona virus disease 2019” (covid-19), this study investigates the overall and different generational respondents’ health/risk perceptions of and attitudes toward organic food and game meat. the results reveal that, firstly, based on their food health and risk perceptions of healthy and risky food, the respondents’ general attitudes are positive toward organic food but relatively negative toward game meat. secondly, older generations have a more positive attitude and are more committed to organic food. younger generations’ attitude toward game meat is more negative whereas older generations attach more importance to it because of its nutritional and medicinal values. in addition, this research also indicates that the covid-19 crisis influences the respondents’ perceptions of and attitudes toward organic food and game meat consumption. however, the likelihood of its impact on older generations’ future change in diets is smaller, which implies that older generations’ food beliefs are more stable. food choice and consumption are dynamic, situational, and complex, having resulted from the (non-)sensory characteristics of food and influenced by cultural and socio-affective factors as well as reliable information available about the food [1] . it is a daily activity that can result in both good and bad consequences for our bodies. game consumption is complicated, interrelated with growth, prosperity, and consumption habits in economic, cultural, and social aspects. for example, with a growing market, game meat consumption has become a social status and fashionable lifestyle. the symbolic role of wildlife is obvious in china's developed cities. it has become a symbol of elite status and fashionable lifestyle for some people to buy and eat wildlife animals. despite being perceived as healthy based on its natural and nutritional characteristics, game meat consumption is also risky because of the potential microbiological contaminant. in december 2019, a foodborne illness, which was caused by a novel coronavirus (2019-ncov) and reportedly most likely originated from the wild animal pangolin, was first identified in wuhan, the capital of hubei province, china [2, 3] . it has spread rapidly through human-to-human contact in the whole of china and hit the society hard, across the world. the covid-19 crisis has caused a food anxiety about game meat. given the possible microbiological contaminants in game meat, strategies have been conducted in response to the emergence of the covid-19 crisis to discourage the consumption of game meat. the chinese government has temporarily banned the trade in wild animals, including domestic transport and sales in markets, restaurants, and through online platforms [4] . when the coronavirus crisis hit china's farms and food supply chain, the public moved to a high-value organic food for its safer characteristics such as lower microbiological risks and chemical contaminants. as research has demonstrated, food anxiety and health scares caused by food safety crises can change consumers' sensitivity and beliefs about food health, turn them to diets perceived as more natural, and make organic food more popular [5] . however, owing to variegated ways of defining and standardizing organic food, the boundary between organic food and game meat is not clear. the "natural," "nutritional," and "tasty" attributes of game meat lead to a common cognition that game meat is organic. recent studies have revealed that game meat has high protein, low fat, and low calorie [6, 7] . it can add a healthy alternative to the menus of meat lovers [1] . however, being the origin of foodborne crisis, game meat is also regarded as a risky food with microbiological hazards. it constitutes one of the unique sources of foodborne illness in humans [8] . considering the microbiological safety issues, handling, and/or consumption of game meat might expose humans to diverse microorganisms and result in novel diseases [9, 10] . organic food and game meat consumption are complicated issues interrelated with different consumption habits. generational differences in food consumption do exist as age can influence the individual's attitudes and behavior and drive certain wants and needs [11] . identifying a "generational effect" in organic food and game meat consumption is important because sharing historical and social life experiences of a generational cohort impacts the way people of that generation behave and distinguishes them from other generations [12] . as it comes of age, each generation experiences a fresh interaction with traditional values and principles [11] and is likely to develop distinct preferences, which distinguish their attitudes toward food. for example, the millennials, also known as generation y and mainly defined as the 1980s and 1990s generations, who grew up at a time of rapid economic and technological development [13] , differ from previous generations in various ways. for example, they are characterized as being highly diverse, educated, and technology-natives, holding distinctive values and disparate views on food consumption [14] . as turow argues [15] , the younger generations are integrating food into their lives actively and purposefully, attaching more daily importance and value to it than any older generations. in addition, because of china's dramatic and rapid transformations in economy, politics, and culture, the gaps between the new and older generations are arguably larger than in western countries [16] . these arguments enlighten us to explore whether differences in organic food and game meat consumption are linked to generational differences. this research aims to gain a general understanding of health/risk perceptions and attitudes toward healthy/risky food in the immediate context of food crisis as well as to understand the impact of generational difference on perceptions and attitudes. it provides an empirical survey to investigate the overall and different generational respondents' health/risk perceptions and attitudes toward organic food and game meat during the outbreak of the covid-19 crisis in china, utilizing data collected from 1008 respondents in january 2020, when the crisis hit the whole society. food safety is one of the key areas of focus in public health. food safety incorporates hazardous factors such as animal disease-related safety issues and microbiological safety, and represents consumers' health concern regarding residues in food production, processing, and distribution. triggered by nutritional hazards in food crises, food safety issues have received increasing attention in nutritional studies [17, 18] . in this regard, it is considered a priority to implement food safety assurance at the farm level [19, 20] . organic food, generally believed to have higher nutritional content than conventionally grown food, such as higher vitamin c, higher dry matter, and lower nitrate content [21] [22] [23] , is of growing interest due to food safety concerns. food safety is one of the main reasons for organic food purchasing [24] . nowadays, the public is more concerned about food safety because of the extensive food scandals and intensively publicized debates on genetically modified organisms, which have led to increasing awareness and pursuit of safer alternatives [25, 26] . scared of food hazards, many consumers choose organic food to avoid risks. consequently, further attention has been paid to the safety, nutrition, and health aspects of organic food [23] . the definitions and standards of organic food, however, vary according to diverse situations and contexts. although food labeled as organic is commonly perceived to be healthier, tasty, and natural, without additional risk of food poisoning and free from contamination [27] , the criteria are negotiated in the light of experience, practicalities, and moral considerations [28, 29] . it is also claimed that the term "organic" refers to the situated production process instead of the product itself-the label is just a guarantee of a particular process [30] [31] [32] . for example, in addition to their nutritional qualities, african wildlife meats are considered organic for they are reared as free-range and meet the general criteria of organic production [33] . game consumption is a complicated issue interrelated with growth, prosperity, and consumption habits in economic, cultural, and social aspects. in keeping with population growth, increasing buyer power, and globalization, game trade, including skins, medicinal ingredients, and food has become a burgeoning business around the world [34, 35] . it provides an income for some poor people and considerable revenue for the nation [35] . in hainan, china, for instance, with the improvement in the town-dwellers' standard of living, people have become more interested and able to add wildlife to their daily menu, which offers the local villagers a commercial way to increase their income [36] . southeast asia has been identified as a "wildlife trade hotspot" [35] , where the consumption of wildlife for medical, superstitions, and nutritional reasons is culturally rooted [37] . traditional chinese medicines (tcms), with some of the ingredients derived from wildlife, have become an integral part of chinese culture [38] . the perceptions of therapeutic benefits of tcms are based largely on long-standing beliefs dating back thousands of years [38, 39] . similarly, game meat in cambodia for use in traditional medicines is a practice with deep historical roots [40] . in addition, with a growing market, game meat consumption has become a social status and fashionable lifestyle [39] . in vietnam, for example, the majority of wild animals are now embedded in commercial networks to serve the growing urban middle class in provincial towns and cities [41] . the symbolic role of wildlife is also obvious in china's developed cities, especially large cities in south china. it has become a symbol of elite status and fashionable lifestyle for some people to buy wildlife animals as crafts and souvenirs, eat game meats, and dress in animal furs [42] . risk is "the probability that the potential of a hazard will be realized" and "a combination of the probability with the harm itself" [43, 44] . before taking action to control, reduce, or eliminate risks, decisions must be made to estimate which risks are important and which can safely be ignored [44, 45] . food health and risk perception are two vital factors concerning the acceptance of food, and the two are inversely and causally related [46] . risk associated with food can be presented in various forms ranging from microbiological risks, nutritional deficiencies, physical and chemical contaminants to processing, handling, and eating risks [44, 47] . contaminated food is risky since it poses threats to consumers' health and might cause illness and even death [48, 49] . empirical research on food risk originated from debates on the genetic modification of food and considerable food scares in the 1990s, especially the mad cow disease (bse) [50] . with the development of the psychometric paradigm, scholarly attention has been paid to the perception of food risk [50] . owing to several cases of food safety issues, food safety risk perception, which is a perception of the potential risk in food safety, has gained substantial attention in recent years [49] . miles and frewer [51] , for example, argue that food risk perception is multifaceted and results from risks associated with health, environment, economy, animals, and future generations. in terms of the socio-demographic characteristics, nardi et al. [49] highlight that age can positively drive safety risk perception because it encourages consumers to think about life threats. food risk perception plays a significant role in attitudes [49] . attitude is a psychological tendency that is expressed by evaluating things, the self, and others, involving the positive and negative aspects of being favorable or unfavorable, likable or unlikable, and good or bad [52, 53] . it is "the predisposition toward a particular object, reflecting behavioral, normative, and control beliefs that are directly related to the consumer's intention and, consequently, his or her behavior" [49] . attitudes can be judgments, memories, or both and stable or temporary, having resulted from relatively long-term processes such as socialization as well as short-term exposure to information [52] . the construction of attitudes is often concerned with and reciprocally related to affects, beliefs, and (overt) behaviors that can serve as bases for attitudes [52, 54] . albarracín, johnson, & zanna [52] note that affect is the feeling that people experience; beliefs are cognitive thoughts about the perceived likelihood that an attribute is related to an object or event-the referent of a belief is a proposition and it can also refer to subjective experiences; and behaviors are conceptualized as the overt actions of an individual [55] [56] [57] . in terms of feeling, clore & schnall [58] argue that "decision-relevant feelings might come from vividly imagined consequences of a decision." affect is also associated with risk perception [59] . sensory inputs can generate visceral reactions, which can automatically induce avoidance [52] . emotions such as fear, guilt, and empathy are the strongest affective responses and fear, which is driven by uncertainty, appears more salient in food crises [60] [61] [62] [63] . this research is part of a bigger research project aimed to investigate mutual relations between organic food consumption, game meat consumption, and foodborne illness. the survey was conducted with a random sampling approach in january 2020. wechat (the most used social media application in china) was employed to recruit questionnaire participants. the questionnaire was posted through a web-based link on wechat. this link was generated through a free chinese professional survey website wenjuanwang (https://www.wenjuan.com/, a website like surveymonkey), which designed the online questionnaire (in chinese). wenjuanwang also enables researchers to establish, distribute, collect, and manage their questionnaires online. potential respondents could fill in the questionnaires through wechat on their mobile phones, which accelerated the data collection during the outbreak of the covid-19 crisis. a total of 1008 usable responses were collected for data analysis. table 1 shows the socio-demographic profiles of the respondents. in china, the generation is always described as "the post-80s generation", "the post-90s generation", etc. to investigate age differences, the respondents were divided into four age groups: aged below 20, 20-29, 30-39, and 40 and above. data analysis was carried out with the statistic software spss, computed as means, standard deviations, and f-tests of differences. a structured four-section questionnaire was formulated based on a literature review involving perception, attitude, behavior, and intention of organic food and game meat consumption [1, 7, 8, 10, [64] [65] [66] [67] , as well as other projects conducted by the authors associated with research in organic food production and consumption. it included questions on the relation between game meat consumption and foodborne illness, perceptions of and attitudes toward organic food and game meat, and demographic profiles of the respondents. only part of the questionnaire that is related to this research is presented here. health/risk perception of and attitudes toward organic food and game meat were measured by means of the items of four measurements: "organic" consciousness and attitudes toward organic food, health/risk perception and attitudes toward game meat, perceived change in future diet: stability of attitudes toward organic food, and perceived change in future diet: stability of attitudes toward game meat. the statements were rated on a five-point likert scale. "organic" consciousness and attitudes toward organic food. the respondents' attitudes toward organic food was measured by their "organic" consciousness with questions about how they perceive organic food, in terms of both individual and societal cognitions. items 1 to 4 (see table 2 ) were used to measure consumers' attitudes toward organic food associated with personal considerations, with questions about how they rate the overall liking, importance of organic food in a daily diet, necessity of shifting from traditional food to organic food, and how wise they think it is to buy organic food. the societal considerations of organic food were reified with items of environmental and animal ethics. health/risk perceptions and attitudes toward game meat. the respondents' health/risk perception and attitudes toward game meat, including the healthy and risky attributes of game meat, were assessed on a five-point scale. the assessment ranged from the overall liking, importance of game meat in daily diet, and food safety risk to health benefits (see table 3 ). perceived change in future diet: stability of attitudes toward organic food. to measure the stability of attitudes toward organic food, respondents were asked to estimate their frequency of daily organic eating, future possibility of increasing organic food eating frequency, and extent of influence of the covid-19 crisis on future organic food eating (see table 4 ). perceived change in future diet: stability of attitudes toward game meat. questions about the frequency of daily game meat-eating, future possibility of increasing game meat-eating frequency, and extent of influence of the covid-19 crisis on future game meat-eating were employed to measure the respondents' stability of attitudes toward game meat (see table 5 ). ("of" as organic food; * significant at a 0.05 level; superscript "a" indicates the lowest score; superscript "b" indicates the highest score). table 3 . the means, standard deviations, and f-tests of differences of the measurement "health/risk perceptions and attitudes toward game meat" across age. ("gm" as game meat; * significant at a 0.05 level; superscript "a" indicates the lowest score; superscript "b" indicates the highest score). ("of" as organic food; * significant at a 0.05 level; superscript "a" indicates the lowest score; superscript "b" indicates the highest score). ("gm" as game meat; * significant at a 0.05 level; superscript "a" indicates the lowest score; superscript "b" indicates the highest score). as table 2 reveals, the respondents' attitudes toward organic food as health belief differs significantly among the four groups aged below 20, 20-29, 30-39, and 40 and above. however, the items of the environmental and animal ethics of organic food are not statistically significant across age. all the mean scores are above 3, which means the respondents have positive consciousness about organic food. the respondents aged 40 and above scored the highest among all four groups on "the extent of organic food favor," "the importance of organic food in a daily diet," and "the necessity of changing traditional food to organic food," while the respondents aged 20-29 scored the lowest on "the extent of organic food favor," "the importance of organic food in daily diet," and "buying organic food is wise." in general, the respondents aged 40 and above have significantly more positive attitudes toward organic food than other age groups, while the 20-29 group shows the lowest perceptions. as shown in table 3 , the respondents' attitudes toward game meat are significantly different among the four disparate generations. it indicates that the respondents have a relatively negative attitude toward game meat. however, the respondents aged 40 and above showed a comparatively more positive attitude toward game meat than the other three age groups which expressed similar levels of concern about game meat hazards. the 40 and above age group had the lowest perceptions of the food risk of game meat, which was reflected in items 3 to 5. they had a more positive attitude toward game meat because of its nutritious and medicinal values. the 20-29 age group had the lowest perception of the nutritional and medicinal values of game meats. in general, the younger generations' attitudes toward game meat were more negative than that of the older ones. as shown in table 4 , the respondents' eating frequencies of organic food are significantly different among the four disparate generations. respondents under the age of 20 had the highest frequency of eating organic food in daily life-above the midpoint of 3-while the 30-39 group showed the lowest frequency. although the 40 and above age group respondents also ate less organic food in their current daily life, they showed the highest willingness to increase their organic food eating in the future. in general, the covid-19 crisis has had a positive influence on future increase in organic food eating. however, its influence on the older generations is lesser than on the younger generations. as shown in table 5 , the respondents' eating frequency of game meat is relatively low in their daily diet, and they show a very negative attitude on the future increase in game meat consumption. however, the factor "the future possibility of increasing gm eating frequency" is not statistically significant across age groups. as for the influencing extent of the covid-19 crisis to the future eating of game meat, table 5 indicates that the crisis has an extremely significant impact. the younger generations, particularly the group aged 20 below, are significantly more likely to decrease the amount of game meat in their future diets than the older respondents. thus, the covid-19 crisis has a considerable negative influence on the future eating of game meat. however, its impact on the older generations is smaller than the younger ones. attitudes toward organic food show that generally, respondents aged 40 and above attached more importance on organic food than the other age groups, while the 20-29 age group respondents showed the lowest perceptions. this result is both consistent and contrary to some previous research. from the perspective of the influence of age on organic food consumption, research has been conducted within diverse situated contexts with different results. rimal, moon, & balasubramanian [68] , for example, observed that older respondents are less likely to buy organic food than younger ones. on the contrary, geen and firth [69] concluded that committed consumers of organic food tend to be older than the average population in the uk [67] . however, despite the older respondents attaching more importance on organic food, the younger generations have a higher frequency of daily eating, especially the respondents aged under 20. this interesting result might be explained by the fact that in china, organic food consumption is still in the infant stage. although the amount of organic food consumption is increasing, the total quantity and frequency of organic food eating is still at a low level across the whole of china [70] . parents who consider their children's health constitute the main consumers of organic food, and because of the previous "one-child" policy introduced in 1980, most of them have only one child. however, as the authors were told in another research project by an organic farmer, because of economical consideration, some parents purchase organic food just for their children and seldom eat it themselves. therefore, the behaviors of "eating" and "buying," which both mean "consumption," might be different when the intention of "consumption" is considered. this might also be, at least in part, the reason why the 40 and above age group generally attached more importance on organic food, while the respondents who ate more organic food tended to be younger, especially under 20. further research needs to verify this and investigate other possible explanations with more empirical examinations. this also implies that organic food perceptions of the older generations are based more on health characteristics. this implication is consistent with some previous research [71] [72] [73] . healthfulness is a perceived short-term benefit of organic food [64] . the elders' egoistic motives (health considerations) seem to come first rather than altruistic motives (ethical considerations). in the future, the older generations might become more committed to organic food. they appeared more willing to increase the proportion of organic food in their future diets. except for the considerations of their children's health, and, in this research, the impact of the covid-19 crisis, another explanation might lie in their own bodily needs. as noted by yiridoe, bonti-ankomah, & martin [74] , consumers' preference for organic food is largely influenced by their concerns for health and safety, which is in line with their perceived deterioration in human health over time; therefore, it motivates them to purchase organic food as insurance and/or investment in health. as cullere & dalle zotte [75] put it, health acts as a strong motivation for consumers to change eating habits. however, situated in a particular context, a previous research on the willingness to pay for the organic/green food in china shows a contrary result. it found that younger people are more willing to pay more as the older people are not willing to change their eating habits and pay a premium price for organic food [76] . attitudes toward game meat indicate that the respondents have a relatively negative attitude toward game meat consumption, which signifies game meat as risky food. their negative attitudes are caused by perceptions of its food safety risk, as reflected in their high scores-a mean score of above 4.3-on the statement "eating game meat is of health hazard" (see table 3 ). their negative attitudes might also be enhanced by their anxiety during the severe outbreak of the covid-19 crisis. as research in the uk and european countries reveals, food panics generally spur initial disruption of attitudes and behavior but are also "followed by a gradual return to the previous consumption equilibrium" [77] . this implies that the food crisis has an immediate effect on consumers. when situated in the particular context of the food crisis, humans' food anxiety is enhanced. on the other hand, respondents also attach game meat with somewhat "healthy" meanings, so they still sometimes "venture" to eat game meat, which might result from their perception of the nutritional and medicinal values of game meat. they are generally aware of the hazards of game meat. however, awareness does not necessarily indicate absolute avoidance. as martins and pliner [78] argue, "humans must balance the necessity of obtaining a wide variety of nutrients (typically, through the ingestion of numerous food sources) with the perils accompanying the ingestion of unfamiliar edibles (i.e., the possibility that these foods may be harmful or toxic)." some studies also reveal that despite game meat being perceived as a health hazard with potential microorganisms and toxins and its consumption being far less than that of usual meat such as beef, pork, and fish, it still offers consumers a healthy meat alternative because of its nutritional value such as high protein, low cholesterol and fat, and an optimal ratio of unsaturated to saturated fatty acids [1, 7, 79, 80] . tomasevic et al. [7] , for example, conducted a study on perceptions of different game meat in 10 european countries and pointed out that game meat is regarded as healthy and more organic than other types of meat. although being negative, the older respondents seem to have a significantly higher perception of game meat than the younger generations, which might be based more on its "health" benefits-being nutritious and medicinal-and they practice more "risky" behaviors. in game meat consumption, the eating frequency trend related to age is consistent with the trend of perceived risks. the older respondents eat more and have a lower risk perception of game meat than the younger respondents. this is partly consistent with previous research indicating that age has an impact on how respondents perceive health and food safety risks, but older respondents are more likely to have a higher perception of health and food safety issues as risks than younger respondents [81] . the reason might be that when balancing the benefit and risk of game meat, the older respondents in this research attached more importance to the "medicinal" attributes of game meat, which could also be reflected in their higher scores on game meat's medicinal values. in china, except for its nutritional value, game meat is also perceived to have high medicinal value-as li et al. (2020) note [82] , some consumers hold the belief that game meat has certain therapeutic effects. in addition, another belief rooted in the game meat consumers' mind might derive from the philosophy of medicine food homology, which is misunderstood as that "one is made of the supplements they eat" [82] . considering the age difference, these cognitions are engrained more in the elders' minds. the impact of the covid-19 crisis on respondents' perceptions of health and risk is significant and would lead to the respondents' perceived future increase in the consumption of organic food and decrease in game meat consumption. this is in line with some studies revealing that food anxiety and health scares caused by food safety crises can change consumers' sensitivity and belief about food health, which turns them to diets perceived as more natural and makes organic food more popular [5, 77, 83, 84] . for instance, the discovery of mad cow disease (bse) in canada and the us generated consumer scares about the safety of meat, besides rising the demand for naturally raised and organic meat [77, 85] . in addition, the perceived extent of influence of the covid-19 crisis on future change in organic food and game meat-eating shows that the older generations' food belief is more stable. as this research reveals, the influences of the covid-19 crisis on future change in diets, both organic food and game meat, is smaller on the older than on the younger generations. the older generations have a more fixed view on food health and risk. this research aims to explore health/risk perceptions and attitudes toward healthy/risky food in the immediate context of food crisis, as well as to understand different generations' attitudes toward it. our findings reveal that a statistically significant "generational effect" is found in healthy and risky food consumption. the older generations have a more positive attitude toward organic food, and they have a higher willingness to increase their future eating frequency, which means they would be more committed to eating organic food than would the younger generations. the younger respondents have a more negative attitude toward game meat. the older generations attach more importance on game meat because of its healthy values of being nutritious and medicinal. as people become more affluent, they are able to choose organic food since it has more beneficial nutrients. thus, eating organic food is moving up more and more consumers' agenda. promoting production and trading opportunities for the certified organic food to meet sustainability goals should be a top priority of local government in the developing countries. this research maps a positive future for the organic food market, which might encourage more farmers to involve in organic agriculture. the covid-19 crisis has a positive impact on the respondents' attitude toward organic food and negative impact on their attitude toward game meat, which implies that food anxiety and health scares caused by food safety crises can change consumers' sensitivity and belief about food health and risk. the impact of the food crisis on the older generations' future change in diets is smaller, which means that the older generations' food belief is more stable. based on food health, they have a more solid belief on food than do the younger respondents. however, the covid-19 epidemic has created some opportunities for positive change in china. for example, the government prepares a ban on trade of wildlife to improve public awareness on the health risks of the consumption of non-aquatic wild animals for food. on the supply-side, incentives can be created to encourage more investment on building a healthier food system. in addition, this research also shows a positive future for organic food consumption, which might encourage more farmers to engage in organic food production. this study has a few limitations. firstly, the items used to measure the constructs in this study may not be the best representation for assessing the construct of interest. secondly, the use of internet to aid research practice has become more popular. however, depending on the sampling method, the information collection may not be more accurate compared to offline surveys. thirdly, future research might consider empirically testing other factors that explain why the 40 and above age group generally attached more importance on organic food. consumers' perceptions of african wildlife meat: a laddering study did pangolins spread the china coronavirus to people? the relationship between the migrant population's migration network and the risk of covid-19 transmission in china-empirical analysis and prediction in prefecture-level cities why a permanent ban on wildlife trade might not work in china quality, nature, and embeddedness: some theoretical considerations in the context of the food sector nutrition value of wild animal meat djekic, i. consumers' perceptions, attitudes and 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conventionally and organically produced foodstuffs: a tentative comparison under belgian conditions manufacturing fear: the role of food processors and retailers in constructing alternative food geographies in toronto this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-355066-jm07z3zk authors: ertemel, adnan veysel; ari, ela title: a marketing approach to a psychological problem: problematic smartphone use on adolescents date: 2020-04-04 journal: int j environ res public health doi: 10.3390/ijerph17072471 sha: doc_id: 355066 cord_uid: jm07z3zk background: smartphones have become an indispensable part of the daily lives of adolescents in the 21st century, which is characterized by a highly digitized modern world. besides their many advantages, smartphones might pave the way to compulsive usage and addictive experiences. to remedy this problem, this study proposes an authentic approach which integrates consumer behavior theories and techniques such as unhook and gamification. an education program has been designed based on these approaches to decrease the problematic smartphone use. method: the participants of the education program consisted of 305 students (48.2% girls and 51.8% boys) with a mean age of 14.57 (sd = 0.74). the demographic form and smartphone addiction scale for adolescents (sasa) were conducted before the education program and three weeks after the education. results: the results of the paired sample t-test analysis before and after the education program revealed that the sasa total scores decreased significantly (p < 0.01). there are significant differences in terms of gender, mothers’ education and class levels. conclusion: this research emphasizes the role of an interdisciplinary approach to the addiction problem. the content used in the education program includes strategies that originally aimed at increasing consumption. the effectiveness of the program can be enhanced further in the future along with self-regulatory additions. with more than 3.1 [1] billion worldwide users as of 2019, which is expected to reach 3.8 billion by 2021 [2] , smartphones have permanently changed our daily routines. they have become the de facto means for communication, socialization and access to information; and hence become inseparable in our lives [3] . when separated, individuals may encounter the following incidents: physiological withdrawal-like symptoms [4] , increased anxiety [5] and even phantom vibration syndrome which can be described as the sensation that one's smartphone is vibrating even though there is no notification coming [6] , a syndrome experienced by the majority of users [7] . not surprisingly, problematic smartphone use, which can be categorized as a form of technological addiction [8] , has become a major global concern across societies [3] . technology addiction may be characterized as a non-chemical behavioral addiction involving human-computer interaction [9] . on the other hand, problematic smartphone use, which is also interchangeably called as smartphone addiction or smartphone use disorder [10] , can be defined as the overuse of smartphones in a manner that is difficult to control and has harmful effects on the other areas of life [11] . as smartphones are devices that can be carried anywhere and are available anytime, problematic smartphone use causes various serious potential problems. among those problems pointed in the in playing mobile games. turkish consumers also ranked highest (26%) indicating physical health problems related with heavy smartphone usage [32] . these figures justify that adolescents are more prone to the risks associated with problematic smartphone use when compared to adults. nevertheless, adolescents are more open to guidance for change. undertaking such a study in turkey is especially important since turkey is classified as one of the countries with the highest risk potential of problematic smartphone use. recent figures highlight that the percentage of turkish users using whatsapp heavily is 94% and instagram with 80% is way higher than that of the european union averages which is reported as 55% and 35%, respectively [32] . these rates place turkey either to the first or the second place all over the world and above the averages of european countries. in recent years, digital health related smartphone apps specifically designed to help individuals achieve positive behavior change started to emerge. these apps frequently use persuasive technology itself as a tool to reduce unhealthy, problematic smartphone use. the techniques used incorporate gamification, self-monitoring and goal setting [34] . however, to our knowledge, there is no structured education program that uses gamification, hook and the like techniques, in reverse manner, to decrease problematic smartphone use among adolescents. the highly competitive modern marketing environment of the 21st century imposes unique challenges. whether online or offline, the abundance of marketing messages coming from a variety of sources has caused consumers to have difficulty in devoting their time and attention to those messages. with the advent of the internet of things (iot) and big data, consumers currently witness an even higher level of digitalization, which takes the aforementioned phenomenon to a different level. in such a world, digital ecosystems are characterized by attention economy [35] in which marketers offer their services in exchange for the consumers' attention. monetization occurs indirectly through advertisers. facebook, instagram, youtube, twitter are typical examples which do not charge consumers but monetize their attention in this attention economy. since appealing to the conscious mind in the attention economy becomes increasingly difficult marketers have started to resort to alternative strategies that appeal rather to the unconscious. as such, digital platforms, particularly in the last decade, are in an arms race to grab and keep the consumers' attention using sophisticated techniques in today's always on and connected world. the flow theory, which has the aim of achieving the flow state, an emotional state embracing perceptual distortion and enjoyment [36] is one such strategy. built on flow theory, new marketing strategies like gamification and user experience design which are collectively named as illusional marketing strategies [37, 38] provide shortcuts to consumers by enabling them to take action without effortful thinking. the following sections provide further details on the marketing strategies, namely gamification and hook strategy, which make up the main focus of this paper, and are developed to design addictive experiences by appealing to the unconscious. gamification can be described as the use of game design features in non-game contexts [39] . through a gamified process, game elements and mechanics like achievements, progress bars, badges, leader boards, levels and points are employed to engage users [40] . in the context of marketing, gamification refers to a new marketing strategy that aims at changing the consumers' behavior in predetermined ways to foster engagement and ultimately to buy products [41, 42] . in order to attain this goal, designation of an engaging experience plays a key role. previous studies show that gamified and engaging experiences may result in brand recall and buying behavior [43] . marketing scholars classify gamification as a different kind of persuasive marketing [44] , which raises more ethical concerns than other persuasive marketing strategies like product packaging, personalized digital marketing, etc. some other scholars define gamification as a form of stealth marketing which refers to configuring a product in such a way that people are not aware that the marketer is trying to persuade them to buy it [45] . these concerns arise out of the degree and type of engagement between the brand and consumers due to the highly engaging gamified experience. deep sense of participatory engagement in gamification can also be compared to co-creation marketing [46, 47] in which consumers' co-produce products by actively engaging in the design process [48] . however, gamification can have subversive results. hook is a recent marketing strategy similar to gamification, based on behaviorist thinking related to marketing software products. it has its roots in persuasive technology lab in stanford university, founded by bj fogg, back in 1998. this relatively new field has been named 'captology', which is an acronym for 'computers as persuasive technologies'. the ultimate goal in captology is to provide meaningful input into how software products can be designed to change consumer beliefs and behaviors [49] . habitual behavior is central to such strategies. habit-driven, automatic behaviors occupy the majority of the daily life and are performed with little, or no conscious thinking at all. previous studies show that following a trigger-action-reward loop, a desirable habit can be imposed on an individual [50] [51] [52] . impressed with fogg's work, eyal [53] developed the hook model, which is grounded on the reinforcement theory in forming habitual behavior, which goes back to reinforcement experiments [54] . the hook model advises a four-step loop to make the desired behavior a habitual one. the first step is the trigger, which refers to an external or internal stimulus that tells the user what to do next and how to behave next. the second step, action, refers to the actions of the user based on the information provided by the stimulus. the third stage, namely reward, refers to the acquisition of a variable reward as a consequence of the actions mentioned above. the last step, investment, means having the users make a deliberate effort to invest in the platform as in the form of time, effort, social capital investment to increase the likelihood of the repetitive behavior. the hook model can be illustrated through a typical instagram usage habit. the process starts with a notification message, which is an external trigger. the model aims at starting with an external trigger and gradually making it an internal one. internal triggers are states of mind and emotions. for the behavior to be habitual, the emotion should be somewhat vague and negative like loneliness, boredom, uncertainty, etc. vague emotions allow the desired behavior to become a habit by avoiding reaching the consciousness level while negative emotions cause the individual to take action more easily [28] . action refers to the behavior of entering the instagram application. the key in the action step is to make the desired behavior as effortless as possible. this is because the level of effort required in the behavior directly affects the habitual nature of the behavior [53] . in this context, instead of requiring the user to enter a password, smartphones now enable a mindless sort of authentication by fingerprint or retina scans. this allows consumers to take the action step literally in an effortless manner. auto-activation of the smartphone camera by a single swipe and the similar features serve the same goal. the next step is the variable reward. it is what the notification is all about. for example, the user might have uploaded a photo album that consists of many photos. the variable reward is the discovery of which photo got the most likes, how many likes are received in total, who have commented and what they said about the posts and so on. the fact that the reward is variable allows the unconscious to be stimulated by surprise, causing dopamine release in the brain and regarding the perception of the reward as reinforcing [55] . immediate variable rewards work perfectly well when the brain is in the unconscious mode [55] by gradually associating the reward with the trigger. additionally, it has been documented that this state of mind causes an individual's long run self to have no control over his or her decisions [56] , which in turn causes a compulsive and addictive behavioral pattern. the last step, investment to the platform, refers to invest in a small effort on the platform in such a way that calls for the repetition of the behavior over time, and finally makes it impossible to break off from the cycle. in instagram application, this investment is the number of followers and the photo archive accumulated so far. the more investment is made in the platform, the more addictive it becomes. the system aims to replace the external trigger with the internal trigger in the long term. in instagram application, the internal trigger is the desire not to miss the opportunity to capture a photo of the moment. an individual's spotify list, for example, is perceived as valuable since he/she has spent a considerable amount of effort creating that list. the addictive nature of various digital platforms was confirmed in various studies [31, 57] . some authors who investigated the gamification strategy also warn that the application of variable rewards may create gambling-like addictive experiences, which may lead to consumers being unable to exercise their free will [58] . the flow state is a state of mind characterized with enjoyment and perceptual distortion in time and space contributing to the addictive behavior [36] . the hook model could be classified as a more sophisticated form of gamification since it targets the unconscious, applying gamification elements such as variable rewards and is designed to be addictive in nature. in this study, both hook and gamification strategies will be included in the education program considering their potential to create new habitual behavior [30] . finally, this study first sought to explore the demographic factors influence on the adolescents' problematic smartphone use, namely gender, age, grades and parental education [59] [60] [61] [62] . afterwards, the main focus of the study is to find out how does a marketing based education program reduces the problematic smartphone use of adolescents. further, and last of all, the study investigates how the smartphone problematic use changed after the education according to the above stated demographic factors as gender, age, and grades except parents' education. for all these research aims, the following hypotheses are formulated under three main categories, which are before the education program, about the education program and after the education program. thus, the following hypotheses guided the present study. before the education program; hypothesis 1 (h1). the problematic smartphone use differs according to demographic factors. the problematic smartphone use differs on the basis of gender. age and problematic smartphone use are related. the problematic smartphone use differs on the basis of the adolescents' grades. the problematic smartphone use of adolescents differs on the basis of their parents' education level. hypothesis 2 (h2). the adolescents' problematic smartphone use will decrease after receiving a marketing based education program including gamification and unhook strategies. after the education program, hypothesis 3 (h3). the problematic smartphone use differs according to demographic factors after the education program. the problematic smartphone use decrease differs on the basis of gender after the education. age and the problematic smartphone use after the education are related. the problematic smartphone use differs on the basis of the adolescents' grades after the education. the sample consisted of 337 students from 14 different schools. out of 337 participants, 32 were excluded since they were outliers or had missing data. in total, 144 girls (47.2%) and 161 boys (52.8%) participated in the study. their mean age was 14.57 (sd = 0.74). the researchers have promoted the free education program to decrease problematic smartphone use on the social media platforms of the associated university. after that, the university corporate communications and public relations department e-mailed about the education program to school counselors of various schools residing in istanbul. following this, the education program was scheduled with the school counselors who requested it. afterwards, school counselors have chosen the class sections randomly. then, the school counselors sent to their families two weeks before the parental permission form including an information sheet about the research and a certificate of consent about the adolescent's participation to the education program and research. on the day of the education after the education, those students who volunteer to participate signed an assent form. if the adolescents did not sign the assent form they were not included in the study. thus, only 337 out of 1055 students signed the assent form. then, the researcher explained the procedures to the participants to complete the surveys. the participants were allowed to ask questions if they encountered problems while completing the questionnaires, and the research assistants helped them to resolve their problems. the intervention included a powerpoint presentation accompanied by several striking videos that highlight the non-neutral characteristic of technology. the adolescents were also given flyers that highlight the key points as reminders of the education and a check-list of to-do items to be performed throughout the three-week observation period. the whole program was delivered in one day using two breaks. the education program consisted of eight modules. each module of the program roughly lasted about 15 min. the first module consisted of creating awareness about the problematic use of smartphones. the educator presented famous technology figures' examples and introduced statistics about the problematic smartphone use. the module included evidence based striking facts and insights on how silicon valley-based technology platforms create addictive experiences. for example, twitter, instagram and facebook platforms create a "craving" effect on users by making them wait (on variable time) to get their liking feedback. once the participants were oriented and motivated to be a conscious smartphone user, then the next module was implemented, which showed how to measure and keep track of the participants' screen time. the educator explained in detail the hook strategy that marketers employ to engage users. the next module was about presenting the participants how to unhook from their smartphones. snapchat's snap streaks feature could be regarded as a deceptive example to hook strategy. this feature shows the number of consecutive days someone has messaged to his or her respective friend as a badge. adolescents see it as an indication of how strong their relationships are with their acquaintances and hence they do not want to break the streak. during the education program, some participants reflected by stating that when they were to be offline for a certain period of time (during a holiday with their family, etc.) they gave their user credentials to one of their close friends and asked them to send dummy messages to their stated friends so as not to break their snap streaks. in order to practice unhook strategies, the participants were first asked to identify the applications that made them feel unhappy. these applications were removed with the guidance of the educator. additionally, in this module, the participants were persuaded to hide the social media applications that hooked them inside a folder. the home screen was cleared up and the time consuming applications were saved in another folder. during the third module, participants learned how to turn off all the notifications. also the educator instructed to mute the group messages and to remove the last seen or read information from the account menu under the privacy settings. once all the sources of distractions were removed, the fourth module was initiated. it was in the fourth module that a digital diet program was introduced. the fifth module integrated mindfulness applications as well as attention focusing techniques to control unconscious use. the sixth module included strategies to increase the quality of the participants' social relationships. the adverse effects of being available all the time and its damaging impact on personal productivity were explained along with supportive research findings. afterwards, steps that could be taken to prevent the problem were introduced. on whatsapp, for example, the adolescents were advised to avoid immediate reply to not-so-urgent incoming messages and to put a deliberate delay so that the other party's anticipation for an immediate reply was lowered. then, the educator taught the participants to build the communication rules and facilitate the quality of social communication without phone. recent studies showed that 72% of adolescents (as opposed to 48% of adults) feel an urge to respond to an incoming call or a message immediately [63] . this phenomenon can be attributed to the wrong interpersonal communication etiquette as well as low self-control and peer pressure. therefore, the education module also incorporated the proper etiquette for communication that relieves the individual from feeling the urge to respond to everything immediately. all through the seventh module a gamification strategy was used to engage the adolescents with the use of #iamincontrol hashtag use. this module of the education was about adolescents' controlling their lives. the participants learned how to protect an area they identified as a phone-free zone. the educator taught when, where and how to leave their phone in their daily routines. the participants were also offered many activities they could plan together with their loved ones. along the modules, the participants were asked to do homework and were supported with manuals, digital diet planners, activities list and handy calendars. once all the content was delivered, the researcher scheduled a follow-up meeting three weeks after with the same school. three weeks later, the scales and checklist were collected from the participants with the help of the school counselors. the participants who conducted the demographic questionnaires and the smartphone addiction scale before the education were distributed an id number so that it matched the collected surveys after the program. the researchers prepared an evaluation form to test the effectiveness of each task in the education program. then, the participants were asked to rate about the effectiveness of each step in the program. finally, they rated these steps according to their own usage benefits. demographic form: the form includes gender, age, parents' education, parents' occupation, social media use of the family and the adolescent, purpose of use for the smartphone and the time they started using it and how much time they spent on it on a daily basis. the smartphone addiction scale for adolescents (sasa) measures smartphone addiction. sasa was developed by kwon et al. [60] . the turkish validation study conducted by demirci et al. (2014) consisted of 6 point likert scales ranging from 1 (definitely no) to 6 (definitely yes), 36-items and 7 factors as disturbing daily life and tolerance, withdrawal symptoms, positive anticipation, overuse, social network dependency, physical symptoms and cyberspace-oriented relationships [61] . the correlations between the subscales ranged from 0.22 to 0.51 the highest total scales values indicated a higher risk for problematic smartphone addiction. the cronbach's α's of the seven factors were found respectively as 0.85, 0.81, 0.74, 0.62, 0.59, 0.64, 0.34 and 0.89 for the total scale in this study, which are very close to the validated scale. the pearson correlations coefficients varied between the sasa factors and total varied between 0.18 and 0.75, indicating statistically significant positive relations (all p's < 0.01). since it is a reliable and valid tool of measurement, sasa was conducted to assess the change in the smartphone usage before and after the education program. the data analysis was conducted using spss 21 for windows. descriptive statistics were calculated to investigate the demographic data. in order to test first and third set of hypotheses, the demographics of the participants were compared by independent sample t-tests analysis of variance tests. pearson moment correlation analysis was run to evaluate the relationships between continuous demographics (e.g., age) and the factors of sasa. in order to test hypothesis 2 which aims to evaluate of the effectiveness of education, paired sample t-test was used to compare before and after sasa scores. three hundred and five participants were included in this study. 144 (47.2%) were female, and 161 (52.8%) were male. only 44 (14.4%) of the participants indicated that they had cyber friendship, which they had met online and then later got to know in person. table 1 listed gender, grades, electronics they possess, purpose of use, applications they have and parents' education. smartphone use variable was the reported use of smartphone time as minutes per day (x use = 139.84, sd = 83.68). the daily use of smartphones was declared to be less than 180 minutes for 75%, between 180 to 300 min for 21.5% and more than 300 min for 3.5% of the sample. the first set of hypotheses explored the problematic smartphone use difference in terms of gender (h1a), age (h1b), adolescents' grades (h1c) and parents' education (h1d). in order to test gender differences, an independent sample t-test was conducted. as a result, there were no significant difference between boys (x boys = 81.06) and girls (x girls = 84.99) in terms of total sasa before the education (p > 0.05). then, to test the age and sasa relation (h1b), a pearson moment correlation analysis was conducted. the findings revealed no significant relationship between age and sasa scores (r = 0.01, p > 0.05). in order to test the problematic smartphone use difference on the basis of the adolescents' grades (h1c) an analysis of variance test showed that sasa scores before the education do differ significantly according to the students' grade levels. a tukey post hoc test indicated that the sasa scores increased significantly at 10th grade (x pep = 16.19 x 9th = 17.26 x 10th = 19.33 x 11th 17.06 f (305) = 3.59, p < 0.05 d = 0.3). in order to measure the problematic smartphone difference on the basis of the parents' education (h1d) an analysis of variance test indicated that the adolescents' sasa scores vary according to their mothers' education level. a tukey post hoc test showed that there was a significant difference between high school graduates and college graduates' mothers in terms of their children's sasa scores (x middleschool = 17.39 x highschool = 18.13 x college = 16.52; f (305) = 3.62, p < 0.05). another analysis of variance test revealed that fathers' education also differed in terms of their children's sasa scores. a tukey post hoc test showed that there was a significant difference between high school graduates and college graduates fathers' in terms of their children's sasa scores (x middleschool = 16.95 x highschool = 18.22 x college = 16.89; f (305) = 3.21, p < 0.05 d = 0.3). in order to test the second hypothesis, which evaluated the influence of the education program, a paired sample t-test analysis before and after the education program was conducted. as shown in table 2 , the results revealed a significant decrease in disturbing daily life and tolerance (x pretest = 2.93 x posttest = 2.68), withdrawal symptoms (x pretest = 2.09 x posttest = 1.97), positive anticipation (x pretest = 3.18 x posttest = 2.84), overuse (x pretest = 2.61 x posttest = 2.44), physical symptoms (x pretest = 2.67 x posttest = 2.51) dimensions and in the total sasa scale (x pretest = 17.30 x posttest = 16.19). cyberspace oriented relationships and social network dependence factors did not change significantly after the education program (p 's > 0.05). thus, the effectiveness of the education program has been proven for total and five factors except cyberspace oriented relationships and social network dependence factors as can be seen in table 2 . in order to test the third set of hypotheses that explore the difference of the problematic smartphone use in terms of gender (h3a), age (h3b) and adolescents' grades (h3c). firstly, an independent sample t-test was conducted to compare boys' and girls' sasa scores after the education program (h3a). the results revealed that male adolescents' total sasa dropped significantly more than those of the girls with a medium effect size (x female = 17.17 x male = 15.31; t (305) = 3.63, p < 0.01 d = 0.42). additionally, the sasa scores of the participants after the education have been subtracted from the sasa scores before the education. boys' change is significantly higher than that of girls' change (x girls = −0.58 x boys = −1.58; t (305) = 2.55, p < 0.01 d = 0.30). following this, to test the age and sasa relation after the education program (h3b), a pearson moment correlation analysis was conducted. the findings revealed no significant relationship between age and sasa scores after the education program (r = −0.01, p > 0.05). after the completion of the education, an analysis of variance test indicated that sasa scores varied significantly according to the adolescent's grades. a tukey post hoc test showed that only the sasa scores of preparation grade and 10th graders were significantly different (x pep = 14.56 x 9th = 16.36 x 10th = 17.33 x 11th = 16.23; f (305) = 2.66, p < 0.05 d = 0.02). the percentage of the participants who practice no-tolerance rule to phubbing friends, those who prefer to look to their smartphone screens instead of themselves in a physical conversation were 62% and 56% of them have found this method to be somewhat or absolutely useful. the corresponding percentages for turning-off all notifications (except from real people) were 55% and 58%, putting all whatsapp group messages to silent mode were 68% and 65% and turning off the last seen time and read receipt of whatsapp messages were 58% and 56% respectively. initially, many adolescents had reported that they had hard time trying them. after experiencing these methods, however, many of them reflected that they feel more in control of technology and can now focus more easily on their tasks. this study first aims to investigate the role of demographic factors, namely gender, age, grades and parents' education level of adolescents in assessing their tendency for smartphone addiction before the education. the first hypothesis related to demographics' differentiation in terms of problematic smartphone use is examined separately for gender, age, grades and parental education. the problematic smartphone use did not differ on the basis of gender nor has been associated with age. only the problematic smartphone use differs for grades and parental education. the second hypothesis, which constitutes the main objective of this study, is about inquiring the effectiveness of a novel education program for reducing problematic smartphone use in adolescents. in order to achieve this, a marketing based education program has been developed and then later measured the effect before and three weeks after the program. the change in problematic smartphone use showed a significant decrease. moreover, the last hypothesis is related to the demographic factors, specifically gender, age and grades. these demographics are critical in order to understand which ones differed after the education for future references. gender and grades differed in terms of decreases in problematic smartphone addiction. concerning the first hypothesis, the current study revealed that there is no statistically significant difference between girls and boys in terms of their sasa scores before the education. thus, the first hypothesis of this study is rejected confirming the previous studies [59, 60] . there are many studies that indicated female addiction is higher than males [64] [65] [66] . these studies attribute females' higher tendency for mobile addiction to females' being more likely to engage in interpersonal communication and social relationships via their mobile phone [67, 68] . moreover, demirci et al.'s (2014) study conducted in turkey indicated higher sasa scores for female participants. the fact that the difference between boys and girls is not significant in this present study can be explained first by age factor. the participants of this study consisted of adolescents while demirci et al.'s (2014) study consisted of college students. second, not only the age group might have brought out the discrepancy between these studies but also the six years' difference (2014-2020) might have changed the rates. indeed, gender gap is predicted to decrease over the years with the advances in technology spreads, which also explains the current gender similarity in terms of addiction [69] . the total sasa scores of the adolescents in this study (girls were 84.99 and boys were 81.06) are higher but the gender difference has closed compared to previous findings [60] as (females were 78.7 and males were 72.2). as a matter of fact, this finding confirm that the gender gap is closing and problematic smartphone use has gradually become more prevalent among adolescents in recent years [32] . this study could not find a statistically significant relationship between age and problematic smartphone use. as demirci et al. (2014) study [60] also found non-significant negative relationship between age and smartphone addiction, the results are in line with the previous study. some studies, particularly in the internet addiction domain, find such negative but significant relation between adolescents' age and addiction level stating that this risky behavior is temporary in the adolescence period. this phenomenon is said to wear off with increased familiarity with the technology [70, 71] . the problematic smartphone use differed significantly on the basis of the adolescents' grades. beginning around age 10 adolescent risk taking, reward sensitivity behaviors start increasing, then peak between 13 and 16, and then decline [72] [73] [74] . the problematic smartphone use according to grades is in line with the risk preference trend. the earlier grades' sasa scores are lower than the later ones, then there is a peak at 10th graders and then it drops again. the higher the maternal and paternal education level the lower were the sasa scores except for college graduates. the college graduate parents are mostly white collar workers who might spend less time and control over the adolescents which might have caused more problematic smartphone use. thus, this finding of the present study partially confirms the previous studies in the literature [66, 67] . in the light of these findings, we can conclude that, both parents' education and attention, which ultimately contributes to a more beneficial attitude towards adolescents [66] . the main aim this study is to reduce the problematic smartphone use after a marketing based education program. the education program started with explaining the negative consequences of problematic smartphone use in terms of its harm on cognitive capacity, academic performance and social relationships. afterwards, the internal mechanics of addictive design elements of digital products are explained in detail. the program followed by going through the steps in the hook model aimed at exercising the opposite behavior in each step to prevent unconscious, compulsive smartphone usage and ensure conscious and healthy usage behavior. the education program was coupled with a follow-up meeting three weeks after the education. the education module aimed at building awareness on the specifics of addictive mechanisms that ultimately hook users. concerning the second hypothesis, the results are very promising since the comparison of sasa scores before and after the education program has proven significant decrease in problematic smartphone use. the disturbing daily life and tolerance, withdrawal symptoms, positive anticipation, overuse, physical symptoms dimensions and the total sasa scores decreased significantly after the education program. the cyberspace-oriented relationships and social network dependence factors did not change significantly after the education program. when the cyberspace-oriented relationship factors' questions items are checked closely, there is a distinction between cyber friends and friends. only a small percent of the participants did make cyber friendship (14.1%). this fact might be due to the more conservative nature of families in turkey [75] in which adolescents are still protected closely. finally, the social network dependence factor did not change significantly after the education. the two items that measured social dependence did include social applications as facebook and twitter. the participants' reports indicated that the rate of use for facebook (24.6%) and twitter (18.5%) is considerably low. since most of the participants do not use these applications, these questions might have misdirected them. concerning the third hypothesis, the boys' sasa scores decreased more compared to those of the girls. the addiction literature provides evidence of that women had 2.7 more risk at smartphone addiction than men [76] . when women try to be abstinent, they show greater anxiety and stress compared to men [77, 78] . first, it might be less stressful to reduce the problematic smartphone use for boys than girls. furthermore, girls tend to strengthen their friendships, which keeps them on the smartphones and receive more emotional support, while boys aim to use smartphones to extend their weak social relations [79] . the education program's emphasis on how to build social relationship without the use of smartphones might have reduced boys' problematic smartphone use more than the girls. girls define smartphones as central component of their personal existence [80] which could bring more resistance to reduce their smartphone use. it was found that there is no significant relationship with adolescents' age and smartphone addiction levels after the education program. there are in the literature longitudinal and cross sectional studies where the expected behavior and age were not correlated after the intervention either [81, 82] . a meta-analysis about the intervention programs applied to subjects under 18 years of age revealed that age did not have an influence on the success of the programs [83] . however, the later study mentioned about the possibility of cognitive developmental level, which might be related to grades. the problematic smartphone use differed significantly on the basis of the adolescents' grades after the education. as a matter of fact, this finding pattern is very similar to the case before education. this illustrates that adolescents at earlier grades are still more open to guidance for healthier and more proper communication suggestions. this can be also explained by the fact that the education could be more influential when the habitual behavior of using a smartphone has recently started. the results also reveal that, with a 97.2% usage rate, smartphone use is much more prevalent than the use of any other technology products. the results also show that among the responding adolescents, 57.6% check their social media from their smartphone more than 10 times a day. whatsapp was found to be the most frequently installed mobile app; almost all the responding adolescents (98.2%) use it. instagram (80.5%) was found to be the second mostly used app among the adolescents. overall, the results of the study suggest that educational guidance for healthy usage of technology is missing or not adequate in the visited schools. unfortunately, the current educational system fails to provide even the basic communication etiquette to adolescents. that is, adolescents do not know and are eager to learn the proper way to communicate with their peers (importance of face to face communication etc.). this is especially valid for younger adults as opposed to their older counterparts. due to the peculiar characteristics of this special age group, namely adolescents, self-reported inventories like the one in this study have self-assessment bias risk. the results may also differ in terms of participants' self-involvement level, sincerity, beliefs etc. in addition, this study has been conducted in a relatively more conservative culture, which might have driven participants to give desirable answers. all in all, the program is distinguished in that an improvement is achieved using a structured program. however, in the future, longer and more thorough educational programs could be designed to achieve more lasting effect. in addition, such an educational program could have much more impact if coupled with a digital health app usage that tracks individual behavior. technology platforms have been creating increasingly more addictive experiences that result in spending prolonged periods of time on screens, which ultimately leads to more profitability in the attention economy. some of these addictive features include the lack of stop sign facilitated by infinite scroll feature, the hooking technique that relies mainly on the unconscious and employs mechanisms like variable rewards. problematic smartphone use increasingly becomes more of a concern globally especially among adolescents. in this study, a marketing approach was adopted in an education program. consumer-engaging methodologies are used to increase awareness on specifics of hooking strategies and to disengage adolescents from their phones. the results are significant in that an apparent improvement in problematic smartphone use is accomplished with a short and structured education program. although there are some mindfulness-based intervention studies that have proven to reduce smartphone use [84] , to our knowledge, this is the first study in which a marketing-focused education program has been developed to approach smartphone addiction. the program also offered practical, ready-to-use tips to restrain oneself from unconscious, compulsive smartphone use. this study makes significant contributions to the existing literature in several aspects. firstly, looking from a marketing perspective, it uses the strategies employed to increase compulsive, unconscious smartphone usage, but in reverse direction to prevent excessive and hence problematic smartphone use. in addition, an educational program was introduced with a special emphasis placed on the conscious usage of smartphones. living without digital technologies has become almost impossible. this is particularly true as global pandemics (i.e., covid-19 virus a.k.a. corona virus) and the like developments are poised to change our daily habits radically. however, the key question in our relationship with technology is about which party will be in control. unconscious, compulsive smartphone usage lets technology control users. it will be only by educating the society with the proper way of smartphone use that we can turn the situation the other way around. the conducted study was scheduled as a one-time education. however, if these eight modules could be spread across the eight-week period with more supportive homework and with more detailed monitoring, the benefits could be improved. future studies 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writing, reviewing and editing were distributed equally between the two authors. all authors have read and agreed to the published version of the manuscript.funding: this project was funded by istanbul commerce university. we would like to acknowledge istanbul commerce university for funding to our project and oya özkardeş for her guidance. special thanks to project fellows dilara güler and zehra özalp for their technical support in data analysis, ahu dereli dursun and ipek sarıgöz for her rigorous work in editing process. the authors declare no conflict of interest. key: cord-354619-pftjhtpo authors: farronato, marco; tadakamadla, santosh k; ali quadri, mir faeq; acharya, shashidhar; tadakamadla, jyothi; love, robert m.; jamal, mohamed; mulder, riaan; maspero, cinzia; farronato, davide; ivanov, alexander; neefs, dirk; cagetti, maria grazia; de vito, danila; gupta, rishi j.; connelly, stephen thaddeus; tartaglia, gianluca m. title: a call for action to safely deliver oral health care during and post covid-19 pandemic date: 2020-09-15 journal: int j environ res public health doi: 10.3390/ijerph17186704 sha: doc_id: 354619 cord_uid: pftjhtpo the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) outbreak started just a couple of months ago and it grew rapidly causing several deaths and morbidities. the mechanism behind the transmission of the virus is still not completely understood despite a multitude of new specific manuscripts being published daily. this article highlights the oral cavity as a possible viral transmission route into the body via the angiotensin converting enzyme 2 receptor. it also provides guidelines for routine protective measures in the dental office while delivering oral health care. the recent ongoing outbreak of the sars-cov-2 was officially declared a pandemic on the 11th of march 2020 by the world health organization [1] . the origin of the infection, causing covid-19 disease (coronavirus disease 2019), is related to a mutation at the whole-genome level of a virus belonging to the genus β-coronavirus, bat-sl-covzc45 and bat-sl-covzxc2, both normally found in wild non-aquatic mammalians of the order of chiroptera (rhinolophus affinis bat) showing 88% identity with a peak in the s2 protein demonstrating around 93% of sequence homology and 98.7% in the e gene [2] . there have been an ever-increasing number of papers published on covid-19 since january 2020. according to pubmed, there have been more than fifty thousand papers published [3] , at a publication rate of almost 250 per day. the estimated basic reproduction number (r0) of covid-19 is around 2.2. it means that on average, each patient spreads infection to 2.2 people [4] . the mechanism behind the transmission of the human-human infection still needs to be understood in more detail. in particular, understanding specific function and location of virus-host interactions are extremely important to prevent further transmission, to protect health care workers (hcw) and to outline the safety guidelines going forward [5] . the norms and operating procedures for hcw who tend to work in close contact with general public-such as dentists, doctors, nurses and other health personnel-will be of extreme importance for the safety of the community because no specific drugs or vaccines are yet available for covid-19 with sufficient supporting evidence of their efficacy and safety [5] . early diagnosis and management are still crucial for containing the outbreak. hcw have been addressed as the most affected by the contagion according to the italian national institute of health [6] . dentists and other oral health professionals, collectively called dental health care workers (dhcw), who work in close proximity of the oral cavity could be at even more risk due to the frequent use of instruments which generate aerosols that could be contaminated by the virus [7] . particularly, with all the non-urgent treatment procedures having been delayed during the lockdown, dental practices are now encountering a swarm of back-logged patients. therefore, new personal protective equipment (ppe) protocols have to be adopted to effectively prevent the dental offices from becoming a new nidus of viral transmission in the community. moreover, during normal daily interactions, contact is more frequently related to functions of the mouth, rather than other sources of transmission such as the nose, the eyes, or the urogenital tract [8] . angiotensin converting enzyme 2 (ace2) have been identified as cell entry receptor for sars-cov-2 [9] [10] [11] . the virus attaches to its punitive receptor (ace2) via binding the s1 region of the spike (s) protein, which must be exposed through an initial enzymatic step mediated by a serine protease transmembrane serine protease 2 (tmprss2) or through a co-expressed membrane endopeptidase of the ace2 receptor, furin. ace2/tmprss2 has been shown to be expressed in type 2 alveolar cells in the lung and ace2/furin has also been recently demonstrated to be expressed on oral epithelial cells [12] . thus, there is evidence for viral entry via both the lungs and oral cavity. in this paper, we aim to present information from the existing literature about the transmission of sars-cov-2, focused on evidence of transmission via the oral cavity. it also aims to gather data to provide evidence-based guidelines which will be of vital importance for determining the protection strategies to adopt while delivering health care, primarily focusing on dhcw's and their practices. we initially searched for relevant literature in the national library of medicine (medline via pubmed) in march 2020, which was repeated again in june 2020. the search was conducted using the keywords "covid-19", "sars-cov-2", "dentistry", "transmission", "saliva", and "recommendations"; appropriate boolean logic was used. we found 38 articles as appropriate. the guidelines proposed in this review were implemented at sst dental clinic in segrate (mi), italy during the italian phase 2 from 15th of may 2020 to 15th of july 2020 under the clinical coordinator supervision. the ethics committee of the clinic approved the use of serological tests (ethic committee number irb022020 doc so 02) and patients requiring testing were informed about the procedure. after all their questions were answered, they (or their legal representatives in case of minors) agreed to take part in the test by signing the informed consent form. data includes all the patients attending the clinic for routine dental care who were on the clinic waiting list during the lockdown. all the patients provided signed consent as indicated by the national dental association's guidelines to be self-declared as healthy and fit to work for dental consultation. data were collected by the clinical process manager using statistiche trattamenti grid (clinical manager version: 3.1.0.0). for outcomes identified as missing, clinical notes were reviewed and data were added retrospectively if available. all dhcw working in the clinic were tested with serological quick test for igm/igg detection on 15 may 2020. the colloidal gold-based immunochromatographic (icg) strip targeting viral igm or igg antibody was used. its sensitivity and specificity were previously investigated by pan et al. [13] . the oral cavity is purported to be one of the main host sites, both for entry and transmission, implicated in sars-cov-2 spread either through contact, droplet, aerosols, or saliva. sars-cov-2 has been isolated in saliva and recent studies highlight how contamination of the oral environment could occur via fecal-oral transmission for an extended period of time [14] [15] [16] [17] . even though bai et al. recommend caution while interpreting their data for the possible influence of confounders, it has been reported that the viral load in potential spreaders' feces has rna persistent for nearly five weeks after the patients swab tested negative [18] . based on the above evidence, it might be reasonable to suggest that the risk of transmission through saliva could also last for up to five weeks and this possibility needs significant consideration while making decisions on appropriate precautions in the dental office. chen et al. [19] confirmed the presence of sars-cov-2 in salivary glands in 75% of the critically ill patients. it can be easily drawn that, excluding direct inhalation, the oral cavity could be a critical source of infection among the population. this is further dependent on the size of the particles involved. droplets and aerosolized particles between 10 and 100 µm tend to deposit in the upper airway and particles under 5-10 µm in size can penetrate deep into the lungs [20] . thus, for all but the smallest particles, the oral cavity could be one of first sites of viral entry. this could be consistent with the evidence that shows the sense of taste is affected in more than 60% of mildly symptomatic individuals [21] . according to hamming et al. [22] , ace2 expression was observed in the basal layer of the non-keratinizing squamous epithelium mucosa of the nasal, oral cavity, and nasopharynx, whereas they did not observe its expression on the surface of epithelium. this could suggest that these anatomical areas are not the primary site of entrance for sars-cov but areas of virus deposit where favorable environmental conditions for its replication exist. normal and breathing on exertion result in aerosol production, that would easily reach alveolar pneumocytes in the lower respiratory tract where ace2 is expressed by endothelial cells from small and large arteries and veins [22] . human ace2, responsible for the inhibition of the angiotensin 2, has high-affinity binding capacity to both sars-cov and sars-cov-2 coronaviruses. there is evidence that considers it as the main co-receptor involved in the infection, but it is suggested that it might not be the only one involved [19, 23] . in the initial stages of infection, cholesterol-rich lipid rafts play a fundamental role in viral entry into the cell [24] . these membrane microdomains facilitate both the interaction between the viral spike protein and the cellular ace2 receptor [25] and the endocytosis process that takes place in the early stages of internalization of coronaviruses [26] [27] [28] . the importance of cholesterol and other lipids that constitute the lipid rafts is confirmed by a study that shows that cholesterol-supplemented mouse fibroblasts show increased susceptibility to fusion with murine hepatitis virus [29] . in vitro cell models expressing the ace2 membrane protein have shown that depletion of cholesterol by metil-β-cyclodextrin halves the number of bonds with viral s glycoproteins [25] . therefore, targeting host lipids via the use of cyclodextrins seems a very promising antiviral strategy [29, 30] . nevertheless, the possibility to interfere with ace2 receptor glycosylation, which could help to prevent sars-cov-2 binding to target cells, should be considered in the therapeutic management of covid-19 [31] . moreover, ulcers and periodontal pocket bleeding would mix with the saliva and become part of the particles produced by breathing, exacerbating the risk to the lower respiratory tract for viral penetration [19] . here we propose a series of suggestions and a clinical protocol that should be taken into consideration by dhcw in hospitals and clinics supplemented by current best evidence and their national guidelines. the proposed protocol was implemented by the lead author (g.m.t.) and colleagues in their daily practice post lockdown. since its implementation, there is no evidence of cross infection of sars-cov-2 between patients and dhcw and vice-versa. for this protocol to be implemented efficiently there is a need to understand a few important considerations associated with aerosol generation [20] : 1. the mechanism of spread (contact, droplet, or aerosol); 2. the minimum viral titer and length of exposure required to cause an infection for each of these modes of spread 3. factors that increase host susceptibility to infection; 4. host factors that predispose to more severe covid-19 disease. evidence suggests that the classic mechanism of transmission, contact and droplet spread, can be contained mostly by isolating symptomatic patients and by the use of facial masks/facial coverings, which de facto provides a physical barrier to the oral cavity and nose, the primary source of infection for droplets and larger aerosol particles. thus, patients and all dhcw (clinical and non-clinical) should be educated and encouraged to wear high quality face masks on a regular basis. sars-cov-2 has been shown to survive in a closed environment for at least 3 h with an estimated half-life of 1 h [32] . increased airflow and treatment room air exchange rates will be important actions to modify viral particles that remain suspended in micro-aerosols in the environment. if adequate high-volume air exchange mechanics are not in place, then it would be reasonable to rotate use of patient treatment rooms with a 1-3 h quarantine time between use. if complete disinfection of all the surfaces and air change cannot be guaranteed after each patient, the use of disposable coverings should be considered together with disinfection of the surfaces at reach of the contact with the patient's body. in addition, measures for spatial distancing of >2 m between every non-operating person, including the waiting room, need to be implemented. careful scheduling of appointments could also help in ensuring spatial distancing by limiting the number of patients scheduled at one point in time. the potential appointments should be encouraged to follow the protocol of 'calling-in, before walking-in'. a structured questionnaire has to be readily available to implement a phone-triage, and all patients entering the dental practice should be treated as potential carriers. the dominant signs and symptoms of covid-19 that should not be missed during triage are fever, cough, and fatigue, while other rare clinical features that should also be taken into consideration are congestion, rhinorrhea, sore throat, and diarrhea [33] . however, the evidence on the symptoms of covid-19 is ever changing with new epidemiological research. dental practices should consider placing placards and warnings in their facility necessitating the use of face masks, avoiding touching of the face, and other recommendations prescribed by the regulatory agencies in their respective countries. these clinical considerations should be considered to be applied compulsorily. if complete disinfection of all the surfaces and air change cannot be guaranteed after each patient for every dental practice (i.e., rapid checks or visits), the use of disposable covering should be considered together with disinfection of the surfaces at reach of the contact with the patient's body. the salivary system is activated during the motion of the mandible and with the function of speech, this could represent a source of contagion at the reception and operating room, face masks could help prevent such transmission. in addition, contact with documents, papers, and all the shared objects should be avoided as much as possible [34] . 'calling-in, before walking-in' protocol would help reducing contact with documents and billing should be encouraged while cash payments should be discouraged [35] . digital documents or mobile applications should be used if required, for instance to sign the consent. along with currently known disease confinement measures, access to toilets should be limited in the health care facilities and the frequency of cleaning and disinfection of the toilets needs to be increased. in addition, strict preventive measures should be in place for the eateries and dining areas, given that fecal shedding of sars-cov-2 could cause significant environmental contamination [36] . those patients who require emergency treatment but present covid-19 symptoms should be delayed or referred to another facility with negative pressure room. unless the practice is equipped with negative pressure treatment rooms, the patients should not be scheduled for dental procedures and referred to such facility. dhcws should refer to their governmental guidance for treatment and referral of these patients to ensure no ethical and treatment protocols are compromised. in addition, medical advice should be sought in special circumstances, such as patients with covid-19 symptoms, who are elderly or who have underlying medical comorbidities [37] [38] [39] . other measures include use of a pre-procedural mouthwash with active ingredients that decrease the virus load (hydrogen peroxide, povidone iodine, high molecular weight combination of cetylpyridinium chloride and hyaluronic acid) [40] [41] [42] . the four-handed technique is suggested along with the use of rubber dam complementary to saliva ejectors to reduce the production of aerosols [43] . the use of clothing should include: microparticulated respirators (n95 authenticated by the national institute for occupational safety and health or ffp2-standard respirators set by the european union as an equivalent to n95) combined with wearable facial transparent screens and disposable water-resistant shoes, hair and full body covers [44, 45] . proposed covid-19 testing criteria and treatment procedures based on covid-19 diagnosis in dental practice are summarized in figure 1 . in particular, it would be important to have knowledge of the exposure/infection status of clinical staff and patients to sars-cov-2. in this regard, it would be pivotal to rely on serological tests for specific anti-sars-cov-2 igm (low affinity) or igg (high affinity), although there are some concerns of cross-reactivity with phylogenetically related coronaviruses causing common cold remains [46] . conversely, to diagnose the presence of sars-cov-2, nasopharyngeal or salivary swabs followed by viral genome amplification, hopefully not only qualitative but also quantitative, remains currently the most reliable tool [47] . irrespective of the testing protocol and due to the risk of false negatives, it is of absolute importance that all patients are considered potentially positive. it is expected that dhcw will maintain a high degree of attention adopting the routinely standard infection control precautions. figure 1 . proposed covid-19 testing criteria for staff and patients in dental practices during the covid-19. positive triage indicates presence of fever and/or cough and/or at least two of the following symptoms: sore throat, headache, diarrhea, vomit, asthenia, muscle pain, joint pain, and loss of taste or smell in the past 15 days prior to the consultation or with pcr blood test positive for igm/igg. red light, dental procedure is recommended to be postponed; green light, dental procedure can be safely delivered. there were a total of 1278 patients (mean age 47.02 years ± 21.52, minimum 4 years old and maximum 92 years old); 665 females and 613 males, over the 10 weeks period resulting in 2968 clinical consultations. from that, 648 consultations were conducted during the first two weeks post lockdown; 1561 consultations in the entire month of june and 759 consultations during the first two weeks of july. overall, 671 patients were seen for a single consultation only (e.g., dental hygiene) and 607 patients came for more than one visit (mean 3.72 visits). all the positive triaged patients were investigated with serological quick test for igm/igg detection. twelve positive patients were further investigated with salivary swab but were found to be negative (table 1) . three from the total of 32 dhcw were igg positive. all three of them were detected as negative from the salivary polymerase chain reaction (pcr) swab. during the period from 15th of may 2020 to 15th of july 2020 one dhcw was isolated due to covid-19 symptoms, who was tested negative in pcr serological test, therefore returned to work the day after (table 1) . in total, 15 positive serological tests were observed, which indicates a prevalence of 1.15% (95%confidence interval 0.70-1.88%), in accordance with the prevalence observed in the italian municipality of city vo` (1.2% (95% ci: 0.8-1.8%) [48] . all consultations were made by appointment and followed the above-mentioned recommendations. the majority of these consultations were for adult service (>16 years old; 89%, n = 2642), with 11% (n = 326) being for pediatric service and 9.3% (n = 246) for orthodontic services. positive triage indicates presence of fever and/or cough and/or at least two of the following symptoms: sore throat, headache, diarrhea, vomit, asthenia, muscle pain, joint pain, and loss of taste or smell in the past 15 days prior to the consultation or with pcr blood test positive for igm/igg. red light, dental procedure is recommended to be postponed; green light, dental procedure can be safely delivered. there were a total of 1278 patients (mean age 47.02 years ± 21.52, minimum 4 years old and maximum 92 years old); 665 females and 613 males, over the 10 weeks period resulting in 2968 clinical consultations. from that, 648 consultations were conducted during the first two weeks post lockdown; 1561 consultations in the entire month of june and 759 consultations during the first two weeks of july. overall, 671 patients were seen for a single consultation only (e.g., dental hygiene) and 607 patients came for more than one visit (mean 3.72 visits). all the positive triaged patients were investigated with serological quick test for igm/igg detection. twelve positive patients were further investigated with salivary swab but were found to be negative (table 1) . three from the total of 32 dhcw were igg positive. all three of them were detected as negative from the salivary polymerase chain reaction (pcr) swab. during the period from 15th of may 2020 to 15th of july 2020 one dhcw was isolated due to covid-19 symptoms, who was tested negative in pcr serological test, therefore returned to work the day after (table 1) . in total, 15 positive serological tests were observed, which indicates a prevalence of 1.15% (95% confidence interval 0.70-1.88%), in accordance with the prevalence observed in the italian municipality of city vo' (1.2% (95% ci: 0.8-1.8%) [48] . all consultations were made by appointment and followed the above-mentioned recommendations. the majority of these consultations were for adult service (>16 years old; 89%, n = 2642), with 11% (n = 326) being for pediatric service and 9.3% (n = 246) for orthodontic services. a defined as presence of fever and/or cough and/or at least two of the following symptoms: sore throat, headache, diarrhea, vomit, asthenia, muscle pain, joint pain, and loss of taste or smell in the past 1 to 15 days prior to the consultation or with pcr blood test positive for igm/igg. the first two days of consultations (15) (16) may 2020) were used for staff training under the supervision of the clinical coordinator. the number of clinical consultations increased during the first two weeks from 246 in week one to 348 in week two, before stabilizing after week three around an average value of 360 per week corresponding to 65% of the maximum clinical capacity. both genders were equally represented in those accessing the service (48% male and 52% female). in terms of patient ethnicity, 99.4% of patients attending clinical consultations were recorded as white caucasian. black, asian, and minority ethnic (bame) made up 0.06%. following the above proposed guidelines, no cases covid-19 disease transmission after single or multiple dental consultations was registered among the dhcw or patients. closing down the dental health facilities or limiting the services to emergency treatments for the last few months have undeniably contributed towards slowing down of the rapidly spreading virus. however, further extension of lockdowns or the strategies post-lockdown should be carefully planned after keeping in mind the role played by the dhcw in reducing the burden of oral diseases, which impact people's general health and quality of life. classified as operative and non-operative, depending on their ability to work in the oral cavity or/and provide an essential outside support, the dhcw and the patients visiting the dental practice are undeniably at higher risk of sars-cov-2 infection and further transmission [41] . however, careful planning and implementation of strategies based on scientific evidence can be an effective way that may help in adapting to this challenging situation [49] [50] [51] . the dhcw are bound with the moral obligations to extend their services, but a general consensus is that moral obligations should go hand-in-gloves with evidence-based decision making, and the safety of the health care providers and their patients should be a priority [52] . the current report has presented the readers with protocols concerning the dhcw, which can be regarded as the key steps while marching towards a complete normalcy. based on the common experience during this pandemic lockdown from different countries, those patients presenting to the dental emergencies could be classified into four categories already proposed by izzetti et al. [42] : (1) subjects with known sars-cov-2 infection; (2) subjects who have recovered from covid-19; (3) subjects at potential risk of infection; and (4) subjects with unknown risk of infection, which represents every other patient. it is, however, important that we appropriately identify patients to prevent transmission in the dental practice. given that patients could be asymptomatic for prolonged period of time, groups 2 and 3 could be merged into a group of potentially asymptomatic sars-cov-2 infected individuals [48] . moreover, the classification needs to be extended to both clinical and non-clinical staff. ideally, as health care providers, in time it should be a reasonable expectation that all members of the dhcws be tested for sars-cov-2 and the associated antibody, however, this should not alter the established covid-19 protective protocols. with most countries already returning to the new-normal, several recommendations are already in place from their governing bodies. the main limitation of these recommendations is represented from covid-19 asymptomatic patients (negative to triage) that are not at the moment correctly identified. the prevalence of asymptomatic cases could only be clarified by a cross-sectional serological survey of the entire population. similarly, the sample used for presenting these preliminary clinical data consists of mostly caucasian patients from a single clinic in italy. the analysis of different samples also including minorities from different countries on large populations is needed. the recommendations put forth in this report are based on the currently available scientific information. they have been developed through a consensus gained through discussions between several dental practitioners and researchers across the continents. we do however acknowledge that with rapid developments in the knowledge on transmission of sars-cov-2, the recommendations are entitled to change. it is also important to note that different countries are going through different transmission phases, therefore the guidelines proposed here are applicable to those countries which have already returned to new-normal. it is also extremely important that the dhcws stay abreast with the updated guidelines and recommendations from their respective governments and regulatory agencies. public fear of dental offices and between dhcws is still currently high but our experience demonstrates that by following appropriate guidelines and recommendations, cross-infection of sars-cov-2 in dental offices could be easily avoided rendering them a safe place for dhcws and patients too. this is, to our knowledge, the first study that has reported a testing protocol of high exposure volunteers (dhcws and dental patients). no transmission between the patient and dhcws in the period of two months was recorded following the proposed guidelines. these data moreover reinforce the importance of epidemic multi-timepoint surveillance of dhcws and dental 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resistance profile surface environmental, and personal protective equipment contamination by severe acute respiratory syndrome coronavirus 2 (sars-cov-2) from a symptomatic patient clinical characteristics of coronavirus disease 2019 (covid-19) in china: a systematic review and meta-analysis clinical and demographic characteristics of patients dying from covid-19 in italy versus china covid-19 lombardy icu network. baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region hfsa/acc/aha statement addresses concerns re: using raas antagonists in covid-19 transmission routes of 2019-ncov and controls in dental practice covid-19 transmission in dental practice: brief review of preventive measures in italy covid-19): emerging and future challenges for dental and oral medicine personal protective equipment for preventing highly infectious diseases due to exposure to contaminated body fluids in healthcare staff a scoping review of respirator literature and a survey among dental professionals a systematic review of antibody mediated immunity to coronaviruses: antibody kinetics, correlates of protection, and association of antibody responses with severity of disease virological assessment of hospitalized patients with covid-2019 suppression of a sars-cov-2 outbreak in the italian municipality of vo' novel coronavirus-important information for clinicians the covid-19 pandemic in the us: a clinical update available technologies, applications and benefits of teleorthodontics. a literature review and possible applications during the covid-19 pandemic dentistry and coronavirus (covid-19)-moral decision-making this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license we thank guido poli, vita-salute san raffaele university of milano, italy, for helpful discussions and critical reading of the manuscript and akusia onlus in the name of the president atty. lomboni for having provided the diagnostic kit. santosh kumar tadakamadla acknowledges support by nhmrc fellowship, australia. all authors declare no conflict of interest. key: cord-340545-mgq3a4t9 authors: mead, darryl; sharpe, mary title: aligning the “manifesto for a european research network into problematic usage of the internet” with the diverse needs of the professional and consumer communities affected by problematic usage of pornography date: 2020-05-15 journal: int j environ res public health doi: 10.3390/ijerph17103462 sha: doc_id: 340545 cord_uid: mgq3a4t9 the manifesto for a european research network into problematic usage of the internet was published in may 2018. it was written from the perspective of the cost action network, a programme of the european cooperation in science and technology ca16207 and is expected to have significant influence on research funding priorities over the next decade. the manifesto identified nine key research priorities to advance understanding in the field. our analysis shows that while at the most general level it identified problematic usage of pornography (pup) as a key research priority, it then barely mentioned it again within the body of the report. this paper uses the manifesto’s framework to suggest research areas into the problematic usage of pornography which are of particular relevance to clinicians and other professionals working in the field who want to develop approaches to assist individuals and target groups affected by pup. it also looks at potential research opportunities inspired by the lived-experience of users withdrawing from pup. a large number of opportunities are identified for new work on pup across all nine key research areas of the manifesto. the publication of the manifesto for a european research network into problematic usage of the internet (pui) [1] in may 2018 was a milestone in planning the roadmap for the behavioural addictions' community. it provided an international focus for developing policy across different elements of the research landscape for behavioural addiction over the next decade. the manifesto was written from the perspective of the framework of the cost action network, a programme of the european cooperation in science and technology ca16207. the manifesto identified nine key research priorities to advance the understanding of pui (table 1) . the manifesto identifies pornography usage as a potential pui. we have called this activity problematic usage of pornography (pup). table 1 . summary of key research priorities to advance the understanding of pui [1] 1. "reliable consensus-driven conceptualisation of pui (defining main phenotypes and specifiers, related comorbidities and brain-based mechanisms) 2. age-and culture-appropriate assessment instruments to screen, diagnose and measure the severity of different forms of pui 3. characterise the impacts of different forms of pui on health and quality of life 4. define the clinical courses of different forms of pui 5. reduce obstacles to timely recognition and interventions 6. clarify the possible role of genetics and personality features in different forms of pui 7. consider the impact of social factors in the development of pui 8. generate and validate effective interventions, both to prevent pui, and to treat its various forms once established 9. identify biomarkers, including digital markers, to improve early detection and intervention". since 2008 pornography consumption has transitioned from the model where a market supplied physical media such as magazines and dvds to consumers through retail networks, to a transnational, internet-based system mainly operating on a freemium trading model [2] [3] [4] . in the process it has scaled from predominantly national businesses reaching an audience of millions through shops and mail-order, to a world-wide online one with perhaps a billion customers [5] [6] [7] [8] . today, pornography is generally accessed on smartphones and other devices. its consumption has the potential to develop into a large-scale form of pui [9] [10] [11] . this technology-driven progression has massively increased the number of people potentially exposed to pup, while simultaneously removing barriers moderating individual levels of consumption. some consumers uncomfortable with the apparent impacts of their pornography use have now gathered together in large-scale, online recovery communities [12, 13] . many of these are self-help groups who try to support individuals to manage their consumption, or to end it all together. a growing community of professional therapists [14] [15] [16] [17] , coaches [18] and mental health experts [19] has developed to support these self-help groups, as well as people accessing mental and physical health services through more mainstream medical, psychological and psychiatric routes. academic research and public policy to support consumers, recovery communities and professionals is still at an early stage of development. much of the motivation for writing the current paper comes from the opportunity the manifesto offers when it says: "additionally, through an interactive dissemination plan (including website, social media, blogs) we are reaching out to relevant stakeholders at international and national levels with an emphasis on encouraging people with the lived experience of pui to become involved in the action" [1] p. 1235. this paper is a result of the authors heeding this call to action. first, it discusses the extent to which the topic of pornography usage is carried through in the nine key research themes. next it considers how the manifesto tries to address the diverse needs of the professional and consumer communities affected by pup. it then goes on to suggest additional areas of research to bridge any identified gaps. our research question is "what topics should be included within future research proposals under the manifesto to meet the diverse needs of consumers, recovery communities and professionals impacted by the problematic use of pornography"? the current study has used the content of the manifesto [1] as its target document. its authors created the manifesto both in the hope of influencing future research directions around pui and to improve the availability of funding to support those aspirations. as far as the authors are aware, the manifesto is the only research planning and policy document of its type currently available, which is relevant to the field of pui. rather than developing a mechanism to choose to include some parts of the manifesto and to exclude other portions, the target document is sufficiently short for it to be analysed as a single entity. each and every paragraph referencing pornography within the manifesto has been identified and is reproduced in this paper to provide context to allow consideration of both what has been said, and just as importantly, what has been omitted. the manifesto began by setting a level playing field for different problematic internet usage behaviours. it also introduced the central focus on health impacts. "we use the umbrella term pui to encompass all potentially problematic internet related behaviours, including those relating to gaming, gambling, buying, pornography viewing, social networking, "cyber-bullying," "cyberchondria" among others. pui may have mental and physical health consequences" [1] p. 1234. the nature of the health impacts is then developed further. the next step was to contextualise the behaviours according to their form, their place within the international medical diagnostic frameworks and as issues affecting identifiable user populations. "as noted, pui envelops a wide range of activities including video gaming, pornography viewing (and other compulsive sexual behaviours), buying, gambling, web-streaming, social media use and other behaviours. some of these behaviours may fall into an existing mental disorder in psychiatric nomenclature (e.g., gambling disorder), whereas others are likely to be formally recognized in future dsm/icd revisions, notably internet gaming disorder (kim et al., 2016b). different types of pui often start in childhood or adolescence (volpe et al., 2015), but broad age ranges can be affected (ioannidis et al., 2018). age and gender relate importantly to pui behaviours, with younger people typically having problems with gaming and media streaming, males with gaming, gambling and pornography viewing and females with social media and buying (andreassen et al., 2016)" [1] p. 1234. the manifesto then moves into a process of exploring the individual research priorities according to the list above. the clinical aspects of some internet-related behaviours appear phenomenologically much like addiction (e.g., gambling or viewing pornography), and demonstrate impaired control (unsuccessful attempts to reduce or cease the behaviour), preoccupation (craving), associated functional impairment ( for problematic online sexual behaviour (e.g., cybersex), three structural elements have been highlighted as being important contributors per the so-termed triple a model involving: accessibility, affordability, and anonymity (cooper, 1998; cooper et al., 1999) , though more research is needed on this topic (brand et al., 2016a; wery and billieux, 2017) . another similar proposed framework is the ace model (anonymity, convenience, and escape) (young, 2008). for excessive streaming (watching videos excessively), important structural features may include the ability of given programmes to grab attention by activating a biological 'orientating response', mediated through techniques including the use of attention-grabbing noises, zooming/panning, and presentation of rewarding stimuli (e.g., of a sexual or thrilling nature) (flayelle et al., 2017 (flayelle et al., , 2018 . collectively, public research into the structural elements that may promote pui in different contexts is lacking" [1] p. 1241. however, this is the only mention of pornography after section 1. so what is missing and what areas of research would be useful to the consumer, recovery and professional communities affected by problematic usage of pornography? this paper sets out to determine "what topics should be included within future research proposals under the manifesto to meet the diverse needs of consumers, recovery communities and professionals impacted by the problematic use of pornography"? the manifesto tells us that pup is a part of pui and provides some discussion on phenomenologies, comorbidities and brain-based mechanisms. it introduces pornography in the context of how to classify it as a disorder. some early models of pornography consumption are discussed in research priority 7. beyond these initial pointers, direct reference to the manifesto provides little specific guidance for policy-makers considering the research environment for pup. unlike other behavioural disorders such as gambling and gaming, which were referred to repeatedly in the manifesto, with pornography the manifesto was mostly silent. it did not try linking pup to assessment instruments, characterisation, defining clinical forms and removing obstacles to recognition and treatment. equally it did not recommend directly relevant research on issues around genetics, personality features, interventions for prevention and/or treatments, or the field of biomarkers. is the absence of more mentions of pornography viewing as a pui in the manifesto accidental or driven by other factors? we will not attempt to answer this. we recognise that the manifesto's authors covered a great deal of ground in 7000 words and some omissions were always likely. several of the authors have published widely in the field of pup. while still limited in comparison with research in areas such as gambling and gaming, the scale of literature investigating pornography viewing as a pui is growing rapidly. during 2018 we read over 200 papers on pornography usage, about 90% of them published in 2017-2018. new work which has appeared since the manifesto was published revealed previously unquantified consumer patterns. the diagnostic category of compulsive sexual behaviour disorder (csbd) was published in icd-11, two months after the manifesto appeared [20] . over 80% of people now seeking treatment for csbd have a pornography-use related issue, a statistic not widely known when the manifesto was published [21] . subsequent pornography-consumer behaviour has also been significantly influenced by entirely new factors such as the covid-19 pandemic [22] . so, where does an analysis of the manifesto leave policy-makers, funders, researchers and other interested parties? our discussion now approaches this from two separate, though linked, directions. first, we consider how pup can be researched to meet the needs of the different stakeholder communities. we then consider the potential for future research, as seen through the lens of the nine priorities set out in the manifesto. pornography accessed for free via the internet is now used on a frequent basis by hundreds of millions of people. for most users any problems only emerge slowly over time. however, the scale of the consumer population suggests that problematic pornography usage has the potential to impact the health of millions of people across the nine key research priorities set out in the manifesto. to make wise choices for research resource allocation, policy-makers and funders need to have sight of a research landscape that addresses each priority. what might it look like? the following is a pragmatic assessment based on a consideration of the existing literature, mediated by the constraints set within the manifesto. this assessment is supported by the author's wide-ranging dialogues with professional, recovery and consumer communities. since 2016 we have had face-to-face discussions on pornography consumption with over 9000 people in the united kingdom, the republic of ireland, france, germany, croatia, hungary, the ukraine, turkey, japan, australia and the united states [23, 24] . what else do therapists, medical practitioners, counsellors and sex educators want to know about the mental and physical health implications of problematic pornography usage? what are the issues that their clients, the problematic pornography users, want to have investigated? it is unhelpful that the diagnostic manuals do not mention the word "pornography" when over 80% of people seeking treatment for compulsive sexual behaviour have a pornography-related issue [21] . further, the nature of the condition for many meets the criteria for addictive disorders and should be clearly categorised as such to enable healthcare professionals to respond with appropriate treatments. both groups have an interest in distinguishing between classifying pornography usage as a potentially addictive disorder versus it being considered as an impulse control disorder. at any rate, there is clear desire in both lay people and professionals to have the word "pornography" appear in any given classification of a future edition of the international classification of diseases [20] and the diagnostic and statistical manual of mental health disorders [25] . it is apparent from our experience in meeting researchers from all parts of the world [23, 24] that the therapists' own knowledge, attitudes and prejudices are very important issues in terms of delivering access to appropriate treatment services. while the internet brings pup to all parts of the world, different cultures have different taboos and even blind spots about what is pup, what is unacceptable behaviour and what sorts of treatment might be considered appropriate. the legal systems of different countries are also relevant, and there are no universal standards for most sexual behaviours. for the last four years the authors have been teaching healthcare professionals about internet pornography and behavioural addiction. these audiences have consistently expressed a desire for the health and social implications arising from pornography usage to be taught as a component of general medical education. clinicians have also expressed interest in integrating the management of compulsive sexual behaviour disorder into the regular functioning of national healthcare systems. it would be desirable for the manifesto to address the concerns of the online pornography recovery communities and members of 12-step programmes such as sex addicts anonymous [18, 19, 26] . so far, we know of no quantitative research that has investigated elimination of digital porn use to reverse sexual dysfunction and a variety of mental health disorders reported by those who quit [27] . the focus within recovery communities begins with recognition/identification/diagnosis of problematic pornography usage. the first question is "do i have a problem?" if they do have a problem, this quickly becomes "how do i stop?" with a focus on tools, techniques and support. it then becomes "how do i maintain my desired level of sexual sobriety?" here we need more longitudinal research on the mechanisms and techniques for overall programmes of quitting pornography usage, on abstaining from pornography viewing, and the issue of managing masturbation. unlike most puis such as gambling, shopping or gaming, pornography viewing is linked to very deep biological sexual and reproductive drives, with the option of the interactive reinforcement by masturbation. the pornography, masturbation and orgasm (pmo) cycle reinforces the viewing behaviour, making simple abstinence strategies difficult to maintain for many former users. when you stop gaming you can get rid of your game console or you can have yourself banned from gambling venues, but you cannot stop being a sexual being. there are some specific characteristics of problematic pornography viewing which merit more research, particularly issues around triggering and flatlining. a deeper understanding of pup triggering factors would be useful to help individuals and clinicians build better strategies and models for avoiding problematic usage. flatlining is the term for the severe and sustained, short to medium-term loss of libido some users report upon quitting a cycle of problematic pornography viewing. while widely reported in community forums such as nofap [12] and rebootnation [13] , it is not well-covered by the academic literature [28] . the medical establishment has an ongoing interest in the development of new approaches to support quitting pornography viewing by identifying effective drug treatments. naltrexone is a medication that is used often in drug and alcohol addiction. it blocks the effects of drugs known as opiates. it competes with these drugs for opioid receptors in the brain. naltrexone can reduce a patient's desire for drinking thereby helping them remain abstinent. three papers have looked at the effect of naltrexone on problematic pornography use [29] [30] [31] . given the similarity of brain changes in substance abuse disorders and behavioural addictions, this could prove a fruitful area for further research. very recently transcranial magnetic stimulation has been suggested as a novel treatment [32] . investment in research to try to demonstrate the value of such approaches to clinical populations at scale would be very helpful. therapists operating within the context of organisations such as the association for the treatment of sexual addiction and compulsivity (atsac) in the united kingdom [16] and the society for the advancement of sexual health (sash) in the united states [15] would benefit from more research into behavioural modification techniques to help their clients stop internet-based behaviours. this might include the creation of apps and other internet tools. very recently metacognitive therapy has claimed to be three-times as effective as traditional cognitive behavioural therapy. it deals successfully with 'desire thinking' and rumination, a behaviour that often predicts relapse. extending new work on this to clinical populations of recovering pornography users would be helpful [33, 34] . pornography viewing is now a widespread behaviour in most countries where there is good quality access to the internet [8] . to have a protective effect on health and wellbeing, consumer-facing academic research on pup needs to have impact in the wider community. this is a science communication issue. little published research has looked at the ecology of spreading this type of message. there is scope for developing a very diverse array of effective communication strategies and toolkits. more research is needed on what would help adults to avoid situations and behaviours that might lead to pup. there is more active research focused on schools and adolescents. the manifesto could support the sort of educational work the reward foundation does in schools to help equip young people with the knowledge about the reward system of the brain and the skills they need to avoid not just pup, but pui in all its forms [35] . other educational programmes are available from an array of non-governmental organisations such as culture reframed, echildhood, and the naked truth project. common to all programmes is a lack of longitudinal studies evaluating their effectiveness over time, across cultures and among varying age groups. we also need to recognise that pup is not just a first-world issue. the reward foundation website operates in english, but uses the machine translations system gtranslate to make all pages available in over 100 languages. as a result, a significant proportion of our traffic is now in african languages such as hausa and somali. these people have a need for information about pup, but it is not readily available from within their own language communities. world-wide data from pornhub shows that heaviest usage of pornography is by people in the 18 to 34 years age brackets. it is strongly tilted towards male consumers, but supply-side drivers are slowly pushing consumption towards gender parity [5] [6] [7] [8] . research over the past decade has shown that pornography viewing correlates with higher levels of sexual assaults and dating violence, pathways into domestic violence and reduced levels of bystander intervention [36] [37] [38] [39] . the next generation of research should help move us from noting these as correlations to investigating questions of causation (or not) in these fields. the categories in the following discussion are directly based on the manifesto's nine research priorities, simply substituting 'problematic usage of pornography' for the wider pui category. they map out some of the ways the manifesto could respond to the needs of the professional and consumer communities. research area 1: reliable consensus-driven categorization of problematic usage of pornography (defining main phenotypes and specifiers, related comorbidity and brain-based mechanisms) [1] . separate and interlocking strands of research would be useful in the two main fields analysing sexual behaviour; compulsive sexual behaviour towards people and the usage of pornography. in particular, the overlap between them needs more work. there would also be considerable value in research on the overlap of pornography viewing with other pui's involving sexual behaviour-related activity, especially dating apps and social media. research area 2: age-and culture-appropriate assessment instruments to screen, diagnose and measure the severity of different forms of problematic usage of pornography [1] . the number of screening, diagnostic and measuring tools for pornography usage keeps expanding. there would be considerable value in testing and calibrating the best of the existing crop of tools, such as the brief pornography screener and problematic pornography use scale, across genders, age groups and societies [14, 40] . extending field trials would materially improve the ease with which these tools can then be rolled out for widespread adoption by clinicians and other people who are in the first line of contact by individuals concerned about pup. even among the experts the brief pornography screener is not universally known [41] . separately, major international reviews of erectile dysfunction have not referred in any way to the behavioural addiction field for data [42] . tolerance and escalation are classic behavioural symptoms of the journey towards an addictive disorder. each contributes to some consumers developing problematic usage. more research would be useful in relating the roles of tolerance and escalation in the pup of viewers who escalate to viewing child abuse material. this seems to have become a wide and growing aspect of cybercrime around the world [43, 44] . more knowledge of effective crime-fighting strategies could lead to better policy-making on prevention and to better risk-based advice for the courts and judges around sentencing and disposal. standardised and tested risk assessment tools would be particularly useful. problematic usage of pornography seems to be creating a new separate sub-population of consumers who choose to view child abuse material without having any particular sexual interest in children in real life. they appear to be a separate clinical population to individuals with a paedophilic sexual orientation. another area where screening tools are woefully lacking is in the categorisation of the use of pornography by people on the autistic spectrum. whereas about 1% of the population have autism spectrum disorders, crime statistics suggest that a disproportionately large number of the people (circa 30%) who escalate to viewing child abuse material come from specific vulnerable communities such those with as autism spectrum disorders, adhd and those with learning difficulties [35] . these vulnerable populations are often considered 'asexual', and not requiring any sex education. this is wrong as many use the internet as a substitute for relationships that they find so difficult to negotiate in real life. people with asd are rarely represented in other crime categories. their emotional immaturity and inability to interpret social rules can result in an attraction to younger people online who match their emotional age better. more research needs to be done on this group to improve prevention of access to child abuse material and to consider their special needs in terms of disposal following a conviction. for example, they do not function well in groups, which are the typical types of setting for sex offender rehabilitation [45] . this question can be explored by research into the pornography, masturbation and orgasm cycle. in turn, this line of work could lead to consideration of the extent to which pmo may be driving depression, social isolation and other mental health issues in the wider population. is it a bi-directional process -to what extent are these mental health issues powering the pmo cycle? work in this space to test causation was recommended as far back as 2016 [27] , but has yet to gain funding. bi-directional work would also be helpful for studies exploring health links or problematic pornography usage and the big-5 personality factors. first, factors such as narcissism are regularly shown as correlates of heavy pornography usage [46] , but few studies look at what happens to personality factors after people end problematic pornography use. do they remain constant or is there an individual and/or population tendency for them to revert to what they were before the individual began engaging in pup [27] . other recent studies have highlighted the need for longitudinal studies in this area [47] . similarly, conference reports [23, 24] and our informal discussions with both individual problematic pornography users in the community [26] and among sex therapists [15, 16] , suggest that there are co-morbidities with other addictions, both to substances and behaviours. developing new and/or improved strategies for treating complex webs of problematic usage are always of value. more literature would be helpful on the impact of problematic pornography use at different points in the human life-cycle. most research published to date has focused on teens or university students, though around half of all pornography viewers are older [8] . this makes case studies or more specific work on older people very rare [48, 49] . it would also allow us to look at the potentially very different trajectories of younger populations who began with access to unlimited, free streaming videos in or around 2008, and older users who may have transitioned through several successive modes of access to pornography such as magazines and dvds, to internet use. the many roles of pornography in forming, sustaining and ending couple relationships would benefit from further research. the majority of research to date has been on users, and to a lesser extent their sexual partners. there would be value in unpacking the factors relating to pornography consumption as they impact on various aspects of an individual's health and quality of life in the context of a dyad [18, 19, 28] . this focus on couple relationships naturally tends to exclude work on the lack of relationships among young heavy users, around 50% of whom are virgins and not in relationships [12] . the other area needing more work is on the way pornography creates expectations of "how partnered sex will be" [35, 46] . the literature of wider family and community impacts of pornography use across the human lifespan is also limited [48] . additional research into the impact of accessibility would be valuable, as problematic pornography usage would seem to be a case where the pui strongly links to private viewing. this is especially true for mobile platforms which can be used alone or with sexual partners. smartphones are also now used widely for technology-enabled flirting including "sexting" with diverse relationship, social and potentially legal implications. how does pornography consumption relate to the health and quality of life in a couple or a family? the authors frequently train social workers and criminal justice professionals who report that consumption of pornography, particularly violent pornography, is a consistent negative factor in the out-of-control domestic situations they encounter in their work. unlike mainstream television where intimate partner violence in programmes tends to be simulated, most violence depicted in pornography is real [37, 50] . it is not simulated and may offer viewers ethically challenging issues while they are viewing. it may also lead to post traumatic stress disorder and related symptoms after they stop. once seen, real violence and intimate partner violence shown in pornography cannot be unseen. where the real rape of minors is being streamed as entertainment by major commercial pornography sites, the legal and ethical challenges can be even more complex [51] . to what extent does acting out violent, coercive or controlling pornography scripts with real partners drive domestic violence and a growing appetite for dangerous practices such as sexual strangulation [52] ? these questions are key in many different cross-disciplinary approaches to understanding pui and pup. the manifesto noted that: "remarkably little prospective research has been conducted on the courses of different forms of pui and we remain relatively ignorant of key factors affecting long-term out-comes. such data are of crucial importance in understanding aetiology, planning treatment and improving prognostication. for example, for some individuals pui may represent a temporary phenomenon and spontaneously resolve (e.g., in some young people as brain systems mature), whereas for others pui may become chronic." [1] p. 1238. these observations apply very strongly to pup. there are many areas where we have little data. in simple terms, pup can lead to the individual failing to stop their use when faced with consequences, following the model set out in the diagnosis for compulsive sexual behaviour disorder [20] . however, icd-11 is careful not to set out the details of the specific sexual behaviours that are causing the distress. equally it is vague about the progression of the disorder from the perspectives of screening, assessment and diagnosis. this gives considerable scope to clearly define the clinical courses of each and every form of pup. we suggest that there are two fundamental classes of pup, and each needs more research. the first is where the consumption of pornography leads to problems directly attributable to the consumption process. the user cannot stop their use and it is leading to negative consequences. this is applicable to csbd as an impulse control disorder [20] and would also apply if a future version of the international classification of diseases gave it an entry in the addictive disorders section. we propose that the second category is where the development of a pup comes from the ideas it introduces into a viewer's mind and life. these can range across a whole spectrum from requiring to replay sexual scripts from pornography in your head to get aroused during partnered sex, to learning to ignore the need for consent in sexual activities, to promoting rape myths, the diminution of bystander intervention and the promotion of practicing dangerous activities such as autoerotic asphyxiation. other problematic uses can encompass escalation to criminal activities around viewing or creating images of child sexual abuse. it can also lead individuals to engage in sextortion, 'capping', and other illegal activities towards minors [35] . other new populations are the technology-enabled voyeurs whose illegal activities are also directed at adults, encompassing upskirting, hidden cameras, revenge porn and sharing sexual material without permission. pornography has also appeared that was secretly recorded on baby monitors lacking password protection. pornography-induced erectile dysfunction (pied) [28, 53] has been identified as a key factor that causes male sufferers of pup to seek treatment [54] , but this area still lacks clear before and after brain-imaging studies [27] . pied has also been linked to escalation to child abuse material. as desensitisation, tolerance and hypofrontality develop, a problematic pornography user needs more shocking material to feel any arousal. therapists need to know how long it can take for a pup to develop and what external or internal factors can act as triggers. reports from the recovery communities talk about the triggering influence of everything from life events and rites of passage, to social networks and the manipulation of viewer's taste by the algorithms used by the commercial pornography suppliers. the withdrawal process from pup, both physical and mental, seems generally similar to that of other puis. the only unique characteristic of pup identified so far is 'flatlining'. the literature does not adequately characterise the features of flatlining as a symptom across the population of users withdrawing from pup. this means that when it happens, problematic users can relapse to try to feel aroused again and overcome their feeling that their sexuality might be permanently 'broken'. more studies of co-morbidity, both between pup and other behavioural or substance addictions, and with other compulsive sexual behaviours, would also be welcome. there are other elements research could reveal about the general characteristics of pup. what are the characteristics of the incubation periods of pup at both the individual and population levels? do they have characteristics driven by gender or other factors? this in turn leads to the need for wider studies looking at gender, lifestyle and sexuality-based approaches to tease apart key elements in the pup process. what commonalties and differences exist across the lgbtqi++ spectrum? in parallel, is pup in the chemsex community driving addiction, or is its influence bi-directional [55] ? existing brain-imaging studies [56, 57] hint that both the quantity of pornography viewed and the period the viewing is spread across can have impacts on the development of pup. however, the current crop of brain studies on pornography are restricted to people in their 20s and 30s and they also draw on very narrow demographic and cultural samples. in a world where an average age for boys' first exposure is 12 years or younger, brain development issues need investigation [2] . more women-focused studies would be beneficial. how is pup the same for women as for men, and how is it different? are the genders the same in the etiology of compulsive use? to what extent is sex toy used [58] a component of women's pup? some research has suggested that pornography usage by women has influenced their behaviour in couple relationships [59, 60] . are there differences according to ages and points in the lifecycle? we are unaware of any pup studies in women controlling for stages across the menopause as a variable. age and stage of life should also be addressed from other perspectives. virgins make up perhaps 50% of the recovery community [12] . what are the longer-term implications of early pup across their lives as sexual beings? separately, how do the challenges faced by older addicts, who used a lot of pornography before the internet, compare to those of purely internet-based consumers? what are the impacts of pup on relationship formation, sustainability and sexual health? a study of korean men in stable relationships suggested they had developed a preference for viewing violent pornography as an alternative to real sex with their dyadic partner [61] . this also raises the issue of the nature of the content of the pornography being viewed. in line with the self-reports from the recovery community, a swedish and italian study of university students demonstrated that unusual sexual content creates more excitement. it also concluded that lots of the acts considered "unusual" by the researchers in 2015, already had become mainstream to many viewers and did not seem "unusual" at all [62] . research area 5: reduce obstacles to timely recognition and interventions [1] . obstacles around the timely recognition of pup and in delivering interventions exist both within the user population and among professionals. the interests of the groups overlap where there is a desire to develop, test and deploy more public health intervention strategies to draw the attention of pornography users across society to indicators of problematic usage. at the widest level there is value in developing strategies to have the issue of pup accepted by national healthcare systems. it can now be diagnosed as compulsive sexual behaviour disorder, coded 6c72 under the parent category of impulse control disorders [20] . some clinicians are using this categorisation, but there will be considerable lags before it is adopted by nations world-wide. in some countries such as the united states, the need for clinicians to have a code for csbd to allow patients to claim on medical insurance is paramount. a separate issue revolves around making effective training for professionals more widely available. there is a need for the right balance of availability of practitioners (numbers, skills, geographical spread) to the scale of needs of people with issues. training can be built into continuing education programmes for professionals, as it is in the united states through the society for the advancement of sexual health and the international institute for trauma and addiction [15, 17] . in the uk this is done through the association for the treatment of sexual addiction and compulsivity and the college of sexual and relationship therapists [11, 16] . however, csbd and pup are very new ideas and they have not become part of general medical training in most tertiary institutions. proof of concept was demonstrated by a 2017 paper [63] examining links between gene methylation and hypersexual disorder. the study found that the epigenetic state in the crh gene may contribute to explaining the biological mechanisms of hypersexual disorder. thus, some genes appear to play a role in hypersexual disorder. within the recovery community there is a strong desire to find answers to the 'why me' question. what is the relationship between predisposition to pup versus acquiring it through consumer behaviour in a changed technological environment? epigenetic factors need to be further researched. informal evidence from the online recovery communities indicates that certain character traits or personality types thought to be fixed actually change when regular use of a supernormal stimulus such as hardcore pornography ceases. for example, in some users out of control hypersexual or narcissistic or sensation seeking or aggressive behavioural traits remit or disappear when the stressor is removed. several separate, but overlapping strands of research around social factors would be useful. five are highlighted here as requiring more investigation: the technologies of the attention economy; women's changing role as consumers; environmental impacts; social acceptability; and the potential for early exposure to pornography to be considered as an adverse childhood experience. first, the manifesto in research area 7, in section 2 above, identified "for excessive streaming (watching videos excessively), important structural features may include the ability of given programmes to grab attention by activating a biological 'orientating response', mediated through techniques including the use of attention-grabbing noises, zooming/panning, and presentation of rewarding stimuli (e.g., of a sexual or thrilling nature)" [1] p. 1241. this neatly summarises the core behaviour of people engaged in pup, where watching is generally accompanied by the viewer masturbating. this is absolutely an area where public research is required into the structural elements of commercial pornography sites as a part of the attention economy. commercial sites seem to have adopted the structural concepts pioneered by b.j. fogg at stanford university and the behavioural design work of nir eyal [64, 65] . this allows them to build websites and apps that change users' thoughts and behaviour without their knowing. in particular, the pornographers target the unconscious mind via dopamine pathways in the reward centre to stimulate cravings that keep users coming back for more, resulting in pup for increasing numbers of consumers. artificial intelligence is being deployed by the commercial pornography suppliers to learn about user's sexuality to deliver the most engaging experience possible. this has implications for privacy. as some research suggests that pornography viewing can change a person's sexual tastes, this is a very slippery area. do we really want a big-porn machine algorithm to reshape our sexual templates [66] ? another area ripe for research is the issue of intentional manipulation of consumption patterns by commercial interests in the pornography industry. in particular, since 2016 there has been a sustained increase of usage by women as a world-wide phenomenon [5] [6] [7] [8] 67] . to what extent has this resulted from deliberate female-focused promotional strategies of the commercial pornography suppliers and what are its implications for dyadic relationships, family structures and society in general? pornography sites get heavy, repeat traffic from users. the largest supplier, pornhub, streamed 115 billion videos in 2019 to a world-wide audience of perhaps 1 billion individual viewers [8] . it would be extremely helpful to have reliable calculations for the world-wide use of pornography. the industry is now so large that it has been calculated to consume 27% of the energy used by the internet and is currently responsible for 0.2% of all greenhouse gas emissions world-wide, roughly equivalent to the domestic energy use of every household in france [68] . the environmental impact is large enough for researchers to calculate a quantifiable contribution to rising sea levels. across cultures and within cultures, the phenomenon of "normalisation" of pornography consumption as a socially acceptable activity has grown rapidly. since the arrival of the iphone in june 2007, supported by high-speed network services, the smartphone supplying "free" commercial pornography has removed barriers and increased temptation through its triple-a model of effectively unlimited access, affordability and anonymity [69] . the speed of this adoption has outstripped the capacity of researchers to place it in context and to include it in theoretical models. it is clear that the arrival of smartphones, wi-fi and 4g networks leads to most societies adopting pornography as a more acceptable form of recreation, especially among the young. the trajectory of this change can be unique to each country [2] . many stories circulate within the recovery community suggesting that childhood exposure to pornography in general, and internet pornography in particular, should be considered an adverse childhood experience (ace). however, at present this cannot happen. the list of definitions of aces pre-dates the arrival of problematic usage of pornography from the internet. it would mean revisiting the research field of defining, testing and verifying the validity of pup as an ace. this would be a very worthwhile project. these tend to revolve around whole-population approaches to changing the ease of access to internet pornography. after three false starts, will age verification legislation in the uk prove to be a successful intervention? how and where might it be tried in other countries? how will it be validated and will it achieve the intended outcomes? there is an established and diverse commercial ecosystem of blocking technologies now available for individuals and groups to prevent access to internet pornography. their characteristics tend to be specific to their local geographies. they can operate at the individual level, usually by subscription. many internet service providers (isps) offer filtering on either an opt-in or opt-out basis. academic analysis of the effectiveness of these measures would be helpful. pup research could also look to public health models used for other areas of addiction, particularly online gambling, where the business models and delivery mechanisms are often quite similar. policy research into new models of control, monitoring and product delivery limitation involving the government, commercial and voluntary sectors could be developed. this remains minimally charted territory. a recent development in pornography delivery (and sometimes production) is the increasing role of social media as a point of access. while games delivery platforms are now a significant source of pornography for some consumers, we have also encountered adolescents getting around parental controls via the internet of things. a poorly protected smart refrigerator could get a grounded teen online. individual or community approaches to treatment from counsellors, schools, churches or other local units can be successful, especially when linked to demand-side reduction measures. accountability partners are popular in some communities [26] . again, more external validation of success, or not, of different approaches would be valuable. are all pornography consumers at risk of developing pup? the simple answer is probably not, but we do not know for certain. if the general characteristics of pup are broadly similar to other better studied behaviours with a propensity to lead to behavioural addiction, the answer is 'no'. a proportion of users will be likely to move first into problematic use and then addictive use. some studies suggest that all pornography consumption generates brain changes, even at quite low durations [56, 57] . so far, the world health organization only considers the research base is strong enough to support the diagnosis of compulsive sexual behaviour disorder under the parent category of impulse control [20] . at the same time, few pornography consumers have been exposing themselves to large volumes of online erotica for longer than two decades, so we have only explored it as a factor for, at most, half of the duration of a human beings' sexual life-cycle. we do know that the more pornography some people consume, the more likely they are to develop compulsive behaviours as a result. it is the sort of issue that could respond well to the development of a risk-managed framework. such a framework could balance benefits of pornography consumption at the individual and society levels with the inevitable side-effects from some individuals being unhappy with the consequences arising from their use. where consumers do develop concerns, many practitioners believe that the solution to pup is rooted in consumer education. as a society we can choose to try to reduce the strength of demand for access to pornography. some individuals who see pornography as a valuable part of a sex positive culture would be uncomfortable about this, but it is up to each society to consider what restrictions may or may not be appropriate if some individuals may be harmed by excessive consumption. more systematic assessments of the success of educational strategies would show how effective they can be as risk-reduction strategies. what role will learning about the addictive potential of pup play in reducing demand? does learning about porn-induced erectile dysfunction reduce consumption? thousands of anonymous self-reports on the recovery websites show that the availability of knowledge of the effects of internet pornography on the brain was sufficient to encourage users to experiment with quitting porn [12, 13] . when they did, a range of mental and physical health problems remitted or cleared up. only when heavy users quit porn did they realise that those conditions were related to their porn use. formal research into this phenomenon would be valuable. a separate investigation into the issues of prevention versus cure would be interesting. we are suggesting research to compare the benefits of never beginning pornography usage versus treating the problem when it has been 'cured'. at a population level, are people who quit ultimately as mentally and physically healthy as those who never engaged in pup in the first place? what methodologies might help unpack this question? the development of possible drug treatments is still at an early stage. in theory adjusting brain chemistry with substances could reduce libido and cravings for pornography. the most common approach is to look at substances that are already approved for clinical use and to begin the process of taking them through stages from case reports and on to small and then large-scale clinical trials. what drugs might discourage pup and what pathways should be targeted? a major review was published by sniewski and colleagues in 2018 [70] . early work focused on possible similarities to obsessive compulsive disorder and suggested trying drugs known as selective serotonin re-uptake inhibitors (ssris). recent case reports have been published for paroxetine [71] , nalmefene [49] and aripiprazole [72] , with mixed results. research area 9: identify biomarkers, including digital markers, to improve early detection and intervention [1] . this is a new area, but it may have real potential to help improve health at the individual and population levels. as far as we are aware, biomarkers are not currently in use for detecting or diagnosing pup. would there be value in their introduction? research might be able to separate out the underlying tendency of some individuals or groups to be susceptible to problematic usage. this could be contrasted to the potential for internet pornography to lead to problematic usage as a natural characteristic in and of itself. the issue here is "are you the problem?" versus "is pornography the problem". co-morbidity studies involving other puis would also be helpful-many users find themselves trying to unhook from gaming or recreational drugs and pornography at the same time. biomarkers are a high-tech intervention. in face-to-face situations, such as a doctor's surgery or a counsellor's office, are they a better solution than simply asking a person about their level of pornography consumption? the brief pornography screener with five questions on a single a4 sheet of paper can be administered in three minutes and seems to be both sensitive and reliable [14] . a different line of research would be to look at the potential for widescale interventions using internet data. it might even extend to artificial intelligence algorithms at commercial pornography suppliers or the isp level. it would mean monitoring people for signs of problematic usage and then invoking a warning or even a cut-off protocol. this has privacy and data management implications, but the reality seems to be that monitoring rather like this is already at the core of the business model of major commercial pornography suppliers. could governments consider introducing national level intervention programmes? how would they operate and what would be the success criteria? at the same time, the pornography supply companies are very reluctant to share their data. in this they follow the lead of other industries supplying addictive substances like tobacco and alcohol. the commercial pornography suppliers are quite vulnerable to a 'smoking gun' which showed that were trying to induce addictive behaviour as a part of their business model. when you consider the conclusions in the manifesto [1] in the light of the current paper, there is nothing recommended for research into pui that does not equally apply to the sub-discipline of pup. to come back to our research question, "what topics should be included within future research proposals under the manifesto to meet the diverse needs of consumers, recovery communities and professionals impacted by the problematic use of pornography"? the comments in this section have been grouped to answer these questions individually, but there is, and should be, overlap between them, so we begin by looking at general questions about the field of research. the management and treatment of pup requires the right approaches to meet the specific needs of everybody in this mental and physical health ecosystem. given the massive scale of use of pornography and its potentially negative outcomes for some users, it is important for the european union's problematic usage of the internet (eu-pui) network to have a visible and trusted champion for pup, just as it should for other behaviours. linked to this, europe should hold a planning conference under the umbrella of cost action to design its response. the opportunity for pup data to be made accessible to researchers through shared multinational databases is extremely attractive. to assist the world health organization in improving the classification of compulsive sexual behaviour disorder in future to include the word pornography, research is required to separate out the natural history of pup from compulsive sexual behaviours focused on people. experimental work to investigate causation through longitudinal studies would provide a better strategic foundation for pup. this would be stronger if it included large-scale brain imaging studies to gather evidence before and after people have quit or have been given treatment. it is essential to develop a wider evidence-base covering all ages and stages of the human life-cycle for people engaging in pup. there should be much more research focus on women as they are now the main sector of growth for pup. equally our data should embrace sexual diversity and investigate the usage among lgbtqi++ communities where levels of mental health disorders and chemical dependencies are higher than in the mainstream heterosexual population. could pup be a contributing factor? the 2020s is the decade when training of health and social care professionals should begin to incorporate a deep and broad understanding of all puis as a matter of course. this will be a communication and public relations programme. it should be recognised that within the field of pup we are starting from a low-base with modest levels of training or resources available for people working as professionals and therapists. new research should be leading towards giving professionals a wider toolkit to support treatment of all the different forms of pup. ideally the next ten years will see a rising quality of research into pup, moving us towards a landscape with more double-blind placebo trials for drugs and longitudinal studies covering time periods that allow us to take a broader view on pup. it is a disorder that is slow to develop and potentially also slow to heal. we should encourage better and deeper validation of a few assessment tools across diverse populations. standardisation is helpful and surely two proven ones are sufficient. link this to a strong communication programme to make them known widely in communities from general practitioners (mds) and urologists to sex therapists, relationship counsellors, school counsellors and parents. the next decade should see the debate around pornography use and erectile health fully resolved. dialogues about the impact of pornography use in the context of violence against women and children also require more experimental approaches if the discussion is going to be able to move from correlation to causation. the next few years will clearly be a time of great advances in linking genetic data and behaviour and we will monitor the contributions that this form of high-technology can make to epigenetic changes in humans. at the low-tech end, the most important thing is to initiate a research and development programme to determine if early exposure to internet pornography can be recognised as an adverse childhood experience (ace). success in that project could have a profound impact on raising awareness of the need to reduce early exposure and thereby reduce the risk of subsequent pup. work monitoring the success, or otherwise, of age verification legislation around the world will be important for policy development. for individuals and communities, it is important that we learn which interventions are sustainable and cost effective. could commercial pornography suppliers be encouraged to take a pro-active role in heading off the development of pup, rather than following their current laissez faire view that a customer can never have too much pornography? it will be important to have research to boost the accountability of suppliers. accountability can be achieved through government intervention or industry self-regulation. so far the latter does not seem to be working in the consumer's favour. in general the access to pornography is free, but the consumption risks are all transferred to the user. the powerful position of commercial pornography suppliers within the context of the attention economy leaves the average consumer poorly informed about how their tastes and behaviour are being influenced by 'free' pornography. commercial pornography suppliers use the data that gather to develop a deep understanding of consumer behaviour. commercial players also benefit from the access to artificial intelligence and other data-mining tools to build market share and develop new markets. good academic studies of the recovery communities, be they nofap, sex addicts anonymous or others, could be revolutionary. recovery communities are a cheap solution to a potentially very expensive medical problem. however, often the communities do not really want to be studied. members just want to be healed or to help others to heal. there is some acceptance that good research could help. there is also a recognition that for some pup members, recovery communities are only part of the answer and that they may also need help from therapists and other professionals. quantitative research looking at the elimination of pornography is the highest priority. does it really reverse sexual dysfunctions and have a positive impact on a variety of mental health disorders? the field currently has extensive anecdotal evidence to support these suggestions, but that is not a substitute for large-scale, well-grounded studies. it is now nearly two years since the manifesto was published. in that time there has been a continuing growth world-wide in the volume of research appearing on pornography use in general and pup in particular. however, most of the work being done tends to be at the easier, cheaper end of the scale. as far as we can tell as frequent observers of this field, there remains a general lack of vision and large-scale co-ordination between the many research groups around the world. the future needs to be more about designing investigations to test causation, not just to demonstrate yet more correlations. the time is right for the cost action team and the eu-pui network to create, fund and promote a visible and trusted champion for pup research. europe has sufficient resources to support such a role. perhaps the research ideas sketched in this paper could be a positive contribution towards cost action accepting it should deliver a leadership role in the field of pup. focusing on the manifesto is a limiting strategy, in that many researchers in the pornography field around the world are unlikely to be familiar with it. our approach has been to work with what is already available to build a more coherent research environment. at the same time, focusing on the manifesto is essential. it is the only major published document which deals with the whole policy context of problematic use of the internet. it is europe-wide in its reach and is designed to endure for a decade. by writing a response homing in on the issues around pup, we hope to encourage researchers to have conversations to advance the field in ways that will benefit the continent's taxpayers and publicly funded research programmes. our methodology of simply analysing all of the manifesto as a whole through the particular lens of pup is a limitation. this approach was taken to balance achieving the clearest level of understanding of what readers could infer from the document with an open agenda to build the strongest possible set of recommendations to shape the future of pup research in europe over the next decade. manifesto for a european research network into problematic usage of the internet the risks young people face as porn consumers. addicta-turk the internet's impact on sexuality: a critical review of 15 years of research online sexual activity experiences among college students: a four-country comparison pornhub insights 2017 year in review year in review the 2019 year in review when pornography becomes a problem: clinical insights a current understanding of the behavioral neuroscience of compulsive sexual behavior disorder and problematic pornography use college of sexual and relationship therapists clinical characteristics of compulsive pornography users: a military sample society for the advancement of sexual health association for the treatment of sexual addiction and compulsivity international institute for trauma and addiction professionals addicted to internet porn understanding and treating sex and pornography addiction: a comprehensive guide for people who struggle with sex addiction and those who want to help them international classification of diseases, 11th revision (icd-11) revisiting the role of impulsivity and compulsivity in problematic sexual behaviors pornography use in the setting of the covid-19 pandemic pornography and sexuality research papers at the 4th international conference on behavioral addictions. sex. addict. compulsivity pornography and sexuality research papers at the 5th international conference on behavioral addictions sex addicts anonymous; international service organization of saa eliminate chronic internet pornography use to reveal its effects is internet pornography causing sexual dysfunctions? a review with clinical reports internet sex addiction treated with naltrexone naltrexone for the treatment of comorbid tobacco and pornography addiction treatment of compulsive pornography use with naltrexone: a case report positive response of compulsive sexual behavior to transcranial magnetic stimulation desire thinking: a new target for treatment of addictive behaviors? advances in metacognitive therapy the reward foundation -love, sex and the internet the impacts of sexual media exposure on adolescent and emerging adults' dating and sexual violence attitudes and behaviors: a critical review of the literature pornography and sexual assault. in handbook of sexual assault and sexual assault prevention pornography and sexual violence problematic pornography use and physical and sexual intimate partner violence perpetration among men in batterer intervention programs the development of the problematic pornography consumption scale (ppcs) online porn addiction: what we know and what we don't-a systematic review epidemiology update of erectile dysfunction in eight countries with high burden promotion and protection of all human rights, civil, political, economic, social and cultural rights, including the right to development motivational pathways underlying the onset and maintenance of viewing child pornography on the internet family and abuse characteristics of 700 british child and adolescent sexual abusers are adolescents who consume pornography different from those who engaged in online sexual activities? problematic pornography viewing from a big-5 personality perspective diverse sexual behaviors and pornography use: findings from a nationally representative probability survey of americans aged 14 to 60 years nalmefene in the treatment of internet pornography addiction-a case report and review of literature aggression and sexual behavior in best-selling pornography videos: a content analysis update. violence women florida man arrested after 58 porn videos, photos link him to missing underage teen girl characteristics of individuals who participate in autoerotic asphyxiation practices: an exploratory study erectile dysfunction: a review of comprehensive treatment options for optimal outcome your brain on porn: internet pornography and the emerging science of addiction bdo): a literature review with a focus on uk fatalities related to non-medical use brain structure and functional connectivity associated with pornography consumption: the brain on porn neural correlates of sexual cue reactivity in individuals with and without compulsive sexual behaviours characteristics of vibrator use among women individual differences in women's pornography use, perceptions of pornography, and unprotected sex: preliminary results from south korea exploring new measures of online sexual activities, device use, and gender differences korean men's pornography use, their interest in extreme pornography, and dyadic sexual relationships unusual online sexual interests in heterosexual swedish and italian university students methylation of hpa axis related genes in men with hypersexual disorder tiny habits: the small changes that change everything hooked: how to build habit-forming products online sexual activities: an exploratory study of problematic and non-problematic usage patterns in a sample of men the official xhamster 2019 trend report climate crisis: the unsustainable use of online video; the shift project surfing into the new millennium the assessment and treatment of adult heterosexual men with self-perceived problematic pornography use: a review paroxetine treatment of problematic pornography use: a case series hypersexuality and new sexual orientation following aripiprazole use this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the authors would like to thank julius burkauskas, the science communications manager of the cost action dissemination plan for encouraging the preparation of this paper. the authors declare no conflict of interest. key: cord-354345-p4ld0tun authors: bonadonna, lucia; la rosa, giuseppina title: a review and update on waterborne viral diseases associated with swimming pools date: 2019-01-09 journal: int j environ res public health doi: 10.3390/ijerph16020166 sha: doc_id: 354345 cord_uid: p4ld0tun infectious agents, including bacteria, viruses, protozoa, and molds, may threaten the health of swimming pool bathers. viruses are a major cause of recreationally-associated waterborne diseases linked to pools, lakes, ponds, thermal pools/spas, rivers, and hot springs. they can make their way into waters through the accidental release of fecal matter, body fluids (saliva, mucus), or skin flakes by symptomatic or asymptomatic carriers. we present an updated overview of epidemiological data on viral outbreaks, a project motivated, among other things, by the availability of improved viral detection methodologies. special attention is paid to outbreak investigations (source of the outbreak, pathways of transmission, chlorination/disinfection). epidemiological studies on incidents of viral contamination of swimming pools under non-epidemic conditions are also reviewed. swimming pools have been implicated in the transmission of infections. the risk of infection has mainly been linked to fecal contamination of the water, generally due to feces released by bathers or to contaminated source water. failure in disinfection has been recorded as the main cause of many of the outbreaks associated with swimming pools. the majority of reported swimming pool-related outbreaks have been caused by enteric viruses [1, 2] . sinclair and collaborators reported that 48% of viral outbreaks occur in swimming pools, 40% in lakes or ponds, and the remaining 12% in fountains, hot springs, and rivers (4% each) [1] . viruses cannot replicate outside their host's tissues and cannot multiply in the environment. therefore, the presence of viruses in a swimming pool is the result of direct contamination by bathers, who may shed viruses through unintentional fecal release, or through the release of body fluids such as saliva, mucus, or vomitus [3] . evidence suggests that skin may also be a potential source of pathogenic viruses. we carried out a comprehensive literature review aimed at investigating waterborne viral outbreaks linked to swimming pools, to explore the etiological agents implicated, pathways of transmission, associations between indicator organisms and disease, and key issues related to chlorination/disinfection procedures. viral outbreaks are summarized in table 1 . the presence of enteric viruses in swimming pools under non-epidemic conditions was also reviewed. different databases (scopus, pubmed, and google scholar) were accessed using the terms norovirus, norwalk virus, adenovirus, enterovirus, echovirus, coxsackievirus, and hepatitis a, in combination with terms recreation, swimming, pool, and water. switched off, to avoid eye irritation with chlorine. within one week, 25 of the 36 exposed swimmers became ill. children swimming in the afternoon, when chlorination was still working, did not get sick. the infection was shown to spread in families having index cases (20 infected contacts). analyses of water were done approximately 14 days after the presumed exposure. for this reason, attempts to isolate the virus from the water failed. an outbreak of acute conjunctivitis due to hadv type 7 occurred in kansas, usa in 1973: 44 cases and one hospitalization were documented [14] . eye symptoms predominated (red or pink eyes, swollen eyes), but a variety of other signs were also noted (mainly fever, headache, and nausea). a school swimming pool was identified as the source of infection. chlorine concentration was low due to an equipment failure. the epidemic was easily controlled by raising the pool's chlorine level. unfortunately, tests for viruses and bacterial indicators were carried out after super-chlorination and consequently results were negative. in 1977, two outbreaks associated with swimming pools occurred in georgia, usa. the first, due to hadv type 3, involved at least 105 cases [15] , with patients showing different symptoms, including sore throat, fever, headache, anorexia and conjunctivitis. in this case, a private swimming pool was the source of infection. a temporary malfunction in the water filtration system of the pool associated with inadequate chlorine levels was recorded. both waterborne and person-to-person transmission occurred. in the second outbreak, hadv type 4 was recognized as the etiological agent of pharyngoconjunctival fever in 72 persons [16] . an insufficient amount of chlorine was found in the water of the pool. to stop the spread of infection, the pool was closed during the summer and adequately chlorinated. adenovirus was recovered from the water sampled from the pool. in oklahoma, usa, an outbreak of pharyngitis caused by hadv type 7a was recorded in 1982 among 77 children attending a swimming pool [17] . symptoms included conjunctivitis, fever, sore throat, headache, and abdominal pain. two cases were hospitalized with dehydration from persistent vomiting. a malfunction of the automatic pool chlorinator was identified as the cause of the outbreak. in fact, during the two weeks preceding the epidemic, its failure forced the pool operator to manually add chlorine to the pool. another outbreak was recorded in 1995, in greece, where 80 athletes under 18 years of age presented with fever, conjunctivitis, sore throat, weakness, and abdominal pain, after swimming in a pool [18] . seven athletes were hospitalized. virological analyses on clinical samples were not performed and the illness was attributed to hadv on the basis of clinical symptoms alone. water samples from both the pool and the distribution system were tested for hadv, enterovirus, and hepatitis a virus by molecular methods. the water of the pool tested positive for hadv and negative for the other viruses, demonstrating its role as the source of infection. samples from the water system were negative for all viruses tested. chlorine levels were found to be low, probably due to a malfunctioning of the pool chlorination system. five hadv outbreaks associated with swimming were recorded in the 2000s. in the year 2000, an outbreak of pharyngoconjunctival fever occurred in north queensland, australia, where, after a school camp, 34 children aged 4-12, got sick [19] . in addition to primary cases acquired at the camp (n • = 25), nine other cases were acquired within the households. the school camp had a large saltwater swimming pool. adenovirus 3 was isolated from eye and throat swabs. a pcr analysis of water samples for hadv did not yield positive results. it was, however, demonstrated that the pool was not properly maintained, and that the level of residual chlorine was inadequate. an outbreak of pharyngoconjunctival fever affecting 59 children under 15 was recorded in a municipality of northern spain in july 2008 [20] . forty-three cases were recognized as primary cases, all of whom attended a municipal swimming pool. the remaining 15 children were secondary cases, which had been in close contact with a primary case. adenovirus type 4 was detected in pharyngeal swabs. electrical system failures causing the intermittent breakdown of the pool's bromine dosing pumps and the slowing down of water circulation were assumed to have been the cause of the outbreak. swimming was only allowed after the disinfection system was restored and appropriate concentrations of bromine were reached. due to logistic problems, no water samples were taken from the swimming pool for virological analysis. in 2011, children (4-9 years old) who had attended a swimming training center in eastern china showed symptoms of pharyngoconjunctival fever. adenovirus type 3 was recognized as the etiological agent [21] . a total of 134 cases were confirmed from among 900 amateur swimmers, with an incidence of 14.9%. fourteen hospital admissions were documented. fever, tonsillitis, sore throat, headache, sneezing, cough, conjunctivitis, fatigue, and diarrhea occurred among the bathers. the low level of residual chlorine in the water, along with excessive crowding in the pool were suggested as having caused the epidemic. in the same year, in a primary school in taiwan, an outbreak of hadv infection occurred among 373 students, with four hospitalizations [22] . most of the students attended a swimming course in two swimming facilities outside the school and presented with fever and symptoms of upper respiratory tract infection. other symptoms included diarrhea, vomiting, skin eruptions and conjunctivitis. throat swabs of affected students were tested for influenza virus, adenovirus, respiratory syncytial virus, coronavirus, metapneumovirus, parainfluenza types 1-4, and herpes simplex virus. samples were found positive only for hadv type 7. water samples were not obtained from any of the facilities for virological analysis. in 2013, an outbreak of pharyngoconjunctival fever involved 55 people (49 students and six staff) at a university in beijing, china [23] . fifty patients (91%) attending the same swimming pool two weeks before the onset of symptoms were considered primary cases. the other five subjects (9%) who had not swum in the pool were defined as secondary cases (person-to-person transmission). human adv type 4 was identified from both eye and throat swabs of the patients and from concentrated swimming pool water samples. gene sequences obtained from the water samples exhibited a 100% match with the sequences obtained from swab samples. control measures included the emptying and closing of the pool, and the disinfection with a high dose of sodium hypochlorite (500 mg/l). enterovirus is a genus in the family picornaviridae, consisting of four human enterovirus species. enteroviruses can cause many illnesses, including paralysis, meningitis, and cardiomyopathy, although most infections are asymptomatic or cause less severe conditions, such as colds and fever. a number of reports have described enterovirus infections linked to swimming pools. the first enterovirus swimming pool-related outbreak occurred in 1987, at a municipal pool in colorado, usa. twenty-six children presented with fever along with at least one additional symptom such as malaise, headache, stomachache, nausea, or diarrhea [24] . it was found that the pool chlorination system was operating improperly, with chlorine levels close to zero. stool specimens collected from the children affected were tested for common enteric bacterial pathogens (salmonella, shigella, aeromonas, and campylobacter), but not for viruses. enterovirus was suggested as a likely etiological agent based on clinical manifestations, course of disease, incubation time, and the exclusion of likely bacterial pathogens. an enterovirus outbreak occurred in ireland in 1992, with 46 cases experiencing vomiting, diarrhea, and headache after attending an outdoor swimming pool in a small seaside village. one subject had vomited into the pool, and echovirus 30 was isolated from this case and from six other cases. chlorine levels were found to comply with health standards, but were inadequate to contain the risk of infection from vomitus [25] . another echovirus 30 outbreak occurred in rome, italy, in late 1997 [26] . children from two schools showed clinical manifestations after swimming in a pool. twenty children had meningitis-like symptoms (fever, headache, and vomiting), and six of them were hospitalized. other 48 children had respiratory symptoms consistent with enterovirus infection. echovirus 30 was isolated from the cerebrospinal fluid and stools of the hospitalized children. based on the epidemiological characteristics, it was hypothesized that person-to-person transmission occurred both at the swimming pool and in a number of classrooms. data on chlorination at the time of the outbreak were not available. virological analysis of pool water was performed one month after the outbreak, but yielded no positive results. in south africa, an outbreak involving 90 children occurred following a summer camp in 2001 [27] . camp activities included swimming and other aquatic sports. symptoms included mainly headaches, sore eyes, and/or abdominal discomfort, with one case of vomiting. four children were hospitalized for meningitis. echovirus 3 was detected in cerebrospinal fluid and stool samples from symptomatic and asymptomatic children. the presence of viruses in the pool was not investigated. water contamination was confirmed through a total coliform count. in germany, 215 cases of aseptic meningitis were recorded from july to october 2001 [28] . swimming in a public, nature-like pond was identified as a risk factor for disease. up to 1500 people visited the pond each day during the summer holidays. echovirus 3 and 30 were detected in cerebrospinal fluid samples taken from some of the patients. an echovirus 30 sequence obtained from one water sample collected from the pond showed a high level of genetic similarity (99% nucleotide homology) with sequences obtained from patient isolates. in august 2003, an outbreak of meningitis occurred among campers staying at a campground in connecticut, usa [29] . a total of 12 cases of aseptic meningitis, four hospitalized patients and 24 cases of enterovirus-like illness with symptoms such as headache, neck stiffness, photophobia, sore throat, chills, or exanthema were identified. echovirus serotype 9 was detected in cerebrospinal fluid samples from three of the patients. the spread of the virus was associated with swimming in a crowded pool, which had low chlorine levels. as a result, the pool water was intermittently contaminated with enterovirus. hepatitis a is a virus causing mild to severe liver disease. globally, there are an estimated 1.4 million cases of hepatitis a every year. the virus is transmitted mainly via the fecal/oral route through the ingestion of contaminated food and water, or through direct contact with an infected subject. there is evidence to suggest that hepatitis a can be acquired by swimming in contaminated water. in september 1979, an outbreak of hepatitis a affecting 56 children (5-17 years old) and causing 31 hospitalizations was recorded in hungary [30] . all of the children swam in a pool at a summer camp. the pool was a non-chlorinated thermal pool/spa, which was overcrowded during the month of august. it was concluded that crowding and poor hygienic conditions, with a suspected accidental fecal release, contributed to the outbreak. another outbreak of hepatitis a was described in the usa during 1989. it involved 20 cases, probably associated with a public swimming pool [31] . it was hypothesized that a cross-connection between a sewage line and the pool water intake line may have been the cause of the outbreak. according to another hypothesis, it was a swimmer who contaminated the water in the pool. however, disinfectant levels in the pools met local standards. seven hepatitis a cases among children from six families were documented in australia in 1997 [32] . the children had attended an outdoor spa pool treated with hydrogen peroxide solution. it was hypothesized that hepatitis a virus was shed by the index case in the spa pool, and subsequently ingested by the others, who became secondary cases. virological analyses of water samples were not performed. noroviruses (novs), formerly known as norwalk-like viruses, are small viruses within the family caliciviridae, subdivided into at least seven genogroups (gi-vii), with gi, gii, and giv infecting humans. they are recognized as a major cause of sporadic and epidemic gastroenteritis in both industrialized and non-industrialized countries. outbreaks have been associated with a variety of settings including childcare centers, hospitals, nursing homes, cruise ships and restaurants. noroviruses are mainly transmitted via the fecal-oral route through contaminated food or water. norovirus-contaminated water-both recreational and drinking water-can thus lead to waterborne infections. a number of nov swimming-pool related outbreaks have been described. in 1977, an outbreak of acute gastroenteritis with the typical symptoms of vomiting, cramping, nausea and diarrhea was documented among 103 students and teachers at a primary school in ohio, usa [33] . serologic studies suggested infection by norwalk virus to be the cause of the outbreak. the first cases recorded were caused by swimming in a contaminated pool, and a person-to-person transmission followed. the water of the pool tested negative for both bacterial and viral pathogens. water contamination was linked to both the pool chlorinator, which was accidentally turned off at the time of the school visits, and a leak in the water supply pipes. a large outbreak of gastroenteritis due to novs was recorded in july 2001 in helsinki. it involved 242 people (children and adults) after bathing in an outdoor wading pool [34] . norovirus and astrovirus were detected in both patient stool samples and pool water, with identical nucleotide sequences. the pool was found to be heavily contaminated with human fecal material carried from public toilets. the pool water had been manually chlorinated three times per week, thus not continuously. to control the outbreak, the pool was emptied, refilled, and the water was heavily chlorinated (up to 10 mg/l of free chlorine). for the subsequent swimming season, the pool was equipped with both a continuous chlorination system and a water filtration system. in 2002, a nov outbreak associated with a swimming pool was reported in minnesota, usa. thirty-six persons of three different youth sports teams became ill after swimming in a hotel pool and spa [29] . unfortunately, there is no other information available on this epidemic. in 2004, an acute gastroenteritis epidemic affected 53 people who had swum in a pool in vermont, usa. vomiting and/or diarrhea occurred within 72 h of attending a private indoor pool. specimens tested positive for nov. at the time of the inspection, no equipment failures or irregularities were identified. nevertheless, deficiencies in pool operation and maintenance, including poorly trained operators, inadequate maintenance checks, failure to alert management, and insufficient record keeping were reported [35] . finally, yoder and coworkers documented a nov outbreak linked to a hotel pool in wisconsin, usa in 2006, with 18 persons exhibiting symptoms of gastroenteritis, related to inadequate disinfection and continued use by ill swimmers [36] . 59 hadv 4 spain not tested 2008 [20] 134 hadv 3 china not tested 2011 [21] 373 hadv 7 taiwan not tested 2011 [22] 55 yes. gene sequences obtained from the water samples were 100% identical to the sequences obtained from the swab samples. 2013 [23] to date, a limited number of studies examined the extent of viral contamination in swimming pools under non-epidemic conditions. the first isolation of viruses from urban wading pools was documented in albany, ny, usa in 1959 [37] . two enteroviruses (echovirus 3 and echovirus 11) were identified from two chlorinated pools, both filled with water from the municipal supply. the same echovirus strains were found to be present in raw sewage sampled at the albany treatment plant, reflecting widespread infection in the community. in toronto, canada, coxsackievirus b1 was isolated from children with pleurodynia, myalgia, and primary peritonitis during 1964. examination for the virus content of a gauze swab, which was placed daily in a wading pool with high bather load located in a congested city area, revealed the presence of the same coxsackievirus type [38] . in 1979 in israel, swimming pool samples were found positive for enterovirus: three for echovirus 7, two for coxsackievirus b6, and one for echovirus 6 [39] . viruses were isolated from water samples with no detectable fecal or total coliform bacteria. different enteroviruses were detected in swimming pools and wading pools equipped with gas chlorine and sand/gravel filters in texas, usa, in 1980 [40] . after virus concentration from water, samples were assayed on cell culture and plaque assays. enteroviruses were found in 10/14 (71%) of the examined samples. coxsackieviruses b3 and b4, poliovirus 1, and echovirus 7 were isolated in pool waters. no correlation was found with total coliform bacteria, as six among the positive virus samples were negative for coliforms. in three samples, viruses were detected in the presence of free chlorine exceeding 0.4 ppm and in the absence of coliforms, indicating that viruses can survive low levels of biocides in actively used pools. cell cultures used in the study were suited for the isolation of enteroviruses, but it is likely that other viruses, not capable of growing on those cell lines, could also have been present in the water. three years later, in 1983, enteroviruses were detected in 28.4% of 116 water samples [41] collected from three outdoor swimming pools. a direct correlation was established between viral and microbial contamination, and the low exchange of water in the pools. in 2004, van heerden and coworkers detected hadv in 12 of 64 samples (18.7%) from an indoor swimming pool and in three of 28 samples (10.7%) from an outdoor swimming pool [7] . quantitative data were also obtained by real-time pcr. application of these results in an exponential risk assessment model, assuming a daily ingestion of 30 ml of water during swimming, indicated a daily risk of infection ranging from 1.92 × 10 −3 to 3.69 × 10 −3 . no acceptable microbial risk has thus far been established for swimming pool water. however, pool water quality is generally considered comparable to drinking water quality (absence of fecal indicators and pathogens). for this reason, a maximum of one infection per 10,000 consumers per year has been recommended as an acceptable level of microbial risk for swimming pools. the risk of hadv infections calculated for the swimming pool water in the study exceeded this acceptable risk. more recently, in 2007 in cyprus, hadvs and enteroviruses were detected in public swimming pools complying with bacteriological standards (such as fecal coliforms and enterococci) [42] . the investigation was performed over a period of 21 months, from april 2007 to december 2008. a total of 126 samples were obtained from swimming pools located in five major cities. bacteriological marker analysis showed that 98% of pools complied with the national regulations. enteroviruses were identified in four swimming pools, one containing echovirus 18, two containing echovirus 30 and one containing poliovirus sabin 1. in four swimming pools, hadvs were detected, all characterized as type 41. in 2013-2014, a study investigated the presence of human enteric viruses (adenovirus, norovirus, and enterovirus) in indoor and outdoor swimming pool waters in rome. bacteriological parameters (fecal indicator bacteria, heterotrophic plate count, pseudomonas aeruginosa, and staphylococcus aureus) were also investigated [43] . moreover, the study was the first to examine the occurrence of non-enteric viruses in swimming pool waters: human papillomavirus (hpv) and human polyomavirus (hpyv). interestingly, enteric viruses were not detected, while both hpvs and hpyvs were identified in 9/14 swimming pool water samples, by means of molecular methods. neither of these viruses had previously been recognized as potential recreational waterborne pathogens, although the who guidelines for safe recreational water environments do include hpvs among non-fecally-derived viruses as viruses associated with plantar warts [3] . a variety of hpvs and hpyvs were found in another study investigating spa/pool waters in rome [44] . recently, disinfected water from sixteen pools and spa collected in rome between 2015 and 2018 were examined for the presence of human enteric viruses (adenovirus, norovirus and enterovirus. viruses were detected in 25% of the analyzed samples by molecular methods: two samples were positive for adenovirus (type 41) and three samples for norovirus gii (type gii.4) (bonadonna et al., unpublished data). starting with the first hadv outbreak recorded in 1951, we reviewed all of the reports concerning swimming-pool related viral illness. the data collected here confirm the involvement of viruses in cases and outbreaks associated with swimming pool attendance. a number of considerations emerge: • the paper reviews 29 viral outbreaks due to adenovirus, enterovirus, hepatitis a virus, and norovirus, accounting for more than 3000 cases. nevertheless, there are likely to have been many other undetected cases and outbreaks. in fact, waterborne diseases are difficult to record because of their wide variety, the difficulty associating symptoms with water use/contact, and the limitations of pathogen detection methods. in the studies described, viruses responsible for reported cases were detected in pool waters only in 21% of the outbreaks, and were found to match with viruses of clinical origin. currently, better and more rapid methods for the detection of viruses in water samples are available than in the past, resulting in better studies and improved reporting of viral recreational outbreaks worldwide. this allows researchers to identify the causes of outbreaks and possible contributing factors for them. an excellent model to follow is the us-waterborne disease and outbreak surveillance system (wbdoss) that has been collecting and reporting data related to occurrences and causes of waterborne disease outbreaks associated with drinking and recreational waters since 1971. • some of the studies found that waters meeting state or local water quality requirements contained enteric viruses and were the source of disease outbreaks, confirming that bacterial indicators are unreliable indicators of the presence of viruses and that enteric viruses are important hazardous waterborne pathogens. indeed, despite the relatively low concentration of viruses in water, they may nevertheless pose health risks due to their low infectious doses (10-100 virions). the human illnesses associated with enteric viruses in the reviewed studies were diverse: the most commonly reported symptoms were gastroenteritis, respiratory symptoms, and conjunctivitis. more severe symptoms were also documented, however, including hepatitis and central nervous system infections (aseptic meningitis). the majority of the outbreaks described involved mainly children and young people less than 18 years of age. this may be attributable to differences in behaviors, susceptibility and/or immune defenses between children and adults. children are known to experience more severe symptoms than adults. • low concentrations of disinfectant/disinfection malfunction in swimming pools were reported in the vast majority of the outbreaks. only in one case the concentration of biocide was considered high. in light of the health hazards posed by swimming pools, it is essential to constantly monitor water quality in swimming pools and to assess the effectiveness of treatment and disinfection processes and compliance with standards. specifically, appropriate chemical and microbial evaluation of water quality should be carried out, especially when large numbers of bathers are expected to use the pools. overcrowding should in any case be prevented. since the behavior of swimmers may affect water quality, strict rules of behavior in the pool should be followed and enforced, including shower before entering the water, wash hands after using the toilet, take children to bathroom before swimming, and, importantly, avoid swimming while sick. viruses in recreational water-borne disease outbreaks: a review the risk of contracting infectious diseases in public swimming pools. a review handbook of foodborne diseases waterborne adenovirus detection and risk assessment of adenoviruses in swimming pool water detection and quantification of human adenovirus genomes in acanthamoeba isolated from swimming pools an epidemic of conjunctivitis in colorado associated with pharyngitis, muscle pain, and pyrexia pharyngoconjunctival fever; epidemiological studies of a recently recognized disease entity the role of the swimming pool in the transmission of pharyngeal-conjunctival fever adenovirus type 3 epidemic associated with intermittent chlorination of a swimming pool epidemic of adenovirus type 7 acute conjunctivitis in swimmers an outbreak of adenovirus type 3 disease at a private recreation center swimming pool pharyngoconjunctival fever caused by adenovirus type 4: report of a swimming pool-related outbreak with recovery of virus from pool water community outbreak of adenovirus type 7a infections associated with a swimming pool detection of adenovirus outbreak at a municipal swimming pool by nested pcr amplification a primary school outbreak of pharyngoconjunctival fever caused by adenovirus type 3 a swimming pool-related outbreak of pharyngoconjunctival fever in children due to adenovirus type 4 two adenovirus serotype 3 outbreaks associated with febrile respiratory disease and pharyngoconjunctival fever in children under 15 years of age in hangzhou, china, during 2011 an adenovirus outbreak associated with a swimming facility a swimming pool-associated outbreak of pharyngoconjunctival fever caused by human adenovirus type 4 in beijing an outbreak of an enterovirus-like illness at a community wading pool: implications for public health inspection programs a community outbreak of echovirus infection associated with an outdoor swimming pool an outbreak of aseptic meningitis due to echovirus 30 associated with attending school and swimming in pools investigation into a school enterovirus outbreak using pcr detection and serotype identification based on the 5' non-coding region an outbreak of viral meningitis associated with a public swimming pond surveillance for waterborne-disease outbreaks associated with recreational water-united states hollos, i. an outbreak of hepatitis a due to a thermal spa an outbreak of hepatitis a associated with swimming in a public pool an outbreak of hepatitis a associated with a spa pool an outbreak of norwalk gastroenteritis associated with swimming in a pool and secondary person-to-person transmission wading pool water contaminated with both noroviruses and astroviruses as the source of a gastroenteritis outbreak outbreak of norovirus illness associated with a swimming pool surveillance for waterborne disease and outbreaks associated with recreational water use and other aquatic facility-associated health events-united states enteric viruses in wading pools enteroviral syndromes in toronto relationship of viruses and indicator bacteria in water and wastewater of israel occurrence of enteroviruses in community swimming pools enterovirus contamination of swimming pool water; correlation with bacteriological indicators analysis of enterovirus and adenovirus presence in swimming pools in cyprus from first detection of papillomaviruses and polyomaviruses in swimming pool waters: unrecognized recreational water-related pathogens? detection of oncogenic viruses in water environments by a luminex-based multiplex platform for high throughput screening of infectious agents author contributions: l.b. and g.l.r. conceived and wrote the paper, and approved the submitted version.funding: this research received no external funding. the authors declare no conflict of interest. key: cord-353173-5c4n4tsf authors: comunian, silvia; dongo, dario; milani, chiara; palestini, paola title: air pollution and covid-19: the role of particulate matter in the spread and increase of covid-19’s morbidity and mortality date: 2020-06-22 journal: int j environ res public health doi: 10.3390/ijerph17124487 sha: doc_id: 353173 cord_uid: 5c4n4tsf sars-cov-2 virus (covid-19) is a member of the coronavirus family and is responsible for the pandemic recently declared by the world health organization. a positive correlation has been observed between the spread of the virus and air pollution, one of the greatest challenges of our millennium. covid-19 could have an air transmission and atmospheric particulate matter (pm) could create a suitable environment for transporting the virus at greater distances than those considered for close contact. moreover, pm induces inflammation in lung cells and exposure to pm could increase the susceptibility and severity of the covid-19 patient symptoms. the new coronavirus has been shown to trigger an inflammatory storm that would be sustained in the case of pre-exposure to polluting agents. in this review, we highlight the potential role of pm in the spread of covid-19, focusing on italian cities whose pm daily concentrations were found to be higher than the annual average allowed during the months preceding the epidemic. furthermore, we analyze the positive correlation between the virus spread, pm, and angiotensin-converting enzyme 2 (ace2), a receptor involved in the entry of the virus into pulmonary cells and inflammation. on 11 march 2020, the world health organization (who) declared the coronavirus pandemic: the sars-cov-2 virus (covid-19) is a threat to the population's health. air pollution is also one of the greatest challenges of our millennium, and some early studies have highlighted a positive correlation between air pollution and the spread of the virus. therefore, it is crucial to define which role the atmospheric particulate plays in the spread, morbidity, and mortality of the virus. in this context, two hypotheses should be highlighted. first, covid-19, similarly to other viruses, could also have an airborne transmission, and particulate matter (pm) could act as a carrier through the aerosol, conveying the virus and increasing its spread. secondly, pm could instead have induced damage to the lung cells, increasing the inflammation state [1] . this rise of inflammation may increase the mortality rate and the severity of expression of the disease in the most polluted areas. the virus binds to the angiotensin-converting enzyme 2 (ace2) receptor to enter the cell; ace2 generates an anti-inflammatory peptide and is overexpressed to play its role in the case of inflammation from pm exposure, thus increasing the probability of covid-19 entering the cells [2] . these hypotheses, which be applied in closed environments to decrease the probability of spreading these viral pathogens [8] . this phenomenon has been analyzed in a hong kong hospital during the 2003 epidemic. in this analysis, it is observed that the droplets are moist, but begin to evaporate after release by decreasing their size and may become small enough to circulate in the air. in the hong kong hospital, the distribution of air was analyzed, and it was shown that an unbalanced air diffuser distribution led to the spread of the sars-cov-1 virus in the 8 a department, where a greater incidence of the number of infections occurred [9] . a similar study was conducted in amoy garderns, a group of residential buildings in hong kong that recorded an outbreak of sars in 2003. the investigators analyzed the ventilation system and the air transmission of the virus, focusing on the residence buildings with the most elevated number of infections. this analysis further confirms the need for reviewing the internal air quality and ventilation designs in buildings, offices, homes, hotels, and hospitals [10] . the transmission modes of sars-cov-1 and covid-19 are very similar, as covid-19 also persists in the air, and thus it can be assumed that it is also transported at greater distances than those observed in close contact infection. despite the similarities between the new and previous viruses, why has the new coronavirus displayed a higher spread rate in some areas? the air is composed of 78% nitrogen, 21% oxygen, and 1% other gases. man is introducing into the air new components that can be harmful to the environment and human health. air pollution is the result of the presence of gas and contaminating particles in the atmosphere. the gases include carbon monoxide (co), nitrogen oxides (nox), ozone (o 3 ), sulfur dioxides (so 2 ), ammonia (nh 3 ), and volatile organic compounds (vocs), as well as some gaseous forms of metals. particulate matter (pm) instead includes a mixture of compounds that can be grouped into five major categories: sulphates, nitrates, elemental carbon, organic carbon, and crustal materials (such as earth and ash). pm, as defined by the environmental protection agency (epa), is a term that indicates the set of particles dispersed in the air for enough time to be diffused and transported. there are many sources of these particles. pm is classified as pm10 and pm2.5 based on a diameter of less than 10 micrometers or 2.5 micrometers, respectively [11] . pm are inhalable corpuscles that cause various damage to human health owing to their small size. their toxicity is then increased as they can adsorb other substances such as polycyclic aromatic hydrocarbons (pahs) and heavy metals. hydrocarbons derive from oil and are higher in concentration during winter [12] . pahs are hydrocarbons made up of two or more joined aromatic rings. metals, on the other hand, are natural constituents of the earth's crust. metals that are toxic and tend to accumulate are mercury, chromium, cadmium, arsenic, lead, and uranium [13] . air pollution is a global public health emergency that affects people of all ages in every part of the world. nowadays, addressing ambient air pollution is the priority of the government, and the who issues air quality guidelines to defend the population in general, and the most vulnerable in particular [14] . numerous epidemiological studies have shown the effects of air pollution on respiratory and cardiovascular systems. short-term exposure to air pollution at higher levels reduces life expectancy by aggravating pre-existing respiratory and cardiovascular diseases [15] . cardiovascular effects induced by pm are linked to particles' deposition in the lungs, to their translocation through the air-blood barrier to extra-pulmonary sites, and to the resulting systemic inflammation [16, 17] . particles' deposition rates are strictly linked to the particle size-smaller particles have the highest deposition efficiency. numerous studies also highlight correlations between the effect of pm and male infertility [18] as well as neurodegenerative diseases [19] [20] [21] . in lombardy (north of italy), diesel combustion and solid biomass burning are responsible for 15% and 50% of the primary fine particles production, respectively [22] . diesel exhaust is a complex mixture of solid, condensed (or liquid), and gaseous corpuscular fractions [23] . the solid fraction is represented by diesel exhaust particles (deps), with a bio-persistent core of about 10-30 nm in diameter [24] . these primary particles, composed of elemental carbon, can then agglomerate into larger soot aggregates with mean diameters of 60-100 nm [23] . the dep surface can adsorb more than 300 chemical compounds, which include pahs, aliphatic hydrocarbons, quinones, transition metals, and others [25] . moreover, biomass burning (bb)-derived particles are obtained as a result of inefficient combustion that generates a multitude of partially oxidized organic chemicals, many of which have been associated with adverse health impacts [22] . however, dep has been shown to be even more toxic than bb [26] . these particles are included in pm2.5 fraction, are less than 0.1 micrometers in size, and thus can be classified as ultrafine particles (ufps). ufps can show worse and different toxicity profiles in comparison with those of larger particles with the same composition, as their specific interaction with lung cells and their capability to translocate across the alveolar epithelial barrier [27] . nonetheless, it cannot be excluded that systemic toxicity may be mediated also by pm or ufps associated water-soluble components and/or biochemical mediators released in the lung and then translocated in blood circulation. who has also indicated air pollution as responsible for a great risk for environment and health. even more harmful to health is indoor air pollution in large urban areas. it is thus essential to have correct ventilation systems in closed environments as the particulate matter in the aerosol can also host pathogens such as viruses and bacteria, which can thus be easily transmitted. air is a vehicle through which microbial agents can move around the environment. plants and cellular fragments, bacteria, fungi, viruses, parasites, and spores can be components of the bioaerosol [5] . atmospheric pm would function as a carrier, or as a transport vector, for many viruses. thus, pm may have increased the effectiveness of the virus spread in the aerosol as it creates a microenvironment suitable for its persistence [28] . pm10 and pm2.5 can be inhaled and, in addition to the polluting particles, the associated microorganisms are inhaled, too. recent studies also indicate that microbial community composition and concentration are significantly affected by particle concentration and dimension [29] . the particles could also act as carriers, which have complex adsorption and toxicity effects on bacteria [30] . certain particle components are also available as nutrition for bacteria and the toxic effect dominates in heavy pollution. the analysis of franzetti et al. [31] of microbial community in pm10 and pm2.5 sampled in winter and summer in milan (italy) showed large seasonal variations in the microbial communities, with plant associated bacteria dominating in summer and spore forming bacteria in winter. the results obtained also indicate not only that the pm source can influence the presence of specific bacterial groups, but also that environmental factors and stresses can shape the bacterial community. in addition, inhalation transports the particles deep into the lungs, especially those smaller than 2.5 microns (pm2.5 and ufps), and this allows the virus to develop within the respiratory tract and to cause infections. in 2007, ciencewicki and jaspers [32] reviewed different epidemiological and experimental studies, examining the association between and the effect of air pollutants and viral respiratory infections, though potential mechanisms mediating these effects are largely unexplored. in beijing, china, the composition of organisms in the air pollutants during a period with a high smog level was tested in a metagenomics analysis. sequences of several pathogens including viral particles (0.1% in both pm10 and pm2.5) were identified. the quantity of these pathogens for the respiratory tract increases with the increase in the concentration of pollutants [33] . the avian influenza virus (h5n1) could be transported across long distances by fine dust during asian storms [3] , and the correlation between pm concentration and the virus spread has been observed in the case of the spread of measles in china. pm2.5 concentrations in 21 chinese cities and the number of measles cases per day per city were studied. the analysis showed a positive correlation between those two factors. the 10 µg/m 3 increase in pm2.5 per day is associated with a significant rise in the disease incidence [34] . a similar analysis of the children's respiratory syncytial virus (rsv) spread in china in 2015 shows the same correlation. rsv is a virus that causes damage to the lungs and bronchitis. a positive correlation between the virus and pm concentration was observed. in fact, pollution increases the risk of rsv infection [35] . a 2018 analysis, carried out in the po valley, associates hospitalizations and the number of new rsv cases with pm10 concentration. the data for the analysis were collected by arpa (regional environmental protection agency) in the region. the results of this analysis showed that, in the designated period, the highest number of hospitalizations occurred in milan, the city that had reached the maximum concentration of pm10. this study also shows a correlation between short-and medium-term pm10 exposures (in particular, in the two weeks preceding hospital admission) and increased risk of hospitalization owing to rsv bronchiolitis among infants [36] . there are several mechanisms by which pm induces an increase in infected cases. a mechanism can be that the virus is bound to particles and transported, if favored by climatic conditions [34] . concerning the effect of pm pollution and the spread of viruses in the population, several recent studies have analyzed whether the different areas of the world with a high and rapid increase in covid-19's contagion were correlated to a greater level of air pollution. at present, there are three world areas where there has been a high number of people infected by covid-19: china, where the pandemic started; italy; and the usa, and the link between these countries is the very high level of air pollutants. this is the reason that recent studies have focused on these areas to find a possible correlation in air pollution and covid-19's contagion. the investigation of this possible correlation should be analyzed at two levels: (a) the high level of air pollution over the last years, which has made the population more sensitive to covid-19 (long-term exposition); or (b) the sensitivity to the virus, which is linked to the high level of air pollution in the period when the virus appeared (short-term exposition). it is known that chronic exposure to atmospheric pm contributes to increased hospitalizations and mortality, primarily affecting cardiovascular and respiratory systems, causing various diseases and pathologies including cancer [37] . premature deaths due to acute respiratory diseases from such pollutants are estimated to be over two million per year worldwide [38, 39] . to evaluate the long-term exposition hypothesis, pansini and fornacca [40] investigated the geographical expansion of the infection and correlated it with the annual indexes of air quality observed from the sentinel-5 satellite orbiting around china, italy, and the usa, using annual means, and analyzed different pollutant (pm10, pm2.5, sulfur dioxide, carbon monoxide, nitrogen dioxide, and ozone). the authors found positive significant correlations between covid-19 infections and air quality variables in each country and concluded that higher mortality was also correlated with poor air quality, namely, with high pm2.5, carbon monoxide, and nitrogen dioxide values. regarding italy, fattorini and regoli [41] and conticini and collaborators [42] came to the same conclusions. it is known that the distribution of atmospheric pollutants (pm2.5, pm10, nitrogen dioxide, and ozone) in italian regions during the last four years exceeds regulatory limits; in northern italy, particularly affected by covid-19 contagions, the population has been constantly exposed to a chronic high level of air pollution. the conclusive data of these papers indicate that long-term air-quality significantly correlated with the cases of covid-19 in up to 71 italian provinces, providing further evidence that long-term exposure to air pollution may represent a favorable context for the spread of the virus. finally, pansini and fornacca [43] , associating several annual satellite and ground indexes of air quality in china, iran, italy, spain, france, germany, united kindom, and usa with the covid-19 infection, found statistically significant positive correlations between the high level of air pollution and covid-19 infections. in italy, the correspondence between poor air quality and covid-19 appearance and its induced mortality was the starkest yet. recently, wu et al. [44] , fitting zero-inflated negative binomial mixed models (corrected for confounders), estimated for the united states a relationship between long-term exposure to pm2.5 and mortality rates to covid-19. they found statistically significant evidence. according to this analysis, a 1 ug/m 3 increase in long-term exposure to pm2.5 is associated with a 15% increase in covid-19 mortality rate. the results of this article suggest that long-term exposure to air pollution increases vulnerability to the occurrence of more severe covid-19 results. these findings are in line with the known relationship between pm2.5 exposure and many of the cardiovascular and respiratory comorbidities that significantly increase the risk of death in covid-19 patients [44] . concerning the effect of the short-term pm exposition and the spread of viruses in the population, the position paper proposed by the italian society of environmental medicine (sima) considers pm as an important carrier that has contributed to the spread of covid-19 [28] . the high, rapid spread of the covid-19 virus in the po valley, which is also the foremost place of polluted air in europe, could be related to the high concentrations of pm present in lombardy, before the covid-19 pandemic [45] . for example, bergamo, one of the italian cities with the highest number of infected, presents concentrations higher than the permitted annual average of pm10 and pm2.5 during the months of january and february 2020. the limits are 40 µg/m 3 for pm10 and 25 µg/m 3 for pm2.5. during these two months, a central unit of the city (via meucci station) has detected an average daily concentration of 44.28 µg/m 3 for pm10 and 38.31 µg/m 3 for pm2.5, both values above the maximum limit set. the number of days in which daily concentration values beyond the allowed threshold was observed for pm10 and pm2.5 to be 33 and 44, respectively ( figure 1 ). in brescia, during the same period, an average of 51.49 µg/m 3 for pm10 and 40.68 µg/m 3 for pm2.5 was observed by the control unit located in villaggio sereno, all values above the threshold. there are 42 days for pm10 and 46 days for pm2.5 in which the daily concentration exceeds the average annual concentration allowed ( figure 2 ). the same observation can occur in milan with the control unit in the città studi area, which showed an average concentration of 55.59 µg/m 3 for pm10 and 42.18 µg/m 3 for pm2.5 over the two months. moreover, in milan, 45 and 49 days were observed (for pm10 and pm2.5, respectively) with daily concentration values above the annual average allowed (figure 3) . from the analysis of the data collected by arpa (www.arpalombardia.it/pages/aria/qualita-aria. aspx) in the italian region during the months of january and february, concentrations of pm10 and pm2.5 were measured above the limits established by the country's regulatory parameters. in these same provinces, there is a high and rapid increase in covid-19's contagion ( figure 4 ). int. j. environ. res. public health 2020, 17, x; doi: www.mdpi.com/journal/ijerph concentrations higher than the permitted annual average of pm10 and pm2.5 during the months of january and february 2020. the limits are 40 μg/m 3 for pm10 and 25 μg/m 3 for pm2.5. during these two months, a central unit of the city (via meucci station) has detected an average daily concentration of 44.28 μg/m 3 for pm10 and 38.31 μg/m 3 for pm2.5, both values above the maximum limit set. the number of days in which daily concentration values beyond the allowed threshold was observed for pm10 and pm2.5 to be 33 and 44, respectively ( the same observation can occur in milan with the control unit in the città studi area, which showed an average concentration of 55.59 μg/m 3 for pm10 and 42.18 μg/m 3 for pm2.5 over the two months. moreover, in milan, 45 and 49 days were observed (for pm10 and pm2.5, respectively) with daily concentration values above the annual average allowed (figure 3) . from the analysis of the data collected by arpa (www.arpalombardia.it/pages/aria/qualitaaria.aspx) in the italian region during the months of january and february, concentrations of pm10 and pm2.5 were measured above the limits established by the country's regulatory parameters. in these same provinces, there is a high and rapid increase in covid-19's contagion ( figure 4) . www.mdpi.com/journal/ijerph months. moreover, in milan, 45 and 49 days were observed (for pm10 and pm2.5, respectively) with daily concentration values above the annual average allowed (figure 3) . from the analysis of the data collected by arpa (www.arpalombardia.it/pages/aria/qualitaaria.aspx) in the italian region during the months of january and february, concentrations of pm10 and pm2.5 were measured above the limits established by the country's regulatory parameters. in these same provinces, there is a high and rapid increase in covid-19's contagion (figure 4) . this evidence was confirmed by different studies. frontera et al. [47] , analyzing air quality in italy and china, in the period of maximum covid-19 virulence, found that pm2.5 and nitrogen dioxide levels were particularly high, and marteletti and marteletti [48] arrived at the same conclusions. according to recent sima analysis, these authors speculate that the atmosphere, rich of air pollutants, together with certain climatic conditions, may promote a longer permanence of the viral particles in the air, as a carrier, thus favoring an "indirect" diffusion. setti et al. [49] showed that a high frequency of pm10 concentration peaks (exceeding 50 μg/m 3 ) results in a spread acceleration of covid-19, suggesting a "boost effect" for the viral infectivity. they also found significance differences both in pm10 exceedances and covid-19 spreading between northern and southern italian regions and placed a focus on milan and rome. zhu et al. [50] analyzed the relationship between concentrations of six daily measured air pollutants (pm10, pm2.5, sulfur dioxide, carbon monoxide, nitrogen dioxide, and ozone) and confirmed covid-19 cases in 120 cities in china between 23 january 2020 and 9 february 2020 (shortterm exposition). the authors examined the effects of the six air pollutants using six separate models to reduce collinearity, as some of these pollutants were highly correlated. they found significant positive associations of pm2.5, pm10, carbon monoxide, nitrogen dioxide, and ozone with covid-19 confirmed cases, while sulfur dioxide was negatively associated. the authors conclude that there is a statistically significant relationship between short-term exposure to higher air pollution and an increased risk of covid-19 infection. the hypothesis that the atmosphere, rich of air pollutants, together with certain climatic this evidence was confirmed by different studies. frontera et al. [47] , analyzing air quality in italy and china, in the period of maximum covid-19 virulence, found that pm2.5 and nitrogen dioxide levels were particularly high, and marteletti and marteletti [48] arrived at the same conclusions. according to recent sima analysis, these authors speculate that the atmosphere, rich of air pollutants, together with certain climatic conditions, may promote a longer permanence of the viral particles in the air, as a carrier, thus favoring an "indirect" diffusion. setti et al. [49] showed that a high frequency of pm10 concentration peaks (exceeding 50 µg/m 3 ) results in a spread acceleration of covid-19, suggesting a "boost effect" for the viral infectivity. they also found significance differences both in pm10 exceedances and covid-19 spreading between northern and southern italian regions and placed a focus on milan and rome. zhu et al. [50] analyzed the relationship between concentrations of six daily measured air pollutants (pm10, pm2.5, sulfur dioxide, carbon monoxide, nitrogen dioxide, and ozone) and confirmed covid-19 cases in 120 cities in china between 23 january 2020 and 9 february 2020 (short-term exposition). the authors examined the effects of the six air pollutants using six separate models to reduce collinearity, as some of these pollutants were highly correlated. they found significant positive associations of pm2.5, pm10, carbon monoxide, nitrogen dioxide, and ozone with covid-19 confirmed cases, while sulfur dioxide was negatively associated. the authors conclude that there is a statistically significant relationship between short-term exposure to higher air pollution and an increased risk of covid-19 infection. the hypothesis that the atmosphere, rich of air pollutants, together with certain climatic conditions may promote a longer permanence of the of viral particles in the air, thus favoring an "indirect" diffusion in addition to the direct one (individual to individual), has been postulated in a recent letter to the editor of journal of infection [47] . considering a period of latency owing to the incubation of about 14 days, a positive correlation can be observed between the pm concentration data and the number of infections (figure 4) . the high concentrations of pm during january and february could have increased the virus spread rate and speed in late february/early march in lombardy more than in other italian regions. lastly, another point to consider is the climatic conditions that could also have played an important role in increasing the contagion. in fact, the main atmospheric circulation pattern during february 2020 was characterized by an anomalous anticyclonic system over the western mediterranean basin, centered between spain and italy, and lower pressures over northern europe. this climatic condition, which produces dry conditions over southwestern europe, may have provided optimal meteorological conditions for the virus propagation, both indoors and outdoors, in addition to the direct and indirect contact and short-range droplets [51] . thus, pm may have played a carrier role for covid-19. however, this remains one of the hypotheses, as the positive correlation between pollution in lombardy and in other countries and the outbreak of the epidemic could also be the result of other reasons. in fact, it is known from both in vitro and in vivo data and from epidemiological studies that lasting exposure to airborne pollutants induces a state of chronic lung inflammation [12, 32, [52] [53] [54] [55] [56] . numerous epidemiological studies have noted an association between pollution levels and hospitalizations for many reasons including respiratory diseases. an increase in the mortality rate of several viral diseases has also been observed. so, in addition to analyzing the pm role in transmission, it is important to understand how exposure to pollutants can increase the susceptibility and severity of these diseases. as already discussed, pm has small dimensions and, for this reason, it can be inhaled. the repeated inhalation of these particles causes damage to lungs' health. long-term exposure to particulate matter can induce systemic damage [32] . exposure to pollution has also been linked to the high mortality of the sars-cov-1 virus. cui et al. [57] , using the air pollution index (api), showed that, in the regions where this index was high, there was double the chance of death than the areas with a low api index. similarly, in areas with a moderate api index, there was an 84% probability of increased risk of death from sars. the authors conclude that lasting exposure to pm would increase the virus mortality rate. after having demonstrated the positive correlation between viral infections in the respiratory tract and exposure to pm, it is necessary to analyze the mechanism by which exposure to these agents can impact the subject's susceptibility and immune response to infection. as respiratory tract cells are the first target of pm, as well as the first target of respiratory viruses, pathogens will invade already compromised cells if subjects are exposed to pm for a long time. two mechanisms have been demonstrated to be induced in lungs after pm exposure, both in humans and experimental models [58]: oxidative stress; exposure to these pollutants induces the production of free radicals that induce damage the cells. inflammation; pm induces the activation of the immune response and thus the cell enters in an inflammatory state. begalli et al. [53] analyzed the effect of different deps on lung and vascular cells in vitro. the analysis highlights the increase in ros (reactive oxygen species) a marker of oxidative stress ( figure 5) . int dep is rich in many metal oxides toxic to humans. an analysis on lung cells a549 has shown a significant increase in il8, an interleukin used as an indicator of the pro-inflammatory response following exposure to pollutants ( figure 6 ) [52] . dep is rich in many metal oxides toxic to humans. an analysis on lung cells a549 has shown a significant increase in il8, an interleukin used as an indicator of the pro-inflammatory response following exposure to pollutants ( figure 6 ) [52] . dep is rich in many metal oxides toxic to humans. an analysis on lung cells a549 has shown a significant increase in il8, an interleukin used as an indicator of the pro-inflammatory response following exposure to pollutants ( figure 6 ) [52] . in fact, it has been observed that there are numerous mechanisms acting at the level of inflammation. for example, another mechanism to consider is the ability of pollutants to have effects on immunity by modulating the antiviral response of exposed subjects. a fundamental role of the inflammatory response is given by macrophages, cells that can incorporate foreign particles, including microorganisms, into their cytoplasm and destroy them (figure 7 ) [56] . however, some studies have shown that exposure to pollution can reduce the phagocytosis ability of macrophages, which thus will not be able to properly inactivate the viruses [54] . health 2020, 17, x; doi: www.mdpi.com/journal/ijerph inflammatory response is given by macrophages, cells that can incorporate foreign particles, including microorganisms, into their cytoplasm and destroy them (figure 7 ) [56] . however, some studies have shown that exposure to pollution can reduce the phagocytosis ability of macrophages, which thus will not be able to properly inactivate the viruses [54] . summing up, the exposure to polluting agents alters the immune response of the lung cells and induces an increase in oxidative and inflammatory stress. this cellular condition facilitates the attack of viruses and increases the severity of viral infections in exposed subjects. for example, pneumonia, often of viral origin, increases as a result of episodes of high pm10 pollution. a 1999 study already investigated how pm10 alters respiratory tract inflammatory responses to the syncytial virus (rsv), a frequent cause of viral pneumonia in infants and the elderly. it has been observed that, at high levels of pm10, the response to the virus is reduced because the immune response to both the virus and pm10, simultaneously detected, is less effective than the single immune response focused on defense against the rsv [59] . the po valley in northern italy, where milan is located, represents one of the most polluted areas of the country for both the high number of industries present and for its particular geographical conformation as it is enclosed between the alps and the apennines. during 2010, in milan torre sarca, pm10 and pm2.5 samples were collected, and administered to mice for the purpose of analyzing the damage due to exposure to these particulates in the lung. the microbiological analysis revealed the presence of pathogens adsorbed to the particles [31] , and in alveolar cells and in the summing up, the exposure to polluting agents alters the immune response of the lung cells and induces an increase in oxidative and inflammatory stress. this cellular condition facilitates the attack of viruses and increases the severity of viral infections in exposed subjects. for example, pneumonia, often of viral origin, increases as a result of episodes of high pm10 pollution. a 1999 study already investigated how pm10 alters respiratory tract inflammatory responses to the syncytial virus (rsv), a frequent cause of viral pneumonia in infants and the elderly. it has been observed that, at high levels of pm10, the response to the virus is reduced because the immune response to both the virus and pm10, simultaneously detected, is less effective than the single immune response focused on defense against the rsv [59] . the po valley in northern italy, where milan is located, represents one of the most polluted areas of the country for both the high number of industries present and for its particular geographical conformation as it is enclosed between the alps and the apennines. during 2010, in milan torre sarca, pm10 and pm2.5 samples were collected, and administered to mice for the purpose of analyzing the damage due to exposure to these particulates in the lung. the microbiological analysis revealed the presence of pathogens adsorbed to the particles [31] , and in alveolar cells and in the lungs, pm activated strong inflammatory responses. in fact, high levels of pro-inflammatory cytokines such as tumor necrosis factor (tnf)-alpha and il6 have been found [12] . it should be noted that il6 is responsible for the inflammatory storm that occurs in the most serious cases of patients with covid-19. pm10 performs a toxic action on the lung parenchyma; the analysis of the content of balf, a fluid resulting from mouse bronchoalveolar lavage, has shown an increase in cytotoxicity markers. pm also contains metals with a very high cytotoxic effect on cells. prolonged or persistent exposure to pm is supposed to exert heavy adverse effects on cell homeostasis mediated by a direct particles cell interaction within the district that pm reaches (lung, myocardial, or even neuronal tissues), or by the induction of a chronic inflammation, resulting in a general systemic inflammation and sustained oxidative stress status [59] . a systemic spreading of lung inflammation in pm10sum-treated mice has been related to the increased blood total cell count and neutrophils percentage, as well as to increased blood myeloperoxidase (mpo). the blood-endothelium interface activation has been confirmed by significant increases of plasma endothelin 1 (et-1) and sp-selectin. furthermore, pm10sum induced heart endothelial activation and pah metabolism, proved by increased et-1 and cytochrome p450 1b1 (cyp1b1) levels. moreover, pm10sum causes an increase in brain heme oxigenase 1 (ho-1) and et-1. these results state the translocation of inflammation mediators, ultrafine particles, lipopolysaccharide (lps), and metals associated to pm10sum, from lungs to bloodstream, thus triggering a systemic reaction, mainly involving the heart and brain. these results provided additional insight into the toxicity of pm10sum and could facilitate shedding light on mechanisms underlying the development of urban air pollution related diseases [55, 56] . another analysis showed that exposure to pm2.5 also determines a variation in the expression of some genes; the effect of pm acts systemically on the human body. sancini et al. [60] found that et-1, heat shock protein 70 (hsp70), cyp1a1, cyp1b1 and hsp70, ho-1, and mpo each increased within lung and heart of pm2.5win-treated mice. the pm2.5win exposure had a strong impact on global gene expression of heart tissue (181 upregulated and 178 down-regulated genes), but a lesser impact on lung tissue (14 up-regulated genes and 43 downregulated genes). therefore, prolonged exposure to high quantities of pm is a significant threat to people, especially the elderly, who may be apparently healthy, but with compromises in the lung and cardiovascular tissue [60] . recently, farina et al. [26] demonstrated in vivo the activation of inflammatory response (cox-2 and mpo) in both respiratory and cardiovascular systems, after exposure to ufps (dep or bb, biomass). exposure to dep also results in increases in pro-and anti-oxidant (ho-1, inos, cyp1b1, hsp70) protein levels, although stress persists only in cardiac tissue under repeated instillations. statistical correlations suggest that stress marker variation was probably the result of soluble components and/or mediators' translocation from the first deposition site. this mechanism appears more important after repeated instillations, as inflammation and oxidative stress endure only in the heart. in summary, the chemical composition of ufps influenced the activation of different responses mediated by their components or pro-inflammatory and pro-oxidative molecules, indicating dep as the most damaging pollutant in the comparison [26] . studies have shown that patients with systemic diseases have an increased risk of developing severe forms of covid-19 infection [61] . therefore, it cannot be excluded that the virus would be facilitated in the action on cells already in deficit. this cell's deficit would lead to more complex prognoses when there are damages to the lung and heart also owing to exposure to polluting agents. coronaviruses can generate mild or very serious pathological responses. when these viruses attack the lower part of the respiratory tract, they cause serious respiratory damage, which can be fatal. inflammation is an indispensable component of the response of our immune system. however, already for sars-cov-1, it was observed that, in patients with a worse course of the disease, there is a "cytokine storm", an excessive and dysregulated response [62] . the new covid-19 virus can also lead to several pathological effects, from milder ones, like colds and fever, to more severe ones, like pneumonia, that can get worse in acute respiratory distress syndrome (ards), a type of respiratory failure responsible for the accumulation of fluid in the lungs and excessive reduction of oxygen in the blood. ten percent of covid-19 cases can come to this pathological condition in which mechanical ventilation is involved and, in some cases, lead to death. the course of the disease is more complex for the elderly and for patients with other concurrent pathologies [63] . in the blood of the patients with severe symptoms of covid-19, very large quantities of il6 are detected, a marker of the inflammatory state. an inflammatory storm is observed; the immune response of the infected cells is to release cytokines that signal inflammation, but an excess of these pro-inflammatory signals can be harmful to the cells of the pulmonary epithelium [64] . the italian medicines agency (aifa) has authorized the first clinical trials to use drugs already available for treatment in covid-19. one approach is to lower the inflammation generated by a too strong immune response. in fact, among these trials, many concern anti-inflammatory drugs aimed at quenching the inflammatory storm. for example, tocilizumab is a monoclonal antibody that binds to the il6 receptor by deactivating it. therefore, blocking the il6 transduction pathway, the inflammatory state could be decreased [65] . there are some predispositions to the inflammatory storm owing to the presence of other pathologies. patients with a particular pathogenesis start from higher inflammatory cytokine levels and the advanced age unbalances the body towards a pro-inflammatory state. another option is that may there are some genetic predispositions. to these hypotheses, we could add a predisposition due to pm exposure. we observed that one of the pm mechanisms of action on cells is to trigger an inflammatory state, with the production of interleukins such as il8 or il6. we could thus assume a predisposition by the subjects most exposed to pm over time to a manifestation of this storm of cytokines following the covid-19 infection, and thus a more complicated course of the pathology. this hypothesis could explain the positive correlation between covid-19, the pm concentration, and the high mortality rate in some polluted areas, such as in lombardy. the analysis of conticini et. al. [42] of march 2020 proposes the correlation between air pollution and covid-19 lethality, which varies in the different regions in italy; in lombardy and emilia romagna on 21 march 2020, it was 12%, while in the rest of italy, it was 4.5%. exposure to polluting agents makes the inhabitants of these areas more prone to developing severe respiratory conditions and it would be a predisposition to add as a co-factor [42] . covid-19 is characterized by the presence of spike proteins on its crown, which allow it to bind to the angiotensin-converting enzyme 2 (ace2) receptor present on the cells. the virus enters the cells by endocytosis, infecting them. ace2 is a membrane enzyme found in the lungs, arteries, heart, kidney, and intestines' cells, and it regulates blood pressure by catalyzing the cut of the vasoconstrictor peptide, angiotensin 2, into angiotensin 1-7, which is instead a vasodilator and anti-inflammatory molecule [66] . it is hypothesized that, because increasing age leads to an increase in blood pressure, as a compensatory response, our body expresses a greater number of ace2 on cell membranes to respond to this effect. however, this increase in expression also heightens the targets that allow access to the covid-19 virus. some hypertensive drugs increase the expression of ace2, so this correlation should be verified. ace2 also has another task, as the angiotensin 1-7 peptide also has an anti-inflammatory function. it has been observed that the activation of ace2 can reduce the severity of lung damage from hyperoxia by inhibiting the inflammatory response and oxidative stress. ace2 can in fact inhibit the intracellular signal of nuclear factor kappa-light-chain-enhancer of activated b cells (nfkb) (pathway that activates the inflammatory response) and activate that of nuclear factor erythroid 2-related factor 2 (nrf2) (pathway that activates the anti-inflammatory response), as a protective mechanism against ros [67] . thus, an increase in ace2 increases the probability of attack by covid-19, but on the other hand, the virus, by binding to ace2, blocks its activity, which instead seems to be very important for the immune defense and protection against inflammation that we have seen to be the major cause of deaths from covid-19. a lasting exposure to pm2.5 triggers oxidative stress and inflammation, and the two pathways activated are those mentioned above: nrf2 to respond to oxidative stress and nfkb, which instead stimulates the inflammatory state [68] . in 2018, lin and coauthors [2] saw that exposure to pm2.5 induces acute lung injury (ali) in mice, leading to an increase in inflammation with an increase in cytokine levels. the effects of pm2.5 were observed in both wild type (wt) and in ace2 (knockout) mice. it was observed that, while in wt mice, there was an improvement in lung damage after a few days, in mice lacking ace2, the improvement was less evident. this confirms the fundamental role of ace2 in the defense of our cells from the pro-inflammatory action of pm2.5. however, the important point is that, in wt mice, the exposure to pm2.5 induces a significant increase in ace2 [2] . in conclusion, ace2 is important because (a) it activates the nrf2 (anti-inflammatory) pathway and instead turns off nfkb (inflammatory) to avoid a dysregulated inflammation response; (b) covid-19, by binding to ace2, alters this mechanism; and (c) ace2 is over-expressed following exposure to pm2.5, and thus it may be plausible that it could increase the probability of covid-19 infection, with ace2 being the entry key for the virus. recently, asselta et al. [69] have analyzed the possible genetic explanation for the male predisposition to covid-19 infections; the analysis focuses on two genes, tmprss2 and ace2. the first seems to be an excellent candidate because of the presence of a certain allelic variant in the italian male population. ace2, on the other hand, was not related to the sex-predisposition, but a single nucleotide polymorphism (snp), rs2285666, was detected in the italian and east asian population. this snp had already been analyzed as a potential risk factor for hypertension, type 2 diabetes, and coronary artery problems, and thus could be a genetic variant indicating a comorbidity for the virus. according to the study, ace2 would play an important role, but it remains to be assessed whether the increase in the level of lung gene expression is related to an increase in the susceptibility and severity of covid-19. this increase in the level of expression of this variant could be owing to exposure by pm [69] . these analyses on the pm and covid-19 correlation are the foundations to start wider research. the correlation between these factors is positive, but it is important to understand the mechanism that explains it. all mentioned studies indicate that both long-term exposure and short-term exposure to high levels of pollutants are correlated to an increase in covid-19 contagion worldwide. thus, it may be interesting to perform a systematic study, placing pm collection units at strategic points all over the world, for example, hospital departments with a low ventilation rate, and to analyze the microorganisms present in the search for covid-19 viral rna by metagenomics. preliminary data obtained by setti and collaborators [70] would support this hypothesis, as sars-cov-2 rna can be present on 34 outdoor samples collected in industrial site of bergamo province, in a three-week period, from 21 february to 13 march 13. on the other hand, the populations (also considering gender, age, and genetic factors) that live in areas at high levels of pollutants are in a chronic inflammatory state, which makes them more susceptible to respiratory and cardiovascular diseases. lastly, covid-19 infection should be investigated in relation to ace2 expression after pm exposure in order to verify the different susceptibility to infection by pm exposed and non-exposed cells. author contributions: conceptualization, s.c. and p.p.; writing-original draft preparation, s.c.; writing-review and editing, c.m. and p.p.; supervision, p.p. and d.d. all authors have read and agreed to the published version of the manuscript. funding: this research received no external funding. the authors declare no conflict of interest. the effect of fine particulate matter on the inflammatory responses in human upper airway mucosa instillation of particulate matter 2.5 induced acute lung injury and attenuated the injury recovery in ace2 knockout mice ambient influenza and avian influenza virus during dust storm days and 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angiotensin ii stimulation in vascular cells angiotensin-converting enzyme 2 attenuates inflammatory response and oxidative stress in hyperoxic lung injury by regulating nf-kappab and nrf2 pathways air pollution-derived pm2.5 impairs mitochondrial function in healthy and chronic obstructive pulmonary diseased human bronchial epithelial cells ace2 and tmprss2 variants and expression as candidates to sex and country differences in covid-19 severity in italy 2020 sars-cov-2 rna found on particulate matter of bergamo in northern italy: first preliminary evidence this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-355133-s1az6o5c authors: farronato, marco; boccalari, elisa; del rosso, ettore; lanteri, valentina; mulder, riaan; maspero, cinzia title: a scoping review of respirator literature and a survey among dental professionals date: 2020-08-17 journal: int j environ res public health doi: 10.3390/ijerph17165968 sha: doc_id: 355133 cord_uid: s1az6o5c severe acute respiratory syndrome coronavirus 2 (sars-cov-2) virus was discovered in china in late 2019 and subsequently triggered a global pandemic. dentists, like many other health professionals, are at an increased risk of contracting the virus as they work in close proximity to patients, especially when performing aerosol-generating procedures. thus, in order for dentists to protect themselves and their patients, it is recommended that practitioners wear filtering facepiece 2 (ffp2) respirators. the prolonged use of these ffp2 respirators has been linked to several side effects. the aim of this paper is to assess the perceived experience associated with n95/ffp2 respirators based on the available literature and data collected through an online survey completed by italian dental professionals. articles were included up to may 2020 and literature searches were conducted through the national library of medicine, cochrane central register of controlled trials, and embase databases. the search terms included covid-19, respirators, masks, and discomfort. an online survey was administered to 256 italian dentists. the results from this survey were in agreement with the available literature. the findings concurred that the prolonged use of respirators was associated with headaches (47.5%), severe exertion and discomfort (50.8%), moderate concentration problems (54.3%), moderate breathing difficulties (63.5%), and consequently, an impaired work ability (85.5%). these findings were not influenced by the number of hours spent wearing the respirator. despite several side effects, ffp2 respirators are fundamental in protecting dentists and their importance was acknowledged. the virus termed severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (covid-19-coronavirus disease 2019) was discovered in wuhan, hubei province, china late december 2019 [1] . it has triggered a global health crisis and in march 2020 [2] , the world health organization (who) declared covid-19 a pandemic. covid-19 infections have exceeded 13 million, with at least 578,000 deaths reported [3] . the most common symptoms are fever, dry cough, fatigue, sometimes associated with sore throat, headaches, runny nose, loss of smell, and diarrhea. scientists all over the world started studying covid-19 and based on the data collected from previous similar infectious diseases, protocols were swiftly implemented in order to minimize disease transmission. caps, face shields, goggles, gowns, shoe covers, and the appropriate filtering face pieces. many countries have advocated all of the aforementioned items during the performance of agps. covid-19 is associated with a very small viral particle size and ability to infect the lower respiratory tract. a clear difference exists between examination earloop masks and surgical masks that are produced following the technical standards uni en 14638. surgical masks are divided into three types in accordance with their filtering capacity (which is determined by the fabric, the bacterial filtering efficiency, and the facial seal) and resistance to splashes. surgical masks under the standard uni en 14638 are divided into: type i, ii, and iir (where r stands for resistance against spraying and humidity). for the technical standard astm f2100-11, surgical masks are divided into levels 1 to 3 and are similar to the aforementioned uni en 14638. type iir/level 3 surgical masks filter an average particle size of 2.7 µm and are resistant against droplets and splashes. hand hygiene is always advised before donning, doffing, or adjusting any mask or respirator. filtering face pieces (ffp) or respirators, without an exhalation valve, provide two-way protection for the wearer and the patient. these ffp respirators provide a greater facial seal compared to surgical masks. ffp respirators are classified, according to european classification standard en149:2001 based on their filtering efficiency of <0.3 µm droplets (ffp2 and ffp3). ffp2 can filter up to 94% of particles between 0.1 and 0.3 µm, extending this filtering capacity to 99% for particles of 0.75 µm and are made to the equivalent standard of the n95 respirator, which follows the niosh/fda american standards. ffp3, meanwhile, filter up to 99% of particles with <0.3 µm of diameter and are similar to the american n99. the n99/ffp3 respirators have one-way valves. however, there are conflicting approaches towards the efficacy and implementation of various levels of surgical masks versus n95/ffp2-and even n99/ffp3 respirators among different countries. the italian "istituto superiore di sanità" (iss) produced a document [15] in which, foreseeing a future global lack of ppe, highlighted the necessity to rationalize their use. it is important to prioritize the most at risk healthcare workers, such as those working in agps and/or in a long-term exposure environment. the iss document highlights the importance of adequate training that educates healthcare professionals of professional exposure risks. such a training program would provide them with an overview of the suitable ppe for various clinical and infrastructure scenarios. n95/ffp2 and n99/ffp3 respirators with the other aforementioned ppe are recommended for agps. surgical masks type iir/level 3 are sufficient when giving direct assistance to covid-19 patients, if filtering face pieces are not available. public health england's guidelines (department of health and social care in the united kingdom) require an n99/ffp3 respirator in case of agps and in some procedures which carry a high risk of infection, such as patients' intubation and extubation [16] . for direct care to covid-19 patients, type iir/level 3 surgical masks are recommended, and if there are none, an n95/ffp2 respirator is a suitable alternative [17] [18] [19] [20] . healthcare workers experienced masks and respirators differently based on their design features. the design features additionally allow their experience of discomfort and exertion to differ significantly during an 8 h work cycle [21] . the impact of prolonged respirator use, based on government regulations and ppe shortages, remains a growing problem for healthcare workers (hcw). in order to reduce the surface contamination of the respirator, an overlay with a medical face mask had been advised, purely to protect the respirator [22] . moreover, hypercapnia-related problems after many hours of wearing these respirators have been a concern to healthcare workers (hcw) and have been studied under in vitro conditions [23] and in vivo studies for respiratory fit tests [24] . laferty et al. focused on oxygen and carbon dioxide levels of subjects wearing n95 respirators in a test hood and results showed an increase in co 2 levels and a decrease in o 2 levels due to the important breathing resistance offered by n95 respirators. hypercapnia was also assessed, in another study, based on a normal working period of one hour [25] . during normal clinical activity, the healthcare workers experienced a decrease in o 2 and an increase in co 2 levels with the two respirators assessed. furthermore, several studies assessed the perceived effects of the respirators on the healthcare workers, but no studies have been completed with dental professionals. the objectives of this paper were to evaluate the relevant findings in the literature regarding the rationale for use of an n95/ffp2 respirator related to agps particle sizes [26] that could contain the covid-19 virus [6] in dental healthcare workers and assess the perceived symptoms experienced by dental professionals with the use of these respirators. the analysis of the survey results of the perceived symptoms from dental professionals would be valuable considering their elevated risk of transmission due to the various aerosol-generating procedures. this paper aims to compile the different survey questions based on a scoping review of the literature. all the literature was evaluated in the various search engines, although they could have evaluated responses from healthcare workers of different levels of surgical masks (type i, ii, and iir) and disposable respirators (n95/ffp2). additionally, a survey was completed with italian dental professionals in order to evaluate their perceptions and perceived experience while wearing the advised n95/ffp2 respirators. our review followed prisma guidelines for a scoping review. the studies included in this review matched the predefined criteria according to the picos (patients, intervention, comparator, outcomes, study design) process as reported in table 1 . studies not reporting the positive or negative effects of the use of masks and/or respirators. types of studies and participants: cross sectional and case control studies focusing on healthcare workers. type of intervention: use of respirators and/or masks in daily practice and their clinical side effects such as discomfort, exertion, breathing difficulties, and headaches. language: papers in english, italian, and spanish were included. the exclusion criteria were reviews (historical or systematic), opinion letters, case reports, case series, congress abstracts, papers not written in english, italian, and spanish, and studies not reporting the positive or negative effects on the use of respirators and/or face masks. three electronic databases were used in the search for studies satisfying the inclusion criteria for studies published until the 31 may 2020: the national library of medicine (medline via pubmed), cochrane central register of controlled trials, and embase. the search was limited to human subjects. the search strategy employed was the following: ((covid-19) and ('mask' or 'respirator' or 'ppe', or 'protections', or 'discomfort', or 'headache', or 'exertion', or 'prevention', or 'transmissions', or 'dentist')). cross-references were also considered together with the personal collections of the authors. all the resulting articles were assessed for eligibility by edr-mf reviewers independently, who screened the titles and abstracts for possible inclusion in the review, according to the inclusion criteria listed above. the agreement between the reviewers was also calculated (percentage agreement and kappa scores). reviewers were first trained and calibrated for study screening against another reviewer (cm) with experience in conducting systematic reviews. abstracts were excluded if they did not fulfil the inclusion criteria. to avoid the exclusion of potentially relevant articles, abstracts not providing the required information were included in the full-text analysis. full texts of potentially relevant studies were independently assessed by the same reviewers. any disagreement was resolved by discussion between reviewers. inter-observer agreement was assessed by means of kappa scores. papers mentioning sars-cov-2 or covid-19 transmission mode and ppe worn to protect from a possible contagion were included in this review, particularly the ones citing surgical masks and/or n95/ffp2 respirators. duplicates were removed, articles were sorted by title, abstract, and then, full text. once a paper was found eligible, its references were screened in order to find new papers for the revision. moreover, we submitted an anonymous online structured survey to 430 dental professionals belonging to an online community of dentists in order to assess their perceptions while wearing n95/ffp2 respirators. the assurance that the participants were members of the italian register of dentists was given by the fact that it is a closed community and access is granted only if it is provided a registration to the professional order. the 256 questionnaires obtained allow to estimate 47% headaches with an error at 6% and a 95% confidence level (ci95%). the survey was structured in 3 main domains and we asked a total of 16 questions. the first part of the survey regarded demographics (age, gender), the second focused on their medical respiratory and smoking history and the number of hours spent wearing an n95/ffp2 respirator. the third part was about several possible perceived symptoms related to hypercapnia such as muscular pain, breathing difficulties, headaches, sleepiness, abnormally frequent urination, drop in attention levels, and consequently, drop in work ability. questions about age, hypertension, headaches, muscular pain, and sleepiness were dichotomic (yes/no questions), whereas questions about drop in attention levels, drop in work ability, breathing difficulties, and exertion were assigned a score ranging from 0 to 10 (0 = not experienced, 10 = extremely), categorized in three groups: 1-3 mild symptoms, 4-7 moderate symptoms, and 8-10 severe symptoms. all the questions referred to the experience of healthcare workers in the recent months of the pandemic situation wearing ffp2 respirators. inclusion criteria: all questionnaires returned, being at least 23 years old, and registered in the italian national register of dentists. data were extracted independently by two reviewers using specially designed data extraction forms. contents of the data extraction included the following: • basic information of the trial: trial id, title, authors, journal information; • eligibility reassessment: all the items in inclusion criteria, final decision; authors of the primary studies were consulted to obtain any further information not available in the paper. when the study results were published more than once or results were presented in multiple publications, the most complete dataset was identified, and data were included only once. all data collected were analyzed using the software ibm spss statistics 25 (armonk, new york, ny, usa). numbers and percentages of dichotomic variables were reported. exact binomial ci95% was reported for headache. spearman's rank correlation coefficient test (spearman's ) was calculated in order to assess whether there were correlations between variables. chi square test was used to evaluate the relationship between sex and reported variables such as headache and concentration problems. all tests are to be considered with a 0.05 statistical significance level. following the search criteria in this scoping review, five papers were included, from three nations worldwide. though the database research identified 72 documents, after having read the abstract and removal of the duplicates, only 35 papers were fully read. as shown by the flow diagram (figure 1 ), 6 of them were reviews and therefore, were excluded and 24 did not comply with the criteria and were excluded. results from the reviewed papers, following the outcomes, are shown in table 2 . all the available articles were about healthcare workers but there were not any dentists in the sample pool, since in the current literature, there were no studies among dentists experimenting the analyzed outcomes. authors of the primary studies were consulted to obtain any further information not available in the paper. when the study results were published more than once or results were presented in multiple publications, the most complete dataset was identified, and data were included only once. all data collected were analyzed using the software ibm spss statistics 25 (armonk, new york, ny, usa). numbers and percentages of dichotomic variables were reported. exact binomial ci95% was reported for headache. spearman's rank correlation coefficient test (spearman's ρ) was calculated in order to assess whether there were correlations between variables. chi square test was used to evaluate the relationship between sex and reported variables such as headache and concentration problems. all tests are to be considered with a 0.05 statistical significance level. following the search criteria in this scoping review, five papers were included, from three nations worldwide. though the database research identified 72 documents, after having read the abstract and removal of the duplicates, only 35 papers were fully read. as shown by the flow diagram (figure 1 ), 6 of them were reviews and therefore, were excluded and 24 did not comply with the criteria and were excluded. results from the reviewed papers, following the outcomes, are shown in table 2 . all the available articles were about healthcare workers but there were not any dentists in the sample pool, since in the current literature, there were no studies among dentists experimenting the analyzed outcomes. two of these five studies [27, 28] focused on headaches, particularly lim et al. [27] , who found 37% had headaches which presented after donning an n95/ffp2 respirator, and percentages up to 81% in ong et al. [28] . those high numbers were correlated to the numbers of daily hours wearing an ffp2/n95 respirator. shenal et al. [21] investigated discomfort and exertion, through a self-reported scale and borg exertion scale, in healthcare workers wearing masks and respirators for 8 h shifts with doffing periods every two hours. their findings revealed a notable increase in discomfort and exertion over time even with doffing periods. rebmann et al. [29] studied the tolerance of operators regarding n95 respirators in a 12 h shift (with doffing periods) in a little sample of nurses working in a medical intensive care unit and investigated the reason behind each removal: in 22.1% of cases, nurses reported the removal was associated with discomfort and breathing difficulties. the last article we analyzed, by chughtai et al. [30] , regarded medical masks, not respirators, worn by 148 doctors and nurses in three different hospitals in china and among the problems reported, there were breathing difficulties (16.9%), headaches (6.1%), and discomfort (9.5%) even just with surgical masks. table 3 represents the age distribution and each outcome of this survey for dental professionals based on the culmination of questions obtained from the scoping reviewed articles. the original sample size consisted of 430 dental professionals. two-hundred-fifty-six (256) dental professionals (59.5%) fully completed the survey and their answers were indeed taken into consideration. the reasons for not answering three or more questions (thus, labeling the survey as incomplete) of the other colleagues were unknown to investigators (we suppose they were related to privacy or personal reasons). the final sample size with fully completed surveys was equally distributed between male (129) and female (127). all dental professionals wore the n95/ffp2 and 77.7% wore these n95/ffp2 respirators more than 4 h per day. headaches were one of the most reported perceived side effects, reported by nearly half (47.5% ci95% 41.2-53.8) of the dental professional participants. headaches were more reported in females than in males (55.9% of females vs 39.1% of males, p = 0.007). headaches were negatively correlated with age ( = −0.151, p < 0.05) but not correlated with the number of hours spent wearing n95/ffp2 respirators. moderate difficulties in breathing were reported by 162 participants (63.5% of the sample), with 20.8% of the participants experiencing severe breathing difficulties. breathing difficulties were not correlated with the hours spent wearing n95/ffp2 respirators. moderate concentration problems are also reported by the survey with at least 139 participants (54.3%). concentration problems became more severe for 66 dentists (25.8%) and medical histories indicated the presence of comorbidities (such as asthma, rhinitis, and osas) that has an effect on concentration problems among the participating dental professionals. discomfort and exertion, which are common reports from the study, were a severe consequence of prolonged n95/ffp2 use for 50.8% of the sample (130 participants) and were related to gender, particularly with females (it was severe for 58.2% of females and 43.4% of males, p = 0.012) but not with the number of hours spent wearing respirators. the presence of concentration problems, exertion, breathing difficulties, and headaches resulted in a moderate impaired working ability for 85.5% of our sample. in fact, an impaired working ability was strongly correlated to headaches ( = 0.212, p < 0.01), breathing difficulties ( = 0.566, p < 0.01), concentration problems ( = 0.748, p < 0.01), and exertion ( = 0.620, p < 0.01). this survey with italian dental professionals and the literature concur that headaches appear to be the primary result of prolonged wear from respirators. lim et al. investigated a sample of 212 healthcare workers at healthcare facilities in china during the sars outbreak in 2003-2004. headaches were reported in 37.3% (79 hcw) from respirator use. among these 79 hwc, 62.7% previously presented with no headaches and experienced it when they wore an n95/ffp2 respirator [27] . moreover, they identified the prolonged duration of hours spent wearing an n95/ffp2 as an important risk factor for the development of headaches. these data are corroborated by another study conducted in singapore during the covid-19 pandemic, where in a sample of 158 hcw with comorbidities, 128 (81%) reported bilateral headaches. the majority of the respondents (81.3%) reported a headache within 60 min of donning an n95 respirator and resolved within 30 min for most (88.3%) participants [28] . the discomfort experienced by hcw, which developed into a headache, has been noted to have a bilateral localization matching the areas of contact from the face mask or goggles and their corresponding head straps. the authors suggested that pressure and traction from mask straps are likely to be concurrent in the pathogenesis of those headaches, along with hypercapnia, hypoxemia, and stress from the current pandemic situation and its consequent workload. the combination of n95 respirators and protective eyewear along with a prolonged use (>4 h/day) have been identified among the risk factors. additionally, 82.8% of those with a de novo headache linked to ppe reported a slight decrease in work performance [28] . data from our survey, indicating headaches as one of the main outcomes related to ffp2 wear, but not correlated to the hours spent wearing a respirator, is in contrast with previous reports from the literature [27, 28] . moreover, in our survey, there was a statistical difference in headaches among genders, whilst in lim et al. [27] , the difference was not significant. another significant side effect and relevant outcome in our survey was breathing difficulties, at least moderate for 63.5% of our sample, but not correlated with the hours spent wearing n95/ffp2 respirators. chughtai et al. [30] detected only 12.2% breathing difficulties in their sample of 148 hcw. such substantial differences among our studies are attributable to differences in the respirators worn by participants. our sample is based on dentists wearing n95/ffp2 respirators without a valve, while the study by chughtai et al. [30] was based on surgical disposable masks. rebmann et al. [29] , conversely, investigated the effects of n95 respirators but subjects reported removing respirators for a few minutes and in 22.1% of cases, the reason was discomfort linked to breathing difficulties. rebmann et al. [29] was the only included article to measure o 2 and co 2 levels, resulting in a statistical increase in co 2 levels compared with baseline measurements, even though this increase was not clinically relevant, and there were no changes in o 2 levels. unfortunately, the results were not assessed in correlation to the headaches, visual challenges, and lightheadedness investigated by the authors. dental professionals usually take off masks between patients. we conjecture that the lack of correlation between headaches, breathing difficulties, and other symptoms with the numbers of hours spent wearing a respirator is the result of doffing periods between one patient and the subsequent one. this also applies to shenal et al. [21] , who analyzed the level of discomfort and exertion in 27 hcw, noticing how even with predetermined doffing periods every 2 h, discomfort and exertion increased over time, still partially in contrast with our report, where this feature was not assessed despite them being commonly seen outcomes reported being severe from 50.8% of our sample. an impaired working ability (iwa), not assessed in the examined literature, was one of the strongest outcomes of our sample. it is interesting to note that iwa showed a strong positive correlation with breathing difficulties, concentration problems, and exertion. this could be explained with the perceived hypercapnia phenomena. despite experiencing iwa and the other side effects, 49.2% of our group confirmed that ffp2 respirators are essential for the wellbeing of patients and healthcare workers, in agreement with italian and international guidelines [15, 19] . this survey is the first in italy to assess a problem that, given the actual pandemic situation and consequent rise in the use of respirators, will be a common finding in future months. the results of our survey coincide with the current available literature. however, our study has some limitations, in fact, given the current pandemic situation, we were unable to test a control group of dentists wearing only facial masks. moreover, it was a self-administered survey, not with an independent operator. n95/ffp2 respirators without valves are currently recommended in order to prevent covid-19 spread and preserve hcw wellbeing. n95/ffp2is acknowledged by the majority of dental professionals, although the majority experienced several perceived side effects. the practitioners wore the n95/ffp2 respirator for prolonged periods of time and the perceived side effects, such as breathing difficulties, headaches, and concentration problems, lead to an impaired working ability. there are no well-structured studies that correlate the o 2 and co 2 to the physical symptoms of healthcare workers. thus, further studies are required with pulse oximetry to determine the level of hypercapnia in relation to headaches and an impaired working ability. additionally, the pulse oximetry could assist in the assessment of valve respirators with a surgical mask in an attempt to decrease hypercapnia, since the literature is not conclusive. genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding advice on the use of masks in the community, during home care and in healtcare settings in the context of the novel coronavirus (2019-ncov) outbreak european centre for disease prevention and control time kinetics of viral clearance and resolution of symptoms in novel coronavirus infection aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 the presence of sars-cov-2 rna in the feces of covid-19 patients aerosol and surface distribution of severe acute respiratory syndrome coronavirus 2 in hospital wards turbolent gas clouds and respiratory pathogen emissions: potential implications for reducing transmission of covid-19 the efficacy of the rubber dam as a barrier to the spread of microorganisms during dental treatment being a front-line dentist during the covid-19 pandemic: a literature review high expression of ace2 receptor of 2019-ncov on the epithelial cells of oral mucosa overview of transnational recommendations for covid-19 transmission control in dental care settings epidemiological aspects and psychological reactions to covid-19 of dental practitioners in the northern italy districts of modena and reggio emilia indicazioni ad interim per un utilizzo razionale delle protezioni per infezione da sars-cov-2 nelle attività sanitarie e sociosanitarie (assistenza a soggetti affetti da covid-19) nell'attuale are uk doctors getting sufficient protective equipment against covid-19? considerations for acute personal protective equipment (ppe) shortages. available online rational use of personal protective equipment for coronavirus disease (covid-19) and considerations during severe shortages. interim guidance center or disease control and prevention. interim infection prevention and control recommendations for patients with suspected or confirmed coronavirus disease 2019 (covid-19) in healthcare settings. 2020. available online european centre for disease prevention and control. guidance for wearing and removing personal protective equipment in healthcare settings for the care of patients with suspected or confirmed covid-19 discomfort and exertion associated with prolonged wear of respiratory protection in a health care setting covid-19: focus on masks and respirators-implications for oral health-care workers evaluation of n95 respirator use with a surgical mask cover: effects on breathing resistance and inhaled carbon dioxide physiologic effects and measurement of carbon dioxide and oxygen levels during qualitative respirator fit testing physiological impact of the n95 filtering facepiece respirator on healthcare workers transmission routes of 2019-ncov and controls in dental practice headaches and the n95 face-mask amongst healthcare providers headaches associated with personal protective equipment-a cross-sectional study among frontline healthcare workers during covid-19 physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses contamination by respiratory viruses on outer surface of medical masks used by hospital healthcare workers we would like to thank gm tartaglia, for his valuable assistance in all the manuscript preparation phases. the authors declare no conflict of interest. key: cord-355318-qm79gz8w authors: smit, albertus j.; fitchett, jennifer m.; engelbrecht, francois a.; scholes, robert j.; dzhivhuho, godfrey; sweijd, neville a. title: winter is coming: a southern hemisphere perspective of the environmental drivers of sars-cov-2 and the potential seasonality of covid-19 date: 2020-08-05 journal: int j environ res public health doi: 10.3390/ijerph17165634 sha: doc_id: 355318 cord_uid: qm79gz8w sars-cov-2 virus infections in humans were first reported in december 2019, the boreal winter. the resulting covid-19 pandemic was declared by the who in march 2020. by july 2020, covid-19 was present in 213 countries and territories, with over 12 million confirmed cases and over half a million attributed deaths. knowledge of other viral respiratory diseases suggests that the transmission of sars-cov-2 could be modulated by seasonally varying environmental factors such as temperature and humidity. many studies on the environmental sensitivity of covid-19 are appearing online, and some have been published in peer-reviewed journals. initially, these studies raised the hypothesis that climatic conditions would subdue the viral transmission rate in places entering the boreal summer, and that southern hemisphere countries would experience enhanced disease spread. for the latter, the covid-19 peak would coincide with the peak of the influenza season, increasing misdiagnosis and placing an additional burden on health systems. in this review, we assess the evidence that environmental drivers are a significant factor in the trajectory of the covid-19 pandemic, globally and regionally. we critically assessed 42 peer-reviewed and 80 preprint publications that met qualifying criteria. since the disease has been prevalent for only half a year in the northern, and one-quarter of a year in the southern hemisphere, datasets capturing a full seasonal cycle in one locality are not yet available. analyses based on space-for-time substitutions, i.e., using data from climatically distinct locations as a surrogate for seasonal progression, have been inconclusive. the reported studies present a strong northern bias. socio-economic conditions peculiar to the ‘global south’ have been omitted as confounding variables, thereby weakening evidence of environmental signals. we explore why research to date has failed to show convincing evidence for environmental modulation of covid-19, and discuss directions for future research. we conclude that the evidence thus far suggests a weak modulation effect, currently overwhelmed by the scale and rate of the spread of covid-19. seasonally modulated transmission, if it exists, will be more evident in 2021 and subsequent years. a novel coronavirus, thought to have made a zoonotic transition from bats, infected a human host in wuhan, hubei province, china [1] . by late january 2020, the virus, newly named sars-cov-2, and the disease it causes, covid-19, had spread to 18 other chinese provinces, and to japan, south korea, taiwan, thailand, and the usa. on the date of submission of this review (15 july 2020), there were 13,331,879 confirmed cases, in virtually every country worldwide (213 countries and territories, figure 1 ). at the time, it was reported that 577,825 people infected with the virus had died; both numbers have subsequently risen. the only comparable acute respiratory disease pandemic was spanish influenza (h1n1), transmitted from birds to people in 1918, which lasted until 1919 and killed an estimated 50 million people worldwide. in the current highly interconnected world, the impact of the covid-19 pandemic is likely to be felt for many years [2] [3] [4] . it is therefore crucial that all potential determinants of the rate and location of the pandemic spread receive careful consideration in order to make appropriate plans for its management. epidemiological models have been used worldwide to guide the imposition (or not) of policy and regulatory intervention [5, 6] . these models can be modified to include aspects of social characteristics of the infected populations; and they can also be adapted to reflect the modulating effect of environmental influences on the processes that determine transmission. many related respiratory diseases show a connection between climate variables and the dynamics of the disease. it is thus plausible that such a dependency could exist for sars-cov-2 (reviewed in section 4) . given that the covid-19 outbreak began in mid-winter in the northern hemisphere, where it was (at the time of writing) peaking toward the middle of the boreal summer, and that the opposite scenario seems to be playing out in many southern hemisphere countries, it is tempting to associate this pattern with climate seasonality, as many publications have suggested. however, it is also plausible that the association is spurious, related simply to coincidental spatial connectivity between countries. it is necessary to critically assess the evidence for environmental sensitivity, in both the virus and the disease, before arriving at conclusions that may have significant implications. in terms of a response to the pandemic, we need to understand whether and how environmental variables influence the infection rate. this knowledge provides clues for policy and practice to reduce the spread of the virus and potential for treatment options. for example, if analyses show that absolute humidity is strongly associated with reduced infection rates (e.g., influenza [7, 8] ), artificially epidemiological models have been used worldwide to guide the imposition (or not) of policy and regulatory intervention [5, 6] . these models can be modified to include aspects of social characteristics of the infected populations; and they can also be adapted to reflect the modulating effect of environmental influences on the processes that determine transmission. many related respiratory diseases show a connection between climate variables and the dynamics of the disease. it is thus plausible that such a dependency could exist for sars-cov-2 (reviewed in section 4) . given that the covid-19 outbreak began in mid-winter in the northern hemisphere, where it was (at the time of writing) peaking toward the middle of the boreal summer, and that the opposite scenario seems to be playing out in many southern hemisphere countries, it is tempting to associate this pattern with climate seasonality, as many publications have suggested. however, it is also plausible that the association is spurious, related simply to coincidental spatial connectivity between countries. it is necessary to critically assess the evidence for environmental sensitivity, in both the virus and the disease, before arriving at conclusions that may have significant implications. in terms of a response to the pandemic, we need to understand whether and how environmental variables influence the infection rate. this knowledge provides clues for policy and practice to reduce the spread of the virus and potential for treatment options. for example, if analyses show that absolute humidity is strongly associated with reduced infection rates (e.g., influenza [7, 8] ), artificially raising indoor absolute humidity during periods of low ambient humidity may be an effective intervention. second, if environmental variables do influence the trajectory of the pandemic, the seasonal progression of the disease will lead to different implications across the globe, varying by hemisphere, region, and climatic zone. in the extratropical northern hemisphere, there would be a real possibility of a second wave appearing during the next winter [9] . conversely, there is a danger that the initially slow pace of the epidemic in the southern hemisphere could be misinterpreted to mean that proactive management has supressed the disease spread. given that in the south, where the peak of covid-19 incidence is likely to coincide with the winter peak of other endemic respiratory illnesses, complicating diagnosis and placing additional strain on the health systems, missing the environmental drivers of covid-19, if they exist, would be profoundly damaging. as we will argue, many southern hemisphere countries are particularly vulnerable (they are in the developmental 'global south' as well as the geographical south). for these regions especially, clarifying the environmental sensitivity will assist the prioritisation of resources. third, for longer-term management of the disease, we need to understand whether the seasonal effect will manifest as it does in established or endemic respiratory viruses, in the absence of being able to predict in what period of time (in years) the virus will be eliminated [10] . in this review, we consider all the pertinent studies relating to the effect of a range of specific environmental and climatological variables on the biology of the virus and the epidemiology of the disease. in section 2, we develop our reasoning for why southern hemisphere countries can benefit from the lessons learnt in the north, if the application of that knowledge takes heed of particularly southern hemisphere issues. in section 3, we briefly present the main classes of epidemiological models, since key parameters revealing environmental modulation are derived from such analyses. in section 4, we explore environmental sensitivity in extant respiratory viral diseases and past epidemics in order to suggest why seasonally coupled environmental influences are also likely to exist for sars-cov-2. section 5 then critically reviews evidence for such signals in the literature that had accumulated to 15 july 2020. section 6 summarises our findings, and offers suggestions for future analyses of the seasonal modulation of covid-19. the situation regarding covid-19 in southern hemisphere is different from that in the north in three ways. first, while the northern hemisphere is moving out of winter at the time of their peak of infections, the southern hemisphere is moving into winter. second, a much larger proportion of countries in the southern hemisphere are developing countries, with significant resource limitations in their healthcare systems. third, many of the countries in the southern hemisphere, and on the african continent in particular, have a much higher incidence of pulmonary diseases such as tuberculosis, immunocompromising diseases such as hiv-aids, and a higher prevalence of diseases such as cholera and malaria, which may not be recognised as comorbidity risks in covid-19 but do place coinciding stressors on the health system. to their advantage, the delayed arrival of covid-19 in much of the southern hemisphere has allowed these countries the time to observe the efficacy of containment and treatment practices in the global north, and to adapt their healthcare and policy response accordingly. the initial outbreak of covid-19 in china, early epidemics in iran, italy, and later much of europe and the united states took place during the coldest months of their year, and were distributed within a narrow climatic band [11, 12] . during the early period of the outbreak in january and february 2020, few known cases had been recorded in the southern hemisphere, which was experiencing peak summer conditions. this could reflect a climate sensitivity, but could just as plausibly reflect dominant trade and human movement patterns [13] . thus, the initial relatively low rates of spread and mortality in southern africa, australia and some regions of south america may simply be a result of being at an earlier stage in these epidemics. however, in both the northern and southern hemisphere, influenza and other coronavirus diseases peak during their respective winter seasons [14] . thus, if climate factors do play a role in covid-19 infection rates, the concurrence of transition of southern hemisphere countries to their winter season with the mid-stages of the disease transmission trajectory is of concern, especially with respect to containment policy and health system resource allocation. the status of healthcare services in the global south is of concern even without a climatic component to covid-19. while australia and new zealand have healthcare services as good as any in the northern hemisphere [13] , much of south america and sub-saharan africa struggle with access to quality healthcare. this is associated with poverty and socio-economic inequalities and result in poor health outcomes and financial risk to the state and individuals [15] [16] [17] [18] . the healthcare sectors are understaffed, underresourced, and understocked under normal conditions, which were working at maximum capacity even before the covid-19 pandemic [19] , and will be severely challenged as covid-19 cases increase [20, 21] . early evidence from china shows a significant correlation between mortality and the healthcare burden in covid-19 cases [22] . efforts to model the preparedness of african countries have highlighted concerns relating to the staffing of testing centres, stock for testing, and the ability to implement effective quarantining both inside and outside of healthcare facilities [20] . the prevalence of pre-existing infectious diseases compounds this issue. in the period 2016-2018, 41 african countries have experienced at least one epidemic, while 21 have experienced at least one epidemic per year [23] . south america is currently struggling with outbreaks of measles in 14 countries, and a tripling of the incidence of dengue fever in four countries [24] . recent outbreaks of diphtheria, zika and chikungunya have further stretched the healthcare systems [24] . the most prevalent infectious diseases in sub-saharan africa include cholera, malaria, viral haemorrhagic fever, measles and malaria [19] . of particular concern in the global south is the possibility of comorbidity with hiv-aids and tuberculosis (tb). many tb cases are pulmonary in nature [25] , while patients with hiv are significantly immunocompromised [26] . there is considerable tb-hiv comorbidity [27] . corbett et al. [28] found a 38% incidence of hiv in tb-infected patients across africa, and for the countries with the highest hiv prevalence, up to 75% of tb patients also tested positive for hiv. comorbidity has decreased from 33% to 31.8% over the past decade, and over the period 1990-2017, tb incidence, tb mortality rate and hiv-associated tb have declined in a number of southern african countries [26] . south america has much lower cases of both hiv and tb, and a comorbidity of approximately 10% [29] . while results from spain suggest that hiv-positive patients currently on antiretroviral treatment have no higher risk of severe sars-cov-2-induced illness [30] , the comorbidity of those with a longer hiv history and tb comorbidity, with or without hiv, is unknown. there are further related concerns pertaining to continued hiv [31] and tb [32] care during covid-19, as social distancing requires people to stay indoors and hospitals are overstretched. finally, the relatively delayed spread of covid-19 to the southern hemisphere has allowed these countries to 'get ahead of the curve' through evidence-based management derived in the north [33] . recent experiences of two ebola epidemics have meant that many countries in sub-saharan africa implemented temperature screening at airports long before the first covid-19 cases were reported [20] , and contact tracing and epidemic management plans are in place [19] . south africa, kenya, uganda and zambia were reported as having all been particularly proactive in planning for their eventual covid-19 cases [19] . south america has arguably not been as prepared (rodriguez-morales et al. 2020). studies on modelling risk for the african continent are largely related to importation risk [20] , which has been capped due to lockdown in many countries. this form of response is important in delaying the peak and "flattening the curve", but is unlikely to completely avoid extreme pressure on already stressed healthcare systems [16, 22] . when assembling datasets from many different locations to test the effects of environment on covid-19 progression, it is essential that the criteria for determining the infection and mortality rates are consistent across sources. the data used to calibrate and validate epidemiological models (e.g., the covid-19 data repository, center for systems science and engineering (csse), johns hopkins university) consist of time series of infections, which often include only those with symptoms sufficiently severe that the patients sought medical assistance, and who subsequently tested positive using a pcr-based test for the presence of the sars-cov-2 virus [34] . this is known as the 'case rate'. as the number of tests increases and includes community-based testing, as opposed to testing only those displaying symptoms, the case rate will converge on a true infection rate. pcr testing is accurate (though reporting is often delayed by days to weeks [35] ), but if testing is mostly performed on those presenting symptoms and their close contacts, estimates of the true infection rate inevitably include large biases, especially given the high occurrence of asymptomatic or mild cases. compensating for this bias requires that the sample frame be weighted to be representative of the population as a whole. as antibody-based tests become more widely used, datasets that indicate post facto what fraction of the general population was exposed to the virus will emerge. antibody tests have variable accuracy, both in terms of false positives and false negatives [35] ; nevertheless, their overall accuracy is much better than the guesswork that otherwise goes into estimating the number infected from the medical case rate alone. it is suspected that mildly infected people and even asymptomatic cases can spread the disease [36] , but perhaps less effectively than severely ill individuals. it is likely that recovery from sars-cov-2 provides subsequent immunity, with initial indications that this may be persitent [37] . the models that predict mortality use a time series of recorded deaths. at a minimum, this includes the deaths recorded in hospitals for people being treated for sars-cov-2 at the time of death. more complete records are supplemented with data on people who died in the community or in nursing homes, and were inferred from the symptoms they displayed to have died from covid-19. for severely-affected areas, it is possible to estimate the anomalies between the covid-attributed death rate relative to the seasonally adjusted expected population death rate, and infer that these additional deaths ('excess deaths') were caused by the pandemic [38] . where this has been carried out, it suggests that the death rate is substantially higher than that initially reported; however, this approach conflates deaths directly caused by sars-cov-2, and those that may have resulted from overburdening the health system. making accurate estimates of transmission rates requires a sufficient number of cases. often the models are initiated only once 30 or 100 cases have occurred in a location [39] so that the effect of importation of cases due to travelling may be minimised. therefore, if the area selected for analysis is too small, the number of cases may be inadequate to support the more data-intensive approaches. in most countries, data are collected daily, but the daily data show a lot of noise, partly for stochastic reasons; also, for spurious reasons such as the effect of weekends, laboratory delays, or recoding the date of reporting rather than the date of testing or infection (section 5.1). smoothing the data over periods of a week helps to solve irregular daily data patterns [40, 41] , but this also means that the analyses are unresponsive to events at finer timescales. the need to match the time period for which infections and deaths are recorded and the period over which environmental drivers are integrated is widely accepted. similar considerations also apply to spatial resolution. covid-19 outbreaks are apparently highly clustered, often in small areas. environmental drivers are also spatially heterogeneous, some much more so than others. the resolution chosen for the environmental data needs to be appropriate for both the grain of the infection process and the grain of the environmental variable. several analytical typologies have been applied to epidemiological models, mostly based on what factors they take into account [42] . table 1 is a pragmatic classification of the types thus far predominantly used for covid-19 projections, based on the logic of their construction. most of these model types can be implemented either deterministically or stochastically for age-structured or non-age-structured populations; for a single, equally-exposed population or for a spatially disaggregated population with transfers between groups; and using frequentist or bayesian approaches. cuevas [49] simple extrapolation and phenomenological models are suitable for projections of less than one month into the future, whereas the somewhat mechanistic epidemiology models are more robust for projections months or years into the future. the various classes of models can in principle run at any spatial scale and over any time period, but in practice there are data-imposed constraints. environmental influences can be introduced into the basic model structures at a variety of points ( figure 2 ). where they are introduced and what the models are able to say about the relationship between the environmental influences and infection or mortality rates depend on the theoretical basis of the model ( table 1 ). models that best capture the functional relationship of confirmed daily cases across time are best suited for revealing environmental drivers. the phenomenological and compartmental models are the strongest contenders here. the raw time series of confirmed infections and deaths can be time aggregated, and time lagged with respect to the environmental factors, to find the best fits, as long as this is performed consistently, and considers the time lags already built into the model structure. one approach is to establish correlations, either over time or across space, between the infection rate at a given time and simultaneous metrics of environmental factors such as temperature, humidity and uv (see section 5.4). in seir and similar models, two metrics are available for this infection rate: r 0 , the basic reproductive number, and rt, the effective reproductive number. r 0 is defined as the expected number of secondary infectious cases generated by any single average infectious case in an entirely susceptible population. r 0 should be largely free from signals attributed to imposed factors that affect human behaviour. it is typically derived from the initial portion of the growth curve when the disease spreads in a population where everyone is susceptible, before control measures have been put in place (i.e., completely 'natural conditions' sensu shi et al. [50] ) or herd immunity had been attained. neher et al. [51] note that "r 0 is not a biological constant for a pathogen" (p. 1) but it is affected by factors such as the infectiousness of the virus, susceptibility of the hosts (e.g., due to age or an assortment of comorbidities), duration of the infectious period, density of susceptible people (also population density and the proportion of the population that is urbanised) or the contact rate with them (including aspects of mobility), and environmental influences (as shown in figure 2 ). these aspects are subject to localised idiosyncrasies across the globe and must be accounted for in regional or global analyses when calculating or comparing r 0 . one approach is to establish correlations, either over time or across space, between the infection rate at a given time and simultaneous metrics of environmental factors such as temperature, humidity and uv (see section 5.4). in seir and similar models, two metrics are available for this infection rate: r0, the basic reproductive number, and rt, the effective reproductive number. r0 is defined as the expected number of secondary infectious cases generated by any single average infectious case in an entirely susceptible population. r0 should be largely free from signals attributed to imposed factors that affect human behaviour. it is typically derived from the initial portion of the growth curve when the disease spreads in a population where everyone is susceptible, before control measures have been put in place (i.e., completely 'natural conditions' sensu shi et al. [50] ) or herd immunity had been attained. neher et al. [51] note that "r0 is not a biological constant for a pathogen" (p. 1) but it is affected by factors such as the infectiousness of the virus, susceptibility of the hosts (e.g., due to age or an assortment of comorbidities), duration of the infectious period, density of susceptible people (also population density and the proportion of the population that is urbanised) or the contact rate with them (including aspects of mobility), and environmental influences (as shown in figure 2 ). these aspects are subject to localised idiosyncrasies across the globe and must be accounted for in regional or global analyses when calculating or comparing r0. rt is a measure of observed disease transmissibility, defined as the average number of people a case infects at any time (t) once the epidemic is underway. rt incorporates changes in a society's behaviour (self-regulated responses and non-pharmaceutical interventions or npis [52] ) as the disease becomes widespread, and varies day to day. these effects are typically stronger than the environmental influences, and can easily mask them or generate spurious associations. it is not advised to base assessments of environmental effects on rt due to the 'noise' that the signal will contain, unless there is sufficient information that permits inclusion of the interventions as continuous, time-varying factors. for the compartment models, it is possible to derive the values of the key model parameters by model inversion, in near-real time, and from these, calculate r0. this needs at least one more observation than there are free parameters to be estimated. in practice, accurate estimates of r t is a measure of observed disease transmissibility, defined as the average number of people a case infects at any time (t) once the epidemic is underway. r t incorporates changes in a society's behaviour (self-regulated responses and non-pharmaceutical interventions or npis [52] ) as the disease becomes widespread, and varies day to day. these effects are typically stronger than the environmental influences, and can easily mask them or generate spurious associations. it is not advised to base assessments of environmental effects on r t due to the 'noise' that the signal will contain, unless there is sufficient information that permits inclusion of the interventions as continuous, time-varying factors. for the compartment models, it is possible to derive the values of the key model parameters by model inversion, in near-real time, and from these, calculate r 0 . this needs at least one more observation than there are free parameters to be estimated. in practice, accurate estimates of confidence limits require many more data points than parameters. the multiple observations can come from a single-population time series, but this would limit the degree to which changes over time can be resolved within the parameters themselves. if there are multiple time series from different populations, both temporal and spatial variation of the parameters can be obtained. phenomenological approaches typically use a variety of parametric regression models (see section 5.4). it is sometimes necessary to fit a piecewise model to accommodate the breakpoint that develops when country-specific npis are introduced. it is generally only possible to compare the parameters of the curves across locations (rather than within locations, over time) to determine whether there is a systematic pattern that relates to any environmental predictors. this is because fitting multi-parameter non-linear curves using data from only a part of the curve (in epidemics, usually just the initial part) is notoriously difficult and uncertain. if the effect of the environmental factors on the model parameters was known, they could be used to alter the curve parameters dynamically, and thus the projected outcomes; but the parameters typically have no intrinsic biological meaning. seasonality of prevalence is a common feature in most persistent and established or endemic respiratory infectious disease [53] [54] [55] [56] [57] [58] [59] [60] , as well as many other infectious diseases [61, 62] , in diseases (or endemic tolerated infections) of both humans and other animals. peaks incidence periods occur during the shoulder seasons or the winter, oscillating globally with the opposing boreal and austral climate. seasonally varying prevalence has a general latitudinal gradient and is accentuated in highly seasonal temperate and subtropical climates (with some rare exceptions) but is also observed in tropical regions [63] . seasonality is found in a wide range of viral respiratory diseases (vrds)-including influenza viruses, para-influenza virus (piv), human syncytial virus (rsv), rhinoviruses and human coronavirus strains (hcov) [55, 60] . for endemic viruses causing vrds in humans, seasonal peaks are usually quite predictable, but interannual variability in onset and duration of any season, and the virulence of respective seasonal strains, vary. it follows, therefore, that if vrd prevalence follows this climatological pattern, a mechanism(s) that connects and modulates the viral disease progression with seasonally varying climatological variables in individuals or populations must exist. this sensitivity must occur in at least one location of the seir model ( figure 2 ). in the case of novel viruses, the role of seasonality is more contentious, mainly because they have not existed for enough time for seasonality to be unambiguously established. the seasonal prevalence of pandemic strains of virus is often conflated with the so-called second wave, which may be coincidentally associated with the following winter season, suggesting that there is a climate-based modulating effect on its incidence [10, 64] . in the case of sars and mers, the attribution of resurgence to climatological drivers, as opposed to secondary circulation dynamics, remains unresolved [65, 66] . novel viruses are much less predictable than established viruses with respect to their persistence, re-emergence in the following years or seasons, and virulence in later outbreaks [64, 67] . until a novel virus becomes endemic and recycles (in its existing form or as mutated strains), its seasonal prevalence is difficult to assess [68] . the magnitude of the current sars-cov-2 pandemic is likely to result in an extended period of persistence [69] , and thus if seasonal prevalence exists, it should eventually be unambiguously apparent. in the generalised seir model shown in figure 2 , environmental modulation can primarily take place at two stages, namely susceptibility and exposure. environmental sensitivity insights can come from two basic sources. the first is observational data and laboratory studies and analyses of the environmental modulation on the sars-cov-2 virus biology and the incidence of the disease it causes (as in this review). second, we can examine data and information from published studies on respiratory viruses and vrds and related endemic and novel coronaviruses specifically (see [53, 55, 57, 59, 60, 67, 70] for general treatment of this topic). in this section, we examine three sets of hypothetical mechanisms which explain environmental modulation and seasonality of vrds other than covid-19: (i) physical environmental variable modulation, (iii) biological and host behavioural modulation, and (iii) viral molecular and biochemical modulation. physical environmental variable modulation hypotheses focus on the meteorological correlates of seasonality in the diseases [54, 58] and comprise the bulk of such studies. these all follow the basic tenet that selected environmental variables (such as temperature or humidity) vary in space and time with the progressing seasons, and if a mechanism that links them with a vrd can be demonstrated, this makes them a suitable candidate for explaining vrd seasonality. there is a lack of clarity in the literature regarding which definition of humidity is best applied as environmental moderator of respiratory viral epidemiology. studies employ relative humidity (rh), absolute humidity (ah), specific humidity (sh), vapour pressure or dew point (more in section 5 below). this renders comparisons and conclusions difficult to reach [7] . rh and sh have strong dependence on temperature, which further complicates studies that include both temperature and humidity as predictors. the postulated mechanisms are usually tested in laboratory studies which monitor the persistence of viable viruses in aerosol droplets and on surfaces [71] , perform experimental transmission studies in animal models [72] , or study the relationship between observed ambient or indoor environmental variability and infection rate, morbidity and mortality, with the assumption of causality (section 5). notably, results from temperate and tropical climate zones (or with ranging latitude) are often contradictory. this has led to a suggestion that different seasonality mechanisms are at play in different climate zones: humidity (aerosol droplet transmission) as the key driver in temperate regions, and precipitation driving behaviorally mediated contact transfections in the tropics [73] [74] [75] . the environmental determinants of virus transmission in aerosol liquid droplets have received substantial consideration. the premise is that, in winter, characterised by relatively lower humidity, pathogen-bearing aerosol droplets (pbads) are more persistent. pbads expelled by infected individuals often contain viruses or bacteria, in a mixture of mucus, saliva and dissolved salts, and can travel up 8 m from a simple sneeze [76] . upon leaving the airway with moisture saturation close to 100%, pbads are exposed to much drier air which results in evaporation. they can quickly lose up to 90% of their water mass and reduce in size. at an rh of 40-60%, the water loss greatly increases the salt concentration to levels that inactivate viruses. in contrast, for rh < 40%, the dissolved salts precipitate, resulting in a pbad with low salt concentration and a high number of infectious viruses [77] . pbads range in diameters 5-20 µm when the ambient rh is 30-60%, whereas below 30%, a pbad may immediately reduce its size below 0.5 µm, and become a droplet nucleus [78, 79] . thus, conditions of lower ambient rh result in the production of smaller, lighter (longer floating periods), and potentially more penetrative pbads, thereby elevating the exposure component of the seir model [80, 81] . the role of temperature in influencing the prevalence of vrds is more contested and complex. this is partly because temperature and ah together determine rh, which affects the rate of evaporation and thus pbad dynamics, as argued above [72, 82] ; and temperature could also have direct effects. several studies associate temperature with respiratory disease incidence, some by direct association [83, 84] and some focussed on the temperature changes (i.e., lowering temperatures rather than lower temperatures [85] ). temperature may also play a mediating role in other ways. the first set of hypotheses consider the direct effect of temperature on respiratory virus survival. there are very few such studies but they show that viruses in general are surprisingly tenacious, with survival periods of days at room temperature for sars-cov-1. effective inactivation occurs at temperatures of above 56 • c [86, 87] . another temperature-mediated mechanism with substantial literature involves the fomite viability of viruses [88, 89] , particularly in public spaces and hospitals, involving endemic coronaviruses and sars-cov-2 [90, 91] . some studies explore the role of temperature alone on specific surface types [88] , while others look at the combined role of temperature and humidity [90, 92] . respiratory viruses, including human coronaviruses, can remain viable as fomites on a range of surface types, indoors and in sheltered external environments, at room temperature and higher, for periods of hours to days and from days to weeks on refrigerated surfaces at 4 • c. persistence depends on both the surface type and the temperature and humidity range (see table 1 [91] for a recent summary). thus, the risk of infection from fomites (the exposure element of the seir model) increases as temperature decreases. the combination of temperature and humidity has been found important for fomite viability in the endemic human coronavirus hcov 229e (table 2 ). most studies aim to test sterilisation techniques and the efficacy of personal protective gear [91, [93] [94] [95] [96] . one hypothesis posits a predominance of surface contact transmission in the tropical climates, versus transmission through pbads in temperate climates [97] . a range of other physical environmental variables have been cited as moderators of respiratory viral epidemiology. they often co-vary with other causal variables. wind and wind speed are relatively neglected as physical environmental factors in infectious disease epidemiology. given that windy seasons occur in many climates zones, wind should not be discarded as a contributing variable [98] . for influenza, wind has been cited in some instances as a factor in transmission of infectious particles from remote locations, as promoting the extended local transmission of pbads [99, 100] , with a convincing account in one case of equine influenza [100] . barometric pressure has also been considered, for example in the case of respiratory syncytial virus, where it was found to have no statistically significant influence [101] . in other studies, it does have an influence, along with temperature [102] . guo et al. [103] found air pressure to be a predictor of the risk of influenza infection in children in guangzhou, china, with a differential effect by age. rainfall seasonality and disease incidence in general are well described [104] , but literature on the relationship between rainfall patterns and vrd epidemiology is restricted to tropical climates. most studies have considered rainfall either at a very local scale, or as part of a set of meteorological variables being tested. pica and bouvier [105] comprehensively review the literature on this rainfall and vrds, and conclude that for a range of respiratory viruses (primarily influenza and rsv), there are as many studies finding some association as there are studies finding no link. with attenuated intraseasonal temperature variation in the tropics, rainfall provides a key differentiator between seasons, possibly explaining the strong associations between rainfall and respiratory illness prevalence there. the mechanism of association is less clear. there is a suggestion that the tropical rainy season causes crowding, and thus increased exposure [106] , another suggesting that reduced sunlight is associated with pneumonia incidence [107] , and yet another citing diurnal temperature changes [108] . the improvement in air quality and reduction in allergen production following rainfall may be another mechanism [109] . solar ultraviolet radiation (solar uv) varies greatly with season everywhere and is thus an attractive candidate to explain seasonality of vrds. uv radiation in laboratory settings is a very effective means of deactivating viruses, and there are a plethora of studies of this effect on all kinds of pathogens (including coronaviruses sars-cov-1 and mers-cov), mainly targeting hygiene and outbreak management in public spaces and hospitals [110] [111] [112] . studies that consider the environmental effect of solar uv (a component of sunlight) without confounding effects of other variables are rare. sagripanti and lytle [113] state that, for influenza, "the correlation between low and high solar virucidal radiation and high and low disease prevalence, respectively, suggest that inactivation of viruses in the environment by solar uv radiation plays a role in the seasonal occurrence of influenza pandemics" but concede that there are a range of additional factors that need to be considered. despite uv being regarded by several authors as the "primary germicide in the environment", its independent effect as a seasonal driver of vrds remains uncertain (on this point, for influenza, see [114] ). a second set of hypotheses for explaining the seasonality of vrds consider behavioural and physiological responses to changing environmental variables such as temperature [54, 55, 60] , related mostly to the exposure but also the susceptibility component of the model in figure 2 . these include considering the consequences of confining people in sheltered and enclosed spaces during colder weather, with recirculating air and closer proximity to infected co-inhabitants, thus increasing the likelihood of exposure. they also include the idea that exposure to colder and drier air at the cellular level in the respiratory tract results in impaired physical or immune-system defences to infection, and hence increased susceptibility [60, 115] . large (<30 µm) and medium (<10 µm) inhaled pbads are normally captured in the upper nasal mucosa and upper respiratory tract, respectively, and are transported towards the mouth (and expelled) through a synchronised circular movement of cilia. the combination of the mucosal layer and cilia can effectively clear the particles [79] . however, low ambient rh has been demonstrated to reduce the effectiveness of both mucosal production and cilia action [60, 72] . a corroborating study demonstrates that dry air (low rh) impairs host defence against influenza infection in genetically engineered mice with human-like lung tissue, as well as slowing recovery [116] . the third set of hypotheses consider the biochemistry and molecular adaptation of the viral pathogens [55] . these take into account the temperature sensitivities of the various stages of the virus infection cycle, from binding to the host cell, replication of nucleic acids, the stability of secondary structures of viral proteins, and eventual ejection of the virus from the host cell [55] . given that there is a gradient of temperature within the respiratory tract, and that breathed air can greatly alter conditions in the upper respiratory tract, susceptibility can increase under cold conditions, especially to viruses which are adapted to be most efficiently infectious at temperatures slightly below normal body temperature [55, 115] . falling somewhere between the physical, physiological and biochemical hypotheses in explaining seasonality of respiratory viruses is the change in susceptibility with varying serological levels of vitamin d. vitamin d synthesis occurs when the skin is exposed to sunshine, which varies seasonally (confounded with uv, temperature and other variables). vitamin d has been suggested as an important form of defence against microbes, influenza and pneumonia in particular [117] [118] [119] [120] . shaman et al. [121] attempted to model this effect on influenza prevalence in the usa and concluded that seasonal variability in other factors such as humidity and even the school calendar were better at explaining their results. these considerations are incomplete, with a final abiotic aspect that must be included. air pollution refers to a wide range of harmful, primarily geogenic (naturally occurring) and anthropogenic particulate matter, chemicals or gasses that cause negative or dangerous physiological responses and effects in humans and biota. it is well known that poor air quality can have direct and indirect impacts on human health, and in particular on the susceptibility of humans to respiratory viral infections as well and a measurable effect on the severity and mortality rates [122] . gases such as nitrogen dioxide, ozone and especially particulates classified by size (pm10, pm2.5, and pm0.1) have different pathological mechanisms and effects but are all known to be associated with the increases in viral respiratory disease incidence, hospitalisation or attributed deaths, famously during the london fog of 1952 [123] and the 1918 spanish influenza pandemic [124] . clifford et al. [125] , for example, showed that pm10 inhalation exacerbates the response to influenza, and ye et al. [126] showed that 'haze' (a combination of air pollutants) was associated with the spread of respiratory syncytial virus in children. air pollution is also known to have a strong seasonality, driven by both seasonal economic production activity and also by ranging seasonal metrological conditions which can either concentrate and trap pollutants in surface air or conversely disperse pollutants and improve air quality [127] [128] [129] . therefore, it is a further consideration that seasonal variation in air quality and pollution is an additional factor for consideration as a contributor to the seasonality of respiratory viral infections that have been reported. it is most likely that each of these hypothesised mechanisms has some role, either in unison, or independently or that one mechanism dominates in particular conditions [60] . while the precise mechanism that explains the relationship between environmental factors and disease prevalence is important, particularly because it may reveal optimal management interventions (of transmission and for treatment), statistical attribution of a strong correlate may suffice for effective management [8] . evidence from the many studies on viruses not dissimilar from sars-cov-2 suggests that a seasonal and environmentally-mediated signal should be seen in the novel covid-19 epidemic. what do studies to date tell us? we comprehensively reviewed the preprint and peer-reviewed literature on the topic of environmental influences of sars-cov-2 transmission. we used the boolean search capability of google scholar to locate articles with the following keywords in the article title: "(covid-19 or sars-cov-2) and (pollution or humidity or temperature or uv or climate or weather or season or seasonality)". this returned 287 articles on 8 july 2020. on the same day, additional searches for these search terms were conducted in the title fields on pubmed and the title, abstract and subject fields on the who covid-19 literature database (https://search.bvsalud.org/global-literature-on-novel-coronavirus-2019-ncov/), returning 469 and 170 publications, respectively. all searches were constrained to the year 2020. we selected only those studies on infection rates or similar metrics, excluding studies based solely on mortality rates. the combined set, which contained many duplicates and triplicates due to the intersection of three sets of search results, was screened manually and papers suitable for inclusion in our review were retained. five reviews in preprint were excluded from our assessment, but we did verify that we included in our analysis all relevant papers cited in these reviews. since we a priori expected many preprint manuscripts, we did not embark on the review with the intention to be prisma compliant (as would be necessary for a meta-analysis and systematic reviews), and hence we did not count the number of duplicates and triplicates, the ineligible studies discarded, or the reasons why they were discarded. the result of our searches yielded 42 peer-reviewed publications and 80 preprint manuscripts (supplementary tables s1 and s2). the peer-reviewed publications were subject to normal review scrutiny, and form the main body of this section. we did not assess the outcomes of the preprint papers (i.e., they are not discussed in detail as part of section 5.5) in order to avoid erroneous conclusions based on unassessed data, results or interpretations; nor did we attempt to apply our own peer-review process. the peer-reviewed research conducted on the role of climatic variables in covid-19 transmission has been highly interdisciplinary, with authors spanning 25 broad academic backgrounds. the largest number of authors (27) currently work in disciplines of geography, earth and environmental sciences, which incorporate climate science. this is closely followed by the 26 authors working in public health, and 25 authors in disciplines of epidemiology, virology and disease control. a total of 40% of the authors are in fields directly relating to covid-19 and climate. there is, however, a notable spread of authors in more distal academic and medical fields. notably, the authorship of 18 papers included nobody with an explicitly medical background. of the multi-authored papers, only three were by researchers who all come from the same disciplinary background, and for two of these, the backgrounds were epidemiology and medical laboratories. collectively, the peer-reviewed studies provide only weak evidence that sars-cov-2 is more infectious under lower temperatures and lower levels of absolute humidity. similarly ambiguous relationships for air pollution, uv and wind are reported, with a smaller focus on these variables in the literature. there are considerable differences in the ways in which the relationships have been established, resulting from which co-varying variables were included or not; use of different metrics of viral transmission, and which statistical methods were applied. in many cases, insufficient information is provided on the methods and data used, making it impossible to replicate the analyses. this section is relevant because of the high dependence on spatial variance to provide information at this early stage of the pandemic. the geographical coverage of the literature on the environmental influences on sars-cov-2 is heavily weighted to the northern hemisphere. data from bolivia, ecuador, brazil and australia were included in only five studies, i.e., one-tenth of the total. most of the southern hemisphere studies are included in studies claiming to be near global in their sampling. only eight studies focus specifically on a country in the southern hemisphere, brazil [130] [131] [132] [133] [134] [135] [136] [137] , and none of them consider any african country. environmental variables considered in preprint and peer-reviewed publications as modulators of sars-cov-2 transmission rates include mean, minimum and/or maximum daily temperature, and diurnal temperature range; an undefined 'humidity' variable, relative humidity, specific humidity and absolute humidity; dew point temperature; rainfall; wind speed or wind power; air pressure; some metric of solar or uv radiation; and 'air quality' (supplementary tables s1 and s2 ). these choices are apparently strongly influenced by the literature on other viral respiratory diseases. which definition of 'humidity,' is selected is significant challenge for interpreting and comparing studies. humidity broadly refers to the amount of water vapour held by air (which effects on the viability of pathogens in exhaled aerosol droplets-see section 4). studies must account for the fact that atmospheric pressure and temperature modulate the amount of water that a volume of air is able to hold in a gaseous state. a relatively small amount of water vapour is able to saturate cold air, whereas more water vapour is required to bring warm air to saturation. the studies we reviewed that seek to establish whether humidity is a potential driver of covid-19 use absolute humidity, relative humidity or specific humidity. two studies use 'humidity' [138, 139] without qualifying whether it is relative, specific or absolute humidity. this ambiguous use of the term does not permit reproducibility or meta-analysis. absolute humidity is defined as the total amount of water vapour held by air, in units of g·m −3 . a temperature change will not necessarily change the moisture content; it simply changes the capacity of the volume of air to hold water. only if temperature drops to saturation point, will condensation occur and water vapour content (but not relative humidity) will drop. if temperature increases, water vapour content will only increase if a moisture source is available from where evaporation can take place, or if a moist air mass moves in to replace the drier one. relative humidity is the fraction of water vapour, expressed as a %, contained by air relative to the amount of water vapour required to result in saturation of air at a given temperature and pressure. specific humidity is the amount of water vapour per unit mass of dry air (g·g −1 ). the distinction between relative and absolute humidity matters less in situations when the seasonal thermal range is constrained to a narrow band, such as at some mid-latitude coastal locations and near the tropics. however, in space-for-time studies-such as are required for global syntheses of seasonality effects-the reliance on absolute humidity should allow the investigator to arrive at plausible conclusions about atmospheric water vapour's effect on viral transmissibility [140] [141] [142] . environmental data were obtained from various sources such as era interim [143] or local meteorological organisations, and maybe provided as daily data or aggregates on temporal scales from 10 days to months. some use 'seasonal climatologies', i.e., averaged long-term data. since symptoms first manifest 3 to 14 days after infection, analyses sometimes apply lags between the independent and dependent variables of up to 14 [40] or 21 days [41] . lags have been accommodated in the reviewed literature by applying moving average filters to the daily time series of environmental variables with a width of 7, 14 or 21 days [41] . another approach is to base the analysis on 10 day aggregates of environmental data [140] . it is uncertain how such discretised intervals can be aligned with case data that is typically daily, but yet contains various delays. some studies take the mean of the variable over the analytic time period; for example, jahangiri et al. [144] who ambiguously use either the mean temperature over the study period or over the year, or liu et al. [141] and sajadi et al. [12] who use the mean of the environmental variables over the period for which case incidence data were obtained. most studies, do not account for lag effects [138] , or if they do, fail to adequately explain how lags were accommodated [40] . which metric of sars-cov-2 transmission to use as dependent variable is critical in addressing the central question, "do environmental variables modulate the transmission of the virus?" we argue in section 3.3 that the basic reproductive number, r 0 , is the best parameter for this purpose since it excludes the effects spontaneous or imposed non-pharmacological control measures implemented to slow the spread of the disease, but which still incorporates the environmental influence of a particular place. the failure to adequately account for non-entrée influences is the achilles' heel of many of the studies reviewed. of the literature we assessed (supplementary tables s1 and s2) , only six studies base their assessment of the presence or magnitude of environmental influences on r 0 as the dependent variable [39, [145] [146] [147] [148] [149] . jebril [150] , luo et al. [151] , poirier et al. [142] , and wang et al. [152] used r t (see section 3.3) as the response variable. because r t is very context specific and sensitive to social factors and interventions, using this parameter to assess the presence and size of environmental influences will in most instances have a low signal: noise ratio. the usefulness of r t is that it demonstrates how effective npi measures are in controlling an epidemic, and provides information on how regulators must adapt these interventions over time, based on health and economic goals. the non-environmental 'noise' can be filtered out, but this requires a great deal of data regarding the nature of the specific interventions applied, movement patterns, precise knowledge about testing and reporting (which is not necessarily constant), and so forth. none of the r t based studies to date meet these preconditions, and are therefore not able to remove the non-climatic (social) influences from the rapidly fluctuating r t values. another approach that holds merit is to use the growth rate or doubling time estimated from the exponential increase in cases as dependent variable [148, [153] [154] [155] [156] [157] [158] [159] [160] . merow and urban [156] argue that these kinds of metric are robust even if the details of testing and reporting vary from place to place, as long as the detection probabilities at a place remain constant over the estimation period. this argument is equally valid for estimates of r 0 . another variation to this theme of estimating growth rate-related parameters as an indication of transmissibility is to take rates as time required to progress from the first reported case to 200 cases [161] , or to use the cumulative number of cases reached 28 days after the first reported case [162] . however, these approaches effectively fit a linear model to case vs. time data, which does not account for the accelerating rate of increase in number of cases. lolli et al. [163] use the daily icu case anomaly, but this of course entirely excludes all but the most severely ill patients and cannot be seen as being representative of disease transmissibility. other data-related considerations, particularly in relation to studies that use parameter estimates of the exponential relationship that daily new infections has with time, are that care must be taken to omit both (i) cases that result from the importation of infected individuals from the time series (i.e., new cases must be local transmissions only), and (ii) the case data obtained after the intervention period begins. requirement (i) can be affected by including only the portion of the time series after a certain minimum number of cases are present, as has been performed by caspi et al. [154] , merow and urban [156] , and notari [157] . requirement (ii) is met by ficetola and rubolini [155] , merow and urban [156] , notari [157] , and possibly for oliveiros et al. [158] , although it is uncertain how strictly this was implemented due to their statement that oliveiros et al. [158] "considered mainly the initial days of the time series" (p. 4). we will comment on the reproducibility of methods in section 6. requirement (ii) is implicit in the definition of r 0 , but the two requirements constrain the usable data to between 'not too early' and 'not too late'. the bulk of the studies in supplementary tables s1 and s2 used daily new or cumulative confirmed cases as response variables. this practice is not advised for largely the same reasons given for r t . such daily data are likely to carry too many other non-climatic signals to be generally used-unless, of course, analyses included a specific set of controls that would be difficult to extend to the global context. the studies in supplementary tables s1 and s2 employed the following statistical methods to evaluate relationships between environmental variables and the transmission rate of sars-cov-2: various linear, logistic, or exponential parametric models [39, 41, 50, 130, 134, 142, 146, 148, 151, 158, [164] [165] [166] [167] , sometimes with the inclusion of non-gaussian error structures as permitted by generalised linear models (glms) [141, 157, 162, 164, [168] [169] [170] [171] ; generalised additive models (gams) [41, 134, 167, 172, 173] ; distributed lag panel regression models [153] ; machine learning such as support vector machines and decision trees [147] ; local panel projection estimator within a country-level dynamic framework [174] ; loess smoothers/curves [142] ; bayesian methods [157] ; and pearson's, spearman's, and kendall's correlations [40, [138] [139] [140] 154, [175] [176] [177] . regression approaches allow functional relationships to be established between the driver (any of the environmental influences) and response variable (a metric of infection rate), allowing the magnitude of the environmental effect can be determined. robust implementation of a regression approach would include place as a random effect (i.e., as mixed models, also known as panel regressions; for example, [11, 153, 155, 178, 179] ). this allows the fact that the effect of the environment on viral transmission varies from place to place, for social and historical reasons. multiple regression allows the simultaneous evaluation of several predictor variables in terms of the influence they collectively or individually have on the outcome [39, 180, 181] . it is possible to establish which of the drivers, if any, has the greatest contribution to an effect seen in the outcome variable. for example, mollalo et al. [180] used multiple regression to evaluate the simultaneous contributions of environmental and socio-economic influences on usa county case counts. if parameterised properly, multiple regression can be used to rule out contributions of potentially confounding and multi-collinear variables. loess smoothers and correlation approaches, although useful for a qualitative assessment for the presence of environmental influences, cannot inform us about the relative importance of environmental modulators versus other location-specific or social influences. similar non-quantitative approaches that only hint at the presence of relationships include the simple visual mapping of the number of infections in relation to climate zones or latitudes [12, 150, [182] [183] [184] . these methods can at best raise an hypothesis that requires further testing. other approaches worth mentioning include the application of wavelet transforms [185] , multivariate analyses [130] , and ecological niche models [186, 187] . wavelet analysis, which requires a long time series, provides only a qualitative view of disease dynamics as modulated by weather or climate variables. ecological niche models are not suited for studies on covid-19 because disease dynamics are entirely different mechanistically from the principles that govern organisms and ecological systems (as reviewed by carlson et al. [188] ). multivariate methods are useful for examining environmental variable modulation of covid-19, since they provide many, if not all, of the benefits of multiple regressions, plus they have other features that confer flexibility and the ability to accommodate a range of data types. they are ideally suited for situations where there are many factors that might contribute simultaneously to the variation of one or many outcome variables. the application of a multivariate approach by auler et al. [130] uses data on the daily new confirmed cases (see critique above), and for this reason we do not consider the findings of this study further in our review. dynamic or mechanistic models (predominantly the compartment models of the seir family) are useful tools to explore how seasonality may impact on the evolution of the disease, and provide a way to discern the signature of seasonality in near real-time observational data. such an investigation recently reported on by baker et al. [189] concluded that under the high infection rates of covid-19, within the context of almost the entire population being susceptible at the onset of the disease, seasonality effects on the disease evolution will be limited initially. however it cannot be discounted at later stages, if for instance, the immunity gained by recovered patients is temporary, so that they become susceptible again in subsequent years or if herd immunity is not attained before managed abatement of the epidemic (as we are seeing in some countries experiencing resurgences). a similar study by neher et al. [51] came to similar conclusions. we will now discuss only the findings of those studies that have undergone peer review, have selected appropriate environmental data as influential variables, relied on suitable response variables (such as r 0 or parametric estimates) to estimate the local viral transmission rates in the absence of policy control measures, accounted for potential confounding influences, and applied appropriate statistical models. the only peer-reviewed paper that fulfils all of these criteria is that by yao et al. [39] , which undertakes an assessment of the effects that temperature, relative humidity, and uv radiation have on the r 0 . this study has a relatively narrow geographical focus: it includes 227 chinese cities. r 0 was calculated from data over the period 10 february to 9 march 2020. the authors assert that these data are for the "expected number of secondary cases generated by an initial infectious individual, in a completely susceptible population" [39] (p. 1). all daily environmental data were spatially matched as closely as possible to the cities they represent. given the large number of cities, each with its unique climate, this kind of study lends itself to a regression-type analysis if each of the daily observations per environmental variable are averaged over the study period duration before relating them to each locality's r 0 . this study did not find an influence due to any of the environmental variables studied on the rate of sars-cov-2 transmission. a weakness of the study was the failure to account in their multiple regression model for any of a large number of city-level confounding influences. a single published study does not provide robust support for the presence or absence of a climatic influence on sars-cov-2 transmission rates. the preprint studies [11, 147, 152, 153, 155, 156, 162, 174, 190] offer mixed statistical support (none, weak, or strong relationships) for the influence of environmental drivers. carlton et al. [153] show that that uv radiation affects covid-19 growth rates, but not temperature or humidity. merow and urban [156] offer comparable support for a uv radiation effect. according to ficetola and rubolini [155] and wan et al. [190] , covid-19 transmission is greatest at a temperature of 5 and 6.3 • c, respectively; the former authors further show that transmission peaks at a specific humidity,~4-6 g·m −3 (peaking implying optimum conditions above and below which transmission rates drop off). similarly, leung et al. [162] suggest support for the hypothesis that lower temperature and humidity enhance covid-19 transmission. similar responses are seen by lin et al. [165] and wilson [174] with regards to temperature, but they also suggest an interaction between temperature and relative humidity [165] and temperature and mobility [174] in terms of modulating infection rates. in contrast, gupta and gharehgozli [147] show that higher temperatures enhance the spread of the disease; they also show that viral transmission is enhanced under higher concentrations of pm2.5. this pandemic has rapidly mobilised scientists from diverse disciplines in a possibly unprecedented way. scientists have helpfully offered insights and analytical methods based on their own disciplines they did so efficiently and swiftly, particularly in those countries most heavily affected by the pandemic early on. the rush to contribute knowledge about the future spread of covid-19 resulted in a flood of papers appearing on preprint servers [191] , which will in due course be peer reviewed and some will be published. the pressure to speed up the peer-review process, in order to address the urgent challenge, may result in a compromise in the quality of both the review process and the science that is thereby published. in our screening process in section 5, we scrutinised 29 peer-reviewed publications and 23 preprint articles. of these, we found one published and potentially four preprint studies that offer credible insight into the climate-related sars-cov-2 and covid-19 dynamics and epidemiology with a reasonable degree of confidence and rigour. the general prevalence of climatologically-coupled seasonal signals and environmental variable modulation seen in the majority of other viral respiratory diseases creates the expectation for a similar effect on sars-cov-2 and in covid-19 epidemiology. however, this virus and disease have only been spreading for 8 months. observational evidence available to date has not yet been analysed sufficiently thoroughly to show that climate-related modulation is indeed a significant factor. the studies reviewed in section 5 have aimed to find signs for such a signal, but a variety of methodological problems render a definitive conclusion premature. the currently available time series do not capture a full annual cycle at any one location, or globally. the first studies appeared in late january on preprint servers (the majority of these are yet to be formally published as of mid-july 2020). as such, the initial reports looked for spatial variation in infectivity within a region and attempt to explain it in terms of associated variability in temperature, humidity or other environmental factors among these locations. later studies could have benefitted from the larger datasets and a wider range of variation in the environmental drivers, resulting from the global spread, but became increasingly confounded by co-varying differences among the countries' socio-economic conditions and pandemic responses. to date, the 'global' messages coming from the current body of covid-19 research in general, and in respect to the environmental drivers of the disease in particular, do not equitably address the specific dynamics and considerations pertaining to the 'global south'. this is in part likely due to the slightly later arrival of the disease in the southern hemisphere. thus, fewer southern hemisphere countries have suffered outbreaks of the same scale and severity (at the stage of assembling this manuscript) as the epidemics in the far east, europe and the united states. at the time of writing, the situation in some south american countries (such as brazil and peru) was deteriorating quickly. there is also a technical challenge in countries with relatively lower medical health research capacity, such as those in africa [192] . the upshot is a circumstantially driven bias in the current literature which needs to be corrected, for several reasons. neglecting the hemispheric disparities in knowledge regarding the role of environmental variables on sars-cov-2 and the modulation of the covid-19 epidemic influences the discussion on the attribution of the reductions in cases. northern countries are likely to move past peak daily infections coincidentally with the height of summer. it also neglects the urgent consideration of countries which are moving into winter. importantly, many of the countries in the global south have already-stressed healthcare systems, and accurate modelling is critical in determining policy interventions for control measures to protect the lives of some of the world's most vulnerable people. the collective global experience can provide a shortcut to knowledge and information regarding the role of environmental variables on sars-cov-2 biology and modulation of covid-19 epidemiology and seasonality, applicable anywhere, by exploiting the latitudinal phasing of seasons to conduct research in all climates zones simultaneously. this leads us to call for global collaboration on this topic. much of the work we reviewed failed to carefully consider the implications of the choice of available metrics for viral transmission. we deem r 0 to be best suited for the purpose of finding environmental sensitivity and seasonal climatic signals; some parametric estimates from regression models can also work, provided that care is taken to constrain the cases to those that result from local transmissions up to the time when npis come into play. r 0 is closely aligned with the sir-seir model family, and can be derived from the inversion of time series of case rate data using these models (see below). due to the effects of the incubation period, it may be important to use daily data (rather than data averaged over a several days) and a suitable lag period for both environmental and test-result data incorporated in the analysis. in the case of a highly infectious disease such as covid-19, manifesting in a densely populated location, the effect of daily weather variations on transmission mechanisms is likely to be overwhelmed by the sheer magnitude of exposure. it may be that environmental modulation is still an important factor in these circumstances, but may reflect in indoor environments rather than outdoor ambient conditions [193] . once the disease spread begins to approach an equilibrium (r t~1 ), the environmental effect may become more apparent. to date, studies that attempted to discern the effects of climate by comparing infection rates across regions with different climates have been compromised by the heterogeneities that exist across locations and times in terms of control measures applied [194] , and social, economic and cultural conditions that affect the practise of social distancing. most studies have omitted variables such as poverty, population size and demographics (particularly age frequencies of the populace), the density of the population and how much high-resolution clustering is present (such as in the informal settlements in many countries of the south), the degree of urbanisation, access to healthcare, mobility and migration, various types of comorbidities (e.g., tb, hiv, malnourishment), the effect of the bacillus calmette-guérin(bcg) vaccine [195] , and a plethora of additional influences which are still not well understood with regards to how they influence the unfolding of covid-19 across the globe. simple graphing of case numbers across time in relation to some of the potentially influential drivers (as for example permitted by the our world in data coronavirus pandemic data explorer) will help reveal which of the additional variables to admit into the analysis. an important obstacle to finding the seasonal signal in the global covid-19 data is to find a way to deal with the hemispheric disparity (gradient away from the equator) in out-of-phase climatic signals. comparing the evolution of covid-19 for northern hemisphere countries moving from winter to summer to its evolution in southern hemisphere countries moving from summer to winter provides a valuable opportunity to discern the signature of seasonality. however, such a comparison will remain compromised by short time series and can only fully fulfil its potential once both hemispheres have experienced a full annual seasonal cycle. we have concluded that due to high values of r 0 exhibited by sars-cov-2, seasonal climate modulation should not be relied on to significantly dampen the infection rate even in the midst of the northern hemisphere approaching summer. should the disease persist several years into the future, however, under the condition of an increasing fraction of the population of a given region having immunity, it is likely that the covid-19 will exhibit an increasingly clear seasonal cycle as evident in similar endemic human coronaviruses. such insights will only be apparent after the main pandemic surge in 2020. we suggest some avenues for progress in addressing the environmental sensitivity of the disease. in addition to regression and correlative empirical approaches (section 5.4), non-linear methods can also be applied. these may include the use of extended kalman filters and the inversion of compartment models. extended kalman filters are commonly used in data assimilation to infer parameters from high-dimensional input data sets. recently, pei et al. [196] applied an ensemble-adjusted kalman filter to infer the differential spatial distribution of covid-19 infection rates from empirical data collected across different counties in the usa, followed by their application in a seir model. it may be feasible to apply this technique to estimate the relative roles of non-pharmaceutical control measures and seasonality in determining the infection rate. inverse modelling, particularly using seir-type models, can infer infection rates from case and testing data, as demonstrated for the hubai province in china [46] . making use of large ensembles that ingest data from many locations and systematically explore various combinations of the forcings can potentially explore the relative sensitivities of infection rates to npi control measures and seasonality. we recommend the use of regression-type statistical analyses than can be adapted to accommodate many simultaneous driving variables, including both environmental and non-environmental factors, thereby removing confounding influences. these models also readily accept non-gaussian error terms and can account for autocorrelation in time series. lags between exposure and when an individual is confirmed as infected can be accommodated by distributed lag non-linear models [197, 198] . these techniques rely on generalised additive models (gams) for the flexible estimation of smooth responses and parametric terms. the recognition that disease dynamics may differ between locations for a multitude of reasons requires that 'location' be specified as random effect (notable examples involving covid-19 include carlton et al. [153] and wilson [174] ). such approaches can be accommodated by longitudinal models (called panel regressions by economists) (sensu gardiner et al. [199] ), which regress the dependant variable (plus covariates and constraints) as a function of time. care should be given to estimations of uncertainties around model predictions -such estimates of uncertainties are permitted by markov chain monte carlo (mcmc) approaches [42] . knowing the uncertainties is necessary in assessing projections from competing models in the public policy space. finally, multivariate approaches, such as redundancy analysis (rda) or constrained correspondence analysis (cca), will also accept a creative assignment of a host of response and influential variables simultaneously, and can be employed when research is faced with many potentially contributing factors, each of which might explain a portion of the overall variability. we noted a lamentable deficiency in the application of reproducible research practices in many of the publications we reviewed. clear, precise reporting of data sources and quality, data screening practices, listings of the ancillary data sources used, a detailed account of the data processing and statistical procedures and software used, and the exact reporting of all relevant diagnostic and supporting statistics, tables and figures is essential, particularly in this global emergency, where published data and information are used operationally, and where robust guidance is most likely to emerge from meta-analyses of many studies. lives, livelihoods, economies, and the public trust in science depend on rigour and reproducibility. it is thus incumbent upon global research organisations and agencies such as the world health organisation (who) and the world meteorological organisation (wmo) to provide leadership and guidance and to define best-practice protocols for the analysis of data and production of information. to this end, the who has produced a document entitled "a coordinated global research roadmap: 2019 novel coronavirus" [200] . its scope is broad, and thus does not specifically address some of the issues raised in our review. the authors are aware [201] that at the time of writing, the wmo has agreed to set up a task team which will focus on the environmental aspects of the covid-19 pandemic. datasets capturing even the first full seasonal cycle of covid-19 incidence in one locality, region or globally are not yet available and it is not possible at this stage to conclude that a definitive and unequivocal signal of environmental modulation is apparent from the reviewed literature. however, there is some evidence that environmental drivers played a role in transmission in some regions and at some (early) stages of the pandemic. under other circumstances, longer and denser datasets would be a minimum requirement to support a thorough statistical treatment to explore evidence of environmental modulation of the covid-19 pandemic and epidemiological dynamics. pressure for rapid answers and information has prompted impulsive and dubious forays into signal-finding missions, such as those that dominate the current body of literature that had accumulated to date (15 july 2020). analyses based on space-for-time substitutions have been inconclusive, primarily due to lack of care taken to account for the effects of strong confounding variables, such as socio-economic influences and effects of npis, which exist between jurisdictions. in terms of the outcomes of the published work, most studies are insensitive to the idiosyncratic conditions unique to many southern hemisphere countries, rendering it challenging to transfer findings from north to south. rigorous hypotheses, interrogation of assumptions, and careful selection and development of analytical approaches and statistical models are required to examine environmental signals in complex covid-19 incidence datasets, especially prior to longer and denser time series data being available. in the interim, there is merit in comparisons of signals among contrasting locations at different scales, and with due consideration paid to the implementation of npis and other sources of 'noise'. this outcome does not discount the role of environmental drivers in modulating the incidence or seasonality of person-to-person transfection mechanisms, or of the morbidity, severity and mortality associated with covid-19 infections. however, these may become unequivocally discernable only at later stages of the pandemic in 2020 or 2021, and globally coordinated efforts to test this robustly are essential. supplementary materials: the following are available online at http://www.mdpi.com/1660-4601/17/16/5634/s1, figure s1 : discipline backgrounds of authors whose publications were included in this review. table s1: studies that have aimed to establish links between sars-cov-2 infections and environmental variables, notably temperature and humidity. all studies have in common a finding that the transmission of the virus is enhanced under colder, dryer conditions. table s2: studies that have aimed to establish links between sars-cov-2 infections and environmental variables, notably temperature and humidity. all studies have in common a finding that the transmission of the virus is enhanced under colder, dryer conditions. author contributions: the conceptualisation of this study was by a.j.s.; he also performed the data extraction and wrote section 5 "critical assessment of studies of covid-19 climate susceptibility" and section 6 "discussion". data collection was undertaken by n.a.s., j.m.f. and a.j.s.; j.m.f. contributed section 2 "why the southern hemisphere is different". f.a.e. provided editorial input as required, and contributed his thinking around inverse modelling and some of the climatological considerations. r.j.s. provided the text under section 3 "monitoring and modelling the spread of covid-19", and also assisted with thorough language editing of the final document. n.s. added section 1 "introduction" and section 4 "implications for covid-19 of environmental sensitivity in other viral 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